ENCYCLOPEDIA OF

SOCIAL. WORK
20TH EDITION
 EDITORIAL BOARD

EDITORS IN CHIEF

Terry Mizrahi, Ph;D.,MSW

Professor of Social Work Hunter
College

LarryE. Davis, Ph.D., MSW Dean

of Social Work University of
Pittsburgh

AREA EDITORS

Paula Allen-Meares, University of Michigan Darlyne

Bailey, University of Minnesota Diana M. DiNitto,
University of Texas at Austin Cynthia Franklin,
University of Texas at Austin Charles D. Garvin,
University of Michigan Lorraine Gutierrez, University of
Michigan
Jan L. Hagen, University at Albany, State University of New York
Yeheskel Hasenfeld, University of California, Los Angeles Shanti K.
Khinduka, Washington University in St. Louis Ruth McRoy, University
of Texas at Austin
James Midgley, University ofCalifomia, Berkeley
John G. Orme, University of Tennessee
Enola Proctor, Washington University in St. Louis Frederic
G. Reamer, Rhode Island College
Michael Sosin, University of Chicago
 ENCYCLOPEDIA OF

SOCIAL WORK
20rn
EDITION

Terry Mizrahi
Larry E. Davis

Editors in Chief

VOLUME 1
A-C

- -
NASW PRESS

OXFORD
UNIVERSITY PRESS

2008
 - -
NASWPRESS
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I
l
Contents

ix
List of Entries
xv
Introduction
ENCYCLOPEDIA OF SOCIAL WORK

Topical Outline of Entries Volume 4, 439

Directory of Contributors Volume 4,447
Index Volume 4, 471

vii
List of Entries

A Bereavement Practice Comorbidity

Abortion Best Practices Bioethics Compulsive Behaviors
Adolescents Bisexuality Confidentiality and Privileged
Overview Blindness and Visual Impairment Communication
Demographics and Social Issues Brief Therapies Conflict Resolution
Practice Interventions Pregnancy Consultation
Adoption Adult Consumer Rights
Day Care C Contexts/Settings
Adult Protective Services Caribbean Americans Agency and Organization in
Adults Case Management Non-Profit Settings Corporate
Overview Group Chaos Theory and Complexity Settings Faith-Based Settings
Care Advocacy Theory InterorganizationaI Contexts
African Americans Charitable Foundations Private/Independent Practice
Overview Child Abuse and Neglect Settings
Immigrants of African origin Child Care Services Children Continuing Education
Practice Interventions Overview Contracting Out of Social Services
Agency-Based Research Practice Interventions Council on Social Work Education
Aging Group Care Couples
Overview Health Care Crime and Criminal Behavior
Practice Interventions Racial Children's Rights Criminal Justice
and Ethnic Groups Services Child Support Overview
Alaska Natives Child Welfare Criminal Courts
Alcohol and Drug Problems Overview Corrections
Overview History and Policy Framework Crisis Interventions
Law Enforcement and Legal Policy Christian Social Services Chronic Cultural Competence
Practice Interventions Illness Cultural Institutions and the Arts
Prevention Citizen Participation Culturally Competent Practice
Alzheimer's Disease and Other Civic Engagement
Dementias Civil Liberties
Arab Americans Civil Rights D
Asian Americans Civil Society Deafness and Hardness of Hearing
Overview Client Violence Deinstitutionalization Demographics
Practice Interventions Clinical Social Work Diagnostic and Statistical Manual of
Chinese Codes of Ethics Mental Disorders
Japanese Cognition and Social Cognitive Direct Practice
Koreans Theory Disability
South Asians Cognitive Therapy Overview
Southeast Asians Collaborative Practice Neurocognitive Disabilities
Assessment Community Physical Disabilities
Asset Building Authoritative Overview Psychiatric Disabilities
Settings and Practice Interventions Disasters
Involuntary Clients Community-Based Participatory Disparities and Inequalities
Research Displaced People
Community Building Divorce
Community Development Community Dual Degree Programs
Economic Development Community
Needs Assessment Community
B organization Community Violence E
Baccalaureate Social Workers Earned Income Tax Credit
Behavioral Theory Eating Disorders

IX
X LIST OF ENTRIES

Ecological Framework Overview South America Interorganizational

Economics and Social Welfare Practice Interventions Practice Interventions
Education Policy Health Care Financing Interprofessional and Partnered
Elder Abuse Health Care Reform Health Practice Intervention
Employee Assistance Programs Care Social Work Research Interviewing
Employment and Unemployment Historiography HIV/AIDS Intimate Partner Violence
Empowerment Practice End-of-Life Overview
Decisions Environment Practice Interventions
Environmental Justice Children
Epistemology Home-based Interventions J
Ethics and Values Homelessness Jewish Communal Services
Ethics in Research Hospice Juvenile Delinquency
Evidence-Based Practice Housing Juvenile Justice
Experimental and Humanistic Therapies Overview
Quasi-Experimental Design Human Needs Juvenile and Family Courts
Overview
Family L
F Health Latinos and Latinas
Faith-Based Agencies and Social Religion and Spirituality Overview
Work Work and Employment Practice Interventions
Family Human-Other Animal Bond Cubans
Overview Human Rights Mexicans
Practice Interventions Human Sexuality Puerto Ricans
Family Caregiving Hunger, Nutrition, and Food Leadership
Family Life Education Programs Legal System
Family Preservation and Home-Based Lesbians
Services Overview
Family Services I Practice Interventions
Family Therapy Immigrants and Refugees Licensing
Feminist Social Work Practice Immigration Policy Income Life Span
Forensic Social Work Distribution Income Overview
Foster Care Security Interdisciplinarity Development and Infancy (Birth
International Association of Schools of to Age Three)
Fundraising
Social Work (IASSW) International Early Childhood and Pre-School
G Federation of Social Workers (IFSW) Childhood and Latency
Gay Families and Parenting International Social Welfare Young Adulthood
Gay Men Overview Parenting
Overview Older Adulthood/Seniors
Organizations and Activities
Practice Interventions ("Young Old")
International Social Work Overview
Generalist and Advanced Generalist Oldest Senior/Aged-Late ("Old Old")
Education
Practice Long- Term Care
International Social Work and Social
Genetics Welfare
Gestalt Therapy Africa (Sub-Sahara)
Globalization Asia M
Group Dynamics Australia and Pacific Islands Macro Social Work Practice
Groups Caribbean Managed Care
Group Work Central America Management
Europe Overview
H Middle East and North Africa Practice Interventions
Haitian Americans North America Financial
Harm Reduction Human Resources
Hate Crimes Health Quality Assurance
Care Volunteers
 LIST OF ENTRIES
XI

Marriage and Domestic Partners Policy Practice Sexual Harassment

Maternal and Child Health Media Political Ideology and Social Welfare Single Parents
Campaigns Political Interventions Single-System Designs
Medicaid and Medicare Political Process Social Capital
Medical Illness Political Social Work Social Development Social
Men Poverty Impact Assessment Social
Overview Practice Interventions and Research Justice
Practice Interventions Prevention Social Movements
Health and Mental Health Care Primary Health Care Social Planning
Mental Health Privatization Privilege Social Policy
Overview Probation and Parole Overview
Practice Interventions Professional Conduct History (Colonial Times to1900)
Mental Illness Professional Impairment History (190~1950)
Adults Children Professional Liability and Malpractice History (195~1980)
Service System Program Evaluation History (1980 to Present)
Meta-analysis Progressive Social Work Social Problems
Methods of Practice Interventions Prostitution Social Security Program
Migrant Workers Psychoanalysis Social Services
Military Social Work Psychodrama Social Welfare Expenditures
Motivational Interviewing Psychoeducation Social Work Education
M ulticult~ralism Psychometrics Overview
Muslim Social Services Psychosocial and Psychiatric Doctoral
Mutual Aid Societies Rehabilitation Electronic Technologies
Psychosocial Framework Field Work
Psychotropic Medications Human Behavior & Social
N Public Health Environment
Narratives Multiculturalism
National Association of Social . Research
Workers Q Social Welfare Policy Social
Native Americans Qualitative Research Work Practice History and
Overview Quality of Care Evolution Theoretical Base
Practice Interventions Native Quantitative Research Social Work Profession
Hawaiians and Pacific Islanders Overview
R History
Recording Workforce
o Rehabilitation Strategic Planning Strengths-
Occupational Social Work Reproductive Health Based Framework Strengths
Oncology Social Work Research Perspective Suicide
. Oppression Overview Supervision
Organizational Development and History of Research Supplemental Security Income
Change Resilience Survey Research
Organizational Learning Restorative Justice
Organizations and Associations Retirement
Organizations and Governance Rural Practice
T
p S Task-Centered Practice
Pai Scales and Indices Teams
School Social Work Technology
n
School Violence Overview
Palliative Care
Self-Help Groups Technology in Macro Practice
Peace
Settlements and Neighborhood Technology in Micro Practice
Pension and Retirement Programs
Centers Technology in Social Work
Person-in- Environment Philanthropy
Sexual Assault Education
Police Social Work
XII Lisr OF ENTRIES

Tools and Applications of Barton, Clarissa (Clara) Harlowe Folks, Homer

Technology Bechill, William Follett, Mary Parker
Technology Transfer Beck, Bertram Frankel, Lee Kaufer
Temporary Assistance for Needy Beers, Clifford Whittingham Frazier, Edward Franklin
Families Berry, Margaret
Terminal Illness Bethune, Mary McLeod G
Termination Beveridge, Lord William Galarza, Ernesto
Terrorism Blackey, Eileen Gallaudet, Edward Miner
T ransgender People Bogardus, Emory Gallaudet, Thomas Gallaudet,
Trauma Brace, Charles Loring Thomas Hopkins Garrett,
Brager, George Annette Marie Germain,
U Breckinridge, Sophonisba Preston Carel Bailey Gibelman,
Unemployment Insurance Briar, Scott Margaret Ginsburg, Mitchell
Unions , Brockway, Zebulon Reed I. Gonzalez Molina de la
Urban Practice Bruno, Frank John Buell, Caro,
Bradley Dolores
v Burns, Eveline Mabel Gottlieb, Naomi R.
Veteran Services Granger, Lester Blackwell
Victim Services C Gurin, Arnold
Violence Vocational Cabot, Richard Clarke Gurin, Helen
Services Cannon, Ida Maud Cannon, Gurteen, Stephen Humphreys
Voluntarism Mary Antoinette Carlton,
Voter Education Thomas Owen Carter,
Genevieve Cassidy, Harry H
Hale, Clara
W Cassidy, Helen
Hall, Helen
White Ethnic Groups Chavez, Cesar
Hamilton, Gordon
Women Cloward, Richard
Haynes, Elizabeth Ross
Overview Cohen, Wilbur
Haynes, George Edmund
Practice Interventions Coyle, Grace Longwell
Hearn, Gordon
Health Care
Hoey, Jane M.
Workers' Compensation
Hopkins, Harry Lloyd
D
y Howard, Donald S.
Davis, Liane V.
Howard, Oliver Otis
Youth at Risk Day, Dorothy
Howe, Samuel Gridley
Youth Services De Forest, Robert Weeks
Huantes, Margarita R.
Devine, Edward Thomas
Hudson, Walter W.
Dix, Dorothea Lynde
Biographies Du Bois, William Edward Burghardt
'Dunham, Arthur J
A Dybwad, Rosemary Ferguson Jarrett, Mary Cromwell
Abbott, Edith Johnson, Campbell Carrington
Abbott, Grace Abernathy, E Jones, Mary Harris, "Mother"
Ralph David Adams, Egypt, Ophelia Settle
Frankie Victoria Addams, Eliot, Martha May K
Jane Alexander, Chauncey Epstein, Abraham Keith-Lucas, Alan
A. Altmeyer, Arthur J. Epstein, Laura Kelley, Florence
Anderson, Delwin Kellogg, Paul Underwood
F Kenworthy, Marion Edwena
Fauri, Fedele Frederick King, Martin Luther, Jr.
B Federico, Ronald Charles Kingsbury, Susan Myra
Baldwin, Roger Nash Fernandis, Sarah A. Collins Kitano, Harry
Barrett, Janie Porter Fizdale, Ruth Konopka, Gisela
Bartlett, Harriett M. Flexner, Abraham Kuralt, Wallace H., Sr.

L R
Lassalle, Beatriz
Lathrop, Julia Clifford
Leashore, Bogart
Lee, Porter Raymond
Lenroot, Katharine Fredrica
Levy, Charles
Lewis, Har~ld
Lindeman, Eduard Christian
Lindsay, Inabel Bums Lodge,
Richard
Loeb, Martin B.
Love, Maria Maltby
Lowell, Josephine Shaw
Lowy, Louis \ Rothman, Beulah
Lucas, Elizabeth Jessemine
Kauikeolani Low
Lurie, Harry Lawrence
M S
Mahaffrey, Maryann
Manning, Leah Katherine Hicks
Marin, Rosa C.
Marshall, Thurgood
Matthews, Victoria Earle
Mayo, Leonard Withington
Meyer, Carol H.
Miller, Samuel O.
Minahan, Anne
Morris, Robert
N
Naparstek, Arthur
Newstetter, Wilber 1.
Northern, Helen
p Switzer, Mary Elizabeth
Pagan de Colon, Petroamerica
Perkins, Frances
Perlman, Helen Harris
Pernell, Ruby
Pray, Kenneth
Rankin, Jeannette
Rapoport, Lydia
Reichert, Kurt
Reid, William Reynolds,
Bertha Capen Richmond,
Mary Ellen Riis, Jacob
August Ripple, Lillian
Rivera de Alvarado, Carmen
Robinson, Virginia
Robison, Sophie Moses
Rodriguez Pastor, Soledad
Roosevelt, Eleanor
Rothenberg, Elain Zipes
Rubinow, Isaac Max
Rush, Benjamin
Salomon, Alice
Samora, Julian
Sanders, Daniel
Satir, Virginia
Saunders, Dame Cicelv
Schottland, Charles Irwin
Schwartz, William
Scott, Carl A.
Seton, Elizabeth Ann Bayley
Shyne, Ann Wentworth Sieder,
Violet M. Simkhovitch, Mary
Kingsbury Smalley, Ruth
Elizabeth Smith, Zilpha Drew
Snyder, Mitchell "Mitch"
Specht, Harry
Spellman, Dorothea C.
Starr, Ellen Gates
T Competence in Social Work
Taft, Julia Jessie
Taylor, Graham
LIST OF ENTRIES
XIII
Terrell, Mary Eliza Church
Thomas, Jesse O.
Titmuss, Richard Morris
Towle, Charlotte
T ruth, Sojourner
Tubman, Harriet
V
van Kleeck, Mary Ann
Vasey, Wayne
Vigilante, Joseph
Vinter, Robert
W
Wald, Lillian
Washington, Booker Taliaferro
Washington, Forrester Blanchard
Weiner, Hyman J.
W ells- Barnett, Ida Bell
White, Eartha Mary Magdalene
Wickenden, Elizabeth
Wiley, George
Wilkins, Roy
Williams, Anita Rose
Witte, Ernest Frederic
Wittman, Milton
y
Young, Whitney Moore, Jr.
Youngdahl, Benjamin Emanuel
Younghusband, Dame Eileen
Appendixes:
Ethical Standards in Social Work:
The NASW Code of Ethics Evolution
of Selected Organizations Distinctive
Dates in Social Welfare History
NASW Standards for Cultural
Practice
 Introduction

The enduring profession of social work is now in its findings, and emerging trends and directions. We sug-
second century. Grounded in core values, it has with- gested they pay attention to the works or impact of
stood major political, social, and economic changes other disciplines. They were also asked to include the
over time. The scope of its knowledge and skill con- latest and best interventions, methodologies, and tech-
tinues to grow as the profession responds to developing niques, and to highlight any ethical issues as well as
needs in the United States and all over the world . challenges or debates related to the topic. They were
. Many social workers are in the forefront, shaping guided by the question: What do social workers need to
public policies, advancing client interventions, and know or what is the relevance of your subject area to
influencing research agendas. social workers? Many entries end with the roles and
We proudly present Encyclopedia of Spool Work, twentieth implications for social workers at the micro and macro
edition, built upon the legacy of scholarship from levels.
former editors and authors. This edition has been trans-
\
formed by twenty-first century technology and . The Context and Conditions
inforrna- The first seven years of the twenty-first century have
tion inside and outside the field. As editors in chief, our
included some of the most far-reaching and even cata-
responsibility was to circumscribe the knowledge base
clysmic changes for the United States and the world.
of our profession as enormous changes have reshaped
The millennium dawned in the context of globalization
the world's political, social, and economic order since
and interconnectedness, war, worldwide . poverty,
the nineteenth edition. It has been a dauntingchal-
AIDS, and a variety of racial, ethnic, religious, and
lengeand a privilege to present social work knowledge,
tribal conflicts in many parts of the world. This is the
competencies, and values to the world. This edition
era when genetic codes were broken, genes mapped,
represents an exponential growth in the content of our
and the cloning of animals and stem cells occurred
profession and in the methods of delivering that content
amidst celebration and fear.
to its audience. It has grown from three to four
The United States went from unprecedented eco-
volumes, and indudes many new as well as updated
nomic growth and surpluses to deficits and downsizing,
entries. For. the first time, it is being produced by a
and devolution from federal to state responsibility.
partnership of the NASW Press and Oxford University
Social programs have witnessed a continuing shift from
Press. It will be available to the social work community
public to private sector influence on health, education,
and other interested communities in hard copy and in
and human services. A politically and economically
electronic form.
conservative agenda has been dominant. And in
The Encyclopedia conveys the breadth and depth of
addressing health and social problems, the first
the profession's collective expertise. It has been
administration of the twenty-first century has empha-
formulated and written by social workers from many
sized the role of faith-based organizations and volun-
backgrounds and competencies. Encompassing
teerism as well as marker-based solutions known as
diversity in subject matter and authorship, it includes
privatization.
the best thinking, evidence, and practice wisdom
The effects of the events of September 11, 2001,
translated into the best writing. While it is written for
remain profound. The attacks on the United States
predominantly professional audiences, we have striven
resulted in the deaths of thousands of innocent people
to make it accessible to both students and scholars,and
and precipitated an aggressive global "war on terror"
useful to practitioners and policymakers.
conducted by the United States in Afghanistan and Iraq
The entries reflect the composite perspective of the
with a massive amount of resources, manpower, and
United States while taking into account an increasingly
money. They are still shaping the role of and funding
international audience of social workers in academic,
for social work and social services as well as the
policy, and practice settings. All contributors were
attitudes toward many of the people we serve. There are
given a difficult and challenging set of requirements.
fewer dollars to cope with greater social problems, but
Within a limited wordcount, they were asked to address
social workers are more active than ever on the
several thematic areas for' "infusion" into their entries.
national, state, and local political scenes. By 2000,
These include: historical foundations, contemporary
there were six social workers in the U.S. Congress;
issues and practice dimensions, multiculturalperspec-
after the 2006 midterm congressional elections, there
tives, the latest theoretical foundations and research
were

xv
XVI INTRODUcrION
ten: two senators and eight members of the House of
Representatives, in addition to hundreds of social
workers serving in public office at the state and local
levels.
As the United States becomes increasingly multi,
cultural, a virulent anti-immigrant sentiment has risen
dramatically. As science and technology discover myr-
iad new ways to prevent and treat diseases and disabil-
ity, there has been ideological resistance to embryonic
stem cell research and alternative measures to alleviate
pain. As evidence-based practice becomes increasingly
important, there are many examples of political con-
siderations trumping hard data. Social workers are more
active than ever in attempting to shape the public
research agenda to include the social and environmental
factors affecting human behavior. At the same time, the
corporate sector has attempted to control professional
behavior through managed care and behavioral health
contracting. Some who support faith-based initiatives
minimize the need for and value of professionally
trained experts. This is the complex and rapidly
changing scenario-full of contradictions and tensions- in
which the future of social work is embedded.
The major social work professional organization, the
National Association of Social Workers, continues to
develop its programs; policies, and practice standards.
Yet challenges remain. The good news is that all fifty
states have achieved some form of social work licensing
and public recognition. But the bad news is that there
have been divisions within the profession over the types
and levels of licensure, continuing low salaries and job
stresses, and competition from other professions for
limited positions. And the social justice and anti,
discrimination values that have been the underpinning
of the NASW Code of Ethics, the foundation for the
profession, have come under attack by some conserva-
tive critics.
To address these concerns, there have been major
developments over the past few years to bring the
diverse social work organizations together to collabo-
rate on common agendas and the future direction of the
profession. In 2002, the NASW convened a Social
Work Summit, bringing forty-three different organiza-
tions together to begin a process of communication and
cooperation. In 2005, a pioneering Social Work
Congress was held in Washington, D.C., in which over
three hundred social work leaders participated. Ii:
established twelve priorities for the next ten years. By
2007, the major social work organizations were on the
path to consolidation by 2012. These moves toward a
more unified profession, along with a national public
education campaign spearheaded by NASW, could
strengthen and expand its influence, recognition, and
public support.
The Intellectual and Technical
Production of the Twentieth Edition
For us, as the editors in chief, the starting point was to
identify sixteen area editors from a very talented pool of
qualified social workers. We are proud of the team we
chose. They were selected for their wisdom, int ellectual
rigor, experience, and mastery over specific scholarly
domains. They accepted a daunting challenge: that of
producing and compiling what would be the major
representation of our collective knowledge for the next
decade. Their combined wealth of expertise helped
conceptualize the major frameworks of the profession.
Fourteen such thematic areas evolved: stages of the life
span; components of human need; fields of practice;
settings and service systems; population groups (by
race, ethniciry, gender, age, and sexual orientation);
social problem areas; methods of practice intervention;
social work curriculum components (for example,
research, policy, human behavior, and the social
environment); the social profession; social wel fare
policy and history; social justice; technology; inter-
national and comparative perspectives; and special
topics (economics; law; arts and culture). While the
entries are listed alphabetically, each of them falls under
one or more of these topical headings.
There are almost four hundred entries with 437
authors of enormous talent and diversity. The challenge
of establishing a balance for each of the areas and their
respective articles was formidable. For example, how
much basic or general versus specific or specialized
knowledge should be included? How much content
from outside the United States should be included? How
much standardization of entries versus creativity to
allow? How should we gear the quality and detail to a
multilevel group of readers? And should we use curre nt
accepted terminology or "cutting-edge" language of that
specialty, such as "learning disability" versus
"neuro-cognitive disability"?
Encyclopedia Content
The content of the twentieth edition reflects the changes
related to the social work community nationally and
internationally over the past decade. We asked the cri-
tical question: What are the new and expanded content
areas reflected in the various entries? Our tasks are more
challenging today in part because of the complexity of
the social problems in which our profession is engaged.
We cannot always conduct the type of studies or eval-
uate interventions that could produce more definitive
evidence because of ethical, funding, and political
obstacles. We are obligated to protect human subjects.
We are often engaged with unpopular causes,
marginalized populations, and intransigent social
conditions that are

not easily fundable. But we are always searching to
demonstrate that social workers "know something" and,
more importantly, to explain how we know it. As social
workers, we are addressing our rationale for "doing."
We strongly believe that a value base must underpin the
knowledge and skill base. To borrow a phrase from the
famous American sociologist Robert Lynd:
"Knowledge for what?"
There are many important ways in which the rwen-
tieth edition has evolved. From nine overview entries in
the nineteenth edition, there are now thirty-nine entries,
explaining either a major framework or content area.
Among them are: "Contexts/Settings" (for social work
practice); "Human Needs,'? under which there are
seven components; and "Lifespan," under which fall
eight stages ranging from infancy to the oldest seniors.
There are also several overview articles on the various
fields and practice methods.
- The topics of multiculturalism, cultural competence,
and culturally competent practice are all new, in
addition to an expanded twenty-three entries on various
racial and ethnic groups. These include new topics on
Arab Americans, South Asians, and South, eastern
Asians. Spirituality and faith-based subject matter have
grown to include a range of services and practices,
including for the first time "Muslim Social Services."
While the Encyclopedia is a United States-based
undertaking, we have increased the contributions from
and about the international community as a whole and
its component parts. From three entries in the nine,
teenth edition, there are fourteen entries in the current
edition. What is most innovative are the regional over,
views written by one or more authors from that part of
the world: Africa (Sub-Sahara); Asia; Australia and the
Pacific Islands; the Caribbean; Central America and
Mexico; Europe; the Middle East and North Africa;
North America (Canada and the United States); and
South America. There are also new entries on globali-
zation, immigration and immigration policy, and dis,
placed persons. In addition, all authors were asked to
include contributions from other countries and inter-
national perspectives where relevant.
The topics under research methodologies and tech-
nology, advanced in the nineteenth edition and its
supplements, continue to explode. There are now
twenty-five articles including "Technology in Micro
Practice" and "Technology in Macro Practice" as well
as "Research as a Practice Intervention" and "Best
Practice." Each entry, where relevant, contains the
latest research and best practices.
New and enlarged areas of practice as well as
practice interventions were added, including "Forensic
INTRODUCTION XVII
Social Work," "Rehabilitation," "Urban Social Work,"
and "Trauma." In addition, there are several new entries
related to political themes: "Political Interventions,"
"Political Process," and "Political Social Work." The
field of disability has also changed much since 1995. In
addition to the overview entry, a range of disabilities
has been identified as the knowledge base and its
application to practice grow. Included among the new
topics are articles on physical, psychiatric,
neuro-cognitive, and developmental disabilities. The
related areas of mental health, mental illness, and
alcohol and drug problems have been expanded to go
into more depth about these prominent areas of social
work practice and policy. Finally, genetics has been
updated to reflect the science and its implications for
practice.
We have added to the section on social policy and
social welfare four-fold, from two entries on social weI;
fare history and social welfare policy to an overview
article and then a series of articles on the history of
social policy, from the colonial era through the twenty'
first century, along with an entry on social welfare
expenditures. The whole area of social work education
from the bachelors to the doctoral level has also
expanded from one to nine separate entries.
The expansion of practice methods and inter, vent
ions at all levels reflects exciting developments in the
field. In addition to all the clinical areas, there are a
range of new methods and settings, including working
with involuntary clients (authoritarian settings),
bereavement practice, interventions with couples,
families, groups, and new entries related to techniques
such as psychodrama, psychoanalysis, psy-
cho-education, and compulsive behaviors. At the macro
levels, there are additional components of community
and administrative/management practice. In particular,
there is an increasing emphasis on interorganizational
and interdisciplinary practice as well as collaboration.
We have added forty social work luminaries to the
Biography section, which includes deceased social
workers who had a significant national or international
impact on the profession or who had substantially
shaped an area of practice or policy. We are happy to
honor the contributions of this special group in our
Encyclopedia.
The Appendix "Distinctive Dates in Social Welfare
History" has been updated, expanded, and in a few
instances, corrected. This is an important chronology
for understanding the place of social work and social
welfare in the broader social history of the United
States and beyond.
And we are pleased to continue to include the
current range of major social work organizations which
XVlll INTRODUCTION
collectively present the entire social work community.
This is reflective of a kaleidoscope made up of the myriad
interests and identities of our profession. Together, the
whole is greater than the sum of its parts, and represents
the power of social work.
Acknowledgments
Our heartfelt appreciation to the Area Editors: Paula
Allen-Meares, Darlyne Bailey, Elizabeth Clark, Diana
M. DiNitto, Cynthia Franklin, Charles D. Garvin,
Lorraine Gutierrez, Jan L. Hagen, Yeheskel Hasenfeld,
Shanti K. Khinduka, Ruth McRoy, James Midgley, John
G. Orme, Enola Proctor, Frederic Reamer, and Michael
Sosin. They committed themselves to almost three years
of difficult work that included selecting the best authors
for the entries in their domain, critically reviewing and
editing dozens of them, and in almost all cases authoring
their own contribution. We applaud their dedication and
determination to make this Encyclopedia the most
comprehensive and compelling tome yet.
We want to sincerely thank the hundreds of authors
who contributed their time, wisdom, and intellect to
crafting these wonderful entries. I t was tremendously
rewarding to validate the extent of our collective
expertise, and to discover such a wealth of qualified
social workers who are leaders in their fields. Some are
world-renowned and some make their international debut
through this work. We achieved our goal of having the
contributors-with only a few exceptions- come from
within our social work community. And we are extremely
proud of the diversity of scholars in terms of gender, race,
and ethnicity writing on a broad range of important
topics. Several of the authors come from other
countries-Canada, Israel, Australia, and Ethiopia to name
a few. These authors are a combination of well- known
scholars within the social work comm unity and
"newcomers" who are just beginning to receive national
recognition for their scholarship. They include a range of
social work practitioners as well as academic researchers.
In many instances, collaborators with complementary
backgrounds were paired to enrich the entries.
Each entry went through at least three readings and
revisions. We read and were involved in the editing of the
almost four. hundred entries, after receiving feedback
from one or more area editors. We are extre mely grateful
for the talent of Julie Abramson and Anthony Tripodi
who joined our editorial team when we needed additional
professional assistance. And, finally, the skill, sensitivity,
and sophistication exhibited by Oxford University Press
in dealing with
the authors, area editors, and the editors in chief cannot
be overstated. The complexity of moving this massive
enterprise forward with efficiency while emphasizing
quality and comprehensiveness represented a challenge
to all who were involved. Development Editor Eric
Stannard and the staff of OUP kept the process organized
and coherent.
We also want to convey our admiration to the editors
and authors of former editions of the Encyclo pedia. We
are especially in awe of those professional leaders and
scholars who dedicated so much of their time, energy, and
intellect to this enterprise with less and less technology as
we go back in time. It is hard to imagine orchestrating this
project in such a 'timely way without email, the Internet,
and the computer; yet this was how the earlier editions of
the Encyclopedia were produced. And even the nineteenth
edition had limited access to online information and
electronic communication tools. Not only has
communication technology enhanced the process of
producing these volumes, but the product itself has also
been enriched. Readers of the twentieth edition now have
access to Web sites, Web links, :md publications online
among the references and resources cited. These of
course can become outdated or unavailable over time, but
overall they deepen and extend the body of knowledge
available to the audience.
We are confident that this enormous enterprise has
produced a scholarly product that is rich in its knowledge
base and will be informative to all who are either studying
or practicing social work. We hope that all who read these
entries will be informed, b ut also that they will be
stimulated to become more engaged and active as
scholars, practitioners, and critics. While we have
completed our responsibilities, this master work will not
be the final product. To capture and reflect the knowledge
base of social work will continue as an ever- changing and
ever-expanding endeavor.
How to Use the Encyclopedia
There are nearly four hundred entries in Encyclopedia of
Social Work, twentieth edition, arranged in alpha betical
order letter by letter. These are followe d by almost two
hundred biographies of pioneers in the field of social
work. The contributors have sought to write in clear
language with a minimum of technical vocabulary. A
selective bibliography at the end of each article directs the
reader who wishes to pursue a topic in greater detail to
primary sources and the most important scholarly works,
plus the most useful works in English.
I
 INTRODUCTION
XI
X

To guide readers from one article to related discus-
sions elsewhere in the Encyclopedia, end-references
appear at the end of many articles. There are cross-
references within the body of a few articles. Blind
entries direct the user from an alternate form of an entry
term to the entry itself. For example, the blind entry
"Elderly People" directs the reader to "See Aging."
At the end of volume 4 the reader can find a topical
outline (which shows how articles relate to one another
and to the overall design of the Encyclopedia), the
directory of contributors, and a comprehensive index.
Terry Mizrahi
Larry E. Davis
 ENCYCLOPEDIA OF

SOCIAL WORK
20TH EDITION
\
ABORTION
ABSTRACT: Until the 19th century, abortion law was
nonexistent and abortion was not seen as a moral
issue. However, by the tum of the 20th century,
abortion was legally defined and controlled in most
states. The landmark Supreme Court case, Roe v. Wade
(1973), marked the legalization of abortion but-did not end
the controversy that existed. Legislation at both the federal
and state levels has added restrictions on abortion, making it
difficult for women to exercise their reproductive rights.
Social work's commitment to promote the human rights of
women compels social workers to be aware of and involved
in this issue.
KEY WORDS: abortion; Hyde Amendment; Roe v.
Wade; parental involvement; Code of Ethics
The Supreme Court legalized abortion in 1973 (Roe v. Wade,
1973) but this pivotal decision has not prevented the federal
or state governments from adding restrictions to abortion,
that is, parental involvement or the so-called partial birth
abortion ban. Social work is a value-based profession
(Pardeck, 2003) that has a longstanding commitment to
making resources available and accessible to all women.
This is supported by the National Association of Social
Work (NASW) through policy statements aimed at
providing comprehensive sex education, dissemination of
information on safe coritraception, and access to
information on abortion (Haslet, 1997).
Examining the history of abortion-related social policy
provides knowledge as to how people have come to think
and act about abortion (Ginsburg, 1989). From the 12th to
19th centuries, it was not difficult for a woman to end a
pregnancy well into her fifth month because it was believed
that pregnancy did not begin until there was quickening
(that is, independent movement) by a fetus and as a result,
abortion was not seen as a moral issue (Nossiff, 2001).
Legislation to restrict access to abortion services in the
United States began to emerge in the 1800s, when
physicians became concerned about protecting their
professional status, perhaps to try and discourage female
midwives and other nontrainedphysicians from medical
practice in this area (Petchesky, 1990). By the tum of the
20th century the United States transformed
from a nation with no abortion laws to one where abortion
was legally defined and controlled by the states (Mohr,
1978) .:
The lack of consensus among physicians regarding
abortion, the growing movement toward abortion law
reform, and an emerging women's movement provided an
opportunity to explore changing existing abortion
legislation. Griswold v. Connecticut (1965) enabled the
Supreme. Court to rule that that there were areas of privacy
or protected freedoms, which permitted married couples
the right to decide whether or not to use birth control
(Tribe, 1992). Feminists used this decision to provide a
context for the abortion issue by framing the relevant
issues in terms of gender and to define access to
contraception and abortion as a reproductive right.
By the 1970s, abortion laws varied within the United
States, and in 1971, a case from Texas challenged the
existing abortion law. It resulted in the landmark Supreme
Court case Roe v. Wade (1973), which established the legal
right to have an abortion, and extended the Constitution's
guarantee of privacy to abortion. Just 3 years later,
legislators, including Henry Hyde (R-Illinois), brought
attention-to the fact that 33% of abortions were paid for by
Medicaid funds and sought to ban all federal funding for
abortions by introducing an amendment to a Department of
Health and Human Services appropriations bill (later
known as the Hyde Amendment). Passage of the
amendment was an effective method in reducing the
number of abortions despite the Roe v. Wade (1973)
decision because it limited federal Medicaid
reimbursement for abortion.
On July 3, 1989, the Supreme Court upheld restrictions
on abortion in the case of Webster v. Reproductive Health
Services (1989). This Missouri law prohibited public
employees from performing abortions in public facilities,
prohibited the use of public facilities to perform abortions,
and required doctors to test. to see if a fetus was viable
(Craig & O'Brien, 1993). It was a turning point in abortion
policy, because although Roe v. Wade (1973) outlined the
role of the states primarily within the second and third
trimester, the Supreme Court's decision in Webster v.
Reproductive Health Services (1989) provided states with the
necessary authority to impose restrictions as long as it
appeared that the restrictions would not place an undue .
burden on women seeking aborti6ns1Tribe, 1992).
1
2 ABORTION
Following Webster v. Reproductive Health Services in
1989, Pennsylvania passed legislation that imposed a variety
of restrictions on abortion access, including waiting periods,
parental consent, and viability tests. Upon appeal, the
Supreme Court in Planned Parenthood of Southeastern
Pennsylvania v. Casey (1992) upheld the Pennsylvania
provisions, severely limiting access to abortion services, but
reiterated their commitment to Roe v. Wade (1973) upholding
a woman's right to have an abortion. The Court stated that
waiting periods and delays were constitutional unless proven
to be an "undue burden" and affirmed the right of states to
impose further restrictions on abortion access (Wilcox, 1996).
Supreme Court decisions in 2000, and 2007 were both
directed at federal legislation called the Federal Abortion ban
or partial birth abortion ban. Ruling first in 2000, Stenberg v.
Carhart (2000) struck down the ban because it permitted for
no health exception to the woman, but by 2007, with two new
justices on the Court, Gonzales v. Carhart (2007) upheld the
ban, paving the way for states to enact additional restriction.
There are scholars who argue that statutory or court
restrictions alone do not account for the difficulty in obtaining
an abortion and attribute a decrease in the abortion rate to
reasons such as the dwindling number of abortion clinics and
physicians, political issues or policy ideology, and
demographic factors such as race and socioeconomic status
(Berkman & O'Connor, 1993; Haas-Wilson, 1993; Henshaw
& Van Vort, 1994; Meier & McFarlane, 1993; Tatalovich &
Daynes, 1988).
Social work has a long history of commitment and
obligation to make resources available and accessible for
clients. When social workers do not recognize clients'
differences in values and the diversity of their lives, it is
incongruent with social work values (Haynes & Mickelson,
1997).
At the micro level, social workers provide information and
educate individuals about reproductive health issues,
including birth control and abortion, sexually transmitted
diseases, and HIV. Social workers may also help clients locate
and utilize resources, including finding abortion clinics
(particularly problematic in rural areas, where there are fewer
abortion providers), and will help women to access financial
resources to pay for services (through organizations such as
the National Network of Abortion Funds [Jackson, 2007]).
At the macro level, in promoting social justice, the Code
of Ethics requires social workers to uphold the human rights
of women (George, 1999), including reproductive rights. It
necessitates that social workers permit clients to determine
their own course of action (self-determination) and to assist
them with the information and resources needed to make
decisions about
their own lives. The expectation is that clients are permitted
every opportunity to obtain needed information, services, and
resources and that equality of opportunity which defines the
value of social justice be made available to all clients despite
race, age, or level of Incorne (National Association of Social
Workers [NASW], 1999).
Social workers whose religious ideology is in conflict with
a pro-choice stance may be faced with a client seeking
information or assistance in obtaining an abortion. Those
individuals will have to decide whether they can work with
the client despite a personal values conflict or whether they
would do better to refer that client out to another social worker
or agency, if that is possible.
Further, the NASW policy statement on Family Planning
and Reproductive Choice takes a proactive stance in terms of
a woman's right to choose and maintains that women's
reproductive rights are protected through fewer restrictions on
state and federal policies regarding abortion, including
policies that restrict financing abortion services through
health insurance and foreign aid programs (NASW, 2006).
REFERENCES
Berkman, M. B., & O'Connor, R. E. (1993). Do women legislators
matter? Female legislators and state abortion policy. In M. L.
Goggin (Ed.), Understanding the new politics of abortion (pp,
268-284). Newbury Park, CA: Sage.
Craig, B. H., & O'Brien, D. M. (1993). Abortion and American
politics. Chatham, NJ: Chatham House.
George, J.(1999). Conceptual muddle, practical dilemma.
International Social Work, 42(1), 15-26.
Ginsburg, F. D. (1989). Contested lives. Berkeley: University of
California Press.
Griswold v. Connecticut, 381 U.S. 479 (1965).
Gonzales v. Carhart, Nos. 05-380 & 05-1382 (2007).
Haas-Wilson, D. (1993). The economic impact of state restric-
tions on abortions Parental consent and notification laws and
Medicaid funding restrictions. Journal of Policy Analysis and
Management, 12(3), 498-51l.
Haslet, D. C. (1997). Hull house and the birth control move-
ment.AtnUa, 12(3), 261-268.
Haynes, K. S., & Mickelson, J. S. (1997). Affecting change.
New York: Longman.
Henshaw, S. K., & Van Vort, J. (1994). Abortion services in the
United States, 1991 and 1992. Family Planning Perspectives,
26(3), 11 0-112.
Jackson, D. L. (2007). State policy restrictions on abortion:
Implications for social workers. Journal of Policy Practice,
6(4),25-43.
Meier, K. J., & McFarlane, D. R. (1993). Abortion politics and
abortion funding policy. In M. L. Goggin (Ed.), Understanding
the new politics of abortion (pp. 1-18). Newbury Park, CA: Sage.
1
Mohr, J. C. (1978). Abortion in America. Oxford: Oxford Uni-
versity Press. . policies in 1990. Women and Health, 22(1), 99-115.
National Association of Social Workers. ( 1999). Code of ethics.
Retrieved July, 21,2003, fromhttp://www.socialworkers.
org/pubs/code/code.asp.
National Association of Social Workers. (2003). Family planning
and reproductive choice. In Social work speaks (5th ed., pp.
124-131). Washington, DC: Author.
Nossiff, R. (2001). Beyond Roe: Abortion policy in the states.
Philadelphia: Temple University Press.
Pardeck, J. T. (2003). Should abortion rights be an accepted
social-work valuei In H. J. Karger, J. Midgley, & C. B. Brown
(Eds.), Controversial issues in social policy (pp. 249-254).
Boston: Allyn & Bacon.
Perchesky, R. P. (1990). Abortion (.Ind women's choice. New York:
Longman.
Planned Parenthood of Southeastern Pennsylvania v, Casey,
505 U.S. 833 (1992).
Roe v, Wade, 410 U.S. 113 (1973). Stenberg
v, Carhart, 530 U.S. 914 (2000).
Tatalovich, R., & Daynes, B. W. (1988). Introduction: Wh~t is
social regulatory policy? In R. T atalovich & B. W. Daynes
(Eds.), Social regulatory policy: Moral controversies in Amen can
politics (pp.131-152). Boulder, CO: Westview Press.
Tribe, L. H. (1992). Abortion. The clash of absolutes. New York:
Norton.
Webster v, Reproductive Health Services, 492 U.S. 490 (1989).
Wilcox, C. (1996). The sources and consequences of public
attitudes toward abortion. In T. G. Jelen (Ed.), Perspectives on
the politics of abortion. Westport, CT: Praeger,
FURTHER READING
. Alan Guttmacher Institute. (2003, July 1). State policies in brief.
Restricting insurance coverage of abortion. Retrieved July 21,
2003, from http://www.guttmacher.org/pubs/spib_RICA.pdf.
Alan Guttmacher Institute. (2003, July 1). State policies in brief.
Restrictions on postviability abortions. Retrieved July 21, 2003,
from http://www.guttmacher.org/pubs/spib_RPA.pdf.
Althaus, F. A., & Henshaw, S. K. (1994). The effects of
mandatory delay laws on abortion patients and providers.
Family Planning Perspectives, 26(5), 228-231, 233.
Boonstra, H., &Sonfield, A. (2000). Revisiting public funding of
abortion for poor women. Guttmaeher Report on Public Policy.
New York: Alan Guttmacher Institute.
Center for Reproductive Rights. (2003). Access to abortion:
Mandatory delay and biased information requirements. http://
www.crlp.org/pub_fac_manddelay2.html.
Center for Reproductive Rights. (2004). So called "partial-birth
abortion" ban legislation: By state. http://www.reproductive
rights.org/pdf/pub_bp-pba_bystate. pdf.
Fried, M. (1990). Transforming the reproductive rights move-
ment: The post-Webster agenda. In M. G. Fried (Ed.), T
ransf~ng a movement (pp.1-14). Boston: Free Press.
Henshaw, S. K. (1998).Batriers to access to abortion services.
In L. J. Beckman & S. M. Harvey (Eds.), The new civil war (pp.
61-80). Washington, DC: American Psychological
Association.
McFarlane, D. R., & Meier, K. J. (1994). State abortion funding
Planned Parenthood Federation of America, Inc. Global gag rule.
http://wwW .plannedparenthood.org/gag/.
Reagan, L. (1997). When abortion was a crime: Women, medicine,
and law in the United States, 1867-1973. Berkeley:
University of California Press.
Ross, L. (1990). Raising our voices. In M. G. Fried (Ed.), From
abortion to reproductive freedom: Transforming a movement (pp.
139-146). Boston: Free Press.
Russo, N. F., & Denious, J. E. (1998). Why is abortion such a
controversial issue in the United StatesiIn L. J. Beckman & S.
M. Harvey (Eds.), The new civil war (pp. 25-60). Washington,
DC: American Psychological Association.
Schroedel, J. R. (2000). Is the fetus a person? Ithaca, NY:
Cornell University Press. .
Silliman, J., Fried, M. G., Ross, L., & Gutierrez,E. R. (2004).
Undivided rights. Women of color organize for reproductive justice.
Massachusetts: South End Press.
Sollom, T. (1993). State legislation on reproductive health in
1992: What was proposed and enacted. Family Planning
Perspectives, 25(2), 87-90.
-D.LYNN
JACKSON
ACCOUNTING. See Management: Financial.
ADJUDICATION. See Professional Conduct; Codes of
Ethics; Ethics and Values; Appendix, Ethical Standards
in Social Work: The NASW Code of Ethics ..
ADOLESCENTS. [This entry contains four subentries:
Overview; Demographics and Social Issues; Practice
Interventions; Pregnancy.]
OVERVIEW
. ABSTRACT: This article begins with an overview of
biological development based upon empirical research.
The main focus of the article is the presentation of the
major theoretical frameworks that have been employed
to explain the processes involved in the psychological,
cognitive, moral, social, and sexual development of the
adolescent and empirical research findings where
appropriate.
KEY WORDS: adolescent development; adolescence;
psychological development in adolescence; cognitive
development in adolescence; moral development in
adolescence; social development in adolescence; sexual
development in adolescence; biological development in
adolescence
4 AOOLESCENTS: OVERVIEW
Introduction
The concept of adolescence-a period in the life cycle
between childhood and adulthood-was introduced at the
beginning of the 20th century by Hall (1904). Although
Hall considered adolescence to extend from 12 years to
between 22 and 25 years, most researchers and theorists
consider the age span to be from 12 to 18 years .
Adolescence has also been divided into phases or age
groupings, most typically preadolescence, early
adolescence, middle adolescence or adolescence proper,
and late adolescence (Blos, 1941, 1979; Dunphy, 1963 ;
Sullivan, 1953).
Although menarche (the onset of menstruation) serves
as a fairly clear biological marker for the entry of girls into
adolescence, no similar clear-cut crit erion exists for boys.
Adolescence appears to be a phenom enon .primarily of
postindustrial societies. However, puberty, "the biological
and physiological changes associated with sexual
maturation" (Muuss, 1962, p. 5), is formally or informally
recognized across all cultures, and the developmental
sequence is similar, although the time frame may vary
(Brooks-Gunn & Reiter, 1990).
The criteria that can indicate the end of adoles cence
are even less clear. The lack of uniformity in the laws
discriminating between the status of minors and the status
of adults for activities that range from marriage to alcohol
consumption is a pointed example.
Adolescent Development
BIOLOGICAL DEVELOPMENT The development of
primary and secondary sexual characteristics during
adolescence is the result of endocrine changes, which
produce changes in hormone levels. Although the growth
rate during infancy proceeds at a more acceler ated rate,
the magnitude and rate of change experi enced during
puberty is more significant because the adolescent is more
cognizant of the changes he or she is experiencing
(Tanner, 1972). The sequence of devel opment is
considered universal: however, individual timetables for
the various stages differ, and the areas of development
may not be synchronous (Paikoff & Brooks-Gunn, 1991;
Peterson & Taylor, 1980).
Since the beginning of the 20th century ( especially
since the 1950s), physical maturation has continued to
occur earlier with each successive generation. This
"secular trend" is particularly eviden t in the earlier onset
of menarche and in the increases in the rate of growth and
full adult stature over the past century. In the United
States, the average age of menarche at the beginning of the
20th century was slightly over 14 years; by mid-century, i t
was less than 13 years (Tanner, 1962). The average age
after the tum of the
21st century was 12.4 years (Stang & Story, 2005).
Factors hypothesized to explain these phenomena in clude
improvements in health and nutrition as well as the
"hybrid vigor" hypothesis, which attributes the changes to
the intermarriage of various groups because of greater
social mobility (Muuss, 1970). However the age at which
menarche occurs is highly variable; occurring as early as 9
years of age or as late as 17 years of age with factors that
delay the onset of menstruation being restricted caloric
intake and body weight or competing athletically (Stang &
Story, 2005). Reports have found that 6.7% of White girls
and 27.2% of African American girls were showing some
signs of puberty by age 7 (American Psychological
Association, 2002).
Among the most dramatic of the physical changes
during adolescence is the height spurt. Girls generally
experience their increase in height between 9.5 and 14.5
years of age, with the major increase in height occurring
approximately 6-12 months prior to. men arche, or when
they are around 12 years old, about two years before boys
(Stang & Story, 2005). Boys experience their growth spurt
between 12.5 and 15 years; on average the major increase
occurs at 14.4 years of age. However, the length of the
growth spurt has great variation so that for girls it usually
lasts 24-26 months, ending by 16.5 years of age, while for
boys it can continue at a slower rate ceasing between 18
and 21 years of age (Stang & Story, 2005).
Changes also occur in weight; girls develop in creased
subcutaneous fatty tissue and boys usually be come
heavier than girls. Although the hips and shoulders
become wider in both boys and girls, the boys' shoulders
become wider than their hips, and girls' hips wider than
their shoulders. Changes in skin texture and oiliness take
place, along with gradual changes in the timbre and pitch
of the voices of both boys and girls (Faust, 1977; Peterson
& Taylor, 1980; Tanner, 1972).
Early physical maturation generally has a positive
effect on boys; boys who mature early are rated as more
relaxed and poised, higher in self-esteem, less depen dent,
and more attractive to and popular with their peers than
those who mature later (Clausen, 1975; Jones, 1965 ;
Mussen & Jones, 1957; Peskin, 1967; Petersen, 1987 ;
Simmons & Blyth, 1987). Girls seem to have the opposite
experience; early maturation appears to re sult in negative
evaluations, including feel ings of isolation, submissive
behavior, and less popularity with and leadership of their
peers (Clausen, 1975; Jones & Mussen, 1958; Peskin,
1973; Simmons & Blyth, 1987; Weatherley, 1964).
Perceived weight problems also lead to an increased risk
in behaviors such as heavy dieting, caloric deprivation,
use of diet pills or laxatives, severe body image
distortions, and other

eating disorders (Stang & Story, 2005). In any case, research
indicates that the individual's idiosyncratic range of physical
development and its mesh or lack of sync with cultural norms
has an impact on his or her overall development.
Although research in the biological aspects of adolescent
development is straightforward, the literature on other aspects
of adolescent development is characterized by controversy
and conflicting viewpoints. Theorists and researchers agree
that adolescence is a period in the life cycle when notable
development occurs in many areas. They differ, however,
about the following aspects of adolescence:
1. Whether the development is continuous or
discontinuous wijh the preceding and following stages
in the life cycle,
2. Whether the period of adolescence is one of turmoil and
stress or relatively uneventful,
3. Whether it is critical for adolescents to experience or
resolve specific developmental tasks or issues during
this time,
4. Whether internal or environmental factors have a more
significant influence on the experiences and outcome of
adolescent development,and
5. Whether there are specific adolescent responses (such as
coping or defense mechanisms) to internal and external
changes.
For example, Hall (1904), often referred to as the father of the
psychology of adolescence, viewed adolescence as a
discontinuous experience-a period that is qualitatively and
quantitatively different from childhood and from adulthood.
The discontinuity, along with the great physical changes that
adolescents experience, caused Hall to label the period as one
of "sturm und drang" (literally, "storm and stress"). Hall's
biogenetic approach posited that adolescence was a
"recapitulation" of one of mankind's stages of evolution-a
turbulent time for the species and, therefore, for the
individual.
PSYCHOLOGICAL DEVELOPMENT
Psychosexual Theories. Psychoanalytic theorists have
posited a different recapitulation theory. Specifically, they see
the developmental processes of adolescence as a
recapitulation of earlier infantile stages of development
through the reexperiencing of either oedipal or preoedipal
conflicts (Bios, 1941, 1979; Freud, 1948; Freud, 1924/1973 ).
The physiological changes that bring about sexual-
reproductive maturation are considered to usher in the genital
stage, which disturbs the psychological equilibrium achieved
during the latency period (Freud,
ADOLESCENTS: OVERVIEW 5
1924/1973). The sheer "quantity of the instinctual impulses"
(Freud, 1948, p. 164) is thought of as rekindling a conflict
over dominance between the ego and the id, the latter of
which has predominated and matured during the latency
period. The ego is conceptualized as tom between the
impulses and demands of the id and the restrictions of the
superego (Freud, 1948). Consequently, adolescence is viewed
as a period of stress and turmoil and as discontinuous with
other phases in the life cycle ..
According to the psychosexual theorists, two tasks must
be accomplished during this stage if psychological maturity is
to be attained: (a) detachment from the opposite sex parent as
an incestuous love object and (b) establishment of a
nonantagonistic, nondominated relationship with the same sex
parent. This process of detachment may result in negativism
and hostility toward parents and other authority figures for a
time. Freud (1924/1973) believed that this process is seldom
completed ideally.
BIos (1941, 1979) modified traditional psychoanalytic
theory, stressing the importance of the "cultural milieu and
social stratum" (BIos, 1941, p. 7) in personality formation and
positing a reciprocal influence between the individual and his
or her environment. Although he insisted that adolescent
development must be considered in the context of a particular
culture and the family's "unique version of the culture" (BIos,
1941, p. 260), like his psychoanalytic predecessors, he saw
adolescence as a transitional period that involves a
recapitulation of earlier familial patterns of interaction.
However, he considered this process to be qualitatively
different from earlier developmental experiences because of
the significant maturation of the ego (ego supremacy and ego
differentiation) during the latency period (BIos, 1941). This
ego development allows the adolescent in most cases to
resolve the oedipal conflicts and the component infantile
dependencies (Bios, 1979).
According to BIos (1979), the second individuation
process that occurs during adolescence requires a "normative
regression in the service of development" (p, 153); that is,
only in adolescence is regression an essential and normal
process. Though normal, this regression still produces
turmoil, volatile behavior, and anxiety that, if it becomes
unmanageable, may result in the use of a variety of defense
mechanisms such as withdrawal and secrecy, fantasy,
temporary compulsive habit formation, compensation,
intellectualization, rationalization, projection, and changes in
the ego ideal (Bios, 1941).
Chodorow (1974, 1978) has reinterpreted the indi-
viduation process, challenging the male sex bias of earlier
formulations. According to Chodorow, because the male's
first love object-the mother-is of the opposite sex, separation
and individuation are critical to male
6 AooLEScENTs: OvERVIEW
gender identity and development but not to the progress
of female identity development.
Psychosocial Theories. Psychosocial theories of
adolescence, although based on Freud's psychosexual
conceptualization of development, emphasize the impact
of the sociocultural context on individual development.
Erikson (1963, 1968) viewed development as proceeding
through a sequence of stages, each of which is
characterized by a specific crisis. Not only are the crises of
each stage produced by internal mechanisms, they are the
result of the interaction between the individual and his or
her social environment, which makes cultural demands in
the form of social expecta-
tions, norms, and values. . (Bandura, 1969; Gagne, 1970). Differeritial reinforce-
Erikson thought of identity formation as a process
that continues throughout one's life; but he believed that
identity "has its normative crisis in adolescence" 0968,
p. 23). Like the psychosexual theorists, Erikson
described adolescence as a time of turmoil and stress.
However, he (1968) considered it to be the result of an
"identity crisis" that typifies this stage, rather than of a
as a necessary and
period during which the adolescent experiments with
and works to consolidate his or her personal, occupa-
tional, and ideological identity. This identity is formed
through the individual's psychological integration as
well as through the social environment, whi~h serves
critical functions during this process. In the search for
self-definition, conflict arises between the adolescent
and his or her parents as a necessary movement toward
establishing the adolescent's own view of self, of the
world, and of his or her place in that world.
Erikson's conceptualization has been criticized for its
sex bias in that he generalized changes in the life cycle
from a male model of development (Chodorow,
1974,1978; Gilligan, 1979). Gilligan (1979) noted that
individuation and separation from the mother are
accepted as critical for the development of gender
identity among males, but she proposed the opposite
dynamic for females: "Femininity is defined through
attachment" (p. 434) to the mother. According to
Gilligan (1979), "male gender identity will be threat-
ened by intimacy while female gender identity will be
threatened by individuation" (p. 434). Erikson viewed
separation as a healthy sign of progressive development
and attachment as a problem. However, Chodorow
(1974, 1978) and Gilligan (1979) proposed that, in the
course of female development, intimacy may more
appropriately precede separation or at least be fused
with identity formation. . hood into adolescence and adulthood, one notes an
Social Learning Theory. Social learning theorists
describe adolescence as a period of development that,
for the majority of individuals, proceeds from childhood
with great continuity in behavior, interpersonal
relationships, and self-evaluation (Bandura & Walters,
1963). The behavioral and socialleaming principles that
apply in infancy and childhood remain the same, with
the possible expansion of sources of reinforcement in
the environment, a greater number and variety of
models, and an expanded capacity for self-regulated
behavior.
The process of socialization includes the develop-
ment of behavioral repertoires through differential
reinforcement, stimulus and response generalization,
higher order conditioning, modeling, and rule learning
ment refers to the process whereby behavior that is re-
inforced increases in frequency and behavior that is
punished or placed on extinction decreases. For exam-
ple, adolescents shape each other's social behaviors by
positively responding to specific mannerisms, dress, and
the latest slang terms and by ostracizing or ridiculing
behaviors that do not meet the norms of their peers.
Response generalization involves the production of
behaviors (responses) that have properties similar to the
response that has been reinforced. Via stimulus
generalization, the adolescent is likely to respond with
the same repertoire of responses to other peers he or she
perceives as being similar to those from whom he or she
received reinforcement. In higher order conditioning,
certain individuals, environments, objects, words,
symbols, and the like become positive or negative
stimuli for the individual and result in specific responses
because. they are associated with positive or negative
events.
Modeling is a mode of imitative or vicarious learning
that involves the observation, coding, and retention of a
set of behaviors for their performance at a subsequent
time. It is particularly efficient for learning complex
behaviors, such as interpersonal skills. Furthermore,
modeled behaviors are more readily learned in
situations for which the individual has no prior
repertoire of responses. Moreover, the adolescent also
combines behaviors of various models into novel
responses or abstracts a rule that allows him or her to act
as the model would act in a novel situation for which
specific responses have not been observedIlvlehrabian,
1970). Hence, as one moves from childhood into
adolescence and is exposed to a greater number and
variety of models, one's potential behavioral repertoire
increases substantially.
Finally, as an individual progresses through child-
increase in self-regulatory behavior, most notably self-
evaluation and self-reinforcement (Bandura, 1969,
1995). Self-reinforcement is generally established
through modeling as the observer evaluates and rein-
 AooLESCENTS: OVERVIEW 7

the model. Over time, the responses become independent explain the feelings of self-consciousness that are prev-
of the original learning experience and are gener ~ alized to alent during adolescence and "a good deal of adolescent
other situations. Although self-evaluation and boorishness, loudness, and faddish dress" (p. 387).
reinforcement can be independent of social norms, they Also demonstrative of cognitive egocentrism is the
often correspond (Bandura, 1977). complementary development of the "personal fable"
Bandura and Walters (1963) and Bandura (1964) noted (Elkind, 1967, 1974, 1978; Inhelder &Piaget, 1978). The
that empirical research had not borne out the claim that personal fable involves viewing one's thoughts and
adolescence constitutes a sudden and drastic change from feelings as unique experiences, often ones that should be
childhood, particularly in parent-ehild relations. They saved for posterity (via diaries or poetry). Feelings of
indicated that the pattern instead appears to be one of invulnerability accompany this perception and have been
gradual socialization toward independence by means of a linked to such adolescent problems as - the failure to use
gradual change in reinforcement conditions. contraceptives and risk-taking behavior (Elkind, 1967).
This cognitive egocentrism also results in projecting one's
preoccupation with and plans for the future onto the
COGNITIVE DEVELO~MENT According to Piagetian society as a whole and viewing oneself in a Messianic role
theory, cognitive development consists of the (Inhelder & Piaget, 1978). Primarily because of reality
progression through stages of quantitatively and testing and the sharing of perceptions and experiences with
qualitatively more complex thought processes and peers, the egocentrism of early adolescence gives away to
structures. Piaget and Inhelder (l958) emphasized the full formal operations by age 15 or 16 (Elkind, 1978;
discontinuity be tween the concrete operational Inhelder & Piaget, 1978).
thinking of the child and the qualitatively different
formal operations of the adolescent. Piaget (l972 ) MORAL DEVELOPMENT Moral development is incor-
viewed the progression from concrete to formal porated in psychoanalytic theory via the
operations as the product of indivi dual "spontaneous development of a conscience in childhood and such
and endogenous factors" (p. 7) and experiences in the conceptualiza tions as the "reexternalization" of the
environment that stimulate inrellectual growth. superego in adolescence (Settlage, 1972 ) . The latter
Formal operational thought is -- characterized by consists of a conscious appraisal, - challenging, and
hypothetlco-deductive reasoning: As the adolescent's discarding of values and an incorporation into the
thinking is no longer tied to concrete objects, he or she is superego of reap praised ideals and values (which are
able to construct possibilities, to manipulate and reflect no longer mirrors of parental values) (Hoffman,
upon mental constructs, and to assess probabilities. 1980). Erikson (l970) described the adolescent in the
According to Piaget and Inhelder (1958), this new capacity process of identity de velopment as moving from the
enables the adolescent to "analyze his [or her] own thinking specific moral learnings of childhood to the pursuit
and construct theories" (p. 340). The adolescent's thought is of a moral ideology that facilitates identity
no longer tied to trial and error, but can generate formation.
hypotheses regarding all the possible relations among the Piaget (1965) formulated a simple two-stage dichot-
various factors in solving a problem. Moreover, the omous model, moving from moral realism tosubjectivism.
adolescent systematically tests alternative hypotheses, In the stage of moral realism, the child judges the moral
varying one factor at a time while holding all other factors value (rightness or wrongness) of an act by the magnitude
constant (Piaget & Inhelder, 1958). of the damage or injury or simple conformity with stated
Cognitive development also is conceptualized as a rules, irrespective of intention. In the second or
process of decentering. Decentering involves the reduction autonomous stage of subjectivism, intention becomes the
of egocentric thought that thereby allows for the generation foremost consideration in judging the moral value of an
and testing of hypotheses. Formal operations progress act. The subjective nature of rules and the concept of rules
through transitional stages (generally from ages -II to 14) in by mutual consent are recognized.
which the operations of formal thought are confounded by It is only with the attainment of formal operations in
the adolescent's egocentrism. Elkind (l967, 1974, 1978) adolescence that the individual has the capacity for
believes this results in the phenomenon he calls "the developing postconventional morality, recognizing in-
imaginary audience." That is, the adolescent feels as dividual and cultural differences as well as universal
though his or her actions and appearance are constantly principles. Although Kohlberg and Gilligan (1975)
being scrutinized by others. Elkind (l978) believed that this propose that many adolescents regress to an instrumen-
egocentrism may . tal level of moral development, T uriel (1974) describes the
extreme relativism of the adolescent as a transitional
phase. With attainment of formal operations
8 AooLEScENTs: OVERVIEW
and the recognition of differences in perspectives, the
adolescent questions the rigid law-and-order morality of
the conventional stage and rejects the imposition of moral
codes and values on the individual. The adolescent's
extreme relativism results from the rejection of
conventional criteria for moral judgment, which leaves the
individual for a time with the sense that no basis exists for
objectively verifying values.
Hoffman (1980) proposed that the development of
empathy and its transformation during cognitive devel-
opment is the fundamental basis of moral development. As
a result of his or her cognitive development, the adolescent
begins to conceptualize others not only as distinct, but to
project the self into another's experiences beyond the
immediate concrete situation and, therefore, to respond
with empathic distress and "a more reciprocal feeling of
concern for . the victim" (Hoffman, 1980, p. 311).
Moreover, this empathic distress can also be transformed
into feelings of guilt if the victim's distress leads to
self-blame with respect to one's action or inaction. Finally,
one's empathic distress, sense of guilt, and impetus to
relieve the distress perceived in another are viewed as the
significant motivational components for moral action.
In social learning theory, moral values, judgments, and
behaviors are viewed as being dependent on a variety of
environmental factors, such as the long- and short-term
consequences, the setting, the type of act, and the
characteristics of the victim. Moral development involves a
process of learning through direct instruction (rule
learning), reinforcement contingencies, modeling, and
evaluative feedback. By exposure to diverse situations and
models, one learns which factors are important to consider
in various situations when moral judgments are required
(Bandura, 1977, 1995; Rosenthal & Zimmerman, 1978).
SOCIAL DEVELOPMENT The adolescent's social de-
velopment is closely related to his or her psychological
development, particularly identity formation and the need
for intimacy. Sullivan (1953) viewed interpersonal
relations as central to one's individual identity. He posited
three stages of adolescent development, which are distin-
guished by different needs and expressions of interpersonal
intimacy: preadolescence, early adolescence, and late
adolescence. Preadolescence is characterized by the need
for intimacy expressed through strong relationships,
usually with persons of the same sex. These relationships
differ from those of childhood in their exclusivity and
extent of personal intimacy, evidenced by disclosure of
one's secret thoughts, feelings, and aspirations.
The stage of early adolescence is ushered in by the
physiological changes of puberty with the concomitant
appearance of the lust dynamism (Sullivan, 1953). Lust - a
psychological rather than a moralistic construct - refers to
genital drives that impel the individual toward sexual
satisfaction. This new integrating dynamism results in the
shift to intimate relations with persons of the opposite sex
for most adolescents, patterned, to some degree, after
preadolescent same-sex relationships.
According to Sullivan (1953), a person enters late
adolescence when he or she "discovers what he [she) likes
in the way of genital behavior and how to fit it into the rest
of life" (p. 297). By late adolescence, Sullivan claimed,
the majority of adolescents have established their preferred
mode of sexual relationships and continue to develop and
expand their interpersonal skills. Intimacy is the core of
what Sullivan (1953) described as the mature person; it
involves "a very lively sensitivity to the needs of the other
and to the interpersonal security or absence of anxiety in
the other" (p.31O).
More recently, Attachment Theory (Bowlby, 1982) has
been employed to elucidate the nature and development of
interpersonal relationships in adolescence. Expanding her
body of work on attachment in infancy, Ainsworth (1989)
posits a significant, complex, and qualitative change in the
behavioral systems related to attachment: "key changes in
the nature of attachment may be occasioned by hormone,
neurophysiological and cognitive changes, and not merely
by socioemotional experience" (p. 710). Attachment to
parentis] is seen as the basis for peer attachments and
supported by a body of empirical literature, although some
adolescents are spurred to establish peer attachments to
compensate for lack of attachment to parental figures (See
Rice, 1990 and Schneider & Younger, 1996 for reviews of
this literature; Freeman & Brown, 2001; Furman, Simon,
Shaffer, & Bouchey, 2002). The relationship skills,
competencies, and expectations learned in the relationship
with parental attachment figures become the basis for
relationship building with peers; however, parent and peer
attachments may not be parallel and may vary along a
number of dimensions and functions (Black & McCartney,
1997;O"MarJ<.iewicz, Lawford, Doyle, & Haggart,
2006)~~reover, the increase in peer attachments does not
totally replace primary attachment to parental figures or
specific attachment functions (Black & McCartney, 1997;
Freeman & Brown, 2001; Markiewicz et al., 2006).
Bandura (1964) and others (e.g., Harter, 1990;
Steinberg, 1990) have indicated that increased peer
interaction does not usually result in a simultaneous
shifting away from parent relationships and values.
Examining relationships across several decades, re-
searchers found that adolescents and parents viewed

each other positively and that only a limited percentage
experienced disruption in their relationship (Bandura,
1964; Bandura & Walters, 1963; Harter, 1990; Hess &
Goldblatt, 1957; Meissner, 1965; Offer, 1967; Offer &
Sabshin, 1984; Offer, Sabshin, & Marcus, 1965;
Steinberg, 1990).
As early as 1980, Coleman's review of the literature
(1980) pointed out that the need for friendships changes
and that the greatest need (especially for girls) occurs
during middle adolescence. It is during middle
adolescence that the dread of rejection and the lack of
social confidence take their toll. Moreover, girls
experience more feelings of anxiety about friendships
than do boys, probably because the socialization of girls
places greater emphasis on the fulfillment of emotional
needs through relationships. In contrast, boys tend to be
socialized to seek relationships that are focused on
actions. Consistent gender differences have been noted
in the literature, with females demonstrating greater
intimacy, self-disclosure and communication in their
relationships than males. (Belle, 1989; BerndtSc Perry,
1990; Brendgen, Markiewicz, Doyle, & Burkowski,
2001; Buhrmester, 1990; Fischer, 1981; Furman &
Buhrmester, 1992; Macoby & Jacklin, 1974; Nickerson
& Nagle, 2005).
SEXUAL DEVELOPMENT Sexual development is the
result of the interaction of intrapsychic,
sociocultural, and biological factors. The
physiological changes initiated in puberty
influence the individual in a social context (Miller
& Simon, 1980) and via the personal evaluation of
their meaning and significance.
Gender identity and gender role expectations form
the foundation of the young adolescent's sexual identity
"since the sexual and social scenarios of the society are
organized around norms for gender-appropriate beha-
vior" (Miller & Simon, 1980, p. 383). Particularly in
early, adolescence, motivations for sociosexual
behavior may be nonerotic, impelled instead by what
are considered gender-appropriate behaviors in the
specific social context (Miller & Simon, 1980).
With the onset of puberty, the adolescent must add a
sexual dimension to his or her gender identity.
According to Miller and Simon (1980), the progress of
psychosexual development and concomitant sexual be-
havior depend on two factors and their interaction: (1)
"the intrapsychic history and life of the individual" and
(2) "the interpersonal requirements of social life" (p.
388) - the social context. The intrapsychic life of the
individual refers to idiosyncratic values that result in the
eroticizing of events, attributes, relationships, and so
forth. Interpersonal "scripts" are less idiosyncratic
because they reflect the present social expectations
ADOLESCENTS: OvERVIEW 9
and constraints, which vary with time and the indi-
vidual's reference group (Gagnon, 1974; Gordon &
Gilgun, 1987; Miller & Simon, 1980). Hence, majority
and minority adolescent cohorts may have significantly
different interpersonal scripts.
When there is congruence between intrapsychic and
interpersonal factors, sexual identity formation
proceeds smoothly. When these two factors are dis-
cordant, the adolescent must choose to risk either
alienation from others or a sense of self-betrayal. Patti-.
cularly vulnerable in this regard are individuals whose
intrapsychic content is homoerotic, but who feel con-
strained by sociocultural norms and demands (Miller &
Simon, 1980). .
Conclusion
It is particularly important to be aware that develop-
mental processes, though universal, have cultural var-
iations in their manifestation, normative appraisal, and
time frame. Adolescent development occurs within a
cultural milieu, and, therefore, the cultural context must
be taken into account if the developmental process and
the group and individual issues that are generated
during this process are to be understood. For ethnic
minority youth, this.is further complicated by the bi-
cultural socialization process (de Anda, 1984), which
results in development occurring in a dual cultural
context, that of White mainstream American culture
and their culture of origin. Further complicating this
process are structural factors, such as individual and
group social status and income, especially poverty, that
create barriers to the "normal" course of adolescent
development.
The application of theories or principles that address
the impact of various sociocultural factors on an
individual's behavior, values, and beliefs holds the most
promise and is most consonant with the practice of
social work, which ascribes to a
person-in-the-environment perspective, viewing the
individual within his or her psychosociocultural
context.
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York: Basic Books.
ADoLESCENTS: DEMOGRAPHICS AND SOCIAL ISSUES 11
Rice, K. G. (1990). Attachment in adolescence: A narrative and
meta-analytic review. journal of Youth and Adolescence,
19,511-538.
Rosenthal, T. L., & Zimmerman, B. J. (1978). Socia1learning and
cognition. New York: Academic Press.
chneider, B. H" & Younger, A. J. (1996). Adolescent-parent
attachment and adolescents' relations with their peers. Youth
and Society, 28(1), 95-108.
Settlage, C. F. (1972). Cultural values and the superego in late
adolescence. Psychoanalytic Study of the Child, 27,57-73.
Simmons, R. G., & Blyth, D. A. (1987). Moving intoadolescence.
Hawthorne; NY: Aldine.
Stang J., & Story, M. (Eds.). (2005). Guidelines for adolescent
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Education and Training in Maternal and Child Nutrition,
Division of Epidemiology and Community Health, School of
Public Health, University of Minnesota.
Steinberg, L. D. (1990). Interdependence in the family:
Autonomy, conflict and harmony in the parent-child
relationship. In S. S. Feldman & G. R. Elliott (Eds.), At the
threshold: The developing adolescent (pp. 255-276). Cambridge,
MA: Harvard University Press.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry.
New York: W. W. Norton & Co.
Tanner, J. M. (1962). Growth at adolescence. Springfield, IL.:
Charles C. Thomas.
Tanner, J. M. (1972). Sequence, tempo, and individual variation
in growth and development of boys. and girls aged twelve to
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1197-1210.
-DIANE DE ANDA AND TODD FRANKE
DEMOGRAPHICS AND SOCIAL ISSUES
ABSTRACT: This entry begins with a presentation of
demographic data on the adolescent population by age,
gender, and ethnicity from the latest census data on
ages 12 to 19. A summary of the information available
on major issues and problems affecting adolescent
populations is presented from numerous governmental
and empirical research sources on the following topics:
education, runaway and homeless youth, sexual
criminal behavior.
KEY WORDS: adolescents; problems of adolescence;
adolescents and education; adolescent sexual behavior;
adolescent substance abuse; adolescents and STls;
adolescent suicide; adolescents and violence; runaway
and homeless youth
12 AooLESCENTS: DEMOGRAPHICS AND
SocIAL ISSUES
Introduction
According to Census 2000, adolescents constitute
11.5% of the u.s. population (U.S. Bureau of the Census,
2007), an increase of only 0.3% from 1990. The
distribution by age, gender, and ethnicity appears in
Table 1.
Males constitute a slightly larger percentage (51.3 %
) of the adolescent population than females (48.7%) ,
similar to the percentages for 1990 (51.2% versus
48.6%). White adolescents comprise 63.2% (a notice-
able decrease from 69.4% in 1990). The percentages by
ethnic group for the remaining adolescent cohort are as
follows: African American 14.3%, Hispanic Latino
15.5%, Asian/pacific Islander 3.7%, Native American
1.0%, other 0.2%, two or more \
races 2.1 %.
Education
SCHOOL DROPOUTS In 2005, the dropout rate for
16-24 year olds in the 10-12 grades was 3.8%, a de-
crease from 6.1% in 1972 (Laird, DeBell, Kienzl, &
Chapman, 2007). However, over the past decade, the
percentage of school dropouts has varied significantly
by ethnic group, with the rates for White students
declining from 8.9% in 1991 to 6.80/0 in 2004, for
African American students from 13.6% in 1991 to
11.8% i"n 2004, and for Hispanic/Latino dropouts from
35.3% in 1991 to 23.8% in 2004 (Snyder, Tan, &
Hoffman, 2006). The Hispanic/Latino dropouts have
unique characteristics. They consist of the U.Si-born
and educated, the foreign-born who receive some U.S.
education, and the foreign born who receive no U.S.
education (Fry, 2003). Hispanic/Latino youth who are
educated abroad are nearly all high school dropouts
(Fry, 2003). One in three Hispanic/Latino dropouts is
educated abroad and has no involvement with U.S.
formal education (Fry, 2003). Gender differences are
greatest among Hispanic/Latino students (28.5% for
males versus 18.5% for females) compared to White
(7.1% for males versus 6.4% for females) and African
American (13% for males versus 10.2% for females)
students (Snyder et al.; 2006).
Reasons for leaving school reported by high school
dropouts included both school-related (irrelevance of
the curriculum, lack of interest in school, dissatisfaction
with teachers, fear of not fitting in, fear for safety, and
discipline) and non school-related (financial needs,
family problems, substance abuse, pregnancy and mar-
riage) problems (We is, Farrar & Petri, 1989). Low
income students have a 10% rate, twice that of middle
income (~5%) and four times that of high income
( 2.5%)students (Snyder et al., 2006).
rv
There appears to be a direct relationship between
years of school completed and employability. For in-
stance, among 16- to 19 year-olds, unemployment is
19% for those who did not complete high school, com-
pared to 15.9% for those who graduated, and 9.2% for
those with sallie college education. The percentages
vary by ethnic group, with unemployment for 16 to 19
year olds at 15.4% for White students who leave school
and 34.9% and 22.9% respectively for their African
American and Hispanic cohorts (Snyder et aL, 2006).
Unemployment was 23.1 % for high school dropouts
and 25.0% for graduates not enrolled in college (United
States Department of Labor, 2007). However, high
school graduates earned, on average, $9,245 more per
year than high school dropouts. Nevertheless, many
lowskilled, low-paid school dropouts still hold high
career aspirations, suggesting they believe they are not
sacrificing their futures by leaving school before
graduating.
SPECIAL EDUCATION The Individuals with Disabil-
ities Education Act (IDEA). ensures that youth with
disabilities are provided free and appropriate public
school education. The National Center for Education
Statistics' (NCES) The Cqndition of Education annually
reports on the current status of children, aged 3 through.
21, who receive services through IDEA. In the 19761977
school year, the first year data were collected, 3,694,000
children aged 3 through 21 years old were served in
federally supported programs for the disabled; In the
1990-1991 school year, 4,710,089students received
services, and by the 2003-2004 school year, the number
was 6,634,000, increasing to over 6, 7 million by the
2005-2006 school year (8.6% of the total public school
enrollment). Under IDEA, 5.1% of children aged 3-21
were served in 1976-1977 and increased to 8:6% in the
2003-2004 school year. As of 2008, with the exception of
1984-1985, the percentage of total public school
enrollment served under IDEA had not decreased since
the 1976-1977 school year. In 19761977, 8.3% of the
total public school enrollment received IDEA services,
which increased to 13.8% in 2005-2006. This pattern has
continued with increases every year as of 2008.
GRADUATION AND COLLEGE ATTENDANCE
Since the late 1970s, the number of high school
graduates has created a cyclical trend, peaking at 3.16
million graduates in 1978, and dropping to 2.28 million
in 1991. The cycle was at 2,752,106 students graduating
from high school in 2004 (67% White, 14.5% African
American, and 10.4% Hispanic and Latino graduates).
According to the Digest of Educational Statistics, two-
thirds (66.7%) of high school graduates enrolled in
college (68.8% of White, 62.5% of Black and African
American, and 61.8% of Hispanic and Latino gradu-
ates). Of those who graduated and enrolled in college,
 ADoLESCENTS: DEMOGRAPHICS AND SOCIAL ISSUES 13

TABLE 1
Adolescent Population by Age, Gender, and Ethnicity (2000)
AFRICAN WlllTE FEMALE MALE TOTAL AGE
AMERICAN
603,761 2,560,277 1,988,614 2,087,228 4,075,842 12
584,756 2,542,830 1,956,842 2,054,008 4,010,850 13
586,192 2,584,991 1,972,671 2,079,560 4,052,231 14
575,077 2,568,610 1,954,277 2,065,127 4,019,404 15
568,660 2,525,143 1,926,439 2,048,582 3,975,021 16
572,714 2,552,545 1,954,732 2,091,280 4,046,012 17
569,835 2,537,481 1,972,745 2,078,853 4,051,598 18
OrHER Two OR AMERICAN ASIAN OR H!SPANlCOR
MORERA-CES INDIAN PACIFIC LATINO
ISLANDER
9,821 93,425 40,667 140,172 627,719 12
9,143 90,508 39,731 137,621 606,261 13
8,957 88,917 40,038 141,991 601,145 \ 14
8,482 86,630 39,867 143,930 596,808 15
8,382 84,216 39,146 146,943 602,531 16
8,415 83,313 39,820 151,351 637,854 17
9,103 82,391 36,808 159,683 656,297 18
9,563 81,592 36,816 166,592 678,156 19
U.S. Census 2000 Summary File 1 (SF 1) 100% Data, Tables PCT12H-PCT120, unpublished tabulations.

69.5% were White, 13.6% were Black, and 9.6% were
Hispanic and Latino (Snyder et al., 2006).
Between 1999 and 2004, White enrollment in college
dropped from 72 % to 69.5%, with some fluctuation, but no
systematic trend. African American enrollment dropped
from 14.1 % to 13.6%, with much fluctuation. The
Hispanic/Latino enrollment fluctuated between 7.6% and
10.8%, ending with 9.6% enrolled. The enrollment of each
ethnicity and race was examined as a percent of that
specific ethnicity/race that had graduated. White
enrollment fluctuated between 66% and 69% with no
visible trend. African American enrollment started at
58.9% in 1999, dipped down and came back up to end at
62.5% in 2004, with no visible trend. Hispanic/Latino
enrollment data suggested a trend, with the 1999
enrollment of 42.3% rising to 61.8% in 2004, a 20%
increase over a5 year span. While data from 1972 shows
constant fluctuations until 2004, the period between 1999
and 2004 seems to .be the longest sustained period of
growth. In 2000, enrollment shot up to 52.9% and dropped
to 51.7% the year after, nowhere near the 1997-,-1998 drop
from 65.6% to 47.4%. In addition, the 3-year rolling
average has seen consistent growth from 47.5% in 1999 to
58.0% in 2003.
without parent or caretaker permission" (U.S. Department
of Health and Human Services, 1983). Homeless youth are
defined as those 18 or younger unable to live safely with a
relative, or those 18 to 21 who have no shelter available to
them (Ferandes, 2007). A report from
the American Medical Association's Council.onScien: ',i,-tific
Affairs confirmed that most youth on the street are both
runaways and homeless, because they do not have a home to
which they can or desire to return.
Various typologies have been suggested for classifying
and understanding runaway youth. Thee major classifi-
cations of runaways are still used (Zide & Cherry, 1992):
1. Those, usually from a fairly well-functioning family
system, "running to" or in search of some form of
adventure or excitement;
2. Those "running from" a dysfunctional family system
which might include a substance abusing parent and
physical or sexual abuse, which has been found to
occur with higher rates within the runaway
population (Angenet & de Man, 1989; Caton, 1986;
Janus, Burgess, & McCormack, 1987; Whitbeck &
Simons, 1990).
3. Those "thrown-out" by their families, often after a
history of conflict with the family and problems in
school and the community.

Runaway and Homeless Youth Zide and Cherry (1992) add a fourth group they label
Runaway youth are defined as those "under the age of "forsaken," representing adolescents, usually social iso-
eighteen who are away from home at least overnight lates with low self-esteem, who have been abandoned
14 . ADoLESCENTS: DEMOORAPHICS AND SOCIAL
ISSUES
to their own resources for survival due to the inability of
the family to continue to provide support.
The number of nmaway youth has increased at an
alarming rate since the 1990s; in the 1990s there were 1.3 to
1.5 million per year; by the early 2000s, an estimated 2.8
million (Greene, 1995; Hammer, Finkelhor, & Sedlak,
2002; The National Network of Runaway & Youth
Services, 1991a). According to the National Alliance to
End Homelessness (August 2006), it is estimated that
between 500,000 and 1.3 million youth nmaways and
throwaways become homeless. Moreover, the percentage
of homeless youth within this population has appeared to
increase, with the vast majority from economically
disadvantaged families who are no longer able to support
them. (Zide & Cherry, 1992). Furthermore, 40% of youth in
shelters and on the street come from families who received
public assistance or lived in publicly assisted housing
(Greene, 1995).
Runaway youth are a particularly at-risk population.
The NISMART-2 survey in 1999 found that an estimated
1,190,900 (71%) were endangered during their runaway
episode by factors such as substance dependency, use of
hard drugs, sexual or physical abuse, presence in a place
where criminal activity was occurring, or extremely young
age (13 years old or younger) (Hammer, Finkelhor, &
Sedlak, 2002). Many runaways did not seek help at
shelters; 12% of runaway and homeless youth spent at least
one night outside, in a park, on the street, under a bridge or
overhang, or on a rooftop (Westat, Inc., 1997). A 1995
survey revealed that 7% of youth in runaway and homeless
youth shelters and 14% of youth on the street admitted to
having traded sex for money, food, shelter, or drugs in the
previous twelve months (Greene, 1995). Pregnancy is also
a high-risk issue; approximately 48.2% of youth living on
the street and 33.2% of youth living in a shelter reported
having been pregnant (Greene & Ringwalt, 1998). Finally,
runaway youth are 6 to 12 times more likely to become
infected with HIV than other youth (Rotheram-Borus et
a1., 2003).
Sexual Behavior
SEXUAL INTERCOURSE AND CONTRACEPTION On
the Youth Risk Behavior Surveillance, 2005, survey,
46.5% of ninth through twelfth grade youth reported
having had sexual intercourse, a rate relatively unchanged
from the 1999 survey (47.7%). As in the earlier survey, the
percentage increased by grade level (9th ;" 34.3%, 10th =
42.8%. 11th = 51.4%. 12th = 63.1 %). Some differences
were noted by ethnicitv, with African American youth the
highest percentage (67.6%), followed by Hispanic/Latino
(51.0%) and White (43.0%) adolescents. The percentage of
males
and females was the same for White youth (males 42.2%;
females 43.7%), but differed for African American (males
74.6%; females 61.2%) and Hispanic/ Latino (males
57.6%; females 44.4%) youth (Centers for Disease Control
and Prevention, 2000; 2006b).
Nearly two-thirds (62.8%) of adolescents who were
currently sexually active reported using a condom at last
intercourse, with similar percentages for African American
(68.9%) arid 'WJ1ite (62.6%) youth and a somewhat lower
percentage (57.7%) for Hispanic/ Latino youth. Birth
control pill usage was relatively low (17.6%), with the
most frequent use by twelfth graders (25.6%) and White
adolescents (22.3%). African American (10%) and
Hispanic/Latino (9.8%) adolescents had similar, but low
usage (Centers for Disease Control and Prevention, 2006b).
The female contraception rate has remained relatively
consistent since 1988 (32.1 %), at 31.5% in 2002 (Ventura,
Abma, Mosher, & Henshaw, 2006), including 35% of
White and 32.9% of African American adolescent females,
in contrast to Hispanic/Latino adolescent females at 20.4%,
a drop from the 1995 level of 26.1 %. Of those using.
contraception, the majority (53.8%) used birth control pills,
a decline from the 1982 rate of by 63.9%. However,
adolescent females evidenced a 20% increase in use of
condoms as a contraceptive method. Of concern is the
notable increase in female adolescents reporting
withdrawal as a contraceptive method, 15% in 2002 in
contrast to only 2.9% in 1982 (Ventura et al., 2006).
PREGNANCY AND PREGNANCY OUTCOMES After
reaching an all-time high throughout the 1980s and
peaking in 1990, the adolescent pregnancy rate has
consistently and substantially declined each subsequent
year. The pregnancy rate for adolescents 15 to 17 years of
age of 77.1 per 1,000 in 1990 dropped to 67.4 in 1995,50.8
in 2000, and an all time low of 44.4 in 2002. Although
declines were noted across ethnic groups, the rates and the
amount of decline varied, a 43.5% decline among
non-Hispanic White adolescents to 49.0,40.3% among
African American adolescents to 138.9, and 19.2% among
Hispanic/Latina adolescents to 135.2 (Ventura et a1.,
2006).
SEXUALLY TRANSMITTED INFECTIONS Sexually
transmitted infections are a serious adolescent health
problem. Approximately one-fourth of all sexually active
adolescents will contract a sexually transmitted infection
(Centers for Disease Control and Prevention, 2002).
HIV/AlDS. For adolescents aged 13 to 19, the cu-
mulative total for the number of diagnosed HIV/AIDS
cases from 2001 to 2004 was 4,310, with the number of

U.S. HIVIAlDS Cases* (2001-2004) (Age 13-19)
AI/AN API WmTE
F M F M F M F M
1 2 2 0 81 84 56
2 3 2 2 82 83 63
4 2 2 1 83 81 50
3 3 2 3 71 93 46
(*Data from 33 states, Guam & the Virgin Islands-areas with confidential name-based HIV infection reporting)
male cases slightly higher than females (See Table 2).
African American adolescents are particularly at risk, with
an incidence three to four times that of Hispanic/ Latino
and White adolescents. Moreover, only African American
males demonstrate a consistent increase over the four years,
while African American females generally exhibit a
decreasing trend. White adolescents showed a steady and
equal rate for males and females from 2001 through 2003,
with a unique increase for males and decrease for females
in 2004. The figures for Hispanic/Latino youth are more
erratic from year to year. Although Hispanic/Latino males
have an incidence similar to or slightly above that of White
males, Hispanic/Latino females have the lowest rates when
compared with their African American and White cohorts,
both male and female, as well as Hispanic/ Latino males.
The incidence of diagnosed HIV I AIDS is negligible in
Asian/Pacific Islander (API) and American Indian/Alaskan
Native (AI/AN) youth (Centers for Disease Control and
Prevention, 2006a).
Chlamydia. Chlamydia is the most frequently reported
infection, this despite the fact that most cases go
undiagnosed (Centers for Disease Control and Pre-
vention, 2006b). Young women 15 to 19 years of age,
have the highest chlamydia rate (2,796.6 per 100,000) in
the United States (Centers for Disease Control and
Prevention, 2006b). Young men 15 to 19 years of age, by
contrast, have a rate of 505.2, second after 20 to 24 year old
males at 804.7.
As in the U.S. population as a whole, chlamydia rates
are highest among African American youth. In 2005,
African American adolescents had the highest rate of
chlamydia infections of any age group of any ethnicity,
153,777, with the majority among female adolescents
(123,563). White adolescents 15 to 19 years of age at
93,876 (females 84,240) were fourth in frequency after
African American 15 to 19 and 20 to 24 year olds and
White 20 to 24 year olds. A total of 52,224 Hispanic/Latino
adolescents were infected with chlamydia, 43,698 of them
females. These rates show a consistent increase from 2001
to 2005. By contrast,
ADoLESCENTS: DEMOGRAPHICS AND SOCIAL
ISSVES 15
TABLE 2
HISPANIC AFRICAN AM. TOTAL
F M F M
80 431 323 571 489 2001
111 357 356 506 555 2002
85 381 384 520 553 2003
105 317 473 439 677 2004
Centers for Disease Control and Prevention, 2006a.
he number of infections among API and AlAN youth
low and consistent across the same years, 3,761 and 5,964,
respectively, in 2005 (Centers for Disease Control and
Prevention, 2006b).
Gonorrhea. Gonorrhea is the infectious disease
reported second in frequency in the U.S. (Centers for
Disease Control and Prevention, 2006b). As with chla-
mydia, young women 15 to 19 years of age have the
highest rates in the country (624.7 per 100,000). Males
of the same age group have a rate of 261.2, third in
frequency among male age groups. From 1996 to 2005,
there was a slow, but steady, drop in the rate in the 15 to
19 year age group (Centers for Disease Control and
Prevention, 2006b, Figure19).
The incidence of gonorrhea is highest, and substantially
so, among African American youth, with a trend toward a
decreased incidence from 2001 to 2005: 77 ,554 (females
50,862) in 2001; 66,165 (females 43,602) in 2005. White
and Hispanic/Latino adolescents appear to have
maintained a similar frequency ofjnfection across the same
years: White,14,961 (female 12,351) in 2001, 15,758
(female 13,079) in 2005; Hispanic and Latino, 7,095
(female 4,783) in 2001, 7,299 (female 5,165) in 2005. The
incidence of infection for API and AllAN adolescents is
quite low by comparison, 606 and 845, respectively. In all
groups, infections were substantially higher among
females (Centers for Disease Control and Prevention,
2006e, Table 20A).
Substance Abuse
DRUG ABUSE Trends in adolescent drug use showed
an increase from the mid 1970s to 1982, followed by
a slow, but steady, reduction in the use of illegal
substances (Oetting & Beauvais, 1990). However ,
drug abuse began to increase again and peaked in the
mid1990s. Since the mid-1990s, the Monitoring the
Future (MTF) survey has reported illicit drug use
has been on the decline. According to the MTF (U.S.
Department of Health and Human Services, 2006 )
survey of 48,460 students prevalence for 8th grade
drug use dropped by 37% since the peak year
(1996), 25% for l Oth graders
16 ADOLESCENTS: DEMOGRAPHICS AND
SOCIAL . ISSUES
since the peak year (1997), and 14% for 12th graders since
the peak year (1997). Drug use decrease was noted for
marijuana, methamphetamines, inhalants, cigarettes and
nicotine, crack cocaine, heroin, anabolic steroids, and
alcohol. However, some drugs had increased use or did not
change so that their current levels continue to raise
concern. Prescription drugs such as oxycontin and vicodin
remained stable at relatively high levels. The survey
reported the perceived availability of MDMA
(methylenedioxymethamphetamine or ecstasy) dropped for
IOth graders; moreover the levels of disapproval and those
at risk of using "once or twice" and "occasionally" fell
among 8th graders. The survey saw similar results for
hallucinogens, with 'an increase in the number of 8th
graders reporting that they perceived risk of harm from
"taking LSD regularly."
Frequent users of marijuana and poly drug users have
been identified as a subset of the population, manifesting
personality characteristics indicative of psychological
disturbance (Shedler & Block, 1990). Over a decade ago,
some researchers viewed marijuana use as normative
behavior in American adolescents, given developmental
issues and social norms, as long as use remained on an
infrequent and experimental basis (Newcomb & Bentler,
1988; Shedler & Block, 1990). Researchers studying the
effects are moving away from the normative rite of passage
view, to a view of a potentially harmful substance that has
doubled in potency since the mid-1980s (CASA White
Paper, 2004; Office of National Drug Control Policy,
2007).
ALCOHOL ABUSE Since the 1980s, alcohol is the drug
of choice, and the drug most frequently abused by
the adolescent population (Bonnie & O'Connell,
2004; Newcomb & Bentler, 1988). According to the
2006 Monitoring the Future survey, alcohol use
remained extremely high over the preceding decade,
with relatively small drops in use. Among students,
72.7% of 12th graders, 61.5% of l Oth graders, and
40.5% of 8th graders admit to having ever tried
alcohol (Johnston, O'Malley, Bachman, &,
Schulenberg, 2007). Of all drug use, drinking seems
to start early and increases in huge increments over
the years. Of those surveyed, 17.2 % of the 8 th
graders, 33.8% of l Oth graders, and 45.3% of 12 th
graders admitted to drinking in the preceding 30
days (Johnston et al., 2007).
The National Institute on Alcohol Abuse and
Alcoholism (NIAAA) defines binge drinking as a pattern
of drinking alcohol that brings blood alcohol concentration
(BAC) to 0.08 grams percent or above; typically, 5 or more
drinks in one session. Binge drinking in one's lifetime was
reported for 19.5% of 8th graders, 41.4% of IOth graders,
and 56.4% of
12th graders. Binge drinking in the preceding 30 days for
8th graders is 6.2%, for l Oth graders 18.8%, and for 12th
graders 30%.
National Survey on Drug Use and Health (NSDUH)
data show that current alcohol use rates for' 12 to 17 year
olds fell from 17.6% in 2002 to 16.5% in 2005. Accord ing
to the NSDUH, heavy drinkers are those who have 5 or
more drinks in one session, at least 5 different times a
month. Among 12 to 17 year olds, rates fell for binge
drinkers from 10.7% in 2002 to 9.9% in 2005 (Substance
Abuse and Mental Health Services Administration, 2006).
However, heavy drinking did not change drastically, from
2.5% in 2002 to 2.4% in 2005. In the 2002 NSDUH survey,
the rates of current use among youths aged 12 to 17 were
very similar for males and females (17.9% for females and
17.4% for males); however, in 2005, the percentage was
higher for females (17.2%) than males (15.9%).
According to Columbia University's Center on
Addiction and Substance Abuse, more than two-thirds of
youth who start drinking before age 15 are 7.5 times more
likely to use any illicit drug, are more than 22 times more
likely to use marijuana, and are 50 times more likely to use
cocaine than youths who never drank (CASA White
Paper.: 2004). Other studies show that alcohol use by
adolescents can result in (possibly permanent) brain
damage and impair intellectual development (NIAAA,
2006). Finally, alcohol plays key roles in accidents,
homicides, and suicides, the leading causes of death among
youth (AAP, 1998). Furthermore, the availability of
alcohol is high for most 12th graders, with 93% saying that
it is, or would be, "fairly easy" or "very easy" for them to
get alcohol (Johnston et al., 2007).
Suicide
Suicide is the third leading cause of death for 15 to 24 year
olds, in sharp contrast to being eleventh for all ages in the
United States (National Center for Health Statistics,
2006a). Death rate by suicide for youth 15 to 24 years of
age showed a dramatic increase from rates in the 1950s
(4.5) and 60s (5.2) to a peak in 1990 of 13.2 per 100,000,
followed by a trend toward slightly lower rates: 10.2 in
2000, 9.9 in 2001,9.9 in 2002, 9.7 in 2003, and 10.3 per
100,000 in 2004. There are dramatic gender differences,
with the suicide rate for males notably higher. Male rates
decreased from a high of 18.1 in 1990 to 13.0 in 2000 and
11.6 in 2003, with a slight increase in 2004 to 12.6.
Females had a consistently low rate, 3.9 in 1990 to 3.0 in
both 2000 and 2003, which increased slightly to 3.6 in
2004. There are significant ethnic differences (See Table 3)
with the highest suicide rates among American
Indian/Alaskan Native youth, peaking at 49.1 in 1990, with
a decrease to 30.7

2004
30.7
19.0
12.2
9.
3 appear to be any pattern by grade for males. Furthermore,
8.6
10.5
4.0
2.8
2.5
2.2
in 2004. White males also evidenced high rates, 24.4 in
1990 declining to 19.0 by 2004, followed by African
American males, API males, and Hispanic/Latino males
(See Table 3) (National Center for Health Sta tistics,
2006a). American Indian and Alaskan Nati ve and White
females also have the highest suicide rates among females,
a rate two to five times higher than any other group.
African American females have the lowest rates, a rate
maintained from 1990 to 2004. Hispanic and Latino
females have rates slight ly higher than their African
American cohorts (Hoyert, Heron, Murphy, & Kung,2006).
In direct contrast, females have much higher rates of
suicide attempts than males, with both showing slight and
inconsistent fluctuations from 1993 to 2005: 12.5 in 1993
to 10.8 in 2005 for females and 4.5 in 1993 to 6.0 in 2005
for males. Female Hispanic and Latina adolescents had the
highest frequency of suicide at tempts across gender and
ethnic groups, ranging from 11.6 (in 1991) to 21.0 ( in
1995) and fluctuating with a rate of 14.9 in 2005. White
female adolescents followed in frequency, with a high of
11.3 in 1993 and a rateof 9.3 in 2005. African American
adolescents had slightly lower rates most years, ending in
2005 with a rate of 9.8. Among males, from 1991 to 2005 ,
the rates fluctuated, and it varied between African
American and Hispanic and Latino males as to who
possessed the higher rates, ranging from a low of 3.3 to a
high in 2005 of 7.8. Finally, 9th and 10 th graders have a
consistently higher frequency of attempting suicide than
11th and 12th grade students (National Center for Health
Statistics, 2006a).
Suicide risk within the youth population is high lighted
by the larger percentage who have seriously
'
L
AOOLESCENTS: DEMOGRAPHICS AND SOCIAL ISSUES 17
considered suicide and reinforces the need for continu ing
suicide prevention efforts. From a high in 1991 of 29.0 who
engaged in serious suicide ideation, the per centage has
declined consistently to a low of 16.9% in 2003 and 2005 .
The suicide ideation rate was lowest among African
American youth and generally similar for Hispanic/Latino
and White youth. The rate for females has consistently been
nearly double that of males; in 2005, it was 21.8 for female
adolescents and 12.4 for males. Suicide ideation is highest
for females in the 9th and 10th grades, while there does not
suicide risk increases when the youth have made a plan for
their contemplated suicide attempt, reported by 13.0% of
high school youth in 2005 (Centers for Dis ease Control and
Prevention, 2006b; Centers for Disease Control and
Prevention, 2007).
Victimization and Criminal Behavior
Adolescents have the highest rate of violent victimization
(homicide, rape, robbery, and simple and aggravated
assault) of all persons 12 years of age or older in the United
States. An examination of the rates by age grouping from
1973 through 2005 found 12 to 24 year olds to experience
the highest rates across all years, with 16 to 19 year olds
the highest rates for 23 ofthe 33 years. Twelve to 15 year
olds followed in frequency of victimization. The : rates
demonstrated a consistent spike between 1987 and 1998,
ranging in the 12 to 19 year age group from 91.3 per 1,000
persons to 123.9 per 1,000. A sudden drop and decreasing
trend was noted beginning in 1999, with a rate that year of7
4.4 for 12 to 15 year olds and 77.5 for 16 to 19 year olds,
with the lowest rates in 2005; being 44.0 for 12 to 15 year
olds and 44.3 for 16 to 19 year olds (Bureau of Justice
Statistics, 2006a). These rates are substantially higher than
the violent victimization rate for all persons 12 and over of
21.2 per 1,000 (Bureau of justice Statistics, 2006b, Table
2).
Although there are minimal gender differences in
violent victimization rates for ages 25 and older, for age
groups 12 to 15, 16 to 19, and 20 to 24, the male
victimization rate is consistently approximately 40%
higher than the rate for females (Bureau of J ustice
Statistics, 2006b, Table 4). Ethnic differences are also
evident, with violent victimization rates highest for African
American youth, both male and female (Bureau of Justice
Statistics, 2006b, Table 10).
Ethnic and gender differences are particularly dra matic
with regard to homicide. Both African American and
Hispanic/Latino youth have homicide rates sub stantially
higher than their White cohorts, with parti cularly high rates
for young African American males
18 AOOLESCENTS: DEMOGRAPHICS AND SOCIAL ISSUES

TABLE 4 welfare agency" (Federal Bureau of Investigation, 2006,

Homicide Percentages and Rates by RacefEthnicity and Table 68).
Gender (Age 15-24) The Youth Risk Behavior Surveillance survey for 2005
found that 18.5% (29.8% male; 7.1 % female) of U.S. students
PERCENTAGE* RATE** RANK***
reported carrying a weapon in the past 30 days, with the
African American (non Hispanic Black)
Total 37.9 33.6 1 highest rate among White males (31.4%), followed by
Male 44.6 59.7 Hispanic/Latino (29.8%) and African American (23.7%)
Female 15.8 6.6 1 males. The frequency was highest among 9th graders (19.9%)
Latino/Hispanic and decreased each subsequent year to 16.9% by the 12th
Total 21.8 13.8 2
grade. The weapon was a gun for 5.4% of the students, with
Male 25.9 23.9
Female 83 2.6 2 the highest rate for Hispanic/Latino males (11.6%), followed
non-Hispanic White by White (9.7%) and African American (9.4%) males.
Total 4.6 2.9 4
3 Weapons were carried onto school property in the previous 30
Male 4.6 3.9, days by 6.5% of the students, primarily males (10.2% versus
Female 4.7 1.9 4
2.6% for females) and most frequendy by Hispanic/Latino
*percentage of deaths in that age group caused by 4 males (13.7%), followed by White (10.1%) and African
homicide. **per 1000,000. American (6.8%) males (Centers for Disease Control and
***rank order of causes of death for that age Prevention, 2006b).
group. National Center for Health Statistics, More than a third (35.9%; 43.4% male, 28.1% female) of
2003. the students reported being involved in a physical fight one or
more times in the preceding 12 months. The, highest rates
for whom homicide is the most frequent cause' of death (See were among the Hispanic males (49.5%), followed by African
Table 4). Note also that the rate for African American females, American (48.9%) and White (41.2%) males. Ninth graders
though much lower than for African American males, is still fought most frequently (43.5%), diminishing eachyear to 29.1
higher than the rates for non-Hispanic White youth, both % by 12th grade. Physical fights resulted in 3.6% (4.8%
males and females. males, 2.4% female) seeking medical attention from a doctor
The rankings in Table 5 indicate that homicide is a major or nurse for injuries, with Hispanic/ Latino (7.5%) and
health issue for youth, particularly when contrasted with the African American (7.4%) males seeking care most often. It is
overall rank of 15th cause of death for all persons in the interesting that the percentages for African American (3.5%)
United States (Anderson & Smith, 2003). Furthermore, and' Hispanic/ Latino (3.2%) females were higher than those
homicide in youth most frequently involves the use of for both White males (3.1 %) and White females (1.7%)
firearms. In 2005, 361 of the 456 homicide victims 13 to 16 (Centers for Disease Control and Prevention, 2006b).
years of age and 1129 of the 1349 homicide victims nto 19 Finally, fear of victimization led to 6.0% of the students
years of age were killed with a firearm (Hoyert et al., 2006). not attending school in the previous 30 days. The concern was
In 2005, youth ages 10 to 19 accounted for 24.5% of highest among Hispanic/Latino males (10.7%), followed by
offenders arrested, 24.9% (n = 110,852) of persons arrested for Hispanic/Latino females (9.7%), African American females
violent crimes, and 36.9% (n = 441,024) of persons arrested (9.2%), and African American males (8.7%). The percentages
for property crimes (Hoyert et al., 2006). Youth (10 to 19 for White males (3.9%) and females (4.9%) were considerably
years of age) accounted for 35.4% of the arrests for weapons lower. Fear of victimization was highest (7.7%) among 9th
charges (carrying, possessing, and so on) for a total of 50,552 grade students, declining each year to a low of 4.9% by 12th
arrests (Bureau of justice Statistics, 2007). Males were grade (Centers for Disease Control and Prevention, 2006b).
arrested at notably higher rates than females for both violent
(92,120 males; 15,744 females; 10 to 19 years of age) and
property (297,147 males; 125,398 females; 10 to 19 years of
age) crimes (Federal Bureau of Investigation, 2006, Tables 39
and 40). A total of 660,974 juvenile offenders were taken into
custody in 2005, with their disposition as follows: 467,288
"referred to the court," 133,664 "handled within department onclusion
and released," 48,753 "referred to criminal or adult court," It is important to recognize that the issues and problems of
8,808 "referred to other police agency," and 2461 "referred to adolescent populations discussed in the previous sections
often do not exist in isolation, but interact with and exacerbate
one another. For example, depression, hopelessness, and
substance abuse have been

....
,

found to be significant risk factors for adolescent suicide
attempts and completion (Christoffel, Sagerman, &
Bennett, 1988; Connor & Goldston, 2007; Fleischmann,
Beautrais, Bertolote,& Belfer, 2005; Galail, Sussman,
Newcomb, & Locke, 2002; Goldston et al., 2001;
Goldston, Reboussin, & Daniel, 2006; Kandel & Daves,
1982; Kelly, Cornelius, & Lynch, 2002; Kelly, Lynch,
Donovan, & Clark, 2001; Schreiber & Johnson, 1986;
Shaffer et al., 1996; Withers & Kaplan, 1987). Substance
abuse has also been identified as co-occurring with delin-
quent behavior (Ellickson, Saner, & McGuigan, 1997;
lessor, 1985, 1998; Tubman, Gil, & Wagner, 2004). Low
SES and poverty have been identified as risk factors for
dropping out of school, particularly when linked with a
complex of additional familial risk factors (Ozawa, [oo, &
Kim, 2004; Suh, Suh, & Houston, 2007; Weis, Farrar, &
Petrie, 1989).
To address the needs of adolescent populations, social
work practitioners and policymakers need to recognize the
complexity of the contributing factors and take a
multipronged approach. Furthermore, they must overlay
their analyses of needs and problems with a keen
recognition of developmental processes and how
developmental factors interact with environmental and
cultural factors to alter or exacerbate the issues they are
addressing. The social worker must take these multiple
factors into account, along with individual differences and
the impact of structural factors such as individual and group
social status and income (especially poverty), in serving
adolescent clients and their families, and must recognize
how these multiple factors affect the client-worker
relationship, the obtaining of an accurate . assessment, and
the planning and evaluation of appropriate interventions.
Fortunately, more recent literature has begun to provide
information and guidance with regard to diverse adolescent
populations (See, for example, Canino, 2000; Gibbs,
Huang, & Associates, 2003; Ho, 1992; Organista, 2007).
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ADOLESCENTS: PRACTICE
INTERVENTIONS 21
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FURTHER READING
Center on Addiction and Substance Abuse. (1994). Cigarettes,
alcohol, marijuana: Gateways to illicit drug use. New York:
Center on Addiction and Substance Abuse, Columbia
University .
National Center for Health Statistics. (2006b). Health United
States, 2006, with chartbook on trends in the health of Americans
(publication number 2006-1232). Hyattsville, MD:
Author.
U.S. Bureau of the Census. (1992). 1990 Census of the population
(Vol. 1) Characteristics of the population .. Washington, DC: U.S.
Government Printing Office.
U.S. Department of Education, National Center for Education
Statistics (NCES). (2007). The condition of education 2007
(NCES 2007-064). Washington, DC: U.S. Government
Printing Office.
-TODD FRANKE AND DIANE DE ANDA
PRACTICE INTERVENTIONS
ABSTRACT: This chapter summarizes literature and
research related to advances in direct practice work with
adolescents. Social workers are on the forefront of
developing and utilizing a variety of evidence based
practices to address complex client and commu nity needs.
KEY WORDS: adolescence; intervention; evidencebased
practice; risk factors; positive youth development
History and Demographics Adolescence
is a period of physical, social, and emotional transition
from childhood to adulthood. The World Health
Organization (WHO) defines adolescence as the period of
life between ages 10 and 19. In the United States
adolescence is more commonly thought to begin around
ages 12-13; and there are more than 17 million
adolescents (U.S. Census Bureau, 2006). Research
findings indicate that 1 of 20 children has definite or
severe difficulties in emotions, concentration behavior, or
being able to get along with others, and these difficulties
affect children's home life, friendships, learning, and
leisure activities (Simpson, Bloom, Cohen, Blumberg, &
Bourdon, 2005).
Adolescence is a time of rapid dramatic change
marked by the onset of puberty. The physical and
22 AOOLESCENTS: PRACTICE INTERVENTIONS
biological changes associated with puberty follow a
sequential order for males and females, although the
changes vary considerably in the timing of each event.
Puberty is a stage in which a child develops secondary sex
characteristics, triggered by hormonal changes resulting in
rapid maturation of the gonads (ovaries in girls and
testicles in boys) (Tanner, 1962). Often these hormonal
increases are not fully matched by corre sponding
maturation in brain development, particularly those related
to the frontal cortex and advances in executive functioning
governing cause-and-effect thinking. Teens may look and
sound like physically mature adults, but they may not be in
a position to "think" and therefore "act" like a fully ma ture
adult. One of the paradoxes of adolescence is that although
health (strength, stamina), ability (speed, reaction time),
and resilience (immune response) indicators are extremely
high during this period, so is adolescent mortality, which
increases dramatically from childhood to late adolescence,
and primarily relates to problems controlling behavior and
emotions. In 2002, suicide mortality rates increased from
1.2% per 100,000 in 10- to l-l-year-olds to 7.4% per
100,000 in 15- to 19-year-olds. Similarly, mortality rates
related to homicide deaths increased from 1.02% per
100,000 in 10- to l-l-yearolds to 9.3% per 100,000 in 15- to
19-year-olds (Centers for Disease Control and Prevention,
2006).
Related Theory
A number of psychological theories identify important
dimensions of adolescence. In 1904 Hall (1904) coined the
phrase "storm and stress" to characterize three key aspects
of adolescence: mood disruptions, conflict with parents,
and risky behaviors. Although not all adolescents exhibit
these behaviors, adolescence is a develop mental period
when these behaviors are more likely to be evident. Risky
behaviors related to alcohol and drug use,. sexual
promiscuity, fighting, and high-sensation seeking are more
likely to occur together, rather than in isolation. Stage
theorists such as Freud (1958) and Erikson (1959) viewed
adolescence in a sequence of age- related periods, each
with its own defining characteristics or challenges. Erikson
identified crucial struggles between individual
psychological growth and interacting societal supports and
pressures in which each stage is marked by a crisis for
which successful resolution revolves around an important
event. For example, in adolescence the developmental
crisis of identity versus identity diffusion is seen as a
crucial period of increased vulnerability and heightened
potential. The important event during this period (12-18) is
peer relationships because they provide the vehicle for
adolescents to experiment and discover a deeper and more
stable sense of self. Identity diffusion results when there is
turmoil and lack of understanding about one's sexual,
occupational, and self definition. According to Erikson, by
the end of adolescence, one must accomplish a satisfactory
level of self-integration or remain defective and
conflict-laden.
Cognitive theorists, such as Jean Piaget, were also
interested in describing how children and adolescents
thought and constructed knowledge. Cognitive devel-
opment refers to the development and maturation of the
thinking and organizing systems of the brain. These
systems include such aspects as language, reasoning,
problem solving, and memory. For Piaget, the last stage of
cognitive maturity is typically reached between ages 12
and 15, leading to "formal operational" thinking. During
this stage the form of thinking is important, not just the
content. Consequently, the adolescent learns to recognize
underlying connections and relationships in such a. way as
to abstract hypothetical solutions to situations that may
never actually occur (Dilut, 1972).
Cognitive differences are particularly important when
we consider the way adolescents are able to reason and
solve problems. More recent studies suggest that changes
in adolescent brain development may not reach full ma-
turity until the mid-20s, (Sowell, Thompson, Holmes,
Jernigan, & Toga, 1999; Sowell, Thompson, Tessner, &
Toga, 2001). For instance, amygdala, the center of
impulsive and emotional reactions, matures earlier than
the frontal cortex, which is responsible for executive
decision-making. Thus, the adolescent brain may not be
able to fully anticipate the outcomes of its hormone- driven
decisions (Strauch, 2003). Environmental excesses such as
alcohol, drugs, violence, and stress may hinder brain
development, while supportive environments that provide
proper stimulation, team activities, and problem-solving
activities may help brain development.
Positive youth development promotes a belief that all
young people can grow into successful adults if they have
a supportive environment in which to build skills, exercise
leadership, and contribute to their commu nities (Catalano,
Berglund, Ryan, Lonczak, & Hawkins, 1998; National
Clearinghouse on Families and Youth, 2006). Helping
young people reach their potential is the best way to
prevent them from engaging in risky behaviors. The
Family and Youth Services Bureau (2006) encourages
communities to support young people through positive
youth development. This comprehensive youth strategy
involves focusing on strengths and competencies of youth
instead of their weaknesses, promoting ongoing
relationships and connections with adults and adult role
models, providing safe places to go
 ADoLESCENTS: PRACTICE INTERVENTIONS 23

after school, and providing opportunities for communitv suicide have mental health problems that contribute to
involvement. this tendency (Shaffer & Craft, 1999). The most common

Much of the biological and physical science research
on child development since the mid-1980s has focused
on the brain-its internal architecture and responsiveness
to key environmental influences. At the same time,
much ofthe social science research has concentrated on
articulating and studying the socio-ernotional context of
youth development, with an emphasis on fostering
development of essential assets and competencies in
nurturing environments. This dynamic interplay be-
tween "nature" and "nurture"-between brain devel-
opment and socio-ernotional development-provides the
strongest theoretical foundation for conceptualizing
effective prevention and, direct practice approaches.
Latest Comorbidity Research
There is a general consensus in the ~dolescent research
literature supporting the substantial overlap or comer-
bidity among adolescent problem behaviors related to
delinquency, sexual promiscuity, drug abuse, exposure to developmental course, adaptation, and later functioning
violence, victimization, mental health problems, and
school problems (Thornberry, Huizinga, & Loeber,
1995). Of adolescents receiving mental health services,
half have a co-occurring substance abuse disorder
disorders are mood disorders, with or without
co-occurring substance abuse problems (Shaffer et al.,
1996), and certain types of anxiety disorders. Population
studies show that at anyone time, between 10 and 15% of
the child and adolescent population has some symptoms of
depression (Smucker, Craighead, Craighead, & Green,
1986). Proponents of the biopsychosocial causal model
further speculate that a subset of risk-exposed youth
experience a progressive cascade whereby bio-
psychosocial vulnerabilities, chronic adversities, early
behavioral problems, and family dysfunction lead to
movement down a developmental trajectory that includes
school failure, deviant peers, and social mar ginalization.
This results in a vulnerability to victimization, violence,
substance use disorders, and mental health problems. In
both of these conceptualizations, individual and
environmental risk conditions interact with social and
family experiences to significantly impair a child's
in life.
Identification of risk factors is an important first step
in understanding the circumstances that lead to
the development of adolescent problem behaviors. Eliminating or minimizing these risks, in conjunction with increasing assets that mediate or moderate their effects, is a fundamental goal of most effective thera
peutic interventions. The general goal of most prevention and intervention models is to reduce risk factors and enhance protective factors across multiple life domains (that is, individual,

(Greenbaum, Foster-Johnson, & Petrila, 1996), and ) and include a broad range of individual, family, and community variables (Garmezy, 1985; Jessor, Turbin,& Costa, 1998). It is hypothesized
family, peer, situational, and community). Prevention research suggests that protective factors can help to shield youngsters from the full impact of individual, family, and environmental adversities (National Research Council Institute of Medicine, 2002

adolescents having a substance abuse disorder have an & Goldstein, 2004; Rutter, 2003; Sroufe, Carlson, Levy,& Egeland, 1999). According to youth development experts (Catalano, Berglund, Ryan, Lonczak,& Hawkins, 2002), programs are more
that reductions in substance abuse and violence may be more strongly impacted by treatment approaches that also focus on improving protective factors, specifically adaptive functioning (Luthar

increased risk of experiencing other mental disorders successful if they include enhanced competence rather than just risk reduction (Flannery et al., 2003). It is therefore difficult to separate pure prevention strategies from intervention strategies, as in theory and practice they are often integra
ted to address multiple-need populations across different contexts. For the present discussion, we define practice interventions

(Beitchrnan, Adlaf, Douglas, & Atkinson, 2001). It is not

surprising that the SAMHSA Report to Congress on the
Prevention and Treatment of Co-occurring Sub- stance Abuse
Disorders and Mental Disorders (Substance Abuse and
Mental Health Services Administration, (2002)
recommends systematic screening procedures to identify
mental health, substance abuse, and treatment needs for
all at-risk youth, especially in settings such as juvenile
justice and child welfare, where large concentrations of
high-risk youth reside.
It is evident that problems experienced by adoles-
cents in the domains of mental health, substance abuse,
and violence stem from a complex web of interrelated
individual, family, environmental, and social factors
(Dishion, Capaldi, Spracklen, & Li, 1995; Loeber et al.,
2005). The common or shared risk factor model and
biopsychosocial causal model (Dawes et al., 2000;
Lahey, Waldman, & McBurnett, 1999; Riggs, 2003;
Tarter, 2002) have contributed significantly to our
understanding of comorbid youth. The common risk
factor model has shown that a number of risk factors
increase the chances of youth developing health or
behavior problems. Adolescent suicide has associated
risk factors significantly related to mental health
problems. Up to 90% of adolescents who commit
24 AOOLESCENTS: PRACTICE INTERVENTIONS
in relation to indicated prevention strategies targeting
youth who have significant symptoms of a disorder but do
not meet diagnostic criteria, and treatment inter ventions
targeting those who have high symptom levels or
diagnosable disorders (Weisz, Sandler, Durlak, & Anton,
2005).
Evidence,Based Practice
A broad range of terms are used interchangeably (but not
equally) to describe "best" practices. These terms include
the following: best, proven, promising, model, effective,
evidence-based, emerging, exemplary, and commendable.
In addition, there is the question w hether "best practice"
should refer to principles, approaches, or specific
programs. The most commonly used term, evidence-based
practice (EBP), is defined by the Institute of Medicine as
the integration of best-researched evi dence and clinical
expertise with patient values (Institute of Medicine, 2001 ).
McNeese and Thyer (2004) refer to evidence- based
practice as intervention based on the best available science
while Macdonald (1999) has described it as the integration
of scientific knowledge with values, resources, and clinical
judgment. Emerging best practices are treatments. and
services that are promising but less thoroughly documented
than evidence-based practices (Institute of Medicine,
2001). Implicit in these defin itions is the inextricable link
between science and practice; however, there is much
disparity among scientists and practitioners regarding the
definition of evidence-based practice.
Several parallel initiatives have developed across fields
(substance abuse, education, violence preventio n, child
welfare) and organizations that seek to develop
. both a central program registry site and a standardized
methodology to review and rate programs. Organiza tions
such as the Center for the Study and Prevention of
Violence (2006; Blueprints for Violence Prevention),
Substance Abuse and Mental Health Services Admin-
istration (SAMHSA's Model Programs), Washington State
Institute for Public Policy, and the Child Welfare League
of America (2006; Research to Practice Initiative) have
sought to utilize the continuum of research practices to
catalog and grade programs and services. Although each
varies to some extent regarding nomenclature and
selectivity, each generally allows for differential recogni-
tion of programs based upon a hierarchy characterizing the
type and level of evidence supporting each program. In
addition to examining outcomes and research design, many
of these initiatives also examine factors such as theory
behind interventions, costs and benefits, fidelity, overal l
utility, and cultural and age appropriateness. Pro grams are
evaluated and endorsed with respect to a va riety of
outcome dimensions. Practitioners working with
adolescents can easily consult such registries when con-
sidering a direct practice model.
Research has found that several important themes need
to be taken into account when developing or implementing
adolescent practice interventions. The first theme is that
early, immediate intervention should be prioritized, as
behavioral problems, aggression, and other risk factors can
be identified at an early age (Guerra, Huesmann, Tolan,
Acker.: & Eron, 1995; Tremblay, Kurtz, Masse, Vitaro, &
Phil, 1995).
A second theme is that theory-based behavioral or
cognitive-behavioral programs with specific behavioral
targets show the greatest treatment effect. Most effective
programs are based on social-behavioral theories or
combinations of theories with specific behavioralchange
targets.
A third theme is the need for well-coordinated,
rnulticornponent, prevention and intervention models that
impact key risk and protective factors across multiple life
domains. (Henggeler, Melton, & Smith, 1992; Tolan,
Guerra, & Kendall, 1995). Programs that include a family
focus and attempt to change the environment where a child
operates (for example, the . school climate, the family, the
peer group) are also more effective than programs that
attempt to address factors solely at the level of the
individual. Generally, comprehensive and multicomponent
interventions are superior to single component interventions
because they are able to address a range of delinquent
behaviors by orchestrating different methodologies in an
integrated fashion (Flarmery & Huff, 1999). An additional
benefit to such programming is that these types of inter-
ventions often address interrelated problem clusters and
therefore have additional positive benefits promoting
healthy youth development and functioning.
Fourth, programs need to be of sufficient intensity and
duration to obtain the desired treatmen t effect. The notion
of dosage is key in that clients are success fully engaged,
remain in treatment, and receive a suffi cient amount of the
intervention to achieve the desired outcomes. Finally, while
many effective treatment programs have manuals and o ffer
training, it is imperative to have mechanisms with ongoing
training, coaching, and implementation monitoring to
assure fidelity to the underlying principles and change
mechanisms of effective treatment models (Fixsen, Naoom,
Blase, Friedman, & Wallace, 2005).
Challenges, Trends, and Implications
There are a wide range of intervention practices that are
considered effective in working with adolescents. Over the
next decade, most of the adolescents receiving social work
interventions should be benefiting from

evidence-based models. A currertt trend for social work
education, therefore, is to train practitioners in the use of
evidence-based models. Since many of the evidencebased
models address single disorders with mainstream client
populations, researchers and practitioners will need to work
collaboratively to expand the evidencebase of adolescent
direct practice interventions. Research on clinical practices
that effectively address the needs of vulnerable, comorbid,
and culturally diverse adolescents and their families is
limited. Further research is needed to develop intervention
models that can effectively address the complex client
characteristics and interacting social and community
conditions that defmethe realities of modern social work
practice with adolescents.
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AHDladh_over.htm
-DAVID L. HUSSEY
PREGNANCY
ABSTRACT: Although rates of adolescent pregnancy
have exhibited a downward trend since 1991, the
United States continues to have a significantly higher
rate than other industrialized nations. Adolescent
/

pregnancy, especially in early and middle adolescence,
has long-term developmental and economic impact on
the teen and her child, in addition to high Social costs.
This entry describes the current trends in adolescent
pregnancy in the United States, and examines factors
reported in the research literature as associated with
adolescent pregnancy, discusses federal policy directed
toward adolescent pregnancy prevention, and identifies
various intervention programs.
KEY WORDS: adolescents; adolescent pregnancy;
teen pregnancy; abstinence
Epidemiology of Adolescent
Pregnancy in the United States
The first national estimates of adolescent pregnancy
rates were reported in 1976 (Ventura et al., 2006). In
1990, rates in the United States reached an all-time high
of 116.3 pregnancies per 1,000 teens, meaning that 11.6
percent of teens from age 15 to 19 years old had a
pregnancy that ended in a live birth, abortion, or fetal
loss (National Center for Health Statistics, 2004;
Ventura et al., 2006). Reports for 2002 estimated 76.4
pregnancies per 1,000 adolescent females, or 7.6 per cent
of females from age 15 to 19 years old, indicating a 35
percent decline in these rates between 1990 and 2002, or
an average decline of 3 percent per year (Ventura et al. ,
2006). Estimated rates for teens under age 15 declined
from 3 percent in 1990 to 2 percent in 2000 (Ventura et
al., 2004). It is important to note, that nearly 20 percent
of all teen births are repeat births, and that while first
birth rates continue to drop, the repeat birth rate has
stabilized (Abma et al., 2004;
Age of teen
FI GURE 1 Pregnancy rates for teenagers aged 15-17 years and 18-19 years, 1990-2002.
AooLESCENTS: PREGNANCY 27
Franklin, Corcoran, & Harris, 2003). Further exami-
nation of these rates, based on age and race or ethnicity
provides a more complete picture of adolescent
pregnancy.
Age of the pregnant teen is a critical variable, as the
impact of pregnancy on a young adolescent is much
greater than on an older adolescent (Phipps & Sowers,
2002; Reichman & Pagnini, 1997). From 1990 to 2002,
the rate for teens from age 15 to 17 years old decreased
by 42percent, while-rates for older teens experienced a
more modest decrease of 25 percent (Figure 1).
These numbers represent record lows in teen
pregnancy rates since 1976 (Ventura et al., 2006).
Pregnancy rates by race and ethnicity have also shown a
steady decline. Rates for Black and White non-Hispanic
teens experienced a 40% reduction between 1990 and
2002, with rates for Hispanic teens declining by 19%
(Ventura et al., 2006). All age subgroups experi enced a
steady decline in rates except Hispanic teens aged 18 to
19 years, whose rate remained stable (Ventura et al.,
2006). Pregnancy rates for Black teens and Hispanic
teens were similar in 2002, but were still two and
one-half times the rate for non-Hispanic White teens
(Figure 2).
Explanation of the Decline
in Teen Pregnancy Rates
Research suggests several explanations for the decline
in pregnancy rates for adolescents. One is that there has
been a reduction in the number of teens engaging in
sexual intercourse, which includes the proportion of
teens that have "ever had sex" and proportion of teens
that have had multiple partners. Another proposed ex-
planation is the increased use of effettive contraceptive
-1990
-2002
1
28 ADOLESCENTS: PREGNANCY
4.
Non-Hispanic-whlte Non-Hispanic Black
FIGURE 2 Pregnancy rates for tel!nagers 15-19 years, by race and Hispanic origin, 1990-2002.
methods by adolescents (Boonstra, 2002; Darroch &
Singh, 1999). Between 1995 and 2002, the percentage of
teens who reported ever having sexual intercourse declined
from 49% to 46% among females, and from 55% to 46%
among males (Abma et al., 2004). In an an alysis of sexual
behavior and contraceptive use from the 1995 and 2002
waves of the National Survey of Family Growth,
researchers found a major increase in the use of
contraceptives and a decrease in non-use of contraceptives
among adolescents from 15 to 19 years of age (Santelli et
al., 2007). These investigators concluded that increased
use of contraceptives explained 86% of the decline in
pregnancy rates, while changes in sexual behavior (that is,
later initiation of first intercourse) explained only 14%
ofthe decline in adolescent pregnancy rates (Santelli et al.,
2007). An additional possible cause of the declining rate is
the increased attention given to the problem of adolescent
pregnancy at the federal, state, and local levels, which has
prompted the development and implementation of various
prevention initiatives.
Impact of Adolescent Pregnancy Adolescent
child bearing has long-term negative consequences for
both the teen mother and her child. Parenting in
adolescence affects young women's ability to complete
high school and attain higher levels of education, which
subsequently affects their long-term earning capacity and
socioeconomic status' (Hoffman, 2006). Adolescents who
bear their first child before age 15 are at even higher risk of
negative socioeconomic consequences as they are much
more likely t~ve a subsequent birth during adolescence
than' teens who give birth after age 15 (Boardman et al.,
2006).
Studies also suggest that the negative consequences of
teen childbearing may be greater on the children
250
200
150
111990
100
.2002
50
0
Hispanic
than on their mothers. In a study that compared children
born to mothers. aged 17 years or younger. to children
born to mothers from 22 to 29 years old, researchers found
that the children born to the older group of mothers scored
consistently and significantly higher' on measures of
kindergarten readiness such as cognition and knowledge,
language and cornmunication, learning approaches,
emotional well-being and social skills, physical
well-being, and motor development (Terry-Humen,
Manlove, & Moore, 2005).
The cost of adolescent pregnancies is high-not only for
individual teens and their families, but to society as well.
In 2004, societal costs associated with adolescent
parenting were estimated at $9.1 billion. These estimates
included costs' associated with health care, various types
of public assistance, child welfare, and loss of tax revenue
due to lower taxes paid (Hoffman, 2006).
Risk Factors for Adolescent Pregnancy
The literature on adolescent pregnancy is replete with
studies and research reviews that identify both the risk and
protective factors associated with teen pregnancy (Berry et
al., 2000; Hummel & Levin-Epstein, 2005; T alashek,
Alba, & Patel, 2006). Kirby and Lepore (2007) reviewed
more than 400 research studies that examined factors
influencing adolescent sexual behavior, and categorized
the factors into four themes: (1) biological factors (that is,
age, physical maturity, and gender); (2) disadvantage,
disorganization, and dysfunction in the teens' social
environment; (3) sexual values, attitudes, and modeled
behavior; and (4) connection to adults and organizations
that discourage sex, unprotected sex, or early childbearing.
These researchers identified factors that were most
influential, and then scored the factors based on the
feasibility
.J.

of an intervention program to target change in those
factors. The highest ranked factors at the individual
level included sexual beliefs, attitudes, and skills of
teens; highest ranked at the peer level included peer
attitudes and behaviors regarding childbearing and use
of contraceptives; and highest ranked at the family level
included communication about sex and contraception.
Risk factors for repeat pregnancies may be more
specific to the individual than first time pregnancies. In
a study of 581 White, African American, and Latina
teen mothers, Raneri and Weimann (2006) found that
slightly more than 42% of the sample had experienced
a' "rapid repeat pregnancy." defined as a repeat
pregnancy within 24 months. Further, the same re~
\
searchers determined the following characteristics were
predictors of a second pregnancy: not using a long
acting contraception within the first three months post-
partum; having plans for a second child within five
years; not returning to school by three months postpar-
tum, being with an abusive partner, not being in a
relationship with the father of the first child, and being
in a friendship group with other adolescent parents.
It is noteworthy that not all repeat pregnancies are
unintended. In a study using 2002 National Survey of
Family Growth data, Boardman et al. (2006) examined
risk factors for unintended versus intended rapid repeat
pregnancies among teens. Among this sample, 34% of
the teens reported their repeat pregnancy was intended.
Risk factors associated with an intended repeat preg-
nancy included an intended first pregnancy, not living
in an intact family, and not being married. The analysis
from this study also indicated that three subgroups of
teens were at higher risk for unintended, rapid repeat
pregnancies: (1) very young teens, (2) teens with a
history of/'-onconsensual sex, and (3) teens living in
non-intact families.
Although most studies have examined risk factors
for adolescent females, recent studies have begun to
identify risk factors associated with adolescent pater-
nity. For example, in a prospective longitudinal study of
335 urban African American males, researchers found
that childhood aggression (as early as age 8 years of
age) significantly predicted adolescent paternity
(MillerJohnson et al., 2004). In addition, substance use
and involvement with deviant peers significantly
increased the predictive effect of childhood aggression.
Federal Policy
TEMPORARY ASSISTANCE TO NEEDY
FAMILIES Although there is no indication that welfare
reform is effective in preventing teen pregnancy, the
Personal Responsibility and Work Opportunity Act
(PRWOA)
ADOLESCENTS: PREGNANCY 29
of 1996 sought to legislate efforts to reduce teen and
outof-wedlock births (Nathan, Gentry, & Lawrence,
1998). Temporary Assistance for Needy Families (T
ANF) places limits on the amount of time an individual
can receive aid and mandates work requirements intended
to discourage recipients from becoming dependent on
gov- . ernment assistance (Levin-Epstein & Hutchins,
2003). Special provisions were written into the law
specifically addressing minor parents: (1) minor parents
are required to live with a parent, caregiver, or in an
adult-supervised setting; and (2) minor parents are
required to participate in education leading to a high
school diploma or its equivalent (Hummel &
Levin-Epstein, 2005; Levin, Epstein & Hutchins, 2003).
The full impact of this policy on outcomes for teen
parents is still being assessed, but current research has not
shown a significant improve, ment in financial success or
work opportunities for parenting adolescents based on.
this policy (Hummel & Levin-Epstein, 2005).
ABSTlNENCE~ONLY EDUCATION For the last two
decades, the U.S. federal government has consistently
promoted abstinence-only education as its primary
strategy for prevention of adolescent pregnancy (Kirby,
Laris, & Rolleri, 2006; Trenholm et al., 2007). As of
2008, three main federal funding streams exist to
support education programs that focus exclusively on
abstinence as a preventive strategy: the Adolescent
Family Life Act (AFLA); Title V-Welfare Reform Act;
and the Community, Based Abstinence Education
Program. With each new piece of legislation, guidelines
for federally funded abstinence education programs
have become more restrictive, including defining the
terms abstinence and sexual activity as well as advocating
against the inclusion of other strategies to prevent
unwanted pregnancy, such as methods of contraception.'
The AFLA, enacted in 1981, resulted in the creation
of the first abstinence-only curriculum. It pro, moted
chastity andself-discipline to adolescents as the key to
avoiding unwanted pregnancy (Dailard, 2006). In 1996,
Title V of the Welfare Reform Law purported to reduce
not only the number of adolescent pregnancies, but also
all out-of-wedlock births regard, less of parentage
(Levin-Epstein & Hutchins, 2003). Title V allocates
funds in block grants to states that implement
abstinence-only education curricula that teach the
"social, psychological, and health gains of abstaining
from sexual activity" and that "a mutually faithful
monogamous relationship in the context of marriage is
the expected standard of human sexual activity"
(Duberstein, Lindberg, Santelli, & Singh, 2006).
Similar to the AFLA, Title V did not include defl-
nitions of abstinence or sexual activity, allowing states
30 AooLESCENTs: PREGNANCY
the flexibility to decide what constitutes a fund able
abstinence education program. A federal definition of
these terms was not made explicit until 2000 when the
Bush Administration implemented a third program, the
Community-Based Abstinence Education Program
(CBAE). The CBAE provides funding directly to
community-based organizations, including faith-based
agencies, to support abstinence-until-marriage educa-
tion programs. In addition, the CBAE outlines eight
points that describe the federal definition of abstinence combination, of these four areas (Manlove et al., 2004)
education (Dailard, 2006). Unlike Title V, which allows
states discretion in deciding which programs to fund,
CBAE funding is awarded directly from the government
to the requesting organization, and is the strictest of thea community setting, or a school setting either as part of
federally funded abstinence programs (McFarlane,
2006). In 2006, across all three programs, the federal
government committed $176 million to promoting
abstinence education programs (Dailard, 2006;
McFarlane, 2006) with CBAE receiving the majority of
funding (Dailard, 2006). In 1997, Congress authorized a
scientific evaluation of the Title V, Section 510
Abstinence Education Program. Conducted by
Mathematica Policy Research Institute, the evaluation
used an expetimental design, randomly assigning
eligible youth to one of four Title V program groups or a 2004). As of 2008, curriculumbased programs are the
control group. The study found that program group
youth were no more likely than control group youth to
have abstained from sex, and for those who reported
having sex, had similar numbers of sexual partners, and
no differences in mean age of first sexual initiation (See differ from primary prevention programs in that they
Trenholm et al., 2007, for a detailed description of the
evaluation.
TITLE X Established by Congress in 1970, Title X
of the Public Service Act offers affordable, confidential
family planning and preventive health screenings to
low-income women and adolescents. Title X Family
Planning Clinics provide contraceptive and education
services that prevent unintended pregnancies, as well as
testing and treatment for sexually transmitted diseases
(Center for Reproductive Rights, 2004). In 1981, Con-
gress amended Title X to require grantees to encourage
minors to seek family involvement in their family plan-
ning decisions, thus encouraging, but not mandating,
parental involvement {Jones & Boonstra, 2004). Addi-
tional amendments have been proposed that would
require parental consent for adolescents seeking Title X
services. Research indicates that mandating parental
involvement, and the resulting loss of confidentiality,
would deter many adolescents from seeking and receiv-
ing the sexual health care services that they need (Reddy, participant characteristics such as gender, age, race,
Fleming, & Swain, 2002).
Pregnancy Prevention Programs
Specific goals of a pregnancy prevention program
usually fall into four broad categories. Programs may
seek to (l) delay sexual initiation, (2) improve
contraception use, (3) delay first pregnancy, (4) delay
repeat pregnancy among teens who are already
parenting. Other psychosocial risk factors may be
targeted (for example, building self-esteem), but the
majority of evaluated programs focus on one, or a
Most programs focus on primary prevention, or pre~
venting a first pregnancy. Such programs employ var-
ious approaches, and can be implemented with youth in
a normal scheduled school day or after school (Kirby et
al., 2006). Curriculum-based programs use an educa-
tional curriculum implemented over a set period. Youth
development programs focus on developing leadership
among teens and utilizing peer relationships to influence
positive decision-making. Other approaches, such as the
Baby, Think It Over program, allow teens to experience the
demands of caring for a baby using an "infant simulator"
that is programmed to imitate a real infant's feeding,
changing, and sleeping schedule (Didion & Gatzke,
most widely used format, and the approach most
supported by empirical evidence (Kirby et al., 2006).
Other programs target the prevention of repeat preg-
nancies for already-parenting teens. These program s
provide resources and support for adolescent parents in
addition to sex education. Secondary prevention
programs consist of one or more of the following com-
ponents: home-visiting services or case mana gement;
parenting education; vocational or educational skills;
life skills; and contraceptive education (Corcoran &
Pillai, 2007). Klerman (2004) conducted an assessment
and review of programs that sought to interrupt the
intergenerational cycle of early childbearing. Klerman's
findings indicated that several factors may significantly
impact the effectiveness of these programs: (1) service
location and the provider's ability to form a relationship
with the participant; (2) training of program personnel ;
(3) service initiation and length; (4) fidelity of program
implementation; and (5) definitions and measures of
success.
Evaluation of a program's effectiveness must take
into consideration the population served, as few pro-
grams can be applied universally. Depending on the
specific goals and approaches, certain pregnancy
prevention programs may show varying results based on

and ethnicity (Kirby, Laris, & Rolleri, 2006). Therefore, in
reviewing programs, it is important to take these factors into
account. Kirby, Laris, & Rolleri (2006) reviewed 83
curriculum-based programs (national and international) that
demonstrated effectiveness in reducing pregnancy and rates of
sexually transmitted infections. Half of the programs reviewed
used a randomized control design and the others used a
quasi-experimental design. The study results showed eight
content characteristics of curriculum-based programs that
demonstrated effectiveness. They include: 1) focused on
prevention of HIV, STDs, and/or unintended pregnancy: 2)
specifically addressed behaviors leading to these goals, gave
clear messages about these behaviors, and addressed ways to
avoid situations leading to these behaviors; 3) focused on
specific psychosocial factors affecting these behaviors and
changed some of those factors; 4) created a safe environment
for youth to participate; 5) included instructionally sound
activities designed to change targeted risk and protective
factors; 6) employed teaching methods that actively involved
participants, helped participants personalize the information
and were designed to change targeted risk and protective
factors; 7) employed activities, instructional methods and
behavioral methods appropriate to the youths' culture,
developmental age, and sexual experience; and 8) presented
topics in a logical sequence. (See Kirby, -Laris, and Rolleri,
2006, for a detailed description of the programs, their charac-
teristics, 'and the results of the evaluations.)
SCHOOL-BASED HEALTH CENTERS School-based health
centers (SBHCs) were established in the 1970s to ensure that
adolescents have convenient access to important health care
services (Rounds & Ormsby, 2006). However, the inclusion of
reproductive health and family planning services has drawn
criticism from various groups that hold that the availability of
these services may encourage promiscuity and undermine
parental authority (Morone, Kilbreth, & Langwell, 2001).
Types of services offered by an SBHC vary and are largely
influenced by the state and local environments. As of 2008
there are approximately 1,400 SBHCs in 43 states across the
United States. Funding for SBHCs is provided by various
sources, including federal and state grants (such as Title X
family planning and Title V MCH block grants), Medicaid;
and private insurance (Kanaan, 2003; Morone et al., 2001).
An overarching goal of SBHCs is to make health care
services, including mental health screening, prevention
services, and counseling, accessible to the underserved
adolescent population. SBHC offers a comprehensive service
delivery system within the school that relies on collaboration
among school administrators and
. AOOLESCENTS: PREGNANCY
31
community service providers (Olbrich, 2002). Social workers
working in school and community health agencies serve
important roles in facilitating these collaborations, providing
needed services, and advocating for adequate and appropriate
mental health care for youth. Addressing the mental health
needs of adolescents minimizes the risk for development of
serious psychological and social problems and academic
failure.
'REFERENCES
Abma, J. c, Martinez, G. M., Moser, W. D., & Dawson, B. S.
(2004). Teenagers in the United States: Sexual activity,
contraceptive use, and childbearing, 2002. In Vital and Health
Statistics, Series, 23(24). Hyattsville, MD.
Berry, E. H., Shillington, A. M., Peak, T., & Hohman, M. M.
(2000). Multi-ethnic comparison of risk and protective factors
for adolescent pregnancy. Child and Adolescent Social
WorkJoumal, 17(2), 79-96. .
Boardman, L. A., Allsworth, J., Phipps, M. G., & Lapane, K. L.
(2006). Risk factors for unintended versus intended rapid
repeat pregnancies among adolescents. Journal of Adolescent
Health, 39(4), 597.el-597.e8.
Boonstra, H. (2002). Teen pregnancy: Trends and lessons learned.
The Guttmaeher Report on Public Policy 1. Retrieved June 28,2007,
from http://www.guttrnacher.org/pubs/tgr/05/ 1/gr050 107
.htrnl.
Center for Reproductive Rights. (2004). Title X family planning,
Retrieved May 21, 2007, from http://www.reproductive
rights.org/pub_fac_ titlex2.html.
Corcoran, J., & Pillai, V. K. (2007). Effectiveness of secondary
pregnancy prevention programs: A meta-analysis. Research on
Social Work Practice, 17(1),5-18.
Dailard, C. (2006). Legislating against arousal: The growing
divide between federal policy and teenage sexual behavior.
Guttmaeher Policy Review 3. Retrieved June 25, 2007, from
http://www.guttmacher.org.
Darroch, J. E., & Singh, S. (1999). Why is teenage pregnancy
declining? The roles of abstinence, sexual activity and con-
traceptive use. In Occasional Report. New York: The Alan
Guttmacher Institute.
Didion, J., & Gatzke, H. (2004). The Baby Think It Over
experience to prevent teen pregnancy: A postintervention
evaluation. Public Health Nursing, 21(4), 331-337.
Duberstein Lindberg, L., Santelli, J. S., & Singh, S. (2006).
Changes in formal sex education: 1995-2002. Perspectives on
Sexual and Reproductive Health, 38(4), 182-188.
Franklin, c., Corcoran, J., & Harris, M. B. (2003). Risk and
protective factors for adolescent pregnancy: Bases for effec-
tive intervention. In M. W. Fraser (Ed.), Risk and resilience in
childhood: An ecological perspective (pp 281-313). Washington,
DC: NASW Press.
Hoffman, S. D. (2006). By the numbers: The public cosisof teen
childbearing. National Campaign to Prevent Teen Pregnancy.
Retrieved April 21, 2007, from http://www.teenpregnancy.
org/costs/pdf/report/BTN_N ational_Report.pdf.
Hummel, L., & Levin-Epstein, J. (2005). A needed transition:
Lessons from Illinois about teen parent T ANF rules. Center for
32 AOOLESCENTS: PREGNANCY
Law and Social Policy. Retrieved May 3,2007, from http://
www.clasp.org.
Jones, R. K., & Boonstra, H. (2004). Confidential reproductive
health services for minors: The potential impact of mandated
parental involvement for conception. Perspectives on Sexual and
Reproductive Health, 36(5),182-19l.
Kanaan, S. B. (2003). Making the grade: State and local partnerships
to establish school-based health centers. Robert Wood Johnson
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http://www.rwjf.org/reports/npreportsjMakingGrade.
htmwcontents.
Kirby, D. B. & Lepore, G. (2007). Sexual risk and protective factors.
Factors affecting teen sexual behavior, pregnancy, childbearing and
sexually transmitted disease: Which are important? Which can you
change? National Campaign to Prevent Teen and Unplanned
Pregnancy. Retrieved December 7, 2007; from
http://www.teenpregnartcy.org.
Kirby, D. B., Laris, B. A., & Rolleri, L. (2006). Sex and HN
education programs for youth: Their impact and important
characteristics. National Campaign to Prevent Teen Pregnancy.
Retrieved June 8, 2007, from http://www.teenpreg nancy.org.
Klerman, L. V. (2004). Another chance: Preventingadditionalbrrths to
teen mothers. National Campaign to Prevent Teen Pregnancy.
Retrieved May 18,2007, from http://www.teenpreg nancy.org.
Levin-Epstein, J., & Hutchins, J. (2003). Teens and TANF:
How adolescents fare under the nation's welfare program. Center
for Law and Social Policy. www.clasp.org (accessed June
13,2007).
Manlove, J., Franzetta, K., McKinney, K., Romano Papillo, A., &
Terry-Humen, E. (2004). A good time: After-school programs to
reduce teen pregnancy. National Campaign to Prevent Teen
Pregnancy. Retrieved May 12, 2007, from http://
www.teenpregnancy.org.
McFarlane, D. R. (2006). Reproductive health policies in
President Bush's second term: Old battles and new fronts in the
United States and internationally. Journal of Public Health
Policy, 27, 405-426.
Miller-Johnson, S.,Winn, D. c., Coie, J. D., & Malone, P. S.
(2004). Risk factors for adolescent pregnancy reports among
African-American males. Journal of Research on Adolescence,
14(4),471-495.
Morone, J. A., Kilbreth, E. H., & Langwell, K. M. (2001). Back to
school: A health care strategy for youth. Health Affairs, 20(1),
122-136:
Nathan, R. P., Gentry, P., & Lawrence, C. (1998). Is there a link
between welfare reform and teen pregnancy? In Pregnancy
Prevention and Welfare Reform. Washington, DC:
University of Maryland School of Public Policy.
National Center for Health Statistics. (2004). NCHS data on teenage
pregnancy. Centers for Disease Control. Retrieved April 23,
2007, from http://www.cdc.gov/nchs/data/fact
sheets/teenpreg.pdf.
Olbrichs, S. (2001). Children's mental health: Current challenges and
a future direction. The Center for Health and Healthcare in
Schools. Retrieved December 6,2007, from http://www.
healthinschools.org.
Phipps, M. G., & Sowers,M. (2002). Defining early adolescent
childbearing. American Journal of Public Health, 92(1), 125-128.
Raneri, L. G., & Weimann, C. (2006). Which adolescent mothers
are most at risk of repeat pregnancy? Journal of Adolescent
Health, 38, 95-96.
Reddy, D. M., Fleming, R., & Swain, C. (2002). Effect of
mandatory parental notification 'on adolescent girls' use of
sexual health care services. Journal of the American Medical
Association, 288(6), 710-714.
Reichman, N. E., & Pagnini, D. L. (1997). Maternal age and birth
outcomes: Findings from New Jersey. Family Planning
Perspectives, 29(6), 268-275.
Rounds, K. A., & Ormsby, T. C. (2006). Health policy for
children and youth. In J. M. Jenson & M. W. Fraser (Eds.),
Social policy for children & families (pp 131-165). Thousand
Oaks, CA: Sage Publications.
Santelli, J. S., Duberstein Lindberg, L., Finer,L B., & Singh, S.
(2007). Explaining recent declines in adolescent pregnancy in
the United States: The contribution of abstinence and
improved contraceptive use. American Journal of Public Health,
97(1), 1-7.
Talashek, M. L., Alba, M. L., & Patel, A. (2006). Untangling the
health disparities of teen pregnancy. Journal far Special~ ists in
Pediatric Nursing, 11 (1), 14-i7.
Terry-Humeri, E., Manlove, J., &. Moore, K. A. (2005). Playing
catch up: How children born to teen mothers fare. In Putting
What Works to Work. Washington, DC: National Campaign to
Prevent Teen Pregnancy.
Trenholm, c., Devaney, B., Fortson, K., Quay; L., Wheeler,J., &
Clark, M. (2007). Impacts of Four Title V, Section 510
Abstinence Education Programs: Mathematica Policy Re-
search, Inc.
Ventura, S. J., Abma, J. C., Mosher, W. D., &. Henshaw, S. K.
(2006). Recent trends in teenage pregnancy in the United States,
1990-2002. National Center for Health Statistics. Retrieved
April 6, 2007, from http://www.cdc.gov/nchs/prod
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Ventura, S. J., Abma, J. C., Mosher, W. D.; & Henshaw, S. K.
(2004). Estimated pregnancy rates for the United States,
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June 15, 2004.
SUGGESTED LINKS
The Alan Guttmacher Institute (AGI). www.agi-usa.
org/pubs/ state.jn'egnancy_trends .pdf Center for Law
and Social Policy.
www.clasp.org
National Assembly on School-based Health Care.
www.nasbhc.org
National Campaign to Prevent Teen Pregnancy.
www.teenpregnancy.org
National Center for Health Statistics.
www.cdc.gov/nchs/
National Survey of Family Growth (NSFG).
http://www.cdc.gov/nchs/nsfghtm
-KATHLEEN A. ROUNDS AND TRACI L. WIKE

ADOPTION
ABSTRACT: Adoption of children from foster care and
international adoptions have accelerated since 1987.
Federal policy changes have markedly increased th~
termination of parental rights and adoption of children
in foster care. Adoption by relatives and single parents
has also grown markedly. Open adoption is increasingly
normative. Adoption outcomes are generally positive
although there is substantial call for postadoption
support for children adopted from foster care. These
services are emerging but their efficacy. is still untested.
More work is needed on post-adoption services because
there are now' more former foster children in
post-adoptiorestatus than there are children in foster
care.
KEY WORDS: adoption; foster care; special need; trans-
racial; open adoption; home study
Adoption creates a legal family for children when the
birth family is unable or unwilling to parent. Yet, adop-
tion is not a program only for children. Adoption cre ates
new families, expands existing families, and engages
adoptive parents in the priceless costs and benefits of
parenting. Birth parents who voluntarily place their
child with adoptive parents may also benefit from
adoption because itfrees them from the parenting role,
which they judge themselves unready to assume. Those
who involuntarily relinquish children may experience
little relief and substantial loss (Fessler, 2006).
Adoption also offers birth parents the hope of a better
life for their child. At its best, adoption meets the hopes
of the child, the adoptive parents, and the birth parents.
American adoption law and practice have been
developed to address the needs of this adoption triangle.
Communities also have an interest in the policies and
practices of adoption. The future of our communities
and society depends on our children, and their future
requires an adequate family life. Many communities
within our society, especially Native American tribes,
ethnic communities, and other self-defined communities
such as foster parents and gay men and lesbians are
asserting their right to adopt or to have first claim on
children available for adoption. Because adoption
occurs at the intersection oflove and law, it evokes a
powerful response from these communities. Adoption is
a social and legal institution that reflects the status,
interests, and moral views of nearly every social entity.
The Donaldson Adoption Institute estimates that 60% of
Americans are involved in an adoption. For the first
time, the U.S. Census asked in 2000, if the child was an
AOOPTION 33
adopted or a natural-born son or daughter-about 2.1
million children in u.s. households are adopted, about 8%
of all the children of householders in 2000 (Kreider,
2003). Though the percentage of adopted children under
the age of 18 is 2.5%, this varies considerably at the
local county level, from less than 1.9% to as high as
15.7%.
History of American Adoption
Early in U.S. history, children were more likely to be
indentured than adopted. Nonetheless, adoptions date
back to the beginning of the republic: The first governor
of Massachusetts was an adoptive father of an older
child. The end of slavery and indentured servitude re-
sulted in the growth of orphanages, and individual states
first began to-legislate and regulate adoption practices at
that time (Whitmore, 1876). Regulations emerged to
protect birth parents' rights to give or withhold permis-
sion for the child's adoption, adopting parents' rights not
to have their child reclaimed, and children's rights to be
cared for by suitable adopting parents.
By 1929, every state had adoption statutes. Statutes
varied on several counts, but all reflected concern that
adoption promote the welfare of the child. The first
regulations required social investigations of prospective
adoptive parents and trial placement periods in pro-
spective adoptive homes (Heisterman, 1935). A few
states also required home visits by agents of the state
child welfare department, the precursor to today's home
study, although the rationale for the visits was rarely
clarified (a legacy that remains, in part, even today in the
home approval process).
Foster care and adoptions were intertwined in the late
19th century. The great expansion of foster care and
adoption is often associated with Charles Loring Brace
(l859).The middle-class leaders of child care agencies
expected to save both souls and money by placing poor
children in good homes (Clement, 1979). Placing
agencies were concerned less with the needs of the
children than with the social and moral problems
children might create in the larger community. The most
common reason for placement was poverty, not
protection from child abuse or abandonment. This
rationale for foster and adoptive placements was judged
unacceptable by the 1920s.
The nation's involvement in adoption in the middle
part of the 20th century was primarily through place-
ment of infants of young unmarried women, who were
often not so voluntarily having their newborns placed
with decidedly middle class married couples. Adoption
was firmly controlled initially by private, and later,
public agencies, which made the arrangements after
screening and choosing the parents. The dominance
34 Aoornon
of this form of adoption began to wane with the passage
of Roe v. Wode in 1974, although infant adoptions of a
typically more open and voluntary form continue.
Adoption of older children began to reemerge after
World War II. In 1949 the Children's Home Society
began a "new type of child care program in North
Carolina to provide ways and means of placing older
children in institutions, in family homes for adoption"
(Weeks, 1953, p. i). This effort was partly in response to
. waiting lists to place children in orphanages. In 2008,
allAmerican orphanages are closed or converted to
residential care, and foster care is the typical setting for
older children awaiting adoption.
TYPES OF ADOPTION Adoption occurs through a
variety of means involving different types of agencies
and auspices, each with unique procedures and
requirements. Taken together; approximately
119,000 children were adopted in 1990 (Flango &
Flango, 1993). This number grew slightly to 127,000
children in 2000 and 2001 (Flango & Caskey, 2005),
although the types of adoption placements have
changed considerably. Generally, adoptions are
grouped into four categories: stepparent,
independent, relinquishment or agency, and
intercountry. In 1992, 72% of all adoptions were pri-
vate, independent, kinship (non foster care) and tribal
(non foster care) but this number dr opped to only
15% by 2001 (U.S. Department of Health and Human
the authors discuss dra matic increases in organizing
ng for environmental justice,
EPPARENT ADOPTIONS Stepparent adoptions refer
the adoption of children by the spouse of a parent.
Stepparent adoptions differ from other adoptions
because the adoption involves a child who is already
legally in the family. In most states, stepparent
adoptions are about twice as common as
nonstepparent adoptions. Stepparent adoptions are
red separately
adoptions and, because of their impact on the
distribution of family property, are often overseen in
superior court. or probate court.
endant. Probation offiIndependent adoptions occur when
occur when parents place children directl y with
adoptive families of their choice without an agency
serving as an intermediary. Intermediaries are most
often counselors or attorneys. In the 1950s, agency
adoptions and independent adoptions were about
equal in number and primarily involved infan ts.
Independent adoptions held steady at about 20% of all
adoptions in the 1960s and 1970s (Meezan, Katz, &
Russo, 1978) but have increased to nearly one- third
(National Committee for Adoption, 1989). As of
2006, only four states
(CO, cr, DE, and MA) had outlawed independent .".:
adoptions (McDermott, 2007). Nationally, between
15,000 and 17,000 children were adopted independent of
agencies in 1992 (Placek, 1999; Stolley, 1993) and.' this
number may have dropped since then, to about: 13,000 in
1996 (Placek, 1999). No statistics on independent
adoptions are available for more recent years, consistent
with the lack of federal involvement in independent
adoption practice or policy.
AGENCY OR RELINQUISHMENT ADOPTIONS. Agency or
relinquishment adoptions are those that .' follow the
voluntary or involuntary legal severance of parental
rights to the child and are overseen by a public or
private agency providing foster care and adoption. The
intent of the Adoption Assistance and Child Wel~ fare
Act of 1980 and of the Adoption and Safe Families Act
of 1997 was to increase the number of relinquish"
ment adoptions. This has occurred. Although good
.national data has only recently emerged, data from
AFCARS (Adoption and Foster Care Analysis and
Reporting System) shows a doubling of the number of
children adopted from foster care from about
approximately 25,693 in 1995 to ahigh of 52,468 in
2004. This growth appears to have been leveling off
since 2002. At the same time, the number of parental
right terminations has risen to about 70,000 per year
and is also leveling off.
Little information is available to compare inde-
pendent and agency adoptions. Evidence comparing
independent and agency adoptions of infants found few
differences in outcomes between them (Meeian, Katz, &
Russo, 1978). Parent satisfaction is high for both (Berry,
Barth, & Needell, 1996). Efforts to make the infant
home-study process more intensive, to screen adoptive
families more rigorously, or to require exten sive agency
review of placements, have not been founded on
evidence that independent adoptions are less satisfactory
than agency adoptions. Although fingerprint checks for
felonious criminal behavior and assessments of the
safety of the household are undoubtedly warranted to
screen adoption applicants, adoption policies must be
circumspect about using additional criteria to screen out
families seeking to adopt children. These additional
criteria add barriers to the recruitment, approval, and
retention of adoptive.families and may prevent
adoptions. Adoption agencies are especially helpful
when they focus on assisting applicants to determine the
best kind of adoption for them and provide necessary
pre-placement training and postplacement support for
adoptive parents caring for children with special needs
(Emery, 1993). Innovations in home studies-including
SAFE (Structured Analysis Family Evaluation)-are
endeavoring to standardize

the home study format so that it can he used for foster care
and adoptive placements across agencies and jurisdictions
(Crea, Barth, & Chintapalli, in press).
INTERCOUNTRY ADOPTIONS Intercountry adoptions
involve the adoption of foreign- born children by
adoptive families. In the United States, intercountry
adoptions are a small but significant proportion of
adoptions. Federal law requires a satisfactory home
study. Private adoption agencies assist families by
conducting family assessments for Latin American,
Pacific Rim, or Eastern European adoptions. Also,
children who are adopted must clearly be orphans.
These adoptions raise a number of policy issues
such as proper safeguarding of birth paren,t rights,
cultural genocide, and resolving citizenship for the
child. The nature and func tion of international
adoptions merit careful review and analysis. More
than 9,000 foreign-born children were adopted in
the United States in 1991 ( Immigration and
Naturalization Service, 1991); the number grew to
nearly 18,000 in 2000, increasing from roughly 5%
of all adoptive placements to 15%. (Flango &
Caskey, 2005). The percentage of adoptions from
foreign countries has increased from 5% in 1992 to
15% in 2001 (p, 40). Trends include new
restrictions on Korean adoptions a nd an expansion
in the number of countries from which chil dren are
being adopted, including Eastern European
countries and, especially, China, which accounts for
about one-third of all 'US. international adoptions
(US. State Department, 2007).
SPECIAL,NEEDS ADOPTIONS Federal law describes
special-needs adoption as indicating that a child in
foster care cannot or should not be returned to the
home of his or her birth parents and that the child
has a specific factor or condition (such as ethnic
background; age; membership in a minority or
sibling group; or the presence of factors such as
medical conditions or physical, mental, or
emotional handicaps)' that make it reasonable to
1 conclude that the child cannot be placed with
adoptive parents without providing adoption as-
sistance or medical assistance. In addition, the state
must find that a reasonable but unsuccessful effort
1 has been made to place a child with appropriate
adoptive parents without providing adoption or
s medical assistance. This latter requi rement can be,
1 and often is, waived if it would be against the best
interests of the child. State regulations vary widely
in their interpretations of the Adoption and Safe
Families Act, but generally identify special- needs
:l.
adoptions as involving the adop tion of children
S
aged three years or older, ethnic children,
handicapped children, emotionally or intellec tually
e impaired children, or sibling groups of three or
AOOPTION 35
more. Almost all (88%) the children adopted from foster
care are judged to have special needs-the proportion of
these children ranged from 16% (Cf) to 100% (SC) in FY
2001 (Dalberth, Gibbs, & Berkman, 2005) ..
Between 1982 and 1986, the number of specialneeds
adoptions showed little or no growth (National Committee
for Adoption, 1989), but the foster care population grew by
7% (Tatara, 1994). In contrast, by 2000, the growth of the
foster care population was flat and adoptions were
growing. Special-needs adoption of foster children
accounted for about 10% of all exits from foster care in the
early to mid-1980s (Barth & Berry, 1988). Between 1995
and 2004, about 19% of exits from foster care were by
adoption. (US. Department of Health and Human Services,
2007b).
Major Adoption Legislation
INDIAN CHILD WELFARE ACT For the. first 200 years,
American adoption was legislated. locally. The first
major piece of national legislation influencing
adoption was the Indian Child Welfare Act (ICWA)
of 1978. The legislation provides legal guidelines to
promote the stability and security of Native
American tribes and families and to prevent the
unwarranted removal of Native American children
from their homes. The passage of ICW A was
fueled .by the recognition that as many as 30% of
Native American children were not living in their
homes, but .were residing in boarding schools,
foster homes, or adoptive homes. Founders of the
Act asserted that the viability of Native American
tribes was dissipating. in the face of the re moval of
its children. The Act emphasizes protecting tribal
communities.
Within this broad Act are protections specific to
adoption. Most notably, termination of a Native
American's parental rights requires the highest standard of
proof. Child welfare authorities must show beyond a
reasonable doubt that the continued custody of the child by
the parent or Native American custodian is likely to result
in serious emotional or physical damage to the child. Thus,
the court must find with virtual certainty that the child will
be seriously harmed in the future before he or she is freed
for adoption. This high standard protects tribal rights but
leaves little latitude for overseeing the child's right.to be
safe.
Section 1915 of the Act legislates the adoptive
placements of Native American children after termination
of parental rights. Preference is given to placement with a
member of the child's extended family, other members of
the child's tribe, or other Native American families. The
Act places the rights of the tribe above those of the birth
parent. For example, Native American parents who are
tribal members cannot place
36 ADOPTION
their children for adoption with non-Native American
families off the reservation; placement of tribal children is
governed by the tribe.
Asa result of these stringent provisions, ICW A has
never been without controversy. Fischler (1980) argued
that the greater sovereignty for Native American adults
places Native American chil dren in jeopardy: Further, by
regarding children as the property of parents, families, and
tribes, ICW A does not protect children adequately.
Defenders of ICW A argue that a child's right to a lifelong
cultural affiliation deserves at least as much protec tion as
the right to household permanency (Blanchard & Barsh,
1980). They propose that the choice- to protect culture is
what tribal child welfare professionals have made explicit
in their support of ICW A. \
The impact of the Act has undergone little evalua tion.
The only assessment of ICW A implementation indicates
that, as envisioned by the framers of the Act, an increasing
proportion of Native American children are being placed in
foster and adoptive homes with Native American parents.
Yet, Native American chil dren in care are less likely than
other children to have a case plan goal of adoption (Plantz,
Hubbell, Barrett, & Dobrec, 1989). When they are adopted ,
this is very often by aunts. and uncles or other relatives
(Barth, Webster, & Lee, 2002). State and federal courts
have yet to achieve a consistent balance between the inter-
ests of tribal survival, child welfare, and parental author,
ity. The conflict is especially vexing when the parents of
aNative American child want to place the child in a
non-Native American family or a tribe seeks to place a
child on an unfamiliar reservation in which the child has no
close family (Hollinger, 1989). These cases con tinue to be
contested (Cross, 2006). The relationship between
ICWA-which contains a very high s tandard for termination
of parental rights-and subsequent child welfare legislation
that requires time limits on foster care placements and
termination of parental rights when those time limits are
exceeded, is only now being explored.
ADOPTION ASSISTANCE AND CHILD WELFARE ACT
AND ADOPTION AND SAFE FAMILIES ACT The
Adoption Assistance and Child Welfare Act
(AACWA) was passed in 1980, followed by the Adop-
tion and Safe Families Act in 1997. The broad man-
dates in .the AACWA require that child welfare
agencies implement preplacement preventive services,
programs to reunify placed children with their bio-
logical families, subsidized adoption, and periodic
case reviews of children in care. Perhaps most
importantly, AACWA instituted a time line of 18
months for reunification or a decision to free a child
for adoption.
To facilitate adoption, a federal subsidy program was
included that allows federal dollars to be used to match
state contributions made to give subsidies- which could not
be larger than the prior foster care payment- to families
adopting children with special needs. In 1997, Congress
passed the Adoption and Safe Families Act (ASFA) to
strengthen these provisions. The time frame for making
permanency decisions was shortened to 12 months and the
expectations that a child would be free for adoption, even if
there was not an immediately available adoptive family,
were added to the law ,along with many other provisions.
The changes in the focus and completion of adop tions
have, subsequently, been dramatic. In 1982 more than
50,000 children were legally free from their par ents and
waiting to be placed (Maza, 1983). About 17,000 of these
children had the specific permanent plan of adoption and
approximately 14,400 older chil dren were placed for
adoption in the United States (Maximus, 1984). By 2004 ,
more than 118,000 children were legally free for adoption
and more than 52,000 children were adopted, almost all of
whom were given adoption subsidies. The massive
increase since 1975 in the placement of older foster
children and special- needs children for adoption has
greatly changed the historic purpose and scope of child
welfare services,
The Adoption Assistance and Child Welfare Act
encourages states to develop adoption subsidy programs
for special-needs adoption and reimburses the state for
50% of the subsidy costs. The intent was to ensure that
families were not penalized financially for adopting.
Reforms to make subsidies available to families that adopt
special-needs children were passed, over the ob jections
that sentiment should be the only considera tion in
adoption. Instead, law acknowledged subsidies as a means
to facilitate the adoption of special- needs foster children
and promote new adoptions. Subsidies are me ant to
encourage families to adopt. Families that adopt
special-needs children are entitled to subsidies without a
means test, although their financial condi tion can be taken
into account.
Adoption assistance payments are now provided in all
states, and state adoption subsidy programs operate in
virtually every state. Nationwide, adoption assis tance
payments rose from $442,000 in 1981 to an.estimated $100
million in 1993 to more than $2 billion in 2007 (U.S .
Department of Health and Human Services, 2007 a; U.S.
Senate, 1990). In 2006, more money was expected to be
spent by the federal government, each day, on adoption
subsidies than on foster care payments (Spar & Devere,
2001). Concerned about the growing number of children
receiving adoption subsidies, some states have endeavored
to cut adoption subsidies, despite

the fact that they are already lower than foster care or group
care payments and are much less expensive than paying for
children who grow up in out-of-home care (Barth, Lee,
Wildfire, & Guo, 2006). Court challenges to cuts in
existing subsidies have successfully argued that they could
not make such cuts for families that had accepted children
into their families with the understanding of a higher
subsidy payment (Eckholm, 2006).
MUL TlETHNIC PLACEMENT ACT AND
INTERETHNIC ADOPTION PROVISIONS The passage
of the Howard M. Metzenbaum Multiethnic Placement Act
of 1994 prohibits any agency or entity that receives federal
assistance "to categorically deny to any person the
opportunity to become an adoptive or a foster parent; solely
on the basis of race, color, or national origin of the adoptive
or foster parent, or the child, involved; or delay or deny the
placement of a child for adoption or into foster care, or
otherwise discriminate in making a placement decision,
solely on the basis of race, color, or national origin of the
adoptive or foster parent, or the child involved" (S.
553(a)I(A&B). Initially identified as a "permissible
consideration," agencies could consider the cultural, ethnic
or racial background of the child and the capacity of the
prospective parents to meet the needs of the child as one of
a number of factors in determining the best interests of the
child. This was later stricken in the Interethnic Adoption
Provisions, which amended the Multiethnic Placement Act
and added penalties for failing to comply with this Act as a
violation of the Civil Rights Act of 1964. The Acts also
require that states provide diligent recruitment of potential
adoptive and foster families that reflect the ethnic and
racial diversity of children in the state for whom foster and
adoptive homes are needed.
The passage of this Act may have increased the
likelihood of adoption for African American children;
however, this is not a clear result of the law. The U.S.
DHHS has done little else to try to study the impact of the
law. Shaw found no change in the proportion of
multiethnic adoptions in California since the law. Several
states have been successfully sued by the Office of Civil
Rights for failing to implement the law; Ohio received a
$1.8 million fine (US. Department of Health and Human
Services, Departmental Appeals Board, 2006b). At the
same time, the lengths of stay in foster care for African
American children are declining because of more
movement into guardianship and kinship adoptions
(Wulczyn, 2003).
Current Adoption Practice Recruitment of
adoptive parents for foster children is arguably the most
important element of adoption
AOOPTION 37
practice because once adoptive' placements are made,
adoptions generally require few ongoing services.
Recruitment is especially critical for African American
children because they remain strikingly overrepresented in
foster care. Although adoption practices vary broadly,
practitioners struggle to decide how to keep pace with.
emerging trends in a way that fits their agency and is in the
best interests of children, families, and the community.
ADOPTION PLANNING FOR THE CHILD. Permanency
planning legislation provides grounds to free many chil-
dren for adoption, but agencies have been slow to im-
plement the specifics of the legislation, and many barriers
to placement and permanence remain. Determining a
child's eligibility for adoption continues to be a confused
mixture of answers to three questions. Is the child (l) easily
interested in adoption? (2) likely to be adopted? (3) likely
to remain adopted? Adjusting practice to the needs of these
older children includes recognizing that some disruption is
inevitable. As Cole (1986) wrote, "The only failed
adoption is the one you didn't try" (p. 4). Workers who
recognize and accept the possibility of disruption in
adoption find creative ways to facilitate adoptions for all
waiting children and support the placement in accordance
with the risk involved. Recent innovations in adoption
practice are resulting in adoptions even when the person
adopted is older than 21 (Barth & Chintapalli, in press).
Not every child will be better off adopted than in
long-term foster care or guardianship. Although many
adoptive families struggle and may need post-adoption
assistance, the general evidence of positive adoption
outcomes is powerful (Barth, 2002; Triseliotis, 2002). The
value of adoption and the relatively modest disruption
rates of about 11 % (Smith, Howard, Gamier, & Ryan,
2006) make adoption an excellent alternative over foster
care. Experienced child welfare workers have lower
adoption disruption rates for families that had been in their
care. At the same time, children who are not adopted but
whose parents have had their parental rights terminated are
likely to . experience a variety of significant legal and
personal disadvantages (Barth & Chintapalli, in press).
Speedy efforts to place children while they are young
and better able to fit into an adoptive family's home
represent the starting point for successful adoption.
Adoption delayed is often adoption denied. Efforts to
terminate parental rights more quickly when reunification
is improbable and to move children into fosteradopt
situations deserve full support and dissemination. At the
same time, older children, whose parents' rights have been
terminated, are too often unable to be
38 AOOPTION
adopted and are, therefore, suffering the legal conse-
quences of having no legal family ties.
RECRUITMENT OF ADOPTIVE PARENTS Agencies
continue to engage in a variety of methods to find
adoptive families. Recent years have seen advances
in search methods that involve information provided
by the youth who will be adopted. In these
procedures, social workers help youth to identify
people whom they have known and cared about and
who might consider adopting them. In addition, there
is a growing use of people finder firms to seek
relatives of children in foster care.
In addition to exchanges, parent recruitment also
occurs through community education: Broad education
in the community can reach groups of potential parents
who may never have considered adoption. Beginning in
1979, Father George Clements, a priest in Chicago,
challenged every African American church in Chicago
through the One Church, One Child program to accept
the responsibility and opportunity to have one member
of each congregation adopt an African American child
(Veronico, 1983). Federal and state governments sub-
sequently provided years of support to One Church, One
Child to encourage its replication. Many states now
. have a version of One Church, One Child and focus on
recruitment of families from other ethnic groups. The
program continues to be used (Gibson, 2003) but has
not yet been evaluated. . so.that they succeed in their adoptions-for each year of
Another recruitment strategy that has shown prom ise
involves using special features on television or in .
newspapers to present a particular child and a descrip tion
of his or her strengths and needs. These media campaigns
are modestly successful and inexpensive. Ethnic
adoption fairs also bring interested parents and eligible
children together in a picnic situation. Internet services
are a growing tool for identifying children in need of
adoption. More than 7,000 children listed on the
Children's Bureau's Adopruskids.org Web site have been
adopted, as of April, 2007.
PRE,PLACEMENT SERVICES Home study is a nearly
150-year-old tradition and continues to serve the pri-
mary function of screening adoptive families to
protect children from harmful situations (Crea, Barth,
& Chintapalli, in press). A well- established but
secondary function is to help adoptive families clarify
their intentions and flexibility regarding the
characteristics of children they seek to adopt. Since
1998, there has also been a greater use of the group
process for training and support of preadoptive
families so they are more able to parent special- needs
children successfully. The group approach to
preplacement provides particular opportunities for
ongoing support. Many of these groups
prepare participants to become either adoptive or foster
parents. Groups may last for as long as 10 sessions and
include guest presentations by current foster and adop-
tive parents. Prospective foster parents are told that they
may change their minds and become adoptive parents
instead. People who expressly want to adopt (and they
usually outnumber those who want only to provide
foster care) are oriented to the social services system
and the legal and moral responsibility to facilitate the
child's reunification with the birth family when that is
the case goa1. Adoptive families that begin the process
in such multifamily groups often maintain contact. with
peers well beyond their time of contact with the social
worker. Although group home studies have not been
well evaluated, some evidence suggests that they
strengthen high-risk placements (Barth & Berry, 1988)
whereas other evidence suggests that they have little
benefit (Puddy & Jackson, 2003).
Social workers try to provide adopting parents with
all pertinent information about the child during pre-
placement services. Because of the inevitable coord ina,
tion problems and some confidentiality concerns, much
valuable background information is not shared. This
inefficiency could be redressed by rethinking the type of
information that is collected and how it is summar ized .
and transmitted to the families. However they
accomplish it, social workers with more years of
experience are more effective in supporting families
worker experience the adoption disruption rate de-
creases by 2% (Smith et al., 2006).
The strong confirmation by researchers of the im-
portance of information sharing calls for prompt action
(Barth, 1988). Better information is associated with
better outcomes. Also, the success of a few "wrongful
adoption" cases is forcing agencies to change their
information-sharing practices and states to change their
laws to reduce liability. Nonetheless, some social work,
ers continue to withhold information to increase the
likelihood of adoption (Schulte, 2006).
OPEN ADOPTION The practice o f open adoption, or
the continuance of contact or correspondence
between the adopted child and birth parents, is
increasingly common. An estimated 55% of
adoptive families in California during 1988 and
1989 had contact with the birth family in the two
years following placement (Berry, 1991). Henney et
a1. (2003) examined the practices of 31 adoption
agencies from 1987 to 1999 and showed that only
36% of agencies offered fully disclosed
arrangements in 1987 but that, by 1999, 79% offered
fully disclosed arr angements. At the end of that
time, not one agency offered only confidential
adoptions.

The benefits of open adoption are becoming more
accepted, but remain controversial. On ideological
grounds, because outcome data on open adoptions are
scarce, Pannor and Baran (1984) called for " an end to all
closed adoptions" (p. 245). They view the secre cy of
conventional adoptions as an affront to the rights of
adopted children. Kraft, Palombo, Woods, Mitchell, and
Schmidt (1985a, 1985b) countered that open adoptions
may interfere with the process of bonding between the
adoptive parent and child. Other evidence suggests that
the adoptive parents' control over their child's contact
with birth parents is critical to the success of the
placement (Barth & Berry; 1988) and the parents'
comfort with the placement (Berry, 1991; Dunbar, Van
I
Dulmen, Ayers-Lopez., Berge, Christian, Grossman,
et al. 2006). Berge, Mendenhall, Wrobel, Grotevant, and
McRoy (2006) examined adolescents' feelings on
openness and found that "adolescents desired and
benefited from having openness in their adoption
arrangements" (p. 1036). Berge et al. also found that
adolescents desired more contact with "birth moms,"
which demonstrated that the contact with the birth
mothers was not harmful. Von Korff, Grotevant, and
McRoy (2006) ran a study to see if the degree of open,
ness between adoptive and birth family members was
associated with the behavioral and emotional. adjust,
ments of adolescents who had been adopted as babies.
"The adoptive parents' reports indicate no significant
association between openness and adolescent adjust,
ment (p. 531)." Adoptee reports suggested that exter-
nalizing behavior is higher in confidential as compared
with ongoing fully disclosed arrangements" (p. 534) but
the authors make no claims that openness causes better
outcomes. They recommend that openness arrange,
ments be voluntary and that openness decisions be made
on a case by case basis.
Whereas most open adoptions continue to be vol-
untary on the adoptive parents' part, recent case law has
added stipulations to adoption decrees that provide birth
parents with visitation rights (Hollinger, 1993). A few
countries (for instance, New Zealand) have made open
adoptions the requirement for all adoptions on the
grounds that it is in the child's best interest. These
changes are in stark contrast to the historica l notion of
adoption as a parent-child relationship equivalent to the
birth parent-child relationship and without con, dition.
This change occurred despite the absence of noteworthy
evidence that children in open adoptions have better
outcomes than other children.
The potential benefit of open adoption is that it
provides a resource for coping with the typical transi-
tions in the child's understanding about option as he or
she moves toward adulthood. The danger for older
ADOPTION 39
children is that continued contact with birth parents may
disrupt the development of the child's relationship with
the new family. The older adoptive child and parent are
trying to become a family and need a structure to do so.
It may seem that the older a child, the less detrimental
and more natural it is to retain ties to former caretakers.
The danger in this logic is that older children have a
more difficult time developing ties to their new family
because they are also pushing toward independence and
this development may be preempted by contact with
birth families. Open adoption can perhaps best be
viewed as an enrichment to astable placement, not a
necessity for all placements or a pal, liative for a
troubled one.
NONTRADITIONAL ADOPTIONS The traditional re-
quirement that adoptive parents be married couples
who own a home, with a full- tirne mother at home,
severely narrowed the field of possible adoptive
parents. Although these requirements might have
been helpful in reducing the field of applicants
during the infant adoption boom, they were also
erroneously promulgated to protect children from
unsuitable parents. Instead, they limited the
placement of special- needs children. The bigger pool
of parents needed for these waiting children is not
attainable without flexible requirements; Require,
ments for adoptive parents have typically been more
flexible in public agencies than in private ones.
Public agencies supervise adoptions with parents
with lower .incomes, lower education levels; older
ages, and more children in the home than do private
agencies (State of California Department of Social
Services, 1987).
Agencies are beginning to recognize the potential of
unconventional adoptive parents, especially single
parents. An early study of single parent adoptions
(Branham, 1970) found that, in general, applicants were
emotionally mature, tolerant, and independent and had a
supportive network of relatives. Barth and Berry (1988 )
found that single parents adopted older and more
difficult children with no more adoption disruptions
than couples.
Modest changes in agency policy and practice have
opened opportunities for adoption by gay and lesbian
parents (Pace, 2005; Ryan, Pearlmutter, & Groza,
2004). In 2000, 29,000 adopted children lived with a
female head of household and her unmarried partner and
almost 29,000 adopted children lived with a male head
of household and his unmarried partner (Krieder, 2003 ).
These statistics do not indicate what percentage of these
children live with same-sex partners or opposite- sex
partners. Gay, lesbian, and bisexual foster parents face
multiple challenges when beginning the adoption
process, as it frequently begins by becoming
 40 AoornON
oster parents (Downs & James, 2006). Despite being a
valuable resource for our nation's foster children, Downs
and James (2006) found that many gay, lesbian, and
bisexual foster parents were met by . lack of support,
unsympathetic social workers, and even legal resistance.
Results of a study by Leung, Erich, and Kanenberg (2005)
indicated that children who were adopted by gay or
lesbian-headed families had no negative effects for their
parenting. Additionally, higher levels of family functioning
were found in gay or lesbian headed-households with
adopted children who were older, non-sibling grouped, and
had more foster placements. These results indicate that gay
and .lesbian adoptions should be encouraged. Indeed,
agency personnel have a clear understanding that gay and
lesbian families, are a vitally important resource for
achieving the . social goals of ensuring that children have
loving, legal, lifetime families (Brodzinsky, Patterson, &
Vaziri, 2002). A new generation of work is clarifying
important considerations in the assessment and support of
gay and lesbian foster and adoptive parents (e.g., Mallon,
2007; Mallon &
. Womoff,2006).
Adoption of children by kin who cared for them as
foster parents has increased in recent years. Kinship foster
care has become the most common type of foster care in
many urban areas (Barth, Courtney, Berrick, & Albert,
1994) and kinship adoptions have also grown in recent
years. Of the. children leaving home care between 1990
and 2002, 26% of those who were placed in kinship care
were adopted, compared to 21 % of children entering foster
care (Wulczyn, Chen, & Hislop, 2006). This is partially
responsible for their finding that African American
children are now more likely than other children to be
adopted even though their rate of adoption is slower than
other children (Wulczyn et al., 2006). Although this is
generally a more protective legal arrangement for children
than foster care, kinship adoptions are more likely than
other adoptions to be by older, less educated, poorer, single
parents (Magruder, 1994).
POST,PLACEMENT SERVICES Agency support after
placement may be needed for some children. Any
placement will have challenges. The goal for the
agency is to stay close enough to the family to be
aware of these problems and guide the family to
resources to aid in their resolution. However, many
families are reluctant to seek services until it is too
late because they are afraid they will lose their child.
Both the child and the parents have needs in post-
placement services. Agencies typically maintain contact
with the family during the first three to six months to
reassure the child of continuity with his or her
past and to enable the family to explore uncertainties
without feeling lost (Fitzgerald, Murcer, & Murcer, 1982).
The goal is to catch problems early in the placement before
they escalate into unsalvageable disasters. The evidence is
unequivocal that the needs of adoptive families for support
and services last well beyond the first year (Festinger,
2006). Agencies must establish ways to provide services
for high-risk placements throughout adolescence.
Post-adoption services may be useful but they are
specifically geared toward preserving placements on the
verge of disruption. Rather, they tend to serve adoptees
placed as infants, not older adoptees, and help them
reconcile their. adoptions, make decisions about searching
for birth parents, and deal with their concerns as. they
become adolescents and young adults.
Many agencies have introduced support groups of
adoptive families for parents and children. It is often
helpful for new adoptive parents and children to talk to
fellow adopters and adoptees about what is normal in
adoption and to share realistic expectations and feelings
about the process. These groups also facilitate supportive
relationships that parents and children can fall back on.
when they need to. Support groups probably operate best
when started during the home study, but successful
versions have been developed afterplacement to support
high-risk placements.
There is a clamor for the development of postplacement
and post-legalization services that meet the demands of
supporting older-child adoptions. The call is for something
far more than mandatory visits soon after the adoption and
the availability of crisis intervention services. Although the
principles underlying this demand are sound, a few
concerns arise. First, postadoption services should not be
staffed at the expense ofrecruitment and home study
efforts. Resources spent on conventional post-placement
services are not as valuable to agencies and families as
dollars spent on recruitment because most adoptions
succeed with no significant agency effort after placement.
Second, although referral to. outside services is often
useful, social workers or other adoptive families involved
with the family should be available to assess the situation
and coordinate post-placement services from other pro-
viders. Families are less likely to ask the agency for help
when they lose contact with the worker who did their home
study. The home study is a poignant process that builds
strong bonds between the worker and the family. The
organization of services should facilitate a continuous
relationship among the family, social worker, and other
adoptive families who can assist in times of duress.
Adjusting to older-child adoptions is often difficult.
At times, the future of the adoption may be in doubt. With
so much riding on the outcome of such a crisis, it is

unwise to rely on conventional social casework
counseling or office-based psychotherapy. Intensive'
in-horne adoption preservation services may be needed.
Since permanency planning, family preservation
services have emerged in most states. They have been
used primarily for keeping children out of the child
welfare or mental health systems and not to help
preserve adoptive placements.
Relatively few adoptive families now have the ben-
efit of intensive home-based, family preservationser-
vices to prevent adoption disruption, an observation that
has not changed since 1988. Yet, many states have
developed at least some post-adoption services. For
families in crisis, in-horne interventions reduce the
likelihood of alienation that can occur during out-
of-horne care. The specific presenting problems that
\
precipitate adoption disruptions are those' that signal
the breakdown of other families, especially assault, run-
ning away, and noncompliance of latency and teenage
children. Intensive services are costly, but if they are
successful, their costs can be favorably w eighed against
the lifelong benefits that follow adoption. fu of 2008,
there' are no models of post-adoption services that have
been shown to be effective-admittedly a difficult eva-
luation challenge because these services tend to respond
to families with a wide range of backgrounds and con-
cerns. Despite the limitations in post-adoption services,
there appears to be no greater risk of disruption in recent
years than in the period when the adoption rate was only
half as high (Smith et al., 2006).
Conclusion
Recent changes in adoption jeopardize its place in the
child welfare services continuum. The child welfare
service "system" is an amalgam of programs. The out-
comes of efforts to prevent out-of-home placements, to
reunify families, and to provide long-term care all
depend on the quality of the programs that have pre-
viously worked with the children. Each program must
work if the other programs are to do what they are
intended for~ If older ~hildren in the child welfare
system are not adopted or are not able to stay adopted,
then the rationale for moving quickly to terminate the
rights of birth parents (after a determination that chil dren
cannot go home) is weakened. Indeed, even the pressure
to leave children in or return them to unsafe birth
families is intensified when permanent adoptive homes
are unavailable, because social workers fear that
children will experience more harm in a lifetime of
foster care than at home. Many agencies will not free
children from foster care until a stable home is all but
guaranteed. Without the confidence that terminating
parental rights and freeing a child for adoption will
ultimately result in an adoption, judges lose their
AOOPTION 41
conviction to do so, time limits on foster care are
rendered insignificant, and mandates for speedy perma-
nency planning become moot. Successful older-child
adoption services may not be the hub of effective child
welfare services but they are critical.
Not everyone believes that adoption is of great value
to children and American society. Adoption foes are
gaining greater attention as they argue that adoption is a
cause of trauma to children and birth parents and that
both experience irreparable harm from their separation.
If adoption is to maintain a powerful role in child
welfare services, the arguments for the resilience of
children's capacity to make attachments (Barth, Crea,
John, Thoburn, & Quinton, 2005; Eyer, 1992), the
benefits to the children of adoption (Rutter & Rutter,
1993), and the congruence between adoption and
American values need better articulation. and dissemi-
nation (Bartholet, 1993). Many social workers are not as
sure as they once were of adoption's advantages over
long, term foster care or guardianship and may fail to
make a case about its value to foster families and chil-
dren. Often, adoption is not viewed as a clear and
desirable alternative to foster care.
Adoption is facing increasing scrutiny by all inter-
ested adult parties. Birth mothers and fathers, adopting
parents, and adoption agencies and centers are devel-
oping new and more rigorous procedures for trying to
ensure that their needs are met. These efforts may work
against the interests of children who need adoptive
homes. Despite, the general success of adoption for all
the parties involved, a considerable tightening of adop-
tion regulation and more procedural barriers to adoption
may occur in the next decade. These procedures may
result in diminished interest on the part of poten tial
adoptive parents who will instead choose to pursue
surrogacy arrangements or fertility treatments with
lower success rates. Such strategies will not lead to the
adoption of children in need of placement. Of the utmost
importance is the public policy goal of increasing
adoptive placements. In addition, a substantial challenge
exists to find ways to make adoption a way to create and
affirm family, ethnic, and community relationships in
all their manifestations. This involves supporting a
range of adoptive arrangements that allow the child to
recognize the significance of birth parents and siblings,
racial and ethnic make-up, and cultural origins and give
the child opportunities to act on that recognition.
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44 ADoPTION
Whitmore, W. H. (1876). The law of adoption in the United States.
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FURTHER READING
Brooks, D., & Barth, R. P. (1999). Adult transracial and inracial
adoptees: Effects of race, gender, adoptive family structure,
and placement history on adjustment outcomes. American
Journal of Orthopsychiatry, 69, 87-99.
U.S. Department of Health and Human Services, Administration
for Children and Families,'Children's Bureau. (2006a). The
AFCARS report:Preliminary FY 2005 estimates as of . September
2006. Retrieved February 2, 2007, from http://
www.aef.hhs.gov/programs/cb/stats_researCh/afcars/tar/repo
rt13. html.
SUGGESTED LINKS
http://www.adoptioninstitute.org/index.php
http://www.childwelfare.gov/adoption/indexcfm
http://www.nacac.org
-RICHARD P. BARTH
ADULT DAY CARE
ABSTRACT: Adult day care centers provide important
health, social, and support services for functionally and
cognitively impaired adults and their caregivers. The adult
day care services are underutilized, however, because of the
shortage of centers, caregivers' lack of awareness of and
resistance to using services, and the mismatch between the
needs of potential consumers and their informal caregivers
and the services provided by the centers. To foster and
support the expansion of adult day care centers, lessons
learned from national demonstration programs need to be
disseminated, and social workers need to be trained to provide
essential services at the centers.
KEY WORDS: adult day care center; medical and social
model of care; continuum of care; outreach service
Service Types and Funding
Adult day care centers, or adult day services, provide
structured health-promoting programs, social activities, and
support services for adults with functional impairments,
cognitive impairments, or other mental health
or developmental disabilities. The average age of the day care
participants is 72, and more than half of them have some
cognitive impairment (National Adult Day Services
Association [NADSA], 2006).
A national study of adult day services between 2001 and
2002 found that 21 % of the centers are based on the medical
model of care, 37% are based on the social model of care
(without a medical component), and 42% are a combination of
the two (Robert Wood Johnson Foundation [RW]Fl, 2006).
The medical model offers more intensive health and
therapeutic services for individuals with severe medical
problems and for those at risk of nursing home care and
usually requires a health assessment by a physician before
someone is admitted to the program. The social model
provides social activities, meals, recreation, and some health-
related services. Also, 78% of the centers are operated on a
nonprofit or public basis and the remaining 22 % are for profit,
with 74% affiliated with larger organizations such as
homecare, skilled nursing facilities, medical centers, or
multipurpose senior service organizations. In addition to
providing a protective and therapeutic environment for those
needing care, the day care centers offer family caregivers
respite from the burden of caregiving and allow employed
caregivers to continue to work and care for their loved ones at
home.
Currently, there are ,,-,4,000 adult day care centers in the
United States, which is far short of the estimated 8,520 needed
centers (NADSA, 2006; RWJF, 2006). Funding for adult day
care centers comes from federal, state, and local sources such
as the Federal Older Americans Act (OAA) , Social Services
Block Grant (SSBG), the Department of Agriculture's food
reimbursement program, state general fund dollars, philan-
throphic grants and contributions, and consumer fees and
charges. If the day care centers provide medical services, they
may also receive funds from Medicaid, local Veterans Affairs
(VA) medical centers, and Medicare for only rehabilitative
services such as physical or speech therapy. Payment by
private long-term care insurance is rare, but its share may
grow to some extent in the future as more adults buy private
long-term care insurance. Fragmented funding structure and
low utilization rates contribute to the financial problems of
many centers.
Best Practice Models
Propelled by the need for control of the cost of institutional
care and consumer preferences for home- and
community-based care over nursing home care, every state
now provides the Medicaid Home and Community-Based
Services [HCBS, 1915(c)] waiver program.

Adult day care centers, along with assisted living facil-
ities, home health care, and hospice eire, are cost,
effective community, based alternatives to nursing
home care that can benefit both functionally and cog-
nitively impaired adults and their caregivers (Cubanski
& Kline, 2002; Schacke & Zank, 2006; Valadez, Luma-
due, Gutierrez, & de Vries-Kell, 2006). Nevertheless,
adult day care services are underutilized because of the
shortage of centers, caregivers' lack of awareness of and
resistance to using services, and the mismatch between
the needs and wants of potential consumers and their
informal caregivers.
Between 1987 and 2002, national initiatives and
demonstrations to foster and support the' creation and
expansion of adult day.care centers were implemented
with funding from the RWJF. The focus of the initia-
tives was dementia care; however, the findings from the
demonstration programs showed the following elements
of the best practice models for adult day care centers: (a)
accommodation of the needs of caregivers, with
extended hours of services for employed caregivers,
weekend services, provision or arrangement of trans-
portation, and overnight respites; (b) provision of a
continuum of care, including assistance with informa-
tion and referral, case management, in-home personal
care, coordination of medical mental health services,
and caregiver support programs; (c) recruitment and
retention of quality staff; (d) working with participants'
doctors to alleviate participants' dementia-related be-
havioral problems; and (e) development and adoption of
creative strategies to engage' frail and impaired program
participants (Henry, Cox, Reifler, & Asbury, 2000). The
demonstration programs also found that day care centers
were able to achieve financial .sustainability by using
improved marketing to caregivers and formal referral
sources as well as increasing the charges to consumers
(with improved services). To better serve low- income
adults needing care, however, funding levels of the
OAA, SSBG, and Medicaid need to be increased.
Future Directions
Adult day care centers, in conjunction with home health.
care, hold promise to become essential components of
the community-based long-term care service network.
To meet the growing needs for quality long term care in
an increasingly aging society, however, adult day care
centers need to continue to develop and adopt a
comprehensive array of structured nursing,
rehabilitative and personal care, social recreational
activities, educational programs, and respite programs
for family caregivers. Especially with the increasing
ADULT DAY CARE 45
number of older adults who have Alzheimer's disease
and other forms of dementia, the proportion of partici-
pants with cognitive impairments is projected to grow in
the future. Adult day care centers specializing in
dementia care or having staff trained in dementia care
will be in high demand. Trained staff members are key
to provision of quality care (Salari & Rich, 2001).
Increased federal and state support is essential to alle-
viate the day care center shortage in rural and under-
served low-income areas, to develop workforce for the
centers, and to improve the quality of services.
This requires an in-depth knowledge of other coun-
tries' programs with their strengths and deficits.
Roles of Social Workers
Social workers, with appropriate training at the micro
and macro levels, are uniquely qualified to provide the
following services for adult day care centers: (a) out-
reach services to isolated frail adults, their family care-
givers, and formal service providers; (b) assessment of
participants' needs for services and care planning; (c)
design, implementation, and evaluation of programs; (d)
individual and family counseling, group activities, and
case management; (e) referrals to and coordination of
other community services as well as other in-house
supportive services such as transporta tion and volunteer
programs; and (f). advocacy for increased funding for
the services. With the serious current and projected
future shortage of gerontological social workers
(National Association of Social Workers [NASW],
2006), however, adult day care centers are and will be
understaffed with social workers unless concerted
efforts are made to recruit and train them to work in
aging services settings. Social work education curricula
need to continue to strive for incorporating more content
on community-based long-term care services as well as
practice and policy advocacy skills for the elderly and
disabled.
REFERENCES
Cubanski, J., & Kline, J. (2002, April). In pursuit of long-term
care: Ensuring access, coverage, quality. The Commonwealth
Fund Issues Brief. Retrieved December 20, 2006, from
http://www.cmwf.org
Henry, R. S., Cox, N.j., Reifler, B. V., & Asbury, C. (2000).
Adult day centers. In S. L. Isaacs & J. R. Knickman (Eds.), To
improve health and health care 2000: The Robert Wood
Johnson Foundation Anthology. Retrieved December 20,
2006, from http://www.rwjf.org/files/publications/books/
2000/chapter_ 05.htrnl.
. National Adult Day Services Association. (2006). Adult day
services: The facts. Retrieved December 20, 2006, from
http://www .nadsa.org/adsfacts/defualts.asp.
46 ADULT DAY CARE
National Association of Social Workers. (2006). Assuring the
sufficiency of a frontline work force: A national study of licensed
social workers; Executive Summary. Retrieved December 20,
2006, from http://workforce.socialworkers. org/studies/nasw
_06_ execsummary .pdf,
Robert Wood Johnson Foundation. (2006). Report: Shortage of
adult day services in most U.S. counties. Retrieved December
20,2006, from http://wWw.rwjf~org/newsroom.
Salari, S. M., & Rich, M. (200l). Social and environmental
infantilization of aged persons: Observations in two adult day
care centers. International Journal of Aging and Human
Development, 52, 115-134.
Schacke, c., & lank, S. R. (2006). Measuring the
effectiveness of adult day care as a facility to
support family caregivers of dementia
patients. Journal of ~plied Gerontology,
25,65-71.
Valadez, A. A., Lumadue, c., Gutierrez, B., & de Vries-Kell, S.
(2006). Comadres and adult day care centers: The perceived
impact of socialization on mental wellness. Journal of Aging
Studies, 20, 39-53.
SUGGESTED LINKS National Adult Day
Services Association. http://www.nadsa.org
National Association of Social Workers . .
http://www.naswdc.org
Robert Wood Johnson Foundation.
http://www.rwjf.org
-NAMKEE G. CHOI
ADULT FOSTER CARE. See Foster Care.
ADULT PROTECTIVE SERVICES
ABSTRACT: Adult Protective Services (APS) are
empowered by states and local communities to
respond to reports and cases of v.ulnerable adult
abuse, neglect, and self- neglect. While incorporating
legal, medical, and mental health services, APS
programs are part of th e social services delivery
system and incorporate prin ciples and practices of
the social work profession.
KEY WORDS: protective services; empowerment;
adult abuse
Adult protective services (APS) are the principal pub lic
source of response to reports and cases of vulnerable
adult abuse, neglect, and exploitation. APS programs
are empowered by states and local communities to
accept and investigate reports of abuse, neglect, and
financial exploitation of the elderly and younger people
with disabilities (Otto, 2002).
Authority for APS programs comes from state social
service and mental hygiene laws and regulations. Some
additional authority, particularly related to program and
service implementation, emanates from local laws and
ordinances as well. Although Older Americans Act Title
VII addresses elder abuse and mistreatment, this does
not. have the authority of state law to ensure protection
of vulnerable adults including the elderly as related to
parens patriae, the legal concept underlying the APS
program statutes.
Another federal bill before Congress, the ElderJus-
tice Act, would provide a dedicated funding source for
APS programs and propose a uniform definition of elder
abuse and neglect at the federal level. However, it would
continue to give states primary jurisdiction over APS
programs and services. Although different in size and
scope, State APS programs generally focus on
community-dwelling adults at least 18 years of age and
older who are at risk of harming themselves or others
and appear incapable of making informed decisions to
protect themselves or others from harm.
The earliest study of APS was conducted in 1960,
and used as the basis for a national conference held in
1963. The 1961 White House Conference on Aging
'recommended that social service agencies, legal aid and
bar associations, and the medical profession collaborate
on ways to facilitate provision of protective services to
older adults (Hall & Mathiasen, 1963). The newly
established Administration on Aging funded a number
of projects in the 1960s to assess the effectiveness of
selected service delivery systems of older adults identi-
fied as needing protective services (Dunkle, 1984).
However, by 1968 there were fewer than.20 com-
munity-based APS programs in the country. The real
impetus for states to provide APS came with the passage
of the Title XX Amendment to the Social Security Act
of 1974. The act gave permission for states to use Social
Services Block Grant (SSBG) funds for the protection of
adults as well as children (Mixson, 1995).
AlISO states, as well as the District of Columbia, and
the territories of Guam and the Virgin Islands have APS
programs that operate at the state and/or county level.
Annually, these programs receive more than 500,000
reports of abuse, exploitation, and neglect of persons
with disabilities and the elderly (Teaster, Dugar,
Mendiondo, Abner, & Cecil, 2007). While the majority
of APS clients are over 60 years of age, 34% of clients
are young- and middle-age adults who suffer from
disabling conditions including serious and persistent
mental illness (SPMI) , as well as physical

and developmental disabilities. A recent study of
substantiated abuse reports to APS on adults age 18 or older
found that 72.4% involved victims age 60 or older, 62.6% of
the victims were female, 76.1% were Caucasian, and 21.1 %
were African American (Teaster et al., 2007).
APS programs do not have income, resource, or
citizenship eligibility criteria. However, most require the
adults to be unable or unwilling to care for themselves or
incapable of making informed decisions about the situations
that are placing them or others at risk of harm. The most
common situation that brings a person with a disability or an
elder to the attention of APS is self-neglect, followed by.
caregiver neglect, in which another adult with caregiving
responsibilities is incapable of or refuses to prot-ide adequate
care for an at, risk dependent adult (Otto & Bell, 2003). APS
programs also serve adults who are physically, emotionally, or
financially abused or mistreated by others, but have limited
authority to intervene in situations in which adults who have
decisional capacity choose to remain in an unsafe situation or
relationship regardless of risk.
To date, most professional social work educational
initiatives target those social work students and scholars who
may be interested in moving into adult protection as a new .
field of practice. While there is an acknowledgement that
advanced training is imperative for social work with children,
there has not yet been such focus on the need to
professionalize public sector workers who serve the disabled
and elderly through APS (Brownell, 2006).
A national survey of APS training programs found that a
lack of specific funding for APS training was the states'
greatest obstacle. Educational requirements for APS line staff
were usually a bachelor's degree (85.7%) or high, school
graduation (17.1 %). Only a handful of states required
professional certification or licensure, a master's degree, or an
associate's degree. While most states required training for new
workers, the average number of training days was only 6.8.
Two-thirds of the states reported that new workers were
allowed or ex, pected to work in the field before completing
their basic training (Otto, Castano, & Marlatt, 2001).
APS workers have many of the same responsibilities for
detection, assessment, and intervention as child protective
service (CPS) workers. However, because their responsibility
is to investigate situations of adults at risk of harm to
themselves and others, they often have fewer remedies at their
disposal than CPS workers. According to constitutional law,
adults have the right to self-determination based on
presumption of capacity and agency unless determined
otherwise by a court of law (Karp, 1999).
ADULT PROTECTIVE SERVICES
47
Caseworkers and social workers in APS programs must
develop competencies in collaborative work with multiple
disciplines and domains such as law, medicine, psychiatry and
psychology, public entitlements, mental health, and the aging
service network. Critical value dilemmas and ethical conflicts
come to the fore related to autonomy and right to
self-deterrnination balanced against need for protection of
vulnerable adults who may not have the capacity for informed
decision making. In an effort to address ethical issues that
confront APS professionals in daily practice, the National
Adult Protective Services Association (NAPSA) has devel-
oped ethical principles and guidelines for best practices
(NAPSA, 2004).
Social work education provides a strong foundation for
protective work with adults. Role and value con, fliers,
inherent in adult protective service delivery, are addressed
across the curriculum in social work pro, grams. Professional
norms related to professional identity and status, independent
learning and action, and helping capacity are all critical to
worker effectiveness and motivation in this challenging field
of practice (Vinzant, 1998).
REFERENCES
Brownell, P. (2006). Departments of public welfare or social
services. In B. Berkman & S. D' Ambruoso (Eds.),
Handbook of social work in health and aging (pp. 435-443).
New York:
Oxford University Press.
Dunkle, R. E. (1984). Protective services: Where do we go from
here? Social Casework: The Journal of Contemporary
Social Work, Family Service America.
Hall, G. H., & Mathiasen, G. (1963). Guardianship and pro-
tective services for older people. New York: National Council
on the Aging.
Karp, M. B. (1999). Geriatrics and the law: Underswndingpatient
rights and professional responsibilities. New York: Springer.
Mixson, P. M. (1995). An adult protective services perspec-
tive. Journal of Elder Abuse and Neglect, 7(2/3),69-87.
National Adult Protective Services Association (NAPSA).
(2004). Adult protective services ethical principles and best
practice guidelines. Washington, DC: Author.
Otto, J. M. (2002). Program and administrative issues
affecting adult protective services. The Public Policy and
Aging Report, 12(2),3.
Otto, J. M., & Bell, J. C. (2003). Report on problems facing state
adult protective services programs and the resources needed to
resolve them. Washington, DC: National Adult Protective
Services Association (NAPSA).
Otto, J. M., Castano, S., & Marlatt, K. W. (2001). Report on
state adult protective services training programs. Washington,
DC: National Center on Elder Abuse.
Teaster, P., Dugar, T. A., Mendiondo, M. S., Abner, E. L., &
Cecil, K. A. (2007). The 2004 survey of adult protective
services: Abuse of adults 18 years of age and older: A report of
48 ADULT PROTECTIVE SERVICES
the national center on elder abuse. Washington, DC: National
Center on Elder Abuse.
Vinzant, J. C. (1998). Motivation and role conflict in child and
adult protective services. American Review of Public
Administration, 28(4), 347-366.
-PATRICIA BROWNELL AND JOANNE MARLATT OTTO
ADULTS. [This entry contains two subentries: Overview;
Group Care.]
OVERVIEW
ABSTRACT: Various models and theories of adult de-
velopment exist but they are ,more assumptions about
development than theories. The most popular age and stage
theories have lost favor to contextual theories that put more
emphasis on interaction with the environment. It has also
become recognized that adults are a diverse group and do
not follow universal stages of development. The usefulness
of chronological age is also questionable as it does not tell
us much about any particular person. Instead, we have to
know their concerns and the events they are dealing with,
and their dreams and aspirations,
KEY WORDS: age and stage theory; contextual model;
diversity; ecological system theory; life-span theory;
life-course perspective; mechanistic model; organismic
model; plasticity; universality
This overview addresses various models and other dif-
ferences in theories of adult development, selected
challenges faced by adults, trends and directions in the field
of adult development, and implications for social work.
Demographics
In the 20-100 years and older age range, the number of
African Americans is 262,360; American Indian, Alaska
Native 190,700; Asian, 844,800; Native Hawaiian, other
Pacific Islanders 338,000; Hispanic, 247,990; and White,
200,940,000. This adds up to a total of 389,325,000 adults
counted in the 2000 census. The number of immigrants was
275,270 (U.S. Census Bureau, 2oo5a).The median age
(half are younger and half older) in the United States was
353 years in 2000. This is the highest median age ever
recorded and reflects the aging of the baby boomers.
Almost one of five Americans will be 65 years by 2030.
Those aged 85 and older are the fastest growing age group
(U.S. Census Bureau, 2oo5b). These demographics have
increased the interest in and the scholarship on adult
development.
Differences Among
Theories of Adult Development
The current theories of adult development vary by model
and other dimensions. The models include the following:
Organismic Model. Persons are viewed as active with
an internal impetus for development. Development
follows a genetic blueprint and its own timetable. Age
and stage theories follow this model.
Mechanistic Model. Persons are viewed as passive in
regard to environmental influence. They react to their
environment and their experiences. Because each per-
son's experience is unique, there is no preset blueprint
for development. Instead, behavior is thought to be
learned.
Contextual Model. Persons are viewed as developing
from an interaction of their biological and genetic na-
ture, the environment, and a particular historical period.
This model integrates the other two models and is now
more influential than the other two models by
themselves (Lemme, 2006).
Another dimension on which the theories differ is
universality versus diversity. Universality implies that all
adults develop in the same way, in the same sequences, and
at the same rates. Diversity implies that persons develop
differently and in different sequences. Theories also differ
along the dimensions of developmental progress and
developmental change. Developmental progress assumes a
goal or endpoint toward which one moves. Developmental
change does not assume any endpoint, goal, improvement,
or growth. Theories also differ in whether they use stages
(usually linked to chronological ages) or not (Bee &
Bjorklund, 2004).
Related Theory
Several categories of related theory on adults exist. They
include the traditional age and stage theories and the more
contextual theories. Some age and stage theories are
mechanistic as they consider the influence of the
environment on adult development to varying degrees.
However, most of these theories are organismic and attri-
bute development to an innate, genetic blueprint. They also
assume universality in that everyone experiences the same
events or challenges at about the same time.
FREUD AN~ JUNG Contemporary age and stage theory
evolved from Freud's (1920) psychoanalytic theory,
although he did not propose adult stages. Adulthood
represented a reenactment of early childhood experiences.
In contrast, jung (1933) concentrated mainly on the second
half of life. Age 40 is a particularly important turning point
with the beginning of individuation or becoming more of
oneself. Inner conflicts are also resolved between the polar
opposites of masculine

versus feminine, creation versus destruction, youth versus
age, and separation versus attachment.
ERIKSON Erikson (1950) proposed stages of
psychosocial development that continued over the
life span. His work is organismic because there is a
built-in ground plan of development and his stages
are universal and hierarchical. It is also contextual as
it addresses the interaction between persons and
society.
According to Erikson, persons progress through eight
stages. The first five stages cover infancy through
adolescence while the last three stages 'cover young
adulthood through older adulthood. In each stage, one
confronts a psychosocial crisis. The crisis is resolved in an
adaptive or maladaptive way. Maladaptive resolu-
. \ .
tion results in unfinished work and unresolved conflict
so that it is more difficult to resolve the next stage. In an
adaptive resolution, one develops a basic strength or virtue.
Even if an adaptive result, however, the crises are never
permanently resolved. The same issues will come up again
and either adaptive or maladaptive outcomes can result.
Erikson's work is viewed as providing the strongest
momentum for the field of adult development. Because of
this the three adult stages are identified here:
Intimacy Versus Isolation (young adulthood, 20s30s).
For positive resolution, one must develop the capacity to
share with and care about others, without fear of losing
one's identity. The virtue is love. The alternative is to be
alone or experience isolation (Erikson, 1950).
Generativity Versus Self Absorption and Stagnation
(middle adulthood, 40-65). Growing awareness of mor-
tality leads to generativity or concern about future
generations and the legacy one will leave behind. The
virtue is care. Usually, the legacy involves nurturing,
teaching, leading, or in some other .way promoting the
next generation. The alternative is to remain focused on
one's own needs and wants or being self-absorbed. This
results in stagnation.
Integrity Versus Despair (late adulthood to death).
Integrity results when one looks back over one's life and
evaluates it as satisfying and meaningful. The alternative is
despair or evaluating one's life as unsatisfying, having
great regrets, and feeling that there is no time to change
anything.
Erikson's theory is appealing because of its coverage of
the full life span. But its limitations include a lack of
specificity in the stages and lack of applicability to women
and other cultures. For example, women may not
experience a separate stage of intimacy, as it is prevalent in
all stages for women (Gilligan, 1982). And studies of
generativity have shown that it may
ADULTS: OVERVIEW 49
come and go during the life span and in different forms
(Kotre, 1984; Stewart & Vanderwater, 1998). The theory
also relies on clinical observations versus empirical data.
However, others have started to test this theory. One study
by Whitbourne, Zuschlag, Elliot, and Waterman (1992)
found support for the theory, although the developmental
sequence and timetable may be much more variable across
persons.
HAVIGHURST Havighurst (1953) proposed an alter-
native stage theory of life span development. His
theory was based on developmental tasks that are
major accomplishments required of a person at a
particular point in life. Examples of tasks include
selecting a mate dur ing early adulthood, adjusting to
aging parents during middle age, and adjusting to
retirement and reduced income during later life.
LEVINSON During the 1970s, three new books on
adult development were published (Gould, 1978;
Levinson, 1978; Valliant, 1977). Daniel Levinson' s
book has been the most influential. It was based on a
sample of 40 men but a subsequent book on women
was published posthumously in 1996. The males
studied were between ages 35 and 45. Data collection
came . from extensive biographical interviewing that
included
10-20 hr per subject over a 2-3-month .period. A follow-up
interview occurred 2 years later.
Levinson described the life span as having a sequence
of eras lasting about 25 years. They include childhood and
adolescence, early adulthood, middle adulthood, and late
adulthood. Alternating stable and transitional periods occur
throughout life. Stable periods usually last from 5 to 7
years, 10 at the most. Transitional periods last about 5
years and occur within and between eras. Transitions from
one era to another are called cross-era transitions and
represent major turning points.
Within each era, stages begin with a novice stage and
end with a culminating stage. Key choices are made about
the kind of life one wants to live during an era. One sets
priorities and pursues goals compatible with them. But
eventually the choices come into question and this sets up a
transitional period. One reassesses the choices, reaffirms
some choices, explores options, and pursues new
possibilities. Often a sense of separation and loss
accompanies the ending of an old period but excitement
over possibilities and potential occurs as a new period
begins. Each step along the way has its own content to
contend with. For example, the rnidlife transition contains
issues such as awareness of mortality or not realizing one's
dream for one's life. Questions arise such as "What have I
done with my life?" or "What do I want for myself and
others?"
50 ADULTS: OvERVIEW
Levinson noted that the life structure was the key
concept in his study. It represents the underlying pattern or
design of one's life at a given time. It entails choices and
commitments and the social roles and activities that go
along with them. The major central elements of the life
structure are marriage, family, and work.
Levinson's work, although influential, has been con-
troversial. The samples were small and interviews have
potential bias and are difficult to replicate. Although he
found age-related periods in the basic framework, there was
considerable diversity in specific life events. Levinson also
put emphasis on the midlife transition as one of turmoil, but
empirical evidence of this phe- nomenon is mixed ..
Another issue of the Levi~on's first study is. the sample
of only men. In the later publication on women and other
studies. using his approach, women were found to go
through the same sequences of eras and periods at the same
ages as did the men. But women formed different life
structures as their opportunities and constraints were
different. Also the lives of both the men and the women
reflect~d a particular sociohistorical period.
Other theories have no age and stages. In addition, some
put much more emphasis on the effects of the environment
and historical period.
LOEVINGER Loevinger (1976) proposed a theory of ego
development. One can progress in ego developrnent over
time but she did not talk in terms of stages. Instead her
theory proposes milestones or markers along a con tinuum
in the areas of interpersonal relations, mor al judgment,
and conceptual complexity. There is also not a strong link
to ages as persons can be anywhere along the continuum
at any age. The rate of movement also varies widely. The
milestones are as follows:
Impulsive, Or being egocentric. This is representative of
children. If it persists into adolescence and beyond at worst
it could be psychopathic.
Self-protective, or being opportunistic and manipulative.
This is also characteristic of children. In adolescence or
adulthood, it is manifested as expl oitation of or taking
advantage of others.
Conformist, or having respect for rules. One is cooperative
and loyal and thinks in terms of stereotypes and cliches.
Self-aware, or beginning to develop an inner life. Thinks
that exceptions to simple rules are allowable.
Conscientious, or having self-evaluated standards. One is
self-critical and responsible.
Individualistic, or having a broad view of life as a whole.
Thinks in terms of psychological causes, and considers
one's own developmental process.
Autonomous, or seeing the multifaceted nature of the world.
Life is complex and does not have simple answers or even
one best answer. One sees one's own life in a social context.
Integrated, or combining the vital concerns of one's life with
those of the wider society. Has fully worked out one's
identity.
Few persons move beyond the self-aware stage.
V ALLlANT Valliant (1977,1993) also proposed devel-
opmental progress without stages. He was interested in
knowing how adults adapt psychologically to challenges they
face. He studied adaptation in the form of defense
mechanisms. This was Freud's concept for normal, un-
conscious strategies used to deal with anxiety. What Valliant
added was that some defense mechanisms are more mature
than others. Those considered more mature include the
following: anticipation (experiencing emotions prior to events
and developing realistic alternative responses or solutions),
affiliation (seeking others for help or support, not blaming
others for one's problems), altruism (meeting the needs of
others; gratification from others' responses), self-assertion
(expressing feelings or thoughts without being manipulative
or coercive), self-observation (reflecting on one's thoughts,
feelings, motivations, and behavior, and responding
appropriately), sublimation (refocusing potentially
maladaptive feelings or impulses into socially acceptable
behavior), and suppression (intentionally not thinking about
disturbing problems, wishes, feelings, or experiences).
According to Valliant (1977), one copes best with
mature defense mechanisms and will be more successful in
one's personal and professional life. The progression to
using mature defense mechanisms is gradual, and as
Loevinger's theory states, not everyone r eaches the more
mature levels.
BRONFENBRENNER The ecological system theory de-
veloped by Bronfenbrenner (1979) is gaining in promi-
nence because of its contextualism and its view that
persons are active constructors of reality. Reality as
perceived by persons is real in its consequences. Bron-
fenbrenner also proposed that a human being is a com-
plex system of biological, emotional, co gnitive, and
social elements. Persons also experience reciprocal re-
lationships with present and past environments.
The environment is conceptualized as a group of four
nested structures. Each structure is contained with in the
next and is a part of the whole. The person is in the center
of the group of structures. The four structures include the
microsystem, which is the innermost part of

the environment. It involves direct interactions ~ ith people
and objects and has three main elements: activ ities, roles,
and relationships. The mesosystem includes interactions
beyond the microsystem. An example is the relationships
between home and job and the effects they have on each
other. It is the interaction between microsystems that is
important instead of another layer of environment.
Because the mesosystem is a system of microsystems, the
mesosystem expands when one takes on a new role or
enters the settings associated with it. It is reduced when
roles are ended. Shifts in roles and situat ions are called ego
logical transitions and occur throughout the life span. The
exosystem includes settings that we do not directly
participate in, although they act in and influence
microsystems. For example, a
\
company can make a decision at a: board meeting to
downsize the company. Employees not on the board had
nothing to do with this decision, yet it may affect their
work, home life, income, and style of life. The macro-
system entails the widely shared beliefs and values that
determine how social groups are organized. Public policy
also operates at the macrosystem level as it reflects the
beliefs and values of a society. Public policy can maintain
or change the environment and thereby the behavior. The
macro system is also influenced by the sociohi storical
context and so it is fluid and evol ving. There can,
however, be a structural lag when the macrosystem and its
social institutions do not keep up with changes in
individual lives. An example is the increasing length of the
life span and the lack of meaningful roles and other
opportunities available to older adults.
LIFE,SPAN THEORY Another increasingly influential
theory is the life-span developmental perspective be-
cause it relates to constancy and change over the live
span. This theory, developed by Baltes (1987), does
not apply formal stages to adult life because of the
variability in adult lives. Instead of shared stages,
adults adapt to unique constellations of life
experiences.
Life stage theory promotes six beliefs as a way to think
about development:
1. Development is a lifelong process. No time of life is
more prominent than others as at any time new
possibilities may emerge.
2. Development includes both gains and losses.
Gains and losses happen at any time in the life span.
3. Development is multidimentional, multi directional,
and multicausal. Development occurs across many
areas, including physical, social, emotional, and
cognitive. Each area is related but also independent.
They follow their own
ADULTS: OVERVIEW 51
pattern or trajectory and timetable. Therefore,
change can occur in many areas, can proceed in
different directions, and is caused by many different
factors.
4. Development is plastic. Plasticity suggests that
development is modifiable because of life condi tions
and experiences. What are not known are the
conditions under which plasticity occurs, the degree
to which it can occur, or the constraints on its
occurrence.
5. Development happens in historical, cultural, and
social contexts. All aspects of de velopment are
affected by these conditions over one's life span.
Baltes (1979) added three categories of conditions
that influence development: (a) normative age-
graded or predictable, universally experienced
events such as puberty and menopause; (b) norma-
tive history-graded or events that occur in a
particular historical period such as wars, terror
attacks, September 11, 2001, or technological
advances; (c) nonnormative events or unique
experiences that are not predictable and do not
happen to everyone.
6. Development is a multidisciplinary field. Con-
tributions to the study of development are being
made in many different fields of study.
LIFE, COURSE THEORY The last theory discussed here
is life-course theory developed by Elder (1998). It
also looks at the interaction among social structures,
culture, biological components, and psychological
components. Role is one of the key concepts. Role
conflict can occur when one attempts to fulfill the
demands of two or more roles simultaneously. This
conflict occurs when two or more roles are partially or
wholly incompatible logistically or psychologically.
Role strain occurs when one's qualities or skills are a
poor match for the demands of a role.
Other key concepts in life-course theory include life
trajectory, life transitions, and turning point. Life tra-
jectory is the long-term view of change over the course of
a person's life. Life transitions are the short-te rm view
such as the change from being single to being married.
Any transition can also become a turning point if the
transition results in substantive changes. The impact of a
transition may also depend on timing such as becoming a
parent at age 40 or becoming a parent while trying to get
promoted at one's job. An additional factor is the length of
time between two transitions.
Elder identified four principles of life- course theory:
(a) Principle of historical times and places or the fact
52 ADULTS: OVERVIEW
that one's life course is shaped by one's historical times
and place; (b) Principle of timing or the developmental
impact of a transition depends on when it occurs in one's
life; (c) Principle of linked lives or the interde pendence of
lives and the expression of social and historical influences
through this network of shared relationships; (d) Principle
of constructionism or persons construct their own lives
through the choices they make and actions they take
within the constraints and opportunities of historical and
social circumstances.
All the theories of adult development have limita tions.
None of them have been well tested or even qualify in a
formal sense as theories. They are meta theories or
assumptions about development. Some are based on
small and unrepresentative, samples. And the samples
were only from Western culture and were primarily
White and middle-class.
Most developmental theories are in the age and stage
category. And they do not address one's environ ment or
the interaction between one's development and the
environment. They indicate universal progres sion and do
not suggest the variability among adults due to their
environment and life situations such as role changes ..
Only the contextual theory by Bronfenbren ner addresses
the environment. Life span theory also addresses the need
to look at multiple levels that influ ence development. The
theories of Bronfenbrenner, Loevinger, and Valliant do
not use the age and stage approach . Only Loevinger did
empirical research on her theory. Some theories such as
the one developed by Erikson have been examined
empirically by others. Some theories developed from
samples only on men, including those by Valliant and
Levinson (although a theory about women was developed
by his wife and published after his death). In social work
the most used theories are probably those by Freud and
Erikson. But these theories, although useful on some
levels, do not reflect interest in a clients' environment and
life situations and their influence on development. It is
important, therefore, to make additional use of theories
that emphasize the environment and life situations. We
cannot fully understand an adult's life by just looking at
the psychological level.
Selected Life Challenges
The current emphasis on nonstage views of adult devel-
opment was evident in several of the theories discussed.
Issues, events, or processes that apply across adult life are
now the predominant focus in the adult develop ment
literature. As not all the possible topics can be addressed
here, a general view of several processes that are
particularly challenging will be briefly discussed here.
They include differences in cognitive abilities,
physical changes, health and diseases, and life satisfac-
tion. Much more about these and other topics related to
adult development is available in current adult text books
and journal articles.
COGNITIVE ABILITIES This discussion focuses on in-
telligence, although it is not easy to define. One m odem .
definition of intelligence is the mental activity used to
successfully adapt to one's environment. This has been
called successful intelligence (Sternberg, 2004), practical
intelligence, or competence (Birren, 1985). Intelligence is
also increasingly described in contextual terms because
different environments call for different responses.
A major question about intelligence is, what hap pens
to it over time?A decrementalist view of intellec tual
development has been prominent. It predicts universal ,
inevitable, and pervasive decline. But this view has been
challenged. The early studies, which were cross- sectional,
covered up the variation among adults. Later longitudinal
studies found that for many persons cognitive
development remains stable or eve n improves. Some
persons in their 70s outperform some persons in their 30s .
And, most older adults fall well within the normal range
of intellectual performance until their 80s (Schaie, 1996 ).
Some new cognitive abilities may emerge in adulthood
(Perlmutter, 1988). Other abilities such as pragmatic
intelligence tend to increase over time. This involves
application of know 1edge to solve problems and adapt to
different environments (Baltes, 1987). But, individual
differences have been found among adults. F or some of
them, intelligence does decline either slowly or rapidly.
The challenge is, how to avoid decline in intelli gence?
Among the key factors preventing decline is exposing
oneself to stimulation through environmental and
occupational complexity. C omplex environments have a
beneficial effect whereas simple environments have a
detrimental effect (Schooler, 1990). Complex
environments challenge one with more diverse stimuli
and more complicated and ill-defined problems and thus
require more decisions. Simple environments do not
demand high cognitive effort and result in lower cognitive
development or decline (Lemme, 2006). Another strong
factor enhancing cognitive func tioning is mental
flexibility or the capacity to use a variety of approaches
and perspectives resulting in alter native solutions to
cognitive problems (Schooler, 1990).
PHYSICAL CHANGES The challenge here is to not
believe the myths of aging such as all changes as we age
are attributable to biological aging and we cannot control
any of them. Aging is not a purely biological process.
Genetic influence on aging may be as low as

30% (Rowe & Kahn, 1998) so that we may have much
more control over aging and health than we used to
think through lifestyle and environment. Primary aging
is genetically programmed, but secondary aging
rresults from extrinsic factors such as poor diet,
smoking, or too much exposure to sunlight. Persons
experience complex and reciprocal interactions with
various layers of the environment, which results in
enormous diversity in how they age. This diversity
increases as persons get older.
The conclusion here is that the number of pro-
grammed inevitable and decremental aging changes is
probably much less than previously believed; And age-
related decrements are hardly noticeable until they
reach a certain threshold level. ,This may happen quite
late in life or under conditions of extreme stress.
\
HEALJ'H AND DISEASES The peak of health for most
persons happens in young adulthood, but most adults
are in good health and experience few limitations or
disabilities (Older Americans, 2000). Still, health
and mobility does decline with age, especially after
the age of 80. Chronic conditions increase in
frequency after the age of 65. These conditions may
be treatable but are not curable.
Most (two-thirds) Americans will die from heart
disease, cancer, stroke, chronic lower respiratory
diseases, or accidents. Six of ten will die from heart
disease, cancer, and stroke (Centers for Disease Control
and Prevention, 2004). Of these diseases, most
Americans will die from coronary heart disease (CHD),
or heart attack. CHD accounts for about twothirds of
cardiovascular disease, which also includes
hypertension (or high blood pressure), cerebrovascular
accidents (strokes), and rheumatic heart disease
(American Heart Association, 1995).
Significant gender differences have been prevalent
with CHD. Its signs show up 10-20 years later in
women than in men. Before menopause, estrogen
seems to lower the risk of CHD-in women, but when
estrogen production dramatically' drops following
menopause the risk increases (American Heart
Association, 1998). Women are also twice as likely to
die of a heart attack within the first few weeks as are
men, and more women (44%) than men (2-7%) die
within a year following a heart attack (American Heart
Association, 1997). This situation reflects how the
environment impacts persons. The death rate probably
results from later diagnosis for women and so the
disease is more advanced before it is recognized.
Cardiac signs in women are ignored, misinterpreted, or
minimized (Healy, 1991). The death rate for African
American women from CHD is 35.3% higher than for
other women (American Heart Association, 1997).
Women may also not receive
ADULTS: OVERVIEW 53
as aggressive treatment or surgical management of their
heart conditions as men receive (Young & Kahana,
1994). On the other hand, the accepted interventions for
men are often inadequate or ineffective when used with
women (Ayanian & Epstein, 1991).
Years of exclusive focus on men's health left women
disadvantaged regarding the development of effective
preventive strategies, diagnostic tools, and interventions
(Sherman, 1993). The challenge here is external; . the
medical profession has responsibility to change this
situation. Fortunately for women, this change has be-'
gun to happen. Attention to the cardiovascular health of
women has increased. Under federal mandate, research
in this area cannot proceed (without good cause) unless
women and ethnic minority women and men are
included (Marshall, 1994). Ethnic minorities generally
experience more health problems than do Whites, and
the problems develop earlier in life, are more severe, and
more often fatal (American Heart Association, 1997).
Attention is also now given to the bias in diagnosis and
treatment of women (Holm & Penckofer, 1995).
Advances are also being made in breast cancer because
of pressure from women's groups. It has moved to the
forefront of attention because of efforts of the National
Institutes of Health, the U.S. Public Health Services
Task Force on Women's Health Issues, the formation of
the Office of Research on Women's Health, and the
development of the NIH Women's Health Research
Agenda (Woods, 1995). These various circumstances
are an example of when action at the macro level and
social and medical policy levels is required to change
the situation at the micro level. We will see the effects
on persons with CHD and other diseases (in this case
women and ethnic minorities). See the Web sites of the
American Cancer Society
(http://www.cancer.org/docroot/STI/content/STI_1x_
Cancer_Facts_Figures_2006.asp) and the American
Heart Society (http://www .heart.org/presenter. jhtmI?
identifier 1200026) to keep up with rates of illness,
deaths, and other information.
Behavioral factors are also critical here as in
everything else about adult development. Preventive
behaviors, including regular physical exercise, elimi-
nating smoking, adequate calcium intake, eliminating
overweight, and good nutrition, may help hold off
health problems. The 2007 Web site of the American
Heart Association (http://www.heart:org/presenter.
jhtm1?identifier= 1200009) has many useful
suggestions for a healthy lifestyle, including diet,
weight, exercise, and control of cholesterol.
HAPPINESS AND LIFE SATISFACTION Most Americans
are happy or evaluate their lives as positive and say
54 ADULTS: OvERVIEW
that they are satisfied with their lives. Men and women are
equally likely to describe themselves as happy and
satisfied with their lives. No time in life is happiest and
most satisfying; overall subjective well- being does not
decline as we get older (Pinquart & Sorensen, 2000).
Among variables that may affect happiness is income,
as those with higher income are on average happier. But if
everyone in one's comparison group has a similar income,
life satisfaction or happiness does not increase (Bee &
Bjorklund, 2004). Temperament also plays a role in life
satisfaction. Those higher in extraversion and lower on
neuroticism describe themselves as happier (McCrae &
Costa, 2003) .
. The most potent variable affecting life satisfaction is
happiness with one's marriage flld family relationships. As
much as 15-20% of the variation of happiness is
. attributable to this variable (Campbell, 1981). Having a
sense of personal control or being in charge of one's life
and responsible for one's own decisions are also related to
greater levels of happiness (Diener, 1984). The challenge
is to generate and maintain happy social networks and a
sense of control in one's life.
Health is also a potent variable as it is most highly
correlated to life satisfaction, subjective well- being, and
morale (Larson, 1978). But it seems to be perception of
health that matters most. For example, perception of one's
own health is a better predictor of life satisfac tion than a
doctor's objective report. Although current "good health" is
not the same as what one viewed as "good health" when
one was younger. In terms of one's relationships, perceived
adequacy of one's social interactions is most strongly
related to happiness instead of absolute quantity (Bee &
Bjorklund, 2004; Brandtstadter & Greve, 1994). The
challenge here is to think positivel y about our health and
the relationships we have.
Trends and Directions
The age and stage theories have lost support in the field of
adult development. It is moving away from the idea that all
adults develop in the same way and in the same sequence.
These theories are appealing because they imply order in
adult development, but adults seem not to follow an
orderly plan. They also suggest a norm of development. So
if some persons do not meet the norm, do we conclude that
they are not normal? Also, the boundaries of life stages are
fuzzy and fluid in terms of when one enters and leaves.
When one thinks that some adults are in a certain life
stage, they may tell you they are in another stage. For
example, many older persons may say that they are in
midlife because they are mobile, active, and do not feel
old. Chronological age does not help us understand the
subjective life of an adult.
Each era calls for different skills and qualities. So what
predicts success at one era may not predict it at other eras.
Also, we are affected by how we start out in life and by the
choices we make as we go along and our ability to learn
from experiences we face. Success may have more to do
with one's resources and opportunities, what one does with
them, the choices one makes, and what one learns and
applies to one's life (Valliant & Valliant, 1990). We also
have to know the sociohistorical context of persons' lives
as well as what is going on at multiple levels in their lives
and their influences.
Implications for Social Work
Adult development is a field social workers must follow
closely because the ongoing research can significantly
change the knowledge. For example, we now know that
persons have much more control over health and aging
than we used to think. There is also the probability of
maintaining and even advancing intelligence. These are
exciting areas in the adult development field because the
current findings are radically different from what they used
to be. But these findings also tell us that adults have to take
an active role in maintenance of their intelligence and
health. We do not have control over everything but there
often seems to be a payoff from proactive and preventive
behaviors.
Another major change with implications for social
work is the greater importance put on life events and
current issues. What are persons concerned with? What is
at the foreground of their lives? Are they getting married
or getting divorced? What are their aspirations and life
dreams and how are they progressing toward them? This
kind of information is of greater import than chronological
age, which gives us little information about any adult. And
we have to keep in mind that issues are never fully
resolved; they reemerge at different times. Issues now in
the background may come to the foreground at some later
time.
As suggested earlier, adults are diverse and so theories
that suggest universal development often do not fit. The
theories that are not in the age and stage category fit better.
Although all the theories have limitations, the nonstage
approaches are far more practical and realistic to use with
clients as there are many diverse pathways through
adulthood. Several important implications for practice
with adult clients include the following:
1. We have to know the multiple levels of their lives.
Theories such as the ecological systems theory by
Bronfenbrenner can help in this assessment.
2. The age and stage theories can provide under-
standings of certain levels such as the psychological,
but they are seriously limited in their typical view

that development follows a universal and smooth
progression, and there is no attention given to the
environment and life situations.
3. We, will get far more information about adult
clients through asking what they are currently
dealing with in their lives than being concerned
with their chronological age, which rarely
predicts anything useful.
4. As suggested by life course theory, we c an also
understand better what our adult clients are
experiencing by examining their life transitions
and turning points.
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FURTIlER READING
Levinson, D. J. (1996). The seasons of a woman's life. New York:
Knopf.
-SKI HUNTER
GROUP CARE
ABSTRACT: This entry presents information about group
settings that provide residential long-term care for older
adults, focusing on nursing homes and residential
care/assisted living communities. It provides an overview of
both settings, and describes their scope of services, funding,
and clientele. The section Issues in Residential Long-Term
Care addresses issues of special relevance to social workers:
dementia and other psychosocial care needs; quality of life
and quality of care; access to and disparities in care;
end-of-life care; family involvement; and abuse and neglect. It
ends with a section on the role of the social worker in
residential long-term care.
KEY WORDS: nursing homes; quality of care; quality of life;
residential care/assisted living
Group care for older adults who require supportive services
can be provided in nonresidential settings (such as adult day
programs) or residential settings (including nursing homes and
residential care/assisted living communities). This entry will
focus on residential long-term care settings. Nursing homes
are an especially important component of the long-term care
system, and although only 5% of the older adult
population is in a nursing home at any given time, onehalf of
all adults over age 65 spend at least some time there. Further
highlighting their magnitude, there are approximately 17,000
nursing homes in the United States serving 1.6 million
individuals. However, this is only a portion of the residential
long-term care system. Residential care/assisted living
settings have proliferated over the last decade, to the point that
the number of beds in these residences rivals that in nursing
homes. There are approximately 36,000 such communities in
the United States, housing as many as 1 million older adults.
While nursing homes and residential carel assisted living
settings differ, both exist to address the care needs of an older
population, and both confront some of the same challenges
while doing so. This entry will provide an overview of these
close with discussion regarding the role of social work in the
field of residential long-term care for older adults.
Settings of Residential Long, T erm Care NURSING
HOMES Since the inception of Medicare, nursing homes
(also referred to as skilled nursing facilities) have been the
predominant form of residential long-term care in the country.
They provide 24-hr nursing care, supervision, help with
activities of daily living, meals, and medication
administration to people who cannot manage independently.
They also provide rehabilitative services, including physical,
occupational, and speech therapy, to assist those recovering
from acute conditions such as stroke or hip fracture. Thus, the
predominant model of nursing home care is medical, ordered
by. physicians, planned primarily by licensed nurses, and
delivered by professional or paraprofessional staff-although a
"culture change" movement is under way to better orient care
to the psychosocial needs of these residents. The average an-
nual cost of nursing home care is approximately $56,000 with
total national expenditures reaching $78.6 billion (1998
dollars). Medicaid funds the majority of this care (40%, the
equivalent of $31.4 billion in 1998), followed closely by
private out-of-pocket payments (36%, $28.5 billion), and to a
much less extent Medicare payments (13%; $10.4 billion).
The nursing home clientele reflects the demographics of
the older population, and so the majority (almost 75%) of
residents are women. The average age at admission is 84, and
approximately one-half of residents are 85 years of age or
older. Approximately one-third of admissions are for
short-term rehabilitation after hospitalization, although those
receiving rehabilitation occupy less than 10% of beds.
 ADULTS: GROUP CARE 57

An estimated 75% of residents require assistance in three privately, but with the growth and impairment level of the
or more activities of daily living such as bathing, dressing, clientele, there has been a trend toward public subsidies
eating, transferring from a bed to a chair, and using the and by 2003, 41 states provided funding for these services .
toilet. In addition to need for medical an d assistive care, Nonetheless, private sources continue to provide the
there also is need for psychosocial care. One- half of new majority of payments (75%), with minor support from
admissions have dementia (this being a primary reason for long-term care insurance 2%) and managed care 2%).
admission), as do as many as threequarters of long-stay The remaining costs are covered through a combination of
residents; these figures are notably higher than the 15% of, Medicaid waivers, state funds, and supplemental security
community-residing older adults who have dementia. Also, income (SSI).
almost one-half of nursing home residents have depression, Over time, residents in residential care/assisted liv ing
which is higher than the 8-20% prevalence rate in the communities have come to resemble nursing home
community. Overall, the length of time since admission residents of the past. Like nursing homes, the majority
among all residents is 2.5 years. Thus, there is ample time (75%) are female. Depending on the type of residence, as
for social workers and other health care providers to many as 40% of residents are impaired in performing
develop a therapeutic relationship with most residents. activities of daily living, have moderate or severe de-
mentia, or display behavioral symptorris. The exact
composition of the resident profile is somewhat depen dent
RESIDENTIAL CARE/ASSISTED LIVING COMMU- on state regulations, however, as admission and retention
NITIES Residential care/assisted living. communities criteria define the client population and the limits to which
became a boon industry in 1993, as the number of older residents are allowed to age-in-place. One thing that has
adults who needed supportive care (but not medical care) become certain is that residential care/assisted living has
increased, and advocates and businesses sought to provide become a primary provider of residential care for older
housing with services that would overcome dissatisfactions adults with cognitive impairment, with as many as 90% of
with nursing home care. These settings are highly var iable the residents having some level of impairment.
in terms of their structure and services, but have in
common that they provide room, board, 24-hr supervision,
and assistance with medications and activities of daily Issues in Residential Long, T erm Care Nursing
living. While not medical settings, most help coordinate homes and residential care/assisted living communities
and/or access health services, and approximately one- half are complex settings that care for a range of frail,
have a nurse on staff. Initially, the term "assisted living" . c~.,nica1ly ill persons. Not surprisingly, numerous issues
referred to a specific model of care based on principles of exist regarding the optimal provision of care in these
individuality, independence, privacy, dignity, and choice; settings. Those that will be reviewed here are especially
it embraced homelikeness, and had individual sleeping relevant to the field of social work, and include dementia
spaces, full baths, kitchens, and doors that locked; and it and other psychosocial care needs; quality of life and
introduced concepts such as customized care plans. Over quality of care; access to and disparities in care; end-oflife
time, the term assisted living has been used much more care; family involvement; and abuse and neglect.
broadly, to refer to a diversity of facilities regulated by the
states under a variety of designations including board and DEMENTIA AND OTHER PSYCHOSOCIAL CARE
care, residential care, personal care, foster care, NEEDS In the 1990s, almost one-quarter of nursing homes
domiciliary care, and congregate care-and not all of which responded to the preponderance of residents with dementia
subscribed to the listed principles. Because of the by developing and marketing "special dementia care" in
controversy surrounding the use of the term, it is clearer to the form of units dedicated to the care of persons with
refer to all such settings as "residential care/assisted dementia; more recently, residential care/assisted living
living." Today, residential care/assisted living facilities communities have followed suit. These units were thought
range from private, converted houses with fewer than 10 to be a superior treatment environment because they were
beds, to multilevel campuses with more than 1,400 beds. purported to specially select, train, and supervise their
Some have private apartments, whereas others have four staff; provide activities designed for the cognitive1y
residents per room. Rates range from less than $400 to impaired; involve the family in treatment; and have a
more than $6,000 per month, with the average cost being physical environment designed for safety and segregation.
approximately $30,000 a year. Most residents pay However, these components are not always in evidence,
and the provision of "special care" does not consistently
relate to
58 ADULTS: GROUP CARE
better resident, staff, and family outcomes. Further, the
vast majority of long-term care residents with dementia are
not treated in "special" units. Thus, dementia care has
become the province of all long-term care provi ders, but
most staff are not sufficientlv trained in providing
dementia care. Further, there is widespread evidence that
care for the mental health needs of long-term care resident s
is lacking.
QUALITY OF LIFE AND QUALITY OF CARE One of
the most important changes evolving in the field of
residential long-term care is the appreciation that those
who live there are not merely waiting to die. Instead, they
are able to experience joy, meaningful relation ships, a
sense of comfort, and other pleasures that together
constitute quality of life. Thus, there is emerging
appreciation that the quality of care should be judged by
the quality of life achieved by the residents, and now all
long-term care settings are being called upon to help
provide meaning to residents' lives. Consequently, the
quality of long-term care is improving, in part a result of
federal nursing home regulations and state residential
care/assisted living regulations, as well as from grass roots
efforts that emphasize consumer involvement, better
physical environments, and care that is person directed and
focuses on caring for people and relationships, rather than
on the task of care provision (known as "culture change").
In addition, emerging data indicate that overall, the quality
of care does not differ in nursing homes compared to
residential care/assisted living, which is a promising
finding given that nursing home care is significantly more
expensive.
ACCESS TO AND DISPARITIES IN CARE The current
trend is for long-term care in the United States to be
increasingly segregated by payment status. While level of
need determines eligibility for care, nursing homes
primarily serve a Medicaid clientele, and residential
care/assisted living facilities serve those who can pay
privately. Further, even within nursing homes, quality of
care indicators are poorer in homes with more Medicaid
residents, and within residential care/assisted living
settings, the proportion of residents who are minorities is
minimal. Fortunately, such disparities in access and care
are receiving attention. As a case in: point, states are
experimenting with creative models of financing
affordable assisted living, which will increase access for
those with lesser means.
END-OF-LIFE CARE With more older adults living in
long-term care, more are dying there, as welL In fact, as
many as two-thirds of nursing home residents die there
rather than in hospitals or private homes. As of 2008,
the proportion of U.S. deaths occurring in long-term care
is 23%, and is expected to increase to 40% by the year
2040. One of the issues relevant to end-of-life care in
long-term care is the presence and adequacy of available
medical services .. Physician presence is not common in
either residential setting, and long-term care providers
may not be sensitive to changes in resident status that
suggest impending death and the need for palliative care.
Similarly, when families are not present on a daily basis, it
is challenging to know when to contact them so as to
assure their presence at the time of death. Fortunately,
these types of issues are receiving attention, and one
historic limitation of end-of-life care in long-term
care-insufficient use of hospice-seems to be resolving.
F AMIL Y INVOLVEMENT It is the norm, rather than the
exception, that older adults who live in long-term care
settings were cared for by family before their admission,
and that caregiving does not end after admission. In fact,
families visit residents an average of twice a week, for
approximately 4 hr. They constitute an important resource
to staff because they have knowledge of the resident's
history, and they are important to the resident for emotional
connectedness and psychosocial . health. Indeed, family
presence improves resident psychological and psychosocial
well-being, as well as the accuracy of diagnoses and the
resultant care. Also, family members are called upon to
make decisions regarding care for cognitively impaired
residents, and to provide continuity that may otherwise be
lacking due to staff turnover. However, the value of family
members as a resource in long-term care is only beginning
to be realized, and family caregivers still experience stress
and depression just as they do in community settings.
Consequently, efforts have begun to consider how to
integrate them into the fabric of long-term care provision,
while not overburdening them and creating tension with
staff.
ABUSE AND NEGLECT Residents of long-term care
facilities are especially vulnerable to abuse due to their
physical and cognitive limitations, dependency, inability
to report, and fear that if they do, their reports may result
in retaliation. While there are no accurate estimates as to
the prevalence of abuse in long-term care, there is evi-
dence to suggest that it is a notable problem, and that the
quality of staff-resident interactions predicts abuse. Thus,
this is an area that seems ripe for social work intervention.
The Social Worker in
Residential Long- T enn Care
Issues related to dementia and other psychosocial care
needs, quality of life and quality of care, access to and
disparities in care, end-of-life care, family involvement,

and abuse and neglect in long-term care are relevant to social
workers to the extent that they provide services in these
settings. Federal law requires that nursing homes with more
than 120 beds employ a full-time social worker who has a
bachelor's degree (or higher) in social work or similar
qualifications. Smaller nursing homes must provide social
services, but are not required to have a full-time social worker
on staff. Availability is not at all assured in residential
care/assisted living, where despite similar need, a social
worker's presence is not required. However, some of these
residents do receive social work services, including by social
workers not directly employed by the setting (for example,
Medicaid case managers).
The mission of social work practice in long-term care is to
promote residents' social and psychological well-being while
helping them retain individuality, independence, and choice.
Social workers in long-term care frequently (a) facilitate the
admissions process (for example, promote the resident's
participation in decision making and help him/her adjust to the
facility); (b) develop an individualized plan of care; (c)
facilitate the social and psychological well-being of residents
and their families (for example, address mental health dis-
orders such as depression and dementia, as well as issues of a
more social nature including loss' of relationships, control, and
identity); (d) plan discharges to ensure appropriateness and
continuity of care; and (e) involve the entire facility in meeting
residents' psychosocial needs through policy, training, and
advocacy.
Monitoring the quality and appropriateness of psy-
chosocial and social work services in nursing homes has
become an area of increasing concern, and dialogue has begun
as to the need for social work services in residential
care/assisted living, as well. To promote these efforts, the
National Association of Social Workers has set forth clinical
indicators that relate to processes of care (that is, timely and
comprehensive psychosocial assessments and resident and
family involvement in care planning) and outcomes of care
(that is, resident satisfaction with choice and problem
resolution). Also, there is a call to action for social workers to
monitor and measure psychosocial care and quality of life,
including the use of applied measurement tools.
Within this context, recommended social work roles 'and
quality indicators suggest concrete areas for action. For one,
social workers could use quality of life measures to better
understand areas in which an individual's quality of life may be
improved, to intervene to improve quality such as by
increasing the individual's sense of autonomy and control, and
to monitor change over time. Also, they could work to shape
facility policies in accordance with evidence that relates
components of
ADVOCACY 59
care to resident well-being. In addition, because staff training
relates to both resident quality of life as well as staff feelings
of competence and satisfaction, social workers could play an
important role in providing needed in-service education, and
intervene to reduce tensions that result in resident abuse.
Further, family members may be helped to understand the
types of caregiving in which they will be active, so as to ease
their involvement. Given the number of older adults who now
and will live in residential long-term care in the future; the
social work profession has the opportunity to play an
important role in promoting the well-being of millions of
individuals.
FURTHER READING
Assisted Living Workgroup. (2003). Assuring quality in assisted
living: Guidelines far federal and state policy, state regulation, and
operations. A report to the U.S. Senate Special Committee on
aging. Retrieved October 31, 2008, from http://www.
aahsa.org/alw/intro. pdf
Kane, R. A., Kane, R. L, & Ladd, R. C. (1998). The heart of
long-term care. New York: Oxford University Press.
National Association of Social Workers. (1993). NASW clinical
indica tars far social wark and psychosocial services in nursing
homes. Retrieved October 31,2007, from http://www.social
workers.org/prac tice/standards/nursin~homes.asp#process I'
Noelker, L S., & Harel, Z. (200l). Linking quality of long-term care
and quality of life. New York: Springer.
Schulz, R., Heck, E., Sloane, P. D., & Zimmerman, S. (Eds.).
(2005). Dementia care and quality of life in assisted living and
nursing. The Gerontoologist, 45 (1 y. Retrieved October 31,
2007, from http://www.alz.org/national/documents/gmcal1.
pdf
Vourlekis, B., Zlotnik, J. L, Simons, K., & Toni, R. Blueprint far
measuring social wark's contribUtion to psychosocial care in nursing
homes: Results of a National Conference. Retrieved October 31,
2007, from http://charityadvantage.com/iaswr/
Final1GSWIASWRBrief33105.pdf
Weiner, A., & Rench, J. (2003). Culture change in long-term care.
New York: Hawthorne Social Work Practice Press.
Wunderlich, G. S., & Kohler, P. O. (200l). Improving the quality of
long-term care. Washington, DC: National Academy of
Sciences. '
Zimmerman, S., Sloane, P. D., & Eckert, J. K. (200l). Assisted
living: Needs, practices and polides in residential care far the
eUlerly. Baltimore: Johns Hopkins University Press.
-SHERYL ZIMMERMAN
ADVOCACY
ABSTRACT: Social work advocacy is "the exclusive and
mutual representation of a clientts) or a cause in a forum,
attempting to systematically influence
60 ADVOCACY
decision-making in an unjust or unresponsive systernls)."
Advocacy was identified as a professional role as far back
as 1887, and social workers consider client advocacy an
ethical responsibility. Social workers are increasing the
use of electronic advocacy to influence client issues and
policy development. As client and societal needs evolve,
universities should emphasize advocacy in their curricula,
and the National Association of Social Workers should
promote electoral and legislative initiatives that reflect an
emphasis on social and economic injustices.
KEY WORDS: advocacy; influence; policy practice;
social action; representation; social' justice; online
advocacy
Social work is the one profession that has acknowledged,
decade after decade, a healthy tension between individual
needs and the policies of the larger society (Schneider &
Netting, 1999). This recognition often results in
"advocacy."
Definition of Advocacy
Litzelfelner and Petr (1997) stated unequivocally, "The
social work profession considers client advocacy an
ethical responsibility and a primary function of social
work practice" (p. 393). However, some scholars
(Blakely, 1991; Kutchins & Kutchins, 1978; Schneider &
Lester, 2001) believe that advocacy, while long associated
with exciting changes that benefit vulnerable groups,
refers to all kinds of social action without any distin-
guishing or specific characteristics of its own. Sosin and
Caulum (2003) noted that "the role of advocate seems to be
practically synonymous with about all social work roles,
and it is presented in such broad strokes that it cannot be
systematically studied, described, taught, or practiced
[authors'emphasis]" (p. 12). Haynes and Mickelson (2006)
stated, "Advocacy requires no additional skills other than the
ability to aggregate data or mobilize clients" [p. 84). Bateman
(personal communication, October 4, 2001) stated,
"Advocacy was assumed to be something one just knew how
to do."
Schneider and Lester (2001) contributed to the
evolution of the term by analyzing over 90 definitions of
advocacy in the social work literature. Differing emphases
in individual definitions ranged from "pleading on behalf
of someone" to "securing social justice" to "identifying
with the client" to "promoting change" to "accessing rights
and benefits" to "demonstrating influence and political
skills." Since the term advocacy possesses multiple
meanings, it has become a futile term because
practitioners and researchers do not have a
common understanding of the word. By failing to limit the
term, the profession has neglected to sharpen practice
efficacy, that is, how does one advocate well and what is
effective. This failure may lead Social workers to continue
to believe that advocacy is defined primarily by working
actively to meet client needs by arranging services, and not
by partisan intervention when it is needed (Herbert &
Mould, 1992)
Schneider and Lester (2001) developed a new definition
of social work advocacy that appears to advance the ongoing
struggle for specific conceptual clarity. Their definition of
advocacy is clear, measurable, action oriented, and focuses
on what one does as an advocate, and not just on outcomes.
The definition is comprehensive because it can be ap plied to
the myriad .. practice settings where social workers find
themselves, such as working one-on-one with clients,
working for community causes, in legislative arenas, and in
agencies.
Definition: Social work advocacy is the exclusive and
mutual representation of a client(s) or a cause in a forum,
attempting to systematically influence decision-making in an
unjust or unresponsive system(s) (Schneider & Lester, 2001,
pp. 64-68). Let us examine the key words in the
definition:
Exclusive: The relationship between the client and the
advocate is singular, unique, prioritized solely on the
client, primarily responsible to the client, and centered on
client needs.
Mutual: The relationship between the client and .the
advocate is reciprocal, interdependent, joint, and equal;
they exchange ideas and plans together, proceeding in an
agreed-upon direction. Included in the term, mutual, is also
the notion of empowerment that not only enables the clients
to carry out an activity, but also motivates them and
teaches them skills required to interact with the
environment.
Representation: The advocate uses the activities of
speaking, writing, or acting on behalf of another, com-
municating or expressing the concerns of a client, standing
up for another person or group, and serving as an agent or
proxy for another.
Client(s): The clientls) may be an individual person,
small or large groups, a community association, an ethnic
population, individuals with common concerns, or other
loosely or tightly knit organizations. The "clientts)" is not
restricted a priori to certain sizes or numbers.
Cause: A cause is usually a condition or problem
affecting a group or class of people with similar concems.
Circumstances of an individual may be the basis for a
larger group needing the same remedy. An example may
be advocating for the rights for all domestic abuse victims,
not just one client.

Forum: A forum is any assembly designated to dis,
cuss issues, regulations, rules, public matters, laws, or
differing opinions, or to settle disputes. Examples are
public hearings, legislative committees, agency board
meetings, and supervisory sessions. Two features are
usually present: (a)a set of specific procedures to guide
the conduct of the participants, and (b) a
decision-making mechanism (Kutchins & Kutchins,
1987).
Systematically: The advocate applies knowledge and
skills in a planned, orderly manner, analyzing the
circumstances and conditions before deciding how to
proceed.
Influence: An advocate attempts to modify, change,
affect, act on, or alter decisions by another person or
group with the authority or power over resources or
policies that impinge upon a clientts). Some "influen-
tial" activities consist of organizing client groups,
forming coalitions, educating the public, contacting
public officials and legislators, giving testimony, and
appealing to review boards (Hepworth, Rooney,
Dewberry, Rooney, Strom-Gottfried, & Larsen, 2006).
The following are the principles of influence used to
take action:
1. Identify the issues and set goals
2. Get the facts
3. Plan strategies and tactics
4. Supply leadership
5. Get to know decision makers and their staff
6. Broaden the base of support
7. Be persistent
8. Evaluate your advocacy effort (Schneider &
Lester, 2001, pp. 116-147)
Decision,making: This refers to the conclusions, judg-
ments, or actions of those who are authorized to allo-
cate resources, define benefits, and determine
eligibility and access to services, adjudicate grievances,
establish appeals, or make policy for a government or
an agency.
Unjust: Advocates believe that an action, stance,
institution, regulation, procedure, or decision is not in
accord with the law or the principles of justice. "Unjust"
indicates that fairness, equity, lawfulness, jus . tice, and
righteousness are absent to some degree.
Unresponsive: Advocates identify persons or institu-
tions that fail to reply, acknowledge, correspond, or
answer inquiries, requests, petitions, demands, ques-
tions, letters, communiques, or requests for appoint,
ments in a timely fashion if at all.
System( s}: This refers to organized agencies designed
and authorized to provide services to eligible persons,
enforce laws and judgments, and be responsible for key
areas of a society's allocation of resources. Examples
are the criminal justice system, the mental health
system,
ADVOCACY 61
the legislative system, the welfare system; the health
care system, and the transportation system.
This definition provides a coherent and distinguish,
ing set of characteristics for the term advocacy, and
offers a systematic foundation for implementing future
advocacy practice, education, and research.
History of Social Work Advocacy Organized
social work emerged in the 1870s. The term advocacy
was first evidenced in the Proceedings of the National
Conference of Charities and Corrections (1917), where it was
referred to as a social work role as far back as 1887. At
that time, social workers targeted social legislation for
children, prisons, immigration, the courts, and working
conditions of the poor. During the Progressive years,
the late 1800s until 1914, social work advocates fought
for basic human rights and social justice for oppressed,
vulnerable, and displaced populations, including
immigrants, women, children, and.minorities.
Settlement houses such as the famous Hull House in
Chicago promoted equality and social justice. Among
the notable social workers of this era were Jane
Addams, Edward T. Devine, Edith Abbott, Grace
Abbott, Lillian Wald, Sophonisba Breckinridge, Julia
Lathrop, Mary Richmond, Florence Kelley, Simon
Patten, and Samuel M. Lindsay (Schneider & Lester,
2001; T rattner, 1999).
World War I and the postwar years presented nu-
merous challenges, and many social workers focused
their efforts on humanitarianism and international
peace. Two social work advocates subsequently re-
ceived the Nobel Peace Prize-Jane Addams in 1931 and
Emily Greene Balch in 1946 (Bicha, 1986). However,
the development and inclusion of psychology in social
casework techniques had an adverse effect on
advocacy. The individual and the person's inadequacies
became the focus of attention, blame for poverty and
hardship was attributed to the individual rather than the
larger forces of society (Kurzman, 1974).
Following the stock market crash in October 1929,
advocacy reemerged during the Great Depression.
Social workers advocated for economic relief
legislation and measures such as the Temporary
Emergency Relief Administration and the Federal
Emergency Relief Administration (FERA). Harry
Hopkins led FERA and Frances Perkins was appointed
Secretary of Labor in the Roosevelt administration, the
first woman in a president's cabinet. Both were social
workers.
After World War II, the word advocacy disappeared
from the literature, replaced by the term social action.
This term included other concepts such as "citizen
participation," "social change," and "community
organization." In the 1960s, civil rights, poverty, and
62 ADVOCACY
inner city life took center stage. Important programs of
President Lyndon Johnson's Great Society such as the Job
Corps, the Youth Corps, Head Start, VISTA, family
planning services, neighborhood legal services, and
community health centers were developed (Ehrenreich,
1985), renewing interest in advocacy practice for
vulnerable and oppressed populations.
Grosser (1965) provided the first contemporary outline
of a social work advocate's role, as "co-opted from the
field of law." He believed that an advocate should not be an
"enabler, broker, expert, consultant, guide, or social
therapist" but should be "a partisan in a social conflict" (p.
18). In 1969, the National Association of Social Workers
(NASW) appointed an Ad Hoc Committee on Advocacy to
define the term advocacy. One element of its definition
reflected the lawyer-advocate role as "one who pleads the
cause of another" and another element proposed advocacy
practice in the political environment as "one who argues
for, defends, maintains, or recommends a cause or
proposal" (Ad Hoc Committee on Advocacy, 1969, p. 17 ).
During the 1970s, under President Richard Nixon, an
era of benign neglect for social problems began and
opposition to social reform gained strength. Social
workers experienced obstacles in practicing advocacy
because strict limitations were placed on programs funded
through federal grants, diminishing social work's efficacy
with their targeted populations. The 1980 s were also a
particular challenge to professional social work advocates,
as President Ronald Reagan revealed his political agenda
to include (a) reducing the federal deficit and balancing the
nation's budget, (b) increasing emphasis on the military
and national security, and (c) significantly reducing or
eliminating "burdensome" social programs.
Under the Clinton administration in the 1990s,
entitlement programs for the vulnerable and at-risk
populations were devolved to the states, reducing the
federal budget and transferring decision-making authority
for social welfare programs to the states. "Welfare reform"
was passed in 1996 under the Personal Responsibility and
Work Opportunity Reconciliation Act, imposing tighter
access to programs for the poor. During the George W.
Bush administration, 20002008, the issues of the war in
Iraq, terrorism, budget deficits, managed care, increased
devolution of policymaking to the states, and faith-based
initiatives posed a constant challenge to social work
advocates in the public sector. At the tum of the 21 st
century, the Internet and advanced technology emerged as
fundamental features in all sectors of society. Hick and
McNutt (2002) stated, "just as the early social workers
emerged and defined their practice within the
Industrial Revolution, today's social workers must re-
invent their practice to work within the Information
Revolution" (p. 15) (see Electronic Advocacy).
Obligation to Be a Social Work Advocate Are all
social workers obliged to be advocates? Do licensed
private practitioners have such an obligation? The ethical
responsibility to be an advocate flows directly from the
NASW Code of Ethics adopted in 1996 and revised in 1999.
The word, advocacy, is found explicitly six times and
implied in several other phrasings.
In the Preamble, the Code states, "[A]n historic and
defining feature of social work is the profession's focus on
individual well-being in a social context and the wellbeing
of society. Soc ial workers promote social justice and
social change with and on behalf of clients ... these
activities may be in the form of direct practice, community
organizing, consultation, administration, advocacy, social
and political action, policy development and im-
plementation, education, and research and evaluation."
Under Purpose of the Code, it is affirmed that "the Code
is relevant to all social workers ... regardless of their
professional functions, the settings in which they work, or
the populations they serve." It also states that "social
workers should consider the NASW Code as their primary
source" of information about ethical thinking.
Under Ethical Principles, the Code also states that "social
workers challenge social injustice" and "pursue social
change, particularly with and on behalf of vulnerable and
oppressed individuals and groups of people." Further,
"[sjocial workers seek to enhance clients' capacity and
opportunity to change and to address their own needs.
Social workers are cognizant of their dual responsibility to
clients and to the broader society."
Under the Code [Section 3.07(a)), Social Workers' Ethical
Responsibility in Practice Settings, it is stated that "social work
administrators should advocate within and outside their
agencies for adequate resources to meet . clients' needs,"
and in Section 3.07(b), "social workers should advocate for
resource allocation procedures that are open and fair."
Sections 3.09(c) and (d) state that social workers "ensure
that employers are aware of social workers' ethical
obligations as set forth in the NASW Code and the
implications of these obligations for social work practice"
and "[sjocial workers should not allow ... organization's
policies, procedures, regulations ... to interfere with their
ethical practice of social work."
Code section 6.01 of the Social Worker's Ethical
Responsibilities to the Broader Society/Social Welfare, states
that "social workers should promote the general welfare

of society, from local to global levels, and the develop ment
of people, their communities, and their environments.
Social workers should advocate for living conditions
conducive to the fulfillment of basic human needs and
should promote social, economic, political, cultural values,
and institutions that are compatible with the realizat ion of
social justice." Section [6.04(a)] states that "[ sjocial
workers should be aware of the impact of the political
arena on practice and should advocate for changes in
policy and legislation to improve social conditions in order
to meet basic human nee ds and promote social justice."
Section [6.04(c)] states that "[sjocial workers ... should
advocate for programs and institutions that demonstrate'
cultural competence, and promote policies rhat safeguard
the rights of and confirm equity and social justice for all
people."
Regardless of employment setting, social workers'
commitment to practice advocacy flows directly from our
Code of Ethics. It is not an option; it is an obligation.
Barriers to Practicing Social Work Advocacy Despite a
clearly defined professional obligation for all social
workers to practice advocacy, numerous barriers and
attitudes often inhibit them from pursuing it.
Advocacy takes too much time, energy, and perso-
nalfinances (Ezell, 2001; Hoefer, 2006; Schneider &
Lester, 2001). When social workers want to change local ,
state, or national policies and laws, they often do it "off the
clock," using personal leave, and pay for travel and other
out-of-pocket costs themselves.
Sheafor and Horejsi 2003, state that advocacy is
misunderstood and often perceived by social workers as
"confrontation" between professionals, agencies, and
decision makers; it is also perceived as risking important
and necessary collaborative relationships, or even losing
one's job.
Clinical social workers do not prioritize the inter-
relationship of clients' needs and laws. Client efficacy
often requires advocacy at the individual and the system
levels.
Social work agencies and their staff ofte n devote
most of their energies to direct service programs
(O'Connell, 1978). Although job descriptions may in-
clude an advocacy component, social workers may not
be encouraged to take time away from service
delivery.
Some social work practice is dictated de facto by
managerial, not professional considerations. Efficiency is
valued over effectiveness (Reisch, 1986).
Neither universities nor professional organizations
provide sufficient education or training on how to actually
do advocacy (Blakely, 1991). Agencies do not provide
sufficient resources to promote or engage in advocacy
practice (Ezell, 2001).
ADVOCACY 63
Some social workers stand in awe of politicians and are
not comfortable with one-on-one lobbying (Ezell, 2001).
In one study, social work students substantively dis-
agreed with the statement "advocacy is the main thrust of
social work," suggesting an imprecise view of the
profession (Csikai & Rozensky, 1997).
This list is not all-inclusive. In order to overcome such
barriers and attitudes, professional and educational social
work leaders must promote a renewed emphasis on the
professional obligation to advocate, role model, and
communicate core social work values, and provide
efficacious education, training, and supervision on
advocacy practice.
Electronic Advocacy
In the 21st century, social workers are engaging in
electronic advocacy using new tools to address ongoing
client issues and policy outcomes (McNutt, 2006).
Electronic advocacy, often called online advocacy or
cyber activism, refers to the use of e-mail lists, Web sites,
message boards, petitions, blogs, social network ing, cell
phone text messaging, mapping, video and animation,
really simple syndication, and other Internet
communication tools to advocate, organize, and mobil ize
support for community causes, "get out the vote"
campaigns, and coalition actions (Advocacy-
Dev.org,2005). The Internet allows advocates to easily
include participants on an equal basis, regardless of age,
race, gender, or disability (Delany, 2006).
Queiro-Tajallil, Campbell, & McNutt (2003) identify
four key processes characteristic of electronic advocacy:
Issue research: The Internet provides quick and efficient
access to information, research findings, policy problems and
issues, and knowledge about oppositional stances.
Information dissemination and awareness: Through
e-mail and Web sites, advocates can contact supporters and
the public to inform them about social problems or issues.
Advocates can learn about issues, research, and strategies all
on the same day.
Coordination and organizing: Although timeconsuming,
an electronic advocacy campaign to organize supporters is
one of the most critical tasks. The lower costs of multiple
transactions and communications are highly advantageous.
Tracking events, raising funds, monitoring decision makers,
conducting conference-call meetings, and coordinating
personnel and volunteers are all features available through
advanced technology.
Influence: Applying pressure on decision makers through
electronic advocacy tools remains one of its outstanding
features. Politics and policy issues at the federal, state, and
local levels can be shared among
64 ADVOCACY
advocates who can devise strategies and tactics for
influencing elected and appointed officials (pp. 154-156) (see
also Johnson, 2006),
As this technology-based advocacy expands among social
work advocates, professional practice will still require the
traditional commitment to addressing injustices and seeking
equitable access to services for vulnerable populations.
Future Implications for
Social Work Advocacy
Advocacy is an activity requiring patience, tenacity,
compromise, long-term commitment, energy, broad bases of
support, research, political skills, knowledge of government,
and capacity to analyze (Schneider & Lester, 2001).
Fortunately, the centrality of advocacy to the professional
social work mission continues to evolve. The two major
professional organizations, NASWand the Council on Social
Work Education (CSWE) are vital partners in promoting
increased integration of advocacy into social work practice
and education.
Three areas are highlighted for continued support and
future resources:
The CSWE, through its Educational Policy and Ac-
creditation Standards (CSWE, 2001), requires that more
emphasis be placed on policy advocacy practice in under-
graduate and graduate curricula. Educational programs must
build upon this standard and promote faculty and student
involvement in advocacy practice and research. Innovative
field internships in advocacy arenas such as local, state, and
federal legislatures or agencies using electronic advocacy
tools can be developed.
NASW has made significant investments in electoral and
legislative domains at the national and state levels. This
allows the profession to increase its influence and voice in the
election of local, state, and federal officials. Chapters
ofNASW have also developed legislative campaigns to
influence the evolving role of states in welfare policies that
have an effect on traditional clientele populations. Continued
expansion of such activities is necessary in order to permit
members to use their expertise and creativity in informing
lawmakers about laws that will actually meet client needs.
As of 2008, there were two U.S. Senators and eight U.S.
Representatives in Congress who were social workers and
over 60 social workers elected to state legislatures across the
United States. Supporting and encouraging social workers to
run for elective offices at local, state, and federal levels should
be an urgent goal because these individuals will be the actual
decision makers on policies affecting vulnerable populations
served by social workers. This traditional, but often neglected,
role can reinvigorate the profession in a most meaningful way.
REFERENCES
Ad Hoc Committee on Advocacy (NASW). (1969h The social
worker as advocate: champion of social victims. Social Work,
14(2), 16-22.
AdvocacyDev.org. (2005). AdvocacyDev 11 convergence. San
Francisco, CA, 11-13 July. Retrieved October 17, 2006, from
http://www.advocacydev.org
Bicha, K. D. (1986). Emily Greene Balch. In W. L Trattner (Ed.),
Biographical dictionary of social welfare in America (pp. 46-48),
New York: Greenwood Press.
Blakely, T. J. (1991). Advocacy in the social work curriculum.
Unpublished paper.
Csikai, c., & Rozensky, C. (1997). Social work idealism and
students' perceived reasons for entering social work. Journal of
Social Work Education, 33(3), 529-538.
The Council on Social Work Education. (2001). Educational policy
and accreditation standards. Alexandria, VA: Author.
Delany, C. (2006). The tools and tactics of online political advo cacy:
Online politics 101. Retrieved February 26, 2007, from
http://www.epolitics.com
Ehrenreich, J. H. (1985). The altruistic imagination: A history of
social work and social policy in the United States. Ithaca, NY:
Cornell University Press.
Ezell, M. (2001). Advocacy in the human services. Belmont, CA:
Wadsworth/Thomson Learning.
Grosser, C. F. (1965). Community development programs
serving the urban poor. Social Work, 7, 15-21.
Haynes, K. S., & Mickelson, J. S. (2006). Affecting change (6th
ed.). Boston: Allyn and Bacon.
Hepworth, D. H., Rooney, R. H., Dewberry-Rooney, G.,
Strom-Gottfried, K., & Larsen, J. A (2006). Direct social work
practice: Theory and skills (7th ed.). Pacific Grove, CA:
Brooks/Cole.
Herbert, M. D., & Mould, J. W. (1992). The advocacy role in
public child welfare. Child Welfare, 71, 114-130.
Hick, S. F., & McNutt, J. G. (2002). Communities and advocacy
on the Internet: A conceptual framework. In S. F. Hick & J. G.
McNutt (Eds.), Advocacy, activism, and the' internet: Community
organization and social policy. Chicago:
Lyceum Books.
Hoefer, R. (2006). Advocacy practice for social justice. Chicago:
Lyceum Books
Johnson, D. W. (2006). Connecting citizens and legislators.
Retrieved October 11, 2006, from http://www.connectingci
tizens.org/
Kurzman, P. A (1974). Harry Hopkins and the New Deal. Fair Lawn,
NJ: R.E. Burdick.
Kutchins, H., & Kutchins, S. (1978). Advocacy and social work.
In G. Weber & G. McCall (Eds.), Social scientists as advocates:
Views from the applied disciplines (pp, 13-48). Beverly Hills,
CA: Sage.
Kutchins, H., & Kutchins, S. (1987). Advocacy and the adversary
system.]ournal of Sociology and Social Work, 14, 119-133.
Litzelfelner, P., & Petr, C. G. (1997). Case advocacy in child
welfare. Social Work, 42, 392-402.
McNutt; J. G. (2006). Building evidence-based advocacy in
cyberspace: A social work imperative for the new millennium.
Journal of Evidence-based Social Work, 3, 91-102.

National Association of Social Workers. (1999). Code of Ethics
Washington, DC: Author.
O'Connell, B. (1978). From service to advocacy to empowerment.
Social Casework, 59(4), 195-202.
Queiro-Tajallil, I., Campbell, C., & McNutt, J. (2003). Inter-
national social and economic justice and on-line advocacy.
International Social Work, 46, 149-161.
Reisch, M. (1986). From cause to case and back again: The
reemergence of advocacy in social work. The Urban and Social
Change Review, 19,20-24.
Schneider, R. L., & Netting, F. E. (1999). Influencing social
policy in a time of devolution: Upholding social work's great
tradition. Social Work, 44, 349-357.
Schneider, R. L., & Lester, L (2001). Social work advocacy:
A new framework for action. Belmont, CA: Wadsworth!
Thomson Learning.
Sosin, M., &Caulum, S. (2003). Advocacy: A conceptualization
for social work practice. Social Work, 28, 12-17.
to
Trattner, W. I. (1999). From poor law welfare state: A history of
social welfare in America (6th ed.). New York: Free Press
FURTHER READING
Bateman, N. (1995). Advocacy skills: A handbook for human service
professionals. Brookfield, VT: Ashgate.
Briar, S. (1977). In summary. Social Work, 22, 415-416, 444.
Jansson, B. (2007). Becoming an effective policy advocate: from
policy practice to social justice (5th ed.). Pacific
Grove, CA: Brooks/Cole. . disparities
Schneider, R. L., & Lester, L. (2001). Social work advocacy: a new
framework for action. Belmont, CA: Wadsworth/ Thomson
Learning.
Shaefer, B. W., & Horejsi, C. R. (2003). Techniques and guidelines
for social work practice (6th ed.). Boston: Allyn and Bacon.
Wolk, J. L. (1981). Are social workers politically active? Social
Work, 26, 283-288.
SUGGESTED LINKS
http://www .socialworkers .org
http://www .statepolicy. org
http://intemetadvocacycenter . com
http://advocacydev .org
http://www .connectingcitizens.
org http://thePetitionSite . com
http://www . mobileactive .org
http://backspace . com/action
http:// citizenspeak. org
http://www.greatergood.com
http://www .globalexchange .org
http://www.politicsonline.com
http://www .stateline .org
http://www . techsoup. org
http://epolitics . com
http://www.advocacyguru.com
http://www .independentsector .org/programs/gr/lobbyguide. html
-ROBERT L. SCHNEIDER, LORI LESTER, AND JULIA
OCHIENG
AfRICAN AMERICANS: OVERVIEW 65
AFRICAN AMERICANS. [This entry contains three
subentries: Overview; Immigrants of African Origin;'
Practice Interventions.]
OVERVIEW
ABSTRACT: African Americans have been a part of the
nation's history for nearly four hundred years. Although
their history includes the forced imposition of chattel
slavery, the strict enforcement of legal segregation, and
a tenuous acceptance as equal citizens, African Ameri-
cans have been, and continue to be, major contributors,
creators, investors, and builders of America. In this
article we summarize briefly the history of African
Americans, we examine racial disparities in key indica-
tors of social, mental, and physical well- being, and we
highlight persistent strengths that can be built upon and
areas that provide hope for the future. The chal lenge for
social work is to simultaneously celebrate the historical
successes and ongoing contributions of Afri can
Americans to this country while also recognizing the
vestiges of structural racism and fighting for greater civil
rights and social and economic justice.
KEY WORDS: African Americans; race; poverty;
Introduction
The history of African Americans does not begin with
slavery; rather, it begins in west and central Africa where
their ancestors established ancient civilizations and
empires that included great political leaders, scholars, and
nobility (Isichei, 1997). To day, African Americans are a
multiracial people-descendants of Africans to be sure, but
many, if not most, also have European, Native American,
and even some Asian ancestry. Africans and their
descendants have been part of American history for at
least five centuries-coming as part of 15th- and 16th-
century Spanish explorations to the "New World"
(Smallwood, 1999; Van Sertima, 2003). The first Africans
to settle in North America were a group of 20 men and
women brought to Jamestown, Virginia, by the Dutc h in
1619, one year before the arrival of the Mayflower
(Bennett, 2003). Although these Africans probably came
as indentured servants, the nation's thirst for free labor to
fuel European and American capitalism resulted in the
enslavement and transport of as many as 15 million
Africans to the Caribbean Islands and to the Americas
(Franklin, 2007).
Despite having lived under horrific conditions dur ing
slavery, and a hundred years of legal second class
citizenry thereafter, African Americans "still managed
66 AFRIcAN AMERICANS: OVERVIEW
to reinvent themselves, reclaim their humanity and not
just survive slavery but create fresh and vibrant re sponses
to American democracy" (Marsalis, Dodson, & Diouf,
2004, p. 11). Hence, African Americans cor rectly
perceive themselves to have contributed signifi cantly to
the creation and building of this country. It is perhaps this
historical fact that provides a major psy chological
distinction between African Americans as a group and
recent immigrants: African Americans view themselves
not as grateful new arrivals to a rich and powerful
country, but as major contributors, creators, investors, and
builders of America.
Social Political History
Political-legal decisions have, been central to African
Americans' struggle for equality in America. Accord-
ingly, to understand the present day struggles and frus-
trations of African Americans it is important to be aware
of a few key historical legal landmarks:
Emancipation Proclamation (1863). During the
American civil war (1861-1865), President Abraham
Lincoln declared that all slaves in the confederacy were
free. In reality, however, all slaves in both the North and
South were not freed until the end of the war in 1865 ".
African Americans in Texas were among the last to hear
that they had been freed. June 19, 1865, com memorates
announcement of the end of slavery in Texas, which is
why today many African Americans celebrate June 19 or
"Juneteenth" as a date of emancipation.
Plessy v. Ferguson (1896). This Supreme Court
decision gave legal mandate to the states to practice racial
discrimination against African Americans. It gave
sanction to the establishment of what became Jim Crow
Law. States were allowed to legally discrim inate against
African Americans in virtually all areas of public and
private life; most importantly, it supported their legal and
economic disenfranchisement and personal terrorism
against them in many states. The rule of Jim Crow despite
considerable opposition from civil right groups remained
intact until the 1960s.
Brown v. Board of Education of Topeka (1954).
Of all the legal decisions that occurred after the eman-
cipation proclamation this was the most important for
African Americans. The decision in Brown v. Board of
Education of Topeka declared that segregation in public
schools was by its nature unequal and unfair- thus should
be done away with. There were two goals that advocates
of Brown hoped would take place with the passage of this
law: greater integration of African American children into
the American mainstream and parity with respect to
scholarly achievement of these youth. Unfortunately,
neither of these goals has been
achieved. In 1954 African American students attended
schools in which they were the majority of those pres ent.
Today African American students are almost as
segregated in public school today as they were in 1954 .
Moreover, there remains a significant educational
achievement gap between African American and White
youths.
Civil Rights Act (1964). This Act, which was passed
at the height of the civil rights movement, outlawed
discrimination in public accommodations, employment,
and labor unions. African Americans could no longer
legally be denied to entry to hotels, theaters, restaurants,
and other public places where they had" formerly been
forbidden. However, even today many private (and some
Americans.
Voting Rights Act (1965). This act removed the last
impediments to African Americans' right to vote. The
passage of this act resulted in a substantial increase in the
numbers of African American elected officials. In
particular, its passage had major implications for many
areas in southern states where they were the majority of
the population but had historically been denied the right to
vote.
Fair Housing Act (1968). Coming on the heels of the
assassination of Dr. Martin Luther K ing, jr., the passage
of the Fair Housing Act was hailed as a major civil rights
triumph. Segregated housing fosters not only segregated
schools but also undermines the social and economic
opportunities of those who are segregated (00 Bois, 1903;
Massey & Denton, 1993; Taeuber & Taeuber, 1965).
Unfortunately, the passage of the open housing act has not
resulted in an extensively more integrated America
(Massey & Denton, 1993). As is true of segregated
schools, housing segregation is almost as extensive in
2008 as it was when the open housing act was passed in
1968.
For African Americans the struggle for social, eco-
nomic, and political justice has not been easy, nor always
steady; but rather, it has been characterized by both major
advances and setbacks (Klinkner & Smith, 1999). A host
of civil rights organizations have been instrumental in this
fight. Some of the most notable of these groups have been
the NAACP, Urban League, Congress on Racial Equality
(CORE), Southern Christian Leadership Conference
(SCLC), and Student Non-violent Coordinating
Committee (SNCC).
Population Characteristics
The nation's nearly 37 million African Americans
comprise roughly 13% of the American populace. As a
group, they are younger than Whites, with a mean age of
31.3 versus Whites' mean age of 38.9 (McKinnon &

Bennett, 2005). Historically, African Americans were a
rural southern people-this was largely an artifact of their
being located in southern slave states. As a result of the
"Great Migration" (19161930 and 1940-1970)-America's
greatest internal migration- (Marsalis et al., 2004) African
Americans are now foremost to be found in urban centers
(52%) and are almost as likely to be residing outside the
south as in it (45% versus 55%.) (McKinnon, 2003; U.S.
Census Bureau, 2003).
African American children make up 15% of American
children under 18 years. Thirty-six percent live in married
couple households as compared with 76% of Whites, and
63% live in single-parent families as compared with 24~ of
Whites (McKinnon & Bennett, 2005). Approximately 36%
of African American children live below the poverty line
(McKinnon & Bennett, 2005). In addition, African
American children comprise 37% of the total number of
children placed in foster care (Center for the Study of
Social Policy, 2004). Further, 39% of the children awaiting
adoption are African American (Child Welfare League of
America, 2006).
Marital Status
African American adults are significantly more likely than
others to be single. More specifically, African Americans
are less likely to be currently married (34% versus 58% of
Whites), more likely to have never been married (41 %
versus 23% of Whites), and more likely to be divorced
(12% versus 10% of Whites) (McKinnon & Bennett,
2005). There are a variety of reasons for the high
prevalence of singleness among African Americans. One
factor that often goes unmentioned is the significant gender
imbalance that exists among African Americans. There are
two reasons for this imbalance: a high perinatal mortality
rate and a high homicide rate among African American
males. Black men are 6 times more likely than Whites to be
homicide victims, at 19.7 and 3.3 per 1;000,000
respectively (Fox & Zawitz, 2007).
Indications are that since the recording of the census no
other major racial group has experienced a severe or
persistent gender imbalance (Guttentag & Second, 1983).
There are for the ages of 18-44, the most common years
marriages occur, only rv6.6 million African American
males as compared with 7.8 million African American
females. This results in there being roughly 1.2 million
more African American women than men (McKinnon &
Bennett, 2005). Irrespective of race or ethnicity, the
negative effects of gender imbalances on populations (for
example, out of wedlock births, high rates of divorce),
have been well documented (Guttentag & Second, 1983).
AHuCAN AMERICANS: OvERVIEW 67
Moreover, when the factors of education, employment,
and incarceration are also considered along with the gender
imbalance, the number of "marriageable" African
American men available in comparison with the number of
"marriageable" African American women drops
considerably. In fact, there are estimated to be only half as
many African: American men who are "suitable" marriage
partners as there are suitable African American women.
These demographics have resulted in the prediction that as
many as a quarter of all African females will remain
unmarried (Cherlin, 1992). This prediction is at odds with
some research suggesting that over 90% aspire to marry.
(Davis, Emanson, & Williams, 1997; Tucker &
Mitchell-Kernan, 1995; Tucker & Taylor, 1987). Thus a
disparity appears to exist between what most Blacks would
like to happen and what the demographics of the "marital
market place" indicate will happen. This is important to
keep in mind as it suggests that at least part of the low
marriage rate among African Americans is not a matter of
morality or attitudes toward marriage but rather a function
of demographics.
Family Status
Few issues have received more attention from the pro-
fession of social work than the status of the African
American family. For good or ill, the state of the African
American family has been ever present in practice,
research, and policy debates (Billingsley, 1968; Hill, 1972;
McAdoo, 2007; Moynihan, 1965; Murray, 1984; Wilson ,
1987). While others had for some time studied and written
about African American families (Drake & Cayton,
1945/1962; DuBois, 1903; Frazier, 1932a&b, 1957), it was
the Moynihan Report (1965) that catapulted the ''Negro''
family into national controversy.
At the core of this controversy has been the source of
difficulties facing African Americans. Researchers,
scholars, policy makers, and practitioners from across the
political spectrum have waded into this debate with a host
of explanations for-arid responses to the Moynihan Report.
The report identified that 25% of African American
families were single-parent families headed mainly by
women (the rate for Whites at that time was rv 7%). It
argued that a matriarchal family structure and cultural
deficits were the source of the social, economic, and
educational problems being experienced by these families.
It is noteworthy that in 2008 White families on many
dimensions, for example, family structure, look very much
like "Negro" families did in the 1960s.
Although Moynihan did identify problems in the
maintenance and formation of Black families, most social
work scholars argue that he misattributed the source of the
problems facing Black families. That is,
68 AFRICAN AMERICANS: OvERVIEW
he ascribed Black family problems to sources residing
wholly in the family, rather than to factors largely external
to it. Many scholars perceived his report as an attack on the
Black family, which put some on the defensive. Hence, in
response, many Black and White scholars spent decades
refuting Moynihan's cultural condemnation of the Black
family. They rightfully argued that the Black family had
many cultural strengths. This response is best epitomized
by Hill's The strengths of Black families (1972). However, it
might be argued that in the effort to highlight the cultural
strengths and resiliency of Black families that the
difficulties which Black families were in fact experiencing
were given insufficient attention. Clearly it has been
difficult for those wishing to highlight the strengths of the
Black family to simultaneously point out the very serious
problems that the Black family was experiencing.
The debate as to the source of the problems facing
African American families continues. Fundamentally,
political conservatives argue that the problems are due to
cultural deficits, as proposed by Moynihan, or have been
created by thewelfare state itself (Murray, 1984). Social
workers and their allies appear to have aligned themselves
with the structuralist arguments of Wilson (1987, 1996). It
is his position that along with continuing and historical
racial bias, major changes in the economy (for example,
loss of manufacturing jobs) have undermined the
economic capabilities of Black males, and with it, their
ability to form and maintain families. There does exist
strong evidence that among the great est barriers to Black
family formation and maintenance is that there are too few
men with too few jobs and insufficient resources
(Bowman, 1988, 1993; Mincy, 2006; Tucker &
Mitchell-Kernan, 1995; Wilson, 1996).
Labor Force Participation
Relative to their White counterparts, a smaller propor tion
of African Americans are employed (58% versus 63%),
and their unemployment rate is twice as high (10% versus
4.4%) (U.S. Bureau of Labor Statistics, 2005). Even when
race differences in other demographic factors such as
geographic residence, education level, and marital status
are taken into account, African Americans still are
significantly more likely than Whites to be unemployed.
Although African Americans' unemployment rate has been
nearly twice that of Whites since the 1960s, prior to World
War II, Black and White employment rates were roughly
equal (Fairlie & Sundstrom, 1999).
The size of race differences in employment often
varies by gender. For example, although African
Americans, as a group, are less likely than White
Americans to be employed, African American women
are slightly more likely than White women to be in the
labor force (62% versus 59%, U.S. Bureau of Labor
Statistics, 2005). Similarly, the types of occupations that
African Americans and White Americans hold differ
substantially by gender. African American men are most
likely to be employed in blue-collar jobs (that is, 26%
work as machine operators, fabricators, and laborers),
followed by work in service (21 %), and sales and
administrative support jobs (19%). Compared with White
men, a smaller proportion of African American men work
in managerial and professional occupations (21 % versus
33%) or skilled trade jobs in-construetion and repair (13%
versus 19%). African American women are most likely to
be employed in white-collar jobs (33% in sales and
administrative support occupations and another 31 % in
managerial and professional occupations). Compared with
White women, however, a larger proportion of African
American women work in service occupations (27%
versus 18%) (U.S. Census Bureau, 2005a).
There is much dialogue about the economic split
among African Americans that is resulting in a growing
middle class and an increasingly disadvantaged under-
class. Looking at occupational trends historically, how-
ever, the data suggest that most working African
Americans fall into neither category (Horton, Allen,
Herring, & Thomas, 2000). Prior to 1940, the majority of
African Americans worked in "lower class" occupations
(that is, those that earned more than one standard deviation
below the overall mean income). In fact, in 1920, 50% of
African American men and 86% of African American
women worked in these occupations, with less than 2% of
either gender working in "middle class" occupations (that
is, occupations that earned more than one standard
deviation above the overall mean income). By 1990, still
only 12% of the African American labor force worked in
middle class occupations. Since 1970, however, the
majority of African American men and women have been
solidly working class, working in occupations that earned
near the mean income.
Income
African Americans have always earned less than Whites,
but after a brief period of increasing wages, the trend
toward earnings convergence between African American
and White men stopped in the mid-1970s. Among women ,
however, the earnings of African American females
continued to increase through the 1990s and at times rose
more rapidly than for White women (Farley, 1996). By
2005 the median earnings for White men who worked
full-time year round were $44,850 compared with only
$34,433 for African American men (that is, 77% of White
men's earnings).
 AFRICAN AMERICANS: OVERVIEW 69

Similarly, the median earnings for White women in slaves planted and sold their own crops from gardens, 2005 was
$33,237 compared with only $29,588 for sold their own labor for money, and raised their African American women
(that is, 89% of White own livestock. During this same time in the South, women's earnings, Webster & Bishaw,
2006). free Blacks also acquired property and businesses
These race and gender differences in earnings shape (Schweninger, 1990). Even in the face of oppressive the
economic status differences of African American laws and the indignity of not being recognized as full and White
households and families. In 2005, the me- citizens, the pride and independence of being a landdian household
income in the United States was owner was desired and attained by many. In fact, "by $46,326. African American
households are overrepre- - 11360, 16,172 free persons of color in the fifteen slave sented in the lowest income
quintile and their incom~ -. states had accumulated $20,253,200 worth of property, is only 60% of White
households ($30,858 versus or $1,252 per individual property holder" (Schweninger, $50,784, DeNavas-Walt, c.,
ons to Comm, & Lee, C. 1990, p. 96). African Americans have also been (2006). The race disparity in household
income is successful entrepreneurs. Pioneers like Madam C. J. due, at least in part, to the lower percentage of
married Walker and Arthur G. Gatson are well known for being couple and multiple-earner households among
African among the first African American millionaires. Americans. That said, however, even considering per In
spite of such history and the presence of a few capita income, disparities remain with African Amer- highly visible
multimillionaires, African American icans earning 58% that of Whites (DeNavas-Walt, households today have
much lower levels of wealth Procter, & Lee, 2006). When comparing married cou- than their White counterparts. In
2000 the median ple households and single female-headed households net worth for African American households
was only separately, African Americans still earn less than $7,500, compared with $79,400 for non-Hispanic
Whites and other racial and ethnic groups, being much White households (Orzechowski & Sepielli, 2003). less
likely to earn more than $75,000 and having house- Even when controlling for known class correlates such hold
incomes concentrated in the lowest income ranges as income, occupation, and education, wealth differ(Farley,
1996; McKinnon, 2003). ences by race persist (Blau & Graham, 19?0; Keister,
The overall poverty rate for the country was 13% in 2000; Oliver & Shapiro, 2006; Shapiro, 2004). In fact,
2005. Although the numerical majority of the nation's even as income and educational attainment improved poor
are White, the percent of African Americans who for many African Americans in the post- eivil rights were poor
was 3 times the percent of Whites who were era, disparities in net worth remained. In an attempt poor (25% versus
8%) (DeNavas-Walt et al., 2006). to evaluate the extent of wealth disparities, Haveman African Americans are also
more likely to be in extreme and Wolff created a measure of "asset-poverty" (2000). poverty (that is, 12% earning
less than half of the By their definition, a household is asset-poor if it does poverty threshold) (DeNavas- Walt), and
to remain not have enough wealth to sustain itself at the poverty in poverty over time (Naifeh, 1998). Among adult
line for 3 months. Using this framework, African AmerAfrican Americans who reach the age of 75, 91% will icans
are more than twice as likely to be asset-poor than have experienced at least one year below the poverty are
non-Hispanic Whites. In 1999, 76% were asset-poor line and 68% will have experienced at least one year in when
housing equity was excluded, compared with 32 %
extreme poverty (Rank & Hirschl, 1999). for Whites (Caner & Wolff, 2004).
African American children, in particular, are likely Many have tried to understand the intergenera-
to be poor and remain poor for multiple years (Duncan tional factors that influence racial differences in & Rodgers,
1991). In 2005, 35% of African American wealth. Oliver and Shapiro (2006) identify historical children lived in
poverty, compared with only 10% of inequities such as racialization of state policy, explicit White children. The
consequences of child poverty denial of economic opportunities, and the long-term have been well documented and
are often enduring, sedimentation of racial inequality across generations. ranging from low birth weight and poor
health outcomes To provide one specific example, in the late 19th cento lower academic achievement, more
behavior prob- tury the Homestead Act failed to provide land to the lerns, and lower earnings (Aber, Bennett,
Conley, & Li, 4 million newly freed slaves, while in contrast European 1997; Duncan & Brooks-Gunn, 1997;
Mayer, 1997). immigrants received much of the 246 million acres
eventually granted to homesteaders (Williams, 2003).
But even considering contemporary factors, there ap-
Wealth pear to be differences by race in how wealth is
Both before and after slavery, property ownershi p has accumulated. For example, African Americans are less
been an aspiration for at least a portion of the African likely to invest in stocks and high-risk, high-return
American population. Prior to emancipation, some assets
70 AFRICAN AMERICANS: OVERVIEW
(Keister, 2000). This may be because African American
children grow up in households where parents are less
likely to own stocks, which then in tum influences their
own investment decisions (Chiteji & Stafford, 1999).
Whites are also more . likely than Afr ican Americans to
receive and expect inheritances (Menchik & [ianakoplos,
1997; Wolff, 2002).
Home equity is an important component of net worth.
Although homeownership rates have increased since the
mid-1990s, only 48% of African-Americans owned their
homes by 2005, substantially lower than the U.S. average
rate of 69% and that of non-Hispanic Whites at 76% (U.S .
Census Bureau, 2006). In addition to socioeconomic
disadvantages, such: as earning less income, African
Americans also face specific barriers wi thin the housing
market. For example, African Americans are more likely
to have mortgage applica tions rejected and to receive less
favorable interest rates and other terms when a mortgage
is approved (Charles & Hurst, 2002; Krivo & Kaufman,
2004). In addition, even among homeowners, the return
on investment is lower for African Americans. Because
they are more likely to live in heavily minority and
central-city areas, African Americans build less equity for
their level of income, . education, and length of residence
than do non-Hispanic Whites (Krivo & Kaufman, 2004).
Taking a life course perspective, Hirschl and Rank (2006 )
find that Whites are more likely to become home owners at
younger ages than do African Americans. In addition to
having a lower likelihood of becoming homeowners
across all ages, African Americans are less likely to reach
high equity thresholds (such as $100,000), more likely to
exit homeownership, and after losing a home are less
likely to return to homeownership (Hirschl & Rank,
2006).
About 5% of African American households have a
portion of their net worth represented by business equi ty
or a profession, compared with 12% of White house holds
(Leigh, 2006). Yet, the number of businesses owned by
African Americans has been increasing over recent
decades, growing from 424,000 in 1987 to 1.2 million in
2002, generating revenues of $89 billion. Most African
American-owned businesses are small , however, with
only 8% having paid employees, but these larger firms
employ 754,000 persons and bring in 74.2% of gross
receipts (U.S. Census Bureau, 1996, 2006). [See new
2006 Census citation on Black-Owned firms below.]
Not having independently held we alth (whether
precipitated by structural inequities, unemployment,
poverty, escalating debt, low savings, or slowly appre-
ciating home equity) puts extraordinary stress on African
American individuals, children, and families.
Economic insecurity makes planning for the future dif-
ficult and creates strain within romantic relationships.
Growing up in households with little or no wealth has a
negative impact on children (Conley, 1999; Williams
Shanks, 2007). In fact, Conley (1999) finds that racial
differences in net worth, high school graduation, col lege
graduation, repeating a grade, labor force partici pation,
wages, welfare receipt, and female premarital
childbearing between Whites and African Americans are
either no longer significant or dramatically les sen once
parental wealth is considered. Shapiro (2004) makes a
similar case using qualitative interviews to demonstrate
how parents use either personal wealth or money inherited
from their parents' wealth to' create transformative
opportunities for children, particularly via enrollment in
better schools.
Sherraden (1991) theorizes that owning assets has a
range of positive benefits: economic, psychological, so-
cial, and political. When a poor person with no assets
starts on the road to building assets, it can create hope for
the future, improve current well- being and lead others to
view the person differently as well (Schreiner &
Sherraden, 2007; Sherraden, 1991). If one wants to dra-
matically alter the opportunities available to all African
Americans regardless of circumstances and across
generations, the focus should be on reducing the wealth
gap. The persistent racial disparities that exist in wealth
have hampered sustained economic prosperity, even
among those that might otherwise appear successful.
Changing this reality is the next frontier for civil rights.
Education
On average, persons who do better in school and who
attain higher levels of education earn more, have better
mental and physical health, and are less likely to be
involved with the crimi nal justice system than their
less-educated counterparts. A high school diploma is the
basic educational requirement for employment and
admission to college and educational programs. Nation-
ally, 80% of 18-24-year-old African Americans have
earned a high-school diploma or general educational
development (GED) credential, but they still lag be hind
Whites' high school completion rate of 92% (Hoffman &
Llagas, 2003).
At the college level, the proportions of African
Americans who have earned degrees has incre ased over
time, but those who have earned associate degrees has
exceeded the proportions who have earned bachelor's
degrees. Despite the fact that a growing proportion of
African college students attend predominantly White
institutions, nearly a quarter of bachelor's degrees are
earned at historically Black colleges and universities
(Hoffman & Llagas, 2003). Although the percentage

of African Americans who have completed college has
increased significantly over time, they are still much less
likely than Whites to have completed college (18% in 2000
versus 34%) (Hoffman & Llagas, 2003). Moreover, there
exists a considerable gender disparity in college graduation
among African Americans, with two-thirds (66%) of
bachelor's degrees being earned by females (Peter & Hom,
2005).
Criminal Justice
America's incarceration rate has increased for 30 con-
secutive years, resulting in the highest incarceration rate in
the world (737 inmates per 100,000 residents in 2005)
(Harrison & Beck, 2006; The Sentencing Project, 2006).
Compared to other racial and ethnic groups, African
Americans are significantly more likely to be incarcerated.
Because African Americans are particularly
over-represented among drug offenders, they have
disproportionately born the consequences of the nation's
drug-related social policies. As a result, although African
Americans are only 13% of the total United States
population, they were 28% of persons arrested and 40% of
persons who were incarcerated in 2005. If incarceration
rates remain the same in the future, it is estimated that 19%
of African Americans (32.2% of men and 5.6% of women)
born in 2001 will spend time in prison (Bonezar, 2003).
The overinvolvement of African Americans in the
criminal justice system has tremendous social, health,
economic, and political consequences that are of central
concern to social workers (Wheelock, 2005). Some of the
most pressing social consequences of incarceration include
its negative impact on children and families. Incarceration
breaks up families, harms children's mental health, often
places them in unstable out-of-home living arrangements
or foster care, and it greatly increases the probability that
children will engage in problem behaviors such as
delinquency and substance abuse that may ultimately lead
to their own incarceration (Freudenberg, 2001). Other
consequences of incarceration include job loss, limited
employability, individual, familial, and neighborhood
stigma, and the inability to vote, to sit on juries, or to run
for public office (Freudenberg, 2001). Taken in total, the
causes and consequences of African Americans'
involvement with the criminal justice system are among
the most pressing issues that face the African American
community and they are issues to which social work
researchers and practitioners should exert much greater
attention.
Health
Relative to their White counterparts, African Americans
live sicker and die younger. For example, the
AFIuCAN AMERICANS: OvERVIEW 71
average life expectancy of the an African American born in
2004 is 73 years compared with 78 years for a White
American (National Center for Health Statistics, 2006).
African Americans are more likely than White Americans
to die from heart diseases, stroke, cancer, asthma, influenza
and pneumonia, diabetes, HIV/AIDS, and homicide
(National Center for Health Statistics). Infant mortality is
also significantly higher among African Americans than
among Whites (National Center for Health Statistics,
2006). Overall, the race gap in mortality results in 83,570
excess African American deaths each year (Satcher et al.;
2005). Consistent with their higher rates of mortality and
morbidity, African Americans receive lower quality health
care and have less access to care than do White Americans
(U.S. Department of Health and Human Services, 2005).
At least five explanations have been given to explain
the consistent finding of race differences in illness and
death. These explanations include differences in genetic
factors, health behaviors (for example, smoking), socio-
economic status, psychosocial stress (for example, dis-
crimination), and structural factors (Dressler, Oths,&
Gravlee, 2005). Research on the extent to which these
various potential explanations help to account for race
differences in morbidity and mortality suggest that genetic
and health behavior models have relatively little
explanatory power. Instead, health disparities appear to
result largely from historical and contemporary discri-
mination (that is, racism), which result in structural level
social and economic inequalities for African Americans.
These inequalities, in tum, disproportionately place
African Americans in stressful life circumstances that
generate race disparities in health (Dressler et al., 2005).
Accordingly, efforts to reduce and eliminate race
disparities in health will have to address societal level
racism and race disparities in the structural factors that
cause them.
Mental Health
Approximately 26% of American adults-58 million
people-suffer from a diagnosable mental disorder (Kessler,
Chiu, Demler, & Walters, 2005). Because of their history
of racial oppression and the contemporary results of past
discrimination (for example, residential segregation),
African Americans are often thought to be at elevated risk
for mental health problems. Despite this expectation,
surveys of the general population suggest that mental
disorders, including alcohol and substance dependence are
no more, and in some instances are less prevalent among
African Americans than among Whites (Kessler et al.,
2005; Sue & Chu, 2003). Despite having comparable rates
of mental
72 AFRICAN AMERICANS: OvERVIEW
health disorders to Whites, African Americans are less
likely than their White counterparts to use mental health
services, are more likely to terminate services
prematurely, to be misdiagnosed, to use emergency and
primary care providers rather than mental health pro-
viders, and are overrepresented in inpatient treatment
versus outpatient treatment (Snowden, 2001; U.S.
Department of Health and Human Services, 20011-
Potential barriers to the availability, accessibility, and
utilization of mental health services by African Ameri-
cans include the lack of services in their communities,
their lack of insurance with which to pay for services,
and stigma and other attitudes associated with mental
illness (Snowden, 2001; Sue & Chu, 2003; U:S.
Department of Health and Human Services, <lOOl).
African Americans' relatively low rates of mental
disorders, despite their disproportionate exposure to
mental health disorder risk factors, clearly merits
further study. Existing research suggests that family,
friends, and religiosity, as expressed through prayer,
scripture study, attendance at religious services, and
social support from church members and clergy, are
critical to African American coping strategies
(Snowden, 2001; Taylor, Ellison, Chatters, Levin , &
Lincoln, 2000). In light of the growing body of research
that finds a positive relationship between religiosity and
mental health, physical health, academic achievement,
marital stability, and other prosocial behaviors, African
American's relatively high levels of religiosity and
church involvement may help to explain why their rates
of substance abuse, suicide, mental illness and other
problems are not substantially higher than those of
Whites {Johnson, Tompkins, & Webb, 2002; Taylor et
al., 2000; Wallace, Brown, Bachman, & LaVeist, 2003;
Wallace, Myers,& Osai, 2004).
Religion and the African American Church Based
upon traditional measures of religiosity, African
Americans are the most religious people in America.
For example, compared with Whites, African Ameri-
cans report higher rates of church attendance, prayer,
church membership, reading religious materials,
watching religious broadcasts, church leadership roles,
hours of volunteer church service, and ascribing
importance to religion (Krause, 2006; Taylor, Chatters ,
[avakody, & Levin, 1996). The importance of religion
to many African Americans is undoubtedly rooted in
the fact that, historically, churches were among the first
independent institutions built, owned, and controlled by
African Americans. Because of racial barriers to their
participation in the larger society, churches became the
center of the African American community and the
birthplace of African American entrepreneurship,
leadership development, education, politics, and cul-
ture (Lincoln & Mamiya, 1990).
Although opportunities for African Americans'
involvement and leadership in the broader culture have
expanded tremendously, churches continue to be the
primary sources and targets of African Americans'
philanthropy, volunteerism, and civic engagement
< (Barnes, 2004; Billingsley, 1999, Boddie, 2005). That said, however, some scholars suggest that there is a growing disaffection and disconnection between the church and an increasing proportion of African Americans, particularly the young (Lincoln
Mamiya,
& 1990; Smith & Jackson, 2006). According to some, one of the greatest challenges to the importance of religion and faith among young people is the
emergence of hip-hop culture (Smith & Jackson, 2006). In spite of this concern, however, given African Americans' high levels of
. religiosity and the continued importance of churches.in African American communities, there is a tremendous opportunity for the social work profession. to partner with African American churches and other faith-based organizations to accomplish their
hareds missions
to help children, families, the elderly, and other socially and economically disadvantaged populations.
Conclusion
From the first Africans to set foot on American soil
more than 400 years ago to the children who have been
born since 2000, African Americans have been and
wi1lc()~tinue to be an integral part of the history and
vibrancy of the United States. The place of African
Americans in U.S. society has gone through several
radical transitions: from the forced imposition of
chattel slavery to the strict enforcement of legal
segregation to a tenuous acceptance as equal citizens.
But in spite of the hard fought political and social
battles to attain a formal legal status, African
Americans continue to face barriers in their struggle for
parity with their White counterparts-
When reviewing the important indicators that
document quality of life and economic resources;
African Americans often fall woefully short of national
averages. Whether the measure is family stability, em-
ployment, income, wealth, education, incarceration
rates, or health, persistent disparities exist for African
Americans. Although there are many strengths that can
be built upon and areas that provide hope such as
enduring religiosity, resilient mental health, and inter-
nationally recognized contributions to the diverse rich-
ness of arts and culture, it would be short-sighted to
ignore the continuing struggles faced by African
Americans. The challenge for social work is to
simultaneously celebrate the historical successes and
ongoing

contributions of African Americans to this country
while also recognizing the vestiges of structural racism
and fighting for greater civil rights and economic
justice.
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Tucker, M. B., & Mitchell-Kernan, C. (Eels.). (l995). The decline wealth on child development. Journal of Poverty, 1 Ie
in marriage among African Americans: Causes, consequences, and p.93-116.
ed.).
policy implications. New York: Russell Sage Foundation. Wilson, W. J. (1987). The truly disadvantaged: The inner city, t
Tucker, M. B., & Taylor, R. T. (1987). Demographic correlates of underdass, and public policy. Chicago: University of Chica,
asse relationship status among Black Americans. Journal of Press.
t Marriage and the Family, 51, 655-665. Wilson, W. J. (1996). When work disappears: The world of t
,DC: U.S. Bureau of Labor Statistics. (2005). Household data, annual new urban poor. New York: Alfred A. Knopf.
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averages. Washington, DC. Retrieved November 9, 2007, Wolff, E. N. (2002). Inheritances and wealth inequality,
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from http://www.bls.gov/cps/wlf-table3-2006.pdf. 198~ 1998. American Economic Review, 92(2), 260-264.
have
U.S. Census Bureau. (l996). Black-owned businesses: Strongest in
::Na- services. Washington, DC. Retrieved November 8,2007, from
ent of
gislatu E. DAVIS, JOHN M. WALLACE, J AND TRINA R.
http://www .census.gov/apsd/www/statbrief/sb96_ 03 .pdf WILLIAMS SHAN I
U.S. Census Bureau. (2006). Black-Owned firms: 2002 Eco-
.868) nomic census, survey of business owners. Retrieved
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overty
sb0200csblk.pdf IMMIGRANTS OF AFRICAN ORIGIN
14(3), U.S. Census Bureau. (2005a). American community survey. ABSTRACT: The number and percentage of immigran from
,S., Calculated from tables retrieved from http:///www.factfin
& Africa to the United States have increased sul stantiallv
der.census.gov on January 16, 2007. since the mid-1990s. Though still a relative! small percent
son
U.S. Census Bureau, Current Population Survey. (2005b).
of of the immigrant population, immigrarr from Africa
Annual social and economic supplement.
Healt
save? encounter many challenges and are c concern to social
U.S. Census Bureau. (2006). Housing vacancies and homeownership
:h (CPS/HVS): 2005. Housing and household economic statistics work professionals. This entry exarr ines two groups of
:ounts division. Washington, DC: U.S. Governmerit Printing Office. immigrants from Africa: legs migrants and refugees. It
South,
. U.S. Department of Health and Human Services. (200l). provides information on dis tinctive characteristics of
Mental health: Culture, race, and ethnicity-A supplement to mental recent African immigrant: reason for emigration from
t\meri- health: A report of the Surgeon General. Rockville, MD: U.S. Afrka,challenges they fac in the United States, and their
:hford Department of Health and Human Services, Center for settlement (geograph ical distribution) patterns. While
Mental Health Services, Substance Abuse and Mental Health Black Africans ar the focus of this entry, the research
'leTican
Services Administration. literature does ne provide clear distinctions within the
U.S. Department of Health and Human Services. (2005). 2005
mand group of Africa, immigrants. The emphasis is on Black
National health care disparities report (AHRQ Publication No.
uUetin
06-0017). Retrieved April 12, 2007, from http://www. African immi grants to the United States as their
, experience is uniqu in terms of their race in America and
ahrq.gov/qual/nhdr05/nhdr05.pdf download
mnect- Van Sertima, 1. (2003). They came before Columbus: The African the type of stigm and discrimination they face as a result.
Jrove, presence in ancient America. Random House. New York. Critical issue for social work practice are examined
Voting Rights Act of 1965, 42 U.S.C. 1971, 1973-1973p. through a cas, example of a Somali refugee group,
health
followed by impli cations for social work.
ces Re-
76 AFRICAN AMERICANS: IMMIGRANTS OF AFRICAN ORIGIN
KEY WORDS: immigrants of African origin; social
work practice with immigrants; African refugees
Introduction
The nature, form, and process of immigration from
Africa to the United States have changed significantly
over the past few decades. U.S. policies during the first
half of the 20th century and social and political factors
in Africa resulted in the migration of a very small
number of people directly from Africa. Unlike the
Western Europeans, Asians, Eastern Europeans, and
other people of color, including Africans, were
restricted from entering the United States. The
McCarran Walter Act of1962 reversed racially based
quotas by establish, ing new quotas for immigrants from
the Asian-Pacific area. However, it continued to give
preference to North, western Europeans (Helton, 1992 ).
The 1965 Immigration Act phased out the national
origins quota and allowed for immigration to the United
States under four main categories: (a) family
reunification; (b) labor certification, which included
those needed for their work skills in the United States;
(c) refugees for political and humanitarian reasons; and
(d) temporary visitors such as tourists, students, and
diplomats (Bean, Vernez, & Keeley, 1989; Ross-Sheriff,
1995). The 1980refugee act facilitated the entry of a
large number of Africans, among other groups who
came to America (U.S. Immigration and Naturalization
Service, 1993). Two more policies, the 1986
Immigration and Reform Control Act, which gave
amnesty to undocumented people and the 1999
Diversity Visa program opened the doors further for
documentation and entry of Africans to America.
Africans are the least represented groups of immigrants
to the United States and continue to be
disproportionately underrepresented in the U.S.
immigration system (Newton, 2005).
Despite the opening of the doors as a result of
changes arising. from the 1965 Immigration Act, the
numbers of Africans migrating to America did not in-
crease substantially soon after because of two reasons.
First, few qualified under the family reunification cate-
gory (Rockett, 1983). Second, most Africans who had
high levels of education and good skills an d who would
qualify under the labor certification category preferred
to return home to participate in the development of their
nations postindependence. They hoped that
independence would provide opportunities for contri-
butions toward social, economic, and political devel-
opments leading to improvement in education and
health care and greater employment opportunities in
their countries (Takougang, 2003).
Reasons for Immigration
Political instability in postindependent African states
beginning with the 1970s, civil unrest, inter- and intra-
ethnic power struggles, regional tensions, and military
coups in countries such as Angola, Ethiopia, Ghana,
Liberia, Nigeria, Sierra Leone, and Somalia as well as
natural and man-made disasters created a large number
of refugees (Mohammad & Rahman, 1998). During the
same period, deterioration in socioeconomic conditions,
unemployment, and related reduction in standard of
living increased the desire for Africans to migrate to the
United States (Adepoju, 1991; Peil, 1995). Such
conditions, coupled with globalization, including ex-
changes of commodities and capital across interna tional
borders and developments in transportation and mass
communication, resulted in an increase in migra tion of
Africans to America (Massey, 1995; Okome, 2001;
Rumbaut, 1994).
During the 1990s, about 350 million Africans, which
is rv 10% of the population of the African con- tinent,
had migrated to another country (Ricca, 1989). While
most of the refugees sought shelter in neighbor-
ingcountries, there was also an exodus of immigrants
out of Africa to Europe, Australia, and North America
(Dodoo, 1997; Kamya, 1997; Martin & Widgren, 2002;
Takougang, 1995). Between 1990 and 2000, thenumber
of African immigrants to the United States it:J.': creased by
142%, with the largest group arriving from West Africa
(Dixon, 2006).
Other critical considerations in the discussion of
African immigration to America are two pull
factors-educational and professional opportunities in
America from the 1960s to the tum of the century. The
United States, which is considered a major center for
higher education, provided scholarships and other
cultural and educational opportunities that served as
great incentives for Africans from the newly indepen-
dent countries during the 1960s and the 1970s. Oil
revenues, during the boom of the 1970s and early 1980s,
further increased the number of students from Nigeria,
Algeria, and Libya. Some graduates of American
universities never returned home to African COUll' tries,
while others who had selected to returnhome to African
countries migrated back to the Ullited States when
social and economic conditions in their home countries
had deteriorated. Th~se retufu~es served as chain
migrants for their families and friends
(Takougang,2003).
Thus, there has been a small but steady increase of
African immigrants to America. Prior to 1965, the
percentage of immigrants from Africa was 0.7% (Ross '
Sheriff, 1995). By 1992, the percentage of immigrants
 AFRICAN AMERICANS: IMMIGRANTS OF AFRICAN ORIGIN 77

from Africa increased to 2.8% (Ross-Sheriff, 1995). The
largest increase was during the 1990s as a result of the
Diversity Visa Program beginning 1990. In addition,
beginning in 2000, there was a significant increase in
admission of refugees from Africa. As a result, the
percentage of legal migrants from Africa to the United
States has increased from 6% in 1997 to 9.6% in 2006,
and the percentage of refugees from 8.7% to 44.2%
during the same period. (See Table 1.)
Characteristics of Recent African Migrants
As a whole, the African immigrants have higher levels
of education (Carrington & Detragiache, 1999), higher
English level proficiency, and lower unemployment
rates compared with other immigrant groups. They work
in high, level OCcupations in management or pro,
fessional positions and sales, and earn relatively more
than the overall foreign born population in America
(Dixon, 2006). Approximately 90% of African immi-
grants had a high-school or higher education. Forty
percent of these immigrants had a college education and
one-third of households owned their own homes (Dixon,
2006). Compared with the poverty rates of all
Americans in 2000 (which was 11.3 %), the rates of
African immigrants. was about 10% (Dixon, 2006).
However, there is a great variation in the demographic
characteristics of African immigrants and they form a
very heterogeneous group composed of people from
different countries of origin, ethnic groups, cultural,
linguistic, and social backgrounds, as well as their
geographic locations in the United States.
A recent report from Migration Information Source
indicates that African immigrants originate
from Western, Eastern, Northern, and Southern Africa
(Dixon, 2006). While almost all the African countries
were represented among the countries of origin, Butty
(1991) estimated that one out of every four Africans in
the United States was a Nigerian. USing the 1990
Census data, T akyi (2002) found that the largest nurn-
bers of African immigrants were from Nigeria, Egypt,
Ethiopia, Republic of South Africa, and Ghana. Among
the recent immigrants, those from Zimbabwe,
Botswana, and Malawi had high-school educations or
higher; while those from Cape Verde, Mauritania, and
Somalia were least likely to have completed
a-high-school education. In terms of college education,
those from Egypt, Cameroon, and Nigeria reported
having a college degree or higher. Those from Nigeria,
Ghana, Gambia, and Sierra Leone had relatively high
levels of labor force participation. Those from Somalia,
Sudan, and Botswana had the highest rates of
unernplovment.and lived in poverty (Dixon, 2006).
Patterns of Settlement in the United States New
York, California, Texas, Maryland, New Jersey,
Virginia, Georgia, and Massachusetts are eight
states that are selected as destination locations by
Black African immigrants (Takyi, 2002). Based on
the destination locations such as New York, New
Jersey, Georgia, and the Greater Washington
Metropolitan area, T akyi speculates that "black
African immigrants gravi tate more to states with a
significant number of other black residents" (p. 37),
where they settle in large numbers and establish
ethnic enclaves. Established African immigrants
help newcomers from their countries or from their
ethnic, tribal, OF religious groups find employment

TABLE 1
African Immigration to the United States from 1997 to 2006
ent." Local municipalities, NUMBER AND PERCENTAGE TOTAL NUMBER OF NUMBER AND
REFuGEE ARRIVALS TO OF AFRICAN REFuGEES PERSONS OBTAINING PERCENTAG.E OF
THE UNITED STATES ADMITTED TO THE LEGAL PERMANENT AFRICANS OBTAINING
FROM AFRICA UNITED STATES STATUS LEGAL STATUS .
1997 69,276 . 6,069 8.7% 797,847 47,7326%
1998 76,181 6,665 9.3% 653,206 40,585 6.2%
1999 85,076 13,048 15 644,787 36,578 5.7%
2000 72,143 17,624 % 841,002 44,534 5.3%
2001 68,925 19,070 24 1,058,902 53,731 5.1%.
2002 26,769 2,550 % 1,059,356 60,101 5.7%
2003 28,304 10,721 28 703,542 48,642 6.9%
2004 52,835 29,129 % 957,883 66,422 6.9%
2005 53,738 20,750 9.5% 1,222,373 85,102 7%
2006 41,150 18,185 38% 1,266,264 117,430 9.6%
From Yearbook of Immigration Statistics, by u.s. Department of 55%
Homeland Security, 2006, Office of Policy and Office of Immigration
39%
Statistics. Retrieved November 8, 2007. from http://www.dhs.gov/xlibrary/assets/statistics/yearbook/2006/01S_2006_ Yearbook.pdf
44.2%
78 AFRICAN AMERlCANS: IMMIGRANTS.OF AFRICAN ORIGIN
and housing. Takougang (1995) explains that the choice of
location of African immigrants is a function of availability
of jobs. Gozdziak (1989) notes that a large proportion of
refugees find their jobs through informal referrals from
extended family members and friends. Unger (1995)
describes how "Ethiopians in business here prefer to hire
their own compatriots in part because there is natural tribal
identification and affinity for their own people" (p. 226).
Eissa (2005) notes that African immigrants are establishing
small businesses, cultural associations, religious
institutions, and ethnic restaurants in cities across the
country. They share language and cultural background,
which are a great source of comfort during the initial
resettlement and adaptation phase in American society.
This enables them to\ maintain their ethnic identity, which
they value very highly. African immigrants have
introduced their cultural practices and ways of life,
including food, music, and dance, arid "entrepreneurial
ingenuity in the American mosaic" (Eissa, 2005, p. 4), and
their entrepreneurial skills provide economic stability for
their families and communities.
Challenges
Despite their relatively high overall educational and
occupational status and level of employment, a significant
number of recent African immigrants, specifically
refugees, are poor, underserved, and inadequately served
by human service professionals. They encounter chal-
lenges in the workplaces and in residential settings
(Lamphere, Stepick, & Grenier, 1994). Many encounter
serious discrimination and even denial of due process.
Recent immigrants struggle with interethnic conflicts,
racial discrimination, and cultural denigration (Arthur,
2000). The case example of Somali refugees is presented
below to highlight some of the challenges, followed by
implications for social work practice with African
immigrants.
An Illustration of the
African Refugee Experience
Somalis make up the largest African refugee group in the
United States. Among all the refugees admitted to the
United States annually since 2000, a high percentage is
from Somalia, and 75% of this group is women and
children (Cultural Orientation Resource Center, n.d.). Prior
to the 1991 Somali civil war, very few people of Somali
descent resided in the United States. Most recently, the
largest concentration of Somali immigrants in the United
States is located in the states of Ohio (Columbus) and
Minnesota (Minneapolis) (Kusow, 2006). Many have
arrived directly to midwestern America from refugee
camps. Others who were
resettled in other regions of the United States are drawn as
secondary migrants to areas with job opportunities, where
there are perceptions of social support programs. Somalis
have a unique culture, and they have arrived with little
knowledge of English. Almost all Somali refugees are
Muslims. Unlike the predominantly Mexican or Hmong
immigrants who preceded them in the Midwest, they
make. up one of the largest African-born Muslim
immigrant groups (Kusow, 2006). This combination of a
minority culture, religion, and race raises several
challenges for them as well as the host communities.
Muslim customs and practices are typically not well
known in American communities. Lack of understanding
of their cultural practices, including unacceptable practices
such as female genital mutilation,has created several
points of conflict. Somali women who wear head
coverings (hijab) stand out from among the rest of the
population groups. This makes them targets of prejudice
and hate crimes. Lastly, their skin color and their language
make them easily' identifiable as a "foreign" other (Schaid
and Grossman, 2003). Very few Americans speak the
Arabic or Somali languages of this group of refugees,
which makes finding Somali translators much more
difficult for social service professionals.
Implications for Social Work Practice
With African Immigrants
The experience of migration may cause mental disorders
due to factors such as acculturation stress, loss of
employment, premorbid personality, and life events that
occurred before, during, and after admission into the host
country (Bhugra, 2004). Using the Census data from the
period between 1960 and 2002, Bangura (2005) found that
recent African immigrants are establishing permanent
residency in America. This is different from the earlier
population of African immigrants. Today, African
immigrants face many challenges. In response, they have
created individual and community resources such as
churches, religious and spiritual groups, social clubs, and
ethnic restaurants (Watson, 2002). Social work has. a role
to play in the lives of African immigrants and refugees.tc
the United States, and there are implications for social
work practice ~nd research.
Practice
In 1970, it was reported that there ate four significant
experiences immigrants encounter: social isolation,
cultural shock, cultural change, and goal-striving stress
(Kuo, 1976). African immigrants today share a similar
experience. It is important in social work practice to
examine these issues in the context of the social
 AFRICAN AMERICANS: IMMIGRANTS OF AFRICAN GRIe

es are drawn dimension of stress, which includes attitudinal, familial, and provide information on the contributions vibrant
>portunities, IT environmental contexts (Kamya, 1997). The distinctive needs population to the American mosaic. formation is
programs. lave of diverse African immigrant and refugee groups call for much needed to augment the Iii search literature in
arrived l culturally sensitive practice outside of the generic "Western" social work, immigration sn others, on this
Somali retly framework (Betancourt, Green, Carillo, & Ananeh-Firempong, subpopulation of immigrant gn
Mexican in the 2003).
Mid- There has also been a shift in the gender make-up of
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study. Family Practice, 23, 111-115.
-FARIYAL ROSS-SHERIFF AND T AMARAH Moss-KNIGHT

PRACTICE INTERVENTIONS
ABSTRACT: African Americans number about 35 million
or 12% of the US. population. Their life expectancy is
lower than that of White Americans, and despite the
educational gains made since mid-1980s, the
unemployment gap between African Americans and
Whites has increased. Similarly, although the number of
African Americans working in white-collar occupations
has increased, the disparity in wage earnings between
African American and White workers continues.
Regardless of social class African Americans are made to
be cognizant of their race at all times. Today they are still at
risk for social issues such as substance abuse, teen
pregnancy, incarceration, poverty, high rates of female
headed households, infant mortality that is twice as high as
Whites, residential segregation, racism, and
discrimination. As daunting as these problems are, the
strengths of the African American community have
allowed it to thrive even amid arduous circumstances.
KEY WORDS: Strengths perspective; systems
approach; clinical assessment; political activism
The Risks and Strengths of African Americans African
Americans number about 35 million or 12% of the US.
population (US. Bureau of the Census, 2000). They largely
reside in urban. areas and live in southern states. Their life
expectancy is lower than that of White Americans, and
despite the educational gains made since the mid-1980s,
the unemployment gap between African Americans and
Whites has increased (Ferraro, Thorpe, McCabe,
Kelley-Moore, & Jiang, 2006). Similarly, although the
number of African Americans working in white-collar
occupations has increased, the disparity in wage earnings
between African American and White workers continues
(Daniels, 1998; McAdoo, 2007).
Regardless of social class African Americans are made
to be cognizant of their race at all times. Early European
settlers viewed Africans pejoratively (Alexander, 2005;
Hacker, 1992). They were assumed not to have the
psychological capabilities to achieve in education or ever
to achieve professional levels. These assumptions were
supported and continue to be espoused by social scientists
who question the intelligence of people of African ancestry
largely based on theories of genetic inferiority (Cherry,
1995; Lombardo & Dorr, 2006). Today they are still at risk
for social issues such as substance abuse, teen pregnancy,
incarceration, poverty, high rates of female headed
households, infant mortality that is twice as high as Whites,
residential
AFRICAN AMERICANS: PRACTICE
INTERVENTIONS 81
segregation, racism, and discrimination (Child Trends,
Inc., 1993; Hutchison, 1996; MacMaster et al., 2007; US.
Department of Health and Human Services, 1992). As
daunting as these problems are, the strengths of the African
American community have allowed it to thrive even amidst
arduous circumstances.
Strength Within the
African American Community
The African American family is composed of both the
nuclear family, which includes the parents and children,
and the extended. family, which includes the parents,
children, relatives, friends, the minister, and fictive kin
(McAdoo, 2007; Pearson, Muller, & Frisco, 2006).
Hence, family in the African American community
usually includes both biological and nonbiological in-
dividuals. The family is characterized by strong ties to its
members and an egalitarian role sharing (Leashore, 1995).
"The deep sense of kinship has historically been one of the
strongest forces in traditional African life. Kinship is the
mechanism which regulates social relationships between
people in a given community" (Harvey, 1985, p. 13).
Kinship bonds are a major component of the value base of
African American families.
In contrast to the European community these values are
expressed very differently in the African American
community. Male and female roles .are fluid in African
American families. The father is not always the head of the
family. Sometimes, the mother, grandparent, or other
relatives operate in this capacity. Fathers often take on
cooking, cleaning, grooming of children, and household
responsibilities that by traditional European standards are
usually carried out by females (Hill, 1997, 2002).
Additionally, older children sometimes assume the
parental or caregiver role for younger siblings.
When circumstances necessitate, children are often
cared for by relatives or nonkin, and it is not at all
uncommon for children to be raised from birth through
adulthood by extended family members. For instance, the
African concept of children being raised by the entire
village can be seen as a guiding principle for the African
American practice of informal adoption of children.
Informal child adoption services are provided on both
short- and long-term basis. In 1990 rv 1.3 million African
American children were living in homes where a relative
was the primary' caregiver and no biological parent was
present (Scannapieco & Jackson, 1996). Children are not
viewed as being disadvantaged because they are adopted,
and it is uncommon for adoptive parents to treat their
biological children and adopted children differently
(Albert, Iaci, & Catlin, 2004).
82 AFRICAN AMEiucANS: PRACTICE INTERVENTIONS
A second and important strength within the African
American community is the church. The African
American community draws strength from the African
American church, which has long become a symbol of
freedom from White domination (Martin, 2007;
Wingfield, 1998). Lincoln and Mamiya (1990) define
this church as the Black controlled independent
denominations, which make up the heart' of Black
Christianity (Moore & Lott-Collins, 2002). Second only
in importance to the Black family the African American
church serves the community's need for spiritual,
emotional, psychological, physical, social, and moral
support.
It also serves as a coping and survival mechanism
against 'the effects of racism and oppression and as a
place where African Americans are able to experience
unconditional positive regard (Lawson & Thomas,
2007). As a pseudo-family it is a place where its mem-
bers can be nurtured and feel accepted and it is also the
hub of their social and political activity. It has spawned
African American seminaries, colleges and academies,
political movements, and civil associations (Lincoln &
Mamiya, 1990; Smith, 2004).
Specific Issues for
Social Work Policy and Practice
African Americans have a history of being negatively
stereotyped by the social sciences (Douglass, 1993;
Krzysztof & Norris, 2000; Logan, Freeman, & McRoy,
1990; Taylor, 1994) and related to by the majority of
American social institutions from a White Anglo
middle-class orientation (Congress, 1994; Warren,
Orbe, & Kimmel, 2004). They have been viewed as
inferior, unmotivated for treatment, psychologically
impoverished, nonarticulate, and hence not able to
successfully engage in therapy. These stereotypes have
resulted from the lack of a conceptual understanding of
African American culture. African Americans, indivi-
dually and collectively, have been relegated to a position
of marginality and powerlessness by virtue of the
country's socioeconomic and political infrastructure.
They have been systematically denied equal' access to
resources and have endured the inferior treatment of
minority status. This arrangement has had very delete-
rious psychological, emotional, and physical effects on
the Black community in terms of stress and
stress-related disorders and mental health problems that
emerge as individuals, families, and communities
attempt to cope with and often internalize their ascribed
inferior status.
In part, as a result of negative treatment African
Americans are often very suspicious of and reserved
with those from different racial and cultural
backgrounds. This may interfere with trust building that
is vital
to establishing a therapeutic helping relationship. White
helpers are often seen as an extension of White
supremacy or racism and are approached with caution
until they demonstrate an understanding of arid
appreciation for the African American culture and
experience (Duster, 2006). Clients may partially or
totally withhold information that is felt to be private or
they may not be forthcoming with information if they
think that the interpretation of such information could
result in negative consequences. What follows is a
discussion of social work issues for practice and policy
at the micro, messo, and macro levels. These principles
have been adapted from the author's earlier work on
social work practice with African Americans (Dhooper
& Moore, 2001).
Practice Principles and Approaches
MICRO LEVEL CONSIDERA TlONS View the Client from a
Strengths Perspective. Social workers often ap proach
the African American client from a pathos per-
spective and base their assessment of the client
relative to a deficits model (Hepworth, Rooney, &
Laresen, 2006)~ For instance, female- headed
households are often char, acterized as pa thological
and African American men are rarely given credit for
being active in their children's lives. The social
worker must be careful not to portray a negative
valuation of a family type of composition thatis
unfamiliar or different from the married-co uple: ..
withchildren model (McPhatter, 1991). If- the family
is the client system, care should be taken to explore
the families' coping mechanisms and support systems
both, of which may reveal extraordinary survival
skills.
Use a Systems Approach to the Client Assessment.
Explore the clients' problemls) from a systems perspec-
tive. General systems theory helps the social worker
consider the client from a global perspective by con'
sidering the impact of other systems upon the circum-
stances of the client. The client's circumstance must be
considered from a global point of view in order to fully
appreciate. the significance of both internal and external
factors that may serve to facilitate or constrain client
functioning.
Become Familiar with Alternative Ways of Interpreting
Behavior. "The social worker must be well versed in
alternative theoretical explanations to mainstream
explanations of various cultural groups behavior and
functioning" (McPhatter, 1991, p. 15). Ifthe African
American client's behavio r is not referenced against
that of other African Americans it may appear
abnormal or deviant when in fact it may not be.
Involve Extended Support Systems in Intervention. The
involvement of the client's extended support system
may be helpful in a variety of ways. It may help with

information gathering. As a result, a more accurate as,
sessment and treatment plan may result. It may also help to
circumvent misunderstandings or mistrust that the client
may have toward the helping professional.
Be Aware that Not AIl African American Clients Are
Welcoming of African American Helpers. Do not
assume that all African American clients gravitate
toward African American social workers. For a
multiplicity of reasons, a bond between an African
American social worker and an African American
client may never solidify. Differences in values,
beliefs, or life experiences may cause client or
worker incongruence.
Solicit Clients for Feedback on Agency Effectiveness.
Agencies provide services but often forget the importance
of requesting client feedback, either formally or informally,
as to how services are perceived by those who utilize them.
The social worker may unintentionally assume that if
clients make no complaints then all is well. This may be an
erroneous supposition. For any number of reasons African
American clients may not volunteer suggestions and
comments that could be very valuable to the agency. For
instance, they may not believe that their input will be taken
seriously. Program evaluation should be a fundamental part
of program operation. Clients can tell you not only what
they need but can also identify community needs and
resources.
MESSO LEVEL CONSIDERATIONS Appreciate the
Intragroup Distinctions that Exist among African Americans.
Differences exist among African Americans on any
number of variables. such as historical life ex, periences
of different age cohorts, geographic location, region of
origin and the dominant cultural practices of that region,
religious practices and spirituality, and level of
acculturation. For instance, there may be variations in
beliefs concerning religious traditions and dress codes
among African Americans who belong to the same
religious denomination. Many African Americans do
not speak Black English, embrace hip, hop culture, or
eat "soul food." "Not all individuals within a particular
minority culture share similar values and expressions of
behaviors" (Whitler & Calantone, 1991, p. 461).
Appreciate the Diversity of Family Types Among Afri, can
Americans. Be cognizant of the differences in family
structures in order to accurately assess the family system
and appreciate its strengths and challenges. Logan et al.
(1990) differentiate between three types of family
structures within the African American community.
They are (a) the "nurturing or well functioning family,"
which has a high level of functioning and in which
boundaries are well defined and are open for change, (b)
"mid-range functioning family" seen across all
AFRICAN AMERICANS: PRACTICE INTERVENTIONS 83
socio-economic levels, which has well defined but less
flexible boundaries and tend to be less democratic in
nature, and (c) the "dysfunctional family," which does not
operate cohesively and whose members lack self direction
and healthy out-of-family relationships" (Dhooper &
Moore, 2001, p. 127).
MACRO LEVEL CONSIDERATIONS Do Not Discount
Client's Perception of the Impact of Racism and Disciimi-
nation on Their Lives. Social workers sometimes
minimize this impact or do not believe that the client's
problem is a result of racism or discrimination.
Subsequently the client may perceive that the social
worker thinks that the client's problem is self created
or a figment of his or her imagination. This issue will
impede the development of client-worker trust.
Racism and discrimination should be thoroughly
explored from the client's perspective for an accurate
assessment to be made.
Acknowledge the Historical Distrust of African Ameri,
cans Toward the European Professional Community. An
historical understanding of the nature of race relations
and experiences would help a social work agency to
better understand client resistance that might be
encountered. One area of concern within the African
American community that may have an impact upon its use
of social work services has to do with the issue of
participation in human experimentation. African
Americans have, without their knowledge and consent,
been used as human guinea pigs in scientific and medical
experiments by private and governmental organizations
(Lederer, 2005; Washington, 2007; Weasel, 2006). It is
also believed by some African Americans that they have
been injected with toxic substances, forced to eat human
waste, and injected with syphiliscausing organism.
Especially targeted were those individuals who were poor
(Washington, 1994). Some of these beliefs are based on
fact and may account for low client participation in agency
programs, services, and clinical trials.
Include the African American Community in Program
Development. Those responsible for agency program de,
velopment should consult members of the African
American community prior to and during program
development. This signals that constituent input is
important to the agency and may also lessen the like-
lihood of program underutilization.
AIl Agency Personnel Should Receive Diversity Training.
Social workers can gain a wealth of know ledge about the
issues and concerns affecting African Americans and the
means of addressing them by attending forums where these
issues are discussed. For instance Black History Month
programs, many of which take place in African American
churches, housing development
84 AFRICAN AMERICANS: PRACTICE INTERVENTIONS
tenant council meetings, African American church
services, Urban League meetings, and community
forums are but a few forums that can serve as mechan-
isms for learning about African American culture and
issues that are germane to the community.
Regard the Impact of Sodal Policy. Because social
policies often have broader effects than originally
intended, policy makers should consider the short and
long-term implications of policy decisions on the
African American community. The African
American community's ability to access services is
hampered by punitive policies. It is important to
garner as much feedback from the African American
community prior to policy development and
implementation via avenues such as focus groups,
surveys, and town meetings.
Promote Political Activism. Feelings of alienation
from the political process are not uncommon among
some members of the African American community
(Randle, 2007). This perception is manifested at
times through low voter participation. Social work
agencies should identify mechanisms for ensuring
that African Americans are involved in the political
process and ultimately in policy formulation and
implementation. Social workers should be active
advocates for those within the African American
community who feel dis enfranchised and further
should encourage their par ticipation in the political
process.
African Americans bring a unique richness to the
American landscape via their history and culture. They
are a heterogeneous group of people whose intragroup
diversity affords social workers wonderful opportunities
for professional development and personal growth.
African Americans also face a multiplicity of challenges
derived in part from long-standing institutional
structures that have by design or evolution caused pro-
blems and issues for them on micro, macro, and messo
levels. These issues will be ameliorated - by helping
professionals to the extent that social workers become
sensitive to their needs and culturally competent in their
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Daniels, L. A. (1998). The state of Black America 1998.
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Dhooper, S. S., & Moore, S. E. (2001). Social work practice with
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Douglass, B. C. (1993). Psychotherapy with troubled African
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Jiang, Z. (2006). The color of hospitalization over
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Lawson, E. J., & Thomas, C. (2007). Wading in the waters:
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-SHARON E. MOORE
AGED ADULTS. See Aging: Overview.
AGENCy-BASED REsEARCH 85
AGENCY/ORGANIZATION INTERVEN,
TIONS. See Management: Practice Interventions.
AGENCY,BASED RESEARCH
ABSTRACT: This entry reviews agency-based research, and
the unique demands created by the organizational context
where this activity resides. Three primary stakeholder groups
are identified: administrators and program managers,
supervisors, and direct service workers and clinicians. Possible
uses of agency-based research by each of the respective
stakeholder groups are described. Finally, the role of service
consumers in ' agency-based research is discussed.
KEY WORDS: clinical and program evaluation; consumer
involvement; research utilization
Social work is and always has been an agency-based
occupation. Notwithstanding the movement to "pro-
fessionalize" social work through licensure and certification
and the interest in private practice, most practitioners continue
to work within or on behalf of social agencies. Similarly, most
social work clients receive services within agencies. These
organizations may be specifically social work settings or
those in which social workers play important but ancillary
roles, for example, hospitals, schools, prisons, and the like.
Despite the pervasive organizational underpinnings of
social work practice arid the pioneering work of Tony Grasso
(Grasso' & Epstein, 1992, 1993), the value of agency-based
research remains underappreciated within the field. Instead,
most published social work research is carried out under
university auspices with the prevailing paradigm of social
work knowledge development ascribed to social work
academics. More recently, the evidence-based practice
movement has further emphasized the division of labor
between academics as knowledge producers and practitioners
as knowledge implementers (Gambrill, 2006).
By contrast, this article focuses on the conduct of
programmatic" supervisory, and clinical research within social
work agencies, by agency staff. More specifically, it describes
and illustrates the administrative, supervisory, and clinical
uses of agency-based research. In so doing, it suggests how
agency practitioners can conduct their own research for
internal decision-making as well as for making external
contributions to knowledge. This requires the design,
implementation, and utilization of studies that attend
specifically to organizational aspects of service delivery.
As indicated earlier, social work agencies have three sets
of "stakeholders" that have a professional interest
86 AGENcy-BASED REsEARCH

in agency-based knowledge development: (a) adminis- 2006). Single subject design is one research method that
trators and program managers, (b) supervisors, and (c) has been sanctioned and supported by social worker
direct service workers or clinicians, or both. Each have practitioners to assess and evaluate clinical effectiveness.
their own parallel stakes in questions about client need, This technique applies the logic of time series evaluation
service delivery, and client outcome. At the orga- methods to the treatment progression of single individuals
nizational level, the research studies that address these (Di Noia and Tripodi, in press; Rubin & Babbie, 2005;
questions are referred to as planning studies, monitoring Tripodi, 1994). Program Logic models have been used to
studies, and program evaluations. At the direct service create conceptual intervention models that can be used to
or clinical level, research can help assess the needs of organize and facilitate practitioner research projects (Alter
individual clients, the clinical interventions they & Egan, 1997; Alter & Murty, 1997).
receive, and the individual, family, or group outcomes Epstein and colleagues have continued to develop an
that result. Between the programmatic and individual innovative, direct service practitioner-friendly approach
client levels, supervisors may be concerned with the described as clinical data-mining. This method uses the
training and supervisory needs of their unit s or individual clinician as the primary researcher
individual workers and staff responses to supervisory responsible for designing, implementing, and utilizing
interventions. the research. The clinician-derived research questions
To answer these questions, agency-based social are addressed by collecting and analyzing data directly
workers at each level have available to them a wide from the case files. This method has been effective in a
range of research approaches and methods. These in- variety of settings (Auslander, Dobrof, & Epstein, 2001;
clude both qualitative and quantitative methods that can Epstein & Blumenfield, 2001; Peake, Epstein, &
be applied to already available information or make use Medeiros, 2005; Zilberfein, Hutson, Snyder, & Epstein, .
of original information. Available information can come 2001) and in multidisciplinary and international con texts
from within the agency itself in the form of (Joubert & Epstein, 2005).
computerized information or case records, community
informational resources outside the agency, or pub lished
research literature. Original information may be secured Supervisory Uses of Agency-Based Research The
through observation, interviews, or question naires.The information obtained through agency-based research is a
hitter can be based on already available instruments or critical resource for administrators and supervisors
can be completely original. (Schoech, 2000, p. 323). Data from agency-based
Of course, the appropriate use of any of these ap- research is critical to determining whether client out-
proaches requires some degree of research sophistica- comes are being achieved (Poertner & Rapp, in press).
tion, material and technical resources. And they must be Typically, agency-based research by administrators and
used in ways that are ethical and sensitive to the cultural supervisors is completed by exploiting existing data
values and sensibilities of clients and agency staff alike. sources, specifically internal information systems
Agencies may have their own research units, may (Hatry, 2004).
employ outside research consultants, or may colla borate Supervisors are able to use information from clinical
with universities to conduct this research. But what sets information systems to foster the improvement of clin-
agency-based research apart is that its primary purpose ical skills (Mooradian & Grasso, 1993). Current infor-
is to enhance the effectiveness of the agency in serving mation technology provides access to large automated
its clientele and in achieving its mission. In addition the data systems that sort and analyze client information in
research task must accommodate the dynamic context of . custom reports, which allow supervisors to "drill down"
the organization. Epstein (2001) suggests that to key data that address the development of direct
practice-based research principles should be used where service skills. This technology allows supervisors to
the practice setting is the centerpiece and research create. specific staff or team reports that facilitate
activity is conducted in a manner complementary to information-based supervision (Marty & Barkett, 2002;
service processes and activities. Moore & Press, 2002).
Clinical Uses of Agency-Based Research
As noted earlier, a significant gap exists between much Managerial Uses of Agency-Based Research
of the research conducted on clinical practice and the Information technology is equally useful for creating
clinical practitioner's usage of that same material custom reports that allow managers access to key data
(Epstein & Blumenfield, 2001). One of the strategies for that address specific service-related questions. For
addressing this gap is for practitioners to design, example, managers can generate program-specific
implement, and use research on their own practice reports of successful clients, or family contacts reports
within the agency setting (Yonk, Tripodi, & Epstein, organized by workers (Marty & Barkett 2002; Moore &
Press, 2002).
 Program improvement planning efforts integrate
agency-based research with organizational initiatives
directed at improving program performance. Organiza-
tional innovation is complemented by agency-based
research. The implementation and impact of specific
program enhancements targeted at program outcome (for
example, an aftercare program intended to increase
postplacement stability) are evaluated using specific data
collection plans (Hartnett & Kapp, 2003).
Consumer Involvement
in Agency-Based Research
Social work ethical directives focused on empowerment
and the increasing role of th~ consumer in service
provision in more and 'more fields of practice provide
continuing support forthe involvement of consumers in
agency-based research efforts. Consequently, consumer
satisfaction surveys are very common in agency-based
research (Corrigan, Lickey, Campion, & Rashid, 2000;
Fischer & Valley, 2000; Kapp & Vela, 2004; Martin, Petr,
& Kapp, 2002). Although philosophical reasons have been
cited for a more consistent inclusion of service providers in
agency-based research (Boll, 1995), Corrigan and Garman
(1997) argue that consumer involvement is likely to
highlight aspects of service implementation and
effectiveness that may otherwise be overlooked. Accord-
ingly, strategies have been developed and implemented for
including consumers in study design, data collection,
report writing, and utilization of agency-based research
findings (Linhorst & Eckert; 2002). ..
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Schoech, D. (2000). Managing information for decision
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Health Care, 33(3/4),91-104.
-IRWIN EpSTEIN AND STEPHEN A. KAPP
.,
AGING. [This entry contains five subentries:
Overview;
Practice Interventions; Public Policy; Racial and Ethnic
Groups; Services.)
OVERVIEW
ABSTRACT: The rapidly growing older population is
more heterogeneous by health and economic status, gen-
der, race, sexual orientation, and family and living ar-
rangements than any other age group. Although many
adults face vulnerabilities and inequities as they age, most
elders are resilient. This entry reviews this diversity,
discusses concepts of productive, successful, and active
aging, and suggests leadership roles for social workers in
enhancing the well-being of elders and their families.
KEyWORDS: life course; inequities; productive;
successful and active aging; resilience
The dramatic growth of the population aged 65 and older is
referred to as a demographic imperative because it affects
all social institutions-families, the workplace, educational
settings, health and mental health . care delivery systems,
and the leisure industry. It also has
far-reaching implications for social work. Social workers in
all practice arenas and with all age groups increasingly
work with older adults and their families: in child welfare,
family services,. schools, mental health centers, AIDS
treatment clinics, and among the homeless. This entry
reviews the demographics of aging, vulnerabilities and
challenges faced by older adults as well as emerging
opportunities for active, productive, and resilient aging,
and concludes with a discussion of the implications for
social work. Although the older population is growing ,
worldwide, the focus here is on the United States.
Demography of Aging
Americans aged 65 and older comprise 12.4% of the
population, compared to 4% in 1900. The population
aged 65 and older increased l Zvfold compared with a 3-fold
increase in the rest of the population during the 20th
century. With the first baby boomers (for example, those
born between 1946 and 1964) turning 60 in 2006, the
population aged 65 and older will again increase
significantly after 2010. Demographers predict that older
adults may number 72 million by 2030, a 100% increase
over 30 years compared with a 30% increase in the total
population. Those aged 85 and older-the oldest-old-c-are
the most rapidly growing age group. Now forming 13% of
the older population, they are projected to increase 500%
by 2050. The population of centenarians, people aged 100
or older, will also grow substantially since baby boomers
are expected to survive to age 100 at rates never before
achieved. One iii 26 Americans can expect to live to be 100
years by 2025, compared with only 1 in 500 in 2000
(Administration on Aging [AOA) , 2005; U.S. Census
Bureau, 2006).
These demographic shifts are occurring because of
increases in life expectancy (average length of time that
one can expect to live based on the year born). Life
expectancy at birth is expected to grow from 77.9 years in
2008 to 82.6 in 2050. Sex differences ill life expectancy
have declined from 7.4 years in 1980 to 5.3 years currently,
in part because of women's increasing death rates due to
heart attacks and stroke. A fairly constant 5- to 6-year
gender difference in life expectancy is projected well into
the future, although differences will be greater between
African American females and males, whose life
expectancies at birth are 76.5 and 69.8 respectively
(National Center for Health Statistics [NCHS) , 2006).
Most of the gains in life expectancy have occurred in the
younger ages because of better medical care and
eradication of childhood diseases.
Heterogeneity of the Older Population Aging cannot
be defined merely in chronological terms, which only
partially reflects the biological, psychological, and
social-cultural processes as people age. A more relevant
distinction is functional age or the ability to perform
activities of daily living (ADLs) , such as eating, bathing,
and dressing that require cognitive and physi cal
well-being (World Health Organization, 2002). Because
aging is a complex process that involves factors unique to
each individual, older people are morediverse in their
health and socioeconomic status, ethnicity and race, and
family situations than other age groups. Some are
employed; most are retired. Most are healthy; some are
frail, homebound, or have dementia. Most still live in a
house or apartment; a small percent are in nursing homes.
Some receive large incomes from

pensions and investments; most depend primarily on Social
Security and have little discretionary income. Most men
aged 65 years and older are married, while women are more
likely to be widowed and living alone. Intersections among
these variables play out in the poorest group in our society:
older women of color living alone in rural areas (Angel &
Angel, 2006).
As adults live longer, they also tend to manage their
chronic conditions without resulting in frailty or physical
disability. Disability rates have declined in all age groups
65 years and older, especially among the oldest-
. old (Federal Interagency Forum [FIF], 2006; Manton, Gu,
& Lamb, 2006). Although more than 80% of older adults
have at least one chronic condition, this does not
necessarily interfere with their ADLs. Instead, only about
4% are severely disabled and 2% are confined to bed by
chronic conditions (FIF, 2006). The need for assistance
with ADLs typically determines whether older adults can
remain in their homes. Although the baby boomers will be
healthier than prior cohorts, their sheer numbers mean that
by 2030, about 30% of them will have activity limitations
that require some assistance and 20% of this group will
have severe limitations (FIF, 2006; Manton, oo, & Lamb,
2006).
ETHNICITY, RACE, GENDER, AND SEXUAL ORIEN-
TA nON Ethnic minorities comprise 17% of the total older
population (8.3% African American, 6.0% Latino, 2.9%
Asian or Pacific Islander, and less: than 1 % Americ~
Indian or Native Alaskan) (FIF, 2006). These low rates
result from higher fertility and mortality rates among young
adults, creating a smaller proportion of elders compared
with Caucasian population. In addition, elders of color have
a lower life expectancy, as noted earlier, because of lifelong
inequities in access to economic resources, health care, and
preventive services. However, by 2050, the percent of
people of color aged 65 and older is projected to increase to
34%, faster than the rate of growth among the
Caucasianpopulation. This will occur because of the large
percent of children in these groups, who, unlike their
parents and especially their grandparents, are expected to
reach old age (NCHS, 2006; U.S. Census Bureau, 2006);
Women form the fastest growing segment of the older
population, especially among the oldest-old, making the
aging society a largely female society: they represent 58%
of the aged population and 70% of those aged 85 and older.
Females born in 2004 can expect to live about 6 years
(80.1) longer than men (74.8) (FIF, 2006; NCHS, 2006).
Estimates of the number of older gay, lesbian, bisexual,
and transgender (GLBT) adults range from as low as 3% to
as high as 18---20%. This translates into at least
AGING: OVERVIEW 89
2 million older lesbians and gay men, which will likely
increase to over 6 million by the year 2030 (Butler," 2006).
Prevalence rates are probably underestimates because of
the taboo of identifying as GLBT in a survey. The general
invisibility of being old in our society is heightened for
those who are old and GLBT, the most "invisible of an
already invisible minority" (Blando, 2001; Smith, 2002).
Because of the double stigma of being "twice hidden,"
some studies suggest that the aging experience is more
difficult for GLBT adults, while others indicate that such
lifelong marginalization and. skills in managing a
stigmatized status may stimulate adaptive strategies to the
challenges of aging (Gabbay & Wahler, 2002; McFarland
& Sanders, 2003; Thompson, 2006). What is clear is that
GLBT elders still encounter legal and attitudinal obstacles
in receiving and providing care, largely because of lacking
the legal protection of marriage, and service providers must
have the knowledge and skills to work effectively with
GLBT elders (Brotman, Ryan, & Cormier, 2003; Cahill,
South & Spade, 2001 Zodikoff, 2006).
GEOGRAPHIC LOCATION AND TYPE OF LIVING
SITUATION About 52% of all adults aged 65 and older
live in nine states, with the highest proportion in Florida
(17.6%), followed by Pennsylvania and West Virginia
(15.3%), and lowest-In Alaska (6.1%) and Utah (8.7%). In
some states, such as Florida, inmigration of older adults
explains the increase, while in others, such as West
Virginia, the increase is due to the migration of young
people out of the state. These regional differences are
expected to continue (U.S. Census Bureau, 2006).
Residential relocation is relatively rare; in a typical year,
less than 5% of people aged 65 and older move, usually
within the same region, compared with 14% of people
underage 65. The vast majority of older persons (77.4%)
live in metropolitan areas, with only 5% in communities
with fewer than 2,500 residents. The oldest-old are most
likely to relocate, often into or near their children's homes,
which is typically precipitated by widowhood, significant
deterioration in health, or disability (AOA, 2005).
Most elders prefer to remain in. their own home,
regardless of its condition, which reflects the almost
universal desire to "age in place." As a result, 93% of those
aged 65 and older live in independent housing, which
"they typically own, followed by 4% in nursing homes,
and 3% in community housing with services, such as
assisted living. The lifetime risk of admission to a nursing
home increases with age and for women, who are the
majority of residents. Of these residents, about 87% are
White, compared with 10.4% African
90 AGING: OVERVIEW

A~erican, and 3% 'Latino, American Indian, or Asian- spouse as compared with 79% and 58% of men, respec-
Pacific Islander (FlF, 2006; NCHS, 2006). tively. Accordingly,women represent 80% of the older
persons who live alone. The percentages living with a
spouse also decline markedly with age and among African
EDUCATIONAL, EMPL.OYMENT, AND ECONOMIC
Americans and Latinos (Department of Health and Human
STATUS Today's older population is better educated,
Services, 2006; FlA, 2006; Uhlenberg, 2004). Marital
with 70% of those aged 65 and older having a high
status affects living arrangements and the nature of
school degree, compared with less than 20% in 1960 ,
caregiving readily available in case of illness. Marriage
and 19% holding a bachelor's degree or more. Racial
appears to be a protective factor, associated with physical
and generational differences are striking, however.
and mental health, lifesatlsfaction, and happiness,
Among Whites, 82% of older men and women have
especially for men (Lyyra& Heikkinen, 2006). Although
at least a high school diploma. Because of historical
lacking the legal option of marriage, GLBT elders who
patterns of discrimination in educational
have partners tend to be less lonely and enjoy better
opportunities, 58% of older Af rican Americans and
physical and mental health than those living alone (Metlife,
46% of Latinos today have less than a high school
2006). The aging family of the future will be profoundly
education (AOA, 2005). Because educational level
affected by the growing incidence of younger adults who
is so closely associated with economic well- being,
are single and never-married, divorced, and single parents
these racial differences have a major impact on
along with reduced fertility and smaller family size.
poverty levels of persons of color acr oss the life
With increased life expectancy, multigenerational
course and particularly in old age. Not surprisingly,
families-composed of four or even five generations-are
the baby boomers who begin to tum 65 in 2010 as
more common now. At the tum of the 20th century, only 6%
well as adults currently aged 65-69 years are better
of lO-year-olds had all four grandparents alive, compared
educated than the oldest-old, which has implica tions
with 41 % in 2000 (Bengtson, Putney, & Wakeman, 2004).
for economic well-being of future generations of
Accordingly, more adults are grandparents and,
elders. The proportion of older people in the labor
increasingly, greatgrandparents, although they have
force has increased tq 4.8% in recent years: rv 19% of
proportionately fewer grandchildren than preceding
men and 11 % of women aged 65 and older now
generations. Among parents aged 90 and older, 90% are
work full- or part time outside the home. The
grandparents and nearly 50% are great-grandparents, with
majority of these (54% for men, 62% for wome n) are
some women" experiencing grandmotherhood for more than
employed in a part- time or temporary capacity
40 years. This is because the transition to grandparenthood
(Bureau of Labor Statistics, 2004).
typically occurs in middle age, not old age, with about 50%
Older adults' economic status has improved in the last
of all grandparents younger than 60 years. As a result, there
50 years, largely because of Social Security and its annual
is wide diversity among grandparents, who vary in age from
cost of living increases. Social Security is a source of
their late 30s to over 100 years old, with grandchildren
income for 95% of elders. Today about 9.8% of older
ranging from newborns to retirees. Most grandparents
people subsist on incomes below the poverty level,
derive satisfaction from their role and interaction with
compared with 35% in the lateJ950s, and 10.1 % of those
grandchildren (Reitzes & Mutran, 2004; Uhlenberg, 2004).
aged 18-64 years. Another 6.7% of older adults are
Grandparents have traditionally provided care for
classified as "near-poor" (AOA,2005).
FAMILIES AND FAMILY CAREGIVING The family is the
grandchildren, especially within families of color and
primary source of social support for older adults: immigrant families (Cox, 2002). What has shifted since the
nearly 94% of elders have living family members mid-1990s is the 30% increase in grandparents who assume
and 66% reside in a family setting. Although 80% of primary responsibility for their grandchildren. With over
adults aged 65 and older have children, only about 2.4 million custodial grandparents providing such primary
6% of older men and 17% of women live with care, skipped-generation households-the absence . of the
children, siblings, or other relatives, not with a parent generation-are currently the fastest growing type.
spouse or partner. Instead, nearly 55% of those aged Custodial grandparenting crosscuts social class, race, and
65 and older are married and living with a spouse in ethnicity: about 4% of Caucasian children, 6.5% of Latino,
an independent household, while about 4% have and 13.5% of African American live with grandparents or
never married. Significant differ ences exist, other extended kin, and African American children are
however, in living arrangements by gender and age.
Because of women's longer life expectancy, higher
rates of widowhood, and fewer options for re-
marriage, only 57% of women aged 65-74 years and
15% of those aged 85 years are married and living
with a

"' ..

6 times more likely to do so than their White counter-
parts. The majority of sole grandparent caregivers are
White (62%), but Latinos (10%) and African Americans
(over 30%) are disproportionatelyrepre sented, given
their percentage of the total population. In most
instances, the parents-an invisible middle generation-are
absent because of substance use or incarceration. Most
custodial grandparents are women, even among older
couples, and are younger than 65; the 20% who are aged
65 typically deal with age-related changes along with the
emotional stress of feeling alone and isolated from age
peers. Grandparent caregivers have been called the
"silent saviors" of the family; in addition to a greater
likelihood of living in poverty, they face numerous legal,
health-care, and financial barriers. These challenges are
even greater for grandparents who are raising a
chronically ill or "special needs" child, which is
common since the incidence of emotional or behavioral
problems is high (Hayslip & Kaminski, 2005; Kropf &
Yoon, 2006; Musil, Warner, Zauszniewski, ]eanblanc, &
Kercher, 2006; U.S. Bureau of the Census, 2006).
Generally, families experience a pattern of recipro cal
support between older and younger members, with older
adults providing support to children and grandchildren
as long as they are able (Silverstein et al., 2002). As
another example of this pattern, more elders are
providing care for their adult children with devel-
opmental disabilities or mental illness who are now
living longer (McCallion, 2006).
The reciprocal nature of caregiving shifts as more
adults-especially the oldest-old-live longer with chronic
illness and seek to remain in the community. In such
instances, middle-aged adults and partners are the
primary caregivers for older relatives (National Alliance
for Caregiving and AARP, 2004). Nearly 40% of baby
boomers are part of the "sandwich genera tion," facing
demands from employment, dependent children, and
older relatives (Brody, 2004). Families, who provide
rv80% of such care, are a significant factor influencing
whether an older adult will live in a nursing home. Over
80% of older adults with limitations in three or more
ADLs are able to live in the community primarily
because of family assistance. In contrast, 50% of those
with long-care needs but no informal caregiving
supports are in nursing homes, compared with only 7%
of those with informal supports (O'Brien & Elias, 2004;
Schmieding, 2006).
Caregivers are generally adult children (41%), fol-
lowed by partners (23%). Women form about 70% of
the caregivers who have primary responsibility,
although this gender-based pattern is shifting (Family
Caregiver Alliance, 2006b). Women are more likely to
AGING: OvERVIEW 91
provide emotional support and personal care, while men
assist with instrumental tasks such as transporta tion,
home maintenance, and finances. The average caregiver
is 47 years old, female, married, and earning an income
outside the home of $35,000 (Family Caregiver
Alliance, 2006a). Caregiving .for elders occurs across
the life course, however; a growing number of young
caregivers, aged 8-18, are helping a parent or
grandparent and caregivers who are in their 60s or even
70s are caring for centenarians (National Alliance for
Caregiving and United Hospital Fund, 2005).
Although there are gains from caregiving, the phys-
ical and mental health, financial and emotional costs of
care-conceptualized as objective and subjective
burden-generally exceed benefits for the caregiver.
Caregiving is associated with a range of illnesses,
including higher rates of depression, anxiety, heart dis-
ease, and even mortality (Beach et al., 2005; Christakis
& Allison, 2006; Lee, Colditz, Berkman, & Kawachi,
2003). Financial costs encompass the direct costs of
medical care, adaptive equipment, or hired help as well
as indirect opportunity costs of lost income, missed
promotions, or unemployment. Averaging 12 years out
of the paid workforce to provide care to family mem-
bers, women suffer long-term economic costs of care-
giving, including higher rates of poverty inoldage. The
caregiver's appraisal of the situation or subjective bur-
den, such as feeling alone and overwhelmed, is more
salient than objective burden or the actual tasks per-
formed (Family Caregiver Alliance, 2006b).On the
other hand, living with the care recipient, being a
woman, coping with an elder's behavioral problems,
especially those associated with dementia, and long
hours of intensive levels of care are associated with
increased caregiver stress (Chappel & Reid, 2002).
Children and partners typically tum to institutiona-
lization as a "last resort" when faced with their own
illness or severe family strain. Although most caregivers
do not utilize formal services, psycho-educational pro-
grams, support groups, and respite care are relatively
effective interventions in reducing caregiver stress, all
of which have implications for social work roles
(Burgio, Stevens, Guy, Roth, & Haley, 2003; Gonyea,
Connor, & Boyle, 2006; Kuhn & Fulton, 2004;
Mittelman, Roth, Coon, & Haley, 2004; Schulz.et al.,
2002; Toseland & Smith, 2003).
Vulnerabilities and Challenges of Aging
INEQUITIES ACROSS THE LIFE COURSE The
concept of life course is central to understanding the vul-
nerabilities faced by some groups of elders. A life
course approach captures how earlier life experiences
and decisions affect options in later life and for future
92 AGING: OVERVIEW
generations within and across cultures and time. It
recognizes that gender or racial inequities, which limit
earlier opportunities, are intensified in old age, resulting in
increased economic and health disparities and cumulative
disadvantage for older. women and persons of color.
Gender, ethnic minority .status, sexual orientation, low
educational and socioeconomic levels, and increased age
are all associated with reduced social
. capital and increased health disparities (Alwin & Wray,
2005;O'Rand, 2006; O'Rand & Hamil-Luker, 2005;
Williams, 2005). Nevertheless, many older adults who
have experienced cumulative adversity lifetime inequities
demonstrate remarkable resilience and optimism.
The overall economicstatus of older people masks
growing rates of poverty among women, elders of color, the
oldest-old, and those living alone. Older women are almost
twice as likely to be poor as men. And older African
Americans (24%) and Latinos (19%) are far more likely to
be poor than Whites (7.5%). Poverty is higher among elders
in central cities (13%) and in rural communities (11%) (He,
Sengupta, Velkoff, & DeBarros, 2005). Women and
persons of color are least likely to have held jobs with
private pensions and most likely to depend upon Social
Security as the primary source of income. Because of
economic, family caregiving, and health disparities
experienced across the life course, older women, elders of
color, and the oldest-old are most likely to experience
disabling illness along with poverty and inadequate housing
(Gonyea & Hooyman, 2005; Kelley-Moore & Ferraro,
2004). Although the likelihood of chronic illness grows
with age, the origins of risk for such conditions and early
mortality begin in early childhood. Regardless of age,
chronic disability then magnifies the risk of poverty
throughout the life course. When the intersections among
structural variables are examined, it is not surprising that
poor women of color aged 85 and older have the highest
prevalence of multiple chronic illnesses and functional
limitations (Burton & Whitfield, 2003; Whitfield, Angel,
Burton, & Hayward, 2006; Williams, 2005).
PHYSICAL AND MENTAL CHALLENGES The most
frequently reported chronic conditions, which limit
ADLs among older adults and are rooted in heal th
practices across the life course, are hypertension,
arthritis, and heart disease. Heart disease, cancer, and
strokes account for more than 60% of all deaths
among people aged 65 and older (FIF, 2006). Heart
disease is the number-one risk factor among a dults
aged 65 and older, killing 40% more people than all
forms of cancer combined, and accounting for 20%
of ad~lt disabil ities, with the highest rates among the
oldest-old and
among African Americans (American Heart Association,
2005; Office of Minority Health, 2006). Disabling chronic
diseases tend to occur earlier among African Americans,
Latinos, and American Indians than among Whites.
Comorbidity-coping with two or more chronic
conditions-is a concept central to understanding health
status and its secondary consequences, such as depression
and anxiety, and is more common in older women and
elders of color than in Caucasian men.
Although normal aging does not result in significant
declines in intelligence, learning, and memory, the
prevalence of mental disorders ranges from 15 to 25% of
the older population, depending on whether samples
include older residents in institutional settings. In some
instances, these represent mental illnesses that have
occurred across the life course, while others are often
precipitated by losses of old age. Anxiety and depression
are the most common mental disorders in late life, with
minor depression estimated to be as high as 20% among
community-dwelling elders (Blazer, 2003; Gellis, 2006).
This is of concern since depression often coexists with
medical conditions such as heart disease, stroke, arthritis,
cancer, diabetes, chronic lung disease, and Alzheimer's
disease, compounding dysfunction and delaying a recovery
process. Detecting depression is challenging, since older
people often mask or hide symptoms; it is most frequently
misdiagnosed among elders of color. Rates of depression
are highest among women, those lacking social supports,
and low-income elders (Blazer, 2003; Gellis, 2006;
Mitchell & Subramaniam, 2005).
Most older adults with chronic mental disorders live in
the community, but fewer than 25% of those who need
mental health services ever receive . treatment, a pattern
across all service areas (Kaskie & Estes, 2001). The
likelihood of irreversible dementia increases with
advancing age, with some estimates as high as 50% for
those aged 85 and older and 84% for those aged 90 and
older. Alzheimer's disease, the most common dementia in
late life, accounts for 45-55% of all dementias. With the
increased survival of older adults beyond age 85, it is
estimated that between 11 and 16 million Americans will
live with Alzheimer's disease by 2050 (Cox, 2007; Kukull
et al., 2002). Caregivers of elders with dementia may
experience grief over the psychological loss ofa loved one,
long before they die.
LIVING ALONE Although the majority of elders live
with others, about 16% of men and 30% of women
aged 65-74 years live alone; after age 75, these rates
increase to 23% and 50%, respectively. Those living
alone are most likely to be women, elders of color,
the

oldest-old, low-income, and 'in rural areas (FlFA,
2006). Among those living alone, the most vulnerable
are the homeless. Among the homeless, 6% are
estimated to be 55-64 years old and 2% 65 years and
older (National Law Center on Homelessness and
Poverty, 2005). The absolute number of older adults
who are homeless is increasing, especially among
women. Those living alone and the oldest-old are most
vulnerable to being placed in nursing homes, assisted
living, adult family homes, and hospitals.
Approximately 18% of the oldest-old live in a
long-term care setting, compared with 1.1% of those
aged 65-74 (NCHS, 2005).
Opportunities, Resources, and
Incentives for Productive Aging
\.
With the aging of the baby boomers, who may live a
third of their lives in a healthier and more financially
secure retirement than previous cohorts, increasing at-
tention is given to concepts of productive aging and
civic engagement. These concepts recognize that elders
are our society's most underutilized asset, with wisdom,
skills, and life experience to contribute to addressing
social problems. This has translated into growing num-
bers of civic engagement initiatives, such as voluntar-
ism, intergenerational programs, and cross- generational
political advocacy, which are typically associated with
higherlife satisfaction (Harvard/Metlife, 2004).
Another widely used concept is successful 'aging,
defined as a combination of physical and functional
health, high cognitive functioning, and active involve-
ment with society. However, this concept is critiqued
for conveying a middle-age, middle-class norm of re-
maining active as a way to show that one is an exception
to their age peers, that is, "not really old, not aging."
Strategies to avoid being seen as old are put forth by the
mass marketing of exceptionally fit and physically
attractive older adults and the growth of "lifestyle
industries" to preserve "youthfulness." The concepts of
productivity, civic engagement, and successful aging
can implicitly assume that all elders have resources to
age successfully and be productive, such as
volunteering. They may overlook structural constraints,
such as unhealthy communities, limited employment
options, and daily preoccupation with economic
survival, that prevent choosing healthy life styles. Both
policies and social environments need to be modified so
that all adults have opportunities to be productive in the
broadest sense of the term (Hendricks & Hatch, 2006;
Kahn, 2003; Martinson & Minkler, 2006; Wray, 2003).
An emphasis on activity characteristic of
mainstream Western culture may also overlook
elders-often from other cultures-who are spiritual and
contemplative, and experience a high degree of
subjective well-being.
AGING: OVERVIEW 93
A narrowdefinition of successful aging can be stigma-
tizing to older adults with chronic illness who develop
strategies to compensate for their functional disabilities
and experience quality of life. Instead, models of suc-
cessful aging need to recognize that older adults may
experience subjective well-being, engage in personally
meaningful activities, and "age well," even though not
be classified as successful in terms of external factors
(George, 2006).
Because of class, race, and gender biases implicit
within successful aging, the concepts of active aging and
resilience or adaptability may be more useful for
conceptualizing elders' strengths (for example, internal,
family, social, community, and cultural capacities) when
faced with adversity (WHO, 2002). In fact, many older
adults find meaning in their lives because of adversity,
not despite it. Even when impaired, they may contribute
to society in diverse ways (FredriksenGoldsen, 2006).
The concept of "active aging" is relevant to cultu rally
and economically diverse populations since it focuses on
improving quality of life for all people, including those
who are frail, disabled, or require assistance. It is
consistent with the growing emphasis on autonomy and
choice with aging, regardless of physical and mental
decline, that benefits both the individual and society. The
determinants of active aging include individual
behaviors, personal characteristics, the physical and
social environment, structural variables such as gender
and race, economic security, and access to and' use of
health and social services across the life course (WHO,
2002).
Role of Social Workers
Social workers are well positioned to promote active
aging and well-being for all older adults. The
opportunity arid challenge for social work, with its
social justice mission, is to address both increased
longevity along with life course inequities for women,
persons of color, and GLBT individuals. As a first step,
social workers must be prepared to meet the geriatric
workforce challenge, since the need for gerontologically
competent social workers far exceeds the supply. With
its person-in-environment perspective and
strengths-based values, social work is pivot ally placed to
advocate for structural and policy changes to reduce
lifetime inequities (for example, dependent care credits
in Social Security) and to enhance the wellbeing of
adults and their families as they age.
As the primary providers of mental health services,
social workers are also central to addressing growing
rates of depression, substance abuse, and mistreatment
among elders. They are often the lead professionals
supporting multigenerational families, particularly
94 AGING: OvERVIEW
related to psychosocial interventions to reduce the stress of
cross-generational caregiving across the life course. Social
work assessments are strengths-based and take account of
the needs of the total caregiving system, not just the elder.
Similarly, social workers can provide leadership in
developing and testing innovative models of integrated
care or service delivery as well as interventions with
caregiving dyads. As more adults live longer with
disability, social workers are central to community-based
models for chronic disease management, rather than cure,
and to fostering the social supports essential to
health-promoting behaviors. Similarly, social workers,
with their value of self-determination and dignity, play
vital roles in changing the culture of care of institutional
settings to be resident-centered and to empower the direct
care staff. Social workers also can facilitate the use of
assistive technology, including computer-based options,
along with informal social networks to enable. elders to
remain in their homes. In times of shrinking public
resources and increasing societal and moral issues
affecting all ages, social workers can foster
iritergenerational alliances that crosscut traditio nal
age-based approaches to services. And most important,
social workers, by building on the strengths of all elders;
even those with limited functionaldisabil ity, will reaffirm
older adults' dignity and worth.
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FURTHER READING
Berkman, B., & D'Ambruoso, S. (Ed.). (2006). Handbook of
social work in health and aging. New York: Oxford
University Press.
Cox, c., ed. (2007). Dementia and social work practice: Research
and interventions. New York, Springer.
Greene, R., Cohen, H., Galambos, c., & Kropf, N. (2007).
Foundations of social work practice in the field of aging:
ercompetency-based approach. Washington, DC. National
Association of Social Workers.
Hooyman, N., & Kiyak, A. (2007). Social gerontology: A multi-
disciplinary perspective (8th ed.). Boston: Allyn and Bacon.
Mclnnis-Dittrich, K. (2002). Social work with elders: A biopsy- .
chosocial approach to assessment and intervention. Boston:
Allyn & Bacon.
Richardson, V., & Barusch, A. (2006). Gerontological practice
for the twenty-first century. A social work perspective. New
York: Columbia University Press.
SUGGESTED LINKS Administration on
Aging. http://www.aoa.gov
Alzheimer's Association.
http://www.alz.org American
Society on Aging.
http://www.asaging.org
Association for Gerontology in Social Work Education.
http://www .agesocialwork.org
Family Caregiver Alliance.
http://www .caregiver .org
Gerontological Society of America.
http://www.geron.org
John A. Hartford Foundation.
http://www .jhartfound.org
John A. Hartford Geriatric Social Work Initiative.
http://www/gswi.org
National Alliance for Caregiving.
http://www .caregiving. org/
-NANCY R. HOOYMAN
PRACTICE INTERVENTIONS
ABSTRACT: Social workers address older adult issues at all
levels of service planning, policy-making, and delivery and
across a wide range of community and institutional settings.
While various models of practice " intervention with older
adults exist, more recently the focus is on the integration of
micro and macro strategies with an emphasis on strength-based
perspectives to geriatric social work practice. The older adult
population will expand dramatically and become increasingly
culturally, racially, and ethnically diverse, in the; future and
social work services will need to be sensitive to the variety of
issues faced by a more heterogeneous and sophisticated older
adult population.
KEY WORDS: geriatric practice; working with older adults
Practice Settings
Contemporary social work interventions with the aged (also
known as gerontological services) engage practitioners at all
levels of service administration and planning, policy-making,
and delivery and is carried out across a wide range of
community and institutional settings.
Gerontological services provided by social workers at the
micro or clinical level are primarily delivered in health- and
community-based services. Berkman's Handbook of Social
Work in Health and Aging (2006), for example, points to
extensive social work practice expertise with older adults in
hospitals, long-term care institutions (that is, nursing homes,
continuing care retirement communities, assisted living
settings, adult foster care and adult day care, congregate
housing, and

residential care), senior centers, home care agencies, public
welfare and social services, geriatric care man, agement
programs, substance abuse networks, managed care.
organizations, the workplace, and community health and
mental health clinics.
In these settings, social workers address chronic .
physical health conditions (that is, cancer, cardiovascular
disease, HfV-infected or HIV -affected, diabetes, orthopedic
and mobility limitations, developmental disabilities, and
sensory loss). They also address mental and psychological
health conditions including anxiety reactions, depression,
suicide, dementia, and substance abuse (Richardson &
Barusch, 2006). In addition, gerontological social workers
often work with special populations of older adults
including those living in poverty, the oldest old~ immigrant
and refugees, abused elders, those confronting the
end-of-life, and prisoners. Social work practice with older
adults can also mean working with ' elders serving as family.
caregivers of grandchildren and other relatives and those for
whom . family, friends, and neighbors are providing care.
Additionally, gerontological social workers are commonly
called upon to address special social psychological issues
associated with aging including issues related to living in an
aging family, bereavement in later life, and the transition
from work to retirement.
At the macro or policy level, gerontological social work
practice focuses on both interpreting and influencing
aspects of federal, state, and local legislation and regulation
that can affect the economic well-being and the health
status of older persons. This can mean both understanding
and advocating for changes in the Older Americans Act,
Social Security, Medicare, Medicaid, public health policy,
private insurance, and private pensions. Macro level social
workers are also engaged in developing programs for well
and frail seniors and assessing community needs to assure
comprehensive services, transportation networks, and a
variety of formal and informal supports. They also lead and
participate in Interagency Councils, community collabora-
tions, senior leadership programs.
All facets of gerontological social work are further
influenced by the cultural and ethnic context in which
services are delivered. Thus working with older adults and
their families means being sensitive to the possible
influence played by race, ethnicity, nationality, gender, and
sexual orientation. Finally, practice technique and style
with older adults will likely be influenced by
geography-namely, whether an older person lives in a rural
versus an urban community (Butler & Kaye, 2003).
Richardson and Barusch (2006) argue that an em,
pirically based, age-specific approach that recognizes
contemporary issues in aging and social work is essential
AGING: PRACTICE
INTERVENTIONS 97
to successful practice with older adults. Central to their
premise is the importance of integrating micro (individual)
and macro (policy-level) content in the delivery of
gerontological social work services.
THE MANDATE FOR GERONTOLOGICAL
SERVICES While not explicitly identifying
social workers as the providers of c;hoice,the
Federal Older Americans Act (OAA),
established in 1965, served as a major vehicle
for organizing, coordinating, and providing
communitybased services and opportunities
for older Americans and their families.
OAA,legislated services that social workers
and other human service personnel now pro-
vide include outreach, information and
referral, escort, assessment and case
management, in-horne, home health, chore,
home-delivered meals, telephone reas surance,
adult day care; senior center, legal assistance,
elder protection, housing, health insurance
counseling, services to support caregivers,
nutrition. education, and employment
assistance (see Title 42,
SOCIAL WORK CLINICAL ApPROACHES Chapter 35 of the U.S.
There are
Code-
many Programs
different types of for Older
clinical social Americans at
work therapeutic
http://
approaches to working with older adults. Models of
www.access.gpo.gov/uscode/title42/chapter3
practice intervention with older adults and their caregivers
5_.html).
include cognitive behavioral therapy, family and group
interventions, psychodynamic psychotherapy,
reminiscence and life review, strengths-based and
solutions-focused approaches, spiritual strategies, advo-
cacy and empowerment models, and interdisciplinary team
practice (Berkman, 2006). Historically, it was felt that
elders would not benefit from individual counseling,
operating on the premise that learning in later life was
difficult to achieve. However, research has shown this to
be inaccurate (Davis & Collerton, 1997). It has been
suggested that elders feel less stigmatization when
treatment is brief (Corwin, 2002). Reminiscence may be a
helpful tool in the social work counselors' practice with
older adults. Reminiscence group work has been used to
cope with grief, reinforce sense of life meaning, and
improve social relationships (Adamek, 2003).
SOCIAL GROUP WORK SERVICES It was not until the
early 1950s that the social work profession began focusing
on group therapy in a variety of settings. Today, group
work with older adults is informed by a well-established
theory base, structure, range of services provided, and
roles that social workers assume (Garvin, 1997; Toseland,
1995).
There are many different types of groups used in social
work practice. Most groups fall into one of two
98 AGING: PRACTIcE INTERVENTIONS
categories in terms of purpose: groups that provide
direct treatment or service to their members and those
that do not. Social work treatment-centered gr{)UPS
meet to focus on the individual needs of the members.
Examples of treatment-centered groups include therapy
groups, education groups, socialization groups, and
support groups (Kirst-Ashman & Hull, 2002).
Groups that meet for purposes other than direct
service, sometimes called task-centered groups, are
created to complete a specific task or set of objectives.
In terms of practice intervention, this area overlaps with
community organizing methods and strategies. The
purpose of these groups is not to focus on the individual
needs of their members (Henry, 1992). Committees,
boards of directors, legislative bodies, supervision, staff
development, consultation, interdisciplinary teams, and
social action groups are all examples of social work
taskcentered groups. Social work functions in these
groups will vary depending on the needs and structure
of each group. Possible social work roles include
facilitator, leader, and consultant.
CHANGING PHILOSOPHIES AND PRACTICE INTER-
VENTIONS Social work counseling and support ser-
vices for older adults highlight some of the changing
philosophies concerning gerontological practice
interventions overtime (this discussion is abridged
from Ruffin & Kaye, 2006). Older adults access
counseling and support services through a
combination of publicandprivate, community-based,
and institutional organizations. The counseling
services systern consists of private providers funded
by third party insurers an d private pay consumers, and
publicly mandated, not-for-profit, and privately
owned providers funded by the federal government as
well as states, counties, and municipalities.
Institutional or facility-based counseling services
include those provided by acute and long-term
providers, residential treatment centers, and foster,
boarding, or group homes. Community-based mental
health services include outpatient psychotherapy,
partial hospitalization/day treatment, crisis services,
case management, and home-ba sed and "wraparound"
services (U.S. Department of Health and Human
Services [USDHHS],2001).
Other community social service organizations pro-
vide nonmental health counseling services including
Area Agencies on Aging (AAAs), health care facil ities,
community action programs (CAPs), and senior citizen
centers. Services may be offered directly at an agency
or delivered in the elder's home. Over time there
appears to have been a tendency to offer services more
use of video, tele-health, and Internet
technology has figured in making such services more
available remotely (see, for example, Aycrigg, 2006).
Classic techniques of counseling intervention for
social workers include supportive counseling, where
the worker uses supportive listening techniques to help
the client feel understood; financial counseling, in
which the worker or agency helps the client set a budget
or plan for future expenses; and entitlements counsel-
ing, where the worker helps the older person understand
which social service programs, benefits, and services he
or she may be eligible for.'
Counseling programs are often combined with other
services including assessment, case management or
coordination, and referral. Many agencies provide
counseling and support services via telephone hotlines.
For example, the Alzheimer's Association, with local
offices situated throughout the United States, staffs a
24-hour' support and referral service for persons with
Alzheimer's disease and their caregivers. The
Alzheimer's Association also employs clinical social
workers to provide more in-depth counseling support
(see http://www
.alz.orglnational/documents/topicsheet~
safereturn.pdf).
Special geriatric care managers may also provide
counseling services, depending on the qualifications of
the worker. These are commonly master's level profes-
sionals in social work, nursing, and other helping pro-
fessions who have demonstrated competencies' in
geriatric case management and are affiliated. with a
professional care management association. Geriatric
care managers are often self-ernployed or employed by
a private fee-for-service organization.
Faith-based counseling programs are also an option
for elders. Some faith communities employ social
workers as a unique method of delivering health and
social service information and referral services to their
congregants (Kirkland & McIlveen, 2000).
AN ALTERNATIVE CONCEPTUALIZATION An alternative
practice paradigm for working with older adults
reflects a productive' orientation to life (abridged from
Kaye, 2005). Rather thana focus on traditional practice
' dimensions that are problem based and deficit
oriented, such a paradigm is closely aligned with a
strength-based perspective to geriatric social work
practice. It embraces growth, capacity, and potential,
and the continuing aspirations of people over time
regardless of their relative age and health. This
approach is explicitly geared to promoting the
maintenance of productive behaviors. It requires that
social workers have a major role to play in a variety of
nontraditional settings including retirement planning,
travel and recreational programming, employment
training and counseling,

TABLE 1
Human Service Programs
with an Orientation Toward Productive Aging
Volunteer, employment, and civic engagement programs
Continuing education and lifelong learning
Retirement planning
Elder mentor/tutor programs
Social action programs
Gero-therapy and Counseling
Self-help/mutual aid support
groups Intergenerational programs
Health and wellness promotion projects
Travel and elder hostelling programs
Recreation and exercise programs
From Perspectives on Productive Aging: Social Work with the New
Aged (p. 9, Table 1-3), by L. W. Kaye (Ed.), 2005, Washington,
OC: NASW Press, .
volunteer services, self-help programming, health promotion
and exercise programs, and continuing education and lifelong
learning programs. These programs emphasize active
engagement in community life. Table 1 summarizes the range
of these nontraditional social work programs.
Services appropriate for promoting a productive old age
include a willingness by social work~rs to assume, when
necessary, the function of career/workplacecounselors,
volunteer recruiters, retirement planners, public educators,
and environmental change and adaptation specialists.
Adoption Of a diverse skill set and perspective is
particularly relevant for a productive aging orientation to
social work practice. Referred to here is a proactive
orientation to intervention (that is, intervening before
problems and challenges have surfaced or risen to crisis
proportions); creative problem solving; interdisciplinary team
practice; comfort working at multiple practice levels (that is,
micro and macro); and familiarity with nontraditional
community resources and services (for example, recreational,
travel, educational, exercise programs, andso on) (see Table
2).
Trends and Future Directions
As new legislation is drafted, opportunities for social workers
to intervene on behalf of older adults will surface. Such
legislation may not explicitly identify social workers as the
designated professional to deliver the service, but, depending
on the service described and the education and expertise
deemed necessary to deliver the service effectively, social
workers will be prominent among those helping professionals
expected to provide such services. For example, in 2003, the
U.S. Administration on Aging and the Centers for
l f
f
~
.L,d(,
AGING: PRAcrICE INTERVENTIONS 99
TABLE 2 Contemporary Gerontological
Social Work Intervention Skills Sets
Client empowerment strategies
Strength-based counseling
Knowledge of traditional and nontraditional community
resources
Proactive (early) outreach activities
Interdisciplinary team building and
assessment Creative problem solving
Engagement in micro, mezzo, and macro client issues
Expansive perspectives on the life course
From Perspectives on Productive Aging: Sodal Work with the New
Aged (p.12, Table 1-5), by L. W. Kaye (Ed.), 2005, Washington,
OC: NASW Press.
Medicare & Medicaid Services jointly established the Aging
and Disability Resource Centers (ADRCs) meant to represent
part of a state's system of long-term care that promotes a
convenient point of entry for such programs. ADRCs now
exist in a number of states, and social workers are among
those personnel that provide comprehensive information,
personal counseling, and consumer access to the range of
publicly supported long-term care programs.
Legislative developments in the areas of. income
maintenance, personal rights, competency and proxy issues,
Medicare and Medicaid, health, mental health, and caregiving,
private retirement benefits, long-term care, end-of-life care,
community-based social services, housing, and transportation
have the capacity to impact on the social work needs of older
adults and the venues in which gerontological social work
services are delivered (Berkman, 2006). In the future,
attention should also be directed to the anticipated increase in
the number of NaRCs, or naturally occurring retirement
communities in various regions of the country. The healthy
evolution of NOBes will be promoted by social workers and
other human service professionals who bring macro planning
perspectives that consider the program planning and policy
development implications oflocal settings in which high
proportions of older adults make up the resident population.
Leading edge baby boomers entering retirement will
represent a generation quite familiar and comfortable with
using social work counseling and support group services.
There will be fewer stigma attached to their use. A positive,
strengths-based, productive aging philosophy should be
reflected in such interventions with the focus on active older
adult community engagement and personal growth. The term
"vital aging" reflects this trend. It can be expected that certain
subgroups of older adults will continue to exhibit greater
resistance
100 AGING: PRAcnCE INTERVENTIONS

to participation in programming than others (for example, SUGGESTED LINKS

minority ethnic groups, older men) (Kaye, 1997). As the older Aging and Disability Resource Centers. http://www
adult population becomes increasingly culturally, racially, and .aoa .govlprofl agini5-dislbackground.asp
ethnically diverse in the years to come, such services will need
SED SETI W. KAYE
to be sensitive to the variety of issues faced by a
heterogeneous older adult population. And all services will
need to be planned with rather than for the senior population.
PUBLIC POLICY
ABSTRACT: Public policy advances in the field of aging in the
REFERENCES United States have lagged compared to the growth of the older
Aycrigg, B. (2006). Enhancing care through telemonitoring. adult population. Policy adjustments have been driven by
Florida Association of Aging Services Providers Newsletter, ideological perspectives and have been largely incremental. In
2(March/April),1-2. recent years, conservative policy makers have sought through
Adamek,M. E. (2003). Late-life depression in nursing home various legislative vehicles to eliminate or curb entitlement
residents: Social work opportunities to prevent, educate, programs, proposing private sector solutions and touting the
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and alleviate. In B. Berkman & L. Harooryan (Eds.), Social importance of an "ownership society" in which individual
work and health care in an aging society: Education, policy, practice
citizens assume personal responsibility for their economic and
and research (pp. 15-47). New York: Springer.
health security. The election of a Democratic majority in the
Berkman, B. (Ed.). (2006). Handbook of social work in health and
U.S. House and the slim margin of votes held by Democrats in
aging. New York: Oxford University Press.
Butler, S. S., & Kaye, L. W. (Eds.). (2003). Gerontological the U.S. Senate may mean a shift in aging policy directions
social work in small towns and rural communities. Binghamton, that strengthens Social Security, Medicare, and Medicaid, if
NY: the newly elected members are able to maintaintheii: seats
The Haworth Press. over time. The results of the 2008 presidential election will
Corwin, M. (2002). Brief treatment in clinical social work practice. also determine how the social, economic, and other policy
Pacific Grove, CA: Brooks/Cole. concerns will be addressed as the baby boomers join the ranks
Davis, C, & Collerton, D. (1997). Psychological therapies for of older Americans.
depression with older adults: Aqualitative review. Journal
of Mental Health, 6(4),335-345.
Garvin, C. D. (1997). Group treatment with adults. In J. R.
Brandell (Ed.), Theory and practice in clinical social work .
(pp. 315-342). New York: Simon & Schuster. KEY WORDS: baby boomers; ideological
Henry, S. (1992). Group skills in s~cial work: A four-dimensional . perspectives; demographic variables; Social Security;
approach (Znd ed.): Pacific Grove, CA: Brooks/Cole. Supplemental Security Income; Medicare; Medicaid;
Kaye, L. W. (1997). Informal care giving by older men. In J. 1. prescription drug benefit; Older Americans Act;
Kosberg & LW. Kaye (Eds.), Elderly men: Special problems long-term care; White House Conference on Aging;
and professional challenges (pp, 231-249). New York: .
Mandate for Change; the Fair Minimum Wage Act of
Springer.
Kaye, L W. (Ed.). (2005). Perspectives on productive aging: 2007; the Medicare Prescription Drug Price
Social work with the new aged. Washington, DC: NASW Press. Negotiation Act of 2007; National Commission on
Kirkland, K., and McIlveen, H. (2000). Full circle: Spiritual Entitlement Solvency; Commission on Congressional
therapy for the elderly. New York: The Haworth Press. Budgetary Accountability and Review of Federal
Kirst-Ashman, K. K., & Hull, G. H., Jr. (2002). Understanding Agencies; senior citizens
generalist practice (3rd ed.). Pacific Grove: Brooks/Cole. The aging of the U.s. population has been monitored and
Richardson, V. E., & Barusch, A. S. (2006). Gerontological examined for decades in anticipation of 76 million baby
practice for the twenty-first century: A social work perspective. boomers reaching age 65 between 2011 and 2029. Improved
New York: Columbia University Press. socioeconomic status, lifestyle choices, and advances in
Ruffin, L, & Kaye, L W. (2006). Counseling services and medical and drug interventions are expected to contribute in
support groups. In B .. Berkman (Ed.), Handbook of social
the years ahead to exceptional human longevity and an
work in health and aging (pp. 529-538). New York: Oxford
unprecedented number of centenarians and supercentenarians
University Press.
Toseland, R. W. (1995). Group work with the elderly and family (persons 120 years of age and older). As a transformative
caregivers. New York: Springer. demographic phenomenon, population aging in the United
U.S. Department of Health and Human Services. (2001,Janu- States, is generating policy issues and directions that reflect
ary). Older adults and mental health: Issues and opportunities. clearly defined ideological perspectives.
Retrieved June 21, 2004, from
http://www.openminds.com/ indres/seniormh. pdf

Demographics of Aging
Although the rate of the aging of the US. population has
appeared to be dramatic, older persons in Japan, Italy,
Germany, Sweden, Greece, Spain, and other de veloped
nations constitute greater proportions of their nation's
populations. As in other countries around the world,
older women outnumber men in the United States. In
2003, there were 1.40American older women for each
older man aged 65 years and older. At age 85 and older ,
the sex ratio of women to men was significantly higher
at 2.26:1 (US. DHHS, 2004).
Among all other demographic variables, the racial
and ethnic diversity of its older adult population most
distinguishes the United States from the vast majority of
the world's countries. Of more than 36.3 million
Americans 65 years of age and older in 2004, over 18%
were minority elders. By 2020, almost 24% will be
members of ethnic or racial minority groups, with this
proportion rising by mid-21st century to more than 36%
of all Americans aged 65 years and older.
Less than 10% (9.8%) of all older A mericans had
incomes at or below the poverty line in 2004. However,
persons of color, women, and older persons who live
alone tend to be' poor more often than elderly white
Americans, men, and older persons residing with their
families. Elderly Americans in larger cities, the South,
and rural communities are also more likely to be im-
poverished (U.S. DHHS, 2005).
Policy Issues
Arguably, US. public policy advances have lagged since
1965, when Medicare, Medicaid, and the Older
Americans programs were established through the
amendment of the Social Security Act and the passage of
the Older Americans Act. The velocity of growth in the
older American population and the explosion of
. knowledge in the biomedical, social, and behavioral
sciences that has illuminated economic security, health,
and long-term care needs and resulted in the identifica-
tion of numerous policy options for an aging America
have not been followed with the adoption of major
policies. Since 1974, national legislative gains have
been largely incremental and have been inclined in-
creasingly toward private sector solutions.
Social Security. The Social Security Act established
the Federal Old-Age, Survivors and Disability Insur-
ance Benefits (OASDl) Program (Title II) and the
Supplementary Sec urity Income for Aged, Blind, and
Disabled Program (Title XVI). Earned Social
Security retirement benefits are received by nearly 49
million beneficiaries or about 92 % of persons aged
65 years and older. It is the only source of income for
20% of its beneficiaries, 41 % of Hispanics, 40% of
African
AGING: PuBLIC POUCy
101
Americans, 29% of single women, and 28% of Asian
and Pacific Islanders who are older Americans (Na-
tional Academy of Social Insurance, 2005). Means-
tested Supplementary Security Income provides finan-
cial assistance to needy individuals aged 65 years and
older, persons who are blind, or persons aged 18 years
and older who are permanently and totally disabled
(Sec. 1605. [42 U.S.c. 1385 note] (a)[lO]).
In 2008, the OASDI Trust fund had a surplus of $2
trillion. Benefits will be paid fully by the program
through at least 2040, after which about 75% of all
benefits owed will be covered (Social Security and
Medicare Boards of Trustees of the Social Securi ty and
Medicare Trust Funds, 2006). The anticipated shortfall
after 2040 has led to contentious debates over whether
the market or a government-administered payas-you- go
entitlement program should be the mechan. ism through
which Americans ensure their economic
security in old age.
Medicare. The Health Insurance for the Aged and
Disabled Act amended the Social Security Act,
establishing Title XVIII of the Social Security Act,
the $384 billion (FY2007) Medicare program .
Lacking a comprehensive universa l national health or
long-term care policy, Medicare insures rv95% of
older Americans for hospital care and care by
physicians as the nation's largest single payer for
health services. Of Medicare's 37 million
beneficiaries 65 years and older, 88% are enro lled in
the traditional fee-for-services plan through which
beneficiaries can seek care' from health care
providers of their choosing, while 12% have opted
for the private-sector-run Medicare Advantage plan
that requires that care be received from HMOs
(health maintenance organizations), PPOs (preferred
provider organizations), and other contracted
providers. Unfortunately, not all of the 14.4 million
eligible low-income older Americans are enrolled in
the Medicare lowincome (or "extra help") subsidy
program that was established as part of the Medicare
Prescription Drug, Improvement, and Modernization
Act of 2003 to reduce the cost of prescription drugs
(Center for Medicare Advocacy, Inc., 2005).
Compared with the Old-Age and Survivors Insur-
ance (Social Security) Trust Fund, the Hospital
Insurance (Medicare) Trust Fund is 'significantly less
robust. (A Disability Insurance Trust Fund covers dis-
ability benefits.) Medicare Trustees reported in 2006
that the Hospital Insurance Program (Part A) fund
reserves will begin to draw down in 2010 and will be
depleted by 2018, when program income will cover
80% of anticipated expenditures. The Supplementary
Medical Insurance Program (Part B), underwritten in
part by the Supplementary Medical Insurance Trust
102 AGING: PuBLIC POLICY
Fund (also for Part D), will need to be sustained by
higher premiums and well-timed appropriations.
Reductions in the number of beneficiaries; the cost
to the federal government, and the total cost per ben-
eficiary are the three most commonly named options for
resolving Medicare's overall financial shortfalls
(Congressional Budget Office, 2005). The adoption of a
pay-for-performance approach by the Centers for
Medicare and Medicaid Services has also been urged by
the Institute of Medicine to incentivize health-care
providers to achieve health-care quality targets, that is,
safety, effectiveness, patient-centeredness, timeli ness,
efficiency, and equity (2007).
The financial vulnerability of Medicare Parts A and
B is not the program\ only conundrum. The Voluntary
Prescription Drug Benefit Program (Part D), enacted in
2003, inadequately covers beneficiaries, some of whom
have seen drug- costs triple from 1992 to 2002 (Federal
Interagency Forum on AgingRelated Statistics, 2006).
A program rule related to true out-of-pocket costs has
caused many beneficiaries to pay monthly Medicare
premiums on top of the full cost of medications not
covered by Part D. Such gaps in coverage equal an
estimated $2,850 per beneficiary and are expected to
rise by 2013 to $5,063 with inflation indexed benefit
thresholds (Congressional Budget Office, 2005).
Beneficiaries enrolled in Part D are purportedly
overwhelmed and confused by the number of private
health plans from which they must choose. (In
California, there are nearly 140 health plan choices.)
Other dilemmas include Medicare's acute care bias,
although chronic diseases account for six of seven
leading causes of death among persons aged 65 years
and older. Eighty percent of older Americans haveat
least one chronic condition, and half of all persons aged
65 years and older have at least two chronic conditions
(Centers for Disease Control and Prevention and the
Merck Company Foundation, 2007).
Long-Term Care. Older persons are receiving long-
term care primarily from family caregivers. Only 5%
of older Americans are nursing home residents.
Nationwide, 49% of nursing home care costs for
lowincome older persons are assumed by Medicaid,
a $300 billion (FY2006) program established in 1965
via Tide XIX of the Social Security Act, the Grants
to the States for Medical Assistance (Medicaid)
Program. Out-of-pocket long-term care expenditures
equal 19%, Medicare reimbursements for postacute
services amount to 19%, and private long-term care
insurance contributes 7% of nursing home
reimbursements. Federal Medicaid grants to states
(57%) are matched with state
dollars (43%) to finance care for 56 million
low-income Americans. These expenditures represent
states' fastest growing costs.
The Federal government's Centers for Medicare and
Medicaid Services grant Medicaid waivers to states
from institutional care rules for the demonstration of
innovative reimbursed service models. In effect, these
waivers have generated more than 50 different state
Medicaid programs. Tide XX, Block Grants ,to the
States, provides additional funds for home and
cornmunity-based services that can help prevent or
reduce inappropriate institutional care. '
The Administration on Aging administers . the OAA
National Family Caregiver Support Program (enacted
in November 2000), the Nutrition Services Program ,
and the National Long Term Care Ombudsman
Program. Discretionary federal and state matching
dollars fund these and other OAA programs.
The need to finance long-term care, effectively co-
ordinate health and long-term care dollars, create a
better balance of home and community-based services,
and assure the availability and competency of longterm
care professionals and paraprofessionals are among the
most urgent aging policy concerns. Long-term-care
costs vary from community to community by type of
care. In 2006, the average cost of care in a private
nursing home room was $75,190 nationwide (MetLife
Mature Market Institute, 2006). Most older adults prefer
community-based or in-home care, but there is an
inadequate supply of these services and of the pro-
fessionals and paraprofessionals required to staff both
institutional and noninstitutional long-term care pro"
grams. A study by the Office of the Assistant Secretary
for Planning and Evaluation in the U.S. DHHSesti-
mated that 11 0,000 professional social workers will
f'.J
be needed by 2050 to help deliver long-term care
services (U.S. DHHS, 2006).
Ideological and Interest Group Perspectives There
are sharply polarized, ideologically based views on the
policies necessary to address the economic security,
health, and long-term care needs of our aging nation.
The conservative Mandate for Change. has served as the
Bush Administration's blueprint. for policy and
organizational transformation. Guided by ideological
and religious convictions, the Bush Admin-: istration
has sought to uproot government safety net and
entitlement programs instituted by liberal policy
makers, striving to privatize public programs and
reduce the structure and size of the Executive Branch,
while growing the Department of Defense's budget
(Gonyea, 2005),

, In a policy environment populated by special inter, est
lobbyists, the' aging, health care, long-term care, drug,
insurance, financial, and other industries, along with
large and small membership associations, advocacy
groups, and defense-associated think tanks and groups,
have been keenly aware of the implications of
population aging. Conservatives such as Petersen have
argued that an aging society will siphon off resources
needed to finance a strong national defense (Petersen,
1999). Some have warned that the nation's leadership
position in the emerging global economy and our stan-
dard of living will be eroded by unbridled expenditures
tied to an aging America (Committee for Economic
Development, 2003). Reflecting their conservative
roots, the White House and Republican members of
\
Congress have touted the need for an "ownership so'
ciety" in which individual responsibility is a corner-
stone. Citizens in an ownership society should acquire
individual private health insurance plans and savings
accounts to secure' their retirement.
In contrast, liberal organizations such as the National
Committee to Preserve Social Security and Medicare,
OWL (previously the Older Women's League), and
Families USA have maintained that the nation's social
insurance and entitlement programs are fundament ally
sound and keep vulnerable Americans, most
prominently older women and minorities, out of the
jaws of poverty and illness (National Committee to
Preserve Social Security and Medicare, 2001). They
have also pointed out that government-run social in,
surance programs incur significantly lower administra-
tive costs in total and are less likely to inflate the federal
deficit. Liberals have asserted that the market cannot
ensure reliable investment returns and would thus place
retirees at risk (National Committee to Preserve Social
Security and Medicare, 2001).
Policy Trends
In December 2005, President George W. Bush became
the first U.S. President to have refused to attend a White
House Conference on Aging (WHCOA). Also
unprecedented were the management of sub, stantive
content and the structure and processes approved for the
conference by its presidentially appointed organizers
(Gonyea, 2005). Many delegates interpreted the
President's absence as a dismissal of their concerns.
Instead of older Americans, family care, givers, and
service providers, the Conference featured private
industry representatives who lauded the promise of
technology to enable self-reliance and personal
responsibility in the advanced years. Conference offi-
cials also refused to accept evidence-based white papers
AGING: PuBLIC POLICY
103
prepared by experts and minority reports and petitions
from the delegates.
Consistent with its ideological orientation, the Bush
Administration, as of 2007, remained resolute in its
intention to privatize Social Security and Medicare. A
plan to substantially reduce Social Security benefits for
the middle, and higher, income Americans who will
account for more than 70% of future retirees has been
supported by the White House. The White House has'
called for private accounts funded by diverting 4% of
Social Security payroll taxes, a course that would
accelerate the Social Security Trust Fund shortfall by 6
years. At least one analysis has estimated that such
private accounts would result in an additional $5 trillion
national liability, nearly doubling the national debt
within two decades. Ironically, instituting private
accounts would also require cuts to Social Security
benefits (Fuhrman & Greenstein, 2006; National
Academy of Social Insurance, 2005).
Spurred on by the 2006 congressional races,
senators' and members of Congress reauthorized the
OAA in 2006 (Pub. L No. 109-365). To the Act were
added provisions that expand the already stretched
National Family Caregiver Support Program to include
access to caregiver support services. to more
grandparent caregivers, all caregivers of persons with
Alzheimer's dis, ease, and older parents of children with
disabling conditions. The amended Act also called upon
the Secretary of Health and Human Services to engage
in planning and instituting coordinated, comprehens ive
systems that will honor better the preference of older
Americans to be served in their homes and communities.
Unfortunately, the newly expanded OAA programs and
services remain seriously underfunded given the
growing needs.
During the 109th and 110th Congresses, several
Senate and House bills were introduced by Republican
members who sought to eliminate and realign Executive
Branch agencies and entitlement programs. These bills
called for the establishment of a National Commission
on Entitlement Solvency (to focus on Social Security,
Medicare, and Medicaid) and a Commission on
Congressional Budgetary Accountability and Re view of
Federal Agencies. Modeled after the military Base
Closure and Realignment Commission, both com,
missions were to be authorized to advance recommen-
dations with little public notice or debate and with few
opportunities for amendments. Advocates for the aging
feared that, if established, the commissions would has-
ten the privatization of Social Security and Medicare
programs, dramatically restructure Medicaid, and elim-
inate units in the Social Security Administration and
104 AGING: PuBLIC POLICY
the Department of Health and Human Services (Brass,
2006). Although introduced, none of the bills moved
beyond a second reading.
The Fair Minimum Wage Act of 2007 (Pub. L. No .
110-28, Title VIII), and the Medicare Prescription Drug
Price Negotiation Act of 2007, introduced by Democrats ,
with are two measures direct implications for older
Americans. The Fair Minimum Wage Act was signed into
law on May 25, 2007, as a part of the 2007 Ll.S. Troop
Readiness, Veterans' Care, Katrina Recov ery, and Iraq
Accountability Appropriations Act. It raises the federal
minimum wage from $5.15 per hour to $ 7 .25 per hour in
three increments over a 2 years and 2 month period. For all
Americans who work to sustain their families and
themselves, the wage increase is a step toward ensuring a
living wage. Opposed by the pharmaceutical industry and
many conservatives, the Medicare Prescription Drug Price
Negotiation Act of 2007 (H.R. 4, S. 3) passed the House ,
but failed to receive the two-thirds majority needed in the
Senate. The President clearly indicated that he would have
vetoed the measure had it been presented to him for
enactment. Enacted, the Act would have amended Part D
of Title XVIII [section 1860D-11 0)], the "non-
interference" provision of the Social Security Act, and
required the Secretary of Health and Human Services to .
negotiate with drug manufacturers on behalf of Medicare
beneficiaries to lower and make more affordable covered
drug prices. Existing provisions now prohibit the Secretary
of Health and Human Services from participating in the
negotiations between drug manufacturers, pharmacies, and
sponsors of prescription drug plans (PDPs) involved in
Part D of Medicare, or from requiring a particular
formulary or price structure for covered Part D drugs.
Unfortunately, the failure of this Act to become law means
that there is one less provision to assure that prescription
drug prices will be contained.
The election in 2006 of 232 Democrats and 203
Republicans to the Ll.S. House of Representatives and of
51 Democrats to the Ll.S. Senate transferred the reins of
power in both Houses to the Democrats. However, the
Presidential and Congressional elections in 2008 will most
likely determine whether legislative proposals calling for
real income and health security will be reasonable
possibilities for current and future older Americans and
their family caregivers. A powerful array of interest
groups, including the Business Roundtable, the SEIU
(Service Employees International Union) with its
membership exceeding a million workers, and AARP with
a membership of more than 38 million persons 50 years of
age and older, have joined together to make national
health-care reform a
deciding issue by which the United States' electorate can
select its political leaders, in particular the Presi dent of the
United States in 2008 (http://www.aarp.org/
issues/dividedwefailf). Meanwhile, the National Com-
mission for Quality Long Term Care, which includes a
range of members from the public and private sectors, and
the national aging organizations that belong. to the
Leadership Council of Aging Organizations are inde-
pendently calling for long-term care to be a priority item
on the national policy agenda (Leadership Council of
Aging Organizations, 2007; National Commission for
Long Term Care Quality, 2007). What remains to be seen
is whether efforts to develop comprehensive national
health and long-term care policies, in combination or as
separate entities, will be placed at the top of the domestic
agenda and will sufficiently address the complex needs of
a diverse aging population. A narrow window of
opportunity is available before the baby boomers reach 65
years of age. Insufficient lead time to amass the necessary
financial resources and develop the essential workforce to
adequately serve a growing aging population may
constrain ambitious policyexpectations.
The ultimate test of the efficacy of extant and yetto-be
proposed aging policies may be whether the overall
well-being and security of women and racial-ethnic
minorities are truly assured as outcomes. Single older
African American and Hispanic women who live alone
have consistently registered the highest poverty rates
among all older Americans (U.s. DHHS, 2005). Already
Munnell (2006) warns that boomer women may net less in
retirement income than their mothers. If aging policies can
be promulgated to provide all. women, irrespective of race
and ethnicity, with income, health, and long-term care
security, all women and men may have a reasonable
opportunity to achieve not just long life, but also a good
life in their later years.
REFERENCES
AARP. Divided we fail. Retrieved November 6, 2007, from
http://www.aarp.org/issues/dividedwefail/.
Brass, C. T. (2006, July 21). Commis~ion on the accountabiUry
and review of federal agencies (CARFA): A brief overview of
legislative proposals. Washington, DC: Congressional Research
Service. Retrieved March 1, 2007, from. httfJ://
fas.org/sgp/crs/misc/RS21980.pdf.
Center for Medicare Advocacy, Inc. (2005, October 13). The
low-income benchmark premium amount defined. Retrieved
November 5, 2007, from http://www.medicareadvocacy. org/
AlertPDFs/2005 /1 0.13 .05 .BenchmarkPremium. pdf.
Centers for Disease Control and Prevention and the Merck
Company Foundation. (2007). The state of aging and health in
America 2007. Whitehouse Station, NJ: The Merck Company
Foundation.

Committee for Economic Development. (2003). Exploding deficits,
decUning growth: The federal budget and the aging of America.
Washington, DC: Author.
Congressional Budget Office. (2005, December). The long term
budget outlook. A Congressional Budget Office study. Retrieved
February 21, 2007, from http://www.cbo.gov/
ftpdocs/69xx/doc6982/12-15-LongTermOutlook.pdf.
Federal Interagency Forum on Aging-Related Statistics. (2006,
May). Older Americans update 2006: Key indicatars of wellbeing.
Washington, DC: U.S. Government Printing Office.
Fuhrman, J., & Greenstein, R. (2006, June 15). What the new
trnstees' report shows about Social Security. Washington, DC:
Center on Budget and Policy Priorities. Retrieved March 1,
2007, from http://price.house.gov/UploadedFiles/ 2006%2OT
rustees%20Report.pdf,
Gonyea, J. G. (2005). The oldest old and a long-lived society:
Challenges for public policy. In R. B. Hudson (Ed.), The new
poUtics of old age policy. Baltimore; MD: Johns Hopkins
University Press.
Leadership Council of Aging Organizations. (2007, August 1).
LCAO long-term care financing principles. Washington, DC:
Author.
MetLife Mature Market Institute. (2006, September). The MetUfe
market survey of nursing home and home care costs. Retrieved
February 21, 2007, from http://www.metlife.com/
WPSAssets/18756958281159455975VIF2006NHHCMarket
Survey.pdf.
Munnell, A. H. (2006). Female boomers: Retirement's brave new
world. In P. Hodge (Ed.), Baby boomer women: Secure futures or
not? (p, 29). Harvard Generations Policy Journal. Cambridge,
MA: Harvard University.
National Academy of Social Insurance. (2005, January 26).
Uncharted waters: Paying benefits from individual accounts in
federal retirement policy: A study panel report. Washington, DC:
Author.
National Committee to Preserve Social Security and Medicare.
(2001, September 6). Social security~eform. Paper presented to
the Commission to Save Social Security. Retrieved November
5,2007, from http://www.csss.gov/meet
ings/sandiego/Percil_Stanford_Statement. pdf.
National Commission for Long Term Care Quality. (2007).
Final report of the National Commission for Long Term Care
QuaUty. Washington, DC: Author.
Petersen, P. G. (1999). Gray dawn: How the coming age wave will
transform America and the world. New York, NY: Times Books.
U.S. DHHS. (2004). Older women. Washington, DC: Admin-
istration on Aging. Retrieved February 21,2007, from http://
www.aoa.gov/naic/may2000/factsheets/olderwomen.html.
U.S. DHHS. (2005). Statistics: A profile of older Americans: 2005.
Poverty. Washington, DC: Administration on . Aging. Retrieved
February 21, 2007, from http://www.aoa.
gov/pROF/Statistics/profile/2005/10.asp.
U.S. DHHS. (2006, March). The supply and demand of professional
social workers providing long-term care services. A report to
Congress. Washington, DC: U.S. DHHS, Assistant Secretary
for Planning and Evaluation, Office of Disability, Aging and
Long-Term Care Policy.
AGING: RACIAL AND ETHNIC GROUPS 105
FURTHER READING
Committee on Quality of Health Care in America, Institute of
Medicine. (2001). Crossing the quaUty chasm: A new health
system for the 21 st century. Washington, DC: National Acad-
emies Press.
Committee on Redesigning Health Insurance Performance
Measures, Payment, and Performance Improvement Pro-
grams, Institute of Medicine. (2007). Rewarding provider
performance: Aligning incentives in Medicare. Washington, DC:
National Academies Press.
Library of Congress. (2005). H.R. 3282: AboUshment of Obsolete
Agencies and Federal Sunset Act of 2005. Retrieved February 21,
2007, from http://thomas.loc.gov/cgi-bin/ query/z?c
109:H.R.3282.
Library of Congress. (2006). H.R. 5766: Government Efficiency Act
of 2006. Retrieved February 21, 2007, from http://tho
mas.loc.gov/cgi-bin/bdquery/z ?dl 09:h.r.057 66.
Library of Congress. (2007). H.R. 2: The Fair Minimum Wage Act of
2007. Retrieved February 21, 2007, from http://tho
mas.loc.gov/cgi-bin/bdquery/z?dll0:h.r.00002.
Library of Congress. (2007). H.R. 4: The Medicare Prescription
Drug Price Negotiation Act of 2007. Retrieved February 21,
2007, from http://thornas.loc.g~v/cgi-bin/bdquery/z?dllO:
h.r.00004.
Library of Congress. S. 3521. Retrieved February 21, 2007, from
http://thoinas.loc.gov/cgi-bin/query/D?c109:1:./temp/.
-c109ugYYti.
Social Security and Medicare Boards of Trustees of the Social
Security and Medicare Trust Funds. (2006, May 2). Summary
of the 2006 annual report. Washington, DC. Retrieved February
21, 2007, from http://www.ssa.gov/OACT/
TRSUM/trsummary.html.
The Boards of Trustees, Federal Hospital Insurance and Federal
Supplementary Medical Insurance Trust Funds, (2006, May
1). 2006 Annual report of the boards of trnstees, federal hospital
insurance and federal supplementary medical insurance trust funds.
Washington, DC: Centers for Medicare and Medicaid
Services. Retrieved March 1, 2007, from http://
www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2006.pdf.
SUGGESTED LINKS
http://www.aoa.gov
http://www.cbo.gov
http://www.cms .hhs.gov
http://www.ssa.gov
-JEANETTE C. TAKAMURA
RACIAL AND ETHNIC GROUPS
ABSTRACT: Minority elders and older immigrants con-
stitute a greater proportion of the population than ever
before, and are the fastest growing segment of the older
population. Within these racial/ethnic groups, there is
considerable variation with regard to age, gender, coun try
of origin, language, religion, education, income, duration
of U.S. residency, immigration status, living
 106 AGING: RACIAL AND E'n-INIC GROUPS
arrangements, social capital, and access to resources.
The authors summarize research on older adults regard-
ing racial and ethnic disparities, barriers to health and
social service utilization, and dynamics of family care-
giving. Implications are offered for social work practice,
policy, and research.
KEY WORDS: aging; minority elders; immigrant
elders; health disparities; racial/ethnic disparities;
cultural competence; family caregiving; service
utilization
The racial and ethnic composition of the nation's older
population is expected to change profoundly over the
next 50 years. Due to biomedical advances, the aging of
postwar baby boomers, and changing immigration pat-
terns, the number of Americans aged 65 a nd older is
projected to increase from 35 to 82 million (over 20% of
the entire population) in the first half of the 21st century
(Angel & Hogan, 2004). People of color (widely defined
as American Indian/Native Alaskan, Asian, Black or
African American, Latino or Hispanic, and Native
Hawaiian/Pacific Islander) constitute a greater
proportion of the population than ever before, and are the
fastest growing segment of the older population. By
2050, approximately 40% of older Americans are
projected to be people of color and nearly 18% will
. be Latino (FIFAS, 2006). The .increasing ethnic and
cultural diversity among older adults will affect the
lives of all elders, and the work of all social workers in
practice, policy, and research.
Members of ethnic groups typically share a collec-
tive cultural identity and patterns of language, family
structures, social, and religious traditions based on pre-
sumed common history, geographic origins, or geneal-
ogy. Race, a term often used interchangeably with or
encompassingethnicity, emphasizes the notion of com-
mon ancestry based primarily on shared biological
traits, in particular that of skin color (Abizadeh, 2001).
While race is primarily a social construct (based on
cultural and historical as opposed to biological dif-
ferences), members of racial and ethnic "minorities"
face lifelong oppression and adversity that lays the
foundation for cumulative disadvantage in later life
(Dannefer, 2003). The compounded effects of institu-
tional racism, social inequities, and ageism thus repre-
sent "multiple jeopardy" (Stoller & Gibson, 1994) for
elders of color.
Although the literature tends to characterize min-
ority elders broadly, there is' considerable variation
within racial/ethnic groups with regard to age, gender,
country of origin, language, religion, education, in-
come, duration of U.S. residency, immigration status,
living arrangements, social capital, and access to
resources. Across all groups, women live longer than
men, and the majority of older Americans, in particular
the oldest old, are women. It is projected that by 2050,
women will make up 61 % of the population ages 85 and
over (U.S. Census, 2000). Women of all racial/ethnic
groups are more likely than men to live in poverty, to
live alone, and to have more chronic illnesses and
functional limitations. Within racial/ethnic groups,
foreign-born elders differ significantly in many ways
from the native born (Camarota, 2005). The use of broad
racial and ethnic categories such as African American,
Hispanic (or Latino), Asian American, or Native
American can therefore mask differences among
subpopulations and obscure racial/ethnic inequities.
Racial/Ethnic Disparities
Older adults are more likely to be poor than those under
65, and minority elders have a greater chance of liying
in poverty than older whites. Nearly 70% of older
Latinos, two-thirds of older African Americans, and
half of older Asians and Pacific Islanders are poor or
near poor, compared to 38% of White elders. Women ,
Native Americans, and those living alone or with non-
relatives are particularly vulnerable to poverty. Educa-
tional attainment is lower among elders of color than
among Whites, with the exception of japanese, Chinese,
and Cuban Americans. Inadequate education is asso-
ciated with language difficulties, underemployment and
unemployment, lack of health insurance, and lack, of
accumulated wealth during the life course, all of which
can compromise the health and well-being of minority
elders (LaVeist, 2003).
Community-level poverty and lack of resources also
contribute to health disparities among older minority
groups (Robert & Lee, 2002). Low socioeconomic sta-
tus is associated with poorer health across ethnic groups
(Nazroo, 2003), but older people of color (in particular ,
Blacks and Latinos) consistently have worse health
outcomes than white elders (Bulatso & Anderson,
2004). Older American Indians/Alaskan Natives,
African Americans, and Latinos are significantly more
likely to rate their health as fair or poor than non-
Hispanic whites and Asian Americans (NCHS, 2006).
Life expectancy at birth is 6 years higher for Whites
than for Blacks, although these disparities decrease with
age and disappear among those who survive to age 85.
Chinese and Japanese Americans have longer life ex-
pectancies and lower mortality rates than other elders,
but lose this advantage the longer they reside in the
United States, presumably due to adoption of main-
stream diets and lifestyles. In general, foreign- born
immigrants, even controlling for SES, report better
health than native-born racial and ethnic minorities.

All older adults are vulnerable to chronic physical
and mental health conditions, and those over the age of
75 experience an average of three chronic problems at
anyone time. The prevalence of chronic illnesses such as
arthritis, hypertension, heart disease, cancer, and
diabetes is estimated to be twice as high among African
Americans as among Whites, and Blacks develop these
conditions at younger ages than other elders (AHRQ,
2005). Older women of color are particularly vulnerable
to heart disease, diabetes, and hypertension, and experi-
ence more comorbid conditions than White women.
Chronic conditions cause almost half of all disability
among older adults, and require medical management
and care for extended periods. '
Older African and thtive Americans have higher
rates of mortality than do Whites, and men have higher
mortality than women across ethnic groups. Despite
dramatic advances in treatment and increased long- term
survivorship, the HIV/AlDS epidemic has had a
disproportionate impact on people of color in terms of
new cases and mortality rates. In 2002-2003, the rate of
new AIDS cases and HfV-related deaths were 10 times
higher among Blacks and 3 times higher among Latinos
than among Whites (AHRQ, 2005).
An estimated 20% of persons aged 55 and older
experience mental health problems unrelated to normal
aging (DHHS, 2006). The three most common are
anxiety disorders, severe cognitive disorders (for exam-
ple, Alzheimer's disease), and mood disorders (for ex-
ample, depression). The suicide rate for individuals aged
65 and older is higher than that for any other age group ,
and the rate for those 85 and older is the highest in the
nation. The stigma associated with mental illness
presents additional risks to minority elders, as they are
less likely to seek help than White elders. Unfortunately,
there are significant gaps in knowledge among formal
and informal caregivers about geriatric mental health.
Barriers to Service Use
Despite the acknowledged health, mental health, and
service needs of many minority elders, racial and ethnic
disparities remain in the utilization of a broad range of
health and mental health services. Service utilization is
associated with a variety of socioeconomic, cultural, and
structural factors; patterns of use vary widely among and
within racial and ethnic groups. Lack of knowledge and
education regarding health issues and existing resources
appears to be one reason for the underuse of formal
services by minority elders. Many people of color also
view themselves and their families, rather than outside
or institutional providers, as responsible for their health.
AGING: RACIAL AND ETI-INIC GROUPS 107
Stigma surrounding disease and fears of dependen cy
prevalent in some racial and cultural groups, especially
among older cohorts, may present barriers to the use of
physical and mental health services among minority
elders. It is not entirely clear to what extent minority
elders use complementary alternative treatments (for
example, traditional healers or herbal medicines) and
whether their use obviates the need for formal services,
or if elders use alternative treatments because formal
services are not accessible to them.
Structural barriers including language, socioeco-
nomic and legal status, lack of health insurance, and
transportation preclude some minority elders, such as
non-English speakers, undocumented immigrants, and
those in rural areas, from receiving care altogether.
According to the Census Bureau (2003), there are over
300 different languages spoken in homes across the
country, yet assimilationist policies still predominate in
the provision of medical and social services. The
political debate around immigration has brought atten-
tion to the diverse and complex needs of legal and
undocumented immigrants. Since the establishment of
the U.S. Immigration and Customs Enforcement
Agency in 2003, the numbers of raids, detentions, and
deportations have increased each year (Skinner, 2007).
Fear of deportation prevents legal and illegal immi-
grants from seeking and accessing needed services.
Minority elders, particularly Latinos, are less likely to
have health insurance than White elders, and
Asian/Pacific Island elders are the least likely to receive
Medicaid or other public insurance. Older adults of
color are also less likely to have a usual source of health
care, and to have less health-care visits than White
elders (Urban Institute, 2006).
Even minority elders able to access services report
experiencing limitations in their care. Compared to
Whites, Blacks, Asian Americans, and Latinos report
greater communication problems with their physician,
such as feeling their doctor does not listen to them and is
not as involved in their care as they want him/her to be
(Collins, Tenney, & Hughes, 2002). Some research
suggests that minority populations receive poorer qual-
ity care, and that health-care providers exhibit racial
biases in medical diagnosis and treatment (AHRQ,
2005; van Ryn& Burke, 2000), for example, by refer ring
people of color less often for more aggressive treat ments
(Schulman et al., 1999). There is growing evidence that
subjective experiences of racial and ethnic
discrimination contribute significantly to inequalities in
health (Nazroo, 2003; Williams, Neighbors, & Jackson ,
2003), although the underlying processes of these
phenomena are not fully understood. Perception of
racial/ethnic bias may engender feelings of
108 AGING: RACIAL AND ETHNIC GROUPS
powerlessness (Chadiha, Adams, Biegel, Auslander, &
Gutierrez, 2002) or mistrust in dealing with the service
system among elders of color (LaVeist, 2002).
Family Caregiving
The underutilization of formal services among minority
elders rranslates into greater reliance on informal supports,
especially family caregivers. Minority elders are more
likely to live with family, and less likely to live alone or in
institutional settings than Whites, regardless of health
status (Angel, Angel, Aranda, & Miles, 2004). This may be
due to cultural values of filial respect and-expectations of
familial assistance, the high financial costs of formal
services, higher levels of functional disability among
ethnic minority elders that require greater levels of care, or
a lack of access to or knowledge of formal services. It is
unclear whether informal care sufficiently meets the needs
of chronically ill elders, and to what extent they and their
caregivers experience unmet needs.
Due to population aging, increased geographic mo-
bility, and changing workforce participation, the number of
family members available to provide care to older adults
who need care has been dwindling over the past several
decades. Thus, the burden of care is falling on fewer family
members, who may have fewer psychological and
financial resources to provide such care. In one large-scale
study, 41 % of caregivers rated their care experiences as
somewhat or very difficult, and 21% reported that
caregiving has a negative effect on their health (Donelan et
al., 2002).
Compared to White caregivers, nonWhite caregivers
are less likely to be a spouse and more likely to be an adult
child, friend, or other family member. African-American
elders are also more likely than Whites to rely on friends or
fictive kin for support and care (Johnson, 1999). Findings
are mixed regarding appraisal of caregiving burden and
level of depression of various minority group caregivers.
For example, African American caregivers report lower
levels of depression and appraise caregiving as less
stressful than Whites (Janevic & Connell, 2001), but Latino
caregivers report higher rates of depression than all other
caregivers (Adams, Aranda, Kemp, & Takagi, 2002).
Despite the purported value and expectation of family care
among people of color, such extended support is not
necessarily available to minority elders or their primary
family caregivers.
Older adults are not only receiving care, they also are
providing it. Approximately half of all people caring for
elderly family members are themselves older than 60
years, and 2.5 million families in the United States are
maintained by a grandparent (NAC/AARP, 1997). A
growing number of older women assume the primary
care of their grandchildren, most often because of the
biological parent's substance abuse, incarceration, physical
disability, or death (Smith, Beltran, & Butts, 2001). One
large-scale study found that African Americans were twice
as likely to become custodial grandparents as other elders
(Fuller-Thompson, Minkler, & Driver, 1997).
Implications for Social Work
The demographics of aging, diversity, and immigration will
become ever more complex in the next several decades, and
it is incumbent' upon social workers to work toward the
elimination of racial and ethnic' disparities. In order to
ensure equal access to social and health-care services, there
is a critical need for greater outreach employing culturally
and linguistically relevant and accessible information
regarding health and health care. One solution is to make
services available in the elder's native language. Initially,
this may require greater funding and utilization of agency
translators, so that family members are not required to per-
form this role. In the long run, social work schools need to
prioritize training bilingual and multilingual mental . health
practitioners, through active recruitment within
immigrant and minority communities and increased support
through financial aid, scholarships, and 'grants. , Social
workers need to do a better job of providing culturally
competent practice, which will require
1. learning about cultural differences and, the barriers
faced by minority and immigrant elders
2. becoming aware of their own values, biases, and
assumptions about age, aging and older adults,
culture, and human behavior
3. being respectful, nonjudgmental, and empathic when
working with individuals whose cultures differs from
their own
4. encouraging client input in all aspects of treatment
and tailoring services to the unique needs of each
individual or family
5. working to develop and practice appropriate,
flexible, and culturally sensitive intervention
strategies and skills in working with all clients
Mechanisms should' be established to ensure that com,
munity organizations and programs maintain standards in
culturally competent practice, so that every client is
provided with the same quality 'of care. Services need to fit
the needs of the community, accounting for and adjusting
to the barriers minority elders and immigrants face, as well
as their unique cultural beliefs and practices. This may
entail, for example, providing health education and
services through local religious institutions, or working in
conjunction with traditional healers.

Much of the current research on elders of color is about
African Americans, who are presently the largest. minority
group in the United States. Given the demographic growth of
the older Latino population, more research is needed on elders
of Mexican, Puerto Rican, Caribbean, Central, and South
American descent, as well as Native American, Arab, and
Muslim elders, who have been understudied. Another area for
further investigation is the biopsychosocial impact of
immigration and cultural adjustment. In addition, research is
needed on intergroup differences (for example, diversity
within the "Hispanic" and Asian populations) and intragroup
variation in health and health care. Researchers should strive to
conduct culturally competent research that enhances \the
inclusion of minority elders throughout the entire study
process.
In conclusion, social workers have an ethical obligation to
promote social and economic justice, and to work toward
preventing and eradicating institutional racism,
discrimination, and exploitation. We must continue to
advocate for legislation and policies that provide equitable
access to health and social services, and to empower minority
and immigrant elders and their families to advocate for
themselves and their communities.
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Stoller, E., & Gibson, R. (1994). Warldsofdifference. Thousand Oaks,
CA: Pine Forge Press.
11 0 AGING: RACIAL AND ETHNIC GROUPS
Urban Institute and Kaiser Commission on Medicaid and the
Uninsured. (2006). Analysis of March 2006 Current Popula ,
tion Survey. Washington, DC: Urban Institute.
U.S. Census Bureau. (2000, January). Population projections of
the United States by age, sex, race, hispanic origin and nativity:
2000-2050. Retrieved August 27, 2007, from http://www.
census.gov/ipc/www/usinterimproj/natproitab01 a.pdf
u.s. Census Bureau. (2003, October). Language use and english
speaking ability: 2000. Retrieved August 27, 2007, from
http://www .census.gov /prod/2003pubs/c2kbr- 29 .pdf
U.S. Department of Health and Human Services (DHHS).
(2006). Mental health: A report of the surgeon general, 1999.
Hyattsville, MD: DHHS, Substance Abuse and Mental
Health Services Administration, Center for Mental Health
Services, National Institutes of Health, National Institute of
Mental Health.
\ more functional lives (Crimmins, 2004).
Van Ryn, M., & Burke, J. (2000). The effect of patient race
and socioeconomic status on physicians' perceptions of
patients. Social Science & Medicine, 50, 813-828.
Williams, D., Neighbors, H., & Jackson, J. (2003). Racial!
ethnic discrimination and health: Findings from
community studies. American Journal of Public Health,
93(2), 200-208.
FURTHER READING
Haley, W. E., Han, B., & Henderson,J. N. (1998). Aging and
ethnicity: Issues for clinical practice. Journal of Clinical
Psychology in Medical Settings, 5(3), 393-409.
Curry, 1., & Jackson, J. (Eds.), (2003). The science of
inclusion:
Recruiting and retaining racial and ethnic elders in health research.
Washington, DC: Gerontological Society of America.
Institute of Medicine. (2002): Unequal treatment: Confronting
racial and ethnic disparities in health care. Washington, DC:
National Academy Press
Whitfield, K. (Ed.). (2004). Closing the gap: Improving the
health of minority elders in the new millennium. Washington,
DC:
Gerontological Society of America.
-DANIEL S. GARDNER AND CAROLINE
ROSENTHAL GELMAN
SERVICES
ABSTRACT: Despite high levels of functioning among older
adults, chronic health conditions lead to impairment and the
need for help. Family members provide most of the assistance;
yet formal services such as inhome personal and homemaker
services, congregate and home, delivered meals, adult day
services, employment and educational services, transportation,
nursing homes, assisted and supportive living facilities, legal
and financial services, and case management are avail, able.
Even with the growing number and type of services, unequal
access and uneven quality persist. In these settings, social
workers develop and administer programs, provide clinical
care, offer case management
and discharge planning, and contribute to policy
development.
KEY WORDS: aging network; gerontological social
services; continuum of care
The population is aging, both in the United States and across
the world. Demographers estimate that by the year 2030, 20%
of the U.S. population will be over the age of 65 (Centers for
Disease Control and Prevention, 2003); and those adults over
the age of 85 constitute the fastest growing subgroup. Despite
the fact that older adults often experience multiple chronic
healthcondition, most older adults are functionally
independent. Overall, trends are toward not only longer, but
Despite high levels of health and functioning in the older
population, chronic health conditions lead to functional
impairment and the need forassisranee. The number of older
adults who need assistance with activities of daily living
varies. by specific age cohort. Only 8% of people aged 65~9
need assistance, while 35% of people over the age of 80 need
assistance (Administration on Aging, 2004). Johnson and
Wiener (2006) report that about one-quarter of older
Americans living outside of nursing homes. have a dis, ability
that limits functioning including help bathing, dressing, using
the toilet, taking medicines, and mana, ging money.
Families Care giving
By far, family members provide most assistance to older
adults with function impairments. Most older adults (66%)
receive help from informal caregivers without any formal
assistance, while 9% get only formal help, and 25% are
supported by both informal and formal assistance (Federal
Interagency Forum on Aging, 2004). The growing need for
caregivers follows the growth of the over-Sfi-year-olds in our
population. It is often estimated that between 70% and 80%
of all assistance provided to older adults is provided by family
members. The care provided by family and friends (referred
to as informal care as opposed to formal care provided by paid
professionals and paraprofessionals) has been costed at $257
billion a year (Arno, 2002). Females, largely wives and
daughters, provide the bulk of the care. The average caregiver
is a married woman in her midAOs, employed outside the
home, raising her own children, and providing care to a
relative who lives in the area (Coleman & Pandya, 2002). One
out of five U.S. households pro' vide care to someone age 50
or older, and 43% of caregivers are 50 years and older
(National Alliance for Caregiving, 2005).

Caregiving activities range from hands-on personal
care, taking care of household chores, monitoring,
managing any paid help, and providing companion-
ship/emotional support. It is well documented that
caregiving can result in compromised work lives as well as
declining health and mental health. Positive outcomes in
terms of satisfaction with doing the job' and closer
relationships are also documented. Trends that relate to
informal caregiving include the evolution of women's role
in the workplace, increasing ethnic diversity among the
older population, the increase in male caregivers, and
club-sandwiched generations where women raising
children have both parents and grandparents alive (Crewe
& Chipungu, 2006).
Nonprofit and public agencies offer a variety of support
and educational programs with little or no charge to
caregivers. Programs include online and inclass courses,
psychoeducational support groups, telephone helplines,
Internet chat rooms, and peer-to-peer counseling programs
to the caregivers. Professionals and volunteers staff these
programs; and monies come from private funds, some state
revenues, and federal grants made through the Older
Americans Act.
Most research documents small to moderate statis-
tically significant effects (see findings from the REACH
study, Gitlin et al., 2003). The size of the effects vary by
intervention and outcome assessed. Biegel (2006) finds
that group interventions seem to be less effective than
individual in reducing burden; and that caregivers of
persons with dementia experience less effect than those for
nondemented persons. In general, evidence indicates that
mixed interventions, longer interventions, and those
targeted to specific groups of caregivers hold the most
promise.
The Growth of Formal Services
The use of formal services has increased since 1998,
corresponding to caregiver patterns in the workforce and
the growth in formal services. Previously, fewalternatives
to informal care existed. Hospitals and nursing homes
constituted the formal care system, with nursing home care
being the only source for long-term care. Now, a range of
in-home and community-based services can be purchased
with private money, and some publicly funded services are
offered to functionally impaired, lowerincome older adults.
These services are often called the continuum of care,
reflecting their intended response to a continuum of need.
In the United States, these services developed
under various federal initiatives. Although Social
Security does not pay for services directly, this
income source is critical to the financial well-bein g of
the older population, and as such, enables some to
purchase services
_.~ ..
AGING: SERVICES 111
privately out of their own pockets. In 1965, fede~al
legislation established three programs that undergird these
services, namely, Medicare, Medicaid, and the Older
Americans Act. Medicare, the health insurance program,
covers acute medical services, both inpatient and
outpatient, short-term rehabilitation in institutions or at
home, and hospice care in the last 6 months of life.
Medicare does not covet the long-term care services that
are more often needed when chronic conditions lead to
disability. With only 1 % of nursing home costs paid for by
Medicare (Federal Interagency Forum on Aging, 2004
),these funds are only available for shortterm rehabilitative
services. Medicaid offers health insurance for low-income
people, and for older adults, it supplements Medicare to
cover premiums for Part B and copays for Part A. Medicaid
will also cover long-term care. In fact, 48% of nursing
home costs are covered by Medicaid (Federal Interagency
Forum on Aging, 2004). A smaller part of the Medicaid
budget covers long-term care in the community, including
in-home supportive services, day care, and some forms of
residential care.
In 1965, the Older Americans Act (OAA) created
the Administration on Aging (AoA) and provided
grants to states to plan for, develop, and provide
services to older adults. This establishes s upportive
services, senior centers, congregate and
home-delivered meals, training and research,
supportive employment, protective services, and
grants for older Native Amer icans. Monies provided
through the act flow through State' Units on Aging to
Area Agencies on Aging, which are mandated to
assess, plan, organize, and deli ver services to meet
local needs. Services cannot be allocated by income,
but are targeted to those in great est social and
economic need. These administrative structures and
the organizations providing services funded in part by
OAA monies are called the "aging network,"
consisting of 56 State Units on Aging, 655 Area
Agencies on Aging, 233 Tribal and Native
organizations, and 2 organizations that serve Native
Hawaiians. AoA supports the Eldercare Locator, a
national toll-free service to help callers find local
resources (1-800-677-1116) (http://www .aoa.gov ).
The aging' network undergoes ongoing changes to
incorporate new initiatives. For example, the National
Family Caregiver Support Program was funded in 2000 to
focus on caregivers, not older adults. Money is authorized
to provide education, respite, and counseling for caregivers
and custodial grandparents. The newest OAA
reauthorization (Older Americans Act Amendments of
2006, H. R. 6197) calls for the recognition and support of
the civic engagement of older adults. It requests the
development of a comprehensive strategy for utilizing
older adults to address community
112 AGING: SERVICES
needs and to fund programs that expand critical volun teer
services. Despite renewal efforts, the aging network is
criticized for being disconnected from many older adults
and weak advocates in regard to economic and social
issues (Cohen, 1997). Further, it is faulted by some for
being a nonnetwork heavily relying on an agency rather
than a consumer directed model.
Types of Formal Services in
the Continuum of Care
HOMECARE SERVICES' Both health and social service
agencies offer in-home services to maintain people in the
least restrictive environment. Home health care is medically
oriented and requires a physician's order for nursing,
therapies, social work, or personal care services provided
under nurse supervision. Home health care is usually
ordered to transition a patient. out of the hospital and has
an average duration of 2-3 months. Homemaker and
personal care services are usually provided for longer
periods of time and are supportive rather than medically
oriented. Chore workers provide assistance with
instrumental activities of daily living (that is, meal
preparation, housekeeping). Personal-care aides assist
with activities of daily living, such as grooming, bath ing,
transfers, and ambulation. Funding sources include
Medicare, Medicaid, private insurance, Social Service
Block Grants; the OAA, Veterans Administration (VA),
and TriCARE. Most nonpublic providers are for-profit
agencies, but some nonprofit agencies offer sliding scale
fees. Most research demonstrates that homecare services
address unmet need for assistance and are satisfying to
clients; but only a few studies indicate home care
substantially delays nursing home admissions (Gaugler,
Kane, Kane, & Newcomer, 2005; Zarit, Gaugler, & [arrott,
1999). For social work services, literature is mostly
descriptive, indicating clinical relevance, yet results for
effectiveness are inconclusive (Lee & Gutheil, 2003).
CONGREGATE AND HOME-DELIVERED MEAL
PROGRAMS Federal government, the primary financier
for meal programs, emphasizes serving low-income and
disadvantaged older adults without using means tests.
Congregate meals sites provide at least one meal in a social
setting, 5 or more days a week. They are served in church
basements, schools, apartments, senior centers, or other
multipurpose centers, with an average daily census
between 20 and 60 older adults. Home-delivered meal
programs (for example, Meals on Wheels) provide . either
one or two meals per day, generally 5 days a week, to
home-bound older adults. Over 40% of programs have
waiting lists (Wacker, Roberto, & Piper, 2002).
Evaluations indicate that the programs provide
nutritious meals; yet use is declining (Wellman,
Rosenzweig, & Lloyd, 2002).
ADULT DAY SERVICES Adult day services (that is,
adult day care or adult day health care services) are group
programs that offer individualized care plans for adults
with physical and cognitive functional impairments i n a
protective setting during part of a day but less than 24
hours. As a structured and comprehensive program
offering respite to caregivers, it includes personal care,
therapeutic, nutritional, social, nursing, rehabilitation, and
transportation services. Programs are mostly nonprofit
(78%) and affiliated with other medical or social services .
Medicaid, VA, private pay, long-term care insurance, and
voluntary contributions are funding sources (O'Keeffe &
Siebenaler, 2006). Adult
/
day services are underutilized (Gaugler et al., 2005). Yet
caregiver and client satisfaction is high. Mixed results
remain for reducing caregiver burden and delaying nursing
home placement (Zarit et al., 1999).
RESPITE SERVICES Respite services are aimed at care-
givers who need release time fromcaregiving duties. The
services must meet the needs of the care. recipient and can
be supervisory, personal, or medical. Both.forprofit and
nonprofit programs offer respite services, As the most
common form, in-home respite is provided by companions,
homemakers, home-health aides, or nurses for several
hours at a time. Medicaid and a limited amount of OAA
monies are available for inhome respite. Some programs
offer overnight services; yet most overnight respite occurs
in long-term care facilities and is paid out-of-pocket by
caregivers. Respite services can decrease caregiver
distress, yet overnight respite may hasten nursing home
placement and temporarily alter the frequency of
disruptive behaviors (Kim & Hall, 2003; Neville & Bryne,
2005; Zarit et al., 1999).
HOSPICE Hospice offers holistic care and pain control
that "affirms life while neither hastening nor postpon ing
death" for persons with terminal illness (Waldrop, 2006 ).
An interdisciplinary team of medical, . social service, and
spiritual guidance professionals offers individualized
treatment for the patient and family, most often in the
home but also in hospitals, nursing homes, and hospice
houses. The team provides direct care and coordinates
auxiliary services, bereavement and family counseling,
and medical supplies. Medicare, Medicaid, and private
insurance cover hospice. Eligibility requires a
physician-certified terminal prognosis of 6 months and the
forgoing of most curative treatments. Over half of hospice
patients die in their own home (National

Hospice and Palliative Care Organization, 2004). Hos-
pice decreases hospitalizations and intensive medical
procedures. Hospice had quality of care outcomes com-
parable to usual care, thus emphasizing patient choice in
opting for hospice. When compared to usual care,
significant differences include the following: hospice
resulted in a lower percentage likely to experience
persistent pain, patient and- family members were more
satisfied with care, and hospice facilitated grief resolu-
tion for surviving spouses (Gage et al., 2000).
CASE MAN'AGEMENT SERVICES Case management is
the act of identifying, securing, and coordinating
services to cost effectively meet the needs of older
adults with functional impairments and their families
\
(Wacker et al., 2002). It includes the steps of case-
finding (conduct outreach, eligibility determination,
intake), assessment (current status, problem identifica-
tion), care planning (develop plan based on needs),
coordination (arrange delivery of services), follow- up
(monitor client and services), and reassessment (re-
evaluate). The assessment and care arrangements ensure
the continuity of care between acute care and residential,
in-home, community, and informal care systems. Case
managers (mostly licensed social workers or nurses) are
often based in public agencies, Medicaid waiver
programs, managed care organizations, medical groups,
hospitals, private companies, or as self- employed
businesses (Hyduk, 2002; Naleppa, 2006). Funding for
case management is provided by the OM, federal
waivers in 40 states, and private pay from family mem-
bers (Stone, Reinhard, Machemaer, & Rudin, 2002).
For more than two decades, case management has
received mixed results. The first demonstration proj ect,
the National Long Term Care Channeling Project,
identified benefits such as increased use of homecare,
reduction in unmet health care needs, and increased
client confidence and satisfaction. However, case man-
agement did increase the costs of overall care (Kemper,
1988). These contradictory results persist because of
variations in services used, variables studied, and client
populations (Austin, 1996; ferguson & Weinberger,
1998; Gensichen et al., 2005; Hyduk, 2002; Leutz,
1999).
HEALTH AND MENTAL HEALTH CARE SETTINGS Social
workers have traditionally assumed roles in hos pitals,
home health care, nursing homes, hospices, and other
outpatient medical clinics, where they encounter older
adults with comorbid medical needs and functional
impairments. Medicare and Medicaid often include
social services (that is, case management, discharge
planning, interdisciplinary teamwork, and
AGING: SERVICES 113
other psychosocial services) within its reimbursement to
these settings. Increasingly, social workers are devel-
oping, delivering, and evaluating health promotion,
cultural competency, and wellness initiatives (Wacker et
al., 2002).
With older adults mostly seeking mental health
services from primary medical care (Charney et al.,
2003), social workers offer supplemental services in
detection, assessment, psychotherapy, and care man-
agement for issues such as depression, anxiety,
caregiver distress, and grief. Medicare and Medicaid
reimburse diagnostic evaluations, pharmacotherapy,
and outpatient psychotherapy when deemed medically
necessary (although current reimbursement rates are
low and the bureaucratic process very labor intensive).
Social work involvement in collaborative care treatment
models in primary care, supportive housing, and
homecare services has a strong evidence base (Banerjee,
Shamash, MacDonald, & Mann, 1996; Ciechanowski et
al., 2004; Uniitzer et al., 2002).
LEGAL AND FINANCIAL SERVICES Since 1981, the OM
funded legal assistance programs for older adults.' As
of 1992, these services are augmented and overseen
by states through the Vulnerable .Elder Rights
Protection Activities Program. Services include
telephone hotlines, lawyer information and referral
services, and voluntary panels for pro bono or reduced
fees. Problems include divorce, grandparents' rights,
estate plans, income assistance or other benefit plan
problems, age discrimination, insurance problems,
advanced directives, powers of attorney, consumer
fraud, and crime (Wacker et al., 2002).
TRANSPORTATION Safe, reliable, and affordable
transportation is critical, and older adults with cogni-
tive, sensory, or mobility limitation face many chal-
lenges in getting around the community. Older adults
drive their own cars, rely on informal caregivers, use
routine public transportation, and obtain formal trans-
portation services. Due to concerns over safety and the
difficulty of determining when to cease driving, the
American Association for Retired Persons,
government offices, occupational therapists, or health
centers may offer formal assessments and drivers'
education programs. Demonstrations are exploring
how driver safety assessments, highway design,
vehicle design, use of adaptive equipment, and
educational programs can improve safety and ease the
process of driving cessation (Transportation Research
Board, 2004).
Transportation alternatives include (a) fixed-route
services such as buses, trains, or trolleys that follow
predetermined routes with preset stops; (b) service routes
114 AGING: SERVICES
buses or vans that circulate a confined distance within a
neighborhood to reach shopping centers and medical
facilities, and (c) demand~responsive services (that is,
para-transit, dial-a-ride, or call-a-ride) for older, dis-
abled, and/or low-income persons to schedule rides to
medical or social services. Even with the Federal De-
partment of Transportation and the OAA providing
funding, many communities lack these services, and
transportation remains one of the largest unmet needs
among older adults.
SENIOR CENTERS Senior centers are designated focal
points in a community where older adults may come
together for a broad array of services and activities,
including, but not limited ,to nutrition, recreation,
social, educational, information and referral, and fitness
programs (Beisgen &Crouch Kraitchman, 2003). An
estimated 15,000 senior centers are located in old
schools, community centers, churches, or housing proj-
ects. They are predominantly nonprofit organizations
with funding from public sources and in-kind contribu-
tions.Senior centers may ask participants to voluntarily
contribute, but no fees can be charged, as per OAA
regulation (Rozario, 2006). Cross-sectional survey re-
search has identified benefits as access to nutritious
food, to socialization opportunities, and to physical
fitness activities (Whisnant, 2004).
Nevertheless, senior centers participants constitute
only 15% of the aging population, and they tend to be
healthier and minimally diverse. With decrease in
participation rates (Walker, Bisbee, Porter, & Flanders,
2004), senior centers are being challenged to reenvision
their roles and attractiveness to the upcoming boomer
generation. There is movement toward centers that offer
life planning services and other programs With concepts
such as vital and creative aging (Rozario, 2006).
EMPLOYMENT AND V OLUNTEERISM Older
adults are extending their work lives and are seeking
ways to stay longer and transition more slowly out of the
workforce (Pitt-Catsouphes, 2007). With theAge
Discrimination in Employment Act (ADEA) of 1987
and the Older Workers Benefits Protection Act in 1990 ,
workers age 40 and above (with a few exceptions) are
protected from age discrimination in hiring,
terminations, promotions, wages, and health care
coverage. The federal government also provides
employment and training programs for older adults
through the Experience Works program (formally called
Green Thumb), Senior Community Service
Employment Program, and other demonstration
projects.
With over 40% of older adults engaged in volunteer
activities, this is one prominent activity demonstrating
the ongoing productivity of older adults (SaxonHarrold
& Weitzman, 2000). Aging services coordinate
volunteer opportunities and use volunteers in many
services. Private and federally supported programs exist
such as Retired Senior and Volunteer Program (RSVP),
Senior Companions, Foster Grandparent Program, and
Senior Corps or Retired Executives (SCORE).
EDUCA TION The desire. for and benefits of lifelong
learning is a growing service sector (Manheimer,
Snodgrass, & Moskow-McKenzie, 1995). The Adult
Education and Family Literacy Act of 1998 provides
minimal federal funding earmarked for older adult edu-
cation. Area Agencies on Aging are required to provide
information on local tuition-free educational resources.
Alternatively, universities, community colleges, spe cific
Learning in Retirement Programs, the national
Elderhostel network, the Older Adult Service and .
Information System (OASIS), and at-horne learning
services are a growing service sector.
Supportive Housing
While the majority of older Americans live in single-
family homes (82%), about 4% live in noninstitutional
supportive housing (Gonyea, 2006). Supportive housing
programs are residential settings designed to provide
varying degrees of assistance and oversight. Examples
include cohousing such as Elder Cottage Housing
Oppertunities (ECHO), senior congregate housing
facilities, continuing care retirement communities,
board and care homes, and adult foster care; Most of
these public, nonprofit, and for-profit settings offer
private rooms or apartments connected to shared areas
and services for dining, socialization, recreations, and
housekeeping in a secure environment. On-site
providers typically include building managers or social
activity coordinators, not medical or social service
personnel.
NURSING HOMES With the increase in alternatives,
the proportion of older adults residing in nursing homes
has recently declined to about 3 million people
(Vourlekis & Simons, 2006). Nursing homes provide
short-term skilled nursing and therapeutic care for older.
adults expecting to return to the community as well as
longer-term care for older adults who are not likely to
regain the functional ability to be discharged. Nursing .
homes are the least preferred setting by older adults and
their families; and quality of care problems abound
(Institute of Medicine, 1986; Kane, 2001). Of the 16,500
nursing facilities certified by Medicare and/or Medicaid,
most are classified as for profit and free standing.
Medicaid is the predominant payer, followed by
out-of-pocket (45%), Medicare, private long-term

care insurance, or other funds (Federal Interagency Forum
on Aging, 2004).
Trends
With roots in the Americans with Disability Act. of 1990
and the Olmstead decision of 1999, consumer direction of
aging services is a growing initiative. Con, sumer direction
transfers authority for care arrangements from agency
professionals to older clients or a designated
representative. In a national demonstration of
consumer-directed care, called the Cash and Counsel, ing
Demonstration and Evaluation (Mahoney & Simone,
2006), consumers receive a monthly allowance and gui-
dance to make decision about care and manage the assis-
tance they need. Consumers can pay family members or
friends for their personal assistance services. A stringent
evaluation. found that program participants have fewer
unmet needs and higher levels of satisfaction than those in
the comparison group (Foster, Brown, Phillips, Schore, &
Carlson, 2003). In light of this success, the program is
expanding to other states with support from the Robert
Wood Johnson Foundation, U.S. Department of Health and
Human Services, and other state mechanisms. These
movements. are blurring the line between informal and
formal caregivers.
The Program for All Inclusive Care Jor the Elderly
(PACE) is a capitated managed care service, offering
primary, acute, and long-term care services to adults over
the age of 55 who are eligible for nursing home care
according to state regulation and living in a PACE
catchment area. PACE providers receive monthly pay'
ments from Medicare and Medicaid for low, income older
adults enrolled in the program. Older adults with more
income can choose to enroll, and Medicare and private
resources are used to cover the rate. While enrolled, the
PACE program becomes the sole source of Medicare or
Medicaid covered services. The per, capita rate covers all
health and social services needed by the participants
throughout their time of enrollment, including nursing
home and hospice care. The heart of the program is an
interdisciplinary team that works to ensure comprehensive
care to each participant. Most programs utilize an adult day
health center, where elients come at least once a week,
usually more. Staff physicians, nurses, social workers,
dieticians, physical/ occupational/recreational therapists,
drivers, and aides provide as many services as possible in
the home or the day center, including step-down services
after hospital discharge.
Evidence suggests that PACE achieved the follow, ing
statistically significant outcomes; fewer hospitalizations,
fewer nursing home placements, better quality of life, and
more satisfaction with care (Grabowski, 2006).
AGING: SERVICES 115
Success of the model resulted in the Balanced Budget Act
of 2007 establishing the PACE model as a permanent
Medicare program and allows states to service Medicaid
clients through this option. There are cur, rently over 45
PACE or pre,PACE program across the country
(www.npaonline.org, retrieved April 24, 2007). Currently,
CMS is supporting the development of the model in rural
areas. The model is not expanding as quickly as expected
(Gross, Tempkin-Greener, Kunitz, & Mukamel, 2004).
Medicare-only clients are not opting to buy into the model;
clients are reluctant to give up their own physicians; and
states are hesitant to commit in the face of growing
Medicaid budgets and enrollees.
For residential care, the emerging trend is assisted
living. Assisted living has no agreed upon definition nor
federal regulation. In general, the term is used to denote a
residential setting that combines housing and supportive
care in a home, like, social-model environ, ment (Kane,
2006; Zimmerman, Munn, & Koenig, 2006). Tenants have
private spaces (that is, single, occupied apartments with
locked doors) and public shared spaces. The philosophy
focuses on quality of life, autonomy, independence, and
control over one's care, setting, and negotiated risks. The
goal is to meet the scheduled and unscheduled needs of
tenants while accommodating functional changes and
preferences. Services include 24,hr supervision, routine
provision of meals, personal care, nurse monitoring, and
optional services (that is, housekeeping and
transportation). A national survey of over 11,000 assisted
living facilities documents much variation, and only 12%
of facilities offered a mixture of high-level services and
high privacy (Hawes, Phillips, Rose, Holan, & Sherman,
2003). Researchers question the ability to "age in place" in
assisted living since one,third of tenants will transfer to a
nursing home, one-third will move elsewhere, and
one-third will remain until time of death (National Center
for Assisted Living, 2007; Spitzer, Neuman, & Holden,
2004). While some states offer Medicaid coverage, 75% of
assisted living residents are paying out-of-pocket
(Zimmerman et al., 2006), making assisted living
inaccessible to those without adequate income.
The Pioneer Network is a coalition of professional,
providers, families, and consumers, striving for radical
culture change of nursing homes, where quality of life for
residents and staff is paramount. Although no one specific
model is advocated, the idea is perhaps best represented by
the Green House model in Tupelo, Mississippi (Rabig,
Thomas, Kane, Cutler, & McAlilly, 2006). The residential
units are self-contained houses offering private bedrooms
and bathrooms along with common cooking, eating, and
living space to a
116 AGING: SERVICES
maximum of 10 adults. "Universal workers" support the
elders in all aspects of daily life. There are no nurses'
stations, no fixed daily schedules, no medication carts, and
the call system is wireless. Green House residents, family,
and staff have significantly better outcomes in quality of
life and satisfaction while quality indicators were either
equivalent or better than usual care (Kane, Gutler, Lum, &
Yu, 2005; Rabig et al., 2006).
Another current issue in long-term care is the "bal ance"
between Medicaid covered services in the nurs ing home
versus the community. Medicaid has an inherent bias
toward nursing home care. By federal law, states must
provide nursing home care to meet long-term care needs of
Medicaid recipients; but the provision of long- term care
services in the community are optional; further, states can
place limits on the size of community- based programs.
Thus, - home- and community-based services account for
about 36% of total Medicaid spending on long-term - care
(Shirk, 2006). The Centers for Medicare and Medicaid
Services has commissioned a study of this "rebalancing"
(Kane, Priester, Kane, & Mollica, 2006). Results will help
identify state policies and practices that contribu te to more
effective community long-term care, and can shape the
service system of the future.
Gerontological Social Work Services
A specialized body of social work knowledge and skills in
gerontology has emerged, and the demand for ger-
ontological social workers will' continue to increase in
response to our aging society and the ever- expanding array
of aging services (Wilson, 2006). Social workers serve in
all of the settings reviewed above by developing and
administering programs across the continuum of care, by
providing clinical services, case management, and
discharge planning to elders and their families, and by
participating in the development of social policies. In
addition to aging-specific services, gerontological social
workers are found in hospitals, primary health care clinics,
hospices, psychiatric units of acute care hospitals, and
mental health clinics.
Social workers are standard members and even lead ers
of interdisciplinary teams, and they are distin guished
because of their knowledge of community resources; their
psychosocial perspective and multidi _ mensional
assessment skills; and their skills in engaging the elderly
person, family, and community in aspects of problem
solving. They often have the broadest knowledge o f the
client and family and the most frequent contact with the
client's family or friends.
For clinical interventions, social workers organize and
lead therapeutic groups that address all types of challenges,
such as widowhood, caregiving, or
recovering from/adjusting to specific medical condi tions.
Social workers provide individual counseling for
depression or adjustment to multiple late- life losses.
Families often need assistance in dealing with an aging
relative's increasing dependence and in making deci sions
about care arrangements and finances. Along with
Medicare and Medicaid coverage for the specific ser vices
previously described, many agencies and private clinicians
have sliding scale fee schedules. Social work ers at the
macro level can advocate for seamless services along a
continuum of care.
Many of the ethical issues that arise in gerontologi cal
social work are familiar in practice with clients of any age,
but some issues are more common when working with
older clients. Given the patemalismin this society toward
frail older people, issues of self determination versus best
interest and safety abound. Older clients often make
choices that seem unwise to others. For examples, an older
adult may deny supportive services in the face o f great
need or choose to live in situation that appears unhealthy or
dangerous to others. This situation becomes even more
challenging when exploitation or impaired cognition
comes into play. Yet older adults who have not been legally
assessed as incompetent have the right to make their own
decisions, despite any vulnerability.
Social workers often are needed to support client choice
and mitigate risks while working with opposirig
preferences from families, other providers, or the - ser vice
agency. This leads to many questions. Who is the client
when working with older adults and their families? Whose
best interest is primary? What information should be
shared? What is confidential? In fact, empowering older
adults and engaging them and their families in active, open
problem-solving are in line with social work values, even if
it requires time and patience, especially with sensory or
cognitive impairments slowing the pro cess. In sum, social
workers strive to promote quality of life,
self-determination, and choice in all the situations
experienced by older adults and their families.
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-NANCY MORROW-HOWELL AND LESLIE HASCHE
ALASKA NATIVES
ABSTRACT: Alaska Natives represent less than 1 % of
the U.S. population but reside in more than 229
Native villages and account for 40% of federally
recognized tribes. Most Alaska Native communities
shared common Euro-American contact
experiences: exposure to wester n religions,
education, and disease. Historical trauma con tributes
to many of the social welfare problems Natives
experience today: low educational attainment, un-
employment, inadequate health care, substance
abuse, and violence. Service delivery mechanis ms,
lack of cultural appropriateness, and isolation
compound these pressing issues. Locally delivered
social welfare services that take into account
traditional Native worldviews, values, languages,
and intergenerational relationships are effective in
addressing
KEY WORDS:many of diversity,
culture; these issues.
government; historical
trauma; land; rural; subsistence
Overview of Alaska Native
Populations in the United States
The 2000 Census reported 120,766 self-identified Alaska
Natives (0.04% of the total U.S. population). This number
represents a doubling of the Alaska Native population
since 1970. Of the 117,950 Alaska Natives who reside in
the state of Alaska, 63,758 (54%) live in Alaska Native
villages. A full 23% of the total in-state Native population
(27,613) resides in Anchorage. Alaska Natives represent
almost 20% of the population of the state of Alaska, a
higher percentage of American
ALASKA NATIVES
119
Indian/Alaska Native population than any other state in the
United States.
The cultural diversity of Alaska Natives can be
highlighted by five distinct cultural groups: (a) Atha-
bascan, (b) Aleut and Alutiiq, (c) Eyak, Tlingit, Haida, and
Tsimshian, (d) Inupiaq and St. Lawrence Island Yupik, and
(e) Yup'ik and Cup'ik. Within these cultural groups are 229
federally recognized sovereign Alaska Native tribes.
Alaska Native tribes account for almost 40% of the
federally recognized tribes in the United States.
Alaska Natives, while similar to American Indians in
many ways, had different federal policy experiences than
American Indian tribes. To begin, outside contact with
Alaska Natives was more recent, with Alaska not officially
being "discovered" in the name of Russia until the
mid-1700s. Comparatively speaking, Alaska Natives
experienced less armed conflict with EuroAmericans than
Native groups in the continental United States. The federal
government did not become substantially involved in
Alaska until 1931, when it began to provide varied services
including health care, education, economic development,
and welfare assistance. In 1971, with pressure to settle
Native land claims and take advantage of tremendous
economic opportunities to extract newly discovered oil,
Congress enacted the Alaska Native Claims Settlement
Act. This unique land settlement and the institutions it
created have major implications for the delivery of human
services in Alaska.
Specific Issues and Suggestions
for Social Work Policy and Practice
Most Alaska Native communities shared some common
Euro-American contact experiences: the imposition of
Christian religions that were in conflict with Native
religions; western education and boarding schools; massive
epidemics of influenza and other diseases that caused the
deaths of thousands of Natives, who had no immunity to
bacteria and viruses brought into their communities by
outsiders; and rapidly changing ways of life as growing
numbers of Natives adopted nontraditional ways.
Many of the pressing present-day social issues facing
Alaska Natives can be traced to the devastating effects of
Euro-Arnerican contact and the rapid pace of socio-
economic change in even remote Native villages. In-
creasingly Alaska Natives have cited historical (or
intergenerational) trauma and its effects on Native people
as contributors to the social welfare problems they
experience: low rates of educational attainment, low labor
force participation, poor health care (including behavioral
health), substance abuse, and violence.
120 ALASKA NATIVES
Since 1986, Alaska Natives have been educated in
state-run primary and secondary schools. The 2000 Census
reported that 25% of Alaska Natives 25 and older have less
than a high-school degree; 39% are high-school graduates;
28% have some college or an associate's degree. Many Alaska
Natives and Native organizations cite an ineffective school
system, inappropriate curriculum, and the difficulty of
integrating traditional Native education, including subsistence
practices, as' among the most serious problems facing young
Alaska Natives. Lack of educational achievement and few
economic opportunities in Native villages, where half the
Native population resides, result in lower labor force
participation rates and disproportionate poverty rates. Mixed
(cash and subsistence) village economies and limited
mainstream economic opportunities yield an Alaska Native
poverty rate 150% higher than that of the total U.S.
population, with 19.5% of the Alaska Native population living
in poverty.
Due to inadequate funding, many basic health care
services, including preventative care, behavioral health, and
contract services that cannot be provided in the villages are
inaccessible. Likely related to the experience of historical
trauma and the unavailability of effective, culturally
appropriate behavioral health services, Alaska Natives
disproportionately experience high rates of alcoholism,
substance abuse, and violence, including: homicide, suicide,
domestic violence, and accidents.
Underlying these social challenges is the reality that the
last two decades have been periods of rapid
change-technologically, economically, and culturally. With
many remote villages having at least some access to satellite
television and the Internet, Native elders and community
leaders worry about the coming generations and the potential
for loss of connection to culture and community, including a
loss of identity and confusion of youth about their role in the
community.
A variety of service delivery factors, including varying
delivery mechanisms, distance and isolation, and cultural
appropriateness, contribute to these pressing issues. First,
various types of human services are offered by different
providers in different locations, according to varying
eligibility criteria. In some cases, Native village governments
may provide services (for example, child welfare programs),
while related child protection services are provided by the
state, and regional Native nonprofits provide still other family
support services. Coordinating this patchwork of services is
critical, and Native families may require assistance in
navigating multiple service delivery systems to access the
services they need.
The sheer land mass (533,000 square miles) and
topography of Alaska also provide serious service
delivery challenges. Road systems do not connect many of the
villages, and travel frequently requires bush plane, boat, or
snow machine.
Added to the variation in service providers/delivery
mechanisms and distance is Alaska Native mobility between
remote and hub villages, as well as to and from cities.
Balancing traditional subsistence practices, economic
opportunity, and extended family support networks
necessitates a great deal of mobility. Coordinating services in
different places with different providers can be daunting, but
social workers can provide much needed assistance in
integrating services as seamlessly as possible to ensure
continuity of support;
Finally, the importance of culturally appropriate services
cannot be overemphasized. The 2000 Census revealed that in
30% of Native households, a nonEnglish language is the
primary language spoken in the home. Services for Alaska
Native families should take into account traditional Native
worldviews, philosophies, values, languages, and
intergenerational relationships; they should acknowledge the
devastation of historical trauma. Case management and
services should give opportunity and spate for families to tell
their stories, participate in cultural practices and;' ceremonies,
and build or reinforce family and community relationships.
FURTHER READING
Case, D. S., & Voluck, D. A. (2002). Alaska Natives. and
American laws (2nd ed.). Fairbanks: University ofAfaska
Press.
Cornell, S., & Kalt, J. P. (2003). Alaska Native self-govenin1ent
and service delivery: What works? Cambridge, MA: Harvard
Project on American Indian Economic Development.
Huntington, S., & Rearden, J. (1993). Shadows on the Koyukuk:
An Alaska Native's life along the river. Portland, OR:Alaska
Northwest Books.
Langdon, S. J. (2002). Native peoples of Alaska (4th ed.).
Homer, AK: Wizard Works.
Mayo, W. (2002). Introduction: Anchoring values. Alaska
Native ways: What the elders have taught us. Portland, OR:
Graphic Arts Publishing Company.
Napoleon, H., & Madsen, E. C. (1991). Yuuyaraq: The way of the
human being. Fairbanks: University of Alaska Fairbanks,
Center for Cross-Cultural Studies.
National Congress of American Indians. (2003). An introdUC-
tion to Indian Nations in the United States (3rd ed., expanded).
Washington, DC: Author.
Ogunwole, S. M. (2002). The American Indian and Alaska Native
population: 2000. Washington, DC: U.S. Department of
Commerce, Economics and Statistics Administration,
Census Bureau.
Ogunwole, S. M. (2006, February). We the people: American
Indians and Alaska Natives in the United States. Washington,
DC: U.S. Department of Commerce, Economics and Sta-
tistics Administration, Census Bureau.

Olesksa, F. M. (2005). Another culture/Another world. Juneau:
Association of Alaska School Boards.
Tiller, V. E. (2005). Tiller's guide to Indian Country: Economic
profiles of American Indian reservations (Znd ed.). Albuquerque,
NM: BowArrow Publishing Company,
Utter, J. (2001). American Indians: Answers to today's questions (2nd
ed.). Lake/Ann, MI: Woodlands Publishing.
Wallis, V. (2002). Raising ourselves: A Gwich'in coming of age
story from the Yukon River. Kenmore, WA: Epicenter Press.
SUGGESTED LINKS Alaska Inter-Tribal
Council. www.aite.org/
Alaska Federation of Natives.
www.nativefederation.org/
Alaska Native Heritage ~nter, Information about Alaska Native
Cultures.
www.alaskanative.net/2 . asp
Alaska Native Knowledge Network.
www.ankn.uafedu/
Alaska Native Language Center.
www.uaf.edu/anIc/
First Alaskans Institute.
wwwfirstalaskans.org/
U.S. Department of Commerce, Bureau of the Census. American
Indian/Alaska Native Data, 2000.
http://factfinder . census .gov/home/aian/index.html
-SARAH
HICKS
ALCOHOL AND DRUG PROBLEMS. [This entry
contains four subentries: Overview; Law Enforcement
and Legal Policy; Practice Interventions;
Prevention.]
OVERVIEW
ABSTRACT: Social workers commonly encounter
individuals and families that have problems
resulting from alcohol and other drug (AOD)
misuse, abuse, and dependence. This entry provides
an overview of AOD problems in the general
population and within such subpopulations as
young people, the elderly, women, ethnic and racial
minorities, and the gay and lesbian community.
Clinical and policy responses to these problems in
the United States, the roles of social work ers in this
field, and directions for the future are addressed.
KEY WORDS: substance abuse; alcohol and other
drugs; AOD treatment; policy issues; impact on
family; social work role
Problems resulting from AOD misuse, abuse, and de-
pendence affect individuals, families, communities, and
society as a whole. It is critical, therefore, that all social
ALCOHOL AND DRUG PROBLEMS: OvERVIEW 121
workers have some familiarity with the various substances
of abuse and with relevant clinical and policy issues. Due
to space limitations, treatment and policy issues related to
tobacco use are not included.
Definition of Terms
Millions of Americans use alcohol, tobacco, or other drugs
(ATOD), but most do not experience any negative
consequences. It is therefore helpful to conceptualize A
TOD use on a continuum from nonproblematic
experimental and social use to substance misuse (such as
using pain medication in order to get high) to abuse, which
indicates problematic use that affects individuals and their
relationships, and finally, to dependence or addiction, which
implies compulsive use that may require medically
supervised detoxification and/or formal treatment to
abstain or curtail use (Straussner; 2004).
Many substances tend to be abused. They include those
that are legally obtained, such as alcohol, tobacco, and
caffeine; prescription medications (for example;
OxyContin, Vicodin, Ritalin, and Adderall), various forms
of inhalants (for example, glue, paint, and aerosols), and
illicit drugs, such as marijuana, heroin, cocaine or crack,
methamphetamine (known as "ice" or "crystal rneth"), and
hallucinogens (for example, LSD, PCP, and psylocybin
mushrooms). Anabolic steroids and "designer"
(synthetically produced compounds that mimic other
psychoactive substances) or "club" drugs, such as MDMA
(that is, Ecstasy), GHB, or Rohypnol ("the date-rape" drug)
are often misused or abused, particularly by adolescents
(Substance Abuse and Mental Health Services
Administration [SAMHSA], 2005).
The most recent American Psychiatric Association's
(APA) (2000) Diagnostic and Statistical Manual of Mental
Disorders (DSM IV-TR) uses the term substance-related
disorders (SRD) to classify all disorders related to prob-
lematic consequences of substance use. The SRD category
is further divided into Substance-Induced Disorders (SID) and
Substance Use Disorders (SUD). SID includes 11 different
disorders ranging from substance intoxication or
withdrawal symptoms to substance induced mood, anxiety,
psychotic, or sleeping disorders. It is assumed that once a
person stops their abuse or dependence on a substance,
SIDs will disappear within a relatively short time.
Individuals whose psychiatric symptoms do not disappear
over time are likely to have additional diagnoses, variously
referred to as having coexisting, co-occurring, or comorbid
substance and mental disorders.
SUD consists of two subcategories: substance abuse and
substance dependence. Substance abuse is defined as "a
maladaptive pattern of substance leading to clinically
significant impairment or distress" in one or more of
122 ALcoHoL AND DRUG PROBLEMS: OVERVIEW
the following within a 12 month time frame: the con-
tinued use of psychoactive substances despite
experiencing social, occupational, psychological, or
physical problems; inability to fulfill "major role
obligations at work, school, or home"; recurrent use in
situations in which use is physically hazardous, such as
driving while intoxicated; and/or recurrent legal
problems related to the use of a substance (APA, 2000,
pp. 114-115). Substance dependence is defined as the
existence of at least three of the following 7 symptoms
within a 12 month period:
1. Tolerance, as defined by either a need for
increased amounts of a substance to achieve a
desired effect or diminished effect with use of the
same quantity of substances
2. Withdrawal, as characterized by specific with-
drawal syndromes, or using a substance in order
to relieve or avoid withdrawal symptoms
3. T aking the substance in larger amounts or over a
longer period than was intended
4. A persistent desire or unsuccessful efforts to
reduce or control use
5. A great deal of time spent obtaining, using, and
recovering from substance use
6. Important social, occupational, or recreational
activities are given up or reduced because of the
use of the substance
7. Continued substance use despite knowledge of
resulting serious physical or psychological
problems
Once diagnosed with substance dependence, an indi-
vidual can never be diagnosed with the less severe
diagnosis of substance abuse. A substance abuse or de-
pendence diagnosis also calls for one of six "course
specifiers" delineating the longer-term outcome of
these disorders. These specifiers can only be given after
the individual stops using a given substance for at least
1 month. They include (1) early full remission, defined as
being substance-free for more than 1 month, but less
than 12 months; (2) early partial remission, where the
individual resumes some use of a substance (sometimes
referred to as having a "relapse"), and subsequently
meets at least one criterion of abuse or dependence
within the first year of recovery; (3) sustained full remis-
sion, defined as being substance-free for more than 1
year; and (4) sustained partial remission, in which the
individual resumes substance use after 12 months of not
having any symptoms, and then meets at least one
criterion of substance abuse or dependence. The two
final specifiers are (5) on agonist therapy, which is used
when the individual is placed on an agonist medication
(that mimics the action of a naturally occurring sub-
stance) or antagonist (that acts against and blocks an
action) medication to treat the substance of chOice,
such as using methadone as a replacement for opiates;
and (6) in a controlled environment, indicating that the
individual is residing in a substance-free environment,
such as a therapeutic community or prison.
The Scope and Impact
of Substance Abuse Problems
Substance abuse causes more deaths, illnesses, acci-
dents, and disabilities than any other preventable health
problem (Robert Wood Johnson Foundation [RWJ],
2001). Worldwide, the use of substances is increasing
most dramatically in low-incorne countries, which in
the coming decades are expected to suffer from a dis-
proportionate burden of substance-related disability
and premature death (Anderson, 2006). According to
research done for the World Health Organization,
during the year 2000, tobacco was the number one
addiction problem in the world, responsible for 4.9
million deaths, while an estimated 1.8 million people
die annually due to alcohol-related problems; illegal
drugs cause 223,000 deaths. However, over the past
decade, "alcohol has become the number one risk factor
in developing countries ... above tobacco" (News in
Science, 2003).
In the United States, according to 2005 data, an
estimated 22.2 million persons (9.1 % of the population
aged 12 or older) were classified as abusing or
dependent on a substance. Of these, 15.4 million were
dependent on or abused alcohol, 3.6 million abused or
were dependent on illicit drugs, and 3.3 million were .
classified with dependence on or abuse of both alcohol
and illicit drugs (SAMHSA, 2005). An estimated 60.5 .
million persons or 24.9% of the population are current
cigarette smokers (SAMHSA, 2006). It is expected that
smoking will result in approximately 440,000 deaths
each year, and an additional 8.6 million people will have
at least one serious illness caused by smoking (Collins,
2005).
While the magnitude of alcohol problems has been
overshadowed by the political and media
preoccupation with illicit drugs, it is important to note
that the consequences of alcohol-related problems are
more devastating and widespread for both individuals
and society.
ALCOHOL-RELATED PROBLEMS
1. Alcohol contributes to close to 100,000 US. deaths
annually from drunk driving, stroke, cancer,
cirrhosis of the liver, falls, and other adverse
effects (Mokdad, Marks, Stroup, & Gerberding,
2004).
2. Nearly half of all violent deaths (accidents,
suicides, and homicides), particularly of men
below age 34, are alcohol related (RWJ, 2001).

3. Alcohol is a consistent factor in reports of child
physical and sexual abuse, including incest, and in
cases of rape and domestic violence (Isralowitz,
2004; RWJ, 200l).
4. Between 53% and 73% of homeless adults are
affected by an alcohol disorder (Podymow, Turnbull,
Coyle, Yetisir, & Wells, 2006).
DRUG, RELATED PROBLEMS The 6.8 million persons
aged 12 or older classified as abusing or dependent
on iUicit drugs use a wide variety of substances including
heroin, methampherarnines, inhalants, sedativehypnotics,
and designer drugs such as Ecstasy. The largest number of
individuals, however, use marijuana (4.1 million),
followed by cocaine (1.5 million), and narcotic or opioid
pain relievers, such as OxyContin (1.5 million)
(SAMHSA, 2005).
Injecting drugs, such as heroin, with a contaminated
needle leads to high risk of becoming infected with HIV
and of developing AIDS. Having sex with an HIV
-infected individual is also a high risk factor for
HIV/AIDS. This mode of HIV transmission has become
especially detrimental for women: Since the epidemic
began, 58% of all AIDS cases in women have been
attributed to injection drug use or sex with partners who
inject drugs, compared with 34% in men. The transmission
of HIV through drug injection or sex with an infected
individual is disproportionally high among black and
Hispanic men and women (Centers for Disease Control
and Prevention [CDC], 2006).
Substance Abuse Problems
Among Special Populations
Substance abuse and dependence vary according to age
and gender, ethnic and racial factors, as well as sexual
orientation.
SUBSTANCE ABUSE BY YOUTH Unlike the relatively
constant rate of alcohol and drug abuse by adults
over the years, young people's substance use has
fluctuated over time, reflecting the availability of
particular sub, stances and their popularity among
certain subgroups; some of the variation reported is
also attributable to changes in government data
collection methods (Straussner, 2004). After a
relatively high use of illicit substances by young
people in the 1960s and 1970s, the proportion of
high-school and college students using any illicit
drug has decreased significantly, with the exception
of prescription opioids abuse (National In stitute on
Drug Abuse [NIDAl, 2006). Currently, the most
frequently abused substances by young people are
alcohol, marijuana, the so- called club drugs, such as
ALCOHOL AND DRUG PROBLEMS: OvERVIEW
123
Ecstasy, and the nonmedical use of the pain reliever,
Vicodin (NIDA, 2006).
The heavy use of alcohol by young people is often
viewed as a "gateway" to other drugs; research studies
have showed that among heavy drinking youths, 66% were
also current illicit drug users, compared to only 4.2%
nondrinkers who were current illicit drug users (RWJ,
200l). In addition, there is growing evidence of an
association between young age of first use of alcohol or
other drugs and problematic use of these substances during
adulthood (SAMHSA, 2005). According to the R WJ
(2001), "More than 40 percent of those who started
drinking at age 14 or younger developed alcohol
dependence, compared with 10 percent of those who began
drinking at age 20 or older. High school students who use
illicit drugs are also more likely to experience difficulties
in school, in their personal relationships, and in their
mental and physical health" (p. 30). Thus there is a
growing focus on prevention programs aimed at
postponing the age of initiation of drug use.
SUBSTANCE ABUSE BY OLDER ADULTS Compared to
the general popul ation, substance abuse problems are
less common among older adults. However, the
number of elderly persons who misuse or abuse illicit
drugs and alcohol is increasing. This is due to the
growing number of aging baby boomers who tend to
have a history of hi gher rates of alcohol use, as well
as abuse and misuse of prescription and
over-the-counter medications (Bogunovic, Shelly, &
Greenfield, 2004).
GENDER AND SUBSTANCE ABUSE Studies over the last
decade show that adult males are about twice as
likely to be classified with substance dependence or
abuse as females (12.0% versus 6.4%) (SAMHSA ,
2005). However, the rates of nonmedical use of psy-
chotherapeutic drugs (pain relievers, tranquilizers,
stimulants, and sedatives) were similar for both
males and females (1.8% versus 1.7%, respectively )
(RWJ, 2001). Gender differences in substance
dependence are dimin ishing among young people,
portending a growing sub stance abuse problem
among younger women as they age (SAMHSA,
2006).
While there are numerous issues unique to substance
abusing women (see Straussner & Brown, 2002), one
important aspect is the impact of their substance use on
their children. Although studies show that most women
tend to reduce their substance use during pregnancy
(SAMHSA, 2005), some women, especially those
dependent on alcohol, crack cocaine, or methamphet-
amine, continue their substance use (Sampson et al., 1998).
These substances are then transmitted to the fetus resulting
in a child who may be born addicted
124 ALCOHOL AND DRUG PROBLEMS:
OVERVIEW
and/or who may suffer permanent brain or other phys-
iological damage (Azmitia, 2001).
It is important to keep in mind that the impact of fetal
exposure to AOD is determined by many factors, including
the type of substance, the gestation age of the fetus at
exposure, the route and duration of exposure, the dosage
and frequency of drug intake, other substances consumed
simultaneously, as well as environmental factors including
nutrition and prenatal care (Nadel & Straussner, 2006).
RACE AND ETHNICITY SUD rates vary by race and
ethnicity, In 2005, the rate of substance dependence or
abuse for those age 12 and over was highest among
American Indians and Alaska Natives (21.0%), followed
by Native Hawaiians or other Pacific Islanders (11.0%),
persons reporting two or more races (10.9%), Whites
(9.4%), Hispanics (9.3%), and Blacks (8.5%). The lowest
rate was found among Asians (4.5%), although rates vary
greatly among different Asian populations (SAMHSA,
2006; Straussner, 2001).
Studies also reveal that among young adults (aged
18-29), White males have the highest risk for alcohol
problems, while among those who are middle aged and
elderly rates are highest for Black men and women
(Isralowitz, 2004). Socioeconomic factors also correlate
with race and gender: Limited education and poverty are
related to alcohol dependence in Black males but not in
White males (RWJ, 2001).
SEXUAL IDENTITY There has been much controversy
regarding the rates of AOD use among gay men and
women. After a careful review of the literature on alcohol
use, Bux (1996) lists the following four conclusions:
1. Gay men and lesbians are less likely to be abstainers
from alcohol than heterosexuals.
2. Gay men appear to have little increased risk of
alcoholism over heterosexual men.
3. Lesbians appear to be at higher risk than heterosexual
women for alcohol abuse, and match both
heterosexual and gay men in heavy and problematic
drinking.
4. Gay men appear to have reduced their consumption
of alcohol by the mid-1990s.
The pattern of drug use among this population is similar to
that of alcohol use: Gay men have been found to be less
likely to abstain from marijuana and cocaine, but have
similar rates of heavy use of these substances as
heterosexual men. Marijuana and cocaine use by lesbian
women, however, exceeded that of heterosexual women,
but was similar to that of heterosexual
and gay men. Finally, the usage of drugs by older gay men
and women did not decrease as much as usage among the
older heterosexual population (McKirnan & Peterson,
1989).
Certain drugs have particularly high usage in the gay
male community. Methamphetamine, for example, has
increased dramatically among gay and bisexual men who
report rates 10 times greater than the general population
(Halkitis, Shrem, & Martin, 2005).
Etiology of Substance Use Disorders
There is no single etiological factor that accounts for why
some people develop a SUD and others do not. Among the
factors often cited in the literature are
1. Biochemical and Genetic Factors. Substance depen-
dence is increasingly conceptualized as biologic-
ally and genetically based, and as a "brain disease"
rather than a "moral weakness or lack of
willpower" (Brain Chemicals Trump Willpower in
Addicts, 2006).
Familial Factors. Early separation from one or both
parents and inadequate care during childhood, as well as
physical or sexual abuse during childhood are some of
the familial factors. contributing to substance abuse
problems (Roberts, Nishimoto, & Kirk, 2003).
Substance abuse has also been seen as serving as. ap.
important stabilizing force in dysfunctional families
(Steinglass, Weiner, & Mendelson, 1971) .
. 2. Psychological Factors. These factors encompass various
perspectives, including classical and modem
psychoanalytic theory, developmental and person-
ality theories, and behavioral, conditioning, and
cognitive theories (Beck, Wright, Newman, & Liese,
1993; Peele, 1998).
3. Environmental and Sociocultural Factors. This.view
links substance abuse to a variety of environmen-
tal, social, cultural, and economic factors (RWJ,
2001; Wagner & Anthony, 2002). Studies of fe-
male substance abusers, in particular those in
lower socioeconomic classes, show a high corre-
lation between their substance abuse and that of their
spouses or boyfriends (Straussner & Attia, 2002).
4. Multifactorial Perspective. This perspective views
substance abuse and dependence as resulting from
a combination of factors, including biochemical,
genetic, familial, environmental; and cultural
ones, as well as personality dynamics. SUDs ate
thus seen as a multivariate syndrome in which
multiple patterns of dysfunctional substance abuse
occur in various types of people with varying
prognoses requiring a variety of interventions
(Pattison & Kaufman, 1982; Straussner, 2004).

Clinical Issues
Less than one-fourth of all individuals who need help
for their abuse or dependence on alcohol or other drugs
receive treatment (SAMHSA, 2005). Nonetheless, stu-
dies indicate that for those who do obtain treatment,
treatment does work (RWJ, 2001). Horgan (1995) notes:
"The improvement rate for people completing substance
abuse treatment is comparable to that of people treated
for asthma and other chronic, relapsing health
conditions." During 2005, almost 4 million per sons aged
12 or older (1.6% of the population) received treatment
for SUD.
Clinical interventions with substance abusers, as
with all clients, need to begin with a comprehensive
screening and assessment followed by appropriate
inter-
\
vention. A growing number of social workers are using
standardized screening and assessment instruments
(King & Bordnick, 2002). Among the most frequently
used are various versions of the CAGE for assessing
alcohol problems and the CAGE-AID that assesses for
other drugs (Brown & Rounds, 1995; Mayfield, Mcleod,
& Hall, 1974); the Substance Abuse Subtle Screening
Inventory (SASSI) (Feldstein & Miller, 2007)j the
Michigan Alcohol Screening Test (MAST) (Selzer,
1971)j the Alcohol Use Disorders Identification Test
(AUDIT) (Babor et al., 1992); the Drug Abuse
Screening Test (DAST)j the Addiction Severity Index
(ASI) (McLellan et al., 1992), and CRAFFf for
assessing adolescents (Knight et al., 1999).
An important area of assessment is differentiating
between substance abuse and other psychopathology.
Individuals with a diagnosis of SUD may also suffer
from another major psychiatric (Axis I on DSM VI-R)
disorder and/or have an underlying personality disorder
(Axis 1I) necessitating a comprehensive psychiatric
assessment in addition to assessment of their substance
abuse (Straussner & Nemenzik, 2007).
A comprehensive assessment must also consider the
client's motivation for treatment. As a rule, substance
abusers do not enter treatment voluntarily. While a
highly motivated client is likely to make better use of
treatment, recovery from substance abuse is not always
dependent upon whether or not the initial contact with
treatment was voluntary. In fact, studies show that some
individuals who are coerced into treatment have as
good a recovery rate as those entering treatment
voluntarily (Kelly, Finney, & Moos, 2005).
Practice Interventions
An important task for social workers is to determine
appropriate forms of treatment for clients with SUDs.
Medically supervised detoxification is often the first step
in the treatment of those physically addicted to opioids,
ALCOHOL AND DRUG PROBLEMS: OvERVIEW
125
alcohol, barbiturates and other sedative hypnotics, and
amphetamines. It is not required for those dependent on
cocaine, crack, or marijuana.
Traditionally, all detoxification had been carried out
on a medical or psychiatric inpatient unit, however with
the advent of managed care, it is now often provided in
outpatient clinics or by physicians in private practice.
Heroin addicts can be detoxified on an outpatient basis
with the help of such chemicals as clonodine or
decreasing doses of methadone.
Detoxification is usually only the beginning of a
long process of recovery. Short- and long-term inpatient
and outpatient rehabilitation programs, drug-free
residential therapeutic communities, and ongoing sup-
portive counseling can help substance abusers examine
the impact of alcohol and/or other drugs upon their lives
and the necessary changes in their lifestyle that they
must undertake if they want to recover from substance
abuse (Straussner, 2004).
The use of methadone as a substitute for opiates or
narcotics can lead to better prognosis for rehabilitation
and allow narcotic addicts to avail themselves of coun-
seling and educational or vocational training; it can also
help them improve the overall quality of their lives once
the daily concern about obtaining drugs is alleviated
(Friedman & Wilson, 2004). Moreover, the potential for
becoming infected with HIV is an important factor in
referring - intravenous narcotic users to methadone
maintenance programs. While used less extensively,
opioid antagonists such as naltrexone can prevent
addicts from experiencing the effects of narcotics.
Unlike methadone, naltrexone has no narcotic effect of
its own and is not physiologically addictive. Under the
trade name of Re Via, it also is being used for people
with alcohol- dependence. The use of other medications,
such as Acamprosate(for alcohol dependence) and
buprenorphine (for opioid dependence), has been
increasing (Erickson & Wilcox, 2001). A chemical that
is sometimes used to help alcoholics is disulfiram,
commonly known as Antabuse. This medication-blocks
the normal oxidation of alcohol so that acetaldehyde, a
by-product of alcohol, accumulates in the bloodstream
and causes unpleasant, and at times even
life-threatening, symptoms, such as rapid pulse and
vomiting. The use of Antabuse thus serves as a
conscious deterrent to drinking. A number of substance
abuse treatment settings have also incorporated non-
traditional treatment approaches such as acupuncture,
yoga, and meditation.
Twelve-Step Programs, such as Alcoholics Anon-
ymous (AA), Narcotics Anonymous (NA), Pills
Anonymous, and Cocaine Anonymous, have proven to
be particularly helpful and are free and available in
126 ALCoHOL AND DRUG PROBLEMS:
OVERVIEW
every community. These groups allow members not only
to receive help but also to give help to others, thereby
enhancing self-esteem (Spiegel & Fewell, 2004): Other
self- or mutual-help groups for substance abusers, such as
Women for Sobriety, Rational Recovery, SMART groups,
Social Workers Helping Social Workers, and Double
Trouble/Recovery groups for those with co-occurring
mental disorders, are available in many communities.
Patients with SUDs also experience various social
problems. Thus, an essential aspect of helping this
population is the provision of financial and social sup-
ports, including adequate housing, vocational rehabili-
tation, and legal assistance.
Harm-reduction approaches, which can range from
\
needle exchange programs to the provision of housing,
social and psychological services without focusing di-
rectly on the elimination of substance use, have been
increasing throughout the United StatesIoieger, 2004).
These approaches remain controversial since abstinence is
not their primary goa1.
Treatment of substance abusers must take into ac count
the clients' ethnocultural norms and values (see Straussner,
2001), history of trauma, as well as issues of sexual
behavior including safe sex practices. Treatment of
minorities, particularly African Americans, needs to take
into account that they are more likely to enter treatment
through the courts than through formal intervention
processes or 12-step programs. Also, they are more likely
to access treatment much later and thus have a more
difficult recovery process (O'Connell, 1991). Lastly, it is
important to remember that substance abuse, "like many
other medical problems, is a chronic disorder in which
recurrences are common and repeated periods of treatment
are frequently required" (U.S. Department of Health and
Human Services [USDHHS], 1991, p. 4).
Impact of Substance Abuse on the Family Between
9% and 29% of all children in the United States are
exposed to familial drug or alcohol abuse
(SAMHSA,2003). While many children from substance
abusing families are highly resilient and do not exhibit
blatant problems (Peleg-Oren & Teichman, 2006; Werner
& Johnson, 2000), research indicates that a large number
are at risk of developing. a variety of physical,
psychological, and social problems (Anda et al., 2002;
Gruber & Taylor, 2006; Johnson & Leff, 1999).
Child neglect and, in more disturbed families, vio lence
between parents, child abuse, and incest are some of the
consequences and correlates of substance abuse.
Substance abuse is present in at least two-thirds of the
families known to public child welfare agencies
(Hampton, Senatore, & Gullotta, 1998). Studies highlight
the need to address the intergenerational cycle of
substance abuse and child abuse if effective progress is to
be made on either problem. During 2006, expert panels of
social work educators, practitioners, and researchers,
working under the auspices of the National Association
for Children of Alcoholics (NACoA) and chaired by one
of the authors (Straussner), developed a set of core
competencies needed by social workers in order to work
effectively with this population (NACoA, 2006).
Couples and family therapy, including multifamily
groups, are effective modalities for families with substance
abusers who are already chemically free or working on their
recovery. One evidence-based family-oriented treatment
approach is Community Reinforcement and Family
Training (CRAFT) (Miller, Meyers, & Tonigan, 1999). It
is also beneficial to refer family members to such
mutual-help groups as Al-Anon, Pill-Anon, Co-Anon, or
Nar-Anon. These groups help adult family members
examine their own role in the "enabling" behavior. There
are also support groups for adolescent children of alcohol-
and. narcotic-abusing parents, such . as .. Alateen and
Narateen. Adult Children of Alcoholics (ACOA) groups
may be helpful for mature adolescents and adult children of
alcoholics.
Policy History
Treatment programs and practices are driven not only by
clinical needs, but also by social policies. Substance abuse
policies in the United States are generally consistent with
prevailing ideology and tend to parallel public attitudes, and
not necessarily the prevalence of a particular substance
(Isralowitz, 2004). For example, in Colonial America and
the early 1800s, drinking and even drunkenness were seen
as acceptable behaviors. It was only during the latter part of
the nineteenth century that any use of alcohol was perceived
as problematic, resulting in the growth of the temperance
movement. At the same time, during the 1800s, opiates and
cocaine were legal and used widely, particularly as . patent
medicine by middle-class women (Straussner & Attia,
2002).
Beginning in 1906 the Pure Food and Drug Act, the
Harrison Narcotic Act of 1914, the Volstead Act that
ushered in Prohibition in 1919, and the 1937 Marijuana
Tax Act led to public policies that criminalized the users
of various substances while at the same time limiting their
access to medical treatment (Isralowitz, 2004). Following
the repeal of Prohibition in 1933, the social use of alcohol
once again became widely acceptable,

while problematic alcohol use was seen as a sign of an
individual's shortcoming (Nadel & Straussner, 2006).
The passage of the Hughes Act in 1970, authorizing
the establishment of the National Institute on Alcohol
Abuse and Alcoholism (NlAAA) and the National
Institute on Drug Abuse (NlDA), had a profoundim pact
on the treatment of both drug and alcohol abusers. It
provided the impetus for the decriminalization of public
drunkenness; increased federal funding for substance
abuse research and model treatment programs; and
prompted coverage by health insurance companies for
AOD treatment.
Faced with growing drug use among young people
and concern about heroin-addicted servicemen return-
ing from Vietnam, on 17 June 1971, President Nixon
\
declared that drugs were America's number one enemy,
marking the start of the United States' "War on Drugs."
Nixon appointed Dr. Jerome Jaffe to head the new
Special Office for Drug Abuse Prevention. Between
1971 and 1973, Jaffe developed a network of metha-
done treatment facilities all over the United States, and
in 1973, the Drug Enforcement Administration (DEA),
whose mission was to fight the drug war, was
established (Frontline: Interview with Dr. Jerome Jaffe,
n.d.)
In 1988, under the Reagan administration, the Office
of National Drug Control Policy (ONDeP) was created
to coordinate drug-related legislation, security,
research, and health policy throughout the government.
The director of ONDCP, commonly known as the Drug
Czar, was raised to cabinet-level status by Bill Clinton
in 1993 (A History of the War on Drugs, n.d.).
Other important legislation has been the passage of
the 1997 Adoption and Safe Families Act (ASFA) [P.L.
105-8.9] that addressed the need for children in out-of-
home placements to have a permanent home. Child
protection workers are mandated to terminate clients'
parental rights and free their children for adoption if
substance abusing parents/caregivers do not improve
within 15 months. Although ASFA identified the need
for addiction treatment, few new resources have been
provided to meet this need (Gustavsson & MacEachron,
1997).
Current federal policy efforts, under the auspices of
The White House ONDeP and the Substance. Abuse
Mental Health Service Administration (SAMHSA),
may be conceptualized as consisting of a three-pronged
approach: domestic and international law enforcement,
or interdiction, focusing on the "supply" of drugs to the
United States public; and two approaches addressing
the "demand" side: (1) drug prevention and prevention
research and (2) drug treatment and treatment research
(Nadel & Straussner, 2006).
ALCOHOL AND DRUG PROBLEMS:
OvERVIEW 127
The "Supply-Side" approach tries to prevent drugs
from reaching U.S. consumers and focuses on foreign
crop eradication, border and marine interdiction, and
arrests of distributors and drug dealers. These programs
claim the largest percentage of the federal
substance-abuse budget-more. than the other two areas
combined (Veillette, 2006). Substance abuse pre-
vention and treatment, the "demand-side," seeks to
prevent or decrease the use of drugs through various
education/prevention activities, treatment programs,
and research on treatment effectiveness and program
evaluation (Nadel & Straussner, 2006).
Roles of Social Workers
Despite the historically iimited focus on substance
abuse education in schools of social work (Amodeo &
Litchfield, 1999; Straussner & Senreich, 2002), social
workers in the United States have always been involved
with addicted individuals and their families. As early as
1917, Mary Richmond, one of the founders of social
work, rejected the moral definition of alcoholism of her
day with its characteristic view of alcoholics as "sin-
ners." In her groundbreaking book, Social Diagnosis,
Richmond (1917) stated that "inebriety is a disease"
and provided a description that is entirely consistent
with the disease model of alcoholism as described al-
most half a century later by jellinek (1952) and
reflected in the latest version of the APA's (2000) DSM
IV-TR. Richmond viewed social workers as having an
"important role to play in gathering the pertinent social
data," offering the assistance necessary to supplement
the medical treatment, and "providing the long period
of after-care which is usually necessary" (Richmond,
1917/1944, p. 430).
Currently, social workers contribute greatly to the
field of addictions. The profession's unique biopsycho-
social perspective, its flexibility in adapting to new
streams of thought and incorporating them into prac-
tice, and its ability to integrate disparate programming
into a systemic whole make it a profession extremely
well suited to the ever changing field of addictions.
Thus, social workers are important players in program
development, organizing community collaborations,
administration, and treatment. of substance abusers and
their families, and are increasingly involved in
addictions research, education, and policv xlevelop-
ment. Concern regarding the spread of HIV and AlDS
among their clients has led many social workers to
become active in the growing harm-reduction move-
ment and in various prevention programs.
As the largest group of mental health professionals
in the United States, all social workers must become
128 ALCOHOL AND DRUG PROBLEMS: OVERVIEW
knowledgeable about screening, assessment, motiva tional
interviewing, treatment, and referrals of those with
substance abuse problems. They also need to have a much
greater role in primary and secondary preven tion. The
currently diminished role of social workers with families
of substance abusers resulting from the lack of managed
care payments for such services calls for greater advocacy
in this area and for greater innovative practices to help
families. Finally, social workers need to demand federal
and state drug policies that are more equitable and
effective in addressing this tremen dous individual,
familial, and social problem.
Current health insurance benefits for substance abuse
treatment are unequal to mandated medical in surance for
other medical and mental health
, condi-
tions. This lack of parity continues to be a serious
concern as it excludes many from needed substance abuse
treatment. The lack of insurance coverage is partly
responsible for the ethnic treatment disparities with
African Americans less likely than Whites to have access
to substance abuse or mental health care (25.4% versus
12.5%), and with Hispanics receiving delayed or less care
than Whites (22.7% versus 10.7%) (Wells, Klap, Koike, &
Sherbourne, 2001).
Another challenge for social workers is addressing the
impact of drug-related arrests. The United States has the
highest incarceration rate in the world. As of 2006, a
record 7 million people were behind bars, on probation, or
on parole (compared with second-ranked China, with 1.5
million people). At the end of 2003, federal prisons held a
total of 158,426 inmates, the majority (55%) of whom
were drug offenders. It is important to note that more than
two-thirds (70%) of the 260,000 people in state prisons
serving time for nonviolent drug-related charges are
Black or Latino (Huffington, 2007), vastly
over-representing their numbers in the general
populations.
Trends and Future Directions
The field of substance abuse or addictions is constantly
evolving with new substances of abuse, new populations
to treat, new treatment approaches, and changing po licies.
An important current issue is the incorporation of
evidence-based practice (EBP). The harm reduction
movement, well established in most of western Europe,
Canada, and Australia, appears to be growing rapidly in
the United States, although how it will be incorporated
within traditional AOD treatment facilities in this country
remains to be seen.
From an international perspective, illicit substance use
and its consequences (for example, crime and vio lence,
military and police intervention, lost work, fa mily
destruction, property confiscation, and massive
allocations of funding resources for treatment and health
maintenance) constitute a major public concern. For the
drug trade, nationalities and borders do not exist, and its
negative impact on individuals and communities in the
United States, as well as on our public policies will
continue to be an issue for social workers in the future
(Isralowitz, 2004).
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-SHULAMITH LALA ASHEN BERG STRAUSSNER AND
RICHARD ISRALoWITZ
 ALCOHOL AND DRUG PROBLEMS: LAW ENFORCEMENT AND
LEGAL POLlCY 131

LAW ENFORCEMENT AND LEGAL POLICY
ABSTRACT: Historically, U.S. policy has been charac-
terized by long-standing ambivalence evident in the
changing emphasis placed on prohibition as the aim of
drug policy, and in debate about the relative merits of
various approaches to drug control. Often characterized
as supply reduction versus demand reduction ef forts,
significant changes have occurred over time in these
efforts, and in the emphasis placed on them. In the last
quarter of the twentieth century, U.S. drug policy
adopted a more prohibitionist stance, with increased
reliance on a variety of law enforcement, and even
military actions, to control the supply and use of drugs,
even in the face of evidence for the effectiveness of
prevention and treatptent, and high costs associated with
the burgeoning incarceration rates.
KEY WORDS: drug policy; drug war; substance abuse;
prohibition; demand reduction; supply reduction; par-
ity; substance abuse prevention; substance abuse
treatment
Historically, U.S. policy has been characterized by
long-standing ambivalence toward the use of psychoac-
tive substances including alcohol, tobacco and other
drugs (ATOD), and has been marked by ongoing con-
troversy about the best approaches to control the avail-
ability and use of these substances. Ambivalence is
evident in the changing emphasis placed on prohibition
versus regulation, and moderation, or mitigation of
harm, versus elimination of use as the aim of U.S. drug
policy. Debate about the control of both licit and illicit
substances often centers on the relative merits of supply
versus demand reduction approaches to control, pitting
interdiction and law enforcement strategies against pre-
vention and treatment. In recent years, although evi-
dence has increased for the effectiveness of prevention
and treatment, more emphasis has been placed on the
use of interdiction and law enforcement to wage a "war
on drugs."
Perhaps the best example of the ambivalence in
which substance use is held in the United States is the
passage and repeal of the National Prohibition Act, also
known as the Volstead Act. The 18th amendment to the
U.S. Constitution made the manufacture, transpor tation,
import, export, and sale of alcohol illegal. A firestorm of
controversy ensued, in particular as a thriving
underground market in alcohol trafficking developed,
along with escalation in related, often violent, criminal
activity. With the repeal of the Volstead Act in 1933,
alcohol regained its legal status. The legal status of
substances matters because of implications for the
definition of problems associated with use or abuse,
for responses to violations of restrictions on use, as well
as broader social and fiscal consequences.
In the last quarter of the twentieth century, the
United States became caught up in a new wave of
anti-drug sentiment. President Richard M. Nixon in-
troduced the drug war metaphor with the passage of the
Comprehensive Drug Abuse Prevention and Control
Act (1970). In 1973, the Drug Enforcement Adminis-
tration (DEA) was created to enforce drug control
provisions by generally elaborating upon an approach
that originated nearly a century ago with the Harrison
Narcotics Act (1914). The Harrison Act set forth a legal
structure that places tight controls on the medical and
scientific uses of opiates, cocaine, and other con trolled
drugs, prohibiting production and distribution of these
drugs for non-medical and nonscientific uses.
Prohibitions regarding drug use. have since been met
with increasingly severe criminal sanctions under both
federal and state laws. These trends have exacerbated
difficulties associated with reducing the illicit use of
controlled substances without interfering with their
legitimate medical use, 'a conflict that became evident
within a few years following the enactment of the
Harrison Narcotics Act (10M, 1996). Legal restrictions
have, for example, limited administration of effective
doses in methadone programs (10M, 1995). Thus, much
of the debate about U.S. drug policy reflects
disagreement about whether A TOD problems ought to
be the purview of the health care or criminal justice
system.
Debate about supply reduction versus demand re-
duction efforts has increasingly been challenged by
claims that the dichotomy represents an oversimplifica-
tion of approaches to drug control. Nevertheless, the
supply reduction-demand reduction' dichotomy has
been the. mainstay of reporting on federal spending for
drug control since 1973, and Congress originally statu-
torily required the use of this framework for budgetary
reporting with the passage of the 1988 Anti-Drug Abuse
Act. This Act created the Office of National Drug
Control Policy (ONDeP), headed by a "drug czar" who
occupies a position in the Executive Office of the
President. The ONDeP is charged with devel oping a
coherent and coordinated National Drug Control
Strategy. More recently, this has included expectations
for clearly articulated goals and objectives to be
achieved in specified amounts of time. By some counts,
more than 50 federal agencies are involved in some way
in drug control efforts, cutting across both functional
lines and governmental jurisdictions. Although
coordination is daunting, it is vital to reduc ing
duplication of effort and maximizing benefits from the
work of various agencies.
132 ALCOHOL AND DRUG PROBLEMS: LAW ENFORCEMENT AND LEGAL POLICY
The most recent ONDCP report on the National Drug
Control Strategy (2007) has attempted to move away from
the supply/demand duality and uses three foci to
characterize its strategies: Prevention, T reatment, and
Enforcement. Although budget figures vary, estimates are
that the U.S. government spends around . twenty billion
dollars annually on drug control, and states and
municipalities spend many times more than that amount.
Estimating federal expenditures and tracking them over
time has become more difficult; however, because in 2003
the ONDCP changed the way federal spending for drug
control was reported. According to Peter Reuter (2005),
exclusion of large expenditures by the Bureau of Prisons
and prosecutorial expenditures has resulted insignificant
understatement of current expenditures for interdiction and
enforcement. Thus, estimates that approximately 70% of
federal drug control dollars go to interdiction and
enforcement may not accurately reflect the actual dis-
tribution of current federal spending.
Trends in Supply Reduction Efforts Policies
related to supply reduction have changed over time in
relation to historical events and shifts in the role of the US.
government at home and abroad. Sup ply reduction efforts
have evolved around three controversial themes:
expanded use of police powers by governmental
jurisdictions at all levels; globalization and militarization
of U.S. drug control strategies; and a renewed focus on
interdiction at borders and ports of entry into the United
States following the major attack on the United States on
9/11/2001.
Expanded use of legal authority. U.S. drug policy has
come to rely more heavily on law enforcement to control
drug supply through stepped up enforcement of
anti-money laundering and seizure and forfeiture laws.
Billions of dollars have been confiscated by ratcheting up
efforts to make drug trafficking less lucrative through
closer scrutiny of money transfers, and by seizing prop erty
used in or garnered from drug trafficking. Seizure and
forfeiture .laws are particularly controversial because the
standard of evidence for civil confiscation of property is
lower than for criminal proceedings, and most individuals
who have property seized are never charged with a crime.
The most striking consequence of law enforcement's
increased role in the war on drugs has been the rapid rise
of incarceration rates in the United States. More emphasis
h~ been placed on disrupting local markets through the use
of "sweeps" by law enforcement offi cers across
neighborhoods to arrest individuals engaged in street level
drug transactions. The rhetoric of "zero tolerance"
signaled that users, as well as sellers,
were to be targeted by these measures, crossing the
traditional supply-demand divide by introducing greater
use of law enforcement as a deterrence strategy aimed at
preventing and reducing use. Mandatory sentencing,
longer sentences, and "three strikes" provisions produced
a surge in the prison population which quadrupled
between 1980 and 2000. The prison population in the U.S.
continues to grow, although at a slower rate.
Increased emphasis on a law enforcement approach to
drug control has blurred the lines between care and
control. Although initially conceive d of as "diversion"
programs, court-ordered treatment is increasingly used as
an adjunct rather than and alternative to incarcera tion,
blending criminal justice and treatment approaches
(Weisner, 1986; Burke, 1992; DiNitto, 2002). Incarcera-
tion of large numbers of drug involved offenders has
resulted in the provision of more drug treatment in prisons
and jails, although concern remains about the existence of
a "treatment gap" for offenders who need treatment but do
not receive it (Mears, Moore, Travis, & Winterfield, 2003;
Belenko & Peugh, 2005).
An increasingly punitive approach to drug control
policy in the U.S., focused on adjudicating, or otherwise
sanctioning drugs users, has had far-reaching repercus- .
sions for ex-offenders and persons with alcohol and other
drug (AOD) problems, influencing policy in a number of
seemingly unrelated domains (Diblitto, 2000; 2002 ).
Although past AOD problems areac knowledged as a
disability by the 1990 Americans/ with Disabilities Act
(ADA), persons with active AOD use disorders are not
provided the same employment pro tections afforded to
persons with other disabilities by the ADA. Nor are they
eligible for assistance from Social Security Disability
Insurance (SSDI) or Supplemental Security Income (SSI)
since AOD disorders are not recognized as qualifying
disabilities for participation in these programs. Moreover,
welfare reform provisions of the 1996 Personal
Responsibility and Work Oppertunity Reconciliation Act
(PR WORA) made it possible to deny Food Stamps or
income supports through Temporary Assistance to Needy
Families (TANF) to adults convicted of using alcohol and
other drugs. PR WORA also authorized testing of welfare
recipients suspected of drug use and sanctioning those
who test positive. Similarly punitive sanctions face
individuals in public housing who use drugs, or who are
convicted of a drug offense as adults and later seek federal
assistance to pursue higher education (see DiNitto, 2002
for a more detailed discussion).
Militarization and globalization of U.S. supply reduction
policy. Supply reduction efforts have been marked by
increasing use of the U.S. military, along with efforts to
 ALCOHOL AND DRUG PROBLEMS: LAW ENFORCEMENT AND
LEGAL POLICY 133
involve new partners around the world in drug control.
In 1981, Congress passed and President Reagan signed
an amendment to the Posse Comitatus Act of 1876,
which had prohibited military involvement in lawen,
forcement. This amendment allowed state and local law
enforcement officials to use military assistance for train,
ing, intelligence gathering, and investigation of drug law
violations. The amendment also provided for the use of
military equipment by civilian agencies to en, force drug
laws (Doyle, 2000). Moreover, the Anti Drug Abuse Act
of 1986 authorized appropriations for the Department of
Defense to support drug interdiction activities, as well as
increasing resources for the Coast Guard and the
Customs Service.
Foreign policy conctrns, globally and in particular
regions of the world, have led to increased efforts by the
United States to target production of drugs at their
source. These efforts include crop eradication and sub-
stitution programs, as well as efforts to train and support
source countries in the use of military and police ac tions
to reduce drug trafficking. In the wake of 9/11, supply
reduction efforts have been reinvigorated by concerns
that proceeds from the drug trade are used to finance
terrorist organizations and their activities. The United
Nations Office of Drugs and Crime Control (UNODC)
estimated the world market for illicit drugs at more than
322 billion dollars in 2003 (UNODC, 20057), a sum that
dwarfs the economies of many na- . tions, ,especially
those in the so-called developing world. A number of
global and regional partnerships have been forged to
combat the use of "narco-dollars" and counter the
"three-dimensional threat" of drugs, organized crime,
and terrorism (cf. UNIS, 2005).
Renewed focus on border security and interdiction. Con,
cerns about terrorism have also renewed interest in
interdiction at borders with neighboring countries, and at
other ports of entry into the United States. Along with
stepped up inspection of vehicles and con, tainers
transporting people and cargo into the United States,
pilot programs are under way, deploying new equipment
to scan the contents of containers trans, ported across u.S.
borders. The u.S. Customs Ser vice, the Department of
Defense (DOD), and the ON DCP, are partnering to
further develop nonintrusive detection technology to aid
in countering narcotics trafficking and intercepting other
contraband such as weapons and explosives. Since 2001,
fueled by Homeland Security concerns, expenditures for
border security have doubled from $4.6 billion to $10.4
billion in 2006, and by 2008 the Bushadrninistration
expects to have doubled the number of border patrol
agents (White House Press Release, 2006). In addition, a
number of recent proposals have been made
to counter illegal immigration, drug trafficking and
terrorism through a combination of physical and "vir,
tual" fences along U.S. borders with neighboring
countries. The Secure Fence Act of 2006 includes pro ,
visions for the construction of 700 miles of new physical
fencing along the U.S. border with Mexico. More
recently, a $2.5 billion contract was awarded to Boeing
to begin development of a "virtual" fence as part of the
Secure Border Initiative Network (Slslnet).
The centerpiece of demand reduction policies has
been the development of a national infrastructure for
prevention and treatment programs, funded, in large
part, by federal Substance Abuse Prevention and Treat,
ment (SAPT) block grants. Funding for research has
also become an integral part of federal demand reduc-
tion efforts, aimed at monitoring the nature and extent of
drug use by U.S. citizens, better understanding the
causes and consequences of substance abuse, and
effectively intervening to reduce or ameliorate
substance abuse. The more recent focus on promoting
greater use of evidence-based practices in drug
prevention and treatment acknowledges the gains made
in under' standing how. to prevent and treat drug
problems. Ensuring that such treatment is available to
all those who need it is a growing source of concern,
contributing to calls for parity in insurance coverage.
Increasing emphasis on research into AOD use and related
problems. Since the 1970s funding for research into A
TOD problems has increased dramatically. Most of that
funding has been provided by the National Insti tute on
Drug Abuse (NIDA) and the National Institute on
Alcohol Abuse and Alcoholism (NIAAA) situated,
since 1992, within the National Institutes of Health
(NIH). In 2006, however, NIH experienced the first year
of real decline in funding in 36 years; NIDA and
NIAAA funding was cut in FY 2006. The Substance
Abuse Mental Health Services Administration
(SAMHSA), and the Centers for Substance Abuse
Treatment (CSAT) and Center for Sub, stance Abuse
Prevention (CSAP), formed in 1992 to promote the
availability and monitor the quality of substance
treatment and prevention practices, face dramatic
funding cuts.
Research on A TOD problems has been important in
shaping the current understanding of substance use and
abuse, demonstrating that such problems can be pre,
vented or ameliorated. The most recent national drug
control strategy acknowledges that "once viewed as
essentially a moral problem or character defect, drug
use is now more accurately considered a complex
behavioral problem with personal, social, and biological
underpinnings" (ONDCP, 2007). Since 1997, research
at the National Institutes has increasingly embraced
134 ALCOHOL AND DRUG PROBLEMS: LAW ENFORCEMENT AND LEGAL POLICY
the notion that addiction is a "brain disease" (NIDA,
2007). Proponents of such an approach assert that ad-
diction is a complicated state, involving changes in the
structure and chemistry of the brain. Changes in the
brain are believed to be related to the behaviors com-
monly associated with addiction such as compulsive use
in the face of serious and even tragic consequences.
Critics of funding for so-called wet bench reseaich on
addiction assert that such studies are expensive and
compete for funds needed to study other aspects of
substance abuse prevention and treatment. These
include studies tracking changing social and behavioral
antecedents. of drug use and its consequences,
particularly in tbecontext of an aging and more
culturally diverse U.S. population. They also
includeresearch on services utilization and studies
needed to improve access and effectiveness of
prevention and treatment.
Promoting polices on effective approaches to prevention
and treatment. Since the passage of the Government
Performance and Results Act (GPRA, 1993) all federal
agencies are responsible for demonstrating positive
program results by adopting data-driven systems for
decision making about "resource allocation and
monitoring performance. As the lead federal agency,
SAMHSA, and its CSA T dlvision, have subsequently
begun working with the single-state agencies (SSA).
responsible for allocation of federal Substance Abuse
Prevention and Treatment (SAPT) block gi-ant funds to
comply with "these expectations. Federal agencies have
also been challenged to translate and disseminate
research findings and promote the adoption of
evidence-based practices. These efforts include
specification of the key principles associated with
effective prevention and treatment efforts;
identification of promising, evidence-based a nd model
(best practice) programs; and development of protocols
for implementing effective programs, supported by a
range of training and technical assistance mechanisms.
Pursuing parity policy in coverage for substance abuse
treatment. Although many youth and adults use ATOD,
the proportion of individuals who develop abuse or
dependence disorders as indicated by responses to items
using criteria set out in the Diagnostic and Statistical
Manual (DSM IV), is generally low. (See Lala and
Richard's Overview article.) The 2005 National Survey of
Drug Use and Health (NSDUH) survey data indicate
that 9.3% of survey respondents, age 12 and older,
reported some kind of substance dependence or abuse
problem in the past year, predominantlyalcohol, These
figures were not significantly different from those
obtained from household surveys each year since 2002.
These data indicate, however, that more than
22 million people in the United States have a substance
abuse disorder in a given year, and lifetime prevalence
rates are higher still. Another consistent finding is that
only a tiny proportion of those who needed treatment
actually received it, and more than half of those who
received treatment did so by attending a self-help group.
A humber of factors have worked against increasing
the availability of and access to such services. Federal
funding for substance abuse prevention and treatment
(SAPT) block 'grants, that account for about 40% of
public ~enditures for treatment nationally, were cut in
2005 and 2006 and the current Federal administration
proposes funding for FY 2008 at FY 2007 levels
(NCCBH, 2007). Shifting resource allocation decisions
and program accountability from the federal to the state"
and local levels has increased local control but has also
brought with it increased costs for monitoring decision
making and performance. Moreover, although treat ment
outcomes of alcoholism and drug addictionservices
compare favorably with those for other chronic recurring
disorders, many insurers have not yet granted equal
status to this health issue.
This inequity has given rise to a quest for achieving
parity in coverage for treatment of substance abuse
disorders. Equal coverage for drug and alcohol treat"
ment requires health insurers to recognize addictions as
a disease and provide Coverage for treating alcohol and
drug addiction that is equal to treatment coverage for
other chronic, relapsing disorders such as diabetes and
hypertension. Most people who use illicit drugs-or who
have problems with alcohol are employed. Many
insurance policies require higher deductibles and co-
payments, provide fewer visits, days of coverage, and
lower annual or lifetime dollar limits for alcohol and
drug dependence treatment than for other chronic health
problems (Goplerud & Cimons, 2002).
A number of states have moved to mandate com"
prehensive parity for all citizens, or some lesser level of
coverage that approaches parity. Analysis of the im pacts
of such policy decisions in 11 states reveals that
equitable coverage increases the number of people who
receive treatment, reducing long-term cost to the stat e
and producing cost savings many times greater than the
amount spent on treatment. In addition, in these states,
more persons in need of treatment were treated in out-
patient settings, reducing the length of more costly
hospital stays. Evidence to date counters concerns by
opponents to parity that no effective treatment exists for
substance use disorders or that providing coverage for
such disorders will increase costs for health care and
insurance premiums.
 ALCOHOL AND DRUG PROBLEMS: LAW ENFORCEMENT AND
LEGAL POLlCY 135
Key Challenges and Controversies
The policy debate about how much to invest in con-
trolling the availability of substances, versus preventing
their use or ameliorating the negative consequences of
use, will remain at the center of the drug policy debate.
Too little is yet known about supply reduction efforts in
terms of "their efficacy in reducing the availability of
drugs in illicit markets; their impact on the wealth and
power of ongoing criminal organizations; and their
impact on foreign policy objectives" (Moore, 1990). In
1997, the U.S. Government Accounting Office as serted
that "there are some promising initial research results in
the area of demand reduction but that international
supply reduction efforts have not reduced the
availability of drugs': (Testimony, 05101/97, GAOl
T-GGD-97-97).
More recently, reptesentatives of the UNODC as-
serted that "though there has been an epidemic of drug
abuse over the last half century, its diffusion into the
general population has been contained" (UNODC, 2004,
p. 13). These assertions are widely disputed, how ever,
given the continued difficulty in tracking and measuring
production and distribution of illicit drugs (GAO, 2005).
It is difficult to determine how the volume of drugs
seized relates to underlying levels of drug production.
Indications are that only a relatively small proportion of
drugs destined for U.S. markets are likely to be
interdicted. Pricing and purity are regarded by some as
better indicators of supply, but many problems are
associated with obtaining and interpreting such
measures as well. Moreover, in 2006, the UNODC
countered previous evidence for success in opium crop
eradication by issuing an alert regarding record opium
production in Afghanistan, the leading source world-
wide for this drug (UNODC, 2007).
A closely related issue is the need to better under-
stand the role that legal controls may play in reducing
use, abuse, and dependence on illicit drugs while taking
into account the full cost of such measures. Monitoring
and tracking expenditures consistently, over time, is an
important element of this debate, and more work is
needed to develop and adopt an appropriate budget
framework (Reuter, 2006). The application of legal tools
to discourage consumption and limit availability has
been a key element of public policy regarding the use of
alcohol and tobacco, but within a regulatory framework
rather than a prohibitionist one The most costly side
effects of a prohibitionist drug policy are those
associated with arrest, prosecution, and incarcera tion of
persons who violate drug laws. Although prices vary
significantly from one jurisdiction to another, on
average, in 2005 it cost approximately $22,000 per year
to incarcerate an individua1. By contrast treatment for A
TOD problems typically costs a fraction of that amount
(Belenko, Patapis, & French, 2005). Moreover, recent
research findings suggest that every dollar spent on
treatment generates 7 dollars in benefits such as reduced
health care costs (Ettner, et al., 2006). Increas ing the
availability and access to effective A TOD treatment
may become more important in' the face of burgeoning
costs for maintaining a large, and still grow ing, offender
population.
Achieving parity is another policy proposal that
could provide greater access and reduce the costs of
treatment. By shifting more of the burden to private
insurance funds for those who are employed, more
public dollars will be available for individuals who have
no other recourse than to seek treatment in publicly
funded settings. Mandating additional insurance cover-
age for substance abuse treatment is particularly chal-
lenging in the context of rapidly rising health care costs,
and more general concerns about the provision of health
services in the United States.
A recent report from researchers at the Rand Cor-
poration advocates that efforts be made to' "press for a
more dispassionate debate" (Caulkins, Reuter, Iguchi, &
Chiesa, 2005). Given the intense feelings about this
topic, and, the intersection with other volatile issues
such as concerns about terrorism, homeland security,
immigration, civil and human rights, it is difficult to
imagine a less polemical debate. To the extent that the
policy debate can become more focused on the effec-
tiveness of various drug control efforts, perhaps the U.S.
can reduce drug use, its consequences, and costs at the
same time.
REFERENCES
Belenko, S., Patapis, N., & French, M. T. (2005) . Economic
benefits of drug treatment: A critical review 'of the evidence for
policy makers. University of Pennsylvania: Treatment
Research Institute.
Belenko, S., & Peugh, J. (2005). Estimating drug treatment
needs among state prison inmates. Drug and Alcohol Depen-
dence, 77(3), 269-281.
Burke, A. C. (1992). Between entitlement and control:
Dimensions of U.S. drug policy. Social Service Review, 66
(4),571-82.
Caulkins, J. P., Reuter, P., Iguchi, M. Y., & Chiesa, J. (2005).
How goes the war on drugs? An assessment of U . S. drug policy
and problems. Report prepared for the Ford Foundation by
the Drug Policy Research Center. Santa Monica, CA: Rand
Corporation.
DiNitro, D. M. (2002).War and peace: Social work and the
state of chemical dependency tr eatment in the United
States. Co-published simultaneously in Journal of Social
136 ALCOHOL AND DRUG PROBLEMS: LAW ENFORCEMENT AND LEGAL POLICY
Work Practice in the Addictions (The Haworth Social Work
Practice Press) 2, (3/4), 2002, pp. 7-29; and International
Aspects of Social Work Practice in the Addictions (ed: Shulamith
Lala Ashenberg Straussner,and Larry Harrison) pp. 7-29.
DiNitto, D. M. (2000). Social welfare: Politics and public policy.
Boston: Allyn & Bacon.
Doyle, C. (2000). The Posse Comitatus Act & related matters:
The use of military to execute civilian law. Washington, D.C.:
Library of Congress. Congressional Research Service. Doc.
call no.: M-U 42953-1 no. 95-9645 Last updated June 1, 2000.
Retrieved November 16, 2007, from http://www.fas.
org/sgp/crs/natsec/95-964.pdf.
Ettner, S. L., et al. (2006). Benefit-cost in the California treatment
outcome project: Does substance abuse treatment "pay for
itself'? Health Services Research 41 (1), 192-213.
Government Accountability Office (GAO). (1997). Drug control:
Reauthorization of the office of national drug control policy
(Testimony, 05/01/97, GAO/T-GGD-97-97). Retrieved November
16, 2007, from http://www.globalsecur ity
.org/security/library/report/gao/ggd97097 .htm
Government Accountability Office (GAO). (2005). Drug control
agencies need to plan for likely declines in-drug interdiction assets,
and develop better performance measure for transit zone
operations. Report to Congressional Committees. Washington,
DC: GAO (GAO-06-200). _
Institute of Medicine (10M). (1995). Federal regulation of
Methadone Treatment. Washington, DC: National Academy
Press.
Institute of Medicine (lOM). (1996). Pathways of addiction:
Opportunities in drug abuse research. Washington, DC:
National Academy Press.
Mears, D. P., Moore, G. E., Travis, J., and Winterfield, L. (2002).
Improving _ the link between research and drug treatment in
co;ectional settings. Washington, D.C.:
Justice Policy Center, The Urban Institute.
Moore, M. H. (1990). Supply reduction and drug law en-
forcement. In N. Morris, & M. Tonry (Eds.), Drugs and Crime,
Vol. 13. (pp. 109-158). Chicago: University of Chicago Press.
Office of National Drug Control Policy United States (ONDCP).
(2007). National Drug Control Strategy 2007. Washington, DC:
ONCDP. Retrieved November 16, 2007, from
http://www.whitehousedrugpolicy.gov/publications/
policy/ndcs07 /ndcs07 .pdf
Reuter, P. (2006). Estimating government drug policy expen-
ditures. Addiction, 101,315-322.
ReuterP, (2005). An assessment of ONDCP's budget concept.
Testimony presented to the House of Representatives Com-
mittee on Government Reform, February 10, part of the Rand
Corporation testimony series. Santa Monica, CA:
The Rand Corporation Retrieved November 16, 2007, from
http://www.rand.org/pubs/testimonies/CT236.
United Nations Information Systems (UNIS). 2005. UNODC , and
European Commission agree drugs, crime, and terrorism inextricably
linked: Bilateral solutions needed to combat new threats. Press release
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(UNIS/NAR/87 6). http://www.unis.unvienna.org/unis/
pressrels/200S /unisnar876.html
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from http://www.unodc.org/pdf/WDR_2()04/
Executive_Summary.pdf
United Nations Office on Drugs and Crime (UNODC). (2007).
United Nations Office on Drugs and Crime AnnUal Report 2007:
Making the world safer from crime, drugs and terrorism. Vienna,
Austria: Vienna International Centre. Retrieved November 16,
2007, from http://www.uriodc. org/pdf/annuaCreport_2007 /
AR063ullreport.pdf
Weisner, C. M. (1986). The transformation of alcohol treatment:
Access to care and the response to drinking-driving. Journal of
Public Health Policy,7 (1), 78-92. "
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Act of 2006. Washington, DC: Office of the 'PreSs Secretary,
The White House. Retrieved November 16; 2007, from
http://www.whitehouse.gov/news/releases/2006/
10/20061026-1.html
FURTIlER READING
Caulkins, J. P., Reuter, P., Iguchi, M. Y., & Chiesa, J.' (2005).
How goes the war on drugs? An assessment of U.S. drug policy and
problems. Report prepared for the Ford Foundatioriby the Drug
Policy Research Center. Santa Monica, CA: Rand
Corporation.
Mauer, M. (2003). Comparative international rates of incarceration:
An examination of causes and trends. The Sentencing Project.
Report presented to the U.S. Commission on Civil Rights.
Washington, DC.
-ANNA CELESTE BURKE
PRACTICE INTERVENTIONS
ABSTRACT: This entry focuses on practice interven-
tions for working with families and individuals
including behavioral marital therapy, transitional
family therapy, and the developmental model of
recovery, as .well as motivational interviewing,
cognitive-behavioral therapy, relapse prevention
training, and harm reduc tion therapy. A commonality
in these intervention frameworks is their view of the
therapeutic work in stages-- from active drinking and
drug use, to deciding on change, to movement toward
change and recovery. We also identify skills that equip
social work practi tioners to make a special
contribution to alcohol and other drug (AOD)
interventions and highlight factors to consider in
choosing interventions.
There are a range of practice interventions" for clients
with AOD problems based on well-controlled research.
.. ~
 ALCOHOL AND DRUG PROBLEMS: PRACTICE
INTERVENTIONS 137

KEY WORDS: motivational interviewing; cogmtrve-
behavioral therapy; harm reduction therapy; behavioral
marital therapy; developmental model of recovery; AOD
and trauma; AOD and co-occurring psychiatric disorders
Drug Abuse Treatment Principles
Social work practitioners are encouraged to consider a
range of counseling methods and modalities, choosing the
ones that best meet the needs of the AOD client, couple, or
family. The National Institute on Drug Abuse publication,
Principles of Drug Addiction Treatment: A Research-based Guide
(NIDA, 2000), a valuable guide for practitioners working
with AOD clients, provides the scientific evidence for a
range of currently accepted treatment approaches.
Organized around treatment principles, ft discusses issues
such as appropriate treatment goals, optimum length of
treatment, treatment effectiveness, and the role of
medications for AOD and co-occurring psychiatric
conditions. Among the recommended supplemental
supports is Alcoholics Anonymous, which can improve
client outcomes when used as an adjunct to formal
treatment (T onigan & Hiller-Sturmhofel,1994).
CHOOSING INTERVENTIONS Decisions about how to
intervene with AOD clients should be based on several
factors: the severity and urgency of the client's problem
(for example, hazardous use, abuse, dependence), the
client's level of awareness of the problem, the client's stage
of readiness to change the dysfunctional behavior
(DiClemente, 1991; Prochaska & DiClemente, 1983), the
client's goal for change (for example, controlling use,
reducing use, or quitting), the point at which the client
seeks help (for example, during active drinking! drug use,
early abstinence, or ongoing recovery (Brown, 1995)), and
the client's cultural background, identification, and
experiences. Additional considerations will be the amount
of time available, the organizational setting and its view of
the worker's role, the client's voluntary or mandatory
status, and financial considerations.
also seen as involving necessary life changes above and
beyond abstinence: repairing relationships damaged
through AOD use, dealing with shame and self-hatred,
addressing experiences of early trauma, and giving up
self-defeating patterns acquired during addiction.
ETHNOCULTURALLY COMPETENT AOD. TREAT-
MENT Ethnocultural competency (Orlandi, 1992;
Straussner, 2001) includes practitioner self-awareness, a
basic understanding of the ethnoculture of one's clients,
and an ability to adapt one's practice to fit the client's
ethnocultural background (Amodeo & Jones, 1997; Lum,
1996; Orlandi, Weston, & Epstein, 1992; Straussner,
2001). Factors such as the client's level of acculturation,
the culture's view of the causes and remedies of AOD
problems, and the level of shame associated with
AODproblertlS influence the client's and family's ability to
respond to typical or mainstream treatment methods
(Amodeo & Jones, 1997). Effective treatment for some
clients may include use of an indigenous community
healer, joining the neighborhood Pentecostal church,
residing at the local Buddhist temple, or going to a sweat
lodge (Amodeo, Robb, Peou, & Tran, 1996; Delgado,
1994, 1995). Talking with clients about their ethnocultural
background and identification is central to AOD
assessment and treatment because it can point to stressors
(for example, family conflict related to acculturation,
workplace discrimination) and resources (for example,
culturally encouraged coping methods, finding recovering
individuals from the cultural group who can serve as role
models) that can hinder or assist in the client's recovery.

ABSTINENCE AND RECOVERY Although some indi-

viduals may be treated for misuse of AOD and return to
moderate, nonproblem use, practice experience supports
the need for abstinence as a treatment goal for those who
have developed alcohol or drug dependence (Hester &
Miller, 1995). In the U.s. AOD treatment system, absti-
nence is the predominant goal, however new approaches
are being used to help clients moderate their use and reduce
the harm associated with use. Recovery is seen as a
developmental process occurring over time; although
individuals may have made a commitment to abstinence,
they continue to be vulnerable to relapse. Recovery is
 Practice Interventions: Families
BEHA VIORAL MAR IT AL THERAPY Behavioral
interventions focusing on marital interaction have been
studied more extensively than family systems and
psychodynamic approaches, and currently have the
greatest empirical support (O'Farrell, 1995). O'Farrell
(1995) describes a number of these behavioral interven-
tions within three stages of recovery: (a) initial commit-
ment to change, (b) the change itself, and (c) the long-term
maintenance of change. Although O'Farrell's model talks
explicitly about family alcohol problems, the approach fits
families of drug addicts as well. Recommended
interventions are behavioral contracting, structuring the
spouse's arid alcoholic's role in the recovery process,
decreasing family members' behaviors that trigger or
enable drinking, and dealing with drinking that occurs
during treatment. To improve marital and family
relationships, O'Farrell prescribes shared recreational
activities and homework (O'Farrell, 1995).
138 ALCOHOL AND DRUG PRoBLEMS: PRACTICE INTERVENTIONS
TRANSITIONAL F AMIL Y THERAPY Stanton and
Heath (2005), seeking a model that integrates manage ment
of the: substance abuse problem, the psychosocial
environment, and interventions related to how the problem
originated in the family's history, have devel oped
Transitional Family Therapy that works to intensify certain
dysfunctional family interactions in order to evoke
counteractions, and consequently, new behaviors, while
introducing competing behaviors that block the family's
typical patterns. This work occurs in six stages: (a)
problem definition and contracting, (b) establishing the
context for a chemical-free life, (c) halt ing substance
abuse, (d) managing the crisis and stabilizing the family,
(e) family reorganization and recovery, and (f) ending
therapy. In contrast with O'Farrell's (1995) behavioral'
work, this model brings together various family therapy
and intergenerational approaches.
DEVELOPMENTAL MODEL OF RECOVERY A
unique feature of the recovery model of Brown (1985,
1995) and Brown and Lewis (1999) is the incorporation of
cognitive, behavioral, psychodynamic, and family systems
theories. The model assumes that clients and families often
come for treatment for reasons other than AOD problems,
and the clinician needs to be active in conducting a
thorough assessment and bringing AOD issues to the
forefront. Although focusing on alcohol and alcoholism,
the model applies equally well to drug abuse in suggesting
interventions at each stage from active drinking and/or
drug use, transition, early recovery, and ongoing recovery.
Practice Interventions: Individuals
THE STAGES OF READINESS FOR CHANGE This
framework can be used by practitioners regardless of their
theoretical orientation (for example, psychodynamic,
behavioral, 12 step) (DiClemente, 1991; Miller &
Rollnick, 1991,2002; Prochaska & DiClemente, 1983).
The stages were derived from studies of addicted smokers
who successfully stopped (Prochaska, DiClemente, &
Norcross, 1992). Its tenets include the following. In
changing significant problem behaviors, we all go through
predictable stages. Moveinent through these stages is not
necessarily linear, and sometimes individuals remain at a
particular stage and do not progress. Reasons for not
changing are powerful. Even when we finally effect a
change, maintaining the change over time is generally very
difficult. Because most people return to the addictive or
habitual behavior once change has been established,
relapse or recurrence is built into the model and is seen as
an opportunity for the individual to identify situations to
avoid in the
future when change has been reestablished. The stages. are
(a) precontemplation (person has never considered
changing), (b) contemplation (person is considering
change but is very ambivalent), (c) preparation (person has
made the decision to change and is preparing to do so), (d)
action (person makes the change andsustains it at least for
a brief period), (e) maintenance (person maintains the
change over months/years), and/or (e) recurrence (person
returns to addictive or habitual behavior). Heavy emphasis
is placed on (a) using specific counseling techniques for
each stage, (b) working through ambivalence in the
contemplation stage, (c) helping clients move one stage at
a time, sO the treatment goals are realistic and immediate
and permanent change is not routinely expected, and (d)
educating clients about the stages of change and engaging
them in dialogue about where they are and where they
want to be.
MOTIVATIONAL INTERVIEWING Relying heavily on
reflective listening, this counseling method emphasizes
four principles: express empathy, develop discrepancy,
roll with resistance, and support self-efficacy (Miller &
Rollnick, 2002, p. 36). Client ambivalence about change is
seen as a predictable dynamic, and clinicians. are
encouraged to validate its presence. Helping clients
examine the pros and cons of changing a behavior: and the
pros and cons of leaving the behavior unchanged can tip
the balance of the ambivalence, freeing clients up to make
a change. The choice of whether and when to change rests
with the client, as does the nature of the change (for
example, quitting, cutting down, changing the
circumstances). This approach contrasts with previous
confrontational methods used in counseling AOD clients
and has been found to be effective with populations as
disparate as adolescents, medical pa tients, alcoholic
couples, mandated clients, and clients with HIV infection
(Miller & Rollnick, 1991).
COGNITIVE BEHAVIORAL THERAPY (CBT) Key to
this counseling approach is the functional analysis, an
assessment that examines the connections between the
client's thoughts, feelings, and behavior leading to
excessive AOD use (Beck, Liese, & Najavits, 2005; Miller,
2004). The goal is to help clients learn an array of specific
skills to interrupt various thoughts-feelingsbehavior
cycles. Clients with AOD problems often perceive
themselves to be helpless in the face of crav ings or
exposure to others using AOD; CBT (Beck, Freeman,
Davis, et al, 2003; Beck, Wright, Newman, & Liese, 1993;
Carroll, 1998, 1999) teaches that relapse to excessive use
is not inevitable. Client self-education through reading and
self-monitoring through the use of
 ALCOHOL AND DRUG PROBLEMS: PRAcrICE
INTERVENTIONS 139
behavioral tools are emphasized. This approach has been
found to be effective with clients from disparate age
groups, racial and ethnic groups, and educational levels,
and with a range of AOD problems.
RELAPSE PREVENTION TRAINING Relapse is the
return to use after a period of committed abstinence
(Daley, 1987; Marlatt & Gordon, 1985). In general, clients
with AOD problems are considered to be at high risk for
relapse during the first year of abstinence, and depending
on the client, for periods that are much longer. Specific
relapse-prevention methods, often originating in CBT,
include avoiding high-risk situations, developing a
drug-free peer group, identifying personal signs of
impending relapse (physical, emotional, and cognitive),
and utilizing a predesigned plan to avoid acting on relapse
impulses. This work relies on techniques such as role
playing to teach clients AOD refusal skills, worksheets to
help clients identify high-risk relapse situations,
sociograms to identify positive and negative influences in
the client's social network, and practice in between
sessions to ensure that learning is transferred to real-life
situations.
HARM REDUCTION THERAPY The primary focus of
this approach is helping clients reduce harm associated with
their AOD use. Harm reduction (Denning, 2000; Marlatt,
1996, 1998) recognizes that some clients are unable or
unwilling to work toward abstinence, but can be helped to
limit the harm they do to themselves and others. This
approach is especially helpful with clients who have
multiple problems (for example, substance abuse,
psychiatric problems, HIV + diagnosis, and homelessness)
and limited emotional and material resources to deal with
them. Principles include working closely with the stated
goals of the client rather than pressuring the client to
change, valuing small accomplishments (for example, the
client uses drugs in a safe place rather
. than a shooting gallery or uses clean rather than dirty
needles to inject), and assisting clients in making more
substantial changes when and if they choose to do so.
Moderation management is an approach that shares
similarities with harm reduction (Vanicelli, 2001).
AOD AND CO-OCCURRING PSYCHIATRIC DISOR.
DERS One of the most challenging issues for the AOD
treatment field is addressing the chronic relapsing behavior
of clients with dual disorders. General themes in
approaching treatment are educating clients and their
families about the symptoms of both disorders; monitoring
client adherence to medications, since stopping
medications is a significant risk for relapse; reinforcing
small accomplishments; and engaging in active outreach if
clients miss sessions (Busch, Weiss, & Najavits,
2005; Drake, Essock, et al. 2001; Drake & Mueser, 2000).
Further, clients need an integrated treatment approach, that
is, several evidence-based interventions such as
medications, psychosocial treatments, family support,
urine testing used in combination, and delivered by the
same clinicians working in one setting. The agency or
providers take responsibility for combining the service
interventions into one coherent package (Drake, Goldman,
et al., 2001; Drake et al., 1998). In the absence of such
resources, practitioners need to identify programs that treat
each condition separately and the practitioner needs to
supplement this dual focus with case management
services. The helping relationship isa critical factor (Owen,
Rutherford, & Jones, 1997) that spans the range
of.interventions for people with co-occurring disorders
(Minkoff & Regner, 1999).
AOD DISORDERS AND TRAUMA Posttraumatic Stress
Disorder (PTSD) often accompanies AOD disorders;
many addicted women in treatment have extensive trauma
histories. For at least some clients, AOD use seems to have
suppressed the trauma memories and provided temporary
help with the anxiety, panic, depression, sexual
dysfunction, and other PTSD symptoms. Relapse has been
common among such clients if the trauma work is done too
soon, for example, in the first 3 months of abstinence. On
the other hand, some clients may relapse because the
trauma work is not done soon enough. A differential
assessment is necessary, and clinical tools and guidelines
are still evolving. Thought containment, visualization, and
stress reduction methods common to CBT are
recommended in early abstinence until clients are
emotionally and physically stable (Najavits, 2002, 2004;
Najavits, Weiss & Liese, 1996; Rosenthal, Lynch, &
Linehan, 2005). Many AOD and trauma experts are now
questioning the benefits of requiring that clients recall the
trauma in detail and work through the associated feelings .
From Micro to Macro Practice Interventions There are
additional AOD practice interventions at the micro, mezzo,
and macro levels. These include screening and brief
intervention, case management, and advocacy at the micro
level. There are also a variety of group therapies,
organizational interventions, community mobilization
methods, primary and secondary prevention approaches,
and activities directed at policy change in which social
workers engage (McNeece & DiNitto, 2005; Straussner,
2001, 2004).
SOCIAL WORK SKILLS Among the social work skills
contributing to effective work with AOD clients and their
families are the ability to (a) use differential
'140 ALCOHOL AND DRUG PROBLEMS: PRAcrlCE INTERVENTIONS
treatment approaches depending on client and family needs,
(b) engage and assist the family whether or. not the drinker
ordrug user comes to treatment, (c) partner with clients to
assess the problem, choose appropriate goals, and implement
changes, (d) anticipate client ambivalence about changing
habitual behavior, (e) choose culturally and linguistically
appropriate interventions, (f) utilize such resources as 12-step
programs, natural support networks, and community service
systems, and (g) identify and manage countertransference
reactions that can hinder the therapeutic relationship
(Amodeo, 1997). The ecological perspective of the social
work profession increases the likelihood that they will adopt a
holistic approach. Rather than assuming that the problem
resides onlX in. the individual or the environment, the
ecological perspective looks at the interaction between both
(van Wormer, 1995). SociQl workers need to be aware of their
own reactions and attitudes toward AOD since
countertransference reactions are common (Amodeo &
Drouilhet, 1992).
The coming years will see several challenges as well as
scientific and clinical advances in AOD treatment. The stigma
that keeps individuals and families from seeking treatment is
likely to continue, although to a somewhat diminished degree.
PTSD diagnoses are likely to increase as family-,
cornmunity-, and combatrelated violence and exposure to
natural and man-made disasters continue. Medications will
increasingly be used in AOD treatment. This will be a
welcome advance for the field but practitioners will need to
become knowledgeable about these medications to ensure the
judicious use of them as a complement rather than a substitute
for psychosocial treatments. More extensive use of
evidence-based practices should improve client retention and
recovery rates, and services research should assist us in better
matching clients with clinicians andtreatment modalities.
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-MARYANN AMODEO AND Luz
LOPEZ
PREVENTION
ABSTRACT: Prevention is a proactive science- based
process that aims to strengthen existing p rotective
factors and to diminish or eliminate other factors that
put individuals, families, and communities at risk for
substance abuse; Prevention is important because
alcohol and drug abuse are a leading cause of
morbidity, mortality, and health expe nditures in the
United States. Alcohol and other drug abuse is also
associated with
142 ALCOHoL AND DRUG PROBLEMS: PREvENTION
infectious diseases, chronic diseases, emergency room
visits, newborn health problems, family violence, and auto
fatalities. The comorbiditv of drug and alcohol abuse with
mental health disorders and HI\( adds urgency to the
development, evaluation, and implementation of
comprehensive and effective prevention interventions. The
social work profession plays a key role in substance abuse
prevention as it not only targets the use and abuse of
alcohol and other drugs but also aims at reducing the
related negative health and psychosocial outcomes and
economic burden they produce on individuals and society
at large.
KEY WORDS: drugs; alcohol; prevention; best
practices
Defining
\
Prevention
The Center for Substance Abuse Prevention (CSAP)
provides the following working definition of prevention:
Prevention is an anticipatory process that prepares
and supports individuals and systems in the creation
and reinforcement of heal thy behaviors and
lifestyles. Alcohol, tobacco and other drug problem
prevention focuses on risk and protective factors
associated with the use of these substances,
concentrating on areas in which research and
experience suggest that success in reducing abuse
and addiction is most likely (Center for Substance
Abuse Prevention, 2007).
This definition highlights effectiveness and notes that
prevention efforts are conducted in different contexts and
settings such as the family, social service agencies,
schools, and communities at large. Since most people who
use alcohol, tobacco, and other drugs start before the age of
20 (Skara & Sussman, 2003), the bulk of prevention efforts
takes place with children and youth in schools. These
efforts aim at addressing alcohol and drug problems before
they emerge or as youth start to experiment with
substances in order to avert the onset of addiction and other
negative health consequences. Specific types of services
vary, but evidencebased prevention interventions rely on
problem-solving skills, drug resistance strategies; and
linking youth and their families to existing support
services.
Alcohol and drug prevention grew out of the public
health field and has a strong interdisciplinary tradition in
which social work plays avery important part. Social work
practitioners conducting prevention colla' borate with a
wide array of professionals and paraprofessionals. Social
workers provide community-based alcohol and drug
prevention services across the life span to those of diverse
socioeconomic status, race and ethnicity, gender, sexual
orientations, and ability status (NASW, 2000).
History
The Temperance Movement of the early 1800s can be
considered one of the first organized prevention efforts. It
began in response to dramatic increases in the production
and consumption of alcoholic beverages. Regardless of its
actual success, the movement established the foundation
for the development of prohibition laws and to some
degree was the preamble to the "abstinence only"
prevention paradigm that inspires much of contemporary
U.S. prevention policy (Mann, Hermann, & Heinz, 2000).
In the 1960s scare tactics became a popular prevention
tool, later used by school-based programs such as DARE
(Bikerland, Murphy-Graham.xs, Weiss, 2005). They relied
on graphic and often exaggerateddepictions of the
consequences of alcohol and other drug use on the body
and mind. The approach was found ineffective as people
did not change their behavior as a result of hearing such
messages (Witte & Allen, 2000).
In the 1970s accurate information emerged in part as an
attempt to address the shortcomings of scare tactics. These
efforts were mostly atheoretical but were based on the idea
that knowing the harmful consequences of alcohol and
drugs will deter people from using regardless of their
environmental conditions. However, providing detailed
and accurate information about the consequences of using
alcohol and .other drugs was found to motivate some youth
to experiment with drugs, or, in other words, selected
members of the target population became educated
consumers of drugs (Borvin, 2000; Flay, 2000).
The last two decades of the 20th century saw the
emergence of Life Skills Training, with an emphasis on the
etiology of drug abuse or the behaviors that may lead to
alcohol and drug use. Once behaviors are identified,
alternative skills are taught in order to appropriately and
competently resist drug offers (Botvin, 2000, 2002).
There are many approaches to preventing alcohol and
other drug use and misuse, and often more than one
approach is used in combination with others, leading to the
application of eclectic approaches to prevention (Dishion
& Kavanagh, 2000). Interventions can take place at
different levels, such as the individual, family,
neighborhood, school, and larger society. The more levels
the interventions target, or the more comprehensive the
approach, the more promise it has to achieve effectiveness
(Botvin & Griffin, 2002; Hawkins, Catalano, & Arthur,
2002). Effective prevention interventions are sensitive to
social and cultural environments, integrate existing assets,
and address unique contextual risks. Although they may
differ in their

specific content, effective prevention interventions tend
to be grounded in ecological perspectives familiar to
social workers (Botvin et al., 2000; Epstein, Griffin, &
Botvin,2001).
Flelated llneory
Ecological perspectives, and in particular risk and resi-
liency approaches, provide the appropriate theoretical
foundation for prevention. The premise behind this
theoretical approach is that there are factors or condi-
tions that protect individuals against alcohol and drug
abuse while other factors and contextual conditions
may make them more vulnerable to alcohol and drug
abuse (Catalano, Berglund, Ryan, Lonczak, & Hawkins,
2004).
Protective factors ate individual or environmental
assets or safeguards that increase or boost a person's
ability to cope with stressful events or risky situations
and help them to adapt and be competent in resisting
those risks (Marsiglia, Nieri, & Stiffman, 2006). Risk
factors on the other hand are individual or environmenta l
vulnerabilities associated with a higher likelihood that a
negative outcome will occur (Arthur, Hawkins, Pollard,
Catalano, & Baglioni, 2002; Mrazek & Haggerty, 1994).
Prevention programs work to strengthen protective
factors and weaken or eliminate risk factors (Hawkins,
Catalano, & Arthur, 2002).
Although there is an ongoing debate about what
constitutes a protective or a risk factor, some commonly
identified protective factors for alcohol and other drugs
at different ecosystemic levels that are reinf orced by
prevention interventions are listed below (Hawkins et
al., 2002).
Community protective factors: social cohesion, caring
adults, shared norms, and ethnic or cultural identity.
Family protective factors: effective and horizontal
parent-ehild communication, clear rules, consistent
consequences, religiosity and spirituality,
intergenerational shared fun time.
. School protective factors: Positive school climate,
welcoming and caring environment, clear rules and
expectations, academic excellence.
Individual and peer protective factors: high academic
achievement, active in extracurricular activities,
problem-solving and critical thinking skills, adult role
models, antidrug norms.
Risk factors are individual or environmental vulner-
abilities that are associated with a higher probability that
an undesired or negative outcome will occur (Arthur et
al., 2002; Mrazek & Haggerty, 1994). Selected risk
factors commonly targeted by prevention interventions
are as follows (Arthur et al., 2002; Hawkins et al., 2002 ):
ALCOHOL AND DRUG PROBLEMS:
l'REvENTION 143
Community risk factors: social disorganization, low
neighborhood attachment, easy access to alcohol, to-
bacco, and other drugs.
Family risk factors: lack of communication or poor
communication, lack of parental monitoring, lack of
or inconsistent rules and expectations, family history
of addiction.
School risk factors: Low or inconsistent academic
standards and support, lack of discipline and chaotic
environment, unclear policies regarding alcohol and
other drugs.
Individual and peer risk factors: antisocial behaviors,
sensation seeking, easily influenced by peers, pro
drug norms, low school achievement, and young age
of initiation (Sobeck et al., 2000).
Current Research
Although environmental variables play a key role in the
availability of alcohol and other drugs and their
consumption, biological vulnerabilities also appear to
have some explanatory power in the etiology of drug
use (De Bellis et al., 2000). Some youth drink in excess
from an early age and using in excess leads them more
rapidly to addiction. Brain research has shown that
adolescents and children are more vulnerable to
addiction than are adults because their brains are not yet
fully developed and lack the same ability to control use
as a fully developed adult brain (De Bellis et al., 2000 ).
Translational neuroscience research has identified
the prefrontal cortex and ventral striatum as key areas of
the brain related to impulsivity and mot ivational stimuli
such as using or not using alcohol and other drugs
(Chambers, Taylor, & Potenza, 2003). The
neurotransmitter dopamine has been identified as a key
player in these processes. Dopamine acts as a chemical
messenger that affects the brain processes that control
movement, emotional response, and the capacity to feel
pleasure and pain. It is active in the frontal lobe and
regulates the flow of information coming in from other
areas of the brain. A shortage of, or problems with the
flow of, dopamine can cause a person to lose the ability
to think rationally while a sudden increase in dopamine
may increase risk-taking. Neurodevelopmental changes
during adolescence may lead to a sudden increase in
dopamine, which can make adolescents more
vulnerable to addiction (Greydanus & Patel, 2005).
This type of neurological research has provided
more evidence about the importance of accounting for
the biological aspects of drug use in combination with
psychosocial factors. These findings are being
integrated into different treatment modalities but much
144 ALCOHOL AND DRUG PROBLEMS:
PREVENTION

remains to be done to integrate them into prevention case aims at deterring or delaying the onset of
interventions with adolescents and preadolescents. substance use; for example, all 7 th graders in a
classroom, without tailoring the message to those at
Best Practices different levels of risk. Interventions using this kind
There is no consensus in the field about best practices, but of strategy combined with a zero tolerance or
some agreement has emerged about what not to do (Flay, abstinence messages may come across as naive and
2000). For example, using scare tactics to convey too basic for youth who are already experimenting.
prevention messages and using large school assemblies to 2. Selective prevention targets those at risk for substance
deliver the prevention message have been found to be abuse because of their membership .in a subgroup of the
mostly ineffective. On the other hand, best practices tend population that is known to be vulnerable. For example,
to provide content on social influences and nor mative selective prevention strategies have been designed for
education, develop social skills, provide infor mation on dropouts, children of adult alcoholics, or victims of
perceived harm, target protective factors, and t each refusal family violence. Although not all individuals identified
skills or strategies, (Kulis et al., 2005). Interactive as part of a selective group may be at risk with a
techniques have been identified as the preferred delivery presumption of alcohol or drug use or abuse, they
modality because this approach is more conducive to receive the intervention because of their group
behavioral and attitudinal changes than are lectures. The membership. This approach risks alienating or in-
use of small group discussions and activities, role plays, appropriately labeling some individuals.
the Socratic Method, hands-on projects, videos and stories 3. Indicated prevention targets those already using or
portraying real life situations, as well as other techniques engaged in behaviors known to lead to drug use. These
that facilitate selfreflection and participants' active individuals do not meet criteria for addiction but show
involvement are also part of effective interventions that early signs such as using gateway drugs (tobacco,
deliver desired prevention outcomes (Holleran, Dustman, alcohol) and underperforming in school. These
Reeves, & Marsiglia, 2002). interventions aim at cessation or reducing the severity of
If children and youths' drug use behaviors are as sessed use. Indicated interventions tend to focus more on the
along a continuum, the majority would be at the nonuse individual and less on community variables than the
end and a small minority would be somew here between other two classifications. Sometimes there is no. clear
experimenting, heavy use, and the addiction end of the distinction between indicated prevention and treatment,
continuum. Existing epidemiological data continue to which can lead to overemphasizing the risk factors over
challenge professionals and policy makers with the the protective factors needed for success.
question of where to place limited resources? Should the
priority be on nonusers who may benefit the most from
primary prevention, or should it be on pre vention efforts
that also reach higher risk youth or youth who are already
experimenting? Primary preven tion interventions are
designed to enhance protective factors of all students in
Although the 10M classification system is useful, the
order to keep problems from emerging. Secondary
boundaries between the three classifications can. be
prevention interventions are de signed to reverse the harm
fuzzy. For example, a model universal prevention pro-
from exposure to known risk factors for a selected group
gram implemented in middle schools was found to have a
of students. Tertiary prevention interventions are designed
significant effect on the reduction and discontinu ation of
to reduce instead of reverse ha rm among a select group of
use of high numbers of participants who were already
students who are most at risk (Walker & Shinn, 2002).
experimenting with alcohol and other drugs at the time of
The Institute of Medicine's framework for disease
their participation (Kulis, Yabiku, Marsiglia, Nieri, &
prevention has been broadly adopted in the substance
Crossman, 2007).
abuse field as a guide in detemiining when and with whom
A rich array of universal, selective, and indicated
to intervene. The framework expands on the primary,
interventions have been developed, "manualized," arid
secondary, and tertiary categories and offers three basic
tested since the mid-1980s. The SAMHSA National
classifications of interventions based on the kind of
Registry of Evidence-based Programs and Practices
population they target (Institute of Medicine, 1994 ;
(http://nrepp.samhsa.govf) provides a comprehensive list
Offord, 2000).
of evidence-based prevention interventions. These model
L Universal prevention targets all individuals
programs are very diverse but tend to provide content on
regardless of their level of risk,
normative education, social skills, social influences,
Prevention in this
perceived harm, protective factors, and refusal skills.

Ethical Issues
Substance abuse prevention shares many of the same
ethical dilemmas as alcohol and other drug treatment.
Confidentiality is paramount, but since most prevention
interventions target youth, confidentiality could present
an ethical dilemma. Children and youth participating in
a prevention intervention often disclose to the social
worker or other preventionist their activities or
situations they experience at home. If the students are
minors and make known that they are engaging in an
unlawful behavior, such as purchasing and consuming
alcohol and other drugs, the social worker or
preventionist has an ethical obligation to follow school
or agency policy about addressing the behavior. The
same procedures need to be applied if
\
minors report drug use by their parents or other adults
that may be associated with child abuse or neglect.
Although law enforcement is meant to deter the illegal
-or dangerous behavior of parents, their involvement
may also negatively affect the child. Involving law
enforcement is often necessary to ensure the safety of a
child, such as when reporting a parent or other adult for
providing alcohol or drugs to a minor or because the
parents abuse drugs, but reporting it to the police may
lead to the arrest of the parents or the removal of the
child from the parents' home.
On the other hand, social workers conducting re-
search must ensure confidentiality in order to protect the
participants. The participants must feel comfortable and
confident that their responses will not be associated with
their names when the results of the study are reported.
Therefore, as interventions are e valuated, strict
confidentiality needs to be assured in order to attain
reliable data from the participants. The use of unique
identifiers instead of any personal identifiers is
recommended.
Challenges and Dilemmas
Although studies have shown prevention programs to be
efficacious, each community has its own unique
demographics, strengths, and challenges, and imple-
menting or adapting an identified model program, while
maintaining fidelity, may be difficuit (Kulis et al.,
2007). Social workers, educators, and researchers also
need to increase their effectiveness in promoting
proven programs and convincing policy makers to adopt
policies and provide funding for implementation of
programs,
Cultural, Racial, Ethnic, and
Other Populations
Alcohol use rates vary among racial, ethnic, and cultural
groups. Within each group there are also differences
ALCOHOL AND DRUG PROBLEMS: PREvENTION 145
in consumption based on gender, sexual orientation, and
socioeconomic status. Studies indicate that Latino gay
males are less likely than Whites to use metham-
phetamines or cocaine (Colfax et al., 2005), but they
report higher rates of alcohol use than do heterosexual
Latinos (Tori, 1989). African American lesbians report
higher rates of alcohol use than do heterosexual African
American women (Hughes & Eliason, 2002).
"Culturally neutral" prevention has been questioned as it
does not allow for an integration of unique character-
istics, including assets, coming from culture of origin
(Marsiglia, 2002). Adaptation of standard prevention
intervention to serve the needs of members of ethnic
minority groups has also been challenged.
There is a movement to recognize multiple factors as
part of the clients' holistic experience, and as such,
prevention aims at reaching the clients at the intersec-
tion of these factors (Kulis et al., 2007). From this
perspective, prevention programs recognize the unique
needs and strengths of each diverse population and
ensure that programs provide culturally competent and
effective services (Resnicow, Soler, Braithwaite,
Ahluwalia, & Butler, 2000; Saleet al., 2005). Culturally
grounded or culturally specific interventions, are being
developed and evaluated in order to better integrate
cultural strengths as part of the design of the
intervention and not as an afterthought . (Marsiglia,
Kulis, Wagstaff, Elek, & Dran, 2005).
Social Justice
Compared with Whites, people of color are more likely
to have low incomes, and low-income communities are
disproportionally affected by alcohol and other drug use
(Resnicow et al., 2000). Children residing in lowincome
communities are at a greater risk for consuming alcohol
and other drugs (Arthur & Blitz, 2000). Poor. living
conditions, violence at home or iri the commu nity, high
dropout rates, and the availability and accessibility of
drugs and alcohol must be addressed comprehensively.
Ethnic minority youth tend to have less access to
evidence-based prevention interventions (Back inger,
Fagan, Matthews, & Grana, 2003). Prevention programs
must assess the strengths and assets as well as the
vulnerabilities of communities in order to build more
positive environments.
International Connections
Substance use is a global problem. Worldwide, 5% of all
deaths of people between 15 and 29 years of age can be
attributed to alcohol use (Foxcroft, Ireland, ListerSharp,
Lowe, & Breen, 2003; Jernigan, 2001). In Europe ,
alcohol-related deaths account for 25-33% of all deaths
in that age group (World Health Organization, 200l).
146 ALCOHOL AND DRUG PROBLEMS: PREVENTION
As a result of globalization, prevention programs ori-
ginating in one country are being utilized in other
countries, and prevention researchers are actively col-
laborating in developing and adapting effective programs.
Social work researchers are participating in the design and
implementation of international prevention adaptation
trials and in multisite international prevention
interventions through randomized trials and pilot
exploratory studies (Marsiglia, Kulis, MartinezRodriguez,
Becerra, & Castillo, 2007).
Roles and Implications for Social Work Social
workers provide essential preventive services to diverse
communities at the micro and macro levels. They are
often responsible for developing as well as
\
implementing prevention programs in schools and
other community settings and evaluating their effec-
tiveness. A prevention program cannot be developed or
implemented without funding, and to secure funding from
federal, state, county, and municipal levels, prevention
programs must often be selected from an evidence-based
list such as SAMHSA's National Registry of
Evidence-based Programs and Practices. Social workers
must therefore utilize existing research or conduct new
research in order to secure funding for programs that would
best meet the needs of the communities or individuals they
work with. The connection that social workers have to the
community allows for research on substance abuse and
prevention to be more culturally competent, relevant, and
applicable to the communities they work with (Kulis et al.,
2005). As a result, social workers are valued members of
the community and are able to develop collaborations with
educators, representatives 'of community-based
organizations, and community members at large in order to
provide not only alcohol and other drug prevention
programs, but also the most effective and efficient services
possible to address a variety of social and behavioral health
issues.
In clinical settings social workers have unique op-
portunities to conduct alcohol and drug prevention by
including key screening questions with all clients re-
gardless of their age or other demographics. As a result of
the high comorbidity of substance abuse with other
behavioral and mental health conditions, social workers
playa significant role in early detection and prevention
regardless of the presenting problem. Including a few
screening items in the intake form can assist practitioners
with this integration (Brown, Leonard, Saunders, &
Papasouliotis, 2001) by triggering a conversation and
making an appropriate referral when necessary. Social
workers are uniquely positioned to intervene throughout
the prevention-to-treatment continuum as they practice in
different fields and use
different practice modalities. Not only do social workers
provide services in the community, but they are mandated
by the NASW Code of Ethics to promote social justice and
advocate for social change on behalf of clients (NASW,
2000). As a result, social workers also play key roles in
advocating for social policies and developing substance
'use and prevention programs that are evidence-based and
meet the needs of diverse populations (NASW, 2000). The
combination of research, clinical, ,community
organization, and social advocacy skills allow social work
professionals to be effective at working with individuals,
groups, or communities, to promote positive outcomes.
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-FLAVIO F. MARSIGLIA AND DAVID BECERRA
148 ALIENS
ALIENS. See Displaced People; Immigration Policy;
Immigrants and Refugees; Migrant Workers.
ALZHEIMER'S DISEASE AND OTHER
DEMENTIAS
ABSTRACT: Dementia is not a disease, but a group of
symptoms so severe that they inhibit normal
functioning. Alzheimer's disease is the most common
type of dementia in older persons impacting not only
the person with the illness but the entire family.
Obtaining an accurate diagnosis is essential" in order
to assure appropriate and timely care and to exclude
reversible causes of dementia. Social workers care
play key roles throughout the course of the illness as
educators, therapists, sup porter and advocates for
improved policies and services.
KEY WORDS: dementia; Alzheimer's disease; cognitive
impairment
Background
Dementia is not a disease; it refers to a loss of mental
functions in two or more areas (such as language, mem-
ory, visual and special abilities, and judgment) to the
extent that the person's daily life is affected. Although
some slowing in cognitive functions" and memory loss
often accompanies aging, such changes are usually very
mild, and, in contrast to the changes associated with
dementia, they do not interfere with daily functioning.
Dementia is also associated with mood, behavior, and
personality changes (Wicklund & Weintraub, 2005).
Dementia is not a necessary part of aging, but its
prevalence increases with age. Alzheimer's disease, which
affects more than 4.5 million persons in the United States ,
is the most common source of dementia. The risk of
developing Alzheimer's disease doubles every 5 years
after 65 years, affecting ",2% of the population aged
65-74, 19% of those aged 75-84, and 42% of those aged
85 and older (Alzheimer's Association, 2007).
Accordingly, nearly 13% of people older than 65 years
have Alzheimer's disease. By the year 2050, between 11
and 16 million persons are expected to be diagnosed with
the illness.
Causes and Types of Dementia
Many conditions-such as depression, delirium, alcohol or
drug use, malnutrition, vitamin use, hormone imbalance,
and infections, as well as medications can cause
dementia-like symptoms, or reversible demen tia. In such
cases, once the cause is discovered and
treated, the symptoms may disappear. Other causes of
reversible dementia include metabolic abnormalities that
affect the thyroid, hypoglycemia, pernicious anemia,
nutritional deficiencies (including dehydration), emotional
problems, and infections such as meningitis and
encephalitis.
Dementia is considered irreversible when there is no
cure for the symptoms. Consequently, it is critical that any
diagnosis of dementia exclude conditions that may be
treatable. or even cured. Alzheimer's disease is the leading
cause of dementia among older persons but there are also
non-Alzheimer's dementi as caused by neurodegenerative
diseases and vascular disease. These include Lewy Body
disease, primary progressive aphasia, frontotemporal
degeneration, Pick's disease, Parkinson's disease,
Huntington's disease, AIDS, and vascular dementia
(Mesulam, 2000).
Alzheimer's Disease
The exact cause of Alzheimer' disease (AD), the most
common form of dementia in older persons, is still not
known, although the greatest risk factors are increasing age
and a family history of the illness. Other possible risk
factors are high cholesterol, hypertension, diabetes, and
low levels of the vitamin folate. Although there are no clear
preventive measures against AD, research is on " to
examine the roles that mental, physical, and social activities
may playas protectors (National Institute of Aging [NIAl,
2006).
Memory loss is the most notable symptom, but AD
also affects language, object recognition, and functioning.
Common behavioral symptoms include psychosis,
depression, agitation, and wandering. Unfortunately, early
symptoms of the disease may be ignored by family
members, who perceive them as a normal part of the aging
process. Such delayed responses mean that interventions
and medications, such as cholinesterase inhibitors, that
prevent the breakdown of acetylcholine (a chemical in the
brain that affects memory and can help to improve
cognition), and Memantine, a drug that regulates
glutamate (a brain chemical that affects learning and
memory), are often not used. Delays in treatment also
prevent the person with the illness from being actively
involved in care planning (Kuhn, 2007).
Alzheimer's disease tends to progress through a series
of stages, although there is also great heterogeneity among
persons with the illness, meaning that the progression
itself is not uniform (Cottrell, 2007). In the earliest stage
people have difficulty remembering new information.
As the disease progresses, symptoms become so" se-
vere that they prohibit normal functioning, and at the late
stage, the person is unable to recognize familiar

people or places, forgets how to do simple tasks, and has
difficulty speaking, reading, and writing. Often there are
pronounced personality changes. Eventually, total care
for the person is required.
Diagnosis
Diagnosing the cause of dementia requires a compre-
hensive physical examination, including laboratory
tests, an imaging test, and a thorough medical history.
Such examinations can be carried out by an Alzheimer's
Disease Center funded by the NIA. There are 31 of these
centers in the United States and each specializes in
clinical services for persons with dementia, including
assessment, treatment, and research (U.S. National
Institutes of Health, 2007). Physicians, particularly
geriatricians, may also screen for dementia. A cognitive
screening tool such as the Mini-Mental State
Examination can help to determine the level of impair-
ment, although more extensive testing is required for a
more accurate diagnosis. Computerized tomography or
a magnetic resonance imaging scan is often a part of an
initial evaluation. Guidelines for diagnosing dementia
are available in the report of the NINCDS-ADRDA
workgroup (McKhann et al., 1984); the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition
(American Psychiatric Association, 1994); and the
Presidential Task Force on the Assessment of Age-
Consistent Memory Decline and Dementia (American
Psychological Association, 1998). The Quality Stan-
dards Subcommiteeof the Academy of Neurology has
also written on the best evidence for assessing and
managing dementia (Doody et al., 2001).
Dementia and the Family
There is no greater impact of the illness than that on the
informal caregiver, the family member who con tinues
to provide the bulk of care throughout the course of the
illness. These caregivers have been termed "The Hidden
Victims" (Zarit, Orr, & Zarit, 1985). They spend more
time per week providing care than do other professional
caregivers, while also reporting greater strain and
impacts on employment, mental and physical health,
and leisure time (Alzheimer's Association and National
Alliance for Caregiving, 2004).
Dementia can strain many family relationships,
especially where there are insufficient familial and
financial resources to assist with the care needed. The
primary caregiver may feel overwhelmed and resentful
toward siblings who may not be as involved in the
caregiving process. Marital relationships can be stressed
as caregivers become exhausted, young children may
feel neglected, and caregivers may be increasingly
guilty
ALZHEIMER'S DISEASE AND OrnER
DEMENTIAS 149
that they are not meeting other family needs. More over,
families may disagree about the type of care required
and may have differing attitudes toward services and
institutionalization.
Culture and Dementia
Culture can be a major factor shaping persons' re sponses
to dementia and consequently the course of care. Ethnic
beliefs and values can influence the way in which
symptoms are perceived and thus acted upon. Whether
memory loss and behavior change among older persons
are considered as normal and expected, the result of evil
spirits, or stress can strongly influence the willingness to
seek treatment or services. Thus, families may perceive
erratic behavior in an older person as a normal part of
aging and be reluctant or even resistant to seek care.
Caregiver roles may be strongly influenced by
traditional norms and values that dictate their patterns of
involvement and use oHormal services. In fact, in some
cultures the term "caregiver" does not exist, as providing
assistance to older persons is simply a norma tive duty.
sary to breach the client's
mmitment hearing (Massachusetts General Laws
2007). This is generally Social work
Social work interventions can playa major role at the
micro and macro levels. They can assist both the in-
dividual with the illness and the family to adapt to the
diagnosis and deal with reactions such as anger, loss,
and grief. Throughout the course of the illness social
workers can play important roles as educators, thera-
pists, and brokers who assure that persons are linked
with needed services. Social workers must be cognizant
of the influence that culture may have on any individual
while also guarding against assumptions and stereotypes
that undermine the heterogeneity also existing among
ethnic populations.
Social workers can help to ensure that individuals
receive accurate diagnoses and that they have essential
information and resources to support them throughout
the course of the illness. They can act as brokers and
links to services such as case management, respite care
that temporarily relieves the caregiver, day care, and
support groups. As therapists they can be critical in
helping persons adjust to and deal with their many
conflicting feelings and concerns, identify areas of
stress, facilitate the expression of grief and expecta tions,
and develop future plans. Within institutions, social
workers can help to ensure that staff is educated about
dementia and responsive to the special needs of this
population (Johnson & Hartle, 2007).
150 ALZHEIMER'S DISEASE AND OrnER DEMENTIAS
As advocates and at the system, community and policy
levels, social workers have major roles in translating cases
into cause as they work toward the development of policies
and programs that address the myriad needs of those with
dementia and their families. This must include advocating for
more funding for research and services that can assist in
alleviating the burdens associated with the illness.
Alzheimer's disease and other dementias are major
concerns and challenges for older persons and their families,
and indeed, for all of us. Dementia has become a major public
health problem as the numbers it affects continue to soar.
Similar to other public health issues, it requires a plurality of
interventions and professionals to provide care and assistance
to the person with the ill-
, Neurology, 34, 939-944.
ness and the family. Social workers, with their knowl-
edge and skills and with their focus on the individual within
the environment, can play key roles in providing this care. As
educators, counselors, advocates, and researchers, they can
help to assure that needs are met effectively and appropriately.
At ~ same time, it is essential that they always recogniz that
the person is not the disease but is a person who h a specific
illness. This recognition and understanding is critical as a
foundation for empathic and sensitive care. Those confronting
dementia and their families require knowledgeable and
sensitive practitioners who will effectively guide them and
assist them through its many phases. Consequently, dementia,
as it places immense demands on individuals, families, and
societies, may also be perceived as a major challenge for the
caring profession of social work.
REFERENCES
Alzheimer's Association. (2007). Every 72 seconds someone in
America develops Alz}Jeimer's. Alz}Jeimer's Disease Facts and
Figures. Chicago: Author.
Alzheimer's Association and National Alliance for Caregiv ing.
(2004). Families care: Alz}Jeimer's caregivingin the United States,
Chicago: Alzheimer's Association.
American Psychiatric Association. (1994). Diagnostic and sta-
tistical manual of mental disorders (4th ed.). Washington, DC:
Author.
American Psychological Association, Presidential Task Force
on the Assessment of Age-Consistent Memory Decline and
Dementia. (1998). Guidelines for the evaluation of dementia and
age-related cognitive decline. Washington, DC: American
Psychological Association. http://www.apa.org/practice/de
mentia.html.
Cottrell, V. (2007). Assessment of individuals with dementia .
In C. B. Cox (Ed.), Dementia and social work practice:
Research and interventions (pp. 45-68). New York: Springer.
Doody, R., Stevens, J., Beck, c., Dubinsky, R., Kaye, J.,
Gwyther, L., et al. (2001). Practice parameter: Management
of dementia (an evidence based review). Report of the
Quality Standards Subcommittee of the American Acad-
emy of Neurology. Neurology 56, 1154-1166.
Johnson, J., & Hartle, M. (2007). Social work and dementia
care within adult day services. In C. B. Cox (Ed.), Dementia
and social 'work practice: Research and interventions (pp.
305-320). New York: Springer.
Kuhn, D. (2007). Helping families face the early stages of
dementia. In C. B. Cox (Ed.), Dementia and social work
practice: Research and interventions (pp. 111-128). New York:
Springer.
McKhann, G., Drachman, D., Folstein, M., Katzman, R.,
Price, D., & Stadlan, E. (1984). Clinical diagnosis of
Alzheimer's disease: Report of the NINCDS- ADRDA
Work Group under the auspices of Department of Health
and Human Services Task Force on Alzheimer's Disease.
M.-M. (2000). Aging, Alzheimer's disease,
dementia: Clinical and neurobiological perspectives; In
M.-M. Mesulam (Ed.), Principles of cognitive and behavioral
neurology (pp. 439-522). New York: Oxford University
Press.
onal Institute on Aging. (2006). Dramatic changes in U.S.
aging highlighted in new census. NIH media report.
Washington, DC: Author.
Wicklund, A. K., & Weintraub, S. (2005). Neuropsycho logical
features of common dementia syndromes. Turkish Journal of
Neurology, 11,56&-588.
Zarit, S., Orr, N., & Zarit, J. (1985). The hidden victimSbf
Alzheimer's disease. New York: NYU Press.
SUGGESTED LINKS
Alzheimer's Disease Education and Referral (ADEAR) Center.
http://www.alzheimers.org/adcdir.htm
Mather Lifeways - Powerful Tools for Caregivers.
http://www.matherlifeways.com/re--P<Jwerfulto61s .asp The
caregiver guide. National Institute on Aging. http://www .
nia. nih .gov/ Alzheimers/Publications/caregiver guide.htm
Caregiver resources from the Alzheimer's Association.
http://www .alz.org/Resourcesrr opicIndex/Caregivers .asp
Alzheimer's caregivers: How to cope? Mayo Clinic.
http://www.mayoclinic.com/health/alz}Jeimers-caregiver/
AZ00038
Alzheimer's Caregiver Support Online.
http://alzonline . net/
National Alzheimer's Association.
www.alz.org
-CAROLE B. COX
AMERICAN INDIANS. See Native Americans:
Overview.
ANOREXIA. See Eating Disorders; Hunger, Nutri.tion,
and Food Programs.

ARAB AMERICANS
ABSTRACT: This entry defines the term Arab Amencan,
followed by a discussion of the two waves of immigration:
before 1924 and post-1965. A demographic overview is
presented next, drawing from data available through
analysis of the ancestry question on the long form of the
United States ce~s. Previously invisible in the scholarly
and practic literatures, key concerns related to stereotypes
ema ting through recent world events, assumptions about
gender relations, and struggles concerning family relations
are highlighted. Finally, practice implications are
considered, with an emphasis on cultural sensitivity and
social justice.
The term Arab Amer,ican is relatively new, signifying a
pan-ethnic term meant to capture a diverse group of people
who differ with respect to national origins, religion, and
historical experiences of migration to the United States.
Arab American refers to those individuals whose ancestors
arrived from Arab-speaking countries, including 22 nations
in North Africa and West Asia. Religious faiths include
both Christian and Muslim; Lebanon is the number one
country of origin for Arab immigrants to the United States,
followed by Syria and Egypt. Defined objectively, any
individual with ancestral ties to an Arabic-speaking
country may be considered an Arab American. This
characterization, however, rests upon a language-based
definition, obscuring the cultural and structural variations
that differentiate those who fall within this pan-ethnic
category (Ajrouch& Jamal, 2007).
KEY WORDS: Arab; ethnicity; gender; Muslim; stereotype
Immigration History
Immigration from Arab-speaking countries occurred in
two major waves. The first wave began during the late
1800s, and ended in 1924 with the passage of the National
Origins Act. The majority were of the Christian faith,
originating from the Levant, or modem-day Syria,
Lebanon, Jordan, Israel, and Palestine, and emigrated
primarily to seek economic opportunities. Those arriving
in the first wave were originally farmers who in the United
States became peddlers. The later wave began in 1965, had
a majority who were from the Muslim faith, and arrived
from all over the Arab world. The largest group was
displaced Palestinians, but also included those from Egypt,
Iraq, Yemen, North Africa, as well as Lebanon and Syria.
The circumstances surrounding their emigration differed
substantially from the first wave. Political turmoil and war
marked their countries of origin, and many arrived in
America with
ARAB AMERICANS
151
an Arab political consciousness unknown to earlier
immigrants. The second wave was composed of two
primary groups: (a) those with more education-many either
held college degrees, or came to the United States in order
to earn them; and (b) refugees fleeing conflict in the region.
Demographics
Based on the 2000 Census, at least 3.5 million Americans
are of Arab descent. There are 11 states where one finds
the majority of Arab Americans, including California,
Michigan, New York, Massachusetts, Illinois, Pennsylva-
nia, Ohio, Texas, New Jersey, Florida, and Virginia.
California boasts the largest number of Arab Americans in
the country, but southeastern Michigan is home to the
biggest, most visible concentration. Immigration to
Michigan from an Arab-speaking country grew by 65%
between 1990 and 2000.
Approximately two-thirds of Arab Americans report
belonging to the Christian faith, and one-fourth to Islam.
Americans with Arab ancestry are more likely to be born in
the United States than to bean immigrant, and the majority
of immigrants from Arab-speaking countries are
naturalized u.S. citizens (Brittingham & de la Cruz, 2005).
Compared to the average American, those of Arab descent
are more .likely to have a postgraduate degree, more likely
to work in management or professional or the service
sector, and on average report a higher mean annual income.
Some new arrivals struggle economically, however,
resulting in a poverty rate close to 10%
(http://www.aaiusa.org/arab-americans/22/ demographics)
..
Practice Implications
Stereotypes. Some refer to Arab Americans as an invis-
ible minority in the United States (Ajrouch, 2005;
Cainkar, 2003). Research that empirically documents
lives of individuals with ancestry from an
Arab-speaking country provides important insights into
the pragmatics of their attitudes and experiences.
Perhaps most relevant for social work practice is that
Arab Americans are not a homogenous ethnic group, but
instead are quite diverse with varying needs depending
on characteristics such as age, education level, and
geographic location.
Arab Americans now, more than ever, face critical
judgments and stigmatized identities because of recent
world events. Arab Americans are officially classified
non-Hispanic Whites, yet attention is increasingly directed
toward them because of the events and aftermath of
September 11, 2001. Stereotyped perceptions of Arab
Americans become the primary means by which most of
the United States understands Americans of Arab origin
(Cainkar, 2003).
152 ARAB AMERICANS
(
Gender relations represent an area. that social work
must approach with a keen sense of cultural sensitivity.
Assumptions that Arab American women/girls are uni-
laterally oppressed and devalued because of culture can
pose an obstacle to effective service delivery. Patriarc hy
has historically characterized relations between men and
women in the United States regardless of ethnicity, a
critical detail that provides a context for understand ing
Arab American women's experiences and situa tions.
Another delicate issue among Mus lim Arab Americans
concerns the veil or hijab. Some women wear it while
others do not. It is not mandated, but instead derives from
interpretations of religious teach ing. Some young Muslim
women in the United States choose to wear hijab as a
symbol of their identity.
Family relations constitute another area of impor tance.
Similar to other immigrant groups, relations between
parents and children may involve conflict because of
adaptation and acculturation processes. For instance, in a
study (Ajrouch, 1999) focusing on adolescent children of
immigrants and their parents, it was found that parents
increased restrictions on their daughters' behavior in the
need for medical facts with the psychotherapist's
daughters themselves expressed a desire for more
personal freedoms, but concurrently reported a sense of
security and belonging through parental and communal
restrictions.
An emerging area of importance concerns the situa tion
of older Arab Americans. In particular, many of the oldest
generation left their homelands before hav ing to
experience caring for their own parents, and so norms of
elder care have been forged more on the basis of ideals
than learned experience. Research (Ajrouch, 2005 )
suggests that a preference for independence coexists with
high value placed on children's help, yet a simultaneous
wish not to burden their children. Social workers should
consider that Arab Americans struggle to address the
increasing challenges faced by the demo graphic reality of
longer life expectancies, smaller families, and women
who increasingly are employed outside the home. Caring
for older adults is often shouldered alone, without the
benefit of community resources, support, or co- ethnic
validation of the challenges associated with care giving
situations.
Cultural ideals within this ethnic group are impor tant
to recognize and carefully evaluate. For instance, family is
the traditional source of security for Arab Americans, an d
so should be viewed as a strength and resource in times of
need, yet must not be assumed to serve as the sole source
of support. Similar to other groups in the United States,
families act in response to environmental and societal
challenges, and hence
may be vulnerable. Effective practice and policy will
recognize both the strengths and vulnerabilities within
Arab American families. Social workers at various levels
ought to recognize that a challenge for Arab Americans is
to find a way to both ask for and accept formal support
without implying or acknowledging any disappointment
or neglect on the part of the family.
As in working with clients from any given ethnic
group, social workers should evaluate their own percep-
tions and beliefs about Arab Americans, determine the
source of those attitudes or beliefs, and then evaluate each
case on its own terms. Arab Americans are quite diverse,
and issues. of concern may vary by national origin,
religion, and immigrant status. Owing to the wide range of
diversity and identity parameters, social workers should
not necessarily assume that they under stand the
predicament an Arab American client faces. The clients
and issues in need of attention may depend upon setting.
For example, a social worker employed by a .human
services agency may be more likely to work with a recent
immigrant or a refugee with relatively more pressing
economic and social . services needs. When working with
Arab Americans, social workers must consider the o verall
context or family situations of
. clients to address such challenges with cultural sensi-
tivity, empathy, and social justice.
REFERENCES
Ajrouch, K. J., & Jamal, A. (2007). Assimilating to a white
identity: The case of Arab Americans. International Migration
Review 4l( 4), 860--879.
Ajrouch, K. J. 2007. Resources and well-being among Arab-
American elders. Journal of Cross Cultural Gerontology,
22(2),167-182.
Ajrouch, K. J. (2005). Arab-American immigrant elders' views
about social support. Ageing and Society, 25(5),655-673.
Ajrouch, K. J. (1999). Family and ethnic identity in an Arab
American community. In M. Suleiman (Ed.), Arabs in
America: Building a new future (pp. 129-139). Philadelphia:
Temple University Press.
Brittingham, A., & de la Cruz, G. P. (2005). We the people of Arab
ancestry in the United States. Current population reports.
Washington, DC: Department of Commerce. Retrieved May
18, 2006, from http://www.census.gov.
Cainkar, L. (2003). No longer invisible: Arab and Muslim exclusion
after September 11. Middle East Report. Retrieved August 31,
2006, from http://www.merip.org/mer/mer224/ 224_
cainkar.html
FURTHER READING
Arab American Demographics. Washington, DC: Arab American
Institute. Retrieved May 30, 2007, from http://
www.aaiusa.org/arab-americans/22/demographics
Nassar-McMillan, S. C. (2003, January). Counseling Arab
Americans: Counselors' call for advocacy and social justice.

Counseling and Human Development. Retrieved May 30,
2007, from http://findanicles.com/p/articles/mi_qa3934/
is_20OJOl/aCn9170054.
Read, J. G. (2004). Culture, class, and work among Arab-
American women. New York: LFB Scholarly Publishing LLC.
ETIINGS: A J. AJROUCH
ASIAN AMERICANS. [This entry contains seven
subentries: Overview; Practice Interventions; Chinese;
Japanese, Koreans; South Asians; Southeast Asians.]
OVERVIEW
\
Social Wor The term Asian Americans encompasses
the immigrants coming from all parts of Asia. This
heterogeneous cluster of Asian Americans, while shar-
ing some common characteristics, also has unique fea-
tures among its different ethnic groups. This entry
presents an overview of this cluster, including key data
relating to individual groups. In addition to specific
practice guidelines for effective social work inter-
ventions, . essential knowledge and skills to work with
a variety of Asian groups are discussed throughout the
text.
KEY WORDS: Asian Americans; Chinese Americans;
Filipino Americans; Indo-Americans; Japanese
Americans; Korean Americans; So uth Asian
Americans; South East Asian Americans; new
immigrants
Introduction
The United States of America, the land of immigrants,
is called home by people coming from virtually every
continent, ethnic and racial background, and religious
and linguistic group. The first to arrive were people
from western and northerh Europe -, Contrary to the
common belief that Asians came only in thetnid-19th
century, there is evidence that Chirtese sailors came to
Hawaii in 1778. Many of them married Hawaiian
women and settled in the islands. A few from India also
came during the 1790s, adopted English names,
married African Americans and settled on the east coast
(Jensen, 1988). A group of Filipinos came to Louisiana
in the late 18th century by jumping the Spanish galleons
in the Gulf of Mexico and settled in the bayous. These
early settlers established the fishing villages of St. Malo
and Manila, south of New Orleans.
The large scale Asian migration from China and
Japan began in the mid 1800s, and most of the
immigrants worked as laborers on the transcontinental
ASIAN AMERICANS: OvERVIEW 153
railroad. Also, Chinese, Japanese and Koreans were
brought as contract laborers, mostly to work in the
Hawaiian sugarcane plantations. In the late 19th cen-
tury, a surge of Asian immigrants came to the western
states. The first to arrive were from China, followed by
migrants from Japan, the Philippines, Korea and India.
These individuals were primarily farmers and arrived
alone in the United States, leaving their wives and
families at home. As the number of Asian migrants
continued to increase, the local citizens of European
backgrounds became worried that their communities
would be "polluted" by these new arrivals who had
distinctly different ethnic and racial features. Their
religious practices and food habits were unlike anything
they were accustomed to. So were their customs, tradi-
tions, and spoken languages. The threatened White
settlers referred to the Asian arrivals as "yellow peril."
They also responded by passing punitive and restrictive
legislations at local and national levels, denying the
Asians access to community resources and freedom of
movement, requiring them to pay exorbitant taxes, and
prohibiting them from owning land. All these restric-
tions culminated in the enactment of the Chinese
Exclusion Act of 1882, which restricted Asians enter ing
the United States for ten years. This discrimination and
prejudicial treatment continued til11965, when an
Immigration and Naturalization law was enacted, abol-
ishing the quota of immigrants admitted every year. The
abolishment of the quota and replacing it with a
preferential system of employment skills and provisions
for family reunification dramatically changed the Asian
presence in this country. At the present time, in 2007,
the United States Congress is debating whether the
family reunification provisions need to be changed in
the new immigration bill, Needless to say, because of
close family ties and collectivistic orientation, Asian
groups are very concerned about the possibility of this
provision's elimination.
Prior to the 1960s, Asians in the United States were
identified. simply by their original nationality, as
Chinese, Japanese, Koreans and so on. In the 1960s, the
activists advocated for American identity and the
hyphenated term Asian-American. Now this Pan Asian
group identity is officially accepted. This term
encompasses the immigrants coming from all the coun-
tries, whether they are in East,' South East or South
Asia, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippines, Thailand
and Vietnam (U.S. Bureau of Census, 2000). Unfortu-
nately in reality the South Asians (people from
Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan,
and Sri Lanka) are often excluded from the Asian
American cluster. Academics and scholars, community
154 ASIAN AMERICANS: OvERVIEW
6.
groups, media and society at large, tend to refer to Asian
Americans as those coming from East Asian countries,
with the noticeable absence of people from South Asia.
However, it needs to be noted that South Asian groups also
place themselves apart from other Asian Ameri cans,
because they often find themselves unnoticed, unheard,
and marginalized in the larger context of Asian Americans
(Shankar & Srikanth, 1998).
Demographic and Other Characteristics
POPULATION At the beginning of the 21st century,
Asian Americans are one of the fastest growing immi-
grant groups in the United States. Since 1965, there has
been a dramatic increase in their numbers. According to
the 1990 US. census, the (\sian American population was
a little under seven million (U.S. Bureau of Census,
n in most states. Many problems arise in the application
on of the
number of U.S. residents who identified themselves as
Asian, or Asian in combination with one or more races,
totaled1404 million (U.S. Census Press Release, 2007).
In 1978, a congressional resolution established the
Asian Pacific American Heritage Week. The first ten days
of May were chosen to recognize two major dates in the
Asian Pacific history: the arrival of the first japanese
immigrants (May 7, 1843), and the contributions of
Chinese workers in the completion of the transcontinental
railroad (May 10, 1869).
In 1997 the Asian Pacific was separated into two
categories: the "Asian" and "Native Hawaiian and Other
Pacific Islander." As shown in Figure 1, according to the
latest statistics available, Chinese Americans continue to
be the largest Asian American group, totaling 3.3
3.5
3
2.5
2
1.5
1
0.5
o ~t::> roO .~O
~ .,,0 .N
r:O0~' .,*'<
~C>
<tS'
FIGURE 1 Ethnic Group Population, 2005 (in millions).
million, followed by Filipinos (2.8 million), Indo-
Americans (2.5 million), Vietnamese (1.5 million), Korean
Americans (104 million), and japanese Americans (1.2
million), with other Asian groups accounting for 1.6
million (US. Census Press Release, 2007).
The three states of Califomia, New York, and Hawaii
account for 51 % of the Asian American population. Other
states among the top ten are Texas, Illinois, New jersey,
Washington, Florida, Virginia and Massachusetts. Asians
tend to concentrate in urban and coastal areas.
EDUCA TION The percentage of single-race Asians 25
years and older, with at least a bachelor's degree or a
higher level of education.was reported as 49%, com pared
to 27% for the same age group for the total U.S.
population. The number of Asian Americans who have a
graduate or professional degree is (20%) double that of the
national percentage (U.S. Census Press Release, 2007 ).
The two main reasons for the higher educational levels
among Asian Americans are: first, Asians mostly migrate
to the United States voluntarily and they tend to bring
education and middle class backgrounds from their
countries of origins; and second, the Immigration Act of
1965 abolished national quotas and introduced
employment-based preference as a category, thereby
permitting individuals who possess skills that are in
p. 171-195) New York: Russell Sage.
L TH AND MENTAL HEALTH It is often assumed
that due to their traditional diets and culture, the health of
Asian Americans is good; on the contrary, diseases such as
diabetes, and breast, stomach, and liver cancers occur at an
even higher rate than for nonHispanic White Americans.

The three major causes of death for this racial cluster
are heart disease, cancer, and stroke. Death due to stroke is
higher for this population than non-Hispanic White
American groups (Kagawa-Singer & Ong, 2005). It is
important to note that in this diverse cluster certain
illnesses predominate among some subgroups. For ex-
ample, South Asians have an unusually high rate of
coronary artery disease, diabetes, and high blood pressure
(South Asian Public Health Association, 2002); parasitic
infections are particularly widespread among Southeast
Asian refugees, and Vietnamese women's cervical cancer
rate is unusually high (National Library of Medicine,
2006). The Asian Americans have lower tHV/AIDS rates
than their minority counterparts. Although the number of
individuals infected with this virus is low, it has been tising
steadily from 266 reported cases in 2001 to 429 in 2005
(CDC, 2006). Asians in the United States have the highest
TB rates among all racial or ethnic groups (25.5 per
100,000 compared to nonHispanic Whites with 1.3 per
100,000). They accounted for 23 percent of all new TB
cases in 2005 (American Lung Association, 2006).
Prevalence of alcohol depen dency is low among this
group; however the emerging dat~ give a different picture.
Asian American women seeking assistance from women's
shelters frequently share the correlation between the
perpetrators' drinking and the occurrence of the abuse. Of
course due to cultural taboos of speaking against their
spouses, Asian American women are. reluctant to disclose
the reasons for their abuse. According to the South Asian
Women's Network, there are more than 30 shelters located
within 18 states and this number is rapidly increasing. The
main reason for this increase in the ethnic specific shelters
is that they provide safe and culturally sensitive
environments (SA WNET, 2007).
As a significant number of Asian Americans were born
outside the United States, their attitudes toward mental
health and seeking services for these ailments are
influenced by various factors such as religious beliefs,
cultural heritage, degree of acculturation, socioeconomic
status, educational achievements, pat terns and history of
immigration, including traumatic experiences; and family
dynamics (Lu et a1., 2002). A national study by Abe-Kim
and colleagues (2007) iden tifies barriers negatively
affecting the use of mental health services as stigma and
loss of face, culturally unresponsive services (lack of
language and ethnic match, and poor cross-cultural
understanding), and limited access to services, including
insurance coverage. This first major study based on a
national sample reports tha't Asian Americans appear to
have lower rates of mental health-related service use.
Compared with the general population, only 8.6% of Asian
Americans
ASIAN AMERICANS: OVERVIEW 155
sought help from any service versus 17.9% of the general
population. This difference persisted even though 34.1 %
of all Asian Americans demonstrated the need for services
compared to 41.1 % of all individuals who had a DSM~IV
diagnosis in a l Zvmonth period in the sample (Abe-Kim
etal., 2007).
INCOME, POVERTY, AND HEALTH INSURANCE Median
household income for single-race Asians in 2005 was
reported as $61,094, the highest among all race groups.
Poverty rate for the same year was accounted as 11.1 %
and 17.9% had no health insurance. In the prior reporting
year (2004) the rates for poverty and having no health
insurance were reported as 9.8% and 16.5% respectively
(U.S. Census Press Release, 2007).
SMALL BUSINESSES More Asian Americans own small
businesses than any other major racial or ethnic groups.
The reason for this is to avoid "labor market
discrimination" due to lack of fluency in English; edu-
cational or professional credentials from the home
country not being recognized; and employer
discrimination. Another reason for going into business
is the easy availability of ethnic support networks for
start-up capital and labor resources. A third reason is
that the dominant Euro- American business owners and
distributors do not want to deal with Afri can American
and Hispanic working- class customers because they
fear for their personal safety 'as well as losing money,
and use Asian immigrants, especially Korean
Americans, as "middlemen" to deal with these
minorities.
In 2002 the number of Asian American businesses
numbered 1.1 million, up 24% from 1997 and an esti-
mated 319,468 Asian-owned businesses had receipts
totalling more than $291 billion. Research data illustrate
how certain Asian groups dominate specific industries.
For example, three-quarters of all Asian owned hotels and
motels belong to Indo-Americans migrating from the
western Indian state of Gujarat, two-thirds of all fishing
and hunting businesses are owned by Vietnamese and half
of all the apparel shops and beauty salons are owned by
Korean-Americans.
Unique Characteristics
INDIVIDUALISM-COLLECTIVISM The individualism-
collectivism theory links culture and social behavior.
"Individualism" implies an ability to depend on oneself,
assuming responsibility for actions and living styles, and
not succumbing to social pressure to conform. "Collec-
tivism" implies a greater emphasis on the views, needs,
. and goals of the group; that is, social norms and duty are
defined by the group, and there are higher expectations to
integrate and cooperate with members of the group
156 ASIAN AMERICANS: OVERVIEW

(Balgopal, 2000). The United States has an individua-
listic culture, with an emphasis on self-reliance, com-
petition, and independence (Triandis, Botempo, &
Villareal, 1988). The identity of the Asian Americans is
enmeshed with the identity of their significant groups
such as family and ethnicity, whereas the identity of the
. Euro-Americans is explicitly reflected in their
individual person (Segal, 2002).
. and practicing cultural customs. The majority of Asian
F AMIL y Asian families are generally patriarchal, and in
traditional families age, gender, and generational status
determine the roles that members are expected to play.
Usually, the father is the head of the family, and his
authority is unquestioned; he is the main disciplinarian
and is less approachable and more
, distant; the
mother is the nurturer and caretaker (Mikler, 1993;
Sue, 1981). The main duty of the son is to be a good
son; the son's obligations as a husband and father be-
come secondary. Children are expected to take care of
their parents in old age. They usually live with their
parents until their marriage, and in many cases, con-
tinue to live with their parents even after they are
married (Mikler, 1993).
Because the family members' roles are explicitly
defined, there is little co~flict in the family. Family
harmony is. stressed and family members are expected
to control their emotions to preserve it (Sue & Wagner,
1973). Problems are kept within the family, and sharing
negative information outside the home is discouraged
to avoid disgrace to the family (Lum, 1986).
The strong emphasis on obligations to the family
and inculcation of guilt and shame act as social controls
(Sue, 1981).
In Asian American families, the extended family
structure is common, and often two or more generations
live together. After the arrival of new Asian immigrants
sponsored by their immediate family members
(parents, siblings, and other relatives) they are readily
accepted and expected to stay in the family unit.
Parents expect their adult children to live with them at
least till they are married. The inter- generational living
arrangements provide many supportive services
including child-care, assistance with family finance,
teaching
American children live in two-parent families and this
is attributed as the reason for better educational
performance, lower behavioral problems, and less
likelihood of experiencing poverty (Sakamoto & Xie,
2006).
It is important to note that a handicap typically
faced by foreign-born and foreign-educated Asians is
that the economic value of their educational credentials
is often discounted (Sakamoto & Xie, 2006). Korean
Americans particularly encounter this problem and it is
one of the reasons for their opening small business
establishments.
Comparative data in Table 1 illustrate some inter-
esting family characteristics of present-day American
families. The percentage of two-parent families is
higher among Asian Americans than among the Euro-
Americans and African Americans. The ethnic varia-
tions among the Asian groups are striking; for example,
80% of Indian families have two parents, where as only
65% of the Japanese live in intact families. The tradi-
tion of parents living with married children and adult
single children living in the same household seems
prevalent among Asian Americans as indicated by. the
high percentages of multigenerational families. The
larger size of the Asian families is not necessarily due
to more children but because of stable marriages and
multigenerational membership. Regarding family in-
come, results show that both mean ana median.incomes
for Asian Americans are higher than Euro-Americans

TABLE 1
Family Characteristics, 2000
INCOME-TO- MEDIAN FAMILY MEAN FAMILY MEAN % MULTI- %Two ETHNICITY
NEEDS!tATIO INCOME ($1,000) INCOME ($1,000) FAMILY GENERATION PARENT
SIZE FAMILIES FAMILIES
3.3 55 70 3.5 5 67 Euro-Americans
2.4 35 45 3.9 14 40 African Americans
3.2 61 77 4.2 15 73 All Asians
3.3 63 8.2 3.9 15 73 Chinese
3.7 74 91 3.2 5 65 Japanese
3.5 70 81 4,4 22 73 Filipino
3.1 53 71 3.7 10 74 Korean
3.5 70 94 4.0 14 80 Indian
2.8 52 6.5 4.7 16 72 Vietnamese
Adapted from Sakamoto & Xie, 2006.

and African Americans. But this is not necessarily a
direct indicator of economic well-being in terms of
income per person. The data in the last column of the
table indicate the mean income-to-needs ratio, which
refers to family income divided by the official poverty
income threshold that is based on the family size and
composition. A larger ratio indicates greater economic
well-being: that is, it has more income relative to its
basic needs (Sakamoto & Xie, 2006).
MARRIAGE AND CHILD REARING Asian American
parents generally attempt to restrictjheir children's
choice in mates. They expect the potential partners to
belong to their own ethnic groups, and insist on a
final say in the selection Pfocess. However,
increasingly, sons and daughters have greater control
over decisions about whom they will marry. The
traditional custom of arranged marriage is practiced
mainly among South Asian American (Bangladeshi,
Indian, Nepali, Pakistani, and Sri Lankan) families.
Dating is generally frowned upon in Asian families
as it might lead to sexual activities which are unaccep-
table before marriage. Thus, frequently, dating among
Asian American youngsters occurs in secret. Religious
difference is also a major reason for disapproval of
interracial dating. Achievements and success are highly
stressed and Asian parents are particular that their
children date or marry individuals who meet their
expectations. Grandparents playa significant role in
approving their grandchildren's choice of mate. Dating
and marriage are major issues of family conflict, espe-
cially among recent immigrants. About 75% of Asian
Americans are married within their own ethnic group.
Asian Americans who marry outside their ethnic group
usually are married to Euro-Americans. Asian Ameri-
cans are less likely to be divorced than the general
population. It is estimated that 5-6% are currently
separated or divorced compared to 10-12% of the U.S .
population (National Healthy Marriage Research
Center, 2005).
Children enjoy a privileged position in the Asian
families. When asked their reason for emigrating to the
United States, Asian parents answer without hesitation
it is so their children could get a good education and
later, better career opportunities. The parents would
work on two and even three jobs so that the children can
put all their energies into their studies. Even children
from working class Asian American families sel dom
hold part-time jobs while in school. There are high
expectations from the children to excel in their studies
and to acquire high-paying jobs. Frequently, grandpar-
ents and extended family members serve as nurturers
and role models, as well as providing child care.
ASIAN AMERICANS: OvERVIEW 157
he older generation is also instrumental in the pres-
ervation of the native language and cultural heritage
(Balgopal, 1995).
GROUP SPECIFIC KEY FEATURES As discussed earlier,
there are some common cultural characteristics
among most Asian Americans, but each of these eth-
nic groups has some specific features. The specific
features of the' five major Asian American groups are
examined here.
Chinese Americans: They were the first to arrive in
large numbers and continue to do so. Obligation to
the family and bringing honor to it, and respect to
elders are stressed. Strict discipline is maintained. In
Chinese American families boys receive preferential
treatment. They also' keep close. ties with China
Towns and their activities.
MLBR."http://www.hawThis group maintains a str ong
ethnic identity, especially after the internment
experience. Loyalty to family and institutions is
important. Filial piety, perseverance and modesty are
essential features of Japanese American families.
They have the highest rates of out marriages
(marrying someone who is not of their race, for
example, Euro-Americans) and divorces.
Filipino Americans: Cooperation and mutual support,
strong kinship and social networks are the important
characteristics found in Filipino families. Reciprocal
obligations and maintaining cordial relationships
with bilateral extended families are essential. Unlike
other Asian groups, in Filipino families husband and
wife practice an egalitarian relationship.
Korean Americans: This is a very homogenous
group; all speak only Korean and most new
immigrants have little proficiency in English. Korean
Americans are extremely religious and their family
activities are church centered. Due to language
difficulties, many Korean immigrants own small
business establishments such as gro cery, liquor, dry
cleaning, and beauty prod ucts stores, especially for
African American clients. Frequently these
businesses are located in African American
communities, where they are viewed as exploiters.
Indo-Amencsns: This group stands out from other
Asian American groups regarding race, religion, diet,
and marriage customs. Indo-Americans practice a num-
ber of different religions, including Hinduism, Islam,
Christianity, Sikhism, and jainism. Two major Indian
cultural features, Dharma (conformity to one's duty) and
Karma (persons' destiny determined by their fate and
actions), guide their behavior. Most of them prac~ tice
arranged marriages, a strict vegetarian diet, and ethnic
dress codes such as women wearing saris.
158 ASIAN AMERICANS: OVERVIEW
Religious Diversity
There is wide diversity in the religious backgrounds of
Asian Americans. The East and Southeast Asian cul tures
have been primarily influenced by the teachings and
philosophies of Confucianism, Taoism and Buddhism. In
addition, these societies have been practicing ancestor
worship and Shamanism. Among the Japanese, Shinto, or
devotion to deities of natural forces, is practiced. Koreans,
Filipinos, and Vietnamese were converted to Christianity
by missionaries and European colonizers. After migrating
to the United States, the majority of Koreans followed the
tradition of Presbyterianism introduced to them by
American missionaries. The primary religion of Korean
Americans is Christianity, though of different
denominations. Filipinos were converted to Catholicism by
the Spanish, but iri recent years many have joined
Protestant denominations. The Vietnamese were converted
to Catholicism by the French and the religion is practiced
by the majority of them. The Asian American Christian
community is strong and growing and their ethnic churches
serve as the primary institution of support for a wide range
of needs. The Korean American community has the most
number of churches per capita compared to any other
ethnic group in the country. Religious services in these
ethnic churches are conducted in the native languages.
Chinese immigrants from the Peoples Republic of China
were not able to practice any religion, but many of them,
coming from other Asian countries like Taiwan, Singapore
and Hong Kong, were Christians prior to their arrival in the
United States. At present there is a pronounced resurgence
of Christianity among these Asian groups. Asian
American. students on college campuses aggressively
follow and promote teachings from the Bible. Many
Japanese Americans have a Buddhist background, but tend
to attend an all-Japanese American Christian church
(Kitano, 1969). Buddhists are tolerant of other faiths and
do not have a rigid institutionalized religion. Ethical
behavior with parents, friends, and strangers is the focus of
all religious training among them (Balgopal, 1995). New
Buddhist temples are being built by immigrants from
Thailand and Myanmar. Islam is the main religion for
immigrants from Bangladesh, Indonesia, Malaysia, and
Pakistan. Many immigrants from India also follow Islam.
Most immigrant Muslims adhere strictly to their religious
teachings and practices, and go to mosques every Friday to
offer prayers. Many mosques have been built in a number
of American communities with support from American
and overseas Muslims.
For the majority of Indo-Americans Hinduism is the
main religion, and in most American Hindu homes, a
designated place of worship or altar is set up. Hindus
believe that a person is not a separate individual, but that
the self or "Atman" is part of the cosmic absolute or
"Brahman," that physical satisfaction and knowledge are
illusions and that life consists of impermanence, suffering,
and the absence of ego, and that one's future is determined
by one's deeds in the present (Balgopal, 1995). Hinduism
is not an organized religion; it does not have a hierarchical
power structure. There is no set time of service and
devotees visit the temple per their convenience . Attitude of
Hinduism toward other religions is acceptance and not
mere tolerance (Ganapathy, 2004). Hindus in urban
communities are increasingly building temples. These
structures are very authentic and serve not only as a place
of worship but also as a community center for other social
and cultural functions.
CONSEQUENCES OF RELIGIOUS DIVERSITY The United
States has prided itself on being a pluralistic society, which
includes truly diverse populations who have emigrated
from all comers of the globe. Its members speak numerous
languages and practice a variety of religions. Recent
patterns of immigrants are changing the American tapestry
drastically. Now, in the American landscape, one can see a
Protestant church next to a Muslim mosque or a Hindu
temple; a Jewish synagogue next to a Buddhist temple; and
a Catholic church next to a Sikh gurudwara. Most
Americans are tolerant about the rapid emergence of the
socio cultural diversity in their country. But as the saying
goes, "I am all for integration as long as it does not touch
my pocketbook or my neighborhood," so when it comes to
religious diversity, it has its limits. Wouthnow (2005)
reports challenging and disturbing results, based on a
threeyear national research project that included more than
300 in-depth interviews conducted in 14 metropolitan
areas, and a national survey that included a representa tive
sample of 2,910 adults. Some of the findings include the
following: 57% percent of the public think the Muslim
religion is closed minded, 47% think Islam is fanatical,
and 40% say it is violent. Fifty-three percent think
Hinduism is peace loving and 63% say this about
Buddhism; however, about a third of them think these
religions are closed minded. Almost 60% of the
respondents said they would not welcome a Muslim
mosque in their community and 35% said the same about a
Hindu temple. Wouthnow's (2005) analysis is important as
it notes that the negative responses toward Muslims are
fueled by fears of terrorism, and such negative responses
are rooted in old-fashioned American nativism. Added to
these the survey also found many Americans believe that
only Christianity is true and America is and should be a
Christian nation.

Model Minority
The Model Minority image of Asian Americans has
been a controversial and much debated issue. This term
became a catch phrase in 1982 after Newsweek headlined
a favorable feature, "Asian Americans: A Model
Minority" (Kitano & Daniels, 1995). Asian Americans
are referred to as a"Model Minority," to celebrate their
hard work, high educational achievements, professional
and vocational success, law abiding behavior coupled
with sound personal values, and minimal dependence on
public entitlements. It is ironic that the image of Asian
Americans has transformed from "pariahs to paragons,"
in such a brief period (Rose, 1985).
It is increasingly recognized that the "model minor-
ity" stereotype of Asian Americans is a myth and it does
harm to all the minority groups. Often, pitting this group
against African Americans does more harm to the
already existing tensions. Asian Americans continue to
bump into glass ceilings, receive lower pay even with the
same or higher qualifications, have significant numbers
living below the poverty level and their numbers are
increasing every year. Due to the "model minority"
myth, the public programs in the Asian communities are
.drastically under-funded or discontinued, and often
members of this group are ruled ineligible to receive
benefits from affirmative action programs.
Asian Americans are shown to earn the nations
highest median family income, but this statistic does not
reflect the whole picture. Income earned by this group
includes a significant number of families at both ends of
the spectrum. According to the 2000 U.S Census,
poverty rates for Euro-Americans was 9%, African
Americans 24%, and for all Asian Americans 11 %. The
same census reports alarming rates of poverty for those
belonging to the main Indo-Chinese groups: Vietnamese
17.7%, Cambodian 30.8%, Laotian 22.3%, and Hmong
40.3%.
Suicide rates among Asian American students are
very high and this is attributed to "model minority
identity pressure" (Amusa, 2006). There are numerous
incidents where Asian students have ended their lives
violently, to avoid facing academic or. personal rela-
tionship failures. Similarly, violence committed by
Asian Americans also occurs, and. the worst exam ple is
the Virginia Tech massacre of April 16, 2007, when a
Korean American student killed 32 students and faculty
members, and wounded many more before committing
suicide. As is to be expected, such tragic incidents raise
negative reactions against Asian Americans who have to
live in the shadow of the myth of model minority.
ASIAN AMERICANS: OVERVIEW
159
Violence and Discrimination
There are numerous incidents of physical violence and
sexual assaults against Asian Americans. Historically,
there is ample evidence of such behavior by the majority
group, which led to the passage of the Chinese
Exclusion Act of 1882. Exactly one hundred years later,
a Chinese American, Vincent Chin was brutally
murdered by two Euro-American men who accused him
of robbing them of their jobs. Similar hate crimes have
been regularly directed toward all Asian American
groups. IndoAmerican women are victimized by a
group called "Dotbusters," a reference to the red dot or
hindi, worn by Indian women on their foreheads
(Balgopal, 1995).
As per the saying "History repeats itself," the South
Asian . American became the prime target of hate
crimes after the terrorist attack on September 11, 2001,
which is exactly the same treatment Japanese
Americans received after Pearl Harbor was bombed.
President Franklin Roosevelt's Executive Order forced
more than 120,000 Japanese Americans into intern ment
camps. At times of national anxiety, members of
minority immigrant groups become scapegoats and are
blamed and hated. Sikhs, Pakistanis, and other South
Asian Americans with Muslim names who resembled
Arabs are regularly harassed and their civil rights are
violated by the authorities. The post-9/11 backlash
against South Asian Americans generally manifests in
terms of hate crimes, bias at work places, schools and
racial and religious profiling at. airports and highways
(SAALT, 2005). Sadly, such violence and bigotry are
often not reported by the mainstream media.
Implications for Best Practices
The major points to be recognized for best practices are:
1. Although the Asian American groups have a
number of similar cultural features, it is essential to
recognize the extensive diversity related to
language, religion, history of coming to the United
States, and the socio economic and educational
backgrounds of the different Asian ethnic groups.
2. Understand the unique characteristics of different
Asian ethnic groups.
3. Accept that this group values privacy and is
cautious in readily sharing personal data.
4. For Asian Americans, the family is the pivotal unit
and collectivistic life style is emphasized.
Empowering family members should be done
within their cultural norms and values.
5. Family roles are clearly delineated in the Asian
American families and the same need to be
respected.
6. Understand their pride and shame in receiving help
from outside the family network and so avoid
confronting these clients.
160 ASIAN AMERICANS: OVERVIEW
7. Although most families have a patriarchal struc ture,
women have an important status and power, which
they use subtly without threatening the male
members.
8. Many of these families are in need of mental health
services, and the practitioners have to be sensitive in
picking up subtle clues. Some of the major emerging
problem areas are suicidal'idea tion and depression,
alcohol and substance abuse, 'gangs and other
criminal activities, domestic violence, marital
conflicts, parent-child conflicts, and
inter-generational conflicts due to different
expectations based on native customs and Amer ican
expectations.
9. Service providers need to be located near the Asian
American ethnic enclaves, such as China town and
Koreatown.
10. The presence of Asian American professionals who
have a working knowledge of Asian lan guages is
very important to develop t rust and establish
meaningful relationships.
In short, to be effective in working with Asian
American clients, social workers have to be aware of the
vast differences in this group and need to have some basic
background knowledge of specific groups. A gen eralist
model based on an ecological perspective is well suited
for best practices.
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Abe-Kim, J. et al. (2007). Use of mental health related services
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American Lung Association. (2006). Asian Americans/Pacific
Islanders and . lung disease fact sheet. Retrieved June 4, 2007,
from http://www .lungusa.org.
Amusa, M. (2006). Asian women face 'Model Minority' pressure.
Retrieved June 6, 2007, from http://www.womensnews. org.
Asian Americans and Marriages. (2005). National Healthy
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http://www .healthymarriagesinfo.org.
Balgopal, P. R. (1995). Asian Americans overview. Encyclopedia of
social work. (19th ed.), Washington, DC: NASW Press.
Balgopal, P. R. (Ed.). (2000). Social work practice with immigTants
and refugees. New York: Columbia University Press.
. CDC. (2006). Cases of HLV infection and AIDS in the United States,
2005. (HIV/AIDS Survelliance Rep.) VOL. 17, Table 1.
Washington, DC: Author.
Ganapathy, T. N, (2004). A bird's eye view of Hinduism and Indian
philosophy. Chennai, India: Ravi Publications.
Kagawa-Singer, M., & Ong, P. M. (2005). The road ahead
barriers and paths to improving AAPI health. AAPI Nexus,
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Kitano, H. H. L. (1969). Japanese Americans: The evolution of a
subculture. New York: Prentice Hall.
Kitano, H. H. L., & Daniels, R. (1995). Asian Americans:
Emerging ministries. Englewood Cliffs, NJ: Prentice Hall.
Lu, F. G. et al. (2002). A psychiatric residency curriculum about
Asian-American issues. Academic Psychiatry 26(4), 225-236.
Lum, D. (1986). Social work practice and people of color: A
process-stage approach. Monterey,CA: Brooks Cole.
Mikler, S. R. (1993). Asian Indian immigrants in American and
Socio-cultural issues in counseling. Journal of Multicul_ tural
Counseling and Development, 21, 36-49.
National Library of Medicine. (2006). Asian American health.
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Rose, P. 1. (1985). Asian Americans from pariahs to paragons.
In N. Glazer (ed.), Clamor at the gates: The new American
immigTation. San Francisco: ICS Press.
Sakamoto, A., & Xie, Y. (2006). The socioeconomic attainments
of Asian Americans. In P. G. Min (Eds.), Asian Americans:
Contemporary trends and issues. Thousand Oaks, CA:Sage.
SA WNET. (2007). South Asian women's NET: [South Asian
Women's Organizations]. Retrieved June 4, 2007, from
http://www .sawnet.org.
Segal, U. A. (2002). A framework for immigTation: Asians in the
United States. New York: Columbia University Press.
Shankar, L. D., &Srikanth, R. (Eds.). (1998). Apart, yet apart.
Philadelphia: Temple University Press.
South Asian Public Health Association. (2002). A brown paper:
The health of South Asians in the United States. Berkeley,
CA:Author.
Sue, D. W. (1981). Counseling the culturally different: Theory and
practice. New York: Wiley.
Sue, S., & Wagner, N. N. (1973). Asian Americans: Psychological
perspectives. Ben Lomond, CA: Science and Behavior Books.
Triandis, H. c., Botempo, R., & Villareal, M. J. (1988). Indi-
vidualism and collectism: Cross-cultural perspectives on
self-in-group relationships. Journal of Personality and Social
Psychology, 54, 323-338. .
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Washington, DC: Government Printing Office.
U.S. Bureau of the Census. (2000).2000 Census of the popula~ tion.
P.L. 94-171. Washington, DC: Government Printing Office.
.S. Bureau of the Census. (2001). Office of the asian populaticm:
2000,2001 Statistical Abstract of the United States, TableNum-
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diversity. Princeton, NJ: Princeton University Press.
- P ALLASSANA R. BALGOPAL
 ASIAN AMERICANS: PRACTICE
INTERVENTIONS 161

PRACTICE INTERVENTIONS valuing and focusing on family instead of self, main-

ABSTRACT: This entry describes the diversity among taining protocol, and valuing education (Lee, 1997; Uba ,
Asian American populations, setting the context to 1994). However, mixed race children or 1.5 gen-
understand the need for different practice interven tions. It . eration individuals commonly hold mixed Asian and
explains the role of cultural va lues in the underpinnings of non-Asian values. Ascertaining the role of cultural values
the selection of theoretical frame works that guide chosen to the Asian American individual and family is key when
practice interventions. Indigenous and biculturalizations creating and selecting practice interventions for work with
of interventions (Fong, Boyd, & Browne, 1997) are Asian Americans (Fong, 2007; Rhee &
discussed as they relate to general and specific problems Huynh-Hohnbaum,2007).
relevant to this popula'tion, Challenges and dilemmas are
raised as ethical decisions are made among practitioners,
Theoretical Frameworks for Practice
who serve the Asian American native born, immigrant,
Social work practiee with Asian Americans is driven by
and refugee populations.
theory, which in turn needs to support the client's particular
ethnic, cultural, and religious values (RossSheriff &
Husain, 2001). American-born Asians may share many
KEY WORDS: Asian American clients; Asian Ameri can American cultural values while also incorporating
practice interventions; cultural values; indigenous traditional values from their countries of origin.
interventions; biculturalization of interventions Traditional cultural values should be viewed as strengths.
These strengths should be utilized when selecting
Asian Americans are a diverse population of East Asians interventions. For example, an intervention that focuses
(Chinese, Japanese, Korean, Filipino), South Asians exclusively on self, but neglects the role of the family, may
(Asian Indians, Pakistani, Bangladeshi, Sri Lankan, thwart healing and growth. Practice interventions must
Nepalese, Bhutanese), and Southeast Asians (Vietnamese, match the individual and his or her cultural values.
Cambodian, Laotian, Hmong, Thai, Burman, Malaysian, Cultural values as strengths are protective factors but
Indonesian). Consequently, Srinivasan (2001) observes they can also be risk factors. Lee et al. (2001) state ,
that, "The concept of 'Asian American' subsumes under "Cultural values such as the emphasis on maintaining
one heading various cultures, social histories, and interpersonal and social harmony cause individuals to be
experiences of immigration and is, therefore, ambiguous, more cautious and sensitive to others and the ex ternal
having consequences for health, mental health, legal and environment" (p. 163-164). However, this cautiousness
social service access, delivery, and development" (p. 155 ). can also prevent action and confrontation when needed, in
Lee, Lei, & Sue (2001) also note Asian American cases of physical abuse or family violence.
heterogeneity and the "differences in cultural back- Because of the diversity among Asian American
grounds, native countries of origin, circumstances for populations and practice interventions used, the strengths
coming to the United States, generational statuses, and perspective as a theoretical framework captures the
native language spoken" (p. 160). While "Asian variety of issues dealt with in assessments and treatments
American" usually refers to a native-born American of in working with these groups of people.
Asian descent, multiracial children and adults with some
parents of Asian heritage may also be included. Others
may self-identify as Asian American, such as 1.5
generation persons, which refers to those who come from
Asia to the United States at an early age, and individuals Assessments and Practice Interventions Before a
from Asia adopted by non-Asian parents. (Fong, 2007). practice intervention can be used with Asian Americans it
Undocumented immigrants and refugees from Asian is critical that a thorough assessment be done in terms of
countries may also be included under the rubric of Asian their cultural backgrounds, immigration experiences if
American despite their political status, requiring that their applicable, cultural meanings to physical and mental
political statuses and migration experiences be illnesses, and modes of expression of illnesses. A
differentiated when discussing practices and interventions presenting problem may not be the actual
related to this population (Fong, 2004). . problem and the intervention set up may have cultural
Asian American diversity is reflected in the differ ent barriers.
cultural values held by each group. Traditional cultural Assessment issues among Asian Americans may be
values usually include respecting elders, tied into shame and not reporting the actual problems,
despite the generational differences and practices in the
162 ASIAN AMERICANS: PRACTICE
INTERVENTIONS
United States. The tendency to somaticize problems
instead of verbally sharing them may exist among some
Asian American family members. For example, "the
teachings and philosophy of a Confucian, collectivistic
tradition discourage open displays of emotion in order
to maintain social and familial harmony or avoid ex-
posing personal weakness. Thus either consciously or
unconsciously, Asians are taught to deny the experi-
ence and expression of emotions" (Lee. et al., 2001, p.
165). Yet those Asian Americans who are born in the
United States or 1.5 generation persons may live in
multigenerational households where family members
are in conflict with cultural values, and practice
interventions are difficult to determine to meet all the
members' needs.
Practice Interventions
There are many practice interventions from which to
choose when working with Asian American
individuals and families; however, factors affecting
selection include the age, gender, and role of the
family member and immigration status. Those practice
interventions that are family oriented may need to have
theoretical frameworks that support cultural values of
respecting males, and honoring hierarchal family
systems if the Asian American family holds true to
adhering to any traditional cultural values. Theoretical
frameworks of practice interventions should match the
cultural values so that they are supportive of each other
rather than in conflict. For example, if some Asian
American clients may not be able or willing to talk in
therapeutic interviews about their emotions, but tend to
somaticize their problems, to insist that the practice
intervention only focus on communication skills may
miss the whole point of the need of cultural
translations in interpreting cultural meanings in the
communication transpiring between the client and the
therapist. Author Marshall jung (1998)ofChinese
American Family Therapy talks about "adjusting the
Western lens and using the best clinical model of
therapy that "best suits the clients' needs" (p. 89). He
discusses how Structural Family Therapy, Strategic
Therapy, Planned Short-term Treatment;
Rational-Emotive Therapy, Solution-Focused
Therapy, and Contextual Family Therapy "provide
therapists with a multidimensional and comprehensive
framework for diagnosing and treating Chinese fa-
milies" and because these models allow therapists to
"adapt to the expectations of [Chinese) clients and the
style in which they work best" (p. 89). For example,
Structural Family Therapy (SFT) reinforces the tra-
ditional Asian cultural value of the importance of ac-
knowledging the male and female roles in the structure
of the family and is compatible in working with
Chinese families who still adhere closely to traditional
values and behaviors. Thus, using SFT in practice
would be adapting to the Chinese family's familiar
belief system.
Adapting to clients' preferences may also include
not just Western models but also indigenous practices.
Some elders living in Asian American families may
prefer traditional healing methods such as acupuncture,
cupping or oxybustion, a form of treatment using suc-
tion for healing, or herbal medicines. Some may refuse
Western medicines or prescriptions because they dis-
turb the chi, or the yin and yang. Asian American
immigrant and refugee families may come from coun-
tries of origin that use traditional healers like shamans
or acupuncturists. When they migrate to the United
States they often seek to continue with these familiar
ways of treating physical and mental ailments. There
needs to be a better integration of Western interven-
tions with indigenous methods of healing. This is done
through adopting an approach of selecting and imple-
menting both kinds of practice interventions. .
Biculturalization of Interventions
The biculturalization of interventions is the practice of
combining an indigenous intervention with a Western
intervention (Fong, Boyd, & Browne, 1997). It has five
steps: (a) The practitioner identifies the relevant values
in the ethnic culture that are important to the client and
can be used to reinforce therapeutic interventions; (b)
The practitioner selects a Western intervention whose
theoretical framework and values are compatible with
the ethnic cultural values of the client system; (c) The
practitioner and client analyze and select an indigenous
intervention familiar to the ethnic client system in
order to determine' what techniques can be integrated
and reinforced with 'a Western intervention; (d) The
practitioner develops an approach that integrates the
values and techniques of the ethnic culture with the
Western intervention; and (e) The practitioner applies
the Western intervention while at the same time
explaining to the client system how the Western
intervention reinforces the ethnic cultural values and
supports the indigenous intervention.
Indigenous interventions are important and need
better integration into the Western methods that cur-
rently dominate the choices of treatment. To insist that
only Western interventions are the prescribed treat-
ment not only may ignore culturally competent
practice but also may promote greater challenges by
alienating Asian American clients who may then
become reluctant to seek treatment. For example,
acupuncture, which is a common indigenous treatment
in Asia,

is becoming a more acceptable form of practice inter,
vention in some managed care systems, used by Asians
and non-Asian clients.
Challenges and Dilemmas
There could be several dilemmas for the practitioner in
working with Asian American families. Some may be
related to language and translation difficulties; others
may be related to shame and fear of losing face. It is
commonly found that many Asian Americans do not
seek treatment because of shame factor (Lee, 1997;
Uba, 1994). However, if a problem is severe and creat-
ing major stressors to the family, members will be more
likely to seek treatment (Fong & Furuto, 2001; Lee, Lei,
& Sue, 2001, Lum,\2007). Therefore, silences in
treatment sessions may be common if the client is
forced to come for treatment as the family's last resort
to obtain help. Discomfort and unfamiliarity with terms
or practices need careful time spent in the problem,
solving process.
The use of children or youth as cultural and Ian-
guage translators for immigrant and refugee parents or
other family members creates special dilemmas. This
may cause tension and miscommunication because of
the inappropriate burden on children put in this role.
This may also pose an ethical dilemma for the practi-
tioner because language interpreters are not easily
found and cultural practices are not easily understood
by persons who are not part of that cultural community.
Cultural protocols frequently need some interpretation
and the tendency to use Asian American children and
youth because they are conveniently available may
cause tensions and roie reversals in the family system
and additional stressors for the young people.
While there is a need to integrate indigenous inter,
ventions with Western treatments, problems may arise
with issues related to evidenced-base practices.
In using indigenous interventions or biculturaliza-
tion of interventions, there may be problems with
agencies offering practice interventions whose mea,
sures of effectiveness in evidence-based practice may
be in conflict or not as supportive of the indigenous and
traditional healing practices. These dilemmas point to
challenges and the need to identify and remove those
obstacles preventing the offering of best practices to
Asian American individual and family clients.
Our changing demographics with the increase of
multicultural and multigenerational Asian American
families, forces practitioners to examine the theoretical
approaches and kinds of treatments offered to this pop'
ulation. The offering of culturally competent bicultur-
alization of practice interventions needs to become an
ASIAN AMERICANS: PRACTICE INTERVENTIONS 163
integrated part of treatment, replacing the tendency to
solely use Western interventions, which do not always
best fit this culturally heterogeneous population. A
changing paradigm is needed in the larger context of
practice to meet the complex needs of these diverse
Asian American populations.
rategies is Fong, R. (Ed.). (2004).
Fong, R. (Ed.). (2004). Culturally competent practice with immigrant
and refugee children and families. New York: The Guilford
Press. .
Fong, R. (2007). Culrural competence with Asian Americans.
In D. Lum (Ed.), CulturaUy competent practice: A frame, work for
understanding diverse groups and justice issues' (pp. 328-350). San
Francisco, CA: Brooks Cole.
Fong, R., Boyd, T., & Browne, C. (1997). The Gandhi technique:
A biculruralization approach for empowering Asian and
Pacific Islander families. Journal of Multicultural Social Work, 7,
95-110.
Fong, R., &. Furuto, S. (Eds.). (2001). Culturally competent
practice: SkiUs, interventions, and evaluations. Boston, MA:
Allyn and Bacon.
lung, M. (1998). Chinese American family therapy: A new model for
clinicians. San Francisco, CA: )ossey Bass.
Lee, E. (1997). Working with Asian Americans: A guide for
clinicians. New York: The Guilford Press.
Lee, )., Lei, A., & Sue, S. (2001). The current state of mental
health research on Asian Americans. In N. Choi (Ed.),
Psychosocial aspects of the Asian-American experience (pp.
159-178). New York: The Haworth Press.
Lurri, D. (Ed.). (2007). Culturally competent practice: A framework
for understanding diverse groups and justice issues. San
Francisco, CA: Brooks Cole.
Ross-Sheriff, F., & Husain, A.(2001). Values and ethics in social
work practice with Asian Americans: A South Asian Muslim
case example. In R. Fong & S. Furuto (Eds.), CuI, turaUy
competent practice: SkiUs, interventions, and evaluations (pp.
75-88). Boston, MA: Allyn and Bacon.
Rhee, S., & Huynh-Hohnbaum, A. (2007). Child welfare practice
with Asian and Pacific Islander American children, youth, and
families. In N. Cohen, T. Tran, & S. Rhee (Eds.), Multicultural
approaches in caring for children, youth, and their families.
Boston, MA: Allyn and Bacon.
Srinivasan, S. (2001). "Being Indian," "Being American": A
balancing act ora creative blend. In N. Choi (Ed.), Psychosocial
aspects of the Asian,American experience (pp. 135-158). New
York: The Haworth Press.
Uba, L. (1994). Asian Americans: Personality patterns, identity,
and mental health. New York: The Guilford Press.
SUGGESTED LINKS
Asian Pacific Islander Institute on Domestic Violence.
http://www.apiahf.org/apidvinstitute/default.htm National
Research Instirute on Mental Health Research.
http://psychology . ucdavis .edu/nrcaamh/
-ROWENA FONG
 164 ASIAN AMERICANS: CHINESE
CHINESE
ABSTRACT: Chinese Americans were the first group of
immigrants from Asia who came to the United States in the
mid- 19th century. A second wave of immigrants came
following the Immigrant Act of 1965. These new
immigrants had more diverse backgrounds and introduced
new patterns of lifestyle. Since 1965, the Chinese
population has increased lO~fold to reaching 2.9 million in
the 2000 census, becoming 1 % of the total U.S.
population. Chinese Americans are in a varied back-
. ground and with diverse identities. Two-thirds are
foreign-born and experiencing stereotype, prejudice, and
acculturation adjustment.
KEY WORDS: Chinese Americans; Chinese immigration
history; Chinese American families; model minority;
Chinese American identity and styles; mental health
services and Chinese Americans
Chinese were the first and largest Asian immigrant group
to enter the United States. Their arrival in the mid- 19th
century was officially recorded by the U.S. immigration
commission in 1820. According to official data, there were
only 11 Chinese settled between 1820 and 1840. The gold
rush in 1848 induced mushrooming of Chinese immigrant
numbers. Between 1850 and 1880, the Chinese population
ural. Individuals are
identity and cultural solidarity. Nevertheless, because of
f the whole. True knowledge, or ulti-
y drug currently aetition and sociopolitical racism led
led to the Chinese Exclusion Act of 1882. As a result of
this legislation, Chinese immigrants were restricted to
living quarters in the Chinatowns, socially and econom-
ically isolated urban enclaves. In 1943, during World War
II and after 60 years of legal exclusion, Congress passed
the Magnuson Act, which repealed the Chinese Exclusion
Act of 1882 and assigned the Chinese a total quota of 105
people. The 1965 passage of the McCarran Immigration
Act brought a new wave of Chinese immigration to the
United States. In the 30 years after the McCarran Act, the
Chinese American community increased from 237,292 to
1,645,472, and by the year 2000 it was 2.9 million, nearly 1
% of the total United States population. More than
two-thirds of all Chinese Americans are foreign-born, and
approximately a quarter of the people who are
American-born have foreign-born parents (Znd
generation), and about 10% have foreign-born
grandparents, belonging to the 3rd- (and plus) generation
group.
The majority of Chinese immigrants are from China,
Hong Kong, and Taiwan. Smaller numbers
come from Vietnam, Cambodia, Malaysia, and the
Americas. Among these people there is a wide range of
linguistic and cultural backgrounds. New immigrants are
no longer predominantly male, uneducated peasants, or
unskilled laborers. They come from diverse socioeconomic
and educational backgrounds. Many come in families, with
financial resources, and upwardly mobile employment and
residential settlement. Chinatown is no longer the only
settlement place for a new Chinese immigrant. By the year
2000, census records reveal that Chinese Americans make
up 20% of suburban America. Sixty-five percent of the
foreign-born Chinese (age 25-39) have attended at least
four years of college as compared with 30% found in the
mainstream (White) population. All recent Asian
immigrants share the phenomenon of the "astronaut
djudication of criminal behaviors, and the punishment of
pursue education, while they, one or both parents, return to
their country of origin for mostly economic reasons.
When 20th-century Chinese immigrants arrived,
Chinatowns across the country had developed a viable
economic structure, which provided some low-income
families with jobs in developing garment industries and
restaurants. These employment opportunities made the need
to learn English less urgent than it might have been. While
these Chinese enclaves slowed immigrants' acculturation
into mainstream culture, they prevented the loss of ethnic
social class and cultural constraints, children who grew up
in Chinatown faced a greater risk of permanent poverty. In
contrast, Chinese American children living in middle class
suburban neighborhoods grew up speaking English
predominantly within the open society, which brought
openness at the cost of cross-cultural conflicts with their
immigrant parents.
Lastly, most recently, since the mid- 1980s, there has
been an influx of illegal immigrants from China to the
United States. Most of these people come from Fuzhou, in
the southern province of Fuji an. Many are forced to work
as indentured slaves to payoff their transportation debts.
This group lives underground and faces a unique set of
social problems and cultural adjustment issues.
Model Minority:
Stereotypes Engendered from Tradition CHINESE
CULTURE Research suggests that Chinese Americans are
rooted in the traditional value systems of Confucianism,
Taoism, and Buddhism. These traditions place
interpersonal harmony as a norm that exists within a
hierarchical structure, particularly with family members
and friends. There is no separation between humanity,
nature, and the supernatural. Individuals are

the extension of the whole. True knowledge, or ulti mate
reality, comes from intuition and meditation.
Traditionally, Chinese have extended families and live on
both a vertical and a horizontal level. The vertical includes
parents, grandparents, and ancestors; all are viewed as a
continuous generational unit. The horizon tal further
includes aunts, uncles, and cousins. Children are relied on
to perpetuate family continuity and be the source of their
parents' future security. People assume the parental role
with serious purpose. Their ultimate goal is to rais e a
stable, conforming, sensitive, and self controlled child,
who will foster familial and collective self- identity rather
than take on an individualistic sense of self, like a
Westerner.
Traditional Chinese culture emphasizes shame oriented
group norms over guilt-oriented individual norms. For the
Chinese, shame is an important positive
character-building mechanism. one can only experi ence
shame when one cares deeply and sustains self respect
within the desire for relationships, grief for loss of
relationships, and a yearning for restoration of rela-
tionships.It is believed that the feeling of shame will not
be aroused if there is a loss of self- respect. Western
psychology, which is rooted in a commitment to indivi-
dual moral autonomy, tends to minimize t he emotion of
shame. Understanding the dynamics of shame is critical to
the understanding of Chinese mental processes.
Chinese ctilnrre values a strong extended family
structure. The ideal behaviors of extended family mem-
bers include filial piety, close control of children, age
hierarchy, clearly defined patriarchal roles, vertical
authoritarian social directives, and a focus on collective
solidarity over individual interests. It is believed that these
ideals contributed to Chinese immigrants' educationa l and
economic advancement. In fact, the higher family income
exists only because of its extended family structure. The
extended family has more workers rather than a high
individual income. The overall portrait propagates a
"model minority" myth, which do wnplays the racial
discrimination encountered by Chinese Americans and
places performance pressure on Chinese youth. In reality,
the quality of life in Chinatown was less satisfying and far
below that of Americans overall.
The Divergent Identities and Social Work Practices with
Chinese American Clients Many Chinese Americans are
facing challenges of acculturation and psychosocial
adjustment. Chinese American identities are
heterogeneous and multifaceted, shaped by unique
environmental context of personal experiences, hist~ rical
treatment of Chinese immigrants, American foreign
policies, and the current
ASIAN AMERICANS: CHINESE 165
national politics of multiculturalism. The identity issue is
subjective, ultimately personal and constantly chan ging.
one's identity is a biopsychosociological experi ence, and a
total experience of race or ethnicity, social class, gender,
age, sexual orientation, and religion.
While an immigrant client's English language fluency
is a barometer of the level of his or her accul turation, the
language issue must be navigated by a service provider.
Understanding the complexity of within- family cultural
diversity is also of critical impor tance to the provision of
competent services to the Chinese immigrant population.
Second-generation Chinese Americans, with immigrant
parents and growing up as a minority in the racist society
of the United States, are acutely conscious of their racial
marginality and confronted with both ethnocultural and
racial apprehensions. The 3rd- (and plus) generation
group of Chinese Americans, cognizant of historical legal
and structural barriers, grew up with a strong racial
identity, rather than ethnic identity, which is a part of self
usually transmitted through Chinese language and
life-style acquisition. Although this group confronts
racism and oppression, they are nevertheless socialized
into the American mainstream cultural identity. The
recent emergence of multiculturalism in U.S. society
imposes an implied expectation for Chinese Americ ans to
possess both Chinese language and cultural practices.
This often results in feelings of displacement in them, a
nonmainstreaming experience that instigates a yearn ing
for root search.
Recognizing the diverse identity of this ethnic group is
critical to understanding needs and providing ade quate
social services. Social workers need to keep this
uniqueness in mind when conducting intake sessions, and
frame questions accordingly. In reality, with the racial
politics of the United States, Chinese Amer icans are often
regarded as others or perpetual foreigners, regardless of
their generations.
In working with Chinese American and immigrant
clients, both Asian and non-Asian social work practi-
tioners need to be cognizant of their own ethnic aware-
ness, bias, and personal achieving styles (which affect
their clinical decisions and their styles of interaction with
clients); only then, can they proceed to the devel opment of
cultural sensitivity and competence (Lu, Lum, & Chen,
2001). Research findings on personal achieving styles
(Lu, 1994) show that demographic variables of age ,
gender, and education reflected signif icant differences in
the achieving styles of Asian American and non- Asian
American practitioners. Later findings of Lu (1996 )
indicate that Asian American practitioners are more
process oriented and place more emphasis on family
dynamics (that is, gender-role
166 ASIAN AMERICANS: CHINESE
reversal, age of arrival, intrafamily cross-cultural corn-
munication difficulties), and the use of nondirect inter-
vention styles. Additionally, the Asian American
practitioners tend to assess the immigrant client as less
severe and predicted a better prognosis than do nonAsian
practitioners. These differences in approach and
perspective must be taken into consideration when mak ing
efforts to design equitable cross-cultural services, which
are often delivered to Asian clients by non-Asian
practitioners. Further empirical and theoretical inquiry
into cross-cultural service for Chinese Americans and
immigrants is needed. We also need to move beyond
ethnocentric measurement instruments and thus conduct
more comprehensive cross-cultural studies.
Differential Use of Health,
Mental Health, and Social Services Research data
show that Asian Americans (including Chinese) have low
utilization rates and high dropout rates of health and
mental health services. There is a widespread use of folk
medicine for minor physical ailments. Chinese herbal
medicine is a vital part of the Chinese health care system
historically. Wherever they settled, Chinese immigrants
used herbal medicine as a transitional object, while
moving from one cultural tradition to another and forming
a hybrid identity. Chinese medicine represents a link to the
homeland and continuous lifestyles though overseas.
Major illness might strike, and Chinese herbal medicine
usually supplemented Western medicine. Whatever the
clashes between Chinese health beliefs and practices, and
those of mainstream Western medicine, the traditions were
used side by side.
There is a different pattern of usage in mental health
service programs. Very few Chinese immigrants seek
outpatient services, while there is a comparatively high er
use of emergency and in-patient, hospital services. The
strong stigma of mental illness in Chinese culture and the
tolerance of psychosomatic illness may account for these
findings. However, linguistic and cultural mismatch
between the mental health se rvice providers and their
clients remains an obstacle. Furthermore, the quality of a
mental health clinical assessment depends on both the
validity of the diagnostic criteria and the cultural
sensitivity of the provider. In the American Psychiatric
Association's DSM IV-R both the concept of disorder, as
well as the specific diagnostic categories are shaped by the
mainstream cultural norms of the United States.
Cross-cultural variability in the DSM IV-R is limited.
Description of specific syndromes is not culturally
sensitive. Most fail to address the subtle ways a disorder or
diagnosis is affected by culture. The very concept of
mental disorder is
viewed as universal. The sociocultural factor of the
etiology is generally disregarded. Chinese clients may
have adopted Western urban, social organization, or
participate in Western religious activities, but this does not
necessarily mean that they have integrated a Western
worldview. The addition of cultural cornpetencytraining
to mental health service providers is very much needed.
The understandings of these persistent situations had led
to the establishment of bilingual and bicultural
minority-focused health, mental health, and social service
programs in the 1980s. Because.of the scarcity, there
tends to be a long waiting list for linguistic and cultural
congruent services.
REFERENCES
Lu, Y. E., Lum, D., & Chen, S. (200l). Cultural competency and
achieving styles in clinical social work: A conceptual and
empirical exploration. Journal of Ethnic and Cultural Diversity in
Social Work, 9(3/4), 1-32.
Lu, Y. E. (1994). A comparison of achieving styles of Asian
American and non-Asian American psychotherapists.
Psychotherapy in Private Practice, 13(2),45-69.
Lu, Y. E. (1996). Underutilization of mental health services by
Asian American clients: The impact of language and culture
in clinical assessment and intervention. Psychotherapy in
Private Practice, 15(2),43-61.
FURTHER READING
Siu, S., Lee, A., & Lu, Y. E. (Eds.). (2005). Asian and Pacific
Americans: A selected bibliography (1995-2004) withannotations
and teaching resources for sodal work educators. Alexandria, VA:
Council on Social Work Education.
-YAHWA EVA Lu
JAPANESE
ABSTRACT: This overview of the Japanese American
community includes a brief history of the community in the
United States, an overview of some distinct characteristics of
the community, and a review of current literature highlighting
the particular issues of" the community salient to social
work research and
#. .
work professionKEY WORDS: Asian Americans;
KEY WORDS: Asian Americans; Japanese Americans;
internment; model minority
History of the Community in the United States The bulk
of Japanese immigration to the United States had occ urred
already by the early 20th century. Beginning with the
Chinese Exclusion Act of May 6, 1882 (22 Stat. 58) and
culminating in the Immigration Act

of 1924 (43 stat. 153), the nation's immigration policies
had specifically blocked Asian immigration. Until the
1924 Act, also known as the "Japanese Exclusion Act"
(Kim, 1994, p. 114), the Gentleman's Agreement of
1908, a federal treaty made between the United States
and Japan, had provided a loophole for Japanese immi-
grants from the various exclusionary law (Kim, 1994).
The race-based exclusion provision of the 1924 Act,
however, eliminated all such exceptions.
A key factor in the long history of state-sponsored
anti-Asianism in the United States was the Naturaliza-
tion Act of 1790 (lstat.l03), whose Whites-only pro viso
denied citizenship rights to all Asian immigrants on the
basis of race. Aside from .the obvious effect of barring
Asian immigrants from participating in the
\ .
nation's polity, the denial of citizenship had multiple
other discriminatory functions. A prime example was
California's 1913 Alien Land Act (similar laws were
enacted at different times in multiple states) that barred
aliens ineligible for citizenship from the right to
"acquire, possess, enjoy, transmit, and inherit real
property" (Kim, 1994, p. 104), and eventually limited
even the leasing of land for agricultural purposes to
three years (Millis, 1978). These measures, specifically
targeting the Japanese immigrants ("Common welfare:
California preparing to deal with immigrants" 1913, p.
151), was finally declared unconstitutional in 1948 by
the U.S .. Supreme Court and subsequently lost
enforcement capacity.
As the Alien Land Acts attest, the antipathies against
Japanese immigrants played out in the interstices of
economic competition and racialized prejudice. As a
1937 study published by the Social Science Research
Council opined, "The major sin of the rural Japanese,
then, appears to have been his success as a wage worker
and as a farmer, success which was prob ably
exaggerated by the magnifying power of his striking
racial visibility" (Young, 1972, p. 81, first published in
1937) .. But even against so many odds, the Japanese
immigrants succeeded in becoming a economically po-
tent force on the West Coast agricultural landscape,
growing 30-35% by value of all commercial crops in
California, Washington, and Oregon, by the eve of the
Second World War (Miyamoto, 1942).
The racial targeting of Japanese Americans reached
its height in the Second World War. From February
1942, when the Japanese American residents of Ter-
minal Island near Los Angeles Harbor became the first
group to be forced from their homes, to Ma~ch 1946
when the last of the ten Relocation Camps were finally
closed, approximately 120,000, two-thirds of whom
were native-born U.S. citizens, were incarcerated by the
federal government. Technically, the wartime
{
,
ASIAN AMERICANS:
JAPANESE 167
removal and incarceration programs affected only the
West Coast. But since the pre-war national population
of 126,947, excluding 157,905 and 263, respectively, in
the then u.s. territories of Hawaii and Alaska (Daniels,
1983), was highly concentrated on the West Coast, with
113,000 living in the three coastal states (United States
Army, 1943), the internment affected nearly the whole
of the Japanese American population of the nation. The
Congressional Commission on Wartime Relocation and
Internment of Civilians estimated the total wartime
losses of Japanese Americans to be between $810
million and $2 billion in 1983. In 1988 President Ronald
Reagan signed The Civil Liberties Act of 1988
providing each surviving internee (about 60,000) a
onetime sum of $20,000.
Although the absolute number of Japanese
Americans has grown since 1940, due to the lack of
significant new immigration, the community's relative
size among Asian American groups has diminished,
from first to sixth. According to the U.S. Census
Bureau's 2005 American Community Survey (2007),
the current population is 1,204,205, approximately 31
% of whom are rriixed-race/ethnicity. Despite dozens of
incidents of targeted violence, economic boycotts,
public protests, and governmental resettlement policies
geared toward preventing them from returning in large
numbers to the West Coast, most Japanese Americans
did largely do so as they were released from the intern-
ment camps, and settlement patterns remain similar
today, with the largest communities still in California
(394,896), Hawaii (296,674), and Washington (56,210).
The smaller concentrations in New York (45,237) and
Illinois (27,702) are attributable in part to the federal
government's post-camp resettlement policies that,
presaging refugee resettlement policies in the years to
come, was a planned scattering of the population
intended to prevent regional concentration and the
reformulation of enclaves and to facilitate assimilation
(United States War Relocation Authority, 1946, p. 218).
The plans met with limited success overall, but New
York and Chicago were two targeted destinations with
modest success rates of resettlement.
Distinct Characteristics of the Community
Because large- scale Asian immigration to the United
States was restricted until the passage of the 1965
Immigration and Nationality Act, many
contemporary Asian American communities are
composed of significant nu mbers of relatively recent
immigrants. The Japanese American community is
an atypical Asian group in this sense, with 71.2%
(compared with 37.4% of the Chinese, 44.7% of the
Filipino, and 30.7% of the Korean) of the population
composed of native-born
168 ASIAN AMERICANS: JAPANESE
citizens. Consequently, unlike 43.8% of Korean Amer-
icans and 41.7% of Chinese Americans, for instance, only
19.2% ofJapanese Americans report that they speak
English less than very well, and 63.6% report that they
speak only English at home.
According to the 2005 Census estimates (U.S.
Census Bureau, 2007), the Japanese American community
outstrips the general population of the United States in
almost every marker of socioeconomic attainment.
Educational attainment for those over 25 are greater across
the board, regardless of gender, compared with the general
population, with only 6. 7% of community members with
less than a high school diploma compared with the general
population rate of 15.8%. Those with college degrees, or
higher rate at 42.9% compared with 27.2%. The median
household income for Japanese Americans is $55,924,
nearly $10,000 more than that of the general population,
and the median family income of Japanese Americans is
$73,878, about $18,000 more than the general population.
Conversely, poverty rates among Japanese American
families is only about half (5.5%) that of the general .
population (10.2%).
The Japanese American population enjoys, in general,
better health and a longer life-expectancy rate than the
general population of the United States, with lower rates of
cardiovascular diseases, obesity, and overweight. Like
other Asian American groups, however, Japanese
Americans have a higher rate of gastric cancer (twice the
rates of most other populations in the United States), which
has been linked by some researchers (Tsugane, 2005; Wu
et al., 2005) to elements of traditional diet. Another disease
that has a higher prevalence among Japanese Americans
than their counterparts in either Japan or Caucasians in the
United States is Type II Diabetes (Fujimoto et al., 1996).
Research suggests that Asians have a higher percentage of
body fat for a given Body Mass Index (BMI) compared
with Caucasians and that the threshold for developing
obesity and nutrition-related noncommunicable diseases in
Asians occurs at a lower BMI level than for other
populations (McNeely et al., 2001; WHO Expert
Consultation, 2004). BMI and other criteria used for
identifying risk of obesity and nutrition-related non-
. communicable diseases are usually not population specific,
and have generally not been normed on Asian populations,
and may not adequately predict risk in Japanese American
populations.
Social Work Implications
Except for a brief period during World War II, when social
workers were employed by the federal government
to facilitate the removal and internment of the West Coast
population (Leahy, 1946; Webb, 1946), the Japanese
American community has had relatively little contact with
social work. There are, however, some issues that social
workers must understand with regard to the Japanese
American community.
Researchers have found that Japanese Americans retain
elements of what are commonly considered traditional
Asian cultural values such as affiliation and dependence
(Connor, 1974), identification of hierarchical family roles
(Ching et al., 1995), especially age and
gender-differentiated hierarchies (Yoshihama, 2000),
emphasis on collectivism, family obligation, and duty
(Marsella, 1993). But such studies of cultural values and
behaviors have been few and generally conducted on small
samples. As the only Asian American group with a
predominantly native-born population who are three and
even four generations removed from immigration, with a
relatively large proportion of mixed-race! ethnicity
individuals, such information should be used with
particular judiciousness in social work practice in the
Japanese American community. Furthermore, given the
high proportion of mixed-race individuals in the
population (30.8%) as well as evidence that persons of
mixed-race or ethniciry heritage are likely to experience
more stress within society (Berry, Kim, Minde, & Mok,
1987; Williams et al., 2002), social workers working with
members of this community should be aware of salient
issues of bicultural and multicultural identity in child
development and in adult adjustment. Overall, the need for
a nuanced and flexible approach to the issues of racial or
ethnic identity and cultural affiliation, necessary in all
social work practice, is of particular importance in work
with this population.
Despite the community's overall high ranking in
socioeconomic indicators, Japanese Americanjndivlduals
and families share many of the same difficulties that other
Asian American families face in so far. as issues of racism
and prejudice are concerned. Moreover, in addition to
long-term exposure to racial discrimination, the Japanese
American community has suffered the unique experience of
internment. The experience . has been conceptualized by
researchers (Merckelbach, Dekkers, Wessel, & Roefs, 2003;
Nagata & Cheng, 2003) as an acute race-related trauma,
which has had significant impact on the development of
both the larger Japanese American community and the
individuals within it. The intergenerational transmission of
the trauma have also been studied (Nagata, Trierweiler, &
Talbot, 1999), and though results are inconclusive, social
workers should be aware of its possible effects on both
family dynamics and in individuals of younger generations
within the community.

REFERENCES
Berry, J., Kim, u., Minde,T., & Mok, D. (1987). Comparative
studies of acculturative stress. International Migration Review,
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- YOOSUN PARK
KOREANS
ABSTRACT: This overview of the Korean immigrant
community includes a brief history of immigration and a
review of the distinct characteristics that have helped
establish a strong and fairly successful community. It also
describes a new generation of young adults who are
distinct from their parents in their cultural, social, and
economic adaptation. In addition, the challenges and
difficulties that the community and its families may face
are discussed along with implications for social work
interventions.
KEY WORDS: Asian Americans; Korean Americans;
middleman minority
The first wave of immigrants from Korea arrived in the
United States in the early 1900s as labor migrants for sugar
plantations in Hawaii, picture brides (similar to mail-order
brides, these women were selected primarily using
photographs via matchmakers), political refugees, and
students (Hurh, 1998). Between 1950 and 1964, 150,000
Koreans arrived in a second wave, mainly as wives of
American servicemen or war orphans from
170 ASIAN AMERICANS: KOREANS
he Korean War (Hurh, 1998; Min, 2006). Contempor-
ary Korean immigrants, like many other immigrants
from Asia and Latin America, arrived largely after the
Immigration and Nationality Act of 1965. Korean im-
migration peaked in the 1980s, declined significantly
during the 1990s, and has increased slightly in recent
years (Min, 2006). Contemporary immigrants are gen-
erally drawn from the well-educated, urban, middleclass
population (Hurh, 1998; Park, 1997). Korean Americans
are the fifth-largest Asian group, and they live mainly in
metropolitan areas such as Los Angeles, New York,
New Jersey, Washington, DC, San Francisco, and
Chicago (Min, 2006).
Distinct Characteristics of the Community
The Korean immigrant community is characterized by its
strong ethnic attachment and solidarity (Hurh, 1998;
Min, 2006; Park, 1997), which is reflected in its
economic, social, and cultural adaptation (Min, 2006), as
well as in family culture and interactions (Kibria, 2002 ).
Three distinct characteristics of the community have
contributed to this solidarity: the homogeneity of culture
and common language, Korean ethnic churches, and the
high. concentration in small business (Min, 2006).
Unlike other Asian American groups, Koreans share
one common language, which offers a strong informa-
tional resource, strengthens solidarity, and promotes ties
with their country of origin (Min, 2006). Korean
immigrants are also disproportionately Christian (75%
versus 25% among Koreans in Korea) (Hurh, 1998).
They attend mostly Protestant Korean churches, which
helps maintain cultural heritage and values, strengthens
ethnic solidarity, mobilizes political participation, and
serves the social and psychological needs of the immi-
grants (Hurh, 1998; Min, 2006; Park, 1997). These
churches also frequently provide social services (mostly
informal), including assistance in early settlement and
employment, counseling, and Korean language and
cultural programs for children.
Many Korean immigrants (as many as 53% of
households) have gravitated to small business because
of inability to find jobs commensurate with their
education (Min, 2006). They pool resources from
families and other community members, and seek
opportunities in disadvantaged minority neighborhoods
where competition is lower (Park, 1997). Korean small
businesses are generally labor intensive (for example,
grocery or liquor stores, imported goods, dry cleaning,
and manicure services) and heavily dependent on
kinship laborers (Hurh, 1998; Min, 2006; Park, 1997).
The high concentration in small business has placed
them as a middleman minority in the racially segmented
economy, with White landlords or wholesalers, Black
customers, and Latino workers (Min, 1996). This can
sometimes 'create severe frictions with other racial-
ethnic groups. Prominent examples include the boycotts
by Black customers in New York and the Los Angeles
riots in the early 1990s. These experiences have struc-
tured the Koreans' ideology of race andethnicity, mak-
ing them more aware of their minority status in this
society and the disadvantages it confers (Park, 1997).
However, they maintain largely peaceful and civil rela-
tionships with various groups despite the sometimes
exaggerated images posed by popular m~~ia (Lee,
2002).
Recent Changes and the Future:
Emerging 1.5 and 2nd Generations
One of the notable changes in the Korean immigrant:
community is the significant increase in the number of
"1.5" (those who immigrated during adolescence) and
second-generation (U.S. born) Korean Americans (Min,
2006). This emerging group creates and practices a
culture that is distinct from their parents' culture (Zhou
& Lee, 2004). Unlike their parents, who are
concentrated in small business, the younger generation
is more likely to work in the mainstream economy. They
are also culturally more integrated into the mainstream.
Although significant numbers remain christian, they less
often form ethnic churches, which has resulted in a
loosening of the ethnic attachment that is common
among their parent generation (Kim, 2004; Min, 2006).
The new generation's primarily Englishspeaking
congregations tend to serve more strictly religious
purposes (Min, 2006). They are also more often
evangelical with a primary identity as Christian not
Korean (Kim, 2004). Ethnic solidarity to fight for
common interests is no longer needed given that this
generation is not limited to one sector of the economy
(Min, 2006). They also have different views on cultural
and political preferences and racial relations, which
sometimes cause intergenerational conflicts (Chung,
2004). For example, the younger generation aspires to
integrate other minority groups in community activities
and services much more so than their parent genera tion.
However, this emerging generation has not completely
discounted the older generation, but is trying to
accommodate the perspectives and resources of their
parents while integrating new ideas (Chung, 2004).
Despite their parents' reluctance, interracial marriages
are common among young adults, especially among
Korean American women (Min, 2006). This new trend
is likely to change the characteristics and dynamics of
the Korean immigrant community in significant ways.

Social Work Implications
ocial context is an important factor in culturally competenes
that other Asian American families face. Intergenerational
conflicts are common, especially among families with
adolescents (Min, 1998). Due to long working hours,
parent-child contact tends to be limited. Parents may be unable
to freely communicate with their children because of their
limited English, and they may adhere to the traditional culture,
while their children rapidly acculturate to the mainstream (Min,
1998). Korean immigrant women are more likely to be
employed than native-born white women, and many work for
their family's small business (Hurh, 1998). Despite their
significant economic contribution and a critical role in
business, their disadvantaged status with- . in the family often
remains unchanged (Hurh, 1998; Min, 1998; Park, 1997). For
example, the gender relationships in the family are continually
ment issues in the study of community
2 CoMMUNITY VIOLENCE
. Journal of Community Psychology, 28(6), 571-587.
they work outside the home (Park, 1997). Furthermore, the
inevitable changes in gender roles and parent-child
relationships (Min, 1998; Park, 1997) can cause psychological
stresses among family members, including behavioral and
mental health problems.
The distinct characteristics that strengthen ethnic solidarity
discussed above have made it possible to build a strong and
fairly successful community, but they have also contributed to
cultural, social, and economic segregation (Min, 2006; Park,
1997). Korean immigrants are often singled out for racial
conflicts and victimization, such as store boycotts in New
York and L. A., and disproportionate damages to the
Korean-owned businesses during the L. A. riots and are often
identified as a culturally marginalized and separated group.
They also report high levels of stress associated with accul-
turation (Berry, Kim, Minde, & Mok, 1987).
Korean immigrant families tend not to seek outside help
for difficulties, and when they do, they seek help within their
small support network, such as from church members or
relatives (Park, 1997). Thus, when families contact formal
social services, the problems are often serious and prevention
and intervention can be challenging. It is important to note,
however, that there is a vast range of individual differences in
the level of acculturation and intergenerational conflicts in
families and how they cope with the challenges. Individuals
and families also differ socioeconomically and in their reasons
for and routes of immigration. Thus, it is critical to assess each
client and family individually.
..
ASIAN AM8UCANS: KOREANS 171
Paraprofessionals, mostly from the first generation, have
been a primary group of service providers in the social
service sector. Their contributions have been valuable in
helping this immigrant community especially in its early
years of the immigrant history. In recent years, however, the
emerging 1.5 and 2nd generation has been taking over that
role and significantly changing the contents and pattern of the
service delivery (Chung, 2004). For example, the social
service agencies that used to serve exclusively Korean
immigrants have expanded their scope to serve people in need
regardless of their race and cultural backgrounds. In addition,
the professionalization among social workers has been rapid
and will continue, which should help the quality of interven-
tions and services (Chung, 2004).
REFERENCES
Berry, J. W., Kim, u., Minde, T., & Mok,D. (1987). Comparative
studies of acculturative stress. International Migration Review,
21,491-511.
Chung, A. Y. (2004). The dawn of a new generation: The
historical evolution of inter-generational conflict and co-
operation in Korean-American organizational politics. In I. J.
Kim (Ed.), Korean-Americans: Past, present, and future (pp.
101-120). Elizabeth, NJ: Hollym International. .
Hurh, W. M. (1998). The Korean Americans. New Americans.
W~stport, CT: Greenwood Press.
Kibria, N. (2002). Becoming Asian American: Second generation
Chinese and Korean American identities. Baltimore: Johns
Hopkins University.
ian's need for medical facts with the psychotherapist's Korean
Korean American campus evangelicals. In M. Zhou & J. Lee
(Eds.), Asian American youth: Culture, identity and ethnicity
(pp. 235-250)~ New York: Routledge.
Lee, J. (2002). Civility in the city. Cambridge, MA: Harvard
University Press.
Min, P. G. (1996). Caught in the middle. Berkeley: University of
California Press.
Min, P. G. (1998). Changes and conflicts. New Immigrants Series.
Boston: Allyn & Bacon.
Min, P. G. (2006). Korean Americans. In P. G. Min (Ed.), Asian
Americans: Contemporary. trends and issues (pp. 230-259).
Thousand Oaks: Pine Forge Press.
Park, K. (1997). The Korean American dream: Immigrants and
small business in New York city. The anthropology of con-
temporary issues. Ithaca, NY: Cornell University.
Zhou, M., & Lee, J. (2004). Introduction: The making of culture,
identity, and ethnicity among Asian American youth. In J. Lee
& M. Zhou (Eds.), Asian American youth: Culture, identity and
ethnicity (pp. 1-30). New York: Rutledge.
FURTHER READING
Choi, G. (1997). Acculturative stress, social support, and
depression in Korean American families. Journal of Family
Social Work, 2, 81-97.
172 ASIAN AMERICANS: KOREANS
Danico, M. Y. (2002). Internalized stereotypes and shame: The
struggles of Lfi-generation Korean Americans in Hawaii.
In L. T. Vo & R. Bonus (Eds.), ConremporaryAsian American
communities: Intersections and divergences (pp. 147-160).
Philadelphia: Temple University Press.
ive need for confidence and trust" (Jaffee at p. 1928 citing
differences in Korean and Anglo-American preschoolers'
social interaction and play behaviors. Child Development,
66, 1088-1099.
Kim, I. ]. (Ed.). (2004). Korean-Americans: Past, present, and
future. Elizabeth,N]: Hollym International.
Kim, S., Conway-Turner, K., Sherif-Trask, B., & Woolfolk, T.
(2006). Reconstructing mothering among Korean immi-
grant working class women in the United States. Journal of
Comparative Family Studies, 37, 43-5&.
Kim, S., & Rew, L. (1994). Ethnic identity, role integration,
quality of life, and depression in Korean-American women.
Archives of Psychiatric Nursing, 8, 348-356.
Kim, U., & Choi, S. H. (1994). Individualism, collectivism,
and child development: A Korean perspective. In P. M.
Greenfield & R.R. Cocking (Eds.), Cross-cultural roots of
minority child development (pp. 227-257). Hillsdale, N]:
Lawrence Erlbaum.
Kwak, K., & Berry,]. W. (2001). Generational differences in
acculturation among Asian families in Canada: A
comparison of Vietnamese, Korean, and East-Indian
groups. International Journal of Psychology, 36, 152-162.
Lee, j., & Zhou, M. (Eds.). (2004). Asian American youth:
Culture, identity and ethnicity. New York: Routledge.
Lee, S. ]. (1996). Unraveling the model minority stereotype.
New York: Teachers College, Columbia University.
Takaki, R. (1998). Strangers from a different share: A history of
Asian Americans. New York: Penguin Books.
Tuan, M. (1995). Korean and Russian students in a Los
Angeles high school: Exploring the alternative strategies of
two high-achieving groups. In R. G. Rumbaut & W. A.
Cornelius (Eds.), California's immigrant children:
Theory, research and implications for educational policy (pp.
107-130). San Diego, CA: Center for U.S.-Mexican Studies,
University of California.
Uba, L. (1994). Asian Americans: Personality patterns, identity and
mental health. New York: Guilford.
Waters, M. C., Ueba, R., & Marrow, H. (Eds.). (2007).
The new Americans: A guide to immigration since 1965.
Cambridge, MA: Harvard University Press.
-YOONSUN CHOI
SOUTIl ASIANS
ABSTRACT: This entry briefly profiles the dynamic
fusion, fluidity, and future of South Asians in America.
While Diaspora India is emblematic of immigrant cul-
ture as a whole, South Asian duality still remains
uniquely enigmatic. People from South Asia represent a
confluence of diversity and complexity that calls for
understanding and acceptance as a model to decon struct
a tolerant and successful pluralist society.
KEY WORDS: South Asia; Diaspora India; postcoloni-
aliry: globalization; inanity of practice research, and
cultural fusion and alienation
South Asians in America, like characters from a Mira Nair
film, are products of the "push and pull" theory, which makes
pluralist fusion and fluidity a multicultural, global
phenomenon. Cultural fluidity is America's new thrust for
integrative pluralism. They add to America's diversity with
their rich heritage, culture, and educational background. South
Asian ideals of Karma and dharma have helped them morph
into living karam-yogis in pursuit of prosperity and hap- .
piness. Indian Americans are postmodern yogis in pursuit of
material happiness earned by a classic Hindu work ethic that
puts premium on dedicated action.
As creators of a transplanted culture, their IndoAmerican
ethos and enthusiasm bubbles with Diaspora nostalgia and
unabashed attraction amid pervasive alienation. Indian
Americans live a schizophrenic duality of life in America:
they love and loathe what they have acquired and what they
have lost in a foreign land. As a group they. enjoy the benefits
of a free and open society; as members of a caste-ridden
culture, however, they seem perplexed with suffocating
foreign exclusions. As an overwhelming majority of South
Asians come from middle class (and higher castes), they find
pervasive exclusionary practices both puzzling and dis-
criminatory. Between the Black and White paradigms-of
American society, the Browns' destiny still remains at odds
with their cherished American Dream. Pankaj Mishra (2006,
p. 112) writes
A decade of proglobalization policies has created a
new aggressive middle class, whose concerns dom-
inate public life in India. This class is growing; the
current members are between 150 and 200 millions.
'There are also millions of rich Indians living outside
India. In America, they constitute the richest mi-
nority. It is these affluent, upper-caste Indians in India
and abroad who-largely bankrolled the rise of power of
Hindu nationalists. In the global context, middle class
Hindus are no less ambitious than those who in the
Roman Empire embraced Christianity and made it an
effective mechanism with which to secure worldly
power.
The South Asians in America constitute a reality that
represents what is good in a world that is once again "flat"
(Friedman, 2005). The new earthers, however, are not wedded
to a single-minded orthodoxy. They are expertly bright,
amazingly self-reliant, and pragmatically resilient. It is,
however, a myth that all South Asians are rich and affluent,
though as a group,

they constitute one of the most prosperous segments of our
pluralist society.
South Asians in the United States Diaspora
India dates back to early 19th century. "Between
1820 and 1976 a total 6f over 130,000 East Indian
immigrants entered the United States; fewer than
17,000 of these came before 1965" (Balgopal,
1995a, 1995b; Jensen, 1980, pp. 296-30l).The
passage of the Immigration and Nationality Act of
1965 marked a watershed event in the patterns and
policies that dramatically increased South Asian
emigration (for details see Joan M. Jensen in
Thernstrom (1980, pp. 296-301) and Pallasana R.
Balgopal (1995a, 1995b. According to, the 2000
U.S. Census, the South Asian population is in
excess of 2 million people. Of this approximately
90% are Asian Indian, 7% Pakistani, 2 %
Bangladeshi, and 1 % Sri Lankan. If undocumented
immigrants and historical undercounting are considered,
the number of South Asian households is estimated to be
750,000 (http://www.namastetv.com/ aboutus.html,
retrieved March 15,2007).
South Asians, also called Asian Indians, Indian
Americans, and Indo-Americans, represent 'rhe hetero-
geneity of the Indian subcontinent although most of them
(at least 85%) are Caucasian (Jensen, 1980, p. 296). India
is a land of unity in diversity. Despite many a sociocultural
difference, their ethnic evolution on the subcontinent
marks a mutifaceted trajectory. Although most immigrants
tend to settle in coastal areas, their varied occupational and
professional callings bring them to almost every part of the
country in business, education, health care, information
technology, engineering, journalism, social work, industry,
politics, and other fields.
Three recent developments distinguish South Asians
from other immigrants:
1. globalization and India's technological ad-
vancements;
2. transformation of postcoloniality into postideological
free market economy; and
3. the post-9fl1 impact on Indo-American collaboration
with strategic implications for future interactions.
On the micro level, most South Asians tend to be
industrious, motivated, English-speaking; god-fearing, and
law-abiding citizens, permanent residents, or visitors. The
India that they left continues to be a source of inner tension
even after computers, l-Chat, media networks, cell phones,
affordable air travel; Bollywood entertainment is "dished"
out in their fabulous media rooms. Culture seems to
TORS
D
ASIAN AMEIuCANS: SOUTH ASIANS 173
Syndrome-a benign, hitherto nonexistent behavioral
category. India Syndrome, however, is a kind of neurosis
with undefined parameters with well-acknowledged
behavioral patterns chiefly characterized by a pervasive
ambivalence toward their past, present, and future.
Policy, Practice, and Research Issues
Social work education, practice, policy, and research have
a symbiotic relationship with South Asians. This creative
interface has enriched social work as a profession, and
South Asians have benefited both professionally and
materially. For example, certain fields in social work owe a
special debt to these South Asian pioneers:
Shankar Yaleja (policy practice), Rainesh Mishra (social
welfare and policy), Sumanti Dubey (social administra-
tion), Shanti Khinduka (social development), Saiyid Zafar
Hasan (social security and administration), Daniel Sanders
(international social work), Frank Paiva and Rama Pandey
(social development), and Brij Mohan (comparative social
welfare and social work theory).
Modeis of ethnically sensitive and culturally competent
practice have largely focused on target populations with
emerging needs for personal and social services. As the
immigrants begin to grow roots, family and child welfare
services, health and mental health, aging, immigration,
refugees, and disabilities demand better and adequate
research and intervention. Our newest models of
practice-based on strength, resilience, and ecological
perspectives-correspond closely with South Asian. cultural
values that help cope with and adjust to life's cycles in a
myriad of ways.
Counseling, especially adolescent and marital, is an
area for practice that has not yet received the attention it
demands. There is no other sphere of concerns that is more
worrisome and at times even traumatic than raising young
girls in a permissive society. Many parents consider
attendance at Hindu temple to be a way of encouraging a
proper sense of values in their daughters, thereby
discouraging them from dating. There is ample evidence
that the children of the first-generation immigrants are
doing exceedingly well in personal, intellectual, and
professional lives. While most South Asians tend to be
adaptive and resilient, many of them choose to live in
denial about their children's dreams and perceptions.
Needless to say, the existing practice models will yield no
satisfying outcomes. They were originally designed for
different counseling-prone target populations. The South
Asian genius, temperament, and perspective on life are
remarkably immune to the Western model of practice
research in crisis and precrisis situations (Mohan, 1992b;
1989a).
As regards social and public policy, social work
practitioners must understand that even the most
174 ASIAN AMERICANS: SOUTH ASIANS
successful and affluent people are often subjected to
humiliation, harassment, and discrimination in their working
environments and beyond. As newly added colors of the
American diversity rainbow, South Asians confront many
American practices and behaviors that thwart their
aspirations. Where business and in, dustry largely look for
their "bottom lines," educational and professional settings,
ironically, tend to be restrict, ive and discriminatory,
unmindful of the fact that American multicultural society has
morphed beyond the old "Black and White" paradigm; change
of a passport does not change identity (Mohan, 1989b).
Notwithstanding a stunning success, the South Indian remains
a marginalized person in search of a new identity lurched
inside the world's two most important democracies (Mohan,
1992a).
The new generation of South Asians is contributing to
American diversity and ingenuity in fields that were
traditionally confined to the privileged class of White
Americans. Literature (Salman Rushdie, [umpa Lahiri, arid
Kiran Desai); medicine (Sanjay Gupta); music (Nora Jones)
politics ("Bobby" Jindal was elected governor of Louisiana,
the first Indian American to be elected governor); diplomacy
(Bhishma K. Agnihotri); economics (Amartya Sen and
Jagdish Bhagwati): films (Deepa Mehta, Mira Nair (see
James, c. 2007; corporate business (Indira Nooyi, CEO
Pepsi Cola); and wellness and spirituality (Deepak Chopra).
Infosys Technologies founded by an Indian recently- sent
2,500 Americans to seek IT training in India. India's medical
tourism further validates the turn' ing point in the
Indo-American dyad. Medical tourism is outsourcing of
medical treatment and care outside the U.S. borders. India,
Singapore, and Thailand are main centers of providing
cheaper and better medical services. More than 6,000
Americans went to India for such treatment last year. The
world events have, however, widened a sense of cultural
identity. After 9/11, says Mira Nair, "the experience of those
who were like us became so different. Suddenly we were the
others. It has abated to some extent, but at times continues to
rear its jingoistic head. You realize it's not so simple to blend
in" (http://wwW.namastetv. com/aboutus.html, retrieved
March 15, 2007). The new culture of social work itself
remains an alienating field for some of its South Asian
pioneers (Mohan, 2002,2005).
REFERENCES
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Hopps (Eds.), Encyclopedia of social work (3rd ed., pp.
256-260). Washington, DC: National Association of Social
Workers.
BalgopaI, P. R. (1995b). Asian Americans overview. In R. L
Edwards & J. G. Hopps (Eds.), Encyclopedia of social work
(19th ed., pp. 231-237). Washington, DC: National
Association of Social Workers.
Friedman, T. (2005). The world is flat. New York: Penguin Books.
James, c. (2007, March 11). The endless journey home. New
York Times, pp. 12, 14.
Jensen, J. M. (1980). East Indian. In S. Thernstrom (Ed.), Harvard
encyclopedia of American ethnic groups (pp, 296-301).
Cambridge, MA: The Belknap Press of Harvard University
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Mishra, P. (2006). Temptations of the West (p. 112). New York:
Farrar, Straus and Giroux.
Mohan, B. (1989a). Youth alienation: Indo-American ethnicity
and mental health. Jourruil of International and Comparative
Social Welafre, 5(2),29-41.
Mohan, B. (1989b). Ethnicity, power and discontent: The
problem of identity reconstruction in a pluralist society. Indian
Journal of Social Work, 1, 199-212.
Mohan, B. (1992a). Democracies of unfreedam: India and tile United'
States. Westport, CT: Praeger.
Mohan, B. (1992b). Trans-ethnic adolescence, confluence and
conflict: An Asian Indian paradox. In S. M. Furuto, R. Biswas,
et al. (Eds.), Social work practice with Asian Americans.
Newbury Park, CA: Sage Publications.
Mohan, B. (2002). Social work revisited. Philadelphia: Xlibris,
Random House.
Mohan, B. (2005). Reinventing social work: Reflections on tile
metaphysics of social practice. Lewiston, NY: Edwin Mellen
Press.
-BRI) MOHAN
SOUTHEAST ASIANS
ABSTRACT: The end of the Viet Nam war, officially
concluded on April 30, 1975, created a global diaspora
from the Southeast Asian region. The geographic di-
versity reflects equally the diversity in language, reli-
gion, and ethnicity in the people who settled in the
United States. The inherent diversity in refugee
experiences and personal backgrounds has produced
unequal personal and social adjustment among the
three ethnic groups in their resettlement over the years.
In general, Southeast Asian refugees have attained
social integra, tion as their offspring are developing an
ethnic identity as members of the second- or
third-generation of U.S.born Americans.
KEY WORDS: Southeast Asian Americans; intraethnic
groups; acculturation
Common History, Different History
The term Southeast Asian was deliberately used to describe
the citizens of the countries involved in the

regional U.S.-Viet Nam war. Southeast Asia is a sub,
region of Asia, consisting of two geographic regions: the
Asian mainland, and island arcs and archipelagoes to the
east and southeast. The mainland section consists of
Cambodia, Laos, Myanmar, Thailand, and Vietnam. The
maritime section consists of Brunei, East Timor,
Indonesia, Malaysia, and Philippines. (United States
Catholic Conference [USCC], 1984). The geographic
diversity reflects equally the diversity in language, reli-
gion, and ethnicity in the people who left Southeast Asia
for settlement in the United States. Southeast Asians are
a diverse population encompassing members of as many
as a dozen ethnically distinct groups (for example,
Khmer Krom, Hmong, Iu-Mien, Chinese, Cham, Lao,
Lao Lourn, Meo, Muong), a wide range of religious
belief systems or affiliations (for example, Theravada
Buddhist, Taoism, Confucianism, Mahaya na Buddhism,
Chris, tianity, Animism), and disperse dialectic
languages (for example, Tay, Muong, Khmer, Chinese,
Hmong, Vietnamese, Tai Dam, Chamic) (USCC, 1984 ).
Immigration History
The end of the Viet Nam war, officially concluded on
April 30, 1975, created a global diaspora only matched
by the refugee exodus during the Second World War. To
facilitate the massive. refugee displacement, Con gress
enacted the Indochina Migration and Refugee
Assistance Act to assist in the relocation to the United
States of U.S. government-employed Vietnamese na-
tionals and their families. The large and constant influx
of refugees further motivated the Refugee Act of 1980 to
facilitate the large-scale resettlement of these refu gees to
the United States.
Nearly 3 million Southeast Asian refugees have
settled in the 50 states, accounting for half of the 12
million Asian Pacific Islander population or 1.1 % of the
U.S. population. The following population distribution
is based on the 2005 U.S. American Community Survey
(Census Bureau data): Hmong (184,265), Lao
(193,245), Cambodian (217,438), and Vietnamese
(1,418,334). More than 40% of them chose California
and Texas as the place of refuge.
The inherent diversity in the refugee experiences (for
"example, brutality suffering, family separation) and
personal backgrounds (for example, Western
familiarity, education, vocational skills) has produced
unequal personal and social adjustment among the three
ethnic groups-Vietnamese, Laotian, and Cambodian-in
their resettlement over the years. In general, the South,
east Asian refugees have attained social integration as
their offspring are developing an ethnic identity as
members of the second- or third, generation of
Ll.Si-born Americans.
ASIAN AMFRICANS: SOUTHEAST ASIANS 175
Social Issues in the First Decade (1975-1985) As
personal and social changes were occurring at every
level (that is, language, social customs, job skills, social
network), most Southeast Asians were reluctantly
accepted. Immediately upon resettlement nearly all
Southeast Asians were confronted with these basic
demands or requirements, for example, language acqui-
sition, cultural shock and adaptation, vocational skill
replacement, cultural adjustment, and family reunifica-
tion (see Rumbaut, 1986; Tobin & Friedman, 1984).
Those social demands affected people unequally at dif-
ferent ages or life stages. Children were more adept at
learning a new language and immersing into the
American school environment. Parents had the most
difficulty as they had to search for means toward eco-
nomic independence with the least adaptability to these
social and cultural demands (see Abueg & Chun, 1996;
Carlin, 1990; Tran, 1987). Adolescents were confronted
with their biological development in an entirely new
social environment that may possibly be hostile (for
example, Tobin & Friedman; 1984).
In the first decade most Southeast Asian refugees
made some advances through the involuntary life
transition from their former life and occupation to a new
life and occupation. Many struggled with their own
psychological and psychiatric states while going
through these upheavals and transitions (see Abueg &
Chun, 1996; Kinzie, Frederickson, Rath, Fleck, &
of counseling research and training: The cross-cultural
tural perspective. Journal of Coun & Tor, 1997; Tobin &
& Friedman, 1984).
considerations (Luckasson et and Third
and Third Decades (1985 to Present) Moderate
economic and social progresses were noted in the
second decade, while many Southeast Asians
experienced chronic stressors associated with
underemployment and cultural adaptation (see Beiser,
Turner, & Ganesan, 1989; Clarke, Sack, & Goff, 1993).
English skills for the children, adolescents, and young
adults vastly improved, as the majority achieved aca-
demic successes at all levels. Older adults continued to
face difficulty in language acquisition, cultural adapta-
tion, and skill development, which pattially contribut ed
to the parental schism with their children and their
"Americanized" social attitudes and behaviors.
For many their mental health problems continue,
more than 20 years later (for example, Boehnlein et al.,
2004; Marshall et al., 2006; Marshall, Schell, Elliott ,
Berthold, & Chun, 2005; Sack et al., 1994; Sack, Him, &
Dickason, 1999; Steel, Silove, Phan, & Bauman, 2002).
Substance use and abuse issues began to surface (for
example, Bermingham, Brock, Tran,
176 ASIAN AMERiCANS: SOUTHEAST ASIANS
Yau,& Tran-Dinh, 1999; D'Amico, Schell, Marshall, &
Hambarsoomians, 2007; D'Avanzo, 1997; Nemoto et
al., 1999; O'Hare & Tran, 1998).
Stigmatized problems affecting women (for exam,
ple, Strumpf, Glicksman, Goldberg-Glen, Fox, &
Logue, 200l) and children (Mollica et al., 1997; Rous-
seau, Drapeau, & Platt, 2004; Sack et al., 1994, 1999;
Tobin & Friedman, 1984) began to receive notice
through clinical assessment and research. Domestic
violence and child abuse were unveiled from the
secrecy of shame and ignorance (for example, Futa,
Hsu, & Hansen, 2001; Shin-Thornton, Senturia, &
Sullivan, 2005; Tran & Des jardins, 2000).
Through better health diagnosis and 'increased
aware, ness in the refugee community, physical
diseases began to gain medical attention through
proactive help, seeking behavior and treatinent services
(Chung & Un, 1994; Silove et al., 1997). Health
problems have included high rates of hypertension,
diabetes, heart disease,' stroke and seizures, increasing
risk for oral squamous cell cancer (from chewing betel
nuts), Hepatitis B virus, osteoporosis, and cancer (for
example, Caruana et a1., 2005, 2006; Centers for
Disease Control and Prevention [CDC], 2005;'
Culhane-Pera et al., 2005; Helsel, Mochel, & Bauer,
2005; Hinton, Chhean, Pich, Hofmann, & Barlow,
2006; Sanders, 2006; Wahlqvist, 2002).
Practice and Policy Recommendations
After more than thirty years re-creating a new life as
citizens of a new country, they have proudly considered
themselves Southeast Asian Americans. Despite many
positive changes Southeast Asian Americans (most
have become naturalized citizens) are confronted with
new challenges such as retirement and aging, which
increase their social isolation by poorer health, poor
English skills, and a geographically distant family
network.
Historical evidence shows that the health status of
new immigrants tends to convergence to the status level
of the general population over thesubsequent decades.
This public health concern requires culturally
responsive and effective health promotion and
prevention across all age groups and generations.
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Centers for Disease Control and Prevention (COC). (2005,
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741-744.
Chung, R. C., & Un, K. (1994). Help-seeking behavior among
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Clarke, G., Sack, W. R., & Goff, B. (1993). Three forms of stress
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Culhane-Pera, K., Peterson, K. A., Crain, A. L., Center, B. A~,
Lee, M., & Her, B., et al. (2005) Group visits for Hmong
adults with type 2 diabetes mellitus: A pre-post analysis.
Journal of Health Care for the Poor and Underserved, 16(2),
315-327.
D'Amico, E. J., Schell, T. L., Marshall, G. N., &
Hambarsoomians, K. (2007)' Problem drinking among ,
Cambodian refugees in the United States: How big of a problem
is it?Journal of Studies on Akohol Drugs, 68(1), 11-17.
D'Avanzo, C. E. (1997). Southeast Asians: Asian-Pacific
Americans at risk for substance misuse. Substance Use and
Misuse, 32(7-8), 829-848.
Futa, K. T., Hsu,E., & Hansen, D. J. (2001). Child sexual abuse in
Asian American families: An examination of cultural factors
that influence prevalence, identification, and treatment.
Clinical Psychology: Science and Practice, 8, 189-209.
Helsel, D., Mochel, M., & Bauer, R. (2005). Chronic illness and
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Chun, C. A, & Hambarsoomians, K. (2006). Rates and
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Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S. M., &
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(1997). Effects of war trauma on Cambodian refugee ado-
lescents' functional health and mental health starus.Joerncl of
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Wong, W. (1999). Drug use behaviors among Asian drug users
in San Francisco. Addictive Behaviors, 24(6), 823-838.
O'Hare, T., & Tran, T. (1998). Substance abuse among Southeast
Asians in the U.S.: Implications for practice and research.
Social Work in Health Care, 26(3), 69-80.
Rousseau, c., Drapeau, A, & Platt, R. (2004). Family envi-
ronment and emotional and behavioral symptoms in
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and acculturation. Medical, Conflict and Survival, 20(2), 151-165.
Rumbaut, R. G. (1986). Mental health and the early experience: A
comparative study of Southeast Asian refugees. In T. C. Owan
(Ed.), Southeast Asian mental health: Treatment, prevention,
services, training, and research (pp. 433-486). Bethesda, MD:
National Institutes of Health.
Sack, W. H., Him, c., & Dickason, D. (1999). Twelve-year
follow-up study of Khmer youths who suffered massive war
trauma as children. Journal of the American Academy of Child and
Adolescent Psychiatry, 38, 1173-1179.
Sack, W. H., McSharry, S., Clarke, G. N., Kinney, R., Seeley, J.,
& Lewinsohn, P. (1994). The Khmer adolescent project. I.
Epidemiological findings in two generations of Cambodian
refugees. Journal of Nervous and Mental Disease, 182, 387-395.
Sanders, J. (2006) The new face of refugee resettlement in
Wisconsin: What it means for physicians and policy makers.
WMJ, 105(3),36-40.
Shiu-Thornton, S., Senturia, K., & Sullivan, M. (2005). "Like a
bird in a cage": Vietnamese women survivors talk about
domestic violence. Journal of Interpersonal Violence, 20(8),
959-976.
ASIAN AMERICANS: SOUIHEAST ASIANS 177
Silove, D., Manicavasagar, V., Beltran, R., Le, G., Nguyen, H., &
Phan, T., et al. (1997). Satisfaction of Vietnamese patients and
their families with refugee and mainstream mental health
services. Psychiatric Services, 48(8), 1064-1069.
Steel, Z., Silove, D., Phan, T., & Bauman, A. (2002). Longterm
effect of psychological trauma on the mental health of
Vietnamese refugees resettled in Australia: A populationbased
study. Lancet, 360(9339), 1056--1062.
Strumpf, N. E., Glicksman, A, Goldberg-Glen, R. S., Fox, R. c.,
& Logue, E. H. (2001). Caregiver and elder experiences of
Cambodian, Vietnamese, Soviet Jewish, and Ukrainian
refugees. International Journal of Aging and Human Development,
53(3), 233-252,
Tobin, J. J., & Friedman.]. (1984). Intercultural and develop-
mental stresses confronting Southeast Asian refugee adoles-
cents. Journal of Operational Psychiatry, 15,39-45.
Tran, T. V. (1987). Alienation among Vietnamese refugees in the
United States: A causal approach. Journal of Social Service
Research, 5(1), 59-75.
Tran, C. G., & Des [ardins, K. (2000). Domestic violence in
Vietnamese refugee and Korean immigrant communities. In J.
L. Chin (Ed.), Relationships among Asian American women (pp.
71-100). Washington, DC: American Psychological
Association.
United States Catholic Conference. (1984). Refugees from
Southeast Asia: A look at history, culture, and the refugee crisis
(Refugee Information series). Washington, DC: Author.
Wahlqvist, M. L. (2002) Asian migration to Australia: Food and
health consequences. Asia Pacific Journal of Clinical Nutrition,
11 (3), S562-568.
FURTHER READING
Kinzie, J. D., Sack, W. H., Angell, R. H., Clarke, G., & Ben, R.
(1989). A three-year follow-up of Cambodian young people
traumatized as children. Journal of the American Academy of
Child and Adolescent Psychiatry, 28, 501~504.
Rousseau, c., & Drapeau, A (1998). Parent-child agreement on
refugee children's psychiatric symptoms: A transcultural
perspective. Journal of the American Academy of Child and
Adolescent Psychiatry, 37(6), 629.c..636.
Rousseau, c., Drapeau, A, & Platt, R. (1999). Family trauma and
its association with emotional and behavioral problems and
social adjustment in adolescent Cambodian refugees. Child
Abuse and Neglect, 23(12), 1263-1273.
SUGGESTED LINKS Southeast Asia Community
Resource Center.
http://www.searac.org/resourcectr.html
mong Cultural Center.
http://www.hmongcenter.org/
RBIDITY udies Journal.
http://www.hmongstudies.org/HmongStudiesJournal
Leadership, Education for Asian Pacifies, Inc.
http://www.leap.org/
Center for Southeast Asian Studies, Northern Illinois University.
http://www.seasite.niu.edu/
178 ASIAN AMERICANS: SOUTHEAST AsIANS
Cambodia Information Center.
http://www.cambodia.org/
Virtual Viet Nam Archive, Texas Tech University.
http://www.vietnam.ttu.edu!virtuaIarcmve/
Nam Viet Net . "
http://www.namviet.net!
Hmong Homepage.
http://www.hmongnet.org/
Viet Nam: Yesterday and today.
http://servercc.oakton.edu!-wittman/vietlink.htm#news The
Mekong Network.
http://www.mekong.net!
Lao Study Review, Web academic journal on Laos.
http://home.vicnet.net.au!-Iao/1aostudy/1aostudy.htm Web site
of the NIU Center for Southeast Asian Studies.
www.seasite.niu.edu
. \
The East Asia Center of the University of Virginia.
http://www.virginia.edu!eastasia/
-PAUL DUONOTRAN
ASSESSMENT
ABSTRACT: Assessment is an ongoing process of data
collection aimed at identifying client strengths and
problems. Early assessment models were based on psy-
choanalytic theory; however, current assessment is
based on brief, evidence-based practice models. B oth
quantitative .and qualitative methods may be used to
create an integrative skills approach that links assess-
ment to intervention. Specifically, assessment guides
treatment planning, as well as informs intervention
selection and monitoring.
KEY WORDS: assessment; diagnosis; integrative skills
assessment; qualitative methods; quantitative methods
Assessment is an ongoing process of data collection
aimed at understanding clients in the context of their
environmental systems (Jordan & Franklin, 2003, p.l).
Multiple methods should be used to formulate a com-
plete picture of this intricate system; these may include
both quantitative and qualitative techniques. Quanti-
tative techniques are methods that allow for operation-
ally defining clients' problems. An example is a scale
that gives a numerical score of the client's depression.
Qualitative techniques, on the other hand, describe the
complexity of clients' problems in more detail. An
example of a qualitative measure is a mapping tech-
nique such as a genogram. This entry will address as-
sessment as an integrative approach, linking assessment
and intervention, and will discuss quantitative and
qualitative methods.
An Integrative Skills Assessment Approach Several
practice models have made an important contri bution to
social work assessment. Jordan and Franklin (2003, pp.
7-12) reviewed early assessment models, including the
psychosocial model of Florence Hollis, Gordon
Hamilton, and Helen Perlman. The term
person-in-environment originated in this approach, and its
goal is to determine a client's psychosocial diagnosis. An
adaptation of the psychosocial model is the functional
approach that deemphasized history and focused on
clients' problem-solving ability. These models were
based on psychoanalytic theory early on, and ego
psychology as the model evolved. Specific techniques'
used included classical psychiatric inter viewing, as well
as testing, observations, and interpretations. In contrast,
today's assessment has been influenced by brief,
evidence-based practice models. Contributors include
Eileen Gambrill and Richard Stuart, whose behavioral
approaches brought the measurement perspective into
social work practice. Hudson (1982) developed a
clinical assessment system of computerized scales to
easily measure clients' inter- and intrapersonal
problems. Kevin Corcoran and Joel Fischer published
the first volume of their Measures for Clinical Practice in
1987; this book of measures was designed for use in
daily clinical work. In 1995,}mdan and Franklin
attempted to integrate qualitative and quantitative
approaches to create 'a comprehensive assessment
approach that they referred to as an integrative skills
assessment approach. An integrative skills assessment
model has these characteristics: theoretical and technical
eclectism and a de-emphasis on history, as well as an
emphasis on problem and strengths. defining, treatment
planning, and outcome monitoring. Building
collaborative relationships with clients is an important
component of the assessment; the quali tative techniques
may help with this. Also, collaborative relationships
may help the client move successfully from the
assessment phase into intervention.
Linking Assessment and Intervention
Today's assessment is an evidence-based approach,
CLINICAL DECISION-MAKING Evidence-based ap-
proaches assume that the best evidence is used along
with critical thinking skills, knowledge of best
practices, and client input (Gibbs & Gambrill, 2002;
McNeece & Thyer, 2004). Assessment is an ongoing
process beginning with problem (and strength)
identification using both quantitative and qualitative
techniques.
PROBLEM MONITORING Qualitative data help the
practitioner to understand clients' contextual issues

and to establish rapport, while quantitative data may be
used to monitor clients' problems and strengths. Mon-
itoring may be structured by using a single subject design
approach (Bloom, Fischer, & Orme, 2005). Problems
targeted for change are monitored over the course of
treatment, usually weekly or even daily. That is, the client
completes the same measurement over time so that
comparisons may be made to track im- provements. These
improvements are tracked over the phases of treatment,
usually baseline (assessment), treatment, and follow-up.
Data are analyzed using a variety of simple statistical
procedures. The intervention may be changed if necessary,
if the monitory reveals that no progress is occurring.
TREATMENT PLANNING
Moving from Assessment to Intervention. Jordan and
Franklin (2002) presented an evidence-based framework
for treatment planning with families, including the
following steps: problem selection, problem definition,
goal development, objective construction, intervention
creation, and diagnosis determination. Interventions
should logically follow from the problems identified at the
assessment (beginning) phase, called baseline. The baseline
data indicate the extent and severity of the problem, as well
as appropriate outcomes or goals. Following with an
evidence-based approach, practitioners search the
literature for interventions showing the best evidence at
solving the client's particular problem.
Quantitative Clinical Assessment. Methods
Quantitative assessment methods provide us with a
numerical representation of clients' problems or strengths.
RATIONALE FOR INCLUDING QUANTITATIVE
MEASURESIN ASSESSMENT Four reasons help us
understand the benefit of using quantitative measures in
client assessment (Jordan & Franklin, 2003, pp. 73-74).
First, understanding, measuring, and monitoring improve
the treatment process. This allows treatment to be changed
if no progress is seen. Second, use of clinical research
methods allows practitioners to contribute to the clinical
practice knowledge base. Third, practice evaluation
provides the accountability necessary for managed care
and external funders. Fourth, today's practice environment
requires social workers to possess greater measurement
skills to be competitive with other similar professionals.
QUANTITATIVE METHODS OF MEASURING
CLIENT BEHAVIOR Examples of quantitative methods
that may be used by practitioners include the following:
ASSESSMENT 179
(a) client self-reporting and monitoring, (b) self-anchored
and rating scales, (c) questionnaires, (d) direct beha-
vioralobservation, (e) role play and analogue situations, (f)
behavioral by-products, (g) psychophysiological
measures, (h) goal attainment scaling, (0 standardized
measures, and (j) projective measures.
RESOURCES AND GUIDELINES Guidelines for devel-
oping a measurement system for assessment include the
following: (a) using multiple methods, (b) developing
baseline indicators of client functioning, (c) using repeated
measures, and (d) using both global and specificmeasures.
A resource for obtaining quantitative methods is Corcoran
and Fischer's Measures for Clinical Practice (2005).
Qualitative Clinical Assessment Methods Qualitative
assessment methods seek to understand the meaning of the
client system by using contextual techniques and add an
extra level of depth to the clinical assessment.
RATIONALE FOR INCLUDING QUALITATIVE MEA-
SURES IN ASSESSMENT Qualitative techniques such as
biographical narratives, interviews, or experiential
exercises seek a holistic understanding of the client. Five
unique contributions that qualitative assessment measures
bring include, first, the ability to uncover
. realities that would be missed. when using only
quantitative approaches (Jordan & Franklin, 2003, pp.
143-146). For example, a client may be asked to keep a
diary to add context to her standardized measurement
recording her depression. Second, the standardized
instruments used in quantitative assessments have limited
usefulness for people of color. Qualitative assessments
offer open-ended process-oriented techniques to access
clients' cultural scripts and meanings. Third, qualitative
assessments promote practitioner's self-awareness and
therefore a positive therapeutic alliance. Fourth, the
holistic nature of qualitative assessment encourages a
reciprocal client-social-worker relationship. Finally, a fifth
rationale relates to qualitative technique's fit with many
theoretical and therapeutic perspectives, including family
systems, ecosystems, cognitive-constructivist, feminist
therapies, and so forth.
QUALITATIVE METHODS OF MEASURING CLIENT
BEHAVIOR Qualitative method~ include ethnographic
interviewing; narrative approaches such as process re-
cording, case studies, and self characterization; repertory
grids; graphic methods; and participant observations.
180 ASSESSMENT
RESOURCES AND GUIDELINES Validity and reliabil ity are
very important in qualitative assessment and re st on the
credibility and completeness of the data col, lected.
Questions to ask include the following: Were multiple
measurements used? Does the information tell the whole
story? Do the conclusions drawn make sense? Are there
any unexplained gaps? and so forth. For a resource, see
Deborah Padgett's The Qualitative Research Experience
(2003).
eatment aAssessment is an
Assessment is an ongoing, process . whereby qualitative
and quantitative assessment methods may be used to-
gether in data-gathering. The use of multiple methods is
necessary to improve the .reliability and validity of
clinical information. Specifically, qualitative methods
may enhance the clinician's understanding of the con, text
within which problems occur, while quantitative methods
provide information on the specific nature of the problem.
The assessment then informs treatment planning and
guides intervention selection.
Future Trends
With the. increasing emphasis on evidence-informed
practice, assessment i s certain to latch on to this broad, er
definition as well. Evidence-informed practice is defined
by the Institute of Medicine as consideration of research
evidence, clinician expertise, client values, in addition to
contextual variables in clinical decision making
(http://www.ebbp.org/AboucEB.html). Add, ing
contextual variables to the assessment equation gives a
meatier picture of the client-in-situation, taking us as
social workers back to our roots.
REFERENCES
Bloom, M., Fischer, J., & Orme, J. (2005). Evaluating practice;
Guidelines for the accountable professional (5th ed.). Boston:
Allyn & Bacon.
Corcoran, K., & Fischer, J. (2005). Measures for clinical practice.
New York: Free Press.
Gibbs, L., & Gambrill, E. (2002). Evidence-based practice:
Counterarguments to objections. Research on Social Work
Practice, 12(3),452-476.
Hudson, W. (1982). The clinical measurement package.
Homewood, IL: Dorsey Press.
Jordan, C., & Franklin, C. (1995). Clinical assessment for social
workers; Quantitative. and qualitative methods. Chicago:
Lyceum Books.
Jordan, c., & Franklin, C. (2002). Treatment planning with
families: An evidence-based approach. In A. Roberts &
G. Greene (Eds.), Social worker's desk reference. New York:
.The present experiences oJordan, c., & Franklin, C. (2003).
Jordan, c., & Franklin, C. (2003). Clinical assessment for social
workers: Quantitative and qualitative methods (2nd ed.).
Chicago: Lyceum Books.
McNeece, A., & Thver, B. (2004). Evidence-based practice and
~ocial work. Journal of Evidence-Based Social Work, 1 (1),
7-24.
Padgett, D. (2003). The qualitative research experience. Belmont,
CA: Wadsworth.
FURTHER READING
Hoefer, R., & Jordan, C. (in press). Missing links in evidence-
based practice for macro social work. In M. Roberts-
DeGennaro (Ed.), Journal of Evidence-Based Social Work.
SUGGESTED LINKS
Walter W. Hudson's WALMYR Publishing Co.-Assessment
Scales.
http://www.walmyr.com/scales .html Psychological
Assessment http;//www.apa.org/joumals/pas/
http;//www.guidetopsychology.com/testing.htm
-CATHELEEN JORDAN
ASSET BUILDING
ABSTRACT: Since 1991, a new policy discussion has
arisen in the United States and other countries, focus ing
on building assets as a complement to traditional social
policy based on income. In fact, asset- based pol; icy
already exists in the United States, with large public
subsidies. But the policy is regressive, benefiting the rich
far more than the poor. The goal should be a universal and
progressive asset-based policy. One prom ising pathway
may be Child Development Accounts beginning at birth,
with greater public deposits for the poorest children.
KEY WORDS: assets; saving; social policy; develop ment;
Individual Development Accounts; Child Devel opment
Accounts
Assets are the stock of what people own or have, while
income is the flow of resources over a period of time.
Asset inequality is much greater than income inequal ity.
For example, this is especially evident by race. On
average, Whites have an average income about. 50%
greater than those of African Americans and Latinos,
which is a large inequality. But Whites have an a verage net
worth at least 10 times (1,000%) greater than those of
African Americans and Latinos (Kochhar, 2004; Oliver &
Shapiro, 1995).
Income (as a proxy for consumption) has been the
standard definition of poverty in the social policy. But
today there is increasing questioning of income as sole
definition of poverty and well-being. Sen (1993) and

others are looking toward capabilities. Asset-based
policy can be seen as part of this larger discussion, one
measure of long-term capabilities. As public policy,
asset building may be a form of "social investment"
(Midgley, 1999; Sherraden; 1991). From this perspec-
tive, asset-based policy could be an explicit comple-
ment to income-based policy.
ENCE nt examples of Ll.S, asset-based policy include
home ownership tax benefits; investment tax benefits;
defined contribution retirement accounts with tax ben-
efits at the workplace, such as 401(k)s, 403 (b)s, and
away from the workplace, such as Individual Retirement
Accounts (IRAs), and Roth IRAs. Other asset accounts
with tax benefits include State College Savings Plans
important factor in culturally competenned contribu-
contribution policies, i.e., individual accounts wherein
benefits depend upon the amount of assets accumulated,
have all appeared since 1970 and are growing rapidly.
Unfortunately, the poor receive almost none of the
benefits. Public subsidies operate through tax defer-
ments and exemptions and are tied to income in a
regressive way. The larger the income, the greater the
tax subsidy. The United States spends over $300 billion
annually in tax expenditures for asset building in homes,
investments, and retirement accounts, and over 90% of
this expenditure goes to households with incomes over
$50,000 per year (Corporation for Enter prise
Development, 2004; Howard, 1997).
As a response to regressive policy, in 1991 Indi-
vidual Development Accounts (IDAs) were proposed
asa universal and progressive asset-building policy
(Sherraden, 1991). As originally proposed, IOAs would
include everyone, provide greater support for the poor,
begin as early as birth, and be used for key development
and social protection goals across the lifespan, such as
education, home ownership, business capitaliza tion, and
retirement security in later life. IDAs have instead been
implemented in the form of short-term "demonstration"
programs targeted toward the poor. We have learned a
great deal during this demonstration process (Mills,
Gale, Patterson, & Apostolov, 2006; Schreiner &
Sherraden, 2007; Sherraden & McBride, in press). But
this is far from a comprehensive' assetbased policy.
Perhaps the most important contribution to date is
that saving and asset accumulation by the poor, which
was seldom discussed 15 years ago, is today a main-
stream idea in the United States, and political support is
bipartisan. Both Republicans and Democrats use the
language of "asset building," "asset-based policy,"
"stakeholding," and "ownership society." As always,
diversity of political support presents both opportunities
and risks. In this case, one political risk is that
ASSET BUILDING 181
asset-building policies might be viewed as a substitu te
for-rather than a complement to-income support
policies.
Asset-building policy may make the most sense
across a lifetime, beginning with children (Goldberg,
2005; Lindsey, 1994; Sherraden, 1991). In a major
policy development in 2001, Prime Minister Tony Blair
of the United Kingdom proposed a Child Trust Fund for.
all children, with progressive funding (Blair, 2001). In
April 2003, Blair announced that he would go forward
with the Child Trust Fund (H.M. Treasury, 2003). Since
2005, each newborn child in the United Kingdom is
given an account at birth, and children in lowincome
families receive more. Thus, the UK Child Trust Fund is
both universal and progressive.
In U.S. policy initiatives, the bipartisan ASPIRE Act,
which would create a savings account for every newborn
in the United States, has been introduced in the Congress
since 2004, and at this writing four other bills for
children's accounts are in the Congress. In applied
research, the Ford Foundation and several other
foundations are supporting a large demonstration of
Child Development Accounts (CDAs) in the form of the
Saving for Education, Entrepreneurship, and Down-
payment (SEED) initiative. The goal of SEED is to
model, test, and inform a universal and progressive
CDA policy for the United States (SEED pages on Web
site of the Center for Social Development at Washington
University in St. Louis, http://gwbweb.
wustl.edu/csd/SEED/SEED.htm) .
It is not possible to predict where this will lead.
Some of the policy advantages of asset building are that
it is simple and clear, is flexible and adaptable, appears
to have multiple positive outcomes, and has widespread
political appeal and acceptance. A considerable disad-
vantage is that current asset-based policy is very
regressive. The goal should be a universal and
progressive asset-based policy. If every person and
household has assets to provide for social protections
and invest in future development, this would contribute
to improved life chances and reduced inequality, both of
which are core values in social work.
REFERENCES
Blair, T. (2001, April 26). Savings and assets for all [Speech].
London: 10 Downing Street.
Corporation for Enterprise Development. (2004). Hidden in plain
sight: A look at the. $335 billion federal asset-building budget.
Washington, DC: Author.
Goldberg, F. (2005). The universal piggy bank: Designing and
implementing a system of savings accounts for children. In M.
Sherraden (Ed.), Inclusion in the American dream: Assets, poverty,
and public policy. New York: Oxford University Press.
182 ASSET BUILDING
H.M. Treasury. (2003). Details of the child trust fund. London:
Author.
Howard, C. (1997). The hidden welfare state: Tax expenditures and
social policy in the United States. Princeton, NJ: Princeton
University Press.
Kochhar, R. (2004). The wealth of Hispanic households.
Washington, DC: Pew Hispanic Center.
Lindsey, D. (1994). The welfare of children. New York: Oxford
University Press.
Midgley, J. (1999). Growth, redistribution, and welfare: Towards
social investment. Social Service Review, 77(1),3-21.
fied soG., Gale, W. G., Patterson, R., & Apostolov, E. (2006).
What do individual development accounts do? Evidence from
a controlled experiment [Working paper]. Washington, DC:
Brookings Institution.
Oliver, M., & Shapiro, T. (1995). Black wealth/white wealth.
New York: Routledge. \
Schreiner, M., & Sherraden, M. (2007). Can the poor save!
Saving and asset accumulation in IndiVidual Development
Accounts. New York: Transaction.
Sen, A. (1993). Capability and well-being. In M. Nussbaum & A.
Sen (Eds.), The quality of life (pp. 30-53). Oxford:
Clarendon.
Sherraden, M. (1991). Assets and the poor: A new American welfare
policy. Armonk, NY: M. E.Sharpe.
Sherraden, M. S., & Mcbride, A. M. (in press). Asset accumulation
in low-income households. Ann Arbor: University of Michigan
Press.
-MICHAEL SHERRADEN
AUTHORITATIVE SETTINGS AND
INVOLUNTARY CLIENTS
ABSTRACT: Social workers are increasingly working
with involuntary clients. Since the early 1990 sthe field
has been developing new ideas and skills that are equally
useful in working with voluntary and involuntary clients.
In the process, worker authority is now less viewed as a
way to gain client compliance and more understood as the
opportunity to build partnerships with clients that lead to
changes that are enduring and more meaningful to clients.
KEY WORDS: authority; client choice; involuntary cli-
ents; motivational interviewing; practice guidelines;
resistance; solution-focused interviewing
Although social workers seem reluctant to say it openly,
they know they are in practice because they have been
granted authority to be in practice. This authority comes in
part from belonging to a profession that requires them to
complete a course of formal education and a licensing
examination that guarantees they
possess the knowledge, skills, and values for effective
practice. Their authority also is derived from the settings in
which they practice. Although there are social workers in
private practice, most practice is in agency settings,
continuing to reflect that social work isa profession formed
out of the challenges of working in an agency context
(Compton, Galaway, & Cournoyer, 2005). The reluctance
of social workers to draw attention to their authority is
especially prevalent when practicing directly with clients.
This is the case because they rightly perceive that doing so
can easily risk undermining their wish to build
cooperative, supportive, working relationships with their
clients and their desire to respect and foster client
self-determination.
Involuntary Clients
Social work draws a distinction between voluntary and
involuntary clients. Voluntary clients are those who freely
choose to participate in social work services while
involuntary clients have been pressured or even forced into
services by others who have power over them. The sense of
"no choice" with which involuntary clients enter services is
especially noticeable with those who have been legally
mandated into social and mental health programs. Clients
are frequently mandated to . receive services in child
welfare, probation and delinquency, and mental health
settings.
Many professionals believe that having "no choice"
renders involuntary clients more resistant, difficult,
uncooperative, and even more hostile than voluntary
clients (Kadushin, 1997). This assessment has been in-
creasingly alarming to the field because the majority of
clients seen by social workers in public agencies are
mandated or are at least to some degree involuntary
(Ivanoff, Blythe, & Tripodi, 1994; Rooney, 1992). It is also
alarming because the field's practice models historically
were based on the assumption that practitioners work with
voluntary clients (Ivanoff et al., 1994). Social workers who
have little expertise in engaging and working with
involuntary clients found themselves reluc tantly leaning on
their authority as a way to motivate seemingly resistant and
unmotivated clients to make use of services. The dearth of
effective ways of working with involuntary clients led
Hutchison (1987, p. 595) to declare: "If there is to be a
place for soci~l work in the social welfare system, the
profession must make .... an academic commitment to the
development of improved practice models for social work
with mandated clients."
Toward Different and More
Effective Use of Authority
After reviewing related research, Rooney ( 1992) and
Ivanoff et al. (1994) conclude that developing
 AUlHORITATIVE SETTINGS AND INVOLUNTARY CLIENTS
"motivation congruence" between clients and practi tioners
is key to effective practice with involuntary clients.
Improvement in practice applies to both those clients who
are legally mandated, as well as clients who are pressured
into services by the school, parents, or an intimate partner.
These sources suggest strategies that simultaneously
attempt to foster clients' sense of choice and control while
being respectfully straightforward about any
nonnegotiable matters such as those mandated by the
court. Among these strategies are (a) exploring clients'
understandings of their situations to reduce anger, (b)
reframing to increase fit between clients' wishes and
outside pressures, (c) rewards to increase compliance with
nonnegotiable requirements, and (d) accepting as
worthwhile and useful the client's goal to get the pressuring
agent "off my back and out of my life." The use of
authority to gain compliance with services is also
downplayed in these strategies. Confrontations of client
perceptions, for example, are generally used sparingly and
in nondirective forms, while the open confrontation is used
only in relationship to nonnegotiable matters.
Motivational and solution-focused interviewing are
two recently developed practice models with research
support that are increasingly being adopted for work with
involuntary clients. Both approaches build cooperative
working relationships with clients without relying on
confrontation or insisting that clients accept that they have
"a problem."
Motivational Interviewing Motivational
interviewing is a client-centered, huma nistic approach that
allows clients to describe their problem and circumstances,
and accepts the client's viewpoints without direct
confrontation. Motivational interviewing was developed in
work with substance abusing clients and provides evidence
in numerous clinical trials that show its efficacy (Miller &
Rollnick, 2002). This interviewing makes use of the nat-
ural tendency of clients to be ambivalent about e mbarking
on change; realizing that people want to change but have
an ambivalence about the change process. Ambivalence is
believed to be normal human behavior, and motivational
interviewing offers strategies for helping clients resolve
their ambivalence about change.
Using motivational interviewing, the social worker
notes and reflects back to the client anything heard that
reflects a discrepancy between his substance use and what
the client states is important, such as job performance,
relationships to family members, self concept, and so
forth. Discrepancy between clients' goals and their
behavior leads to resolution of the
183
ambivalence by helping clients see the advantages of
change. It is an increasing sense of ambivalence about the
outcomes of substance use, for example, that is thought to
motivate clients to do the work of making real and lasting
changes.
Solution-Focused Interviewing Interviewing
using the techniques of solution-focused, brief therapy is
built around the notion that clients are people who make
choices about future acts, including whether or not they
will do something different in an involuntary situation. The
research on the effectiveness of solution-focused, brief
therapy is emerging, with more and more studies being
added each year, suggesting that this approach achieves
promising outcomes (Gingerich & Eisengart, 2000; Kim,
in press). Solution-focused interviewing is not
problem-specific but aims at building client-specific
solutions by inviting clients to build visions of what they
may want different in their futures and to construct ways of
making those preferred futures happen. This interviewing
is done in the client's frame of reference and with a "not
knowing" posture toward clients, that is, curious and
inquisitive about the clients' situation. When this approach
is used, the client resistance ceases to be a concern and
work with voluntary and involuntary clients proceeds
sirni-. lady (De jong & Berg, 2001; de Shazer, 1984,
1985, 1988). Involuntary clients, similar to voluntary
clients, are invited to share their understandings of their
situations with the worker listening for hints of what is
important to the client and what they (she or he) may want.
Solutions are built in the clients' context by "not
knowingly" . asking clients "relationship questions" about
how any particular goal or strategy they are shaping may fit
with their significant other expectations, and in the case of
involuntary clients, the expectations and pressuring
persons from authoritative agencies. Social workers do not
attempt to shape client solutions, with direction about what
to do in their situations, involuntary or voluntary, being left
to clients as their responsibility (except in the rare
instances when a client demonstrates a clear intent to
physically harm self or others).
Engaging Involuntary Clients Involuntary
clients are unlikely to acknowledge their problems in the
same manner as a pressuring agent perceives them and
respond to active benefits of the social-worker-client
relationship in the same way as a voluntary client would
respond. For example, involuntary clients are less likely to
respond to warmth, genuineness, and empathy as the
primary means of engaging them (Ivanoff et al., 1994;
Kadushin, 1997). Useful
184 AUTHORITATIVE SEITINGS AND INVOLUNTARY QIENTS
guidelines and skills for working with involuntary
clients include the following (Berg & Kelly, 2000; De
[ong & Berg, 2008):
Assume clients probably start out not wanting
anything workers might offer.
Assume clients have good reasons to think and act
as they do.
Suspend evaluations and agree with clients'
perceptions that stand behind their cautious,
protective stance.
Listen for who is and what are important to clients,
including when they are angry.
When clients are angry, ask what else could have
been done.
Listen for and ask for flients' understandings of
their situations and what is in their best interests,
that is, ask for what clients want.
Use relationship questions (not confrontation or
education) to address clients' context; for exam ple,
"Knowing the court as you do, what is it expecting
you to do different?" "Suppose you did that, what
would be different for you?"
Respectfully provide information to clients about
any nonnegotiable requirements and immediately
ask for the clients' perceptions of these.
Ask about what clients are able and willing to do in
their situations.
Always stay "not knowing," that is, formulate
questions so that clients are put in the position of
telling their workers about their perceptions.
Conclusion
Several advances in how to work with involuntary
clients have been made since the early 1990s. As these
innovations evolve, awareness is growing that working
with involuntary and voluntary clients is not as different
as once believed. Major practice texts are incorporating
knowledge and skills for working with mandated
clients. (Compton et al., 2005; Hepworth, Rooney, &
Larsen, 2002; Sheafor & Horejsi, 2006). Social work
literature emphasizes that effective practice results from
building partnerships with all clients around what clients
want and helping them work in that direction by
building on their strengths and resources; secondarily,
the practitioner identifies useful community resources to
support the clients' goals (Compton et al., 2005; Miley ,
O'Melia, & DuBois, 2007; Saleebey, 2007; Sheafor &
Horejsi, 2006). With this reorientation, the authority of
the social worker is not used for purposes of social
control or as a force to gain client's compliance. Instead,
authority serves to legitimate the role of social workers
as professionals
who move alongside their clients as partners, inviting
them to build more satisfying lives for themselves and
their families.
REFERENCES
Berg, I. K., & Kelly, S. (2000). Building solutions in child protective
services. New York: Norton.
Compton, B. R., Galaway, B., & Cournoyer, B. (2005). Social wark
processes (7th ed.). Belmont, CA: Thomson Brooks/ Cole.
De jong, P., & Berg, I. K. (2001). Co-constructing cooperation
with mandated clients. Social Wark, 46, 361-374.
De jong, P., & Berg, I. K. (2008). Interviewing far solutions (3rded.).
Belmont, CA: Thomson Brooks/Cole.
de Shazer, S. (1984). The death of resistance. Family process,
23,79-93.
de Shazer, S. (1985). Keys to solution in brief therapy. New York:
Norton.
de Shazer, S. (1988). Clues: Investigating solutions in brief therapy.
New York: Norton.
Gingerich, W., & Eisengart, S. (2000). Solution-focused brief
therapy: A review of the outcome research. Family Process, 39
(4),477-496.
Hepworth, D. H., Rooney, R. H., & Larsen, J. A. (2002). Direct
social wark practice: Theory and skills (6th ed.). Pacific Grove,
CA: Brooks/Cole.
Hutchison, E. D. (1987). Use of authority in direct social work
practice with mandated clients. Social Service Review, 61,
581-598.
Ivanoff, A., Blythe, B. J., & Tripodi, T. (1994). Involuntary
clients in social wark practice: A research-based approach. New
York: Aldine De Gruyter.
Kadushin, A. (1997). The social wark interView (4th ed.). New
York: Columbia University Press.
Kim, J. (in press). Examining the effectiveness of solutionfocused
brief therapy: A meta-analysis. Research on Social Wark
Practice.
Miley, K. K., O'Melia, M., & DuBois, B. (2007). Generalist social
wark practice: An empowering approach. Boston: Allyn & Bacon.
Miller, W. R., & Rollnick, S. (2002). Motivatiooal interviewing
(Znd ed.). New York: Guilford.
Rooney, R. H. (1992). Strategies far wark with involuntary clients.
New York: Columbia University Press.
Saleebey, D. (Ed.). (2007). The strengths perspective in social wark
practice (4th ed.). Boston: Allyn & Bacon.
Sheafor, B. W., & Horejsi, C. R. (2006). Techniques and guide~ .
lines for social work practice (7th ed.). Boston: Allyn & Bacon.
SUGGESTED LINKS
http://www.ebta.nu
http://www . motivationalinterview .arg
http://www.sfbta.arg
http://www.solutions-centre.org
http://www.talkingcure.com
--INSOO KIM BERG
BACCALAUREATE SOCIAL WORKERS
ABSTRACT: Defining today's baccalaureate social
workers as entry workers to the social work
profession is indeed a paradigm shift. "Clearly, the
social work profession is at a crossroad. If there are
to be adequate numbers of social workers to respond
to the needs of clients in the 21st century and
beyond, the sufficiency of this frontline workforce,
must not only be ensured, it must be prioritized"
(Whitaker, Weismiller, & Clark, 2006, p. 35). In our
ever-changing society, the social work profession
must rethink the various levels of the profession and
recognize, as well as promote, a professional career
trajectory that embraces the Baccalaureate Social
Work professional.
KEY WORDS: generalist social worker; strengths per-
spective; problem-solving approach
Historical Overview of
Baccalaureate Social Work
Baer and Federico (1979) define Baccalaureate social
work (BSW) as the ability to (a) enhance the problem-
solving, coping, and developmental capacities of peo ple:
(b) to promote the effective and humane operation of the
systems that provide people with resources and services;
and (c) to link people with systems that provide them
with the resources, services, and opportunities (p. 61),
Evolution of BSW Programs
The development of standards for the accreditation of
baccalaureate programs was formally initiated in June
1973 and implemented by the Council on Social Work
Education (CSWE) in 1974. The council recommended
a common set of objectives that were required of all
programs; it was acknowledged that the selection of the
overall program objectives must remain within the
purview of each program. Differences in BSW
curriculum are often driven by geographic location, the
racial and ethnic make up of its population, and whether
the program is located in an urban or rural area (Baer &
Frederico, 1979; Cressy-Wells & Federico, 1998).
All BSW curricula have components in the Strength
Based Perspective, Generalist Model, and
185
Problem Solving Method. The strengths perspective
(which focuses on the clients' abilities, positive social
networks, strengths, and resources instead of patholog y,
problems, and social and personal defects (Leashore,
1995 is based on the assumption that all people,
regardless of their life circumstances, have the skills and
abilities to play an active role in solving their
difficulties. Conversely, the problem solving approach
(based on the belief that all people have the ability to
solve difficult and complex problems, and to interact
productively with their environments, and to direct their
own lives (Perlman, 1957 acknowledges that an
individual's ability to solve problems may be impeded or
exacerbated by environmental influences (Weick, Rapp,
Sullivan, & Kirsthardt, 1989).
Objectives of BSW Education
BSW graduates are educated as generalist social work
practitioners ( Generalist social work professionals
master the core knowledge, values, and skills to
empower consumers, navigate a variety of host settings,
and evaluate service outcomes to improve the quality of
client services by using the problem solving process,
critical thinking skills, and the strength-based per-
spective) who are committed to the mission of social
work as put forth by the National Association of Social
Work. The generalist social work curriculum combines
liberal arts courses with professional social work
foundation courses. The objective is to prepare BSW
graduates to work with individuals, families, groups,
communities, and organizations. Baccalaureate social
workers have strong advocacy skills and are able to seek
the appropriate services (or systems) that bring effective
and efficient change for the client (National Association
of Social Workers [NASWl, 1999).
The Center for Health Workforce Studies (2005)
reports that the demand for social workers will be par-
ticularly high given the 54% projected growth in the
number of older adults by 2020. As individuals live
longer, and our society ages, the need for baccalaureate
social workers is critical. Older adults face increasing
challenges, and BSW advocates who are strong
frontline workers will provide needed services for older
adults, caregivers, children, and grandchildren. Bureau
of Labor Statistics (2006), in Occupational Outlook
Handbook 2006-07 Edition, projects that the demand for
new social workers will increase 18-26% by
186 BACCALAUREATE SOCIAL WORKERS

the year 2014. Careerjournal.com recently placed social BSW Accredited Programs
work on the "best careers" list (Keogh, 2006).
As of 2006
BSW Programs Accredited-439
BSW Curriculum and Generalist BSW Programs in Candidacy-18
Social Work Practice
Baccalaureate Social Workers work with people of all ages,
race, ethnicity, socioeconomic levels, and increasingly
with cross-cultural groups and the global community. All BSW Degrees/Certificates
qualified baccalaureate social workers have an by Gender and Ethnicity-2004
undergraduate degree from an accredited social work
program in a college or university. Differing institutional Total Graduates 9,889 (100%)
Male 1,112 (11.2%)
goals make each accredited BSW program unique in its Female 8,747 (88.5%)
focus; however, all BSW students study a rigorous core Unknown 30 (0.4%)
curriculum as required by-the Council on HE ARTS Indian 112 (1.1 %)
Social Work Education. \ Asian American 198 (2.0%)
The BSW curriculum is built on the values and ethics of Blacks/African Americans 2,112 (2104%)
the social work profession. It includes liberal arts courses, Mexican 364 (3.70/0 )
Puerto Rican 227 (2.3%)
electives, and foundation courses in human behavior in the Other Latino 356 (3.6%)
social environment, social work practice, policy, research, Other 86 (0.8%)
and most importantly field practicum of at least 400 hr. The Pacific Islander L (0.3%)
field practicum is an essential component of the BSW Multiple Ethnicity NSTI (0.4%)
Foreign ITUT (0.5%)
curriculum. It provides students with valuable learning
White TIO (62%)
opportunities through supervised, practical experiences in Unknown AND (1.9%)
approved agency settings. As mandated by CSWE,
Programs Accredited-446
supervisors must be experienced, preferably with a BSW or Programs In Candidacy-17
MSW in order to maintain the high standards of the
This is from only programs that self-report to CSWE.
profession.
Field coordinators or faculty members have an MSW
degree and a minimum of two years work experience. The social work is to assist the public through identification of
on-the-job professional training ensures that all BSW standards for the safe professional practice of social work.
graduates are equipped to practice in an everchanging work Each jurisdiction, defines by law what is required for each
environment and able to address issues that are relevant to level of social work li:censure" (Association of Social
the consumer. Work Boards [ASWB], 2002-2006, para. 1).
There are sixteen states in the United States that do not
Employment and Profiles require licensing at the BSW level. Until legislation is
of Baccalaureate Social Workers Baccalaureate passed in all states, it is difficult to determine an accurate
Social Workers who graduate from CSWE accredited number of BSW practitioners. Accordingt to BPD and
social work programs are highly respected, and employed CSWE there currently no mechanism in place to capture
in all facets of the workforce in both public and private the data on the number of BSW graquates who enter MSW
sectors. Graduates are often found in frontline positions programs versus the number who remain in professional
that provide needed services. The BSW degree provides practice.
specific, targeted education that focuses on the
person-in-environment in multiple settings such as nursing Challenges
homes, child welfare, hospitals, hospice, substance abuse Fragmentation of the profession is a major challenge for
programs, community action organizations, as well as. social work education. lt is critical that all social work
others social service agencies. organizations convene and develop a plan that promotes
CSWE Annual Statistics Baccalaureate Social Work social work education and the profession. BPD was started
Programs (Tracy, 2006 [e-mail correspondence from over 20 years ago by a group of BSW Pro-' gram Directors
CSWE]). with the aim of sharing their concerns over issues related to
The Association of Social Work Boards (ASWB) social work education. In over two decades the
states, "The purpose of licensing and certification in organization has grown with over 400 members across
North America (BPD Website, 2007).
 BACCALAUREATE SOCIAL WORKERS
187

Streamlining the social work organizations would result in should provide treatment interventions that have been proven
the public understanding the various levels of social workers effective and validated by empirical investigations (Ryan,
and the competencies that are expected at each level of social 2007).
work education.
Advance standing is another long debate that must REFERENCES
be resolved in order forthe profession to develop a much Association of Social Work Boards. (2000-2006). Licensing
needed career trajectory path for social work education. requirements. Retrieved December 30, 2006, from http://
Advance standing allows BSW students to study for an www.aswb.org/lic_req.shtml
MSW without having to take the required social work Baer, B. L., & Federico, R. C. (1979). Educating the baccouiur-
foundation courses. In today's ever-changing world, it is eate social worker. A curriculum development resource guide.
critical that MSW students have the required advance Cambridge, MA: Ballinger Publishing Co.
knowledge that would assist consumers as well as find Bureau of Labor Statistics U.S. Department of Labor. (2006 ).
Social workers. Occupational outlook handbook (DOH),
viable practice solutions through research. 2006-07 edition. Retrieved January 30, 2007, from http://
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for MSW students without the BSW degrees. However, Center for Health Workforce Studies. (2005). The impact of the
this curriculum change would allow MSW programs to aging population on the health workforce in the U.S. Rensselaer.
teach an array of advanced social work courses during NY: Center for Health Workforce Studies, School of Public
the two years of study. The challenge is that social work Health, State University of New York, at Albany.
educators would have to agree that the BSW is the only Cressy-Welle, C., & Federico, R. C. (1998). Social Work day~
degree that qualifies students to enter an MSW program to~day: The experience of generalist social work practice (3rd
without additional coursework. Requiring students, who ed.). New York: Longman Publishing Group.
have other baccalaureate degrees take bridge courses, Guy-Wells, P. (2007). Exploring cultural competence prac-
tice in undergraduate social work education. Education, 4,
before entering MSW programs, would need the imagi- 569-580.
to create and maintain interorganizational collaborations and B. (2006). This social~work manager feels she makes a
consumers. difference. Retrieved July 12,2006, from http://www.career~
The proliferation ofBSW programs does not necessa-
journal/reports/bestcareers/20060711~keogh.html?cjpos=home_
rily correlate with an increase in the number of graduates whatsnew_major
prepared to address issues related to oppression affecting Leashore, B. R. (1995). African Americans overview. In
people of color. Meanwhile, Gutierrez, Fredrickson, R. L. Edwards (Ed.), Encyclopedia of social work (19th ed.,
Soifer (1999) conducted studies which explored social Vol. 1, pp. 101-115). Washington, DC: NASW Press.
work faculty attitudes towards issues relating to racism, National Association of Social Workers. (1999). Code of
ethics of National Association of Social Workers.
Retrieved diversity, and oppression. The authors found that many
January 2, 2007, from http://www.socialworkers.org/pubs/
faculty deemed issues relating to diversity more appropri- code/code.asp
ate than issues relating to power and oppression The Perlman, H. A. (1957). A problem~solving process. Chicago:
trend suggest more research need to be conducted to University of Chicago Press.
assess social work faculty's perceptions on appropriate Ryan, D. J. (2007). Clinical decisions-making in complimentary
content knowledge on issues relating to discrimination and alternative medicine: The use of evidence. Journal of the
and racism (Guv-Wells, 2007). Australian and Traditional Medicine Society, 13(2), 81-83.
The National Association of Social Worker's Code Tracy, C. (2006). Coundl on social work education annual
of Ethics states "the primary mission of the social work statistics. E-mail correspondence.
profession is to enhance human well-being and to help Weick, A., Rapp, c., Sullivan, W. P., & Kirsthardt, W.
(1989). A strengths perspective for social work practice.
meet the basic human needs of all people, with parti-
Social Work, 34(4), 350--354.
cular attention to the needs and empowerment of. _ Whitaker, T., Weismiller, T., & Clark, E. (2006). Assuring
people who are vulnerable, oppressed, and/or living in the suffidency of a frontline workforce: A national study of
poverty." (National Association of Social Workers licensed social workers. Executive summary. Washington,
[NASW], 1999, para 1). DC: National Association of Social Workers. Retrieved
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http://workforce.socialworkers.org/
evidence-based practice as the profession will demand studies/nasw_06_execsummary.pdf
SUGGESTED LINKS
greater accountability from health care pracricioners. The BPD Association Baccalaureate Social work Program
term evidence-based was attributed to Archie Cochran who directors. www.bpdonline.org
coined the term "evidence-based medicine. Cochran believed
that health care providers
 188 BACCALAUREATE SocIAL WORKERS
re required (McNeece & Roberts, 2001).
www.cswe.org
ASWB Association of social work board.
www.aswb.org
NASW National association of social workers.
www.naswdc.org
The New Social Worker
www.socialonline.com
-LARRY D. WILLIAMS AND MILDRED JOYNER
BA TIERING. See Intimate Partner Violence.
BEHAVIORAL HEALTH. See Mental Health:
Overview.
BEHAVIORAL THEORY
ABST:RACT: Behavioral theory seeks to explain
human behavior by analyzing the antecedents and
consequences present in the individual's environment
and the learned associations he or she has acquired
through previous experience. This entry describes the
various traditions within the behavioral perspective
(classical
. conditioning, operant conditioning, cognitivelv medi-
ated behavioral theory, and functional contextualism)
and the clinical applications that are derived from them.
Common criticisms are discussed in light of the ongoing
evolution of behavioral theory and the fit of its tenets
with the field of social work.
KEY WORDS: behavior therapy; operant; reinforce-
ment; contingency; learning theory; conditioning; social
learning
Origins of Behavioral Theory Behavioral
theory holds that psychological events can be described
and explained in terms of observable behavior and its
associations with environmental stimuli and
occurrences. Although behavioral theory is a
fundamental theoretical perspective within the field of
social work (Reid, 2004), it originated within
psychology, where it is known as both a methodological
frame of reference and a theory of human and animal
conduct. Methodological behaviorism, commonly
associated with the work of psychologist John B.
Watson (1878-1958), served in part as a reaction against
psychodynamic perspectives that dominated psychology
in the early 20th century, which focused
upon subjective phenomena and employed introspective
methods of inquiry. Watson (1913) argued, in contrast,
that the study of behavior should embrace a fully
objective scientific approach, focusing on what
organisms do, not on their internal or mental states.
Applied Behavioral Theory
In line with Watson's methodological stance, funda-
mental behavioral principles were first derived from
carefully controlled laboratory investigations of learn ing
processes in animals. Later, beha~ioral theorists grew
interested in applying these principles to the
understanding and amelioration of human problems.
Interventions spawned by this new subdiscipline of
applied behavioral theory are based on several premises
that (a) clinical problems, regardless of their origins or
subjective manifestations, may be expressed in terms of
overt behavioral referents; (b) the learning history of an
individual provides understanding about the devel-
opment of problematic behavior and a potential avenue to
behavior change; and (c) effective treatments rely upon
active processes, such as learning new behaviors, rather
than talking about problems as the primary vehicle for
relieving emotional distress. Thoughts and feelings are
not viewed as unimportant, but are conceptualized as the
by-products of behavior processes, not the engine of.
them. Thus, the behavioral practitioner seeks to modify
problematic thoughts and feelings by changing behavior
rather than by changing the thoughts and feelings di-
rectly, as would be the case with a cognitive approach.
For instance, behavioral approaches to depression call for
increasing activities in order to increase a client's oppor-
tunities for pleasure, which in tum may elevate depressed
mood (Emmelkamp, 2004).
As will be detailed below, applied behavioral theory
is often classified into two related yet distinct streams,
classical conditioning and operant conditioning
(Kazdin, 2000). Behavioral principles and techniques
based on respondent or classical conditioning are
sometimes referred to as behavior therapy; whereas
those predicated on operant conditioning are commonly
referred to as behavior modification or applied behavior
analysis. Both streams form the basis of clinical
interventions employed within the field of social work;
however, social work interventions have also been
influenced by a general widening of behavioral theory
from its classical formulations of respondent and oper~
ant conditioning. Contemporary behavioral approaches
thus form a large umbrella of approaches that include,
for example, hybrid cognitive-behavioral models as
well as neo-operant approaches known under the rubric
of "contextual behaviorism" (Hayes, Follette, &
Follette, 1995).

Classical or Respondent Conditioning
Also known as stimulus-response learning theory,
respondent conditioning represents the earliest behavioral
approach and derives from applications of Ivan Pavlov's
(1849-1946) pioneering experiments on digestion. In these
studies, Pavlov demonstrated that an experimenter could
condition a reflex response (salivation) in a dog by ringing
a bell if he paired the ringing bell with an event already
known to reflexively elicit salivation (presenting the dog
with food). In so doing, Pavlov demonstrated that reflexive
behaviors could be acquired through associative learning.
Following on Pavlov's work, John Watson and his
students demonstrated that Pavlovian principles could be
employed to experimentally induce fear responses in
children. Turning these insights to a novel therapeutic use,
Joseph Wolpe (1915-1997) and others derived clinical
techniques to decrease learned fear responses using
stimulus-response principles. Wolpe (1995) contended that
behavior disorders such as phobic anxiety represent
maladaptive conditioned responses and developed a
counterconditioning technique known as systematic
desensitization, in which the client is exposed to
progressively anxiety-evoking stimuli while at the same
time performing muscle relaxation to inhibit the
conditioned anxiety response (a process Wolpe termed
reciprocal inhibition). Since the conditioned response
(anxiety or fear) is incompatible with relaxation, the client
gradually becomes desensitized to the anxietyprovoking
stimulus over a series of repeated trials.
Exposure is another therapeutic technique based upon
classical conditioning, in which clients with learned an-
xiety or fear are repeatedly exposed, either through guided
imagery or in vivo, to the feared stimulus (for example,
dogs, elevators). Exposure has been shown to be
particularly effective when conducted in vivo, and indeed,
in-vivo exposure is currently considered the treatment of
choice for phobias (Antony & Roemer, 2003). Another
counterconditioning technique is cue avoidance or
stimulus control (Prochaska & Norcross, 2007), which is
used to inhibit an unwanted problem behavior (for
example, drug use) by limiting exposures to high-risk cues
(drug-using peers), instead substituting stimuli that cue
desired behavior (for example, spending time with
nondrug-using friends or family). Newer treatments for
trauma-based disorders, such as Eye Movement Desensi-
tization and Reprogramming, are likewise informed by
principles of respondent conditioning (Wolpe, 1995).
Operant Conditioning or Applied
Behavior Analysis
The operant or applied behavior analysis tradition derives
from the radical behaviorist theory of B. F. Skinner
BEHAVIORAL THEORY
189
(1904-1990). In contrast to the classical conditioning
paradigm, Skinner and his followers did not focus upon
learned reflex responses, but on the way that learning and
behavior may be shaped by modifying the consequences
that follow them. Applied behavior analysis emerged as a
distinct subfield within psychology during the 1960s, led
by psychologists such as Donald Baer, Todd Risley, and
Teodoro Ayllon,who sought to harness behavioral prin-
ciples to assess, evaluate, and change behavior to benefit
humans' adaptation and functioning in everyday life (for
example, Baer, Wolff, & Risley, 1968).
The linchpin of operant theory is that behavior is
controlled or governed by its consequences (for example,
behavioral or environmental events that follow it). The
process by which a consequence leads to an increase in a
given behavior is called reinforcement. For example,
parental attention that increases a child's aggressive
behavior toward a sibling would be considered a reinforcer
of aggressi ve behavior in that particular child. On the other
hand, parental withholding of a privilege following
aggressive behavior, which in tum reduces its frequency, is
a type of punishment. The relationship between the
reinforcer (or the punishment) and the subsequent outcome
(increased or decreased aggressive behavior) is called a
contingency; that is, in the example just described,
aggressive behavior would be considered contingent upon
parental responses (attention or withholding of privileges).
In addition, descriptions of contingencies ("If you do not
pay your taxes on time, you must pay a penalty fine"), if
they are meaningfully linked to the individual's learning
history, may also evoke behavior, a phenomenon Skinner
(1969) referred to as rule-governed behavior.
In applied behavior analysis, the therapist seeks to
discern, through observation and questioning of the client
or family, the environmental contingencies that govern
problematic behavior so that the environment might be
altered to shape desired behavior. The systematic
examination of the antecedents and consequences of
behavior is referred to as functional analysis, a funda-
mental preliminary task of the behavioral approach
(Haynes & O'Brien, 1990). Functional analysis differs
from traditional casework assessment methods in the level
of precision sought in the definition and characterization of
target behaviors (including frequency, duration, and
intensity). Because this analysis serves as the basis for
intervention planning (for example, the modification of
reinforcement contingencies), such precision is essential to
minimizing decision-making errors.
A common application of operant principles is con-
tingency management, the systematic application of
positive reinforcement following a desired behavior and
withdrawal of reinforcement or punishment following
190 BEHAVIORAL THEORY
undesired behaviors. For example, practitioners may train
parents to establish explicit rules for their children wherein
they reinforce desired behaviors (for example, perfor-
mance of chores) with rewards (for example, allowance)
and punish off-limits behaviors (for example, aggression)
with withdrawal of reinforcement (for example, removal of
privileges). In drug treatment programs, desirable goods
such as money or food may be used to. reinforce group
attendance or abstinence (for example, drug-free urine)
(Petry, 2000). These contingency plans may also be
formalized by a contract between a client or child and a
treatment provider or parent, which permits all parties to
have a voice in the development of the plan and may
thereby enhance its success (Kazdin, 2000).
A token economy is another type of contingency
management system, commonly found in classrooms,
inpatient psychiatric settings, and psychiatric day treatment
programs, in which contingencies are established between a
specified set of desired behaviors. and the provision of
backup reinforcers (such as poker chips) that may be
exchanged for goods or privileges. Although controlled
studies show that token economies foster appropriate
behavior within the controlled setting of . their application,
the treatment gains are difficult to
maintain and transfer outside that setting. In addition, these
programs are costly and challenging to mount in
community settings, where most contemporary mental
health treatment takes place. (Dickerson, . T enhula, &
Green-Paden, 2005; Glynn, 1990).
Operant principles are also integral to applications
seeking to develop skills or behaviors. In many interven-
tions with developmentally disabled children, for example,
shaping procedures are used to guide the learning of skills
by reinforcing successive steps toward the desired
behavior. Skills are also taught through instruction (where
the helper verbally guides the client through the process of
performing a skill) and modeling (in which the helper or a
peer modeler demonstrates the skill to help the client
acquire it themselves). Combinations of the foregoing
procedures are often featured in programs of social skills
training, and commonly employed with adult psychiatric
clients and children with behavior disorders.
Cognitively Mediated Behavioral Theory
In traditional operant theory , the focus of inquiry was
limited to observable behavior and therefore excluded
thoughts and feelings. Many applied behavioral theorists
found strict behaviorism constraining when trying to
explain complex human processes and therefore sought to
incorporate language, thought, and affect. One of the
leading figures in this endeavor was Albert Bandura, who
developed social learning theory
(1977), a variant of behavioral theory that gave inde-
pendent weight to cognition as a factor that interacted in a
reciprocal manner with behavior and the environment. For
example, he argued that people may acquire behavior
through vicarious experience (modeling), rather than
simply through contingent responding. He demonstrated
this principle of social learning through a set of
experiments in which children began to acquire aggressive
behaviors after observing adults hitting and kicking a large
inflatable doll. Bandura also posited that self-efficacy of
the individual was an important mediator of intervention
and therefore warranted focus as an intervention target
(Bandura & Adams, 1977). His later formulation, social
Cognitive theory (Bandura, 1986), also departed from
radical behavioral tenets by positioning the individual as a
self-regulating agent whose functioning is multiply
determined by internal processes (motivation, thoughts,
expectancies) and the social environment.
Bandura's ideas have not only influenced the devel-
opment of an independent subfield, cognitive theory
(Reinecke & Freeman, 2003), but also revolutionalized
behavioral theory by suggesting that thoughts and feelings
could be modified alongside behavior (Hayes, 2004). This
paradigm shift spurred the development of cognitively
oriented behavioral interventions such as relapse
prevention, problem-solving training, and stress
inoculation training. While the inclusion of cognitive
mediators in treatment models have been criticized from an
orthodox point of view (for example, O'Donohue &
Krasner, 1995; Skinner, 1977), this broadening of behavior
theory has unquestionably increased its purchase within
social work and other helping fields.
Influence on the Field of Social Work Behavioral
theory began to shape the development of social work
interventions during the 1960s and 1970s, particularly
through the efforts and leadership of Edwin Thomas at the
University of Michigan. Many of his former students, like
Eileen Gambrill, Bruce Thyer, as well as fellow professor
Sheldon Rose, took positions in schools of social work and
developed empirical research programs testing behavioral
interventions (Reid, 2004). The infusion of behavioral
theory into social work practice also influenced the
movement toward empirically based interventions,
single-system practice evaluation, and more recently,
evidence-based practice. Scholars like Pinkston (1997) and
Mattaini and Moore (2004) have extended the use of
behavioral principles to analyze organizational and system
change. Behaviorally based principles are also featured in
the task-centered casework model (Reid, 2000) as well as
many introductory direct practice texts (Hepworth,
Rooney, Rooney,

Strom-Gottfried, & Larsen, 2006), attesting to their in, fluence
on generalist social work practice methods.
Criticisms of Behavioral Theory
Due to its lack of explicit focus on subjective experiences,
radical behaviorism has been criticized as being mechanistic,
reductive, and inadequately attentive to context. Responding
to these critiques, many behavior, ists (Gambrill, 1997;
Kohlenberg, Hayes, & Tsai, 1993; Sweet; 1984) have argued
that such criticisms bespeak common misconceptions about
behavioral theory. They point out that "behavior," contrary to
popular notions, encompasses private events such as thoughts
and feelings in addition to overt 'actions. Thus, behavior
evoked by a stimulus could include, for example, fear,
sadness, or joy. Moreover, subjective phenomena are
implicitly considered in behavioral concepts such as a
stimulus. A stimulus for becoming anxious, for example, will
depend on the particulars of the individual's environment,
their unique learning history, and idiosyncratic personal
meaning. Since individuals perceive the same stimulus in
different ways, these particularities must be taken into account
in the formulation of behavioral problems and their solutions.
In this sense, behavioral theory is inherently concerned with
context and meaning.
A second criticism is that behavioral theory overlooks the
importance of the therapeutic alliance as a curative common
factor (Kohlenberg et al., 1993; Reid, 2004). More damning
from an ethical standpoint is the claim that behavioral
techniques constitute a form of manipulation, a perception that
may have resulted from early behavior therapists referring to
themselves as social engineers or programmers (Sweet, 1984).
Given that some behavioral formulations discuss the necessity
of core helping and engagement skills in the behavioral
practitioner (for example, Gambrill, 1977), these criticisms
are perhaps exaggerated. However, recent writ, ings on
behavioral theory dedicate special attention to therapeutic
relationship issues. For example, neobehavioral theorists from
the contextual behaviorist school foreground the role of the
therapist in facilitating the helping relationship by observing
carefully for minute clinical improvements (such as improved
assertiveness) and providing immediate, spontaneous ther-
apeutic social reinforcement (Kohlenberg et al., 1993). Other
new generation approaches that are predicated on the "radical
acceptance" of the helper, such as dialectical behavior therapy
and acceptance and commitment therapy, eschew notions of
therapists controlling client behavior through the
manipulation of contingencies. As Berlin (2005) suggests,
these approaches resonate with social work sensibilities since
radical
BEHAVIORAL THEORY
191
acceptance by a helper is designed to foster client
authenticity, self-acceptance, and positive change.
Future Directions
Hayes (2004) opines that behaviorism has reached a third
wave in a 50-year history of intellectual and practical
evolution. Following the development of hybrid
cognitive-behavioral interventions-now more common than
either element alone (Antony & Roemer, 2003 )-emerging
behavioral approaches adopt an even more explicitly
contextual focus and increase flexibility of the therapeutic
repertoire to include phi, losophical and spiritual dimensions
such as mindfulness meditation alongside cognitive and
behavioral elements. As the evidence base supporting these
treatments grows, the field of social work faces the challenge
of adapting them to the local context of social work practice
while ensuring their faithful adoption.
Another important challenge for behavioral theory is the
movement toward client-centered approaches that mandate
the full involvement of client as partner in the treatment
process. While social work incarnations of behavioral theory
have been intentional in their support of client agency and
autonomy (for example, Gambrill, 1977; Reid, 2000), the field
of behavioral theory as a whole must also do so to ensure its
survival. For instance ,
incorporating self-control principles may help behaviorism to
shed the mantle of behavioral engineering and control.
Self-control training involves therapists as teachers who train
clients to design their own plans of behavior change, monitor
target behaviors, and selfreinforce behavior of their own
choosing (Karoly, 1995). Since client self-determination is a
longstanding organizing principle of the field of social work,
the field represents an untapped potential asset to the
movement toward client-centered behavioral treatment.
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direct practice: A historical and contemporary view. Social
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Dickerson, F. B., Tenhula, W. N., & Green-Paden, L. D. (2005).
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FURTHER READING
Briggs, H. & Rzepnicki, T. (Eds.), Using evidence in sodal work
practice: A behavioral approach. Chicago, IL: Lyceum.
Schwartz, A., & Goldiamond, I. (1975). Social casework: A
behavioral approach. New York: Columbia University Press.
Skinner, B. F. (953). Sdence and human behavior. New York:
Macmillan (also available for free download at www.
bfskinner.org).
SUGGESTED LINKS Association for Behavior
Analysis International. http://www
.abaintemational.org/
Association for Behavioral and Cognitive Therapies.
http://www.abct.org/
Association for Contextual Behavioral Science.
http://www .contextualpsychology .org/
-BETH ANGELL
BEREAVEMENT PRACTICE
ABSTRACT: Bereavement, which is the circumstance of
having experienced the death of a significant other, is
associated with significant emotional, cognitive, spir itual,
physical, and social disruption. Given its ubiqui tous nature,
nearly everyone is affected by bereavement at some point,
and opportunities for social work inter vention with the
bereaved are many and varied. This entry provides a brief
summary of our extant knowledge about bereavement
including its theoretical underpin nings, psychosocial
sequelae, and empirical evidence of related interventions.
KEY WORDS: bereavement; grief; complicated grief; loss;
death of significant other; mourning

By its very nature, life for most of us includes bereave-
ment, which is the circumstance of having experienced
the death of a significant. other. Whether expected or
sudden, self-inflicted, or the result of an accident, vio-
lent crime, disease, or disaster, death comes to everyone
(some 50 million people globally each year) and leaves
many more survivors in its aftermath. Notwithstanding
its frequency and universality, bereavement is typically
accompanied by grief, a complex and often distressing
condition that affects people emotionally, cognitively,
spiritually, socially, and physically. Furthermore,
although grief is also experienced with other losses (for
example, divorce, health, a job, a home), it is generally
understood to be especially challenging when connected
with the death of a loved one and can be accompanied by
significant physical and psychological morbidity. For all
of these reasons, opportunities for social work
intervention with the bereaved are many and varied.
This entry provides a brief summary of our extant
knowledge about bereavement including its
. theoretical underpinnings, psychosocial sequelae, and . .
empirical evidence of related interventions.
Most bereaved individuals adapt (that is, mourn)
successfully, albeit in different ways and in different
time frames depending upon individual and loss specific
factors (for example, type or emotional intensity of
relationship with the deceased, meaning ascribed to the
death), and do not experience psychopathology. This
normative adjustment to bereavement, referred to
variously as "normal," "simple," and "uncomplicated,"
has been described extensively in the literature and is
commonly depicted as a series of stages or tasks pro-
posed most notably by John Bowlby, Colin Murray
Parkes, Elizabeth Kubler-Ross, and William Worden.
Stage theories suggest that individuals experience dis-
belief or denial of the loss, yearning, anger, depression,
and acceptance after being bereaved and must face these
feelings actively in order to mourn successfully.
This sizeable literature purports that as the bereaved
successfully negotiate these distressing psychological
conditions and tasks, the death becomes more inte grated
into their lives and the suffering of grief is
simultaneously ameliorated. The time required for this
process is a topic of considerable interest in the popular
literature and is often of great concern to the bereaved.
Professionals tend to agree that while grief is
permanently transformative, its intensity begins to shift
within months to several years after a death and thus
becomes less preoccupying. Although the
predominantly conceptualbereavement literature has
been widely accepted despite limited empirical
examination, there is some new evidence to support a
stage theory of grief in which individuals experience
disbelief, yearning, anger, depression,
BEREAVEMENT PRACTICE 193
and acceptance over the first 2 years of bereavement.
(Maciejewski, Zhang, Block, & Prigerson, 2007).
Recent research, however, suggests that many of the
long-held assumptions about the bereaved and their
grief do not have empirical support. Some, such as the
assertions that "letting go" of emotional attachments to
the deceased and repeated confrontation of events re-
lated to the death (that is, "grief work") are essential to
healthy resolution of bereavement, have been chal-
lenged. In their place, newer paradigms including the
"Continuing Bonds" framework popularized by Klass,
Silverman, and Nickman (1996) and the Dual Process
Model proposed by Stroebe and Schut (1999) have
further examined and specified the multiple processes
that comprise bereavement. This contemporary work
and that of other scholars have brought increased at-
tention to the wide range of thoughts and feelings
experienced by the bereaved and to the myriad ways
cultural and sociopolitical forces shape the experience.
This scholarship, in tum, has broadened our percep tions
of "normal" bereavement and has stimulated exciting
research that pushes our conceptualizations from the
more simplistic and categorical into the more complex
and interrelated spheres in which bereavement most
likely belongs (for examples of recent research see
issues 8 and 9 of Death Studies, 30, November 2006).
Because bereavement is generally viewed as a dis-
tressing but normative experience it is listed as a V code
in the DSM-IV-TR (APA, 2000). Accordingly, clini-
cians must use existing criteria for other -disorders to
diagnose people with neced psychopathology thought to
be grief related. While the psychological symptoms of
grief may be similar to those for depression and anxiety,
generally speaking when they occur within the first 3
months after the death of a loved one and are not
accompanied by other signs of possible pathology (for
example, a morbid preoccupation with worthlessness,
thoughts of death other than the survivor feeling that
she/he would be better off dead, nothing brings even
momentary relief from distress) an Axis I diagnosis is
not made.
Research does suggest that most bereaved indi-
viduals experience uncomplicated grief. However, a
clinically significant subset does undergo difficulties
extending beyond those viewed as normal. For example,
when deaths are sudden, violent, or perceived as unjust,
such as those within the context of disasters and other
potentially traumatic events, survivors may ex perience
an overlap of trauma and grief that leads to
complications. This response process, referred to most
recently as "complicated grief," is thought by some to
manifest in a set of core symptoms that resemble those
associated with major depressive disorder and
194 BEREAVEMENT PRACTICE
posttraumatic stress disorder but reflects a distinct psychiatric
syndrome with additional characteristics such as intense
pining for the deceased (for detailed information about
complicated grief and its evolution as a construct see
Horowitz et al., 1997; Jacobs, Mazure, & Prigerson, 2000;
Lichtenthal, Cruess, & Prigerson, 2004). A related proposal to
include complicated grief as a diagnostic entity is the next
iteration of the DSM and is currently being evaluated by an
international group of experts. However, concerns about its
validity as a unique disorder, its applicability to all groups of
bereaved individuals (for example, those with intellectual
disabilities), and potential negative ramifications of the
medicalization of grief have been raised and must be given
serious consideration,
Given the lack of expert consensus surrounding the
conceptualizations of normal and pathological grief, it is no
surprise that extant knowledge about interventions for the
bereaved is similarly provisional. Although survivor and
death, specific support groups (for exam, ple, for bereaved
parents, survivors of homicide victims, partners of those who
died of cancer) are increasingly common and have strong
anecdotal support from both participants and social work
facilitators, they and other types of grief interventions have
little empirical support of effectiveness. Research reveals that
interventions for uncomplicated bereavement are at best
minimally effective and in some cases may even be harmful.
There is some evidence that interventions for certain sub,
groups of the bereaved including those who are selfreferred or
at high risk for complications (for example, widowers,
survivors of sudden or violent deaths, those who exhibit
intense anger, depression, or rumination early after the death)
may lead to improved client out, comes. Similarly,
interventions that are delivered to individuals, incorporate
more sessions, occur closer to the date of death, and are
provided by highly trained practitioners have also shown
greater promise of effectiveness (for a detailed examination of
the research literature see Jordan & Neimeyer, 2003). Finally,
an intervention developed specifically for individuals
exhibiting symptoms of complicated grief has recently
demonstrated effectiveness for that group (Shear, Frank,
Houck, & Reynolds, 2005).
In conclusion, bereavement is a universal experience
accompanied by a range of challenging emotional and
relational sequelae. Overall, extant empirical data suggests
that most bereaved people will not need pro, fessional
counseling to cope with their grief but rather will draw upon
their preexisting internal and external resources to heal from
this most painful experience. Nevertheless, given the vast
numbers of people affected by bereavement, there
undoubtedly will be many among them who seek additional
support and guidance from
social workers or who will benefit from it because their grief
becomes atypically problematic. In each of the varied settings
that social workers are based, we are likely to work with an
individual or family who is grieving the death of a loved one.
Whether that grief is the present issue or an important
contextual factor shaping it, social workers in generalist
practice as well as in specialty areas, such as end-of-life care
or trauma, must be knowledgeable about bereaveinent and
related interventions. Given the expansion of research in this
field, it is essential for clinicians to keep abreast of new em,
pirical findings. Ideally, social workers will contribute to this
knowledge not only through active participation in
intervention development and evaluation but also through
collaborations with researchers who will benefit greatly from
their practice wisdom.
REFERENCES
Horowitz, M. J., Siegel, B., Holen, A., Bonanno, G. A., Milbrath,
c., & Stinson, C. (1997). Diagnostic criteria
for complicate grief disorder. American Journal of
Psychwtt),154,904-910.
Jacobs, S., Mazure, c., & Prigerson, H. (2000).
Diagnostic criteria for traumatic grief. Death
Studies, 24, 185-199.
Jordan, J. R., & Neimeyer, R. A. (2003). Does grief counseling
work? Death Studies, 27, 765-786.
Klass, D., Silverman, P. R., & Nickman, S. L. (Eels.). (1996).
Continuing bonds: New understandings of grief. Philadelphia; PA:
Taylor & Francis.
Lichtenthal, W. G., Cruess, D.G., & Prigerson, H. G. (2004).
A case for establishing complicated grief as a distinct mental
disorder in DSM, V. Clinical Psychology Review, 24, 637 .:...ti6i
Maciejewski, P., Zhang, B., Block, S., & Prigerson, H. (2007).
An empirical examination of the stage theory of grief. lAMA,
297(7), 716---723.
Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005).
Treatment of complicated grief: A randomized controlled trial.
lAMA, 293(21), 2601-2608.
Stroebe, M., & Schut, H. (1999). The dual process model of
coping with bereavement: Rationale and description. Death
Studies; 23(3), 197-224.
FURTHER READING
Bowlby,]: (1969, 1973, 1980). Attachment and loss (eols. 1-3).
New York: Basic Books.
Colin Murray Parkes homepage. http://hometown.aol.co.uk/
cmparkes/myhomepage/aboutme.html
Death Studies. http://www.tandf.co.uk/joumals/titles/07481187.
asp
Elizabeth Kubler-Ross homepage. http://www.elisabethkuble-
rross.com/
Kubler-Ross, E. (2005). On grief and grieving: Finding the
meaning of grief through the five stages of loss. New York:
Scribner.
Matthews, L. T., & Marwit, S. J. (2004). Complicated grief and
the trend towardcognitive-behavioral therapy. Death Studies,
28, 849-863.
1

Maciejewski, P. K., Zhang, B., Block, S. n, & Prigerson, H. G.
(2007). An empirical examination of the stage theory of grief.
lAMA, 297(7), 716-723.
Parkes, C. M. (2006). Love and loss: The roots of grief and its
complications. London: Routledge.
Report on Bereavement and Grief Research. (November 2003).
Center for the advancement of health available at
http://www.cfah.org/pdfs/griefrepon.pdf
Worden, J. W. (2002). Grief counseling and grief therapy: A
handbook for the mental health professional (3rd ed.). New York:
Springer Publishing Company.
-MARY SORMANTI
\
BEST PRACTICES
ABSTRACT: This entry describes best practi ces as these
are used in social work. The term best practices originated
in the organizational management literature in the context
of performance measurement and quality improvement
where best practices are defined as the preferred technique
or approach for achieving a valued outcome. Identification
of best practices requires measurement, benchmarking,
and identification of processes that result in better
outcomes. The identification of best practices requires that
organizations put in place quality data collection systems,
quality improvement processes, and methods for a nalyzing
and benchmarking pooled provider data. Through this
process, organizational learning and organizational
performance can be improved.
KEY WORDS: best practices; practice guidelines; em-
pirically supported practices; evidence- based practice;
performance measurement; outcomes measurement;
quality improvement; benchmarking
The term best practices first emerged in the business
management field, specifically the area of knowledge
transfer where researchers grappled with the concept of
"sticky" information (Szulanski, 1996). The problem,
which exists to some extent in all organizations', is that
most job-related knowledge is held by individuals, and
most organizations lack systems to facilitate informa tion
sharing among coworkers. In this context, best practices
refer to performance measurement and quality
improvement, and the term is defined as the preferred
technique or approach for achieving a valued outcome (for
example, Szulanski, 1996). Indeed, an organiza tion's
capacity for recognizing, disseminating, and implementing
best practices frequently distinguishes industry leaders
from unsuccessful companies (Kramer & Glazer, 2001)
because the shared knowledge raises
BEST PRACTICES 195
e overall level of effectiveness and productivity.
Although the term originated in a business model, the
concept of best practices has spread to every field, with
each domain seeking to identify its particular set of best
practices to enhance productivity or outcomes.
The term best practices originated in the organizational
management literature in the context of performance
measurement and quality improvement where best
practices are defined as the preferred tech nique or
approach for achieving a valued outcome (for example,
Szulanski, 1996). The ability to identify and implement
best practices differentiates successful organizations from
unsuccessful ones by using comparative techniques in
order to distinguishing best and worst performers (Kramer
& Glazer, 2001).
Identification of best practices requires measurement,
benchmarking (that is, identifying the standard against
which the practice will be compared), and identification of
processes that result in better outcomes (Watson, 1993 ).
The steps in describing best practices include (a)
identifying the practice of interest; (b) identifying
potential benchmarking candidates (for example, other
organizations of similar size or other units within an
organization); (c) comparing data; and (d) establishing
goals and activities to improve the benchmarked practice
(Cartada & Woods, 1995). Determining what comprises
best practices requires that organizations implement
high-quality data collection systems, systematic quality
improvement processes, and sound methods for analyzing
and benchmarking pooled provider data (Rosenthal,
2004). Through identifying, documenting, and imple-
menting best practices, the organizationalleaming (that is,
knowledge transfer) and the quality of organizational
performance can be improved. The best practice frame-
work links outcomes measurement with process mea-
surement. Identifying best practices seeks to answer the
key question of what activities incorporated into rou tine
practice will result in preferred outcomes (Mullen, 2004;
Mullen & Magnabosco, 1997).
In social work, best practices most often refers to
recommendations regarding the practices most appropriate
for routine use in service systems with particular
populations and problems (Roberts & Yeager, 2004). Best
practices have been identified in a range of practice areas,
including professional training (Hoge, Huey, & O'Connell,
2004) and evaluation (Patton, 2001). Best practices have
been developed and applied at the individual, program
(Bedell, Cohen, & Sullivan, 2000), and system levels of
practice (for example, Minkoff, 2001).
The development of best practice guidelines and
treatment protocols has been one approach to codifying
best practices for application to social work. These
guidelines have been described as emerging from
empirical and evidence-based outcome studies
196 BEST PRACTICES
conducted within commurunes, and supported as a means
to allow practitioners to provide "optimal treatment or
intervention to any individual, family, or group seeking
assistance" (Roberts & Yeager, 2004, p. 3).
Many organizations such as federal governmental
agencies, authoritative review groups (for example,
committees set up by professional organizations), and
nonprofit organizations have produced recommended
assessment, intervention, and evaluation practices iden-
tified as best practices (Roberts & Yeager, 2004). The
specific methods used by each organization to identify best
practices have varied; however, review groups have often
used both available scientific evidence and professional
consensus, while also weighing the feasibility and cost of
the recommended best practices (Roberts & Yeager).
Other methods of identifying best practices have been
described outside of social work, such as the use of
benchmarking or performance measures in business and
health care (Billings, Connors, & Skiba, 2001) and
formalized consensus panel methods in medicine
(Rycroft-Malone, 2001). According to Rosen and Proctor
(2003), best practices should be developed from deliberate
research and yield best practice protocols.
Although there is broad agreement that best practices
should be identified through sound scientific research
based on high-quality comparative data, it is generally
acknowledged this has not always been the case. As noted
by Mueser and Drake (2005, p. 221), best practices " can be
biased by the current beliefs or theories of experts, by the
prejudices of guild organizations (for example,
professional groups), or by the successful marketing of
industry. Best practices are often proven incorrect by
scientific research." Currently, there are no generally
accepted criteria for identifying best practices, and
although research evidence and expert testimonials may be
considered, other factors such as lobbying and marketing
may promote the adoption of interventions and assessment
tools as best practices (Munson, 2004; Rosenthal, 2004 ).
Sources of knowledge or evidence that may be used to
develop best practice recommendations include empirical
evidence, practice wisdom, client need, consensus
between stakeholders, case studies, program evaluati ons,
and other research efforts of varying quality, or some
combination thereof. Best practices have been criticized
for being overly general, failing to adequately address the
specific context and individual needs of clients, and in
some instances, appearing indistinguishable from other
general terms such as lessons learned (Patton, 2001; Woolf,
1998). Therefore, if best practices are to be useful in social
work, clarification of the' criteria and procedures for
determining what constitutes a best practice is
needed, including specific guidelines that will ensure that
practices are evidence based (Munson, 2004).
However, the concept of best practices may soon be
replaced in social work by newer terms such as clinical
practice guidelines, empirically supported practices, and
evidence-based practices (Corcoran & Vandiver, 2004;
Roberts, Yeager, & Regehr, 2006). Clinical practice
guidelines in health care have been defined by the Institute
of Medicine as "systematically developed statements to
assist practitioner and patient decisions about appropriate
health care for specific clinical circumstances" (Field &
Lohr, 1990). Although consensus guidelines (that is, based
on expert practitioner judgment) have been predominant,
there is a rapid movement toward evidence- based
guidelines, which are systematically developed through
critical appraisal of the empirical evidence (Rosen &
Proctor, 2003 ).Similarly, empirically supported practices
are based on evidence from system atic scientific research.
Nevertheless, it is important to recognize that best
practices in current use, unlike empirically supported
practices or evidence-based practice guidelines, mayor
may not be based on systematic research evidence.
However, as defined in the organizational literature,
best practices differ from these newer terms in important
ways. Guidelines, empirically supported practices, and
evidence-based practices focus on specific-practice ques-
tions and specific client situations, whereas identification
of best practices requires an organizational approach for
assessing variations in practice (measurement, bench-
marking, and identification of practices that enhance
outcomes; Rosenthal, 2004). It is likely that guidelines,
empirically supported practices, evidence-based practices,
and best practices will complement one another to the
extent that afl come to be based, to a greater degree, on
high-quality empirical evidence. Current trends suggesting
a continued emphasis on improving the quality and
accountability of social work practice in the future should
influence the development and application of best
practices to social work.
REFERENCES
Bedell, J. R.,Cohen, N. L., & Sullivan, A. (2000). Case
management: The current best practices and the next gene
eration of innovation. Community Mental Health Journal,
36(2), 179-193.
Billings, D. M., Connors, H. R., & Skiba, D. J. (2001).
Benchmarking best practices in Web-based nursing courses.
Advances in Nursing Science, 23(3), 41-52.
Corcoran, K., & Vandiver, V. L. (2004). Implementing best
practice and expert consensus procedures. In A. R. Roberts &
K. R. Yeager (Eds.), Evidence-based practice manual: Research
and outcome measures in health and human services (pp. 15-29).
New York: Oxford University Press.

Cortada, J. W., & Woods, J. A. (1995). The McGraw-Hill encyclopedia
of quality terms and concepts. New York:
McGraw-Hill.
Field, M. J., & Lohr, K. N. (Eels.). (1990). Clinical practice
guidelines: Directions of a new program. Washington, OC:
National Academy Press.
Hoge, M. A., Huey, L. Y., & O'Connell, M. J. (2004). Best practices
in behavioral health workforce education and training.
Administration and Policy in Mental Health, 32(2), 91-106.
Kramer, T. L.,& Glazer, W. N. (2001). Best practices:
Our quest for excellence in behavioral health care. Psychiatric
Services, 52(2), 157-159.
Minkoff, K. (2001). Developing standards of care for individuals with
co-occurring psychiatric and substance use disorders. Psychiatric
Services, 52(5), 597-599.
Mueser, K. T., & Drake, R. E. (2005). How does a practice become
evidence-based? In R. E. Drake, M. R. Mertens, & D. W. Lynde
(Eds.), Evidence-based mental health practice:
A textbook (pp. 217-241). New York-Norton.
Mullen, E. J. (2004)'. Outcomes measurement: A social work
framework for health and mental health. Social Work in Mental
Health, 2(2), 77-93.
Mullen, E. J., & Magnabosco, J. L. (1997). Outcomes measurement in
the human services: Cross-cutting issues and methods. Washington,
oc: NASW Press.
heir parental rights terminated. Sexual harassment of femtized and
abused children. In A. R. Roberts & K. R. Yeager (Eds.),
Evidence-based practice manual: Research and outcome measures in
health and human services (pp. 252-262). Oxford:
al competence is conceptuaPatton, M. Q. (2001). Evaluation,
Patton, M. Q. (2001). Evaluation, knowledge management, best
practices, and high quality lessons learned. American Journal of
Evaluation, 22(3),329-336.
Roberts, A. R., & Yeager, K. (2004). Designing, searching for,
finding, and implementing practice-based research and evi-
dence-based studies. In A. R. Roberts & K. R. Yeager (Eds.),
Evidence-based practice manual: Research and outcome measures in
health and human services (pp. 3-14). Oxford: Oxford University
Press.
Roberts, A. R., Yeager, K. R., & Regehr, C. (2006). Bridging
evidence-based health care and social work. In A. R. Roberts & K.
R. Yeager (Eds.), Foundations of evidencebased social work (pp.
3-20). New York: Oxford University Press.
Rosen, A., & Proctor, E. K. (2003). Developing practice guidelines for
social work interventions: Issues, methods and research agenda.
New York: Columbia University Press.
Rosenthal, R. N. (2004). Overview of evidence-based practice.
In A. R. Roberts & K. R. Yeager (Eels.), Evidence-based practice
manual: Research and outcome measures in health and human
services (pp, 20-28). Oxford: Oxford University Press.
Rycroft-Malone, J. (2001). Formal consensus: The development of a
national clinical guideline. Quality and Safety in Health Care,
10,238-244.
vent leading to sudden disequilibrium, failed coping, and dments to
the transfer of best practices within the finn. Strategic Management
Journal, 17, 27-43.
BIOETHICS 197
Watson, G. H. (1993). Strategic benchmarking: How to rate your
company's performance against the world's best. New York:
Wiley.
Woolf, S. i-I. (1998). Do clinical practice guidelines define good
medical care? The need for good science and the disclosure of
uncertainty when defining "best practices." Chest, 113(3),
166S-171S.
-EDWARD J. MULLEN, JENNIFER L. BELLAMY, AND
SARAH E. BLEDSOE
BIOETHICS
ABSTRACT: Bioethics and biomedical ethics are
defined. Common bioethical concepts, exemplary
moral values, fundamental ethical principles, general
ethical theories, and approaches to moral reasoning are
reviewed. The scope of topics and issues, the nature of
practice situations in bioethics, and social work roles on
organizational bodies that monitor and respond to
bioethical issues are summarized, as are trends in
bioethics. Practice contexts, from beginning to end of
life, are highlighted with biopsychosocial facts, ethical
questions and issues, and implications for social work- a
profession uniquely positioned in giving bioethics a
social context.
KEY WORDS: bioethics; biomedical ethics; health care
Bioethics is a multidisciplinary field encompassing the
traditional clinical health care professions and the
academic and legal professions. The field of bioethics
focuses on ethical issues in health care. Ethics, a branch of
philosophy, involves "ought thinking"- what should or
should not be done with respect to people. Distinct from
but related to professional standards and codes of ethics,
philosophic ethics is a systematic discussion of morality,
of right and wrong conduct. Bioethics is "the systematic
study of the moral dimensions-including moral vision,
decisions, conduct, and policies- of the life sciences and
health care, employing a variety of ethical methodologies
in an interdisciplinary setting" (Reich, 1995, p. xxi ].
Bioethics includes biomedica l ethics, which is "one type
of applied ethics-the application of general ethical the-
ories, principles, and rules to problems of therapeutic
practice, health care delivery, and medical and biologi cal
research" (Beauchamp & Childress, 1983, pp. ix, x).
Bioethics is both a theoretical and clinical pursuit.
Respect for people, life, and liberty are exemplary
moral values in bioethics. Autonomy (right to freedom in
choices and actions), beneficence (duty to benefit
198 BIOETIlICS
others), nonmaleficence (obligation not to inflict harm on
others), and justice (responsibility to allocate benefits or
burdens in a fair, equitable manner) are fundamental
principles in biomedical ethics (Beauchamp & Childress,
2001). Principles are formed by general ethical theories
ranging from deontological - or non-eonsequentialist
theories, which define actions as inherently right as a
matter of principle, duty, or right, to teleological or
consequentialist theories, which define right actions as
those that attain the best outcomes or most desirable
consequences. Justice, as one of the principles of biome-
dical ethics, employs the ethical concept of distributive
justice, for which there are four universal conceptions: to
each equally (egalitarian), to each according to need
(utilitarian), to each according to merit (libertarian), and to
each according to community-derived standards
(communitarian). Ethical analysis at the level of general
principles is referred to as principlism. Other approaches to
moral reasoning that are more contextual in focus include
virtue ethics-character based ethics (ernphasizes the
virtuous character of individuals who make the choices),
feminist ethics (values caring, comrnunitarianism, and
democracy), narrative ethics (attention to story and voice of
individuals), and casuistrycase-based ethics (focus on
particular case facts and circumstances) .
The scope of topics in bioethics ranges from begin, ning
to end of life, encompassing ethical issues such as sanctity
vs. quality of life, privacy and confidentiality vs. duty to
inform or warn, truth telling vs. deception or benevolent
lies when patients have a right to know the truth about their
diagnosis and prognosis, efficiency vs, (e)quality of care,
and primacy of individual vs. the common good in
biomedical research and resource allocation. Such issues
often involve hard choices, marked by competing values,
principles, rights, and duties, and may produce situations
with practical if not moral dilemmas, requiring ethical
analysis and decision, making. Adherence to the NASW
Code of Ethics and a strong personal and professional
identity is needed to manage conflicting moral claims,
rights, and duties that characterize practice situations in
ractice situations in bioethics are
Practice situations in bioethics are psychosocial, bio-
medical, and medico-legal in nature. Psychosocial
situations include, for example, issues of quality of life,
discussing advance directives, limits of confidential, ity,
patient-family-provider value, and interpersonal conflict;
biomedical situations encompass issues of medical
negligence, pain control, treatment futility, and with,
holding or withdrawing of treatment (Foster, Sharp,
Scesny, Mclellan, & Cotman, 1993). Medico-legal si-
tuations include, for example, issues of decision-making
capacity, competency, guardianship, and HIPPA
compliance. Social workers and bioethicists, along with
others on the health care team, blend descriptive (what is?)
and normative (what ought to be?) perspectives to
elucidate morality of clinical actions and outcomes (Foster
& Mclellan, 2002).
e impact on the person. to cases involving ethical issues
issues at the organizational level, such as mediating
patient-staff conflict and minimizing the negative impact
of managed care and cost-containment on quality health
care. Relevant is The Social Wark Ethics Audit (Reamer,
2001) for promoting ethics-related policies and procedures
and minimizing ethics, related risks in health care settings
(Kirkpatrick, Reamer, & Sykulski, 2006). Typically,
organizational bodies that monitor and respond to
bioethical issues include hospital ethics committees
(HECs) and institutionai review boards ORBs). As
members of HECs, social workers take part in committee
functions of ethics education, policydevelopment, and case
consultation and review (Furlong, 1986). Social work
contributes to all three functions, although case
consultation and review has been found to be most central
to its role (Csikai & Sales, 1998); for example, social
workers may consult on cases involving questions with
respect to end of life options and consult as advocates on
behalf of patients and families regarding health disparities
based on race, gender, class, and sexual orientation. Social
workers with their personin-environment framework
contextualize ethical decision-making by including facts
about the patient's environment-. the family and its
culturally related values, beliefs, and rituals associated
with decisions about health, illness, and treatment. As
members of IRBs, social workers serve both researchers
and participants. They ensure accountability of researchers
by reviewing submitted studies; in addition to the quality
and scientific merit of a study, of concern are ethical issues
of informed consent, confidentiality, risks and benefits,
coercion, and conflicts of interest (financial or otherwise).
As patient advocates, attentive to the lived experience in
clinical trails, social workers help evaluate, monitor, and
mange risks inherent in biomedical research.
Future Trends
Noting issues drawing bioethics onto new paths, jonsen
(2001) asserts that "renewed concern over the ethics of
genetics, the organization and financing of health care, and
the promotion of public health cannot be pursued without a
more robust appreciation of social ethics" (p, 23). [onsen
proposes a moral perspective of social responsibility,
which resonates with calls for broadening the bioethics
agenda (Brock, 2000) and giving bioethics a social context
(Hoffmaster, 2001). As Keenan (2005) observes, there is a
shift in perspective from the private

world, as in traditional clinical bioethics and its focus on
biomedical advances and issues arising in physician-
patient relationships, to the public world, as in public
health and its focus on epidemiological measures of
population sectors, necessitating a tum from philoso-
phical to empirical bioethics. According to Kleinman
(1999), this requires adapting ethical deliberation to
local contexts and attending to local moral processes,
utilizing an ethnographic mode of doing bioethics.
Beyond the basic knowledge of ethical theory, moral
reasoning, and common bioethical concepts, there is a
new blend of "is" and "ought" perspectives, serving to
bridge bioethics, medicine, and social science [including
social work) as each responds to ethical issues arising in
health care from the beginning to the end of life.
Reproduction
Bioethical issues in reproduction draws attention to
three primary areas: assisted reproductive techriologies,
prenatal screening and diagnosis, and abortion.
ASSISTED REPRODUCTIVE TECHNOLOGIES Egg
and sperm donation, in vitro fertilization, freezing or
trans, fer of human embryos, selective embryo
reduction, pre-implantation genetic diagnosis, and
surrogacy have increased both options for and
complications in family planning for infertile couples
and individuals-heterosexual, gay, and lesbian. That
fertility treatments are followed by an increase in high,
risk multiple pregnancies and birth defects begs the
question of prevention or reduction of such pregnancies
and who decides (Pennings & deWert, 2003). The right of
ex, wives to gestate frozen embryos created with former
husbands has been litigated (Stowe v. Davis, 1993), as has
genetic rights in claims of parenthood and visit, ation
privileges in surrogacy contracts (Matter Baby, 1988;
Johnson v. Calvert 1993). Patchwork laws on sperm and
egg donor anonymity in third party conception raises
issues of privacy and confidentiality (Morris, 2006):
should donors and surrogates be given confidentiality
but not anonymity?
Potential exploitation of surrogate mothers,
especially poor women, underscores the imbalance of
burdens and benefits associated with costly assisted
reproductive tech, nologies. Also, financial incentives in
the recruitment of oocyte or egg donors raise the ethical
debate of just compensation vs. potential harms to the
donor, especially when coercion by payment may
jeopardize informed con, sent (Steinbrook, 2006). And ,
the potential for selective breeding renews fears of
eugenics and genetic discrimination rooted in racism,
sexism, and economics. Conceiving a child as a future
donor of bone marrow to a sibling with terminal cancer
(Pennings, Schots, & Liebaers, 2002) also raises the
question whether children should
BIOETHIC'3
199
be viewed as reproductive means. Social workers in
fertility clinics are being challenged to re-examine the
limits of procreative liberty, the ethics of which requires
attention to culture, gender, and power, especially the
social position of women and children in society.
PRENATAL SCREENING AND DIAGNOSIS Early
diagnostic methods such as amniocentesis, ultrasound,
fetoscopy, and genetic testing provide considerable
information to diagnose abnormal fetuses, but not with- .
out a corresponding increase in maternal-fetal conflict
and the question of whether or not to terminate a
pregnancy. Presence of genetic defects such as cystic
side the prison while incarcerated. Thus, harsher
es and fewer rehabilitative measures are required
Neece & Roberts, 2001).
es of equal and intrinsic value of
mother and what constitutes a meaningful life and for
whom. If there is fetal surgery, does the fetus have
patient rights and thus personhood? Prenatal ge, netic
testing raises issues of privacy, insurance r isks, and
st, 48, 45-48.
. G., & Sue, D. W. (Eds.). (2005). The American
ical Association's guidelines on multi c
"
ABORTION Although a constitutionally protected right
to abortion was held in the 1973 Roe v. Wade decision
and reaffirmed in the 1992 Planned Parenthood v. Casey
decision, failure to achieve a national consensus on
abortion is related to unresolved definitions of when life,
personhood, and viability begin. Is not prevention of
grave harm to the mother justification enough for
partial-birth abortions? Should abortion for reasons
other than life, saving procedures such as situations of
rape, incest, and significant fetal anomalies be an uri-
challenged right? Required waiting periods, parental
consent, and lack of abortion facilities are associated
with increases in medical risks, especially for young and
poor women of color; women living below the federal
poverty level have more than 4 times the abortion rate
than women above 300% of poverty level (Gutrmacher
Institute, 2006). Social workers in abortion counseling
weigh the risks, burdens, and benefits of abortion de,
cisions in the context of conflicting interests-those of the
patient, family, and community.
Adolescent Health
Unintentional injury, homicide, and suicide are the lead,
ing causes of adolescent deaths (Park, Mulye, Adams,
Brindis, & Irwin, 2006), with obesity fast becoming a
chronic illness among adolescents (Sinaiko, Donahue,
Jacobs, & Prineas, 1999). And, despite a decrease in
teenage sexual activity, pregnancy, and abortion rates
since the mid,1990s, U.S. teen birth rates remain higher
200 BlOETHICS
than those of other industrialized nations (Kids Count,
2006); according to the Guttmacher Institute (2006), teens
are more likely to delay having an abortion and thereby
increase medical risks. Among sexually active high school
students, issues persist with respect to sexual encounters
that include violence and substance abuse, and an increase
of AIDS, especially among minority and female youth
(Kaiser Family Foundation, 2006). What is society's
responsibility to adolescents who engage in high-risk
health behaviors, especially when such beha viors may not
be the result of informed, reasoned, and voluntary choices?
According to experts in adolescent medicine (Farrow et
al., 1991), many of these youth are homeless or runaways,
with multiple health and mental health needs, and are
seeking confidential services for problems that "should be
viewed as a human rights issue with roots in poverty and
victimization" (p. 717). Indeed, adolescents are more
vulnerable than adults in accessing health care because
they are less likely to have health insurance,
transportation, information about services, and are more
likely to have fears about seeking health care (Kaiser
Family Foundation, 2006). That a 16-year-old cancer
patient's legal fight to forgo a second and more intensive
round of chemotherapy ended in victory for the adolescent
(Associated Press, 2006) challenges the legal presumption
of a minor's incompetence and raises the issue of
benevolent paternalism. In such situations, on whose
behalf does a social worker act-the adolescent in terms of
autonomy and right to informed consent, the parents or
legal guardian, or the health team's professional integrity?
Transplantation
Altruism in organ donation has been insufficient in closing
the gap between supply and demand for donor organs.
Proposals to close the gap range from presumed and
required consent to use of financial incentives (Burrows,
2004). Ethical issues pertain to donor and recipient
selection criteria, informed consent, burdens and benefits,
safety and efficacy of transplant, compliance with
transplant protocols, and resource allocation. Issues vary
depending on whether a donor is living or dead; living
donors are used for skin, kidneys, and bone marrow,
whereas deceased donors are used for organs such as
corneas, heart, liver, pancreas, kidneys, and lungs. Related
living donors may be coerced by family pressure. With
pediatric donors, informed consent is difficult because of
their maturity level and decisional capacity. In cadaver
donations, defining death is a unique ethical issue:
"cadaveric donors, although legally dead, appear very
much alive; thanks to support systems their skin is warm,
their color is good, and they
continue to digest and eliminate" (Davis, 1993, p. 119 ).
Organ procurement and standards of death are inextricably
connected. Should brain-dead patients, either infants with
anencephaly or adults in a persistent vegetative state
(PVS), be kept on life support to be a source of vital
organs? Should the "dead donor rule" be revised to su pport
premortem organ retrieval?
That costly transplants are beyond the reach of many
people raises questions of distributive justice: should
transplantation be based on medical need, merit, ability to
pay, or universal entitlement? Inequities in access to bone
marrow and peripheral stem cell transplants on the basis of
race (CIBMTR, 2007) and in allocation of organs on the
basis of race, gender, ethnicity, income, and proximity to a
transplant center serve as a barrier in transplantation
(Douglas, 2003). Eligibility based on psychosocial criteria
has been explored in bone marrow (Foster et a1., 2006)
and solid organ (Dobbels et al., 2001; Leveson & Olbrisch,
1993) transplantation; compared with biomedical criteria,
use of psychosocial eligibility criteria remains
controversial. Beyond screening for psychosocial risk
factors and conducting informed. consent interviews in
transplantation, social workers can educate the public and
advocate for equitable organ procurement and allocation
policies; whereas a natural scarcity of organs requires
rationing, political decisions about lack of resources
creates disparities, and ethical dilemmas for health care
professionals (Bodenheimer & Grumbach,2002).
End of Life
Bioethical issues at the end of life surround definitions of
death, withholding and withdrawing of life support, and
assisted suicide and euthanasia.
DEFINITIONS OF DEATH The President's Commission
for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research (1981) re-
commended that "An individual who has sustained
either (a) irreversible cessation of circulatory and re-
spiratory functions or (b) irreversible cessation of all
functions of the entire brain, including the brain stem,
is dead" (p. 2). This rules out the definition of death in
terms of higher-brain (cerebral) death, which charac-
terizes people in a PVS. At issue for both advocates
and critics of this definition of death is the question of
personhood. Should definition o f death be expanded to
include those who have never had or who have lost
their capacity to think, feel, or be capable of
meaningful relationships? Unresolved definitions of
death and when personhood ends raise ethical issues in
the use of life supports.

WITHHOLDING AND WITHDRAWING LIFE SUPPORT
Artificial nutrition and hydration are con, sidered
forms of life support and can be used to accelerate
death or prolong life. Are withholding and
withdrawing life support morally equivalent? When
is either optional or obligatory? Symbolism of food
and water is central to the ethics of forgoing life
support, as are definitions of death, medical futility,
and decisional capacity, especially in patients with
progressive dementia and neurological disease.
Should neurologically impaired people who find life
burdensome and without discernible meaning be
kept on life support? Should family wishes to
prolong life be upheld when patient's advance
directives are to the contrary? Public intrusion into
the life and death, of Terri Schiavo in 2005 is a
reminder that even at life's end the personal is
political; memorable is how biopolitics, religious
rhetoric, and the media weighed in on the end of life
debate (Pence, 2008; Perry, 2006). Consistent with
landmark decisions in the 1976 Quinlan case and the
1990 Cruzan case, both of which recognized rights
of dying patients and substituted judgment, the
Schiavo case underscores (but not without
controversy and national angst and debate) health
professionals and family members have an obli-
gation to honor withholding or removal of treatment
that does not hold promise for quality of life
consistent with a patient's wishes or advanced
directives. An ad, vance directive is an oral
statement or a formal written document (living will
or durable power of attorney for health care)
indicating an individual's choices regard, ing
end-of- life care if and when the individual become s
incapacitated. Social workers clarify advanced
direct, ives, advocate for a patient's right to choose,
provide supportive counseling, act as liaison to the
health care team, and encourage family involvement
and the ex, ploration of end-of-life options and
AssISTED SUICIDE AND EUTHANASIA To die with
resources
dignity is (NASW Press, 1994).
a moral value. Is there a time when being
alive no longer means having a life capable of
meaning? At that time, is physician, assisted suicide
death with dignity? Is there a moral difference
between killing (active euthanasia) and letting life
go by omitting therapeutic treatment (passive
euthanasia)? Are age and chance of survival,
especially among underinsured or uninsured
terminally ill people, just criteria for passive
euthanasia? When does a competent patient's right
to self-deterrnination include right to choose death
over life? The U.S. Supreme Court in 1997 rejected
prior arguments (Compassion In Dying v. State of
Washington, 1996; Quill v. Vacco, 1996) in a decision
that said a fundamental right to die did not exist in
the
BIOETHICS 201
Constitution but that individual states could grant that right
to its citizens and that the distinction be, tween
physician-assisted suicide and refusing life, sustaining
treatment is not arbitrary (Pence, 2008).
Although euthanasia is increasingly being considered a
moral option among hopelessly ill people who are dying in
pain, distress, and inhumane situations (Emanuel, 1998),
the only country in which voluntary euthanasia is legal is
the Netherlands, and the only state in the U.S. that has
legalized physician-assisted suicide is Oregon. Although
challenged, Oregon's 1997 law was upheld in 2006 by the
Supreme Court in its ruling that drug interdiction laws do
not apply in the practice of medicine. Yet, an attitude of
ambivalence, if not reticence, toward active termination of
life prevails in the helping professions and this is reflected
in calls for better pain management and hospice, inspired
strategies of caring for terminally ill people. NASW Social
work speaks has a policy statement on its position con,
cerning end, of, life decisions and social work's role
(NASW Press, 1994, pp. 58-61).
Health Disparities
Is health care a right or privilege? Should allocation of
health care be based on need, merit, age, or chances for
survival? Do undocumented immigrants have a moral
claim on health care resources in the United States? Do
individuals who pursue lifestyles that appear to be self-
destructive have a moral claim on health care? What is a
just allocation of health care? Such questions are being
asked in the context of efforts to eliminate significant
disparities in health status, care, and outcomes.
Health disparities is defined by the Healthy People
2010 initiative as the "unequal burden in disease rnorbidiry
and mortality rates experienced by ethnic/racial groups as
compared to the dominant group" (U.S. Department of
Health and Human Services, 2000). De, bates exist in the
literature over whether health disparities are based on both
race and class as co-determinants of health status and
outcomes (Kawachi, Daniels, & Robison, 2005; La Veist,
2005). Debates notwithstanding, inequities in health and
health care throughout the life span do not favor poor
people of color, as evidenced by increased rates of high,
risk pregnancies, higher rates of infant mortality,
low-birth-weight babies, and children with congenital
defects and disabilities (Oberg & Rinaldi, 2006) Also,
according to Newacheck et al. (2003), socioeconomic
status accounts for significant disparities in adolescent
health and health care. And, Smedley, Stith, and Nelson
(2002) report that diseases that can be prevented or delayed
in adults, such as diabetes, hypertension, heart disease,
cancer, and AIDS, are diseases for which minority groups
are at a much higher risk.
202 BIOETHICS
Despite managed care, health care costs are rising
markedly (Appleby, 2006) and levels of health insurance
are lower among minority populations, who account for
half of the 45 million uninsured Americans (Kennedy,
2005). Sarto (2005) notes that "insurance status, more than
any other demographic or economic factor, deter mines the
timeliness and quality of health care received" (p. 1190).
Health care decisions based on costs rather than potential
benefit to patients, as in health care rationing, is an ethical
dilemma for social workers. Cultural competence,
language translation services, health literacy, diversity of
health care professionals, and health promotion/disease
prevention are also key issues in addressing disparities in
health care. Health disparities based on demographics,
differential access, and health care delivery factors are
increasingly viewed as unjust and a violation of basic
human rights and equal opportuni ty .
Biomedical Research
Ethical issues in biomedical research pertain to (a) the
freedom of patients or subjects to participate in research
without coercion (autonomy), (b) the benefit of the
research to present or future patients or subjects and
society (beneficence), (c) the risk of harm to patients or
subjects (non-maleficence), (d) the reasonableness of
costs to patients or subjects (justice), and (e) the privacy of
patient or subject information (confidentiality) (Kanoti,
1983).The current NASW Code of Ethics includes a
substantial section on ethical standards related to social
work evaluation and research (Standard 5.02), which
addresses the protection of research participants.
Participation In biomedical research is viewed as
justified when it is in the best interest of the patient or
subject, or when the likely benefits outweigh possible risk
of harm. However, with respect to areas of research
directly related to patients or subjects, in whose best
interests are randomized clinical trials-the individual
patient or future patients? In pediatric research, legal
presumption of a minor's incompetence raises the question
of individual autonomy; whether adolescents should be
considered more like children or more like adults depends
on their cognitive, emotional, and social maturity,
although IRBs in most states utilize the age of under 18 as
the age of a minor. Similar consideration is given to
inclusion of mentally impaired people in nontherapeutic
research, but greater safeguards may be necessary because
of social worth criteria; such criteria may be based on
perceptions of desirable biological, psychological, and
sociological traits and functioning.
Areas of research posing ethical issues indirectly
related to patients include finders' fees, or payment to
physicians for referral of patients as research subjects,
and corporate reimbursement for entering patients into
clinical trials testing drugs or products (Shimm & Spece,
1991). There is also an ethical debate related to
pharmaceutical sponsorship of clinical trials in pris ons,
which may invite exploitation and coercion of prisoners
and, as a result, undermine informed consent (Beauchamp
& Childress, 2001). And research that poses ethical
concerns on a more global scale includes the Human
Genome Project, which involves mapping the entire gene
system to increase the ability to search for and predict,
through genetic testing and screening, the future disability
of oneself or one's children (McCarrick, 1993). Who
should have the option and results o(DNA tests revealing
presence or absence of a lethal gene? Society's use of this
information, particularly by law enforcement officers,
employers, and insurers of life, health, and disability, is a
significant concern (Murray, 1993). DNA profiling raises
fears of genetic discrimination on the basis of cost savings
as well as social desirability criteria.
Ethical controversies as well as promising break-
throughs in biomedical research have come with human
embryonic stem (hES) cell research and experimenta tion.
Human embryonic stem cells may be used to gen erate
replacement cells and tissue to treat degenerative diseases
such as Parkinson's disease, cystic fibrosis, Huntington's
chorea, multiple sclerosis, or spinal cord injury (deWert &
Mummery, 2003; Hansen, 2002). However, destruction of
human embryos is used to derive the embryonic stem cells.
This raises questions about the moral status of the embryo
and the ethical issue of life itself ve rsus the quality of
another's life. And, given the risks and potential harm to
donors in egg donation (Steinbrook, 2006), as well as
potential for a . handsome compensation, is there not a
moral difference in informed consent when embryonic
stem cells from
egg donors are utilized for research instead of reproduc-
tive purposes? When is creating embryos for research
justifiable?
As we move from biotechnology to nanotechnology
-or molecular manufacturing-the gap between science and
ethics potentially widens. According to The Nanoethics
Group (2007), new drugs that target cancer cells and
viruses, repair defective genes (as in gene therapy), and
repair cells that can modify the aging process (as in
regenerative medicine) bring new challenges with respect
to privacy and confidentiality, informed consent, and
assessing harms and benefits.
Challenges and Opportunities
Since the first entry on bioethical issues in the 19 th edition
of the Encyclopedia of social work, shortcomings of
managed care and return of inflationary costs

have renewed concerns about organization and financing of
health care. This, along with an increased aging population,
Incidences of chronic illnesses and infectious diseases, and a
prevalence of health disparities has led to a movement
promoting public health and health care reform. Paralleling
such trends and concerns has been a move to broaden the
agenda in bioethics, addressing the social determinants of
health, adapting ethical deliberation to local contexts, and
attending to local moral processes.
Social work has a leadership role in advancing this new
agenda. Like bioethics, social work, with its dual focus on
enhancing individual well-being and promoting social and
economic justice, is -inherently normative and a moral
enterprise; But unlike bioethics, social work has been (and is)
anchored in the empirical world-the lived moral experience of
poverty, oppression, and discrimination, including inequality
in health and health care; therefore, social work is committed
to social justice as part of its code of ethics. Such a person-
in-environment focus and commitment uniquely positions
social work in giving philosophical bioethics a social context.
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Pennings, G., Schots, R., & Liebaers, I. (2002). Ethical
considerations on preimplantation genetic diagnosis for HLA
typing to match a future child as a donor of haernatopoietic stem
cells to a sibling. Human Reproduction, 17, 534-538.
Perry, J. (2006). Biblical biopolitics: Judicial process, religious
rhetoric, Terri Schiavo and beyond. Health Matrix: Journal of Law
Medidne, 16(2),553-630.
Planned Parenthood v. Casey. (1992, June 30). NIT, p. A8.
President's Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research. (1981). Defining
death. Washington, DC: GPO.
Quill v. Vacco. (1996).80 f.3d 716.
Reamer, F. G. (2001). The Social. Work Ethics Audit. A risk
management tool. Washington, DC: NASW Press.
Reich, W. T. (1995). Introduction. In W. T. Reich, (Ed.),
Encyclopedia of bioethics (rev. ed. Vol. 1, p. xxi). New York:
Simon & Shuster Macmillan.
Roe v. Wade. Supreme Court Reporter, 93, 410 US 151, pp.709-762.
Sarto, G. (2005). Of disparities and diversity: Where are we?
American Journal of Obstetrics and Gynecology, 192, 1188-1195.
Shimm, D. S., & Spece, R. G., Jr. (1991). Industry reimbursement for
entering patients into clinical trials: Legal and ethical issues.
Annals of Internal Medidne, 115(2), 148-151.
Sinaiko, A. R., Donahue, R. P., Jacobs, D. R., & Prineas, R. J. (1999).
Relation of weight and rate of increase in weight during childhood
and adolescence to body size, blood pressure, fasting insulin, and
lipids in young adults. Circulation, ' 99, 1471-1476.
Smedley, B., Stith, A, & Nelson, A. (Eds.). (2002). Unequal
treatment: Confronting racial and ethnic disparities in health care.
Washington, DC: National Academy Press.
Steinbrook, R. (2006). Egg donation and human embryonic stem-cell
research. The New England Journal of Medidne,
354(4),324-326. .
Stowe v. Davis. (1993). 113 S. Ct. 1259.
The Nanoethics Group (2007). The ethics and societal impact of
nanotechnology. www.nanoethtcs.org/good.html
U.S. Department of Health and Human Services (] anuary 2000).
Healthy people 2010: National health promotion and disease
prevention objectives. Washington, DC.
-LARRY W. FOSTER
BIRTH CONTROL. See Abortion; Family Life
Education.
BISEXUALITY
ABSTRACT: This entry explores past and present
social-scientific lenses conceming bisexuality. The
author traces the rise of a bisexual movement in the
1970s to present times. The entry concludes by
addressing social work's limited contributions to
understanding bisexuality and proposes trends and
directions for future practice and research with
diverse groups of bisexuals.
KEY WORDS: bisexuality; GLBT history; community
organizing; human sexuality
Bisexuality is difficult to define due to evolving social-
scientific paradigms for understanding human sexuality and
shifting political discourses of the gay, lesbian, bisexual, and
transgender (GLBT) organizing movements. Freud was the
first notable 20th-century Westem thinker to locate
bisexuality as a universal psychosexual phenomenon. He
professed that all individuals have bisexual tendencies in
childhood but that they learn to repress their desires, resulting
in either a
 BISEXUALITY
205

heterosexual or homosexual orientation. In the late 1940s, the San Francisco Bisexual Center, the world's first
Alfred Kinsey used data from his pioneering research on specifically bisexual institution, opened in 1976.
human sexual behavior to define sexuality on a scale By the middle of the 1980s, many of these pioneering
ranging from zero, representing exclusive heterosexual bisexual groups had disbanded as bisexual men turned
behavior, to six, representing exclusive homosexual their energies toward the growing HIV/AIDS epidemic.
behavior. He located bisexuality in the vast space between Bisexual women began to initiate their own groups and to
these opposite positions. Dr. Fritz Klein (1978), a noted locate spaces-separate from bisexual men and from
psychiatrist, later expanded on the Kinsey scale to create lesbians-to affirm their identities. Although bisexual
the Klein Sexual Orientation Grid. This grid broadened women distinguished themselves from the lesbian
Kinsey's definition by incor- . porating seven different separatist movement, feminist principles and
aspects of sexuality and indicating shifts in orientation overwomen-centered spaces were still a foundation of these
the passage of time. In the mid-1990s, Weinberg, Collins, early bisexual women's groups.
and Pryor's 1994 book Dual Attraction advanced a: A more gender-unified and visible bisexual movement
simplified version of Klein's grid, including three main began to take root when the call for a bisexual contingent
dimensions: sexual feelings, sexual activities, and romantic at the historic 1987 March on Washington for Les bian and
d mental health treatment, substance abuse treatment, or Gay Rights laid the groundwork for the establishment of
the North American Bisexual Network (later changed to
arch and Theory, 10,359rating definitions of bisexu- BiNet U.S.A.). The mission of this organization was to
one can see a wide range of orientations for individuals increase the visibility of bisexuals and fight bias from the
who do not identify with, or whose behavior does not fall heterosexual mainstream and from within the gay and
into strictly "heterosexual" or "homosex ual" categories. As lesbian movement. Linking forces at times with the
an undefined and somewhat "hidden" population (that is, transgender movement, bisexuals advocated for
bisexuals may visibly blend in with gays and lesbia:ns or recognition within the gay and lesbian movement, which
with heterosexuals, depending on their partner choice), the was slowly making inroads into mainstream legal,
prevalence of bisexuality is very difficult to measure. political, and social arenas.
Perhaps due to the complexities involved in its meaning Since the historic March on Washington, the bisex ual
and measurement, bisexuality has not received academic, movement has continued to expand. Books, magazines,
popula:r, or social work attention on par with academic journals, and other resources specifically for
"homosexuality" (typically meaning gay male expression) bisexuals have sustained the visibility of the bisexual
or lesbianism. Yet in spite of the elusiveness of the voice. Yet, despite. this presence, social work has not
category and tendencies toward invisibility, bisexuality has made significant contributions to advancing knowledge
a unique history of community organizing that merits about bisexuality. For example, although a plethora of
attention. professional literature has been published on and about
Although bisexual-specific organizations did not de- gay men and lesbians in the I oumal of Homosexuality and
velop in the United States until the 1970s, bisexual more recently in the Journal of Gay and Lesbian Social
individuals were involved in many of the early 1950 s and Services, the mainstream social work publications have
1960s U.S. and European "homophile" groups whose lagged behind several of the other helping professions,
mission was to organize for gay and lesbian social most notably psychology, in understanding and exploring
acceptance. However, because the early homophile groups the diverse needs of bisexuals.
were not necessarily trusting of bisexuals, many members Given the scarcity of resea:rch on bisexuality in social
of this group were not open about their attractions to both work, opportunities for future research on bisexuality and
sexes (Marcus, 1992). the development of practice wisdom are abundant. Social
By the 1970s, the gay and lesbian liberation movement work practitioners, educators, and researchers can parti-
as a whole was more accepting of bisexuality and groups cipate in the vital role of supporting this marginalized
that advocated free expression of sexual behavior, and it group by educating themselves about the spectrum of
even celebrated bisexuality's potential for liberation from human sexuality and conducting community-based re-
heterosexual or homosexual constraints. During this time search on the diversity of the bisexual population and its
period, many bisexuals-and in particular, bisexual needs and experiences. A thorough exploration of the
men-began founding their own organizations that were psychosocial issues facing this diverse group, of the pro-
separate from gay men's organizations. For example, the cesses of self-labeling and self-identification in relation to
National Bisexual Liberation Group was formed in New sexuality (examining bisexuals' involvements in same and
York City in 1972, and opposite-sex relationships), and of the role of risk behavior
in health maintenance is needed in order
206 BISEXUALITY
to better understand bisexuality and human sexuality, in
generaL
Speaking to the diversity within the GLBT community, the
NASW publication Social Work Speaks notes that lesbian,
gay, and bisexual youth, older people, and people of color are
often underserved due to invisibility (NASW, 2003). Given
the underserved status of bisexuals and its various subgroups,
the evidence base for best practices with bisexual clients is in
great need of elaboration. Social workers should consider
bisexuality not solely as part of human behavior in the social
environment, but also as an important social movement that is
parallel to, yet distinct from, the gay and lesbian movement for
civil rights that occurred during the last half century.
REFERENCES
Klein, F. (1978). The bisexual option. New York: Arbor House.
Marcus, E. (1992). Making history: The struggle for gay and lesbian
equal rights 1945-1990: An oral history. New York:
Harper Collins.
NASW. (2003). Social work speaks: Lesbian, gay, and bisexual
issues. Washington, DC: NASW Press.
Weinberg, M. S., Williams, C. J., & Pryor, D. W. (1994).
Dual attraction: Understanding bisexuality. New York:
Oxford Press.
FURTIIER READING
Morrow, G. D. (1989). Bisexuality: An exploratory review.
Annals of Sex Research, 2, 283-306.
SUGGESTED LINKS
http://www .biresource .org/
http://www . binetusa. org/
-LAURA S. ABRAMS
BLACK PEOPLE. See African Americans:
Overview.
BLINDNESS AND VISUAL IMPAIRMENT
ABSTRACT: Significant visual impairment affects ",8
million Americans, 1.8 million of whom are blind and must
find nonvisual methods of performing life roles. Social
workers should not assume that people with visual impairment
or blindness are unable to work, have families, or engage in
sports or travel, or that vision limitations are necessarily a part
of every presenting problem. Key roles for social workers
include
assisting in access to services and training and advocacy to
combat discrimination and exclusion.
KEY WORDS: blindness; visual impairment; disability; civil
rights
People having little contact with those who are blind may
imagine that a person's blindness precludes functioning
competently in the world. While a 1991 survey reported that
blindness is a "more accepted" disability than is mental illness
and that 47% of the survey population considered themselves
"very comfortable" when meeting a blind person (Louis
Harris and Associates, 1991), many people including
professionals equate blindness with helplessness. As Warren
(2000a) points out, "it may seem self-evident that vision
impairment would produce an adverse impact on personal
functioning in every area, but this issue is one for research
rather than conjecture; the relationships are frequently not
those that intuition might suggest" (p. 321). After training in
managing oneself as a person with visual impairment, and
when not barred by fears of others, people who are blind or
visually impaired study, hold jobs, raise families, go to
restaurants, and participate in
typical life roles and activities. .
There are millions of people who have some degree of
visual impairment, but can rely on their vision (perhaps
augmented by glasses) to perform tasks of daily living. This
entry focuses on those people with vision impairments and
blindness that require special services or adaptations.
History
The earliest approaches to helping people who were blind or
visually impaired in the United States stressed special,
separate education for children, sheltered or specialized
noncompetitive employment for adults, and a specialized
system of service agencies to meet the social and recreational
needs of clients. Social and educational programs for people
with visual impairment taught such adaptations as Braille,
travel with a long cane or a guide dog, and some methods of
cooking, sewing, and other activities of daily living. They also
engendered in their clients a belief that visual impairment
prevented them from participating in their former employment
or community activities and that they needed to develop new
outlets and new lives as "blind" people (Scott, 1969). The
challenge to this separation came from people who were blind
or visually impaired, particularly those who founded the
National Federation of the Blind (NFB)-the first major civil
rights group of people with disabilities in the United States
(Asch, 1985; Matson, 1990). With its civil rights and
 BLINDNESS AND VISUAL IMPAIRMENT
207

minority-group approach to blindness, NFB endorsed the
need for high-quality rehabilitation training, training in
alternative techniques of living for people who could not
always rely on vision, and the right of "blind people to speak
for themselves" to combat laws and practices that excluded
them from ordinary educational, work, civic, and leisure-time
activities.
Profile of the Population with
Visual Impairment
The 2005 National Health Interview Survey (NHIS) estimates
that among non-institutionalized persons aged 18 and above
~20.2 million people have trouble seeing, even when wearing
glasses'{Pleis & LethbridgeCejku, 2006), while the, 2002
Survey of Income and Program Participation (SIPP), using a
more conservative definition of visual impairment, estimated
that 7.9 million people aged 15 and above have difficulty
seeing well enough to read a newspaper, even with glasses
(Steinmetz, 2006). The SIPP also estimates that 0.5% of
children aged 6-14 have difficulty seeing. Because both
datasets exclude those living in institution~l settings, these
counts slightly underestimate the true total. Furthermore,
because only visual limitations with reference to reading are
explored, these data do not indicate how many people cannot
manage tasks . that require intermediate or distance vision,
such as seeing a computer screen, spotting a building or a
familiar person across a street, or watching television.
Globally, using data collected in various national formats, the
World Health Organization estimates that, in 2002, 36.9
million people were blind (a prevalence of 0.57%) and
another 124 million had low vision (prevalence of 2%)
(Resnikoff et al., 2004).
Visual impairments increase with age, and females have
higher rates of visual impairment at every age (Table 1).
Visual impairment also varies with race, with African
Americans, American Indians, and Alaska Natives having the
highest rates. This variation may be related to racial
differences in poverty rates, as visual impairments are more
prevalent among people living below or slightly above the
poverty line. Persons with severe visual impairment have a
48% employment rate and those with less severe visual
impairment have a 57% rate (Table 2); both rates are
substantially lower than the 88% employment rate for those
with no disability (Steinmetz, 2006). Both the median and
mean annual earnings of the working people with visual im-
pairment are "'$10,000 lower than those of workers with no
disability. The low level of earnings (median annual earnings
of $22,189) implies that even for those who are employed,
many will be counted among the poor or near poor.
CAUSES OF VISUAL IMPAIRMENT People with visual
impairment, including those considered "legally blind,"

TABLE 1
Percentage of Adults Having Trouble Seeing Even with Glasses or Contacts (NHIS, 2004)
CHARACTERISTICS % % % OF
Age MALE FEMALE ADULTS
18-44 4. 5.8 5.1
45-54 4 13.1 11.2
55-64 9. 11.7 10.5
65-74 2 15.9 14.
75 years and above 9.1 21.4 1
19.
12.
9
Race and Ethnicity 0
White only 17. 8.8
Black or African American only American 7 10.
Indian and Alaska Native only Asian only 3
Native Hawaiian and other Pacific 14.8
Islander 5.1
Two or more races
Hispanic or Latino (any race) Not 11.0
Hispanic or Latino (any race) 8.
8
8.9
Poverty Status
Below 100% of the poverty line 14.
100% to less than 200% 2
200% or more 12.
0
Source: From Table 59 of Health, United States, 2006, With Chartbook on Trends in the Health of Americans, by National Center
8.2 for Health
Statistics, 2006 (which cites National Health Interview Survey, 2004), Hyattsville, MD.
208 BLINDNESS AND VISUAL IMPAIRMENT
"TABLE 2
Employment Status and Earnings of Adults Having Visual Impainnent (SIPP, 2002)
VISUAL IMPAIRMENT % MEDIAN EARNINGS
Difficulty seeing words/letters, severe EMPLOYED
Difficulty seeing words/letters, not 48.0
severe Total U.S. population, 21-64 57.2
years 88.2
From Table 5 of Americans with Disabilities: 2002 Household Economic Studies, by E. Steinmetz, 2006, Current Population
Reports, P70-107, U.S. Census Bureau.
d November 9, 2007, from
people have some usable vision, but they may be unable to
distinguish faces or the lettering of signs or they may not
have central or peripheral vision. Of the estimated 7.9
million adults having some visual impairment, 1.8 million
report being unable to see (Steinmetz, 2006,
SIPPestimate). The most frequent causes of vision
ale prison inmates were HIV -positive, compared ions
whose prevalence increases with age and are experienced
by adults. These causes are diabetic retinopathyv age-
related macular degeneration; cataracts, and glaucoma
(CDC, 2004). For a small percentage of persons, visual
impairment or blindness is traceable to genetic condi tions
such as retinitis pigmentosa or retinoblastoma. Injury also
accounts for a small percentage of adult onset visual
impairment or blindness. The association be tween aging
and visual impairment indicates that the prevalence of
visual impairment and blindness is likely to increase with
the aging of the large baby boom cohort.
Low vision and blindness are uncommon among
children, with most of the few cases occurring before birth
or within the first month of life. Such conditions
retinopathy of prematurity, albinism, hydrocephalus,
congenital cytomegalovirus, and birth asphyxia are the
most common causes of visual impairment in children
below 10 (CDC, 2004).
Services and Legislation Affecting
People With Visuallmpairrnent
People who have visual impairment benefit from the
services, agencies, and legislation that are intended for all
people with disabilities. However, some legislation and
services are targeted at people who meet the federal
legislative definition of "legal blindness": clinically
measured visual acuity of 20/200 or less in the better eye
or a visual field of 20 or less after optimal correction
(American Foundation for the Blind, 2007). The person
whose vision meets this definition can see at 20 feet what
someone with perfect vision can see at 200 feet, and the
width of vision is substantially narrower than that for
someone whose sight is unimpaired. Some . government
and private agencies provide vision-related services only
to those who meet the definition of
,
MEAN EARNINGS
$15,842 $22,189
$15,951 $22,088
$25,046 $32,870
legal blindness; others may serve the broader visually
impaired population. Although nearly half of the popu-
lation with visual impairment is above age 65, the service
system is still geared primarily to children and
working-age adults.
ACCESS TO THE PRINTED WORD Special services
and legislation to ensure access to the printed word have
existed since 1879 when federal legislation enabled the
expansion of the activities of the American Printing House
for the Blind to produce books for people who were blind
(American Printing House for the Blind, 2004). Other
federal legislation authorized sending Braille materials as
"free matter for the blind," to avoid the cost to libraries of
mailing the heavier Braille and other materials. Federal
law also established the Books for the Blind program, now
National Library Service for the Blind and Physically
Handicapped (NLSBPH), which provides Braille and
recorded literary and music materials to anyone unable to
read standard print because of a visual, learning, or
physical disability (National Library Service, 2006).
With computer technology and the Internet now being
major vehicles for the dissemination of information,
ensuring access to words and graphics in electro nic and
online media has become important. Section 508 of the
Rehabilitation Act requires that all federal government
Web sites and related materials be acces sible to persons
with visual impairment. The access standards are set by the
Access Board (Architectural and Transportation Barriers
Compliance Board). While Secdo; 508 does not apply to
the private secror, it has spurred the development of
voluntary guidelines for Web and other media access that
many organizations have adopted (the World Wide Web
Consortium developed guidelines described at
http://www.w3.org/TR/ WAI-WEBCONTENTf). There
also has been litigation under the Americans with
Disabilities Act, challenging organizations that use
technologies that rely on screen instructions or touch
screens, such as A TMs and cell phones, to assure access
for people with visual impairment. This concern can apply
to human service agencies as they implement new
technology in providing

information and other services to clients through Web sites
or through electronic or video media.
EDUCA nON AND REHABILIT A nON The Individuals
with Disabilities Education Act (IDEA), originally PL
94-142, and the Rehabilitation Act of 1973 apply to all
people with disabilities, including those with visual
impairments. Under the Rehabilitation Act, states may
develop a separate agency to provide services exclusively
to persons classified as legally blind. Just over half the
states have established a separate agency. Where there is no
specialized agency, services for people who are legally
blind are delivered through the broader state rehabilitation
agency. Some states with separate agencies may restrict
services to those who meet that state's definition of legal
blindness, but others serve anyone with significant visual
problems. Social work clients who need vision-related
services should first be referred to a specialized agency; if
services are not provided because the individual's vision
does not meet the eligibility criteria, services should be
requested from the state's general rehabilitation agency.
Veterans with visual impairment may receive services,
assistive devices, and assistance with housing adaptations
through the Blind Rehabilitation Service of the Veterans
Administration (VA) or a V A medical center. The Blind
Rehabilitation Service consists of 10 regional blind
rehabilitation centers, visual impairment services teams
(VISTs), VIST coordinators located at VA medical centers
and outpatient clinics, and other rehabilitation personnel
whose work may include computer access training or
training for those with low vision or who are blind (U.S.
Department of Veterans Affairs, 2007). The Blind
Rehabilitation Service provides services to all veterans who
are blind or have low vision, regardless of whether the
visual impairment is service-connected,
SPECIAL EMPLOYMENT LEGISLA nON Two laws
from the 1930s give people who are legally blind access to
sheltered and. noncompetitive employment: the
Wagner-O'Day Act (PL 75-739), which established a
system of sheltered workshops, and the RandolphSheppard
Act (PL 74-734), which gives people who are legally blind
preference as operators of vending facilities on federal
properties. These laws and their subsequent amendments
have helped to provide work for thousands of people who
are blind, but the working conditions have not always been
compared favorably with the conditions in the general
labor force. Workshop employees are considered workers
under federal law, but some agencies have attempted to
treat them as clients and have denied them the right to
organize for improved wages and working conditions. The
National
BLINDNESS AND VISUAL
IMPAIRMENT 209
Labor Relations Board has upheld the rights of workshop.
Employees to form unions and to bargain collectively, yet
some of these workers still earn less than the Federal
Minimum Wage, legal under Section 14C of the Fair Labor
Standards Act. While vendors are considered
self-employed entrepreneurs, the state agency that serves
people who are blind issues their operating licenses and
supervises their work and service requirements. The 1971
javits-Wagner-O'Day Act, an expansion of the original
1938 Wagner-O'Day Act, creates employment
opportunities for persons who are blind (or who have
severe impairments) via government purchases of products
and services provided by nonprofit agencies employing
such individuals. The National Industries for the Blind, a
nonprofit agency, coordinates the implementation of the
program for persons who are blind (more information is
available at http:// www.nib.org).
INCOME SUPPORT The determination of blindness or
visual impairment for disability income support is based on
a set of vision standards used by both the social insurance
and the income-tested benefit programs administered by
the Social Security Administration. People who are blind or
visually impaired and who are no longer able to work but
have worked and contributed to the Social Security trust
applied for jobs in the city of Milwaukee. Her dependent
ariable was whether an employer
applied to all SSDI beneficiaries. However, the earnings
standard for people who are blind or visually impaired who
subsequently become employed (referred to as substantial
gainful activity, SGA) is higher than the standard for other
SSDI recipients (the SGA, for 2007, for example, is $1,500
(1991). The metaphysics of morals. New York:
ge University Press. (Original work published 1796)
months will no longer be paid an
although those who are blind can have their payments
resume promptly should their earnings fall below SGA.
Poor adults who are blind or visually impaired and who
have no labor force experience or too little for SSDI
eligibility may receive support from the income-tested
Supplemental Security Income program (SSI). The federal
SSI benefits for people who are blind are the same as those
for people with other disabilities, although some states
supplement the federal SSI grant to provide greater cash
assistance for recipients who are blind (Social Security
Administration, 2006). If the ssm benefit and other income
are below the income standard for SSI, it is possible to
receive support from both programs. While the SGA
standard is applied in
210 BLINDNESS AND VISUAL IMPAlRMENT
some cases for initial SSI eligibility, it is not used for the
continuing eligibility of employed SSI recipients. Instead,
countable earnings are computed by first deducting work
expenses and $85 of disregard, and then calculating 50% of
that amount. Recipients are no longer eligible for SSI when
countable earnings and other income exceed the income
eligibility standard. Unlike other SSI recipients, SSI
recipients who are blind are allowed to include in
deductable work expenses all work-related expenses,
whether or not they are directly related to the impairment.
SERVICES TO DEAF BLIND AND OTHERS WITH
MULTIPLE IMPAIRMENTS A segment of the popula-
tion of persons who are visually impaired or blind
identified as having unique and sometimes unmet needs is
people with hearing impairments as well. The pre valence
of concurrent hearing and visual impairment is estimated
at 3.3% overall; however, among persons above age 79,
lishing whether it is reasonable to think that a crime was
rime was committed and that the suspect did it. An
n arraignment is a hearing where the defendant is formally
lly charged and then entersaired also incur hearing loss that
that precludes use of some alternative techniques and
necessitates the development and teaching of new
techniques at this center.
Learning the techniques to function without sight may
be more difficult if individuals have manual dexterity
problems that prevent them from reading Braille or hearing
problems that prevent their use of sound in orientation and
travel. Some people with visual impairments and cognitive
impairments arising out of mental disabilities or brain
injuries will need services from agencies and organizations
that specialize in cognitive rehabilitation. Agencies that
serve people with hearing, mobility, or cognitive
impairments may fear taking on clients who have visual
disabilities as well. In such circumst ances, social workers
can playa crucial case management and advocacy role to
ensure that clients with multiple disabilities receive the
services to which they are entitled.
SERVING CLIENTS WITH VISUAL IMPAIRMENT IN
GENERAL SETTINGS People with visual impairment,
like other people, seek social services for marital or family
problems, as part of their employment, or on behalf of
relatives. In these instances, blindness is in cidental or
irrelevant to the request for assistance. The social work
with such clients should concentrate on the family's or
couple's dynamics, and not assume that blindness is the
chief issue or that people with visual disabilities need
services from specialists in blindness. However, if
blindness comes up repeatedly as a source
of friction, the worker may need to explore how the visual
impairment is affecting the other issues that are the focus
of concern.
CIVIL RIGHTS All people with disabilities, including
those who are blind or visually impaired, are protected
against discrimination in employment and in utilizing
public and private services by the Americans with Dis-
abilities Act and the 1973 Rehabilitation Act. These laws
have no special provisions for persons with visual
impairment, but they serve as the basis of an employer's
obligation to provide "reasonable accommodation" in the
form of readers or other assistive devices. The Act
mandates that public and private agencies evaluate
whether they are physically accessible and accessible in
terms of their program rules, regulations, and .proce dures.
to consumers and clients having visual impairmerit. What
is required for full access is still being contested. For
example, the Social Security Adrninistra tion is being sued
for communicating with benefit recipients who are blind
or visually impaired in print formats they cannot read, and
then suspending their benefits for subsequent failure to
comply with its requests (American Council of the Blind et
al. v.lo Ann B. Barnhart, Commissioner of the Social
Security Administra~ tion, in her official capacity, and
Social Security Administration, complaint available at
http://www.dredf.org).
ifespan Approach to
Blindness and Visual Impairment
Social workers may come into contact with people who
are blind or visually impaired at all stages of develop ment,
and may assume a variety of roles in relation to this
population.
INFORMATION When individuals or family members
discover that they or their loved ones are likely to have
serious visual problems, they may react with emotions
such as distress, sadness, fear, and confusion. Such clients
and their families need accurate information about laws,
services, and alternative techniques for perform ing tasks
that people customarily imagine cannot be handled
without vision. Although the onset of visual impairment
sometimes necessitates in-depth counsel ing and therapy
for an individual or a family, social workers are cautioned
against assuming as in the past (Carroll, 1961) that
blindness brings about a new psychology or gives rise to
completely different personality problems (see critique in
Asch & Rousso, 1985). Instead, social workers can steer
clients to information about services and to possibilities
for maintaining their work, school, family, and leisure
roles with guidance available from the National Center for
the Blind, the

services listings of the American Foundation for the Blind,
and books like If Blindness Comes (Jernigan, 1994).
Silverstone et al. (2000) offer comprehensive information
about services and research on visual impairment and
blindness across the lifespan.
CHILDREN WITH VISUAL IMPAIRMENTS IN THE
FAMILY, AT SCHOOL, AND IN THE COMMUNITY
Social workers dealing with infants and toddlers who are
blind or their families can get some valuable suggestions
from the advocacy and parent groups discussed here and
listed in the references. In his comprehensive review of
research on children and. youth with visual impairments,
Warren (2000b) points out that it is dangerous to assume
th~ lack of vision, rather than lack of stimulation, causes
delays in development of such activities as crawling,
walking; and discovering the ~orld around them. The
National Organization of Parents of Blind Children, the
American Council of the Blind, journals such as Future
Reflections, and state and private service agencies can
provide advice to social workers and parents on whether a
child should learn Braille, will need assistance in learning
to get around safely using the long cane, or even guide
them to toys and games. that offer stimulation. Because
many childhood eye conditions are progressive and the
demands of school and social life expand as a child grows,
social workers in school settings could aid parents to
participate in meetings about their child's educational
future and help them become experts in technological
devices and alternative methods that allow children who are
blind or visually impaired to participate in sports, rec-
reation, music, art, and extracurricular activities, as well as
academic activities in school (Willoughby & Duffy, 1989;
Castellano, 2005).
BLINDNESS AND VISUAL IMPAIRMENT DURING
THE WORKING YEARS Many working-age people who
develop vision problems fail to learn about available
rehabilitation services from ophthalmologists or
. hospitals and as a result may give up their valued activities.
Social workers can be advocates for their clients in
rehabilitation agencies, can tell clients about guide dog
schools, or convince apprehensive families that work,
independent travel, and family life are still feasible.
Consonant with a strengths approach, they can focus
attention on the talents and capacities that remain despite
vision loss. Sometimes the person will not be able to fully
return to prior employment or activities, but the social
worker sh~uld refer a client to the tools and skills that will
enable him or her to continue in the chosen and valued
roles when possible.
Blindness should not be assumed to prevent the safe
conduct of other adult roles. In particular, social
BLINDNESS AND VISUAL
IMPAIRMENT 211
workers in the field of child-protective services should not
presume that an infant or older child cannot be safely cared
for by a parent (or parents) with visual impairment. Child
protective workers and parents with visual impairment can
contact through the Looking Glass
(http://lookingglass.org) to learn more about and to obtain
resources for parents with blindness or visual impairment.
As with all child protection cases, decisions to remove a
child should be made on a caseby-case basis after a careful
and thorough assessment of the parents' parenting skills
and supports.
BLINDNESS IN LATE LIFE Older persons with impaired
vision are generally new at dealing with sight loss, and may
be experiencing other health problems as well (Ainlay,
1988). They may experience difficulties attributabl~ to
lack of training in dealing with blindness or from other
health problems, and not from blindness, itself. The
Rehabilitation Act Amendments of 1992 provide for
increased services for older people with visual
impairments, and are intended to keep them active in their
homes and communities by providing tools for daily living,
travel, and communication. Social workers who see clients
in senior citizen centers and nursing homes should be
especially alert to the clients' deteriorating vision and
should link their clients with the specialized services that
will enable them to continue their activities.
Professional Issues for .Social Workers
TRAINING AND WORKING WITH
COLLEAGUES WHO ARE BLIND People with
visual impairments have been in the social work
profession for decades, and there are many instances
of field placements and agency accommodations.
However, fieldwork sites and employing agencies
sometimes still display stereotypes and fears about
blindness (Tannenbaum, 200l). A university or
agency can seek help through the Council on
Disability and Persons with Disabilities of the Coun-
cil on Social Work Education ( http://www.cswe.org/
CSWE/about/governance/councils/Disability+Counc
il. htm) or through the Web site of the National
Federation of the Blind's Human Services Division,
whose membership includes professional social
workers with visual impairments who are interested
in providing employment assistance to persons in the
profession who are blind or visually impaired.
(http://www.nfbnet.org/mailman/ listinfo/humanser)
.KEY CONCEPTS AND PRACTICE PRINCIPLES FOR
SOCIAL WORKERS Regardless of service setting, there
are some common principles and concepts in working with
individuals or groups where one or all clients have visual
impairment or blindness. The principles and
212 BLINDNESS AND VISUAL IMPAIRMENT
concepts listed below are synthesized from general prac-
tice principles for social work with people with disabil ities
(Mackelprang and Salsgiver, 1999; Raske, 2005;
Rothman, 2003), and from disability etiquette guidelines
for interactions with people with blindness or visual im-
pairment (Cohen, 2003; Federal Communication Com-
mission, 2003; Wayne State University, 2007).
The first practice principle is to focus on the indivi-
dual's presenting problem in assessment and response,
rather than assuming that visual impairment is the key
problem to be "solved" or the key source of the individual's
problems. A second practice principle is not to assume that
the presence of severe visual impair ment or blindness will
preclude active engagement in life's usual
activities-schooling, employment, intimate relationships,
parenting, care and support of others, cooking and
housecleaning, travel, sports, and other leisure activities.
Social work with clients who are blind or visually
impaired should aim to facilitate engagement in these life
activities and the development of environmental
accommodations and personal skills that enable ful l
participation and enjoyment. The third principle is to
incorporate a strengths perspective, which empowers the
client to act in his or her own behalf. Fourth, social
workers should be knowledgeable about the range of
special services and programs for persons with blindness
or visual impairment, even while supporting independence
and selfdetermination. An important advocacy role for
social workers is to be vigilant for discrimination and de
facto exclusion in the delivery of services and by other
organizations and businesses, and to help the client learn
how to advocate against or challenge discrimination or
exclusion when they occur.
Social workers also need to be knowledgeable about
what is referred to as "disability etiquette" when they are
working with people with blindness or visual impairment.
The key elements of etiquette include not making
assumptions in interpersonal interactions, but to be guided
by the individual regarding whether help is required, and
what kind of help. For example, if the re are forms to fill
out, clients should be asked what format and process they
prefer. Especially for social work encounters, it is
important to respect privacy and confidentiali ty . Two
mistakes that agencies sometimes make are to ask family
members to fill out a paper form for someone without
sight, without first determining that it is acceptable to the
client and an appropriate task for a family member, or to
have a staff member fill out the paperwork by asking the
client for the information in a very public location. Other
elements of etiquette involve identifying oneself and
others present at the start of the encounter, and waiting for
the client to
indicate whether or not assistance navigating the office
space is required. Another point of etiquette is to know
how to direct or guide a person with limited or no sight to
another location in a manner that does not violate personal
space. Finally, if people with and without sight are part of
the social work encounter, social workers need to be alert
to any tendency on their part or the part of other staff in the
setting to address inquiries to the person with sight that
properly should be addressed directly to the person who is
blind or visually impaired. More specific information
about disability etiquette for working with people who are
blind or visually impaired can be found at the Web sites of
the references named at the beginning of this section.
A key approach to working with people with blindness
or visual impairment is to recognize that it is a social as
well as an individual problem. Contact with active
members of organizations of people with blindness or
visual impairment, such as the National Federation of the
Blind, the Blinded Veterans Association, and the American
Council of the Blind, is indispensable in helping people
new to visual impairment appreciate that Braille, cane or
guide dog, recorded materials, live readers, adapted
computers, and new ways of managing a home and work
life can be as efficient as the ways that relied on sight.
Other individuals and advocacy organizations in the
disability rights movement are also invaluable in providing
allies to battle discrimination and exclusion when it occurs.
Issues for the Twenty-first Century
For people with visual impairment or blindness there are
options in the 21st century that did not exist in prior
centuries. In the United States, the Americans with
Disabilities Act prohibits discrimination in employ ment
and public life. Twenty-first century technology supports
participation in work, family, recreation, cultural
activities, and sports with ever greater ease. Portable
electronic equipment assists in orientation, travel, and the
translation of visual text to accessible media. New
assistive devices and medical procedures offer some
people possibilities for increased usable vision .
. Nonetheless people who are blind or have visual
impairment still report experiencing exclusion from work,
housing, travel, and leisure activities. These ac tions
include conscious exclusion from employment due to
concerns about safety and liability; refusal to rent housing
or seat in a restaurant or admit to community venues a
person with a service dog; and de facto exclusion from the
use of public transit or the Internet because appropriate
accommodations are not in place. The summaries of the
discrimination complaints received and investigated by the
U.S. Department of
.;....'a-:

Justice, the Equal Employment Opportunity Commis-
sion, and the other federal agencies with enforcement
responsibilities under the ADA indicate that discrimi-
nation in these areas still occurs (links to the different
agency reports are on the ADA Home Page, http://
www.usdoj.gov/crt/ada/adahoml.htm). Issues of dis-
crimination and barriers to accessing the latest services
and technologies may be compounded for persons who
also belong to racial, ethnic, or low-income groups who
have historically experienced disadvantage and
discrimination in the United States. To be compliant
with antidiscrimination law, decisions about excluSion
need to be based on an individualized assessment of .
safety and risk, and nota "one size fits all" policy. A
related issue is the tendency to still use disability segre-
gated programs and services, even when participation in
mainstream programs can occur with or without
accommodation. The rapid dissemination of new tech-
nology is another challenge because not . all new
technology is designed with universal access in mind. .
For example, new ovens and washing machines use
touch screens for settings. Transportation is another area
of challenge because the sprawl of urban and suburban
life has occurred without an equal commitment to the
maintenance and extension of pubic transportation. The
introduction of. electric-gas hybrid automobiles
presents a different transportation challenge beca use the
silence of these vehicles poses a hazard to those who
rely on their hearing to travel safely. The National
Federation of Blind has brought this issue to the
attention of the public and car manufactlirers and there
are hopes that a mutually satisfactory solution can be
developed (Flandez, 2007). As the 21st century unfolds,
new technologies will continue to improve the quality of
'iife and affect the manner in which people work and
play in the United States and throughout the rest of the
world .. Social workers can assume many roles as
culturally competent services providers, program
planners, and as allies in advocacy of those who have
visual impairments or blindness so that the advantages
of progress can be enjoyed by all.
Acknowledgments: We thank Corinne Kirchner,
A.Judith Chwalow, several field directors, and key
informants who have visual impairments forhelping us
identify the resources and key issues presented in this
entry.
REFERENCES
Ainlay, S. C. (1988). Aging and new vision loss: Disruptions of the
here and now. Journal of Social Issues, 48(1), 79-94.
American Foundation for the Blind. (2007). Key definitions of
statistical terms. Retrieved February 1, 2007, from http://
www.afb.org/Section.asp?SectionlD= 15&DocumentlD=
1280
BLINDNESS AND VISUAL IMPAIRMENT 213
American Printing House for the Blind. (J004). The history of the
American Printing House for the Blind: A chronology.
Retrieved March 15, 2007, from http://www.aph.org/about/
highlite.htm
Americans with Disabilities Act of 1990, PL 101-336.
Asch, A (1985). Understanding and working with disability rights
groups. In H. McCarthy (Ed.), Complete guide to employing
persons with disabilities (pp. 172-184). Albertson, NY: Human
Resources Center.
Asch, A, & Rousso, H. (1985). Therapists with disabilities:
Theoretical and clinical issues. Psychiatry, 48( I ), 1-12.
Caban, A]., Lee, D. ]., Gomez-Marfn, 0., Lam, B. L., Zhen, D. D.
(2005, November). Prevalence of concurrent hearing and
visual impairment in US adults: The National Health
Interview Survey, 1997-2002, American Journal of Public
Health,95(11),1940-1942.
Carroll, T.]. (1961). Blindness: What it is, what it does, and how to live
with it. Boston: Little, Brown.
Castellano, C. (2005). Making it work: Educating the blind! visually
impaired student in the regular school. Charlotte, NC:
lAP-Information Age Publishing, Inc.
Centers for Disease Control and Prevention. (2004). Vision
impairment, National Center on Birth Defects and
Developmental Disabilities, Atlanta, GA. Retrieved February
2, 2007, from http://www.cdc.gov/ncbdddfdd/vi-
sion3.htm#common
Cohen, ]. (2003). DisabiUty etiquette: Tips on interacting with people
with disabilities (Znd ed.), ] ackson Heights, NY: United Spinal
Association. Retrieved September 27, 2007, from
http://www.unitedspinal.org/pdf/DisabilityEtiquette.pdf
Federal Communication Commission. (2003). Disability etiquette,
Section 504 Handbook, Washington, DC. Retrieved
September 26, 2007, from http://www.fcc.gov/cgb/dro/504/
disability_primer_ 4.html
Flandez, R. (2007, February 13). Blind pedestrians say quiet
hybrids pose safety threat, Wall Street Journal.
Individuals with Disabilities Education Act (originally PL 94-142,
Education of All Handicapped Children Act), 20 U.S.C.
1400.
]avits-Wagner-O'Day Act of 1971, expanded Wagner-O'Day
Act of 1938, (41 U.S.C.46-48c). .
ystem social work (McNeece &If blindness comes. Baltimore:
ng, also known as actively explorinLouis Harris & Associates.
Louis Harris & Associates. (1991). Public attitudes toward people
with disabilities. Washington, DC: National Organization on
Disability.
Macke1prang, R., & Salsgiver, R. (1999). Disability: A diversity
model approach in human service practice, Pacific Grove, CA:
Brooks/Cole Publishing Company.
Matson, F. (1990). Walking alone and marching together: A history of
the organized blind movement in the United States, 1940-1990.
Baltimore: National Federation of the Blind.
mation, and call upon the profession to ensure Health United States,
2006, with Chartbook on trends in the health of Americans.
Hyattville, MD.
National Library Service. (2006). History. Retrieved March 15,
2007, from http://www.loc.gov/nls(abouchistory.html. U.S.
Library of Congress.
214 BLINDNESS AND VISUAL IMPAIRMENT
Pleis, J. R., & Lethbridge-Cejku, M. (2006). Summary health
statistics for U.S. adults: National health interview survey,
2005. National Center for Health Statistics. Vital and Health
Statistics 10(232).
Randolph-Sheppard Act, PL 74-734.
Raske, M. B. (2005). The disability discrimination model in social
work practice, In G. E. May and M. B. Raske (eds.), Ending
disability discrimination: Strategies for social workers (pp.
99-112). Boston: Pearson Education, Inc.
Rehabilitation Act of 1973, PL 93-112, and subsequent
amendments.
Resnikoff, S., Pascolini, D., Etya'ale, D., Kocur, L'Pararajase-
garam,R., Pokharfel, G. P., et al. (2004, November). Global
data on visual impairment in the year 2002. BuUetin of the
World Health Organization, 82(11), 84+-852.
Rothman, J. C. (2003) .. Social work practice across disability,
. \
Boston: Pearson Education, Inc.
Scott, R. A. (1969). The making of blind men: A study of adult
sociqlization, New York: Russell Sage Foundation.
Silverstone, B., Lang, M. A., Rosenthal, B., Faye, E. F., (Eds.).
(2000). The Lighthouse handbook on vision impairment and vision
rehabilitation, New York: Oxford University Press.
Social Security Act of 1935 as amended, especially Title II
(Disability Insurance), Title XVI (Supplemental Security
Income-SSI).
Social Security Administration. (2006). Automatic increases,
substantial gainful activity, Retrieved February 2, 2007, from
http://www.ssa.gov/OACT/COLA/SGAhtml Stelnrnetz. E.
(2006, May). Americans with disabilities: 2002, household
economic studies, current population reports P70-107,
Washington, DC: U.S. Census Bureau.
Tannenbaum, J. A (2001). Blind workers struggle to find adequate
jobs, CareerJounal.com, The Wall Street Journal Online.
Retrieved September 26, 2007, from http://www.
careerjournal.com/myc/survive/200 1 0 l l l-tannenbaum. html
U.S. Department of Veterans Affairs (2007). Services for blind
and visually impaired veterans, Blind Rehabilitation Service,
Rettieved February 28, 2007, from http://wwwl.
va.gov/blindrehab/page.cfm?pg=4 (last update, February
20,2007).
Warren, D. (2000a). Visual disorders: The psychosocial per-
spective-Overview. In B. Silverstone, M. A Lang, B.
Rosenthal, & E. F. Faye (Eds.), The Lighthouse handbook on
vision impairment and vision rehabilitation. New York: Oxford
University Press.
Warren, D. (2000b). Developmental perspectives: Youth. In B.
Silverstone, M. A. Lang, B. Rosenthal, & E. F. Faye (Eds.),
The Lighthouse handbook on vision impairment and vision
rehabilitation (pp, 325-335), New York: Oxford University
Press.
ayne State University. (2007). Disability etiquette, educational
accessibility services, Retrieved September 27,2007, from
http://www.eas.wayne.edu/etiquette.php
Willoughby, D. M., & Duffy S. L. M. (1989). Handbook for
itinerant and resource teachers of blind and visually impaired
students. Baltimore: National Federation of the Blind.
SUGGESTED LINKS
American Council of the Blind.
http://www.acb.org
ADA Home Page- Information and Technical Assistance on the
Americans with Disabilities Act, U.S. Departtnent of Justice,
http://www.usdoj.gov/crt/adaladahoml.htm
American Foundation for the Blind. http://www.afb.org
Blind Rehabilitation Service, U.S. Department of Veterans
Affairs.
http://wwwl.va.gov/blindrehab/
Blinded Veterans Association.
http://www.bva.org
Disability Rights Education and Defense Fund (DREDF).
http://www.dredf.org
National Federation of the Blind.
http://www.nfb.org. A list of divisions and contact emails are at
http://www.nfborg/nfb/Divisions_and_Committees.asp? SnID=
171723160#Seniors
-ADRIENNE ASCH AND NANCY R. MUDRICK
BRIEF THERAPIES
ABSTRACT: Research and meta-analysis of research
on psychotherapy outcome have consistently
supported the use of therapy that is planned from the
beginning to be brief. In recent years several brief
therapyapproaches have been developed, often by
social workers, and found to be effective. This entry
provides an overview of the research supporting the
use of brief therapy and describes the basics of the
major approaches to brief therapy such as the
task-centered approach, the psychodynamic
approaches, interpersonal therapy,
cognitive-behavioral therapy, emotion-focused ther-
apy, the strength-based approaches, couples and
family therapy, and group therapy.
KEY WORDS: brief therapy; solution-focused therapy;
narrative therapy; single-session therapy;
motivational interviewing; strategic therapy
What Is Brief Therapy?
Brief therapy (BT) "refers to a family of therapeutic
interventions in which the practitioner delibera tely limits
both the goals and the duration of the contact" (Wells,
1994, p. 2). There are a number of theoretical approaches
to BT. Although the upper limit of the number of sessions
can be as high as 45, most are between 10 and 20. Several
of the BT approaches have criteria for client selection:
motivation to change, good ego strength, history of
meaningful relationships, ability to focus on one issue for
treatment, capacity for

self-reflection, willingness to examine feelings and c on,
fliers in relationships, and absence of psychosis or per,
sonaliry disorder. Most BT approaches have the
following guidelines (Bloom, 1997; Hoyt, 2003; Wells
& Phelps, 1990): (a) Develop a positive, collaborative
therapeutic alliance as quickly as possible; (b) Identify a
focus usually in the form of a concretely and specifically
defined problem; (c) Rapidly assess the client's problem
and level of functioning and de-emphasize the use of
formal diagnosis; (d) Emphasize the client's present life
and future (goals) rather than past experiences and
memories; (e) Focus on changing repetitive proble matic
patterns of client's feeling, thinking, and behaving,
especially in significant relationships: (f) Be active and
keep the work centered on the client's focus and
continually provide structure to therapy; (g) Believe in
the client's capacity to change and expect the client will
change; (h) Emphasize the client's resilience, strengths,
competencies, and resources; (I) Mutually develop with
the client between session tasks (home, work); and (j)
Specify the number of sessions from the beginning work
to make the most of each session.
Why Brief Therapy?
Research has found that even when the clinician prefers
time-unlimited therapy, most clients end up limiting
their time in therapy, with the mean number of sessions
being between 5 and 8, and 70% of clients leaving
therapy by the lOth session and 90% by the 25th
(Messer, 2001; Olfson & Pincus, 1994). In are, view of
research on the dose-response effect of therapy, Messer
hey commit crimes against people outside the prison
ile incarcerated. Thus, harsher sentences and fewer
abilitative measures are required (McNeece & Roberts,
oberts, 2001).
of clients improve within an average of 12.7
sessions. Messer points out that these studies were of
treatments that were mostly brief "by default" rather
than "by design" and if the therapy had been brief by
design the res';'lts would probably have been ac hieved in
even fewer sessions (p. 2). Given these research
findings, managed behavioral health-care companies
universally limit the number of therapy sessions they
will approve for clients in order to control their costs.
Social Work and Brief Therapy
Though BT was not part of the language of social work
practice in the early days of the profession, practice
principles and philosophy were consistent with it. For
example, Mary Richmond took a person-environment
perspective and emphasized a problem-focus, a colla-
borative relationship with clients, as well as active roles
BRIEF THERAPIES
215
by both the worker and the client (Richmond, 1917,
1922). Richmond frequently refers to the importance of
working with client's "assets," "untapped resources,"
and "possibilities," which is consistent with today's
strengths and empowerment perspectives. In the 1930 s
and 1940s the functional approach to social case work was
developed in which the worker developed a mutual
relationship with the client, worked with client
strengths, and set time limits (Robinson, 1930; Smalley,
1970). In the 1950s the functional approach was one of
the major influences in the development of the problem,
solving approach to practice (Perlman, 1957, 1970). The
problem-solving approach was very influential in the
development of the task-centered (TC) approach to
social work practice in the 1960s and 1970s (Reid &
Shyne, 1969, 1972). The TC approach was, the first
evidence-based model developed in social work and
designed from its beginning to be brief. TC practice has
been found to be effective with a wide variety of client
problems and populations. In the 1980s social workers
developed two approaches to BT that emphasize
working with clients' strengths: solution, focused therapy (de
Shazer et al., 1986) and narrative therapy (White & Epston,
1990). These approaches do not have selection criteria
and have been used success, fully with a wide variety of
clients. Solution-focused therapy has some empirical
support for its effectiveness (Franklin, Kim, & Tripodi,
2006; Gingerich & Eisengart, 2000). Although many
therapists in the world use it, narrative therapy has little
empirical support for its effectiveness. One reason for
this lack of support is that the developers of narrative
therapy have discouraged manualizing it, which is
necessary for establishing empirical support of its
effectiveness. Another reason for the lack empirical
support of narrative therapy is that it is very much
influenced by postmodernism which posits that it is not
possible to establish universal knowledge and thus does
not support the evidence-based perspective. However,
despite the lack of empirical support, elements of this
therapy have been integrated into existing
evidence-based approaches.
What Are the Other
Major Approaches to Brief Therapy?
Although social workers did not develop them, there are
a number of other theoretical approaches to BT that are
evidence-based: psychodynamic therapy [intensive
short-term dynamic psychotherapy (Davanloo, 1980),
short-term anxiety-provoking psychotherapy (Sifneos,
1992), supportive, expressive psychoanalytic psycho-
therapy (Luborsky, 1984), time-limited dynamic psy-
chotherapy (Strupp & Binder, 1984)]; interpersonal
216 BRIEF THERAPIES
therapy (Schwartz, 2001); and errwtion,focused therapy
(Greenberg, 2006a, 2006b). The upper limit of the
length of treatment of these approaches is between 20
and 40 sessions; they also have clear selection criteria.
Other BT approaches tend to have lower upper limits in
duration (10-20 sessions) and to not use selection
~riteria. These include the following: M~tal Research
Institute Approach (Watzlawick, Weakland, & Fisch,
1974); cognitive, behavioral therapy [cognitive therapy
(Beck, 1976), rational emotional. therapy (Ellis, 1962),
cognitive-behavioral modification/stress inoculation
training (Meichenbaum, 1977),. multi modal therapy
(Lazarus, 1997)]; single,session therapy (Bloom, 1997);
motivational interviewing (Miller &; Rollnick,2002);
couples and family therapY [brief strategic family therapy
(Horigan et al., 2085), multisystemic therapy
. (Schoenwald & Henggeler, 2005),multidimensional
family therapy (Liddle, Rodgriguez, Dakof, Kanzki, &
Marvel, 2005), functional family therapy (Sexton &
Alexander, 2005)]; and group therapy (Piper &
Ogrodniczuk,2004).
Conclusion
Numerous approaches to brief therapy have been devel-
oped and fou~d to be effective with a wide variety of
clients in various practice settings. However, clients with a
thought disorder or personality disorder usually do not
benefit as much from BT. Several of the abovementioned
brief therapy approaches have been adapted for use in
longer term therapy. Such clients, though, tend to cycle in
and out of therapy for only short periods of time often
when they are in crisis and end up getting BT. Given the
research support, the realities of practice; and the influence
of managed behavioral health care, it is clear that BT is
here to stay, and social workers need to be skilled in at
least one of the approaches to BT. Meta-analyses of
research have also consistently found that no one approach
to therapy is superior to others and that factors they have in
common account for their effectiveness (Drisko, 2004).
Therefore practitioners should also become skilled in these
common factors.
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Bloom, B. L. (1997). Planned short-term psychotherapy: A clinical
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Hansen, N. B., Lambert, M.]., & Forman, E. M. (2002). The
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Horigan, V. E., Suarez-Morales, L., Robbins, M. S., Zarata, M.,
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Lazarus, A. (1997). Brief but comprehensive psychotherapy: The
Multimodal way. New York: Springer. .
Liddle, H. A., Rodgriguez, R. A., Dakof, G. A., Kanzki, R,&
Marvel, F. A. (2005). Multidimensional family therapy:
A science-based treatment for adolescent drug abuse. In J. L.
Lebow (Ed.), Handbook of clinical family therapy (pp.
128--163). New York: Wiley. .
Luborsky, L. (1984). Principles of psychoanalytic psychotherapy:
A manual for supportive-expressive (SE) treatment. New York:
Basic Books.
Meichenbaum, D. (1977). Cognitive-behavior modification: An
integrative approach. New York: Plenum Press.
Messer, S. B. (200l). What allows therapy to be brief? Introduction
to the special series. Clinical Psychology, 8, 1-4; Miller, W. R., &
Rollnick, S. (2002); Motivational intervieWing:
Preparing people for change (2nd ed.). New York: Guilford
Press.
Olfson, M., & Pincus, H. A. (1994). Outpatient psychotherapy in
the United States. II: Patterns of utilization. American Journal
of Psychiatry, 151, 1289-1294.
Perlman, H. H. (1957). Social casework: A problem-solving process.
Chicago: University of Chicago Press.
Perlman, H. H. (1970). The problem-solving approach to casework
practice. In R. W. Roberts & R. H. Nee (Eds.) , Theories of social
casework (pp. 129-179). Chicago: University of Chicago Press.
Piper, W. E., & Ogrodniczuk.]. S. (2004). Brief group therapy.
ainst people outside the prison while incarcerated. Thus,
T. Riva (Eds.), Handbook of group counseling and psychotherapy
(pp. 641-650). Thousand Oaks, CA: Sage.
 BULIMIA 217

Reid, W. J., & Shyne, A. (1969). Brief and extended White, M., & Epston, D. (1990). Narrative means to therapeutic
casework. ends. New York: Norton.
New York: Columbia University Press.
Reid, W. J., & Shyne, A. (1972). Task-centered casework. FURTHER READING
New York: Columbia University Press. Bloom, B. L. (2001). Focused single-session psychotherapy:
Richmond, M. E. (1917). Social diagnosis. New York: Russell A review of the clinical research literature. Brief Treatment and
Sage Foundation. Crisis Intervention, 1, 75-86.
Richmond, M. E. (1922). What is social case work? An introductory
description. New York: Russell Sage Foundation. SUGGESTED LINKS Milton Erickson
Robinson, V. P. (1930); A changing psychology in social casework. Foundation. www.erickson-foundation.org
Chapel Hill: University of North Carolina Press. Mental Research Institute.
Schoenwald, S. K., & Henggeler, S. W. (2005). Mutlisystemic www.mri.org
therapy for adolescents with serious externalizing problems. Brief Family Therapy Center.
in J. L. Lebow (Ed.), Handbook of clinical family therapy (pp. www.brief-therapy .org Solution-Focused
103-127). New York: Wiley. Therapy Association. wwwsfbta
Schwartz, A. (2001). Interpersonal therapy. In P. Lehmann & N. The Beck Institute for Cognitive Therapy and Research.
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New York: Wiley. Institute for the Study of Therapeutic Change.
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treatment manual. New York: Basic Books. Center for Emotionally Focused Therapy.
malley, R. E. (1970). The functional approach to casework www.e[Lca
practice. In R. W. Roberts & R. H. Nee (Eds.), Theories of social Motivational Interviewing.
casework (pp; 77-128). Chicago: University of Chicago Press. www.motivationalinterview.org
Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key:
A guide to time-limited dynamic psychotherapy. New York:
Basic Books.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: -GILBERT J. GREENE
Principles of problem formation and problem resolution. New York:
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Wells, R. A. (1994). Planned short-term treatment (2nd ed.).
New York: The Free Press.
Wells, R. A., & Phelps, P. A. (1990). The brief psychotherapies:
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Handbook of the brief psychotherapies (pp. 3-26). New York:
BULIMIA. See Eating Disorders; Hunger, Nutrition,
Plenum Press. and Food Programs.
CAREGIVING. See Family Caregiving.
CARIBBEAN AMERICANS
ABSTRACT: The diverse group of people referred to
as Caribbean Americans come from the
Circum-Caribbean region, which includes the island
nations of the Carib, bean Sea and the nations of
Central America from Belize to Panama-35 nations in all.
The heterogeneity of the Caribbean population is due to the
colonization and geopolitical division of the region among
English, Dutch, Spanish, and French colonizers, which
resulted in many different cultures, ethnic groups,
languages, educational systems, religious beliefs, and
practices: However, the majority of the Caribbean
populations share an African ancestry.
KEY WORDS: immigrants; Caribbean; cultures; lan-
guages; religious beliefs; African ancestry
History
The Caribbean region is of tremendous historical signif-
icance, that is, it was among the earliest European ex-
periments with the globalization of capitalism lasting for
more than 400 years. On Christopher Columbus's second
trip to the New World in 1493, he brought sugarcane from
the Spanish Canary islands for cultivation in the tropical
climate of the region, which relied on the use of the
overseas agricultural experiment we now know as the
plantation system. When work in the cane fields proved to
be too onerous for the local Indians, the need . for a labor
force quickly gave rise to the slave trade and the large-scale
enslavement of African peoples in the New World (Mintz,
1985). By 1516, the first ships laden with refined sugar left
what is now known as the Dominican Republic bound for
the nations of Europe.
The social structure of Caribbean people. is deeply
rooted in the history of slavery, plantation life, and
colonialism. As a result of forced enslavement, African
family structures were destroyed, religions forbidden, and
immeasurable suffering endured for centuries. Later, as
territories of the Caribbean region achieved independence
some became free democratic states. Others favored a
ruling class with little opportunity for upward mobility for
the masses. One such example is Haiti,
219
a former French colony that secured its independence as
early as 1791 to become the first independent Black
republic, which has endured an oligarchy for many decades
(Antoine, 1985).
The presence of Caribbean peoples in the United States
dates back to the 1920s, when a mostly professional
working-class group of immigrants settled among
native-born Blacks and quickly became assimilated into
the larger Black population (Thomas, 1977). The second
wave of Caribbean immigrants atrived after the passage of
the 1965 Hart-Cellar Reform Act, a measure that
eliminated the national quota.system that favored
immigrants from European countries and allowed for
increased immigration from the Caribbean region. Unlike
the previous wave, the vast majority were unskilled
laborers seeking greater economic opportunity and up'
ward mobility.
Kasinitz (1992) describes the third and largest co' hort
of immigrants from the Caribbean region as coming from
every sector of Caribbean society, including well-educated
members of the urban elite seeking to protect their wealth
in volatile economies, children of the middle class
searching for broader opportunities, and large numbers of
poor people looking for a standard of living above mere
subsistence (p. 27) (Kasinitz).
Demographics
Since the mid, 1980s, the United States has undergone a
major demographic shift. The 2000 Census indicates that
minority residents, African Americans, Hispanics, Asians,
American Indians, and other racial and ethnic minorities
now account for nearly half of the population of the
nation's largest cities (US. Census, 2000). There are about
1.9 million persons of Caribbean ancestry in the United
States according to Census 2000 and they can be found in
virtually every state in the Union, with the vast majority
settling in New York State. New York City, historically
recognized as a Mecca for immigrants from around the
world, is also considered the most culturally diverse place
on earth. A review of Census data shows that the city's
share of foreign-born increased from 28.4% in 1990 to
35.9% in 2000. In contrast, the native-born population
declined from 71.6% in 1990 to 64.1 % in 2000 (U.S.
Census). This figure does not take into account those
persons who are undocumented, which demographic
pundits estimate to be anywhere from 50,000 to 250,000.
220 CARIBBEAN AMERICANS
Socioeconomics
The picture of how Caribbean Americans in the United
States are faring is mixed. On one hand, marty among
them are highly educated or own skills that are highly
sought in the labor market. On the other hand, there are
those who appear to live on the periphery of the American
society, and are vulnerable to the vicissitudes of the labor
market. Portes, Guarnizo, and Haller (2002), however,
point to research studies that show that the economic
prospects of immigrants do not hinge exclusively on their
conditions of employment in host country labor markets,
but also on the chances for self, employment (Portes,
Guamizo, & Haller, 2002). En, trepreneurship, strong work
ethics, and high aspirations for themselves and their
families are likely contributing factors to the very
impressive profile of Caribbean immigrants along lines of
home ownership, presence in the professions, and their
overall advancement.
New immigrants with low levels of English compe-
tency often experience difficulty finding good paying jobs.
Instead, many work within their ethnic economies where
language proficiency and technical knowledge are not
required. The disadvantage of this is that small employers
are not able to pay competitive salaries nor offer
employment-based health insurance. These immigrant
workers face the dual difficulty of falling below the
economic poverty line because of low wages while also
bearing the burden of health disparities that beset the poor
due to their poverty inability to access health care services.
Health Indicators
Since the mid-1970s,the general population in the United
States experienced a decline in overall death rates from all
causes, specifically infant mortality, which is unparalleled
by other mortality reductions in the past century (Centers
for Disease Control and Pre, vention, 1999). Despite this
advancement, Caribbean immigrants continue to show a
distressing disparity in key health indicators that measure
health status of a community. A study on infant mortality
in NYC by Bayne-Smith, Graham, Mason, and Drossman
(2004) pointed out that despite reports from the New York
City Department of Health in 2002 indicating a citywide
infant mortality rate (IMR) average of 6.9 per 1,000 live
births, there were population groups in the city with IMRs
much higher than the citywide average. Not surprisingly,
the groups with the highest lMRs in NYC were
predominantly from countries in the Circum-Caribbean
region (Bayne-Smith et al.).
Religion
Spirituality is one of the most profound aspects of Black
culture and has significant influence on behavior.
Caribbean people embrace a wide range of religious faiths
with Catholicism, Protestant, and Pentecostal
denominations in the majority. There are many who also
simultaneously practice ancestral religions as part of
traditional practices brought to these islands by their
African ancestors during slavery. In the same way that
Santeria and Catholicism coexist in Spanish, speaking
countries as a benevolent religious practice, which is not
equated with sorcery or "black magic," (Frank, 1985), in
Haiti and other islands for example, people practice
Catholicism and do not see a conflict with Voodoo,' which
is not only an ancestral religion but also a way of life. As
such Voodoo and Santeria are embedded by practitioners in
literature, family, cultural expressions, . the performing arts,
building a house, planting, harvesting, health, and illness
(Frank, 2001).
Health Beliefs and Practices
The health beliefs and practices of Caribbean people
consist of a mixture of traditional folk health and main,
stream medical systems and variy from one individual to
the next. While one cannot generalize about the use of
traditional folk healers, Western or biomedical practices or
a combination thereof, providers need to know that these
multiple systems of health care not only exist for Caribbean
people but also at times can intersect depending on belief
systems. Most middle class Carib, bean immigrants utilize
the mainstream Western medical systems because services
are more financially accessible, but they are not the
majority of immigrants. The majority of Caribbean people
who migrated post' 1965 came from working and lower
class backgrounds. Given the difficulties associated with
obtaining good paying jobs that offer health insurance, they
often rely on cheaper folk medicine, which is readily
available in their communities.
The number of "Botanicas" throughout Caribbean
communities that offer herbal and alternative treat, ments
provides evidence that folk healers do good business in the
United States. The literature on illness behavior suggests
that variation in the practice of folk health within groups is
much greater than it is between groups, and that social class
sometimes plays an important role (Mcl.aughlin, 1985). In
NYC substantial segments of Caribbean populations
continue to rely in varying degrees on these alternative
therapies not only because their model of care closely
resembles that of the home country of the immigrant, but
also in the nature of the relationship between provider,
patient; and fa, mily (Graham, 2005).
CARIBBEAN IMMIGRANT WOMEN Caribbean culture
shows a strong pattern of women caring for themselves
1
 CARIBBEAN AMERICANS 221

and their children regardless of male support. Emigra- Elderly Caribbean immigrants are not exempt from
tion promises improved economic, employment, and . the impact of the emigration process. In their, home-
educational opportunities for the, women themselves, lands, they are deferred to and accorded much respect.
but more importantly for their children.' For others, Young couples often look to them for advice about all
emigration may signal the opportunity to escape poli- important family matters. In the United States, they can
tical or ideological systems that limit their power and lose that status as they must now depend on the younger
choices. Unlike other ethnic groups, women from the generation to help them navigate various systems.
Caribbean not only migrate in larger numbers than men, Additionally, as they become older, they face the
but also tend to precede other members of their family in possibility of living in a nursing home, an unpopular
the migration process. They also migrate in their prime concept that is 'not very acceptable in the Caribbean.
(15-44 age range) childbearing years.
The gendered nature of women's work makes assim-
Language
ilation into American society less difficult for Caribbean
The major formal languages spoken' throughout the
immigrant women than for men. The American market
multilingual Caribbean are English, Spanish, French,
has essentially created a niche for immigrant female
and Dutch, as well as a number of dialects that are a
workers, documented' and undocumented in the areas of
combination of a major formal language and. various
child care, housecleaning, and taking care of the elderly
African tongues. The dialects are mostly oral, and are in
and infirm. These jobs often require long hours with
some instances the main means of communication for
tanding-the person-inenvironment perspective-that only
individuals who are not formally educated. Caribbean
especially' those with children left behind in their
immigrants whose primary language is not English face
homelands, are obligated to fulfill the care giving
major barriers in accessing services in the United States.
expectations of the job, as a means of provid ing
They must oftentimes accept low-paying jobs where
transnational support for family networks still at home.
they do not have to rely on language skills. Language
ated. Sexual harassment of female inmates by male
barriers also restrict their ability to advance themselves
concentrated in areas of nursing, teaching, and social
personally, and participate in their chil dren's education.
work. Whether skilled or professional, immigrant
Caribbean women are more adept at navigating new sys-
tems and accepting change than their male counterparts.
Legal and Immigration Issues
The immigration status of Caribbean people', in a simi-
FAMILY SYSTEMS AND ROLES The ability of Caribbean lar manner as other groups, creates many barriers espe-
women to navigate and assimilate into new systems in cially in the areas of employment, education, and the use
the United States may result in a reversal in the of and entitlement to health care services. Inade quately
male-female headship role. Women not only serve as knowledgeable of their rights and fearful of being
sole family provider during reunification but also they deported, many immigrants for go benefits to which
often must guide their spouses through an unfamiliar they are entitled by law and endure employment
and frequently hostile system that has historically made discrimination in the form of low-paying jobs, longer
it difficult for men of color to connect to labor and work hours, often in hazardous conditions, and without
other social institutions. These factors undermine the health insurance. The undocumented, who have little or
family structure and contribute to tensions within no recourse, are often victims of unscrupulous
Caribbean families that can result in divorce or separa- employers.
tion. The frustration experienced by Caribbean men is Recent legislation passed in the U.S. House of Con-
often expressed in alcohol abuse, family conflicts, and gress denies' many new permanent residents access" to
domestic violence. health care for the first two years of gaining that status.
Parental migration also affects children and their This requirement affects immigrant health status be-
caregivers in the home country. Grandparents and other cause many naturalized citizens or permanent residents
family members assume' care of children until parents who are in the process of sponsoring relatives prefer not
are settled in the new country and this separa tion may to use public benefits of any kind for fear that this may
result in the erosion of emotional bonds be tween parents jeopardize their ability to sponsor their relatives.
and their children. When reunification occurs years Further, many immigrant children, eligible for the State
later, families often experience problems Child Health Plus Insurance (SCHIP) are not enrolled
ther than secondary defensive emotions; because their undocumented parents fear detection. The
ive process rather than theproblematic iss uCARIBBEAN undocumented shy away from services until their
222 CARIBBEAN AMERICANS
ear of loss, change, and the unrgency and then they present
themselves in a hospital emergency room.
Community Leaders and Resource Agencies Gatekeepers
play a significant role in immigrant com, munities. They are
bridges that help to build networks and connections, which
enable these communities to access resources. Gatekeepers in
the Caribbean immigrant community possess a certain level
of credibility within the community and are relied upon to
protect the community's interest and preserve their culture and
values. They include lawyers, doctors, and other health
professionals, religious leaders, community activists, political
leaders, academicians, heads of organizations, or traditional
healers. Because of their position, gate, keepers are influential
in the acceptance, development, or implementation of
programs and services in the community and can facilitate or
impede their progress.
Community institutions playa critical role in immigrant
communities. Among these institutions are churches,
community, and civic organizations. Historically, churches
have been th~ core institutions and are among the first
organizations to take root, serving congregants' spiritual,
a
social, political, and health care needs and as clearinghouse
for disseminating inforrnation (Thomas, 1977, p. 129).
Thomas also points out that Caribbean immigrants tend to join
associations immediately upon their arrival, characterizing
these associations as the lifeblood in the growth and devel-
opment of their communities.
Social work policy must value community culture and its
powerful influence on individual behavior. Suecessful social
work practice will hinge on acknowledge, ment of the role of
gatekeepers and community leaders as essential partners in
building community collaboration. As part of the fabric of
increasingly diverse com, munities, Caribbean Americans are
best served by the development of an understanding of their
ial work, and theology. Social work contributions
REFERENCES
Antoine, I. B. (1985). Mental health care; cultural beliefs, and
compatibility of health services in the Caribbean. Paper
presented at the Caribbean Women's Health Association's
conference: Delivering Culturally Compatible Health Care to
Immigrants. New York.
Bayne-Smith, M., Graham, Y. J., Mason, M. A., & Drossman, M.
(2004). Disparities in infant mortality rates among immigrant
Caribbean groups in New York City, Journal of Immigrant and
Refugee Services, 2(3/4), 29-48.
Centers for Disease Control and Prevention. (1999). Healthier
mothers and babies. MMWR, 48, 849-857.
Frank, H. (1985). Voodoo, Santeria, and folk health practices.
Paper presented at the Caribbean Women's Health
Association's conference: Delivering CulturaUy Compatible
Health Care to Immigrants. New York.
Frank, H. (2001, December 7). Understanding Haitian religious
beliefs, cultural issues, challenges and barriers to acceptance
of conventional HIV/AIDS care. Paper presented at the Health
Conference on AIDS in the Caribbean-American community. New
York.
Graham, Y. J. (2005). Case study: The Health Keepers model of
service delivery. In M. Bayne-Smith, Y. Graham, & S.
Guttmacher (Eds.), Community,based health organizations:
Advocating for improved health. California: [ossey- Bass.
Kasinitz, P. (1992). Caribbean New York: Black immigrants and the
politics of race. Ithaca, NY: Cornell University Press.
Mclaughlin, M. (1985). Cultural and linguistics barriers: A reality
for English speaking immigrants. Paper presented at the
Caribbean Women's Health Association's conference:
Delivering CulturaUy Compatible Health Care to Immigrants. New
York.
Mintz, S. (1985). Sweetness and power: The place of sugar in modem
history. New York: Viking Press.
Pones, A. Guarnizo, L., & Haller, W. (2002). Transnational
entrepreneurs: An alternative form of immigrant economics
adaptation. American Sociological Review, 67, 278-298.
Thomas, B. J. (1977). Caribbean voluntary associations and the
development of Brooklyn. In The New Muse Community Museum
of Brooklyn: An introduction to the Black contribution to the
development of Brooklyn. Brooklyn, NY: New Muse
Community Museum of Brooklyn.
U.S. Census. (2000). U.S. Census data. Summary File 3 (SF3).
Retrieved from www.census.gov
SUGGESTED LINKS
U.S. Census.
www.census.gov.
-MARCIA BAYNE-SMITH AND ANNETTE MAHONEY
CASE MANAGEMENT
ABSTRACT: A generic set of case management functions are
performed in most practice settings. To. irnprove outcomes
within a complex service delivery system, case managers
need to collaboratively work with clients and care providers.
By incorporating the paradigm of evidence-based practice,
case managers can improve decision making through
integrating their practice expertise with the best available
evidence, and by considering the characteristics,
circumstances, values, preferences, and expectations of
clients, as well as their involvement in the decision making.
KEY WORDS: case management; evidence-based practice;
generalist practice; task centered; social work functions

Barker (1999) defined case management as, "A proce-
dure to plan, seek, and monitor services from different
social agencies and staff on behalf of a client" (p. 62 ).
Usually, one agency takes primary responsibility for the
client and assigns a case manager to coordinate services
and to advocate for the client. The reader should refer to
the NASW (1992) Standards for Social Work Case
Management that clarifies the nature of case management
as well as the role of a case manager.
A generalist model of case management practice
consists of several functions in which the case manager
is primarily responsible for coordinating and expediting
the care delivered by others and for involving the client
in the decision making (Roberts & Stumpf, 1983;
Roberts-Deffennaro, 1986, 1987, 1988, 1993). Most of
these functions are generic to different types of case
management in various practice settings with diverse
client populations (Madden, Hlcks-Coolick, & Kirk,
2002; Minkoff & Cline, 2004; Naleppa & Reid, 2003;
Reid & Fortune, 2006; Tolson, Reid, & Garvin, 2003;
Ziguras & Stuart, 2000).
Good case management implies continuity of services,
rational decision making in designing and executing a
treatment package, coordination among all 'providers of
services, effective involvement of the elients, timeliness
in moving clients through the process, and maintenance
of an informative and useful case record (Cohn &
DeGraff, 1982, p. 30). Designating one person as the
case manager ensures that there is someone who is
accountable, who helps the client hold the delivery
system accountable, and who cannot "pass the buck" if
services are not delivered quickly and appropriately
(Miller, 1983). Rothman (1992) contends that it may be
taxing for a practitioner to take full responsibility for the
diverse elements of any given case, if many cases are
assigned to the practitioner.
In some agencies, the comprehensive responsibility
for the case is assigned to an interdisciplinary team
rather than to an individual case manager. An inter-
disciplinary team usually consists of a case manager and
a variety of professionals from different disciplines. If
the team structure is not appropriate or feasible, ade quate
support must be provided to the individual case
managers (Intagliata, 1991).
In designing a case management system, adminis-
trators need to fully understand the functions performed
by case managers, as well as the practice realities of
serving the client population. "Without the support of
appropriate administrative' structures and community
organization, case managers are relegated to a role not
unlike the proverbial Dutch child who had only fingers
to plug a leaking dike" (Moore, 1990, p. 447). In tum, the
case managers should be aware of the issues that
CASE MANAGEMENT 223
administrators must address in designing, planning, and
evaluating services.
'. The philosophy and process of evidence-based
prac-. tice (EBP) supports the expertise of case
managers in using their professional judgment to
integrate information about each client's unique
characteristics, circumstances, preferences, and actions
with external research findings (Gambrill, 2004).
Taking appropriate action guided by evidence includes.
ensuring that data on intervention and case progress are
systematically collected and used to make decisions on
whether to continue, revise, or discontinue the
problem-solving effort (Rzepnicki & Briggs, 2004).
The EBP paradigm supports the ethical obligation to
involve clients as informed participants and to promote
client selfdetermination (Gambrill, 1999, 2003; Gray,
2001; Sackett, Richardson, Rosenberg, & Haynes, 1998;
esponsibilities of the criminal justice system ineneralist
Generalist Case Management Functions
Job descriptions of case managers vary among service
areas (Zastrow, 2003, p. 21). Yet, there are a generic set
of functions that are performed by case managers in
developing a resource network, accessing the clients,
assessing the client's needs and strengths, developing
the care plan, designing the service network, establish-
ing a written contract, implementing the care. plan,
monitoring and evaluating the services, closing the case,
and conducting follow-up.
DEVELOPING A RESOURCE NETWORK Both the ad-
ministrative and case management staff need to work
together to develop a formal network of resources
that can be accessed for and with the client. In
building a network of resources, the primary focus
should be on the continuity of care that is needed by a
client popula tion. Usually, this requires interagency
cooperation, coordination of services, and
information sharing.
In establishing the resource network, case managers
should be aware of existing informal networks and use
these when appropriate. Self-help groups, families,
friends, and others can provide on an informal basis the
kinds of reinforcements, social supports, and casual
caring activities that enhance a client's capacity to attain
the desired outcome (Collins & Pancoast, 1976).
ACCESSING THE CLIENTS In some agencies, an out-
reach concern is case finding or recruiting clients to
use services, especially if new programs are being
tested or implemented: In other agencies with
waiting lists, out reach activities may focus on
educating prospectiv e clients of the eligibility
requirements of the program
224 CASE MANAGEMENT
and promoting awareness of other resources that may be
available in the interim.
In neighborhoods where prospective clients reside, it
may be helpful to conduct orientation sessions on the
nature of the program at local civic, religious, and
community group meetings. An interdisciplinary team is
useful in a program's outreach efforts, because its
members have links with other significant agencies in
the community.
ASSESSING THE CLIENT'S NEEDS AND STRENGTHS
Case managers collaborate with the client to assess
the sources of limitation as well as strengths that the
client brings to resolving the situation. The focus
should be on enhancing the client's ability to
function more effectively in life situations. From the
ecological perspective of Germain's (1973, p. 327 ;
Germain & Gitterman, 1996) life model, problems
are defined not as reflec tions of pathological states,
but as consequences of interactions between the
individual, the family,service organizations, the
environment, and others.
Case management practice, regardless of the setting
in which it is utilized, focuses on the client's strengths
and needs rather than a laundry list of problems. In cases
where there are multiple needs, priorities must often be
established.
DEVE,LOPING THE CARE PLAN It is essential that case
managers include clients. in the decision making
during the assessment process. The case manager
and the client should assess the client's strengths,
needs, and situation. Based on this assessment, the
case manager and the client collaborate to develop a
specific and measurable goalls) related to a desired
outcome. Clients should be able to choose what they
want help with and what they do not (Reid, 1978,
2000; Reid & Epstein,' 1972; Reid & Fortune, 2006).
The NASW (1999) Code of Ethics states that social
workers have an ethical responsibility to respect and
promote the right of clients to self-determination and
assist clients in their efforts to identify and clarify their
goals.
The tasks that are necessary to reach each goal
should be specified (Reid, 2000). Task planning- is
intended to clarify and. specify procedures for both the
client and practitioner (Rothman & Sager, 1998). Every
participant in the care plan should have at least one
specific task to perform for which he or she is
accountable.
DESIGNING THE SERVICE NETWORK After developing
the care plan, the case manager and the client select
the services, and supportive resources for the
client's individualized service network. This is a
collaborative
and integrative process that includes a systematic
search, appraisal, and synthesis of the evidence in an-
swering a practice question such as, "What is the most
effective intervention to best meet the client's needs and
attain the desired outcome?" (for example, see Gibbs,
2003).
In designing the service network, other factors need
to be considered including (a) professional values and
ethics, for example, "How can the case managers
advocate for the client to receive fair and equitable
services?"; (b) thoughtful professional judgments, for
example, "How can the case managers use their prac tice
experience and available evidence to help the client?";
and (c) consideration of the characteristics, values, and
condition of the client, for example, "Is the client
willing or able to receive the services?".
EST ABLISHlNG A WRITTEN CONTRACT Before im-
plementing the care, plan, a primary contract is con-
structed between the client and the case manager. A
secondary contract is established' between the case
manager and a service provider, such as a
psychotherapist to whom the client was referred. At
least six items should be included in the contract
(Jones & Biesecker, 1979; Stein, Gambrill, &
Wiltse, 1977):
1. Realistic goals from the care plan based on an
assessment of the client's situation
2. .Time limits of the contract terms
3. Planned actions that the client, case manager, and
others will take to realize the stated goal. The
actions should be defined in terms of what, where,
when, and with what frequency
4. Individual responsible for carrying out the planned
actions in their specific time frames
5. Costs for failure to carry out the contracted
responsibilities
6. Signatures of all parties, for example, case
manager, client, and the significant others,
responsible for carrying out the planned actions
IMPLEMENTING THE CARE PLAN Implementation of
the care plan is the setting into motion of
professional actions by the various service
providers. This means that the client is engaged
with these service providers in achieving the goals
of the contract. The case man ager should help the
client to set into motion the energies, such as
self-motivation, that are necessary to benefit from
the services.
The case manager orchestrates the services of the
collaborating providers according to the timetable in the
contract, maintains communication with the service
providers, and meets on a regular basis with the

client. Likewise, the case manager should have frequent
communication with the natural helping network. These
persons need to have a sense of accomplishment and
worth in helping the client.
MONITORING THE SERVICES The case manager needs
to systematically record and verify the delivery of
intended services in the care plan. The case manager
should be able to identify what services have been
provided to the client during the time frame of the
contract terms; By using the secondary or collateral
contract with other service providers, the case manager
can identify whether reports have been received, for
example, from a consulting psychologist. Communica-
tion with the service providers, as well as the natural
helping network, is necessary to be aware of what re-
sources are being provided to the client, as well as the
level of involvement from the client.
Ev ALVA TION The case manager, client, and other
significant persons can collaboratively measure the impact of
the services and assess whether desired program and client
outcomes were attained. An evaluation is the best guide to
improve the provision of services, as well as document any
unintended consequences from implementing the care plan. A
fundamental principle in any case management system is to
help the client assume an appropriate level of responsibility
for achieving and evaluating' progress in attaining their
desired outcomes.
CLOSING THE CASE Planning for termination begins
when the case manager initially discusses with the
client (a) eligibility requirements to receive services,
(b) evidence on which services are based, (c) case
manager's practice expertise in service coordination,
(d) expected outcomes from receiving the services, and
(e) restrictions in delivering the services. The case
CRIMINAL Bilitates the decision- making process
the client around case closure and informs other service
providers about progress made or not made. In
programs with time, limited services, the client should
be alerted to the circumstances of need and eligibility
that can lead to reentry into the program.
FOLLOW,UP A plan should be made at the last client
session for the case manager to follow up with the
client. These contacts are important, especially when
the services were terminated prematurely by outside
contingencies or unrealistic optimism (Mcbroom,
1984). Follow-up provides an opportunity to determine
if any new problems or recurring ones have emerged
that require further intervention and to assess whether
CASE MANAGEMENT 225
the intervention was effec tive. This learning should be
shared with administrators and other case managers to gain
a greater understanding of what client strengths are
necessary to resolve a situation, when using cer tain
evidence-based interventions. A learning network of case
managers, administrators, and other practi tioners should
be constructed to manage and store the evidence of best
"practices" so that it is easily accessible
, (Roberts' DeGennaro, in press-a, in press-b).
Conclusion
A competent case manager has the knowledge, skills, and
values to appraise and use evidence in selecting
interventions and organizing the delivery of these inter,
ventions across agency boundaries. An effective case
management system' advocates for clients to be in, volved
in the decision making to determine what they hope to
achieve from their participation in the care plan.
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CHAos THEORY AND CoMPLEXITY THEORY 227
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-MARIA ROBERTS-DEGENNARO
CASE SOCIAL WORK. See Clinical Social Work.
CERTIFICATION. See Licensing.
CHAOSTHEORYANDCO~LEnTY
THEORY
ABSTRACT: Chaos theory and com plexity theory, col,
lectively known as nonlinear dynamics or dynamical
systems theory, provide a mathematical framework for
thinking about change over time. Chaos theory seeks
an understanding of simple systems that may change in
a sudden, unexpected, or irregular way. Complexity
theory focuses on complex systems involving
numerous interacting parts, which often give rise to
unexpected order. The framework that encompasses
both of them is one of nonlinear interactions between
variables that give rise to outcomes that are not easily
predictable. This entry provides a nonmathematical
introduction, discussion of current research, and
references for further reading.
KEY WORDS: chaos theory; complexity theory; non,
linear dynamics; dynamical systems; system
dynamics; agent, based models
Since the late 1960s chaos theory and complexity the, ory
have grown out of a variety of fields, including
228 CHAOS THEORY AND COMPLEXITY
THEORY
physics, biology, and social science, in which research-
ers grapple with systems in which multiple variables
interact, affect each other, and change through- time
(Bak, 1997; Ball, 2004; Gleick, 1987; Hudson, 2000;
Sprott, 2003; Strogatz, 1994; Waldrop, 1992; Warren ,
Franklin, & Streeter, 1998). General systems theory,
which with its focus on feedback and dynamics is
familiar to social workers, is an important precursor of
both (Ashby, 1962; Boulding, 1956; Sterman, 2000;
Von Bertalanffy, 1968).
Collectively known as dynamical systems theory or
nonlinear dynamics, neither chaos nor complexity the-
ory is a theory in the ordinary sense of the word. Neither
attempts to explain a specific phenomenon. Rather, each
is a collection.of mathematical arid computer models
and empirical techniques aimed at understanding the
way in which systems change through time. Chaos
theory addresses simple feedback systems of a small
number of variables that nevertheless show complicated
and often unpredictable behavior (Briggs & Peat, 1990;
Gleick, 1987; Kaplan & Glass, 1995; Peak & Frame,
1994). Complexity theory seeks an understanding of the
ways in which large, complex systems emerge from
local interactions, as well as the ways in which they
change and develop over time (Bak, 1997; Ball, 2004;
Barabasi, 2003; Kohler & Gumerman, 2000; Resnick,
1994; Strogatz, 2003). Together, they offer a lens
through which social scientists have examined human
systems including individuals (Hufford, Witkiewicz,
Shields, Kodya, & Caruso, 2003; Warren, 2002) ,
interacting dyads (Gottman, Swanson, &
Swanson,2002; Warren,Newsome, &Roe,2004),small
groups (Pincus & Guastello, 2005), schools (Warren ,
Craciun, & Anderson-Butcher, 2005), neighborhoods
(Fossett, 2006; Schelling, 1,971), geographic regions
(Parker, Berger, & Manson, 2002), societies (Gunduz ,
2000), and even international systems (Saperstein, 1996 ;
Turchin, 2003).
Theoretical Foundations
DYNAMICS Dynamical systems are simply those that
move or change over time (Williams, 1997). At least
since Heraclitus' comment that no one can put a foot in
the same river twice-the second time it is not the same
river, and she or he is not the same person-there has been
no doubt that all social systems are dynamic (Haxton,
2001). The systematic study of processes of change is
known as dynamics (Sprott, 2003; Strogatz, 1994;
Williams, 1997).
NONLINEARITY Anyone who remembers high-school
algebra or introductory statistics remembers the form of
a linear equation y = mx + b, the equation for a
straight line, in which m represents the constant slope,
b the, intercept, and x and yare variables. On the other
hand, as Williams (l997)states, " A nonlinear equation
is an equation involving two variables, say x and y,
and two coefficients, say band c, in some form that
doesn't plot as a straight line on ordinary graph
paper." (p. 9, bold letters in the original). Of course,
nonlinear equations may involve more than two
variables. Typical nonlinear equations involve
multiplying two different variables or raising a
variable to some power (Sprott, 2003; Strogatz,
1994).
Scientists use mathematical equations to describe the
world, and nonlinear equations often provide a better
description. For instance, if one student studies for 5 hr
per week and another for 10 hr per week, most people
would expect the second student to outperform the first,
all other things being equa1. But if one student studies
for 40 hr a week and the other for 45, would the
difference be as great? Would there be any improve ment
at all? Eventually, the student reaches the limits of her
capacity- and, of course, she cannot get better than an A
+. A linear equation, which implies the same change in
grade for any change in study time, cannot capture such
ceiling ~ffects. A nonlinear equation, on the other hand,
implies that change in the effect will vary over the range
of the cause (Williams, 1997). A nonlinear equation
therefore implies that the effect is not necessarily
proportional to the cause (Pryor & Bright, 2003).
NONLINEAR DYNAMICS Nonlinear dynamics
involve nonlinear change over time. For instance,
population growth often starts out slowly, speeds up,
and then levels off as resources are exhausted, a pattern
known as logistic growth (Kaplan & Glass, 1995).
Logistic growth is quite common, applying to situations
ranging from increasing animal populations to
construction of subway systems (Modis, 1992). Other
processes for which there is some evidence of
nonlinearity include human development, aggressive
behavior, and substance abuse (Hufford et al., 2003;
Thelen & Smith, 1994; Warren et al., 2004).
Nonlinear dynamics give rise to surprising beha-
viors. Two of these have been of particular interest to
social scientists. Bifurcations involve sudden changes in
the state of a system (Strogatz, 1994). For instance, it is
possible for systems to show a sudden increase or de-
crease in values. Such changes are known as "catas-
trophes" (Strogatz, 1994, p. 69; see also Guastello ,
1995). There is evidence that relapse into substance
abuse can best be modeled as such a sudden change
(Hufford et a1., 2003). Bifurcations can also involve

change from a stable equilibrium to an oscillation
(Strogatz, 1994). Such a bifurcation could explain volatility
in human behaviors such as aggression (Warren et al.,
2004).
In some cases, a series of bifurcations can lead to
deterministic chaos, after which chaos theory is named
(Gleick, 1987; Sprott, 2003; Williams, 1997). Determi-
nistic chaos is an oscillation that never repeats itself (Peak
& Frame, 1994). Chaotic systems have the interesting
property that any change in value, no matter how small, will
tend to grow over time (Gleick, 1987; Strogatz, 1994). This
fewer rehabilitative measures are required (McNeece &
ts, 2001).
Sprott, 2003). The point of the latter phrase is that the flap
of a butterfly wing in the Amazon rain forest can, in theory,
eventually change the path of a tornado in Texas (Lorenz,
1996). This idea has worked its way into popular culture
and has formed the basis of several movies, including
Sliding Doors (1998) and Run, Lola, Run (1998). It has
ial justice and to serving the needy. A coalition between the
the religious social services and social work is alWhether
Whether linear or nonlinear, dynamical systems frequently
move toward an attractor. This could be a point ora cycle
that values tend to approach regardless of where they start
out (Strogatz, 1994). Because chaotic systems do not repeat
their values, their attractor is neither a point, which would
effectively give the same value over and over again, nor a
simple cycle, which would give a series of repeated values.
Rather, their attractors include an infinite number of
possible cycles within a limited range. Such attractors are
known as strange attractors (Gleick, 1987; Sprott, 2003;
Strogatz, 1994). Strange attractors are typically fractals, the
term for objects that have a fractional dimension (Gleick,
1987; Strogatz, 1994).
COMPLEXITY, CONNECTION, AND EMERGENCE
Chaos theory enlightened scientists to the surprising,
complex behavior that simple systems of a few interacting
variables can show (Gleick, 1987). From the 1970s, and
intensifying greatly in the 1980s, a concerted effort was
under way to apply ideas from nonlinear dynamics to
complex systems, which might have dozens, hundreds, or
even thousands of varlables-characterized by nonlinear
interactions (Cowan, Pines, & Meltzer, 1994; Lewin, 1993;
Schelling, 1978; Sterman, 2000; Waldrop, 1992).
There are several possible ways to do this. One is to use
nonlinear equations that are similar to those used in chaos
theory, but to use more of them. Not surprisingly, this has
become easier with the advent of powerful desktop
computers. The use of computers to construct
CHAos THEORY AND CoMPLEXITY THEORY
229
visual models of dynamic equations shown as feedback
loops between variables, known as system dynamics, has
been particularly influential due to its flexibility and ease
of use (Hovmand, 2003; Sterman, 2000). Robards and
Gillespie (2000) have suggested that the traditional social
work educational emphasis on systems be revised to
include system dynamics modeling.
A second way of grappling with complex systems is to
treat them as collections of interacting agents, rather than
interacting variables. These agents might represent people,
but they might also represent automobiles, primates,
insects, or even grains of sand (Bak, 1997; Fossett, 2006;
Kohler & Gumerman, 2000; Resnick, 1994). Each agent
has a set of rules that govern how it interacts with others.
Interactions could occur within a particular geographic
space, or they could occur on a social network or through
set interactions between the agents (Axelrod, 1997; Kohler
& Gumerman, 2000). Order in the form of large-scale
social structures frequently emerges from the decentralized
interactions of the agents, a process known as emergence
(Fossett, 2006; Holland, 1998; Kohler & Gumerman,
2000). The emergent order, in tum, constrains the actions
of the agents (Fossett, 2006; Resnick, 1994).
A classic example of this approach is the model of
segregation developed by Nobel Prize winning economist
Thomas Schelling. The agents could represent any two
groups, but they are typically demarcated by color, most
obviously black and white. Agents prefer that some
percentage of their neighbors be of their own color. That is
the only rule in the model, which consistently produces
two results. The first is that agents end up living with a
much larger percentage of neighbors of their own color
than the minimum that they would prefer (Resnick, 1994).
The second is that segregation locks in, since any agent that
breaks the pattern will move into a neighborhood with
fewer of its own color than it prefers. Thus; segregation
arises through interactions between agents, and once it has
arisen it constrains the actions of the agents (Chen, Irwin,
]ayaprakash, & Warren, 2006; Fossett, 2006; Resnick,
1994; Schelling, 1971; Schelling, 1978).
Applications in Social Science and Social Work
Application of nonlinear dynamics to social science has
grown apace (Vallacher, Read, & Nowak, 2002). The
remainder of this entry will review some applications of
potential relevance to social workers.
INDIVIDUAL PROCESSES Dynamical systems theory
has led to an increased focus on human processes,
particularly those that involve fluctuation, irregularity,
230 CHAos THEORY AND CoMPLEXITY THEORY

or sudden change (Vallacher, Read, & Nowak, 2002). THERAPEUTIC GROUPS AND MILIEUS Authors have
Simply acknowledging the fluctuations and capacity for long noted that the life cycle of therapy groups shows
self-organization of human systems can be of considerable periods of rapid organization, and have even proposed the
value. For instance, Pryor and Bright (2003) have possibility of mathematical models of group interac-
developed a "chaos theory of careers," which "seeks to tions(Lewin, 1951; Yalom, 1985). Dynamical systems
understand individuals as complex dynamical, nonlinear, theory, withits focus on rapid change and emergence of
unique, emergent, purposeful open systems existing and order through decentralized interactions, appears to be a
interacting with an environment comprising systems with promising framework for the study of groups, and a number
similar characteristics" (p. 123). At least one randomized of authors have called for the use of dynamical systems
experiment supports the effectiveness of their intervention theory in understanding group interventions (Fuhriman &
(McKay, Bright, & Pryor, 2005). Witte, Fitzpatrick, Burlingame, 1994; Rubenfeld, 2001). Empirical work has
Warren, Schatschneider, and Schmidt (2006) quantified begun to yield a dynamical understanding of group
the variability of suicidality in a sample of undergraduates, processes. For instance, Pincus and Guastello (2005) found
and found evidence that those with previous suicide complex but coherent patterns of tum-taking in a
attempts show increased variability. Warren and Knox six-member therapy group for adolescent sex offenders.
(2000) and Warren (2002) applied a piecewise linear Since the 1980s there has been the development of an
model, in which two straight lines are separated by a immense literature on the ways in which interactions lead
threshold (Tong, 1993), to time series of problem to cooperation in groups. This literature began with
behaviors of sex offenders. Both studies found evidence of Axelrod and Hamilton's (1981) seminal work on the
nonlinearity that could lead to extreme variability and maintenance of cooperation through reciprocity-you
cycling in these behaviors. scratch my back, I'll scratch yours-and includes work on
Regular fluctuations, known as oscillations, have been the maintenance of cooperation through reputation (Nowak
the subject of several studies. Bisconti, Bergeman, and & Sigmund, 2005)-.-you scratch someone else's back, I'll
Boker (2004) applied a differential equation, which scratch yours. This literature offers the possibility of a
predicts the rate of change over time, to the emotional fruitful theory for the maintenance of cooperation in both
well-being of recently bereaved widows. The equation small groups and treatment milieus such as therapeutic
predicted that emotional well-being would oscillate. Their communities for substance abuse. In an exploratory study
statistical analysis found a cycle lasting about 47 days on of residents at one therapeutic community, Warren and
average, but also found that it flattened after about 98 days. Harvey (2006) found evidence of reciprocity and possibly
One study has modeled relapse in substance abuse as a reputation effects.
bifurcation in which current consumption is a nonlinear
function of past consumption; beyond a certain level of
past drinking, current drinking gets suddenly worse, a
ORGANIZATIONS The study of organizations is another
situation known as a cusp catastrophe (Huffordet al.,
area in which researchers apply dynamical systems theory
2003).
(Guastello, 1995). The system dynamics approachto the
study of complex systems has largely been developed for
DYADIC PROCESSES Interactions between two people the modeling of organizations (Sterman, 2000).
are obviously important in marriage, and in recent years System dynamics-based studies of organizations are
researchers have developed several approaches to studying appearing in the social work literature. For example, Cho
the dynamics of such interactions. A team of psychologists and Gillespie (2006) have analyzed the feedback
and mathematicians led by John Gottman (2002) has relationship between government and social service
developed a nonlinear model of the influence that spouses agencies, concluding that the feedback mechanisms are
have on each other. Influence can be either positive or sufficiently complex so that government regulations can
negative, with negative influence happening more quickly inadvertently lower the quality of services that they
and easily than the positive one. Each spouse can influence . are meant to improve. Further, the time lag between
the other, and this pattern can produce attractors in which government intervention and results in the community is
each influences the other either positively or negatively. sufficiently long that regulators may be tempted to
These patterns are evaluated by observing a IS-minute intervene too frequently. .
conversation between the couple. They have proven to
have predictive power and Gottman's group has begun
designing interventions based on them, in some cases with Conclusion
success (Gottman et aI., 2002). Chaos and complexity theory address important aspects of
human experience, particularly sudden change,

fluctuations, and the ability of groups and organizations to
self-organize. Applied social science based on dvnamical
systems theory is no longer a rarity. However, those social
work researchers and social workers who wish to apply
dynamical systems theory face at least three challenges. The
first is theoretical. How do we connect social work theory with
the mathematical models that underlie chaos and complexity
theory? Current practice ranges from the frankly metaphorical
to the development of complex nonlinear differential
equations. The second is empirical. How do we find the data
with which to test our models? It seems clear that improved
observational techniques are leading to progress in this area
(Gottman et al., 2002; Joy-Bryant, 1992; Pincus & Guastello,
2005). The third is pragmatic.
\
How do we integrate dynamical systems theory into
social work practice? Much of this integration may simply
involve a greater appreciation for the role of sudden change,
fluctuations, and self-organization. But clinicians are
beginning to develop interventions based on dynamical
systems theory that could have an enormous influence on
social work and other helping professions in the future
(Gottman et al., 2002; Pryor & Bright, 2003).
Further Reading
Smith (2007) offers an excellent introduction to the basics of
chaos theory for individuals with no mathematical background
beyond high-school algebra. Peak and Frame (1994) also offer
an excellent nonmathematical introduction to chaos theory and
touch on such complexity theory concerns as emergence. For
those who have at some point studied introductory calculus,
Williams (1997) has written an excellent introduction with
extensive discussion of the basics of empirical work. Kaplan
and Glass (1995) also provide an excellent introduction that
includes discussion of emergence. The first half can be read
with only a background in algebra, while the second half
requires some calculus. Strogatz (1994), the standard
introductory undergraduate text, does assume some
background in differential equations. Sprott (2003) gives an
encyclopedic treatment of chaos theory, with a well-written
text that makes the highly mathematical treatment easier to
follow. Resnick (1994) gives a thought-provoking
introduction to agentbased models and Kohler and Gumerman
(2000) offer numerous applications to human systems.
Vallacher, Read & Nowak (2002) provide a useful discussion
of the place of dynamical systems theory in psychology, while
Gottman, Murray, Swanson, Tyson, and Swanson (2005) offer
a model of marriage and marital therapy based on nonlinear
differential equations.
CHAos THEORY AND CoMPLEXITY THEORY 231
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SUGGESTED LINKS
http://www.societyforchaostheory .org
http://necsi.org/iridex.html
http://www.santafe.edu/
http://www .systemdynamics .org/
http://ccl.northwestem.edu/netlogo/
http://repast.sourceforge.net/
http://sprott.physics. wisc .edu/fraetals .htm
-KEiTH WARREN
CHARITABLE FOUNDATIONS
ABSTRACT: Foundations are private institutions for
public benefit. With a long history that reaches back to
antiquity, foundations are experiencing a renaissance
and increased attention paid to them by policy makers.
Already by the mid-1980s, observers had begun to re-
port the end of the relative decline in the overall size
and importance of the foundation sector- a trend that
had characterized the previous decades. Some analysts
suggest the possibility of a new, third "foundation
wave," after a first growth period in the late Middle
Ages, alongside the rise of commerce and finance, and
a second period of growth in the late 19th century ,
following the industrial revolution. Political stability,
an increase in demand for social, educational, and
cultural services of al l kinds, and economic prosperity
are certainly significant factors behind this growth.
Yet a more immediate reason is the way in which
foundations have been suggesting themselves as
instruments of welfare state reform in the broadest
sense.
KEY WORDS: charity; philanthropy; nonprofit sector;
grant-making foundations; operating foundations;
community foundations
CHARITABLE FOUNDATIONS 233
sive straFoundations are private
Foundations are private institutions for public benefit.
Foundations have a long history, reaching back to antiquity,
and with equally long traditions in most world
cultures.Despite this long heritage, the modem foundation is
often associated with the rise of the large grant-making
foundation in the United States in the early 20th century, and
its replication in other parts of the world, in particular in
e skills and the elimination of blaming statements. In the
weekly sessions, the participants learn nine skills
economies are a product of the period since the 1970s, having
benefited from prolonged economic prosperity, political
stability, and, in many countries, more favorable legislation.
In this sense, as nonprofit institutions, foundations are both
old and recent phenomena.
In the United States, the political theory that most clearly
defines a place for foundations and other nonprofit
organizations is pluralism. The U.S. nonprofit sector came
with the separation of church and state and with the
19th-century development of autonomous corporations.
Foundations were a late addition to the U.S. nonprofit sector.
As stewards of significant charitable funds, U.S. foundations
can reinforce pluralism by devoting resources to the interests
of minorities of many kinds-be they religious or cultural,
those demanding educational or artistic excellence, minorities
concerned with a rare disease, or those with an unusual hobby.
But foundations may also act to reduce pluralism, if they
disproportionately privilege only certain kinds of causes or
needs.
DEFINITIONS In its most basic form, the foundation
idea is based on the transfer of property from a donor
to an independent institution whose obligation it is to
use such property, and any proceeds derived from it,
for a specified purpose or purposes over an often
undetermined period of time. Since this process
involves the transfer of property rights, most countries
provide a regulatory framework that usually also holds
some measure of definition.
Under common law, foundations typically take the form of
a trust, which is, legally speaking, not an organization but a
relationship between property and trustees. Most common law
countries use this rudimentary legal definition, and leave the
actual development of foundation law to case law. One
exception is the United States, which, in 1969, established a
precise, though negative, definition: Foundations are
tax-exempt organizations under section 50 l( c) (3) of the
International Revenue Code that are neither public charities
nor otherwise exempted organizations. This means that under
American tax law, foundations are those charitable
234 CHARITABLE FOUNDATIONS
organizations that receive most of their resources from
one source and are as such considered to be donor
controlled. By contrast, in civil law countries, the es-
sence of a foundation, as a legal personality, is the
presence of an independent endowment. The emphasis
on endowment puts foundations apart from the other
major type of nonprofit organization in civil law sys-
tems: the membership-based association. In other
words, while foundations are endowments, associations
are based on membership.
A basic definition sees foundations as private assets
that serve a public purpose, with five core characteris-
tics (see Anheier & Daly, 2006):
1. Nonmembership-based organization based on an
original deed, typically signified in a charter of
incorporation or establishment that gives the entity
both intent of purpose and permanence
2. Private entity institutionally separate from gov-
ernment, and "nongovernmental" in the sense of
being structurally separate from the public sector
3. Self-governing entity equipped to control its own
activities in terms of internal governance
procedures
4. Nonprofit distributing by not returning profits
generated by either use of assets or the conduct of
commercial activities to its owners, members,
trustees, or directors'
5. Serving a public purpose that goes beyond a
narrowly defined social group or category, such as,
members of a family, or a closed circle of
beneficiaries.
TYPOLOGY The nature of the assets can be stock and
other shares in business firms, financial, real. estate,
patents, and so on. There are basic categories that
group the most common types of foundations
according to type of activity and type of founder.
Type of activity
1. Grant-making foundations, that is, endowed
organizations that primarily engage in grant
making for specified purposes.
2. Operating foundations, that is, foundations that
primarily operate their own programs and
projects.
3. Mixed foundations, that is, foundations that
operate their own programs and projects and
engage in grant-making on a significant scale.
Other types include the family foundation, grant-seek-
ing foundation, church foundations, fund-raising foun-
dations, and political foundations, among others.
Type of founder
1. Individual, that is, foundations founded by an
individual, group of individuals, or family
whereby
donors bring their private assets into the founda-
tion, for example, the Rockefeller Foundation in
the United States or the J.R. Rowntree Foundation
in the United Kingdom.
2. Corporate foundations, such as the company-
related or company-sponsored foundation based
on corporate assets, vary by the closeness to the
parent corporations in terms of governance and
management, for example, the Vodafone Founda-
tion or the Toyota Foundation.
3. Community foundations, that is, grant-making and
operating foundations that pool revenue and assets
from a variety of sources (individual, corporate,
public) for specified communal purposes, for
example, the Cleveland Foundation or the
California Community Foundation.
4. Governmentally linked foundations, that is,
foundations that either are created by public
charter or enjoy high degrees of public sector
support for endowment or operating, for example,
the German Environmental Foundation.
Over 70,000 US. foundations had assets of $550 billion
in 2005, and paid out $41 billion in 2006 (Foundation
Center, 2007). Nearly 9 out of 10 Ll.S, foundations are
grant making, and 6.3% are operating foundations.
Community fo~dations make up only a relatively small
segment of US. foundations (1%), as do corporate
foundations with 3.5%. However, in terms of assets,
community foundations are relatively larger,
commanding 6.4% of total assets.' Over time, the
composition of the US. foundation sector has not
changed much, although community foundations and
corporate foundations have become relatively more
numerous. Like the United States, Europe experienced
a veritable foundation boom, with the majority of its
estimated 100,000 foundations having been created in
the last two decades of the 20th century (Anheier,
2001).
FUNCTIONS A major distinction is made' between
charity, as the alleviation of suffering, and philanthro-
py, which refers to a longer-term, deeper commitment
to public benefit that seeks to address the roots of social
. problems. This distinction was important in the emer-
gence of the modem philanthropic foundation that
emerged in the United States in the early 20th century,
with the Rockefeller Foundation and Carnegie Cor-
poration as prime exemplars.
Through the first half of the 20th century, many of
the best-known foundation leaders emphasized a
"scientific approach." They hoped that strategic invest-
ments in scientific, medical, and even social research
 CHARITABLE FOUNDATIONS 235

would yield solutions to many human problems. They 2. Redistribution, whereby foundations engage in, and
also hoped new research universities and reformed . promote, voluntary redistribution of primarily eco-
institutions of collegiate and secondary education would nomic resources from higher- to lower-income
produce researchers who would find solutions and groups.
effective innovators who would put solutions into 3. Asset protection, whereby a foundation keeps funds
practice. The philanthropy model sees foundations as for use by other institutions that cannot protect or
enabling institutions and as social entrepreneurs. It is manage their own assets due to political factors, a
important to note that many donors continued to favor perceived lack of financial capability, or some other
the charity model, and that their numerous foundations reason.
continued ancient traditions of support for immediate
relief and for religious and other cultural institutions. In the field of social welfare, U.S. foundations have
In recent years, analysts have further specified the provided funding to help meet social, economic, edu-
various roles associated with either charity or philan- cational, and health needs by supporting organizations
thropy, and although sot:?e overlap exists among them, and individuals, and also by influencing social policies.
they are distinct enough and lead to different implica- In the United States, foundation support for social
tions for foundation impact and policy (Anheier & welfare has traditionally ranked third in terms of funder
Hammack, forthcoming). priority behind education and health, although at times
has been the highest priority among leading funders
such as the Lilly Endowment, the Annie E. Casey,
Charity Charles Stewart Mott Foundation, or the Ford
1. Complementarity, whereby foundations serve Foundation. The role of foundations in social welfare
otherwise under-supplied groups under conditions of evolved from a more charitable role (offering short term
demand heterogeneity and public budget constraints. solutions on case-by-case basis) in the 19th century, to a
2. Substitution, whereby foundations take on financial more philanthropic role (investing in research, helping
functions otherwise or previously supplied by the to create collaborations, and focusing on ways to
state, particularly local government. In this role, increase self-sufficiency of grantees) in the mid-20 th
foundations substitute for state action, and foundations century to that of policy advocate in recent decades.
become funders of public and quasi-public. Although foundations are not large enough to re-.
good provision. place government funding or to redistribute wealth in a
significant way, they sometimes do seek to act in these
ways, and can have some stabilizing, even
Philanthropy self-empowering impact on local communities and in
1. Innovation and the promotion of innovation in social fields with severe public budget problems (for example,
perceptions, values, relationships, and ways of doing taking care of welfare functions in select communities
things has long been a role ascribed to foundations. and for select causes such as low-income housing).
We note that innovation can yield both positive and
negative outcomes and impacts. Some innovations
are not only controversial but become generally Trends
accepted as unfortunate or worse, while others yield Current discussions of the need for a new philanthropy
sustained and positive change. tend to focus on ways and means to capture more private
2. Social and policy change, whereby foundations pro- money for public good, on using such funds more
mote structural change, give voice, fostering rec- efficiently (Frumkin, 2006), and on becoming more
ognition of new needs, and seek empowerment for transparent and accountable (Fleishman, 2007). With
the socially excluded. endowment values at historically high levels in most
developed market economies since the late 1980s,
foundations have been exploring new ways to gain
Other roles suggested in the literature that cut across greater leverage and impact. What is more, both
the charity versus philanthropy distinction and that are nationally and internationally, new forms of
less relevant in the U.S. context are philanthropy are emerging, with donor-advised funds,
1. Preservation of traditions and cultures, whereby donor-designated funds, and e-philanthropy, that is, the
foundations preserve past lessons and achievements use of the Internet for making donations, as prime
that are likely to be "swept away" by larger social, examples. These new forms are likely to add new
momentum to philanthropy.
cultural, and economic forces, or forgotten.
236 CHARITABLE FOUNDATIONS
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Anheier H. K., & Daly, S. (Eds.). (2006). Politics of foundations:
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Foundation Center. (2007). http://foundationcenter.org/gain
knowledgefresearch/pdfffy 200Lhighlights.pdf
Frumkin, P. (2006). Strategic giving: The, art and science of
philanthropy. Chicago and London: The University of
Chicago Press. \
- HELMUT K. ANHEIER
CHILD ABUSE AND NEGLECT
ABSTRACT: The true extent of child abuse and neglect is
unknown but reports to state agencies indicate over 3 million
reports concerning maltreatment of 6 million children made
each year. Confirmed reports, involved almost 900,000
children in 2005. Yet, less than 30% of the children known to
professionals in the community (for example, teachers,
physicians in emergency rooms, day care providers) as
maltreated are investigated by child protective services. The
perplexing dilemma in surveillance and service delivery is
how to identify those that need help without spuriously
including those who do not. This entry focuses on the
definition of maltreatment and provides an overview of the
history, etiology, and consequences of child abus e and neglect
as well as the current trends and dilemmas in the field.
KEY WORDS: child abuse and neglect; child maltreat-
ment; definitions of maltreatment; etiology of child
maltreatment; consequences of child maltreatment;
evidence-based practice; disproportionality; cultural
competence
The World Health Organization estimates 40 million .
children are abused each year around the world. Estimated
annual rates of child homicide vary from 6 per 100,000 in
Japan to 7 per 100,000 in the United States and 25 per 100,000
in Estonia (WHO, 2001). While much can be said about
differences in definitions and data collection methods among
various political and
geographic entities, concern regarding children's health and
safety is universal. Yet any type of maltreatment short of the
most severe physical battering or deprivation is often subject to
wide ranging definitions. In one' comparative analysis,
Freysteinsd6ttir (2004) reported that parents in. Iceland
generally do not use physical force (a commonly cited risk
factor for abuse) to discipline children. On the, other hand, due
to the safety of the communities there, leaving children alone at
a relatively young age is commonly practiced and not regarded
as maltreatment to the extent that it is in the United States. This
international context sets the stage for understanding the wide
ranging differences in standards and laws within the United
States as well as internationally;
History
In the western European tradition, child protection concerns
centered more on children who were orphans and paupers than
on their maltreatment. Gradually attention shifted to
maltreatment. By the mid- to late 1800s, agencies had been
established to protect children from excessive harm in their
own homes. In Philadelphia, for example, children needing
out-ofhome placement were described as being from families
who were either "too poor or too vicious" to care for them
(Clement (1978) as per Lindsey, 2004). From that time
through the 1950s, a complex network of private and public
agencies developed to protect children from harm at the hands
of their caretakers. These agencies were supported by a mix of
public and private funds within the framework of state.laws
and local ordinances prohibiting the maltreatment of children.
Until 1974, no federal laws existed to. enforce national
standards throughout the United States. Many state laws of the
1960s and, later, the Child Abuse Prevention and Treatment
Act of 1974 (CAPTA) were prompted by a public outcry
following the documentation of child abuse through the study
of x-rays of children's multiple fractures (Kempe, Silverman,
Steele, Droegmueller, & Silver, 1962). CAPT A signaled
federal interest in mandated reporting of maltreatment by
professionals and. mandatory investigation of reports. As a
result, recorded reports of child maltreatment serious enough
to trigger an investigation rose from 60,000 in 1974 to 3.3
million in 2005 .
Definitions
Definitions of child maltreatment in the United States focus on
three major forms of abuse or neglect: physical abuse, sexual
abuse, and neglect. Further, child abuse and neglect are
defined by the fact that the

maltreatment is perpetrated by a parent or caretak:~r.
(see the Child Welfare Information Gateway sponsored
by the United States Children's Bureau for further
information on definitions (www.childwelfare.govj). For
example, a beating by a stranger would be considered a
matter for law enforcement. CAPT A, "as amended by
the Keeping Children and Families Safe Act of 2003,
defines child abuse and neglect as: (1) any act or failure
to act on the part of a parent or caretaker which result s in
death, serious physical or emotional harm, sexual abuse
or exploitation; or (2) an act or failure to act which
presents an imminent risk of serious harm" (Child
Welfare Information Gateway, 2006). More specifically ,
in defining maltreatment for the purpose of measuring the
prevalence of child abuse and neglect in the United
States, Westat Inc. developed the definitions in Table 1.
These definitions have changed very little since the first
National Incidence Study on Child Abuse and Neglect
(NIS,1) in 1980 and are also reflected in the 19 th edition
of the Encyclopedia of Sodal Work.
State laws mayor may not include all of the situa-
tions described in Table 1. The parameters of the fed,
eral definition of maltreatment are addressed in the
CAPT A, referenced earlier. The states may vary on a
number of dimensions including the definition of the
term, "caretaker," what is included in medical neglect,
and whether certain specific acts constitute maltreat,
ment. For example, the definition of caretaker mayor
may not include a school bus driver. Other sources of
variation concern the types of incidents that are dis,
allowed, often combined with the age of the child. In one
state, for example, educational neglect or truancy is not
reportable to child protective services (CPS). School
attendance is handled by another governmental agency.
Conversely, in another, if a child is under 12 and has
7days of unexcused absences that child will, by law, be
reported to CPS as neglected (Chtld Welfare Inforrna-
tion Gateway, 2005; Zuel & Larson, 2005). In addition,
localities may vary in how state laws are applied.
Prevalence
The National Child Abuse and Neglect Data System
(NCANDS) reports 3.3 million referrals to CPS in 2005
involving 6 million children in the United States and
Puerto Rico. Sixty-two percent were screened in for
investigation or assessment by CPS (see also Child Care
Services). Almost 30% of the investigated reports were
substantiated or indicated cases of maltreatment. These
reports involved 889,000 children or 12.1 per 1,000
children. Table 2 details the types of abuse experienced
by these children.
Cnnn ABUSE AND NEGLECf 237
TABLE 1
Actions or Inactions of Caretakers Defined as Abusive or
Neglectful by the National Incidence Studies on Child Abuse
and Neglect
Physical assault
Sexual abuse or exploitation such as forcible or consensual rape,
incest, intercourse, molestation
Close confinement such as tying or binding of arms or legs,
locking in a closet
Anyother pattern of assaultive, exploitative, or abusive
treatment, such as threatened or attempted assault, habitual or
extreme verbal abuse
Abandonment or other refusal to maintain custody
Permitting or encouraging chronic maladaptive behavior, such
as delinquency
Refusal to allow needed treatment for a professionally
diagnosed physical, educational, emotional, or behavioral
problem
Failure to seek or unwarranted delay in seeking competent
medical care
Consistent or extreme inattention to the child's physical." or
emotional needs
Failure to register or enroll the child in school, as required
by state law ..
The definition of maltreatment is further defined by the type
of injury sustained. ..
Harm is defined as: fatal, serious, moderate, or probable Fatal-. the
abuse or neglect is suspected to have been the
cause of the child's death ..
Serious injury/condition-injury or impairment serious enough to
significantly impair the child
Moderate injury/condition-behavior problem or physical/
mental/emotional condition with observable symptoms
lasting at least 48 hr
Probable impairment-maltreatment that is so extreme or inherently
traumatic in nature that significant emotional injury or
impairment may reasonably be assumed to ha~e occurred
Additional cases many be identified by determining whether the
child was endangered:
Endangered-child's health or safety was or is seriously
endangered, but child does not appear to have been harmed.
From Westat, Inc. (2007). NIS-4. A Web site sponsored by the
Adininistration for Children and Families. Washington, DC: U ,S,
Department of Health and Human Services. Retrieved July 9,2007,
from https://www.nis4.org/DefAbuse.asp. Adapted with permission,
Children known to CPS, however, do not tell the
whole story of children who are victimized by child
maltreatment. In a 1993 survey of child serving profes-
sionals such as teachers, day care providers, and emer -
gency room physicians, the Third National Incid ence
Study on Child Abuse and Neglect (NIS,3) found over
1.5 million children were harmed by maltreatment
(fatal, serious, moderate, or probable injury, as
described
238 CHILD ABUSE AND NEGlEC[
TABLE 2
Types of Maltreatment Experienced by Children Found to
Have Been Maltreated in 2005 by a CPS agency
nt, or MAL'IREATMENT PERCENT"
Neglect 62.8
Physical abuse 16.6
Sexual abuse 9.3
Psychological maltreatment 7.1
Medical neglect 2.0
Other (for example, abandonment, 14.3
threats of harm,
drug-exposed infants)
a Adds to over 100% because a child may have more than one
type of maltreatment. .
in Table 1) and less than 30% of these children were
investigated by CPS. The children whose maltreatment
was not investigated may have never been referred to
CPS or they may have been referred and screened out
before investigation. Currently, the Fourth National
Incidence Study on Child Abuse and Neglect (NIS-4) is
under way and will be reported to Congress and on the
World Wide Web in 2008. It should be noted that there
is some discussion regarding the "true" prevalence of
maltreatment due to the methodological variations in
counting in various studies .. For example, the NISstud-
ies miss counting those cases known only to family or
neighbors if they are not also reported to CPS.
NCCANDS recorded 1,460 child fatalities from
maltreatment in 2005. These include only those known
to CPS. With data from other sources the number is
estimated to be fairly consistent at about 2,000 annually
(McClain, Sacks, Froehlke, & Ewigman, 1993). The
same researchers report children under 5 years old
account for 90% of fatal maltreatment; 41 % of the
maltreatment deaths are those of infants. They also
report about 85% of child maltreatment deaths are
reported to be from other causes and recommend
changes to reporting of child deaths to capture more
accurate information.
Characteristics of Children and Families Younger
children are more likely to be maltreated than older
children and more likely to experience neglect.
Although African American children are no more likely
to be maltreated than white children they are most likely
to be reported and found as maltreated (19.5 per 1,000)
compared to white children (l0.8 per 1,000) (Sedlak &
ltural Anthropology, 19(3), 402-411.
8). Theater and offender rehabilitation:
from the USA. Research in nitiatives described
elsewhere in this encyclopedia.
American Indians, Alaskan Natives, and Pacific
Islanders are also dramatically overrepresented in the
child welfare system compared with their proportionate
representation in the population." The NIS-3 (Sedlak &
Broadhurst, 1996) found slightly more females than
males are maltreated, more males than females are
killed or seriously injured, and children of single parents
are at higher risk of maltreatment and injury. Compared
to families with incomes over $30,000 per year in 1993,
those with incomes under $15,000 per year were 22
times more likely to be harmed by maltreatment and 44
times more likely to be neglected. The issue of poverty
and neglect is of particular concern due to the potential
confounding of the two. Sometimes families will be
referred to CPS due to lack of food, shelter, or clothing
that is solely due to lack of money and not a result of
maltreatment. In Illinois, the Norman v. McDonald lawsuit,
settled in 1991, led to a special fund to aid families who
were in danger of child placement due to economic
distress (for example, lacking food or housing) but who
were not maltreating their children, thus keeping
children and families out of CPS when there is no
suspicion of maltreatment.
Causes and Consequences
of Child Abuse and Neglect
One of the most thorough treatments of etiology of
maltreatment is the National Research Council's 1993
book on Understanding Child Abuse and Neglect. In addition
to poverty, risk factors for maltreatment in chide parental
drug abuse, parental history of having been maltreated;
unresolved or untreated parental mental health problems,
age of the mother at the birth of her first child, child
behavior problems, child disability, lad~ of familial
social supports, situations perceived by family members
as causing high stress, and family violence among adults
in the household. Different types of maltreatment will
have differing dynamics. For example, physical abuse in
some families may be characterized by unrealistic
expectations of the children, feelings of helplessness
inre~pbndi~g to the child's 'needs, and situations of high
perceived stress. Examples of social structural and
institutional factors- creating environments within w hich
maltreat- . ment may be more likely to occur or to be
reported include poverty and low wages requiring longer
hours of work, a culture that promotes violence through
the media, a culture of substance abuse, negative peer
influences, and racism.
The sequel of child maltreatment are well documen-
ted and include but are not limited to higher risk of drug
abuse, behavior problems, delinquency, arrest and

incarceration, failed relationships, and maltreatment of
offspring. Protective factors are now known to be critically
important in determining vulnerability to, and outcomes of,
child maltreatment. Fraser and T erzian (2005) report that
communication and problem solving and parental
competence in child discipline and supervision are
important factors mediating the effects of poverty. Sources
of resilience come not only from one's own biological,
cognitive, and personal experiences but also from the
school, the neighborhood, and the cornmunity at large. The
child who ismost likely to fend off or minimize deleterious
consequences is able to use resources available, engage in
opportunities for support from others, and has a source of
support in the larger environment (Fraser & Terzian, 2005).
\
Best Practices
Effective interventions may focus on prevention or
remediation; and may involve broad based social change,
community organization Or development, social policy
change, or direct intervention with children and families.
They may, for example, address the reduction of poverty,
building social and support networks, changing child
welfare laws and policies to enable family maintenance, or
interventions in parenting styles, respectively. Most
importantly; they should combine attention to both the
evidence base of the practice to be used in concert with the
degree to which the intervention is culturally competent
(Wells, 2007). The evidence may be developed based on
large-scale policy interventions such as subsidized
guardianship for kinship caretakers or may be more
specific to direct interventions with children and families
(see Chaffin & Friedrich, 2004; DePanfilis, 2005;
Kauffman Best Practices Project, 2004; Testa, n.d.).
Challenges and Debates
The challenges in preventing and responding to child
maltreatment are many. The first is the definition of
maltreatment itself. Definition affects every part of
society's response with respect to funding, court inter-
vention, and even out-of-home placement. There is a
constant push/pull relationship between families who are at
lower levels of risk within the CPS system to ensure they
receive services or helping them through voluntary services
which, in many cases, are less well funded. This leads to the
second concern, the degree to which governmental
agencies should be intervening in family life. The
disproportionate representation of children of color in the
system, particularly African American and aboriginal
peoples, argues for a more circumspect look at reporting,
intake, and placement of children and families in difficulty.
Studies of alternative response to
CHILD ABUSE AND NEGLECr 239
reports of maltreatment determined to be at lower risk have
been important in guiding state laws and policies (Loman
& Siegel, 2004). Alternative response systems allow the
government agency to respond to a low-risk report by
doing a voluntary assessment of the family's needs. In this
case, the family is not compelled to cooperate unless, upon
further inquiry, the worker refers the situation back to child
protection services for a nonvoluntary or mandatory
investigation. A third concern is the relative
cost-effectiveness of focusing on prevention versus
remediation and treatment. With limited resources
available because of the less-thanfavorable public
sentiments toward public social services, the argument is
not frivolous.
Trends include ongoing social concerns, the prolif-
eration of violent media that reinforce all forms of
violence, and the concurrent dwindling support for
families in their communities. At the level of individual
and family intervention, the question is whether basic
services such as housing and substance abuse treatment are
available. In addition, practitioners and policy makers are
questioning whether evidence-based practices are known
and readily available to all families in need; The need for
evidence-based practices is great and the research capacity
to meet the need is severely limited by the available
funding.
Role of and Implications for Social Work
Profession and Interdisciplinary Connections The social
work profession has historicallybeen involved in the
design and delivery of CPS as well as in addressing the
social conditions that perpetuate the problem. A current
challenge is to improve practice by understanding and
applying research and by opening the door for ongoing
practice evaluation. In addition to ongoing quality
improvement, addressing public perceptions regarding
funding of social services and preventive efforts could be
tackled through the conducting and use of
cost-effectiveness studies to show how much financial and
societal cost can be saved by early intervention. At the
same time, efforts to address the social issues that
perpetuate risk cannot be neglected. All of this work will
continue to be done in the context of interdisciplinary
relationships. Child maltreatment touches all
professions-medicine, law, education, child care, and many
others. It is only through an interdisciplinary focus that
progress can be made.
REFERENCES
Chaffin, M., & Friedrich, B. (2004). Evidence-based treatments in
child abuse and neglect. Children and Youth Services Re~ew,26,
1097-1113.
240 aULD ABUSE AND NEGLECT
Child Welfare Information Gateway. (January 2005). Definitions of
child abuse and neglect: Summary of state laws. Washington, DC:
Author, Children's Bureau, Administration for Children Youth
and Families, U.S. Department of Health and Human Services.
Retrieved July 9, 2007,
" from: http://www.childwelfare.gov/systemwide/laws-policies/
statutes/defineall.pdf
Child Welfare Information Gateway. (April 2006). What is child
abuse and neglect? Washington, DC: Author, Children's
Bureau, Administration for Children Youth and Families, U.S.
Department of Health and Human Services. Retrieved July 9,
2007, from: http://www.childwelfare.gov/pubs/fact-
sheets/whatiscan.cfm
Clement, P. E (1978). Families in foster care: Philadelphia in the
late nineteenth century. Social S~vice Review, 53, 406--420 as
cited by Lindsey, D. (2004). The welfare of children (p. 17). New
York: OXford University Press.
DePanfilis, D. (2005). Family connections: A program for
preventing child neglect. Child Maltreatment, 10(2), 108-123.
Freysteinsd6ttir, E J. (2004). Risk factors for repeated mal-
treatment (Doctoral Thesis, Universityof Iowa, Iowa City, lA,
2004). Retrieved July 9, 2007, from http://etd.lib.uiowa.
edu/2004/ffreysteinsdottir. pdf
Fraser, M. W., &Terzian; M. A. (2005). Risk and resilience in
child development. In G. P. Mallon & P. M. Hess (Eds.), Child
welfare Jor the 21st century. New York: Columbia University
Press.
Kauffman Best Practices Project. (2004). Closing the quality chasm
in child abuse treatment: Identifying and disseminating best
pracnces. Charleston, SC: National Crime Victims Research
and Treatment Center.
Kempe, C. H., Silverman, E, Steele, B., Droegmueller, W., &
Silver, H. (1962). The battered-child syndrome. Journal of the
American Medical Association, 181, 17-24.
Loman, L. A., & Siegel, G. L. (2004). Minnesota alternative
response evaluation: Final report. St. Louis, MO: Institute of
Applied Research.
McClain, P. W., Sacks,J. J., Froehlke, R. G., & Ewigman, B. G.
(1993). Estimates of fatal child-abuse and neglect, United-
States, 1979-1988. Pediatrics, 91(2),338-343.
National Academy Press. (1993). Understanding child abuse and
neglect. Washington, DC: National Academy Press.
Norman v. McDonald, 930 E Supp. 1219, 1227 (N.D. III 1996)
Sedlak, A., & Broadhurst, D. (1996). The third national incidence
study on child abuse and neglect. Washington, DC: Children's
Bureau, Administration for Children, Youth and Families,
U.S. Department of Health and Human Services.
Testa, M. (n.d.). Encouraging child welfare intervention through N-E
waivers. Urbana: Children and Family Research Center,
University of Illinois at Urbana-Champaign.
Wells, S. J. (2007). Evidence-based practice in child welfare in the
context of cultural competency. Presentation at an invitational
forum of the same name hosted by the School of Social Work
in the College of Education and Human Development at the
University of Minnesota in Minneapolis, Minnesota, June
11,2007.
Westat Inc. (2007). NIS-4. A Web site sponsored by the
Administration for Children and Families, U.S. Department of
Health and Human Services, Washington, DC. Retrieved July
9, 2007, from: https://www.nis4.org/DefAbuse.asp.
World Health Organization (WHO). (2001). Prevention of child
abuse and neglect; Making the links between human rights and
public health. Paper submitted to the Committee on the Rights
of the Child for its Day of General Discussion, September
28,2001. Geneva, Switzerland: Author, Department of Injuries
and Violence Prevention.
Zuel, T., & Larson, A. (December 15, 2005). Child protection and
educational neglect: A preliminary study. An unpublished
manuscript posted on the WWW.St.Paul .. MN:
Center for the Advanced Study of Child Welfare, School of
Social Work, University of Minnesota. Retrieved July 9, 2007,
from: http://ssw.che.umn.edu/img/assetsj4467/Final%
20 12-154l5.pdf .
-SUSAN J. WELLS
'I,:
CHILD CARE SERVICES
[.;:-;;{;:;~~::._; AesrnxcrrChtld
care servi2~~;:~nabling parents to commit
themselves to paid employment while providing
a supervised environment for their children,
have a long' and complex history in the United
States. Child care services can provide children
with educational and other advantages, as well
en, A. (2003). Integrative behavioral couple
apy. The clinical handbook of couple's therapy
pp. 251-277). New York: Guilford Press.
ital therapy: A research-based approac other
risks or disadvantages, but many of these
children and their families remain unserved be-
cause of gaps in programs and lack of support
for WORDS: Head
KEYsubsidies, Start;
while otherdayfamilies
care; purchase the
services they need.
pre-kindergarten; child care; welfare; preschool;
education
Child care services perform two roles. First, child care is a
key service enabling parents to enter and remain in paid
employment. Subsidized child care supporting low income
parents is increasingly important in the current era of
welfare reform as mothers of young children are
encouraged into jobs and away from public cash transfers.
Second, families, child care professionals, and policy
makers remain concerned that the care settings available
for young children provide educational and
developmentally appropriate environments, as well as
safety and good basic care. However, the systems by which
families obtain child care services in the United States are
complicated. Some child care is bought and

paid for by individual families. Other care is provided
through public subsidies, even though the service may
be provided by an independent agency or family mem-
bers. Government child care programs are not entitle-
ment programs, and many families are on long waiting
lists for their desired program. Families and the social
workers assisting them are often confused by the op tions
and frustrated by the IR limited access.
History
As is the case with many important. social services,
child care and early childhood education programs in
the United States are under pressure to meet often
competing goals for educational and developmental
services to children and support for their workin g
parents (Scarr, 1998). These multiple complex goals
have led to the creation over the past century of a
complicated and sometimes disjoint set of services for
preschool children in the United States. These com-
plexities are rooted in the history of child care in the
United States going back to the 1840s when care was
provided for the children of widows and the working
wives of sailors (Boschee & Jacobs, 1997; Scarr &
Weinberg, 1986). Later, settlement houses, many in-
spired by Jane Addams's Hull-House, of fered similar
services to the immigrant mothers of young children
who worked long hours (Carlson, 1993). At various
points in United States' history, different approaches and
rationales for early childhood care and education have
gained ascendancy.
Types of Publicly Supported Child Services The
three large programs available today (child care center
and family home care, Head Start, and prekindergarten
programs) emerged from different periods, with
different rationales, are structured and staffed differe ntly
from one another, and are aimed at somewhat different
but overlapping, groups of children. They have
responded to the politics and policies of issues of race,
immigration, and language in distinctive ways. Their fee
structure, staffing, and explicit goals are dif ferent. None
of them serve everyone who wishes to use them, and in
many places they serve only a fraction of those eligible.
Funding for these programs has been irregular (Cohen,
1996; Lynn, 2002).
CHILD CARE CENTERS AND FAMILY HOMES
The United States has a child care system, both
subsidized and at market cost, that includes child care
centers, and family child care homes, developed
primarily as a service for families where all adults are
employed. Beginning in the 1800s, child care programs
I were designed to
1
CHILD CARE SERVICES
241
improve the early lives of underprivileged children, as
well as provide safe care for the children of employed
mothers. Early child care programs, often based in
agencies such as settlement houses, were aimed more
specifically to improve conditions for children in highly
impoverished immigrant neighborhoods, while allow-
ing their parents greater opportunities to seek and sus-
tain work.
While child care programs had been in place in the
United States for nearly a century, only in 1933 did the
federal government become involved in the provision of
child care. The Works Progress Administration (WP A)
was responsible for fundirig a nursery sch~ol program
for children in "home relief' families. Between 1933 and
1938, funding for the program exceeded $10,000;000.
This program remained focused specifically on families
in need.
Unlike those established during the Depression, the
child care facilities (funded in part by transfers of funding
from the original WPA program) developed by the
federal government in the 1940s were designed. for
steady workers with war industry jobs. During World
War II, the federal government provided care for 400,000
preschool children, whose mothers were needed for work
in war-related industries Even so, the program only
served a fraction of those in need of care. Then, after
thewar, national policy reversed to encourage these
mothers to leave the workplace, and the federal support
for child care programs ended in 1946 (Damplo, 1987).
Other than the birth of the Head StartProgram under
President Lyndon Johnson (discussed. belo~), there was
little new federal child care programming 'until 1974,
when funding was incorporated into Title XX of the
Social Services Amendment to provide funding for child
care, although amounts declined over the years. Funding
was affected in the years immediately preceding the
welfare reform act of 1996 when the 1990 Child Care and
Development Block Grant (CCDEG) focused on children
on Aid for Families with Dependent Children (AFDC)
and the children of the
working poor. .
Other families also needed child care, and a lively
market has emerged in the United States to serve a wide
range of children, in addition to those subsidized by
public funding. This market in turn drew on a number of
models: Someday care centers are private businesses;
some are service arms of another organization, such as a
church or community; some are administered by non-
e defendant does not wish to contest the charges (Lynch,
h, 2003). In 2002, 1,114,000 adults were convicted in
in federal and
ICE: OvERVIEW
s tot
242 Q-IlLD CARE SERVICES
homes. The regulation of child care is a state function,
but state criteria for registering and overseeing child
care vary considerably. Many of these facilities care
both for children receiving subsidies and for children
whose parents may the full fee for care.
With the advent of welfare reform in 1996 encoura-
ging impoverished mothers to leave welfare and attain
jobs, increased funding became available for subsidized
child care for poor families. Although subsidies were
important to many impoverished mothers moving into
the job market, they continued to reach only a fraction
of those eligible. Furthermore, given the costs of child
care, not all those in need of subsidies were eligible.
This situation was further complicated by the increased
devolution of responsibility for regulating care to states
and, in some states, to more localized areas
(Schexnayder et al., 2004).
HEAD START In contrast to subsidized child care,
Head Start, originally sponsored by the Office of Eco-
nomic Opportunity in 1965, began as an eight-week
educational program for the children of impoverished
families. (Administration for Children and Families,
2006,
http://www.acf.hhs.gov/programs/hsb/about/history.
htm). While expanding its focus and program substan-
tially, it is still primarily intended as an educational
program for impoverished children. More expensive to
support than subsidized child care, Head Start was
designed to improve long-term outcomes for young and
impoverished, often minority, children through
education, nutrition, and intensive work with their
parents (for detailed discussion of its early history,
theory, and background, see Zigler & Valentine, 1979).
Some requirements of the program such as the .
expectation that parents participate actively in their
children's education conflicted with use of the program
by employed parents as child care. Since the late 1980 s
studies have shown effects from Head Start (Lee,
Brooks-Gunn, Elizabeth Schnur, & Liaw, 1990; U.S.
Department of Health and Human Services, 2005),
extending even into the adult years (for example,
Barnett, 1995, Garces, Thomas, & Currie, 2002); some
studies indicate that the potential impact of Head Start is
minimized by other life factors experi enced by attenders
(for example, Lee & Loeb, 1995). Now housed at the
Administration on Children, Youth, and Families, Head
Start programs (with the exception of migrant programs
and Native American programs) are managed locally
through community-based organizations and school
systems, under grants from the federal government.
Head Start serves only a fraction of eligible children.
Recent figures indicate that the children enrolled were
roughly one-third white,
one-third African American, and one-third Hispa nic
(Center for Law and Social Policy, 2006, http://
www.acf.hhs.gov/programs/hsb/about/history.htm ).
However, researchers believe that eligible children of
immigrants are less likely to be enrolled than other
eligible groups (Takanishi, 2004).
PRE-KINDERGARTEN While as early as the late
1890s at least one state, Wisconsin, allowed
four-year-olds to enroll in kindergarten, only three states
allowed school districts to use state aid for
four-year-olds before 1960. At roughly the same period
that Head Start was developing, prekindergarten
programs (many of which are in the public schools)
emerged to promote schoolreadiness among children
facing risks, including lack of language; cognitive, or
social skills. While the program is focused on
school-readiness, prekindergarten is often used by
parents as part of their child care strategy, sometimes
combined with an after-school program. However,
prekindergartens are considered school programs aimed
primarily at developing the necessary cognitive and
social skills for successful school entry. They often do
not provide the flexibility and extended services
required by employed parents.
The complexity of the child care system and the
shortage of child care subsidies leave many families,
particularly those among the working poor, struggling to
arrange for child care. Parents' performance on the job,
and children's healthy development both depend on
access to stable and appropriate child care. Child care
remains a central concern for social workers in their
roles as advocates and service providers.
REFERENCES
Administration on Children and Families. (2006). Head Start
history. Retrieved January 15, 2007, from http://www.ad.
hhs.gov/programs/hsb/about/history .hrm
Barnett, S. W. (1995). Long-term effects of early childhood
programs on cognitive and school outcomes. The Future of
Cm~ren,5(3), 25-50.
Boschee, M. A., & Jacobs, G.M. (1997). Child care in the United
States: Yesterday and today. National network for child care.
Retrieved March 13, 2007, from http://www.
nncc.org/Choose.Quality .Care/ccyesterd.htnil
Carlson, H. L. (1993). Early child care and education at Hull
House: Voices from the past, challenges for the future. Early
Education and Development, 4(1),68-79.
enter for Law and Social Policy (CLASP). (2006). Head Start
participants, program, families, and staff in 2005. Retrieved
January 17, 2007, from http://www .clasp.org/pub-
lications/hs_2oo5data_sep06.pdf
ohen, A. J. (1996). A brief history of federal financing for child
care in the United States. The Future of Children. 6(2), 26-40.

Damplo, S. (1987). Federally sponsored childcare during world
war II: An idea before its time. Georgetown University Law
Center. Retrieved january 2, 2007, from http://www.law.
georgetown.edu/glh/damplo.htm
Garces, E., Thomas, D., & Currie, j. (2002). Longer-term effects
of head start. The American Economic Review, 92(4), 999-1012.
Lee, V. E., Brooks-Gunn, j., Elizabeth Schnur, j., & Liaw, F.-R.
(1990). Are Head Start effects sustained? A longitudinal
follow-up comparison of disadvantaged children attending
Head Start, no preschool, and other preschool programs. Child
Development 61 (2),495-507.
Lee, V. E., & Loeb, S. (1995). Where do Head Start attendees end
up? One reason why preschool effects fade out. Educational
Evaluation and Policy Analysis, 17(1),62-82.
Lynn, L. E. (2002). Social services and the state: The public
appropriation of private charity. Social. Science Review.
Retrieved january 2, 2007, from http://hatrisschool.
uchicago.edu/about/publications/working-papers/abstract.asp
? paper_no =01.13
Scarr, S. (1998). American child care today. American Psyclwlogist,
53(2), 95-108.
Scarr, S., & Weinberg, R. (1986). The early childhood enterprise:
Care and education of the young. American Psyclwlogist,
41(10),1140'-1146.
Schexnayder, D., Schroeder, D., Tang, Y., Lein, L., Beausoleil,j.,
& Amatangelo, G. (2004). The Texas child care subsidy program
after devolution to the local level: A product of the study of child care
devolution in Texas. Austin, TX: The Ray Marshall Center for
the Study of Human Resources.
Takanishi, Ruby. (2004). Leveling the playing field: Supporting
immigrant children from birth to eight. The Future of Children,
14(2),61-80.
U.S. Department of Health and Human Services, Administration
for Children and Families. (2005). Head Start impact study: First
year findings. Washington, OC. Retrieved March 13, 2007,
from http://www.acf.hhs.gov/prograrns/opre/hs/
impaccstudy/reports/frrscycexecsum/firscycexecSum.pdf
Zigler, E., & Valentine, j. (Eds.). (1979). Project Head Start:
A legacy of the War on Poverty. New York: The Free Press,
Macmillan.
-. LAURA LEIN
CHILD FOSTER CARE. See Foster Care.
CHILDREN. [This entry containsfoUT subentries: Overview;
Practice Interventions; Group Care; Health Care.]
OVERVIEW
ABSTRACT: Children are interesting, resilient
people, whose lives are often perilous. Social
I workers deal
J
CHILDREN: OvERVIEW 243
extensively with children and families, and with policies
that affect children, to help children and families overcome
family disruption, poverty, and homelessness. Social
workers also provide mental health care while working .. to
ensure that children get medical care. Schools are areas of
practice for social workers dealing with children. The
issues of ethical practice and social justice for children are
complex.
KEY WORDS: children's behavior; th eories of
behavior; child development; child poverty;
substandard housing; homelessness; medical care for
children; health impacts of diet and exercise on
children; family break- up and reconfiguration;
children functioning as parents; living with
grandparents; children's mental well-being; com mon
childhood mental disorders; children's responses to
trauma; drug use among children; education; testing;
bullying; ethics
Children in Society
Children, ideally, should enjoy life, with time to imagine,
play, learn, and develop in safety and love, but many
children's lives fall short of that ideal. Social workers work
to enrich children's relatioriships and experiences, and to
help adults understand that a child's behavior is a complex,
interactive system affected by physical and mental health,
family and home factors, spiritual influences, community
and societal concerns, and economic issues. Adults who
want to help children must take a broad perspective,
creating strategies that integrate these various factors.
However, children are amazingly resilient, and often
develop their own successful strategies to deal with
difficulties.
Approximately 73.5 million children under 18 live in
the United States, and that number is expected to grow to
85.7 million by 2030 (Child Trends Data Bank, 2007
www.childtrendsdatabank.org).Worldwide.children
number a staggering 2.2 billion (Shah, 2006 www.glo-
balissues.org/T radeRelated/Facts.asp).
Child Development
Children, because they are unique human beings living in
and reacting to unique circumstances, defy easy
classification of their development. Professionals classify
child development, drawing on several theoretical
frameworks, including Multicultural Theory, which
maintains that the child should be viewed as developing
within the context of family, community, and culture
(Ashford, LeCroy, & Lortie, 2001).lt is critical to be
sensitive to the child's cultural identity, verbal and
nonverbal communication, language, and spiritual beliefs.
244 CHILDREN: OVERVIEW
5). Toward a theory of the voluntary nonl thinking
about how children develop.
Psychodynamic Theory presumes that behavior is
conscious' (the person is aware' of the behavior ~ d its
meaning); unconscious (the person is not aware of wha t is
driving behavior, but senses feelings that influence
behavior); or preconscious (thoughts and feelings can be
brought into the conscious realm). The individual relives
the past in present relationships, and is driven by the id (in
which human drive is born), the ego (in which the
individual makes executive decisions about how to
behave), and the superego (the individual's conscience) .
Ego Psychology Theory focuses, on the ego, the
personality's executive, highlighting ego functions (ran-
\ ectly with the poor, and working with policy makers to
ging from weak to strong) such as testing reality, making
judgments, developing thought processes, and mastering
behavior. This theory divides development into eight
stages in which the child: (1) learns to trust or mistrust; (2 )
learns to feel autonomous or to feel shame and "doubt; (3)
initiates activities orfeels guilty; (4) becomes indus trious
or feels inferior; (5) the adolescent develops personal
identity or becomes conf~ed in role identity; ( 6) the
young adult learns to be intimate or feels isolated; (7) the
adult generates productivity or stagnates; and (8 ) .
develops integrity or descends into despair.
Object Relations Theory posits that children seek
stimulation, establish connections, and promote at-
tachments by relating to people or objects as a func tion of
their inborn drive to survive. Developing children learn to
identify with objects or people, and learn to separate from
them. Their feelings are split (like both loving and hating
a parent) until they develop object constancy, allowing
them to internalize the parent and hold that idea in their
minds.
Cognitive Theory maintains that individuals'
behaviors are determined by the way they structure their
world. People's emotions flow out of what they believe or
assume, and those assumptions may be out side their
conscious thinking. Dysfunctional thoughts may result
from organic, psychological, or chemical problems.
Behavio~ Theory centers on how people learn to
behave and change behavior. Behavior is conditioned by
particular responses (classical conditioning) while
operant conditioning. refers to a person's 'ability to
change a behavior when the behavior's antecedent or
consequence is changed. Social learning theory indi cates
that behaviors are learned through imitating, modeling,
and observing. Cognitive behavioral con structivist theory
focuses on how and why people develop and are affected
by stories about important life events.
Feminist Theory maintains that females develop . largely
in response to relationships. Healthy children develop by
enhancing connection with others through engagement,
empathy, and empowerment.
The Economic Circumstances of Children
In the United States, 13 million children live in poverty,
according to the U.S. Census Bureau in 2004. Throughout
the world, almost every other child, or about 1 billion
children, exists in poverty (Shah, 2006;
www.globalissues.org/TradeRelated/Facts.asp ). Social
workers are committed to helping people escape the
negative consequences of poverty through working dir-
develop societal strategies that attack poverty. Poverty's
effects on children range from the obvious to the subtle,
but are universally negative and become increasingly
negative the longer a child lives in poverty (Downs,
Moore, McFadden, & Costin, 2000). Poverty breeds
housing and food insecurity, poses real barriers to getting a
strong education, and factors into the development of
serious health issues. And poverty has racial implica tions:
the National Center for Children and Poverty stated in
2006 that, of U.S. children living in poverty, 10% are
White; 35% are Black; 28% are Latino; 11 % are Asian;
and 29% are American Indian ( http://www.nccp.
org/state_detail_demographic_poor_US.html).
SUBST ANDARD HOUSING AND HOMELESSNESS Poverty
usually leads to substandard housing. An estimated 1.35
million American children, according to' Horizons for
Homeless, will experience homelessness over the course
of a year (www.horizonsforhome1ess
children.org/Statistics_N ational_ Statistics.asp), while,
according to Shah (2006),1 in 3 children (640 million)
worldwide go without adequate shelter in a year (www.
globalissues.org/T radeRe1ated/Facts.asp). Children
who are homeless-or afraid of being homeless-are often
depressed and frightened. Homelessness interrupts
schooling and makes life more dangerous. Children
living. on the streets or in poor neighborhoods are more
at risk of gunshot wounds, the second most frequent
cause of death in children aged 10-19 after vehicular
blic. The role of the government as a funder of both
cultural and social weloor children often live in and
Poor children often live in and attend school in
crowded, moldy, vermin-infested conditions where they
are more susceptible to contagious diseases, respiratory
illness, and injuries (Gracey, 2002). Children exposed
(even before birth) to toxins such as lead, mercury, or
pesticides are at risk of serious developmental dam age.
The majority of children live in cities where such
. . .&0

substances are found (Gracey, 2002). Megacities with the
most uncontrolled growth (such as San Paulo, Brazil;
Mexico City, and Shanghai), have populations larger than
nations such as Australia and, because they are
overwhelmed with new residents, cannot keep up with the
infrastructure necessary to protect children from disease and
injury. As urban areas spread, creating more impervious
surfaces such as roads and parking lots, water supplies
increasingly collect pathogens, metals, and chemical
pollutants, contributing to the growth of waterborne
diseases to which children are particularly susceptible.
According to Shah (2006), 1 in 5 children worldwide have
no access to safe drinking water.
Children who have been living in foster care or other .
substitutes for parental <rare face acute housing problems
when they "age" out of foster care, typically at age 18. They
need transitional services, such as those authorized by the
John Chafee Foster Care Independence Program of 1999,
which funds states to assist foster care youths up to age 21
with educational and vocation~l services. Numerous
child-caring agencies have "transitional living" programs for
aging-out children.
SINGLE PARENTS AND POVERTY Currently 26% of
American children under 18 live or have lived in a
single-parent home, typically headed by a woman
(Factbook htip://www.pobronson.com/factbook/pages/.
43.html). Sixty percent of births to black women in their 20s
are to single women; 13% of births to 20-something white
women are to single women (U.S. Census Bureau, 2004).
Fewer than half the young men who father children with
teen moms finish high school, so their earning potential is
low (Kids Count Data Book, 2004).
Statistically, three elements increase a newborn's risk of
child poverty: being born to a teenager, being born to a
mother who has not completed high school, and being born
to a mother who never married. Women who give birth as
teens attain, on average, three years less education than
women who delay childbearing till after their teen years,
and only an estimated one-third of teen mothers go on to
graduate high school (Kids Count Data Book, 2004).
Raising children is expensive, and teen moms are ill
prepared to pay the bills. Because they have had less time to
mature through adolescence, they often lack adult skills in
their decision making and behaviors.
ACCESS TO MEDICAL CARE World wide, 270 million
(1 in 7 children) have no access to health services (Shah,
2006). In the U.S., poor children often do not receive the
immunizations or medical care they need because of lack of
funds or insurance, lack of transportation,
CHILDREN: OVERVIEW
245
confusing communication or language distinctions, and
differences in cultural values.
Children of color, particularly, often have lower access
to medical care because of poverty. They are more likely to
visit emergency rooms rather than medical offices or
clinics, and are less likely than White children to have
completed their immunizations (Moniz & Gorin, 2003).
Children of immigrants. may lack immunizations and
health care if their parents are afraid of seeking care and
thereby exposing themselves to questions about their
immigration status.
DIET AND EXERCISE Poverty also affects children's
diets and their ability to exercise sufficiently. In 2002, the
U.S. Department of Agriculture reported that nearly 35
million Americans-including over 13 million
children-worried about how to secure their next meal
(Children's Defense Fund, 2004). Fast food chains, with
their inexpensive "extra value meals" and high saturated
fats, are quite popular in low-income neighborhoods, while
nutritious fresh vegetables and fish are too costly for many
poor people to buyand they may not have the kitchen
appliances, electricity, and equipment to prepare foods in
healthy ways. Nutrition-related problems, such as obesity
and diabetes, are increasing in the United States. Lack of
exercise contributes to the "super-sizing" of American
children. Parents in poor neighborhoods may not allow
children to play outside because play areas are limited or
unsafe. Increasingly, children entertain themselves with
sedentary pleasures, such as television. Lack of
imaginative play with other children may increase a child's
sense of isolation, decrease creativity, and limit
opportunities to "practice" relating to others (Noble &
Jones, 2006).
EDUCA TION AND POVERTY Children of poverty
often are not well prepared for school because their
opportunities "to learn how to learn" are limited, they may
be hungry and tired because of crowded and inadequate
home conditions, and their families may not understand
how to help them learn. Such children may be more likely
to end up in special education programs, a stigmatizing
experience (Oswald; Coutinho, Best, & Singh, 1999).
Cultural issues, such as the child's most familiar language
and patterns of eye contact, can unnerve teachers. Poor
African American children are 2.3 times more likely to be
identified by their teacher as having mental retardation
than poor White children, and in some regions, Latino/a
and Native American children are also overrepresented in
special education (Oswald, Coutinho, Best, & Singh,
1999).
246 CHILDREN: OvERVIEW
/www.cswe.org/NR/"http://www.cswe.org/NR/
Children are usually reared in: families, but family
configurations vary and affect the type of care
children receive. Families, for instance, may be
headed by divorced parents or by grandparents, while
children in the family may be half-siblings or
step-siblings; sometimes people who are not related
by genetics or by law function as families. Social
workers help parents and caregivers develop the best
plans possible for children while securing the
resources they need for the children. Social workers
conduct home studies, mediate between parties
seeking custody and child support, and testify in court
(Noble & Ausbrooks, 2007).
F AMIL Y BREAK-UP AND F\AMIL Y BLENDING Every
year, more than 1 million children have parents who
separate or divorce (Women's Educational Media in
2007; http://www.womedia.org/taCstatistics.htm ).
When families break up, children usually experience
lowered family financial resources, and child support
issues are troublesome (Downs, Moore, McFadden, &
Costin, 2000). Children caught in. highly emotional
arguments between parents may experience fear,
anger, and even physical danger (Noble & Ausbrooks,
2007). Children often see parents leaving one
relationship for another relationship. Two- thirds of
divorced parents marry again. (Hetherington & Kelly,
2003), and children in blended families must adapt to
stepparents and step-siblings.
PARENTS' EMPLOYMENT Work provides not only
money to care for the family; it also gives people a
sense of meaning and identity. When parents are
unemployed, the strain on the family is both financial
and emotional, and children may be confused, angry,
or fearful. Often, employed parents have to place
children in child care, which can be very costly. Some
AGENCY AND ORGANIZATION IN
pecialized knowledge regarding the challenges their
r clients face, communicating that information to
Moore, McFadden, & Costin, 20(0).
CHILDREN WHO FUNCTION AS PARENTS When parents
have drug or alcohol habits, or mental or physical
disabilities, children may be "parentified" by helping
their parents take care of themselves, tending to
younger siblings, and seeking ways to bring money
into the family (Win:ton, 2003). Particularly in poor
families, when adults are working and cannot
purchase or otherwise provide child care, children
may be left to fend for themselves while tending to
siblings (Winton, 2003).
INCARCERATED PARENTS Children may also have to
function as parents when their parents are
incarcerated.
At the beginnin:g of the 21st century, 1,498,800 children
had at least one parent in prison (Temin, 2001). Mothers,
when arrested, sometimes do not reveal that they have
children, fearing that the state will remove the children
from their custody. During a father's incarceration, 89% of
children will live with their mothers. During the
incarceration of a mother, about 25% of children live with
their fathers; 51% live with their grandparents; 20% live
with other relatives, 9% live in foster homes, 4% live with
friends, 2% live in an institution, and 2% live alone (Young
& Smith, 2000).
LIVING WITH GRANDPARENTS In the United States,
about 6 million children live in households headed by
grandparents or other relatives. About 2.5 million of
these children live in: homes in which neither parent is
present, so the relative is in charge of rearing the child,
a steep assignment for grandparents who are on a fixed
income and have limited energy or resources
(Financial assistance for grandparents, 2004).
Depending on state regulations, caregivingrelatives
may be eligible for financial assistance through
Temporary Assistance for Needy Families (T ANF),
foster care payments, subsidized guardianship or
kinship care payments, subsidized adoption
arrangements, or Earned Income T ax Credit, The child
who is disabled, poor, and under 18 may be eligible for
Supplemental Security Income (SSI) payments
(Financial assistance for grandparents, 2004).
GA Y AND LESBIAN F AMILlES Children sometimes ' live
with gay or lesbian parents, having been born during a
parent's previous heterosexual relationship, conceived
through reproductive technology, or adopted. They
often face questions and misunderstanding from
community members, as well as teasing or oppression
from their contemporaries. Since, in most jurisdictions,
gay and lesbian families lack typical family legal
protections; children of gays or lesbians face unique
family issues when parents break up and argue about
custody, or parents become ill or die.
Children's Physical Well-Being
How well children reach developmental milestones is
directly related to their physical well-being. Social workers
have been active in developing and delivering
health-related programs, such as Medicaid (health cov-
erage for qualifying poor families) and. the Women,
Infants, and Children's Program (WIC) (health in infants).
INJURIES Historically, the biggest killer of children has
been infectious disease, for example, diphtheria.

Now the most common cause of child death in indus-
trialized countries is injury (Gracey, 2002), particularly
in areas where children must cope with poisonous sub,
stances, heavy traffic, the risks of falling from tall
structures, limited play space, exposure to drugs and
alcohol or users, and violent actions from others (Noble
& Jones, 2006.)
PUBLIC PROGRAMS FOR POOR CHILDREN'S
HEALTH CARE Of all the industrialized countries, the
United States is the only one that has no Universal health
care. Twelve percent of American children are not
covered by any health insurance (Kids Count Data Book,
2004). Medicaid, establi.$hedby Congress in 1967 and
financed through federal and state taxes,
\
provides medical assistance (as well as screening for
certain health conditions) to qualifying low-income
families. In 1997 Congress created the State Children' s
Health Insurance Program (SCHIP) to help states insure,
children whose parents are too poor to buy insurance but
who are not poor enough to qualify for Medicaid. This
program varies widely between states in structure and
eligibility criteria. Some states have been slow to
implement the program,' and many families which might
be eligible for coverage do not know about or understand
how to apply for the pro, gram. Nonetheless, SCHIP has
made a difference in children's access to health care; 6
million children
. nationwide are covered (The State Children's Health
Insurance Program).
Most states have adopted some form of "Baby
Moses" laws, which allow parents to legally abandon an
infant 60 days old or younger at a "safe baby site," such
as a fire station or hospital. Such legislation provides
parents a way to legally give a child to an emergency
care provider, rather than illegally abandon the child in a
dangerous or unprotected location.
Children's Mental Well-Being
Not only do children need to be physically safe, cared
for, and healthy, but they also need environments that
support their mental and emotional needs. From 12% to
22% of all children under age 18 in the United States
need services for mental, emotional, or behavioral
problems, and approximately 1 out of every 50 children
(1.3 million) receive mental health services (Latest
Findings in Children's Mental Health, 2004; UCLA
Center Report, 2003). Many of those services are de-
signed and delivered by social workers.
Insurance or Medicare coverage' is typically limited
for mental health services. Social workers, however,
have been instrumental in crafting legislation such as
the Juvenile Justice and Delinquency Prevention Act,
CHILDREN: OvERVIEW 247
which established juvenile drug courts to help young-
sters conquer alcohol and drug use, as well as advocat-
ing for more community-based programs to help
children avoid and deal with mental and emotional
difficulties.
A child's mental and emotional health is affected by
complex interactions between physical environmental
factors (such as overcrowding), family issues (such as
the parent's mental health status), emotional environ-
mental elements (such as parents' knowledge of appro-
priate discipline), and the child's inborn characteristics
(such as genetic make-up). Social workers develop and
deliver mental health programs, work with children and
parents to overcome problems, participate in emer gency
response teams during traumas, and advocate for public
policies that help enhance children's mental health.
Children need positive, stable support from family
members, Social workers, school officials, clergy and
religious groups, and community programs and
priorities that help them build buffers against mental
problems.
COMMON CHILDHOOD MENTAL DISORDERS
Anxiety disorders, attention deficit hyperactivity
disorder, post-traumatic stress disorder, depression, and
conduct disorder are common among children who have
been maltreated; have lost a family member to death,
militarydeployment, or incarceration; or have witnessed
violence (Noble & Jones, 2006). Learning disorders and
pervasive developmental disorders (such as autism and
Asperger's Disorder) are linked to toxins such as
environmental pollutants and fetal alcohol syndrome
(APA, 2000). Environmental toxins, drug exposure in
utero, and a history of child abuse and multiple foster
care placements are related to Attention Deficit Hyper-
activity Disorder (ADHD) (Harvard Mental Health
Letter, 2004). Conduct disorder is associated with such
inconsistent child-rearing practices as harsh discipline,
lack of supervision, maternal smoking during preg-
nancy, and exposure to violence (APA, 2000). Opposi-
tional defiant disorder is more prevalent in children who
have had a succession of different caregivers or who live
in families with harsh, inconsistent, neglectful
child-rearing practices (American Psychiatric Associa-
tion [APA], 2000). Almost a third of all children re-
ceiving mental health services suffer from two or more
psychiatric disorders, making treatment more difficult.
The most common diagnostic combination is ADHD
and mood disorders (Latest Findings, 2004).
RESPONSES TO TRAUMA Children can view natural
disasters, terrorist acts, school shootings, and other dis-
tressing events on television and the Internet at any
 248 OIILDREN: OVERVIEW
time. Some trauma is time-limited (such as a sudden
change in living situation) and may result in post,
traumatic stress disorder. When the trauma is chronic
(such as long-term incest), its cumulative effects open
the child to additional psychopathology. A child may
react to trauma by internalizing the pain and
experiencing depression, withdrawal, and self- injury, or
the child may externalize the pain and act it out in
aggression-all reactions that interfere with normal
social, educational, and physical development (Noble &
Jones, 2006).
Children who suffer maltreatment, witness frequent
family violence, or exist in dangerous living condi tions
are also more likely to suffer intellectual deficits (Noble
& Jones, 2006). The child who is desensitized
. \
to violence may expect violence and become aggres-
. sive. Traumatized children can experience impaired
memory or speech development, fearand guilt,
unpleasant memories, repetitive behavior, emotional
numbing, and a sense of hopelessness. Traumatized
children are also more vulnerable to suicide attempts
(Noble & Jones, 2006). On an average day, four
American teens commit suicide (Kids Count Data
Book, 2004), though the actual number may be higher
because some suicides are listed as accidental deaths.
INTELLECTUAL DISABILITY Intellectual disability is a
physical and mental condition rather than a
psychiatric illness, but children with intellectual
disabilities (once called "mental retardation") may
also have psy, chiatric and physical difficulties.
Intellectual disabilities can originate in biological
factors, prenatal damage due to toxins, deprivation
of nurturance or stimulation, fetal malnutrition,
premature birth, viral infections during pregnancy,
and childhood infections, injuries, or poisonings
(APA, 2000). These children may also exhibit
anxiety, conduct disorders, or impaired
development.
USE OF ILLEGAL DRUGS AND PSYCHOTROPIC MEDICA
nONS Children easily learn how to acquire illegal
drugs and alcohol, and some indulge in these
substances. Such behavior can trigger a downward
spiral, bringing children into contact with criminals,
stunting their development and education, impairing
their judgment, making them more vulnerable to
sexual activities and sexually transmitted diseases,
and increasing their chances of dangerous behavior,
injury, or death (Gracey, 2002; Noble & Jones,
2006). Educating children about the dangers of
drugs and alcohol, limiting their chances of
acquiring these substances, and sup porting children
in healthy drug and alcohol-free activities are
strategies that go hand-in-hand with enforcing
stop the continuation of criminal behaviors and the
off-limits for children.
nnual interviews c medications to treat children is
controversial (FDA requires warnings for use of anti-
depressants on children, December 10, 2004).
Most antidepressants, for instance, have not been
widely tested on children, though physicians may still
prescribe such medications "off-label" (for a use other
than that approved by government regulations). Pre-
scribing medications "off-label" for children requires
caregivers to guess about dosage and duration of treat-
ment. Some authorities blame some antidepressants for
sparking suicidal or violent actions in children (Anti-
depressant medications for children and adolescents,
February 8, 2005). Medical authorities across the world
are examining whether to ban prescribing antidepres-
sants for children (as Britain recently did), while the
U.S. Food and Drug Administration now requires that
antidepressants commonly prescribed for children carry
strong warning labels that the drugs can spur suicidal
behavior. Nonetheless, one-third of all children in
mental heath services are treated with psychotropic
drugs, particularly if they suffer from more than one
diagnosis (Latest Findings, 2004). Using seclusion ,
physical restraints, or chemical restraints on children is
controversial and open to legal challenge (Latest
Findings, 2004). The cost of treating children and ado-
lescents for mental healdi concerns is estimated at
nearly $12 billion (UCLA Report, 2003).
How Educational Realities Affect Children All the
challenges that children face merge in their educational
settings. In order to learn, children need to feel safe in
their schools and their neighborhoods, and they need to
be healthy and cognitively able to focus on schoolwork.
While some social workers operate directly in school
settings, many other social workers are also involved in
school issues that affect children. Social workers help
teachers understand the impact of culture and family
resources on children's and parents' behavior, while
emphasizing positive development in children. They
work with children who are suddenly removed from
their homes because of danger and are now in an
unfamiliar foster home and a strange school with
different classmates. In cases of sudden traumatic
events, such as school violence, social workers are
invaluable in helping children stay safe and cope with
their fear and anger.
Social workers also . advocate for programs such as
Head Start, a comprehensive child development
program authorized through the Economic Opportunity
Act of 1965, which has helped millions of disad-
vantaged children get a head start in school, and the

National School Lunch and Breakfast programs, which
feed hungry children in school. Social workers also assist
schools, as well as children and their families, to protect
children's confidentiality under the Family Educational
Rights and Privacy Act (FERP A) and the Health Insurance
Portability and Accountability Act (HIPAA).
CHILDREN WITH SPECIAL NEEDS Children who pri-
marily speak a language other than English need
partieular attention in the U.S. educational arena.
How best to teach limited English-spe aking (LEP)
children is controversial, particularly in light. of
emotional responses to immigration (Meyer &
Patton, 2001).
Various federal education laws, such as the Improving
America's Schools Act of 1994 and the No Child
Left.Behind Act of 2002, address strategies to teach LEP
children. Social workers can build bridges between LEP
families and the school.
Social workers are often involved with processes
generated by the Individuals with Disabilities Educa-
tionAct (IDEA) of1990(P.L. 94-142), which provides
federal money to states to augment special education for
children with mental, physical, or emotional dis, abilities.
This legislation states that every child is en, titled to a free,
appropriate public education, and that parents should be
included in making their children's educational plans.
Children, who are guaranteed pro, cedural due process
under the law, are to be placed in the "least restrictive
environment" that can meet their educational needs. IDEA
also includes a provision for the Handicapped Infant and
Toddlers Program, an in, terdisciplinary system of early
intervention for disabled babies and their families.
Because children with special education needs are often
economically and socially disadvantaged, social workers
deal with them to solve a broad array of social service
needs. For instance, because poor children sometimes
come to school wearing hand-me-down, ill, fitting shoes
and thus cannot participate effectively in physical
activities, social workers have helped develop resources to
meet clothing needs.
TESTING Children are often grouped and labeled by
standardized tests- the results of which tend to shape
students' careers, The U.S. Department of Education
presses school districts to m eet testing standards in
order to access federal funds, and the No Child Left
Behind initiative relies heavily on testing for
account, ability and for determining whether children
progress in school. The stress of this high- stakes
testing takes a toll on s chool districts, families, and
children (Chil dren's Defense Fund, September
2004).
CHILDREN: OvERVIEW
249
Children who have some hope of doing well in tests
tend to study hard. But children who are not academically
oriented and are depressed about testing may remove
themselves, either by literally dropping out or by
disengaging from studying and perhaps indulging in escape
behaviors such as drugs. If students look like poor risks for
success on these high-stakes exams, schools may
encourage them to move into a General Education Diploma
(GED) program to avoid the test, ing, or may retain them in
the grade preceding the testing grade to avoid having the
students. pull down the test score (Children's Defense
Fund, September 2004). Reports are widespread of schools
"teaching to the test" and shifting time away from untested
sub, jects, such as health. Testing may more accurately test
the adults who operate schools than the children in the
school. Social workers help students and teach, ers to cope
with the pressures of this test, intensive environment.
Success in school is critical. As the United States
becomes more mechanized, the job market and potential
earnings for people without high school diplomas are grim
(Children's Defense Fund, August 6, 2004).
Social workers help school children stay in school, find
jobs, and plan for their future. They may train children how
to interview for jobs, for instance, and how to develop
habits like timeliness, required in the workplace.
BULLYING One reason children may stop engaging in
their studies or even going to school is fear of
violence, including the everyday possibility of being
bullied by classmates (Duncan; 2004). Bullying
attacks a child's self, esteem and interferes with
schooling. Social workers have be en instrumental in
developing and deliver ing "stop bully abuse"
programs for students, and in developing strategies to
help children treat others with respect. Social
workers involve parents of the "bully" to stop the
discourteous and dangerous behavior; they also deal
with people who witness or are victims of bullying.
Issues of Ethics and
Social Justice in Children's Work Children's
legal rights have grown over the last century, and
those rights often create tension between children,
adults, and social institutions. Society continues to
debate whether children are mentally and
emotionally prepared to make decisions, and which
person or entity is best prepared to make appropriate
decisions concerning children (Noble & Ausbrooks,
2007). The court system has become increasingly
important as the arbiter of decisions in child
custody, the extent to which children should be held
culpable for criminal behavior,
250 CHILDREN: OVERVIEW
child medical issues, child discipline, abortion, religious
practices that affect children, educational priorities, sex
education and sexual activity, children's rights to free speech,
censorship of materials available to children, financial
liabilities for children's behavior, inheritance, and other
complex situations (Badeau, 2003). Social workers in various
service systems are involved in all these issues.
The limits and boundaries of ethical behavior in working
with children are often hard to determine. A social worker
must always think through how children and parents may
interpret activities such as hugging the child, discussing
spiritual or religious issues with children, or transporting a
child in a vehicle. Social workers are also obliged to
understand state and federal regula-
\
tions regarding confidentiality of children's medical or
educational records and the circumstances under which
release of children's records is allowed. They should be aware
of laws related to children, such as children's rights to seek
different medical treatments without parental consent.
Social workers should also keep focused on the rewards of
working with children. Children are fascinating, and working
with them is always interesting and challenging-and it 'is an
investment in the future of the world.
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www.behavenet.com/capsules/ disorders/dsm 4 TRclass ifi
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Antidepressant medications for children and adolescents. (February
8,2005). Retrieved May 28, 2005, from http://www.
nimh.nih.gov/healthinfor mation/antidepressants_child.cfm.
Badeau, S. (2003). Child welfare and the courts. Retrieved August 8,
2005, from http://pewfostercare.org/docs/index.
Children's Defense Fund. (2004, June 2). 13 million children face
food insecurity. Retrieved January 30,2005, from www.
childrensdefense.org
Children's Defense Fund. (2004, August 6). Joblessness for minority
youth reaches historic. high. Retrieved May 15, 2005, from
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Children's Defense Fund. (September 2004). High School Exit
Exams. Retrieved May 21, 2005, from www.childrensde
fense.org.
Children's Defense Fund. (2005, January 31). A moral outrage:
One American child orteen killed by gunfire nearly every 3 hours.
Retrieved January 1, 2006, from www.childrensde fense.org
Child Trends Data Bank. (n.d). Retrieved May 10,2007, from
www.childtrendsdatabank.org
Downs, S. W., Moore, E., McFadden, E. J., & Costin, L. B. (2000).
Child welfare and family services: Policies and practices (6th
ed.). Boston: Allyn & Bacon.
Duncan, K. A. (2004). Bullying as child abuse: Intervention strategies
schools can employ. American Counseling Association: Retrieved
July 30, 2005, from http://www.counsel ing.org,
Factbook: Eye-opening memos on everything family. (n.d.).
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factbook/pages/43.html
FDA requires wamingsfor use of antidepressants on children.
(December 10, 2004). New York Times, p. A 36.
Financial assistance for grandparents and other relatives raising
children. (July 2004). Children's Defense Fund. Retrieved January
1,2006, from www.childrensdefense.org Gracey, M. (2002). Child
health in an urbanizing world. Acta Paediatrica, 91, 1-8.
Harvard Medical School (2004). An update on attention deficit
disorder. Harvard Mental Health Letter, 20(11), 4-7.
Hetherington, E. M., & Kelly, J. (2003). For better or worse:
Divorce reconsidered. New York: Norton.
Horizons for Homeless Children. (n.d.). Retrieved May 10, 2007,
from wWw.horizonsforhomelesschildren.org/Statistics_N anonal
Statistics.asp
Kids Count Data Book. (2004). Baltimore, MD: Annie E.
Casey Foundation.
Latest Findings in Children's Mental Health. (Winter 2004).
Institute for Health, Health Care Policy, and Aging Research:
Rutgers University. Retrieved January 1, 2006, from
www.ihhcpar.rutgers.edu
Meyer, G., & Patton, J. (2001). On the nexus of race, disability, and
overrepresentation: What do we know? Where do we go?
National Institute for Urban School Improvement. Retrieved May
15,2005, from www.inclusiveschooIs.org. ,
Moniz, c., & Gorin, S. (2003). Health and health care policy:
A social work perspective. Boston: Allyn & Bacon.
National Center for Children and Poverty. (2006). Columbia
University, Mailman School of Public Health. Retrieved May 10,
2007, from http://www.nccp.org/state_detail_ demographicpoor ,
US.html
Noble, D. N., and Ausbrooks, A. (2008). Serving Children. In D. M.
DiNitto & C. A. McNeece, Social Work: Issues and Opportu~ities
in a Challenging Profession Ord ed.). Chicago:
Lyceum.
Noble, D. N., & Jones, S. H. (2006). Mental health issues affecting
urban children. In N. K. Phillips & S. L. A. Straussner (Eds.),
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practice (2nd ed., pp. 97-121). Springfield, IL: Thomas.
Oswald, D. P., Coutinho, M. J., Best, A. M., & Singh, N. N. (1999).
Ethnic representation in special education: The influence of
school-related economic and demographic variables. Journal of
Special Education, 32(4), 194-206.
Shah, A. (2006). Poverty: Facts and stats. Retrieved May 10, 2007;
from www.globalissues.org/TradeReiated/Facts.asp Temin, C.
(200l). Let us consider the children. Corrections Today, 63, 66-68.
The State Children's Health Insurance Program (SCHIP). (n.d.).
Retrieved from May 10, 2007, from http://www. results.org/we
bsite/article.asp ?id&equals; 1561

UCLA Mental Health in Schools Center Report. (December 2003).
Youngsters' mental health and psychosocial problems:
What are the data? Retrieved January 1, 2006, from http://
smhp.psych.ucla.edu
U.S. Census Bureau. (2004). Poverty: 2004 Highlights. Retrieved
January 1,2006, from http://www.census.gov{hhes/
Www/poverty/poverty04/pov04hi.htmI
Winton, C. A. (2003). Children as caregivers: Parental and
parentified children. Boston: Allyn & Bacon.
Women's Educational Media: That's a Family! (2007).
Retrieved May 10, 2007, from http://www.womedia.org/
taCstatistics.htm
Young, D., & Smith, C. (2000). When Moms are incarcerated:
au personnel interview 42,000 household members aged 12 and
Society, 81,130-141.
FURMR READING
U.S. Department of Justice. (1998). Bureau of Justice statistics
sourcebook of criminal justice statistics. Washington, DC: US
Government Printing Office.
-DORINDA N. NOBLE
PRACTICE INTERVENTIONS
ABSTRACT: Social work has a long tradition of direct
practice with children in a range of settings, such as child
welfare, child guidance, hospitals, schools, and
neighborhood centers. This entry focuses on general
principles and strategies for direct social work practice
with preadolescents and, to a lesser extent, their families,
within an eclectic conceptual framework.
KEY WORDS: children; direct practice
Children as Clients
Children are not little adults; they are human beings
with unique qualities, characteristics, and needs. As a
result, work with children as clients embodies special
features, with numerous variations depending on the
child's age, ethnic and racial background,
socioeconomic status, health and family structure,
among other factors (Pecora, Whittaker, Maluccio,
Barth, & DePanfilis, in press). With that said, there are
several considerations that a practitioner should take
into account when working with children.
First, there is the matter of fluid ego development.
Children are highly susceptible to external influences,
both positive and negative, and their defenses are not
rigidly set. They have limited ability to deal with inter-
nal impulses and external demands. Psychological con-
flicts are close to the surface and are not necessarily
repressed or suppressed, as they typically are with
adults. Children's behaviors (for example, crying by a
CHILDREN: PRAcrICE INTERVENTIONS 251
2-year-old or fear of leaving parents expressed by a
3-year-old) often reflect age-appropriate qualities or
regular developmental tasks, and are not necessarily
symptoms of pathological deviations.
Second, children are characterized by action
language-that is, they act out their feelings, are more
spontaneous than adults, and view play as real and as
work. Third, children experience less-rigid boundaries
between reality and fantasy, and their fantasies and
dreams are less disguised .. Fourth, children are depen-
dent on their parents or other adults, and therefore,
social work practice with children usually involves
work with their parents or other caregivers as an integral
part of the service. Various models of family therapy
can be used, including psychodynamic approaches such
as object relations theory; experiential models
. such as Gestalt therapy; behavioral therapy; and play
therapy, depending on the agency setting, child and
family needs and characteristics, as well as the pre-
ference and style of the practitioners (d. Goldenberg &
Goldenberg, 2004).
Finally, children who come to the attention of social
workers are, for all intents and purposes, "involuntary"
clients, and need to be approached as such. They are
generally brought to an agency because their behavior is .
troubling to someone in their environment. Depending
on the particular setting and the children's presenting
problems, social workers are called on to play a variety of
roles, the most frequent of which are clini cian, advocate,
mediator, and educator (Goldenberg & Goldenberg,
2004; Pecora et al., in press).
The Helping Relationship
The principles involved in engaging children in the
helping relationship with a social worker are similar to
those for adults, especially adults who are involuntary
clients, but they are applied differentially in response to
such aspects as age, developmental status, and reasons
for referral.
OBJECTIVES Typical objectives in early sessions with the
child include the following:
gaining the child's confidence and establishing a
trusting relationship;
learning about the child's views regarding her or
his situation, needs, and difficulties;
observing how the child responds to the social
worker and other helping persons;
arriving at an initial assessment of the child's
functioning, qualities, and coping patterns; and
establishing a tentative working agreement with
the child, to an appropriate extent and in a suitable
form.
252 CHILDREN:'PRACIlCE INTERVENTIONS
GUIDELINES There are no clear-cut or rigid rules for
accomplishing the earlier-mentioned objectives, as each
child is unique as well as-changing. There are, however,
general guidelines for the practitioner to fol low, such as
letting the child set the stage, choose what to talk
about, and have as much control as appropriate
offering a frank yet simple explanation of why the
child is there
focusing on the child as a person in her or his own
right, on what she or he is thinking, feeling and
doing now
conveying respect for the child and her or his
capacity to grow
structuring the relationship, through such means
\
as explaining the nature of the child's freedom
and responsibility; setting limits (for example,
what the child can and cannot do in the office); and
establishing' the format and extent of
confidentiality
Conveying a sense of hope about the child's
situation, potential, and opportunities
Avoiding directing the child toward areas that are
of concern: primarily for the parents or another
adult before the child is ready and sufficiently
comfortable
Putting aside formal interview procedures ~nd
letting the session flow naturally, using activities
and nonverbal tools as appropriate
RESISTANCE In line with the analogy of the involun-
tary client, one may expect that a child will manifest
resistance in the child-worker relationship. It is crucial
to perceive such resistive behavior within the context of
the child's struggle to adapt, rather than as a primarily
negative phenomenon.
In particular, one should understand that children
may typically fight efforts to change them-efforts that
represent a rejection of their identity or selfconcept.
Children must be accepted and cherished for who they
are before they are ready to open themselves to change.
It is not easy to convey such a sense of acceptance,
because children generally get. to a social worker when
parents, teachers, or others are directly or indirectly
conveying some complaint against them.
TRANSFERENCE AND
COUNTERTRANSFERENCE Within
psychoanalytically oriented agency settings, there may
be emphasis on the concept of transference-that is, the
irrational repetition of patterns of behavior originating
in early relationships. This concept must be modified in
social work practice with children. In
particular, one should recognize that a child is
realistically dependent on adults and may be fearful of
the social worker's power or authority. In a setting such
as a foster care agency, for example,. transference
reactions are not simply symbolic, but reflect a child's
feelings toward a social worker who has the authority to
move her or him from one placement to another or to
provoke some form of punishment.
Social workers must also be aware of their own
potential or actual countertransference reactions. In
child welfare settings such reactions may include the
rescue fantasy common among practitioners wh6' work
with children subjected to child abuse or neglect; the
tendency to identify with parents of demanding adoles-
cents; or the inclination to provoke or encourage the
child's acting-out behavior. Learning to deal with such
reactions is an essential component of practice
(Goldenberg & Goldenberg, 2004).
THERAPEUTIC VALUE OF THE RELA TlONSHIP
Perhaps more so than in work with adults, the helping
relationship is often the chief therapeutic vehicle in
direct practice with children (Pecora et at, in press).
Children typically view such a relationship as a natural
life experience rather than as an artificial event. Thus, in
play therapy a child is not engaged in play (which is an
adult concept), but in life itself.
The helping relationship can have therapeutic value;
through it, the child can come to regard herself or
himself as important and accepted and gradually reduce
the behaviors that elicit negative feedback from others.
To be effective in this way, practitioners need to re spond
to children with sensitivity, maintain a sincere belief in
children, and present themselves as genuine human
beings.
To promote therapeutic relationships with children,
social workers also need to pay attention to issues of
confidentiality and limit setting. Confidentiality is not
absolute-a child needs to be helped to see that what goes
on or what is shared is confidential between her or him
andthe social worker, except when there is a threat of
hurting him/herself. If certain kinds of information must
be revealed to someone else, such as the parents, the
child should be involved as much as possible in the
decision. The parents' understandable need for feedback
can be met through joint sessions or through sharing
overall themes, rather than specific points from sessions
with the child.
Setting limits with children in the treatment session
can be an. important part of a. corrective emotional
experience. The treatment session may indeed be
viewed as a laboratory for life, in which the child can
learn and grow. For example, when a child threatens

a social worker or someone else with physical harm, it is
essential to deal with the child's fear of loss of con trol by
restraining him or her. This action, of course, must be
carried out in a way that avoids being punitive,
conveying rejection, or displaying anger.
Assessment
Children who come to the attention of social workers
present a wide range of backgrounds, problems, needs,
and diagnostic categories. In light of social work's em-
phasis on the person-in-situation, it is useful to view the
assessment within an ecological framework that takes
into account the children's cultural, socioeconomic,
ethnic, and racial diversity; child development theor ies;
and findings of research on coping and adaptation
\
(Crosson-Tower
, 2004).
Such a framework incorporates three key features:
The child's social situation
The child's development, including functioning and
adaptive patterns
The interaction between the child's situation and
her or his development and functioning.
CHILD'S SOCIAL SITUATION The process of
formulating an assessment begins with a broad
understanding of the environment that impinges on the
child, including family dynamics and interactions;
culture, social context and social systems; ethnic and
racial characteristics; and environmental pressures,
demands, and opportunities. Because the environment
covers a great deal of ground, the so~ial worker selects
the most significant factors that are impinging on the
child and family at a particular time, following the
concepts of the family as a system of forces in
interaction with other systems in its environment.
The major practice principles flowing from systems
concepts include:
"Parents from different ethnic groups employ
culturally prescribed strategies to teach children
how to cope with anxiety" as well as how to cope
with other challenges to their development (Gibbs,
Huang, & Associates, 1989, p. 4).
Children may be reacting to certain pressures or
realities within the family. For instance, parental
discord in a family with a child who is about to go
to school for the first time may exaggerate the
child's fear of separation (Allen-Meares, 2004).
Children may be the focus of family tension or
conflict, and their behavior may reflect the
environment. For example, a child's fear of
interacting with other children may be com-
pounded by the family's realistic concern about
living in a neighborhood with a high crime rate.
CHILDREN: PRAcnCE
INTERVENTIONS 253
Child's Development and Functioning. The purpose
of this area of the assessment is to achieve an indepth
understanding of the child's growth and functioning
within the impinging environment. To do so, the social
worker can ask key questions. such as the following:
Where is the child developmentally?
What is expected of her or him in that particular
social situation?
What are the crucial tasks in that life stage?
How effectively is the child managing these tasks?
What are her or his adaptive patterns or typical
ways of coping?
Following are three principles for addressing the
foregoing questions. First, understand where the child is
in relation to what is expected in that particular
developmental phase. Is the child showing age-appro-
priate behavior? Where is the child in relation to her or
his sexual identity? Is the child retarded in some aspect
of development? Is the child regressing in response to
some traumatic life event? In considering these ques-
tions, it is important to pay attention to sociocultural and
other variations. One should view the stages of child
development proposed by various theorists (see, for
example, Newman & Newman, 1987) as guidelines
rather than as fixed traits. As research on human devel-
opment among diverse ethnic groups has shown, there is
a broad range of behaviors that can be considered
normal. In this connection, Germain (1991) has con-
ceptualized human development, life transitions, and
life events as the outcomes of person-environment
processes, "rather than as separate segments of life
confined to predetermined ages and stages of experi-
ence" (p. 141). In addition, Gibbs et al. (1989) have
presented a conceptual framework for assessing the
influence of ethnicity on the development of children of
color.
Second, understand the child's unique ways of cop-
ing and how they can be .. strengthened if useful and
modified if necessary. In particular, children use a range
of coping techniques to handle stress. Children of color,
for example, demonstrate diverse coping strengths in the
face of oppressive conditions (Erera, 2002; Pinder-
hughes, 1989). Yet, the child welfare system reflects
inferior treatment of black children and limited appre-
ciation of their capabilities (Roberts, 2002).
Third, analyze what the child is conveying through
her or his behavior. For example, what does the beha-
vior indicate about the child's ego functioning and
coping? The child's symptoms reflect her or his adaptive
mechanisms. Some children in foster care, for instance,
express their fears about being removed and placed in
254 CHlWREN:PRAcnCE INTERVENTIONS
another setting through anger, withdrawal, or other
behaviors that suggest "I'm afraid 'to grow up" (Pecora
et al., in press).
Use of Diagnostic Tools. To help analyze a child's
behavior and development, social workers use formal
evaluations conducted by psychologists, psychiatrists,
neurologists, and other specialists. In addition, they may
use a variety of diagnostic tools, including drawings,
questionnaires, play materials, games, stories, and picture
books that complement direct interviewing and
observations of a child.
The choice of diagnostic tools depends on factors
such as the social worker's comfort level; the
appropriateness of the tool in relation to the child's
developmental status and other characteristics; and the
social worker's primary purpose, which may include
bbtaining fantasy material, testing the child's ability to
concentrate, or eliciting feelings and perceptions of self
or family.
Whatever the purpose, the findings should be used as
part of the overall complex of information that has been
gathered, rather than viewed in isolation. Guided by a
research perspective, the social worker needs to test any
hypothesis or inference derived from the use of
diagnostic tools against the available evidence.
Moreover, it is important to analyze the findings within
the developmental context of the particular child, so as
to avoid the danger of ascribing pathology when the
main issue may be one of immaturity in development.
These questions, and their answers, may involve
several practice principles that prompt practitioners to:
Analyze what is happening in the parent -child
interaction. The idea of the reciprocal nature of the
relationship between a child and her or his parents
is especially noteworthy. Children are active
participants in interactions with others and initiate
behaviors in response to their own needs and traits,
as well as in reaction to others. For example, a
child who tends to whine is likely to provoke
parental frustration and rejection. The parents'
subsequent response may lead to further negative
behaviors by the child and perhaps abuse by the
parents, particularly if they are overwhelmed by
other problems.
Understand that the parents' capacity to meet a
child's needs may vary. with each phase of
development. Some parents, for example, are
much more comfortable or competent with
younger children than with adolescents.
Identify resources in the environment that may be
helpful for the child. A teacher, for instance, may
seek to be supportive to a child whose parents are
in the process of a divorce.
Identify blocks in a child's developmental process.
In schools, for example; children whose organic
impairments, such as hearing loss or visual
impairment, are not detected for a while may tend
to act out, be withdrawn, or have learning
problems.
Identify the supports that the parents need to be
more effective in their roles. For example, research
in child welfare agencies has demonstrated that in
some families out-of-home placement of children
can be prevented by the
. provision of supports such as day care, self- help
groups, and income maintenance (Fraser, Pecora,
& Haapala, 1991; Pecora et al., in press). More-
over, it has been shown that birth families can be
helped to serve as permanency resources for
children who have been placed in long-term care
(Mapp & Steinberg, 2007).
Approaches to Treatment
On the basis of the analysis and assessment described
thus far, a social worker can formulate treatment inter-
vention that is geared to the unique needs and char-
acteristics . of a particular child and his or her family
system. Treatment plans and goals may be established
through the use of a variety of different approaches that
generally include, to one degree or another, working not
only with the child but also with the parents; the family
system; or collaterals, such as teachers; and other
significant persons such as close neighbors (Maluccio,
Pine, & Tracy, 2002).
The major approaches that social workers employ in
direct practice with children are typically psychoanaly-
tically oriented. However, practitioners increasingly use
cognitive therapy, family therapy, and psychoedu cation.
Some social workers consistently use one approach,
whereas others draw from various modalities in an
eclectic fashion or in response to what seems to work
best with each child.
The eclectic orientation has been found to be partic-
ularly effective in child welfare settings. In addition,
there is growing attention to the potentialities of
evidence-based practice, which is becoming prominent
in the field of social work in general. Its application in
work with children and. their families can lead to the
design and implementation of timely and individualized
services.
T ennination
Each of the earlier-mentioned approaches pays careful
attention to the meaning and handling of termination in
each case, As much as possible, the decision to end
I
.
.

treatment is based not only on evidence of removal of the
symptoms or of the pathology, but also on an appraisal of
the child's development and capacity to cope with
environmental challenges. The emphasis in the termination
phase is on helping the child to consolidate treatment gains
and helping parents to strengthen their parenting skills. As
has long been noted in child welfare practice, the process of
termination can be used to promote growth in children, as
well as in parents, their coping patterns can be reinforced,
and their connections as family members can be
highlighted.
REFERENCES
Allen-Meares, P. (2004). Social wark services in schools (4th
ed.). Boston: Pearson Education.
\
Crosson-Tower, C. (2004). Child welfare: A practice perspective
(3rd ed.). Boston: Pierson Education.
Erera, P. I. (2002). Family diversity: Continuity and change in the
contemparary family. Thousand Oaks, CA: Sage.
Fraser, M., Pecora, P., & Haapala, D. (1991). Families in
crisis.
New York: Aldine de Gruyter.
Germain, C. B. (1991). Human behavior in the social environment:
An ecological view. New York: Columbia University
Press.
Gibbs, J. T., Huang, L. N., & Associates. (1989). Children of
color: Psychological interventions with minority youth. San
Francisco, CA: [ossey-Bass.
Goldenberg, I., & Goldenberg, H. (2004). Family therapy: An
overview (6th ed.). Pacific Grove, CA: Thomson-Brooks/
Cole.
Maluccio, A. N., Pine, B. A., & Tracy, E. M. (2002). Social
wark practice with families and children. New York: Columbia
University Press.
Mapp, S. c., & Steinberg, C. (2007, January/February ).
Birth families as permanency resources for
children in long-term foster care. Child Welfare, 86(1},
29-51.
Newman, B. M., & Newman, P. R. (1987). Development
through life: A psychosocial approach. Chicago: Dorsey
Press.
Pecora, P. J., Whittaker, J. K., Maluccio, A. N., Barth, R. P.,
& DePanfilis, D. (in press). The child welfare challenge:
Policy, practice and research. New York: Transaction Books.
Pinderhughes, E. (1989). Understanding race, ethnidty, and
power. New York: Free Press.-ANTHONY N. MALUCCIO
Roberts, D. (2002). Shattered. bonds: The color of child welfare.
New York: Basic Books.
GROUP CARE
ABSTRACT: This entry addresses the current state of
group care services for children. Demographic
programmatic trends and research findings are
reviewed, as are emergent issues and critical
questions for further
CHILDREN: GROUP CARE 255
research and practice innovation. Suggestions for im-
provement of group care services are offered in the context
of an overall spectrum of services for children and families.
and the co residential
treatment; out-of-home care;
care; child caring institutions; group care; family
involvement; children's mental health; child
welfare; juvenile corrections
Introduction
Group care for children remains a service in flux. Concerns
about effectiveness, child safety and costs continue within
the services research community as well as in discussions
of best practices and policies for children and families
(Whittaker, 2004, 2006). For example, recently expressed.
concerns about "deviancy training" in group treatment
conditions of all kinds including group care settings for
antisocial youth continue to surface, though recent rigorous
analyses provide little empirical support for such claims
(Dishion, McCord, & Poulin, 1999; Poulin, Dishion, &
Burraston, 2001; Weiss et al., 2005), Social workers at the
BSW and MSW levels continue to play key roles in group
care services for children-as direct care staff, therapists,
program administrators, and family workers-- and other
Master's level and PhD level social work researchers are
involved in clinical research and program evaluation in a
wide range of group care settings within child mental
health, child welfare and juvenile justice: residential
treatment centers, in-patient child psychiatric units, group
homes, juvenile detention facilities, and sheltercare
facilities, for example. Several social workers are involved
in reform efforts in sectors like child mental health and
child welfare through national associations like NASW and
through various national, regional and local advocacy
efforts designed to achieve system reform. While it is
difficult to summarize the commonalities of all these
efforts, a general trajectory seems to be away from
residential services and toward community and
family-centered alternatives for those children and youth in
need of intensive services. The following quote from
Richard Barth, one of social work's leading child welfare
researchers and scholars, captures in tone and substance
much of current progressive thinking about group
(residential) care for children, based in part on the available
corpus of research:
Group care is expensive and restrictive and should
be used only when there is clear and convincing
evidence that the outcomes will be superior to those
of foster care and other community-based services
... his review indicates that there is virtually no
256 CHILDREN: GROUP CARE
evidence to indicate that group care enhances the
accomplishment of any of the goals of child
welfare services: it is not more safe, or better at
promoting development, it is not more stable, it
does not achieve better long term outcomes, and it
is not more efficient as the cost is far in excess of
other forms of care (Barth, 2002, p. 31 quoted in
Whittaker, 2006).
Such sentiments echo those expressed by others in the
child mental health sector including the previously cited
concerns about the dangers of "deviancy train ing,"
institutional abuse, and a lack of effectiveness data in the
corpus of residential care outcome research (Barker, 1998 ;
English, 2002{ Kutash & Rivera, 1996). A research
review prepared for the U.S. Surgeon General's Report on
Mental Health observes:
Given the limitations of current research, it is risky
to reach any strong conclusions about the effective-
ness of residential treatment for adolescents
(Burns, Hoagwood, & Mrazek, 1999).
Nor are concerns about continued use of residentia l
group care for children exclusively a U.S. preoccupa tion
as the following observation by a leading U.K. children's
services researcher suggests: "The context of the attack on
residential homes is that many people no longer believe in
them" (Sinclair, 2006, p. 207).
Considering the weight of what could only be called an
increasingly skeptical consensus about the con tinued
reliance on residential care and treatment as a major child
mentaf health service, or as an alternative to foster care,
or, largely for reasons having to do with the potential for
institutional abuse, social work researchers and
practitioners need to direct serious attention, includ ing
both theoretical and empirical analysis, to the pur poses,
change theories, treatment protocols, expe cted outcomes,
comparative advantages and organizational requisites for
residential treatment if group child care is to retain its
legitimacy as a viable service option for troubled children
and their families. .
This entry includes the following:
1. Brief summary of issues and concerns about the
impact of group care on children.
2. Overview of demographics, service trends, and
outcome research in residential treatment, and
3. Identification of several key questions for improv ing
group care practice and research.
Reasons for Concern About Group Care
1. Lack of diagnostic indicatars.
The identification of scientifically based diag nostic
criteria for favoring residential placement
over family and community-centered alternat ives
continues to elude program planners and clinicians.
2. What is assumed to be a preference within some service
systems far placement without first attempting some less
radical community and family based interventions. An
observation strengthened by the fact that "intensity"
of treatment, once thought the sine qua non of
residential treatment, may now be found in equal
measure-in less restrictive, community and
family-centered alternatives such as "treatment
foster care," "wraparound services," and "multi-
systemic therapy" (Kutash & Rivera, 1996, p. 120;
Swenson, Henggeler, Taylor, & Addison, 2005).
3. A presumption of "intrusiveness" and concerns about
attachment far the children placed in group care .
. A set of concerns voiced, in particular, where very
young children are involved (Berrick, Barth, Nee-
dell, & [onson-Reid, 1997).
4. Fear of abuse and neglect within residential settings.
A story that will not go away: either in recently
voiced concerns about past practices, including some
highly regarded treatment settings, or cur rent
exposes of institutional abuse in sectarian group care
settings here and abroad.
5. Questionable effectiveness of residential treatment.
Virtually every review of residential treatment re-
search begins with a comment about the uneven ness
of the research corpus, with virtually none of the
benefit of the doubt given as iris, say, to newer
interventions that fit more closely wit h the value
base of systems of care thinking (Barth, 2002; Curry ,
1991; Pecora, Whittaker, Maluccio, & Barth, 2000).
6. A lack of consensus on critical intervention components .
A U.S. General Accounting Office (GAO) study
(1994) conducted in the 1990s, established that while
various lists of intervention components ex ist, there
is little indication of which are necessary and which
are sufficient ingredients in a quality resident ial
treatment program: for example, "therapeutic
alliance" (Rauktis, Vides de Andrade, Doucette,
McDonough, & Reinhart, 2005).
7. A lack of residential treatment theory development.
It is telling that recent reviews in child mental health
(Bums & Hoagwood, 2002 and U.S. Department of
Health & Human Services, 1999 (Surgeon General's
Report on Mental Health) must reach back to a model
from the 1960s (Hobb's Project Re-ED) to muster
even the most muted

enthusiasm for any form of residential care and
treatment.
8. Cost of care.
A first order argument for system reform is that
70% of service dollars continue to be spent on
residential provision when lower cost, commu-
nity-centered alternatives are available (Duch-
nowski, Kurash, & Friedman, 2002, p. 30)
9. A continuing bias for family-based alternatives.
At least till the first decade of the 21st century,
there exists a presumption that residential care if
used at all ought to be seen as a "last resort" (that
is, when all other options are exhausted). This is
particularly so when child dependency is the pri-
mary issue. Preference should go to foster family
care, adoption, guardianship' or other alternatives.
In child mental health, this translates to viewing
treatment foster care as a more desirable alterna-
tiveto residential treatment.
For out-of-home placement as a whole, the most
single stable trend in child welfare for much of the 20 th
century was the shifting ratio of children in foster family
versus residential care as a proportion of the total
number of children in out-of-home care. As Kadushin
(1980) notes, from approximately the early 1930s to the
mid 1970s, the percentage of children in residential care
declined from 57% to 15%, while the percentage in
family foster care increased from 43% to 85% for the
total population of children served in out of home care.
Recent estimates of the numbers of U.S. children in
group care suggest a single night count approximating
200,000 of all types, although the authors caution about
the difficulties involved in obtaining valid and reliable
information on the total number of children in
residential care (Little, Kohm, & Thompson, 2005).
Despite a brief flurry of interest in "orphanages,"
which surfaced in ,the mid 1990s in part as the result of
a growing backlash against "family preservation" and
the perception that at least in public child welfare, some
children were being kept far too long in unsafe family
situations, policy in the main has been supportive of
family based alternatives (for example, adoption in-
centives) for childre~ for whom there is little hope of
return to parents of origin. At the level of individual
states, "family group conferencing" originating in New
Zealand has replaced intensive family preservation
service as the "cutting edge" of practice innovation
(Pennell & Anderson, 2005). Serious discussions of
group care options for long term care occur only at the
margins of policy and practice debate: for example, in
the interest sparked by the Pew Memorial Trust, San
CHILDREN: GROUP CARE
257
Diego County, and others in '''residential academies"
(Whittaker, 2006).
Evidence of the Effectiveness and
Recent Service Innovations
While space limits what can be included here, Curry
(1991), Pecora, et al., (2000) and more recently, Barth
(2002) offer a detailed analysis of residential care re-
search in an American context. For European perspec-
tives, please see Hellinckx, Broekaert, VandenBerge,
and Colton (1991), the excellent U.K. review authored
by Roger Bullock, Michael Little, and Spencer Millham
for the Dartington group (1993) and a recent meta-
analysis of European residential research. by Knorth,
Harder, Zandberg, and Kendrick (2007). The thoughtful
and previously cited review by Barth (2002) examines
four key components of group care service outcomes:
safety and well-being of children while in care,
permanence and reentry from care, long term success of
children in out-of-home care and costs of out-of-home
care. Barth notes precious little evidence favoring group
care settings over family-centered alternatives in any of
these areas and concludes that "placement in group care
settings is not an essential component of child welfare
services systems of care for the vast majority of
children" and that "group care should only be
considered for those children who have the most serious
forms of mental illness and selfdestructive behavior"
(2002, p. iii and p. 31). While the author joins other
children's services researchers in calling for the
development of new and empirically tested models of
residential care, he finds little in the existing corpus of
residential care research to warrant service expansion.
Conversely, much interest has been generated in
recent years through successful randomized control
trials involving several promising non-residential alter-
natives such as "Multisystemic Therapy," "Multi-
Dimensional Treatment Foster Care," and "Wraparound
Services" (Bums & Hoagwood, 2002) and, increasingly,
service agencies once wholly residential in their service
now reflect a range of service options to meet
differential needs of children in need of intensive
services. One hopes that the increasing integration of
these "evidence-based practice" models in existing
child and family service agencies will encourage cross-
fertilization and the development of new and empiri-
cally tested intensive treatment services that include a
group care component (Whittaker et al., 2006). A recent
initiative championed by Substance Abuse and Mental
Health Services Administration (SAMSHA) (2006)
seeks to "build bridges" between residential provision
and other services in "systems of care."
258 CHILDREN: GROUP CARE
A critical question for practice and practice research
will be aligning and integrating what is known to be
"culturally competent" practice with what is known to
be "evidence-based practice" (Blase & Fixsen, 2003;
Miranda et al., 2005) This exploration should include a
broad investigation of successful strategies for recruit-
ing and engaging families of color in related service
areas, such as adoption (Leigh, 1998; McRoy, 2005).
Key Questions for Group Child Care Looking
to the future, group care for children presents social
work and sister disciplines with a series of inter-
related questions:
Questions of definition
What precisely do we mean by the variety of forms
of service that make up the spectrum of out-
of-horne care such as group homes; intensive
residential treatment; and therapeutic foster care?
What are the critical elements in and defining
characteristics of each?
How do we balance and integrate the care and
treatment needs of children? What implications
does each raise, specific to group residential care
settings (Whittaker, 2000)?
There is an acute need for more focused work on the-
oretical model development in residential care. and
treatment. As we move from "service" centered plan-
ning to "child/family" centered planning, there is some
danger that we will lose a needed focus on residential
care as a total milieu intervention. In my judgment, both
types of planning are needed if we are truly to
understand the power of the residential milieu and then
use it in creative ways to meet the specific clinical and
developmental needs of individual children and their
families.
Questions of intake
For what types of child behavior problems is
residential treatment or other forms of placement
the. "treatment of choice" as opposed to "the last
resort"?
What are the "offsets" to some of the presumed
negatives associated with placement (for example,
separation from family/community/culture)? For
example,
the intensity of the treatment provided
the physical safety of the child-the protection
provided for both the community and the child.
Residential treatment is an expensive, complex,
and radical intervention. It should be used
judiciously and where it can achieve the most
good. To achieve this will require some critical
rethinking of conventional wisdom. For
example, for an individual youth whose life tra-
jectory is headed toward adult incarceration,
maybe, as Mary Beth Curtis of Boys Town
notes, the "least restrictive environment" is the
one in which the most growth (academic, social,
physical) can occur for the immediate future or
where "safe passage" may be provided.
Questions of outcome
What span of indicators signal "success" in
residential care?
At what time points should they be measured and
where?
Should there be a "statute of limitations" on
residential outcomes?
Discussion of "outcomes" is proceeding at a very fast
pace in the United States, largely as a result of the
fascination with "managed care" and "evidence-based
treatment" closely linked to service contracting. In the
residential arena, while there have been some benefits
that derive solely from the outcomes discussion (a focus
on realistic and well-specified goal setting, for ex-:
ample), it is clear that any discussion of outcomes must
be linked to a discussion of intake and program design
issues as well. Otherwise, some residential estab-
lishments may find themselves being held accountable
for child and family outcomes in areas where they are
service-deficient, or for promising "results" in cases
where they have inadequately assessed both risk and
acuity.
Conclusions
Whi~taker and Maluccio (2002) advance several
specific prescriptions for innovation in placement
services. These remedies, while partial, hold the
promise, collectively, of helping to shed light on many
of the questions posed previously for group care of
children.
First and foremost, the authors argue the need to
design a new service continuum that softens the differ,
ences and blurs the boundaries between in-home and
out-of-home options such as shared care, respite care,
and partial placements; for a more fulsome discussion
of the "placement" issue, see Whittaker and Maluccio,
2002. Kinship care may be a step in that direction.
Moreover, it is critical that those who believe residen-
tial care and treatment have a niche to fill in the overall
service spectrum make the case based on analysis but,
tressed by empirical outcome data in ways that allow us
to see the relative contributions and best uses of wrap'
around, treatment foster care, and multisystemic treat'
ment,along with residential treatment in an overall
system of care.

Some other helpful ideas include:
Renewed commitment to the development of
culturally competent group care practice models
and joining this effort, inextricably, with efforts to
integrate "evidence-based practices" into group
care settings
Redoubling our efforts at parent involvement
(Braziel, 1996; Jenson & Whittaker, 1987)
Expanding residential respite options for parents of
high-resource needs children
Developing more creative short term residential
treatment
Focusing on child well-being and family function-
ing as outcome measures
Studying honestly \ the limits as well as the
potential of family centered service delivery
Developing models of whole family care, for
example, by combining respite with holiday time
and skill building for families
Working to personalize residential care settings
and reinforce primary caregivers (T rieschman,
Whittaker, & Brendtro, 1969).
Examining the potential for the co-location of
services: for example, family support and residen-
tial care
Seeking partners to locate our residential programs
in an overall service network
Conduct longitudinal research to study develop-
mental outcomes for youth in shared care and those
temporarily placed
Redesigning some group care settings for perma-
nent living for special subgroups of youth and
reexamining communal alternatives (Levine,
Brandt, & Whittaker, 1998) Achieving even a few
of these modest changes, absent a more focused
and thoughtful discussion on substitute care as a
whole, will not be easy. It is imperative that social
work researchers and practitioners bring the w orlds
of policy, research, and practice in residential and
foster care much closer so that we can assess what
the challenges and strengths are in each domain
and then chart a course of action for renewal. To do
this, the field sorely needs fresh conceptual
thinking on both the varieties of group care for
children, and empirical research to test the efficacy
of innovative group care designs. International
perspectives on group tare such as those cited
earlier (Knorth, et al., 2007) will help to shed light
on the issue of the proper place of group residential
care and treatment in an overall service continuum
and will be helpful as well in broadening and
stimulating our limited and, typically, parochial
discussions in the states. Social work has a clear
CHILDREN: GROUP CARE 259
stakehold in addressing the issue of group care's
future, based on the profession's long-standing
involvement in service delivery, research and
training, and advocacy on behalf of children and
youth in need of intensive services.
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interventions. Applied Developmental Sdence, 5(4),214-224.

Rauktis, M. E., Vides de Andrade, A. R., Doucette, A.,
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peutic alliance between youth and treatment parent, Inter-
ABSTRACT: Despite rapid medical advances, children
national Journal of Child & Family Welfare, 8(4),146-163.
SAMHSA. (2006). Building bridges between residential arid in this country still face significant barriers to adequate
community based service delivery providers, families and health care, including unequal access to insurance youth. Retrieved
November, 2006, from http://www.system- and health care. Social workers play an important role
sofcare.samhsa.gov . in assisting children and families facing health care
Sinclair, I. (2006). Residential care in the UK. In C. McAuley, crises by providing supportive services, advocacy, cul-
P. J. Pecora, & W. Rose (Eds.), Enhandng the well-being of turally grounded assessment, and evidenced-based int-
children and families through effective interventions: Inter- erventions to improve care and quality of life. Children
national evidence far practice (pp. 203~216). London: Jessica. face societal risks to their health and development
Swenson C. C, Henggeler, S. W., Taylor I. S., & Addison, that include violence, exposure to smoking, and access
0. W. (2005). Multisystemic therapy and neighborhood part- to alcohol and other drugs, as well as poor nutrition
ntive strategies is needed to stop the continuation of crimi New York and London: Guilford Press. and
T New York and London: Guilford Press. and lack of opportunity for exercise. Social work is an
h A E Wh k J K & B d L K (1969) important discipline to assist children and
farnilies in
nesc man, .., itta er,.., ren tro, ., .
The other 23 hours: Child care work with emotionally disturbed the areas of health promotion and adaptation to illness

KEY WORDS: children; health; pediatrics; insurance
Despite rapid medical advances, children's health varies
widely based upon history, socioeconomic status, access to
health care, insurance, race, ethnicity, and geography.
Many children and families are uninsured or underinsured.
Health care disparities based upon race, ethnicity, and
income continue to be a problem in this country. Even for
families that are well insured, chronic and life-threatening
conditions such as asthma, obesity, sickle cell disease,
HIV/AIDS, and cancer are of increasing national concern.
The roles for social workers in children's health care
include counseling, support, prevention, education,
( advocacy, assessment, resource provision, coping,
symptom management, and health promotion. Because of
the inequities in today's health care system, social workers
playa critical role in advocating for all children and
families to have affordable, quality, and culturally
appropriate health care.
According to the National Research Council and the
Institute of Medicine (2000) children's health is "a devel-
opmental, multifaceted state that. is socially and culturally
defined ... has profound implications for later health and
well-being during adulthood." The experiences of
childhood, both behavioral and biological, can greatly
impact children's physical and mental health as adults
(NRC & 10M, 2004). Childhood injury, malnutrition,
illness, and . health behaviors all predict strength and
fragility of the growing individual and affect future health
outcomes. At each stage of development, previous health
impacts current and future health (NRC & 10M, 2004).
Since concepts of health and illness are social constructs,
created in a social context, family cultural values must be
considered in addressing children's health needs (NRC &
10M, 2004). Ideas about healing and health care vary
widely between cultural groups and impact the child and
family's health care decisions. Com,
. munity determinants also impact health priorities and a
family's ability to consider their child's health needs, that is,
families living in poverty must meet basic needs of
housing, food, and safety before they can attend to non-
emergency health care and prevention.
Health Status of Children
Children under 18 constitute 25% of the U.S. population
and in 2004, there were 73 million children living in this
country, an increase of 900,000 from the year 2000;
(FIFCFS, 2006). Children's health and well, being are
influenced by many societal, familial, and economic
factors. According to the U.S. Department of Health and
Human Services, 84.1 % of children were in excellent or
very good health, by parent reports (USDHHS, 2005). The
rate of children in excellent
Q-!ILDREN: HEALTH CARE
261
or very good health varies however by several important
factors, including family income, race, and ethnicirv.
Non-Hispanic White children were the most likely to be in
excellent or very good health (90.7%), and non, Hispanic
Black children were the second most likely (78.9%) while
Hispanic children were the least likely (64.4%).
Poverty greatly influences children's health and
well-being. In 2004 there were 12.5 million children in the
U.S. (17%) living with families whose income fell below the
national poverty level. Children living in female-headed
households were disproportionately affected by poverty. In
2004, children living in female-headed families continued to
experience a: higher poverty rate (42%) than children living in
two-parent families (9%). Disparities also persisted by race
and Hispanic origin. Black children had a poverty rate of 33%
in 2004; Hispanic children had a poverty rate of 29%; and
White, Non-Hispanic children had a rate of 10% (USDHHS,
2005).
Children whose family incomes were below 100% of
the federal poverty level (FPL) were least likely to be
reported by parents to be in excellent or very. good health
(66.8%), followed by those with family incomes of 100 to
199% ofFPL (80.9%), and those with family incomes
of200 to 399% ofFPL (90.2%); children with family
incomes .of 400% of FPL or above were the most likely to
be in excellent or very good health (93.8%).
Insurance Coverage
According to the Centers for Disease Control and
Prevention (CDC), 6.8 million children under the age of 18
were uninsured during the first six months of 2006 (CDC,
2006). While nearly 75% of all uninsured chi I, dren are
eligible for either Medicaid or State Children's Health
Insurance Program (SCHIP), obstacles such as
requirements to recertify, document, and keep up with
monthly premiums often lead to passive dis enrollment
(Fry-johnson et al., 2005). Since each state is able to
determine how its Sa-IIP program is executed,many have
adopted policies that increase barriers to coverage
(Fry-johnson et al., 2005). In addition, insufficient out,
reach is made to extend coverage to qualified families.
According to one study, the most common. reason that
parents fail to enroll qualified children was that they were
not aware that their children were eligible (Vivier, 2005).
Since family coverage is a predictor of whether eligible
children are enrolled in Medicaid or SCHIP, splitting
coverage for low, income children and adults into separate
programs seems counterproductive (Sommers, 2006).
Nearly 3.6-4.25 million children who are eligible for
SCHIP are not receiving it (Families USA, 2006). At the
time of writing, the current SCHIP funding
262 CHILDREN: HEALTH CARE
is in danger because President Bush vetoed the SCHIP
reauthorization bill on September 27,2007.
Insurance coverage is an issue that is not only im-
pacted by income but also by race and geography. In
2003,27% of Hispanic, 27% ofAsian/Pacific Islander,
19% of African American, and 16% of White children
were uninsured (Fry-Johnson et al., 2005). The percen-
tages of uninsured children vary greatly by state. In 2003
less than 6% of children living in Vermont, New
Hampshire, and North Dakota went without insurance
while over 16% of children in Florida, Oklahoma, and
Texas were uninsured. According to the Kaiser
Commission on the Uninsured (2003), 20.6% of
children living in rural, nonadjacent areas are uninsured
compared to 15.8% in rural, adjacent areas and 14.:> %
in urban areas.
According to the National Center for Children in
Poverty (2002), 1 out of every 5 children under the age
of 18 in the U.S. was estimated to have at least one
foreign-born parent in 2000. As the Kaiser Commission
on Medicaid and the Uninsured (2004) reports, ap-
proximately half of the 33.5 million immigrants living in
the United States do not have any type of health
insurance. Even with 25 states extending some form of
health benefits to legal immigrants, 40% of non- citizen
children still remain uninsured (Kaiser Commission,
2004). Lack of coverage has important consequences
since these children are less likely to receive both pre-
ventative and prescriptive care. As one study of
U.Sc-bom Mexican American children showed, health-
Care utilization varies among Mexican Americans based
on generational status, with the children of immigrants
remaining especially . at risk for lacking insurance and
not. seeing physicians for illnesses or accidents
(Hamilton et al., 2006) ..
Unfortunately, coverage by public programs, w hich
provide insurance coverage to over a quarter of all
children in the U.S., doesn't guarantee quality health
care (Vivier, 2005). Children covered by Medicaid can
still face significant barriers to medical care, particularly
for specialty care such as dentistry. Medi caid coverage
has been shown to be a predictor of delayed diagnosis
and treatment. The Early Periodic Screening, Diagnosis,
and Treatment (EPSDT) Program is the child health
component of Medicaid. It is required in all states and
specifically designed to improve the health of
low-income children, by providing financing for
necessary pediatric services. However the Deficit
Reduction Act of 2005 gave states options to modify or
limit coverage (HRSA, 2007). According to the 2002
National Ambulatory Medical Care Survey, 95% of
physicians surveyed reported that they would accept
new patients, yet almost a quarter confided that they
would not accept new Medicaid-insured patients.
In another study, more than one-third of families re-
ported denial of care for their Medicaid-enrolled chil-
dren. Among the reasons listed by physicians for not
offering care were excessive administrative burdens and
low monetary reimbursement (Vivier, 2005).
Insurance status clearly influences the quality and
quantity of care and, consequently, the health outcomes
of children. Families of uninsured children often delay
seeking care; they are also less likely to experience
continuity with the same health care provider or
adequate visit time to address their special needs
(Fry-Johnson et al., 2005).
Selected Current
Health Care Issues for Children
OBESITY The childhood obesity epidemic has gained
much national attention in recent years. Between
1980 and 2000, the incidence of overweight children
between 6 and 11 has doubled while the incidence for
adolescents from age 12 to 19 has tripled (Harper,
2006). Children's caloric intake from snacks alone
increased 30% between 1977 and 1996 (Harper,
2006). These and other dietary impacts are further
aggravated by a decrease in physical activity.
According to a recent study from the Harvard School
of Public Health (2006), America's overweight teens
are consuming ali average of 700-1,000 calories
more than required each day to support normal
growth, physical activity, and body functions.
Various social and cultural factors contribute to this
growing gap. For example, unsafe neighborhoods
may force children indoors, as do the growing
popularity of television, the Internet, and video
games.
Obesity accounts for 4.3 to 9.1 % of total direct health
care costs in the U.S. in the form of treatment of diseases
such as hypertension, hypercholesterolemia, type 2 dia-
betes, and coronary heart disease (Harper, 2006). There
are also costs associated with loss of productivity when
parents need to take time from work to care for their ill
children as well as impacts on education resulting from
school days missed. Nonmedical problems that social '
workers should be concerned about include eating dis-
orders, poor self-esteem, and depression.
As with most health problems, the impact is felt .
disproportionately across the continuum of race and
class. Across all SES . groups, the prevalence of being
overweight is much higher in Blacks than in Whites
(Wang & Zhang, 2006). In 2004, 18% of children 6-17
were overweight; however, 25% of Black Non-Hispanic
children were overweight, more than their White Non-
Hispanic and Mexican American counterparts at 16%
and 17% respectively (FIFCFS, 2006).
Both health care and educational organizations have
issued a variety of position statements that have

successfully brought the issue to the attention of national,
state, and local policy makers and promoted action at
these various levels of government (Harper, 2006). Since
95% of all children attend school, programs have been
directed toward the school environment (Harper,
2006).Population-oriented approaches have the most
potential for preventing obesity, are costeffective, and
extend to vulnerable segments of the population (Budd &
Haymen, 2006). This requires action on the part of health
care workers and can be an area in which social workers
advocate for policy changes that support more healthful
environments.
ASTHMA From 1980 to 2003, the prevalence of asthma
in children increased about 6O%-from 3.6% to 5.8%
(COC, 2006). After pneumonia and injuries, asthma is
now the third-leading cause of hospitalization in the U.S.
among individuals under 18 years of age. At least 6
million children have asthma in the U.S., with the disease
disproportionately impacting those living in inner cities.
- as alcoholism and cancer. Binge drinking in adolescents
The U.S. is not alone in this epidemic. Worldwide the
prevalence has doubled between 1985 and 2001. There
are over 250,000 asthma-related deaths each year and,
according to the World Health Organization, this number
could increase by 20% over the next 10 years. Dozens of
theories abound as to how individuals develop asthma,
ranging from second-hand smoke to allergens to obesity,
yet none are conclusive (CDC, 2006). As a result, the
only definitive recommendation that doctors offer for the
prevention of asthma is the avoidance of passive and
active exposure to smoke since there is sufficient
evidence to suggest a causal link. Children who are poor
and members of ethnic minorities may - be
overrepresented in communities that are exposed to
pollutants, smoke, and other dangers in their commu-
nities. This environmental racism can negatively affect
their health disproportionately to other groups.
LIFE- THREATENING INJURIES AND
CONDITIONS While U.S. childhood mortality rates
have steadily declined from approximately 100 deaths
per 1,000 live births in 1915 to 7.1 per 1,000 in 1999,
childhood illness and death still cause enormous
suffering for the child, family, and community (10M,
2003). Approximately 53,000 children die each year
(10M, 2003). Despite declining infant mortality rates,
about half of all childhood deaths occur during infancy,
usually from congenital abnormalities, complications
related to childbirth or pregnancy, or sudden infant death
syndrome (SIDS) (10M; 2003). According to the
Maternal,Child and Health Bureau, in 2004, 3.6% of
women received no or late prenatal care (HRSA, 2006).
After
CHILDREN: HEALTH CARE
263
infancy, the next highest rate of childhood death (25% )
occurs in adolescents between 15-19 years of age. For
older children and adolescents, injury caused by homi-
cide, suicide, accidents, and abuse are the leading causes
of death. Overall, injury accounts for 30% of childhood
death (10M, 2003).
Some of the injuries that lead to childhood impair-
ment or death are a result of high risk behaviors of
children and adolescents (Clark, 2001). Of particular
concern are risky behaviors such as smoking, drinking,
use of illicit drugs, and serious violent crime. Com bined,
these factors can lead to serious immediate risk to
children and adolescents and to health care problems in
the future. In 2005, 4% of 8th graders, 8% of 10 th
graders, and 14% of 12th graders reported smoking
everyday for the past 30 days while 11% of 8th graders ,
21 % of 10th graders, and 28% of 12th graders reported
having 5 or more consecutive drinks at least once in the
past two weeks (FIFCFS, 2006). Tobacco and alcohol
use put young people at risk for adult health issues such
can lead to immediate dangers such as drunk driving,
risky sexual behavior, and sudden death. Given the
behavioral, societal, and familial indicators of poor
health for children and adolescents, educational efforts
to prevent SIDS, child abuse, and risky behaviors pre-
sent a critical opportunity for social work.
Among life-threatening conditions, childhood cancer
is the leading cause of non-accidental death in children.
While 75% of children diagnosed with cancer survive ,
nearly 2,300 children die of complications of the disease
each year. Children with cancer still face significant
suffering, including pain and psychosocial distress at the
end of life (Wolfe et al., 2000); Survivors of childhood
cancer can face physical and psychological late effects
for many years. There is a need for inter disciplinary
palliative care teams, survivorship programs, and a
range of supportive services that include social work
(Jones, 2005).
Roles of Social Work
PREVENTION AND EDUCATION Since many of the
health care challenges faced by children today have
social and behavioral components, social workers can
be instrumental in health promotion efforts. One im-
portant and obvious arena for social work involvement
is the prevention of injury of children. In schools,
hospitals, and clinics, social workers playa critical role
in the identification of risk of child abuse and neglect.
Social workers should continue to educate children and
families about the risks of smoking, drinking, drug use,
risky sexual behavior, and lack of physical activity and
nutrition. Social workers can create new programs and
 264 CHILDREN: HEALTH CARE

implement evidence-based interventions designed to work has much to offer to the national dialogue on Familie
ameliorate the risk factors and promote health for chil- children's health care including evidenced-based, hol- from
dren and adolescents. istic, family-centered interventions, and advocacy that rolln
incorporate the child and family perspective and pro- Federal
mote successful health outcomes, empowerment, and (200
COUNSELING AND SUPPORT Social workers have long
weU-
been providing supportive services in medical settings improved quality of life.
Prim
to children and their families (Fort Cowles, 2003). ation in
However, in the current health care crisis, funding for Challenges and Trends (200
social work has diminished and many hospital-based At this moment in our nation's history, health care 753-
social workers have to fight to maintain their positions. disparities are a significant problem and prevent equal Hamiln
Many social work departments have been cut or folded access to care for all. Health care access is differentially (20
available, based on age, race, ethnicity, geography, 0
into other departments, These factors, combined with
education, insurance, and citizenship status. Recent cuts U.S.
. rapidly increasing caseloads, have put many medical
in health care financing and funding for health care terly,
social workers in a professional dilemma of not having
Harper,
adequate time or support to provide the services they research have further exacerbated this problem. Social
vent
~re most trained to deliver: counseling and support. workers are challenged to continue to advocate for full
Harvan
Considering that social workers are the primary provid- health care coverage for all in an environment that is press
finds
er of mental health services in this country, it is parti- financially burdened. This is a particular struggle Health
U.S.
because many medical social work positions have been Title
cularly distressing that hospital social workers are 200
cut in this same time period, putting increased burden Octc
facing challenges to their jobs and professional role in 7
Health
medical settings. Particularly for hospitalized children, and case loads on individual social workers.
Chill
the importance of social work services cannot be However, social workers in health care are integrally
involved in efforts to develop integrative care, palliative
from -
overstated. When children face illness or injury, they are grapl
catapulted into a frightening new environment that care, and wellness programs. The future of health care in 1nstit
requires developmentally appropriate supportive ser- the United States will require trained social work utt
vices. Likewise, their families often experience intense clinicians and advocates to continue this development. hoocb
11
anxiety, helplessness, and fear. Social workers help Shor.
children and families cope with feelings, negotiate the ingtl
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 CHILDREN'S RIGHTS 265

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ABSTRACT: Children's rights can refer to moral
H. (2002). skills casebook. F. Yuen, G. Skibinski, & J. Pardeck (Eds.),
Binghamton, NY: Haw~rth Press. rights-basic human rights regardless of age or station- and
Iber
legal rights, those awarded based on chronological age or
2002). 1
Povertv
level of maturity. They are
266
7.
CHILDREN'S RIGHTS
conceptualized in three categories; protection rights (the
right to be free from harm and exploitation), provision
rights (the right to have their basic needs met), and
participation rights (the right to have a say). Children's
rights can conflict with family autonomy, and state
intervention is based on the common law doctrine of
parens patriae. The UN's Convention on the Rights of the
Child is the most comprehensive statement of children's
rights to date.
KEY WORDS: Convention on the Rights of the Child ;
parens patriae; child protection; youth liberation; youth
empowerment; moral rights; human rights; civil rights;
legal rights; constitutional rights
\
The idea that children themselves have rights-rather
than derived through family or bestowed at adult-
hood-is a very modern one (Archard & Macleod, 2002;
Brighouse, 2002; Franklin, 1995; Hawes, 1991; John,
2003; Purdy, 1992). Although children's rights have
received a good deal of public attention, the notion of
what actually constitutes children's rights and the
theory underlying those rights are contested. In a fre-
teaching self-disclosure skills and the elimination of
article written by Hillary Rodham-Iater First Lady
Hillary Clinton-she declared that children's rights "was
a slogan in search of a definition." The "slogan," as she
called it, is problematic . because embedded within it
are contested ideas about what constitutes "childhood,"
what is meant by "rights," and how the two concepts
interact.
pproacood is sometimes defined in absolute terms,
as those younger than the age of majority (generally set
at 18). It is also considered a period of development
and growth. Differing assumptions of what constitutes
a child (or adolescent) and how that period is
delineated-by chronological age or level of maturity
(based on some emotional, social, or physical
dimension)-are embedded in various policy and
program approaches.
The notion of "rights" can encompass moral rights,
as posited by theologians and philosophers, or legal
rights as framed .by lawyers, judges, and politicians. In
general, moral rights are deemed basic human rights;
children should have the same claim to them as adults
do. Alternatively, legal rights for children, including
political, constitutional, or civil rights, are more often
ted couples.
s show improvement based on the reliable change
understanding of rights are questions of context.
Should rights vary according to religious, cultural, and
community practices? Issues such as female
circumcision, child labor, and capital punishment of
minors trigger such contextual debates.
Tensions in characterizing youth as both dependent
and independent beings can be unintentionally aggra-
vated by child and youth advocates who argue "youth
rights" from narrow, dichotomized perspectives. Advo-
cates of the former, for example, speak of paternalistic
child policies based on assumptions that children need
protection, while those of the latter speak of child
liberation approaches based on assumptions that youth's.
participatory interests and rights of self-determination
ought to be honored. Those who advocate exclusively
from either one position or another may lose sight of a
more complicated, comprehensive picture of children's
rights.
Scholars who think broadly about the issue seek to
integrate the various perspectives. For example, Harry
Brighouse, a professor of philosophy, has argued that
children differ from adults in three important ways
(Brighouse, 2002). First, they are dependent on others.
because of their inability to provide for their own needs.
Second, given this dependency, they are also uniquely
vulnerable to decisions made by others. Finally, children
have the capacity to develop in a way that will one day
allow them to meet their own needs. He then
distinguishes between welfare and agency rights and he
further divides these based on immediate interests and
future interests. Note the important matrix of . concerns
that result. This comprehensive framework considers the
immediate and future welfare rights of children, as well
as their immediate and future agency rights. However, it
raises additional questions about how and when those
assorted rights should be allocated and who should
enforce or even monitor these rights if children are not in
a position to do so themselves. The two primary actors
involved are the family and the state (Goldstein, Freud,
Burlingham, & Solnit, 1979; Goldstein, Freud, Solnit, &
Burlingham, 1979; Purdy, 1992).
Parents or legal guardians are charged with the care,
discipline, and nurturance of their children. The right of
legal caretakers to be free from state intervention is
generally protected. Alternatively, English common
law doctrine of parens patriae-literally parent or father of
his country-has justified state intervention in family life
on behalf of children under certain conditions. This
happens in abuse and neglect, custody and visitation,
and adoption and paternity proceedings, among others.
The interventions tend to be paternalistic in nature and
litigated based on the child's "best interests" (Goldstein,
Freud, Solnit, & Burlingham, 1979).
Children's rights can come into conflict with the
notion of family autonomy because some argue that
state intervention on behalf of the child usurps parental
rights.

In the United States, leading scholars on children's
rights have tended to write about them either as embedded
in larger social movements (such as the Progressive Era or
civil rights movement) or in terms of various topical
domains (child labor, education, juvenile justice, health,
protective services, and so forth) (Hawes, 1991; Nasaw ,
1979, 1985). During the Progressive Era, many reformers
te for successful practice (dren (later earning themselves
the label of "child savers"). At the tum of the 19th century ,
anti-childlabor campaigns led to protections; compulsory
education was introduced as a way of raising responsible
citizens; and child-friendly institutions-which recognized
differences in children and adults-v-were introduced, such
as juvenile courts, reform schools, and orphanages. In 1912
the Children's Bureau-the first federal agency devoted to
better than 83% of untreated couples.
66% of couples show improvement based on the reliable
e index.
In the 1960s and 1970s-perhaps in partial response to
demographic trends that saw the "baby boomers" growing
through their teenage and young adulthood years and a
conflation of other rights-based movements (women's
liberation, gay rights, civil rights, and so forth)- there was a
renaissance of interest in youth rights. Arguably, the
modem children's rights movement is traceable to
significant judicial decisions and legislative enactments
dating from this period.
Important federal legislative initiatives dur ing the
1960s included the Elementary and Secondary Education
Act of 1965, Head Start of 1965, and the Child Nutrition
Act of 1966. In the mid-1970s a burst of federal legislative
energy consolidated and articulated many child and youth
policies, which included the Child Abuse Prevention and
Treatment Act (CAPT A) of 1974, the Juvenile Justice and
Delinquency Prevention Act (JJDPA) of 1974, the Indian
Child Welfare Act of 1978, and the Education of All
Handicapped Chitdren Act of 1973 (now IDEA). Although
the United States does not have a single, comprehensive
statement of child policy, embedded in these various pieces
of legislation are indicators of the scope of rights and
protections afforded to children and adolescents in diverse
domains such as education, child welfare, and juvenile
justice.
The U.S. Supreme Court has also actively recog nized
constitutional rights for children during this pe riod. For
example, the court began protecting children's procedural
due process rights in juvenile court while not affording
them the full constitutional protections of adults (Kent v.
U.S., 1966; In re Gault, 1967); it protected youths' rights to
political free speech in school
CHILDREN'S RIGHTS
267
settings and their right not to be expelled from school
without due process (Tinker v. Des Moines, 1969; Goss v.
Lopez, 1975) and declared unconstitutional practices that
excluded "mentally retarded" children from attending
public schools (PARC v. Pennsylvania, 1972). Although
this is not a comprehensive list of youth rights, it
demonstrates the judiciary's recognition of children's
limited legal and political rights.
Furthermore, many important associations and com-
missions have taken up the issue of children's rights in the
United States. The National Association of Social Workers
(NASW) issued a position statement called the "Children
and Youth Bill of Rights" that was first adopted by the
delegate assembly in 1975 and reconfirmed by the
assembly in August 1990. This bill of rights notes, "It is
essential that public social policy recognize children as
individuals with rights, including the right to be part of a
family." In 1991, the National Commission on Children
issued an important report entitled "Beyond Rhetoric: A
New American Agenda for Children and Families."
Among other things, it proposed an agenda that included
"ensuring income security, improving children's health,
increasing educational achievement, supporting the
transition to adulthood, strengthening and supporting
families, protecting vulnerable children and their families,
making policies and programs work, and creating a moral
climate for children."
The international community has also been concerned
with children's rights. In November 1959, the United
Nations' General Assembly adopted die Declaration of the
Rights of the Child, basing it on 10 guiding principles.
Among them were the right to healthy development
(including mental, moral, and spiritual); education; a name
and nationality; family or a state-provided substitute;
social security benefits, broadly defined; protection from
neglect, cruelty, and exploitation; freedom from
discriminatory practices (based on gender, race, ethnicity,
religion, and so forth); and special treatment, education,
and care for handicapped children.
Building on this earlier initiative and following a
decade of negotiation, the United Nations adopted the
Convention on the Rights of the Child (CRC) in November
1989. Every country, except the United States and
Somalia, has ratified the CRC. Child advo cates and
scholars have conceptualized children's rights in this
influential document in three areas: protection rights (those
that guard children against physical harm, economic or
sexual exploitation, and so forth), provision rights (those in
which children are entitled to have their basic needs met),
and participation rights (those in which the child's voice is
respected). Although
268 CHILDREN'S RIGHTS

interpretation of the enumerated rights listed in CRC Amnesty International.

varies by country, all of them must be enacted under a http://www.amnestyusa.org/children/index.do
set of guiding principles offered at the outset of the Center for Law and Social Policy. www.clasp.org
document. Included among these are the right of "non, Child Trends.
discrimination" (Article 2) and the requirement that the www.childtrends .org
"child's best interests" be promoted (Article 3). The Child Welfare League of America.
www.cwla.org
CRC arguably represents the most comprehensive
Children's Defense Fund.
statement of children's rights-what they need to live and
www.childrensdefense. org
thrive-to date. Children's Legal Rights.
http://www.megalaw.com/top/children. php
REFERENCES Children's Rights.
Archard, D., & Macleod, C. M. (2002). The moral and political www.childrensrights .org
status of children. New York: Oxford University Press. Children's Rights Alliance for England
Brighouse, H. (2002). What rights (if any) do children have? http://www.crae.org.uklcmslindex.php?option comJrontpage&
In D. Archard & C. Macleod (Eds.), The moral and political ltemid= l
status of children (pp. 31-52)~ New York: Oxford University Clearinghouse on International Developments in. Child, Youth,
Press. and Family Policies.
Franklin, B. (Ed.). (1995). The handbook of children's rights: www.childpolicyind.org
Comparative policy and practice. New York: Routledge. Convention on the Rights of the Child.
Goldstein, J., Freud, A., Burlingham, D., & Solnit, A. J. (1979). http://www.unhchr.ch/html/menu3lblk2crc.htm Global
Before the best interests of the child. New York: Free Press. March Against Child Labour.
Goldstein.j., Freud, A., Solnit, A. J., & Burlingham, D. (1979). www.gIobalmarch.org
Beyond the best interests of the child. New York: Free Press. Human Rights Watch.
Goss v, Lopez, 419 u.s. 565 (1975). http://hrw.org/children
Hawes, J. M. (1991). The children's rights movement: A history of National Youth Rights.
advocacy an4 protection. Boston: Twayne. http://www . youthrights. org
In re Gault, 387 u.s. 1 (1967). UNICEF
John, M. (2003). Children's rights and power: Charging up for a new www.uniceforg
century. New York: Jessica Kingsley.
Kent v.U.S., 383 U.S. 541 (1966).
Nasaw, D. (1979). Schooled to order: A social history of public tions rM. STALLER

schooling in the Untied States. New York: Oxford University

Press.
Nasaw, D. (1985). Children of the city: At work and play. Garden CHILD SUPPORT
City, NY: Anchor Press/DoubIeday.
Pennsylvania Association for Retarded Children (PARe) v, ABSTRACT: Child support is the legal mechanism re,
Commonwealth of Pennsylvania, 334 F. Supp. 1257 (E.D. PA
quiring parents to share in the economic support of their
1972).
children. Under the law, parents are obligated to support
Purdy, L. M. (1992). In their best interest? The case against equal
rights for children. Ithaca, NY: Cornell University Press. their children regardless of whether they reside with them.
Tinker v. Des Moines Ind. Comm. School Disc, 393 U.S. 503 Support calculations for noncustodial parents are based on
(1969). many different factors, which vary from state to state.
Enforcement is the single biggest challenge in the area of
FURTHER READING child support. The federal government continues to pass
Edmonds, B. c., & Fernekes, W. R. (1996). Children's rights: A laws enhancing states' enforcement capabilities. Recipients
reference handbook. Santa Barbara, CA: ABC-CLIO.
of child support differ by race. and ethnic group. Child
.Primary vulnerable The moral status of children: Essays on the rights
support obligations are distinct from alimony and are
rights of the child. The Hague, The Netherlands: Kluwer Law
International. usually independent of parenting time.
reeman, M. D. A. (1983). The rights and wrongs of children.
KEY WORDS: child support; arrears; noncustodial
London: Frances Pinter.
Pardeck, J. T. (2006). Children's rights:.Po/icy and practice (Znd
par, ent; enforcement; alimony'; parenting time
ed.). New York: Haworth.
History
SUGGESTED LINKS Administration for
Child support is the payment by a noncustodial parent to
Children and Families. www.acfdhhs.gov a custodial parent, caregiver, or guardian, for the care
and support of children when the noncustodial parent

resides elsewhere. Child support is generally awarded in
family law proceedings involving divorce, marital sep-
aration, dissolution, annulment, and paternity. His-
torically, the support of a child was the father's
responsibility. Today, both parents share responsibility
for supporting their children (McNeely & McNeely,
2004). Child support awards reflect the basic policy that
parents should share in the cost of raising a child. This
duty extends to biological and adoptive parents, and in
some cases, to nonparents who have established a
parent-child relationship.
Determination
The Family Support Act of 1988 requires states to
establish and enforce \ child support obligations.
Although federal law does not establish state support
calculations or goals, it requires states to adopt verifi-
able guideline calculations and requires that economic
responsibility be divided between the parents. State
formulas differ, but usually consider the parent's in-
come, age of the child, number of other dependents,
amount of child visitation exercised, taxes; insurance
costs, and other factors to determine payment amounts
(McNeely & Mcl-leely, 2004). Procedures to obtain
child support awards vary from state to state.
Enforcement Trends
Congress passed the federal child support program in
1974 to recoup welfare payments made to custodial
parents by requiring absent parents to reimburse the
state for those welfare payments (Comanor, 2004).
Since 1974, Congress has continued to pass legislation
to enhance state support enforcement capabilities
(Henry, 2004). States now have the power to collect
support through mandatory income withholding,
interception of federal and state tax returns, and placing
liens on financial accounts and personal property.
Delinquent payers may be punished through
i~carceration or through suspension of driver's a nd
occupational licenses.
Specific Challenges
The single biggest challenge in the area of child support
is enforcement. The Federal Office of Child Support
Enforcement spent over 3 billion dollars in 2000 to
recoup less than 1 billion dollars in delinquent. child
support payments. Put another way, for every dollar the
federal government spent on child support enforce ment,
it recouped only 32 cents (Comanor, 2004). The
fundamental dilemma is that obtaining child support
payments from parents who earn little or no in come is
difficult, if not impossible. Most delinquent payers
simply do not have the resources available to make their
child support payments (Cammett, 2005).
aULD SUPPORT 269
The incarceration of such payers only exacerbates the
situation by inhibiting the parent's ability to earn.
Additionally, once. parents are released from incarcera-
tion they may have accumulated high arrears balances
that they cannot realistically reduce (Cammett, 2005).
ultural Demographics
The U.S. Bureau of the Census (2006) reports that as of
spring 2004, 14 million parents had custody of 21.6
million children while the other parent resided else-
where. Five of every six custodial parents in 2004 were
mothers (83.1%) and one in every six were fathers
(16.9%). Of the 14 million custodial parents in 2004, 8.4
million (60%) had some type of agreement or court-
awarded financial support from the noncustodial parent.
Of those parents owed child support in 2003, 76.5%
received some money from the noncustodial parent, a
figure that is statistically unchanged since 1993.
Those receiving full child support differed by race and
ethnic groups. The highest proportion receiving
payments were White. Of the 9,601,000 White custo dial
parents, 63% had court awards or agreements for child
support of which 49% received full payment compared to
20% who received none. Of the 3,554,000 Black
custodial parents, only 52.1% had court awards or
agreements for child support of which 33.7% received
full payment compared to about 34% who received none.
Of the 1,977 ,000 Hispanic custodial parents, 49.9% had
court awards or agreements for child support, of which
44.6% received full payment compared to nearly 30%
who received none. In 2003, one in four custodial parents
and their children were living below the poverty level,
compared with 1993, when one in three was living in
poverty (U.S. Bureau of the Census, 2006). Thus, while a
slightly higher percentage of Black than Hispanic
custodial parents had child support awards or
agreements, Hispanic custodial parents received full
payment at rates more than 10% higher than their Black
counterparts.
Related Themes
T SETTINGS olved with child support issues often raise
number of related questions. First, alimony and child
support obligations are distinct. While child support is
designed to provide for the child's needs, alimony is
designed to equalize the incomes of the two households
that result from divorce or separation (Braver &
Stockburger, 2004). Courts now award alimo ny less
frequently because both parents typically have employ-
ment. Regardless, courts may still order alimony and the
calculation and conditions surrounding an alimony
award are entirely independent of any child support
award.
270 CHILD SUPPORT
Second, courts usually view support and parenting
time independently. Thus, a noncustodial parent is
entitled to parenting time regardless of whether he or
she pays child support. Similarly, a parent who has been
denied parenting time may not withhold child support as
retaliation. Despite this general rule, some contend that
that support orders should be adjusted when parenting
time is wrongly denied (Ellman, 2004).
Third, "father's rights" initiatives have been intro-
duced in a number of states beginning in the mid- 1990s
(Crowley, 2003). Most initiatives focus on allowing
fathers equal physical custody of children and seek to
alleviate perceived prejudice against fathers in the court
system. An award of equal custody will necessarily
affect a child support award, typically making child
support a moot point. Further, even if equal custody is
not granted, most courts will decrease the amount of a
child support award if the noncustodial parent's contact
with the child substantially increases.
Finally, research indicates the failure to collect child
support payments increases the incidence of child de-
linquency and inhibits the general psychological and
social development of children (Antecol & Bedard,
2004; Comanor & Philips, 2004; Wallerstein &
Huntington, 1983).
Implications for Social Workers
Though the authors' research did not reveal precise data,
it has been estimated that approximately only 10-15% of
child support enforcement officers are social workers (].
Challa, personal interview, November 19th, 2007).
Child support issues often arise tangentially in social
work practice. To establish or modify child support
orders, persons must either retain an attorney or
represent themselves. A nonattorney who seeks to ass ist
a person in this process is at risk for the unlicensed
practice oflaw (Fischer & Lachmann, 1990). However,
social workers' knowledge of this, area is essential given
the likelihood that child support issues may affect eli-
ents. Although only a licensed attorney may advocate in
court, an understanding of these issues will enable social
workers to appreciate their client's circumstances. Thus,
social workers may enable clients to advocate for
themselves and may' also advocate for policy changes,
including policies designed to help delinquent payers
find meaningful employment that will make' the
payment of child support a realistic possibility.
REFERENCES
Antecol, H., & Bedard, K. (2004). Teenage delinquency: The role
of child support payments. In W. S. Comanor (EeL), The law
and. economics of child support payments (pp. 241268).
Northampton, MA: Edward Elgar Publishing, Inc.
Braver, S., & Stockburger, D. (2004). Child support guidelines
and equal living standards. In W. S. Comanor (Ed.), The law
and economics of child support payments (pp, 91-127). North-
ampton, MA: Edward Elgar Publishing, Inc.
Cammett, A. (2005). Making work pay: Promoting employment and
better child support outcomes for low~income and. incarcer~ ated
parents Newark, NJ: NJISJ.
Comanor, S. (2004). Child support payments: A review of current
policies. In W. S. Comanor (Ed.), The law and economics of
child support payments (pp. 1-30). Northampton, MA: Edward
Elgar Publishing, Inc.
Comanor, S., & Philips, L. (2004). Family structure and child
support: What matters for youth delinquency rates? In W. S.
Comanor (Ed.), The law and economics of child support payments
(pp. 1-30). Northampton, MA: Edward Elgai:
Publishing, Inc.
Crowley, J. E. (2003). The politics of child support in America.
Cambridge: Cambridge University Press.
Ellman, I. M. (2004). Should visitation denial affect the obli-
gation to pay child support? In W. S. Comanor (Ed.), The law
and economics of child support payments (pp. 178-209).
Northampton, MA: Edward Elgar Publishing, Inc.
Family Support Act of 1988, 42 USC 667.
Fischer, J., & Lachmann, D. (990). Unauthorized practice' handbook:
A compilation of statutes, cases, and commentary on the
unauthorized practice of law. Buffalo, NY: Wm. S. Hein.
Henry, R. (2004). Child support policy and the unintended
consequences of good intentions. In W. S. Comanor (Ed.), , The
law and ec~omics of child support payments (pp. 91-127).
Northampton, MA: Edward Elgar Publishing, Inc.
McNeely, R., & McNeely, C. (2004). Hopelessly defective:
An examination of the assumptions underlying current child
support guidelines. In W. S. Comanor (Ed.), The law and
economics of child support payments (pp, 160-177).
Northampton, MA: Edward Elgar Publishing, Inc.
U.S. Bureau of the Census. (2006). Custodial mothers and fathers
and their child support: 2003. Washington, DC: U.S.
Government Printing Office (Series P-60, No. 230).
Wallerstein, J., & Huntington, D. (983). The parental child support
obligation. Lexington, KY: Lexington Books.
-DELANIE P. POPE AND JOSEPH KOZAKIE\'\ncz
CHILD WELFARE. [This entry contains two suben-
tries: Overview; History and Policy
Framework.]
OVERVIEW
ABSTRACT: The mission of child welfare is multi-fa-
ceted and includes the following tasks: (a) to
respond to the needs of children reported to public
child protection agencies as being abused, neglected,
or at risk of child maltreatment; (b) to provide
children placed in out-of-home care with
developmentally appropriate services; and (c) to
help children find a permanent

home in the least restrictive living situation that is
possible. This section describes the mission, scope, and
selected issues of major child welfare program areas.
KEY WORDS: adoption; child protective services;
child welfare; family group conferencing; foster care;
kinship care; racial disproportionality; sexual minorities
Child Protective Services
Child maltreatment is the primary reason that parents
and children are referred or reported to child welfare
agencies for service. In 2004, nearly 3 million US.
children were reported as abused and neglected, with
872,000 confirmed victims (US. Department of Health
and Human Services, National Clearinghouse on Child
Abuse and Neglect Information, 2006a, summary, p.l ).
Many public and private child welfare programs and
staff are concerned with protecting children from some
form of abuse or neglect by strengthening the ability of
families to protect their children, or provide an alter-
native safe family for the child. The staff investigates
reports of child maltreatment and provide families with
a range of clinical and "concrete" services to address
family needs or problems as a way of preventing or
treating child maltreatment (National Association of
Public Child Welfare Agency Administrators; 1999).
Family Support, Preservation,
and Reunification Services
Although "family support" is sometimes used as an
umbrella term for an array of child maltreatment inter-
ventions, it more often refers to community-based ser-
vices broadly intended to promote family and child
wellness and stability (but not necessarily designed to
prevent child maltreatment). Support services that are
available to anyone qualify as a "universal" prevention
program, whereas family support services aimed at fa-
milies considered challenged or at risk, such as poor
families, qualify as "selected" prevention (Mrazek &
Haggerty, 1994).
"Family preservation" as a distinct child welfare
intervention targets families who are at relatively high
risk of removal of the child or children (or families who
need support for reunification with a child removed
already). Child maltreatment has been identified in these
families and the goal is to prevent its reoccurrence (a
form of "selected or indicated" prevention). Case
management, counseling, therapy, education, skill-
building, advocacy, and other concrete services are
provided. Most programs are currently found in child
welfare agencies but these services are also being pro-
vided in mental health centers and juvenile justice and
aULD WELFARE: OVERVIEW
271
family reunification programs (Henggeler & Sheidow,
2003; Pope, Williams, Sirles, & Lally, 2005; Walton,
Sandau-Beckler, & Mannes, 2001).
Out-of-Home Care
OVER VIEW As a result of child maltreatment or to
help families address child behavioral problems that are
severely disrupting family functioning, about 800,000
children every year are served in the US. foster care
system in family and non-family settings, with about
500,000 served on any given day (U.S. DHHS, 2005,
2006b). The numbers of children in foster care have
risen substantially since 1980 and have only recently
decreased slightly (U.S. DHHS, 2006c).
Social workers are involved an all the major func-
tions of out-of-home care including emergency protec-
tion, crisis intervention, assessment and case planning,
reunification, preparation for adoption, and preparation
for independent living. To implement such functions
and to meet the unique needs of different children on the
basis of such factors as nature of problem, age of the
child, reason for referral, situation of parents, and in-
tensity and length of service required; diverse forms of
out-of-home care are required, including emergency
foster care, kinship foster care, placement with unre-
lated foster families, treatment foster care; foster care
for medically fragile children, shared family foster care,
and family group homes (Curtis, Grady, & Kendall,
1999; Pecora, Whittaker, Maluccio, & Barth, 2000;
Wulczyn, Barth, Yuan, Jones-Harden, & Landsverk,
2005). Of the children in out-of-home care in 2005 with
court-approved case plans (over 90% at any point in
time), most have a plan of reunification with their
parents (51 %) or discharge to the care of other relatives
(4%). The second most common plan is adoption (20%),
followed by emancipation to independent living (6%)
and guardianship (3%). In addition, long-term foster
care is an option for a small number of youths (7%) for
whom reunification with family and adoption are not
viable permanency planning options (U.S. DHHS,
2006b). Statistics on the characteristics of children in
out-of-home care in the US. in 2005 reflect preliminary
estimates for the out-of-home care population on
September 30, 2005, from the Adoption and Foster Care
Analysis and Reporting System (U.S. Department of
Health and Human Services, 2006).
FAMILY FOSTER CARE Traditional family foster
home care, where children are cared for by adults who
are not related to them, remains the most common form
of out-of-home care in the US. In September 2005, 46%
of children in out-of-home care (236,775) were living in
non-relative foster family care. Family foster
272 CHILD WELFARE: OvERVIEW

care meets the needs of children and youth of all ages apartments, group homes, campus based facilities, and
and with a wide variety of needs. Since the late 1970s, other self contained facilities, and secure units. Two of
specialized family foster care programs such as treat- the most dominant forms of residential care include
ment foster care have been developed for children and campus-based residential treatment centers and com-
youths with special needs in such areas as emotional munity-based group homes; 10% (51,210) of the chil-
disturbance, behavioral problems, and scholastic under- dren in out-of-home care in the United States in 2005
achievement. These programs employ specially trained were served in some kind of institution and another 8%
foster parents and caseworkers with lower caseloads than (43,440) were served in comrnunity-based group homes
traditional family foster care (for example, Chamberlain, (U.S. DHHS, 2006b).Within these settings, children
2003; Foster Family Based Treatment Association, and families obtain a mix of services including
2004). counseling, education, recreation, health, nutrition,
daily living experiences, independent living skills,
KINSHIP FOSTER CARE Care of children by extended reunification services, 'aftercare services, and the like
family members is quite common; more than 6.1 million (Braziel, 1996).
children in the United, States live in households headed Continuing the historical debate over the proper
by relatives other than their parents, who provide place of residential and family-based out-of- home care,
full-time care, nurturing, and protection (U.S. Census recent critics have argued that there is little evidence that
Bureau, 2006). Most are cared for by their grandparents residential care is a superior alternative to foster care,
and the vast majority of these children live with kin as a particularly for children and youth with serious
behavioral and mental health problems, and that it may
980 be harmful to many (Dishion, McCord, & Poulin, 1999;
reimbursement for out-of-home placement of children Poulin, Dishion, & Burraston, 2001). As residential
with kin was made comparable to reimbursement for programs move forward to adopt and adapt many of the
non-kin placements, states began to use kinship foster family focused practice innovations. incorporated in
care as a placement option for children in court-ordered treatment foster care, wraparound services, and mul-
out-of-home care (Hegar & Scannapieco, 1998). In 2005, tisystemic treatment, it is critical that these efforts be
kinship foster homes provided care for 124,153 (24%) of accompanied by rigorous evaluations to ensure their
The clinical handbook of couple's therapy (pp. 251-277). relationship to the ultimate outcomes of interest: com-
). New York: Guilford Press. munity adjustment and integration for children and
youth returning home from care (Whittaker, 2006).
rch-based approacxperience greater placement stability
than children in non-family settings but that they also Independent Living Services
spend longer time in care (Wulczyn, Kogan, & Harden, Each year about 24,000 youth leave foster care through
2002; Wulczyn et al., 2005). Much remains to be learned legal emancipation. rather than through reunification
about the best ways to support kinship foster parents and with birth family or adoption (U.S. DHHS, 2006). In
ensure the success of kinship care placements for order to comply with the provisions of the John Chafee
children (Geen, 2003; Hegar & Scannapieco, 1998). r Foster Care Independence Program, states are required
to provide foster youth with a written transitional in-
dependent living plan. They can use the funds they
RESIDENTIAL GROUP CARE According to the Child receive through the program to provide a variety of
Welfare League of America, the primary purpose of services to foster youth in transition, including out reach
residential services "is to provide specialized therapeu tic programs to attract eligible youth, training in daily
services in a structured environment for children with living skills, education and. employment assistance,
special developmental, therapeutic, physical, or counseling, case management, and written rran sitional
emotional needs" (Child Welfare League of America. independent living plans.
[CWLA], 2004, p. 20). Residential care is generally States can also use some of the Chafee Program
reserved for children and youth who are perceived as in funds for room and board and in recent years have been
need of services that cannot be provided in a family able to support post-secondary education for the youth
setting, though residential care providers increasingly through the Chafee education and training voucher
work directly with the families of children in their care program. In spite of these services, research on out-
(CWLA, 2004). Programs and services are provided in a comes for foster youth making the transition to adult-
wide range of settings, including community based hood shows that too many still experience unfavorable

outcomes, including limited educational attainment,
unemployment, poverty, homelessness, mental illness,
crime, and victimization (Courtney, Dworsky, Piliavin,
& Zinn, 2005; Pecora et al., 2006).
Adoption
Adoption is a "social and legal process whereby a par-
ent-child relationship is established between persons not
so related by birth" (Costin, 1972). It provides an
opportunity for children who have been orphaned,
abandoned, or voluntarily or involuntarily relinquished
by their birth parents,' to have a permanent family
(McRoy, 2006). About 1.6 million children under the
age of 18 were adopted and living in households in the
United States (US. Census Bureau, 2004 using 2000
\ .
Census data). The National Adoption Information
Clearinghouse, a service of the Children's Bureau of the
US. Department of Health and Human Services'
Administration for Children and Families, states that
there is no current public or private attempt to collect
comprehensive national data on adoption, despite
sporadic attempts over the last 50 years (see www .
calfb.com/naic/stats). About 500,000 currently or for-
merly married women between 18 and 44 were seeking
to adopt a child in 1995 (Chandra, Abma, Maza, &
Bachrach, 1999). Social workers are involved in all
forms of adoption, in both the private and public sector.
For example, social workers counsel birth parents who
are considering relinquishing a child for adoption, as sess
the needs of children available for adoption, recruit
potential adoptive parents, perform assessments o f the
suitability of homes as adoption resources, and counsel
adopted children and their parents.
The adoption of children who have been perma nently
removed from their birth parents due to parental abuse,
neglect, or abandonment is typically handled through
public child welfare agencies. According to the
AFCARS report, as of September 30, 2005, there were
114,000 children waiting to be adopted through public
child welfare services and 51,323 children left
out-of-home care inthe United States through adoption
in fiscal year 2005 (US. DHHS, 2006b). Although
criteria vary across states, children in out-of- home care
who are adopted and are members of a sibling group,
members of a minority group, are older, or have an
emotional, physical, or developmental disability, are
considered to be children with "special needs" under
federal law, making their adoptive families eligible for
federal adoption subsidy payments. One concern is that
too many children (114,000 in 2005) are waiting for
adoption while placed in foster care (the child's case
goal is adoption or parent rights have been terminated).
CHILD WELFARE: OVERVIEW
273
For example, in federal fiscal year 2005, 42% of those
adopted had waited a year or more to be adopted after
TPR, and 15% had waited two years or more (US.
DHHS,2006b).
Theoretical Frameworks Underlying
Child Welfare Policies and Programs
While there is not universal agreement, a number of
theoretical models appear to underpin many aspects of
child welfare program design and- policy: the ecological
model (Bronfenbrenner, 1979, 1986; Cicchetti & Lynch,
1993), child de~elopment theories such as attachment theory
(e.g., Ainsworth, 1989; Weinfield, Ogawa, & Sroufe,
1997), trauma theory (e.g., Briere, 1992; Cohen,
Mannarino, Zhitova, & Capone, 2003); social learning
theory (e.g., Bandura, 1977, 1997), and social support theory
(Bailey, 2006; Whittaker & Tracy, 1990), and models of
risk and protective factors (Fraser, Kirby, & Smokowski,
2004; Rutter, 1990).
Trends, Challenges, and Debates
IMBALANCE IN FUNDING AND EMPHASIS UPON
PLACEMENT Most of the children placed in foster care
came from poor families-often f amilies that were barely
managing to survive on limited income from public
assistance programs (Lindsey, 2004). And yet there is a
great imbalance in funding between family
strengthening and other forms of preventive services
versus out-of-home care. Consequently, some critics
argue that children are being inappropriately moved out
of their homes--with insufficient' efforts to help the
parents to care for them (Lindsey, 2004; Walton, et al.,
2001)~ In recent years, advocates have proposed
alternative funding schemes that would allow states to
more flexibly use federal funding to meet the needs of
children and families coming to the attention of child
welfare authorities without resorting to out-of-home
care (Pew Commission, 2004).
INNOVATION IN FINDING PERMANENT HOMES
FOR CHILDREN MORE QUICKLY Agencies in
Illinois, New York City, and other areas are making
successful efforts to reduce the length of stay of children
in out-ofhome care, to reduce the level of restrictiveness
of child placements, and to increase the proportion of
children placed with relatives or clan members (U.S.
DHHS, Administration for Children and Families,
2004). In addition, the number of children being
adopted or securing a form of permanence through
guardianship has increased since the late 1980s, as some
states have significantly decreased the time to adoption
(Avery, 1998; U.S. DHHS, 2004). These innovations
may
274 CHILD WELFARE: OvERVIEW
expand further with new initiatives under way. These
include child welfare demonstration waivers, expedited
adoptive parent assessments, expedited approvals of
subsidy applications, increases in judicial personnel, and
heightened attention by the agencies and courts to the
need for more timely permanency planning.
F AMIL Y GROUP CONFERENCING AND
DECISION MAKING Family Group Decision Making
(FGDM) is an umbrella term used to describe a variety
of practice approaches to working with and engaging
families in problem solving,. Many public child welfare
organizations have elected to incorporate FGDM within
the Child Protective Services program, while other agen-
cies use FGDM at other key-points in the service deliv-
ery process, such as in determining when to reunify and
to help prepare youth as they emancipate from foster
care. Internationally, there are a number of models,
known by different names, and they all share the com-
mon principle that families must be involved in the
decision-making process in order to protect and assure
the safety of their children. The main differences be-
tween the models relate to how much control the family
has over the decisions made at the conference and the
development of the case plan. It is difficult to determine
exactly how many families have been served by this
approach, but FGDM, Family Team Meetings (North
American Council on Adoptable Children, 2005) and
other forms of family conferences are becoming widely
used in child welfare agencies across the country. While
few rigorous studies have been conducted, some
research provides evidence supporting the effectiveness
of FGDM conferences over traditional services (Texas
Department of Family and Protective Services, 2006).
DISPROPORTIONALITY AND THE ROLE OF
RACE! ETHNICITY IN POLICY AND PRACTICE
Children from minority families-especially Black,
Hispanic, and Native American-e--are
disproportionately represented in foster care, and many
have had less positive service outcomes. But
disproportionality and the disparitiesin outcomes for
children of color receiving child welfare services have
been recognized as major ethical, policy and program
design issues that require critical attention from policy
makers and. practitioners (Hill, 2006; Hines, Lemon ,
Wyatt, & Merdinger,2004; Roberts, 2002; see
www.racemattersconsortium.org).
ADDRESSING THE NEEDS OF SEXUAL
MINORITIES IN CHILD WELFARE PROGRAMS
There has also been relatively little attention directed
toward sexual minorities involved in child welfare
services. Nearly a decade
ago, a special committee of the Child Welfare League of
America called attention to the needs of gay and les bian
children and youths in the foster care system:
"Because of negative societal portrayals, many gay
and lesbian youths live a life of isolation, alienation,
depression and fear. As a result, they are beset by
recurring crises disproportionate to their numbers in the
child welfare system" (Child Welfare League of
America, 1991, p. 2).
Although attention is beginning to be given to their
situations and needs, gay and lesbian children and youth
continue to be. poorly understood and underserved.
Ongoing challenges for practitioners include
appreciating the uniqueness of gay and lesbian adoles-
cent development; helping the adolescents to negotiate
life within a hostile environment; helping them to
confront the consequences of breakdown of the family
system and the lack of family support (Wilber, Ryan, &
Marksamer, 2006; Wornoff & Mallon, 2006) and un-
derstanding the rights of lesbian and gay parents in
regard to child custody and visitation (Mallon, 2007).
FOSTER PARENT. SCREENING, RECRUITMENT,
AND SUPPORT Some of the innovative approaches to
permanency planning. depend upon foster parents who
can help the child maintain or develop healthy family
connections. While many of the situations and chil dren
require a high degree of skill and patience on the part of
the foster parents, there is a shortage of quali fied foster
parents (Barbell & Freundlich, 200l). Better recruitment
and assessment must take place to best match child
needs with foster parent capacities and strengths.
CONTINUING EMPHASIS UPON
ACCOUNTABILITY ASFA included provisions to
establish national performance standards for the federal
government to assess states' progress in maximizing the
safety, permanency, and well-being of children
receiving child welfare services. The resulting Child and
Family Services Reviews have engaged the federal
government in working with states to create a stronger
focus on outcomes and results for children and families,
providing technical assistance to assist states in
improving their child welfare programs, holding states
accountable for noncompliance with national standards
(including fiscal penalties), and engaging the states in
creating "program improvement plans" that are intended
to improve outcomes over time. Unfortunately, state and
county policies to promote evidence-based practice
models and performance-based contracting have been
hampered by a lack of knowledge of baseline
conditions, sound target goals, infrastructure funding
gaps, and a lack of

information about what practice models are currently
evidence-based (Freundlich & Gerstenzang, 2003). In order
to improve accountability in child welfare services
provision, some child welfare agencies are implementing
Continuous Quality Improvement systems to enable them
to steadily improve practice (Mordock, 2002; Pecora, Selig,
Zirps, & Davis, 1996).
IMPROVING THE RELATIONSHIP OF THE CHILD
WELFARE SYSTEM TO OTHER SYSTEMS The efforts
of multiple systems such as public assistance, health,
mental health, juvenile justice, substance abuse, and
domestic violence will be needed to address the major
factors that bring families into contact with the child
welfare system. For example, fragmented funding streams
and policies fail to encourage effective treatment of
co-morbid (that is, co-occurring conditions) that are much
more common in the United States than commonly thought
(Johnson, Knitzer, & Kaufmann, 2003; Kessler et a1.,
2005). Similarly, the changing nature of the public
assistance caseload in the wake of welfare reform may have
increased the overlap between welfare, to-work and child
welfare services populations, providing an opportunity for
greater involvement of public welfare programs in
supporting struggling parents (Courtney et a1., 2005).
INCREASING ADHERENCE TO THE INDIAN CHILD
WELFARE ACT AND IMPROVING EQUITY OF TITLE
IV -E FUNDING FOR TRIBES The Indian Child Welfare
Act was intended to reduce the number of Native American
children entering foster care, the majority of whom had
traditionally been placed in non-Indian homes. The Indian
Child Welfare Act, however, has been inadequately funded
and unevenly implemented. As noted by Bending (1997, p.
151), "noncompliance, jurisdictional indifference, and
culturally insensitive services have hindered full
implementation" of the Act. Various authors propose
specific child welfare training programs (Bending, 1997) as
well as approaches for balancing child protection and
family preservation in child welfare services for Native
American children and families (Hand, 2006; Red Horse,
Martinez, Day, Day, Poupart & Scharmbarg, 2000).
Conclusion
As they have been doing since the beginning of the child
saving movement of the 19th century, child welfare
practitioners still struggle with the often competing values,
and demands, of protecting children while trying to
preserve families. Although many child welfare programs
are burdened, professionals, families, and advocates across
the country are experimenting with new
CHILD WELFARE: OvERVIEW
275
policies and procedures designed to ensure children safe
and permanent living arrangements.
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UGGESTED LINKS
American Humane Association.
http://www .americanhumane. org/site/PageServer ?pagename
pc_home
American Public Human Services Association.
http://www.aphsa.org/Home/home_news.asp Child
Welfare League of America.
http://www .americanhumane .org/site/PageServer ?pagename
pc_home
. Foster Care Alumni of America (FCAA)-a national organization
of alumni of the foster care system. http://fostercarealumni .org/
Race Matters Consortium.
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U.S. Department of Health and Human Services, Administration
for Children and Families, Children's Bureau.
http://www:acfhhs.gov/programs/cb/pubs/cm04/summary.htm
-PETER J. PECORA
HISTORY AND POLICY FRAMEWORK
ABSTRACT: Child welfare services in the United States
evolved from. voluntary "child saving" efforts in the 19th
century into a system of largely governmentfunded
interventions aimed at identifying and protecting children
from maltreatment, preserving the integrity of families that
come to the attention of child welfare authorities, and finding
permanent homes for children who cannot safely remain with
their families. Since the 1970s, the federal government has
played an increasing role in funding and creating the policy
framework for child welfare practice. That child welfare
services are disproportionately directed toward members of
ethnic and racial minorities has been an enduring concern.
278 aULD WELFARE: HISTORY AND POLICY
FRAMEWORK
KEY WORDS: children; youth; families; abuse;
neglect; foster care; adoption; social policy; race and
ethniciry: history
Social work practice in the field of child welfare in-
volves the provision of child welfare services. Child
welfare services in the United States are a response to
society's commitment to protecting children from mal-
treatment by their primary caregivers. This commitment
and early social work responses emerged in the context
of what has been referred to as the "child saving'
movement." Prior to that time, children were considered
the property of their parents; parents were genetally
allowed to treat their children as they wished.
History
In the mid-19th century, societal attitudes regarding
parental authority and the needs of children had changed
to the extent that religious and civic leaders began to
seriously question the wisdom of allowing children to
remain in what came to be considered "unfit" homes.
Criminal cases involving child abuse in the United
States date to the 17th century and by the 19th century,
many localities had laws that codified Poor Law tradi-
tions allowing children to be indentured in order to
protect them from neglect or remove, them from the
streets (Bremner, 1970). In addition, by the 19th cen-
tury, some voluntary "child rescue" societies had begun
to investigate complaints of child neglect, exploitation,
and cruelty. Nevertheless, historical accounts generally
trace the origin of widespread media attention and
public concern over the plight of maltreated children to
the case of Mary Ellen Wilson, a young girl living in
New York City, who was removed from the home of her
abusive caregivers in 1874 due to the intervention of the
leader of the New York chapter of the American Society
for the Prevention of Cruelty to Animals, Henry Bergh
(NYSPCA) (Costin, 1991). After intervening for Mary
Ellen, Bergh and others established the Ne..w York
Society for the Prevention of Cruelty to Children
(NYSPCC). Within a few years, many large cities had
similar organizations, to whom courts gave
quasi-judicial power to remove children from homes
that were deemed unfit and place them in foster homes
or children's institutions. Most of the early SPCCs made
little or no effort to rehabilitate the parents of these
children, believing them to be characterologically
deficient and therefore beyond help.
Decades earlier, Charles Loring Brace, motivated by
a deep commitment to Protestant religious charity and
influenced by the terrible living conditions he witnessed
in his charitable work in the Five Points
neighborhood of New York City, founded rhe Chtl-
dren's Aid Society (CAS) (O'Connor, 2001). Brace had
seen that many children of the European irnrnigrants
who lived in the neighborhoods where he worked ended
up largely fending for themselves on the street or living
in very tenuous conditions with their families. He came
to believe that these children could find a better life
living away from the evils' of the city with good
Protestant families. Reflecting this belief, begin ning in
1854, the CAS took in orphans, "half-orphans"
(children with only one parent), and children whose
parents were convinced to relinquish them to the CAS,
and put them on "orphan trains." The trains transported
the children primarily to small towns and rural areas
where families would come forward to take the children
in and raise them in what Brace and his supporters
believed were more suitable surroundings than New
York City for the rearing of children (O'Connor, 2001).
As the first large-scale effort at foster family care,
the orphan trains represent a milestone in the develop-
ment of child welfare services, but they are also impor-
tant for another reason. Unlike the later child-saving
efforts of the Societies for the Prevention of Cruelty to
Children, Brace and the CAS did not remove children
from their homes with the rationale that they were
trying to save children from parental maltreatment (that
is, from "deviant" parents); rather, they were interested
in moving them from the dangerous conditions that
were typical of the immigrant communities and families
in which the children lived into "better" homes and
communities. In this way, the programs of the CAS
represent an early example of the use of child welfare
services to "save" children by removing them from
ethnic or racial minority families and communities and
assimilating them into majority families and
communities. A later example of this use of child wel-
fare services can be found in the removal of Native
American children from their homes from the late 19th
to mid-20th century, and placing them in boarding
schools where they were prohibited from engaging in
the cultural practices of their home communities
(Holt, 2001). "
Progressive Era reformers with a broader set of
interests in children also influenced early child pro-
tection efforts. For example, laws restricting child labor
both reflected and contributed to changing expectations
regarding society's responsibility for the well-being of
children (Costin, 1991). Moreover, many advocates for
legislation affecting children, particularly early
feminists, were also involved in child protection efforts.

FRAMEWORK
Although protecting children from harm by their
caregivers, or removing them from '''undesirable'' com-
munities, were the foci of the late-19th century child savers,
this did not mean that the sanctity of the family as a social
institution had been entirely lost. For example, early in its
work, the Massachusetts Society for the Prevention of
Cruelty to Children, while taking on the child placing
function of other SPCCs, focused on trying to help families
that came to its attention to be able to care for their children
(Costin, 1992). The Progressive Era championing of the
family reached a high point in 1909 during the First White
House Conference on the Care of Dependent Children,
which had been called largely in response to concern about
institutional placement of children. \The conferees
concluded that "home life is the highest and finest product
of civiliza-' tion" and recommended that measures be taken
to prevent the removal of children from their homes and to
place them with families instead of in institutions (U.S.
Children's Bureau, 1967). The U.S. Children's Bureau, the
first department of the federal government devoted to the
welfare of children, was created in 1912 in response to the
recommendations of the 1909 White House Conference; to
this day the Children's Bureau remains the agency
primarily responsible for implementing federal child
welfare initiatives.
Child Welfare Policy in the u.s.
Today, child welfare services are provided by state and
local public child welfare agencies and by voluntary
agencies, the latter receiving most or all of their funding
from government sources. The U.S. government influences
child welfare services primarily through provision of
funding to states, which is contingent upon states using
these funds in ways that are consistent with federal law.
Some key U.S. laws influencing the provision of child
welfare services are described below.
THE CHILD ABUSE PREVENTION AND
TREATMENT ACT (CAPTA) Enacted in 1974 and
amended several times since then, CAPT A represents the
federal government's commitment to protecting children
from maltreatment. It provides funding to states for child
abuse and neglect prevention, identification, prose-. cution,
and treatment activities. It also provides grants to public
agencies and nonprofit organizations for demonstration
projects. CAPT A defines the federal role in supporting
research, evaluation, technical assistance, and data
collection activities pertaining to child maltreatment. To
receive CAPT A funds, states must meet a number of
requirements, including enacting statutes that define and
prohibit child maltreatment;
Q-IrLD WELFARE: HrSfORY AND POLICY
279
establishing a child maltreatment reporting system;
designating an agency responsible for investigating child
maltreatment; providing immunity from prosecution for
individuals making good faith reports of suspected or
known instances of child maltreatment; and protecting the
confidentiality of data generated by the maltreatment
reporting system.
THE SOCIAL SECURITY ACT The Social Security Act
includes the most significant federal laws that provide the
legal framework and funding for child welfare services.
The federal government started providing grants to states
for preventive and protective services and foster care
payments in 1935 with the Child Welfare Services
Program (Title V), which in 1967 became Title IV-B.
Beginning in 1961, legislation provided for foster care
maintenance payments under the Aid to Dependent
Children Program, Title IV -A of the Social Security Act.
Title IV-A was amended in 1980 to create the Title IV -E
Foster Care and Adoption Assistance program. The Title
XX Social Services Block Grant was created in 1975 to
provide states with funding for a wide range of social
services, including those targeted at preventing or
remedying child maltreatment, preserving, rehabilitating or
reuniting families, and preventing or reducing
inappropriate institutional care. Since its creation in 1997,
the Title IV -A T emporary Assistance to Needy Families
program (T ANF) has also become a significant source of
funding for child welfare services. States may use T ANF
funds for family reunification, parenting education,
in-home and crisis intervention services, and to support
children whom child welfare agencies have removed from
their parents' homes and placed with relatives or kinship
caregivers. Lastly, state child welfare agencies use
Medicaid (Title IXX) funds to pay for transportation,
targeted case management, and therapeutic and psychiatric
services provided in children's institutions. Federal, state,
and local government funding for child welfare services
totaled over $23 billion in fiscal year 2004, with at least
$11.7 billion in federal funds from Titles IV-A, IV-B, IV
-E, lXX, and XX of the Social Security Act accounting for
approximately 96% of those expenditures (Scarcella, Bess,
Zielweski, & Geen, 2006). Private sources also provide an
unknown, but relatively small, amount of funding for child
welfare services in the United States.
TITLE IVB AND TITLE IV.E Titles IV-B and IV-E
account for over half of federal expenditures and provide
the legal framework for child welfare services in the
United States. Title IV-B now has two parts. The
280 CHILD WELFARE: HISTORY AND POUcy FRAMEWORK ,
Subpart 1 Child Welfare Services program provides
states with federal funding directed toward protecting
and promoting the welfare of all children; preventing
and responding to problems that may result in child
maltreatment, exploitation, or delinquency; preventing
the unnecessary separation of children from their
families; reunifying children in out-of-home care with
their families; placing children in adoptive homes; and
assuring adequate care of children in out-of- home care.
Subpart 1 requires states to create a state plan for the
delivery of these child welfare services, approved by the
federal government, that specifies how such services
will be coordinated with services funded under Title
XX, T ANF, and the Title IV -E foster care program.
The budget authorization for Subpart 1 is $325 million
per year. Subpart 2, Promoting Safe and Stable Families ,
allocates funds to states for a more targeted set of
services: coordinated programs of community-based
family support services; family preservation services ;
time-limited family reunification services; and adoption
promotion and support services. The budget authoriza-
tion fot Subpart 2 is $345 million per year. Historically ,
Congress has generally not appropriated the full amount
possible under Title IV-B.
The TitleIV-E Foster Care and Adoption Assis tance.
program provides funds to states for the board and care
and administrative costs of out-of-home care of children
removed from families deemed unwilling or unable to
care for them and subsidy payments to the parents of
children adopted from state-supervised outof- home care.
Eligible children are those 18 years old and younger,
who have been removed from their parents' custody and
whose families would have been income-eligible under
the old Aid to Families with Dependent Children
program (AFDC), the predecessor of T ANF. The latter
eligibility requirement reflects the fact that the federal
foster care program emerged from federal anti-poverty
efforts and has always providedreimbursement primarily
for the care of poor children. Federal law uses the term
llan.
me hollow state. Journal of Policy Administration
rch and Theory, 10,359-379.
means-tested entitlements under Title IV - E, meaning
that there is no cap on federal expenditures and states
can claim reimbursement for expenses incurred on
behalf of all eligible children in the state. Amendments
to Title IV-E, b~ing in the late 1980s have added
funding for independent living services intended to help
foster youth make a successful transition to adulthood
and education and training vouchers that can be used to
support post-secondary education and training.
Congressional appropriations
for independent living services and education and
training vouchers are currently limited by law to $140
million and $60 million per year respectively. States
used approximately $5.8 billion in total Title IV-E funds
in fiscal year 2004 (Scarcella et al., 2006).
Title IV -E embodies the "permanency planning"
philosophy that has guided child welfare practice since
the enactment of the Adoption Assistance and Child
Welfare Act of 1980 and was reinforced by the Adoption
and Safe Families Act of 1997 (ASFA).ln general, states
only receive IV -E funding for children in out-of home
care who are placed there by order of the juvenile or
family court of the relevant jurisdiction in order to
protect them from abuse or neglect; voluntary child
placement agreements between child welfare agencies
and parents are only eligible for time-limited federal
reimbursement. Title IV -E requires child welfare agen-
cies to make "reasonable efforts" to prevent placement
of children in out-of-home care, usually in the form of
social services for their families. If the child welfare
agency and court deem these efforts unsuccessful and
the child enters out-of-home care, the court must ap-
prove a "permanency plan" for the child according to
timelines provided in Title IV-E. Most commonly, the
court requires the child welfare agency to make reason-
able efforts to preserve the child's family of origin, in
this case by providing services intended to help reunite
the child with the family. In many cases, however,
children cannot return to the care of their families. When
this happens, consistent with the goals of Title IV -E, the
child welfare agency and the court attempt to find
another permanent home for the child through adoption
or legal guardianship.
Although this basic approach to child welfare prac-
tice has been supported by federal law since 1980, ASFA
shifted the balance between family preservation and
child safety and permanency in a child-focused direction
in a number of ways. ASFA identified circumstances
under which courts can waive reasonable effort
requirements (for example, in cases of "chronic abuse"),
shortened by six months the time that courts are allowed
after a child's placement to hold a hearing to determine
whether to send a child home, and required states, with
certain exceptions, to file a petition to terminate parental
rights when a child has been in foster care for 15 or more
of the most recent 24 months. ASFA also required the
federal government to work with states to establish a set
of measures of child safety, permanency, and well- being
to be used to assess state performance in delivering child
welfare services and a mechanism for tying part of state
reimbursement under Titles IV-B and IV-E to these
outcome measures. This led to the creation of an ongoing
process of Child and
J

FRAMEWORK
Family Service Reviews through which the Children's
Bureau compares state performance to a set of national
standards and monitors state progress in improving
performance.
Challenges: The Continuing Influence of
Race, Ethnicity, and Cultural Heritage
on Child Welfare Policy
The debates between child advocates during the 19th
century over whether it was appropriate to try to "save"
poor immigrant children from their communities were
certainly not the last time that issues of race, ethnicity,
and culture came to the fore in discussions of child
welfare policy. In recent decades..observers have noted
that families and children, from immigrant and minority
communities often receive treatment that is distinct
from that provided to children and families from rna-
joriry communities and have often been represented in
child welfare services populations at rates in excess of
their representation in the overall population (Billings-
ley & Giovannoni, 1972; Courtney et al., 1996; Holt,
2001; Roberts, 2002). This has raised concern on th e
part of the leaders of these communities and other child
welfare advocates. The debate over the proper influ ence
of race, ethnicity, and culture in child welfare practice
has contributed over the years to significant changes in
child welfare policy.
Even before the passage of the Adoption Assistance
and Child Welfare Act, the cornerstone of U.S. child
welfare policy, Congress saw fit to enact the Indian
Child Welfare Act (ICWA) in 1978. At that time,
advocates had called attention to the fact that courts
were removing a high proportion of Indian children
from their families and tribes (25% and higher in some
states) and placing them overwhelmingly in non-Indian
settings (Cross, Earle, & Simmons, 2000; Holt, 2001).
There was growing concern that these children were
losing their Indian culture and heritage and that court
systems did not take into consideration either the tribal
relations of Indian people or the child-rearing standards
of Indian communities. ICW A established federal
standards for the removal of Indian children from their
families and termination of parental rights for children
in state care, required state and federal courts to give full
faith and credit to tribal court decrees, granted
preference to Indian family environments and setting s
that reflect Indian culture in adoptive or foster care
placement, and gave tribes exclusive jurisdiction over
all Indian child custody proceedings when requested by
the tribe or parent. The law also provides funding and
technical assistance to tribes in the operation of child
and family service programs. ICWA privileges the
importance of heritage
CHILD WELFARE: HISTORY AND POLICY
281
and culture in the provision of child welfare services,
though critics have questioned whether the law has eve r
been adequately implemented or funded (Cross
et al., 2000). .
In contrast, the Multiethnic Placement Act of 1994
(MEPA) and the Interethnic Adoption Provisions of
The. Small Business Job Protection Act of 1996 (IEPA )
amended Title IV-E and Title IV~B to severely restrict
the ability of child welfare agencies and courts to take
into account race, color, or national origin in making
foster care or adoption placement decisions. The push
for MEPA and IEP A came from advocates concerned
about the disproportionate representation of children of
color, particularly African American children, in the
child welfare system (Brooks, Barth, Bussiere, &
Patterson, 1999). Advocating for a "color-blind" ap-
proach to child welfare practice, they argued that the
longer length of stay in out-of-home care for minority
children was due to delays caused by race matching
policies that existed in some jurisdictions at the time and
child welfare practice that favored the placement of
children with families that reflected the race and culture
of the child. They also argued that available evidence
suggested that transracial adoption appeared to convey
no lasting harm to children. Opponents of the legislation
argued that the disproportionate representation of
minority children in out-of-horne care had little to do
with race matching policies and that children from
minority communities would be harmed if placement
practices did not take into account their race, ethnicity,
and culture.
Taken together, MEPA and IEP A prohibit states and
other entities that receive federal funding and are in-
volved in foster care or adoption placement from delay-
ing, denying or otherwise discriminating when making a
foster care or adoption placement decision on the basis
of the parent or child's race, color or national origin.
They similarly prohibit these entities from categorically
denying any person the opportunity to become a foster
or adoptive parent solely on the basis of race, color or
national origin of the parent or the child. MEPA allowed
an agency to consider the cultural, ethnic, or racial
background of a child and the capacity of an adoptive or
foster parent to meet the needs of a. child with that
background as one factor when making a placement, but
IEPA repealed that part of the law. MEPA and IEP A
also require states to develop plans for recruitment of
foster and adoptive families that reflect the ethnic and
racial diversity of the children of the state.
Legacy
In summary, child welfare services in the United States
have emerged since the mid- 19th century out of public
282 . CHILD WELFARE: HISTORY AND POLICY
FRAMEWORK
concern about protection of children, tempered by a strong
preference for allowing parents to raise their own children and
a growing inclination to place children in need of out-of-home
care in families rather than institutions. Since the 1970s, the
federal government has become increasingly involved in
funding child welfare services, particularly out-of-home care,
and in tying such funding to state compliance with evolving
Ll.S, child welfare policy.
REFERENCES
Billingsley, A., & Giovannoni, J. M. (1972). Children of the
storm: Black children and American child welfare. New York:
Harcourt, Brace, Jovanovich.
Bremner, R. (Ed.). (1970). Children and youth in America:
A documentary history (Vol. 1, pp. 1600-1865). Cambridge,
MA: Harvard University Press.
Brooks, D., Barth, R. P., Bussiere, A., & Patterson, G. (1999).
option and race: Implementing the multiethnic place-
ment act and the interethnic adoption provisions. Social
Work, 44(2), 167-78.
s rather than second. Unraveling the Mary Ellen legend:
Origins of the "cruelty" movement. Social Service Review,
65(2),203-23.
Costin, L. B. (1992). Cruelty to children: A dormant issue and
its rediscovery, 1920-1960. Social Service Review, 66(2),
i77-98.
Courtney, M. E., Barth, R. P., Berrick, J. D., Brooks, D.,
Needell, B., & Park, L. (1996). Race and child welfare
services: Past research and future directions. Child Welfare,
75(2),99-137.
Cross, T. A., Earle, K. A., & Simmons, D. (2000). Child abuse
and neglect in Indian country: Policy issues. Families in
Society, 81 (1),49-58. .
Holt, M. I. (200l). Indian orphanages. Lawrence: University
Press of Kansas,
O'Connor, S. (200l). Orphan trains: The story of Charles Loring
Brace and the children he saved and failed. Boston: Houghton
Mifflin.
Roberts, D. (2002). Shattered bonds: The color of child welfare.
New York: Basic Books.
Scarcella, C. A., Bess, R., Zielweski, E. H., & Geen, R. (2006).
The cost of protecting vulnerable children V: Understanding state
variation in child welfare financing. Washington, DC: The Urban
Institute.
U.S .. Children's Bureau. (1967). The story of the White House
conferences on children and youth. Washington, DC:
Author.
FURTHER READING
U.S. Department of Health and Human Services, Administra-
tion on Children, Youth and Families. (2006). The AFCARS
Report: Preliminary FY 2005 estimates as of September 2006.
Retrieved November 6,2007, from http://www.acf.hhs.gov/
programs/cb/stats_research/afcars/tar/reportI3.htm
flow back into peU.S. Department of
U.S. Department of Health and Human Services, Administra-
tion for Children and Families, Administration on Children,
Youth and Families, Children's Bureau (2006). Child Welfare
Information Gateway.
http://www.childwelfare .gov/index. cfm
-MARK E. COURTNEY
CHINESE. See Asian Americans: Chinese.
CHRISTIAN SOCIAL SERVICES
ABSTRACT: The term "Christian social services" refers to
the involvement of persons and agencies that identify
themselves as having a Christian faith orientation in providing
services to meet the material and interpersonal needs of
persons not met by family or the larger community. These
services are often provided informally, in response to the
needs of neighbors, community members, and strangers. This
entry describes formalized services provided through
organizations, including congregations, as well as agencies
andorganizations affiliated with congregations.
KEY W DRDS: Christian; ministry; volunteers; congre-
gations; faith-based; religion; religiously affiliated; so-
cial service
Christian thought is based on Judaism, which teaches the
importance of loving one's "neighbor" as much as one loves
oneself (Leviticus 19:18). Jesus taught that every person in
need is considered a neighbor, one worthy of care (Luke
10:30-36). A central tenet of Jesus' teaching is that the way to
know God is to care for a child, representing the most
vulnerable and powerless in society (Mark 9:33-37).
Moreover, Jesus said that his followers will be judged by the
extent to which they care for the needs of persons who are
poor and oppressed: "whatever you did for one of the least of
these brothers and sisters of mine, you did for me" (Matthew
25:31-46, TNIV). The earliest church was kriown for its care
of the poor and abandoned in society, providing meals,
financial support, and inclusion in a community of care (Acts
2:44-45). For more than 2000 years, Christians have cared
through their congregations and religious organizations for
those in need.
"Christian social services" refers to the involvement of
persons and agencies that identify themselves as

having a Christian faith orientation in providing services
to meet those material and interpersonal needs of
persons, not met by family or the larger community.
These services have often been provided informally, in
response to the needs of neighbors, community mem-
bers, and strangers. This entry will discuss the forma-
lized services provided through organizations, including
congregations and agencies and organizations that are
affiliated with congregations. Christian social services
through congregations and organizations are provided
by persons who may be "ordained," or formally identi-
fied as leaders of the church, as well as by laypersons,
that is, members of the church. Both clergy and
laypersons may serve either as-volunteers or as paid
staff. Social workers are located in all these varying
groups of Christian social service providers- ordained
and laity, volunteers and paid staff.
Historical Overview
Through the centuries, recipients of Christian care have
included immigrants; frail elderly adults; persons who
are developmentally and physically challenged; the ill
and dying; persons in poverty; persons who are
homeless; widows; prisoners; and children who are or-
phaned, abused, or abandoned. For example, long be-
fore there was any vision that government had a
responsibility toward the most vulnerable members of
communities in the United States, people of faith were
adopting orphaned children into their own families and,
when their homes were no longer adequate to the need,
founding and supporting orphanages so that children
were not sent to poorhouses (Garland, 1994). These
orphanages evolved into religiously affiliated child and
family service organizations that continue to be
essential and often central partners in many corn-
munities' child welfare services (Catholic Health Asso-
ciation, 2001). As care for persons in need became
formalized into organizations, and volunteers sought to
be effective in their helping efforts, the social work
profession was born. The influx of Catholic immigrants
in the mid- 19th century was accompanied by a dramatic
increase in Catholic charitable sisterhoods. In 1850, the
number of priests and sisters was fairly equal, but by
1900, 40,000 sisters outnumbered priests by a margin of
3.5 to 1. The sisters engaged in social services, nursing
and teaching in parish schools (Oates, 1995, p.20).
In the Protestant church, Jane Addams, heavily
influenced by the Social Gospel movement, founded the
most famous of the social settlement houses in the
United States in 1889. She was actively involved in a
Protestant evangelical congregation and saw
Hull-House as "an alternative structure to traditional
CHRISTIAN SOCIAL SERVICES
283
houses of faith, one that did not separate people into
communities of particular faiths, sects, or denomina-
tions" (Keller, 2001, p. 79) Somewhat later, in the
1930s, Peter Maurin and Dorothy Day founded the
Catholic Worker movement. Much like settlement
houses, Catholic Worker Houses were resident commu-
nities where reform-minded laity and members of reli-
gious orders could develop ways of addressing social
problems and share housing, food, material resources,
and companionship with the poor (Oates, 1995).
Jane Addams had close ties to the Chicago Training
School, founded by the deaconess movement of the
Methodist tradition: "Training schools," established in a
number of denominations at the tum of the 20th century,
were the forerunners of schools of social work. These
schools were organized by women who wanted to
express their Christian faith through service but were
denied involvement in established church institutions by
men (Scales, 20bO). There, women received the
education they needed to establish and manage chari-
table institutions, including settlement houses, hospi tals,
schools, and orphanages for the poor in the United States
and throughout the world (Keller, 2001). The courses of
study in these early social work programs included
social science research projects and culminated in
applied clinical experience, followed by field placement
(Myers, 2006), not unlike social work education today.
Congregations as well as social service agencies
were segregated by race in the South until the Civil
Rights legislation of the 1960s. In such a racist culture ,
the Black church and other ethnic minority churches
became major service providers as well as a political and
organizing force for social justice. They provided
opportunities for leadership a~d for affirmation of
personal worth and dignity, as well as social services,
for those in their communities (Deveaux, 1996; Malone ,
1992). Dr. Martin Luther King [r., the most famous and
influential of the many leaders of the U.S. Civil Rights
movement, was a church pastor and based his leadership
in Christian teachings.
Understanding the Causes
of Poverty and Suffering
There are multiple streams of Christian beliefs about the
causes of poverty and suffering that influence the nature
of Christian social services. For example, Chris tian
ideas motivated the Charity Organization Society (COS)
movement and the Social Settlement movement, the
twin roots of the social work profession in the late 19th
and early 20th centuries (Scales, 2000). The COS
writings saw poverty as a sign of personal failing or even
as God's punishment for wrongdoing
284 CHRISTIAN SOCIAL SERVICES

(Amato-von Hemert, 1998). The focus of serving, Congregations and Religiously Affiliated
therefore, was helping-saving individuals from themselves. Organizations Today
Walter Rauschenbusch and Washington Gladden, both Both Christian religiously affiliated social service agencies
pastors, co-founded the Social Gospel movement that and congregations provide social services but are
strongly influenced the Social Settlement movement. They organizationally very different.
reasoned that unjust social structures created poverty and
suffering, and Christians should work to create societal CON GREGA nONS Congregations are aggregates of
structures that would create the "kingdom of God" on earth people that gather regularly and voluntarily for worship at
(Amato-von Hemert, 1998). Just, human, social and a particular place (Ammerman, 1997; Chaves, Konieczny,
economic arrangements ought to be the goal of a Christian's Beyerlein, & Barman; 1999; Warner, 1994; Wind & Lewis,
service, according to both Catholic and Protestant thought 1994). Besides being organizations, the two key
(Coughlin, 1965). Theologian and social activist Reinhold characteristics of congregations in the United States are
Niebuhr challenged social workers not to accept that they are voluntary. and they are communities. People
"philanthropy as a substitute for real social justice" (1932, gather regularly for worship, religious education, and
p. 82). Liberation theologians such as Gustavo Guttierrez simply to be together (often called "Christian
taught that "in a divided world the role of the ecclesial fellowship"), as well as to serve others. Congregations
community is to struggle against the radical causes of social are primary communities with which their members
division" (Murray, 1998, p. 58). Jim Wallis, a Christian identify (Ammerman, 2002). Therefore, not only
evangelical leader in the early 21st century, emphasizes organizational theories but also community theories
social structures as the cause of poverty and suffering, apply in assessing and working with congregations.
referencing the Old Testament book of Micah: "Micah Most congregations are small; 71 % of congregations
knew that we will not beat our swords into plowshares; we have fewer than 100 regularly participating adults. Only
will not overcome war, will not be safe, will not protect our 10% of American congregations have more than 350
families, and will not prevent further wars-or further regular participants. Most participants go to large
terrorism-until more people have their own vines arid fig congregations, however (Chaves, 2004). Obviously, size is
trees" (Wallis, 2005, p. 192). In short, Christian thought critical to the capacity to provide social services. In the
also perceives that persons in poverty and suffering are median congregation with social service programs, about
victims of unjust social and economic systems. 10 individuals are involved as volunteers (Chaves, 1999),
making congregations a significant source of social service
volunteers (Garland, 2003). Moreover, 6% of
congregations have a staff person devoting at least a quarter
of their time to social services (Chaves, 2003), and at least
Christian Faith and Social Services Although some of these congregational staff members are social
awareness of need prompts Christians to serve others, workers. A majority of congregations participate in or
relationship with God also motivates Christian service support social service activity at some level, although only
(Garland, Myers, & Wolfer, submitted-b, Unruh, 1999a, a small minority of them operate their own programs. If
1999b). For Dorothy Day of the Catholic Worker they do have programs, they are likely to be short-term,
movement, service was much more than obligation to God; small-scale poverty relief of various sorts-food and clothes
Christians are to celebrate Christ through actions of love pantries and emergency financial assistance operations
and mercy toward others (Forest, 1995). She believed that (Clerkin & Gronbjerg, 2003). The most typical social
the most radical thing Christians can do is to try to find the service activity of congregations is supporting programs
face of Christ in others, not just those with whom they are operated by other organizations (Cnaan, 2001).
comfortable, but also those who make them uncomfortable. Congregations send volunteers to Habitat for Humanity or
"Those who cannot see the face of Christ in the poor are hiatry, psychology, clinical social work, and theology.
atheists indeed" (Forest, 1995, p. 22). Others have Social work contributions were documented in the early
emphasized that commitment to service to the poor is a way ly work of Mary Richmond in her 1928 book, Concern of.
to communicate to others that God is committed to justice, he Community with Marriage.
especially for persons who are marginalized: "Jesus says 33% with secular organizations to develop and deliver
that such small and seemingly insignificant projects are community service programs (Cnaan, 2001).
actually seeds out of which will come the full-grown
manifestation of the Kingdom of God" (Conn, 1987, pp.
185-186). ZATION IN NONFFILIATED ORGANIZATIONS
"Religiously affiliated" is a more accurate descriptive term

for social service agencies than "faith-based" organ-
izations,because all organizations hold basic beliefs about
ultimate truths that are implied in the term "faith-based"
(Jeavons, 2004). The term "religiously affiliated" connotes
that there is some organizational affiliation with a religious
group. Religiously affiliated organizations (RAOs) are
characterized by one or more of the following variables: (1)
the mission and values of the organization derive from
religious beliefs and practices; (2) the organization identifies
with one or more religious congregations or-other religious
organizations, often expressed in the organization's name
and funding streams; (3) the policies reflect the
organization's religious mission, such as hiring only
persons who are members of a religious group, or requiring
or. inviting
. ,
staff or clients to participate in religious practices; and
(4) the goal of service is that service recipients embrace
religious beliefs and values, and program evaluation
strategies may measure this outcome. Social work as,
sessment in these settings includes learning what it means
for a particular organization to be religiously affiliated
(Garland, 1992, 1994, 1995; Rogers, Yancey, Singletary,
Garland, & Homiak, 2006).
It can be difficult to distinguish between "religious" .
and "community-based" organizations. Many organizations
that may consider themselves "community-based" have
extensive involvement by religious institutions. They may
have originated in church basements and have many church
volunteers engaged because of religious motivation or
conviction. Many secular organizations may have begun as
a religious group.Wineburg's research has found that
congregations are "community spawning grounds for social
change" (2001, p. 141). As one of many examples, Ed
Bacon, Rector of All Saints Episcopal Church in Los
Angeles, initiated one of the first programs caring for
persons with AIDS, which subsequently became
incorporated as a public ministry (Ed Bacon, Personal
Communication, October 14, 1996.)
There is almost no. research to determine how many
private social service agencies are religiously affiliated, or
what proportion of services is being provided by this sector.
A pilot lO-state survey of child welfare agencies found that
30% self-identified as religiously affiliated. Child welfare
has historically been a focus of religious communities in
this country, and in fact, these agencies are larger on
average than their public or private nonsectarian
counterparts (Garland & Gusukuma, 2005).
Funding Sources
Historically, congregations and religiously affiliated or-
ganizations (RAOs) have often worked collaboratively
with nonsectarian and public programs of service, as
CHRISTIAN SOCIAL SERVICES 285
social work, and theology. Social work contributioning
public funding as soon as governments began to support
social services. The orphanage founded in 1727 by
Ursuline nuns in New Orleans received an annual subsidy
from the French government, for example (Baker, 2006).
Government funding of Christian social services is thus
common and long-standing. The Charitable Choice
political initiative at the tum of the 21st century gave public
visibility to the funding of religiously affiliated
organizations and made it possible for congregations to
apply for public monies directly (Chaves, 2003; Garland,
Rogers, Singletary, & Yancey, 2005b; Wineburg, 200l).
In a national research study of urban congregations and
RAGs, 6% of congregations and 24% of RAOs reported
receiving government funds (Garland et al., 2005b). In
contrast with congregations, the IOestate study of child
welfare organizations found that child welfare RAGs
receive on average 47% of their funding from government
sources. Half of the agencies were more than 30 years old;
they had been receiving government funds long before the
faith-based initiative (Garland & Gusukuma, 2005). The
study of urban RAGs found that they are less likely to
receive government funding if they use religious faith as an
explicit requirement in staff hiring (Garland et al., 2005b).
The ability of. RAQs to generate income from sources
other than clients enables them to offer services to clients
who are unable to pay fees and to offer services that may
not be reimbursable from government or insurance
sources. RAGs receive 21 % of their budgets from gifts,
compared to only 5% of the budgets of non-religiously
affiliated services. Religiously affiliated agencies receive
less than half (47%) of their funding from government
sources, compared to more than three-quarters (76%) of
the budgets of non-religiously affiliated organizations
(Garland & Gusukuma, 2005).
RAOs and Congregations
as Social Work Settings
Many RAOs serve as intermediaries between government
and other funders and those congregations that do not have
the infrastructure to make these connections. RAGs are
coupling financial resources with the social capital of
social networks, informal support, and volunteers that
characterize faith communities (Garland et al., 2005b).
Similarly, RAGs connect to children and families that
otherwise are inaccessible to large public agencies
(Belanger & Cheung, 2006). For example, Campbell et at
(2003) found that RAOs working with T ANF recipients
are able to reach and successfully equip some of the
hardest to employ (for example, parolees, recovering
substance abusers, and
286 CHRISTIAN SocIAL SERVICES
thehomeless). Public health professionals have success-
fully collaborated with congregations to increase the use
of early detection health screenings, to teach heart-
healthy eating and exercise, and to promote the cessa tion
of smoking (U.S. Department of Health and Human
Services, 1999). A 2007 study identified the significant
role congregations play in health care in the United
States (Lindner & Welty, 2007).
Often, staff members and volunteers in RAOs state
that they have a high level of personal commitment to
the work because of the religious purpose. Benefits also
go in the other direction, as congregations and RAOs
leverage in-kind services, volunteers as mentors and
foster parents, and neighborhood-based familyresource
programs in congregations \(Garland& Gusukuma,
2005; Garland et a1., 2005b). As illustration, Bennett
Chapel Missionary Baptist Church in Possum Trot,
Texas, population 215, has adopted 69 special needs
African American children. The research team re ported
that although the social worker who provided support to
these adoptive families did not share the religious faith
of the families, she developed cultural competence with
them by attending worship services and learning about
their culture and faith. When the social worker, died, her
funeral was conducted in the congregation she had
served, graced by a choir of the children who had been
adopted through her work (Belanger & Cheung, 2006).
Challenges and Controversies
RAOs and congregations also present some challenges
as contexts for social work practice. Some RAOs have as
a goal that service recipients transform their lives by
embracing religious beliefs and values (Campbell et a1. ,
2003; College of Biblical Studies n.d.; Monsma, 2002;
Myers, 1999; Nelson, 2004; Sherman, 1997, 2002 ;
Sherwood, 2006). Even in RAOs where this is not an
organizational goal, it may be a goal of religiously
motivated volunteers and staff members (Garland,
Myers, & Wolfer, 2005a). Many social workers are
concerned when volunteers and program staff use social
services as an opportunity to attempt to convert clients to
their religious group. Instead of distancing them selves
from these issues, social workers' could help volunteers
learn more effective ways to live their religious faith
without breaching' the self-deterrnination of service
recipients. Volunteers usually have not had the
opportunity to explore what it means to be a client
dependent on service, and the resulting power differen-
tial between volunteer and recipient that makes any
verbal expression of religious faith implicitly a pressure
on the recipient to agree. Breaching another's self
determination is incongruent with many religions'
teachings and practices as well as social work ethics.
For example, Christian beliefs of the soul-freedom of
persons would not support attempts to impose values or
beliefs on others, or to treat them as less worthy because
of their beliefs, choices, or actions (Sherwood, 2002 ).
All host settings for social work practice (for example,
schools, hospitals, the military, and nursing homes)
have the potential for ethical dilemmas for social
workers employed in, or in field placements in, those
settings. In the case of RAOs, those dilemmas may be
related to policies on topics such as gender roles, sexual
orientation, and reproductive rights. Whenever possible,
social workers need to provide leadership to these
organizations as they address these dilemmas,
recognizing that' otherwise, these organizations will
continue to serve clients and communities without such
leadership.
In order to work in these settings, social workers
must develop cultural competency, understanding the
traditions, rituals, teachings, language, values, and
beliefs of the particular organization or community just
as one would in working with an ethnic minority group.
Given the historical ties between social work and
Christian social ministries, and the commitment of
churches and their organization to care for those in need,
developing competence for work in these settings is a
worthy goal for the profession of social work.
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Chaves, M. (2004). Congregations in America. Cambridge, MA:
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Chaves, M., Konieczny, M. E., Beyerlein, K., & Barman, E.
(1999). The national congregations study: Background,
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Religion, 38(4), 458-476.
Clerkin, R., & Gronbjerg, K. (2003, March 6). The role of
congregations in delivering human services. Paper presented at the
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Washington, DC.
Cnaan, R. A. (2001). Keeping faith in the city: How 401 urban
religious congregations serve their neediest neighbors. Phila-
delphia: Public/Private Ventures.
College of Biblical Studies. (n.d.). Faith-based affordable housing
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Conn, H. (1987). A cIa.rified 'llisionfor urban mission: DispeUing
urban stereotypes. Grand Rapids, Ml: Zondervan.
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Forest, J. (1995). What I learned about justice from Dorothy Day.
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Garland, D. R. (Ed.). (1992). Church social work. Philadelphia:
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herwood, D. A. (2002). Ethical integration of faith and social
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stration Research and Theory, 10,3Saving souls, saving society:
The role of evangelism in church-based social ministries. Paper
presented at the Religious Research Association Conference,
Boston, MA.
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doesn't get it. Ne'w York: Harper San Francisco.
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(Eels.), American congregations (Vol. 2). Chicago: University of
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welfare, and social service. New York: Columbia University Press.
FURTIIER READING
Cnaan, R. A., Boddie, S. c., Handy, F., Yancey, G., & Schneider, R.
(2002). The invisible caring hand: American congregations and the
provision of welfare. New York: New York University Press.
Garland, D. R. (2007) Religiously affiliated organizations and the
opportunities and challenges of "faith-based" social initiatives.
Garland, D. R., Myers, D. M., & Wolfer, T. A. (2007) "Learning to
see people as God sees them: Outcomes of community service for
congregational volunteers."
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Westrninster Press.
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faith informs practice informs faith. Social Work & Christianity,
32(1),56-72.
SUGGESTED LINKS
Alban Institute.
www.alban.org
Baylor Center for Family and Community Ministry.
www.baylor.edu/CFCM
Center for Renewal.
www.centerforrenewal.org
Center on Faith in Communities.
www.centeronfic.org
Children's Defense Fund.
www.childrensdefense . org
Christian Community Development Association.
www.ccda.org
Christians Supporting Community Organizing.
www.cscoweb.org
FASTEN Network.
wwwfastennetwork.org
North American Association of Christians in Social Work.
http://www . nacsw. org
-DIANA R. GARLAND
CHRONIC ILLNESS
ABSTRACT: There is a paradigm shift occurring in medicine,
from models focused on treating acute illnesses to those
concerned with managing chronic conditions. This shift
coincides with the higher prevalence of chronic illnesses
resulting from factors such as lower mortality from formerly
fatal illnesses and an aging population. The chronically ill do
not fare well in an acute care model, and as a result, it has
become imperative to develop new models effective for these
chronic conditions. These new care models will require com-
prehensive, coordinated case management, an activity in
which social workers can playa significant role.
KEY WORDS: chronic illness; phase-based interven-
tion; traumatization; coordination of care; persistent
acute illness; aging population; managed care; Fennell
Four Phase Treatment Model; comprehensive case
management; chronicity
History and Context
There is a paradigm shift occurring in medicine. With the
greatly increased prevalence of chronic illness, it has
become imperative to develop new models of care that
will be effective for these chronic conditions. These new
care models will require comprehensive case
management, an activity in which social workers can
playa significant role (Fennell, 2007).
In the past the medical profession has focused
primarily on acute illnesses because they were dra-
matically obvious and had the potential to be cured. Once
an acute disease was diagnosed, doctors could apply
whatever treatment had becom e appropriate, and the
patient either recovered or died. Chronic ill nesses have
always existed, of course, but until the late 20th century ,
most medical practice attended to illnesses that had a
recognizable onset, course, and conclusion.
In this opening decade of the 21st century, however ,
significantly more attention is being paid to chronic
illness. This is largely due to the enormous increase in the
number of people judged to have a chronic illness.
Advances in medicine in the developed world have mad e
it possible to stabilize the condition of many patients with
serious acute illnesses, even though these interventions
may not effect a cure. Examples would be those with
cardiovascular and respiratory conditions, survivors of
stroke and cancer, those with obesity prob lems and
diabetes, and individuals on dialysis. Other patients now
classified as having a chronic illness are the huge cohort
of individuals with a "persistent acute illness" such as
HIV or AIDS. Such patients reclassified
 CHRONIC ILLNESS 289

as having a chronic rather than an acute illness now medicine, but are directly attributable to needs sternming
account for the greatest numbers of thooe with chronic from the chronic illness.
illness. In the less economically developed world, many of Traditional chronic illnesses manifest differently from
these conditions still exist as acute conditions, and it will acute illnesses. They frequently do not have a clearly
take distinct improvements in the health infrastructure of identifiable onset; instead, they are usually a nebulous
those countries to arrive at the situation existing in the collection of symptoms that emerge over time. The
United States. symptoms change; they also ebb and flow, increasing or
In addition, as people in the technologically ad vanced deceasing in severity, sometimes remain ing the same.
world live longer, most individuals will even tually either Often it is not possible to measure the symptoms by
suffer from a traditional chronic illness or survive an acute standard tests or with instruments, and thus health
illness in a condition that requires persistent attention. professionals must rely on the patient's self reporting,
Many will suffer several conditions at the same time. Many which the profession frequently regards as unreliable and
aspects of even healthy old age can resemble those of nonquantifiable. Chronic illnesses also tend to affect
living with chronic illness. Wit h the Baby Boom several different body systems at the same time. The
generation about to enter old impact of chronic illness on patients' physi cal, emotional,
\
age, the numbers of people so afflicted will increase and social life is persistent and affects their reporting,
significantly. compliance, and coping.
There are, therefore, essentially four groups of the Chronic illness patients may suffer traumas in addition
chronically ill: those with the traditional chronic ill nesses to the actual physical manifestations of the ill ness. There
such as multiple sclerosis or lupus; those who survive an is the trauma produced by a prolonged diag nosis period,
acute illness either with lingering symptoms that may be as well as the trauma of the actual onset or diagnosis
recategorized as a new illness or with conditions that -itself, There is the stigmatizing response of family,
require ongoing care, including cardio vascular diseases; society, and workmates as they become frustrated by the
those with persistent acute illnesses such as HIV and unpredictability of symptoms and by chronicity because
AIDS; and the aging population, who present a variety of the patients never "get better" and do not return to
illnesses (Fennell, 2007). fulfilling their previous responsibilities. The chroni cally
ill may also suffer frompremorbid and comorbid traumas.
Prevalence They can also suffer trauma caused by responses on the
In the United States, chronic diseases are the leading cause part of the medical establishment, which can range from
of death and disability (CDC, 2004). Approximately 1.5 impatience to disbelief. Moreover, the re peated exposures
million people (two-thirds of all deaths) die of a chronic to the medical establishment that chronic illnesses
condition such as heart disease, stroke, cancer, and occasion increase the likelihood of such trauma (Fennell,
diabetes. Cardiovascular disease affects about 79 million nd the Prany problems faced by those with chronic
Americans; diabetes, 20 million; kidney disease, 19 Many problems faced by those with chronic
million; Alzheimer's disease, 4 million. Ar thritis and other illness--especially after medical. interventions have
ilward, H. B., & Provan, K. G. (2000). Governing me stabilized their condition-involve reactions to their
state. Journal of Policy Administration Research and condition and its economic consequences. Entire family
10,359-379. patterns often need to be reorganized. Patients may need
ongoing care just to manage the activities of daily living.
fatigue syndrome (CDC, 2002, 2006; Lupus Foundation of Some may not be able to work or can work only at greatly
America, 2006; Na-. tional Multiple Sclerosis Society, reduced hours. Medical costs become an issue, even if
2005). The most common condition in children is asthma patients are covered by medical insurance.
(American Academy of Allergy, Asthma and Immunology, Chronic illnesses affect segments of the population
6). The list goes on. differently. Certain diseases are more prevalent among
About 40%(369 million of 910 million) of all doctor' s women than among men or among different ethnic or
visits in the United States are for chronic conditions, and racial groups (Anderson). In addition, patients' experi ence
the cost of medical care for persons with chronic diseases of chronic illness is differentiated by their gender,
accounts for 78% of the total medical care expenditure in ethnicity, religious or philosophical belief, social and
the nation (Hing, Cherry, & Woodwell, 2006; National economic status, and the geographic region of the country
Alliance for Caregiving and AARP, 2004). And this figure in which they live, with its particular political and
does not include costs that are no~ directly associated with economic environment.
It can be argued that, by their very nature, chro nic
illnesses were, in the past, unsatisfactory for
290 CHRONIC illNESS
professionals to treat because patients were not cured.
They were, at best, maintained, and often not very
satisfactorily. Diseases such as rheumatoid arthritis, lu-
pus, multiple sclerosis, and chronic fatigue syndrome
are among the many that have always been chronic.
Treatment Interventions
Patients with chronic conditions can fare poorly in the
acute-care model of care delivery. Effective care usually
requires longer visits than are common in acute care. In
treating chronic illnesses, the same intervention may
change in effectiveness depending on when in the
course of the illness the intervention occurs. Necessary
interventions can require the input of multiple disci-
plines, interdisciplinary teams, and to be effective, they
\
require dose, careful coordination and active patient
and, at times, family participation (Fennell, 2003).
Historically, there has been little coordination across
the multiple settings, providers, and treatments of
chronic illness care. Several variations of managed care
have emerged in the past decades in an effort to improve
care, reduce unnecessary service u tilization, and control
spiraling costs, but managed care has not achieved truly
coordinated care. In actual operation it appears to
emphasize fiscal goals. Managed care does not address
the complexity of chronic conditions, and, in the inter-
ests of cost-cutting, tends to reduce time with patients
rather than increase it (Ware, Lachicotte, Kirschner,
Cortes, 2000). At the present time, moreover, any care
model must work within Medicare and Medicaid guide-
lines from the federal government and other programs at
the state level, with their documentation and procedural
requirements.
Roles of Social Work
Given the number and types of psychosocial issues that
emerge with chronic illness, social workers have an
essential role to play in the care of patients and their
families.
In the latter part of the 20th century a number of
pioneering researchers began to investigate the special
issues that they found existed in the assessment and
treatment of the chronically ill. Nurse researchers were
often on the front lines of actual care for patients with
ongoing treatments for conditions such as diabetes or
renal failure (Baker & Stem, 1993; Burckhardt, 1987;
Lubkin & Larson, 2002; Wellard, 1998). They
recognized that their patients experienced a trajectory of
"phases," and that during some of these phases the
patients responded quite differently to the same
interventions.
At about the same time, many individuals suffering
from chronic illnesses gave detailed accounts of their
experiences and made significant suggestions about
how to manage living with chronic illness (Register,
1987; Wells, 1998). Associations proliferated for those
with specific conditions (Sjogrens syndrome, peripheral
neuropathy, and so forth), and these groups engaged in
advocacy work, acted as clearinghouses for information,
and began funding research.
Wagner developed a Chronic Care Modelthat pro-
vides . a holistic framework and methodology for trans-
forming health care so that patients receive coordinated
care from a trained interdisciplinary health-care team,
that includes a planned follow-up (Wagner, 1998). The
Stanford Self-Management Program is a community-
based self-management program that helps people with
chronic illness gain self-confidence in their ability to
control their symptoms and manage how their health
problems will affect their lives (Lorig, Sobel, & Stewart,
1999). Partnership for Solutions, a Johns Hopkins and
Robert Wood Johnson collaborative, conducts research
to improve the care and quality of life for individuals
with chronic health conditions (Anderson & Knickman,
2001).
In the late 1970s and early 1980s, stage- or phase-
based models began to be developed. Prochaska and his
colleagues described a model of behavior change as a
process rather than an event (Prochaska, DiClemente, &
Norcross, 1992). They advocated assessment and
treatment based on the patient's stage in the process.
Fennell, working on the experiences of imposed change
(such as illness, grief, or trauma), developed the Fennell
Four Phase Treatment Model (Fennell, 2003).
This work recognized that time itself-. the chang ing
actualities and perceptions that chronic illness patients
have of their illness and the changing interventions
required as time passes-determines how chronic
illnesses can be best managed. The conceptual
frameworks that appear to offer the most promising
results are those that focus on where patients are on a
time continuum-that is, what phase they are in.
Moreover, although the phases were first utilized in
treating patients with traditional chronic diseases such
as multiple sclerosis and lupus, they apply equally well
to those who survive a stroke, manage a persistent heart
condition, or undergo regular dialysis.
To achieve real-life changes in all the domains of a
patient's life requires a comprehensive case manage-
ment approach in addition to clinical treatment (Fennell,
2007). Given their expertise in just such an approach,
social workers have an essential- role to play in the
treatment of chronic illness. As professionals well
acquainted with systems, they are uniquely posi tioned to
help patients comprehend and manage all their
intervention needs and their behavioral and attitudinal
changes. In addition, social workers are attuned
1

to the differences that socioeconomic group, race, eth-
nicity, and gender can add to this mix (Alito, 2007).
One effective treatment model assumes the involve-
ment of multiple body systems in chronic illness and
addresses both the complexity and the chronicity of the
illness (Fennell, Jason, & Klein, 1998). The model
recognizes the involvement of four phases in patients'
lives: crisis, stabilization, resolution, and integration.
Within each phase, four domains of patient experience
are addressed: the physical or behavioral, the psvcholo-
gical, the social and economic, and the philosophical or
spiritual. Without comprehensive understanding that
considers the universe of the chronic condition, it is not
uncommon for a vicious. cycle to occur in which the
patient moves perpetually from crisis to stabilization
\
and back to crisis again. Taking a svstems-based, multi-
disciplinary approach that "maps" the chronic illness
process for both patients and clinical providers, it
matches best medical practice to phase. This enhances
compliance with and effectiveness of treatment, thereby
saving time and resources. The concept that patients'
experience may need to be understood as a function of
the particular phase of the illness has been supported by
research (Fennell et al., 1998; Jason et al., 2000a ,
2000b).
Comprehensive case management is necessary to
continually assess the patient's self-management capac-
ities and provides a "world view" for patients, their
families, and their social .units. Where possible, case
managers train patients to manage their own care. The
work of the case managers also helps clinicians target
resources to current and ongoing problems and
concerns. It. focuses on four areas: disability, treatment
and triage support, psychological support, and matching
intervention to phase.
Disability is an extremely important issue for those
with chronic illnesses, and it is poorly understood by
many in the health-care field. It is incumbent on the case
manager to make a disability assessment, including a
thorough record review, as soon as possible. The case
manager also refers the patient for related legal, medi cal,
and auxiliary social services, as necessary; prepares the
patient and family for medical and psychological
disability assessment; and readies the patient for court
proceedings, if required.
Treatment and triage support proceeds out of pa-
tients' ability to understand their medical situation and to
network with the multiplicity of disciplines necessary to
treat their cases. Psychological support comes in the
form of the manager orienting patients to and educating
them about chronic illness. This support also includes
working to improve patients' agency, returning to them
the locus of control in their lives, making them aware of
and able to deal with societal issues, and developing
J
I
CHRONIC ILLNESS 291
in patients a sophistication with regard to the health
system. Matching intervention to phase alters as patients
negotiate the phases (Fennell, 2003, 2007). In the first,
or crisis, phase where the clinical goal is trauma and
crisis management, the case management goal is to
establish a case management focus. This includes
restructuring the activities of daily living, engaging in
family case management, assisting patients in
navigating the health-care system, intervening in the
workplace if necessary, and acting as the patients'
advocate.
In the second phase the clinical goal is stabilization.
The case management goals are collection of data from
patients and activity restructuring. With the help of the
case manager; patients assess and restructure their
activity levels and develop new parameters and norms.
The case manager continues to help with family case
management, negotiation of the health-care system,
intervention with the employer, and patient advocacy.
The third phase, resolution, has as its clinical goal
the development of meaning and patients' construction
of a "new self." The case management goal is helping
patients develop self-management skills. Patients learn
to monitor their activities, coordinate their medical care,
become their own health-care advocates, and in general
assume advocacy for themselves in the world at large.
Phase four has integration as its clinical goal, and the
case management goal is to deepen patlentsvself-
management skills with established criteria for data
collection and self-monitoring, which is periodically
reviewed by the clinician.
Challenges, Future Trends,
and Ethical Considerations
As chronic illnesses become more prevalent, govern-
ment, the health-care profession, and reimbursement
organizations will need to adapt their policies and prac-
tices to the new chronic illness era. This changing
environment will present significant ongoing challenges
to all concerned-patients, members of the . health-care
professions, government-to achieve arrangements for
health care that are efficient, encompassing, and ethical.
One essential ethical and financial consideration in
chronic . illness management is the phenomenon of
chronicity itself; clinicians and health-care systems
must acknowledge the reality that they will be working
with patients to manage their illnesses and disabling
conditions intermittently across the life span. Although
self-management has often been advocated as a lower-
cost method for management of chronic illnesses, recent
research has shown that self-management has limited
efficacy, and therefore there remains an essential and
ongoing role for clinicians in chronic illness
292 CHRONIC ILLNESS
treatment and management (Griffiths et al., 2007). An
integrated clinical treatment and case management
approach captures the essential elements of experience
that can' determine whether interventions will be
successful. It particularly points to the necessity of solv-
ing problems-familial, social, economic, and philoso-
phical, among others-that are rarely part of the
conventional medical treatment model. Teamwork is
essential among a broad array of different professionals,
all committed to involving the patient whenever possible
in the process (Abramson & Mizrahi, 2003). The case
management approach seems best suited to accomplish
this in a successful, efficient, and ethical manner.
REFERENCES
Abramson, J. S., & Mizrahi, T. (2003). Understanding
collaboration between social workers and physicians:
Application of a typology. Social Work in Health Care, 37(2),
71-100.
Alito, T. A (2007). Pain: How social workers help with pain
management [Online publication]. National Association of
Social Workers. Retrieved http://www.helpstartshere.org/
health_and--, wellness/pain/how _sociaL workers_help/pain_-
_ how _social_ workers_help.html
Anderson, G., & Knickman, J. (2001). Changing the chronic care
system to meet people's needs. Health Affairs, 20(6), 146-159.
Baker, c., & Stem, P. N. (1993). Finding meaning in chronic
illness as the key to self care. Canadian Journal of Nursing
Research, 25(2), 23-36.
Burckhardt, C. S. (1987). Coping strategies of the chronically ill.
Nursing Clinics of North America, 22(3),543-550.
Fennell, P. A (2001). The chronic illness workbook. Oakland, CA:
New Harbinger.
Fennell, P. A. (2003). Managing chronic illness: The Four Phase
Approach. New York: Wiley.
Fennell, P. A (2007). Behavioral health with a CFS perspective:
Delivering care in the new chronic illness era. Paper presented at
the International Association for Chronic Fatigue Syndrome
Biannual Conference, Fort Lauderdale, FL, January 13, 2007.
nnell, P. A, Jason, L., & Klein, S. (-1998). Capturing the .
different phases of the CFS illness. The CFIDS Chronicle, 11
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(2007). How effective are expert patient (lay led) education
programmes for chronic disease? British Medical Joumal, 334,
1254-1256.
Hebert, L. E., Scherr, P. A., Bienias, J. L., Bennett, D. A., &
Evans, D. A (2003). Alzheimer disease in the US population:
Prevalence estimates using the 2000 census. Archives of
Neurology, 60(8), 1119-1122.
Hing, E., Cherry, D. K., & Woodwell, D. A (2006). National
Ambulatory Medical Care Survey: 2004 summary. Advance data
from vital and health statistics, No. 374. Hyattsville, MD:
National Center for Health Statistics.
Jason, L. A., Fennell, P. A., Taylor, R. R., Fricano, G., & Halpert,
J. (2000a). An empirical verification of the Fennell Phases of
the CFS illness. Journal of Chronic Fatigue Syndrome, 6(1),
47-56.
Jason, L.A., Fricano, G., Taylor, R. R., Halpert.]., Fennell, P.A,
Klein, S., et al. (2000b). Chronic fatigue syndrome: An
examination of the phases. Journal of Clinical Psychology,
56(12):1497-1508.
Lorig, K., Sobel, D., & Stewart, A (1999). Evidence suggesting
that a chronic disease self-management program can improve
health status while reducing hospitalization: A randomized
trial. Medical Care, 37, 5-14.
cs and our sense of social and economiChronic illness: Impact and
interventions (5th ed.). Sudbury, MA: Jones and Bartlett.
Lupus Foundation of America. (2006). Introduction to lupus.
Retrieved www.lupus.org
National Alliance for Care giving and AARP. (2004). Caregiving
in the U.S. Available at www.caregiving.org/data/
04finalreport.pdf
National Multiple Sclerosis Society. (2005). Who gets MS?
Retrieved www.nationalmssociety.org.
Prochaska, J. 0., DiClemente, C. c., & Norcross, J. C.
(1992).
In search of how people change: Applications to addictive
behavior. American Psychologist, 47(9),1102-1114.
Register, C. (1987). The chronic iUness experience: Embracing the
imperfect life. Center City, MN: Hazelton.
Wagner, E. H. (1998). Chronic disease management: What will it
take to improve care for chronic illness? Effective Clinical
Practice, 1,2-4. http://www.improvingchroniccare.org
Ware, N. c, Lachicotte, W:S., Kirschner, S. R., & Cortes, D. E.
(2000). Clinician experiences of managed mental health care: A
rereading of the threat. Medical Anthropology Quarterly; 14(1),
2-27-
Wellard, S. (1998). Construction of chronic illness. International
Journal of Nursing Studies, 35, 49-55.
Wells, S. M. (1988). A delicate balance: Living-successfully with
chronic illness. New York: Plenum Press.
SUGGESTED LINKS Chronic illness
workbook. http://chronicillnessworkbook
.com/ Improving chronic illness care.
www.improvingchroniccare.org Partnership
for Solutions.
http://www . partnershipforsolutions. org
-PATRICIA A. FENNELL
CITIZEN PARTICIPATION
ABSTRACT: Citizen participation is a process through which
people served by government and nonprofit organizations can
provide input about how these services are offered. Citizen
participation is particularly beneficial in low-income
neighborhoods. Local control of neighborhood decision
making helps low-income

people and communities of color counter the effects of
economic and social oppression. Social workers can
work with communities to increase their power and
influence in public decision-making. They can also
facilitate the development of leadership and political
skills among agency clientele by creating organizational
structures that encourage their participation in agency
decision-making.
KEY WORDS: client participation; civic engagement;
political empowerment
Defining Citizen and Client Participation
Citizenparticipation can be defined as efforts by residents
of low-income communities to improve the quality of
neighborhood life and advocate for changes in public
policies (Ohmer & Beck, 2006). The term citizen par-
ticipation was used extensively in the 1960s to describe
government-mandated efforts to provide opportunities
for clients to serve on the boards of nonprofit organiza-
tions. However, it is often used more generically to
describe the participation of average citizens in public
decision-making (Richards & Dalbey, 2006). According
to. Putnam (2001), civic participation strengthens the
fabric of community life and enhances democratic
institutions.
Appropriate venues for citizen participation on the
part of social workers are service on public boards or
providing testimony at public hearings (Gamble & Weil,
1995). In addition, a major component of community
organization practice focuses on providing assistance to
community residents or members of marginalized
groups who wish to increase their power and influence
in public decision-making. Research on civic engage-
ment strongly indicates that members of low-income
neighborhoods and communities of color vote less often
and are less likely to participate in local organizations
(Putnam, 2001; Verba, Schlozman, & Brady, 1995).
Consequently, some social workers believe that it is
essential to engage in voter registration and other initia-
tives to increase the political power and influence of
marginalized communities (Piven & Cloward, 2000).
The term client participation is used to describe the
participation of people served by social service agencies
in organization decision-making (Itzhaky & Bustin,
2005). The NASW Code of Ethics states that social
workers should respect a client's right to self-determin-
ation. In macropractice, self-determination is often
interpreted as meaning that people who receive services
should have a collective role in deciding how services
are planned, implemented, and evaluated (Gutierrez,
Parsons, & Cox, 1998; Rose & Black, 1985). To
CITIZEN PARTICIPATION 293
facilitate such participation, government and nonprofit
organizations establish advisory committees or reserve
seats on boards of directors for organization clientele.
Historical Overview
The term citizen participation has its origins in the War on
Poverty during the 1960s (Arnstein, 1969). Program
planners viewed citizen participation as a mechanism for
ensuring the effectiveness of service delivery and
making these services more responsive to people in
need. The participation of clients in community-based
organizations was also intended to train community
leaders as political activists and provide a greater sense
of inclusion in mainstream society for low-income
people (Gittell, 1980). Community Action projects,
funded by private foundations and federal Office of
Economic Opportunity (OEO), were operated through
nonprofit organizations. Some of these organizations
fulfilled government requirements for "maximum feas-
ible participation" by placing residents of poor commu-
nities on their boards of directors.
According to research conducted by Marris and Rein
(1982), OEO program planners made it clear that in
addition to community residents and clients, repre-
sentatives of other local institutions such as religious
leaders, business people, and elected officials were to be
given roles in the decision-making process. However,
engagement in social protest and scattered efforts to
challenge local political elites by some of the Commu-
nity Action agencies reduced public and governmental
support for the programs. In 1967, Congress cut funds
and limited the role of OEO-funded programs to job
creation (Moynihan, 1969).
Linking Citizen
Participation to Empowerment Practice
In the 1970s, some social workers and psychologists
began to look at citizen and client participation as a
mechanism for assisting members of marginalized
groups (for example, people with low incomes, persons
with disabilities, and individuals with mental illnesses)
to overcome personal feelings of powerlessness a nd
oppression (Zimmerman & Rappaport, 1988). This
examination of how to increase the personal and poli-
tical power of service recipients led to the development
of the empowerment model of social work (Rose &
Black, 1985; Solomon, 1976). The development of a
sense of self-competency through skill development and
self-advocacy was an essential component of the model.
Self-advocacy and empowerment are important
components of all types of community practice and
social movement organizing in the 21st century
(Gamble & Weil, 1995).
294 GTIZEN PARTICIPATION
Empowerment-oriented practice requires that service
users work collaboratively with social workers at the micro
and macro levels-in determining interventions, planning
services, and evaluating programs. Inclusion in
decision-making is believed to improve service quality, ensure
that the cultural values of clients are respected, and increase
the likelihood that people will use the service (Parker & Betz,
1996). Another assumption associated with both citizen
participation and empowerment practice is that people
involved in organization decision-making, social action, and
electoral politics become empowered as a consequence of
acquiring leadership 'skills and gaining political influence
(Gutierrez, Parsons, & Cox, 1998).
\
Research on the Effectiveness of Client and
Citizen Participation
There are different opinions about and assessments of the
levels and impact of citizen and client participation at the
agency and community levels. Arnstein (1969) has argued that
efforts to empower community residents and clients by
providing seats on organization boards or establishing
advisory groups have produced varying results, running the
gamut from token representation, manipulation, and
co-optation to community partnership and control. Research
indicates that many government-mandated citizen
participation, efforts have been unsuccessful in transferring
power from established political elites to members of
low-income groups (Gittell, 1980; King, Feltey, & Susel,
1998; Marris & Rein, 1982; Rose, 1972; Silverman, 2003).
Nevertheless, there are numerous examples of successful
community-based, citizen participation efforts (Brody,
Godschalk, & Burby, 2003; Checkoway & Zimmerman, 1992;
Itzhaky & York, 2002; Ohmer & Beck, 2006; O'Neill, 1992;
Zimmerman & Rappaport, 1988). Many of these studies have
also documented that individual participation in social change
is associated with increases in personal feelings of
self-efficacy and empowerment.
( in neighborhood organizations. Administration in Social Work,
Limitations of Citizen and Client Participation
Community or client control of decision-making may not
always produce decisions that are consistent with social work
principles (Hardina, 2004). For example, a community group
may oppose the location of a group home or a shelter for the
homeless in their neighborhood. The, responsibility of a social
worker in such situations is to advocate for the adoption of
alternative plans, ensure that participants have access to
information about all possible options and their consequences,
and in extreme situations refuse to implement the plan or
terminate employment. Other
practice dilemmas related to client and citizen participation are
lack of support by staff members for client involvement in
decision-making, conflicts among various groups involved in
the decision process, and difficulties inherent in finding funds
or political support to enhance services or make community
improvements (Reisch & Lowe, 2000).
Implications for Practice
Citizen and client participation works best when organizations
contain formal structures for participation, have sufficient
funds to increase services, and have staff members who are
ideologically committed to empowering community residents'
and clients (Linhorst.Eckert, & Hamilton, 2005). Clients are
most likely to feel empowered in organizations in which the
administrator empowers staff members by providing
opportunities for professional development, skill training, and
participation in organization decision-making (Gutierrez,
GlenMaye, & DeLois, 1995). In community practice, social
workers often recruit community residents for participation on
public ~d nonprofit boards. They also partnerwith community
groups to prepare testimony for public hearings, conduct
participatory action research, and use strategies and tactics to
achieve social change (Gamble & Weil, 1995). Social workers
can also be involved in acting as advocates for people left out
of organizational and political decision-making processes. In
addition, they can establish coalitions and collaborations that
bring all stakeholders (clients, residents, organization staff,
and government officials) to the bargaining table.
REFERENCES
Arnstein, S. (1969). A ladder of citizen participation. Journal of the
American Institute of Planners, 35(4), 216-224.
Brody, S., Godschalk, D., & Burby, R. (2003). Mandating citizen
participation in plan making: Six strategic choices, American
Planning Association Journal, 69, 245-264.
Checkoway, B., & Zimmerman, M. (1992). Correlates of participation
16(3/4),45-64.
. mmunity Toolbox. (2~06). Encouraging involvement in community
community work. Retrieved November 24, 2006, from
http://ctb.ku.edu/tools/en/chapter_l 006.htm.
Gamble, D., & Weil, M. (1995). Citizen participation. In R. L.
Edwards (Ed.), Encyclopedia of social work (19th ed., pp.
483-494). Washington, DC: National Association of Social
Workers.
Gittell, M. (1980). Limits to citizen participation: The decline of
community organization. Beverly Hills, CA: Sage.
Gutierrez, L., GlenMaye, L., & DeLois, K. (1995). The organizational
context of empowerment practice: Implications for social work
administration. Social Work, 40(2), 249-258.

Gutierrez, L, Parsons, R., & Cox, E. (1998). Empowerment in
social work practice: A sourcebook. Pacific Grove, CA:
Brooks/Cole.
Hardina, D. (2004). Guidelines for ethical practice in community
organization. Social Work, 49, 595-604.
Itzhaky, H., & Bustin, E. (2005). Promoting client parricipation
by social workers: Contributing factors. Journal of Community
Practice, 13(2), 77-92.
Itzhaky, H., & York, A. (2002). Showing results in community
organization. Social Work, 47(2), 125-131.
King, C, Feltey, K., & Susel, B. (1998). The question of partici-
pation: Toward authentic public participation in public ad-
ministration. Public Administration Review, 58(4), 317-327.
Linhorst, D., Eckert, A., .& Hamilton, G. (2005). Promoting
participation in organizational decision making by clients with
severe mental illness. Social Work, 50(1),21-30.
arris, P., & Rein, M. '(1982). Dilemmas of social reform.
omplying with the y of Chicago Press.
Moynihan, D. (1969). Maximum feasible misunderstanding.
New York: Free Press.
Ohmer, M., & Beck, E. (2006). Citizen parricipation in neigh-
borhood organizations in poor communities and its relation-
ship to neighborhood and organizational collective efficacy.
Journal of Sociology and Social Welfare, 23(1), 179-202.
O'Neill, M. (1992). Community participation in Quebec's health
system. International Journal of Health Services, 22(2), 287-301.
Parker, L, & Betz, D. (1996). Diverse parrners in planning and
decision making. Partnerships in education and research.
Retrieved November 24,2006, from http://cru.cahe.wsu.edu/
CEPublications/wrep0133/wrep0133.htrnl.
Piven, F. F., & Cloward, R. (2000). Why Americans still don't vote.
Boston: Beacon.
Putnam, R. (2001). Bowling alone. New York: Touchstone.
Reisch, M., & Lowe, J. (2000). "Of means and ends" revisited:
Teaching ethical community organizing in an unethical
society. Journal of Community Practice, 7(1), 19-38.
Richards, L, & Dalbey, M. (2006). Creating great places: The role
of citizen parricipation. Journal of the Community Development
Society, 37(4), 18-32.
Rose, S, (1972). The betrayal of the poor. Cambridge, MA:
Schenkman,
Rose, S., & Black, B: (1985). Advocacy and empowerment.
Boston: Routledge & Kegan Paul.
Silverman, R. (2003). Citizens' district councils in Detroit:
The promise and limits of using planning advisory boards to
promote citizen participation. National Civic Review,
92(4),3-13. .
Solomon, B.j1976). Black empowerment: Social work in oppressed
communities. New York: Columbia University Press.
Verba, S., Schlozrn:an, K. L, & Brady, H. (1995). Voice and
equality: Civic voluntarism in American Politics. Cambridge,
MA: Harvard University Press.
Zimmerman, M., & Rappaport, J. (1988). Citizen participation,
perceived control, and psychological empowerment. American
Journal of Community Psychology, 16(5), 725-750.
-DONNA HARDIN A
CIVIC ENGAGEMENT 295
CIVIC ENGAGEMENT
ABSTRACT: Civic engagement is the backbone of the
social work profession. Through ou r civic mission, we
have long organized and empowered citizens in com-
mon pursuits to address social, economic, and political
conditions. In the United States, the status of social
and political engagement is of heightened concern,
particularly as emerging research demonstrates a range
of effects. The challenge for social work- is to increase
the capacity of the nonprofit sector to promote and
maximize engagement, especially among low- income
and low-wealth individuals, through theory- driven,
evidence-based interventions.
KEY WORDS: civic engagement; political action; vol-
untary action; volunteer; inclusion; institutional ca-
pacity; civil society; nonprofit organizations;
community
In the social work profession, community participation,
active citizenship, social capital, and voluntary action are
different terms that. are often used to refer to similar
aspects of citizen life, that is, citizens' involvement in
public activities that affect the individual as well a s the
common good. Civic engagement is a contemporary term
used by a number of scholars, both within and outside of
social work, to refer to a broad range of social and
political actions. "Civic" pertains to the public arena,
connoting public benefit. It harks us back to the Greek
polis, where city-states were organized around the vote
and contribution of independent citizens. "Engage ment"
connotes action, which in this case aims to affect the care
or development of others and influence public
decision-making and resource distribution (Brint & Levy,
1999).
Civic engagement is the backbone of the social work
profession. From the voluntary action of the "friendly
visitors" to the political advocacy ofjane Addams and the
suffragists to today's volunteer- driven nonprofit
organizations, social workers have long organized citi zens
in common pursuits. We have also worked to ameliorate
or prevent living conditions that hamper civic
engagement, be it poverty or lack of social rights and
knowledge. These efforts at promoting civic life and a
vibrant civil society have far-reachingconse quences.
Caring for one's neighbor, volunteering, con tributing
philanthropically, and voting are not isolated behaviors. If
large numbers chose not to engage in them, the status of
democracy, civil society, and communi ties would be
affected.
A growing body of evidence demonstrates a range of
positive outcomes at the individual, community, and
societal levels that ensue from civic action. In an
296 CIVIC ENGAGEMENT
expansive review, Morrow-Howell (2000) finds that older
adults who volunteer have higher perceived well-being and
life satisfaction, and may also be healthier and live longer.
Youth who volunteer are found to have higher self-esteem
and better job skills and may be more likely to be civically
engaged in other ways, and this is especially true for youth
from disadvantaged circumstances (Corporation for
National and Community Service [CNCS], 2007a; Pritzker
& McBride, 2006). Volunteers and philanthropic
contributors increase the capacity of nonprofit
organizations, which provide crucial services that benefit
the public. Civic action also promotes .collective identity
and cohesion, and may even spur economic prosperity and
justice (Putnam, 1993, 1996, 2000) . .,
In the following, the status of civic engagement in the
United States is presented. It is beyond the scope of this
entry to address civic engagement worldwide, even though
it is of concern to an increasingly international profession.
On the basis of the status of civic engagement and its place
in the profession, two challenges are discussed for
promotion of civic engagement: inclusion of all citizens,
especially those of iow income and low wealth, and
capacity building of the nonprofit sector. The implications
for social work are then addressed, focusing on the
development and application of evidence.
Demographics
Civic engagement is a complex construct, which actually
includes civic knowledge, skills, attitudes, and behaviors.
This entry focuses on civic behavior. Knowledge, skills,
and attitudes are requisites of behavior, but behavior is the
indicator of choice when assessing status. For clarity, civic
engagement is divided into two spheres of action, social
and political, based on the arena of performance and
impact (McBride, Sherraden, & Pritzker, 2006). Social
engagement includes actions that connect individuals to
others and that relate to care or development (Wuthnow,
1991). Behaviors in the social sphere include acting as a
member of, donating or contributing to, and volunteering
for an individual, group, association, or nonprofit
organization. Political engagement includes those
behaviors that influence the legislative, electoral, or
judicial process such as voting and advocacy at the local,
state; and national levels.
SOCIAL ENGAGEMENT In the United States, attention
to social engagement is flourishing. From Putnam's origi-
nal claim in the late 1990s that we are "bowling alone" to
the much discussed spike in volunteering and philanthropy
following the events of September 11, 2001, and Hurricane
Katrina, voluntary action is emphasized as the glue of
society. And when Putnam's claim is paired
with the statistics mentioned later, present generation
Americans are considered to be less civically engaged
overall than were previous generations. However, a
cautionary note is warranted: as scholars we can never be
too sure whether civic engagement overall has decreased
or whether our measurement has not kept pace with the
development of new forms of engagement
(Skocpol & Fiorina, 1999). .
Since 2002, the federal govemmenthas tracked the
levels of volunteering at the national level. On average,
almost 30% of individuals volunteer in the United States,
and recent data suggest that asmall, yet significant decline
in this rate is occurring (CNCS, 2007b). Philanthropic
contributions have experienced a similar blip as we head
into the latter part of the decade, although the $10 trillion
transfer of wealth is still much anticipated .. But who
engages, for how long, and in what forms differ
measurably by age, educational level, income, and race and
ethnicity, and this begs questions of how to intervene.
Consistently, older adults volunteer more hours per
year than does any other age group (U .S. Department of
Labor, 2005). A range of studies has found that young
people have increased their volunteering since the late
1990s, although at fewer overall hours per year and in
shorter stints through episodic volunteering as well as
intensive service programs (Helms & Marcelo, 2007; U.S.
Department of Labor, 2005). Those with less education
and income and those who are of minority group status are
less likely to be socially engaged across a range of
measures, including volunteering and philanthropic
contributions.
This is not to say, however, that they are not civically
engaged. McBride, Sherraden, and Pritzker (2006) suggest
that. informal voluntary action at the community level may
be more prevalent among these groups but less measured
on surveys. These groups may also tithe through their
religious congregations but not consider this philanthropic
giving, thus eliminating them from counts. Nevertheless,
these remain civically disenfranchised groups on
traditional measures.
ate practice. The expansion ofat disconcerting, there are
are a number of active efforts to increase volunteerism (for
example, Points of Light Foundation recruiting 500,000
new domestic volunteers and the Brookings Institution
doubling the number of international volunteers by 2010).
Anecdotally, it is believed that the forms of organized
voluntary action are proliferating, especially those that are
ts to specifically identify the numbers and profiles of
private independent practitioned civic service) (McBride,
Sherraden, Benitez, & Johnson, 2004).

POLITICAL ENGAGEMENT As an industrialized nation,
the United States ranks among the lowest in voting by
eligible voters at just over 60%. According to the U.S .
Census Bureau (2006), the voting rate in presidential
elections experienced a peak in 2004 at 64%. In the
years without a presidential election, federal- level
voter rates can be as low as 35%, while local-level
elections may tum out only 25% of eligible voters.
Consistent with correlates of social engagement,
. older citizens and those who .are not of color but are
higher educated and have more income are more likely
to vote. In fact, the voting rate for citizens aged 55 and
older was 72% in the 2004 presidential election, corn-
pared with 47% among 18~ to 24~year~0Ids.
Other measures of political engagement reflect po-
litical party activity and advocacy around social, eco-
nomic, and political issues. For example, an emerging
form of political action is "buy-cotting" or using one's
dollar to express opinion. The demographic for these
behaviors is similar, except that research finds that
minority youth, specifically, tend to be more politically
engaged across most measures than their white counter-
parts (Lopez et a1., 2006). This will be a trend to watch
with shifting national demographics.
Social Justice Issues
Paramount among these statistics is the lack of parity in
civic engagement across all citizens: those who are
socially and economically disadvantaged are generally
civically disenfranchised as well. As research demon-
strates positive effects for those who are engaged, it is a
justice issue as to whether opportunities to engage are
equally available to all groups (McBride, 2005). A
primary concern for social workers is how to promote
access to civic action among those who have the interest
and desire to be engaged. There are a range of
engagement predictors and chief among them may be
issues of access and incentives.
Time constraints are commonly noted as limiting
volunteering. In the previously mentioned study
(McBride, Sherraden, & Pritzker, 2006), a 32~year~ old,
low-income, single mother of two stated, "I try to be
involved in the community. But I have to work two jobs
to make my ends meet, so I'm not as involved as I would
like to be." It has also been found that the amount of time
spent in daily transportation is related to lower rates of
volunteering (CNCS, 2007b), especially for some who
use public transportation. Lack of time, conflicting work
schedules, and disability are the commonly cited reason s
for not voting (U.S. Census Bureau, 2006). Flexible
opportunities may be needed. For example, family-based
volunteering is an emerging innovation (Family
Strengthening Policy
OVlC ENGAGEMENT 297
Center, 2006). This includes group projects on the
weekend or "Big Family" approaches to Big Brothers or
Big Sisters. Also, there is a need for an increase in
Web~based or technology-based volunteerism, such
that projects can be completed or services delivered
through technology in one's home (see http://www.
onlinevo lunteering.org/ for example).
Moreover, an overarching predictor of volunteering
and philanthropy is that those who do were "asked" to do
so. It has also been demonstrated by a range of studies
that people become involved when they are informally
asked or informed about opportunities by family,
friends, and coworkers, in particular. Inclusion in formal
outreach also matters, in that mirroring oc curs when the
advertised civic actors look like the populace and not
just majority groups.
Challenges
Inclusion issues relate strongly to structural disad-
vantage, and raise an important critique of this litera-
ture: how much more can the poor-or even the
nonpoor-be expected to do among family and ern-
ployment responsibilities? There is a strong argument
that without their civic empowerment, however, their
interests and their skills are not integrated into develop-
ment and public action. This has long been the point of
community organizing as well as economic
development. Promoting civic engagement is about
empowerment.
The nonprofit sector has evolved into the primary
mobilizer of the citizenry with social work at the center.
The capacity of the sector and the profession is ex-
panded through resources as well as innovation. It takes
staff to manage volunteers, and staff requires funding.
Volunteer management is yet to attain the status in the
profession that it deserves (as an example, there is one
article in Social Wark Abstracts on "volunteer manage-
ment" specifically). Skilled volunteer managers with
dedicated time to create opportunities and conduct
outreach help to leverage engagement. Recent research
suggests that the current decrease in volunteering may
be attributable to a lack of meaningful volunteer tasks,
supervision, and support (CNCS, 2007b). As govern-
ment and philanthropy call for greater civic engagetnent
by the populace, attention is warranted on the staffing,
which can effectively channel an influx of volunteers to
meet society's most pressing needs.
As for political engagement specifically, large- scale
economic development would quite likely go far in
empowering a stake in society (Sherraden, 1991), but so
would policies and efforts to promote voter registra tion
and extended voting times and educational campaigns
to increase knowledge of policy issues and influence
the political process. It is common knowledge
298 OVIC ENGAGEMENT
that the capacity of the sector to respond is constrained in this
area, because many nonprofit organizations believe that they
are prevented from advocating or will alienate potential
donors if they do so.
Implications for Social Work
Given these contextual challenges regarding inclusion and
capacity, there are opportunities for social work to claim its
civic mission and have a marked effect on the status of civic
engagement (McBride, 2005). The following outlines possible
strategies.
DEVELOPMENT OF THEORy-DRIVEN EVIDENCE The
evidence base on civic engagement has grown markedly since
the 1970s, especially since the mid1990s. The evidence that
exists is largely atheoretical and descriptive, which does help
us understand the scope and nature of the phenomenon, but
theorydriven interventions subjected to rigorous designs are
now needed. If the statistics are true, interventions that focus
on those who are excluded and that address the justice and
capacity challenges are needed. In addition to flexibility and
incentives as noted earlier, information and skill-building are
key (Verba, Schlozman, &
Brady, 1995). .
CIVIC OUTCOMES OF SOCIAL WORK INTERVEN-
TIONS Social and economic development interventions have
long considered civic engagement a means and an end.
Promoting civic engagement and better understanding its
predictors mean considering it an intervention as well as an
outcome of other social work interventions (McBride, 2005).
For example, if developing social networks among those who
are depressed reduces their symptomology, then involvement
in civic efforts may be a viable intervention.
CIVIC ENGAGEMENT ACROSS THE LIFE COURSE Few
scholars or practitioners are thinking about civic engagement
across the life course, but social workers are experts on the
young and the old and it is our scholars who are calling for this
view (Morrow-Howell & Tang, 2007). Blanket approaches
are most likely not effective. For example, baby boomers
desire long-term, meaningful, skill-based volunteering and
youth desire shortterm, project-based service that develops
their skills while making an impact. A view across the life
course also means thinking of the civic trajectory of our youth.
Primary, secondary, and postsecondary schools as well as
national and international service programs implement
strategies based on the premise that young people should be
involved in the community in order to learn
about it and their civic role (McBride et al., 2004 ).An
opportunity for social workers to meet needs while' training a
civic generation is to partner as sites for these experiential
programs or service-learning courses (McBride, Pritzker,
Daftary, & Tang, 2006).
To be sure, there are challenges to understanding the status
of engagement in America and we may not have the correct
measurement, but if the current statistics are any indication of
reality, interventions are needed. Civil society and civic life
tend to be the parlance of political scientists, educators, and
public administrators, although it is social work that is primed
to claim this field. We are a large portion of the nonprofit
sector; we are on the front line of every major social,
economic, health, and mental health issue; we have as a
mission the empowerment of the poor and disadvantaged; we
think systemically. The status of democracy and civil society
can be affected by the institutionalization of civic engagement
across the profession.
REFERENCES
Brint, S., & Levy, C. S. (1999). Professions and CIVIC engagement.
In T. Skocpol & M. P. Fiorina (Eds.), Civic engagement in
American democracy (pp. 163-210). Washington, DC:
Brooking Institution Press.
Corporation for National and Community Service. [CNCS].
(2007a). Leveling the path to participation: Volunteering and civic
engagement among youth from disadvantaged circumstances.
Washington, DC: CNCS, Office of Research and
Policy Development. .
Corporation for National and Community Service. [CNCS].
(2007b). Volunteering in America: 2007 city trends and rankings.
Washington, DC: Corporation for National and Community
Service, Office of Research and Policy Development.
Family Strengthening Policy Center. (2006). Family volunteering:
Nurturing families, building community (Policy Brief No. 17).
Washington, DC: National Human Services Assembly.
Helms, S. H., & Marcelo, K. B. (2007). Youth volunteering in the
states: 2002-2006. College Park: University of Maryland,
CIRCLE.
Lopez,M. H., Levine, P., Both, D., Kiesa, A., Kirby, E., &
Marcelo, K. (2006). The 2006 civic and political health of the
nation: A detailed look at how youth participate in politics and
communities. College Park: University of Maryland, CIRCLE.
McBride, A. M. (2005, September). Claiming the civic mission of
social work: Toward inclusion, capacity building, and evidence. Fall
2005 academic convocation address, George Warren Brown
School of Social Work, Washington University in St. Louis.
McBride, A. M., Pritzker, S., Daftary, D., & Tang, F. (2006).
Youth civic service: A comprehensive perspective. Journal of
Community Practice, 14(4), 71-90.
McBride, A. M., Sherraden, M., Benitez, c., & Johnson, E.
(2004). Civic service worldwide: Defining a field, building a

knowledge base. Nonprofit and Voluntary Sector Quarterly,
33(4),8S-21S.
McBride, A. M., Sherraden, M. S., & Pritzker, S. (2006). Civic
engagement among low-income and low-wealth families:
In their words. Family Relations, 55, 152-162.
Morrow-Howell, N. (2000). Productive engagement of older
adults: Effects on well-being [Report]. St. Louis: Washington
University, Center for Social Development.
Morrow-Howell, N., & Tang, F. (2007). Youth service and
elder service in comparative perspective. In A. M. McBride
& M. Sherraden (Eds.), Civic service worldwide: Impacts and
inquiry (pp. 157-180). Armonk, NY: M.E. Sharpe.
Pritzker, S., & McBride,A. M. (2006). Service-learning and
civic outcomes: From suggestive research to program
models. In K. M. Casey, G. Davidson, S. H. Billig, & N. C.
Springer (Eds.), Advancing knowledge in service-learning:
\ .
Research to transfarm the field (pp, 14-44). Greenwich, CT:
lAP.
Putnam, R. D. (1996, Winter). The strange disappearance of
civic America. The American Prospect, 24, 34-48. http://epn.
org/prospect/24/24putn.html
Putnam, R. D. (2000). Bowling alone: The collapse and revival of
American community. New York: Simon & Schuster.
Sherraden, M. (1991). Assets and the poor: A new American
welfare policy. Armonk, NY: M.E. Sharpe.
Skocpol, T., & Fiorina, M. P. (1999). Making sense of the civic
engagement debate. In T. Skocpol & M. P. Fiorina (Eds.), Civic
engagement in American democracy (pp. 1-26). Washington,
DC: Brookings Institution Press.
U.S. Census Bureau. (2006). Voting and registration in the
election of 2004. Washington, DC: Author.
U.S. Department of Labor. (2005). Volunteering in the United
States, 2005. Washington, DC: Author.
Verba, S., Schlozman, K. L., & Brady, H. E. (1995). Voice and
equality: Civic volunteerism in American politics. Cambridge, .
MA: Harvard University Press.
Wuthnow, R. (1991). Acts of compassion: Caring for others and
helping ourselves. Princeton, NJ: Princeton University Press.
SUGGESTED LINKS
Brookings Institution Initiative on International Volunteering
and Service.
http://www.brookings.edu/global/volunteer/volunteer_hp.htm
Center for Information and Resources on Civic Learning and
Education (CIRCLE), University of Maryland.
http://www.civicyouth.org/
Center for Social Development (CSD), George Warren
Brown School of Social Work, Washington University in St.
Louis. http://gwbweb.wustl.edu/csd/service/index.htm
Corporation for National and Community Service. http://www .
nationalservice .gov/about/role_impact/performance_ research.
asp
Points of Light Foundation.
http://www.pointsoflight.org/
United Nations Volunteers World Volunteer Web.
http://www . worldvolunteerweb .org/
-AMANDA MOORE McBRIDE
QVIL LIBERTIES 299
CIVIL LIBERTIES .
ABSTRACT: Civil liberties refer to certain freedoms granted to all
citizens. They have been established as bills of rights in the
constitutions of such countries as the United States, India, South
Africa, and Great Britain. Civil rights differ from civil liberties in
that the former are expressed in statutes enacted by legislative
bodies. Civil liberties limit the state's power to interfere in the
lives of its citizens, whereas civil rights take a more proactive role
to ensure that all citizens have equal protection. Civil liberties are
most endangered during national emergencies when governments
infringe on individual liberties to safeguard the nation.
KEY WORDS: civil rights; Fourteenth Amendment; bill
of rights; constitution; international civil liberties;
role of social workers
A bill of rights is what the people are entitled to
against every government on earth, general or par-
ticular; and what no just government should refuse or
rest on inference.-Thomas Jefferson.
Introduction
Civil liberties refer to certain freedoms guaranteed to all citizens.
In the United States, civil liberties are rooted in the Bill of Rights,
which are the first 10 amendments to the federal Constitution.
These liberties include freedom of speech, of religion, of
assembly, and of the press (First Amendment), and they
provide for the separation of church and state (First
Amendment). They safeguard us from unreasonable search
and seizure (Fourth Amendment), and they place restrictions
on the state's ability to act against us without due process of
law (Fifth through the Eighth Amendments and the Fourteenth
Amendment). State constitutions also provide for civil
liberties; however, the focus of this note is on the federal
Constitution ..
The concepts of civil liberties and civil rights overlap, but
they are not synonymous. Civil rights are expressed in statutes
enacted by legislative bodies for the purpose of protecting
citizens from discrimination based on such characteristics as
race, gender, disability, and sexual orientation or -of
protecting certain rights such as the right to vote. Civil
liberties limit the state's power to interfere with our lives,
whereas civil rights highlight a positive role the state assumes
to ensure equal protection to all citizens regardless of specific
characteristics.
300 CIVIL LIBERTIES
The Birth of Individual
Liberties in the United States
The federal Constitution was drafted in 1787. It estab-
lished the executive, legislative, and judicial branches of
the government, and it described the powers granted to
each. However, the Constitution was flawed because it
did not include any declaration of individual rights.
Stated otherwise, it did not impose limits on the feder al
government to interfere with the individual. Four years
would pass before the Bill of Rights was adopted and the
colonists had assurance that the freedoms they had won
from the autocratic English crown would not be taken
away by their newly created government.
Originally the Bill of Rights was binding only on the
federal government. This allowed the states to enact
legislation limiting freedoms guaranteed by the national
government. Thus, although emancipation ended
slavery, there was resistance in some southern states to
grating full citizenship to Black residents. Resistance
took different forms, including Jim Crow laws, named
after an antebellum minstrel show character, which
created a caste system based on race. Congress had to
enact legislation before the federal government could
intervene to ensure that the states did not undermine the
rights guaranteed by the federal Constitution. In 1866,
Congress passed a Civil Rights Act, codified in 1868 as
the Fourteenth Amendment to the Constitution. The
Fourteenth Amendment includes the phrase: "No State
shall make or enforce any law which shall abridge the
privileges or immunities of citizens of the United States;
nor shall any State deprive any person of life, liberty, or
property, without due process of law; nor deny to any
person within its jurisdiction the equal protection of the
laws."
International Civil Liberties
Some countries that emerge after a struggle to overcome
a colonial past, such as the United States, South Africa,
and India, develop bills of rights to assure their citizens
that they are protected from the tyrannies that
characterized their colonial past. Some countries do not
have a bill of rights, and others, such as Great Britain,
did not develop a written bill of rights until the dawn of
the 21st century, when the Human Rights Act gave
British citizens their first unambiguous statement of
their basic legal rights. A bill of rights is significant . It
empowers the individual to sue the government if it tries
to limit the rights expressly granted; it also limits the
power of a legislative body to pass a law that conflicts
with clearly established individual rights.
Curtailing Civil Liberties
Civil liberties are most endangered during periods of
national emergency when the government claims that
it must act in ways that threaten individual liberties in
order to safeguard the nation. This happened during the
Second World War when Congress enacted legislation
that provided for the interment in concentration camps
of Japanese people living in certain parts of the West
Coast. Interment was sanctioned by the U.S. Supreme
Court as a legitimate exercise of the government's power
even though two-thirds of the Japanese people interred
were U.S. citizens whose loyalty to the country was not
questioned. According to the majority opinion, its deci-
sion was not race-based but due to the impossibility of
separating the loyal from the disloyal Japanese.
Since the attacks on the World Trade Center in New
York City on September 11, 2001, civil liberties . groups
have questioned some of the methods used by the federal
government in its war on terrorism out of a concern that
individual liberties have been unnecessarily constrained.
The questioned methods include (a) the treatment of
detainees at Guantanamo Bay, Cuba; (b) the
government's increased powers of surveil lance under the
Patriot Act and the Reform and Terrorism Prevention
Act of 2004; and (c) the order signed by President
George W. Bush in December 2005, authorizing the
National Security Agency to eavesdrop, without judicial
warrants, on the overseas electronic communications of
U.S. citizens and foreign nationals in the United States.
Those who question government acts face a conun-
drum since the government often claims that revealing
why certain actions have been taken would itself jeop-
ardize national security. The strength of civil liberties
lies in the ability of citizens to challenge in public fora,
in the press, and in a court of law the actions taken by the
government.
The Role of Social Work Professionals
As professional social workers we are bound by our
code of professional ethics to be informed of national
events that may have an impact on the profession and on
the clients that we serve. There are many ways to help
our clients when their civil liberties are threatened or de-
nied, including the following: (a) working with profes-
sional organizations such as the National Association of
Social Workers, (b) working with advocacy groups that
represent the interests of our clients, (c) testifying at
legislative hearings, (d) collaborating with other
professionals such as attorneys and local legislators, and
(e) engaging in acts of peaceful civil disobedience.
FURTHER READING
Washington, H. A. (Ed.). The writings of Thomas Jefferson:
Being his autobiography, correspondence, reports, messages,
addresses, ana other writings, official ana private (9 vols., pp.
1853-1854).

Hale, B. (2006). Understanding children's rights: Theory
and practice [Family court review]. Fourth Annual World
Congress on Family Law and Children's Rights [Special
issue], 44, 350-360.
Executive Order No. 9066, 7 Fed. Reg. 1407 (February 19,
1942); Act ofMar~h 21,1942,56 Stat. 173.
Korematsu v, United States, 65 S. Ct. 193 (1944). Three
Justices dissented in part by recognizing that the
decision to excludejapanese, but not Italian- or
German-Americans, was a race-based extension of the
prejudice that Japanese citizens had repeatedly faced.
-THEODORE J. STEIN
CIVIL RIGHTS
ABSTRACT: Civil rights are rooted in the English laws
that tried to protect citizens from abus es by the state.
As the United States matured as a democracy, so did its
citizens. Since World War II, there has been a virtual
explosion in the awareness of. citizens to the diverse
needs and rights of individuals that require protection.
Citizen awareness and actions have truly moved the
civil rights struggle beyond a focus on color. Greater
attention is being paid to fundamental protection. and
expanded understanding of human rights and
responsibilities.
KEY WORDS: civil rights; equality; discrimination;
social justice; diversity
Civil rights protect the individual from arbitrary abuses by
the state or other people. Basic rights of citizens are
identified in the Bill of Rights of the Constitution of the
United States. During the past 200 years, the pas sage of
several amendments has enabled a greater num ber of
individuals previously not considered to be full members of
the society to share in the advantages of citizenship, a
privilege previously reserved for White me n. The history of
the United States and the subse quent expansion of civil
rights reflect a number of efforts to extend civil liberties to
several oppressed groups: women, African Americans,
Hispanics, American Indians, other people of color, gay
men, lesbians, people with disabilities, unborn children,
and others.
Civil rights are intended to act as a protection to ensure
that people-regardless of race, creed, color, phvs-
icallimitations, or gender or other characteristics-- are
treated fairly and are not discriminated against. In addi tion,
civil rights have also protected individuals from artificially
established forms of discrimination that pre vent access to
opportunities to meet the basic needs and privileges offered
to others in society
CIVIL RIGHTS 301
Background
m was developed in the Roman the United States reflects
that have given impetus to changes attempting to ensure
that all people are treated fairly in their normal intercourse
with other citizens and with the governmen t. The early
history of the United States is marked by several notable
examples of resistance to infringe ment on the rights of the
individual. Mayflower passengers and later the victims of
the Bunker Hill massacre were among the earliest
advocates of civil rights. Even tually, the American War of
Independence led to the establishment of strong principles,
which were to provide a springboard for the attainment of
civil rights for classes of citizens who had been ignored by
the founders, who enslaved people; denied women rights;
and advocated the killing of American Indian men, women,
and children.
ORIGINS IN ENGLISH LAWS The concept of civil rights
in the United States has its origins in English laws that
concern the protection of the individual from abus es by
the state. These laws have given the United States a
background and tradition that have emphasized
protecting the rights of the individual from the actions
of any force attempting to discriminate against or op-
press citizens. The idea of individual r ights helped to
force the development of the Magna Carta of England
under King Johnin 1215 (Bums, Ralph, Lerner, &
Meacham, 1986), under its provisions,
No freeman shall be taken or imprisoned or
diseased (dispossessed) or exiled or in any way
destroyed, nor will we go upon nor send upon him,
except by the lawful judgment of his peers or by the
law of the land .... To no one will we sell, to no one
will we refuse or delay rights or justice
The Magna Carta determined that no individual could be
imprisoned or have property taken without legal sanction.
In 1689 the English Parliament adopted the Dec laration
of Rights and Liberties, which extended rights to protect
the individual. The act prohibited excessive fines and cruel
or unusual punishment, guaranteed the right to a jury trial
with impartial jurors, prohibited fines or forfeiture of
liberties unless an individual was convicted, guaranteed
rights to petition the king and speak freely, and denied the
king the right to suspend or levy taxes without approval of
Parliament. In 1694 these rights were extended to subjects
in British colonies.
The principles enunciated in the Magna Carta pro vided
the foundation of the legal system that currently operates in
the United States and in England, and they provided the
foundation on which U.S. civil rights are
302 CML RIGHTS
founded. The English people who founded the original
13 colonies did so as an act of protest against the
capricious behavior of the king of England, but they did
not fare so well as colonists either. Not only were the
colonists taxed without representation, but also limits
were placed on their right to free speech, their right to
bear arms, and their right to elect people of their choice
to represent them. These 'conditions led to the fight for
independence. But the principles were so powerful that
they have been adopted by the men and women enslaved
by the colonists and generations of their descendants,
who even today resist efforts to limit individual
freedom.
Civil Rights in the United States
Civil rights laws in the United States have been created
and revised as a means of protecting citizens from the
abuses of the government and people who regard them-
selves as superior because of their race, gender, class, or
other ascribed indicator of privilege. Civil rights are
expected to protect citizens from biased treatment under
the law, regardless of race, gender, age, national origin,
or religion. It is generally agreed that basic civil rights
include voting, equal employment opportunities, equal
education, and equal treatment in the acquisition of
housing and the use of public accommodations.
Although these principles seem rather simple on the
surface, they have been difficult to implement. During
the past 200 years, the history of the United States has
been dominated by the civil rights issues shaping the
thinking and behavior of citizens. Following the Amer-
ican Revolution, a young United States was forced to
make major decisions about who were citizens and what
protections and privileges they should have. These civil
rights have continued to be at the forefront of American
political thought, encompassing not only race and
gender but also sexual orientation, physical conditions,
language, and other concerns.
LIBERTY AND EQUALITY Principles of liberty and
equality were among the many revolutionary ideals
that shaped the philosophy of the early Americans
and their struggle for independence. These same
ideals were later to revisit the founders as they
grappled with the question of slavery and later
generations as they grappled with the question of the
rights of women.
Before the Revolutionary War could be concluded,
leaders had to make decisions about slavery. The men
who signed the Declaration of Independence and
framed the Constitution were forced to confront the
contradictions imposed by owning slaves at the same
time they espoused language and values in support of
freedom, democracy, and the pursuit of happiness.
Eventually the men who had the greatest influence were
those who convinced others that slavery was necessary.
This decision meant that freedom and rights enjoyed by
White men were not to be extended to the enslaved
men, women, and children of African descent. These
sentiments were to guide the laws and practices of the
United States until well into the 20th century. Racist,
sexist, and homophobic policies and practices were the
result of this legacy of the subordination of others until
abolitionists defended the civil rights issues in the 19th
century and advocates of women's rights did so in the
dawn of the 20th century.
FUNDAMENTAL HUMAN RIGHTS The individual's
claim to privacy and the right to bear arms were also
protected by civil rights enunciated in the Constitu-
tion. Constitutional rights also ensure the
individual's authority to vote and to have access to
public accommodation. For many groups the civil
rights struggle has emerged more as a conflict over
fundamental human rights, rather than the legal
authority granted to all citizens. Such was the case of
African Americans, who were victimized by t heir
enslavement before the Emancipation Proclamation
and the Jim Crow era that defined Black and White
relations following Reconstruction and beyond. The
idea of the civil rights struggle being a fight for human
rights seems true also for American Indians, who were
victimized by genocide efforts before, during, and after
the American.War of Independence. The massacres at
Sand Creek and Wounded' Knee (Brown, 1971)
indicate the atrocities that the native people had to face
in a nation that has since become an advocate of human
rights throughout the world. Further, the idea of a
struggle for human rights is reflected in the ongoing
efforts of women to be recognized as people who
should be judged by their character and productivity,
rather than by their gender. This concept is also shared
by proponents of the civil rights of gay men and
lesbians, as well as people with disabilities.
18TH AND 19TH CENTURIES In the 18th and 19th
centuries, civil rights were privileges accorded only
to White men. During these ye ars, some of the most
infamous atrocities in the history of the United
States occurred. People of color throughout the
United States experienced all kinds of abuse. In
addition to the violence and physical abuse suffered
by African Americans, Native Americans suffered
death and genocide in massacres by American
troops in the West (Brown, 1971), and Asian
immigrants from China and Japan
...

suffered abuse while they provided the backbone for the
labor that helped build the West (Kitano, 1980).
AMERICAN INDIANS For American Indians the 19th
century was a period in which their civil rights struggle
consisted primarily of staying alive. The years following .
the Civil War in the United States were tragic ones for the
Indians of the Plains as they were systematically removed
from their lands either by treaties or by war. The Sand
Creek Massacre and Wounded Knee demonstrated how
the people suffered genocide that was implemented to
make the West safe for "civilized" p~ople. Like other
oppressed groups in the United States, Native Americans
can question the nature of justice, as well as law and
order. Their civil rights were violated by genocide, their
forced adaptation of a strange way of life, and their
isolation On reservations, not unlike the homelands
where Black South Africans were forced to live under
apartheid. For American Indians, the matter of civil rights
was one of no rights respected by White men. Their
struggle in the 19th century and even today has beena
struggle for the right to be recognized as human beings
and accorded the rights and privileges due to them as
citizens.
Late in the 1840s, gold was discovered in California ,
and thousands of fortune seekers from the East headed
for the territories that the United States had recently
acquired from the defeated Mexican government. This
transition occurred as the people in the eastern United
States were beginning to have strong debates over the
question of slavery. The discovery of gold encouraged
the rapid migration of Americans to "golden opportu-
nities" in the West. Washington policy makers justified
the "permanent Indian frontier"as manifest destiny. This
concept of destiny assigned to Europeans and their
offspring the responsibility of ruling everything within
the United States, including the Indians, their land, and
the wealth it contained. The inevitable conflicts with the
Indians of the Plains led to several broken treaties and
countless armed conflicts. The epitome of the civil rights
struggles for Native Americans was the 14th Amendment
to the Constitution, which granted equal rights to all
people, except Indians. This deliberate exclusion, the
decision to deny liberty and equality to the native people
of America, implied a refusal to recognize the humanity
of America's original people.
AFRICAN AMERICANS Because millions of people of
African descent were forced into slavery in the United
States, slavery has been a major civil rights issue for the
country. Following their war of independence, the 13
original colonies entered an uneasy peace that was
shattered by the emergence of an abolitionist
OVIL RIGHTS
303
ukee. Her dependent variable was whethzed protest
against the institution of slavery. After the war; several
states discontinued slavery for people who had served
in the Continental Army, and other states ended
involuntary servitude, regardless of prior service. These
acts formed the foundation for what was to become the
movement to abolish slavery.
Abolitionist Movement and the Civil War. The
abolitionist movement was the genesis of the American
civil rights movement. Frederick Douglass and Harriet
Beecher Stowe were among the people who most viv-
idly expressed protestations against slavery and Stowe's
Uncle Tom's Cabin (1851) was among other forces that
contributed to an escalation in sentiment against slav-
ery. Early civil rights protesters were joined by Under-
ground Railroad conductors and the radical challenges
of John Brown and others. No factor, however, had a
more profound impact on relationships between the
North and South than the Dred Scott decision in 1857
(Lipsitz & Speak, 1989). This Supreme Court ruling
declared that the Missouri Compromise, which banned
slavery in certain territories, was unconstitu tional; the
decision favored slave-holding interests by suggesting
that the Missouri Compromise would deprive citizens of
their property-slaves-without due process of law. The
14th Amendment in 1866 eventually overturned the
Dred Scott decision, but not before a civil war tore the
country apart in a bloody four-year conflict.
On January I, 1863, President Abraham Lincoln
declared the enslaved people residing in the rebellious
states of the South to be free. Although the Emancipa-
tion Proclamation can be seen as a war measure, it
called attention to the need for additional legislation to
ensure the civil rights of African Americans. In 1865 the
13th Amendment, which prohibited slavery, was
passed.
Post-Civil War. In subsequent civil rights legisla-
tion, all African Americans were freed from their en-
forced servitude by the passage of the 14th Amendment .
Enactment of the 14th Amendment ensured that most
citizens (Indians were excluded from the Act) were
allowed equal protection under the law by preventing
states from establishing laws that would deprive any
person the right of citizenship without due process of
law. The 14th Amendment has the reputation of being
the most frequently challenged amendment because it
was the catalyst for using the Bill of Rights as protection
against state action. Until the passage of the Civil Rights
Act in 1964, the matter of state's rights was often used
by states in the South as a means to restrict liberties that
had been promised to African Americans by the 14th
Amendment. The 15thAmendment,passed
304 QVIL RIGHTS
in 1870, extended the right to vote to African Americans;
however, this right was to be short-lived because of
changes in voting eligibility in many southern states that
were intended to minimize the effect of the mandate.
In the years following the Civil War, in spite of the 13th,
l-lth, and 15th amendments, the southern states continued
to develop procedures and, in some instances, laws that
restricted the citizenship of Black people. Before the Civil
War, all the southern states had enacted codes that were
designed to control and discipline enslaved people. These
slave codes, as they were called in some places, became
Black codes in the years following the Civil War, designed
to restrict the freedom of African Americans and regulate
their relationships with White people, In many ways these
practices became the foundation on which Jim Crow laws
were established to regulate the social, political, and
economic life of African Americans. Jim Crow laws
continued well into the 20th century until the Civil Rights
Act was passed in 1964.
, social exchange theoray for the Jim Crow laws, and the
the Plessy v. Ferguson decision in 1896 firmly entrenched
laws that severely restricted the civil rights of African
Americans. In upholding Plessy v. Ferguson, the U.S.
Supreme Court established the idea that the doctrine' of
separate but equal accommodations was justifiable use of
state power (LipsitzSc Speak, 1989). This "separate but
people are more interdependent. Financial and opportunity
costs rise, and fear of loss, change, and the un-
opportunities for education and employment for all
Americans.
MEXICAN AMERICANS Among other groups in the
United States who were victimized by discriminatory
practices are men and women of Mexican descent.
Mexicans, who had a long history of residence in what is
now the southwest part of the United States, were among
this country's earliest citizens. In February 1848 the Treaty
of Guadalupe Hidalgo ended the Mexican-United States
War (Mclemore, 1980). This treaty, ratified in October
1848, forced Mexico to give to the United States
approximately one-half of Mexico's land, including what' is
now the states of Arizona, California, Nevada, New
Mexico, Texas, and Utah, as well as parts of Colorado and
Wyoming (Graebner, 1984). Texas had gained its own
independence in 1836 but was then annexed to the United
States by the 1848 treaty. Mexican Americans are one of
the oldest arid largest racial and ethnic groups in the United
States. As non-Hispanic Ll.S citizens began to settle in the
lands acquired from Mexico, conflicts emerged with the
former citizens of Mexico and as a result, these "new" US.
citizens lost their land in American courts.
Although the Treaty of Guadalupe Hidalgo had ensured
that land ownership would be respected for Mexicans
remaining. on the conquered lands, American courts found
Mexican titles and Spanish land grants worthless and
allowed others to acquire the land. This support of racism
by the American legal system resulted in the denial of due
process and fundamental civil rights to another group of
early Americans.
20TH CENTURY The 20th century began with continued
efforts at improving conditions and opportunities for
previously disenfranchised people-women as well as
people of color. In 1920 the 19th Amendment granted
women the right to vote. However, the struggle for civil
rights for all citizens continued.
SPECIFIC POPULATIONS
African Americans. African Americans fought cour-
ageously in segregated units during World War I, as they
continued to fight for civil rights. Not until 1923 did the
Supreme Court use its authority to interpret the Con-
stitution to enforce the civil rights amendments and the
statutes passed after the Civil War. Moore v. Dempsey
involved Black sharecroppers in Phillips County,
Arkansas, who had tried to improve their economic
condition by organizing; frightened White people reacted
violently and more than 200 people were killed. Twelve
Black people were accused of murder. In determining that
their civil rights to a fair trial had been violated, the
Supreme Court initiated an era in which de facto realities
were to be more important than de jure laws in considering
civil rights cases.
The National Association for the Advancement of
Colored People (NAACP), the most active ally of Black
citizens at the time, was a powerful force in supporting the
defendants. This civil rights organization found much work
to be done for civil rights, in spite of modest gains.
Japanese Americans. Another area of discriminatory
practice was heightened by the entry of the United States
into World War II following-the Japanese bombing of Pearl
Harbor. After the United States entered the war, over
110,000 Japanese American citizens, who were determined
to be security risks, were incarcerated (McLemore, 1980).
They were forced to abandon their homes and sell their
farms before being sent to concentration camps. In spite of
this denial of rights, some Japanese Americans fought and
died in the European Theater. Senator Daniel Inouye from
Hawaii, who lost an arm in battle, was one of these
soldiers. The denial of civil rights to the Japanese
Americans during World War II illustrates the ease with
which civil rights can be eliminated or restricted.

. Mexican Americans. By 1910, in spite of being
unwanted and mistreated, Mexicans began a significant
movement north to the United States. The upheaval
during the Mexican Revolutionary War (1910-1920)
was a contributing factor to this movement. However;
even before their migration began to become visible, the
Mexicans' civil rights were retarded by the same forces
that exhibited ethnic antipathies toward African
Americans and American Indians. De facto segrega tion
in schools, housing, and employment emerged as
Mexican Americans settled in barrios and worked at the
menial jobs many were forced to take. During th e Great
Depression of the 1930s, there were massive
deportations of over 400,000 people-many of these
citizens were blamed fprthe economic hardship brought
on by the stagnation of the economy and deported as
scapegoats. Some of those deported had been U.S.
residents for over 10 years, and the forced repatriation
included their children, who had been born as citizens in
the United States. These violations of civil rights
reflected the deep sentiments that have continued to
make the struggle for civil rights an ongoing concern for
other population groups.
Although there were some modest gains for Mexican
Americans, in the 1960s Cesar Chavez became a force
for civil rights for Mexican Americans and others as he
provided leadership on behalf of migrant workers. His
organizational skills and nonviolent approach to civil
rights made him a hero and role model to many. During
this period, legislation provided new tools. In 1968 the
Bilingual Education Act was passed to provide federal
aid for bilingual instruction. Bilingual instruction was
not new to the United States, as it had begun in the
1840s in Cincinnati, New York City, and other places .
The Bilingual Education Act probably gave impetus to a
decision by Jose-Angel Gutierrezpresident of the School
Board of Crystal City, Texas. In the early 1970s ,
Gutierrez ordered elementary school classes in that city
to be taught in both English and Spanish (Rivera, 1984).
His decision was supported in 1974, when the U.S.
Supreme Court unanimously ruled in the case of Lau v.
Nichols that public schools must provide specially
designed programs for students who speak little or no
English. Gutierrez was a founding member of the La
Raza Unida Party, a political party established to
enfranchise Mexican Americans.
COURT DECISIONS In the latter half of the 20th
century, there have been many Supreme Court decisions
related to civil rights. The following are among some of
the key decisions.
Education. In 1954, the Supreme Court's decision in
Brown v. Board of Education overruled the "separate
CIVIL RIGHTS
305
but equal" doctrine that had been valid since 1896. The
court ruled that segregation of school children on the
basis of race was unconstitutional even if the facilities
were of equal quality. This decision resulted in the
elimination of overt racial discrimination in public areas
of transportation, hotel and restaurant accommodation,
theaters and auditoriums, parks, recreational areas, and
even barber shops. However, it took years of activism to
implement the full implications of the decision.
Health. In 1973, the Court's decision in Roe v.
Wade gave women the right to abortion and what many
believe to be control over their own bodies. Almost
simultaneously, however, as a spin-off from the "moral
majority" movement, "right-to-life" groups began to
mount an offensive against the decision. This "civil
rights" movement on behalf of fetuses continues and has
culminated in the deaths of at least two doctors who
provided abortions.
Housing. In Shelly v. Kraemer in 1948, the Court held
that private arrangements to maintain racial segregation
in housing patterns could not be recognized.
Justice. In Gideon v. Wainwright in 1963, the Court
determined that indigent accused have the right to secure
appointment of legal defense at the government's
expense. The Miranda decision in Arizona in 1966
established the Fifth Amendment privilege . against
self-incrimination. The decision required that police
inform a person taken into custody of the right to remain
silent and the right to legal counsel. Since 1966, the
Supreme Court has modified this decision in a number
of ways. With the In re Gault decision in 1967, the Court
established protection for juveniles, including the right
to representation by legal counsel, right to timely notice,
right to confront and crossexamine complainants, and
right to protection against self-incrimination.
CIVIL RIGHTS LEGISLATION The first civil rights
act since 1875, the Civil Rights Act of 1957 (EL.
85-315), established the Commission on Civil Rights
and strengthened federal enforcement powers. In the
early 1960s, a number of events, including the
assassination of President John F. Kennedy, protest
actions by civil rights groups, and the civil rights
commitments of President Lyndon B. Johnson,
established a climate for advanced civil rights
legislation. The result was the Civil Rights Act of 1964
(Pt. 88-352).
The act strengthened voting rights and mandated
equal access in a number of key areas. Any program
receiving federal funding was forbidden to discriminate
on the basis of race, color, religion, or national origin.
Victims of discrimination on the basis of race, color,
306 CIVIL RIGHTS

religion, or national origin in cases that involved interstate

Americans were being dehumanized and discriminated
commerce were granted injunctive relief; that is, the Court against, not because of the quality of their character, but
has the power to order certain acts to be done. The u.s. because of their sexual orientation.
Department of Education was authorized to desegregate . The years between the two demonstrations reflect the
public education. The Civil Rights Commission was given transformation that is taking place in the United States, as
expanded investigative power. The Equal
the matter of civil rights has become more inclusive and as
EmploymentOpportunity Commission was established to the legal claims and privileges of a greater number of
oversee civil rights in employment. To help communities people are being protected. Diverse groups now call
resolve pwkl'ems involving discrimination, the act set up a attention to the manner in which established customs and
Community Relations Service in the U.S. Department of laws have deprived citizens of fundamental rights. For
Commerce. example, people have challenged the insensitivities that
The Education for All Handicapped Children Act of 1975 denied people access to facilities because they could not
(Pt. 94-142) extended national public education policy to manipulate a wheelchair in a bathroom or use an elevator
mandate free public 'education for all children withthat gave directions only for sighted people. In Michigan
disabilities. In 1986 the Education of the Handicapped Act an individual's right to assisted suicide was challenged by
Amendment (Pt. 99-457) expanded services to children conflicts between those who believe it imperative to
with disabilities from birth . through age five years. In
maintain life and those who believe the individual has a
1990, the Americans withright to end his or her own life under special circumstances.
Disabilities Act gave the United States an opportunity to Elsewhere, proponents of the rights of the unborn child
remove yet another deterrent to full citizenship for anotherhave taken their struggle to such extremes that violence and
class of U.S. citizens. The implementation of the Act took adeath have occurred.
significant step not only toward making the workplace Since the tragedy of September 11, 2001, the civil
more accessible to people with disabilities, but also rights struggle has taken on a new look as citizens have
ensuring that the world is more open and receptive to all responded to governmental actions that have been designed
people, including those who were prevented from to impose sanctions on those believed responsible for the
obtaining services because they were not sighted or horror that led to the loss of so many lives. In addition,
because they were dependent on a wheelchair for security measures have been developed to avoid future
transportation. ttagediessuch as those witnessed on September 11, 2001.
The Civil Rights Act of 1991 (PL. 102-166) reversed a Perhaps, it was the loss of the security felt by many
set of Supreme Court decisions that had eroded protection ofAmericans that led to the actions taken by the government
women and people of color in the workplace. The Act of the United States. The bombing of the World Trade
mandates monetary damages for victims : of intentional Center and the other events of September 11 were tragic
discrimination based on race, gender, disability, or religion.
reminders of the fragile nature of American civil rights.
Age, however, was not included as a discriminating factor. A consequence of the events of 9/11 was the alleged
abridgment of the rights of persons charged with being an
enemy of the United States for supposedly being engaged in
OTHER STRUGGLES FOR CIVIL RIGHTS On an August terrorist acts. For many it appeared as though the country's
afternoon in 1963, Dr. Martin Luther King, [r., officials acted quickly to safeguard the nation by so quickly
shared his dream of a United States free of the racial rounding up suspected terrorists in the days and months
bigotry that had been so carefully preserved by the following 9/11. For many othershowever, the rights
authors of the Jim Crow legislation that governed guaranteed by the Constitution of the United States were
Black and White relationships in the South: violated as people were rounded up and jailed without due
Although Dr. King's enduring words motivated change for process. The fact that "many persons were incarcerated and
some, - the struggle has continued for disenfranchised not afforded a right to counsel nor a speedy trial raised
groups. questions as to whether or not the United States government
Almost 30 years after Dr. King's address, gay men, was running roughshod over American civil rights.
lesbians, and bisexuals filled the streets of Washington, Fundamentally, some citizens were asking if we can do this
DC, to demonstrate for civil rights. The importance of this now, where it will end? Others simply wondered if citizens
large demonstration lies in the fact that U.S. citizens of the United States should give up some of their rights
witnessed another 20th century milestone in the history of
human rights. The 1993 March on Washington called
attention to the fact that millions of

j

in order to be secure from further terrorist activities.
Actions by some government officials appear to give
cause to wonder about the civil rights of citizens. In the
interests of national security, government wiretapping
has apparently been expanded. It appears as though the
sanctity of the home is now threatened by a greater
good, national security. Many now question whether or
not civil rights are being eroded in the name of national
security.
n addition to wiretapping, arrests, and incarcera-
without a speedy trial, there also appears to be a sense of
discrimination in the name of national security, if one
looks like a terrorist. Increasingly there are accounts
being reported of individuals being removed from
planes because of rpe apparent irrational fears of some
persons who believe the behavior of some passengers
many. The danger may well be that the nation may find
L CONTns about whether the nation is headed toward a
scenario that will permit the expulsion or discrimina tion
of persons because their manner and behavior is simply
different. Some wonder whether or not racial profiling
has taken on a new look as is reflected in discriminatory
behavior toward persons of Middle Eastern descent.
lic. The role of the government as a funder of both
immigrants, seems to have become intolerant of some
immigrants. Contemporary America is becoming re-
plete with illustrations of a nation that-appears to be
more selective about which immigrants are welcomed
and which ones are not. While some of the backlash
against immigrants appears to be derived from the
aftermath of 9/11, some of the anti-immigrant reac-
tion is race- and class-based. Regardless of their roots,
the antipathies directed at immigrants has resulted in
extremist behavior that seems to rival that directed at
Blacks in the 1880s; and the negative behavior direc-
ted at Mexican Americans following the American
expansion in the far West during the middle of the
19th century.
Antipathies aimed at immigrants come in a variety of
forms including the more overt forms of discrimination
that have come to characterize the American
experience. But several other strategies have surfaced
that are designed to control or minimize the influx of
immigrants, especially those from Mexico and South
America.In the Southwest, a wall is being built to keep
out of the United States the men and women who try to
come across the border in Texas, Arizona, and New
Mexico. In addition, vigilante groups of citizens have
been formed in some parts of the United States to keep
out immigrants in their attempts to cross the border.
Some wonder how these groups differ from the actions
CIVIL RIGHTS 307
of the Klu Klux Klan and the White Citizens Council of
the old South In other parts of the country various laws
are being enacted that are designed to contain or force
immigrants out of communities. In some locations com-
munities have enacted laws that restrict the number of
adults who can live in a house. In other places efforts
are being made to limit the total number of persons
living in a household. Such efforts to make immigrants
unwelcome seem very similar to the lawlessness of the
old South to establish laws that were designed to con-
trol the lives of African American citizens. In other
locales, local communities are seeking to impose sanc-
tions that would prevent immigrants from receiving
social services and access to education. While these and
similar measures may not yet be enacted across the
country, the sentiments they express are supported by
itself resorting . to bad habits by forgetting its history.
At this point in time, none of these measures have
been tested in the Supreme Court. However, one can
assume that it is only a matter of time before these laws
will be challenged in American courts. The civil rights
enjoyed by most in the United States have come be-
cause of the sacrifice and support of men and women
who believe that equality is best served by the guaran-
tee of civil rights. The threat to these rights may be a
threat to all that the constitution of the United States has
come to represent. The 20th century was challenged by
the color line. The 21st century also seems to be
challenged by color, culture, and language. The
challenge for social work as it moves forward will be to
ensure that the broad definition of civil rights be in-
clusive so that none is deprived of the right to life,
liberty, and the pursuit of happiness.
THE SOCIAL WORK PROFESSION AND CIVIL
RIGHTS Social work has its origins in the turbulent
years of the Progressive Era. Those were years of con-
stant change as the United States experiencecl rapid
growth resulting from the immigration of Eastern
Europeans and other populations seeking opportunities
in the land of democracy. During those years, large
numbers of African Americans migrated north to flee
the racial antipathies of the southern J im Crow
policies. Although they were not always in the forefront
of civil rights and social justice, the leading social
reformers eventually developed a stance consistent
with democratic values and a belief in the rights of all
people regardless of race, color, or creed. As a foun ding
member of NAACP, Jane Addams was one of the social
reformers who joined with W. E. B. Du Bois to
establish
308 CIVIL RIGHTS
this early civil rights organization. Such action set the
standard for what has become the social work profes-
sion's commitment to civil rights.
The advocacy role of social work forces the contin-
uationofbehavior that is supportive of civil and human
rights. The settlement house movement from which
social work originated supported actions that increased
the diversity of the profession. This diversity is
reflected not only by the people who deliver services,
but also by the profession's willingness to offer services
that are sensitive to people's differences. Now that
social work comprises individuals who are of diverse
backgrounds, the profession should be increasingly
closer to the forefront in advocating for human rights.,
The struggle for civil rights should continue, as long as
any group of people is oppressed and not permitted the
opportunity to achieve,
During the past several years, the major social work
organizations have taken steps to ensure that all their
members have an opportunity to participate fully in the
management of their organizations. They have
achieved this goal by developing standards and organi-
zational bylaws that value the diversity of their mem-
berships and by establishing mechanisms that ensure
the widest possibility for participation of individual
members.
For several years, NASW has worked with a number
of civil rights groups. In addition, NASW has made
elimination of racism, sexism, homophobia, and pov-
erty major national priorities. The NASW Delegate
Assembly, the organization's governing body, has de-
veloped public policy statements relating to disabilities,
gay men and lesbians, women, abortion, people with
acquired immune deficiency syndrome (AIDS), people
of color, and other civil rights issues. Similarly the
Council on Social Work Education, which accredits
schools of social work, has expressed a strong commit-
ment to addressing concerns related to oppressed
groups in its curriculum policy statement and
accreditation standards. Thus, cultural diversity,
women, and sexual orientation are mandated areas for
curricula of accredited social work programs.
FUTURE ISSUES The arrival of the 21st century
finds social workers faced with a new set of civil
rights issues. Among them will be the question of
how immigrants to the United States will be
treated. With civil wars in Eastern Europe and
poverty in the Caribbean and in Central and Latin
America, the plight of immigrants- who they are,
who they should be-will be a subject of debate.
Unlike the immigrants of the last century, many of
the current ones are people of color. During the
1994 general election, Californians voted
overwhelmingly to deny basic services to many immi-
grants. This and other actions call to question the
changing nature of racism as we struggle to understand
why the new immigrants are not as welcome as the
"huddled masses struggling to breathe free" were in the
waning years of the 19th century On the other hand, the
previous history of the civil rights struggle in the United
s by deprofessionalizing the workforce and encroaching
g on the autonomy of professionals in inde-
is
Until the late 20th century, it was presumed that people
should not have decision-making authority over how
their lives may end. However, activists are suggesting
changes. Choice In Dying promotes living wills, the use
of other advance directives, and attention to civil rights
for people who face the end of their lives. Other groups
also address rights in dying, and a physician promotes
the right to die by offering aid to people who want to end
their lives.
The 20th century began with attention to the civil
rights problems of African Americans who were forced
by law into a condition of second-class citizenship. As
the United States has matured, its citizens have become
less tolerant of some forms of discrimination and have
expanded this nation's capacity to extend and promote
civil rights to a larger group of citizens.
Since the 1963 March on Washington, there have
been renewed efforts to break down the formal and
informal barriers that disadvantage women. Equity in pay
and employment benefits still remain key concerns of
women. In addition, women still must deal with the
hostility that is manifested in violence by men who
consider women property-a situation not unlike the
slavery that existed before the U.S. Civil War. Shelters
provide a refuge for women who are the victims of
violence, just as the Underground Railroad provided
refuge for African Americans fleeing the bondage of
slavery Yet, more remains to be done so that women have
the legal means to shelter themselves from the violence
of men that often ends in a woman's death, because
current laws do not provide adequate protection from
abuse.
The 20th century has witnessed civil rights trans-
formed from a focus on African Americans in the early
1900s to an enlarged perspective that is more inclusive.
The citizens of the United States are now more aware of
their diversity and diverse needs. The founders of this
country were White men who, in the early years, served
their own needs. Now that the citizenry is represented by
elected officials who more accurately reflect that
citizenry, those officials have brought focus to issues
that reflect their differences. Today's elected officials

are not all White men. They are women, and they are
Americans of African, Puerto Rican, Cuban, Mexican,
Native American, and Asian descent. Elected officials
today may be gay or lesbian. They may be people with
disabilities. The diversity this country has begun to
embrace has led to a greater awareness of the need for
legislation thatwill ensure that all people are valued and
that all have equal protection under the law.
Since it became a nation, the United States has
struggled with how to reduce the arbitrary discrimina-
tion faced by people who suffer persecution because
they are members of an oppressed group. The civil
rights struggle continues today because this nation has
not found ways to ensure that all people have equal
access to the right of citizenry. The process to include
different populations under the civil rights umbrella has
been incremental and dependent on the identification of
oppressed groups. The struggle continues because, as
one group-be it disabled people or gay men and
lesbians-advances, another oppressed group finds both
the courage and the support to mount its own struggle
for civil rights.
Finally the struggle for civil rights continues
because obstacles such as bigotry in diverse forms still
pose threats to equal opportunity for all citizens.
Although these . threats may seem small, represented
by fringe groups such as the KuKlux Klan or the Aryan
Nation, they serve as reminders of the diversity of this
nation. And they reinforce the idea that civil rights have
been granted to those who have fought for them, rather
than having them awarded as a birthright of a privileged
class.
REFERENCES
Americans with Disabilities Act of 1990. (1991). P.L. 101336,
104 Stat. 327.
Bilingual Education Act of 1968. (1968). P.L. 89-30.
Brown, D. (1971). Bury my heart at Wounded Knee. New York:
Holt, Rinehart, & Winston.
Brown v, Board of Education of Topeka, Kansas. 347 U.S 483.74
S. Ct. 686 (1954).
Bums, E. M., Ralph, P. E., Lerner, R. E., & Meacham, S.
(1986). World civilizations. New York: W. W. Norton.
Civil Rights Act of 1866. (1866). Ch. 31, 14.stat. 27.
Civil Rights Act of 1957. (1957). Pt.85-315, 71 Stat. 634. Civil
Rights Act of 1964. (1964). FL. 88-352, 78 Stat; 24. Civil Rights
Act of1991. EL. 102-166,105 Stat. 1071, 1991. Education for All
Handicapped Children Act of 1975. (1975).
Pt. 94-142, 89 Stat. 773,.
Education of the Handicapped Act Amendment. (1974).
Pt. 99-457, 100 Stat. 1145.
Gideon v. Wainwright. (1963) 83 S. Ct. 792.
Graebner, N. A (1984); Mexican war. In World book encyclopedia
(VoL 13, pp. 369-371). Chicago: World Book Inc.
CIvIL RIGHTS 309
In re Gault. (1967).387 US. 1.
Kitano, H. L. (1980). Race relations. Englewood Cliffs, NJ:
Prentice-Hall.
Lau v, Nichols. (1974).414 US. 563, 94 S.tt. 786.
Lipsitz, L., & Speak, D. M. (1989). American denwcracy. New
York: St. Martin's Press.
Mclemore, S. D. (1980). Racial and ethnic relations in America.
Boston: Allyn & Bacon.
Miranda v. Arizona. (1966). 384 US. 436
Moore v, Dempsey. (1923).43 S. Ct. 265
Plessy v, Ferguson, (1896).163 US. 537
Rivera, F. (1984). Jose Angel Gutierrez. In World book encyclo-
pedia (Vol. 8, p. 428). Chicago: World Book Inc.
Roe v. Wade. (1973).93 S. Ct. 705 Shelly
v, Kraemer. (1948). 68 S. Ct. 836
Stowe, H. B. (1851). Uncle Tom's cabin. New York: National.
FURTHER READING
Baker, R. S. (1964). Following the color line. New York: Harper &
Row.
Branch, T.(1988). Parting the waters: America in the King years
1954-63. New York: Simon & Schuster.
Compton, B. (1980). Introduction to social welfare and social work.
Homewood, IL: Dorsey Press.
Du Bois, W. E.B. (1983). Blackreconstruetion in America. West
Hanover, MA: Halliday Lithography.
Franklin, J. H. (1947). From slavery to freedom. New York:
Alfred A. Knopf.
Higginbothan, A. L. (1980). In the matter of color. New York:
Oxford University Press.
Lawson, K. (1998). Proceedings from Leadership Conference on
Civil Rights Education Fund, Building One Nation: A Study of
What Is Being Done in Schools, Neighborhoods and the
WorkPlace.
Leadership Conference on Civil Rights Education Fund and
Commission on Immigration, American Bar Association,
American Justice Through Immigration Eyes. AB.A Doc.
ISBN No. 1-59031-384-4 (2004).
Leadership Conference on Civil Rights Education Fund, American
for Fair Chance, Anti Affirmative Action Threats In the States,
1997-2003, January 30, 2004.
. Leadership Conference on Civil Rights Education Fund, Wrong
Then, Wrong Now: Racial Profiling Before and After
September 11, 2001, http://www.civilrights.org/publi
cations/reports/racial_profiling (2003).
Meier, A., & Rudwick, E. M. (1966). From plantation to ghetto.
New York: Hll & Wang.
Myrdal, G. (1944). An American dilemma. New York: Harper &
Row.
Woodward, C. V. (1966). The strange career of Jim Crow.
London: Oxford University Press.
USA PATRIOT Act, H.R. 3162, 107th Congress, Public Law
107-56, October 26, 2001.
USA Patriot Improvement and Reauthorization Act of 2005, H.R.
3199, 109th Congress, Public Law 109-177, March 9, 2006.
-WILLIAM L. POLLARD
310 CIVIL SOCIETY
CIVIL SOCIETY
ABSTRACT: Considerable definitional vagueness exists
regarding civil society, in part due to the concept's
long history and multiple underlying schools of
thought. Issues of multiculturalism and social justice
are central to the term. Civil society is also a global
concept, referring to the supranational sphere. The
social work profession can benefit from collaborative
and encroaching on the autonomy of professionals in
s in inde- as politically organized commonwealths, or nation- states.
KEY WORDS: civil society; social' capital; networks;
collective action; associations: democracy
Overview
In community practice, the notion of civil society is far
from novel, despite changing definitions over time.
Consensus around the term suggests that civil society
comprises the sphere outside of the government and
market in which private voluntary associations, linked by
dense networks of trust and reciprocity, work collec tively
to address common problems (Figueira-McDo nough,
2001; Foley & Edwards, 1996). Civil society includes a
variety of actors, such as nongovernmental organizations
(NGOs), charities, foundations, neigh borhood
committees, faith-based organizations, profes sional
associations, trade unions, self- help groups, social
movements, business associations, and interest groups
(Centre for Civil Society, 2004).
Recognition of the three interrelated roles of civil
society is useful. In economic terms, civil society focuses
on promoting individual and collective well-being, pro-
viding services that states and markets fail to offer, and
fostering social values, networks, and institutions that
undergird productive market economies. In the social
context, a "civil" society is one in which positive social
norms, cultural traditions, and innovation are pro moted. " welfare states, civil society associations are instrumen tal
Through membership in civil- society groups, citizens
demonstrate their commitment to pursuing the common
good. Finally, the political role of civil society focuses on 2001; Anheier & Seibel, 1990; Kramer, 2000).
strengthening civic associations, fomenting transparency
and accountability among governmental organizations,
and increasing citizen participation in the political
process (Edwards, 2004).
Historical Context
One rationale for the definitional overlap is that, be cause
of the concept's long history, it is possible to use diffe rent
philosophical understandings of civil society to support
current ideologies and goals. It is thus helpful
to understand the origins of the term, influenced by
philosophers from Ancient Greece, the Middle Ages, and
the Age of Enlightenment.
According to the classical school of thought, there was
no division between civil society and the state. Aristotle's
polis consisted of a religious and political association in
which active citizens shared the tasks of ruling and being
ruled. The state was consider ed the "civil" form of society
and shaped both institutions and policies. This meaning of
civil society continued through the Middle Ages, as the
late medieval school of thought characterized civil society
In these rights-based societies, rulers and the ruled were
governed by law, which consisted of a social contract
among citizens (Edwards, 2004).
Subsequently, Enlightenment thinkers began to em-
phasize capitalism as a replacement for feudalism "and as
the grounds for new individual rights and liberties. Civil
society thus became separate from the state and more
narrowly associated with the market, as capitalism was
presumed to produce democracy, fair allocation of
resources; and social respect (Edwards, 2004; Figueira-
McDonough, 2001). Voluntary associations became es-
sential in minimizing centralized power and protecting
individuals' newly acquired rights from the state. How-
ever, with the expansion of capitalism, society soon
recognized the "uncivil" consequences, among them
increasing income disparity between the rich and poor
(Edwards, 2004; Figueira-McDonough, 2001). This pre-
cipitated yet another definitional revision of civil so ciety:
As a sphere of voluntary institutions of public life
independent of both the state and the market (Anheier,
Glasius, & Kaldor, 2001; figueira-McDonough, 2001).
Today, the notion of civil society shares conceptual
overlap with similar terms, such as the "indepe ndent
sector," "third sector," "nonprofit sector," and "volun tary
sector." Within both Western democracies moving toward
privatizing and contracting out services, as well as in
former communist governments downsizing their
in promoting individual well-being, along with so cietal,
economic, and political progress (Anheier& Kendall,
Theoretical Positions
Definitional overlap can also be explained by the three
predominating schools of thought underlying the con cept
(Edwards, 2004).
First, civil society is considered a part of society,
characterized by "third sector" associations separate from
the state, market, private business, and corporate
structures, in which membership and activities are

voluntary. Theories of civil society as associationallife
explain how to address institutional and community
challenges through nonstate means. Two key works that
support this perspective are French political thinker de T
ocqueville' s (1947 [1835]) account of the prolific nature of
voluntary associations in 19th-c;entury America and
Putnam's (2000) longitudinal analysis of civic engagement
and social capital in 20th-century America.
. Second, civil society is also perceived as a kind of
society, characterized by positive norms and values,
including cooperation, trust, tolerance, and nonviolence.
Theories of the good society describe the normative values
and goals associated with the societal pursuit for
democracy, equality, 'and human progress. Rosemblum's
(1998) key, virtues of democracy, including civility and
challenging societal injustices, are consistent with this
position.
Lastly, civil society is considered as the public sphere, or
an arena in which collective dialogue, deliberation, and
negotiation regarding the common good can occur (Fisher
& Karger, 1997). Theories of the public sphere provide a
framework for democratic discussion and negotiation
around social goals and the strategies needed to achieve
them. The work of German philosopher and sociologist
Habermas (1984), on critical theory and the public sphere,
and by British political theorist Keane (1998,2003) support
the notion of civil society as the public sphere in which an
informed polity deliberates democratically about the
common good.
Multiculturalism and Social Justice
To understand the application of civil society theories in
practice by people of different religions, ethnicities, .
classes, and ideological perspectives, multiculturalism and
social justice are paramount: Civil society as a concept in
social work is often grounded in local community
development. When communities succeed in organizing
themselves and securing needed services and resources,
multiculturalism is central to promoting democracy
(Figueira-Mcfjonough, 200l). A multicultural perspective
acknowledges and utilizes the community's cultural
diversity while concurrently aiming to dismantle structures
that perpetuate inequality (Gutierrez, Alvarez, Nemon, &
Lewis, 1996; Rivera & Erlich, 1998). Participation in civic
associations that work collectively toward local
development is one means through which residents achieve
structural change and social justice. Voluntary associations
also promote proactive participation and leadership.
Global Civil Society
In addition to civil society as a domestic concept, there is
growing literature on the global nature of civil society
CIVIL SOCIETY
311
(Anheier et aI., 2001, 2005; Edwards, 2004; Keane, 2003).
Global civil society comprises an international social
sphere within which interest groups, social movements,
and individuals dialogue and negotiate with each other and
with governmental actors and transnational corporations
around social, economic, and environmental issues. In an
age of increasing international economic and cultural
integration due to globalization, global norms and
standards are needed to protect universal human rights,
promote equitable cooperation, and achieve the peaceful
resolution of conflict around the world.
Within this global civil sphere, civil society actors from
international development organizations to media to social
movements are engaged in dialogue, debate, and
organizing around the future direction of globalization,
democracy, and development. For instance, mobilization
of voters by civil society groups and global media sources
have increased citizen awareness and participation in the
political process and influenced local and national election
outcomes in India, Spain, Great Britain, and the United
States. Further, global philanthropy-orchestrated through
transnational civil society groups and social
movements-has been a major catalyst in the economic and
social development and rehabilitation of regions and
countries affected by natural disasters, economic
recessions, and political strife (Anheier, Glasius, & Kaldor,
2005). Despite positive achievements, transnational citizen
mobilization and action remain limited in their capacity to
effect global economic and political reform, as systemic,
sustainable change requires participation from
governmental and corporate actors as well.
ated (Mauer, 2006). Reports have
Creating Civil Society .
Civil society as a sphere of voluntary associations is also
relevant to social work, for it is within this arena that
practitioners engage disadvantaged groups in collective
action and participatory democracy. The following roles
provide guidelines for social workers to create and
strengthen civil society locally, nationally, and globally.
As practitioners, combating all forms of inequality and
discrimination at the individual, organizational, and
societal levels will extend civil rights to more individuals
and increase their opportunities to actively participate in
society. As policy makers, encouraging institutional
partnerships, supporting natural forms of associational
activity, and strengthening the financial independence of
civil society groups will help create the necessary
infrastructure and prerequisites for collective action
(Edwards, 2004). As advocates, ensuring the
312 CIvIL SOCIETI
sustainable voluntary associations
in a community or region while simultaneously continuing
to garner governmental support and resources will create
public-private partnerships to address local issues.
fu researchers and evaluators, strengthening
university-agency partnerships-using
participatory action research and engaging
communities and policy makers in the
research process will foster sustainable
practice and policy responses to complex
social issues (Lerner, Fisher, & Weinberg,
2000; Soska & Johnson, 2004). Finally, as
educators, integrating the Global Standards for the
Education and Training of the Social Work
Profession into social work curricula will facilitate
the preparation of locally and globally minded social
workers as well as the reciprocal inclusion of social
work more fully into civil society, and civil society
more fully into social work '(IFSW, 2005; Sewpaul,
2005).
REFERENCES
Anheier, H. K., Glasius, M., & Kaldor, M. (200l). Introducing global
civil society. In H. Anheier, M. Glasius, & M. Kaldor (Eds.) ,
Global civil society (pp, 3-22). Oxford: Oxford University Press.
Anheier, H. K., Glasius, M., & Kaldor, M. (2005). Global civil society
2004/5. Thousand Oaks, CA: Sage.
Anheier, H. K., & Kendall, ]. (Eds.). (2001). Third sector policy at the
crossroads: An international nonprofit analysis. New York:
Routledge.
Anheier, H. K., & Seibel, W. (Eels.). (1990). The third sector:
Comparative studies of fum-profit organizations. New York:
WaIter de Gruyter& Co.
Centre for Civil Society. (2004). Introduction. Retrieved December
13, 2006; from http://www.lse.ac.uk/collections/
CCS/introduction.htm
De Tocqueville, A. (1947) [1835]. H. S. Commager (Ed.),
Democracy in America, Translated by H. Reeve. New York:
Oxford University Press.
Edwards, M. (2004). Civil society. Cambridge, UK: Polity Press.
Figueira-McDonough, J. (2001). Community analysis and praxis:
Toward a grounded civil society. Philadelphia: Brunner-Routledge,
Taylor & Francis Group.
Fisher, R., & Karger, H. (1997). Social work and community ina
private world.: Getting out in public. New York: Longman.
Foley, M. W., & Edwards, B. (1996). The paradox of civil society.
Journal of Democracy, 7(3), 38-52.
Gutierrez, L., Alvarez, A. R., Nemon, H., & Lewis, E. A .. (1996).
Multicultural community organizing: A strategy for change.
Social Work, 41(5), 501-508.
Habermas, ]. (1984). The theory of communicative action, T ranslated
by T. McCarthy. Boston: Beacon Press.
International Federation of Social Workers (IFSW). (2005).
Global standards for the education and training of the social work
profession. Retrieved December 18, 2006, from http://www.
ifsw.org/cm_data/GlobaISociaIWorkStandards2005.pdf
Keane, J. (1998). Civil society: Old. images, new visions.
Stanford, CA: Stanford University Press.
Keane,]. (2003). Global civil society. Cambridge: Cambridge
University Press.
Kramer, R. M. (2000). A third sector in the third millennium?
Voluntas: International Journal of Voluntary and Nonprofit
()rganizations, 11(1), 1-23.
Lerner, R. M., Fisher, C. B., & Weinberg, R. A. (2000).
Toward a science for and of the people: Promoting civil society
through the application of developmental science. Child.
Development, 71 (1), 11-20.
Putnam, R. D. (2000). Bowling alone: The coUapse and revival of
American community. New York: Simon & Schuster.
Rivera, F. G., & Erlich,]. L. (Eds.). (1998). Community organizing in a
diverse society (3rd ed.). Boston: Allyn &. Bacon.
Rosemblum, N. (1998). Membership and morals: The personal uses of
pluralism in America. Princeton,N]: Princeton University Press.
Sewpaul, V. (2005). Global standards: Promise and pitfalls for
re-inscribing social work into civil society. International Journal
of Social Welfare, 14,210-217.
Soska, T. M., & Johnson, A. K. (Eds.). (2004). Universirycommunity
partnerships: Universities in civic engagement. Binghamton, NY:
The Haworth Press.
SUGGESTED LINKS
Center for Civil Society Studies, Institute for Policy Studies, Johns
Hopkins University. . http://www.jhu.edu/-ccss/
Center for Civil Society, University of California, Los Angeles,
School of Public Affairs. http://www.spa.uda.edu/ccs/
Center on Philanthropy and Civil Society, The City University of
New York, The Graduate Center. http://www.philanthropy .org/
Center on Philanthropy and Public Policy, University of Southem
California, School of Policy, Planning, and Development.
http://www.usc.edulschoo!s/sppd/philanthropy/
Centre for Civil Society, London School of Economics.
http://www.!se.ac.uk/coUections/CCS/introduction.htm
Civicus: World Alliance for Citizen's Participation.
http://www.civicus.org/
Development Gateway Foundation: Civil Society.
http://topics.developmentgateway.org/civilsociety
Independent Sector.
http://www . independentsector .org
International Federation of Social Workers (lFSW).
http://www.ifsw.org/
International Society for Third-Sector Resear~h (ISTR).
http://www.istr.org/
Nonprofit and Public Management Center, University of Michigan.
http://nonprofit.umich.edu/
Public/private Ventures.
http://www.ppv.org
United Nations and Civil Society.
http://www . un
.org/issues/civilsociety/

United Nations Development Programme (UNDP), Civil Society
Organizations (CSO) Division. http://www.undp;org/partners/cso/
United Nations Global Civil Society Forum.
http://www.unep.org/dviLsociety/GCSF/index.asp
World Bank and Civil Society.
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/ CSO/O,
pagePK:220469-theSitePK:228717,OO.html
-KRISTIN M. FERGUSON
CLIENT VIOLENCE
ABSTRACT: Client violence and workplace safety are
relevant issues for all social workers across practice
settings. This entry addresses why and how social
work, ers may be targets for a client's violent behavior,
and what we know about who is at risk of encountering
violence. Understanding violence from a biopsychoso-
cial perspective, identifying risk markers associated
with violent behavior, and an introduction to guide lines
for conducting a risk assessment will be discussed. The
entry concludes by identifying and describing some
general strategies for the prevention of client violence.
KEY WORDS: safety; client violence; risk management;
risk assessment; violence; risk markers
Introduction
Violence in the workplace is a critical issue in the United
States today for a wide range of workers includ ing retail
clerks, taxi drivers, police officers, teachers, nurses, and
social workers (LeBlanc, Dupre, & Barling, 2006). Some
social work practitioners may assume that if they have not
encountered violence in the past, there is no need to be
concerned about safety (Griffin, Montsinger, & Carter,
1995). However, much has changed in the practice of
social work since the 1990s, and the reality is that client
violence toward social workers and workplace safety are
issues relevant for all social workers today, regardless of
practice setting or years of experience (Griffin, 1995).
Most people choose to become socia l workers be, cause
they want to foster social justice and help disad vantaged
people in need. They may not, however, anticipate that
some individuals may not want a social worker's help and,
under certain circumstances, may even strike out at the
very person who is attempting to help them.
What causes social workers to be targets of a client's
violent behavior? The answer to this is complex and not
CLIENT VIOLENCE
313
entirely clear. Some argue that such violence simply
represents a barometer for America's violent society
(Dillon, 1992). Long-standing social problems such as
unemployment, poverty, and racism create an environment
in which violence can thrive. Budget cuts, the ensuing
understaffing of many social service agencies, and rising
caseloads further compound social workers' vulnerability.
Others argue that the answer also lies in the unique
nature of the social work profession. Social work is caring,
but can also be controlling, since it often in, volves the task
of interpreting government regulations and mandates, and
determining eligibility for resources that clients desperately
need (Newhill, 2003). Through this process, a client's rage,
frustration, and feelings of helplessness may emerge
(Euster, 1992). For example, in June 1991, 34,year-old
Arnold Bates walked into a Baltimore, Maryland, welfare
office to apply for food stamps. When told he was not
eligible, he became enraged, pulled out a knife, and stabbed
to death one of the caseworkers. The aggressive public
reaction to this tragic incident included phone calls to the
agency, threatening to "take out more of you social
workers" (Dillon, 1992, p. 1). This example illustrates how
ains strong among the modaught between desperate clients
and a government that is perceived by them as a cause of
their problems or an entity that cannot or will not help them.
Society asks social workers to be both agents of social care
and agents of social control (Townsend, 1985). Deciding
whether to remove a child from a home because of
allegations of abuse, or whether to involuntarily commit a
client to a psychiatric hospital are prime examples of the
bound by red-tape and can easily experiment with new
violence to occur. Further' more, because of confidentiality
restrictions, social workers are often unable to explain or
defend their actions publicly.
The Prevalence and Nature of
Client Violence Toward Social Workers
Over the past three decades, there have been more than . two
dozen studies addressing the issue of client violence toward
social workers, with the bulk of the studies published since
1988 (Newhill, 2003). Researchers in the United Kingdom
led the way toward investigating this topic (Rowett, 1986)
and, since then, there have been several studies conducted in
the United States which collectively demonstrate that the
issue of client violence is a serious practice concern. For
example, Newhill (1996) conducted a study examining the
nature and prevalence of four types of client violence
toward social workers-property damage, threats, attempted
physical attacks, and actual physical
314 CLIENT VIOLENCE
attacks-employing a random sample of 1 ,600 members
of the National Association of Social Workers. The
study had a survey . return rate of 71 % (N = 1,129) and
reported the following conclusions:
1. Client violence is not a rare event, that is, a
majority (58%) of the respondents reported
experiencing one or, more incidents of client
violence at some point in their career.
2. Practice setting affects level of risk, with the
highest risk settings including criminal justice
services, drug and alcohol services, and child
welfare.
3. Male social workers are significantly more likely
to report experiencing client violence than female
social workers and greater numbers of incidents,
although females are more likely to report
concerns about safety.
4~ Experiencing an incident of client violence exacts a
significant emotional toll on the social worker
involved and may result in changes in practice
habits and feelings about social work.
Other studies (see, for example, Beaver, 1999; Mace,
1989; Rey, 1996) have reported comparable findings,
suggesting that the issue of safety and violence is not
. just a perceived issue, but a real issue for many social
workers in their day-to-day practice. It is critical that
strategies for assessing and preventing client violence
be developed that will serve to enhance safety while not
compromising client services.
A Biopsychosocial Framework for
Understanding Violence
The most appropriate framework for understanding
violent behavior is a biopsychosocial systems approach.
Violence is a multifaceted multidimensional phenom-
enon that results from interactions between individuals
and certain situational and environmental factors, and
affected by certain aspects of the histories of the indi-
viduals involved (Newhill, 2003).
The question of whether clinicians can reliably
prediet violence has received considerable research
effort since the late 1970s, with the conclusion that
clinicians are generally inaccurate when predicting
future violence over the long term (Monahan &
Steadman, 1994). They most often err toward false
positive predictions, that is; predicting that a client 'will
be violent when, in fact, the client does not behave
violently.
The cornerstone to improving the assessment of
violence risk over the short term, that is, 24-48 hr, is
knowing how to properly assess the client within the
context of his or her individual attributes, history, and
environment. By relying on a thorough knowledge of
what we know about the risk markers associated with
violent behavior, a social worker can more likely
determine which aspects of the client's situation suggest
there may be an elevated risk for future violence. This
knowledge, then, can help shape the choice of an
appropriate and effective intervention.
In the area of violence risk assessment, the term
"risk marker" is preferred over. the term "risk factor"
because many of these markers are associated with an
elevated risk for violence, but are not established causal
predictors of violence (Kraemer et al., 1997). That is, a
client may evidence a particular risk marker, or even
several risk markers, but that does not mean that par-
ticular client will definitely engage in violence. Vio-
lence has a low base rate, meaning that in the range of all
possible human behaviors, violence is a cornparatively
rare event. However, certain risk markers do represent
"warning flags," and the more "warning flags" a client
has, the greater is the probability that future violence
may occur. Thus, some kind of intervention to address
and mitigate these warning flags is warranted. Some
risk markers are unchangeable, for example, biological
sex, but others can be mediated via various clinical and
environmental interventions, many of which social
workers can provide .
Risk Markers Associated With Violent Behavior Risk
markers associated with violence fall within three
spheres: individual/clinical risk markers, historical risk
markers, and environmental/contextual risk markers
(Monahan et al., 2001; Newhill, 2003).
There are three categories within the sphere of in-
dividual/clinical risk markers: demographic risk mark-
ers, clinical risk markers, and biological risk markers.
Demographic risk markers include age, gender, and
socioeco~omic status. Although results are somewhat
mixed, the bulk of existing research suggests an
association between younger age and violent behavior,
with the highest risk occurring between the ages of 15
and 24. In general, as individuals age, rates of viole nce
fall (Swanson, Holzer, Ganju, & [ono, 1990). Being
male also elevates risk for violence; however, since the
late 1980s, reports of violence among women have in-
creased dramatically (Newhill, Mulvey, & Lidz, 1995;
Vaughn, Newhill, Litschge, & Howard, in press). Low
socioeconomic status operates as a risk marker because
individuals who live in lower socioeconomic strata
have a greater probability of being a victim of violent
crime, being forced to live in a dangerous neighbor-
hood, and being exposed to violent group norms, all of
which enhance risk of violence (Silver, Mulvey, &
Monahan, 1999).

With respect to clinical risk markers, although the
vast majority of individuals with mental illness are not
violent, certain psychiatric symptoms are associated
with aggressive behavior (Link & Stueve, 1998). These
symptoms include (a) paranoid delusions and auditory
command hallucinations, particularly if the individual is
under stress and not taking prescribed medication to
control symptoms; (b) repetitive fantasies ofharrning
others; (c) certain personality features, such as impuls-
ivity, and overwhelming negative emotions, for
example, intense anger; and (d) substance abuse,
particularly alcohol (Monahan et al., 2001). Finally,
there are biological risk markers, most significantly
neurological impairment, for example, dementia and
traumatic brain injury (Crowner, 2000).
\ .
The second sphere of risk markers is historical risk
markers. The best single predictor of future violence is a
history of recent, repetitive past criminal violence
(Monahan et al., 2001). The second risk marker is a
history of repeated exposure to violence in one's family
or social environment. Such early exposure to violence
includes experiencing severe abuse by a parent or other
caretaker or being a witness to domestic violence; being
severely neglected or rejected by a parent or other
primary caretaker; having a parent with serious mental
health or substance abuse problems; and being raised
with tacit family approval of cruelty toward other people
and/or animals. Two other historical risk markers
include having a history of repetitive economic in-
stability or unemployment, and having a history of
involuntary psychiatric treatment and hospitalization.
The final sphere of risk markers is environmental/
contextual risk markers, including the level and quality
of the individual's social support network; peer pressure
from peers who endorse violence to achieve power and
status; the influence of popular culture that endorses use
of violence, whether the individual has means for
violence, that is, access to lethal weapons and knowl-
edge of how to use them; and finally, whether the
individual has access to potential victims. It is impor tant
to note that the best single protective factor against
violence is stable positive social support.
All three domains-individual/clinical, historical, and
environmental/contextual risk markers-must be
considered when conducting a violence risk assessment
or providing treatment targeting violence and aggres-
sion. The strength or weight of each risk marker varies
across individual clients and, thus, one must examine
the client's situation ecologically on a case-by-case basis
when determining risk status. Furthermore, iden-
tification of risk markers must be paired with
identification of protective factors that can mitigate
against violence. For example, a young chronically
unemployed
CLIENT VIOLENCE 315
man who abuses alcohol and has problems with anger
and impulsivity evidences several risk markers for vio-
lence, but if he also has a strong social support network,
he may be able to manage the problems in his life
including any violent thoughts or impulses without
harming others or himself.
Practice Interventions
As the first step, the social work profession must openly
acknowledge that client violence is a real and legitimate
practice concern. Second, agency administrators and
supervisors must take the lead in developing a risk
management approach to facilitate the development of a
safe workplace, including providing high-quality safety
training that meets workers' self-identified needs. To
develop a safety policy specific to an agency's needs,
staff can convene a safety committee to guide the de-
velopment and implementation of safe workplace stra-
tegies including policies on how to respond to and
support workers who have experienced client violence
(see, for example, Griffin et al., 1995). Underreportin g
of client violence is common (Rowett, 1986); thus,
agencies should develop a user-friendly means for re-
porting and tracking all incidents of violence toward
staff and strongly encourage and support staff in docu-
menting such incidents (for an example of a violence
report form, see Newhill, 2003).
Social work educators and the Council on Social
Work Education must continue to acknowledge the risks
faced by social work students and field instructors, and
respond by requiring content on safety and risk
assessment and skills for practice with involuntary and
violent clients in both undergraduate and graduate cur-
riculums. Field faculty should ensure that field
placement agencies have a safety policy in place and a
plan for student orientation to the policy.
Table 1 provides an overview of guidelines for con,
ducting a violence risk assessment.
following the evaluation, consultation from col-
leagues must be obtained and written documentation
provided that sufficient risk assessment information has
been obtained and evaluated, and that the decision as to
whether the client poses a potential for violence has
been based on that information and a follow- up plan for
reevaluation of violence potential has been implement-
ed. Social workers must strive to give a clear, consistent
message to clients that using violence to solve problems
is not acceptable and assist clients in developing skills in
nonviolent approaches to resolving problems.
There have been a number of positive recent devel-
opments suggesting a trend by government and social
service . agencies toward taking the issue of social work
safety seriously by providing resources to support
316 QIENT VIOLENCE

TABLE 1
Guidelines for Conducting a Risk Assessment
Background/collateral information
review available official documents including clinical and criminal justice records
determine whether there is any past history of violence toward self or others or any history of abuse either as perpetrator or
victim
Clinical assessment of the client
note anything significant about the client's physical appearance suggestive of risk for violence including scars, tattoos, or
certain dress patterns
note if the client is angry, hostile, agitated, threatening, or verbally abusive
note the extent to which the client is compliant with routine requests and procedures as an indicator of the client's ability to
control his or her behavior
conduct a diagnostic assessment to determine the presence of any psychiatric or medical risk factors including whether there
is evidence of substance abuse
inquire about the client's' potential for violence towai:d others including who, why, how, and when he or she may harm
another individual '
inquire about the' client's potential for violence toward self
Following evaluation, obtain consultation from colleagues and provide written documentation that sufficient risk assessment
information has been obtained and evaluated, and that the decision as to whether the client poses a potential for violence has
been based on that information and a foUow-up plan for reevaluation of violence potential has been implemented.

prevention strategies. Fo~ example, in April 2007, a bill to
improve protections for social workers was signed into law by
Kentucky Governo~ Ernie Fletcher six months after' social
service worker Boni Frederick, from the Kentucky Cabinet
for. Health and' Family Services, was killed by a client during
a home visit. This new law provides 6 million. dollars to
improve safety for state social services workers, including
funding the hiring of more staff and security improvements at
state child welfare offices (Associated Press, 2007).
Most recently, in July 2007, the National Association of
.Social Workers sponsored a news conference and Capitol Hill
briefing to promote a federal bill that supports protecting
social workers from violence by asking Congress to authorize
5 million dollars each year for the next five years to fund the
development of safety measures with state matching funds.
The proposal is named after Teri Zenner, a social worker who
was stabbed to death by a client in 2004 during a routine home
visit (Pace, 2007). These are just two examples of the efforts
currently being made to protect social workers and clients
from violence.
In the world of social work today, client violence is
increasingly recognized as a common occupational hazard.
Everyday across the country,. family and community stresses
and problems, magnified by worsening economic conditions
and scarcer benefits and services, boil over into acts of
violence directed at individuals both within and outside of the
family, including toward social workers. Agencies must
acknowledge the reality within which their staff practice and
take definitive
preventive action to foster worker safety. Social workers who
are prepared with the resources and skills to meet the
unexpected are in the best position to protect themselves and
continue to provide the best services for their clients.
REFERENCES
Associated Press (2007, April 6). Kentucky: In slain social
worker's name. New York Times.
Beaver, H. W. (1999). Client violence against professional social
workers: Frequency, worker characteristics, and impact on
worker job satisfaction, burnout and health (unpublished dis-
sertation). Fayetteville, AR: University of Arkansas.
Crowner, M. L. (Ed.). (2000). Understanding and treating
violent psychiatric patients. Washington, DC: American
Psychiatric Press.
Dillon, S. (1992, November 18). Social workers: Targets in a
violent society. New York Times. pp. AI, C18.
Euster, S. (1992). Societal barometer. New York Times, De-
cember 4, Letter to the editor, p. A14.
Griffin, W. (1995). Social worker and agency safety. In R.
Edwards & J. Hopps (Eds.), Encyclopedia of social work
(19th ed., pp. 2293-2305). Washington, DC: NASW Press.
Griffin, W., Montsinger, J., & Carter, N. (1995). Personal
safety handbook. Durham, NC: Brendan Associates and
ILR, Inc.
Kraemer, H. c, Kazdin, A. E., Offord, D. R., Kessler, R. c.,
Jensen, P. S., & Kupfer, D. J. (1997).Coming to terms with
the terms of risk. Archives of General Psychiatry, 54(4),
337-343.
leBlanc, M. M., Dupre, K. E., & Barling, J. (2006). Public-
initiated violence. In: E. K. Kelloway, J. Barling, & J. J.
Hurrell (Eds.), Handbook of workplace violence (pp.
261-280). Thousand Oaks, CA: Sage.

. ... ~

Link, B. G., & Stueve, A. (1998). New evidence on the violence
risk posed by people with mental illness. Archives of General
Psychiatry, 55, 403-404.
Mace, P. (1989). The effect of attitude and belief on social workers'
judgments concerning potentially dangerous . clients (unpublished
doctoral dissertation). Los Angeles: University of California ..
Monahan, J., & Steadman, H. (Eds.). (1994). Violence and
mental disorder: Developments in risk assessment. Chicago:
University of Chicago Press.
Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins,
P., Mulvey, E., et al. (2001). Rethinking risk assessment: The
MacArthur study of mental disorder and violence.
New York., Oxford University Press. .
Newhill, C. E. (1996). Prevalence and risk factors for client
violence toward social workers. Families in Society, \
77, 488-495.
Newhill, C. E. (2003). Client violence in social work practice:
Prevention, intervention and research. New York: Guilford.
Newhill,C. E., Mulvey, E. P., & Lidz, C. W. (1995). Charac-
teristics of violence in the community by female patients seen
in a psychiatric emergency service. Psychiatric Services, 46,
785-789.
Pace, P. (2007, September). Worker safety bill promoted.
NASW News, p. 52.
Rey, L. (1996). What social workers need to know about client
violence. Families in Society, 77(1),33-39.
Rowett, C. (1986). Violence in social work. Cambridge, MA:
Institute of Criminology.
Silver, E., Mulvey, E. P., & Monahan, J. (1999). Assessing
violence risk among discharged psychiatric patients:
Toward an ecological approach. Law and Human Behavior,
23(2), 237-255.
Swanson, J. W., Holzer, C. E., Ganju, V. K., & jono, R. T. (1990).
Violence and psychiatric disorder in the community: Evidence
from the epidemiological catchment area surveys. Hospital and
Community Psychiatry, 41, 761-770.
Townsend, D. (1985). Letter to the editor. The Guardian, May 1.
Vaughn, M. G., Newhill, C. E., Litschge, C. M., & Howard, M. O.
(in press). Cluster profiles of residentially incarcerated .
adolescent females: Violence and clinical mental health
characteristics. Residential Treatment for Children and Youth.
FURTHER READING
Slaby, A. E. (1986). Handbook of psychiatric emergencies (3rd
edition). New York: Medical Examination Publishing
Company.
Tardiff, K. (1996). Assessment and management of violent patients
(Znd ed.). Washington, DC: American Psychiatric Press.
Weinger, S. (2001). Security risk: Preventing diem violence against
social workers. Washington, DC: NASW Press.
Zanarini, M., & Gunderson, J. (1997). Differential diagnosis of
antisocial and borderline personality disorders. In D. M. Stoff,
J. Breiling, & J. D. Maser (Eds.), Handbook of antisocial
behavior (pp, 83-91). New York: Wiley.
G..INICAL SOCIAL WORK 317
SUGGESTED LINKS
A Look at Safety in Social Work.
http://www.ssw.unc.edu/fcrp/cspn/Vo13_oo2.htm
OSHA Guidelines for Preventing Workplace Violence for
Healthcare Workers and Social Services Workers.
http://www.osha.gov/Publications/osha3148.pdf
Project Safe.
http://www .albany .edu/ ssw/projeetsafe/about.html Personal
safety when visiting patients in the community.
http://apt.repsych.org/cgi/contentffull/8/3/214
Canadian Centre for Occupational Health and SafetyViolence in
the Workplace.
http://www.ccohs.ca/oshanswers/psychosocial/violence .html
-CHRISTINA E. NEWHILL
CLINICAL SOCIAL WORK
ABSTRACT: The soldiers from the wars in Iraq and
Afghanistan, as well as large numbers of nonwounded
soldiers, experience post- traumatic stress disorder.
Further, the families, groups, and communities from
which all U.S. service men and women come, during
and after these and other wars, have experienced their
own warrelated trauma. Stories on the nightly news
reveal soldier reaction to combat stress, including
intrusive . memories, racing thoughts, nightmares,
troubled sleep,
riment with new methy, fear, isolation, depression anger, poor
concentration, hyper- or hypovigilance, exaggerated
responses, and increased alcohol and other drug abuse. The
stories of family, friends, and community are filled with war
stress symptoms of their own. Charged with keeping their
families together, bills paid, jobs afloat, children safe and
growing, families may experience a drop in income,
loneliness and isolation, long deployments, multiple last
minute combat redeployment and duty extensions, anger,
frustration, depression, increased alcohol and other drug
abuse, loss of trust, fear, increase in domestic violence, and
school disruption. Not all of the change for family is negative
as some spouses and children who are left behind find they
have new skills and new independence with which to
negotiate their world. The returning soldier's response to this
newfound independence . and skill may require the services of
the clinical social worker.
KEY WORDS: psychosocial functioning; cogrunve
behavior therapy; dysfunction; social constru ctivism;
narrative therapy; strengths- based therapy;
existentialism; postmodernism; radical theory; critical
realist philosophy
318 CLINICAL SoCIAL WORK
Introduction and Context
At the writing of this entry, America has been at war in
Iraq for over five years (March 20, 2003 the invasion
began) with over 3,200 U.S. soldiers confirmed dead by
the Department of Defense and an estimated 24,300 other
U.S. soldiers wounded (http://icas ualties.orgJoif/). The
warin Afghanistan, begun in October 2001, has gone on
even longer. At the drafting of this entry, an estimated
16,000 of the Iraq war wounded soldiers have been
diagnosed with post-traumatic stress disorder; It is certain
that large numbers of nonwounded soldiers also
experience post-traumatic stress disorder. Further, the
families, groups, and communities from which all U.S.
servicemen and women come, during and after these and
other wars, have experienced their own war- related
trauma. Stories on the nightly news reveal soldier reaction
to combat stress including intru sive memories, racing
thoughts, nightmares, troubled sleep, irritability, anxiety,
fear, isolation, depression, anger, poor concentration,
hyper- or hypo-vigilance, exaggerated responses, and
increased alcohol and other drug abuse. The stories of
family, friends and community are filled with war stress
symptoms of their own. Charged with keeping their
families together, bills paid, jobs afloat, children safe and
growing, families experience a drop in income, loneliness
and isolation; long deployments, multiple last minute
combat redeployment and duty extensions, anger,
frustration, depression, increased alcohol and other drug
abuse, loss of trust, fear, increase in domestic violence,
school disruption, and failure. Not all of the change for
family is negative as some spouses and children who are
left behind find they have new skills and new
independence with which to negotiate their world. The
returning soldier's response to this newfound
independence and skill may require the services of the
clinical social worker.
Clinical social work preparedness in response t o the
ravages of war is embedded in the history of casework in
the broader field of social work. By the time soldiers
fighting in the trenches of World War I were diagnosed
with what came to be known as shell shock, social case
work specializations in medical social work, psychiatric
social work, and school social work were significantly
developed with a broad range of skills to address the needs
of servicemens-zheir families, and their communities.
The sophistication of these specializations continued to
grow as illustrated in the field's response to the combat
fatigue diagnosis in World War II and Korean War
soldiers and veterans. It was not until the Vietnam War
that the depth of the mental health issues related to war
were codified as post-traumatic stre ss and later,
post-traumatic stress disorder (PTSD).
rs in times of calamhancing and maintaining their
patients' physical, psychological, and social functioning,
clinical social workers are at the forefront of professionals
responding to the needs of servicemen and women, their
families, and their communities. The legacy of the wars in
Iraq and Afghanistan will linger long after the publication
of this entry. With roots in responding to immigration (the
Settlement House movement), and addressing the
psychosocial consequences of violence, degradation, and
war (psychiatric social work movement) beginning the
contextuallzation of this entry on clinical social work
seems fitting tribute to our troops, their families, friends,
and communities and a good place to start to understand
the history, continuing evolution, and the depth and
breadth of clinical social work.
POSTSCRIPT Clinical social work interventions that
address the individual, family, group, and community
responses to war and other trauma issue s include, but are
not limited to, cognitive behavioral therapy, (CBT), eye
movement desensitization and reprocessing (EMDR),
and in some cases referral for antidepressant therapy to
help alleviate the depressive symptoms. For family
members, clinical soci al workers assist in the form of
mental health services, referrals, school social work
counseling, self-help, and support groups (Gillespie,
Duffy, Hackmann, & Clark, 2002). Clinical social
workers are increasingly a part of front- line and postwar
intervention teams, which also include psychiatrists,
psychologists, nurses, and psychopharmacologists, etc.,
recommended to intervene within hours to several days of
ession to ensure that consumers know their
Hackmann, & Clark, 2002; Thomas & O'Hara, 2000). The
effectiveness of the clinical intervention team approach
coupled with immediacy of response is reponed
to alleviate symptoms and severity of PTSD. .
Definition of "Clinical Social Work"
The National Association of Social Workers (NASW)
defines Clinical Social Work as follows: "Clinical social
work shares with all social work practice the goal of
enhancement and maintenance of psychosocial func-
tioning of individuals, families and small groups. Clin ical
social work practice is the professional application of
social work theory and methods to rhe treatment and
prevention of psychosocial dysfunction, disability, or
impairment, including emotional and mental disorder. It is
based on knowledge of one or more theories of human
development within a psychosocial context. Clinical social
work services consist of assessment; diagnosis; treatment,
including psychotherapy and

counseling; client-centered advocacy; consultation; and
evaluation. The process of clinical social work is
undertaken within the objectives of social work and the
principles and values contained in the NASW Code of
Ethics" (NASW, 1999).
The six core values of social work practice include
service, social and economic justice, dignity and worth
of the person, importance of human relationships, and
integrity and competence in practice. While embracing
the mission and core values of the social work profes-
sion, clinical social workers diagnose, design prevention
programs, and treat biopsychosocial disability and
impairment-including mental and emotional disorders
and developmental disabilities. These methods of
clinical work are aimed at the support and enhance-
. ment of client strengths and functioning within the
framework of the environment, and within the context
of professional relationships with individuals, couples,
families, and groups. Clinical supervision is also an
important tool in clinical social work (Osman,
DungeeAnderson, Holzhalb, Martin, & Timberlake,
2002).
History of Clinical Social Work
Mary Richmond was the primary organizer of the first
training program for professional social workers in
1898. She was also the founder of social casework, the
precursor to clinical social work as we know it today. In
the 1920s the Settlement House Movement provided an
alternative to the focus of Charity Organizations that
sent Friendly Visitors into the homes of the poor, to that
of focusing on helpers living in the neighborhood
among the disadvantaged people being served
(Ginsberg, 2001). Living in the milieu, settlement house
workers became increasingly aware of community and
societal level contributions to the problems faced by
immigrant and poor families. Consequently, the set-
tlement house movement evolved to include group
work and community organizing for more humane
labor laws, and treatment of children, immigrants, and
women (Strean, 1978).
The foundation of clinical social work is grounded in
the person-in-environment concept as developed by
Mary Richmond in 1922 as she presented her
perspective on social casework, later termed direct social
work. Richmond considered the essences of the "work"
as resulting from the direct action of the clientworker
relationship, and the indirect action of finding,
advocating, and developing, and the subsequent use of
environmental resources by both client and social
worker (Cornell, 2006). The 1930s saw a rise in the
numbers of social workers interested in psychoanalytic
theory and intervention. The growing person-
in-environment movement slowed with the allegiance
QINICAL SOCIAL WORK
319
to Freudian theory by social workers such as Gordon
Hamilton, who was reported to later "reaffirm social
work's traditional concern with the environment"
(Cornell, 2006, p. 51). The psychoanalytic focus lasted
well into the 1950s. Often supervised by psychiatrists,
direct practice social workers who were increasingly
challenged to help establish the credibility of workers in
their profession, clung to psychoanalytic perspectives
as the strategy for obtaining professional credibility.
Disaffection with structural inequity and boiling
sociopolitical unrest awakened social workers in the
1960s. Attuned to the Civil Rights movement, they
began to shift focus from promotion of-acculturation of
clients to fit into prescribed societal norms, "to great er
affirmation of differences and recognition of the need to
offer services attuned to the client's view of her or his
life circumstances shaped by her or his cultural world
view" (Hokenstad & Midgley, 2006). Schools of social
work moved away from the theoretical focus of the
1930s, 1940s, and 1950s to defining the profession's
responsibility for social justice and social action. In
response, clinical social work evolved to emphasize its
client advocacy perspective.
Today, with this varied practice history to inform us,
and in the context of traditional and dynamically
shifting theoretical frameworks, clinical social workers
are more prepared than ever to address the range of
problems faced by individuals, families, and groups in
society today, including HIV / AIDS, physical and
sexual abuse, immigration and emigration, mental
illness, substance abuse, domestic violence, violent
crimes, physical illness and disability, aging, teen
pregnancy, and school drop 'out (Goldstein, 2007).
Theories of Clinical Social Work Practice The
American Board of Examiners in Clinical Social Work
(ABECSW) defines clinical practice knowledge as
incorporating "theories of biological, psychological,
and social development. It includes, but is not limited
to, an understanding of human behavior and psycho-
pathology, human diversity, interpersonal relationships
and family dynamics; mental disorders, stress,
chemical dependency, interpersonal violence, and
consequences of illness or injury; impact of physical,
social, and cultural environment; and cognitive,
affective, and behavioral manifestations of conscious
and unconscious processes" (ABECSW, 2002).
Today, systems and ecological theory provide an
underlying perspective in all clinical social work. This
is particularly true given the increasing influence of
postmodern philosophies on psychodynamically
framed perspectives. While the core influence of
person-inenvironment is evident in social work
professional
320 CLINICAL SOCIAL WORK
practice in general, with the advent of postmodern
perspectives, the influence of person-in-environment on
areas of clinical practice that did not historically regard
environment to any significant degree (for example,
psychoanalytic theory and ego psychology) is
increasing. Given these changes, the vitality and
evolution of clinical social work is most exciting.
Clinical social workers who take on a postmodern
constructivist perspective, for example, find appeal in
work that "negates the claims of universalism and valu-
ing of dominant worldviews over those of oppressed or
devalued cultures" (Cornell, 2006), and are pushing to
interject the role of environment in shaping subjective
experience and internal processes at the same time.
The different theoretical.perspectives taken on by
clinical social workers are discussed throughout this
volume from traditional behavioral approaches, cogni-
tive behavioral therapy, crisis intervention, ethnic,
sensitive practice, Gestalt therapy, feminist social work
practice, problem solving, group therapy, and family
therapy. Postmodernism, constructivism, solu-
tion-focused, existentialism, radical theory, and critical
realist philosophy frame the newer developments in
cllnical.practice theory and will be discussed briefly
here.
SOCIAL CONSTRUCTIVISM AND NARRATIVE
THERAPY Narratives or the stories clients use "as the
descriptions and explanations given to events, interac-
tions, and experiences ... are cultural tales that set
parameters for what is possible" (Biever, Gardner, &
Bobele, 1999, p. 143).
SOLUTION FOCUSED A client, centered, strengths,
based therapy model that creates an environment where
together with the client the clinical social worker exam,
ines previous problem-solving successes to derive
insight and awareness needed for behavioral change
(Franklin & Moore, 1999). Having a distinctively
cognitive and behavioral base, the emphasis for
solution, focused work is on future behavior and goal
attainment.
EXISTENTIALISM The principles for practice based
on existentialism include "the concept of a shared
subjective journey, authenticity in confronting difficult
choices, responsibility and solidarity, self-creations as a
prerequisite for political liberty, recognizing contin-
gency and choice as opposed to stability, and recogniz-
ing and managing the dynamic tension between
authority and non, directive practice in social work"
(Cornell, 2006, p. 55).
POSTMODERNISM The clinical social worker who is
interested in the ways language, power, social factors,
and history shape the views and realities, and therefore
behaviors, interactions or events, of individuals, fam-
ilies, and groups, is likely to be attracted to postmodem
therapies (Biever, Gardner, & Bobele, 1999).
RADICAL THEORY The clinical social worker is well
versed in "structural inequities inherent in a capitalist
society and the role of culture and belief systems in
perpetuating inequality" (Cornell, 2006, p. 54). Cllnical
work focuses on the environment and "educating clients
and empowering them to change the structure that
contribute to their oppression rather than helping them
to adapt to the status quo" (Cornell, 2006, p.64).
CRITICAL REALIST PHILOSOPHY Clinical social
workers integrate the societal and the individual level
understandings in their work from the critical realist
perspective. Individual subjective experience, choice,
and action are considered in the context of the more
external societal dynamics, including inequality and
events such as war, a major traumatic event, and
experience that began this discussion of clinical social
work.
Fields of Clinical Social Work Practice and
Work Settings
In a 2000 Practice Research Network survey ofNASW
membership, "59% of members reported their principal
role in their primary practice area as direct practice. 17%
identified their role as administration, 8% identified
case management.and 4% identified clinical super,
vision as their principal roles. 12% identified 'other'"
(NASW PRN, 2007). In the same survey, the most
frequently cited practice area was mental health at 39%
of members responding, followed by 8% reporting
health as their primary practice area, 8% child welfare
and families, and 6% school social work as their primary
practice area. A combined total of 11 % reported aging,
adolescents, addictions, and international as primary
practice areas while 28% identified multiple areas or
other categories.
Clinical social workers are prepared by educational
requirements that include having a master's or doctoral
degree in social work with an emphasis on direct practice
clinical experience. Clinical credentials also . require at
least two years supervised postgraduate clinical work
experience. Fields of practice where clinical social
workers can be found include administration and
nds to start new programs.
CONTEXTS/SETTINGS: AGENCY AND
FIT SETTINGS
international social work, justice and corrections, mental
health, organizational consulting, private practice, and
school social work (Gibelman, 2004). Today's

clinical social workers are trained to work in a variety of
settings to provide mental health services to address
problems in a range of areas. Settings in which you
might find a clinical social worker include community
mental health centers, psychiatric hospitals, residential
treatment centers, day treatment and outpatient centers,
public and private welfare agencies, employee as-
sistance programs, schools, child and family service
agencies, Head Start and child day care, shelters, crisis
centers, VA hospitals, police departments, courts, jails
and prisons, corporations, government agencies, NGOs,
and private practice. More specifically, NASW Practice
Research Network survey data from 2000 indicates that
an estimated 75% ofNASW members are employed in
an organizational (as opposed to a private practice)
setting. "Of these, 22% are employed in outpatient
mental health setting, 10% are employed in schools, 9%
in social services agencies, 8% in hospitals with a
mental health unit, 6% in universities, and 5% in gov-
ernment social services agencies" (NASW PRN, 2007).
Clinical Social Work Intervention and Methods While
clinical social work practitioners draw their
intervention and methods from several theoretical
models, all clinical practice occurs within the ethical,
philosophical, and value base of the social work
profession. Each practice setting within which the
practitioner provides services, "imposes special con-
straints upon interventions, not only in regard to its
specific purposes, but also in regard to the availability
of resources" (Myer, 1993, p. 68).
ASSESSMENT The purpose of clinical assessment is to
help the practitioner "understand the nature and func-
tioning of individuals, and the structures, functions, and
processes involved in the families and groups [includi ng
communities] with which she or he lives and works"
(Myer, 1993, p. 78). Myer (1993) recommends that
assessment reflect the reality of special constraints that
every social work practitioner faces, and "this reality
that no organization and no practitioner can do
everything that a client needs or wants" (p. 68). This
. reality encourages the clinical practitioner to focus the
intervention to reflect the specific purposes and needs
being addressed to effect change. Whether in a single
service, such as a halfway house for recovering females
newly released from prison, or a multiservice agency,
such as one that combines preventive, foster care, and
adoption services, the clinical social worker is faced
with the differential impact on assessment strategies, of
field of practice and setting, time frames for and phases
of service delivery, practice modalities, and client
characteristics (Myer, 1993). And as is mentioned
QINICAL SOCIAL WORK
321
throughout this chapter, "the political context affects
the level and type of services that can be provided to
clients" as well (Gibelman, 2004, p. 44).
Myer presents the example of the child welfare set-
ting, and the process of matching a child and a place-
ment. The age of the child, race/ethnicity, religious
background, existence of special needs, the availability
of kinship care, the history of success or failure in other
placements, and maternal and paternal functioning, all
contribute to the development of a case assessment that
will increase the possibility of making an effective
match and subsequently case planning after the place-
ment is made. During the assessment process, the clin-
ical social worker gains a sense of the distinctions
between practice with individuals, families and groups
in relation to the presenting problem and task at hand.
In the case of the placement of a child subsequent to
confirmed allegations of severe abuse and neglect, as-
sessment provides the information need to discern the
choice of intervention and modality with individuals,
families, groups, and even the community.
DIAGNOSIS Thorman (1981) noted that diagnosis " is
only as accurate as the facts on which it rests ....... goes
beyond the gathering of facts on which it rests ... [and]
must reflect on the meaning of the facts and see the
client's problem as involvinga complex and dynamic
interaction between the client interacting with others
and functioning within a social situation" (p. 12).
Thorough assessment enables the clinical social worker
to clarify and effectively diagnose and target the
problems to be addressed in working with clients.
Gibelman (2004) notes for example "the problems
addressed by social workers in mental health include
those associated with the stressors of everyday living;
behavioral deficiencies; crises brought on by
emotional, environmental, or situational occurrences;
eating disorders; parent-child problems; marital
problems; depression; schizophrenia; bipolar disorders;
and other forms of psychopathology" (p.45).
DIRECT PRACTICE Clinical social workers engaged,
via personal contact, in interventions with individuals,
families, and groups, are generally, considered to be
engaged in direct practice. The terins treatment and
intervention are usually used to identify direct practice
approaches. Clinical social workers are increasingly
called upon to develop skills in both direct and indirect
practice methods.
INDIRECT PRACTICE Clinical social workers are
engaged in interventions on behalf of individuals,
families, and groups through work with other agencies,
in
322 CLINICAL SocIAL WORK
government, developing policy, and work in advocacy or
research groups. Clinical supervision, agency or program
administration, consultation with colleag ues, advocacy,
program development, teaching, policy analysis, grant
writing, research, and publication are various forms of
indirect practice approaches (ASWB, 2003).
EVALUATION The importance of evaluation is to as sure
practitioner and agency accountability and respon-
sibility for the safety of and provision of effective
services to clients and the public. Accountability to the
client and the public is a primary social work prac tice
value and the rationale behind licensure and ere-
dentialing efforts. Accountability requires the clinical
.
eekends and as such is available for service delivery .
.
in the use of evidence-based intervention, evaluating
practice outcomes as well as the capacity to contribute to
the research endeavors. An emphasis on account ability and
evaluation can help to avoid repeating the provincial
tendencies of the profession reminiscent of the 1930s ,
1940s, and 1950s in its efforts to maintain the credibility ,
portability, and reimbursement creden tials of clinical
social work. Thyer (2007) emphasizes that the clinical
social work field must be careful not to base its knowledge
so firmly in psychodynamic theories to the "exclusion and
marginalization of clinical social workers who base their
practice upon other theoretical orientations" (p. 26 ).
Current practice evaluation ap plications will enable us to
move forward in this important endeavor.
Schalock (2000) emphasizes current applications of key
accountability concepts including report cards;
benchmarks, performance measurement, i nformatics,
national databases, empirically based practice guide lines,
and participatory action research. Schalock sug gests that of
the goals of practice evaluation, current trends tend toward
increasing "precision, certainty, comparability, and
generalizabilitv of the evaluation's results" (p. 69). The six
traditional outcome-based de signs used to meet these goals
include (1) experimental/ control, (2) matched pairs
(cohorts), (3) hypothetical comparison group, (4 )
longitudinal status comparisons, (5) p re/post change
comparisons, and (6) person as own comparison.
Choice of design is influenced by questions asked,
phase in the life of the program, the ability to conduct or
approximate the experimental design (or degree of
precision related to maximizing internal and external
validity) (Schalock, 2000).
Single System and Performance,Based Evaluation.
The person-, family-, group-, or community- referenced
indicators (behavior/performance), and outcomes reflect
both the results of the intervention provided and the
resulting quality of life for the service recipient, whether
enhanced or not enhanced (Schalock, 2000, p. v).
Outceme-Based and Impact Evaluation. Clinical
social workers are interested in the effectiveness, im pact,
and/or cost-benefit of intervention (Schalock, 2000 ).
Impact evaluations, a subset of outcome- based evaluations
help the clinician determine whether an intervention or
program made a difference compared with either no
program or an alternate program (Schalock, 2000).
Policy Evaluation. Clinical social workers are also
interested in the equity and effectiveness of policy outcomes
at the organizational, community, state, and federal levels.
The No Child Left Behind Act of 2001 [PL 107-110] provides
one example of policy that is receiving a lot of evaluation
attention today ..
rically Based Practice
Moving toward knowing which interventions work best for
whom, we are increasingly called upon to know about the
effect of gender, age, race/ethnicity, and other influences
on outcomes.
Accountability
"Clinical social work is astate-regulated professional
practice. It is guided by state laws and regulations"
(NASW, 2005)~
In this regulatory context, the standard education
requirement for clinical social workers is a master's or
doctoral degree in social work from an accredited school of
social work, with supervised clinical intern, ship, and at
least two years of postgraduate supervised clinical field
employment. The National Association of Social Workers
and the American Board of Examiners in Clinical Social
Work are the primary providers of professional credentials
for clinical and direct service practitioners (Ginsberg,
2001).
ACCREDITATION The Council on Social Work Edu-
cation certifies departments and schools of social work
as meeting formal official requirements of academic
rigor and excellence in curriculum and programming.
LICENSURE Licensure has been the standard of clini-
cally based agency and private social work practice
since the 1960s; One of the most important reasons for
licensure is the restriction of the use of the title "social
worker" to those who meet the education and training
requirements set out by the state (Ginsberg, 2001 ).
According to the Association of Social Work Boards,
the purpose of licensing and certification in social work
is to assist the public through identification of s tandards
for the safe professional practice of social

work. Each jurisdiction defines by law what is required
for each level of social work licensure. The four typical
categories of practice that jurisdictions may legally
regulate include Bachelors, Masters with no post-degree
experience, Masters in Social Work with two years
post-degree supervised experience, and Masters in So-
cial Work with two year post-degree supervised clinical
social work practice [http://www.aswb.org/lic_req.
shtml].
CREDENTIALS AND CERTIFICATIONS FOR SPECIAL
AREAS OF PRACTICE Addressing the need for uni form
national professional criteria for clinical practice,
credentials assist practitioners who are seeking
appropriate referral sources (or clien ts as well as
colleagues for consultation and collaboration, and
finally for ade quate and fair reimbursement for
professional services. Licensure and specialization
credentials provide assur ance to employers, clients,
colleagues, and payors that the clin ical social worker
is guided by a code of ethics and conduct, standards,
and principles with the purpose of protecting the
public (Ginsberg, 2001; NASW, 1999).
The NASW credentials two levels of clinical social
work practice skill and experience, the Qualified
Clinical Social Worker (QCSW) , and the Diplomate in
Clinical Social Work (DCSW). Both require that the
social worker be licensed by the state, have a masters
from a CSWE accredited program, postgraduate degree
supervision,' and pass an examination. The QCSW
requires a master's degree and 3,000 hr of supervised
postgraduate work, the DCSW requires a master's or
doctorate from a CSWE accredited program, and five
years postgraduate supervision, plus 20 hr of clinical
course work. Clinical specialty certifications
recognized by NASW include the Clinical Social
Worker in Gerontology (GSW~G), and the Certified
Clinical Alcohol, Tobacco, and Other Drug Social
Worker. NASW certifications are not a substitute for
required state licenses or certification. Most states
require continuing education to maintain licensure or
certification.
Focused solely on clinical social work as a "field of
practice" within the profession of social work with
numerous specialty areas of practice expertise, the
American Board of Examiners in Clinical Social Work
(ABE) credentials one level of clinical social work prac-
tice, the Board Certified Diplomate in Clinical Social
Work (BCD). To be BCD eligible, the social worker
must have five years and 7,500 hr of postgraduate
clinical practice (3,000 under supervision), a master's
degree from a CSWE accredited program, and the
highest state license available.
CLINICAL SocIAL WORK 323
The Survey of Licensed Social Workers in the United
States by NASW Center for Workforce Studies (2005)
reports that the most commonly held social work certi-
fication, including nearly half of the licensed social
work respondents reporting, was clinical social work.
The survey included a random sample of 10,000 li-
censed social workers.
MARRIAGE AND F AMIL Y THERAPY, SCHOOL SOCIAL
WORK, AND V A CREDENTIALS Ginsberg (200l )
highlights the value of membership in the American
Association of Marriage and Family Therapy
(AAMFT) and in some states licensing in this
specialization as an added credential. Requiring
similar accredited master's and or doctoral degree
training and postgrad uate supervision, maintaining
AAMFT requirements involves additional marriage
and family educational requirements. The AAMFT
credential adds to a clinical social worker's skills,
value, and mobility within and across practice
settings, including private practice.
The School Social Work Specialist Credential
(SSWS) is an NASW administered specialization ere-
dential that similarly positions clinical social workers in
terms of skills, value, and mobility. The specialist
credential requires that the social worker pass the
National Teachers Examination School Social Worker
Specialty Area Test. Although this credential is not
generally required by school districts, it is increasingly
an important way to address job vulnerability in the
wake of fluctuating funding priorities across districts.
The School Social Work Association of America is an
important resource for social workers interested in
pursuing this specialization.
The Department of Veterans Affairs (VA) assists in
the training of health professionals, including clinical
social workers. USDHHS (2006) report to Congress on
the supply and demand of professional social workers
providing long-term care services states that "approxi-
mately 45,000 students and trainees in associated health
education programs at the undergraduate, grad uate, and
post-graduate levels receive clinical experience at the
VA facilities. The VA is affiliated with over 100
Graduate Schools of Social Work, and operates the
largest and most comprehensive clinical training pro-
gram for social work students-training approximately
600-700 students per year. Student funding support of
$38.8 million is provided each year and includes 45
Geriatric Assessment Stipends of 500 hr each, 340
MSW student stipends at VA medical centers annually,
and 557 stipends for MSW programs at $4,112 each.
Moreover, the Veterans Health Administration (VHA)
requires that all applicants for the position of social
worker must have an MSW from a school
324 CLINICAL SOCIAL WORK
of social work accredited by the CSWE and be licensed or
certified at the master's level to independently prac tice
social work in a state. In addition, VHA has devel oped a
core competency requirement for its long- term care social
workers, including an annual aging- related competency
assessment every year in which each social worker must
present a psychosocial assessment and participate in peer
review of cases" (p. 16).
LICENSURE, CREDENTIALS, AND THIRD PARTY
REIMBURSEMENT Clinical social work credentials
provide evidence to third party payers of a practitioners
experience and knowledge to provide and charge for
services.
Medicaid budget cuts are, a particular concer n for
clinical social workers, not just because of the negative
impact on reimbursement, but because of the cut in
person-in-environment sensitive services provided to the
most vulnerable populations in our society through
Medicaid. Cuts tend to result in restrictions to reim-
.bursement for diagnostic, screening, preventive, and
rehabilitative services typically provided by licensed
clinical social workers.
Medicare reimbursement amounts that are too low to
cover ancillary services such as social work is a concern
of clinical social workers and social workers in general
across the spectrum of services. The Medicare Social
Work Equity Act (MSWEA) of 1999 is an example of
legislation that recommended the exclusion of social
workers in payment from skilled nur sing agencies for
services instead exempting clinical social workers from
consolidated billing to clinical social workers having to
bill Medicare directly (Barth & Pho, 2001). A further
concern regarding the 1999 MSWEA was the blurring of
the difference between definition of social services and
the services provided by clinical social worker. The
reimbursement and care policy decisions of federal, state,
and local government has a significant impact on social
workers-clinical social workers in particular. The push to
balance budgets may result in recom mendations that
relegate clinical social workers to unnecessary ancillary
work that can be done by counselors and other staff with
fewer degrees or credentials and requiring less pay.
HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIP AA) Given the com-
plexity of the HIPPA privacy regulations for client health
information, modifications since 1999, and the social
work profession's efforts to respond to this legis lation, a
detailed discussion is beyond the scope of this entry. It is
important for clinical social workers to
review practice notices from credentialing and licensure
bodies regarding HIP AA regulations and social work
practice. NASW provides a detailed brochure entitled
"What Social Workers Should Know About the HIP AA
Privacy Regulations" (NASW, 2001). For example, all
clinical social workers should know that psychotherapy
notes are accorded special privacy protections under HIP
AA, where written client consent is required before the
notes can be disclosed to anyone. There are aspects of the
psychotherapy note that are excluded from this rule,
including counseling session start and stop times,
medication monitoring, frequency of treatment, results of
clinical tests, and any summary of diagnosis, functional
status, treatment plan, symptoms, prognosis, and
information on client progress to date (NASW, 200l). A
more recent revision to HIPAA involves the National
Provider Identifier (NPl) (DHHS, 2004). Beginning May
2005 through May 2008, clinical social workers "must use
only their NPIs to identify themselves in standard
transactions such as claims, eligibility inquiries and
responses, claim status inquiries and responses, referrals,
and remittance advices" (Coleman, 2006, p. 1). The NPI
will replace current provider identifiers used by clinical
social workers and eliminate the need for them to use
different identification numbers to identify themselves
when conducting standard transactions with multiple
health plans.
Future Trends and Standards
Advances in technology present today's and future clinical
social workers with training, collaboration, treatment, and
evaluation options that will require sensitivity to access
and privacy issues. Council on Social Work Education
accredited social work programs are receiving more and
more queries about distance education courses.
Competition with online social work degree programs that
cater to prospective students who work full- time, live far
away from the traditional brick and mortar institutions,
and affordability are all reasons why increasing numbers
of students are considering online social work degrees.
Faculty at traditional brick and mortar institutions are
debating the efficacy of distance practice and other
courses when ability to assess quality of instructor- student
and student-tostudent interaction has been a cornerstone
of assessing student progress-particularly at the Masters
level. It is increasingly common for clinical social
workers to complete licensure and certification exams via
online resources.
Clients are increasingly offered opportunities for
taperecorded or online therapeutic homework
assignments. The evaluation of clinical social work
interventions is

also increasingly mechanized via computers and the Internet.
Important concerns are informed consent, privacy in and access
to computers and systems. A built-in password protection for
client information is one important evaluation for
consideration. More work is required over the coming years to
improve these. protections. Clinical social workers can be at
the forefront of these system and technological enhancements.
Online Therapy
Online therapy, an increasingly available option for clients
who seek the service of clinical social workers, presents as
many challenges as it does opportunities. Discerning the
credentials and credibility of the online therapist presents
achallenge in this age of the proliferation of information.
Which guarantees of safe and secure exchange of information
can the client or clinical social worker seeking consultation
believe?
Teleconferencing and
Online Continuing Education
NASW information on specialty certification programs
indicates the availability of Alternate Supervision, including
group supervision, teleconferencing, and videoconferencing.
Aging and Gerontology: A Burgeoning
Area (or Clinical Social Work Practice
With the increasing aging of the baby boomers, the aging
specialty has significant implications for the future clinical
social work workforce (NASW, 2005). From 1996 to 2001,
the Council on Social Work Education reported a drop in the
number of students who had selected an aging specialization
and were enrolled in MSW programs. Today, there is an
incremental increase in selection of the aging concentration
and increases in undergraduate and graduate students in aging
and gerontology field placements. The increasing challenge is
for accredited social work programs to increase curricular
gerontology content.
REFERENCES
ABECSW. (2002). Professional development and practice compe-
tencies in clinical social work: A position statement of the . American
Board of Examiners in Clinical Social Work, (2nd ed.). Salem, MA:
ABECSW.
ASWB. (2003). Guide to social work ethics course development.
Culpepper, VA: ASWB. . Strean, H. S. (1978). Clinical social work: Theory and practice.
Barth, M. c., & Pho, Y. (2001). The labor market
for social . workers: A first look. The John A.
Hartford Foundation.
ions like to see themselves ashttp://www.sp2.upenn.edu/
gswi/opportunities/iabocmarkecarticie. pdf
SCLINICAL SOCIAL WORK 325
Biever, J., Gardner, G., & Bobele, M. (1999). Social construction
and narrative family practice. In C. Franklin, & C. Jordan
(Eds.), Family practice: Brief systems methods for social work (pp.
143-174). Pacific Grove, CA: Brooks/Cole.
Coleman, M. (2006). National Provider Identifier: Practice news
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http://www .socialworkers.org/practice/clinicalf
csw052oo5.asp.
Cornell, K. L. (2006). Person-in-situation: History, theory, and
new directions for social work practice. Praxis, 6(4),50-57.
Franklin, C., & Moore, K. C. (1999). Solution-focused brief
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Pacific Grove, CA: Brooks/Cole.
Gibelman, M. (2004). What social workers do (2nd ed.).
Washington, nc.: NASW Press.
Gillespie, K., Duffy, M., Hackmann, A., & Clark, D. M. (2002).
Community based cognitive therapy in the treatment of
post-traumatic stress disorder following the Omagh bomb.
Behaviour Research and Therapy, 40(4), 345-357.
Ginsberg, L. H. (2001). Careers in social work (2nd ed.).
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Goldstein, E. G. (2007). Social work education and clinical
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Hokenstad, M. c., & Midgley, J. (Eds.). (2006). Social work
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Washington, DC: NASW Press.
ists in PennsylvaniaAssessment in social work practice.
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NASW. (2005). NASW standards for clinical social work in social
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NASW & Center for Workforce Studies. (2005). Survey of licensed
social workers in the United States. Washington, DC:
NASW.
NASW Behavioral Healthcare. (2001). What social workers
should know about the HIP AA Privacy Regulations. Practice
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http://www.naswdc.org/practice/behavioraLheal th/
mbhOlOl.asp.
NASW Practice Research Network (PRN). (April 5, 2007).
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[http://www .socialworkers.org/naswprn/surveyOne/area.pda.
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Schalock, R. L. (2000). Outcorne~based evaluation (Znd ed.).
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326 CLINICAL SOCIAL WORK
Thorman, G. (1981). Guide to clinical social work. Springfield, IL:
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FURTHER READING
ACSW. (April 16, 2007). Licensing requirements. [http://
www.aswb.org/lic jeq.shtml]. \
Bureau of Labor Statistics, U.S. Department of Labor. (April 5,
2007) Occupational outlook handbook, 2004--05 ed. [http://
www.bls.gov/oco/].
Feit, M. D. (2003). Toward a definition' of social work practice:
Reframing the dichotomy. Research on Social Work Practice,
13,357-365.
Franklin, c., & Jordan, c. (1999). Family practice in today's
practice contexts. In C. Franklin, & C. Jordan (Eds.), Family
practice: Brief systems methods for social work (pp, 3-22). Pacific
Grove, CA: Brooks/Cole.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D.
I., & Koffman, R. L. (2004). Combat duty in Iraq and
Afghanistan, mental health problems, and barriers to care. The
New England Journal of Medicine, 351, 13-22.
NASW. (1989). NASW standards for the practice of clinical social
work. Washington, DC: NASW. .
Simpson, G. A, Williams, J. c., & Segall, A B. (2007). Social
work education and clinical learning. Clinical Social Work
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in Chief), Encyclopedia of social work (19th ed., pp.502513).
Washington, DC: NASW Press.
-DARLENE GRANT
CODES OF ETHICS
ABSTRACT: Social work values and ethics provide the
. foundation for social work practice around the world.
Almost all countries where social work is a recognized
profession have a Code of Ethics. Although there are
many similarities among Codes of Ethics in different
countries, cultural and societal differences have influ-
enced their content and focus. The extent to which
Codes of Ethics have a direct effect on social work
practice has been debated. While Codes of Ethics reflect
societal and national differences, what is univer sal and
fundamental to social work practice from a human
rights perspective should prevail.
KEY WORDS: social work ethics; international ethics;
social work values; comparative ethics; human rights
Background
Similar to other professions, social workers around the
world have developed Codes of Ethics to delineate
important values, principles, and standards for profes-
sional conduct. Ethical codes have been viewed as
essential in
1. Offering guidance to social workers in addressing
ethical issues
2. Protecting consumers from incompetent practice
3. Providing opportunities for social workers to self
govern their professional behavior
4. Delineating standards for ethical practice
5. Protecting social workers from litigation (Reamer,
2006)
In many countries the practice and evolution of the
social work profession has usually preceded the devel-
opment of specific Codes of Ethics. For example,
although social work in the United States began as a
profession over a hundred years ago, it was not until
1920 that American social work pioneer Mary
Richmond developed the first pre-NASW Code of
Ethics. Since the first NASW Code of Ethics in 1960,
the Code has been revised six times, in 1967, 1979,
1990, 1993, 1996, and 1999 (Reamer, 2006). The cur-
rent 27-page, ISS-provisions Code of Ethics looks very
different from the first 1960 NASW I- page document
(Congress, 1999).
During the last century social workers from many
countries around the world developed and revised their
Codes of Ethics. For example, the British Association of
Social Workers Code was first introduced in 1975 and
revised several times until its current version was
adopted in 2002 (Banks, 2006). Similarly, the
Australian Code of Ethics was proposed in 1954,
revised several times until the current acceptance of the
Code in 1999 by the Australian Association of Social
Workers (Congress & McAuliffe, 2006). The Korean
Code was first developed in 1982 and revised in 1992
and 1999 until the current version was adopted in 2001
(Congress & Kim, 2007).
Most developed countries, especially where social
work is a long-standing recognized profession, have
Codes of Ethics. Seventeen countries have their Codes
of Ethics posted on the International Federation of
Social Workers (lFSW) Web site: Australia, Denmark,
Finland; France, Germany, Ireland, Italy, Luxembourg,
Norway, Portugal, Russia, Singapore, Spain, Sweden,
Turkey, United States of America, and the United
 CoDES OF Ennes 327

Kingdom. It should be noted that the Codes of Ethics on Comparative Values Around the World Since the
the IFSW Web site are primarily from countries where first section of national Codes of Ethics usually includes a
English is a primary or strong secondary language. statement of social work values, it is important to look at
In some countries a regulatory body such as the the common values of social workers around the world.
Conselho Fereal de Servigo Social (1993) in Brazil or the Do all social workers share the same values? IFSW and
General Social Care Council in England (2002) has issued IASSW include the following description of common
a Code of Ethics in addition to or in lieu of the professional social work values in their 2000 Statement about Social
organization. Some countries have a governmental Work Practice:
organization that issues a Code of Ethics in addition to the
professional association. In other countries the
Social work grew out of humanitarian and demo-
professional association does not have a Code of Ethics,
cratic ideals, and its values are based on respect for
and thus the regulatory body has issued a Code of Ethics.
the equality, worth, and dignity of all people. Since
Other countries such as Finland rely on the IFSW General
its beginnings over a century ago, social work
Code of Ethics (Banks, 2006).
practice has focused on meeting human needs' and
developing human potential. Human rights and
Intemation~l Code of Ethics
social justice serve as the motivation and justifica-
The IFSW was first developed in 1994 and revised in 2004,
tion for social work action. In solidarity with those
Ethics in social work: Statement of principles, for social
who are dis-advantaged, the profession strives to
workers in cooperation with the International Association
alleviate poverty and to liberate vulnerable and
of Schools of Social Work (IASSW). IFSW is an
oppressed people in order to promote social inclu-
international professional social work organization that
sion. Social work values are embodied in the pro-
represents 83 professional social work organizations
fession's national and international codes of ethics.
around the world, It has been estimated that there are 1.5
(IFSW, 2000, p. 1)
million professional social workers in practice globally
(500,000 of whom belong to professional organizations) There has been limited research on the values of social
and over 2,000 undergraduate and graduate social work workers around the world or how they integrate values
education programs (CSWE, 200l). This international into their actual practice. In a recent study Dominelli
ethics document developed by IFSW and IASSW and (2004) found that most social workers believe in values
approved by member organizations has been used by such as promoting self-determination (96%) and creat ing
many countries as a guide for developing their own codes a just society (72%), while a surprising 16% reported that
of ethics (Banks, 2006).
social work values do not "underpin their practice" (p.
An underlying assumption for this international
163).
statement of ethical principles ha s been that it should
Afrer identifying universal social work values as
reflect ethical practice in developing as well as devel oped
respect for basic rights, sense of social responsibility,
countries. An ongoing. concern, however, has been that the
commitment to individual freedom (social justice), and
IFSWjlASSW document has an individualist perspective
support of self determination, Abbott (1988, 2002) com-
that may not be appropriate for social workers from
pared social workers from different sections of the world,
countries with a greater focus on comrnunitarian
including North America, Asia, Europe, Australia, and
approaches. Because of this issue, the IFSW International
New Zealand. Using the four value categories listed
Ethics committee (where this author is a member) is
above, Abbott learned that social workers from around the
especially seeking input from social workers from
world support the values of respect for basic rights and
developing countries in order to revise the 2004 Statement
support of self-determination, while a sense of social
of Ethical Principles.
responsibility and commitment to individual freedom
This document demonstrates a focus on human rights
were not shared universally.
that is considered fundamental for the advancement of
Research on different values among European social
social work in a global world. Human rights receive
workers looked at the similarities and differences between
varying attention in codes from different parts of the world.
the values of welfare professionals in Denmark and
The' NASW Code of Ethics looks at human rights in the
Britain (Hatton, 2001). English social workers adopt a
last section under social workers' ethical responsibilities to
value base that opposes discrimination and oppression as
broader society, while the largest section of the Code of
manifested in racism and xenophobia, while Danish social
Ethics is devoted to the individual social worker's
workers focus more on social solidarity and cohesion
responsibility to clients.
whereby newcomers are encouraged to assimilate into
Danish society (Hatton, 2001).
328 CODES OF ETHICS
Healy (2007) discussed the issue ofuniversalism and
cultural relativism as applied to ethical decisionmaking
in social work and concludes that given social work's
commitment to human rights a rnoderateuniversalist
approach is best.
In every country social work values are related to
prevailing societal values. To understand values as they
relate to professional practice, social workers are en,
couraged to become aware of societal values as well as
the professional values in the country where they prac-
tice (Congress, 1999). Social work values in the United
States have been viewed as firmly rooted in societal
emphasis on individualism and self-reliance
(McDonald, Harris, & Wintersteen, 2003). The fact that
privacy and confidentiality receives the, most attention
in the NASW Code of Ethics may be some evidence of
this.
Value Differences in Codes of Ethics Around the
world, there seem to be many similarities in the values
delineated in national Codes of Ethics. For example, the
U.S. National Association of Social Workers Code of
Ethics (1999) lists the following six principles (values ):
service, social justice, dignity and worth of the person,
importance of human relationships, integrity, and
competence, while in a similar fashion, the Korean C ode
of Ethics (200l) lists human dignity and worth, the
principle of equality, the right of freedom, right to live,
social justice, and democracy, autonomy and
self-determination, development of pro, fessional
knowledge and skills, and preservation of competence
and dignity. The Australian Code of Ethics (1999) lists
five values: human dignity and worth, social justice,
service to humanity, integrity, and competence. While
the U.S. Code describes its values as ideals toward
which all social workers can aspire and does not rank
them, the Australian Code considers human dignity and
worth and social justice as equal and overarching and
that the pursuit of these values is demonstrated through
service to humanity, integrity, and competence in
professional practice. Of course, it is not known whether
social workers in different countries ascribe different
meanings and interpretations to these terms.
Although an examination of available national
Codes of Ethics demonstrates much congruence of va-
lues, our understanding of this may be limited because
Codes of Ethics from developing countries are not read,
ilv available or may be just taking shape.
Common Principles Across Countries
There has been limited comparative work on Codes of
Ethics in different countries. Exceptions include
Banks's (2003) study of the Codes of Ethics in England ,
South Africa, and the United States, Banks's (2006)
study of 33 Codes of Ethics, Congress and McAuliffe's
(2006) study of the Australia and U.S. Codes of Ethics,
and Congress and Kim's (2007) study of the Korean and
the U.S. Codes of Ethics.
To learn more about the Codes of Ethics from all
countries Banks (2006) looked at the 17 Codes .of
Ethics posted on the IFSW Web site in January 2005 and
also asked the 63 countries not included on the Web site
to submit their Codes of Ethics. The Codes of Ethics she
received from 33 countries differed in length, ranging
from the l-page code from the South Africa Black Social
Work Association (n.d.) to the 27-page code from the
United States (1999). Longer codes, such as that of the
United States, were much more detailed and often
included more content on professional practice
standards in terms of dual relationships and informed
consent.
Codes of Ethics around the world are usually princi-
ple-based rather than utilitarian focused. In other words,
Codes consist more of absolute statements, such as in
the U.S. Code, "Social workers should protect the
confidentiality of all information ... ," whereas a utili-
tarian approach looks primarily at consequences. For
example, confidentiality would only be maintained if it
did not have negative consequences for others. While
Codes that are most detailed such as the U.S. Code often
list some utilitarian (consequential) exception, as for
example, confidentiality can be violated "when dis, closure
is necessary to prevent, serious, foreseeable, and imminent
harm." (1.07c)! the principle is usually presented first. In
countries with much shorter less, detailed codes, principled
statements are often the only content.
A common model is an initial general statement of
values or principles and then a more detailed delinea tion
of standards. National codes usually "do not pro vide a
set of rules that prescribe how social workers should act
in all situations" (NASW, 1999, p. 2). Only one code,
the South African Black Social Work Association
(SABSW A) takes the form of an oath ("I swear")
(Banks, 2006, p, 83.) There is a tendency for codes to
become longer over time and most codes include
content on the responsibility of social workers to clients,
colleagues, agency, society, and profession
(Banks, 2006).
Part of the reason why codes look similar may be that
social workers in different countries have often looked
to other countries as models for development or revision
of their codes. Banks (2006) suggested that Australia
and Korea both reviewed the U.S. Code of Ethics in
developing the revised Australian Code in 1999 and the
most recently revised Korean Code in 2001.

Because of this fact, Banks (2006) argues that differ-
ences in codes do not reflect actual variations in prac tice,
legal standards, or cultural differences. It should be
noted, however, that Banks primarily examined Codes of
Ethics from 33 developed countries where social work is
an established profession and there was much congruity
in values. In many developing countries social work is
an emerging vocational field where social workers have
limited professional education or where it was formed as
an offshoot of another profession or discipline, for
example sociology or psychology. There may not be a
written Code of Ethics, but one can . speculate that if
there were, practice standards as enumerated in a Code
of Ethics might be somewhat different than existing
national Codes of Ethics.
In the Australian and Korean Codes, as well as that of
the United States, confidentiality receives much
attention, possibly because of the societal focus in all
three developed countries on individual rights (Congress
& Kim, 2007; Congress & McAuliffe, 2006). However,
developing countries may pursue a more collective
approach to ethical practice as evidenced in consulting
extended family or village elders, rather than protecting
an individual's right to privacy and confidentiality
(Healy, 2001).
Application of Codes of Ethics to Practice How do
social workers use the Code of Ethics in their practice?
Reamer's book (2006) is helpful to social workers in
understanding different sections of the NASW Code of
Ethics and its application to practice in the United
States. There has been ongoing debate about whether
social workers use the Code of Ethics in direct practice
(Jayaratne, Croxton, & Mattison, 1997) or
administrative practice (Congress & Gummer, 1996).
Congress (1992) has argued that social workers are
knowledgeable about the Code of Ethics and apply it in
ethical decision making, while other research has
suggested that the U.S. Code of Ethics had limited use in
ethical decision making (Holland & Kilpatrick, 1991).
More recently a study conducted by McAuliffe (1999)
found that Australian social workers, although relatively
familiar with the Code of Ethics, did not consider using
it as a resource to assist decision making when
confronted with an ethical dilemma. The Code was seen
primarily as "a useful construct in laying down the basic
values of the profession" (McAuliffe, 1999, p. 19).
)ayaratneet al. (1997) noted that while social workers
may be aware of major code provisions (for example,
avoiding sexual contact with current clients), they are
less knowledgeable of and less likely to adhere to Code
provisions in regard to controversial issues such as
nonsexual dual relationships with former clients.
~
.'
CoDES OF ETHICS 329
Different countries have various.ways of monitoring
adherence to the Code of Ethics. The United States
probably has the most developed system, in which each
chapter of NASW has an Ethics Committee (formerly
Committee of Inquiry) that adjudicates or mediates
cases in which NASW members violate the Code of
Ethics. Sanctions vary depending on the seriousness of
the violation. Sometimes additional education may be
required or the public may be informed through the
NASW News. If the NASW Code violation is also
considered a state licensing violation, the social worker
will be referred to the State Board for appropriate action.
An ultimate sanction: administered by the state might be
suspension or loss of license, which may have serious
employment consequences for the social worker.
Future of Social Work Codes of Ethics
As social work has become a recognized profession in
countries all over the world, national Codes of Ethics
have helped to delineate practice standards for social
workers. To be applicable to a variety of practice situa-
tions, Codes of Ethics have been by necessity general
and abstract. Some have pointed out that the NASW
Code of Ethics cannot always resolve complex ethical
dilemmas (Jayaratne et al., 1997; Reamer, 2001). Cri-
tiques of the Australian Association of Social Workers
(AASW) Code of Ethics have looked at the Code's
failure to address and support issues of cultural aware-
ness (Thorpe, 1996) and political activism (DeMaria ,
1997).
It has been suggested that Codes of Ethics should
reflect the diversity of social workers and clients rather
than the individualistic philosophical statement of pre-
scribed social work values. In other words, a variety of
values, both individualistic as well as communitarian,
that would be appropriate for a Code of Ethics, rather
than one very prescribed model could be presented in a
Code of Ethics. Briskman and Noble (1999) argue that
by "using a community development model, it might be
possible to include the many service users in reframing a
code that speaks to their perception of what social work
is about and how their many realities can be included"
(p. 67).
With increasing globalization and professionaliza-
tion, social workers will continue to look to other na-
tional Codes for revision and modification of their
existing Codes. Thus as Banks (2006) suggests there
may be less attention given to national or cultural
practice differences. Given the increasing diversity of
social workers and clients, Codes of Ethics may not
reflect the multiple social work voices within different
countries. There is always the risk that ethics codes will
serve to perpetuate the dominant ideological position
330 CoDES OF ETHICS
(even if it is a conservative one) both within a country as
well as globally. Already there is some evidence of this in
national Codes of Ethics and the IFSW international
ethics document. The ideal national Code of Ethics
should be reflective of specific ethical practice unique to
the country, but also focus on what is universal about
social work values and practice. Including a human rights
perspective in a Code of Ethics often serves to provide a
universal foundation for ethical social work practice
around the world.
[See also Appendix, Ethical Standards in Social Work:
The NASW Code of Ethics.] .
REFERENCES
Abbott, A. (1988). Professional choices: Values at work. Silver
Spring, MD: National Association of Social Workers.
Abbott, A. (2002). Measuring social work values: A crosscultural
challenge for global practice. International Social Work,
42(4),455-470.
Banks, S. (2003). From oaths to rulebooks: A critical examination
of codes of ethics for the social professions. European Journal
of Social Work, 6(2), 133-144.
Banks, S. (2006). Ethics and values in social work (3rd ed.).
Hampshire, England: Palgrave McMillan.
Briskman, L., & Noble, C. (1999). Social work ethics:
Embracing diversity? In B. Pease & J. Fook (Eds.), Trans-
forming social work practice: Post-modem critical perspectives (pp.
57-69). St. Leonards: Allen & Unwin.
Congress, E. (1992). Ethical decision-making of social work
supervisors. The Clinical Supervisor 10(1), 157-169.
Congress, E. (1999). Social work values and ethics: Identifying and
resolving professional dilemmas. Belmont, CA: Wadsworth
Publishing Company.
Congress, E., & Gummer, B. (1996). Is the code of ethics as
applicable to agency administrators as direct service pro-
viders?In E. Gambrill & R. Pruger (Eds.), Controversial issues
in social work ethics, values and obligations (pp, 137150). Boston:
Allyn & Bacon.
Congress, E., & Kim, W. (2007). A comparative study on social
work ethical codes in Korea and the United States:
Focused on confidentiality, dual relationships, cultural di-
versity and impaired colleagues. Korean Journal ~f Clinical
Social Work, 4(2),175-192,
Congress, E., & McAultffe, D. (2006). Social work ethics:
Professional codes in Australia and the United States. Inter-
national Social Work, 49(2), 151-164.
CSWE. (2001). IASSW, IFSW announce joint definition of social
work. Social Work Education Reporter, 49(3), 31-37.
DeMaria, W. (1997). Flapping on clipped wings: Social work
ethics in the age of activism. Australian Social Work, 50(4), 3-19.
Dominelli, L. (2004). Practicing social work in a globalizing
world. In N. T. Tan & A. Rowlands (Eds.), Social work around
the world III. Berne, Switzerland: IFSW
Hatton, K. (2001 ). Translating values: Making sense of different
value bases-c--Reflecrlons from Denmark and the UK. Inter-
nationalJournal of Social Research Methodology, 4( 4), 265-278.
Healy, L. (2001). International social work: Professional action in an
interdependent world. New York: Oxford University Press.
Healy, L. (2007). Universalism and cultural relativism in social
work ethics. International Social Work, 50(1), 11,---26.
Holland, T. P., & Kilpatrick, A. C. (1991). Ethical issues in social
work: Toward a grounded theory of professional ethics. Social
Work, 36(2), 138-144.
International Federation of Social Workers (lFSW). (2000);
Definition of social work. Retrieved October 24, 2007, from
http://www.ifsw.org/en/p38000208.html .
Jayaratne, S., Croxton, T., & Mattison, D. (1997). Social work
professional standards: An exploratory study. Social Work,
42(2), 187-199.
McAuliffe, D. (999). Clutching at codes: Resources that influence
social work decisions in cases of ethical conflict. Professional
Ethics, 7(3/4), 9-24.
McDonald, c., Harris, J., & Wintersteen, R. (2003).Contingent
on context? Social work and the state in Australia, Britain, and
the USW. British Journal of Social Work, 33(2), 191-208.
National Association of Social Work (NASW). (1999). Code of
ethics. Washington, DC: Author.
ny social workers aEthics education in socidl work. Alexandria,
VA:CSWE.
Reamer, F. (2006). Ethical standards in social work: A review of the
NASW code of ethics (2nd ed.). Washington, DC:
NASW. .
Thorpe, R. (1996, October 3-6). Indigenous challenges to the
social work and welfare work: Codes of ethics in Australia.
Third National Conference for Australian Association far Pro-
fessional and Applied Ethics, Charles Stuart University, Wagga
Wagga.
FURTIIER READING
International Federation of Social Workers. (lFSW). (2004).
Statement of ethical principles. Berne, SW: Author.
SUGGESTED LINKS National Association of
Social Work (NASW). www.naswdc.org
NASW Code of Ethics.
http://www;naswdc.org/pubs/code/code.asp
Council on Social Work Education.
www.cswe.org
SWE EPAS Accreditation Standards (p. 8-Ethics).
http://www.cswe.org/NR/rdonlyres/I II833AO-C4F5-475C-
8FEB-EA740FF4D9F I!O/EP AS .pdf
International Federation of Social Workers.
www.ifsw.org
Ethics in Social Work: Statement of Principles.
http://www . ifsw .org/en/p38000324 .html Ethics
Codes from different countries.
http://www.ifsw.org/en/p38000194.html
........

International Association of Schools of Social Work.
www.iassw-aiets.org
Journal of Social Work Values and Ethics (online).
www.socialworker.com/jswve/
Ethics and Social Welfare (online).
www.informaworld.com/resw
- ELAINE CONGRESS
COGNITION AND SOCIAL COGNITIVE
THEORY
ABSTRACT: Social cognition, refers to the ways in
which people "make sense" of themselves, other
people,
\
and the world around them. Building on social psycho-
logical contributions, this entry summarizes processes
through which we perceive, interpret, remember, and
apply information in our efforts to render meaning and to
interact. Rather than a rationalistic depiction, we see
complex relationships among cognitions, emotions,
motivations, and contexts. Social cognition provides
guidance to mechanisms or venues through which per-
payment purposes. Some social workers believe that
s of HIPAA may actually decrease privacy of health
ion, and call upon the profession to ensure that consumers
mers know thei principal benefit of social cognition for
A principal benefit of social cognition for social work
practice is its empirically supported and broadly
applicable framework for explaining how person-
environment interactions unfold and might be altered in
the service of social work practice and social justice.
Social cognition includes, for example, social knowl edge,
social influences, the relationship between social
structures and categories (age, race, and sex) in con-
structing meaning, stereotyping and other biases in
information processing, encoding of and memory pro-
cesses related to social information , attributions of others'
behavior and motives and of one's own responses and
internal states, identity development, and processes
through which affect, cognition, and neurophysiology
interrelate as people interact with their social
environments.
KEY WORDS: cognition; social cognition; information
processing; schemas; emotion; meaning; memory
Key Concepts and
Processes of Social Cognition
Social cognition refers to the processes through which
people perceive, interpret, remember, and apply infor-
mation about themselves and the social world. These
COGNITION AND SOCIAL COGNITIVE THEORY 331
processes are often relatively automatic in nature and
therefore not fully within conscious awareness.
Meaning-making involves complex transactions be tween
individuals and their environment. Each of us is an
active, but not the sole, participant in creating the
meaning of our lives. The meanings we assign cannot be
independent of the linguistic categories, rules, values,
goals, and structures of our culture. The families, com-
munities, and opportunity structures we are born into and
grow up in provide a foundation of memories and norms
that we use to shape and understand the ongoing flow of
information and experience. Moreover, social cognition
views people not only as products of their environments,
but also as forces that shape the con struction of those
environments. This focus on the person-environment
interplay makes social cognitive theory particularly
useful for social work.
Social cognition extends the social learning theory
developed earlier, adding the understanding that input
from the environment is mediated or filtered. We are
continuously bombarded with far more information than
we can possibly handle. Moreover, much of this
information is complex, ambiguous, and emotionally
evocative. To avoid a paralyzing overload and to allow
functional navigation through our social world, we must
rely on numerous shortcuts or aids to screen, sort,
interpret, manage, store, and recall information that
seems relevant. Research on how the brain interacts with
our sensory-perceptual system and long- and short-term
memory provides the basis for specifying "information
processing"; that is, the mechanisms through which
people go about selectively attending to, interpret ing, and
evaluating environmental inputs. Broad commonalities in
the neurological and physiological functions of social
cognition exist, indicating consistency across people at
the process level. However, the content within these
processes can be highly variable, reflecting the diversity
of persons and the environments within which they are
embedded.
Schemas
Schemas are the cognitive structures or memory repre-
sentations that contain our experiences and learning, for
example about ourselves, other people, attitudes, social
roles, norms, and events. In our ongoing effort to form
meaning, we draw on our knowledge of past situations to
guide us in what to pay attention to, what interpretations
to make, and how to respond. Findings from each new
experience then become recorded as updates to our
existing network of schemas. Language, culture, and
structure play pivotal roles in the develop ment,
communication, and enactment of schemas (Lau, Lee, &
Chiu, 2004).
332 COGNITION AND SocIAL CoGNITIVE THEORY
Schemas are critically important in providing the
preconceptions that make information processing more
rapid, efficient, and often automatic. They are used to fill
in gaps when information is missing and in inter, pre ting
new experiences (Fiske & Taylor, 1991). Thus, schemas
provide relief ftom the processing burden of treating each
situation as new and all stimuli as requir ing careful and
deliberate attention, but in so doing they exact a price.
Schemas incline us to confirm our understanding of
reality, to be highly biased toward information that fits our
expectations, to overlook or discount confusing or
contradictory information, and to rely on relatively
stereotypic images and habitual modes of social
interaction. Depending on the particular cir cumstances,
this tendency toward simplicity and stabil-
\
ity can work as an asset or a liability. It can, for
example, contribute to the tenacity with which both
thewell-adjusted, optimistic person and the clinically
depressed person seek out, find, and build on expect a,
tion-confirming input ftom their experiences and their
environment. That is, expectancies tend to bias infor-
mation processing to reinforce, rather than challenge,
extant schemas.
Schemas do not simply reside in memory as isolated
bits of stored) information. Rather, they are part of a
memory structure that organizes concepts into hier archical
clusters and networks of related knowledge. "Nodes" of
schematic knowledge linked to one another form networks
of ideas, and when nodes are activated they enter
consciousness (short-term or working mem ory) and
thereby play an active role in shaping current information
processing, affective states, and action readiness. Nodes
may also have a deactivation capacity that mutes access to
discrepant forms of stored knowl edge. Although there are
several models of memory functioning (Kunda, 1999 and
Morris, Hitch, Graham, & Bussey, 2006, provide
overviews), social cognition theories have been influenced
by the view that schemas and linkages among nodes are
strengthened by repeated activation. Thus, once we come
to think of certain attributes as meaningfully related (as
with stereotypes), it is very difficult not to think in terms
of these clusters. When we are experiencing a certain
emotional or physiological feeling, we are predisposed to
think about and retrieve information consistent with that
feeling rather than information that. is contradictory to it.
Heuristics and Social Inference
Social inferences involve processes through which peo ple
arrive at judgments or decisions about social phe nomena.
Social inferences take many forms; for example,
attributions about intention s and causal forces,
perceptions about associations, how things go
together or function. We focus here on one form of social
inferences-heuristics-to illustrate this. Be, cause we
cannot constantly gather all possible data and consider all
possibilities of meaning and response, we rely on
heuristics, basically "rules of thumb," when reasoning
under uncertainty or to reduce complex problem- solving
to seemingly simpler judgments (Fiske & Taylor (1991)
and Kunda (1999) provide fuller coverage of social
inferences).
Like schemas, heuristics are double- edged. These thinking
processes are quick, automatic (involving lit, de or no
active awareness), and essential to navigating our complex
social landscapes. Whereas they can be reasonably
accurate, they are also highly vulnerable to biases and, not
uncommonly, errors. Consider how the following
examples of common inferential strategies may function in
positive or negative ways: (1) basing inferences and
judgments on how easily and quickly information comes
to mind, (2) categorizing people or events on the basis of
how much these resemble the observer's preexisting
notions--their schemas--of types of people and events, (3)
predicting the likely outcome of a situation based on how
easily a given outcome can be envisioned and the
emotional intensity of that outcome, (4) attributing
people's behavior to their individual characteristics such as
personality traits, rather than to external factors, and (5)
anticipating a relationship between two variables, leading
one to overestimate the degree of relationship or to impose
a nonexistent one. Now consider that normative biases in
information processing affect us all, including social
workers in their professional roles. Growing awareness of
naturally occurring vulnerabilities such as these is shaping
attention in arenas such as clinical reasoning and
contextualized assessment to include social cognitive
theory as part of professional skill development.
Conscious and Automatic
Modes of Information Processing
In some situations, such as a new environment, we are
more aware of our thinking and reactions as we care" fully
observe our surroundings and monitor ourselves.
However, most of the time people are unaware of their
own cognitive processes. Treating most stimuli in a more
automatic, efficient, and familiar manner allows us to
function without becoming overwhelmed by the enormity
of information available in the environ, ment. Part of what
accounts for this relative lack of awareness are the
differing modes through which memory and information
processing function. These are distinguishable as
conscious or unconscious modes, which roughly denote
controlled or controllable versus more automatic
processing (Morris, Uleman, & Bargh,

2005). Although essential, being on "autopilot" (auto,
matic processing) entails a degree of insensitivity to the
environment, a heavy reliance on past constructs stored
in memory, and thus a lesser likelihood of mak ing
cognitive distinctions and generating creative
responses.
Social work practice often involves helping clients
interrupt prior habits to build new ones by shifting from
unhelpful and problematic, more automatic modes of
processing (associated with the problem) to more
deliberate, adaptive, yet awkward-feeling-controlled
modes (associated with the new patterns) to more
natural, feeling, new, automatic modes (associated with
incorporation of new patterns into one's self-concept
and social niche). As an aid to interrupting problematic
,
patterns and substituting preferred ones, cognitively
oriented practice methods involve fostering meta,
cognitive awareness to assist clients in gaining more
mindful awareness of their information processing
habits (for example, what inferences are made of others'
expressions or behaviors and which self-defining sche-
mas tend to be activated under trigger situations).
Knowing More Than We Can Use
Study of human memory currently argues for the con,
cept of multiple, interdependent memory systems that
are distributed in various regions of the brain. Long'
term memory is generally thought to include storage of
distinct forms of memory, for example, memory for
events we experience, recognition of information we
have been exposed to, semantic information about con,
cepts and the meaning of words, sensorimotor skills
achieved through practice, and value or emotional
memory (Morris et al., 2006). Working memory refers
to the system through which limited amounts of re-
trieved information are held in an active, conscious
state. It is a critical factor in that, although we may have
certain knowledge or skills in memory storage, the
subset that is pulled into working memory most power,
S: AGENCY AND ORGANIZATION IN
to the social work profession. Hasenfeld (1ry acti-
vation are a two' way street. Our contemporaneous state
of mind (expectancies, goals, feelings) influences both
how we encode present events for storage and what we
recruit into working memory. Anxiety, for example,
favors retrieval of anxiety-congruent schemas and in,
hibits access to anxiety, incongruent content. Thus, it is
not enough to assist people in developing new knowl-
edge or skills. If memory retrieval patterns are incon-
sistent with these changes, those new representations
are unlikely to successfully compete with more long,
standing, deeply networked schemas. These existing
schemas are the basis for cognitive change strategies
CooNITION AND SOCIAL COGNITIVE THEORY 333
that work to first illuminate and then progressively
revise inemory retrieval, such that working memory is
purposefully steered to activate the kind of representa-
tions from long, term storage most needed at the mo-
ment (see Young, Klosko, & Weishaar, 2003).
The Self: Situated, Transactional,
and Possible
The self holds a privileged status in information
processing in that information that is irrelevant to the
self is less likely to be noticed, scrutinized, assimilated,
or used to guide social functioning. Yet self-defining
inforrnation is subject to the same memory and
inference pro, cesses described thus far. For example,
although we have enduring beliefs about ourselves, we
do not have "a" self, concept so much as we have
context-sensitive working self, concepts. That is,
different representations of self are more or less likely
to be activated and pulled into working memory at any
given moment. Variability in this continually shifting
subset of self-knowledge is part of why we can view
and experience ourselves quite differently, depending
on the context; for example, myself playing with .my
making a formal
presentation, or winning an award versus receiving
sharp criticism. The situational varia, bility in the
self-concept is important because it influences social
functioning, often in ways not immediately evident to
the individual. Social perceptions of others, as well as
appraisals of self-worth and self-efficacy, re flect
currently active self-schemas.
Recent formulations go a step further, arguing that
we must look to the transactional dynamics of people
and their environments to discern stable, self- defining
patterns. That is, people have stability within what is
psychologically salient for them in particular contexts,
but the characteristics of this stability may differ as the
context changes (which may differ from the seemingly
distinct features of those contexts). Differing contextual
features activate distinctive networks of mental,
emotional representations. Thus, stability in what we
might call identity or personality must include situa-
tions and the if-then (situation-behavior) signatures that
emerge from these transactions-a position quite at
contrast with earlier, more person-focused views
(Mischel & Shoda, 2000). The situated functioning and
responsiveness of the self-concept move important
assessment considerations away from global or
trait-like conceptions to a contextually embedded
approach to the "working self," which tends to vary due
to experience, the situation, or the events a person is
facing (Nurius, 1993; Shoda & Smith, 2004).
We have also learned that the self-concept is not a
catalogue of what "is," but rather contains a variety of
334 CooNI1l0N AND SocIAL COONITIVE THEORY
self-perspectives. For example, in addition to our per-
ceived actual selves, we maintain concepts of ideal and
ought selves-conceptions against which we measure
ourselves and grapple with discrepancies (Higgins, 1998 ).
Self-conceptions bridge time and carry powerful
influence; for example, the ways in which feared past
selves and hoped-for future selves galvanize-e--positively
or negatively-our attention and action. Cognitive
representations of our future or possible selves, including
goals, plans, aspirations, and fears, are often not well
recognized by us, but may be wielding substan tial
influence (Dunkel & Kerpelman, 2006). As reflec tions of
social contexts and transactions, self- schemas developed
in response to adversity, such as trauma and illness, and
social injustices such as poverty and discri-
\
ruination are not immutable, but do manifest a kind of
neural and psychophysiological embodiment of these
formative factors.
Hot Cognitions and Interfaces With Emotions Social
cognition theory offers useful input for questions critical
to practice such as where feeling states "come from," what
factors generate these feeling responses, and how any
given feeling is expected to positively or negatively
influence a client's functioning. Social cognition
addresses how individuals interpret the stimulus they are
responding to (like a facial expression) as well as their
own physiological state (heart beating quickly, skin
temperature rising) and then, based on the meaningthat
they give to these phenomena, assign an emotion label to
themselves ("I am feeling very anxious"). An underlying
premise is that although physiological arousal may occur
with little or no cognitive involve ment, emotions require a
more active role by the individual in assigning personal
meaning-which can lead to different emotional reactions
to the same phenomena.
Evidence indicates that a closely interactive rela -
tionship between affective states and information
strategies is central to understanding how emotion in -
fluences and is influenced by thinking, judgments, and
behavior (Forgas & Smith, 2003). In addition to effects on
what people think, affect also shapes how they think. For
example, a positive mood facilitates more auto matic but
efficient, flexible, and confident information processing,
whereas a negative mood triggers more de liberate,
externally vigilant, . and at times, ruminative processing
style. Indeed, affective states have been found to have a
broad-based effect on the ways that people interpret,
evaluate, and respond to social infor mation, such as
learning, attention, recall, attributions, judgments,
attitudes, self-perception, action readiness, and
interpersonal behavior (Forgas, 2000). The term
"hot cognition" conveys the many ways in which judg-
ments, decisions, and so forth are often less coolly
rational than "heated" by our motivations and emotions
and this heat is carried through our social cognitive
processing.
Some emotion-related research has examined the
process of interpretation in terms of cognitive appraisals,
based on a view that appraisals serve an important
mediational role in linking an individual's goals and
beliefs with situational cognitive interpretations and
emotional responses. This research is particularly relevant
for social work practice because of its application to
questions of coping under ambiguous and stressful
conditions and how cognitive interpretations and emo-
tional responses set the stage for subsequent action that
mayor may not result in effective coping outcomes
(Nurius, 2000). Lazarus's (1991) model, for example,
suggests that appraisals made of threatening circum-
stances yield distinct emotion sets which, in tum, pre-
dispose the individual to action proclivities (Roseman &
Smith, 2001). To illustrate, a problematic situation
appraised to be one's own fault is likely to stimulate guilt
or shame and acquiescence or avoidance, but when others
are seen to be accountable it is likely to stimulate anger or
indignation, fostering efforts toward punishment.
Although much of emotional and appraisal processing is
believed to occur automatically and outside fully
conscious awareness, these processes can be brought
under more deliberative focal attention to allow for more
thorough analysis and reappraisal. Importantly,
knowledge about mechanisms linking emotions to both
consciousness and unconsciousness is rapidly advancing
in social cognition, informing specification as to the
embodiment of emotional knowledge, the neural basis of
interactions between emotion and cognition, and the ways
that nonconscious emotional processes function (Barrett,
Niedenthal, & Winkelman, 2005).
Social Cognitive Neuroscience
Iritegration of neuroscience in the study of relationships
among the cognitive, affective, and neurophysiological
dimensions of people interacting with the social envir-
onment has become increasingly sophisticated and has
yielded compelling new insights. Ochsner and Lieberman
(2001) note, for example, how neural systems mediate
cognitive interactions of social psychological phenomena,
relationships between impaired social cognitive capacities
in producing disabilities such . as autism, and the neural
basis for a range of processes such as stereotyping,
attitudes, and person perception. Especially promising are
advances in illuminating the mechanisms undergirding
relatively automatic,

nonconscious processing; for example in spontaneous
social.inferences (Todorov, Harris, & Fiske, 2006) and in
distilling how varied dimensions of social context are
represented in the brain and exert influence over social
judgments and action (Beer & Ochsner, 2006). Social
cognitive neuroscience also offers a multilevel
framework for specifying linkages between social and
structural factors to patterns of construal and psycho-
physiological responding, yielding either resilient or
compromised health statuses. Gaining a more precise,
nuanced understanding of how to augment control over
maladaptive patterns at these levels of processing may
provide important new assessment and intervention
options to the social work practitioner.
\ Sage handbook of social psyclwlogy (pp. 296-323). Thousand
Conclusion
Part of the value of social cognition theory. is its useful-
ness in connecting knowledge about human behavior in
the social environme~t (under mundane as well as
exceptional circumstances) with theory and strategies for
personal change. Many problems in life are at least partly
the result of the same processes that explain normal,
adaptive patterns of functioning. The content of the
predominant self- and social schemas for the depressed
person and the happy person are likely to be substantially
different. But the functional effects of their schemas, their
patterned ways of drawing on their self- and social
knowledge as they interact in differing contexts, and their
role in shaping their and other's behavior stem from the
same social cognitive processe s. Social cognition is a
body of theorizing and research that underlies models of
learning and social communi cation, approaches to health
promotion such as the health beliefs model,
understandings of stress and coping, and some of the most
widely used treatment strategies today, such as
self-efficacy and collective efficacy interventions,
cognitive and cognitive-behavioral therapies, schema
therapy, emotion management, and self- regulation
strategies.
Future trends in social cognition research will incl ude
an increasing focus on naturalistic settings and questions
of real-world concern. Complex questions of interest to
social work--such as the development of human
aggression, the social cognition of group and cultural
dynamics, and the effects of information pro cessing
systems in mediating social conditions- are now . at the
forefront of investigation (Anderson & Huesman, 2003;
Kashima, 2001; Shoda, 2004). Social cognition work is
becoming increasingly multilevel, striving to capture
processes of transaction between individual and social
forces as well as dimensions such as the built
environment and links between biological systems and
social behavior. Examples of developing
CooNITION AND SOCIAL CooNITIVE THEORY 335
areas include the science of social identities and social
influence, intergroup relations, the roles of his tory and
culture in shaping social cognition, and how emotion and
physiology affect social thinking and behavior. The
future provides opportunity for social
. .
work to test the usefulness of findings in practice, to
press for extension into heretofore neglected areas, and to
actively participate in the ge neration and application of
social cognition work in the service of social welfare.
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Dunkel, C., & Kerpelman, J. (2006). Possible selves: Theory,
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Kunda, Z. (1999). Social cognition: Making sense of people.
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meets brain science (pp. 193-235). San Diego, CA: Elsevier
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Morris, R. R., Uleman, J. S.,& Bargh, J. A. (2005). The new
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Nurius, P. S. (1993). Human memory: A basis for better
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(Eds.), Handbook of social wark direct practice (pp. 349-372).
Thousand Oaks, CA: Sage.
Ochsner, K. N., & Lieberman, M. D. (200l). The emergence of
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717-734.
Roseman, I. J., & Smith, C. A. (2001). Appraisal theory:
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Scherer, A. Schorr, & T. Johnstone (Eds.), Appraisal processes
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Oxford University Press.
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T. Panter (Eds.), The Sage handbook of methods in social
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SUGGESTED LINKS
erview of social cognitive theory and self-efficacy. ,
http://www.des.emory.edu/mfp/effhtml
The International Social Cognition Network.
http://psychology.ucdavis . edu/lO.bs/ sherman/is con/
HYPERLINK"http://www.cswe.org/NR/"http://www.cswe.org/
http://www.socialpsychologyarena.com/
-PAULA S. NURIUS
COGNITIVE THERAPY
ABSTRACT: Cognitive therapy is a perspective on so-
cial work intervention with individuals, families, and
groups that focuses on conscious thought processes
as the primary determinants of most emotions and
behaviors. It has great appeal to social work
practitioners because of its utility in working with
many types of clients and problem situations, and its
evidence-based support in the literature. Cognitive
therapies include
sets of strategies- focused on education, a restructuring of
thought processes, improved coping skills, and in creased
problem-solving skills for clients.
KEY WORDS: cognitive theory; cognitive therapy; dir ect
social work practice; evidence-based practice;
automatic thoughts; causal attributions; cognition;
cognitive deficits; cognitive distortions; cognitive cop-
ing; cognitive restructuring; problem- solving; schema;
Socratic questioning
Definition and Description
Cognitive therapy is a direct practice modality that is
focused on enhancing the rationality of clients' think ing
patterns, or the degree to which conclusions about the self
and the world are based on external evidence (Lantz,
1996). Cognitive therapy asserts that conscious thinking
is the basis for most human behavior and emotional
experience. Cognitions include a person's beliefs,
assumptions, and expectations about the causes of events,
attitudes, and perceptions. Cognitive theory postulates
that people develop habits of thinking that form the basis
for their screening and coding of en vironmental input,
categorizing and evaluating experi ence, and judgments
about how to behave. Ernotions are defined within
thistheory as physiological responses that follow
cognitive evaluation of input (Lazarus & Lazarus, 1994).
The relationship between thoughts, feelings, and
behaviors is such that an activating event produces a belief
or thought that in turn produces an emotion or action (Beck,
1995).
A central concept in cognitive theory is that of the schema,
defined as a person's internalized representation of the
world, or patterns of thought, action, and problem solving
(Granvold, 1994). Schemas include the ways people
organize thought processes and process new information,
and the products of those operations (knowledge). They
develop through direct learning (personal experience) or
social learning (watching and absorbing the experiences
of others); When a person encounters a new situation he or
she either assimilates it to "fit" the existing schema, or
accommodates it, changing the schema. A flexible schema
is desirable, but all schemas tend to be' some; what rigid
by nature. Core beliefs (schemas) are not "correct" or
"incorrect" as much as they are functional or
nonfunctional for one's ability to achieve his or her goals.
"Rational" thinking in cognitive theory can be understood
as thinking that is based on external evidence, is life
preserving, keeps one directed toward personal goals, and
decreases internal conflicts (Ellis & McLaren, 1998).

Major Developers and Contributors Cognitive
therapy's influences include 20th,century developments
in American philosophy, information processing theory,
and socialleaming theory. American philosophers have
always tended to evaluate ideas with reference to
practical applications (Kurtz, 1972). One example is
John Dewey (1938), who wrote that when a person
hat consumers know their
ONSUMER RIGHTS
maintained that ideas are arrived at through plans of
action evaluated for "truth" by their consequences. His
work influenced the systematic procedures seen in the
problem-solving model, described later in this entry.
Logical positivism is another major philosophical
movement that became prominent in the United States
\
in the 1930s (Popper, 1968). The positivists perceived
the task of philosophy to be the analysis and clarifica-
tion of meaning, and they looked to logic and the
sciences as their models for constructing formally per,
fect languages. They were critical of ideas that could
not be empirically tested.
The advances in computer and information tech,
nology were particularly influential in the development
of a "science of cognition" in the social sciences (Bara,
1995). Human service practitioners became interested
in how people processed information and in correcting
cognitive "errors." Information processing theory
established that people receive stimulation from the
outside and code this with sensory receptors in the
nervous system (Ingram, 1986). Information is
integrated and stored for purposes of present and future
adaptation to the environment. People develop
increasingly sophisticated problem' solving processes
through the evolution of cognitive patterns that enable
them to attend to particular inputs as significant.
American psychologist George Kelly (1963) intro-
duced a theory of personality in the late 1950s accord,
ing to which a person's core tendency is to attempt to
predict and control the events of experience. He de,
scribed the essence of human nature as the scientific
pursuit of truth-an engagement in the empirical pro,
cedure of formulating hypotheses and testing them in
the tangible world. This "truth" represents a state in
which perceptions are consistent with a person's inter,
nal construct system. Kelly's model of the "person as
empirical scientist" influenced the ideas of cognitive
theorists who followed him, including therapists Albert
Ellis and Aaron Beck.
Ellis published Reason and Emotion in Psychother, apy in
1962. He believed that people can consciously adopt
principles of -reasoning, and he viewed the elient's
underlying assumptions about himself or herself and the
world as targets for intervention. The major
COGNITIVE THERAPY
337
theme of Ellis's work is that behind most distressing
emotions one can find irrational beliefs about how
things should or must be. Ellis's therapy involved help,
ing people become more "reasonable" about how they
approached their problems. Cognitive therapy became
more prominent with the publication of Beck's Cqgni,
tive Therapy and the Emotional Disorders in 1976. Beck was
ropic insufficiency-non-profits will never be able to
e to sufficiently and reliably provide all the services
that are necessary because of inadequate resources.
featuring themes of personal ineffectiveness, personal
degradation, and the world as an essentially unpleasant
place. Cognitive therapy became an established
modality in the social work profession through the
writings of such scholars as Berlin (2002), Corcoran
(2006), Granvold (1994), and Lantz (1978).
Demographics and Current Applications
Cognitive therapy is applicable to people aged 12 years
and older because recipients must be able to engage in
abstract thought. Some adults with cognitive lirnita-
tions such as mental retardation, dementia, and some
psychotic disorders may not be responsive to the ap-
proach. To benefit from cognitive interventions, clients
must also be able to follow through with directions, not
require an intensely emotional encounter with the so-
cial worker, demonstrate stability in some life
activities, and not be in an active crisis (Lantz, 1996).
Current Change Philosophy and Techniques
According to cognitive theory, many problems in living
result from misconceptions-' -conclusions that are
based more on habits of thought rather than external
evidence-that people have about themselves, other
people, and their life situations. These misconceptions
may develop for any of three reasons. The first is the
simplest: the person has not acquired the information
necessary to manage a new situation. This is often
evident in the lives of children and adolescents, who
face many situations at school, at play, and with their
families that they have not experienced before. This
lack of information is known as a cognitive defidt, and
can be remedied with education.
Secondly, problems 'may be related to causal attribu,
tions, three kinds of assumptions that people hold about
themselves in relation to the environment. A person
might function from premises that life situations are
more or less changeable (I'm unhappy with my job, and
there is nothing that can be done about it), sources of
power to make changes exist either within or-outside
the self, (Only my supervisor can do anything to make
my job better), or the implications of his or her experi-
ences are limited to the specific, situation or are global.
338 COGNITIVE THERAPY
(My supervisor didn't like how I managed that client
with a substance abuse problem. He doesn't think I can
be a good practitioner.)
The final sources of misperceptions are cognitive
distortions. Because of the tendency to develop thinking
habits, people often interpret new situations in biased
ways. These patterns are generally functional because
many situations people face in life are similar to previ-
ous ones and can be managed with patterned responses.
. These habits become a source of difficulty, however,
when they are too rigid to accommodate new informa-
tion. For example, a low-income community resident
may believe that he lacks the ability to advocate for
certain medication benefits and, as a result, continues to
live without them. This belief may be rooted in a
\
distorted sense that other people will never respect him.
The client may have had real difficulties over the years
with failure and discrimination, but the belief that this
will happen in all circumstances in the future may be
arbitrary.
Cognitive theory interventions can help clients
change in three ways. Clients can change their personal
goals to become more consistent with their capabilities,
adjust their cognitive assumptions (beliefs. and expec-
tations), or change their habits of thinking (which in-
cludes giving up cognitive distortions). The
practitioner functions as a collaborator in determining
change strategies with the client, and educates the
client in the logic of cognitive theory. The social
worker may further serve as a model of rational
thinking and problem solving, or as a coach, leading
the client through a process of guided reasoning. The
social worker assesses the validity of a client's
assumptions associated with a problem issue through
focused questioning, known as Socratic questioning
(Granvold, 1994). The social worker focuses on the
following questions:
What are the client's core beliefs relative to the
presenting . problem ?
What is the logic behind the client's beliefs
regarding the significance of the problem
situation?
What is the evidence to support the client's views?
What other explanations for the client's percep-
tions are possible?
How do particular beliefs influence the client's
attachment of significance to specific events,
emotions, and behaviors?
When a client's perceptions and beliefs seem valid, the
practitioner intervenes by providing education about
the presenting issue and implementing problem-solving
or coping exercises. When the client exhibits
significant cognitive" distortions, the practitioner and
client work to identify the situations that trigger the
misconceptions, determine how they can be most effi-
ciently adjusted or replaced with new thinking patterns,
and then implement corrective tasks .. Strategies for
cognitive intervention fit into three general categories
as described below.
COGNITIVE RESTRUCTURING Cognitive restructuring is
used when the client's thinking patterns are distorted
and contribute to problem development and persistence
(Emery, 1985). The social worker helps the client
experiment with alternative ways of approaching chal-
lenges that will promote goal attainment. The ABC
model is the basis of the cognitive restructuring ap-
proach. "A" represents an activating event; "B" is the
client's belief about, or interpretation of, the event; and
"C" is the emotional and behavioral consequence ofB.
For example, if A is an event (the hiring of a new
colleague) and C, the consequence, is the person's
feeling of depression, . then the B (belief) might be:
"He'll be a much better social worker than I am." If the
same activating event occurs, but the resulting emotion
(consequence, or C) is contentment, the client's belief
might be: . "How nice to have someone to share the
workload and learn from!"
In order to change a client's belief systems, three
steps are necessary. The first is to help the person
identify the thoughts preceding and accompanying the
distressing emotions and nonproductive actions. The
second step is to assess the client's willingness to
consider alternative thoughts in response to the pro-
blem situation. One means of addressing this is the
cost-benefit analysis, in which the social worker asks
the client to consider the costs and benefits of main-
taining his or her current beliefs pertaining to the
problem (Leahy, 1996). The third step is to challenge
the client's irrational beliefs by designing tasks that he
or she can carry out in daily life. For instance, if .a
college student believes that if she speaks out in class
everyone will laugh at her, she might be asked to
volunteer one answer in class to see the reactions of
others. By changing clients' actions, their cognitions
and emotions may be indirectly modified, as the actions
may provide new data to refute automatic beliefs about
themselves and the world.
COGNITIVE COPING A second category of interven-
tions is cognitive coping. The practitioner helps the client
learn and practice new or more effective ways of
dealing with stress and negative moods. Cognitive
coping involves education and skills training that
target both covert and overt cognitive operations with
the

goal of helping clients become more effective at man-
aging their challenges. Clients can modify their cogni-
tive distortions when they experience positive results
from practicing new coping skills.
Self-instruction skills development gives clients an
internal cognitive framework for instructing themselves
in how to cope more effectively with problem situations
(Meichenbaum, 1999). It is.based on the premise that
many people, as a matter of course, engage in internal
speech as a means of thinking. Some people have a lack
of positive cues in their self-dialogue. Having a
prepared internal (or written) script for problem
situations can help a client recall and implement a
coping strategy. When using this technique, the social
worker assesses the client's behavior and its rela tionship
to deficits in
\
subvocal dialogue. The client and social worker develop
a step-by-step self-instruction script, including overt
selfdirected speech, following their plan for confronting
a problem. With practice the client gradually moves
from overt self-dialogue to covert self-talk.
sing, preventing, or recovering from them. ide
spectrum of interventions that includes attention to
clients' social, assertive, and negotiation skills. Positive
communication builds relationships and closeness with
others, which in turn help improve moods and feelings
about oneself (Hargie, 1997). The components of com-
munication skills training include using "I" messages,
reflective and empathic listening, and making clear
behavior change requests. "I" messages are those in
which a person talks about his or her own position and
feelings in a situation, rather than making accusa tory
comments about another person. Listening skills
include both reflective listening and validation of the
other person's intent. It decreases the tendency of peo-
ple to draw premature conclusions about the meaning of
another's statement (Brownell, 1986). Reflective
listening involves paraphrasing back the content of the
speaker's message. This conveys that, given the other
person's perspectives and assumptions, his or her
experiences are legitimate and understandable ("I can
see that if you were thinking I had done that, you would
feel that way"). A third component of communication
skills training involves teaching people to make clear
behavior requests of others. Such requests should
always be specific, measurable, and stated in terms of
positive behavior rather than the absence of negative
behavior.
There are a variety of other social skills that can be
taught in cognitive therapy. The process always in-
volves teaching clients about the utility of such skills,
breaking them down into discrete steps, practicing those
steps, and encouraging the client's implementation of
new behaviors in the social environment.
CooNlTlVE THERAPY 339
PROBLEM~SoL VlNG SKILLS DEVELOPMENT The third
category of cognitive intervention is problem solving. This
isa structured, five-step method for helping clients who
do not experience distortions but nevertheless struggle
with how to manage their problems and challenges.
Clients learn how to produce a variety of potentially
effective responses to their problems through the
following steps (McClam & Woodside, 1994);
Clearly defining the problem that the client wishes
to overcome.
Brainstorming to generate as many possible
solutions for a problem as the client can imagine.
Spontaneity and creativity are encouraged. All
possibilities are written down, even those that
initially seem impossible or silly.
Evaluating the alternatives. Any patently irrele-
vant or impossible items are crossed out. Each
viable alternative is then discussed as to its
advantages and disadvantages.
Choosing and implementing an alternative by
selecting a strategy that appears to maXimize
benefits over costs. Although the outcome of any
alternative is always uncertain, the client is praised
for exercising good judgment in the process.
Evaluate the implemented option. If successful,
the process is complete. "Failures" must be
examined closely for elements that may have gone
well. If a strategy has not been successful, it can be
attempted again with adjustments or the social
worker and client can go back to the fourth step
and select another option.
Evidence- Based Practice
Cognitive therapy is supported as effective in numerous
literature reviews. Chambless (l998) compiled a list of
validated cognitive interventions using the American
Psychiatric Association's criteria for weU~established or
probably efficacious interventions. Chambless includes
weU-established cognitive interventions for depression and
well-established cognitive-behavioral interventions for
panic disorder, generalized anxiety disorder, buli-
mia,pain associated with rheumatic disease, and relapse
prevention in smoking cessation. Probably efficacious
cognitive interventions are described for obsessive-
compulsive disorder, opiate dependence, geriatric
depression, social problem solving, and couples' com-
munication training as an adjunct to the treatment of
agoraphobia, social phobia, relapse prevention in co-
caine dependence, benzodiazepine withdrawal in
persons with panic disorder, social skills training for
persons with alcohol dependence, binge eating disorder,
chronic
340 CooNITIVE THERAPY
pain, childhood anxiety, and social skills for persons
withschizophrenia.
A number of meta, analyses of the professional lit, erature
produced between 2002 and 2007 provide further evidence of
the effectiveness of cognitive inter, ventions for a variety of
psychological problems. These analyses support the
effectiveness of cognitive interventions with families in the
mental status improvement of a relative with schizophrenia
(Pilling et al., 2002), and in group settings for general
symptom alleviation (Petrocelli, 2002). The meta, analyses
also support their effectiveness with recovery from social
phobia (Gould & Johnson, 2002), eating disorders (Wilson &
Fairburn, 2002), arid insomnia (Bootziri, 2001).
Cognltive-behavioral interventions also reduce the recidivism
of legal offenders (Pearson, Lipton, Cleland, & Yee, 2002)
and the severity of hallucinations and delusions in persons
with psychotic disorders (Haddock et al., 1998). They
consistently increase the social competence of children and
adolescents in school settings (Topping, Holmes, & Bremmer,
2000).
Another recent literature review of 14 meta, analyses
covering 325 studies provides a summary of the research on
cognitive interventions (Butler & Beck, 2001). It was found
that cognitive therapy was substantially superior to no
treatment, waiting list, and placebo controls for adult and
adolescent depression, generalized anxiety disorder, panic
disorder (with or without agoraphobia), social phobia, and
childhood depressive and anxiety disorders. Cognitive
interventions were moderately superior in the treatment of
marital distress, anger, childhood somatic disorders, and
chronic pain. Cognitive therapies were somewhat superior to
antidepressant medication in treating adult depression. A year
after treatment discontinuation, depressed clients treated with
cognitive therapy had half the relapse rate of depressed
persons who had been treated with antidepressants. Cognitive
therapy was equally effective as behavior interventions in the
treat, ment of adult depression and obsessive compulsive
disorder. In the small number of direct comparisons with
supportive and nondirective therapy (two for adolescent
depression and two for generalized anxiety disorder),
cognitive therapies were superior. They were somewhat
superior to miscellaneous psychosocial treatments for sexual
offending.
Distinctiveness and Integration
Since the late 1960s, social workers have success, fully
integrated techniques from cognitive theory with strategies
from other approaches. With its focus on practicality,
precision in problem definition, and
outcome measurement, it fits perhaps most obviously with
behavioral therapy, as clients can integrate rein, forcement
systems as they experiment with new activities related to their
adjusted thought processes (Thyer & Wodarski, 2007). With
its recognition of the per, son's active construction of reality, it
also fits well with postmodern approaches to therapy such as
narrative therapy (Williams, 2006). It also fits well with solu-
tion-focused therapy, another therapy approach that is
concerned with concrete, practical change strategies and
respecting the client's personal perspectives on his or her
reality (De [ong & Berg, 2002). Finally, cognitive therapy can
be incorporated into the structural family intervention
approach, as it considers communication skills and the
rationality of the functions of family power, rules, roles, and
boundaries.
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Berlin, S. (2002). Clinical social work practice: A cognitive-inte,
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Ellis, A. (1962). Reason and emotion in psychotherapy. New York:
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Ellis, A., & McLaren, C. (1998). Rational emotive behavior therapy:
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Ellis, P. M., Hickie, 1. B., & Smith, D. A. R. (2003). Summary of
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Emery, G. (985). Cognitive therapy: Techniques and applications.
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Basic Books.
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iveness of cognitive-behavioral treatment and pharma-
cotherapy for social phobia: Meta-analytic outcome. In S. G.
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MA: Allyn & Bacon.
Granvold, D. K. (1994). Concepts and methods of cognitive
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treatment: Methods and applications (pp. 3-31). Pacific Grove,
CA: Brooks/Cole.
Haddock, G., Tarrier, N., Spaulding, W., Yusupoff, L., Kinney,
c., & McCarthy, E. (998). Individual cognitivebehavior
therapy in the treatment of hallucinations and de-
lusions:Areview. Clinical Psychology Review,
18(7),821-838.
Hargie, O. D. W. (Ed.) (997). The handbook of communication skills.
New York: Routledge.
Ingram, R. E. (Ed.) (986). Information processing approaches to
clinical psychology. Orlando, FL: Academic Press.
Kelly, G. A. (1963). A theory of personality: The psychology of
personal constructs. Oxford, England: W. W. Norton.
Kurtz, P. (972). American philosophy. InP. Edwards (Ed.), The
encyclopedia of philosophy (Vol. 1, pp. 83-93). New York:
Macmillan.
Lantz, J, (1978). Cognitive theory and social casework. Social
VVork,23(5),361-366
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York: Free Press.
Lazarus, R. S., & Lazarus, B. N. (994). Passion aru1 reason:
Making sense of our emotions. New York: Oxford University
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Leahy, R. L. (996). Cognitive therapy: Basic principles and
applications. Northvale, NJ: Jason Aronson.
McClam, T., & Woodside, M. (994). Problem solving in the helping
professions. Pacific Grove, CA: Brooks/Cole.
Meichenbaum, D. (1999). Cognitive-behavior modification: An
integrative approach. (Ist ed.) Cambridge, MA: Perseus.
Pearson, F. S., Lipton, D. S., Cleland, C. M., & Yee, D. S. (2002).
The effects of behavioral/cognitive-behavioral programs on
recidivism. Crimeand Delinquency, 48(3),476-496.
Petrocelli, J. V. (2002). Effectiveness of group cognitive-be-
havioral therapy for general symptomatology: A meta-an-
alysis. Journal for Specialists in Group VVork, 27(1), 92-115.
Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J.,
Orbach, G., et al. (2002). Psychological treatments in
schizophrenia: I. Meta-analysis of family intervention and
cognitive behavior therapy. Psychological Medicine, 32(5),
763-782.
Popper, K. R. (968). Conjectures and refutations: The growth of
scientific knowledge. New York: Harper & Row.
Thyer, R A, & Wodarski,J. (Eds.) (2007) Social work in mental
health: An evidence-based approach. Hoboken, NJ: Wiley.
Topping, K., Holmes. E. A, & Bremmer, W. (2000). The
effectiveness of school-based programs for the promotion
COLLABORATIVE PRACTICE 341
of social competence. In R. Bar-On & D. A. Parker (Eds.), The
handbook of emotional intelligence: Theory, development,
assessment, and applications at home, school, and in the workplace
(pp. 411-432). San Francisco, CA: jossey-Bass.
Williams, N. R. (2006). Narrative family interventions. In A. C.
Kilpattick & T. C. Holland (Bds.), Working with families: An
integrative model by level of need (4th ed., pp. 194-219). Boston:
Allyn & Bacon.
Wilson, G. T., & Fairburn, C. G. (2002). Treatments for eating
disorders. In P. E. Nathan & J. M. Gorman (Eds.), A guide to
treatments that work (2nd ed., pp. 559-592). London: Oxford
University Press.
FURTHER READING
Aponte, H. J., & DiCesare, H. J. (2000). Structural theory. In F.
M. Dattilio & L. J. Bevilacqua (Eds.), Comparative treatments
for relationship dysfunction (pp. 45-57). New York:
Springer.
Beck, A T. (967). Depression: Clinical, experimental, and theoretical
aspects. New York: Hoeber,
Butler, G., Fennell, M., Robson, P., & Gelder, M. (991).
Comparison of behavior therapy and cognitive behavior
therapy in the treatment of generalized anxiety disorder.
Journal of Consulting and Clinical Psychology, 59, 167-175.
Ellis, P. M., Hickie, I. B., & Smith, D. A R. (200,3). Summary of
guidelines for the treatment of depression. Australasian
Psychiatry, 11 0),34-38.
Kelley, P. (996). Narrative theory and social work practice. In F.
Turner Hid.), Social work treatment (4thed., pp. 461-479). New
York. Free Press.
payment purposes. Theories for direct social work practice. Pacific
Grove, CA: Brooks/Cole.
ds to start new pThe Academy of Cognitive
The Academy of Cognitive Therapy.
http://www.aau1emyofct.org/Iibrary/InfoManage/Guide.asp?
FoIderID=:LO01&SessionLD={2606 1 FAA-92aH
lEI-B41420E7BOA90885 }
The American Institute for Cognitive Therapy.
http://www.cognitivetherapynyc.com/Information for Practice:
Cognitive therapy
http://g~ogle.~yu.edu/search?site == NYUVVeb_Main&client =
NYUWeb_Main&output = xmCno_dtd&proxyreload =
l&poxystylesheet = gh_ipblog&sitesearch = www.nyu.edu%
2Fsocialwork%2Fip&q = cognitivetherapy
The International Association for Cognitive Therapy.
http://www .cognitivetherapyassociation.org/index.aspx
;r-. -JOSEPH
WALSH
COLLABORATIVE PRACTICE
ABSTRACT: Social workers are uniquely prepared to
provide leadership for collaborative practice, espe-
cially when they employ intervention logic. Inter-
vention-driven collaboration develops interdependent
34 2 CollABORATIVE PRACTICE
relationships among people. These relationships are
cemented by norms of reciprocity and trust, enabling
participants to organize for collective action in response
to "wicked" problems characterized by uncertainty,
novelty, and complexity.
Among the family of "c-words" (for example, commu-
nication, coordination), collaboration is the most diffi cult
to develop, institutionalize, and sustain because it requires
new organizational designs, including inter-or-
ganizational partnerships, as well as policy change. Not-
withstanding the attendant challenges, collaborative
practice is a mainstay in multiple sectors of social work'
practice, including mental health, substance abuse, school
social work, complex, anti-poverty initiatives,
international social work, workforce development, and
research. Growing collaboration with client systems con-
nects collaborative practice with empowerment practice
and facilitates the achievement of social work's mission.
KEY WORDS: collaboration; social work practice;
collective action; complex change
Social workers, like . other helping professionals, are
encountering growing needs and opporturunes for
collaborative practice. For example, the limitation~ of
industrial-age professions, organizations; and institutions
are becoming apparent as a new genus of problems
develops. These new problem clusters, called "wicked
problems" because they encompass in tractable dilemmas
and defy ready solutions (Mason & Mitroff, 1981), are
marked by unprecedented complex ity, novelty, and
uncertainty. Examples include concentrated poverty (also
called social exclusion and social isolation) and- the
threats to global sustain ability caused by pollution, food
shortages, wars, ethnic hostilities, and multiple
insecurities. Such wicked problems requir e collaborative
practice, especially forms of collaborative practice led
and performed by social workers who adv'ance
deinocracyas they promote so cial and economic justice
for vulnerable, oppressed populations.
Social workers have made unique, significant con-
tributions to the concept of collaborative practice and for
good reason. An option for some professions,
collaborative practice is an essential, defining feature of
social work practice. For example, social workers,
perhaps more than other helping professionals, strive to
establish collaborative working relationships with their
clients systems. Moreover, social workers often are
instrumental in facilitating interprofessional (inter-
disciplinary) and interorganizational collaboration
(Abramson & Rosenthal, 1995).
This entry is structured to introduce relevant details.
It begins with an intervention-oriented, conceptual
framework for collaborative practice. Then it provides
examples of social workers' collaborative practice in
multiple sectors. Collaborative practice's import for social
work's mission provides a fitting conclusion.
An Intervention-Oriented,
Conceptual Framework
Collaborative practice arguably is a defining character-
istic of "macropractice" because it cross- cuts the other
kinds of practice in this category. These other kinds
include community building and development, inter-
professional practice, interorganizational practice, and
social planning-all foci for other entries in this
Encyclopedia. Because collaborative practice is ern-
bedded in these other kinds of macropractice, it has the
potential to unite them and provide much- needed
coherence. These benefits and others depend on a
research-supported, theoretically sound conceptual
framework. One such framework follows.
ENHANCING THE'LAY DEFINITION WITH
INTERVENTION LOGlc Collaborative practice, in lay
terms, means "working together." While this lay ap-
proach is fundamentally accurate, it also is both
imprecise and incomplete. It c~nceals important
distinctions among a variety of collaborative
practices. This problem carries with it the threat that
well-intentioned social workers will err when they
elect a kind of collaborative practice that does not
correspond to presenting needs, problems, and
opportunities.
Intervention logic, a hallmark of sound, clinical social
work practice, helps prevent collaborative prac tice errors.
It prioritizes the correspondence, or more simply "the fi t,"
between the practice solution (inter vention) and the
presenting problem, need, or opportunity. This logic
requires social work professionals to make theoretically
sound inquiries into "the theory of the problem" so as to
determine its etiology. Such an etiology includes relevant
causes,' correlates, and ante cedents. Three inseparable
questions facilitate these inquiries:
What is wrong that needs to be fixed?
What is good and correct that needs to be
maintained?
How can the answers to these two questions be
pieced together, producing an accurate and coherent
"theory of the problem," that is, one that enables
social workers to select among alternative
strengths-based, solution-focused, and culturally
competent interventions?

Because intervention logic helps to pinpoint the theory
of the problem, it maximizes the probability that social
workers will select the optimal, collaborative practice
intervention.
VARIETIES OF COLLABORATIVE PRACTICE: A introduces increasing complexity. Coordinated,
FRAMEWORK FOR THE FAMILY OF "C,WORDS" Owing
in part to the theoretical and empirical contributions
of social work researchers (Abramson & Rosenthal,
1995; Anderson-Butcher & Ashton, 2004;
Briar-Lawson, Lawson, Hennon, & Jones, 2001;
Bronstein, 2003; Claiborne & Lawson, 2005;
Lawson, 2003, 2004), enhanced conceptual
frameworks for collaborative practice now are
available. Arguably intervention logic has been a
facilitator for framework
. \
development and serves. as a defining characteristic
of the best ones and the optimal practice alternatives
they encompass.
The best frameworks make firm distinctions among a
family of "c-words": communication, consultation, co-
ordination, and collaboration. Unfortunately, all lend
themselves to competing definitions, conceptual confu-
sion, and conflicting practices. Problems like these and
the errors they spawn can be prevented when each
c-word is framed as a special intervention. Then each
can be tailored to special needs, problems, and opportu-
nities (Claiborne & Lawson, 2005; Lawson, 2003,
2004).
Communication. In most conceptual frameworks,
communication is the easiest and most simplistic
form of collaborative practice. Effective
communication with other service providers and also
with service Users is a hallmark of collaborative
practice. Only when people share information and
gain consensus through it can they work together. The
importance of communication is revealed when it is
absent or flawed (Lawson, 2003).
Consultation. Consultation starts with the commu-
nication of information, but it also includes a more
intricate and important "move" toward more
sophisticated collaborative practice. In lieu of
assuming auto- . matically that one professional
knows best what to do, this form of collaborative
practice proceeds with the assumption that other
persons offer invaluable expertise. These persons
include other professiotials,service users, and persons
knowledgeable about service users and their
surrounding social ecologies, including their family
members, friends, and neighborhood communities
(Lawson, 2003).
Consultation entails eliciting these persons' views on
the theory of the problem and gaining their intervention
recommendations. Because it draws on others'
expertise, often in unique practice contexts,
OLLABORATIVE PRACTICE 343
e punishment of contates the identification of diversity
and paves the way for culturally responsive and com-
petent practice (Lawson, 2003).
Coordination. Coordination encompasses
communication and consultation, but it also
collaborative practice is especially salient when
multiple needs, problems, and opportunities are
encountered; and when the efforts of multiple
persons must be orchestrated. In this form of
collaborative practice, social workers must
harmonize and synchronize their assessments,
interventions, and improvement-oriented practice
evaluations with other persons-notably other
professionals and service users. Examples include
interprofessional teams, the several kinds of
family-centered practice, and communitybased work
involving coalitions (Lawson, 2003).
Importantly, in coordinated, collaborative practice
the participants remain autonomous and independent.
They take turns contributing to problem-solving and
opportunity maximization. Just as many sports coaches
must orchestrate the multiple movements of their ath-
letes, someone, ideally a social worker usually is re-
quired to orchestrate, synchronize, and harmonize the
respective contributions of the multiple participants
involved in coordinated, collaborative practice.
Collaboration. Collaboration encompasses the
other c-words. It is the most sophisticated and
complex form of collaborative practice (Claiborne &
Lawson, 2005; Lawson, 2003, 2004). For example,
in compatison to the other c-words, collaboration
requires more time, dedicated resources, and special
leadership. The most costly and challenging of the
various kinds of collaborative practice, it also is the
most difficult to institutionalize and sustain.
Three keynote features of collaboration lend cre-
dence to these claims and others that follow. First,
collaboration both develops and requires interdepen-
dent relationships. Second, collaboration is a warranted
response to needs, problems, opportunities, and situa-
tions manifesting complexity, novelty, and uncertainty,
especially those in which available knowledge and un-
derstanding are limited or even nonexistent. Wicked
problems, identified at the outset, especially require
collaboration. Third, power and authority differentials
must be suspended as much as possible, enabling part-
ner-participants to work together as much as possible as
equals (Lawson, 2003, 2004).
In brief, when social workers opt for collabora tion
with other professionals, service users, and other
needed constituencies, they do so because they cannot
be successful and effective without them. In other
words, interdependent relationships emblematic of
344 CoLLABORATIVE PRACTICE
collaboration develop when no one person can achieve
their aims, goals, and objectives alone. Each fundamen-
tally depends on the others, and so they often adopt
common purposes (Schorr, 2006). This interdependence
is especially apparent when no one knows what to do in
complex, novel, and uncertain situations, and especially
when vexing needs and problems nest in one another
(for example, those accompanying poverty).
Collaboration thus entails developing shared awareness
of this interdependence and inherent complexity,
developing shared goals, and then creating a feasible,
warranted system of roles, rules, and social relations,
which is tied to effective, collective action strategies
(Bronstein, 2003).
The social relations for collaboration are cemented
by norms of reciprocity and ~st. Both are maximized
when "the right. mix" of participants is convened and
organized for collective action. After all, norms of rec-
iprocity (that is, voluntary, mutual "give and receive"
relations) and trust take time to develop and require
mutual familiarity. These special norms and trust rela-
tionships are easier to develop and witness when stake-
holders have enjoyed prior histories of successful
working relationships. Additionally, norms of reciproc-
ity and trust are likely to develop when all of the
participating stakeholders view each other as credible,
dependable, competent, and legitimate. These several
features reduce the risks of depending on others, and
risk. reduction is especially important in today's out,
comes-oriented, accountability practice environments
(Lawson, 2003, 2004).
Collaboration is not, however, without its chal-
lenges-as-opportunities. For example, when everyone
shares responsibility for outcomes, the risk remains that
no one is responsible or accountable. When outcomes
improve and other benefits are evident, questions of ten
arise as to who deserves the credit. Questions about
recognition and rewards are especially likely to arise
when "free riding" occurs, that is when some partici-
pants end up contributing little or nothing to outcomes
even though they are officially recognized as one of the
collaborators (Lawson, 2003).
Above all, conflict is endemic in collaboration. This
unavoidable feature highlights the necessity for conflict
mediation and resolution mechanisms; strengths- based,
solution-focused language; behavioral norms to ensure
high quality, positive interactions during moments of
conflict; and "barrier-busting" protocols. When these
several conflict-related mechanisms are in place, the
positive, generative-creative propensities of conflict and
collaboration can be maximized. Among the benefits are
two kinds of powerful innovations (Lawson, 2004 ).
Collaboration routinely yields process innova tions (new
ways of practicing and "doing business") and
product innovations (new service delivery structures,
programs, and services).
In short, collaboration responds to complexity and
interdependent relationships, and it also promotes them.
New for many of its developers, it also creates both
novelty and complexity. Furthermore, collabora tion is
an innovation, which incubates other innovations in
response to environmental changes. Daunting
complexity like this indicates why collaboration is so
difficult to develop, institutionalize, and sustain. It also
indicates why complexity theory is salient to collabora-
tion's development and theoretical analysis (Warren,
Franklin, & Streeter, 1998).
It follows that collaboration entails a special kind of
leadership, which may be described as adaptive, shared,
and distributed leadership. It must be adaptive to be
responsive to changing needs and context. It must be
shared because top-down, compliance-oriented,
one-person leadership derails collaboration. It must be
distributed because it must span group, family, profes-
sional, organizational, and community boundaries.
Mizrahi and Rosenthal (200l) have identified some of
the competencies associated with this kind of leader-
ship. Fortunately, this is the kind of leadership for which
social workers enjoy special preparation. Indeed, this
cross-boundary, collaborative leadership is en grained in
the history of the profession (Abbott, 1995), and the
future holds prospects for more of it.
THE IMPORT OF ORGANIZATIONAL SETTINGS The
several forms of collaborative practice require
optimal conditions. For example, the organizational
environments (Abramson & Rosenthal, 1995) and
community settings for these practices must be
conducive to collaborative practice. Supportive
policies are another prac tical necessity. A brief
explanation follows.
Social workers and others engaged in collaborative
practices typically do so under the aegis of at least one
organization. When several professions are involved,
the multiple organizations that employ them are also
involved (Abramson & Rosenthal, 1995). These
organizations provide the settings for collaborative
practice. Ideally, these settings are conducive to, and
facilitative of, collaborative practice. Since these
setting-related features do not evolve and occur
naturally, it is important to identify important examples
so they can be created by design. Both intra, and
interorganizational designs are needed.
Interorganizational designs increasingly are called
partnerships. The rationale: Reserving "partner, ships"
for organizations also reserves the family of c- words to
refer to and depict interactions among people.
The features of supportive organizational settings
start with the time, facilities, resources, supports,

incentives, and rewards for collaborative practice. For
example, many organizations have a preferred program
and service model, and it needs to include, support, and
reward collaborative practice. Other features include
leadership, management, and supervisory structures that
are aligned with collaborative practice, including both
top-down and bottom-up mechanisms for obtaining
information and feedback for learning and improvement.
They include data-management systems, both intra- and
inter-organizational. They also include training, technical
assistance, and capacity-building mechanisms needed to
advance collaborative practice (Bardach, 1998; Lawson,
2003).
THE IMPORT OF SUPPORTIVE POLICY ENVIRON-
\ .
MENTS Individual organizations and clusters of them
are disciplined by policies and the institutional arrange-
ments they structure. Social workers, arguably more than
any other profession, are prepared to understand and to
help change policies that do not support collaborative
practice. Since social workers rarely change policies alone,
this policy-oriented leadership comprises another kind of
collaborative practice.
Social Workers and Collaborative Practice The
opportunities and sectors for collaborative practice by
social workers appear to be growing rapidly. Three reasons
are especially relevant. The first is a new policy
environment that favors social workers over other pro-
fessions (for example, psychiatry, psychology). Growing
understanding about co-occurring, interlocking needs
manifested by many service users, especially' the most
vulnerable ones, is the second reason. Concern over the
lack of effectiveness of conventional, clinical-direct
services by a solo professional is the third.
SECTORS FOR COLLABORA TIVE PRACTICE This
short entry can do little more than identifying relevant
sectors of practice and providing references for readers'
personalized follow-up inquiries. After these sectors are
identified, a pivotal distinction between two kinds of
collaborative practice is amplified. This distinction is
especially important to unique social work practice.
Local, State, and National Sectors. Here, then, is a
starter inventory of the service sectors in which social
workers engage in, and often lead, collaborative prac-
tice. These sectors are: (a) schools (Anderson-Butcher,
Lawson, Bean, Boone, & Kwuatkowski, 2004); (b) hos-
pitals (Abramson & Mizrahi, 1996); (c) mental health
agencies (Hodges & Hardiman, 2006); (d) public health
agencies (Roussos & Fawcett, 2000); (e) child welfare
agencies (Sallee, Lawson, & Briar-Lawson, 2001; Smith
& Mogro-Wilson, in press); (f) juvenile
COLLABORATIVE PRACTICE
345
justice agencies (Byrnes, Boyle, & Yaffe-Kjosness, 2005;
Marks & Lawson, 2005); (g) welfare-to-work programs
(Briar-Lawson, 1999); (h) elder-serving agencies
(McCallion, Grant-Griffin, & Kolomer, 2000) and ini-
tiatives (Bronstein, McCallion, & Kramer, in press); (i)
substance abuse agencies (O'Hare, 2002); (j) domestic
violence agencies; (k) youth development agencies
(Anderson-Butcher, Stetler, & Midle, 2006); (1) family
service agencies (Briar-Lawson et al., 2001); (m) agencies
charged with leadership for community-based coalitions
(Mizrahi & Rosenthal, 2001); and (n) agencies charged
with disaster relief (Briar-Lawson, 2006).
International Sectors. Disaster relief in the United
States points toward international needs and opportun-
ities for collaborative practice, and a timely response to
the 2004 tsunami in Indonesia serves as an example
(Hardiman, Martinek, & Anderson-Butcher, 2005). This
international work includes border-crossing assistance
to immigrants and migrants, including the growing
number of divided family systems residing in different
nations (Lawson, 2001). It also includes cross-national
adoptions for needy children (as documented in the
Journal of Community Practice).
New Sectors. As workforce recruitment, retention,
and optimization become priorities, arid as knowledge
grows about how and why organizational contexts "push
out" good workers, a new sector for collaborative
practice has developed. Organizational development,
via organizational design and improvement teams, is
one such emergent opportunity (Lawson, McCarthy,
Briar-Lawson, Miraglia, Strolin, & Caring, 2006).
Moreover, as the limitations of conventional research
methodologies become apparent, another sector is
developing: The research sector. This encompasses
collaborative research (as a collaborative practice), in-
cluding research focused on collaborative practice. It also
entails collaborative research methodologies, including
community-based, participatory research, action science,
and participatory action research (Greenwood & Levin,
2006; Kreuter, Lezin, & Young, 2000).
A PIVOTAL DISTINCTION AND CHOICE POINT
Partly because conventional practices have enjoyed limited
effectiveness, interest is growing in new forms of
collaborative practice involving service users as experts
and providers. Fo'r example, so-called consumer-provided
mental health services are gaining considerable popularity
(Hodges & Hardiman, 2006; Mancini, Hardiman, &
Lawson, 2005), and so are parent-to-parent service
strategies (Briar-Lawson, 2000). In these examples, the
target system (client system) becomes the action system in
close concert with social workers and other helping
professionals.
346 COLLABORATIVE PRACTICE
Arguably, this emergent practice paradigm provides a unique,
splendid opportunity for social work leadership in service of
vulnerable people, also benefiting the profession writ large.
COLLABORATIVE PRACTICE'S IMPORT FOR SOCIAL
WORK'S MISSION The achievement of social work's
mission-to eliminate oppression and alleviate
poverty-fundamentally depends on effective, creative
collaborative practice. Only when social workers
engage other people in this important mission,
building their capacities for collaborative practice and
reinforcing their political will, can this mission be
achieved. Here, collaborative practice meets
empowerment practice. A technical- procedural
challenge in one light, in another this. kind of
integrated, complex practice is a moral obligation and
an ethical imperative associated with the renewal of
responsive democracy. Social work's lea dership for
21st century collaborative practice begins here, and it
spans local, state, regional, national, and international
contexts.
Acknowledgment
Several colleagues were exemplars for collaborative practice
as they generously provided materials and suggestions for
improving this entry.l am grateful to all of them.
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Center for Effective Collaboration and Practice Web site.
http://ceep.air.org/
- HAL A. LAWSON
COMMuNITY. [This entry contains two subentries:.
Overview; Practice Interventions.]
OVERVIEW
ABSTRACT: One of the hallmarks of social work is its
recognition that people grow and mature in a social
context. Communities are one of the many social
systems that touch people's lives and shape their
lndlvidual and group identity. A conceptual overview
of community is presented. Social systems,
ecological systems, and power/conflict are presented
as alternative frameworks for understanding how the
social interaction between
COMMUNITY: OVERVIEW 347
individuals, groups, and social institutions are patterned
within the community. Virtual community is reviewed
as a recent phenomenon that may have implications for
community in modem society.
KEY WORDS: Gerneinschaft; Gesellschaft; community of
interest; social systems; ecological systems; community
power; community conflict; virtual community; com-
puter mediated community
Community has been a central focus of social work
practice since its inception. Communities are one of the
many social systems that touch people's lives and shape
their individual and group identities. One of the
hallmarks of social work is its understanding that
people grow and mature in a social context. Infants first
encounter their immediate family, then extended family
and friends, and then the local community. As people
grow and mature, they learn about and form perceptions
of social structures and develop individual and group
identities through associations that connect them to
life-long community experiences (Newman, 2005). The
characteristics of the community itself can have
important implications for one's life chances.
Communities come in an infinite number of sizes,
shapes, social arrangements, population compositions,
and locations. Communities are composed . of social
relationships that form the basis of communal life, and
the shared perceptions, and common interests of its
members are the glue that bonds the community into a
coherent unit. Moreover, these social relationships and
shared perceptions transcend time, structure, and
location. Some communities are relational in nature and
are based on shared beliefs, values, or interests. Such
communities are not tied to a single location or physical
structure.
Community is the context and setting for social
work at all levels of intervention. For social workers
engaged in direct practice at the micro level, it is critical
that they understand the macro-environment where
their clients live and work, the resources available to
them, and how community dynamics impact individual
behavior. For macro-level social workers whose
practice is focused on social policy, community
organization, programs planning, and administration,
community is central to their work. Community is also
the target or vehicle for change where interventions are
designed to address broader social problems that affect
a large group of people (Fellin, 200Ib).
History of Community as Human Association The
construct of community is often associated with the
German sociologist Ferdinand T onnies in the late
348 COMMUNITY: OVERVIEW
1800s (Harris, 2001). He elaborated two "normal" types
of human association, Gemeinschaft and Gesellschaft.
Gemeinschaft is based on natural, personal, informal,
face-to-face social relationships, where individuals are
accepted for who they are, not what they have done.
Relationships are based on emotion and sentiment, and
people are recognized and accepted for their innate
qualities. Where this type of relationship exists, people
know one another as individuals; social controls are
informal and based on shared mores and beliefs; and
group relationships are more important than individual
goals and desires. Tonnies saw this as the type of human
relationship reflected in families, small groups, and
traditional communities.
By contrast, Gesellschaft relationships are character-
ized by rational self-interest; are more contrived in
nature; and place greater emphasis on specialized, seg-
mented social interactions. The interests of the individ-
ual supersede the interests of the group. People engage
one another as objects to be used to achieve personal
ends. Interactions between individuals are directed to-
ward a utilitarian goal and are often based on some form
of contractual agreement. Social cohesion is derived
from a more elaborate division of labor, and social con-
trol is more formalized, based on laws and rules with
formal sanctions enforced when laws are violated.
T onnies observed that the rise of industrial capital-
ism in Europe and the United States at the end of the
19th century was bringing about major transformations
in the nature of human relationships. While some have
placed value on these alternative forms of human inter-
action, suggesting that Gemeinschaft represents a more
positive type of human relationship, T onnies viewed
them as different forms of human association and an-
ticipated that both would be a permanent part of social
life in modem societies. Viewing them as ends of a
continuum of human interaction allows us to understand
that community is grounded in both informal personal
relationships and in the formal institutional structures
that are part of contemporary life.
Definitions of Community
When social workers think about community as the
context and setting for professional practice, they
typically think about two things simultaneously: (a)
community as shared physical space or geographic
community; and, (b) community based on shared inter-
est or identity or functional community. Brueggemann
(2006) contends that community needs to be embodied
to have existence. By that he means that community
must be identified with a physical space that symbolizes
the community for its members, and for those who are
not part of the community. This might be a territory
with clearly defined boundaries, such as a town or
municipality-sometimes referred to as a localitybased
community The boundaries of these communities are
often established through some political entity, such as a
municipal government, zoning commission, or school
board. But a community might also be embodied in a
physical structure, such as a church, recreation club, golf
course, or union hall where the building itself represents
the embodiment of the community.
Membership in some communities is not dependent
on shared physical space. Such communities are some-
times referred to as communities of interest. They are
generally based on a set of shared interests or common
characteristics that unite the members and provide the
basis for one's personal identity. Things like race,
ethniciry, religion, culture, social class, professional af-
filiation, and sexual orientation often form the basis for
a community of interest. Because such communities are
based on identity and interest, members carry the com-
munity with them; it is not tied to physical location.
Communities of interest sometime overlap with lo-
cality-based communities, as when a residential area
contains a high proportion of people whose personal
identity is tied to one or more specific interest groups.
And mostpeople belong to more than one community,
with varying degrees of identification, interest, and
engagement. These multiple community affiliations can
be thought of as one's personal community network,
representing the various locality-based and inter-
est-based communities that connect the individual to
others, and to the broader society (Pahl & Spencer,
2004). Identifying and assessing these personal
community networks can provide a more complete
picture of the range of formal and informal helping
systems in the community.They can also provide social
workers with a more holistic understanding of social
problems facing their clients and develop more realistic
intervention plans that connect the various levels of
human interaction, micro to macro (Rubin & Rubin,
2008).
Understanding Community
When community is the point of intervention, it seems
logical that social workers need to understand commu-
nity and have useful conceptual frameworks to' analyze
it. Community-based practice requires community the;
ory just as individual models of intervention require
theories of personality and human behavior. T o inter;
vene competently and ethically, social workers need to
understand the. unit they are trying to change. Commu-
nity practice requires that interventions be based on the
characteristics of the community and the nature and
scope of the specific problem that is the focus of inter-
vention (Figueira-Mcfronough, 2001).

Given the complex and multifaceted nature of
communities, no single conceptual framework provides an
adequate theoretical foundation for understanding
community. Kirst-Ashman (2008) suggests that community
theories can be thought of as a series of lenses that focus on
different aspects of community, each highlighting different
dimensions of the community, its dynamic nature, and the
ways it impacts the lives of its members. For our purpose
here, we will focus on three different conceptual
frameworks to help social .workers understand community:
(a) as a social system, (b) as an ecological system, and (c) as
a center for power and conflict.
COMMUNITY AS A SOpAL SYSTEM General systems
theory is deeply rooted in social work practice
and offers a useful framework to analyze and
understand commu nity. General systems theory
posits that a system is composed of multiple
interacting components that re late to one another
in an orderly, functional manner. Mor eover,
systems are embedded within larger systems,
thus providing a framework for understanding
the connection between different levels of the
system. For example, an individual might be
viewed as one element within a family or
kinship group, the kinship group exists within a
community, the community within a state,
nation, or society. Thus, a systems perspective
provides a useful framework for understanding
the structure of community and the processes
that tie the structural elements together.
From this perspective, a community is composed of a
series of interrelated parts or subsystems with each one
performing specialized functions for the community. The
subsystems exist for a specific purpose and the
interdependence of these components produces the
structure of the community. The functions they per-: form
have relevance to the members of the community. Some of
these functions are performed by formal organizations in
the community, such as schools, hospitals, churches, and
corporations. Others are performed through informal
groups such as families, friends, neighbors, peers, and other
social networks.
In the classic book, The Community in America, Roland
Warren draws on these basic social system ideas to define
community as "that combination of social units and systems
that perform the major social functions having locality
relevance" (Warren, 1978, p. 9). He outlines five
majorsocial functions that have locality relevance:
production-distribution--consumptioJ]., socialization,
social control, social participation, and mutual support.
Production-distribution--consumption refers to the
economic function of the community. For people to
CoMMUNITY: OvERVIEW 349
live in a community, they must be able to acquire the
goods and services needed for daily living. At the most
basic level, this means access to food, shelter, and
clothing. But it also means access to a host of other goods
and services; such as transportation, health care, utilities,
and other public services. Not only must these goods and
services be available, but also people must have the
resources needed to acquire them. Accordingly,
employment opportunities, wages, and commodity pricing
are also relevant to understanding this community
function.
Socialization is the. process by which members of the
community learn the formal arid informal social rules,
values, norms, and behavior patterns of the community. It
also involves the transmission of the accumulated
knowledge and skills that are relevant to the community.
Through this process, members of the community become
socialized to the ways of the community. Formal
subsystem, such as schools and religious organizations, are
central to this process, as is the media. However, informal
subsystems, such as families, friends, and peer groups, also
influence socialization.
Communities usually have rules, norms, and standards
of behavior, with mechanisms to ensure that people act in
ways that are consistent with those expectations. Social
control is about enforcement of community norms. It refers
to the formal and informal processes that are used to
pressure individuals into conformity. with community
norms. When someone is unable or unwilling to comply
with community expectations, sanctions are imposed, and
if the noncompliance continues, the individual may be
removed from the community. Typically, this function is
performed by formal governmental entities such as police,
courts, and other code enforcement and regulatory
agencies. However, many subsystems in the community
contribute to the social control function, including
families, schools, churches, and social service agencies.
Sometimes there are organized neighborhood watches and
block associations.
Social participation occurs when people are actively
engaged in the life of the community. This happens
through a variety of formal and informal subsystems.
Participating in a recreational sports league, serving on a
Board of Directors, voting in an election, volunteering at a
homeless shelter, attending a city council meeting, joining
the PTA at your child's school, and attending a community
festival are examples of social participation. Opportunities
for social participation can help create a dynamic and
engaged citizenry. It also allows members of the
community to establish and maintain personal community
networks, share ideas and opinions, and build social
capital.
350 COMMUNITY: OVERVIEW
Mutual support occurs when members of the com-
munity are faced with difficult circumstances that exceed
their capacity to respond. When people become
incapacitated by illness, are faced with the loss of a loved
one, or with the loss of property due to a natural disaster,
or a human-made disaster such as a war, cornponents of
the community often mobilize to provide mutual support.
Traditionally, mutual support wasprovided by an informal
helping network composed of family, friends, or
neighbors. But the complexity of today's urban
environment, coupled with the population mobility found
in modem society, means that this function is increasingly
being performed by specialized formal subsystems. In
fact, this is where social work most often i dentifies its role
in the community.
\
Social problems in the community often occur
when one or more of these social functions are not being
adequately performed. Such failures may be for the entire
community or, more likely, for some subgroup within t he
community. The ability to procure goods and services,
opportunities for meaningful social participation, and
access to mutual support may vary considerably as one
surveys the social and demographic landscape of the
community.
Social participation and mutual support are espe cially
important for the development of social capital in the
community. Social capital refers to the connec tions among
individuals and the norms of reciprocity and
trustworthiness that facilitate civic engagement, social
solidarity, and cooperation for mutual benefit (Putnam,
2000). Social capital is a fundamental source of strength
for a community, both for the members of the community
individually and for the community as a whole (Chaskin,
Goerge, Skylews, & Guiltinan, 2006; Poortinga, 2006). In
communities with strong social capital, it is easier to
resolve collective problems and all social functions are
performed at a higher level. On the other hand, in
communities with weak social capital people often feel
trapped, powerless, and exploited (Homan, 2008).
Social workers need to be able to critically assess how
these subsystems meet, or fail to meet, the needs of their
clients. A community assessment focused on these major
functions can help identify community needs, as well as
community strengths. It can help us recognize when
formal institutional structures that are designed to serve
the community are not working effectively. It can help us
understand the interrelationship between the formal and
informal systems of the community. And it can help us
identify appropriate points of intervention to bring about
change in community subsystems. .
While the social systems perspective can help social
workers understand the communities where they live
and work, increasingly that assessment must be done with
a careful eye on the changing national and global context.
Weil (2005) identifies a number of major shifts occurring
at the national and international levels, such as
globalization, privatization, and the dismantling of the
social safety net, that have had profound impacts on how
communities perform these functions. The move ment of
manufacturing capacity offshore has made the United
States a nation of consumers rather than producers. Some
communities have been hit ha rd with loss of jobs and
industries. Pervasive travel and global pop ulation
migration has made us vulnerable to the rapid spread of
diseases like HIVjAIDS, SARS, and Avian Flu, placing
sudden and intense demands on health care and other
mutual support systems. Rapid expansion in
cyber-comrnunications, including computer Blogs,
instantaneous global news coverage, mobile phone sys-
terns, and virtual communities, has markedly altered the
process of socialization, challenging old community
beliefs and values, and creating access to new ideas and
information in ways that were not possible a few years
ago. In addition, Fisher and Karger (1997) note that one of
the most significant challenges facing social work today is
that in modem societies private space increasingly
replaces public space. People no longer frequent public
spaces, such as parks, libraries, mass transit, preferring
instead to inhabit their own private world. This trend
makes it increasingly difficult to build community and
promote a sense of social solidarity (Fisher, 2005).
COMMUNITY AS AN ECOLOGICAL SYSTEM Germain and
Gitterman (1980) have helped popularize the eco logical
perspective in social work. Drawing on con cepts from
biology, they emphasize the importance of transactions
between humans and their environment to understand and
explain the dynamic nature of cornmu nities (Germain,
1985). Transactions refer to regular exchange
relationships that occur between the various parts of the
community where each part gives and receives in
symbiotic relationships with other parts of the system.
This interdependence produces a state of equilibrium
between the needs of the population and the capacity of
the environment to meet those needs. From this
perspective, a healthy community is one where all of the
various parts fit together into a cohesive system, and that
system has adapted to the constraints of its environment
(Fellin, 2001a).
Where the social systems perspective helps us un-
derstand the social organization of the community, the
ecological systems perspective focuses our attention on
the spatial organization of the community and the social
and economic consequences of the distribution

of people and services. It emphasizes the interplay be,
tween population characteristics (size, density, diver,
siry), the physical environment (land- use patterns,
distribution of services), the social environment (social
stratification, social class) and technology (production of
goods and services, transportation, communica tions). It
recognizes that physical features in the com munity often
have importance social implications. For example , a
highway, railroad tracks, river, even a spe cific street
running through a community can have important
implications for the social organization. of the community
and opportunities for individuals and groups to engage in
meaningful transaction with the ir environment. While
these physical features may de mark important territorial
boundaries in the community, they can also represent
significant social and psychological boundaries that have
important meaning for the self perception of subgroups in
the community and the community as a whole.
The ecological systems perspective can help social
workers understand how community structures emerge
from dynamic processes, such as competition and dom-
inance, centralization, concentration, succession, and
segregation. The concept of competition is central to the
ecological perspective. Competition is the act of one
group striving against others for the purpose of achieving
control of the limited resources of the com munity. One
important area of competition in most communities is
access to and control of natural re sources. For example,
competition for land is common in many communities as
some groups strive to control prime real estate for
residential and commercial devel opment while others
want to maintain public spaces such as parks and hiking
trails. Still others may lament the loss of agricultural land
as community growth encroaches on the hinterland.
Competition for social resources, such as markets for
goods and services, votes, employment opportunities, and
access to education or health care systems, are often tied
to location in the physical landscape of the community.
Through competition, one group or set of social
institutions often becomes dominant over others in the
community. The ability to win control over important
resources in the environment allows one group to achieve
a higher social status relative to others i n the community
(Fellin, 2001a). Dominant members of the community
often reside in the most desirable locations in the
community. But more importantly, dominance often
means greater access to other resources suc~ as the best
jobs, schools, hospitals, police, and fire protection.
Because of its focus on competition and domi nance,
the ecological systems perspective helps us
COMMUNITY: OvERVIEW 351
understand the community's hierarchical structure. The
inequitable distribution of scarce resources in the
community is often tied to social class. A person's
position within this hierarchy has important implica tions
for his or her quality of life. As Fellin (2001b, p. 121 )
points out, "people benefit or suffer as a result of their
social position within comm unities, through differential
life chances, employment opportunities, access to social
and material resources, and social relationships."
This perspective also helps us understand how goods
and services are distributed across the community. The
distribution of goods and services can be examined along
a continuum of centralization. When the major social and
economic institutions of the community are clustered in
one area, the community is said to be centralized. In most
urban areas critical services like ba nking, transportation,
and health and human services were traditionally
centralized in the downtown area, giving the central city
dominance over other areas. More recently, advances in
information technology, as well as population
movements out of the central city to the suburbs, have
made it possible for vital community services to be
decentralized.
The ecological perspective also helps us understand
community processes related to population movement.
Population movement may occur when a dominant group
gains control of a new area and the current residents are
forced out. For example, gentrification of inner- city
neighborhoods may increase housing values to the point
that current residents cannot afford to stay. Sometimes
population movement occurs as part of a natural process
called succession. In cities that serve as ports of entry for
immigrants, the new arrivals often move into the least
desirable areas. As they gain re sources and move to more
desirable locations, other new arrivals take their place.
Sometimes groups who share common characteristics
such as race, social class, or religion become
concentrated in one part of the community and find it
difficult to move to a new location. This process, known
as segregation, tends to isolate and detach indi viduals and
subgroups from the larger community.
The ecological perspective also draws our attention to
community demographics. Population characteris tics,
such as social class, race, ethnicity, gender, age, religion,
are often aggregated across the comm unity to produce a
demographic map or profile of the community.
Geographic Information Systems (GIS) offers social
workers a powerful tool for organizing and pre senting
data that shows the spatial distribution of im portant
community characteristics (Hoefer, Hoefer, & Tobias,
1994). Data from the U.S. Census, the FBI's
352 COMMUNI1Y: OVERVIEW
Uniform Crime Reports, and other federal, state, and local
government agencies can provide a useful snap shot
showing the distribution of population by demo graphic
characteristics, goods and services, as well as social
problems like poverty, crime, and substandard housing in
the community. Moreover, the analysis of such data over
time can provide useful insights into the demographic
development of the community and the dynamic changes
occurring within the community. It can provide a powerful
vi~ual image that reflects the processes of competition,
concentration, segregation, and succession.
The ecological systems perspective can help social
workers understand the relationship between the phys ical
and social environment of the community. By
~
examining macro-level processes like competition, con-
centration, succession, and segregation, we can begin to
understand how the social structure of the community
evolves over time and often places some members of the
community ata disadvantage in terms of access to the
resources needed for daily living.
COMMUNITY AS A CENTER FOR POWER AND CONFLICT
Although the social systems and ecological systems
perspectives provide useful insights into the community
as a context and setting for social work practice, both
have been criticized for their failure to acknowle dge
community conflict and the role of power in determining
opportunities and constraints for com munity members
(Hardcastle, Wenocur,& Powers, 1997; Hardina, 2002 ).
The social systems perspective assumes that the
community is composed of a set of subsyste ms that
perform specialized functions that meet the needs of the
entire community. The actions of those subsystems are
presumed to be coordinated and inte grated in ways that
benefit the community as a whole. However,. one does
not need to look very far in most communities to find
that what is good for the whole community is not
necessarily good for all parts of the community.
Disagreements between different interest groups are
common in most communities. The interests of one part
of the community are sometimes incompatible with the
interests of others and conflicts emerge as these groups
struggle to advance their own interests. This kind of
interest group conflict sometimes results in a
phenomenon known as NIMBY (Not In My Back Yard),
where residents in one part of the community mobilize in
opposition to plans to place something in their
neighborhood, perhaps a homeless shelter, garbage
incinerator, or power plant, that will benefit the larger
community but which they consider undesirable.
With its focus on community processes like compe tit
ion and dominance, concentration, segregation, and
succession, the ecological systems perspective acknowl-
edges power differences and the inequitable distribution
of community resources. But it also assumes that those
who are less successful at competition must find ways to
adapt to the community structures that have been ere ated
by those with more power. It says little about how
different interest groups in the community vie for power
or how those with less power can a cquire power and bring
about changes in the community to better meet their
needs.
The perspective of community as a center for power
and conflict places power and politics front and center in
our understanding of community. It assumes that conflict
and change are central attributes of most American
communities and that community decision making is as
much about confrontation and negotiation as it is about
rational planning, collaboration, and co ordination
(Hardcastle, Wenocur, & Powers, 1997). Communities
are composed of competing groups who are constantly
engaged in conflict over power and the control of scarce
resources. Some groups, ofren based on social class or
race, have less access to power and must constantly
challenge those with power to acquire a ccess to
community resource such as employ ment opportunities,
health care, housing, police and fire protection, and
education. This ongoing conflict can produce significant
pressure for change in the dis tribution of power and
resources in the community (Kirst-Ashman, 2008).
Community conflicts are often classified into two
broad categories: those based on social Class and those
based on interest groups. The idea of class conflict has its
origins in the work of the 19th~century German
economist and philosopher Karl Marx. Marx argued that
society is divided into two groups, those who have access
to wealth and power and who control the means for the
production of goods and services, and those who have
little or no power and are exploited by a small privilege d
group. This system of capitalism inevitably results in
exploitation and poverty and produces class conflict as
people struggle against oppression and strive for a more
equitable distribution of power and commu nity resources
(Clegg, 1989).
Control of economic resources by a small privileged
group extends beyond the means of production into the
realm of politics. Economic power is transformed into
political power as the capitalist elite use their vast
economic resources to dominate the political arena and
gain control of government institutions, which, in tum, are
used to further strengthen their position of

power and to subordinate the lower classes. From this
perspective, social workers can become unwitting par-
ticipants in the domination of the lower classes by the elite.
Because social welfare is primarily a government function,
and the elite control government institutions including
social welfare, social workers can find them selves
reinforcing the status quo and working to change the
attitudes and behaviors of the working poor to support the
demands of the capitalist economic system (Burghardt &
Fabricant, 1987).
Interest group conflict focuses on conflicts that emerge
out of competing values and interests among social groups.
Unlike class conflict, which views power as being
concentrated in the hands of a small elite class, the interest
group perspective views power as being decentralized and
tied to issues rather than class. From this perspective,
power is distributed among different organized groups
with control shifting based on the issue and the ability of
the groups to form coalitions with others who support t heir
position (Dahl 1961, 1967).When there is great diversity
on a community, as is the case in many contemporary
American communities, this type of issue politics is
perhaps a more accurate reflection of the decision- making
process than control over all segments of society by a
small power elite (Martinez-Brawley, 1995).
Viewing community as a center for power and conflict
can help social workers assess the community power
structure, how decisions are made in the community, and
their role as community ch ange agents. It can help them
understand that much of the oppression experienced by
marginalized groups in the community has its origins in
class, race, ability, age, gender, and sexual orientation.
And it can help social workers understand how those in
power can maintain their position of privilege by framing
community social problems in ways that discourage
ordinary people from standing up to challenge the status
quo. (Rubin & Rubin, 2008).
Hardina (2002) argues that the purpose of com munity
organization is for social workers to help members of
oppressed groups to gain power that will increase their
access to decision-making authority, and ultimately give
them greater access to jobs, educa tion, money, and other
community resources. Saul Alinsky, perhaps the best
known community organizer in America, understood the
community as a center of power and conflict. He
understood that disenfranchised people would never gain
access to the power needed to control their own lives
unless they could overcome apathy a nd build
organizations that could challenge the existing power
structure. He worked to mobilize
:
:
CoMMUNITY: OVERVIEW 353
people through churches, neighborhood associations, and
labor unions to give them a voice and to teach them the
skills needed to define common interest, build solidarity,
and challenge the status quo. He understood that it was
only through such "People's Organizations" that people
could "create a world of decency, dignity, peace, and
happiness; a world worthy of man and worthy of the name
of civilization" (Alinsky, 1969, pp.202-203).
The ability to understand community power and to
view conflict and confrontation as a normal part of
community life can help social workers formulate stra-
tegies to challenge the existing power structure of the
community and build the capacity of disenfranchised and
oppressed populations to redefine community prob lems
and challenge the status quo.
Virtual Community
Recent advances in electronic communication tech nology
have given rise to a new kind of community called a
virtual community (Rheingold, 2000). Some times called a
computer mediated community (eMC), a virtual
community is a social group that communi cates primarily
via a computer rather than face-to- face. These
communities are called virtual because they function
without actual physical contact in cyberspace (Kollock &
Smith, 1999).
Because CMCs are such a recent phenomenon, it is
unclear whether they represent an extension of classic
forms of community or if they are a fundamentally new
type of human association (Memmi, 2006). In some ways ,
a virtual community is consistent with T on nies's
observation that modem society is moving toward
Gesellschaft forms of human association. Shapiro and
Varian (1999) have noted that since the 1980s, there has
been a substantial move toward more flexible forms of
group membership where individual par ticipation in
social groups is constantly being re-evaluated and re-
negotiated.People today often belong to many commu-
nities of interest at the same time, with varying degrees of
identification and engagement. This trend is also evident
in recent management practices where the current focus is
on temporary work-teams, subcontract ing and
outsourcing, flexibility and autonomy in work
arrangements (Herr, 2004).
Virtual communities are often large and require a
minimum of shared reference among their members .
Membership is mostly goal-oriented, frequently tem-
porary, and is maintained by minimal cohesion. In their
current popular form, they are quite different from
traditional, tightly connected communities; however, the
technology is still emerging.
354 COMMUNITY: OVERVlEW
Virtual communication technology has the potential
to bring together those people who could not easily meet
otherwise because of distance, accessibility, or stigma.
It also has the potential to unite the voices of those who
are often unheard or ignored and create new
opportunities for wider citizen participation in public
policy debates and community decision-making
processes. For this potential to be realized, access to
information and communication technology must be
available to all sectors of society. Some have raised
concerns about a digital divide, pointing out the gap
between those who have access to this technology and
those who do not. This reflects a new form of social
exclusion and inequality that is every bit as powerful as
exclusion based on race and social class during the Iast
century (Lohmann & McNutt, 2005; Steyaert, 2002).
What is clear is that this technology will have profound
implications for social work practice, both in terms of
the kinds of problems we confront in our communities
and in the strategies we use to respond to those problems
(Hicks & McNutt, 2002; Menon & Brown, 2001;
Quiero-Tajalli, McNutt, & Campbell, 2003; Scheoch,
1999).
Community and Social Work Practice Knowledge
of community structures and processes has been central to
social work since its inception. Historically, community
has been the context and setting of social workers' practice.
It is not surprising that social work, as a profession,
emerged at the beginning of the 20th century during a
period of great societal transformation ushered in by the
rise of industrial capitalism in the United States and
Europe. Early social work pioneers, working through
settlement houses and charity organization societies,
responded to the rapid social changes brought about by
industrialization, the changing nature of cities, population
movements from rural to urban areas, and waves of new
immigrants coming to the United States from Europe. As
Martinez-Brawley points out (1995, p. 545), "In many
ways, social work as a profession became the institutional
response to caring within the context of the industrial
world, its purpose being to address the breakdown of
natural communities."
The challenges facing social workers today in a
postindustrial world are no less . daunting than those
faced by our predecessors at the tum of the last century.
Social workers today must grapple with much more
rapid and far reaching social changes than in the past.
The shift to a massive global economy, increased
privatization, the alignment of corporate and national
interests, shifting national alliances, and marked
changes in information and communication technology
represent significant and difficult challenges for social
workers today (Midgley, 2007; Rihter, 2005; Weil,
2005). This contemporary global context means that
social workers must look beyond their local, state, or
even national environment to understand the nature and
scope of social problems facing their clients and to carry
forward social work's long-standing commitment to
social and economic justice.
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Brueggemann, W. G. (2006). The practice of macro social wark (3rd
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Burghardt, S., & Fabricant, M. (1987). Radical social work. In A.
Minihan (Ed.), The encyclopedia of social wark (18th ed., pp.
455-462). Silver Springs, MD: National Association of Social
Workers.
Chaskin, R. J., Goerge, R. M., Skyles, A., & Guiltinan, S. (2006).
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Clegg, S. R. (1989). Framewarks of power. Thousand Oaks, CA:
Sage.
Dahl, R. (1961). Who governs? Democracy and power in an
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Dahl, R. (1967). Pluralist democracy in the United States: Conflic:t
and consent. Chicago: Rand-McNally.
Fellin, P. (2001 a). The community and the social warker (3rd ed.).
Belmont, CA: Brooks/Cole.
Fellin, P. (2001b). Understanding American communities.
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community intervention (6th ed.).ltasca, IL: F. E. Peacock.
Figueria-McDonough, J. (2001). Community analysis and praxis:
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Routledge.
Fisher, R. (2005). History, context, and emerging issues for
community practice. In M. Weil (Ed.), The handbook of
community practice. Thousand Oaks, CA: Sage.
Fisher, R., & Karger, H. J. (1997). Social wark and community in ~
private warld. White Plains, NY: Longman.
Germain, C. B. (1985). The place of community work within an
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R. W. Roberts (Eds.), Theory and practice of community social
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Germain, c., & Gitterman, A. (1980). The life model of social wark
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Hardcastle, D. A., Wenocur, S., & Powers, P. R. (1997).
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Hardina, D. (2002). Analytical skills for community arganization
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Harris, J. (Ed.). (200l). Tonnies: Community and civil society.
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Hick, S., & McNutt, J. G. (Eds.). (2002). Advocacy and activism on
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social policy. Chicago: Lyceum Books.
Hoefer, R. A., Hoefer, R. M., & Tobias, R. A. (1994). Geographic
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Homan, M. S. (2008). Promoting community change: Making it
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Kirst-Ashman, K. K. (2008). Human behavior, communities,
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Lohmann, R. A., & McNutt, J. (2005). Practice in the electronic
community. In M.'Weil (Ed.), The handbook of community
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Martinez-Brawley, E. E. (1995). Community. In The encyclopedia
of social work (19th ed., pp. 539-548). Silver Springs, MD:
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Memmi, D. (2006). The nature of virtual communities. AI &
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Menon, G. M., & Brown, N.K. (Eds.). (200l). Going the distance:
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Midgley, J. (2007). Global inequality, power and the unipolar
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Pahl, R., & Spencer, L. (2004). Personal communities: Not simply
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COMMUNITY: PRACTICE INTERVENTIONS 355
Warren, R. L. (1978). The community in America (3rd ed.).
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community practice. Thousand Oaks, CA: Sage.
-CAL YIN L. STREETER
PRACTICE INTERVENTIONS
ABSTRACT: Major social changes resulting from
globalization, the increase in multicultural societies,
and growing concerns for human rights, especially for
women and girls, will affect all community practice in
this century. Community practice processes-organizing ,
planning, sustainable development, and progressive
social change-are challenged by these trends and the
ethical dilemmas they pose. Eight different models . of
community practice intervention are described with
examples from around the globe. Thevalues and ethics
that ground community practice interventions are
drawn from international and national literature. Model
applications are identified for direct practice, working
with groups, communities and coalitions, and in
management, administration, and leadership for social
justice.
KEY WORDS: community practice models; social work
values arid ethics; global social changes; community
interventions and development; human rights and
social justice
Introduction
Although community residents have always worked
collaboratively on common needs, the evolution of formal
practice interventions for community work in the United
States has its origins in the late 19th century. With the
formalization of social work as a profession and community
organization as a recognized method of social work,
increasing numbers of professionals began working with
communities. Social work that emerged from this focus on
community issues is now called community practice. While a
parallel development of the profession of social work was
ongoing in many countries, we will refer primarily to the
development of community practice in North America, but
will describe its application in a global context.
HISTORY Several streams of engagement by early community
researchers and practitioners were the antecedents of
community practice social work. The settlement house and
charity organization society movements formed the context
for the development of social work as a profession, and from
its genesis, community practice has been an essential element
(Abbott, 1937; Addams, 1902,
356 COMMUNITY: PRACTICE INTERVENTIONS
1910; Brieland, 1995; Garvin & Cox, 2001). Both move-
ments were adapted from British approaches. After
spending the summer of 1877 studying the work of the
society in London, Stephen Gurteen returned to Buffalo,
New York, to establish the first Charity Organization
Society in America focusing on systematically coordi-
nating philanthropy and developing "scientific" charity
services (Gurteen, 1882). Jane Addams, one of the
founders of the Settlement Movement in the United States,
visited and studied the work of the first settlement,
Toynbee Hall in London during 1881. After returning to
Chicago she and Ellen Gates Starr founded Hull-House in
1889 focusing initially on neighborhood services,
community organizing and group work with the area's
many impoverished immigrant groups, and later
\
expanding to social research, employment and labor is-
sues, and social policy development (Addams, 1930;
Deegan, 1990). A third stream of community work in the
United States was developed through rural extension
workers to help communities build cooperative electric
systems, water and irrigation systems, as well as schools
and community centers (Austin & Betten 1990; Chris-
tenson & Robinson, 1989).
These three historical streams of community inter-
vention form the primary background for the development
of community practice social work, sometimes referred to
as community organization, and the variety of intervention
methods that have emerged since the 1940s (Carter, 1958;
Dunham, 1940; Lurie, 1959; Ross, 1955; Sieder, 1956).
More recent trends in community practice have built
upon these historical streams, further elaborating theories,
models of practice, and research methods. Murray Ross
had a major role in defining professional social work roles
in community organization and the development of
theory-based literature. He envisioned community work in
a range of environments from education, to agriculture, to
community development (Ross, 1955, 1958). In 1968, Jack
Rothman developed a construct of "Three Models of
Community Organization," which he called locality
development, social planning, and social action. Rothman
continued an elaboration of his conceptualization over
time to illustrate the mixing and phasing of models in
actual practice (Rothman et al., in press). Saul Alinsky
introduced a style of organizing currently continuing
through lAPs grassroots work and leadership training,
building a national network of multiethnic and interfaith
community organizations (Alinsky, 1971; Austin &
Betten, 1990; IAF, 2006).
Community practice in the United States has also
reflected the cultural contexts of different communities at
different times in our history, especially relating to African
American groups (Burwell, 1996;
Carlton-LaNey, 2001; King, 1958), Native Americans
(Hawken, 2007; LaDuke, 2005; Lamar, 1998; Sides,
2006), Asian Americans (Rivera & Erlich, 1998), Hispanic
communities, and labor organizations (La Raza, 2006;
Rivera & Erlich, 1998; United Farm Workers, 2006).
Community intervention methods continue to be
refined through practice research and application of theory
and cultural perspectives, most recently by Brown (2006),
Homan (2008), Netting, Kettner, and McMurtry (2007),
and Rubin and Rubin (2007). Weil's edited collection, The
Handbook of Community Practice (2005a), and the Journal of
Community Practice sponsored by the Association of
Community Organization and Social Administration
(ACOSA www.acosa. org) also provide extensive
literature on community practice.
In 1995, Weil and Gamble presented eight models of
community practice in the 19th edition of the Encyclopedia
of Social Work. These models provide a way for community
practitioners to compare and analyze "ideal" intervention
types for community problemsolving approaches (Weber,
1970). The models have been refined and updated in this
entry with the introduction of (Table 1), three major
practice "lenses" that will quite likely permeate
community practice throughout the world in the coming
decades: the effects of globalization; the increase in
multicultural societies as the result of forced and voluntary
migrations; and the struggles to expand human rights,
especially rights for women and girls.
How SOCIAL WORK HAS CONTRIBUTED TO
COMMUNITY PRACTICE INTERVENTIONS Commu-
nity practice interventions within social work incorporate
two important qualifications: practice within a value-base
founded in social justice and human rights and the use of
theory and outcome research to inform practice
interventions. Working from within an identified value
base and being able to benefit from a large body of
literature, research, and practice knowledge are among the
major contributions social work has made to community
practice.
The social work values that guide community practice
come from the National Association of Social Work's Code
of Ethics (1999) and the international Ethics in Social Work,
Statement of Principles (2004). Social workers are directed
(in section 6) toward "ethical responsibilities to the
broader society," and the promotion 'Of "social,
economic, political and cultural values' and institutions
that are compatible with the realization of social
justice."
Community practice social workers make use of a wide
range of literature, from social work, social
8. COMMUNITY: PRACTICE INTERVENTIONS 357

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science, and related disciplines in their education and
practice. Research relating to the outcomes of com-
munity practice interventions is of particular importance
(Coulton & Chow, 1995; Ohmer & Korr, 2006; Padilla &
Sherraden, 2005; Raheim, Noponen, & Alter, 2005).
Eight Models of
Community Practice Intervention
Eight current models of community practice interven tion
are described below, including several refinements .
from their presentation in 1995 (see Table1). For each
model, we define the purpose, identify the theory and
conceptual understandings that ground it, provide one
intervention example, and discuss the primary roles
\ .
played by practitioners working within the model.
Models are ideal types (Weber, 1970) that provide an
opportunity to analyze the goals, actions, and outcomes
that help the community practitioner compare purposes
of the intervention and the roles and skills needed (for
example, when facilitation is more effective than lead-
ership, or when advocacy is more effective than nego-
tiation). In real settings, models are likely to be mixed or
blended, and often communities and practitioners will
progress from one model type to another as the
organization develops and local circumstances change.
NEIGHBORHOOD AND COMMUNITY
ORGANIZING This model relates to organizing that
takes place in a geographic location where face-to-face
encounters occur regularly as part of community
interaction. The organizing effort has a triple focus: to
develop and stimulate leadership and organizations; to
strengthen the organizational capacity by improving
leadership and organizational functioning; and to help
organizations take successful actions toward the
improvement of quality-oflife conditions and
opportunities for their communities.
This intervention model is grounded in personal and
interpersonal, group, empowerment, organizational,
community, globalization, and social change theories.
The most useful concepts from these theory streams for
intervention are related to group process, facilitation,
dialogue, principles of democratic participation, power
and empowerment, social capital, and collective
efficacy (Bandura, 1986; Castelloe & Gamble, 2005;
Couto & Guthrie, 1999; Freire, 1970; Kaner, Lind,
Toldi, Fisk, & Berger, 1996; Putnam, 1993; Rubin &
Rubin, 2007; Toseland & Rivas, 2005; VeneKlasen &
Miller, 2002).
Examples of neighborhood and community organiz-
ing are found in all parts of the world. In San Martin,
Guatemala, World Neighbors' staff assisted Cakchiquel
Indian communities in improving their yields of com
COMMUNITY: PRAcnCE
INTERVENTIONS 359
and beans by 300% in the first seven years of the project .
They built upon local knowledge and experience (for
example, indigenous knowledge of soil, climate,
cultural preferences, local skills, and economic
conditions), and then added external coaching (for
example, methods to enrich soil, prevent erosion, and
facilitating dialogue to build organizations in the
Cakchiquel communities) in a process called "assisted
seif-reliance." Through continued collaboration, the
community members also established a lending
cooperative, co-constructed earthquake-proof
dwellings, and improved their overall. nutrition and
health outcomes (Krishna & Bunch, 1997).
The roles of community practice workers in neigh-
borhood and community organization are primarily
those of organizer, facilitator, educator, coach, trainer,
and bridge-builder. The community practice worker
assists community members to become advocates for
their communities and to take actions on their own
behalf. In this kind of intervention, the social worker is
not the leader and takes care to develop and facilitate
leadership within the community, rather than usurp
leadership positions.
Organizations and resources such as the Center for
Participatory Change (2007), The Highlander Center
(2006), PICO National Network (2007), and the Uni-
versity of Kansas "Community Tool Box" (2006) can
help in conceptualizing the work of neighborhood and
community organizing.
ORGANIZING FUNCTIONAL COMMUNITIES
Functional communities are composed of people who
have specific common interests but do not necessarily
live in proximity. Their interests are in taking actions
toward social justice goals and expanding education and
information about their issues to the wider public. These
are people organizing, for example, to respond to needs
of children with developmental disabilities, to support
people with HIV/AlDS, to prevent trafficking of women
and children for slavery and sexual exploitation, to
establish services for homeless teens, or to eliminate
landmines. Because they are not necessarily located in
proximity to one another, newsletters, telephone, and
Internet sources are primary means of communication,
augmented at times by conferences or direct
opportunities to engage in action together.
This practice intervention model is grounded in
theories dealing with social change, groups and
empowerment, organizational development,
interorganizational work (for example, networks and
coalitions), and communications. Necessary conceptual
understandings include a deep understanding of the
social justice and human rights aspects of the particular
issue, strategies for advocacy (including education),
360 CoMMUNI1Y: PRAcncE INTERVENTIONS
campaigns for or against a particular issue, collaboration,
contest, direct action, and knowledge of a variety of
communication methods that will be culturally effective
and inclusive (Brager, Specht & Torczyner, 1987; Finn &
Jacobson, 2008; Gutierrez & Lewis, 1998; Homan, 2008;
Rivera & Erlich, 1998; VeneKlasen & Miller, 2002; Weil,
200Sa).
Practice examples are found in local and global settings.
Functional community organizing brings people with
similar interests together so that they may learn from each
other, identify and create useful resources, work to change
problematic policies or practices, and benefit from the
emotional connection shared because of their common
concerns. In many parts of the world, organizing occurs to
identify families of children with special needs. In Easter n
Europe and countries of the former Soviet Union,
organizing families of children with special needs is a
relatively recent activity, as children and adults are
gradually being deinstitutionalizedand community services
are nascent. Romania is of particular interest because of the
policies of the former dictator, Nicolae Ceausescu, which
"required" families to have many children and to
institutionalize their babies and children with special needs
(Johnson, Edwards, & Puwak, 1993; Morrison, 2004).
With the fall of Ceausescu in 1989, people began to learn
about the subhuman conditions for children with
disabilities in the government's poorly staffed orphanages.
Two Romanian sisters, Camelia and Carina Botez, were in
Norway when they saw the television documentary about
the orphanages. Upon return to Onesti, Romania, they
surveyed the community and identified many families who
were struggling with a special needs member. In 1992, the
sisters opened a day center for multiply disabled children.
The center, Binecuvintati copiii (Bless the children), has
the objective to "enhance the lives of children with special
needs" with the ultimate goal that the community should
respond to the children in terms of "full inclusion." An
individualized program is set up to meet the needs of each
child. Social workers do family outreach to the surrounding
villages, and the children engage in many community
programs to affirm their equality as community citizens
(personal communication: Gamble with Botez sisters, May
21, 1997).
The roles that are most important for social workers to
work with functional communities are organizer,
advocate, writer, speaker, and facilitator. As an advo cate,
the social worker is always careful to represent
appropriately the views of those who will benefit from the
organizing effort, and strives to incorporate, without
exploitation, the voices of people who directly experi ence
the condition needing to be "changed.
COMMUNITY SOCIAL, ECONOMIC, AND
SUSTAINABLE DEVELOPMENT The United Nations'
Universal Declaration of Human Rights (1948) describes the
conditions for an adequate livelihood: "... the right to
work .... free choice of employment ... right to equal
pay .....a family existence worthy of human dignity ...... .
right to join trade unions .. right to rest and leisure ....... .
standard of living adequate for the health and well being of
self and family ... education ... and right to freely
participate in the cultural life of the community" (Articles
23-27). This model relates to community intervention that
stimulates the development of in .. come, assets, basic and
continuing education, and social support. We speak of
"livelihoods," rather than work or jobs, because all
communities gain from both the paid and unpaid work of
its members, and all families thrive primarily because of
the nurturing and caring labor provided by its members for
each other. The addition of "sustainable development" in
this model recognizes the impact of the natural
environment on a community's livelihood and the
challenges future generations will encounter for livelihood
development. Having depleted extensive nonrenewable
resources and fouled the soil, water, and air, we now need
to rethink personal and global behaviors, policies and
investments to rescue and sustain the planet and its
inhabitants (Gamble & Hoff, 2005; Gore, 2006).
Theory streams and knowledge that inform this model
are from human development, social and eco nomic
development, sustainable development, poverty
alleviation, social capital, environmental reclamation; a nd
adult education. Necessary conceptual understand ings
include the Human Development Index, the role of gender
in development outcomes, opportunities for "green"
livelihoods (for example, environmentally effi cient
construction, local farmers markets, seed preser vation and
trading, recycling), sustainable community indicators, and
networking and mutualleaming opportunities (Ellerman,
2006; Estes, 1993; Haq, 1995; Hart, 1999; Hawken, 2007 ;
Midgley & Livermore, 2005; Prigoff, 2000; Rubin &
Sherraden, 2005; Shiva, 2005; UNDP's Human
Development Reports from 1990-2007; Uphoff, Esman, &
Krishna, 1998).
Practice examples tend to be geographically local but
must be connected to regional markets, support systems,
education and training opportunities, and resources. A
well-documented international example is the Grameen
Bank in Bangladesh. In 1972, Muhammad Yunus, an
economics professor at Chittagong University, asked poor
women what they needed to improve their economic
condition. They responded that they needed small loans to
increase their income, but they had no collateral and
traditional lenders

charged as much as 10% per day. Yunus surveyed the
village and learned that a $30 loan would enable 42
vendors to get the supplies they needed to expand their
micro-enterprises without having to be constantly indebted
to the moneylenders. Using his own money for the first
loans, Yunus began a grand experiment that today serves
as the model for microlending programs on every
continent. Grameencredit is based on trust rather than
collateral or . legally enforceable contracts. Since its
beginning, the Grameen Bank has disbursed more than
US$4.46 billion and currently has more than 3.8 million
poor borrowers in 46,620 Bangladeshi villages, 96% of
whom are women. The borrowers are organized in small
community groups that provide collective motivation and
support to do well economically
\
and live healthy lives. The repayment rate for these
loans is 98.89%, a better rate than commercial banks
(Grameen Bank, 2006; Yunus, 1997).
The roles useful to a community social worker in this
model include negotiator, bridge-builder, promoter,
planner, educator, manager, and evaluator. The social and
economic development plan for a place will be most
successful if local participants are involved from the
beginning to assess needs and resources, and to identify
goals (Pennell, Noponen, & Weil, 2005). The most useful
participatory engagement methods come from popular
education (Freire, 1970) and participatory appraisal
(Chambers, 1997), summarized by Castelloe and Gamble
(2005).
PROGRAM DEVELOPMENT AND COMMUNITY
LIAISON This model involves the initiation or expansion
of services by an agency or coalition of organizations to
respond to underserved populations. It would address
issues such as the recent increase in h omeless teens and
street children, HIV/AIDS patients and their families, and
food security issues. This model involves collaboration
between social workers, allies, and possible bene ficiaries
from expanded services to engage in the reinvention of
services to meet the existing needs, in cluding advocacy for
prevention and public education.
Theory that informs this intervention model is drawn
from organizational development and management, mu-
tual work with clients and communities, strategic plan-
ning, program development, social justice, and health and
human development. Conceptual understanding important
for social workers in this model will relate to community
assessments, community-based participatory research,
organizational development, and resource generation
(Austin, 2002; Brody, 1993; Bryson, 1990; Finn &
Jacobson, 2008; Gortner, Mahler, & Nicholson, 1987;
Israel, Shulz, Parker, & Becker, 1998; Lauffer, 2005;
Mizrahi & Morrison, 1993).
COMMUNITY: PRACTICE
INTERVENTIONS 361
One practice example, from southeastern Missouri,
started with a clinical visit from a social worker to a
woman who suffered depression after losing her baby. The
visit developed into a full-scale organizing effort to
respond to rural women's mental health needs (Price,
2005). In most communities, but especially in rural
communities, people are supposed to be independent,
strong, and never acknowledge the need for help, espe-
cially for mental health. As the social worker explored
women's needs, local women were reluctant to identify
and name their feelings as "depression." With facili tated
discussion to explore how life could be better with certain
changes, women were able to define their own mental
health needs. Collaborating with the social worker, they
developed a public education campaign called "Mental
Health Is Part of Every Woman's Wellness." The
campaign not only brought needed services for women but
also transformed the region's perspective about mental
health (Price, 2005).
Social workers in this model are expected to engage in
a variety of roles, including spokesperson, planner,
manager/director, proposal writer, trainer, evaluator,
visionary, and boundary-spanner. In addition to.having
significant knowledge of the program area and service
organization/network characteristics (for example, mis-
sions, funding streams, policy strengths and limitations,
leadership strength), the community practitioner must also
develop respectful and co-learner relationships with
constituent population groups. It is especially important
not to treat the constituent groups as victims or passive
bystanders. When constituent or beneficiary groups are
engaged in service planning-.-and later implementation,
advising, and evaluation-the resulting service program has
a much greater chance of actually meeting the service
needs and empowering participants.
SOCIAL PLANNING Planning requires forwardlooking
assessments of population characteristics and needs with
an analysis of the resources and structures necessary to
respond to those needs. Social planning is often done
within a community-wide or regional social planning
organization, but it can also occur within. an agency or
neighborhood, or at a national or internationallevel.
"Social" planning cannot effectively occur in isolation, as
it is related to economic and environmental conditions, as
well as available infrastructure and resources. Planning
involves the use of technical skills for assessment, data
analysis, optimal future scenario development, and
evaluation.
At the neighborhood or community level, community
practitioners engage with community members to learn
their perspective on neighborhood conditions,
362 COMMUNITY: PRACTICE INTERVENTIONS
needs, assets, and directions. They share technical skills
with community members and coach them in carrying o~t
assessments, analyses, and community-based plan ning
decisions (Weil, 2005b).
Social planning is grounded in planning and change
theory, as well as theories relating to human develop ment,
participatory planning, and research (Hinsdale, Lewis, &
Waller, 1995; Kretzmann & McKnight", 1993; Rothman,
Erlich, & Tropman, in press; UNDP Human Development
Reports, 1990-2007; Weil, 2005b).
In the Appalachian Mountains of western North
Carolina, an MSW student working for Hospice noted that
an increasing number of the hospice referrals were gay
men who had earlier escaped local stigma regarding their
sexual orientation and, found broader work opportunities
by relocating to large cities. After years in the Northeast or
Midwest, they were returning home to die. Hospice
responded to AIDS patients and their farnilies by helping
them to die with dignity. By the early 1990s, more
effective treatments were available, enabling people with
HIV/AIDS to live much longer with productive lives;
however, local physicians were still referring all patients
living with HIV/AIDS to Hospice. The student realized
that this was not the service these men needed and that new
service planning was necessary. He gathered men living
with HIV/AIDS, hospital and health care providers, human
services staff, and representative citizen groups to talk
about the kind of support that was desirable in this new
reality. A coalition formed to complete needs assessments,
wherein the people with HIV/AIDS conducted the
interviews. This process uncovered a far larger population
needing support services than was previously recognized.
The coalition undertook planning with the constituent
group and presented their proposals to local government
and nonprofit donors. With funding, they opened a new
Support Service Center for people living with HIV /AIDS
and their families (Weil, 2005b, pp. 235-236).
Community. practitioners working in the planning
model can be expected to engage in roles relating to
research (assessments, evaluations, population research,
etc.), proposal writing, communication, planning,
managing, and evaluating. The National Network of
Planning Councils provides examples of social planning at
city and regional levels; social workers are also in valved in
many national social planning efforts related to health
services and prevention, domestic violence, child welfare,
and mental health, among others.
COALITIONS This model brings together organizations
that have a common interest in a social, civic, eco nomic,
environmental, or political concern on a tem porary or
longer-term basis for the purpose of building a
power-base large enough to influence policy decisions,
change conditions, and secure needed resources. Coali-
tions' actions usually include a major public education
campaign to enlarge their ranks and educate the public.
Building a: coalition requires attention to relationships
among the organizations, the relative commitment of each
organization, the comparative competence and resources
of each organization, and their respective contributions
toward the effort (Mizrahi & Rosenthal, 2001).
Theories that inform this work include coalitions,
inter-organizational relations, collaboration, social
change, social movements, power, and empowerment.
Social workers help build coalitions for social justice and
human rights, -and therefore, conceptual understanding of
these value-bases will be important to this work (Finn &
Jacobson, 2008; Mizrahi & Rosenthal, 2001;
Roberts-DefIennaro & Mizrahi, 2005).
While it is sometimes easier to develop and main tain a
coalition in which values, perspectives on needed changes,
and strategies are shared, it is also possible for coalitions
to be built within small communities, bring ing together
geographically close but ideologically distant
organizations to accomplish important social change.
Coalitions can also span the globe, like the International
Baby Food Action Network (IBFAN). In 1977, the U.S.
group Infant Formula Action Coalition (INFAC) started a
campaign to boycott the Swiss manufacturer of the infant
formula, Nestle. The cam paign was based on research in
low-wealth neighborhoods and countries, which showed
higher mortality among infants using commercial formula
in place of breast milk. Use of contaminated water and
dilution of the formula to stretch the supply contributed to
the higher mortality. In addition, unlike mother's milk, the
formula did not contain antibodies to help build babi es'
immune systems to resist certain illnesses. Advertising of
infant formula in hospitals and health clinics made
mothers feel they were depriving their child of
modem-even scientific-benefits if they did not use the
formula. The boycott of Nestle's products and the public
education campaign spread across the globe. The coalition
was instrumental. in persuading the World Health
Assembly to adopt the International Code of Marketing
Breast Milk Substitutes in 1981, which prohibits certain
kinds of advertising and aggressive marketing. IBF AN in
England now coordinates over 200 citizens' groups in 95
countries who monitor the actions of Nestle/Carnation and
other infant formula corporations to prevent free samples
and inappropriate advertising from taking p lace in health
clinics. The boycott was dropped for a period of time to
monitor corporate responsibility, but was resumed in

1988 when monitors found companies were not com-
plying with the Code.
Coalitions require a number of roles to be played by
involved community practice workers. Important roles
include leader, mediator, negotiator, spokesperson,
organizer, and bridge-builder. Understanding
inter-organizational behavior theory, strategies for
social change, and employing empowerment principles
in organization building all relate to effective practice
for workers in this model.
POLITICAL AND SOCIAL ACTION This model is
focused on taking action for social justice by changing
policies, laws, and policy makers: It involves research
that identifies and exposes social, economic, and envir-
onmental injustice, and follows with efforts to engage in
lobbying, class-action lawsuits, testimony, advocacy,
and political campaigns to change oppressive and dam-
aging policies and institutions.
Theories that support this model are derived from
power and empowerment theory, political economy,
participatory democracy, and social change theory.
Conceptual understandings for this model relate to
human rights, social justice, strategy development, pro-
fessional ethics, and advocacy (Couto & Guthrie, 1999;
Hick & McNutt, 2002; IFSW/IASSW Ethics in Social
Work: Statement of Principles, 2004; Jansson, 2007;
United Nations, 1948; VeneKlasen & Miller, 2002).
Examples of this model can be identified in local
settings across the globe, and can be seen in actions that
may have global consequences when successful. In the
most recent U.S. civil rights movement, a variety of
methods were used to change laws that permitted or
even required discrimination against African Ameri-
cans. Direct, nonviolent action was the most widely
used strategy to demonstrate the inhumanity of the
existing laws and practices. In Greensboro, North
Carolina, students organized a sit-in at a lunch counter
where they were customarily denied service. With their
success in integrating Woolworth's, they sparked
actions in other parts of the country to dismantle seg-
regation laws. In Montgomery, Alabama, after the arrest
of Rosa Parks for declining to give up her seat on a
public bus to a white man, African Americans refused to
ride city buses as long as they were prevented from
selecting a seat anywhere on the bus. The bus boycott,
which involved organizing churches, student groups,
and civic groups, lasted over a year, causing enormous
economic harm to the bus system and forcing an
eventual settlement. The Highlander Center in New
Market, Tennessee, began "literacy schools" for African
Americans to overcome the "voting tests" imposed by
many southern states. The
COMMUNITY: PRACTICE
INTERVENTIONS 363
African American Mississippi Freedom Democratic
Party tried to be seated at the Democratic National
Convention in 1964, resulting in a major national
controversy. Though they were unsuccessful in being
seated, the world was made aware of the policies that
kept . them from voting and becoming candidates for
office.
The important roles for social workers engaged in
political and social action are advocate, organizer, re-
searcher, leader, and sometimes candidate. In 2007,
there were 10 members of the National Association of
Social Workers serving in the U.S. Congress. Many
more serve in state and local elected positions. When
Jane Addams found garbage a foot thick over the
cobblestones in the 1890 Chicago slum neighborhoods,
she lobbied for more regular garbage pick-up. When
lobbying failed to achieve the needed results that she
and her neighbors had identified, she campaigned to be
appointed garbage inspector and won. Political and
social action has a long tradition in social work.
MOVEMENTS FOR PROGRESSIVE CHANGE This
model includes activities toirifluence major social
change toward measurable improvements of quality of
life for vulnerable groups and individuals, While social
movements can have goals to prevent positive change for
these groups, our model assumes action toward .
progressive change that will increase opportunities,
human rights, and social justice in accordance with social
work values.
Theories that ground this model draw from social
change, social movement, social transformation, and
collective action theory. Conceptual understandings
that' are useful to social workers involved in social
movement activity relate to ethical practice, collective
efficacy, leadership, coalition building, gender issues,
and a range of strategies for social change (Anderson,
1995; Bandura, 1986; IFSW/IASSW, 2004; Meyer
&Staggenborg, 1996; NASW, 1999; Piven & Cloward,
1977).
An example of a current movement that presents
opportunities for social work involvement is the range
of local-to-global interventions taking place to promote
sustainable development. Estes (1993) describes nine
related movements as the historical antecedents for
sustainable development: environmental/ecological,
antiwar/antinuclear, world order, world dynamics
modeling, green, alternative economics, women's
movement, indigenous peoples, and human rights
movement (pp. 7, 8). All of these local-to-global
movements, which began in the 1960s and continue to
the present, have converged into what Estes (1993)
describes as "successfully uniting widely divergent
theoretical and ideological perspectives into a single
conceptual
364 CoMMUNITY: PRACTICE
INTERVENTIONS
framework" (p.l). For Estes (1993), Richard Falk's
(1972) seven values provide a set of principles that
encompass sustainable development: "unity of humanity
and life on earth, the minimization of violence, the
maintenance of environmental quality, the satisfaction
of minimum world welfare standards, the primacy of
human dignity, the retention of diversity and pluralism,
and universal participation" (p. 12). It is a movement
that has drawn social justice, human rights, and envir-
onmental justice champions from around the globe
(Gore, 1992, 2006; Hawken, 2007; LaDuke, 2005;
Shiva, 2005). This movement offers seven levels of
intervention for social work engagement, beginning
with "individual and group empowerment" through
processes of conscientization, all the way to "world
building," by creating new social, political, economic,
and environmental institutions (Estes, 1993, pp. 16, 17 ).
While social workers may not be the primary leaders
of social movements, the roles they play on many
ditferent levels can be those of advocate, facilitator, and
leader. Whether society is engaged in a movement for
civil rights, women's rights, children's safety, food
security, elimination of sexual and child labor
trafficking, or environmental responsibility and
preservation, we can benefit from the growing body of
interdisciplinary research and documentation to help
move the comrnunities in which we find ourselves
toward progressive social change.
Contexts and Challenges for
Community Practice Interventions
The effects of globalization, the increase in multicultural
societies as the result of forced and voluntary migration,
and the struggles to expand human rights, especially
rights for women and girls, are challenging community
practice intervention processes-organizing, planning,
sustainable development, and progressive change-in the
21st century.
Governments make decisions about global trade
regulations, development assistance, and wars. New
trade rules provide temporary economic benefits for
some communities and eliminate livelihoods in others.
Natural disasters (for example, hurricanes, earthquak es,
and tsunamis) and the global threat of war and war itself
ravages communities, even after state-sponsored hosti-
lities cease (Van Soest, 1997). Making peace has a body
of knowledge easily accessible to proponents of
peaceful strategies for local, regional, national, and
global conflict, but its use requires willing leaders and
facilitators (Elkins, 2006; McConnell & van Gelder,
2003; Moix, Smith, & Staab, 2004).
Communities are increasingly multicultural as pop-
ulation migration makes nearly every country and every
community host to people from different cultures and
ethnicities (UNHCR, 2006). Refugees often flee their
homelands because of ethnic conflicts, natural
disasters, and political oppression. Numerous migrants
also travel to other countries for basic economic
survival. Immigrants from Mexico to the United States,
for example, send approximately $13.3 billion in
remittances annually to their often-destitute families
and communities of origin. Social workers can work to
change the conditions that force migration and can also
engage in working toward integration, mutual
understanding, and inclusion by facilitating dialogue
among different groups and promoting inclusive
economic and social development (Anderson & Carter,
2003; Dessel, Rogge, & Garlington, 2006; Fong &
Furuto, 2001; Gutierrez et al., 2005).
Human rights are a primary concern of social work,
as. outlined in the IFSW /IASSW Ethics in Social Work,
Statement of Principles, and in seven international human
rights declarations and conventions including the
Convention on the Elimination of AU Forms of Discrimination
Against Women and The Convention on the Rights of the
Child. The framers of the Millennium Development
Goals (MDG) agreed that gender equality is a central
focus because "women are agents of development"
(UNDP, 2003, p. 7; United Na~ tions, 2006). Securing
rights for women and girls is a major international
challenge as evidenced by the Gender Empowerment
Measure (GEM) (UNDP, 2003, pp.314-317).
The values and behaviors of community practi-
tioners who engage in organizing, planning, sustainable
development, and progressive change will determine
their ability to be coleamers with members of thecom-
munities in which they work. Coleaming involves set-
ting aside assumptions about the people with whom you
are working and their environments so that you can
learn from their perspectives, in their words, and
through their experiences. Working with community
members and organizations in this way becomes a
collaborative engagement. This process is described by
Finn and Jacobson as "action and accompaniment:' a
rethinking of the roles of social work as "always carried
out in the context of social relationships"
(2008,313-375).
Working within an ethical framework requires
community practice social workers to evaluate their
actions and interventions daily. Along with specific
change goals, practitioners should seek to measure
advances in human rights, increased social capital that
results in open and inclusive community structures,
increased economic opportunity and well-being, and
recovered and protected environments. Community
participant

involvement in reflection on community outcomes
should also be a consistent aspect of community prac tice
evaluation.
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-DOROTHY N. GAMBLE AND MARIE WElL
COMMUNITY,BASED PARTICIPATORY
RESEARCH
ABSTRACT: Community-based participatory research
in social work is a partnership approach to research . and
that involves community members, organizational
representatives, and researchers in all aspects of the
research process. It is community-based in the sense that
the process of social inquiry is informed by and responds to
the experiences and needs of community partners. The
partners contribute their expertise and share responsibilities
and ownership to enhance understanding of issues or
conditions and the social and cultural dynamics of the
community, and to integrate the knowledge gained with
action to improve the well-being
of community members. Various terms have been used to
describe this research, including participatory research,
empowerment research, action research, participatory action
research, collaborative research, and feminist research. With its
focus on knowledge, action, and em- . powerment,
community-based participatory research provides
contemporary social work a change-oriented, value-based
model of knowledge development, a knowledge that comes
from people and community.
KEY WORDS: community-based participatory
research; participatory research; community building;
diversity; knowledge and participation
Introduction
Community-based participatory research (CBPR) is not new to
social work. For over a century, social workers have
endeavored to develop knowledge that can improve programs
and communities and inform social policy. For example,
research on the lives of poor immigrants was closely linked to
community organization and social reform. Studies on the
plight of orphan children on the streets of New York, of
tenement dwellers, and of infants dying in foundling homes
contained integrally woven components of assisting and
advocating for clients, and for advocating social policy at the
national level (Abbott, 1936; Breckinridge, 1931; Lathrop,
1905). Many decades later, the prevailing structure of
professionalization and specialization has separated research
from practice, policy reform, and social change, thereby
limiting efforts of social work to address social problems
comprehensively (Karger, 1983).
Recently, researchers have called for a more com-
prehensive and participatory approach to research and practice
not only in social work but also in other fields such as public
health, community psychology, and education (Fisher & Ball,
2003; Minker & Wallerstein, 2003; Reason & Bradbury,
2001). Although many of the principles and methods of CBPR
are not yet represented in social work research literature, they
represent a growing force within the field.
The fundamental characteristics of CBPR emphasize the
participation, influence, and control of community members
in the process of creating knowledge
change. In any CBPR project, doing research is not a goal
in itself but only a means to achieve the interrelated goals for
all participants: (a) fostering relationships and collaboration
among diverse individuals, organizations, and groups; (b)
creating settings for critical reflections that enable people
from different backgrounds to see themselves in one another;
(c) learning knowledge and skills relevant to the tasks

at hand; and (d) engaging in effective action that wins
victories and builds self-sufficiency (Sohng, 1996 ;
Stoeker, 1999). These principles represent a critical
distinction from the term community-based research, that
emphasizes conducting research in. a community as a
place or setting, in which community members have
only limited involvement, if any, in what is primarily a
researcher-driven enterprise. By comparison, CBPR in-
volves conducting research that recognizes the commu-
nity as a social and cultural entity with shared interests
and concerns (Israel, 2000). The inclusion of the term
participatory here more clearly aligns CBPR with its roots
in participatory research movements (Brown, 1985;
Fals-Borda, 1979; Gaventa, .1988; Hall, 1981; Lather ,
1986; Maguire, 1987; Park, Brydon-Miller, Hall, &
Jackson, 1993).
Key Principles of Community -Based
. Participatory Research
Community-based participatory research is a process
rather than a specific methodology. Common themes are
that the CBPR approach
1. Recognizes community as a unit of coUective and
individual identity. Membership in a family,
friendship network, ethnic group, and geographic
neighborhood, for example, are socially
constructed dimensions of identity (Hatch, Moss,
Saran, Presley-Cantrell, & Mallory, 1993; Steuart,
1993). Community is characterized by a sense of
identification and emotional connection to other
members, common symbols systems, shared
values and norms, mutual influence, common
interests, and commitment to meeting shared needs
(Fellin, 1995; Israel, 2000; National Librar y of
Medicine, http://www.ncbLnlm.nih.gov/books).
CBPR attempts to identify and to work with
existing communities, and to strengthen the sense
of community through collective engagement.
2. Builds on strengths and resources within the cornmu-
nity. CBPR seeks to identify and build on
strengths, resources, and relationships that exist
within communities of identity, and seeks to
support or expand social structures and social
processes that contribute to the ability of
community members to work together to
improve the lives of people (Agency for
Healthcare Research and Quality,
http://www.ahrq.gov/about/cbpr ; DePoy,
Hartman, & Haslett, 1999; Unger, 2004).
3. Facilitates <:ollaborative, reciprocal involvement of all
partners in all phases of the research. These partnerships
focus on issues and concerns identified by
community members, and create processes that
enable all parties to participate and share influence
in the research and associated change efforts
COMMUNIIT-BASED PARTICIPATORY
REsEARCH 369
(Community-Campus Partnership for Health,
http://www.depts.washington.edu/ccph/commbas.
html).
4. Integrates knowledge and action. The lack of critical
information, documentation, and evidence about
how community power works places people at a
disadvantage in their efforts to change their cir-
cumstances. The generation of this type of
knowledge is central to strengthening the
community's problem- solving capacity.
However, the link be tween the knowledge
creation and action must be explicit. That link is
most strong when those who conduct the
research take action themselves within their
organizations or communities. The power t o
name the conditions of injustice, oppres sion, and
domination must be accompanied by the power
to act whereby research and action become fully
integrated.
5. Promotes a coleaming and empowering process that
attends to social inequalities. CBPR is a colearning
and empowering process that facilitates the
reciprocal transfer of knowledge, skills,
capacity, and power (Baldwin, 2001; Stoeker ,
1999). This process involves giving explicit
attention to the knowledge of community
members, and an emphasis on s haring
information, decision- making power, resources,
and support among members of the partnership.
6. links to local capacity and infrastructure building.
There is always the danger that the openings for
community participation will simply mirror the
status quo, and serve to strengthen and reinforce
more dominant voices. Filling such spaces "from
below" requires local capacity-organizations that
are empowered and aware, and who have the abil-
ity to use the participation to negotiate and sustain
their involvement overtime (Gaventa & Cornwall,
2001; Stoeker, 1999; International Institute for
Sustainable Development, http://www.iisd.org/
casl/CASLGuide/ParticipatoryApproach.htm).
Because sustainable change usually depends on the
empowerment of people and organizations, the
research activities should support the community
infrastructure building and leadership.
The question inevitably arises as to which research
method best serves CBPR. Community-based partici-
patory research is not defined by the research tech-
niques. It can employ the whole gamut of research tools
and analytic techniques such as quantitative and
qualitative methodologies, historical reconstruction,
action research, among other research methods. It is
therefore up to each team to select the best mix of
methods to suit their chosen research site or topic.
370 COMMUNITI~BASED PARTICIPATORY
REsEARCH
Not every single method or technique to be used must be
participatory; but the overall ethos of the research must be so,
and the question of the ultimate ownership of knowledge is an
important consideration.
Conclusion
The term community~based participatory research encom-
passes several virtues and vices. As with all methods, its
merits vary with the research situation and the practitioner. At
its best, the process can be liberating, empowering, and
educative, a collegial relationship that brings local
communities into the policy debate, validating their
knowledge. At its worst, it can degenerate into a process of
co-option oflocal communities into an external agenda, or an
exploitative series of empty rituals
" ties. AmericanJoumal of Preventive Medicine, 9(Suppl.), 27-31.
imposing fresh burdens on the community's time and
energy and service primarily to legitimize the credentials of
the implementing agency as "grassroots oriented" (Cooke &
Kothari, 2001). While participation must be integral to the
research process, it must be understood and practiced as a
genuine process. What is most important is that researchers, as
socially and environmentally responsible persons, make
ethical choices in the use of their tools. The ultimate test for
CBPR is whether the research benefits the community and
promotes socially just, culturally diverse community building.
CBPR has evolved through the 1990s and into the 21st
century as it has been applied to various fields such as
community development and service learning projects.
Recently practitioners have moved away from the word
"research" because of its extractive connotations and abstract
meaning to many community members. New names are being
used, such as "participatory action learning, and
"participatory action development."
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-SUNG S. L. SOHNG
J

COMMUNITY BUILDING
ABSTRACT: This article will cover the history,
theory, and empirical and practical knowledge of
community building. Social networks and social
ties contribute to informal social control, while
neighborhood behavior is key to the development
and maintenance of social cohesion. The author will
provide a discussion of the relationships among
these elements and their relation ships to other
community resources, such as civic par ticipation
and collective action. The author will discuss the
empirical work regarding the effective ways to pro-
duce and promote community building in poor
neighborhoods, as well as the practical knowledge
that suggest its importance.,
KEY WORDS: community building; social capital;
social network; community development;
community organization; settlement houses
Introduction
A growing number of community organizing and devel-
opment professionals working to bring about fundamental
and sustainable neighborhood improvement in targeted
low-income areas see themselves as community builders
(Anderson & Milligan, 2006). In social work practice,
community building represents a strengthsbased rather
than a needs-based approach to community work
(Saleeby, 2003) Community building is . grounded in
the feminist notion of "power to" and "power with"
rather than the more masculine concept
of "power over" frequently encountered in traditional
community organizing (French, 1986)
Definitions
The multiplicity of community building definitions can be
attributed to the heterogeneity of community building.
Minkler (2005) defines community building as "an
orientation to community that is strength based rather than
need based and stresses the identification, nurturing and
celebration of community assets" (p. 4). Chaskin, Brown,
Venkatesh, and Vidal (2001) define community building as
"actions to strengthen the capacity of communities to
identify priorities and opportunities and to foster and
sustain positive neighborhood change" (p. 1).
Some authors use the terms "community building,"
"community empowerment," "community capacity," and
"community revitalization" interchangeably. Although the
term "community building" has many different meanings,
all revolve around the notion of tapping into the social
infrastructure of the community as a key step in catalyzing
collective action, building
COMMUNITY BUILDING 371
collaborative relationships among key community
members, and building community capacity. The col-
lective action is intended to address common concerns of
individuals who live within a geographical area, such as a
neighborhood, or with a common interest. Perhaps
community building has different meanings because the
essence of it lies in conceptualizing and relating to
community as an inclusive, complex, and dynamic system;
Such an orientation to practice envisions community as a
multidimensional system, involving people and
organizations at all levels engaged in relationships with
one another, which are manifested in both actions and
consciousness. Community building seeks to engage with
these multiple dimensions of community, recognizing the
range of perspectives and relationships that exist and
integrating diverse strategies and all its participants in
order to operate as community (Anderson & Milligan,
2006; Chaskin, Brown, Venkatesh, Vidal, 2001).
The terms "comprehensive community building" and
"place-based strategies" are associated with community
building and refer to approaches to improve the wellbeing
of people in a particular neighborhood or geographically
defined area. The term community building is also used
within the housing and community development fields to
describe work on the nonphysical aspects of community
development (for example, education, child care, family
supports, among others), as compared with the physical
aspects of development, such as building mixed income or
affordable housing. Furthermore, the term is used by
governments at the international level to describe the work
of helping a community move toward a particular ideology,
as in nation-building at the community level (Anderson &
Milligan, 2006; Ewalt, Freeman & Poole, 2001).
Comprehensive community initiatives are most explicit
about their reliance and intent to rebuild the social fabric of
a particular community. Aspen Institute Roundtable on
Comprehensive Community Initiatives offers a definition
of comprehensive community initiatives that captures
community building:
"Comprehensive Community Initiatives (CCIs) as
neighborhood efforts that seek improved outcomes for
individuals and families as well as improvements in
neighborhood conditions by working comprehensively
across social, economic, and physical sectors. Additionally
CCls operate on the principle that community
building-s--fher is, strengthening institutional capacity at
the neighborhood (or community or reservation) level,
enhancing social capital and personal networks, and
developing leadership-is a necessary aspect of the process
of transforming distressed neighborhoods" (see
aspeninstituteroundtable.org).
372 COMMUNITY BUILDING
What is clear from all these definitions is that com-
munity building always involves a set of power relation-
ships inside and outside of a community; individuals, such
as social workers, and organizations from outside of the
community come into the place to do work or to support the
work of community residents. Sometimes these people are
invited into the community by its members, but many
times, they are not. Whether community building includes
people internal or external to the community, power
relationships play out in terms of resources, governance
decisions, decisions about tactics and strategies, leadership
opportunities, criteria for judging success, and in many
other ways.
Community builders seek to enhance the sense of
connectedness. The formation of social networks com-
prises what has become to be known as social capital,
revived by Putnam (1993). Tremendous interest has de-
veloped through Putnam's work in applying the concept of
social capital to research concerned with community
well-being, democracy, economic and community devel-
opment, social work, public health and political and civic
participation in the U.S. and beyond. Social capital has
been widely used in the literature to describe the nexus of
social factors that define a neighborhood's social life and
fabric in order to achieve particular outcomes, such as
higher levels of employment, improvement of school
achievement, etc. (Anderson & Milligan, 2006).
History
Community building is not new to social work practice at
the community, regional, national, and international level.
Social work practice in communities has been central for
over a century. The idea of social work trying to make
things better in a place, and the pulling together of
resources inside and outside of that place, can be traced
back as far as the work of settlement houses of the late 19th
century and the wide range of services they offered to
residents in low-income neighborhoods (Ewalt, Freeman,
& Poole, 2001). Social policy of the 1960s saw a
resurgence of interest in the approach. In 1961 the Ford
Foundation sponsored the Gray Areas projects, explicitly
emphasizing and promoting institutional reform through
the coordination of activities and a comprehensive view of
needs. Through this effort, as well as Mobilization for
Youth, the President's Council on Juvenile Delinquency,
and the Office of Economic Opportunity, President
Johnson's administration developed first the Community
Action Programs and in the late 1960s, Model Cities were
created. These were designed to foster community
leadership, along with the local identification of abroad set
of neighborhood needs and the development of strategies
to address them (Naperstak & Dooley, 1997).
The revitalization of the community building practice
approach responds to several weaknesses of past efforts to
improve the lives of children, families and communities.
According to Naparstek and Dooley (1997), recent efforts
were stimulated by the 1987 work of William Julius
Wilson, which discussed the internal dynamics of poverty
in Chicago neighborhoods, suggesting that persistent
poverty-the. kind of poverty that endures over many years
and can be passed from one generation to another-is
concentrated in geographic areas. Wilson theorized that
neighborhood poverty is marked by a deteriorated social
infrastructure: absent networks of faith institutions, banks,
businesses, neighborhood centers, and families. The link
between social networks and persistent poverty was
established; conversely, Wilson's work supported the
notion that strong community was important if its residents
are to get out of poverty (Anderson & Milligan, 2006;
Naperstak & Dooley, 1997; Wilson, 1991).
Scholars assert that community building emerged out
of several forces in the 1980s and 1990s that helped to spur
the reemergence of comprehensive community initiatives.
First, rapid changes in governmental policy partially
dismantled the social safety net, diminished funding for
affordable housing, and child welfare (Ewalt, Freeman &
Poole, 2001; Naparstek & Dooley, 1997). With a shift
toward privatization of services from the public sector to
the for-profit and nonprofit sectors beginning with Ronald
Reagan, the reliance upon the private sector led to a
purchase-of-service relationship among the sectors and the
emergence of competitive contracting. These have had
adverse impacts on community-based social service
organizations. Third, there has been a movement fro~
public and philanthropic funders for multidisciplinary.
collaboration and multisector relationships among
organizations, as well as partnerships for the provision and
problem-solving (Cohen & Phillips, 2001).
These factors, along with the response to Wilson's
work, have led human service agencies and foundations to
begin to explore new ways of thinking about and working
on neighborhood poverty. Into the 21st century,
community organizers and developers, and social workers
are working with residents to combat poor school
performance, crime, and substance abuse, create small
businesses, improve the child welfare system, and learn
trades through apprenticeship programs (Anderson &
Milligan, 2006).
Demographics
RESEARCH THEORY The practice of community
building begins with an investment in the neighbor-
hood's social infrastructure. The development of
healthy

and vibrant social interactions in the community produce
the conditions thought to be necessary for more formalized
participation in community institutions, such as
organizations and associations. The attitudes, behaviors,
and relationships that develop as a result of social
interactions within the neighborhood are increas ingly seen
as the elements of a community's social capital.
Integral to the discussion of community building is the
concept of community itself. Community is often thought
of in terms of geography; however, in community
building, communities may be based instead on shared
interests or characteristics, such as ethnic ity, sexual
orientation, occupation, etc, Communities have been
defined as functional units that meet basic needs for
sustenance, units of patterned social interaction, and
symbolic units of collective identity, as well as political
units: people coming together to act politically to make
changes. Clearly, a social work practitioner's view of the
appropriate domains and functions of community is
important to community building processes (Chaskin,
2003; Fellin, 200l). Theoretical work in the area of
community building remains somewhat underdeveloped,
at the same time that the practice has be come increasingly
an important complement to more traditional notions
around community organization.
EVALUATION RESEARCH Evaluation research in
community building has been challenged by several
factors. First, the interventions have been highly
complex, seeking to work across sectors (social, eco- :
nomic, physical) and levels (individual, organizational,
community) simultaneously. Second, they are highly
evolutionary with objectives changing over time.
Third, they are highly contextual, seeking to be
responsive to local circumstances and to have an effect
on the entire community-which is itself an open sys tem
subject to multiple influences beyond any single
intervention-making the counterfactual extremely
difficult. Finally, some of the kinds of outcomes they
seek are imprecisely defined and present a host of
measurement problems (Chaskin, 2003, Kubisch ,
Fulbright-Anderson, & Connell, 1998).
Given these complexities, evaluation research in
community building has mainly focused on a combina tion
of program-level investigations of outputs (such as
housing built or jobs created), community-level inves-
tigations of outcomes as indicated by available data (such
as median family income, or high school dropout rates),
and an understanding the implementation issues for CCls
through a focus on decision-making processes,
organizational arrangements, and the dynamics of par-
ticipation, funding, and technical support (Anderson &
COMMUNITY BUILDING 373
Milligan, 2006; Chaskin, 2003; Coulton & Hollister, 1998;
Rossi, 1999).
Important to community building efforts is the im-
portance of the community's social fabric as both an
outcome and a mediating variable that influences how an d
to what extent community chance can occur. Community
building interventions seek to work through the social
infrastructure of communities in order to achieve
particular outcomes such as improvement in school
achievement, higher levels of employment, etc. Evalua tion
research is almost nonexistent on the extent to which
changes in the community's social fabric are affected
(Chaskin, 2003). The analysis of the evaluation of
community building by Chaskin (2003) shows how social
work evaluation research might move to-
ward filling this void. .
BEST PRACTICES There are an array of opportunities for
social work in community development to effec tively
assist capacity-building in communities. Best practices
dictate an active involvement of the members of the
community (Ewalt, Freeman, & Poole, 2001; Milligan,
Coulton, York, & Register, 1998). Social workers have
taken on the role of change agent t o mobilize
community residents through locality devel opment,
planning, and action (Ewalt, Freeman, & Poole, 2001).
Best practice requires greater emphasis on encouraging
community residents to participate and assume
leadership roles in all phases of commu nity
capacity-building. This role of community builder is
sometimes characterized as a shift from community
organizing by professionals to community building
directed primarily by community residents. In commu-
nity building, community residents have the opportu-
nities and supports to: (a) define community interests;
(b) define existing assets; (c) define assets that are
needed; (4) develop governance capacity; (5) strength-
en helping processes that are shared responsibilities;
(6) identify and strengthen local leadership capabil ities;
(7) improve participation of all populations in the
community, and (8) reform oppressive structures that
undermine community health. Community resi dents
define the help needed in the physical environ ment,
housing, economic opportunity, safety, education, and
health care. Community building as an approach
supports the interrelationship or comprehensive nature
of these needs or issues instead of a categorical
approach to each (Anderson & Milligan, 2006;
Chaskin, 2003).
Best practice for professional social workers who work
as community builders involves a rethinking of how they
understand and approach communities. It requires social
workers to think differently about the breadth of services
provided, empowerment of natural
374 CoMMUNITY BUILDING
systems, style of collaboration and partnership, and a
redefinition of social work roles and functions.
In social work practice, community building often refers
to building relationships and resources in low-income
communities. The strategies involve many different groups
and individuals from a variety of sectors and roles, including
community residents, staff and managers of community
organizations and institutions, technical assistance providers,
data managers and evaluators, government officials and
foundation Boards of Directors, management and staff.
Additionally, each community builder may have multiple
roles. For instance, a community resident may be a designer,
planner, leader, implementer, beneficiary, and employee, all at
the same time. Social workers may have multiple roles as
managers, technical assistance providers, and evaluators.
FUTURE TRENDS Future trends in practice will be affected by
the key characteristics of community building: the merger of
"place-based" strategies, such as buildings, as well as "people
based" strategies in social concerns. Community building
brings together professionals from different fields, such as
public administration, social work, residential and real-estate
developers, and bankers-who rarely train or work together and
know little about it each other-with community residents.
Many social work professionals who have learned to practice
with a top-down, expert-client practice stance with com-
munity residents will need to include a range of collaborative
as well as empowerment tools that appreciates and
incorporates local indigenous knowledge.
Future trends will involve the continued involvement of
current practices such as interdisciplinary practice in
community building practice. Community building requires
practitioners to "work across multiple systems si-
multaneously." Community building helps people who have
fallen on hard times by surrounding them with the supportive
community that it takes ro nurture and sustain them.
Community building has significant implications for social
work's ability to work to improve the delivery and quality of
human services, strengthen community organization,
stimulate economic development, and improve the quality of
life of residents while affecting physical improvements.
In the future, there will be continued learning in how to
use community building to build healthy communities. There
is a growing need to expand theory and knowledge to advance
community building practice. Community building will
require more elaborate and complex research designs and
intensive continuing education. Local knowledge is an
importance value of
practice but is still difficult to use and implement. Building
strong organization is essential to community building
practice but difficult to accomplish in a way that supports
neighborhood development and capacity. This individual and
organizational capacity can be threatened by the effects of
privatization and devolution, resulting in the closing of small
community based organizations. Professional social workers
must be knowledgeable about practice and knowledge
development in order to effectively partner with community
residents and other community stakeholders both today and
future years to come.
REFERENCES
Anderson, A. A., & Milligan, S. (2006). Social capital and
community building. In K. Fulbright-Anderson & A. Patricia
(Eds.), Aspen roundtable on community change. Community
change: Theories, practice and evidence. Washington, DC:
Aspen Institute.
Chaskin, R., Brown, P., Venkatesh, S., & Vidal, A. (2001)
Building community capacity. Hawthorne, NY: Aldine de
Gruyter.
Chaskin, R. ]. (2003). The evaluation of "community building":
Measuring the social effects of communitybased practice. In
A. Maluccio, T. Vachiato, & C. Canali (Eds.), Assessing
outcornes in child and family services: Comparative design and
policy issues. (pp. 28-47). New York:
Aldine de Gruyter.
Cohen, C. S., & Phillip, M. H. (200l) Building community:
Principles for social work practice in housing settings. In P. L.
Ewalt, E. Freeman, & D. Poole (Eds.), Community building:
Renewal, weU-being, and shared responsibility. Washington,
DC: National Association of Social Workers.
Coulton, c., & Hollister, R. (1998). Measuring comprehensive
community initiative outcomes using data available for
small areas. In K. Fulbright-Anderson, A. C. Kubisch, &<!'].
P. Connell (Eds.), New approaches to evaluating community
initiatives, Vol. 2: Theory, measurement, and analysis (pp.
165-220). Washington, DC: Aspen Institute.
Ewalt, P. L., Freeman, E., & Poole, D. (Ed.) .. (200l) Community
building: Renewal, well-being, and shared responsibility.
Washington, DC: National Association of Social Workers.
Fellin, P. A. (200l). The community and the social worker (3rd
ed.). Itasca, IL: F.E. Peacock.
French, M. (1986). Beyond power: On women, men and morals.
London: Abacus.
Kubisch, A., Fulbright-Anderson, K., & Connell, J. P. (1998).
Evaluating community initiatives: A progress. report. In K.
Fulbright-Anderson, A. C. Kubisch, & ]. P. Connell (Eds.),
New approaches to evaluating community initiatives, Vol. 2:
Theory, measurement, and analysis (pp. 1-13). Washington,
DC: Aspen Institute.
Milligan, S., Coulton, C, York, P., & Register, R. (1998).
Implementing a theory of change evaluation in the Cleveland
Community Building Initiative: A case study. In
 COMMUNITY DEVELOPMENT 375

K. Fulbright-Anderson, A. C. Kubisch & J. P. Connell Concepts and Definitions

(Eds.), New approaches to evaluating community initiatives, Community development is a planned approach to improving
Vol. 2: Theory, measurement, and analysis (pp. 45-86). the standard of living and general well-being of people. Two
Washington, DC: Aspen Institute. notions formulate the concept of community development.
Minkler, M. (Ed.). (2005) Community organizing and community The concept of development connotes positive change in
building in health. New Brunswick, NJ: Rutgers University
living conditions through planned improvement. As a planned
Press.
activity, development is a conscious and deliberate process of
Naperstek, A., & Dooley, D. (1997). Community building. In
R. L. Edwards et al. (Eds.), Encyclopedia of social work, analyzing the situation, articulating goals and objectives, and
(19th ed., 1997 supplement, pp. 77-89). Washington, DC: implementing programs to achieve them. The concept of
NASW Press. community connotes a collection of people who interact and
Putnam, R. (1993). Making democracy work: Civic traditions in share common characteristics such as interest, identification,
modern Italy. Cambridge, MA: Harvard University Press. culture, activities, or spatial location. There are two notions of
Rubin, H. J., & Rubin, I. (2005) The practice of community community: geographical or spatial-based community and
Organizing. In M. Weil (Ed.), The handbook of community relational or interest-based community (Gusfield, 1975).
practice (pp. 189-203)~ Thousand Oaks, CA: Sage Spatial-based community refers to people who reside in
Publications.
particular locations identified by marked physical boundaries,
Rossi, P. (1999). Evaluating community development
as is the case with a village, neighborhood, town, or city.
programs:
Problems and prospects. In R. F. Ferguson & W. T. Interest-based community refers to people who share a
Dickens (Eds.), Urban Problems and Community Development common identity through social values, socioeconomic status,
(pp. 521-567). Washington, DC: Brookings Institution Press. ethnicity, and so on. Interest-based and spatialbased
Saleeby, D. (2003). Strengths-Based Practice. In R. L. communities coincide when different groups of people, such
Edwards et al. (Eds.), Encyclopedia of social work (19th ed., as low-income families, elderly people, women, or business
2003 supplement, pp. 150-162). Washington, DC: NASW people, reside in particular spatial locations.
Press. Campfens (1997) identifies some mutually reinforcing
Wilson, W. J. (1991). Public policy research and the truly core values and principles of community development:
disadvantaged. In C: Jencks & P. Peterson (Eds.), The urban
community participation, community integration, selfhelp
underclass (pp. 460-482). Washington,
-SHARONDC:
Brookings
E. MILLIGAN development, and community capacity building. Community
Institution. ,-
participation is the active involvement of residents in
community development activities. Based on the concept of
COMMUNITY DEVELOPMENT human rights, people have a right to participate in making
decisions that impact their lives. Resident participation is also
a means of creating community capacity to implement
ABSTRACT: Community development is a pla nned
development programs. Community integration involves
approach to improving the standard of living and
creating social inclusion by promoting harmonious social
well-being of disadvantaged populations in the United
relationships among diverse groups of residents. Since a
States and internationally. An overview of community
community consists of individuals and groups with competing
development is provided. The objectives of commu-
interests and limited resources, efforts are needed to reduce
nity development include economic development and
conflicts, exploitation, and the marginalization of some groups
community empowerment, based on principles of
by others. Selfhelp development refers to promoting
community participation, self- help, integration,
community self-reliance. As much as possible, a community
community organizing, and capacity building.
should rely on its human, material, and financial resources as
Community building and asset-based approaches are
the basis for improving living conditions. External resources
recent trends and innovations. Community
available through partnerships with government, private
development is interdisciplinary, with models and
institutions, and organizations are used to supplement the
methods derived from disciplines such as social work
community's own resources. Community capacity building
and urban planning. The entry examines linkages
refers to the creation of , conditions for the community to rely
between community development and macro practice,
on the capacity and initiative of its residents in
including an increase in employment oppor tunities for
social workers.
KEY WORDS: capacity building; community; interdis-
ciplinary; macro social work; community
development; participatory approaches; . assets;
poverty reduction; international; urban planning
376 CoMMUNITY DEVELOPMENT
defining problems and planning and executing courses of
action, so as to reduce dependence on external professional
interventions. The objective is to develop community
confidence, competence, and local leadership. Social
empowerment is the process of helping socially excluded or
oppressed individuals and groups to increase their
personal, interpersonal, socioeconomic, and political
strength. Community development practice often includes
helping individuals and groups access social and economic
resources.
The objectives of community development practice vary
according to the needs of the, local community and the
interest of the organization or community group initiating
the development activities. However, since community
development is usually practiced in communities with high
rates of poverty and vulnerable persons, efforts typically
focus on economic development and community
empowerment. Economic deve- lopment is used to improve
material well-being by creating economic. opportunities
through investment in education, business enterprises, and
other employment and income-generating activities; The
assumption is that the lack of employment opportunities is a
major causeof poverty and vulnerability. Commu-: nity
empowerment includes community organizing and
community building to create community-driven de-
velopment, whereby residents can direct or control
development as opposed to control by external institutions
or experts. In this context, broad-based resident
participation builds local leadership, provides essential
skills and knowledge for undertaking development
activities, and strengthens community institutions and
organizations.
HISTORY OF COMMUNITY DEVELOPMENT POLICY administered by communitybased nonprofit organizations
Community development is practiced by both public and
private institutions and organizations. At the international
level, community development is historically associated
with the development activities of European colonial
administrations and the activities of the United Nations
Organization in Africa and other de- . veloping countries
during the colonial and postcolonial periods, respectively.
During the 1950s, the British colonial administration in
Africa adopted community development as a strategy for
mobilizing and raising the standard of living in rural areas. It schools of social work, and there was a rapid expansion in
included basic social and economic services, literacy
programs, health centers, road infrastructure, and
agricultural cooperatives (Midgley, 1994). Later, most
independent African countries adopted community
development as an approach to improving the standard of
living in urban and rural communities. The principles of
community participation and community self reliance are
widely used
strategies for providing basic community services,such as
schools, health centers, roads, storm water drains, and solid
waste disposal. In some cases, however, community
participation and self reliance add an additional burden to
women and other vulnerable groups by requiring them to
participate in development efforts so as to gain food and
other essential community services. Also, some
governments in developing countries have been criticized
for strategically using these principles to avoid the
responsibility of providing services to lowincome
communities. This situation exacerbates poverty and
perpetuates class inequalities and exploitation (Chisanga,
2003).
Community development in the United States has
historical roots in the late 19th and early 20th centuries
through the settlement house movement. Early efforts
organized residents and developed new programs. and
institutions such as playgrounds, day care, skills training,
literacy, and improved housing for huge numbers of
immigrants and other poor families. During the mid 20th
century, community development emerged as a
full-fledged interdisciplinary field of practice involving
professions such as social work, urban planning, public
administration, and public health. In the 1960s, community
development and citizen and client participation was a
response to poverty (and inequality) among America's
minority ethnic groups through the federal War on Poverty,
which institutionalized community development practice.
Title II of the Economic Opportunity Act of 1964, which
created Community Action Programs, was among its
policy reforms. Based on a principle called "maximum
feasible participation." residents in low-income
communities participated in the design and implementation
of poverty eradication programs. Programs were
or public organizations in localities with high
concentrations of poverty, and the federal government
provided much of the funding. Another important policy
was the establishment of the Department of Housing and
Urban Development in 1965, which promoted improved
housing, educational services, and employment
opportunities (Halpern, 1995). At this juncture in the
history of community development policy, community
organization was adopted as a method of practice by U.S.
the number of schools offering new macro social work
concentrations. However, social work education focused
mainly on the community organizing and social planning
components of community development, leaving the niche
of economic development to urban planning and public
administration.
Two major policies in community development in the
1970s included the Housing Act of 1974 and the

Community Reinvestment Act of 1977. The Housing Act
created Community Development Block Grants (CDBG),
which provided fundsfor community development and
services. The Community Reinvestment Act of 1977 was
designed to stop discrimination or redlining in the
provision of housing and related cornmunity services by
requiring banks to serve all neighborhoods in the area in
which they are chartered (Naparstek & Dooley, 1997).
Community development practice in the United States
was further institutionalized with the establishment of
community development corporations (CDCs). They were
first established in 1960s through the federal. Special
Impact Program's and Model Cities. Initiated by racial
minority activists with strong ties to economically
depressed urban and rural communities, these nonprofit
corporations introduced a comprehensive approach that
included both social and cornmunity economic
development. The emphasis was on community
empowerment through increased. resident participation
and housing services, the establishment of small and
medium size retail and manufacturing enterprises,
workforce development, and job training. By the 1980s
and 1990s, however, most CDCs had redefined their
missions to abandon community empower, ment, thereby
concentrating on the narrower economic objective of
providing nonprofit housing (Stoutland, 2000). This was
partly a response to the declining financial base of federal
funds for poverty programs, and the rise to prominence of
neoconservative political and economic thought. In 1993,
federal legislation authorized Empowerment Zones and
Enterprise Cornmunity programs for locality-based
community develop, ment in both rural and urban areas.
The primary objective of these programs was the creation
of employment opportunities in economically distressed
areas (Hyman, 1998; Wang & Van Loo, 1998).
More recently, however, CDCs have responded to the
need to build community capacity in more cornprehensive
ways, including resource, organizational, programmatic,
network, and political components (Glickman & Servon,
1998). This change is accompanied by a growing
recognition of the value of and need for progressive
community organizing in fostering positive outcomes in
community development (Murphy & Cunningham, 2003;
Rubin & Rubin, 2007). Case ex, amples of CDCs also point
to community organizing as an essential component of
sustainability in urban com, munity development (Capraro,
2004).
Beginning in the 1990s, "community building" became
the term used to identify a movement toward more
comprehensive community development. Community
building puts equal emphasis on community
COMMUNITY DEvELOPMENT
377
empowerment and economic development objectives
through its "people-based, place-based" principles that
include the following seven themes: (a) focused around
specific improvement initiatives in a manner that re-
inforces values and builds social and human capital; (b)
community-driven with broad resident involvement; (c)
comprehensive, strategic, and entrepreneurial; (d)
asset-based: (e) tailored to neighborhood scale and
conditions; (f) collaboratively linked to the broader society
to strengthen community institutions and enhance outside
opportunities for residents; and (g) consciously changing
institutional barriers and racism (Kingsley, McNeely, &
Gibson, 2000).
Funding for community development has been en-
hanced by the establishment of Community Development
Financial Institutions (CDFIs) through the Reigle
Community Development and Regulatory Improvement
Act of 1994, which provided CDFI funds through the
Department of the Treasury. These nonprofit institutions
mobilize and provide credit for investment and financial
services to CDCs in economically de, pressed urban and
rural communities. Much of the investment is in the form
of mortgage loans for housing, commercial, and industrial
development (Lehn, Rubin, & Zielenbach, 2004). For
example, Shore Bank is a nationally known CDFI in
financing neighborhood revitalization in Chicago (Taub,
1994).
MODELS OF PRACTICE Because of varied professional
disciplines, different organizational affiliations, and
diverse global and local contexts, community development
practice is fragmented. The growing recognition that
community problems are recalcitrant, multifaceted, and
complex has led to the practical use of knowledge from a
mixture of academic and professional disciplines to help
resolve them. Some models are tied closely to specific
disciplines; others are widely used across disciplinary
boundaries. In practice, stakeholders from various
professions come together in what may be called
interdisciplinary community development, although a clear
definition of this type of community development is not
well developed (Johnson Butterfield & Korazim-Korosy,
i007). To accentuate the complexity as well as the synergy
that takes place when diverse stakeholders come together
in community development practice, Korazim-Korosv et
a1. (2007) liken interdisciplinary community development
to a kaleidoscope, flower, or a salad bowl. Amid this
complexity of disciplines and approaches, it is helpful to
think of the broad field of community development as a
tree and the various models and methods of development as
its branches.
Urban and regional planning is a professional discipline
concerned with orderly and efficient use of land,
378 COMMUNIIT DEVELOPMENT
resources, and infrastructure to promote economic de,
velopment and the health and well-being of urban and
rural communities. With an eye. toward urban renewal
or revitalization, community development is one of the
specialized fields of training and practice for urban and
regional planners. Urban planning is involved in the
development of affordable housing and its related social
services and physical infrastructure, commercial and
economic development, public transportation, and in the
promotion of increased participation of local residents in
community development activities. Another important
area is downtown, neighborhood, and main street
development (Feehan & Feit, 2006). Historically, the
model used by urban and regional planners differed
from the social planning approach advanced by social
work, the latter being concerned with the design of
social and human service programs that have direct
bearing on the well-being of individuals, groups, and
communities. In current practice, urban and regional
planners have incorporated social planning concepts
into their disciplinary practice,
Rural development is an interdisciplinary field of
practice that focuses on the well-being of people who
reside in rural communities, including villages and small
towns. The strategy is to increase economic prod, uctivity
and growth through agricultural and nonagricultural
sectors. This is achieved by undertaking multisector
activities, including investment in social and economic
infrastructure services such as education and health,
transportation, electrification, and communication
technology, It also involves the mobilization and
empowerment of rural populations through in, creased
participation and ownership of development (Moseley,
2003). Overall, the emphasis of rural development is
poverty alleviation (Bradshaw, 2006).
Sodal development is a process of planned change
designed to promote people's welfare within the context of
a comprehensive process of economic development
(Midgley, 1995). It is an approach to development that puts
equal emphasis on the provision of social welfare services
and econ~mic well-being as opposed to emphasizing one
or the other. It considers these two dirnensions of
development as complementary in nature, and thereby
promotes the redistribution of wealth. Invest, ment in social
welfare services such as education and health is considered
as redistributive and essential for economic development
through human resource development. Similarly,
promoting economic development is a means of promoting
social welfare through the erearion of employment
opportunities.
Sustainable development promotes economic devel-
opment and the use of natural resources in a responsible
way to ensure long, term availability of the same.
Sustainable development assumes that continuous irn-
provement in living standards is possible when
community members are mobilized to become active
participants in the design and implementation of
development. Participation is a means of developing the
capacity of community members to control and own its
local resources. Control and ownership by external
agencies does not ensure continuous improvement in the
living standards because development activities are
usually not sustainable after the development agency
disengages from the community (Elliot, 2006).
Asset-based community development is a participa-
tory approach to community capacity building, which
builds initiatives on the skills, talents, and capabilities of
individuals and local associations within impoverished
communities. Only after assets from "inside the
community" are inventoried and mobilized, do
communities call upon outside institutions to fill the
gaps in community development efforts (Kretzmann &
McKnight, 1993). ABCD is similar to Participatory
Rural Appraisal, Asset Building, and Community
Development sponsored by the Ford Foundation,
Community Driven Development utilized by the World
Bank, and Rights Based Approaches that are
extensively used throughout the developing world
(O'Leary, n.d.)
University-community partnerships are based on the idea
that universities and communities both stand to benefit
from mutual relationships. The community benefits from
the university's technical resources; the university benefits
by linking theoretical knowledge to practice through
community problem-solving processes. Such partnerships.
have a long history in the United States (Fisher, Fabricant,
& Simmons, 2004), which includes a growing trend in
university-community partnerships and campus civic
engagement. During the 1990s, Community Outreach
Partnership Center programs provided new financial
incentives for universities and communities. As
universities extended their teaching, research, and service
learning to the community, they became vital partners
through collaboration in community problem solving and
development (Maurrasse, 2001; Soska & Johnson
Butterfield, 2004).
Methods of Practice
As an approach to planned change, community devel-
opment uses a variety of methods and techniques.
Among the widely used methods and techniques include
community assets assessment, empowerment-based ap-
proaches, multisector partnerships and collaborative
networks, community organizing, organizational devel-
opment, and leadership development (Chaskin, Brown,
Venkatesh, & Vidal, 2001). Most of these methods and
techniques derive from the various 'disciplinary

approaches and development models. Community de-
velopment's primary objective of improving the living
standard of marginalized groups is compatible with the
historical mission of social work.
During its formative stages in the late 19th century
and early 20th centuries, social work practice paid
attention primarily to poverty and the needs of special
populations such as children and women. Today, the
majority of social work practitioners focus on men tal
health, . direct practice, and individual problems in
human development. Nonetheless, poverty, social jus-
tice, and inequality still occupy a center stage in the
profession, by infusion within all forms of professional
social work practice. The operational principles and
methods of community {development practice, such as
participation and empowerment and a systems . ap-
proach to problem-solving, are especially compatible
with macro social work practice and consistent with
widely used models of practice with communities, such
as locality development, social action, and social plan-
ning models of community organization (Rothman,
1999). The Association for Community Organization
and Social Administration (ACOSA), and its spon-
sorship of the Journal of Community Practice, works to
strengthen community organization and development,
planning, and social change. The ACOSA Web site
http://www.acosa.org provides resources for
community development and other forms of macro
social work practice. Another organization, the
International Association for Community Development
(IACD) , fosters the idea of interdisciplinary community
development through international conferences and the
Community Development JournaL
Future Trends and Innovations
New trends and innovations in community development
emphasize social networks; technological advances, and
asset accumulation. Social capital is the use of networks
of relationships, social institutions, and traditional
practice wisdom for community problem solving (Diaz,
Drumm, Ramfrez-johnson, & Oidjarv, 2002).
Geographical information systems are computerbased
mapping models used to assess causes and patterns of
community problems, as well as social, economic, and
environmental impacts of community development
(Faruque, Susan, Theresa, & Magnum, 2003). Family-
based community development Is a new approach that
i~cludes the use of housing as a productive family asset
for gardens and home-based urban and rural busi nesses
(Kordesh, 2006). Community gardens are a poverty
alleviation strategy by the urban poor in the United
States, as is the case with the poor peasants in cities and
villages in developing countries. The model is related to
.. ::.::.,..;;,
..
CoMMUNITY DEvELOPMENT
379
efforts to develop entrepreneurship capacity as effective
strategy for poverty reduction. In particular, innovative
methods emphasize various types of financial strategies
for helping poor persons accumulate assets (Green &
Haines, 2001), including the Grameen Bank (Bornstein,
1997; Pickering & Mushinski, 2001), Time Dollars
(Cahn, 2000), microcredit and credit unions (Bhatt &
Tang, 2001; Friedman, 2001), community development
financial institutions (Molseed, 2006), microenterprise
(Sherraden, Sanders, & Sherraden, 2004), and Individual
Development Accounts (Sherraden, 1991).
Opportunities
The interdisciplinary nature of community develop ment
contributes to the richness of its models and methods of
practice, which hail from geography, public policy and
administration, social work, education, public health and
so on. In fact, most community devel opers do not come
from a professional social work, community
development, or community organizing background but
seem to "discover" the field by finding themselves
working in it (Brophy & Shabecoff, 2001).
Although there is an historic linkage between com-
munity development and social work, United States
schools of social work are not at the forefront of pre-
paring students for community development practice,
nor is the profession providing leadership in training for
community development practice. It may be true. But,
the focus of the entry is on the U. S. experience, and we
cannot comment on the situation in other countries
throughout the world where the context and the educa-
tional systems may be very different. In recent years,
there has been a decline in the numbef of schools
offering specializations in macro social work.
According to Fisher and Karger (1997), some reasons
include limited employment opportunities due to
declining government funding for community
organization activities, and a perception that
compensation is inadequate. The reality, however, is the
increasing status of community development in the
United States, with job opportunities ranging from
$35,000 to more than $100,000-most of which are being
filled by people with training backgrounds in sociology,
public and business administration, psychology,
education, and urban planning (Brophy & Shabecoff,
200l). Perhaps, a major underlying factor for the lack of
social workers in community development is their
inadequate training in community development per se.
Since internships often lead to jobs, this problem is
compounded by the failure of schools of social work to
seek out social workers in community development to
serve as supervisors for students in field placement.
Another cause of too few social workers in community
380 CoMMUNITY DEvELOPMENT
development is the lack of information about the diverse
range of employment opportunities. If social work
graduates are unaware of opportunities in the field of
community development, and likewise the transferability
of their skills to jobs in community development, they
simply may not or will not apply for such positions.
There are many international development organi-
zations that provide opportunities for careers and funding
for projects in community development. This includes
bilateral organizations such as United States Agency for
International Development (USAID), and multilateral
organizations such as the agencies of the United Nations,
including UNICEF, UNDP, and UNHCR that are actively
involved in poverty alleviation in developing countries,
Private international development organizations, such as
Care. International, Oxfam, Christian Children's Fund,
World Vision, and InterAction also engage in community
development projects around the world.
Community development has evolved into a com-
petitive interdisciplinary field practiced in a variety of
social and economic sectors, including downtown and
neighborhood development, affordable housing, social
entrepreneurship, workforce development, financial man-
agement, among others. At local, regional, and national
levels, employment opportunities are being generated by
private nonprofit organizations, whose primary focus is on
community development.
The challenge facing social workers is how to take
advantage of the expansion of community development,
and the opportunities to contribute their knowledge, skills,
and core values. To become employed in the field of
community development may mean applying for jobs that
do not list a social work degree among those sought by
employers. Nonetheless, employment in community
development by social workers lends itself to the
profession's expansion into the field of community
development.
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-ALICE K. JOHNSON
BUTTERFIELD AND BENSON
CHISANGA
COMMUNITY ECONOMIC DEVELOPMENT
ABSTRACT: Community economic development (CED) is an
integrated approach to development aimed at building wealth,
capabilities, and empowerment in low-income and
low-wealth communities. Nonprofit organizations partner
with public and for-profit interests to develop social and
economic investment strategies in households and
communities. Social workers in CED engage in
interdisciplinary work and play various roles, including
community organizing, leadership development, program
development, social service management, and policy
advocacy. To achieve large and
382 . CoMMUNITY EcoNOMIC DEVELOPMENT
sustainable success, CED requires solidarity with and
investment in poor communities by society as a whole.
KEY WORDS: community development; asset
building; social development; economic
development; social capital
Community economic development (CED) is an inte-
grated approach to development that aims to build
wealth, capabilities, and empowerment in low-income
and low-wealth communities (Midgley, 1995). CED
addresses structural inequality through community en-
gagement. and interventions that promote social and
economic development and communities (Rubin &
Sherraden, 2004; Sherraden & Ninacs, 1998).
\
CED has roots in the work of early settlement houses
and mutual aid societies, and was influenced by civil
rights movements of the 20th century and advances in
international community development (Halpern, 1995;
Midgley, 1995). Persistent disinvestment, discrim-
ination, neglect, and exclusion convinced leaders that
development would have to be actively organized and
promoted from within communities. Nonprofit
organizations took the lead, with for-profit and pub, lie
partners, in developing housing, businesses, em-
ployment, . and social services. In the United States,
aided by federal policies and programs, such as the War
on Poverty programs in the mid,1960sand the 1977
Community Reinvestment Act, early sue cesses
included modest increases in ownership among the poor
and minorities (Halpern, 1995; Immergluck, 2004).
(Although CED strategies are used in cornmunity
development around the world, the focus here is on the
United States because of space considerations.)
Beginning in the 1980s, changes in domestic econo-
mies driven by globalization, and growing inequality
exacerbated by funding cutbacks, contributed to chal-
lenges faced by poor communities (Fontan, Hamel,
Morin, & Shragge, 2003; Massey & Denton, 1993;
Sassen, 1998; Venkatesh, 2006; Wilson, 1996). In re-
sponse, CED practitioners also adopted intermediary
roles, directing resources and technical assistance to
poor communities and attempting to reverse the flow of
capital out of communities (Ferguson & Stoutland,
1999; Carr & Tong, 2002; Murphy & Cunningham,
2003). Today, CED benefits from growing interest and
innovations in community practice (Weil, 2004).
Theories and Models
CED attempts to "humanize" capitalism by buffering
the effects of the market through regulation, subven tion,
and innovation. Some argue that CED organizations are
not in a position to make structural changes
required to reverse neighborhood decline (Stoecker,
1997), while others suggest that CED represents a
"model for communities to regain a measure of control
over capital and balance its use for private and public
purposes" (Halpern, 1995, p. 142).
One premise of CED is the importance of building
financial and tangible wealth. In this sense, CED aims to
help reverse a historical legacy of oppression, discri-
mination, and public policies that have denied, discour-
aged, and appropriated wealth from poor and minority
communities (Butler, 1991; Gordon Nembhard &
Chiteji, 2006; Oliver & Shapiro, 1995). When policies
and structures are in place, the poor can save and
accumulate assets (Schreiner & Sherraden, 2007), which
may result in a range of positive effects, includ ing
economic stability, stimulation of other assets, hope for
the future, intergenerational well-beingvand in creased
social and political influence (Page-Adams &
Sherraden, 1997; Sherraden, 1991).
Another premise of CED is the importance of build-
ing social capital, the bonds of solidarity and trust
among people that increases access to resources. So cial
capital is a form of capital interchangeable with
financial and human capital (Portes & Mooney, 2002).
As social capital increases through CED, community
residents may be better prepared to realize and control
capital for community benefit, and to build capacity for
subsequent development (DeFilippis, 2001; Woolc ock,
1998).
To achieve broad-based economic reform
that benefits low-income and low- wealth
communities, CED. includes grassroots
organizing, legal advocacy, and
coalition-building (Cummings, 2002; Rubin &
Rubin, 2007). In these ways, CED may
challenge an unfettered free market, aiming for
development through social and economic
investment and economic justice (Midgley &
Livermore, 2006). CED Strategies
Historically, strategies began with housing develop'
ment, but expanded to include microfinance, commer-
cial and industrial development, social services, and job
creation, training, and placement (Ferguson & Dickens,
1999; Murphy & Cunningham, 2003). Strategies are
often combined and used to leverage public and private
investment.
Affordable housing strategies for rental, owner ship,
and co-ownership increase household assets, pro vide
construction and other jobs, and contribute to family and
neighborhood stability. Housing development can
reverse economic deterioration, increase the local tax
base, and improve community safety and local pride.
Some communities adopt land trusts,

historic districts, housing trust funds, and environmen. tal
clean up.
Business development takes several forms, such as
business clusters and incubators, microenterprises, and
social enterprises, providing goods and services to the local
community and a larger tax base (Balkin, 1989; Sherraden,
Sanders, & Sherraden, 2004). Further, business
development may increase local ownership, employment,
and economic and social investments by local
entrepreneurs, as well as safety and community pride.
Employment programs focus on job skills, helping
people locate jobs and find means of transportation,
developing career paths, retaining employed residents, and
combating discrimination (Dickens, 1999). Some CEO
programs focus on training, employees for commu-
nity-based businesses and social services.
Financial services include savings, insurance, capital,
credit, and financial education. At the household level,
matched savings programs, such as individual development
accounts, support home ownership and repair, tax
assistance, education, business development, and other
social investments in low-income and lowwealth
communities (Sherraden, 1991). At the . community level,
programs support asset retention through anti-predatory
lending campaigns and regulatory initiatives, community
development through collective remittances, and local
financing through private market-driven locally controlled
community development finance institutions [Benjamin,
Rubin, & Zielenbach, 2004; Caskey, 1994; Goldring, 2004;
Squires, 2004). Finally, CEO strategies often also include
development of accessible and accountable
community-based human services, such as health care, day
care, recreational, and social services.
Types of CED Organizations
CEO organizations may be for profit, public or nonprofit
organizations whose missions address community eco-
nomic and social development. However, nonprofit
organizations form the backbone of CEO work in poor
communities. Projects may be owned by CEO organiza-
tions wholly, in a cooperative, or in partnership with
private and public interests. As partnerships form and
spawn new organizations, the boundaries across forprofit,
nonprofit, and government become murky. This blurring
has contributed to growth of social enterprises and the
so-called "social economy" (Light, 2006).
Social action groups, neighborhood associations, co-
operatives, human service organizations, and other types of
community organizations engage in CEO, but community
development corporations (CDCs) are explicitly devoted to
CEO (Rubin, 2000; Vidal, 1992). CDCs bring together
local residents and leaders (along
CoMMUNITY EcoNOMIC DEvELOPMENT 383
with representatives of business and the public sector) and
community development professionals to engage in
planning and implementation. The organizations
themselves employ people with diverse training and
background, including community residents and leaders,
housing specialists, financial experts, business developers,
and social service professionals. Although CEO engages
local residents, evidence on community control is mixed,
suggesting that while the community may have voice, the
poorest tend to be less wellrepresented than the more
powerful, including professionals and business
stakeholders (Stoutland, 1999).
Finance for CEO organizations comes from public
(both direct funding and tax benefits), private, and
nonprofit sources, as well as individual donations. In-
termediary organizations often act as brokers and also
provide financial and technical assistance. Additional
support for CEO. comes from community development
financial institutions, such as community development
credit unions, community development funds and banks,
and community foundations (Murphy & Cunningham,
2003).
CED Potential and Challenges for
Sustained Development
CEO uses an array of social investment strategies that
build community capacity, encouraging communities to
address current challenges and create sustainable resources
for future development (Nussbaum, 2002). Poor
communities possess actual and potential strengths that are
a basis for development (Kretzmann & McKnight, 1993).
Although CEO initiatives have achieved noteworthy
success in generating innovations and contributing to local
development, CEO programs are frequently fragile, small,
and vulnerable. Public and private resources are often
lacking for CEO in poor communities, while wealthier
communities benefit from an array of public and private
investments, such as grants, credit, tax subsidies,
infrastructure outlays, arid services. CEO, as a community
development approach, h unable to solve the core issues of
poverty and exclusion on its own, the origins of which lie
in forces well beyond the borders of poor communities
(Halpern, 1995;
. Stoecker, 1997).
Thus, a social and economic justice perspective
demands more than CEO. For CEO to achieve large and
sustainable successes, resource distribution will be
essential (Barr, 2005 a, 2005b; Sherraden, 1991) This
includes tangible resources (for example, assets, infra-
structure, social assistance), as well as intangible resources
(for example, social status and civil, property, and political
rights) that form the basis for economic
384 CoMMUNITY EcoNOMIC DEVELOPMENT
strength and political agency. The success of CED requires a
vision of solidarity and investment in poor communities.
Roles of Social Work
Social workers bring to CED valuable knowledge about how to
work with poor communities. They are effective in building
cultural competence and community participation, and they
have essential skills in organizing, . leadership development,
direct practice, social service management, policy advocacy,
and research (Rubin & Rubin, 2007; Weil, 2004). The
interdisciplinary focus of CED also requires that social workers
develop skills in areas that are not always part of the social
work curriculum, including resource;. development, financial
education and management, consumer law, tax policy, and
urban planning (Rubin & Sherraden, 2004). looking ahead,
social workers have the opportunity and potential to play key
leadership roles in CED, a growing and vital area of
community practice and development.
Acknowledgments
The author is grateful to Herbert Rubin, Ann Chisholm, Toi
Strong, and Bonnie Stanton who made helpful suggestions.
[See also Citizen Participation; Community: Overview; Kretzmann, J. P., & McKnight, J. L. (1993). Building communities
Community: Practice Intervention; Community Building;
Community Development; Community Organization;
Contexts/Settings: Interorganizational Contexts; Social Light, P. (2006). Reshaping social entrepreneurship. Stanford
Capital.]
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Defilippis, J. (2001). The myth of social capital in community
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Dickens, W. T. (1999). Rebuilding urban labor markets:
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Ferguson, R. F., & Dickens, W. T. (Eds.). (1999). Urban problems
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Ferguson, R. F., & Stoutland, S. E. (1999). Reconceiving the
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Dickens (Eds.), Urban problems and community development (pp.
33-68). Washington, DC: Brookings.
Fontan.]. M., Hamel, P., Morin, R., &Shragge, E. (2003). The
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Arbor: University of Michigan Press.
Halpern, R. (1995). Rebuilding the inner city: A history of neigh-
borhood initiatives to address poverty in the United States. New
York: Columbia University Press.
Immergluck, D. (2004). Credit to the community: Community
reinvestment and fair lending policy in the United States.
Armonk, NY: M.E. Sharpe.
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 COMMUNITY NEEDS ASSESSMENT 385

Developments in an emerging field (pp, 303-329). New York: cities, and regions have been affected by the external forces of
Russell Sage Foundation. economic globalization with its transnational flow of capital,
Rubin, H. j. (2000). Renewing hope within neighborhoods of outsourcing of jobs, and shifting demographics of
despair: The community-based development model. Albany: immigration and refugee resettlement. Second, as Kretzmann
State University of New York Press. and McKnight made clear in 1993, assessing only needs is not
Rubin, H. j., & Rubin, I. S. (2007). Community organizing and
enough; it results in an incomplete picture of a community. An
developmend4th ed.). Boston: Allyn & Bacon.
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Rubin; H. j., & Sherraden, M. S. (2004). Community eco-
nomic and social development. In M. Weil (Ed.), The strengths so that a community can know how to use its assets
handbook of community practice (pp. 475-493). Thousand to shore up its deficits. Third, local, national, and international
Oaks, CA: Sage. community building endeavors by nonprofit organizations
Sassen, S. (1998). Globalization and its discontents. New York: have introduced the concept of assets-building into the
The New Press. community practice domain. The purpose is to increase the
Schreiner, M., & Sherraden, M. (2007). Can the poor save? social capital and social capacity of communities in the long
Savings and asset accumulation in individual development ac- term through the empowerment of local residents via decent
counts. New Brunswick: Transacti~n Publisher. schools and effective community-level social networks and
Sherraden, M. (1991). Assets and the poor: A new American institutions.
welfare policy. Armonk, NY: M.E. Sharpe.
Sherraden, M. S., & Ninacs, W. A. (1998). Community eco-
nomic development and social work. Binghamton, NY:
Haworth.
Sherraden, M. S., Sanders, C. K. & Sherraden, M. (2004). KEY WORDS: needs assessment; assets assessment;
Kitchen capitalism: Microenterprise in poor households. Albany: community assessment; community
State University of New York Press.
Squires, G. D. (Ed.). (2004). Why the poor pay more: How to stop It is important for social work practitioners to conceptualize
predatory lending. Westport, CT: Greenwood. the wholeness of rapidly changing communities wherein
Stoecker, R. (1997). The community development corporation problems and unmet needs are identified and carefully
modelof urban redevelopment: A critique and an appraised, relative to existing strengths and assets. This
alternative. Journal of Urban Affairs, 19, 1-23.
approach offers a wider range of
Stoutland, S. (1999). Community development corporations:
. evidence-a balanced framework-e--from which to base
Mission, strategy, and accomplishments. In R. F. Ferguson
& W. T. Dickens (Eds.), Urban problems and community practice decisions and help create innovative solutions. The
development (pp. 193-240). Washington, DC: Brookings. purpose of this entry is to focus on locality- specific,
Venkatesh, S. A. (2006). Off the books: The underground economy geographically bounded communities, and to conceptualize
of the urban poor. Cambridge, MA: Harvard University the new strengths-based community assessment framework
Press. and integrate into it the most salient elements from traditional,
Vidal, A. (1992). Rebuilding communities: A national study of problemfocused approaches.
urban community development corporations. New school for
social research, community development research center.
Weil, M. (Ed.). (2004). The handbook of community practice. The Five Principles of Assessment
Thousand Oaks, CA: Sage. The following principles guide the conduct of a community
Wilson, W. j. (1996). When work disappears: The world of the new
assessment. They reflect a combination of those used in
urban poor. New York: Vintage.
traditional needs assessments that still hold (Tropman, 1995),
Woolcock, M. (1998). Social capital and economic develop-
with those derived from the community building movement.
ment: Toward a theoretical synthesis and policy
framework. Theory and Society, 27(2), 151-208. 1. Value participation from diverse constituencies-
Multiple voices need to be included in a community
assessment, particularly the perspectives and
-MARGARET SHERRARD SHERRADEN experiences of those who are perceived to be excluded
or disadvantaged. It must be recognized that
multi-constituencies will quite likely create discord, as
COMMUNITY NEEDS ASSESSMENT the larger the number and diversity of groups
participating, the more conflict is likely. This is balanced
ABSTRACT: Current approaches to community needs by organizing and managing the interface among
assessments should reflect the changing nature of participants to make constructive use of diverse
communities themselves and new thinking relative to perspectives (Brown, 1986).
their assessment. First, geographically bounded
communities,
386 CoMMUNITY NEEosAssESSMENT
2. Use multiple methods-Both quantitative and
qualitative methods are needed to balance the
strengths and limitations of each.
3. Encourage civic participation and technical
elements-Participation is encouraged in the design of
technical elements (research questions, surveys,
selection of indicators, focus groups, and public
meetings), the collection and analysis of data, and
formulating solutions, when indicated. What are the
needs? According to whom? What
. already works? What does not?
4. Keep the assessment realistic-Community stake-
holders want usable knowledge as evidence for local
decision-making and community improvement.
Large, overly scholarly assessments may never get
implemented. .
5. Value asset-building--Identify and appraise evi-
dence of asset-building activities. These initiatives
(individual development accounts,
micro-enterprises, community banks, locally
owned businesses) are intended to increase the
individual-level and collective assets of a
community as financial capital flows into, not out
of, the neighborhood. The goal is to empower
residents and strengthen the community through
local control of resources.
New Areas of Assessment
The use of a community building framework provides
new areas for community assessment.
PARTNERSHIPS AND COLLABORATIONS The goal of
building social capacity and healthy communities
has brought together people who cooperate to
achieve common purposes, from diverse disciplines
and domains. Identification and appraisal of such
partnerships can help to analyze the "horizontal
patterns" or linkages among community- based
organizations, initia tives, and institutions. That is,
are local entities known to one another? Are they
partnering together, and with what effect?
PUBLIC AND PRIVATE INVESTMENT Government
programs as well as large private philanthropies have
invested revitalization resources in many distressed
urban and rural communities. What has been the
effect of these "vertical links" on local
community-based organizations and res idents? In
what ways has the target community been
strengthened? Which needs have been met or
ameliorated, and which remain unmet?
LARGE SYSTEMS Community building intends to
change social institutions such as public schools,
police departments, and child welfare bureaucracies .so
they are more responsive to residents and consumers in
their localities. What evidence is there of systems
change?
INTEGRA TED COMMUNITY DEVELOPMENT COR.
PORATIONS (CDCs) The traditional role of CDCs as
housing and retail devel opers for financial gain has
shifted to include a social commitment to provide
service, in addition to economic development. Some
examples include family support, workforce
development, housing counseling, financial literacy,
and individual development a ccounts (IDAs). The
shift reflects the realization among CDCs that
investment in the built environment alone will not
reduce neighborhood pov erty. Any strategy must
include both place-based and people- based
interventions.
CAPACITY OF NONPROFITCOMMUNITyBASED
ORGANIZATIONS (CBOs) Unmet needs may be a
reflection of the resources available to residents in a
given low-income community. A community may be
resource-rich or resource-poor. The presence, loca-
tion, and financial stability of nonprofit CBOs are
resources known to strengthen communities. Exam-
ples of nonprofit CBOs include settlement houses,
health clinics, resident associations, recreation cen-
ters, legal aid offices, and child and family centers.
To what extent are these civil society organizations
increasing or decreasing in numbers, size, and
organizational capacity?
Approaches to Assessment
The purpose of an assessment, the research questions
posed, and methods selected, may be influenced by who
the sponsor is and what its goals are. Irrespective of that
political reality, the study should be carefully designed
using a problem-solving approach with a clear objective,
conducted in a systematic way, and in accordance with
the NASW Code of Ethics. Six steps are recommended:
(1) review the evidence, (2) assess local knowledge, (3)
select methods, (4) conduct studies, (5) process and
study the data, (6) report findings (Meenaghan,
Gibbons, & McNutt, 2005).
Some salient factors bear on the assessment process.
First, social workers are encouraged to engage in evi-
dence-based practice (Mulroy, 2007). Therefore look for
theories of change as guideposts in community studies.
What have previous studies found? Track the evidence. An
annotated bibliography is useful to summarize findings.
Established and emerging theories can be used in addition
to related research findings to help guide
J

the development of each new assessment of needs and
assets.
Second, clearly specify the units of analysis to be
studied, such as a newcomer population, a bounded
geographic area served by a senior center, city-wide CDCs,
or some combination of units.
Third, use new technologies such as geographic in-
formation systems (GIS) with which social workers can
map and analyze census and other data, to enhance the
depth and substance of traditional methodologies. Tra-
ditional methods may include community indicators,
surveys, or community processes. Recent practicedriven
studies identify the following indicators as building blocks
for strong communities: (a) healthy families and children,
(b) thriving neighborhoods, (c) living-wage jobs, and (d)
viable economies (http://www.pew,partner
ships.org/newdirections.) Surveys may be used to collect
administrative data on rates of school drop out, teen
pregnancy, or child abuse and neglect, for ex~ ample.
These data and related indicators such as afford, able
housing, public transportation, diversity, arts and culture,
and safety are now tracked through city-based affiliates of
the National Neighborhood Indicators Partnership
(http://www2.urban.org/nnip/whatsnew.html).
Community processes include community visioning of an
ideal future, using the Charette model and traditional uses
of community impressions (key informants) and public
forums.
Fourth, residents and agency personnel increasingly
want to participate in the collection of data and also want
the findings reported back to them, not just to the funder.
Principles of participatory action research can help achieve
these expectations (Brown, 1986).
Trends and Future Directions
The recent trends and future direction of community
assessment point to the study of both needs and assets. This
wider lens invokes more comprehensive studies than those
on need alone, emphasizing the value of . using several
methods. The result provides a more cornplete
understanding of the community, its limitations and its
future possibilities. A participatory approach acknowledges
and values local knowledge from multi, ple constituencies.
Social Work Roles
The role of social work therefore shifts from the top' down
expert planner or researcher to bottom, up partner who uses
assessment knowledge to work cooperatively with a
myriad of involved community workers who may be
doctors, nurses, lawyers, developers, educators, small
business owners, planners, politicians, interested par, ties,
or residents.
COMMUNITY ORGANIZATION 387
REFERENCES
Brown, L. D. (1986). Participatory research and community
planning. In B. Checkoway (Ed.), Strategic perspectives on
planning practice (pp, 123-137). Lexington, MA: Lexington
Books.
Kretzmann, j., & Mcknight, j. (1993). Building community from the
inside out: A path toward finding and mobilizing a community's
assets. Evanston, IL: Institute for Policy Research.
Meenaghan, T., Gibbons, W. E., & McNutt, j. (2005). Generalist
practice in larger settings (2nd ed.) Chicago: Lyceum Books.
Mulroy, E. (2007). University community partnerships that
promote evidence-based macro practice. Journal of
evidence,based social work.
Tropman, J. (1995). Community. needs assessment. In R. L.
Edwards (Editor-in-Chief), Encyclopedia of soda/work. (19th
ed., pp. 563-569) Washington, DC: NASW Press.
FURTHER READING
Bare, j., McPhee, P., & Skarloff, L. (2000, November 16).
Integrating corrununity indicators into grant making. john and
james Knight Foundation. Paper presented at the annual meeting
of the association for research on nonprofit organizations and
voluntary action. New Orleans, LA.
Kingsley, G. T., NcNeeley, j., & Gibson, j. (1997). Community
building: Coming of age. Washington, DC: The Urban
Institute.
SUGGESTED LINKS Asset-Based Community
Development Institute.
www.northwestern.edu/iprlabed.heml
National Neighborhood Indicators Partnership.
http://www2.urban.org/nniplwhatsnew.heml Pew
Partnership for Civic Change.
www.pew,partnerships.org/newdirections Poverty
and Race Research Action Council. www.prrac.org
-ELIZABETH A. MULROY
COMMUNITY ORGANIZATION
ABSTRACT: The authors review the history of comrnu-
nity organization, both within and outside social work,
describe the various sociological and social psycho, logical
theories that inform organizing approaches, and summarize
conflict and consensus models currently in use. We review
the constituencies, issues, and venues that animate
contemporary organizing efforts and indicate demographic
trends in aging, immigration, diversity, and the labor force
that suggest new opportunities for collective action.
Finally, the authors discuss dramatic increases in
organizing for environmental justice,
 388 CoMMUNITY ORGANIZATION
immigrant rights, and youth-led initiatives, as well as new
activities involving information technology, electoral
organizing, and community-labor coalitions.
KEyWORDS: community organizing; social action;
consensus organizing; social development; conflict;
community-labor coalitions; youth- led organizing;
Internet; electoral organizing; social planning;
immigrant rights; environmental justice; social
movements
The purpose, function, definition, and scope of com-
munity organization have been debated from its origins.
. In perhaps the most widely quoted article on commu nity
organization, "Roles and Goals of Community
Organization" (Rothman, 196~) (later revised and ela-
borated in 2001), Rothman describes three community
organization approaches: social planning (involving ra-
tional planning to improve the quality of community life);
social action (building powerful "peoples" organi zations
that can impact policy and condi tions that are injurious to
their members); and social development, which
establishes local economic programs to move people out
of poverty by developing human and social capital (Dore
& Mars, 1981).
Since the late 19th century, all these approaches have
been called "community organizing;" the level of activity,
the contexts and venues used, the organizing
constituencies, and especially the model of organizing
employed have been profoundly influenced by and
responsive to the largV,1political, social, and e conomic
contexts. Fisher (2005) appropriately describes commu-
nity organizing as a "periodic shifting back and forth" in
response to changes, both in national politics and the
economy, as well as the social work profession's re sponse
to those national trends."
While community organizing does have a note worthy
history within social work, it draws from many different
disciplines and has roots, a central core, and multiple
branches thatlie well outside the profession. Certainly,
most community organizers ar e not social workers, and
most social work practitioners are not organizers.
Community organizing has strong linkages to many other
arenas, including, but not limited to, labor, agrarian
reform, racial justice, neighborhood improvement,
welfare rights, the women's movement, senior power,
immigrant rights, the LGBT movement, housing,
youth-led organizing, environmental justice, education,
tax reform, health care, transportation, public safety, city
services, and disability rights.
Beginning with the Progressive Era, a combination of
social development and social action approaches were
used by settlement house practitioners, such as Jane
Addams, Lillian Wald, and Stanton Coit, to respond
to the needs of immigrants arnvmg from Eastern Europe.
World War I ended the stream of immigrants and ushered
in a renewed respect for professions and rational planning.
Community work during the 1920s reflected those trends ,
emphasizing social planning that featured the
establishment of community-wide fund- raising and
community data collection. Social workers such as Follet
(1918), Lindeman (1921), Petit (1925), and Steiner (1925 )
actively applied the "study-diagnosis- treatment"
approach of casework to neighborhoods.
Despite the widespread poverty and dislocation of the
Great Depression, the Lane Report of 1939 conser vatively
defined the role of community organization as social
development. However, outside of social work, labor
unions, the Communist Party, and Saul Alinsky's
Industrial Areas Foundation OAF) introduced more
militant social action approaches. During World War II
and the highly conservative political environment of the
1950s, community organization was defined even more
narrowly within social work (Pray, 1948), although there
were collaborative efforts outside the profession to protest
nuclear weapons and the antiCommunist, "Red Scare"
tactics.
The 1960s and 1970s unquestionably were the hey-
days of social action organizing, which flowered both
inside and outside of social work as new funding sources
became available and public initiatives like the Federal
government's War on Poverty provided political sup port.
Ross (1955), Brager and Specht (1973), Piven and
Cloward (1977), Cox, Erlich, Rothman, and Tropman
(1979), and Spergel (1999) wrote prolifically during this
period, attempting to identify the concepts and skills that
led to successful community action. The anti- war, civil
rights, welfare rights, and women's movements mobilized
constituencies that previously had not been involved in
large-scale social change efforts; A variety of organizing
initiatives, such as National People's Action (NPA), the
Midwest Academy, the Pacific Organizing I nstitute,
ACORN, and Cesar Chavez's United Farmworkers broke
new ground and realized ambitious goals to change
housing policies, challenge lending practices, lower utility
rates, institute tax reform, improve city services, and raise
wages for migrant laborers (Boyte, 1980; Fisher, 1984 ;
Jenkins, 1985; Delgado, 1986; Bobo, Kendall, & Max,
2001).
Certainly, the conservative political economy that
followed this period of insurgency had a dampening effect
on direct action organizing, but nevertheless, movemen ts
for LGBT rights, environmental justice, disability rights,
anti-globalization; youth-led organiz ing, and immigrant
rights have infused new energy into community
organizing since the last 1980s

(Fisher, 2005). And countless other organizing efforts
continue to prosper, including small independent
neighborhood groups, ethnic organizations, community
development corporations (COCs), and large initiatives
such as ACORN, the IAF, PICO, and NPA.
However, at the neighborhood level, NIMBY ("not in
my back yard") issues may arise, and this phenomenon
illustrates the fact that community organizing is not
necessarily progressive. A neighborhood association may
actively oppose the establishment within its midst of
facilities such as a homeless shelter, a youth drop-in center,
. or a home for the mentally ill. Community members may
democratically decide to take positions and actions that
conflict with social work values. When such situations
occur, \difficult ethical challenges are raised. Fortunately,
these instances are the exception rather than the norm, but
they can occur.
Sociological and Social Psychological
Support for Community Organization
In its earliest days, community organization practice fol-
lowed a model of study based on clinical diagnosis and
treatment. Later, social action organizing models em,
ployed conflict theories: Coser's (1956) ideas about con,
flier, Lewin's (1939) notion of cognitive dissonance, Rossi
(1969) and Gaventer's (1980) theories of power, and Piven
and Cloward's (1977) understanding about how the
alignment of political and economic forces allow for brief
moments in which social movements can flourish and
make change. Ideas about participation and work, ing to
empower participants emerged from liberation theology
and popular education (Freire, 1970, 1973).
While those concepts continue to animate organizing,
in the 1970s, scholars began uncovering more compelling
data that contributed to the development of new theories
explaining large-scale social change. Theoretical
constructs of sociologists who studied historical examples
of mass protest and social move, ments provided support
for organizers using social action approaches. These
theorists analyzed collective action by examining three
distinct sets of factors: societal opportunities and
constraints that shaped political protest, such as sudden.
deprivation or rising expectations following deprivation
(Morrison, 1978); the mobilization of formal and informal
organizational resources that enabled collective action
(Gamson, 1975; McCarthy & Zald, 1977; Oberschall,
1973; Tilly, 1978); and the processes by which movement
participants framed perceptions of injustice and developed
a sense of shared identity (Gamson, 1992; Mansbridge &
Morris, 2001; Meyer et al., 2002). While these theoretical
approaches to studying social movements developed
separately, they are frequently combined at
COMMUNITY ORGANIZATION
389
present to provide a more integrated, holistic analysis
(Morris & Mueller, 1992; Ryan & Garrison, 2006).
Scholars have used historical data to develop and
support theories about "protest readiness" (McAdam
McCarthy, & Zald 1996), resource mobilization, the for,
mation of collective identity (Castells, 1997; Gamson,
1992; Taylor & Whittier, 1992), and the development of
"oppositional consciousness" (Mansbridge, 2001; Morris
& Braine, 2001) in order to better explain a broad array of
social movements by groups including but not limited to
women, welfare recipients, environmentalists, LGBT
activists, students, anti-war protesters, and people with
disabilities. Studies of the growth of African American
owned newspapers, businesses, and professionals, and how
this "resource mobilization" encouraged the emergence of
the Civil Rights movement support the irnportance of
building strong independent organizations as vehicles to
press for change.
Social psychologists have studied the social psycho,
logical motivations of potential joiners, members, and
activists. Roth's (2000) research on women's organizations
suggests that "collective identity precedes and results from
collective action" (p. 302). Kiecolt (2000) examines the
self-transformation that occurs among activists and
identifies several factors that enhance col, lective identity.
Owens and Aronson (2000) explore whether participants
join action organizations out of confident or stigmatized
self-concepts. These theorists help organizers understand
people with whom they work, as well as their own
motivations and behavior.
Consensus models of organizing (Eichler, 2007) also
have sought theoretical grounding and have found support
from scholars studying social networks and social capital
(Putnam, 2000). Putnam studied associational behavior
and proposed that joining enabled people to build social
capital, which was much like economic capital. People
could rely on social relationships and use them as an
exchange for support and assistance. Putnam's work
quickly was adopted by those working in community or
social development models (Cattell, 2001; Tempkin &
Rohe, 1998; Woolcock, 2001). Loffler et al. (2004) sees
social capital as the core of organizing. He writes about
the process of building trusting relationships, rnu-
tual understanding, and shared actions that bring
together individuals, communities, and institutions.
This process enables cooperative action that gener-
ates opportunity and/or resources realized through
networks, shared norms, and social agency. (Loffler
et al., 2004)
Kretzman and McKnight's (1993) work on community
building relies heavily on identifying community assets
390 CoMMUNITY ORGANIZATION
and protective factors, as well as involving community leaders
in efforts that build both internal and external networks and
partnerships, create community programs, and foster
collaboration to improve community conditions. It assumes
"strategic interconnectedness among individuals, families and
communities" (Saegert, Thompson, & Warren, 2001).
Finally, international development models in social work
have borrowed on social capital literature (Midgley. &
Livermore, 1998) and combined this approach with theories of
economic development (Dore & Mars, 1981), modernization
(Midgley & Livermore, 2005), and bootstrap capitalism
(Stoesz, 2000; Stoesz & Saunders, 1999). Economic
development approaches have tended to prize individual
entrepreneurs over both collective micro-enterprise endeavors
(Midgley & Livermore, 2005), as well as attempts to
coordinate state, market, and community efforts to manage
pluralism (Midgley, 1995). The addition of social deve-
lopment approaches encourages local participation in these
efforts.
Despite the emphasis on social development as an
international organizing form, a variety of models can be
found in countries throughout the world. liberation theology in
Brazil (Boff, 1987), micro-enterprise development in India
(Dignard & Havet, 1995), organizing for reconciliation in the
Balkans (Despotovic et al., 2007), community development in
Kenya (Ellis et al., 2007), social action in Bolivia (Olivera,
2004), anti-violence work in Northern Ireland (Meyer, 2003),
popular education with indigenous people in Australia and
Chiapas, Mexico (McDaniel & Flowers, 1995; Morrow &
Torres, 2001) are but a small sampling of different approaches
currently being employed around the globe. Community
organizing in the United States certainly has been enriched by
international examples that emphasize a value-based
approach, the development of critical consciousness,
self-reflection, and a focus on intra-group processes (Freire,
1970, 1973; Burghardt, 1982; Hyde, 1996; Minkler, 2005).
Increasingly, academic macro social work programs and
community organizing journals. have begun to. reflect a more
global perspective. Nevertheless, much more can be learned
from the successful work being done in other countries.
Contemporary Community Organizing
As it exists today, community organizing encompasses both
conflict and consensus approaches and includes groups that
organize around interest groups based on identity, geography,
and faith. Community organizers come from within social
work and from organizing networks that are not based within
the profession.
There is perhaps greater diversity in practice today than ever
before.
We define community organization today as
the process of helping people understand the shared
problems they face while encouraging them to join
together to fight back. Organizing builds on the social
linkages and networks that bring people to~ gether to
create firm bonds for collective action. It creates a
durable capacity to bring about change. (Rubin &
Rubin as cited in Weil, 2005 p. 189-190)
Similarly, Staples (2004a) focuses on a definition that
includes "dual emphasis on participatory process and
successful outcomes" and the establishment of disciplined and
structured organ,~,~~~?ns as vehicles for change. This
conception of community organization includes both
community or social development in which people use
cooperative strategies to create improvements, opportunities,
structures, goods, and services that increase the quality of
community life; and social action in which people convince,
pressure, or coerce decision-makers to meet predetermined
goals. Community building or social development models that
encourage consensus and social action models that promote
conflict often can be used simultaneously or sequentially as
targets become allies and allies become targets.
Co-existing Conflict and Consensus Models Despite the
conservative political and economic climate since the mid-
1970s, social action approaches have continued to be used,
most notably in AIDS activism, opposition to violence against
women, environmental justice campaigns, and a variety of
other organizing projects in communities across the United
States. A number of social workers and others have chronicled
this social action extensively, including Fisher (1984),
Gutierrez and Lewis (1994), Hanna and Robinson (1994),
Hyde (1994), Mondros and Wilson (1994), Rivera and Erlich
(1998), Rubin and Rubin (2001), Hardina (2002), Burghardt
and Fabricant (2004), Staples (2004b). These "conflict"
models of organizing assume that people can organize to force
power-holders to acquiesce to community "demands,"
whether they seek more police protection, increased funds for
health services, or better working conditions for migrant
laborers.
Consensus-building social development approaches have
gained popularity and momentum since the mid1980s and
have been used in many neighborhoods and cities. These
approaches, which are described by Kretzman and McKnight
(1993) and Beck and Eichler (2000), feature a data collection
and organizing strategy that focuses on community strengths,
resources, and asset-building, Consensus organizing
encourages

partnering with both internal and external power holders
in an effort to produce community improve ments. The
community building or social development approach is
also the prevailing model used in many international
settings (Midgley & Livermore, 1998; Sherraden, 2001).
Fisher and Shragge (2000) assert that endeavors to bring
about large-scale systemic change can be expected to
produce opposition from those who benefit from the
status quo. Since social action has the potential to
generate the requisite power and pressure to overcome
such resistance, it should be part of any com munity
organization's repertoire.
Coalitions are organizations of organizations that
enable participating identity or shared experience orga-
nizations to maintain special focus on diversity issues,
while also providing a structure through which they can
join with other groups on wider-ranging campaigns,
especially those that bring together low- and moderate-
income people (Mizrahi & Rosenthal, 1992; Rosenthal
& Mizrahi, 1994; Foster-Fishman et al., 2001; Roberts-
DeGennaro & Mizrahi, 2004; Rosenthal & Mizrahi,
2004). Coalitions and other forms of
inter-organizational relations have grown as a form of
complex organizing that brings diverse stakehol ders to
the table, manages tensions, and utilizes strategies of
negotiation and compromise
Organizing Around Identity,
Shared Experience, Geography, and Faith
Community organizing entails collective action to
decrease power disparities and achieve shared goals for
social change. Therefore, it is a logical course of action
for any undervalued societal group that faces
discrimination and disempowerment. Since African
Americans launched the Civil Rights Movement in the
mid-1950s, numerous constituencies have organized
around their common identity-along dimensions of
diversity that include race, ethnicity, gender, age, sex ual Additionally, individual churches, denomina tions,
orientation, and physical or mental disabilities. Others
have organized around issues related to their shared
experience, such as welfare recipients, tenants, prisoners,
students, day laborers, single parents, homeless people,
women, and immigrants. One reason for this
phenomenon has been the failure of existing community
organizations based on geography or selected issues to
effectively meet the needs of diverse subgroups within
their own membership. Frustrated by the inability or
unwillingness of "mainstream" organizing to address
their interests, members of these constituencies have
organized separately around mutual concerns related to
their identity and shared experience.
Community organizing along identity or shared ex-
perience lines has mobilized many new activists who
CoMMUNITY ORGANIZATION
391
previously had not been engaged in collective action to
assert their own rights and has infused fresh energy into
countless initiatives for social change. Pursuing a sepa-
rate issue agenda helps ensure that matters of funda-
mental importance to diverse interest groups are not
swallowed up and lost within broader-based organizing
efforts that cut across dimensions of identity. However,
there is a challenge to prevent the fragmentation and
balkanization that may occur when a more separatist
organizing strategy is employed.
Beyond organizing that focuses primarily on identity
and shared experience, many traditional turf-based geo-
graphic groups and single issue efforts also have tended
to recruit and involve more multicultural memberships
that are reflective of the changing demographics of the
United States. Neighborhoods that once were synon-
ymous with single ethnic group populations frequently
are becoming more diverse. Most community organiza-
tions have embraced this increased diversity but have
been challenged to address new issues, such as immi-
grant rights, interpreter services at health and social
service agencies, bilingual education, and the lack of
cultural competence at a variety of local institutions.
Many also have needed to make adjustments in their
own organizational culture, operating procedures, and
group processes in areas such as meeting sites and
starting times, availability of child care and
transportation, provision of food at meetings,
translation, chairing and
. discussion styles, decision-making processes, and lead-
ership development content and training methods.
Faith-based organizing has been a deliberate recruit-
ment strategy of community organizers since Alinsky
(1969, 1971) built the Back of the Yards organization in
Chicago in 1939. Reaching people through churches,
mosques, and synagogues remains a recruitment strat-
egy for many organizing networks today (Parker, 2000).
free-standing religiously affiliated organizations, such
as Catholics for Free Choice and Progressive Jewish
Alliance, as well as interfaith organizations, such as
Clergy and Laity United for Change in Los Angeles,
have begun to organize as religious communities.
Organizing Within and Outside of Social Work
Currently, there are a number of large community
organizing networks in the United States, such as
ACORN, the Industrial Areas Foundation OAF),
National People's Action, and PICO, as well as training
and support centers, including the Center for Third
World Organizing (CTWO), DART (Direct Action and
Research Training Center), Gamaliel Foundation,
Grassroots Leadership, Midwest Academy, National
Housing Institute, National Organizers Alliance,
392 COMMUNITY ORGANIZATION
ORGANIZEl Training Center (OTe), Organizing and
Leadership Training Center (OL TC), Highlander Cen-
ter, Regional Council of Neighborhood Organizations
(RCNOs), Southern Empowerment Project (SEP), and
Western States Center. Additionally, hundreds of
smaller independent grassroots organizations are not
affiliated with one of the major networks, including
numerous single issue mobilizations (Delgado, 1997).
Social workers can be found in all of these forms of
community organizing. The continued presence of
community organization as a method of social work
practice is strengthened by the existence of ACOSA (the
Association for Community Organization and Social
Administration), as well as the Journal of Com, munity
Practice, which has served as a forum for dissem inating
new issues and approaches to community work since
1994. However, a majority of the organizers come from
other academic disciplines, such as political sci ence,
sociology, urban affairs, women's studies, psych ology,
economics, public health, labor studies, human se rvices,
education, law, or community development, while
others do not have formal educational credentials, but
draw on rich, life experience. Given the fact . that a small
but significant number of social workers are likely to
continue to be employed as community organizers,
macro social work educators should strengthen
interdisciplinary linkages to other academic departments
that are most likely to support this practice modality
(Alvarez et al., 2003).
Trends in Organizing: Constituencies,
Issues, Arenas, and Tools Demographic,
social, and economic trends shed light on not only who
will be the next populations to organize, but also what
the critical organizing issues of the future will be, the
arenas in which collective action is likely to take place,
and the methods and tools that can be employed to
achieve goals for social change. Trend data indicate that
America will experience seismic demographic through
2058. The largest subgroup of the population will be
older adults, the fastest-growing cohort of whom will be
those 85 and above. The aging population will strain, if
not shatter, an already troubled social security and
health-care system. Ironically, organizing for "senior
power" has witnessed a slight loss of momentum since
the late 1990s, but given this demographic imperative,
organizjng among the elderly can be expected to grow
significantly through 2028.
The foreign, born population will reach 40 million
by 2010; By the year 2020, Latinos from various
Caribbean and Central and South American countries
will be the largest ethnic group in the country, requiring
attention to issues of immigration, bilingual education,
health. care, education, employment opportunities, and
adequate wages. In the wake of the 9/11 tragedy in 2001,
immigration reform has become a highly charged
political issue. Increased resources have been allocated
to limit the flow of undocumented immigrants, including
border patrols, the National Guard, high-tech sur-
veillance,and fences along the Mexican border.
Historically, the United States has been a "nation of
immigrants," and the initiatives to decrease the influx of
newcomers have raised controversy across the political
spectrum.
As neighborhoods across the United States have
become more racially and ethnically diverse, often partly
due to the arrival of newcomer groups, community
organizations have begun forming committees and
initiating campaigns that deal with a wide range of
immigrant issues and problems related to employment
and training opportunities, poor working conditions, low
wages, lack of affordable housing, restricted access to
health care, refugee status, mental health problems,
post-traumatic stress, educational and language barriers,
difficulties navigating various public and private .
bureaucracies, changes in family roles, intergenerational
conflicts, tensions between ethnic and religious
subgroups, youth gang violence, inadequate police pro,
tection, and multiple forms of discrimination.
Immigrant worker exploitation is currently a very
real, if largely unacknowledged and hidden, social
problem-especially among those who are undocu-
mented. Immigrant worker centers have sprouted in
low, income communities across the United States to
provide information about rights and to support efforts
by newcomers to organize on their own behalf. In 2003,
an Immigrant Worker Freedom Ride helped draw
attention to this social problem across the United States.
And during Spring 2006, huge rallies and marches in
large cities around the country raised the stakes for
immigration reform. An immigrant rights movement has
begun to gather momentum, and community organizing
in this area can be expected to expand.
Growth in the workforce most likely will be in the
low-wage sector, and young workers with the fewest
skills and least education can be expected to experience
several periods of prolonged unemployment and shifts
in industry during their lifetime. The trends in immi-
gration and workforce development suggest that work-
place issues and venues may again become salient.
Efforts to organize janitors, hotel workers, home health
aides, food service employees, security guards, and
other low-wage sector workers, as well as the secession
of the Service Employees International Union (SEIU)
from AFL-CIO to form the Change to Win Federation,
seem to point to new activity in labor organizing.

There also has been a marked increase in community-
labar coalitions, which assemble community organizations
and labor unions working together on issues outside the
workplace to engage in what Fine (200l) has termed
"community unionism." Typically, these coalitions form
when community organizations and labor unions identify
mutual interests around economic justice issues, such as
state minimum wages, municipal living wage ordinances,
child care, job training programs, welfare policy,
community health benefits, plant closings, or hiring
preferences for local residents on development projects
(Simmons, 2004). Such coalitions have organized
successfully for living wage ordinances in more than 100
cities across the United States. The workers most impacted
by these victories tend to be employed by companies that
contract with local government to provide basic
necessities, such as janitorial work, sanitation, landscaping,
and food services. Very often, these workers live in the
same low-income neighborhoods where community
organizations are active, and frequently they hold dual
membership in both labor unions and "grassroots groups
that participate in the coalitions.
Census Bureau data indicate that nearly one-quarter of
all families that include children and at least one fulltime
worker are still below the poverty line. Only about half of
all workers currently have health insurance. Economic data
show increasingly greater concentration of wealth in the
hands of fewer and fewer people. According to the Survey
of Consumer Finances, the wealthiest 1 % of households
own roughly 33.4% of the nation's net worth, the top 10%
of households own over 71 %, and the bottom 40% of
households own less than 1 %. This erosion of economic
security may generate both traditional "pocketbook" issue
campaigns related to employment insurance, health care,
and affordable housing, as well as new "bread and butter"
concerns that engender organizing around the need for
increased student financial aid and efforts to reduce and
roll back unprecedented increases in college tuition.
Increased numbers of low- and moderate-income people
can be "expected to organize to address the responses of
federal, state, and local governments to these and other
critical economic justice issues.
Community organizing approaches, strategies, and
methods continue to evolve to meet challenges and
opportunities that are a function of the larger sociopolitical
economic context. Technology and globalization will have
profound and unprecedented influence on how people
connect and communicate; there is potential for both
greater closeness and more alienation. Certainly, the
growth of information and communication technology has had
a profound impact on the
COMMUNITY ORGANIZATION 393
greater society and has opened up new possibilities for
community organizing. McNutt (2000) identified six ways
that technology can help initiate and sustain an organizing
campaign: (a) coordinating activity and community with
stakeholders; (b) gathering tactical and strategic
information through online databases and discussion
groups; (c) analyzing data with mapping or Geographic
Information Systems (GIS) programs, community
databases, and statistical packages; (d) using Web pages
for advocacy; (e) fund-raising and recruiting volunteers or
members through online venues; and (f) automating office
and administrative tasks.
A variety of forms can be employed in organizing
campaigns, including cell phones, conference calls, video
teleconferencing, faxes, transmittance of images, video
streaming, text messaging, organization of Web pages,
Webcasting, e-mail discussion lists, chat rooms, Internet
information or resources, and computer programs to
produce flyers, letters, Powerpoint presentations, and
videos (Hick & McNutt, 2002; RobertsDeGennaro, 2004).
Two new software packages, GIS and Social Network
Analysis, show promise for use in community organizing
efforts. GIS is being used to map assets and liabilities in
several cities, and has been employed by organizers to
identify issues and support systems (Mulroy, 2004). Social
Network Analysis has been widely utilized in the public
health field to analyze how networks assist the effective
communication of information about positive health
practices (Cross & Parker, 2004; Valente, 2GQ4). Social
Network Analysis can be easily adapted to examine how to
expand and extend constituency participation, investigate
linkages and overlapping networks, and track the transfer
of community information.
The Internet has facilitated organizing in multiple
locations, making a significant positive impact on the scale
of collective action (Stoecker, 2002). Electronic advocacy,
Internet activism, and online "flash campaign" organizing
methods have been used widely and successfully by groups
such as MoveOn.org to reach individuals and groups
across the United States and around the globe.
Accessibility to technology for lower income people has
increased because of cost reductions and expanded
availability in public institutions, such as libraries and
schools, thereby narrowing the "Digital Divide"
(Golombek, 2002; Hargittai, 2002). The new technology
has had a democratizing effect by opening up access to
information and knowledge that previously was limited to
the privileged.
Nevertheless, many challenges remain, including the
lack of technology literacy, information literacy, and
language literacy (Steyaert, 2002); and Internet content is
still disproportionately in English, thereby
394 CoMMUNITY ORGANIZATION
limiting utilization for members of many ethnic groups.
The potential misuse of "e-dernocracy" by corporate
interests also has been flagged (Spector, 1994; Stoecker ,
2002). Differential access to technology remains as a
significant barrier for many groups, including many
immigrants (especially those who are undocumented),
migrant laborers, the elderly poor, homeless people, de
institutionalized mental health consumers, and large
numbers of low-income people. Community organizing
continues to rest on the strength of interpersonal rela-
tionships and active physical engagement in civic life
(McNutt, 2000; Roberts-DeGennaro, 2004). Technology
offers exciting new possibilities for researching issues,
community mapping, recruiting activists, facili tating
member communication, developing strategies, pressuring
reluctant institutional decision-makers, and evaluating the
results of collective action; however, in most
circumstances, it should be regarded as a supple ment to,
rather than a substitute for, face-to-face community
organizing.
Engagement in a variety of different types of electoral
organizing is another relatively recent phenomenon for
most community organizations. Since their inception,
community organizations have interacted with and
"targeted" a wide array of local, state, regional, and federal
elected officials. However, historically, many, if not most,
such organizations were not involved in the electoral
process. ACORN was the first national community
organizing network to develop electoral strategies;
increasing numbers of groups have followed suit, and a
range of options now are available.
The most basic level of electoral organizing is voter
registration. Between July and the end of November, 2003 ,
ACORN registered 73,684 voters in low- and
moderate-income African American and Latino neigh-
borhoods across the United States. Voter education may
entail "candidates' nights," written materials, e- mails, Web
sites, or print and electronic media publication of the
positions of office seekers on particular issues, policies, or
pieces of legislation, and may be combined with a "Get
Out The Vote" (GOTV) effort designed to mobilize
informed organizational supporters (Staples, 2004a). At
the national level, America Votes, whose founding
members included ACORN, AFL-CIO, AFSCME, League
of Conservation Voters, MoveOn.org, NAACP, National
Voter Fund, Partnership for America's Families, People
For the American Way, SElU, and the Sierra Club, was
formed to register, educate; and mobilize voters for the
2004 elections.
There also- may be certain circumstances under which
a community organization makes a formal en dorsement of
a candidate (Pillsbury, 2004). NASW has a large operation
known as PACE to raise money for
candidates that support NASW values and policies, and
always mobilizes social workers to get out the vote. Last,
but not least, community organizations may put forward,
support, or oppose voter initiatives-proposed laws,
policies, or regulatory processes that have been placed on
the ballot via petitions signed by registered voters.
Examples would include statewide referenda to raise
minimum wages, or local ordinances to establish housing
trust funds or to increase expenditures for school
improvements. Indeed, there has been an explo sion of
electoral activity by community organizations across the
country in recent years, and this trend is likely to continue,
if not expand, in the foreseeable future.
Community organizing also has witnessed dramatic
increases. in issues related to environmental justice. The
environmental movement that emerged during the 1970s
initially tended to mobilize a predominantly middle-class
base. More recently, there has been a rap idly growing
recognition of the twin phenomena of "environmental
racism" and "environmental class ism." Namely, the
dumping and storage of toxic wastes and pollutants can be
found disproportionately in communities of color and
low-income neighborhoods. As residents of despoiled
areas have developed critical awareness about both the
origins and consequences of environmental problems,
there has been an accompanying sense of outrage and
injustice. They have been quick to organize and have
moved NIMBY issues beyond the realm of traditional
parochial defensive and reactive struggles into the arena of
progressive organizing to confront corporate abuse of
power and frequent governmental complicity that raises
deeper societal problems stemming from race. and class
relations in the United States.
The role of youth in the history of community orga-
nizing in the United States usually has been ignored or
barely mentioned in most mainstream "adult-centric"
accounts. Certainly, youth played an important role in the
Civil Rights Movement, and antiracist organizing such as
the Student Non-Violent Coordinating Committee, the
Black Panthers, Young Lords, and Brown Berets. And
college students were at the forefront of the anti- war
movement during the Vietnam era. But youthled community
organizing involving teens (often under the age of 17) in
local issues related to school reform, health promotion,
anti-violence, transportation, health promotion, police
relations, the courts, employment, recreation, and gender
and racial equality has grown exponentially over the past
15 years (Delgado, 2006).
A youth-led paradigm has changed the status of youth
from being "included" in community organizing to varying
degrees to being "in charge" (Delgado &
-'II.

Staples, 2008; Weiss, 2003). This new model of organizing is
youth-driven, including the mission-defined goals and
priorities chosen, issue agendas selected, recruitment
methodology employed, leadership developed, organizational
culture established, decision-making processes utilized,
strategies and tactics selected, and actions undertaken. Youth
leadership is at the center of this organizing, which is of, by,
for, and about youth, their culture and concerns.
Implications for Social Work
Certainly, it is impossible to predict all the trends that may
drive community organizing through 2018. Changing
economic conditions, shifting political alignments, new
cultural phenomena, . and technological advances will
continue to shape the social problems and issues that .emerge,
motivating and mobilizing additional constituency groups to
engage in collective action on their own behalf to change the
circumstances of their lives. Though community organization
is increasingly taught in other venues and practiced by other
disciplines (public health, public administration, urban affairs,
and even architecture), it seems likely that social work will
continue to claim it as a core methodology. Innovation and
creativity are the norm in this dynamic field of practice, which
goes to the heart of social work
. values such as justice, empowerment, participatory
democracy, self determination, and overcoming all forms of
oppression. Driven by the realities of need and funding
(Johnson, 2000, Johnson, 1998), increasingly community
practice theory and skills are integrated into required
curriculum (Pippard & Bjorklund, 2003; Hendricks & Rudich,
2000) rather than taught as a separate method (Fisher et al.,
2001). Educating all social workers to utilize the community
as a context for service and competently engage in community
building attempts to prepare them for all that may lie ahead.
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-JACQUELINE MONDROS AND LEE STAPLES
CO:M1villNITY VIOLENCE
ABSTRACT: Community violence represents a wide-
spread concern receiving increasing attention by
social workers. This article considers the problem of
community violence and our present understanding of
its extent and consequences. Evidence is growing that
identifies risk and protective factors linked w ith
community violence exposure, particularly those of a
demographic nature. At present early evidence points
to potentially helpful ameliorative and preventive
strategies for social workers to consider at the micro
and macro levels.
KEY WORDS: violence; community; adolescence;
trauma
Community violence has gained growing attention as a
problem of concern within the social work profession,
particularly since the beginning of .the 1990s, when studies
began documenting a problem of widespread proportions,
affecting many whom social workers often encounter, with
major physical, mental health, psychosocial, and broader
societal consequences. The notion of "community violence"
remains a vague concept, however, and is perhaps most
appropriately conceived of as an omnibus term, encompassing
a variety of types and manifestations of violence, across a
variety of community settings.
At its most basic, the term community violence denotes acts
of interpersonal violence that occur in community settings,
including neighborhoods, streets, schools, shops, playgrounds,
or other community locales. These acts may include such
incidents as gang violence, rapes, shootings, knifings,
beatings, or muggings. Some scholars also include other forms
of violence under the rubric of community violence, such as
social unrest or riots taking place in community settings, while
still other scholars have included violence occurring in the
home or perpetrated among family members as manifestations
of community violence (Guterman, Cameron, & Staller,
2000). Although the location and persons involved in the
violence (as victims, perpetrators, and potentially as
witnesses) often shape whether an act of violence is
appropriately labeled as community violence, no clear
consensus yet exists as to what boundaries demarcate
community violence from other forms of violence, such as
domestic violence or political violence. It is clearly the case
that one form of violence may overlap with or even "spill
over" into community violence and vice versa, as in the case of
sexual assault between partners, or interclan or interethnic
violence, and community violence incidents may be identified
by different labels, such as "crime," "gang violence," or
"school violence." A lack of clear and precise demarcation of
the term makes it difficult to accurately track the magnitude of
the problem, monitor changing trends over time, or identify
risk and protective factors. The presently diffuse definition of
the term also risks its politicization, or worse, lends itself to be
used in a biased or pejorative way, such as to purvey racist,
classist, or ageist stereotypes about "violent communities" or
demographically defined groups. Further work is therefore
necessary to more precisely define what constitutes
community violence, and how it differs from other
manifestations of violence.
Prevalence of Community Violence Exposure Mindful of a
rather ill-defined demarcation of community violence, the
extent of the problem is, nonetheless, by all measures one of
widespread proportions in the United States, and some have
even labeled the problem, especially for children. and
adolescents, a "public health epidemic." Most indications are
that the risk of severe victimization outside of the home is at
least twice as great for children and youth as it is for adults,
and the risk of lower level victimization is at least three times
as high for children and youth as it is for adults. The National
Center for Injury Prevention and Control of the Centers for
Disease Control and Prevention has reported homicide as the
fourth leading cause of death among children under 12 years
(behind unintentional

injury, cancer, and congenital anomalies), and th~ third
leading cause of death for children aged 12-17 years
(behind unintentional injuries and suicide), with the
juvenile homicide rate in the United States the highest in
the industrialized world. It is worth noting that almost
two-thirds of juvenile homicide victims were killed by
firearms.
Nationally representative self-report surveys focused
on youths have variously reported that upward of 50% of
American children and adolescents experience some
significant acts of physical assault each year, that rv 10%
or greater are threatened each year with a potentially
lethal weapon (such as a knife or a gun), and that about
10% report being sexually assaulted each year (see
Finkelhor, Hamby, Ormrod, & Turner, 20(4) Most
studies of community violence have been focused on
urban inner city children and youths, and these have
reported that the large majority of the children and
youths residing in inner cities in the United States have
been exposed to at least one act of community violence
either as witnesses or as direct victims, with one study,
for example, reporting that 67% of young respondents
had witnessed a shooting, 50% had witnessed a stab bing,
and 25% had been personal victims of some form of
severe violence (Jenkins & Bell, 1997). Studies have
reported wide variations in exposure rates, across urban
settings, differing study methods, time frames,
samplings strategies, and measurement instruments
Although it is difficult to ascertain whether community
violence exposure rates have declined from the peak
years in United States in the early 1990s, it is likely that
there has been some diminishment from the peak crime
years during this period. It is clear that the majority of
violence exposure does not get reported to official
sources, particularly lower-level violence, although re-
ports of homicide have declined significantly from their
peak in 1993.
Risk and Protective Factors
for Community Violence Exposure Currently,
understanding of risk and protective factors for
exposure to community violence is primarily limited to
demographic indicators. Of those, the primary factors
identified include the socioeconomic status of the
family and community of residence, race and ethnic
affiliation, gender, and age.
Socioeconomic Status
In general, studies indicate that risk for exposure to
community violence is associated with community set-
tings characterized by high concentrations of poverty,
as indicated by low incomes, poor housing conditions,
and high rates of residential instability, although this is
COMMUNITY VIOLENCE 399
a broad trend and by no means a one-to-one predictor of
violence exposure risk. Several studies indicate that
although youths living in urban inner city environments
face the highest exposure rates when compared with
those in other community settings, those living in
middle-class suburban and rural settings also face sig-
nificant risk for violence exposure outside the home,
with, for example, findings indicating that about one-
fourth of the youth living in rural areas not defined as
poor have been exposed to gun violence at least once.
Conditions in poor urban neighborhoods are thought
to intensify levels of personal and social stress, and are
also viewed as more prone to illicit behaviors such as
drug trafficking and gang activities from which violent
behavior may often originate. However, concentrated
poverty and community disorganization are not the only
community-level factors that appear to be linked with
heightened risk for violence exposure. Important work
has recently identified "collective effi cacy" as a primary
explanatory factor in predicting the likelihood of
neighborhood crime and violence. Col-. lective efficacy
of a neighborhood is characterized by the degree to
which its residents perceive positive social cohesion
among one another, and the degree to which they
exercise informal social control to maintain positive
social norms (Sampson, Raudenbusch, &. Earls, 1997).
Race and Ethnicity
Studies on community violence have found that
although all ethnic groups in the United States are
exposed to community violence, the rates of exposure
among ethnic minorities are disproportionate. Com-
parative data on Whites, African Americans, Latinos,
and persons from other ethnic and racial groups have
revealed that African Americans, and to a lesser extent
Latinos, experience higher levels of exposure to violent
crime. Even more so, American Indians have been
reported to experience violence exposure at rates twice
as high as those found among African Americans, over
two and a half times higher than those among Whites,
and four and a half times higher than those among
Asians (Rennison & Rand, 2003). It has been argued
that high levels of exposure to violence among some
youth of color may be a function of the socioeconomic
status of their families and localities of residence, as
ethnic minorities are overrepresented in poor urban
areas with high rates of crime and violence.
Gender
Several studies have shown that male children and ado-
lescents are overall more likely than females to experi-
ence and witness violent incidents in the community,
400 COMMUNITI VIOLENCE
across socioeconomic gradients and ethnic groups (see
Selner-O'Hagan, Kindlon, Buka, Raudenbush, & Earls,
1998). Some evidence suggests that while males are at
greater risk of personally experiencing and witnessing
physical violence, females are at greater risk of exposure to
sexual assaults, though the findings on gender are not
uniform. Some evidence suggests that gender differences
in community violence exposure may vary according to
age. For example, some studies have reported no gender
differences in preschool children's exposure to community
violence, and one study found that girls in elemen tary
school reported greater exposure to community violence
than did boys of the same age, although those differences
disappeared in a follow-up study conducted two years later
(Attar, Guerra.ex. Tolan, 1994).
Age
Most studies have revealed an important relationship
between age and rates of exposure to community violence,
although there is some inconsistency in the findings. Data
from official homicide reports indicate an inverted-U
relationship between age and victim, with risk for violent
death from a nonfarnily perpetrator remaining low until
adolescence, then rising dramatically, and peaking at ",20
years, and then gradually declining through the rest of the
life span (Snyder & Sickmund, 2006). Several self-report
studies on nonfatal violence exposure have corroborated
this pattern; however, the findings on this relationship are
not uniform, ~nd may, in part, depend upon the subgroups
studied. For example, several studies indicate quite high
rates of community violence among very young children
from urban settings (see Shahinfar, Fox, & Leavitt, 2000).
Although further information is necessary to understand
the interaction between age and other risk factor s for
community violence exposure, it remains clear that risk for
community violence exposure is present at all ages.
In regard to individual-level psychosocial or beha-
vioral factors that may heighten or lower risk to com-
munity violence exposure, little empirical evidence to date
sheds light on the factors that may be most salient. Some
preliminary evidence has indicated that the use of illicit
psychoactive substances is associated with greater
community violence exposure Not surprisingly,
adolescents with aggressive behavior problems are at a
higher risk for violence exposure, particularly so for males
who also show depressive symptoms. In addition, some
evidence suggests that negative and harsh parent ing might
place children at a higher risk of community violence
exposure by shaping the children's own aggressive
behavior, and by affecting their socializing pat terns with
more delinquent peers. Beyond this, further research is
necessary to identify whether and which
individual- and family-level factors may place individuals
at a greater risk of exposure to community violence.
Consequences of Exposure to
Community Violence
From a medical standpoint, exposure to community
violence is a devastating problem, and murder is one of the
leading causes of death in children and adolescents. Of
particular concern to social workers is the wide array of
psychosocial and behavioral consequences that have been
identified with community violence exposure. Violence
exposure has been shown to interfere with many of the
primary developmental tasks in childhood and early
adulthood (the period of greatest exposure risk), such as
the development of trust, emotional regulation, and the
ability to form and establish social relationships. Even
more so, community violence exposure has been linked
with significant mental health sequelae, including most
notably symptoms of post-traumatic stress disorder, an
anxiety disorder commonly manifested after exposure to a
traumatic event. Also frequently identified in prior-
research are clear links between community violence
exposure and increased aggression, delinquency, and
weapons-carrying. Importantly, longitudinal studies have
been able to document that increases in aggression follow
violence exposure, providing ominous hard evidence that
exposure to community violence may beget further
violence perpetration from victims, suggesting a rippling
"contagion" effect of community violence (see Gorman-
Smith & Tolan, 1998) .
. Several studies have also documented community
violence exposure linked with heightened anxiety and
depression, as well as with somatic complaints that may be
related to anxiety, such as sleep disturbances, headaches,
stomachaches, and increased symptoms of asthma. Still
further studies have linked community violence exposure
with cognitive and academic delays, with attitudes of
hopelessness and "futurelessness" (the belief that one has
no real future). Further, evidence is accumulating that
exposure to community violence, is linked with greater
exhibition of risky behaviors, including sexual risk taking,
reckless driving, and greater use of illicit psychoactive
substances (Guterman & Cameron, 1997). Currently, the
knowledge base linking such problems with community
violence exposure rests almost exclusively on studies
drawing from nonclinically referred samples of children
and adolescents, and some evidence suggests that such
sequelae may manifest differentially for those seen in
clinical settings. This points out a need for social workers
and other allied mental health professionals to be mindful
to conduct careful and specialized assessments with those
who may face some risk of exposure to community
violence.

Interventions to Community Violence Perhaps
because of the recent attention given to community violence
and its effects on mental health and psychosocial functioning,
little has yet been identified in the way of effective social work
responses specifically targeted to community violence per se.
In fact, evidence suggests that clinical social workers, as well
as allied mental health professionals have often overlooked
experiences of community violence exposure in their clinical
work with clients, hampering effective service responses
(Guterman, Hahm, & Cameron, 2002). However, an incipient
knowledge base is emerging that helps guide social workers to
assess for and address the identified consequences of
community violence exposure, as well as to consider risk and
protective factors related to future violence exposure. For
example, a nascent empirical base is identifying factors that
appear to help mitigate the mental health and psychosocial
consequences of community violence exposure after it occurs.
Most notably, perceived support from friends and family
appears to buffer the impact of community violence exposure
on adolescents; and there is limited evidence that prosocial
cognitions may buffer the impact of community violence
exposure, particularly for girls. Such findings, while at the
descriptive stage, can provide important clues for social
workers aiming to mitigate the psychosocial consequences of
violence exposure among their clients.
At the micro level with individuals, families, and
groups, social workers can also turn to well-established
and empirically supported intervention strategies designed
to target common sequelae resulting from com munity
violence exposure. These include, for example, an array of
intervention strategies now available and empirically
supported to assist clients with symptoms of
post-traumatic stress disorder (most notably cognitive-
behavioral interventions), as well as well-developed
intervention strategies aimed at reducing externalizing and
further aggressive behaviors (for example, via parent
training, or behavioral modification strategies). Social
workers can also draw from anxiety management
strategies for clients exhibiting anxiety symptoms in the
wake of community violence exposure. Finally, to help
mitigate its effects and to reduce the risk of further
exposure, social workers can draw from that subset of
descriptive research that identifies factors that mediate the
impact of community violence exposure on clients, and
that predict the likelihood of exposure in the first place. For
example, research suggests the likely benefits of
improving parental support and monitoring for children
and adolescents who may be at risk of violence exposure
and its consequences. Given risk factor research
identifying harsh parenting, children's own aggression, and
choice of delinquent peers as associated
COMMUNITI VIOLENCE 401
with violence exposure risk, social workers can also tum to
preventive parent-child strategies, as well as social skills
interventions to interrupt early patterns that may later lead
to greater risk for violence perpetration and exposure (see
Limbos et at, 2007).
At the macro level, there are many communityoriented
strategies that aim to address the underlying causes of
community violence and crime. These include addressing
neighborhood poverty and the presence of illicit drugs in
neighborhoods, building neighborhoodlevel collective
efficacy and organization, and making available habitable
and safe housing, all appearing as the most promising
strategies to prevent both community violence and its
pernicious consequences. There are also a range of
community-building programs such as community
gardens, street murals, creating or 'strengthening block and
neighborhood associations, supporting community
policing strategies, all of which have merit: Perhaps most
directly targeting the problem of community violence are
anti-gang initiatives and violence prevention
community-based interventions such as "Ceasefire" in
Chicago that mobilize residents to alter local norms away
from violence as inevitable and acceptable, and that
employ streetworkers to resolve brewing conflicts before
they erupt in violent exchanges. Preliminary evidence of
such strategies is highly positive and suggests that
community-based preventive strategies hold great promise
to reduce community violence and its devastating
consequences (see Diehl, 2005; Fritsch, Caeti, & Taylor,
1999).
REFERENCES
Attar, B. K., Guerra, N.G., & Tolan, P. H. (1994). Neighborhood
disadvantage, stressful life events, and adjustment in urban
elementary school children. Journal of Clinical Child Psychology,
23, 391-400.
Diehl, D. (2005). The Chicago Project for Violence Prevention,to
Improve Health and Health Care: The Robert Wood Johnson
Foundation Anthology, VIII, pp. 147-151.
Finkelhor, D., Hamby, S. L., Ormrod, R., & Turner, H. (2004).
The Juvenile Victimization Questionnaire: Reliability, validity,
and national norms, Child Abuse and Neglect, 29(4), 383-412.
Fritsch, E. J., Caeti, T. J., & Taylor, R. W~ (1999). Gang suppression
through saturation patrol, aggressive curfew and truancy
enforcement: A quasi-experimental test of the Dallas anti-gang
initiative, Crime & Delinquency, 45(1),122-139.
Gorman-Smith, D., & Tolan, P. (1998). The role of exposure to
community violence and developmental problems among
inner-city youth, Development and Psychopathology,
10,101-116.
Guterman, N. B., & Cameron, M. (1997). Assessing the impact of
community violence on children and youths. Sodal Work, 42(5),
495-505.
Guterman, N. B., Cameron, M., & Staller, K. (2000). Definitional
and measurement issues in the study of community
402 CoMMUNITY VIOLENCE
violence among children and youths. Journal of Community
Psychology, 28(6), 571-587.
Guterman, N. B., Hahm, H. C., & Cameron, M. (2002).
Adolescent victimization and subsequent use of mental
health counseling services. Journal of Adolescent Health, 30,
336-345.
Jenkins, E. J., & Bell, C. C. (1997). Exposure and response to
community violence among children and adolescents. In J.
D. Osofsky (Ed.), Children in a violent society (pp. 9-31).
New York: Guilford Press.
Limbos, M. A., Chan, L. S., Warf, c., Schneir, A., Iverson, E.,
Shekelle, P., & Kipke, M. D. (2007). Effectiveness of inter-
ventions to prevent youth violence: A systematic review.
American Journal of Preventive Medicine, 33(1),65-74.
Rennison, C. M., & Rand, M. R. (2003). Criminal
victimization, 2002, Washington, DC: U.S. Department of
justice, Bureau \
of Justice Statistics.
Sampson, R. j., Raudenbush, S. W., & Earls, F. (1997).
Neighborhoods and violent crime: A multilevel study of
collective efficacy. Sdence, 277(5328), 918-924.
Selner-O'Hagan, M. B., Kindlon, D. J., Buka, S. L.,
Raudenbush, S. W., & Earls, F. J. (1998). Assessing expos-
ure to violence in urban youth; Journal of Child Psychology
and Psychiatry and Allied Professions, 39, 215-224.
Shahinfar, A., Fox, N. A., & Leavitt, L. A. (2000).Preschool
children's exposure to violence: Relation of behavior
problems to parent and child reports. American Journal of
Orthopsychiatry, 70, 115-125.
Snyder, H. N., & Sickmund, M. (2006). Juvenile offenders and
victims: A national report. Washington, DC: Office of
Juvenile Justice and Delinquency Prevention.
FURTHER READING
Finkelhor, D., Ormord, R., Turner, H., & Hamby, S. L.
(2005).
The victimization of children and youth: A comprehensive,
national survey. Child Maltreatment, 10,5-25.
Garbarino, j., Dubrow, N., Kostelny, K., & Pardo, C. (1992).
Children in danger: Coping with the consequences of community
violence. San Francisco, CA: jossey-Bass.
Luthar, S. S. (2004). Children's exposure to community vio-
lence: Implications for understanding risk and resilience.
Journal of Clinical Child and Adolescent Psychology, 33(3),
499-504.
Osofsky, J. (Ed.). (1997). Children in a violent socierj. New
York:
-NEIL B. GUTERMAN AND MUHAMMAD M. HAJ-YAHIA
Guilford.
COMORBIDITY
ABSTRACT: This entry defines cornorbidity and similar
terms used in various fields of practice. It addresses the
prevalence of comorbidity, suggests explanations for
comorbidity, and discusses integrated treatment for
comorbid conditions and the importance of the concept of
cornorbidity in social work practice.
KEY WORDS: coexisting disorders; comorbidity; co-
occurring disorders; developmental disabilities; dual
diagnoses; intellectual disabilities; medical illness;
mental disabilities; mental disorders; mental illness;
mental retardation; physical disabilities; substance use
disorders
Definitions
Camorbidity has been defined as the 'simultaneous presence of
two or more illnesses or diseases. The term has also been used
to refer to the co-occurrence of unrelated illnesses.
Comorbidity is also used in a broader sense to refer to a
situation in which an individual has two or more physical
(medical), mental (psychiatric), cognitive (intellectual),
and/or substance use disorders or disabilities. Comorbidiry is
further referred to as dual diagnosis or dual diagnoses,
coexisting disorders, and cooccurring disorders. These terms
and their definitions may vary by field of practice. For
example, in the developmental disabilities field, the term dual
diagnosis or dual diagnoses is often used to mean that a person
has intellectual disability (mental retardation) and a mental
disorder or disorders (for example, Graziano, 2002). Mental
health and substance abuse professionals use several terms.
interchangeably when' referring to an individual who has one
'or more mental disorders and one or more substance use
disorders (DiNitto & Webb, 2005). For example, the National
Institute of Mental Health (NIMH) often uses the term
comorbidity, while another u.s. government agency, the
Substance Abuse and Mental . Health Services Administration
(SAMHSA), currently uses the term co-occurring disorders
(Center for Substance Abuse Treatment, 2005). In the past the
term MICD (Mental Illness and Chemical Dependency) has
been used.
In the United States, the American Psychiatric
Association's (2000) Diagnostic and Statistical Manual of Mental
Disorders is generally used as the basis for diagnosing mental,
substance use, and cognitive disorders. The DSM allows for
recording an individual's co-occurring disorders, including
health problems related to or necessary for understanding or
managing these disorders. The American Association on
Mental Retardation, which in 2006 changed its name to the
American Association on Intellectual and Developmental
Disabilities, also recommends a multidimensional diagnostic,
classification, and assessment system. This system allows for
classifying the individual's intellectual functioning and
includes etiological risk factors and physical and mental
health considerations (Luckasson et al., 2002).

Frequency or Prevalence. A recent, major effort to
determine the incidence, prevalence, and co-occurrence of
mental disorders (including substance use disorders) in the
United States is the National Comorbidity Survey
Replication (NCS-R) funded by NIMH. According to the
NCS-R, 26% of the noninstitutionalized population had at
least one mental disorder in the last 12 months; 55% of
those identified as having mental disorders had a single
diagnosis, 22% had two diagnoses, and 23% had three or
more diagnoses (Kessler, Chiu, Demler, Merikangas, &
Walters, 2005). Those with two or more diagnoses
represent nearly 12% of the noninstitutionalized
population. This 12% figure may underestimate the total
population prevalence of co-occurring mental disorders for
various reasons; for example, the institutionalized
population most likely has a higher incidence of
co-occurring disorders, and community residents may be
reluctant to report symptoms of mental illness (Kessler et
al., 2005).
Whitaker and Read's (2006) analysis of the literature
suggests that children with intellectual disability and
adults with severe intellectual disability have higher
rates of psychiatric (mental) disorders than the general
population (they found no convincing evidence that
adults with mild intellectual disability have higher rates
of psychiatric disorders). The literature also suggests
that many mental and physical (medical) disorders are
closely related (for example, Carney, Jones, & Woolson,
2006;Sederer, Silver, Mcveigh, & Levy, 2006).
Etiological Explanations. of Comorbidity
Information about the nature and extent of co- occurring
conditions is useful for prevention and treatm ent, but in
many cases, the reason or reasons some people develop
multiple disorders are not clear. Khantzian (1997) has
suggested that people with mental disorders abuse alco-
hol or other drugs in an attempt to alleviate distressing
symptoms of these disorders, "primarily in regulating
affects, self-esteem, relationships, and self- care," but he
notes that evidence has not consistently supported this
self-medication hypothesis (p. 231). Other theories
suggest that mental and substance disorders may have a
common etiology (such as genetic factors), the relation-
ship between disorders is reciprocal or bidirectional, or
one type of disorder increases risk for the other (Mueser,
Drake, & Wallach, 1998), though mental disorders often
precede substance use disorders rather than vice versa
(Kessleret al., 1996). Mueser et al. (1998) also find
support for the theory that people with severe mental
illness use alcohol and drugs for the same reasons that
others do-in an attempt to alleviate dysphoria.
For people with intellectual disability, hypotheses
are that brain pathology, "poor understanding of one's
COMORBIDITY
403
own emotions or poor self-esteem," may be the predis-
posing factor for psychiatric disorders (Whitaker &
Read, 2006, p. 342). The relationships between co-
occurring medical and mental illnesses may also be
explained in a number of ways. For example, those with
some mental illnesses such as depressive disorders are
more likely to develop particular medical illnesses such
as heart disease, and those with medical illnesses such as
diabetes are more likely to be depressed (Sederer et al.,
2006). Additional explanations for the relationship
between mental and medical illnesses are that smoking
and alcohol and drug disorders, which can lead to
serious health problems, are; more cominon among
those with mental illness; those with mental illness may
have greater difficulty adhering to medical treatment
regimens, increasing the likelihood of medical prob-
lems; and indications are that "novel antipsychotic
medications are associated with complications such as .
obesity, high blood glucose levels, and diabetes"
(Sederer et al., 2006).
Treatment
Recovery from or management of multiple illnesses or
disorders may be more difficult than recovery from or
management of a single disorder (for example, Drake &
Mueser, 2000). Separate and distinct groups of provid-
ers generally treat mental disorders, substance use dis-
orders, intellectual disability, and medical illnesses.
Individuals with co-occurring disorders (or their repre-
sentatives) may find it difficult to negotiate multiple
service providers due to their mental, intellectual, andl
or physicaldisabilities or disorders. Treatment provid ers
from different fields of practice may also have different
treatment approaches or philosophies. For example,
treatment of mental and medical illnesses and
intellectual disability has historically been expert based
(physicians or other professionals prescribe a treatment
or service plan), while approaches to addressing sub-
stance use disorders evolved from the mutual-help
movement Alcoholics Anonymous. To reduce the dif-
ficulties clients face in negotiating multiple social ser-
vice and health care systems that may embrace different
and even conflicting philosophies of service provision,
social workers have supported the concept of integrated
treatment. Integrated treatment combines services for
co-occurring disorders in a unified plan with services
often provided by a single treatment team (for example,
Blankertz & Cnaan, 1994; DiNitto, Webb, & Rubin,
2002; Jerrell & Ridgely, 1995).
Controlled studies have not consistently shown that
integrated treatment for people with mental and sub-
stance use disorders produces superior outcomes com-
pared to standard approaches (treatment as usual) or
404 COMORBIDITY
other comparison treatments (see DiNitto & Webb, 2005).
An evidence-based systematic review published by the
Cochrane Collaboration also did not find support for
integrated treatment over standard care (Jeffery, Ley,
McLaren, & Siegfried, 2007). Nevertheless, integrated
treatment, sometimes provided through case management
models, can make it easier for cli ents to access assistance
for the multiple problems they face (DiNitto & Webb,
2005). An integrated or multidimensional and
multidisciplinary treatment approach has also been
advocated for people with intellectual disability and
mental health problems (for example, Dosen, 2007), and
there is a callto integrate treatment for medical and mental
illnesses (Sederer et al., 2006). Integrated treatment often
requires that service delivery systems as well as individual
treatment providers change the way services are delivered
(DiNitto & Webb, 2005; Sederer et al., 2006).
Future Considerations
Given social work's focus on clients' biopsychosocial
well-being, social workers are concerned about prevent-
ing, recognizing, and addressing co- occurring disorders.
The concept of integrated treatment for co- occurring
disorders is highly consonant with social work practice
and speaks to the continuing need to see clients holis-
tically. The future for treatment of comorbidity (co-
occurring disorders) suggests that social workers will
work more frequently in integrated services systems that
can address the complexities of mental, cognitive,
substance use, and health disorders. Public and private
medical (including mental health) insurance must also
respond to clients' or patients' multiple needs. Future
research will focus on identifying effective health care
systems and practices that can help clients with multi ple
diagnoses. Social work education must respond with
courses that better prepare graduates with the techno-
logical advances necessary to assist clients with
co-occurring disorders.
REFERENCES
AmericanPsychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington,
OC: Author.
Blankertz, L. E., & Cnaan, R. A (1994). Assessing the impact of
two residential programs for dually diagnosed homeless
individuals. Social Service Review, 68, 536-560.
Carney, C. P., Jones, J., & Woolson, R. F. (2006). Medical
comorbidity in women and men with schizophrenia: A
population-based controlled study. Journal of General In-
ternalMedicine, 21,1133-1137.
Center for Substance Abuse Treatment. (2005). Substance abuse
treatment for persons with co-occurring disorders (Treatment
Improvement Protocol (TIP) Series 42. DHHS Publication
No. (SMA) 05-3992). Rockville, MD: Substance Abuse and
Mental Health Services Administration.
. DiNino, D. M., & Webb, D. K. (2005). Substance use disorders
and co-occurring disabilities. In C. A McNeece & D. M.
DiNitto (Eds.), Chemical dependency: A systems approach (3rd
ed., pp. 423-483). Boston: Allyn & Bacon.
DiNitto, D. M., Webb, D. K., & Rubin, A (2002). Effectiveness of
an integrated treatment approach for clients with dual
diagnoses. Research on Social Work Practice, 12,621-641.
Dosen, A. (2007). Integrative treatment in persons with intellectual
disability and mental health problems. Journal of InteUectual
Disability Research, 510),66-74.
Drake, R. E., & Mueser, K. T. (2000). Psychosocial approaches to
dual diagnosis. Schizophrenia BuUetiit, 26, 105-118.
Graziano, A M. (2002). DeveloJmle11tal disabilities: Introduction to a
diverse field. Boston: Allyn & Bacon.
Jeffery, D. P., Ley, A., McLaren, S., & Siegfried, N. (2007).
Psychosocial treatment programmes for people with both
severe mental illness and substance misuse. Cochrane Database
of Systematic Reviews, 2. Retrieved July 2, 2007, from
http://www .cochrane.org/reviews/en/abOO 1 088.html
Jerrell, J. M., & Ridgely, M. S. (1995). Comparative effectiveness
of three approaches to serving. people with severe mental
illness and substance abuse disorders. Journal of Nervous and
Mental Disease, 183,566-576.
Kessler, R. c., Chiu, W. T., Demler, 0., Merikangas, K. R.,&
Walters, E. E. (2005). Prevalence, severity, and comorbidity
of 12~month DSM-N disorders in the National Comorbidity
Survey Replication. Archives of General Psychiatry, 62, 617-627.
Kessler, R. c., Nelson, C. B., McGonagle, K. A, Edlund, M. J.,
Frank, R. G., & Leaf, P. J. (1996). The epidemiology of co-
occurring addictive and mental disorders: Implications for
prevention and service utilization. American Journal of
Orthopsychiatry, 66(1),17-31.
Khantzian, E. J. (997). The self-medication hypothesis of substance
use disorders: A reconsideration and recent applications.
Harvard Review of Psychiatry, 4, 231-244.
Luckasson, R., Borthwick-Duffy, S., Buntinx, W. H. E., Coulter, D.
L., Craig, E. M., Reeve, A, et al. (2002). Mental retardation:
Definition, classification, and systems of supportS (10th ed.).
Washington, DC: American Association on Mental
Retardation.
Mueser, K. T., Drake, R. E., & Wallach, M. A. (1998). Dual
diagnosis: A review of etiological theories. Addictive Behaviors,
23, 717-734.
Sederer, L. I., Silver, L., McVeigh, K. H., & Levy, J. (2006, April).
Integrating care for medical and mental illness. Preventing
Chronic Disease: Public Health Research, Practice, and Policy,
3(2). Retrieved April 5, 2006, from http://www.
cdc.gov/pcd/issues/2006/apr/05 _0214.htm
Whitaker, S., & Read, S. (2006). The prevalence of psychiatric
disorders among people with intellectual disabilities:
An analysis of the literature. Journal of Applied Research in
Intellectual Disabilities, 19,330-345.

SUGGESTED LINKS Dual Recovery
Anonymous. http://draonJine.orgj
Journal of Dual Diagnosis.
http://www.hawOTthpress.com!store/product.asp?sid.= NMLBR.
QASQEP]8G]ET9FPR567CB9N2W9D&sku=]374& AuthType= 4
National Association for the Dually Diagnosed (NAADD).
http://www.thenadd.orgj
National Comorbidity Survey and the National Comorbidity
Survey Replication. http://www.hcp.med.harvard.edu/ncs/index.php
Substance Abuse and Mental Health Services Administration.
http://www .samhsa.gov/
-DIANA M. DINITTO
COMPLEXITY THEORY. See Chaos Theory and
Complexity Theory.
COMPULSIVE BEHAVIORS
ABSTRACT: Seeking gratification through the
reckless response to impulses denotes an impulse
control problem. When impulses produce anxiety
and individuals attempt to reduce this by rigidly
applying mental or behavioral routines, they
experiencecompulsion problems. Fire- setting,
stealing, gambling, excessive sexual activity, and
shopping are some of the specific behav iors
typifying these problems. Treatments commonly
used in addressing these problems include pharma-
cological agents, typically serotonin reuptake
inhibitors, as well as behavioral and
cognitive-behavioral psychotherapies.
KEY WORDS: impulse control disorders (ICDs);
obsessive-compulsive disorder (OCD); gambling;
kleptomania; pyromania; Internet addiction
Everyone has impulses, and everyone responds to these
impulses. Problems emerge when individuals are unable to
resist impulses, drives, or temptations to perform acts that
are harmful tothe individual or others (American
Psychiatric Association, 2000). A failure to heed signs of
risk or danger, and an inability to delay gratification are
indications of impulse control problems (Hollander, Baker,
Kahn, & Stein, 2006). "Impulsivity" relates to one's being
predisposed to rapid, unplanned reactions to impulses
stimuli without regard to negative consequences of these
reactions. Three dimensions of impulsivity include
cognitive (lack of planning), emotional (inability to delay
gratification), and moral processing (lack of empathy and
conscience).
COMPULSIVE BEHAVIORS 405
Specific impulse-control disorders (ICDs) identified in
the DSM,IV,TR include intermittent explosive dis, order,
pyromania, pathological gambling, kleptomania, and
trichotillomania. Additional ICDs related to ex, cessive
Internet use, video gaming, sex, self-injurious behaviors,
and compulsive shopping are included in the "not
otherwise specified" category of ICDs in the DSM (APA,
2000). While impulse control is the central issue in these
disorders, impulsivity is symptomatic of a number of
additional problems, including: conduct disorders, binge
eating disorder, paraphilias, attention, deficit hyperactivity
disorder, cluster B personality dis, orders, bipolar
disorders, and some substance abuse disorders (APA,
2000). Consequently, identifying ICDs is predicated on
their not being better-explained as symptoms of medical
problems or other mental health problems (APA, 2000).
Compulsion-related disorders include obsessive,
compulsive disorder, obsessive-compulsive personality
disorder, anorexia nervosa, and body dysmorphic disorder
(Hollander & Rosen, 2000). These disorders are
characterized by a person's experiencing intrusive or
persistent thoughts about something (obsessions) or
performing ritualized repetitive behaviors or mental acts (
compulsions) in response to impulses. These responses are
abnormal because of the individual's employing rigid
cognitive schema and behavior patterns to limit or reduce
perceived threats or risks provoked by impulses.
Some conceptualize impulse-control and compulsivity
problems on a continuum, with persons experiencing the
former undervaluing harm (or risk) related to their
responding to impulses, and the latter over, exaggerating
this harm (Hollander, 1993; Steketee & Neziroglu, 2003).
Individuals at both ends of this con, tinuum experience
difficulties because of their inability to curtail repetitive
behaviors (Stein, Hollander, & Liebowitz, 1993).
Hollander et al. (2006) have suggested that a decreased
ability to respond to affective states in "normal" ways
characterizes both groups, and that persons may experience
impulse-control problems initially followed by compulsive
behaviors as a means of reducing anxiety felt because of
this decreased ability to deal with their affective states.
Although space con, straints do not allow for the discussion
of the etiology of these disorders here, readers are directed
to Fong (2005) for a concise Powerpoint presentation on
the causes of ICDs, emphasizing the neurobiological basis.
Prevalence
The National Comorbidity Survey Replication study sug-
gests lifetime prevalence rates of 25% and 9% for per, sons
experiencing symptoms within the past 12 months
406 COMPULSIVE BEHAVIORS
for lCDs, making these among the most prevalent of all
mental health disorders (Kessler, Berglund, Demler, jin, &
Walters, 2005; Kessler, Chiu, Demler, & Walters, 2005).
This study also found that lCDs have a greater proportion
of respondents being seriously debilitated than either
anxiety disorders or substance use disorders.
Obsessive-compulsive disorder has 12-month and lifetime
prevalence rates between 1.5% and 3% in the general
population (Kamo & Golding, 1991; Kessler et al., 2005).
Prevalence rates for kleptomania and gambling appear
to be higher than the other specified problems;
"unspecified" impulse disorders have lower prevalence
rates than those that are specified. Increased exposure to
venues where gambling or shopping take place (states with
legalized gambling, shopping network television stations,
et cetera) are thought to increase prevalence rates for
related lCDs. Prevalence rates for some lCDs, such as
sexual compulsions and problematic Internet use, are
unknown. Inwardly directed behaviors (bulimia,
kleptomania, trichotillomania, and impulsive shopping)
are more prevalent in females; outwardly directed
behaviors (intermittent explosive disorder, pyromania,
sexual compulsions, and pathological gambling) are more
prevalent in males.
Comorbidity
The most common comorbid disorders for all lCDs are
substance abuse, affective disorders, and anxiety disorders.
For instance, commonly coexisting with gambling lCD are
substance abuse (primarily alcohol), major depression,
obsessive-compulsive disorder, and ADHD. High
comorbidity exists between obsessive-compulsive disorder
and phobic disorder, major depressive disorder, and
substance abuse (Roth & Fonagy, 2005).
Diagnosis and Assessment
lCDs are typically diagnosed through informal interview-
ing or with structured clinical interviews using DSM- lV-
TR criteria (Grant, Mancebo, & Pinto, 2006). The Barratt
Impulsiveness Scale, version 11 is popular for evaluating
impulsivity. It includes three dimensions: thrill-seeking,
nonplanning, and disinhibited behavior (Flory et al., 2006).
Some instruments are available to measure specific lCDs,
such as the Ke1ptomania Syrup-
. tom Assessment Scale (K-SAS). Despite growing interest
in examining whether nonsubstance-related behaviors
such as gambling, sex, or video-gaming should be con-
sidered addictions, they are not currently so-considered.
The Yale-Brown Obsessive-Compulsive Scale is a popular
measure for obsessive-compulsive disorder, and has been
modified to capture the severity of some specific lCDs as
well (Steketee & Neziroglu, 2003).
Individuals may overestimate or underestimate the
extent of their lCD symptoms and impairment during
assessments, so it is prudent to seek outside sources to
corroborate this information. Childhood trauma is
associated with impulsivity among adults, so this should be
explored. Current stress in the client's life should be
explored, as this may provoke impulsive
responses-particularly aggression. Although specific
cultural associations with lCD have not been noted,
exploring the .individual's personal explanatory mod-
el-how he or she understands their behavior-may be useful.
Finally, simply engaging in gambling, frequent shopping,
or hair-pulling behaviors are not indicative of lCDs;
impulsivity related to these behaviors is the necessary
hallmark for lCDs.
Best Practices
There is much more, and better research on the treatment
of obsessive-compulsive disorder than is available for
lCDs. In general, findings suggest that pharmacological
agents are considerably more effective in the short term
than they are in the long term. Serotonin Reuptake
Inhibitors (SSRIs) seem to be the most effective
pharmacological agents for both lCDs and obsessive-
compulsive disorder (see Figgitt & McClellan, 2000).
Behavioral interventions and cognitive interventions
appear to be the psychosocial treatments of choice for
lCDs, as they have the greatest long term effectiveness (see
Stein, Harvey, Seedat, & Hollander, 2006).
"Brainphysics" and the National Institute of Mental
Health Web sites are recommended for information about
treatment for lCDs that is suitable for lay persons.
Comprehensive reviews of literature for specific lCDs are
found in Dell'Osso, Altamura, Allen, Marazziti, and
Hollander (2006) and the Clinical Manual of ImpulseControl
Disorders (Hollander & Stein, 2006), from which much of
the following summaries were derived:
INTERMlTTENT,ExPLOSIVE DISORDER SSRIs have
produced the strongest response among pharmaceutical
agents; mood-stabilizing drugs have shown positive
benefits as well. Psychotherapy studies are limited, but
suggest that relaxation-training may be as effective as
relaxation combined with cognitive-behavioral inter-
ventions. An overview of the problem and intervention
strategies can be found at http://www.apa.orgjpubinfoj
anger .htrnl.
SEXUAL COMPULSIONS Pharmacotherapy is com-
monly used to treat these disorders. Two common ap-
proaches are to reduce testosterone levels in males,
typically with synthetic progesterones, and the use of
SSRls. CBT and 12-step programs are the psychotherapies
of choice for treating sexual compulsions.

BINGE EATING DISORDER (BED) In reviewing treatment
literature on BED, McElroy and Kotwal (2006) suggest that
tricyclic antidepressants and SSRIs have shown positive
effects with BED and bulimia. FIuoxetine is the only drug
currently approved by the U. S. Federal Food and Drug
Administration for binge eating. Behavioral therapies appear
to have only shortterm effects on BED. CBT and interpersonal
therapy OPT) have been shown to be effective with BED for
extended periods of time; CBT is thought to be the
psychotherapy treatment of choice for BED.
TRICHOTILLOMANIA SSRIs have not shown long-term
effectiveness. Behavioral interventions have shown the
greatest effectiveness. Specifically, response-prevention and
habit reversal training techniques have been most effective
(Neziroglu, Stevens, Liquori, & Yaryura- Tobias, 2000;
Penzel, 2003). The lack of well-controlled studies on CBT
temper positive outcomes noted for this treatment option.
KLEPTOMANIA Serotonin reuptake inhibitors (SRls) appear
to be the most effective drug for this disorder, but no
controlled studies have been done (Dannon, 2002). Behavioral
therapy, specifically aversion and desensitization techniques,
have shown the most prornise among psychotherapies for this
ICD.
PYROMANIA Behavioral interventions appear to be the
treatment of choice, although rigorous studies of intervention
for this problem are absent. No pharmacological interventions
have been sufficiently tested to warrant consideration for this
problem.
COMPULSIVE SHOPPING Cognitive behavioral therapies,
particularly when conducted in groups, have been effective in
treating this disorder. In vivo desensitization, relaxation,
visualization exercises, and cognitive restructuring techniques
are especially recommended (Black, 2006).
Psychopharmacological treatments have produced mixed
results; although SSRls have shown positive results, similar
responses have been noted in control (placebo-receiving)
groups of these studies. Financial counseling or rDstep
p~ograms may be helpful to persons experiencing this
disorder.
COMPULSIVE GAMBLING Many persons seeking pro-
fessional help for this disorder present with substance abuse
problems as well, and treatment for gambling is often
secondary to treating the substance abuse problem. The most
common psychosocial intervention is selfhelp groups,
specifically Gamblers Anonymous (see
http://www.gamblersanonymous.org). Pallanti, Rossi, and
Hollander (2006) indicate that this intervention
CoMPULSIVE BEHAVIORS
407
may not be effective without additional treatment
supplementing it. Especially problematic are reported dropout
rates in excess of 70% within the first year (Moody, 1990).
Cognitive, behavioral, and cognitivebehavioral interventions
show promise with this problem, but no rigorous studies have
been done on these interventions with this population to date.
SSRls, serotonin antagonists, and mood stabilizers have
shown promising results with compulsive gamblers, although
these results are not conclusive. Of note, it appears that
dosages of SSRIs need to be higher than those used for cases
of depression to produce positive effects in pathological
gambling cases. The preferred treatment option is a
combination of medication and psychotherapy.
PROBLEMATIC INTERNET USE This problem is char-
acterized by one's inability to limit use of the Internet, to be
addicted to it. No pharmacological treatments have
demonstrated effectiveness with this only recently identified
disorder. Neither have psychotherapies been tested with it.
CBT and behavior therapies appear to be the interventions of
choice.
OBSESSIVE,COMPULSIVE DISORDER Serotonin reup-
take inhibitors have been found routinely efficacious in OCD.
Tricyclic antidepressants have also been used effectively to
treat OCD. However, SSRIs are the first pharmacological
option for OCD because of their exhibiting fewer side effects
than other forms of antidepressants. The psychosocial
treatment of choice for addressing obsessivecompulsive
disorder is exposure with response prevention (see Beidel,
Turner, & Alfano, 2003). Cognitive interventions are also
effective, but there are inconsistent findings regarding their
sustainability in head-to-head studies between the CBT and
exposure-response prevention (Beide1 et al., 2003; Roth &
Fonagy, 2005; Van Noppen, Himle, & Steketee, 2007).
[See also Eating Disorders.]
REFERENCES
American Psychiatric Association. (2000). Diagnostic and sta-
tistical manual of mental disarders (4th ed., Text Revision).
Washington, DC: American Psychiatric Association.
Beidel, D. C, Turner, S. M., & Alfano, C. (2003). Anxiety
disorders. In M. Hersen & S. M. Turner (Ede.), Adult psy-
chopathology & diagnosis (4th ed., pp. 613-650). New York:
Wiley.
Black, D. V. (2006). Compulsive Shopping. In E. Hol1ander
& D. Stein (Eds.), Clinical manual of impulse-control
disorders (pp. 203-228). Arlington, VA: American
Psychiatric Publishing.
Dannon, P. N. (2002). Kleptomania: An impulse control dis-
order? International Journal of Psychiatry in Clinical Practice,
6,3-7.
408 CoMPULSIVE BEHAVIORS
Dell'Osso, B., Altamura, A. c., Allen, A., Marazziti, D., &
Hollander, E. (2006). Epidemiologic and clinical updates on
impulse control disorders: A critical review. European Archives
of Psychiatry and Clinical Neuroscience, 256(8), 464-475.
Figgitr, D. P., & McClellan, K. J. (2000). Fluvoxamine: An
updated review of its use in the management of adults with
anxiety disorders. Drugs, 60(4), 925-954.
Flory, J. D., Harvey, P. D., Mitropoulou, V., New, AS., Silverman,
J. M., & Siever, L. J., et al. (2006). Dispositional impulsivity in
normal and abnormal samples. Journal of Psychiatric Research,
40(5), 438--447.
Fong, T. W. (2005). Neurobiological basis of impulse control
disorders. Addiction medication clinic, Seminars in addiction.
Retrieved November 26, 2007, from htrp://www.uclaisap. org!
AddClinic/documents/po,\,erPoint/2005/Neurobiol%20
of%20lmpulsivity%20-%20Fong.ppt#266,1
Grant, J., Mancebo, M., & Pinto, A (2006). Impulse control
disorders in adults with obsessive compulsive disorder.journal
of Psychiatric Research, 40(6),494-501.
Hollander, E. (1993). Obsessive compulsive related disorders.
Washington, DC: American Psychiatric Press.
Hollander, E., Baker, B. R., Kahn, J., & Stein, 0. J. (2006).
Conceptualizing and assessing impulse-control disorders. In E.
Hollander & b. Stein (Eds.), Clinical manual of impulsecontrol
disorders (pp. 1-15). Arlington, VA: American Psychiatric
Publishing.
Hollander, E., & Rosen, J. (2000). Obsessive-compulsive
spectrum disorders: A review. In M. Maj, N. Sartorius, A
Okasha, & J. Zohar (Eds.), Obsessive-compulsive disorder (pp.
203-252). New York: John Wiley & Sons Ltd.
Karno, M., & Golding, J. (1991). Obsessive-compulsive disorder.
In L. N. Robins & D. A Regier (Eds.), Psychiatric disorders in
America: The epidemiologic catchment area study (pp. 204-219).
London: Free Press.
Kessler, R. c., Berglund, P. A., Demler, 0., jin, R., & Walters, E.
E. (2005). Lifetime prevalence and age-ofonset distributions of
DSM-IV disorders in the National Comorbidity Survey
Replication (NCS-R). Archives of General Psychiatry, 62(6),
593-602.
Kessler, R. c, Chiu,W. T., Demler, 0., & Walters, E. E. (2005).
Prevalence, severity, and comorbidity of twelvemonth
DSM-IV disorders in the National Comorbidity Survey
Replication (NCS-R). Archives of General Psychiatry,
62(6),617-6].) .. ;
McElroy, S. L.,. G. 'Kotwal, R. (2006). Binge eating. In E.
Holl~nder & 0. Stein (Eds.), Clinical manual of impulsecontrol
disorders (pp. 115-148). Arlington, VA: American Psychiatric
Publishing.
Moody, G. (1990). Quit compulsive gambling. London: Thorsons.
Neziroglu, F. A., Stevens, K. P., Liquori, B., & Yaryura-Tobias, J.
(2000). Cognitive and behavioral treatment of
obsessive-compulsive spectrum disorders. In W. Goodman, M.
Rudorfer, & J. Maser (Eds.), Obsessive-compulsive disorder:
Contemporary issues in treatment (pp. 233-255). Mahwah, NJ:
Erlbaum.
Pallanti, S., Rossi, N. B., & Hollander, E. (2006). Pathological
gambling. In E. Hollander & D. Stein (Eds.), Clinical manual
of impulse-control disorders (pp. 251-289); Arlington, VA:
American Psychiatric Publishing.
Penzel, F. (2003). The hair-pulling problem: A complete guide to
trichotillomania. New York: Oxford University Press.
Roth, A, & Fonagy, P. (2005). What works for whom? (2nd 00.).
New York: Guilford Press.
Stein, D. J., Harvey, B., Seedat, S., & Hollander, E. (2006).
Treatment of impulse-control disorders. In E. Hollander & 0.
Stein (Eds.), Clinical manual of impulse-control disorders (pp.
309-322). Arlington, VA: American Psychiatric Publishing.
Stein, D. J., Hollander, E., & Liebowitz, M. R. (1993). Neuro-
biology of impulsivity and the impulse-control disorders.
Journal of Neuropsychiatry and Clinical Neuroscience, 5, 9-17.
Steketee, G., & Neziroglu, F. (2003). Assessment of obsessive-
compulsive disorder and spectrum disorders. Brief Treatment
and Crisis Intervention, 3(2), 169-186 .'
Van Noppen, B., .Himle, J. A., & Steketee, G. (2007). Obses-
sive-compulsive disorder. In B. A. Thyer & J. S. Woodarski
(Eds.), Social work in mental health: An evidence-based approach
(pp. 377-400). New York: Wiley.
FURTHER READING
Abramowitz, J. S., & Schwartz, S. A. (2003). Evidence-based
treatments for obsessive-compulsive disorder. In A. R.
Roberts & K. R. Yeager (Eds.), Evidence-based practice manual:
Research and OUtcome measures in health and human services (pp,
274-281). New York: Oxford University Press.
Webster, C. D., & Jackson, M. (Eds.). (1997). Impulsivity:
Perspectives, Principles & Practice. New York: Guilford Press.
SUGGESTED LINKS
American Psychiatric Association.
http://www .apa.org/pubinfo/anger .html
American Psychiatric Association.
http://www.psych.org
Brainphysics.
http://www.brainphysics.com/therapy .php Gamblers
Anonymous International Service Office. http://www
.gamblersanonymous. org/
National Institute of Mental Health.
http://www.nimh.nih.gov
Trichotillomania Learning Center.
http://www.trich.org
-GORDON
MACNEIL
CONFIDENTIALITY AND PRIVILEGED
COMMUNICATION
ABSTRACT: Confidentiality of client communications is one of
the ethical foundations of the social work profession and has
become a legal obligation in most states. Many problems arise in
the application of the

principles of confidentiality and privilege to the profes-
sional services provided by social workers. This entry
discusses the concepts of client confidentiality and
privileged communications and outlines some of the
applicable exceptions. While the general concept of
confidentiality applies in many interactions between
social workers and clients, the application of confiden-
tiality 'and privilege laws are particularly key to the
practice of clinical social workers in various practice
settings.
KEY WORDS: client confidentiality; Jaffee v. Red, mond;
privileged communication; HIP AA; privilege;
psychotherapy
History of Confidentiality and Privilege Social
workers have traditionally incorporated adherence to the
principles of client privacy and confidentiality into their
work (N ational Association of Social Workers
[NASW], 2006). The concept of commitment to client
confidentiality was specifically outlined in the NASW
Code of Ethics in 1979 (NASW, 1979). The provisions
regarding privacy and confidentiality were greatly
expanded in the 1996 Code Revisions (NASW, 1996).
Where previously there were five subsections (NASW,
1994), there are now 18 (NASW, 1999). They address
such issues as consent, exceptions to con sent, group and
family confidentiality, disclosures to third- party payers,
disclosures in court proceedings, pro~ tection of
electronic records and information, disposal of records,
use of information in training, and confidentiality for
deceased clients.
Although the issue of confidentiality often arises in
the context of communications between the clinical
social worker and the client, it applies to a number of
other areas in which the social worker provides
professional services. For example, under 5.02(1) of
the 1999 Code of Ethics, social workers who are en-
gaged in evaluations or research should "ensure the
anonymity or confidentiality of participants and of the
data obtained from them." Participants also must be
advised of any limits on this confidentiality. The duty of
the social worker to keep the confidences of a client is
reinforced by the fact that a violation of the Code of
Ethics can be based on the social worker's failure to do
so. In addition, inappropriate disclosure of a client's
confidences can be grounds for a malpractice suit for
breach of confidentiality (Dawkins v. Richmond
Community Hasp., 1993), a breach of contract (Martino
v. Family Service Agency of Adams County, 1982), or a
licensure board complaint (Petition of Sprague, 1989).
CoNFIDENTIALITY AND P1uvILEGED COMMUNICATION 409
Scope of Confidentiality Confidentiality
is defined for social workers in several key places:
-The NASW Code of Ethics
- State licensing laws
- State & federal alcohol and drug treatment laws
- HIP AA regulations and other federal statutes
- Case law.
Confidential communications must occur in a setting in
which privacy is reasonably expected. This would
generally be in the course of consultation, diagnosis, or
treatment and would also include eligibility determi-
nations, referral information, andchart reviews. From a
professional ethical standpoint, all documentation and
information related to or obtained from a client or
patient should be viewed as confidential, whether or not
a specific law or regulation defines it as a confiden tial
medical record.
Obtaining the Client's Consent
In an ethical sense, a breach of confidentiality involves
the release of confidential information about a client
without that client's informed written or oral consent. In
a legal sense, a breach of confidentiality involves the
violation ofa statutory, regulatory, or common law
requirement to maintain the confidentiality of a client's
information and records. There is no breach of confi-
dentiality if the client has consented to the release of
information within the specific circumstances. An ap-
propriate release may be obtained at the commencement
of treatment to permit records or reports to be sent to an
insurance company, referring physicians, or other likely
third-party requesters who have a professignal need to
know the information. The client should be made aware
of the scope and intent of the release.
Many states have legislated or developed through
case law certain exceptions to the rule of confidential-
ity. Whenever a situation requires the nonconsensual
release of information about a client, the social worker
should document the factual circumstances that require
the release and the ethical and legal bases supporting a
professional judgment compelling release of informa-
tion or records without the client's consent ..
HIP AA Privacy Regulations
A set of comprehensive federal regulations addressing
the privacy of medical records (the "Privacy Rule") was
promulgated under the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA"). Clinical social
workers are subject to the Privacy Rule if they work in a
setting where electronic billing or claims processing are
used. The Privacy Rule only compels
410 CONFIDENTIALIlY AND PRIVILEGED
COMMUNICATION

disclosure of confidential health information in two intending to reverse the Ewing outcome; however, the
instances: to the client and to the U.S. Department of courts have not interpreted these.
Health and Human Services (DHHS) for purposes of State laws today reflect a policy debate about what type
investigating alleged HIP AA violations. The Privacy Rule of threat triggers a duty to release confidential client
lists a large of number of permissible ex ceptions to information and fall into roughly three groups. Some states
confidentiality, but also provides that practitioners should (for example, Arizona, Delaware, and Washington)
follow state law if it is more protective of client privacy recognize a duty to warn when there is a general threat, a
than HIP AA. threat against the public at large, or a threat to a foreseeable
Social workers should be aware that heightened class of victims (Connecti cut). Other states (for example,
protection for psychotherapy notes under HIP AA is only Colorado, Kentucky, Louisiana, Massachusetts, Michigan,
available if the clinician's session notes are kept separate Nebraska, New Hampshire, and New Jersey) recognize the
from the client's primary clinical record or case file: The duty only against a specific threat to a readily identifiable
heightened privacy protection for psychotherapy notes is victim. The remaining states have yet to address the issue
twofold: (a) a separate' authorization to release the notes is or have not recognized any such duty at all (for example,
required \( 45 Code of Federal Reg' ulations [CFRJ Florida, North Dakota, Texas) or, although ostensibly
164.508(b)(3)), and (b) health plans and providers may recognizing such a duty, have yet to encounter a situa tion
not require clients to sign an author' ization to release in which they are willing to impose it (for example,
psychotherapy notes as a condition of providing treatment Alabama and Hawaii).
or coverage for treatment (45 CFR 164.508(b)(4)). The
HIPAA Privacy Rule provides federal acknowledgement
that mental health practitioners may keep a set of private CHILD ABUSE OR NEGLECT All states require a men-
psychotherapy notes, and provides additional protection tal health professional to report known or suspected
from routine disclosure of such notes. . cases of child abuse or neglect. These reporting laws
reflect the policy that protection of children supersedes the
preservation of the privacy of individuals. Report ing child
DUTY TO CONTROL OR WARN ABOUT A DANGER. abuse and neglect is generally protected by immunity
OUS PATIENT OR CLIENT In the landmark case, T from suit under state law (for example, California Penal
arasoff v. The Regents of the University of California (1976), Code 111 72,2007).
California was the first state to recognize the duty of a A majority of states have also enacted reporting laws
psychotherapist to release confidential client information designed to protect the interests of elderly, mentally or
in order to protect a third party from the foreseeable harm physically ill, or other classes of vulnerable or dependent
of the client. The California Supreme Court decided that adults (American Bar Association Commission on Law
the relationship between a psycho, therapist and a client in and Aging, 2006; Jogerst et al., 2003); for example, see
the outpatient setting was "special" so as to trigger the duty Massachusetts General Laws Annotated, Ch. 112, I 135A
to take protective action by releasing confidentia l (g) (2007). Social workers should be familiar with the
information about the client to those who are capable of reporting requirements mandated by the statutes in
preventing the threatened harm. In the psychotherapy their own states. The NASW Code of Ethics recognizes a
setting, controlling the client can include warning an duty to report child abuse as an exception to the general
outpatient's caregiver or family, involving the police, duty of client confidentiality.
warning the potential . victim, or involuntarily committing
the client. PREVENTING HARM TO THE CLIENT It is ethically
Four years after the T arasoff decision, the California understood, and confirmed by statute in a few states, that a
Supreme Court clarified the outside limits of the duty to therapist or social worker would ordinarily act to prevent
warn or take preventive action. In Thompson v. County of harm to the client (Connecticut General Statutes, 2007 ;
Alameda (1980) the court concluded that a duty to warn the Massachusetts General Laws Annotated, 2007). The
public at large of the presence of a potentially dangerous client's disclosure of suicidal intent, for example, may
person was neither practical nor likely to be effective. require contact with other professionals or the client's
Since then, an intermediate appellate court in California in family or action for involuntary commitment. Such action
the case, Ewing v. Goldstein (2004), expanded the duty to must be reasonable, professionally appropriate, and taken
warn to include threats of harm by a client that are in consideration of the client's particular circumstances.
communicated to the therapist by a third party, such as a If the client's situation requires involuntary com-
family member. The California legislature responded with mitment, it may be necessary to breach the client's
statutory amendments

1

CoMMUNICATION
confidentiality in the commitment process or during the
commitment hearing (Massachusetts General Laws
Annotated, 2007). This is generally allowed because
release of information about a client protects the client or
society from harm and is necessary because of the serious
nature of the client's condition.
HIV AND AIDS REPORTING An extensive body of
jurisprudence has been developed around the many legal
issues involving the acquired immune deficiency
syndrome (AIDS). However, confidentiality require,
ments remain inconsistent among the states. Although all
states now have some legislation relating to AIDS; many
do not directly address the issue of whether it is mandatory
or permissible to report a client's HIV (human immune
deficiency virus) positive or AIDS status to sexual or
needle-sharing partners ("contacts"). Cases involving high
risk to others should be discussed .with the client's treating
physician or other appropriate medical personnel to
determine who is in the best position to discuss the matter
with the client and the person at risk. Consultation with the
public health department is highly recommended before
any disclosure is made, because there may be a protocol in
place for such notifications.
ALCOHOL AND DRUG REHABILITATION
PROGRAMS RECEIVING FEDERAL FUNDS 42 CFR
2.1-2.67 contains specific rules outlining federal law that
provide limited circumstances for the release of
information from alcohol and drug treatment programs
that receive federal funds. Such treatment programs
should promulgate guidelines to protect the client's
confidentiality that are based on current federal law and
regula, tions. Generally, these records should only be
disclosed based on client consent or a court order, with
limited exceptions.
Privilege and the Release of a
Client's Information in Legal Proceedings Privileged
communication is an important subcategory or
characteristic of confidential communications. The
privilege is the client's legal right to keep certain com,
munications with the social worker private and not
available as evidence in legal proceedings, including
subpoenas of records, pretrial depositions or affidavits,
and testimony at trial.
The privilege against disclosure of confidential com,
munications in legal proceedings is a matter of public
policy. It is grounded in the community value that the
client should be confident that his or her innermost
thoughts can be revealed in confidence, without being
CONFIDENTIALIlY AND PRIVlLEGED
411
subject to public exposure (Jaffee v. Redmond, 1996), and
is intended to protect the client from humiliation,
embarrassment, or disgrace and to promote mental health
treatment. As such; it is a right of the client, not of the
social worker. Although the social worker is obligated to
assert the client's privilege when records or testimony are
demanded, if the client waives the privilege, the social
worker must accede (In re Lifschutz, 1970).
There are a number of exceptional situations in which
courts or legislatures have determined that priv ilege
should not apply or that a client, by bringing a certain type
of legal action, has waived his or her right to privilege. The
most widely accepted group of exceptions is again in the
area of protection of children. Most states make exceptions
to privilege in matters of child custody, adoption,
termination of parental rights, and the reporting of abuse
and neglect. In weighing the importance of admitting
confidential communications into evidence, courts will
consider whether there are other sources for similar
evidence that would make the confidential
communications reported in the clinical setting
duplicative.
A number of actions on the part of the client are
considered to be effective waivers of the privilege. Some
of these are generally accepted, bu t acceptance of others
varies from state to state. A written waiver or release
signed by a competent person in the context of a legal
proceeding is generally accepted as an effective waiver.
Independent disclosure by a client to a third party mayor
may not constitute a waiver, depending on the
circumstances and state law. Most states consider that the
client has waived the privilege when his or her mental
health is made an issue in either a civil or criminal case.
For example, in a civil case, if a patient is suing a third
party for pain and suffering or emotional distress, or suing
a social worker for malpractice, the client's records will
notbe held to be privileged because the content of the
records is central to the claim being adjudicated (Caesar v.
Mountanos, 1976).
The federal law of evidence was clarified by the U.S.
Supreme Court's decision in Jaffee v. Redmond (1996) to
confirm that clients' communications with licensed social
workers in the context of psychotherapy are privileged
communications under the federal rules of evidence.
Therefore these communications are generally not subject to
disclosure as evidence in the federal courts. The Supreme
Court's majority opinion accorded much weight to the fact that
the "psychotherapist privilege is rooted in the imperative need
for confidence and trust" (Jaffee at p. 1928 citing Tramel v.
U.S., 445 U.S. 40 (1980)). The Court contrasted the
physician's need for medical facts with the psychotherapist's
412 CoNFIDENTIALITY AND P!uVILEGED COMMUNICA nON

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414 CONFIDENTIALITY AND PRIVILEGED CoMMUNICATION
dependence on "an atmosphere of confidence and trust in
which the patient is willing to make a frank and complete
disclosure of facts, emotions, me mories and fears" (Jaffee,
p. 1928).
Statutes in 21 states and the District of Columbia grant
privilege to communications between clients and mental
health professionals. These "generic" privilege laws
generally consider communications with psychiatrists ,
psychologists, social workers, and any other listed
professionals to have equivalent importance and rights to
privacy. In 26 states, privilege is granted to social workers
as a profession, and separate statutes identify the privilege
granted to other mental health professions. However, in
Alaska and North Dakota courts or' legislatures have
explicitly denied any privilege to communications with
social workers; in Alabama social workers who meet a
narrow definition as "victim counselors" may have priv-
ileged client communications; and in Pennsylvania
privilege may apply only to social workers who act as
sexual assault victim counselors or who practice under the
supervision of a psychologist. The specific state-by state
breakdown is shown in Table 1.
Future Directions
The social work profession must work toward increasing
the universality and uniformity of state laws protecting
client confidentiality and privilege. The different uses of
terms of art and the lack of common agreement on
meanings can create confusion in applying general rules to
specific situations. Widl the Supreme Court's guid ance
in]affee v. Redmond and the protection to psycho therapy
notes provided in HIP AA, state legislatures should
recognize that the disparity in the protection of social
worker-client communications in particular, and
psychotherapist-patient privilege in general, is detri mental
to the treatment process. Thus, all state laws should follow
the federal sector in granting privilege d status to
communications between clients and their social worker
psychotherapists.
For social workers to better serve the needs of clients
and further the advancement of the profession, they must
become aware of the requirements of the state laws per,
taining to social workers. They and their allies must work
toward consistent treatment of licensed mental health
professionals based on the nature of the services provided.
[See also Bioethical Issues; Civil Rights; Clinical Social
Work; Ethical Standards in Social Work: The NASW Code
of Ethics; Ethics and Values; Human Rights; Legal Issues:
Confidentiality and Privileged Communi cation; Peace and
Social Justice; Professional Conduct; Professional
Liability and Malpractice.]
REFERENCES
American Bar Association Commission on Law and Aging.
(2006). Citations to adult protective services (APS), institutional
abuse and long term care ombudsman program (LTCOP) laws.
Prepared for the National Center on Elder Abuse [Online].
Retrieved November 19,2007, from http://www.
ncea.aoa.gov/NCEAroot/Main_Si te/pdf/publication/ APS%
20Statutes%20Citations.pdf
Caesar v. Mountanos, 542 F.2d 1064 (Cal. App. 1976) cert. denied,
97 S.Ct. 1598.
California Penal Code 11172 (Thomson/W est, 2007).
Connecticut General Statutes, 52-146q( c)(2) (Thomson!
West, 2007).
Dawkins v. Richmond Community Hosp., 30 Va. Cir. 'J77, Not
Reported in S.E.2d, 1993 WL 946057 vs.o-.o. 1993.
Ewing v, Goldstein, 15 Cal.Rptr.3d 864 (Ct. App. 2004).
45 CFR 164.508(b)(3; (b)(4) (current through March 15,
2007).
In re Lifschutz, 467 P.2d 557 (Cal. 1970).
Jaffee v, Redmond, 518 U.S. 1 (1996).
[ogerst, G. J., Daly, J. M., Brinig, M. F., Dawson, ]. D., Schmuch,
G. A., & Ingram, J. G. (2003). Domestic elder abuse and the
law. American Journal of Public Health, 93, 2131-2136 [Online].
Retrieved November 19, 2007, from http://www
.ajph.org/cgi/content/full/9 3/12/2131
Martino v. Family Service Agency of Adams County, 445 N.E.2d
6 (Ill. App. 4 Dist., 1982).
Massachusetts General Laws Annotated, Ch. 112 135A(g)
(Thomson/West, 2007).
National Association of Social Workers. (1979). NASW Code of
Ethics. Washington, DC: Author.
National Association of Social Workers. (1994). NASW Code of
Ethics. Washington, DC: Author.
National Association of Social Workers. (1996). N ASW Code of
Ethics. Washington, DC: Author.
National Association of Social Workers. (1999). NASW Code of
Ethics. Washington, DC: Author. [Online]. Retrieved
November 13, 2007, from www.socialworkers.org/pubs/
code/default. asp
National Association of Social Workers. (2006). Social work
speaks: NASW policy statements (7th ed.). Washington, OC:
Author.
Petition of Sprague, 564 A.2d 829 (N.H., 1989).
Tarasoff v. Regents ofUniv. of Cal., 551 P.2d 334 (Cal. 1976).
Thompson v. County of Alameda, 614 P.2d 728 (Cal. 1980).
FURTHER READING
Barbre, E. S., 50 A.L.R. 3d 563 (2007; Originally published in
1973). Annotation, Communications to social worker as priv,
ileged. Eagan, MN: Thomson/West.
Baytion, C. M. (1995). Toward uniform application of a federal
psychotherapist-patient privilege [Note & Comment].
Washington Law Review, 70, 153-175.
Cutter v. Brownbridge, 228 Cal. Rptr. 545 (Ct. App. 1986).
Knapp, S. J., & VandeCreek, L. (1987). Privileged communi-
cations in the mental health professions. New York: Van Nostrand
Reinhold.
J
:
,
J
Knapp, S. }., VandeCreek, L., & Zirkel, P. A. (1987). Privileged
communications for psychotherapists in Pennsylvania: A time
for statutory reform. Temple Law Quarterly, 60, 267-292.
McMunn v. Florida, 264 So. 2d 868 (Fla. App 1 Dist 1972).
National Association of Social Workers. (2005). NASW standanIs
far clinical social wark in social warkpraetice. Washington, DC:
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www.socialworkers.org/practice/default.asp
Perlman, G. L. (1988). Mastering the law of privileged com-
munication: A guide for social workers. Social Wark, 33,
425-429.
Reamer, F. (2006). Ethical standards in social wark. a review of the
NASWCode of Ethics. Washington, DC: NASW Press.
Shroeder, L. O. (1995). The legal environment of social wark.
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nolo.com/statute/index.cfm
-CAROLYN 1. POLOWY, SHERRI MORGAN, W.
DWIGHT BAILEY, AND CAROL GOREN BERG
CONFLICT RESOLUTION
ABSTRACT: Conflict resolution is a core competency
for social workers, and social workers have
contributed greatly to this thriving field. Conflict
resolution as a field of practice includes
mediation,facilitation, conflict coaching, dispute
system design and management, and arbitration.
Conflict professionals provide pre ventative,
restorative, substantive, procedural, and
decision-making services to people in conflict. The
use of conflict resolution processes is rapid ly'
growing in areas of traditional social work practice
such as child welfare, special education, family
counseling, care of the elderly, and medical care. This
is a tremendous potential growth area for social work.
KEY WORDS: conflict; dispute resolution; mediation;
negotiation; facilitation; communication; decision-
making; arbitration; coaching; system design
In many respects, the social work field has always been about
conflict. We deal with people who are in conflict with social
institutions, communities, their families, peers, and
themselves. One of our basic roles is to facilitate the
interaction between individuals and systems, and our
effectiveness is strongly connected to our ability to handle
conflict. Some of the key skills we bring to our work are
conflict skills. To discuss conflict and its resolution is
therefore to talk about what is at the heart of social work.
CoNFLICf REsOLUTION 415
Conflict resolution as a free-standing field has been
growing rapidly since the 1970 and social workers have been
an important part of that growth. Conflict specialists address
many of the same issues and work with many of the same
populations as social workers do, and social workers are often
participants in conflict resolution processes. But social work
as a professional field and as a set of professional institutions
has not fully embraced conflict resolution. Professional
training programs occasionally include a course in mediation
as an elective, but not as a core part of social work curriculum.
Although, the National Association of Social Workers
(NASW) adopted a set of practice standards for social work
mediators in 1991 (NASW, 1991), these have not been widely
disseminated or updated and are now basically unavailable.
Partly as a result of this, conflict resolution as a practice area
has become increasingly dominated by. other professions,
particularly law. This has meant that the field of social work
has not been enhanced by the conflict resolution field to the
extent that it could be, and that the field of conflict resolution
has not fully benefited from the experience and knowledge of
social work.
In this entry, the conceptual basis of conflict resolution as a
field is discussed, the range of its applications, particularly
insofar as they are relevant to the practice of social work, is
presented, and new applications of conflict resolution in social
work are described.
History
Conflict resolution is not a new endeavor. Examples of
informal and formal approaches to resolving interpersonal
conflict can be found throughout history, but as a recognized
field of practice, it is relatively recent. The modem conflict
resolution field originated with efforts to find less destructive
approaches to disputes between labor and management. The
U.S. Conciliation Service was established in 1918, the
National Mediation Board in 1926; the Federal Mediation and
Conciliation Services in 1947, and the Community Relations
Service of the U.S. Department of justice in 1964.
The conflict resolution field mushroomed in the late 1970s
and the early 1980s spurred on by a desire to deal with the
exploding divorce rate, the great increase in court filings for
civil suits, the increasing power of the environmental
movement, and the need to come up with systemic ways for
dealing with equal employment discrimination complaints,
and related matters. During those years many organizations
promoting the practice of conflict resolution were either
organized or took on anew scope (currently these include the
Association for Conflict Resolution, the Dispute Resolution
Section of the ABA, the International Association of
416 CoNFLICf REsOLUTION
Ombudsman, . and the International Academy of Col-
laborative Professionals). Federal policies also sup-
ported this growth, notably the requirement that federal
agencies appoint dispute resolution coordinators
promulgated by the Clinton administration and the
establishment of the U.S. Institute for Environmental
Conflict Resolution in 1994.
Academic institutions have embraced conflictreso-
lution as well. There are many (probably several hun-
dreds) conflict resolution programs in colleges and
universities in North America, and as many as 50
graduate programs in conflict management, mediation,
or related specialties. Mediation programs have found
their way into primary and secondary education, with a
proliferation of school-based, mediation and restorative
justice programs at virtually all levels of education.
In the past several years, this growth has leveled off.
There are a number of reasons for this, including a
change in focus since September 11th, 2001, the
maturing of the field, and the inevitability that demand
could not keep up with the growth of interest in
providing conflict resolution services. Nonetheless,
conflict resolution as a field of practice and as a
professional discipline is well estab lished, and it is
increasingly institutionalized in courts, public
education, business, academics, government agen cies,
and nonprofit organizations. Although the period of
rapid, even exponential growth may be over, conflict
resolution is a field that will continue to have a strong
presence in the areas that social workers care about.
Related Theory
Like social work, conflict resolution has drawn on many
fields to develop its basic intellectual and practical
skills. Conflict theory has evolved from the social
sciences; law, psychology, international relations, labor
relations, and communication. Social work as well has
had an important impact on the development of the field,
particularly in its focus on the relationship between
individuals and social systems .. Many conflict writers
have characterized the key knowledge and skill base of
conflict specialists (see, for example, Folberg, Milne, &
Salem, 2004; Mayer, 2004; Moore, 1996; Schneider &
Honeyman, 2006). Although these characterizations
vary greatly, the following areas of know 1edge seem
important.
THE NATURE OF CONFLICT Conflict appears in many
different forms and it is multidimensional. Conflict
specialists need to have a framework for understanding
what is really at the heart of a conflict. In one of the
foundational texts in the field, The Functions of Social
Conflict (Coser, 1956), Lewis Coser differentiates
between what he calls the nonnecessary
aspects of conflict (those elements of conflict related to
the need for acknowledgment and "venting" but not to
the need (or a specific outcome) and the necessary
aspects (those elements requiring a solution, outcome,
or agreement). In the most widely used text on medi-
ation, The Mediation Process: Practical Strategies for
Resolving Conflict (Moore, 1996), Moore describes five
components of conflict: relationships, data, interests,
values, and structure. Mayer (2000) suggests three
dimensions to conflict: behavioral, emotional, and cog-
nitive. He also identifies . layers of human needs that
motivate people in conflict, particularly survival, inter-
ests, and identity needs.
INDIVIDUAL APPROACHES. TO CONFLICf ENGAGEMENT
AND AVOIDANCE Conflict specialists work with indi-
viduals who take several different approaches to con-
flict. Discerning the implications of different styles of
engaging or avoiding conflict is therefore very impor-
tant. The most commonly used tool for assessing styles
is the Thomas Kilmann Inventory (Thomas, 1983;
Thomas & Kilmann, 1974). It identifs five primary
approaches to conflict depending on how oriented one
is to meeting one's own needs or accommodating those
of others. These are assertion, collaboration, compro-
mise, accommodation, and avoidance.
NEGOTIATION DYNAMICS Negotiation is a core conflict
resolution tool. Many dispute resolution processes are
oriented to helping people be effective negotiators.
Conflict specialists need to understand negotiation.
The most popular text on negotiation, Getting to Yes:
Negotiating Agreement Without Giving In (Fisher & Ury,
1981), was published in 1981, but is still the most widely
read book in the field. Fisher and Ury urge disputants to
"separate the people from the problem"; to focus on
interests (needs, concerns), not positions (demands or
desired outcomes); to look for principles that can frame an
agreement; and to develop one's "BA TNA" (best
alternative to negotiated agreement) as a means of
promoting one's influence in negotiation.
Others (Lax & Sebenius, 1986; Walton & McKersie,
1965) have suggested that negotiation occurs across two
different dimensions, distributive (dividing up a limited
resource) and integrative (accommodating a greater
range of interests by "expanding the pie"). Lax and
Sebenius suggest that the distributive strategies used to
"claim value," that is, distributive strategies, are
inevitably somewhat at odds with the integrative
approaches aimed at "creating value." Effective
negotiators must be able to handle the tension of both
these approaches without being either overly aggressive
or naive in their approach.

COMMUNICA nON Conflict professionals are generally
engaged to change the communication patterns that
have exacerbated conflict. Conflict practitioners need
an approach to promote effective communication. This
goes well beyond effective listening, but it starts there.
People in conflict need to be heard and to hear others,
but they also need assistance in raising their most
difficult issues in a clear, powerful, honest, and
constructive manner. Often, the narratives people con-
struct to explain conflict lock them into an adversarial
or rigid approach. Understanding how narratives are
constructed and how they can be deconstructed and
modified is important to effective intervention in con-
flict (Hale, 1998; Winslade & Monk, 2000).
In addition to looking at the content and nature of
communication, conflict specialists also focus on the
structure or system of communication. Creating effec-
tive forums, facilitating dialogue; and organizing the
flow of communication are also important to promoting
constructive interaction.
~OWER When dealing with conflict, we are dealing
with power exchanges of some sort. The question that
faces the conflict specialist is how to make this ex-
change as productive as possible. Power is
multifaceted, and every party to a conflict has some
power or there would be no conflict, but power can not
be "balanced" and the "playing field" is often not
"level." The application of power or influence does not
have to be primarily coercive, nor does it have to be
disrespectful. For example, child protection workers
have an obligation to apply the power of the state to
protect children and encourage families to behave in a
different manner, but if this is applied in a primarily
coercive manner it is likely to be counterproductive.
Social work literature often makes reference to the
value of client empowerment, but for this to mean
anything, we have to understand the effective and
legitimate uses of power and appropriate responses to
the coercive use of power.
CULTURE AND CONFLICT Conflict professionals often
deal with different cultural norms and practices that
impede honest efforts to work through a conflict. For
example, in some cultural contexts it is very inap-
propriate to state a concern, raise a conflict, or deny a
request directly, and it is considered somewhat rude to
ask very personal questions in the name of problem-
solving. In other contexts, "straight talk" is valued and
other styles are considered evasive or manipulative. In
working on conflict, we are often working across
cultural boundaries and we therefore need to
understand the different norms that may be operating,
how these affect the conflict, and what can be done to
bridge some of
CONFLICf REsOLUTION 417
these norms. This almost always requires that we start
with a clear understanding of our own embedded and
often unconscious norms so that we can avoid assuming
these are universal or that different norms are in some
way deviant.
THE CONFLICT ENGAGEMENT AND PROBLEMSOL VING
PROCESS Planning and conducting an effective process
of communication, negotiation, and problem-solving
are core conflict intervention skills. Of course, there is
no one correct process, but one role that conflict
professionals play in conflict is to pay attention to
process while working with people who are focused on
their substantive or emotional issues.
Another function of conflict specialists is to help
design systems for dealing with conflict. For example,
in almost all hospital settings, we can anticipate
conflicts among patients, medical staff, families, and
hospital administration. Establishing preventative and
intervention systems for dealing with these is as
important as providing assistance on a case by case
basis.
SYSTEMS Intervening in conflict means dealing with
systems. This is an area in which the social work field
has a great deal to offer the conflict field, since social
work training and practice is very much about looking
at the individual in the system. Whether we are talking
about family systems, communities, organizational
systems, or social systems, conflict practitioners need
to be able to take a system perspective or their efforts
can easily be misdirected.
Some of the most interesting work being done on
conflict draws on the studies of complex adaptive sys-
tems and chaos theory (Jones & Hughes, 2003; Pascale,
Millemann, & Gioja, 2000), which challenge some of
our basic assumptions about diagnosis and planning. In
particular, it calls on conflict interveners to consider the
self-organizing nature of systems and to promote an
adaptive capacity in the face of conflict.
CONFLICT INTERVENTION ROLES AND STRATEGIES
Historically, the field of conflict resolution has been
identified with the role of the third party who se goal is
to help people resolve their conflicts, but this may be
too limiting a view of the field (Mayer, 2004). In this
entry, the term conflict specialist, practitioner, or intervener
has been used to imply a broader view. Conflict
specialists play many roles, some of them as third
parties, but others, such as allies, coaches, advocates,
advisers, or system managers, may be more partisan in
nature. Furthermore, they may be focused on re solving
conflicts, but they may also focus on managing, raising,
preventing, or recovering from them.
418 CoNFLICf 'REsoLUTION

As with all fields of practice, the conflict field con tains victims than do the traditional retributive justice ap-
proponents of many different and sometimes conflicting proaches (Umbreit, 1994). Restorative justice seeks to
approaches for dealing with conflict (Kolb, 1983; Riskin , bring about healing for both victims and offenders and to
1994). Perhaps the most common (although overly simple) undo some of the harm that has occurred.
characterization of the range of approaches poses a Procedural assistance encompasses most sr the
continuum from evaluative (the mediator evaluates the . approaches traditionally associated with conflict
substantive issues, suggests the strengths and weaknesses resolution--mediation, facilitation, coaching, and systems
of each side's cases, and recommends a settlement range) design. Mediation has increasingly been institu tionalized
through facilitative (the mediator focuses on facilitating a in many areas of interest to social workers, including child
communication or negotiation process) to a transformat i welfare, care of the elderly, special education, divorce and
ve approach (the mediator seeks to transform the nature of child custody, workplace, and medical disputes. A rapid
the relationship through empowerment and recognition). growth area in conflict resolution is conflict coaching, an
Conflict practitioners need to understand the range of individualized approach to helping individuals engaged in
intervention styles and to maintain an open mind about a conflict. Coaches, for example, may work with a
which may be the most appropriate under different divorcing spouse as they prepare to negotiate the terms of
circumstances. This is analogous to the requirement of their divorce, with an employee or manager about to enter
mental health practitioners, who need to be familiar with a into a grievance negotiation, or with executives trying to
broad range of therapies, even though they may practice deal with organizational conflict. The common
within a particular discipline. characteristic of procedural assistance is that the
intervener focuses on the process for dealing with the
conflict rather than the substantive aspects of the dispute.
Continuum of Conflict Intervention Services New and Substantive assistance, on the other hand, focuses on the
creative approaches to conflict are developing constantly. issues themselves. A social worker who serves as a child
The proliferation of approaches has reflected and custody evaluator and who prepares a report on the needs
promoted the vibrancy of the conflict field and can be of children in a divorcing family or in placement is
understood as filling in a continuum of services for people essentially acting as a neutral fact finder and is making
and organizations in conflict. This continuum or spectrum recommendations that may become the basis of court
has been described in many ways (Moore, 1996). Mayer action or serve to assist people in a negotiated or facilitated
(2000) suggests five general types of services: prevention, decision-making process.
reconciliation, decisionmaking assistance, procedural Many approaches combine substantive withprocedural
assistance, and substantive assistance. assistance. People are sometimes interested in hir ing an
Preventative approaches include conflict anticipation, expert to both evaluate a particular issue and conduct a
training, system design, partnering, and other mecha nisms decision-making process. Evaluative mediators practice at
designed to deal with issues before they become the boundary between these two types of assistance.
conflictual or before they have escalated. Social workers Perhaps the fastest growing movement in family dispute
are often on the front line of prevention. For example, resolution is collaborative practice (sometimes called
school social workers who identify children with special collaborative law, but involving not only legal
needs and bring together families and school staff (and professionals) (Macfarlane, 2004; Tessler, 2001). Partici-
maybe others) to plan how to address these are in essence pants in this process sign an agreement that they are
acting to prevent a potential conflict between school and engaging their attorneys for settlement purposes only and
family. Similarly, hospital social workers who address should they go to court, they will then have tohire new
families' concerns about medical intervention are often advocates. Mental health and financial profes sionals, as
playing a conflict prevention role. well as financial advisers and divorce coaches, are often
Reconciliation is the partner of prevention in that it involved in this process, and they too agree that they will
involves helping people recover from the effects of a not participate in any court processes should the settlement
conflict, and often is key to preventing future conflicts. efforts not result in an agreement.
This too is a core element of social work practice, and it is Decision-making assistance involves helping people by
also an area of some important emerging developments in providing either binding or nonbinding recommendations
conflict work. In particular, since the late 1990 s there has about outcome. The most prevalent of these approaches is
been a tremendous growth in the use of restorative justice, arbitration, which is particularly commonly used in
victim-offender mediation, and related programs, which grievances or commercial disputes. In these settings,
take a very different approach to offenders and arbitrators most frequently come

from a legal background, but there are other arenas in
which social workers often serve in this function. One
approach to dealing with high conflict divorces, for
example, is for the parents to agree upon, or the court to
appoint, a neutral with child development expertise who
will make decisions about the ongoing conflicts that are
likely to arise in the course of carrying out a parenting plan,
about issues such as holiday plans, education, or transitions
between parents.
Of course there are many variations on these ap-
proaches and many hybrid interventions as well. De,
signing effective linkages among approaches is essential
for making a conflict resolution system work.
Conflict Resolution -and Social Work Practice:
Future Trends
Social work and conflict resolution are allied fields. Social
workers act as conflict interveners as a matter of course in
almost all aspects of their work, and an appreciation of the
techniques, concepts, processes, and systems of the
conflict field can significantly enhance the effectiveness of
what social workers do. Social workers in turn have
brought a great deal to the conflict field. They have been
among the leaders of this field since its inception. Both
fields of practice emphasize client empowerment and self
determination, a systems perspective, a focus on process,
and a commitment to social justice. Formal conflict
resolution processes, especially mediation, have been used
in a wide variety of social work settings (see Kruk, 1997).
Two areas of particular concern to social workers, for
example, where there has been a significant growth in the
use of conflict resolution are child welfare and care of the
elderly. Many jurisdictions have institutionalized media,
tion and family group conferencing to deal with child
protection issues. These programs have mushroomed be,
cause they deal with a fundamental dilemma child pro,
tection workers face-how can they involve families in a
cooperative and constructive way when they must also hold
them accountable for their behavior and act as agents of the
state in protecting children. Mediation has proved to be a
very effective tool for bringing families into the
decision-making process. Family group conferencing is an
approach that brings the extended family system together
to make decisions about the care of abused or neglected
children. When first introduced in the mid, 1980s, these
approaches seemed quite controversial, primarily because
they were unfamiliar to most child welfare practitioners,
but, they have since become widely accepted resources for
social workers, families, lawyers, courts, and child
protection agencies.
As our population ages, so has the use of conflict
resolution with issues of aging. Whenever decisions
CONFLICT REsoLUTION 419
have to be made about guardianship of the elderly, place,
ment of elderly in long-term care facilities, or how to
handle the responsibilities for the care of the elderly, there
is a potential for family conflict. Even when there is no
significant conflict, the decision-making process can be
very painful. Social workers have long acted as facilitators
for family discussions, but in recent years mediation has
been used in a more formal sense to deal with issues
involving the care of the elderly. This has been particularly
important when the aging persons are experiencing
cognitive impairment. Under these conditions, it is often
hard to walk the line between promoting appropriate
family and caregiver involve, ment and responsibility and
not disempowering the elderly. Mediation and variations
onfamily group con, ferencing are increasingly being used
in these arenas.
These are just two examples among the many areas in
which conflict resolution has been applied to social work
settings. With this natural synergy, the question that
remains is why the social work profession has not em,
braced the conflict field more fully. Courses on conflict and
conflict resolution remain at best as electives in some
schools of social work. Professional organizations have not
made the development of conflict resolution a significant
program area. Conflict resolution field place' ments are
rare. This is an untapped potential for growth in the social
work field, and a potential new source of strength for the
conflict field as well. In the years to come, conflict
intervention theory and skills are likely to be, come a much
more integral part of social work education and practice.
The potential is significant, the need great.
REFERENCES
Coser, L. A. (1956). The functions of social canflict. New York:
The Free Press.
Fisher, R., & Ury, W. (1981). Getting to yes. Boston: Houghton
Mifflin.
Folberg, J., Milne, A., & Salem, P. (Eds.). (2004). Divorce
mediation (Znd ed.). New York: Guilford.
Hale, K. (1998). The Language of cooperation: Negotiation
frames. Mediatian Quarterly, 16(2), 147-162.
Jones, W., & Hughes, S. (2003). Complexity, conflict resolution,
and how the mind works. Canflict Resolution Quarterly,
20(4),485-494.
Kolb, D. M. (1983). The mediators. Cambridge, MA: MIT Press.
Kruk, E. (1997). Mediation and canflict resolution in social work and
the human services. Chicago: Nelson-Hall.
Lax, D. A., & Sebenius, J. K. (1986). The manager as negotiator:
Bargaining for cooperative and competitive gain. New York:
The Free Press.
Macfarlane, J. (2004). Experiences of collaborative law: Pre-
liminary results from the collaborative lawyering research
project. Journal of Dispute Resolution, 1, 179.
Mayer, B. (2000). The dynamics of conflict resolution: A practitioner's
guU1e. San Francisco: Jossey-Bass/Wiley.
420 CONmCf REsOLUTION
Mayer, B. (2004). Beyond neutraUty: Confronting the crisis in
conflict resolution. San Francisco: Jossey-Bass/Wiley.
Moore, C. W. (1996). The mediation process: Practical strategies
for resolmng conflict (2nd ed.). San Francisco: [ossey-Bass.
Pascale, R. T., Millemann, M., & Gioja, L. (2000). Surfing the
edge of chaos: The laws of nature and the new laws of business.
New York: The Three Rivers Press.
Riskin, L. (1994). Mediator orientations, strategies and tech-
niques. Alternatives, 12, 111.
Schneider, A. K., & Honeyman, C. (Eds.). (2006). The nego-
tiator's fieldbook: The desk reference for the experienced
negotiator. Washington, DC: The American Bar
Association.
Tessler, P. H. (200l). Collaborative law: Achieving effective
resolution in divorce without litigation. Chicago: Section of
Family Law of the American Bar Association.
Thomas, K. W. (1983). Conflict.and conflict management. In
M. D. Dunnette (Ed.), Handbook of industrial and organiza-
tional psychology. Chicago: Rand McNally.
Thomas, K. W., & Kilmann, R. H. (1974). Thomas-Kilmann
Conflict Mode Instrument. New York: Xicom.
Umbreit, M. (1994). Victim meets offender: The impact of
restorative justice and mediation. Monsey, NY: Criminal
Justice Press.
Walton, R. E., & McKersie, R. B. (1965). A behamoral theory of
labor negotiations. New York: McGraw-Hill.
Winslade, J., & Monk, G. (2000). Narrative mediation: A new
approach to conflict resolution. San Francisco: [ossey-Bass/
SUGGESTED LINKS Association for
Wiley.Resolution. www.acrnet.org
Conflict
Association of Family Conciliation Courts.
www.afccnet.org
Conflict Resolution Information Project.
www.mnfo.org
Conflict Resolution On-Line newsletters.
www.mediate.com
Conflict Resolution Network Canada.
www.cmetwork.ca
-BERNARD MAYER
CONSULTATION
ABSTRACT: Visionaries once anticipated that consul tation
would become a significant field of practice in which
social workers served as consultants. There are
indications that consultation has realized some of that
promise in the 21st century, because consultation is
second only to direct practice in how licensed social
workers spend time at work. And if the primary con-
sumers of social work consultation are social workers
themselves, then this reflects a high standard of prac tice,
as seeking case consultation has been codified as a duty in
social work codes of ethics, practice standards, and
standards of care.
KEY WORDS: consultation, courts, ethics, licensed so-
cial workers, standard.of care, supervision, workforce
Social work is a consulting profession (NASW, 2006).
Perhaps the first written reference to consultation in social
work appeared in the 19th century, when the Boston
Associated Charities described in its-first annual report the
importance of the dispensation of helpful information and
advice to "friendly visitors."
The agent's labor [includes] advising and aiding the
visitors in their work ... The Ward office is a center
where ... the visitors can consult with the agent with
regard to the families whom they have befriended.
(Boston Associated Charities, 1881, pp.20-21)
More than 80 years later, the first issue of the Encyclopedia of
Social Work reviewed the extant history of consultation in
social work, which Rapoport (1965) foresaw as a rapidly
growing field of social work practice. Indeed, fueled by the
infusion .of federal dollars into social welfare programs that
followed World War II, consultation had begun to appear in
many practice settings (Rapoport, 1971), if primarily in child
welfare, health care, and the schools (Kadushin, 1977) . Yet
after Rapoport (1965) called attention to a growing technical
literature on consultation in social work, the social sciences,
and other helping professions, Kadushin's (1977 )
comprehensive review of the literature could find but two
articles on social work consultation in the 40-year index of
articles published in Social Service Review between 192 7 and
1966, and no more than 10 citations in Social Work Abstracts,
from its inception in 1965 through 1976. Even during the
halcyon years of federal support for health and human
services, only 980 members or 1.5% of the National
Association of Social Workers described consultation as their
primary job function in 1976 (Kadushin & Buckman, 1978).
Subsequently, Rapoport (1977) lamented that social workers
were still more often consultees than consultants.
There are several indications that social work has become
a consulting profession in the 21st century. First, an electronic
search for literature published since the appearance of the
19th edition of the Encyclopedia of Social Work in 1995 found
64 dissertations in ProQuest, 229 journal articles in Social
Work Abstracts, and 366 and 535 articles, books, or chapters
indexed in Psychlnfo and Medline, respectively, with the
combined keywords "social work" and "consultation." A
review of those publications indicates that cases in health
care, child welfare, and school settings are still the principal
focus of consultation in social work.
 CONSULTATION 421

Second, in the largest national study of licensed social to unfold in stages (Kadushin, 1977). In the beginning, the
workers conducted to date, the National Association of Social consultee approaches the consultant with a preliminary
Workers (2006) reports that consultation is now second only to description of the problem for which help is requested.
direct service in what social workers do at work. Seventy-three Initially, the consultee may be expected to view the consultant
percent of those surveyed reported spending at least some time with ambivalence as an expert with helpful solutions for
in consultation each week, and 6% reported spending more practice concerns and as an author-
than 20 hr per week in consultation. Although it is unclear what . ity poised to evaluate the consul tee with criticism or praise
percentage of time licensed social workers may have spent in (Kadushin & Harkness, 2002). The consultant may mitigate
the role of consultant versus consultee, an extrapolation barriers to communication associated with the beginning
suggests that the 18,600 or 6% of the 310,000 licensed social stage of consultation by conducting a role induction (Monks,
workers in the United States who spent more than 20 hr per 1996). In addition to clarifying the roles and responsibilities
week in consultation did so in the Tole of consultant. And of consultee and consultant, role inductions introduce the
becausesocial workers spend most of their time in direct elements of informed consent, establishing ethical
sersice, it' appears that the primary focus of consultation in foundations for parallel helping relationships in consultation
social work is still the direct-service case. and practice. With the benefit of appropriate structure, active
Defined as an interactional helping process used to achieve listening helps the consultee tell his or her story and feel
a work-related objective through an interpersonal relationship understood. Until a preliminary "diagnosis" of the problem or
(Rapoport, 1965), case consultation has been conceptualized issue has been made, the judicious use of questions and
as an indirect service, like social work supervision (Kadushin, clarifications will facilitate the formulation and exploration of
1977), in which someone with more knowledge and serial "hypotheses" in collaboration with the consultee and,
experience helps someone with less expertise help someone indirectly, with the client as well.
else (Rapoport, 1971). Another parallel with supervision is that The working phase of consultation should be guided by the
the provision of education and support are essential elements adage that "the devil is in the details" of each case as well as in
of both services (Kadushin, 1977). In addition, an important if the process of social work practice (Kadushin, 1977). That
informal element of the administrative authority found in most practice problems are multidetermined will be reflected
supervision is rooted in the role and expertise ofthe social in the series of prescriptive analyses that the consultant
work consultant (Reamer, 2004). Unlike social work introduces in the working phase of consultation. A form of
supervision, however, consultation is a relatively time-limited interactional feedback, each analysis begins with a restatement
interaction (Rapoport, 1977), usually initiated by the consultee of the problem and reviews what has been done to address it.
(Kadushin & Buckman, 1978), who enjoys considerable As a prescription for how to proceed, a typical recom-
freedom to accept or reject the advice or guidance of the more mendation may suggest a direction that includes both an
expert consultant (Shulman, 1995). Thus, social workers intervention and a plan for gathering additional data. Because
approach one another frequently with requests for case the near-term goal of consultation is helping the worker, the
consultation, and in the informal and episodic collaborations consultant should review and summarize the empirical
that ensure their collegial interactions may be egalitarian in evidence, practice wisdom, and ethical imperatives.and
nature and completed in minutes. Yet many social workers constraints bearing on the consultee's concerns, modeling, and
also enter formal contractual agreements with private teaching problemsolving behavior designed to strengthen
consultants to earn licenses to practice clinical social work, worker performance (Munson, 2004). If at times the narrow
establishing relationships that may last for years and which focus of case consultation broadens to address organizational
resemble supervision. In these blurred arrangements, the and macro-system issues that affect client outcomes, this may
consultant exercises the expert authority conferred by a state also be helpful. Yet because the ultimate goal of consultation
board of social work examiners and conceded by the consultee, is helping the client, the consultant may ask to review client
who retains that measure of autonomy vested in his or her records or conduct a face-toface interview with the client. To
counterbalancing authority as the consultant's employer. temper the mix of dread and relief that such intrusions
engender in consulting relationships, the consultant may use
education, encouragement, and even exhortation at times, to
enlist and sustain the consul tee in the working alliance.
Evaluation, recapitulation, and termination mark the

History
Viewed as a problem-solving process with a social work-
component (Shulman, 1987), consultation appears
422 CoNSULTATION
final stage of consultation. If the consultation has been helpful
to the client, then it is likely that the consul tee will have
experienced help as well. Conversely, if the consultation has
not helped the client, the consultee may take solace in
knowing that even the "expert" has failed to be helpful. In
either event, the ending phase of consultation is an opportunity
for the consultant once again to listen more and speak less,
perhaps asking a series of open-ended questions (Harkness &
Hensley, 1991) to elicit evaluative feedback: "Does the client
feel helped? Can the client teU you what helped, and what was
unhelpful? Do you feel helped? Can you teU me what helped, and
what was unhelpful?" In termination, the-consultant has the
opportunity as well as a duty to recapitulate key findings,
issues, and lessons, learned, and to do so, as may be
appropriate, with both support and authority, praising the
consultee for courage, grace, and effort.
In consultation, a good story makes a good ending.
In December 2005, the Supreme Court of New York County,
New York, ordered an independent examination of a
defendant by a licensed clinical social worker with significant
experience in the evaluation and treatment of persons
suffering from neuropsychological dysfunction and
concurrent mental illness. The defense challenged the social
worker's appointment as a consultant to the court, arguing that
the diagnostic challenges in the case were of a medical nature
beyond the scope of his license for practice. The court rul ed
that diagnosis and treatment of mental disorders that are
organic or result from physical ailment were not only within
the scope of social work practice, but
. .. as a matter of law ... licensed clinical social workers
as licensed health care providers are required by their
scope of practice and the standards of care of their
professions to gather information and make
observations related to the physical condition and
symptoms ... of their patients as part of their initial
assessments and to be alert throughout the course of
treatment to mental or physical symptoms which may
have physical causes or portend the existence of
physical illness ... so that these may be explored, their
impact on the patient's functioning assessed properly
and treated, as necessary, through referral to or
consultation with other health care professionals, as
indicated. The failure to do so would constitute
practice that, per se, violates the professional standard
of care. (People v. R.R., pp.532-533)
Asserting that "[our] expert must be held to a higher standard
than a clinical expert retained by a party" (People v. R.R.,
2005, p. 518), the Court retained the social worker
as its consultant.
Coupled with its broad and ringing endorsement of social
work expertise, the court's analysis underscores the
importance of consultation in social work. All social workers
have an ethical duty (NASW, 1999), and in the common law a
fiduciary duty as well (Reamer, 2003), to seek and provide
consultation in the best interest of the client. That those duties
have now been codified in practice standards for clinical
social work (NASW, 2005b), social work practice with
adolescents (NASW, 2003), and child welfare (NASW,
2005a) establishes case consultation as a cornerstone of the
social work standard of care (Munson, 2004; Reamer, 1995).
REFERENCES
Boston Associated Charities. (November, 1881). First Annual .
Report (pp. 20-22). Boston: Author. Cited in Burns, M.
(1958). The historical development of the process of casework
supervision as seen in the professional literature of social work.
Doctoral dissertation, The University of Chicago.
Harkness, D., & Hensley, H. (1991). Changing the focus of
social work supervision: Effects on client satisfaction and
generalized contentment. Social Work, 36(6), 506-512.
Kadushin, A. (1977). Consultation in social work. New York:
Columbia University Press.
Kadushin, A., & Buckman, M. (1978). Practice of social work
consultation: A survey. Social Work, 23(5), 372-379.
Kadushin, A., & Harkness, D. (2002). Supervision in social
work (4th ed.). New York: Columbia University Press.
Monks, G. (1996). A meta-analysis of role induction stw:1ies.
Doctoral dissertation, The University of Hanford.
Munson, C. (2004). The evolution of protocol-based
supervisory practice. In M. Austin & K. Hopkins (Eds.),
Supervision as collaboration in the human services: Building a
learning culture (pp. 85-96). Thousand Oaks, CA: Sage.
National Association of Social Workers (NASW). (1999).
NASW code of ethics (Revised). Washington, OC: Author.
National Association of Social Workers (NASW). (2003).
NASW standards for the practice of social work with adolescents.
Washington, DC: Author.
National Association of Social Workers (NASW). (2005a).
NASW standards for social work practice in child welfare.
Washington, DC: Author.
Nation~l Association of Social Workers (NASW). (2005b).
NASW standards for clinical social work. Washington,OC:
Author.
National Association of Social Workers (NASW), Center for
workforce studies. (March, 2006). Licensed social workers
in the U.S.-2004. Retrieved from http://workforce.soci~l-
workers.org/studies.asp
People v. R.R., 807 N.Y.S.2d 516 (N.Y.Sup.Ct. 2005)
Rapoport, L. (1965). Consultation. In H. Lurie (Ed.),
Encyclopedia of social work (15th ed., vol. 1, pp. 214-219). New
York: National Association of SOCial Workers.
Rapoport, L. (1971). Consultation in social work. In R. Morris
(Ed.), Encyclopedia of social work (16th ed., vol. 1, pp. 156-
161). New York: National Association of Social Workers.

Rapoport, L. (1977). Consultation in social work. In J. Turner
(Ed.), Encyclopedia of social wark (17th ed., vol. 1, pp.
193-197). Washington, DC: National Association of Social
Workers.
Reamer, F. (1995). Ethics consultation in social work. Social
Thought, 18(1),3-16.
Reamer, F. (2003). Social wark malpractice and liability (2nd
ed.). New York: Columbia University Press.
Reamer, F. (2004). Ethical decisions and risk management. In
M. Austin & K. Hopkins (Eds.), Supervision as coUabaration
in the human services: BuiIJing a learning culture (pp. 97-109).
Thousand Oaks, CA: Sage.
Shulman, L. (1987). Consultation. In A. Minahan (Ed.),
Encyclopedia of social wark (18th ed., vol. 1, pp. 326331).
Silver Spring, MD: Nation,al Association of Social
Workers.
Shulman, L. (1995). Supervision and consultation. In R.
Edwards (Ed.), Encyclopedia of social wark (19th ed., vol. 3,
pp. 2373-2379). Washington, DC: National Association of
Social Workers.
SUGGESTED LINKS NASW Center tor
Workforce Studies. http://warkfarce
.socialwarkers .arg/ NASW Code of Ethics.
http://www .socialwarkers .arg/pubs/code/code .asp
NASW Standards for the Practice of Social Work With
Adolescents.
http://www.socialwarkers.arg/practice/standards/sw_adolescents.
asp
NASW Standards for the Practice of Clinical Social Work.
http://www.socialwarkers.arg/practice/standards/clinicaCsw.asp
NASWStandards for Social Work Practice in Child Welfare.
http://www .socialwarkers . arg/practice/standardsIN ASWChiIJ
WelfareStandards0905.pdf
-DANIEL HARKNESS
CONSUMER RIGHTS
ABSTRACT: Consumers of health and mental health
services are afforded numerous legal rights. Broad
cat, egories of rights include self-d etermination,
access to health information, protections for mental
health con, sumers who are hospitalized, and a right
to community integration. Two areas of consumer
rights are emerging: a greater emphasis on human
rights, and the right of consumers to participate in
developing and implement' ing programs and
services within the organizations from which they
receive services. Various means for enforc ing rights
exist in both the private and the public sectors. Social
workers play critical roles in ensurin g that consumer
rights become a reality.
CONSUMER RIGHTS 423
KEY WORDS: rights; human rights;
self-determination; informed consent; right to refuse
treatment; right to die; advance directives; HIP AA;
confidentiality; involuntary commitment; community
integration; empower, ment; organizational
decision-making
Consumers of health and mental health services in the United
States are afforded numerous legal rights. Some are
controversial, while others are difficult to enforce. In addition
to legal rights, two areas of rights are emerging, those being a
greater emphasis on human rights, and the right of consumers
to participate in developing and implementing programs and
services within their service organizations. Social workers
playa critical role in making consumer rights a reality.
Legal Rights
Legal rights can be grouped into four broad categories. One
category is self-determination. Aspects of self, determination
include informed consent regarding treatment decisions, the
right to refuse treatment, the right to die by refusing
life-sustaining measures or by engaging in assisted suicide,
advance directives, and abortion rights. U.S. courts have
upheld aspects of each of these rights, although Oregon is the
only state to have assisted-suicide legislation. Some rights are
contracting; for example, some states make it more difficult
for women to get an abortion. Other rights are expanding, for
example, using advance directives not only to regulate
medical treatment if incapacitated, but recently to regulate
psychiatric treatment during the onset of severe, acute
symptoms (Srebnik, 2004; Srebnik & Kim, 2006).
Some rights continue to be controversial, such as the right
to die, exemplified in the highly publicized death of Terri
Schiavo in 2005, and abortion rights, which remain a highly
divisive, political issue in the United States.
A second category of legal rights is access to health
information. It has long been held that consumers have a right
to confidentiality and privacy of health information. The
Health Insurance Portability and Accountability Act (HIP
AA), through its Privacy Rule effective in 2003, modified
privacy rights. HIPAA increases consumers' access to their
medical records and ability to correct inaccuracies. It also
waives written authorization to release health information for
routine releases, and instead requires that health providers
give consumers a. copy of their written policy that indicates
how Protected Health Information will be shared routinely for
treatment or payment purposes. Some social workers believe
that aspects of HIPAA may actually decrease privacy of
health information, and call upon the profession to ensure that
consumers know their
424 CONSUMER RIGHTS
rights and the limits of confidentiality and be vigilant in
protecting consumers' health information (Yang &
Kombarakaran, 2006).
A third category of rights is associated with psychiatric
hospitalizations. U.S. court cases in the 1960s and 1970 s
increased consumer rights by restricting the use of
involuntary civil commitment to dangerous individuals,
requiring due process rights for commitment hearings,
setting minimum treatment and physical plant standards
for hospitals, and recognizing the right to lea st restrictive
treatment alternative.
A fmal category of rights is associated with the
community integration of people with medical,
physical, or psychiatric disabilities. The
Rehabilitation Act of 1973 prohibited
discrimination based on disability among en tities
receiving federal funds. The Fair Housing
Amendments Act of 1988 prohibited
discrimination based on disability in public and
private housing. Two years later, the Americans
with Disabilities Act of 1990 sought to . prevent
discrimination based on disability in the areas of
employment, transportation, and access to various
types of public and private facilities and services.
The most recent change, Olmstead v. L.C., by
Zimring (1999), found that people residing in
mental health facilities had a right to community
services under the Americans With Disabilities
Act. This right was limited, however, by requiring
that mental health professionals and con sumers
must approve discharge from hospital into the
community, and Human that states
Rights consider available
resources when establishing needed
Despite the array of legal rights, a legal community
right does not exist
services.
in the United States to health and mental health services or
to the necessities to sustain health, such as food, housing,
employment, and income supports. Over 40 million
Americans are without health insurance, and many more
are underinsured. Internationally, ac cess to health and
mental health services, and to the necessities to sustain
health, is gaining support as a basic human right (Bell,
2005). This is reflected in the United Nations Declaration
of Universal Human Rights and especially in the
International Covenant on Economic, Social, and C ultural
Rights. Social workers are being called upon to support
human rights within the United States and internationally
(Steen, 2006).
Right to Organizational Decision Making Also
emerging is the right of consumers of health, and
particularly mental health, services to participate in
developing and implementing the programs and services
in which they participate. Such participation is consistent
with the Code of Ethics of the National Association
of Social Workers (2000), can improve the effectiveness
of services, promotes consumer empowerment, and assists
in consumers' recovery. Means of participating in
organizational decision making include serving on agency
boards of directors, task forces, and committees as full
voting members; serving on consumer councils that have
decision-making power or advise .program administrators;
being involved in all phases of the program evaluation
process; and operating consumer -run programs and
services (Linhorst, Eckert, & Hamilton, 2005; Salzer,
1997).
Enforcing Rights
Numerous means exist to enforce consumer rights. Federal,
state, and some local governments have rights enforcement
bodies. Seeking remedy for perceived rights violations
through these bodies is a long-term process, however, and
often unsuccessful. In the case of changes resulting from
the Olmstead decision, for example, Mathis (2005)
reported that efforts to further integrate institutionalized
persons into the community have been very slow, and most
states do not have the resources to comply with t he spirit of
the ruling. A second means of enforcement is through the
Centers for Medicare and Medicaid Services, which
evaluates compliance with consumer rights for
organizations that receive Medicare or Medicaid funding. A
third means is through nongovernmental bodies, including
the Joint Commission on the Accreditation of Healthcare .
Organizations, the Commission on Accreditation of
Rehabilitation Facilities, and the National Committee for
Quality Assurance, that accredit health and mental health
organizations and incorporate consumer rights into their
accreditation standards. A fourth means is through the
inclusion of some rights into codes of ethics in professions
such as social work, medicine, nursing, psychology, and
others. A fifth means is through the national system of state
protection and advocacy organizations. These federally
funded, nonprofit organizations are charged with protecting
the rights of people with disabilities. A final means of
enforcing rights is through quality improvement activities
to monitor program compliance with rights within service
organizations and to develop corrective actions when rights
violations are detected.
Implications for Social Work and
Future Trends
Social workers play a critical role in the realization of
rights for consumers of health and mental health services.
At the direct service level, social workers should educate
consumers about their rights, report violations of rights
when observed, provide support to

consumers seeking redress for rights violations, and work
respectfully with consumers in organizational decision
making. Most important, social work administrators should
develop a culture within the agency that is respectful. of
rights. At a minimum, administrators should develop clear
statements of rights, train consumers and staff about
consumer rights and means of enforcement, use multiple
means to integrate consumers into organizational decision
making, establish quality improvement systems to monitor
consumer rights, take definitive corrective action when
rights are violated, and treat consumers with respect in all
interactions to model appropriate behavior to staff and to
support consumers. Finally, at the public policy level, it is
most important for social workers to advocate for the legal
right to a full range of health and mental health services,
and to the social and economic resources needed to achieve
and maintain health.
REFERENCES
Bell, S. (2005). What does the "right to health" have to offer
mental health patients? International Journal of Law and
Psycmarry, 28, 141-153.
Linhorst, D. M., Eckert, E., & Hamilton, G. (2005). Promoting
participation in organizational decision making by clients with
severe mental illness. Social Wark, 50, 21-30.
Mathis, J. (2005, January-February). Where are we five years after
Olmstead? Clearinghouse Review Journal of Poverty Law and
Policy, 561-582.
National Association of Social Workers. (2000). Code of ethics of
the National Association of Social Warkers. Washington, DC:
Author.
Salzer, M. S. (1997). Consumer empowerment in mental health
organizations: Concept, benefits, and impediments.
Administration and Policy in Mental Health, 24, 425-434.
Srebnik, D. (2004). Benefits of psychiatric advance directives:
Can we realize their potential?]ournal of Farensic Psychology
Practice, 4, 71-82.
Srebnik, D. S., & Kim, S. Y. (2006). Competency for creation, use
and revocation of psychiatric advance directives. J ouma! of the
American Academy of Psychiatry and the Law, 34, 501-510.
Steen, J. A. (2006). The roots of human rights advocacy and a call
to action. Social Wark, 51,101-105.
Yang, J. A., & Kombarakaran, F. A. (2006). A practitioner's _
response to the new health privacy regulations. Health and
SociaIWark,31,129-136.
FURUIER READING
Brownlie, 1., & Goodwin-Gill, G. S. (2006). Basic documents on
human rights (5th ed.). New York: Oxford University Press.
Colby, W. H. (2006). Unplugged: Reclaiming our right to die in
America. New York: AMACOM, American Management
Association.
Farmer, P. (2003). Pathologies of power: Health, human rights, and
the new war on the poor. Los Angeles: University of California
Press.
CONSUMER RIGHTS 425
Failer,J. L. (2002). Who qualifies far rights? Homelessness, mental
illness, and civil commitment. Ithaca, NY: Cornell University
Press.
Gruskin, S., Grodin, M. A., Annas, G. J., & Marks, S. P. (Eds.).
(2005). Perspectives on health and human rights. New York:
Routledge.
Hilliard, B. (2004). The U.S. Supreme Court and medical ethics:
From contraception to managed health care. St. Paul, MN:
Paragon House.
Linhorst, D. M. (2006). Empowering people with severe mental
illness: A practical guide. New York: Oxford University Press.
Mason, L. K., & Laurie, G. T. (2006). Law and medical ethics (7th
ed.). New York: Oxford University Press.
McClean, S. A. (2006). First do no harm: Law, ethics, and
healthcare. Burlington, VT: Ashgate.
Morrall, P., & Hazelton, M. (Eds.). (2004). Mental health:
Global policies and human rights. London: Whurr.
President's New Freedom Commission on Mental Health. (2003).
Achieving the promise: Transforming mental health care in
America: Final report. Rockville, MD: U.S. Department of
Health and Human Services.
Quill, T. E., & Battin, M. P. (2004). Physician-assisted dying:
The case far palliative care and patient choice. Baltimore: Johns
Hopkins University Press.
Reichert, E. (2003). Social wark and human rights: A foundation far
policy and practice. New York: Columbia University Press.
Rosenfeld, B. (2004). Assisted suicide and the right to die: The
interface of social science, public policy, and medical ethics.
Washingron, DC: American Psychological Association.
Rothman, D. J., & Rothman, S. M. (2006). Trust is not enough:
Bringing human rights to medicine. New York: New York
Review Books.
Slobogin, C. (2006). Minding justice: Laws that deprive people with
mental disability of life and liberty. Cambridge, MA:
Harvard University Press.
Stefan, S. (200l). Unequal rights: Discrimination against people with
mental disabilities and the Americans With Disabilities Act.
Washington, DC: American Psychological Association.
Tulloch, G. (2005). Euthanasia-Choice and death. Edinburgh:
Edinburgh University Press.
Ulrich. L. P. (1999). The Patient Self-Determination Act:
Meeting the challenges in patient care. Washington, DC:
Georgetown University Press.
U.S. Department of Health and Human Services. (1999).
Mental health: A report of the Surgeon General. Rockville,
MD:Author.
Winick, B. J.(2005). Civil commitment: A therapeutic jurisprudence
model. Durham, NC: Carolina Academic Press.
SUGGESTED LINKS American Society of Law,
Medicine and Ethics. http://www.aslme.arg/.
Bazelon Center for Mental Health Law.
http://www . bazelon.arg
Campaign for Mental Health Reform.
http://www.mhreform.arg
426 CONSUMER RIGHTS

Center for Economic and Social Rights. CONTEXTS/SETTINGS. [This entry contains five
http://www .cesr .org/heaIth subentries: Agency and Organization in Non-Profit
Centers for Medicare and Medicaid Services [CMS]. Settings; Corporate Settings; Faith-Based Settings;
http://www . ems .hhs .gov Interorganizational Contexts; Private/Independent
Commission on Accreditation of Rehabilitation Facilities Practice Settings.]
[CARF].
http://www.carforg AGENCY AND ORGANIZATION IN
Consumer Organization and Networking Technical Assistance NON,PROFIT SETTINGS
Program [CONT AC].
ABSTRACT: Nonprofit organizations serve a wide
http://www . contae.org
variety of functions and play a particularly important
End of Life/palliative Education Resource Center.
role in providing needed social services in the United
http://www.eperc.mcw.edu
Joint Commission on the Accreditation of Healthcare Orga- States. This entry begins by exploring the roles and
nizations OCAHO]. origins of the non-profit sector, reporting on its current
http://www.jointeommission.org , scope and scale, and reviewing federal regulations
National Alliance on Mental Illness [NAMI]. governing nonprofit organizations. Special attention is
http://www.nami.org \ then given to understanding human service
National Association of Protection and Advocacy, Inc. organizations and their financing, including the
http://www.napas.org implications of changing government-non-profit
National Council for Community Behavioral Healthcare. relationships. Four additional issues facing the
http://www.nccbh.org sector-accountability, technology, political
National Committee on Quality Assurance. participation, and diversity, as well as recommendations
http://ncqa.org
for meeting future challenges, are also discussed.
National Empowerment Center, Inc. .
http://www.power2U.org KEY WORDS: non-profit; charities; accountability;
National Health Care for the Homeless Council. diversity
http://www . nhchc .org
National Mental Health Association. The diverse set of organizations known as the non-profit
http://www.nmha.org sector has recently been gaining in both influence and
National Mental Health Consumers' Self-Help Clearinghouse. recognition, as it is increasingly being called upon to help
http://www . mhseljhelp. org strengthen communities, promote civil society, and meet
National Mental Health Information Center. new human service needs (Salamon, 2002). Best known in
http://mentalhealth.samhsa.gov
social work as the organizational form most human service
President's New Freedom Commission on Mental Health.
organizations take, "non-profit" is the term now commonly
http://www . mentalhealthcommission.gov
used to describe organizations that often used to be called
United Nations, Human Rights.
http://www . un .org/rights/ "charities" or voluntary agencies. Unique because of their
United Nations, International Human Rights Statements. dependence on dona- . tions or grants from outside the
http://ohchr.org/english/law/index.htm organization (by individuals, foundations, government),
U.S. Department of Education, Office of Civil Rights. non-profits exist to serve the public, as opposed to private,
http://www . ed.gov/about/offices/list/ocr/index.html good.
U.S. Department of Health and Human Services, Office of Civil The term "non-profit" is synonymous with "not-for-
Rights. profit" andserves as a counterpoint to the business, or
http://www.hhs.gov/ocr/ for-profit, sector. Non-profits are bound by law, by
U.S. Department of Health and Human Services, Office of Civil regulation, the nondistribution constraint, meaning that
Rights, Health Insurance Portability and Accountability Act (HIP when they do make a profit, they must invest those profits
AA) violations.
back into the organization or use them to subsidize future
http://www .hhs .gov/ocr/hipaa/
programmatic efforts rather than distributing those profits
U.S. Department of Housing and Urban Development, Fair
to individual stakeholders in the organization in the way
Housing Laws.
that for-profit businesses do. Other terms are also used to
http://www .hud.gov/offices/jheo/FHLaws/
U.S. Department of Justice, Civil Rights Division Activities and refer to the non-profit sector. It is alternatively known as
Program. the "third" sector (after the governmental "first" sector
http://www.usdoj .gov/crt/activity .html and the commerceoriented, profit-making/proprietary
World Health Organization, Health and Human Rights. "second"), the voluntary sector, and the independent
http://www . who. int/hhr/en/ sector. Nongovernmental organizations (NGOs) is
-DONALD M. LIN HORST another term
 CONTEXTS/SETTINGS: AGENCY AND ORGANIZATION IN NON-PROFIT SETTINGS
sometimes used by international organizations and in
many other countries when referring to non-profit or-
ganizations. Sometimes they are included in what is
termed in developing and former socialist countries as the
"civil society."
Non-profits operate all over the world and in many
different fields, including human services, arts and culture,
health care, education, and civil rights. For example,
hospitals, day care centers, art museums, community
action groups, and softball leagues can all be non-profits,
because all are credited with serving the public good in
some way. Foundations, such as the Ford Foundation or
the Bill and Melinda Gates Foundation, are also
non-profits, as are most 'religious organizations and
congregations. There is also great diversity in the size of
non-profits. Non-profits vary from multibillion dollar
corporations such as Kaiser Hospitals or Harvard
University to tiny all-volunteer networks operating in
low-income rural areas. Despite the diversity of the field,
all non-profits do share some features in common. In their
cross-national work, Salamon and Anheier (1992) have
suggested that five defining elements must be present for
an entity to be considered a non-profit. They must be (a)
actual organizations, not just a single person, (b) private
and nongovernmental, (c) nondistributing of profits, (d)
self-governing, and (e) containing elements of
voluntarism.
Oversight and Regulation
In the United States, although there are informal orga-
nizations run on a voluntary basis that are also consid ered
part of the non-profit sector, organizations are usually
considered to be a non-profit based on their tax status with
the federal agency the Internal Revenue Service.
Non-profits are officially recognized by the U. S.
government if they show that they are organized for public
purposes. They are then regulated and defined under
section 501 of the federal tax code and are granted
tax-exempt status. There are 25 different subsections
under section 501; the tax status granted depends primarily
on what the overall function of the organization is, how it
is structured, and whom it benefits. Non-profits are also
subject to a variety of statelevel regulation and reporting.
Section 501(c)(3) is reserved for organizations serving
what the IRS considers religious, charitable, scientific,
literary, or educational purposes. Most social service
organizations have 501(c)(3) status. Only 501 (c)(3)s
qualify for the important benefit that contributions made to
the organization are tax-deductible for the donor. This is
an extremely important incentive for donors and is critical
in fund-raising for many of these organizations. For this
reason most organizations
427.
that are eligible file as public charities, under section
501(c)(3).
The second most common subsection is 501(c)(4),
which the IRS terms the "civic leagues and social welfare
organizations." These are organizations considered to be
"member-serving" rather than "public-serving," and thus
donations to 501 (c)( 4)s are not tax-deductible. Examples
of 501(c)(4) organizations are service clubs such as the
Lions and Kiwanis, as well as the main arms of political
organizations such as the Sierra Club, the American
Association of Retired Persons, and the American Civil
Liberties Union.
Another primary distinction between 501(c)(3)s
and50l(c)(4)s is in regard to legal restrictions on their
political participation. Although non-profit advocacy has
long been recognized as an important vehicle for citizens
to express their political preferences, one form of
advocacy, namely lobbying, which is defined as the
attempt to influence specific pieces of legislation, is
limited, though not prohibited, for 501 (c)(3 )s. This is
primarily due to the tax-deductible donations received by
501 (c)(3)s. Iflobbying was unlimited for these orga-
nizations, wealthy donors could write off their political
activities simply by lobbying through 501 (c) (3) organi-
zations. However, it is not limited for 501 (c) (4 )s. Other
forms of advocacy, such as public education or providing
information to government committees, are not limited for
either type of organization. Partisan communications
directly related to an election are prohibited for 50l(c)(3)s
and limited for 501 (c)(4)s (Reid, 2006).
In terms of internal oversight, non-profits are generally
governed by self-perpetuating volunteer boards of
directors, which oversee a paid executive director, who
manages the day-to-day operations of the organization.
Board members are responsible for providing financial
oversight, selecting the management team for the
organization, helping to determine the mission and
ongoing strategy of the organization, and monitoring
performance, among other things. The board is legally,
fiscally, and publicly accountable to the outside
stakeholders of the organization, such as donors, con-
sumers, staff, and the community at large. Ensuring
accountability requires maintenance of clear written'
policies, careful communication about expectations and
priorities, and efforts to maintain transparency in
operations (Holland, 2003). The struggles many nonprofits
face in meeting accountability standards will be discussed
more in the following paragraphs.
Scope and Scale of the Non-profit Sector Human
service organizations, a slightly broader term for what are
also called social service organizations, are generally
formed as non-profits and are of special
428 CoNTEXTS/SETIINGS: AGENCY AND ORGANIZATION IN NON-PROHT SETTINGS
interest to the social work profession. Hasenfeld (1983 ,
p. 1) defines them as "that set of organizations whose
principal function is to protect, maintain, or enhance the
personal wellbeing of individuals by defining, shap ing,
or altering their personal attributes." Agencies that
provide material goods and support, individual and
family services, including mental health and substance
abuse treatment, residential care, child care, job train-
ing, and services to the elderly and disabled are all
examples of human service organizations.
The latest version of the Nonprofit Almanac (Weitz-
man, [alandoni, Lampkin, & Pollak, 2002) gives an
overview of the scope and scale of the non- profit sector
in the United States, as well as patterns of growth. The
authors report that, nationally, ~bout 734,000 (45%) of
the rv 1.6 million non-profits in the United States have
501(c)(3) status. The growth rate of 50l(c)(3) s is about
6% a year. There are 140,000 organizations registered
f"V
as 50l(c)(4)s. Religious congregations, another large
group of non-profit organizations, are not required to
file with the IRS, but there are about 354,000 of them
according to estimates. All together, non-profit .organ-
izations involve more than 6 million volunteers and
employ more than 11 million people (9.3% of all
American workers). The employment rate in the non-
profit sector is currently growing at about 3.2% a year ,
which is faster than either the government or business
sectors. That said, the annual wage paid to a non- profit
worker remains almost $10,000 a year less than that
earned by a worker who is not employed in the nonprofit
sector, an enduring problem for recruitment and
maintenance of a quality workforce in the non-profit
sector.
Figures from the Nonprofit Almanac indicate that most
non-profits fall on the smaller side of the spec trum. For
501(c)(3) organizations, about 43% have expenditures
less than $100,000 annually, and about 73% have
expenditures below $500,000. Only 4% have
expenditures over $10 million. Organizational size is
not distributed evenly among all areas of nonprofit
activity, however. Health-related non-profits tend to be
the largest, followed by human service and educational
non-profits. In regard to the number of non- profits
operating in each area, human service organizations
make up about 35% of 501 (c)(3 )s, education 16%,
health 15%, and arts and culture 11 %.
HISTORY Non-profit organizations are not new. The
Elizabethan Poor Laws and subsequent poor law
reforms in Britain in the 17th and 18 th centuries
codified the distinction between the "deserving" and
"undeserving" poor, with religious and voluntary
organizations (that is to say, non-profits) taking care of
the deserving poor,
and state-run workhouses being run to house the
undeserving. The United States largely inherited and
then adapted this system to the developing American
society. In this way, social work has long been asso-
ciated with the non-profit sector through the concept of
charitable work. Early settlement houses and child
protection societies important to social work history,
such as Hull-House and the Children's Aid Society, can
be considered non-profit organizations. Other large his-
torical social service non-profits also have a long his-
tory. For example, the YMCA was founded in 1851, the
Salvation Army in 1878, and the United Way in 1887.
THEORETICAL DEVELOPMENTS There are several
different theories regarding the origin of the non-profit
sector, and how the division of labor between it, gov-
ernment, and the for-profit sector came about. These
theories are generally complementary rather than ex-
clusive. Traditionally, economic theories have focused
on three forms of "failure": market failure, government
failure, and voluntary failure. Market failure, most
closely associated with the work of Hansmann
(1980,1987), asserts that under conditions of
information asymmetry, where the provider of services
has more information about the quality of service
provided than the consumer does, profiteering is likely,
and it is thought that the nondistribution constraint
mentioned earlier makes non-profits less likely to
participate in that kind of behavior. A social service
example of this is in day care centers, inpatient mental
health facilities, or nursing homes, where the user of
the service may not be able to reliably report on the
quality of the services they are receiving. From this
perspective, non-profits exist to provide a more
trustworthy alternative to forprofit services.
Government failure, most closely associated with the
work of Weisbrod (1975), asserts that because of what is
known as demand heterogeneity-the fact that in a
pluralist society different people will have different needs
and desires for public goods-the government will be able
to meet the needs of only the "median . voter" or average
citizen. In this view, non-profits exist to fill the gaps that
government leaves unfilled, providing services to niche
groups. Human service examples include innovative art
and music therapies and faithbased services.
Voluntary failure, most closely associated with the
work of Salamon (1987), identifies four failures on the
part of non-profit organizations, all of which are highly
applicable to the human services sector. First is philan-
thropic insufficiency-non-profits will never be able to
sufficiently and reliably provide all the services that are
necessary because of inadequate resources. There is
 CONTEXTS/SETTINGS: AGENCY AND ORGANIZATION IN NON-PROFIT
SETTINGS 429

also a lack of incentive for people to contribute toward between people, mostly through membership groups,
or pay for services that they can partake in even if they but also through voluntarism. Second, they facilitate
do not have to pay for them [otherwise known as the free civic involvement and political engagement. It is
rider problem (Olson,' 1965)]. Second is philan thropic through non-profits that regular citizens express their
particularism-non-profit organizations and the views and get involved in politics, from a neighborhood
foundations and individuals that donate to them will reform level such as a concerned parents group, to a
have a tendency to focus on some groups or problems to professional level such as a local social service agency,
the exclusion of others, such as only providing services to the national level, such as think tanks and profes-
for the "deserving" poor such as the elderly and sional interest groups. Third, they safeguard and pro-
children. Third is philanthropic paternalism-related to mote cultural, religious, and artistic pursuits and values.
the above, this is when non-profit organizations provide Last, they provide services government and business
services or address problems that they think need either cannot or would not provide.
addressing, but may not necessarily be what so ciety or
the client wants or needs, Clearly, both philanthropic Non-Profit Human Service Organizations TYPES
particularism and paternalism raise strong social This wide range of services has resulted in a very large
. \
justice concerns. Fourth is philanthropic amateur- and diverse sector. Data from the National Center for
ism-poorly funded non-profit organizations may be Charitable Statistics give a rough idea of the number of
more highly dependent on volunteers and low-skilled human service non-profits operating in different fields.
workers rather than on professionals, leading to a lack of Using a very inclusive definition of what fields fall into
expertise in dealing with complex social problems. the broad category of human service, their online
Voluntary failure theory essentially turns the tables on database shows the sector breaking down
the other two failure theories, explaining why we need . as follows for 2006. Out of a total of about 285,684
both non-profit and government-provided services. organizations, 28% were multipurpose, 25% recreation
Although these leading theories are economic in and leisure, 13% health, 9% housing and shelter, 6%
nature, Clemens (2006) points out they are quite con- youth development, 6% mental health, 4% crime and
sistent with dominant political theories, which have legal, 4% public safety, 3% employment, and 2% food ,
focused on a market model of democracy wherein agriculture, and nutrition.
decisions about which public goods will be provided by Financing. The typical human service organization
government and which will be left to the residual is financed by a combination of individual donations,
non-profit sector are made by individuals expressing foundation grants, government grants and contracts, and
preferences through voting. Other political concep tions client fees. The most current information from the
of the non-profit sector have focused on other important Nonprofit Almanac (Weitzman et al., 2002) reports that
roles of voluntary organizations, such as in providing contributions from individuals and foundations com-
outlets for civic engagement and representing diverse prise about 18% of the average organizations budget ,
interests in a pluralistic society (Putnam, 1993; Verba, while government grants comprise about 23 %.
Schlozman, & Brady, 1995). Early chronicler of culture Revenue from fees and government contracts make up
and society in the United States de Tocqueville (1969, p. about half the budget (the way that non-profits are asked
513) noted in the early 1800s that, unlike their European to report this information makes it impossible to tease
counterparts, Americans were "forever forming apart using official IRS data), and income from other
associations" to solve community problems, regulate sources such as investment income and income from
collective goods, or provide services that government special events make up the remaining 10%.
was not providing. Lohmann's (1992) conception of the This funding arrangement can be difficult for orga-
"commons" and the noninstrumental rewards and nizations to manage for many reasons. As will be seen
benefits of non-profit membership are also related to this here, government grants and contracts are fraught with
role of the sector. It is argued that in a liberal democracy, time-consuming difficulties, including the need to meet
people should join together in associations to make their extensive reporting requirements, which can be a major
voices heard and to combine resources for collective drain on staff time. For this reason, as well as others,
action, and non-profit organizations are the result of this government funding tends to go to larger organizations
process. with greater capacity and organizational resources;
Boris (1999) highlights four special roles of the non- Foundation funding generally comes in smaller
profit sector that capture much of the intent of the amounts and is limited to specific programs. Most
literature summarized earlier. First, they serve to build foundations like to see themselves as innovators and
social capital, or networks of trust and cooperation incubators, giving organizations funds to start new
programs.
430 CONTEXTS/SETTINGS: AGENCY AND ORGANIZATION IN NON-PROFIT SETTINGS
They then expect the organization to find additional
funding after the program has completed its grant. They
tend not to support the same programs for years on end,
and grants for general operating expenses are rare. These
types of grants are highly coveted, however, as they allow
the most freedom and flexibility on the part of the
organization to spend the money how they best see fit.
Private donations are often small for the amount of
effort that is spent recruiting them. This trend made the
national news in the aftermath of several recent disasters,
including the trauma of September 11, 2001, and its
aftermath, and the Christmas Day 2004 Tsunami in
Southeast Asia. Many donors were outraged to discover
that their contributions were\going to pay for general
organizational expenses, rather than directly going to
those affected by the tragedy. Communicating to do-
. nors that services cannot be provided if the organization
cannot sustain itself is a difficult task for many non- profits.
Revenue from donations can also fluctuate . greatly from
year to year, making it a fairly undependable source of
income for many organizations.
Finally, increasing revenue by charging fees to clients
is a complicated endeavor for many human service
non-profits. Fees are an attractive source of revenue
because they are fairly predictable and can be spent in
flexible ways. However, many clients do not have the
resources to pay for the full cost of their services, making
an increase in the fees they pay an untenable solution. In
addition, many human service non-profits feel a mission
to keep fees down so as to provide services to those who
need them most. Non-profits who are forced to rely more
on fees may inadvertently exclude lowincome people who
depend on their services the most. Despite this, there is
some indication that reliance on fees is growing. Salamon
(2002) reports that from 1977 income from fees rose over
500% in the non-profit social service sector, the largest
increase among the different funding types.
Government-Non-Profit Relations
The above-mentioned information about how human
service organizations are financed makes clear that
government funding is a very large part of the budget for
many human service organizations. This is largely the
result of an increased trend toward the privatization of
social services in the United States since the mid1970s.
Privatization is the word used to describe the turning over
to the non-profit sector and in some cases the
profit-making sector the responsibility to provide services
that used to be provided directly by the government. A
reflection of the larger ideological shift toward
neoliberalism, this trend began in the 1970s
and 1980s because of fears that government- provided
services were too inefficient and bureaucratic to be
effective. Currently, the social service delivery system in
the United States is very much a "partnership" between
non-profits and government, with government providing a
large portion of the funding, but scaling back direct
services in favor of contracting with non profits (Salamon,
1995).
CHALLENGES Overall; privatization has created both
opportunities and challenges for human service non-
profits. It has opened up new funding streams, but has
also led to a growth in the number of organizations and
has increased competition. As a result of privatization,
many human service non-profits have become overly
dependent on government funding, and have begun to
face increased scrutiny by the taxpaying public. In creased
access to local government agencies has opened up
opportunities for advocacy, but this closer coordina tion
can also lead to legitimacy concerns, with clients or
members of communities feeling as though the orga-
nization is more responsive to government needs than to
their needs (Smith & Grenbjerg, 2006). Additionally,
smaller human service non- profits may be shut out from
receiving government grants and contracts be cause of the
enormous amount of paperwork and documentation
required to both receive and maintain them. This has
strong implications for the diversity of organizations in
communities. Even the large traditional non- profit human
service organizations do not have a lock on these
government dollars, however. Other recent trends and
policy shifts have increased the amount of competition
these traditional agencies experience in regard to both
for-profit competitors and faith-based non- profit
providers (Smith, 2002).
Privatization is also related to two other issues that
help create a complicated environment for human ser vice
non-profits. These are devolution and marketiza tion.
Devolution, the transferring of decision- making and
funding . power to state and local government, is
changing the environment for human service non profits
significantly because it changes who is responsi ble for the
decisions that impact them. Notable in the welfare reform
changes of 1996, this has created a service environment
where rules and regulations may change from state to
state and county to county (De Vita, 1999). Devolution
has also led to new govern ment funding arrangements,
such as block grants, managed care models, and
performance-based contracts, all of which lead to a n
increasingly competitive funding environment for many
human service non-profits.
Marketization is the pressure for non-profit organi-
zations to adopt traditionally corporate marketing and
 CONTEXTS/SETIINGS: AGENCY AND ORGANIZATION IN NON-PROFIT SETTINGS
management strategies. This pressure has grown
largely because of the processes of privatization and
devolution, which have resulted in increased reporting
requirements and more competition. Marketization is a
challenge for many human service non-profits, such as
those that are small, have alternative structures, or
depend on nonprofessional staff (Alexander, Nank, &
Stivers, 1999). There is also some worry that these
pressures will lead human service non-profits to lose
their ability to meet the needs of niche communities and
that the traditional values of the sector, such as public
spirit and commitment to the public good, will be lost
(Van Til, 2000).
Accountability. Non-profits .are often looked at as
prime expressions of ci~il society and as an outlet for
our best human impulses of charity and caring. How-
ever, they are sometimes seen in a more negative light.
Although some in the non-profit sector feel unfairly
targeted, recent alleged ethics violations and misman-
agement at major non-profit organizations such as the
United Way, the Getty Trust, and the Red Cross have
raised concerns for many. In the wake of these scandals
and other locally based stories of corruption, lawmakers
and the press have recently become very concerned
about accountability in the non-profit sector. This is
reflected in highly publicized ethics investigations, as
well as significant new legislation that increases re-
quirements and oversight for non-profits in areas such
as executive compensation, how audits are handled, and
how fund-raising is reported. Although these measures
are important for accountability, they can be very
difficult to implement for small organizations.
The legislative trend toward more restrictive ac-
counting and activities started at the federal level with
the passage of the Sarbanes-Oxley Act in 2002.
Although this law was primarily brought about because
of concerns regarding corporate corruption, it has sig-
nificant implications for the non-profit community and
contains two provisions that do require non-profit
compliance. Good governance practices required for
for-profits and recommended but not required for non-
profits include disclosing financial conditions,
prohibiting personal loans to executives, certifying
financial statements, changing auditors on a regular
basis, and having separate and independent audit
committees. It should be noted, however, that many
states, such as California and Virginia, have passed
their own accountability legislation, which is often
more rigorous than that of the federal government and
can have greater requirements for non-profits operating
in those states.
Technology. Rapid developments in the technology
environment have created several new opportunities for
non-profits. The Internet has allowed
431
non-profits to distribute information about their ser-
vices, location, and areas of expertise, which has cre-
ated major new marketing opportunities. It is also a
powerful tool for soliciting online donations, particu-
larly from new donors (T uckman, Chatterjee, & Muha,
2004). It can facilitate both volunteer and staff recruit-
ment, allowing organizations to choose from a broader
pool of potential applicants. It can also facilitate an
organizations advocacy activity, allowing them to dis-
tribute their message to many more people, at a lower
cost, and to notify stakeholders of important events
(Reid, 2006). Additionally, clients <Zan communicate
with case managers, patients with nurses, or students
with teachers through e-mail, allowing fewer staff
members to serve more people in the same amount of
time, reducing transportation costs for clients and
possibly reducing missed or cancelled appointments.
Finally, the ease of securely sharing digital files allows
small organizations to more easily outsource
managerial and accounting functions (Tuckman &
Chang, 2006).
Despite the important benefits that use of informa-
tion technology may provide non-profits, many organi-
zations have struggled to keep pace, because of
financial constraints or a lack of knowledge about how
to use these new technologies. Building and
maintaining a Web site or other online presence that is
effective, attractive, and up-to-date can be prohibitively
expensive for non-profits that do not generally have the
necessary expertise themselves, leading to a disparity
between wealthier and smaller nonprofits (T uckman,
Chatterjee, & Muha, 2004). Manzo and Pitkin (2007)
support this finding, reporting that depending on their
size and expertise, non-profits face very different chal-
lenges in maintaining information technology infra-
structures and that a significant percentage still do not
have high-speed Internet, networked computers, or
other relatively simple upgrades. The major barriers
that they identified include a lack of funding for tech-
nology needs, high costs of maintenance, a lack of time
to plan how to use it or to train staff, and a lack of access
to needed expertise (Hick & McNutt, 2002).
Political Participation. Finally, finding the financial
resources and making the time commitment to participate
in policy advocacy is a struggle for many non-profits,
especially human service non-profits that are balancing
their main commitment toward service provision (Berry,
2003). There are many good reasons for human service
non-profits to participate in policy . advocacy, though.
As well as helping to secure a more stable funding
environment for the organization itself, policy advocacy
helps communicate the needs of their often marginalized
and underrepresented clients .to lawmakers. As human
service non-profits often have
432 CoNTEXTs/SErnNGs: AGENCY AND ORGANIZATION IN NON-PROFIT SETTINGS

specialized knowledge regarding the challenges their clients ways to more effectively incorporate feedback from
face, communicating that information to policy makers can community members.
help improve policy and the lives of the clients themselves.
Despite these important reasons to participate in policy Future Directions and Trends
advocacy, however, most human service nonprofits have only Eisenberg (2000) gives several recommendations for how the
limited advocacy programs, if they have them at all (Child & non-profit sector can address some of the challenges it is
Grenbjerg, 2007; Mosley, Katz, Hasenfeld, & Anheier, 2003). currently facing. Several recent congressional attempts to
The reasons for this are many. Misunderstandings of the legal limit the rights of non-profits that accept government funding
implications of advocacy for 501(c)(3)s is an important one to advocate on behalf of their ~lients require that non-profits
(Berry, 2003), as are limitations in terms of financial capacity work to promote democracy through defending their
(Grenbjerg, Cheney, Leadingham, & Liu, 2007), support from advocacy rights. Given the increasingly close relationship
board members, (Gibelman & Kraft, 1996), and skilled and between the non-profit sector and government, non-profits
committed leadership need to work to support and promote accountability and
~
(DeVita, Montilla, Reid, & Fatiregun, 2004). effectiveness in government, as well as within the non-profit
To overcome these barriers, researchers have suggested sector itself. The uneven funding environment that many
several solutions. Working in coalition can make it easier to non-profits face may require reforming philanthropy so that
maintain a long-term advocacy presence while possibly funding of general operating support is more common.
reducing risks and costs (Hula, 2000). The use of the Internet Finally, new leadership for the sector will also need to be
can be an effective .and inexpensive tool for distributing an developed, as many executive directors are nearing retirement
organizations advocacy message (McNutt & Boland, 1999). age and talented young managers have not been
Finally, focusing on local policy makers and administrative systematically recruited or paid adequate salaries to ensure
agencies may lead to increased access for many non-profits, their continued commitment to leadership in the non-profit,
while devolution has increased the power wielded by these versus the for-profit, sector.
local decision-makers (Sherraden, Slosar, & Sherraden, 2002). It is also important in this era of increasing competi-
Diversity. Managing diversity is another cha llenge for , tiveness that human service non-profits are aware of the
many human service organizations. This problem is importance of maintaining a clear commitment to their
intensifying as the overall proportion of people of color in original mission and be able to articulate their values clearly.
the United States is growing, and new waves of immigrants Frumkin and Andre-Clark (2000) argue that non-profits are
arrive. Meanwhile, many of these commu nities still face not well-placed to compete on a narrow efficiency basis with
great difficulties in regard to economic, educational, and for-profit organizations and that uncritical acceptance of
social marginalization. This pattern increases the need for performance-based contracts and other market-related
quality human services directed at people of color, while benchmarks is not the answer for long-term survival. In order
systematic structural barriers limit their access to it. These for non-profits to succeed in the current funding and policy
structural barriers include transpo rtation difficulties due to environment, they must find a balance between efficiency,
location of services outside minority neighborhoods, lack instrumentality, and their more expressive, mission-based
of availability of bilingual services and knowledge of what reasons for existing. It is this commitment to a values-based
services are available, and underutilization of services due role in society that makes non-profit organizations and
to cultural beliefs about help-seeking (Gutierrez, 1992 ). associations a unique alternative to for-profit or
Additionally, many organizations struggle to maintain a government-provided social services.
board of directors and staff that reflect the ethnic diversity
of their clients, which contributes to ongoing ethnocentrism
within agencies. To make services more available,
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SUGGESTED LINKS The Independent
Sector. www.independentsector.org
Urban Institute Center on Nonprofit and Philanthropy.
www.urban.org/center/cnp/indexcfm -
Idealist.
www.idealist.org
The Foundation Center.
wwwfoundationcenter.org
BoardSource.
www.boardsource.org
Association for Research on Nonprofit Organizations and
Voluntary Action. \ contemporary commerce: so long as businesses abide by the
www.arnova.org
Chariry Channel.
www.charitychannel.co
m
Center for Lobbying in the Public Interest.
www.clpLorg
OMBWatch.
www.ombwateh.org
-JENNIFER E. MOSLEY
CORPORATE SETIINGS
ABSTRACT: Human service corporations provide op-
portunities that social workers are just beginning to recognize.
Although the commercial provision of services has negative
features, expansion of the for-profit sector bodes well for
those professionals willing to consider it as a practice setting.
Corporations have become prominent service providers in
hospital management, nursing home care, managed care, child
care, welfare, and corrections, Because for-profit firms are
often more competitive than nonprofit agencies, privatization
is likely to contribute to corporatization human services.
KEY WORDS: corporate human services; privatization;
private practice; practice settings
In an advanced market economy, corporations are a primary
vehicle for distributing goods and services. Corporate
involvement in social services is readily evident in the three
sectors of American social welfare: (a) the nonprofit,
voluntary sector, (b) the governmental public sector, and (c)
the commercial, private profitmaking sector. While social
workers have been active in the voluntary and governmental
sectors, historically, participation in the corporate sector has
been much more recent. While posing significant challenges
to social welfare policy, expansion of the corporate sector also
presents important opportunities for social workers.
The fact that the political economy of the United States is
democratic-capitalist virtually assures that large businesses
would be prominent in national affairs. With the growth of the
service sector of America's postindustrial economy, corporate
activity in human services has expanded commensurately.
Corporate activity was catalyzed by passage of Medicare and
Medicaid in 1965, through which the federal government
reimbursed private providers for health care, and subsequently
augmented by the 1973 Health Maintenance Organization
Act, which subsidized managed care ventures. Since then
entire markets have been exploited by corporations: nursing
homes, hospital management, managed care, child care,
corrections, and welfare. This list demonstrates the openness
of the American economy and an ineluctable fact of
law, they cannot be prohibited from establishing markets in.
social services or anywhere else for that matter. To the extent
corporations are more competitive than nonprofit providers
within a market, commercial human service providers stand to
benefit from government outsourcing service provision
through privatization (Donahue, 1989).
Since the mid-1970s astonishing growth in thenumber and
scale of human service corporations has been witnessed. In
1981, 34 human service corporations re~ ported revenues
exceeding $10 million; by 2003 the number had increased to
241. Many human service corporations have become
household names: Beverly Enterprises (nursing homes),
Hospital Corporation of America (hospital management),
Kindercare (child care), Magellan (managed care),
Wackenhut (corrections), and Maximus (welfare). The scale
of several corporations dwarfs public institutions; for
example, in 2004 United Health Group claimed 33,000
employees and $28.8 billion in earnings while Tenet boasted
109,759 employees and $13.2 billion in revenues (Karger &
Stoesz, 2006). Although there is considerable turbulence in
the corporate sector as firms acquire one other, develop new
product lines, expand into new markets, and go out of
business, the future of this sector appears to be robust.
Opponents of Corporatization
Corporate provision of social services presents several critical
issues for social work. Through privatization, corporations
increasingly contract with govenmient for provision of
services, promising more flexibility, lower costs, and
increased accountability, although these outcomes are often
disputed. Criticism of commercial activity in social welfare
abounds. If corporations are particularly aggressive, they may
force nonprofits out of the same market. Corporations may

lower costs by deprofessionalizing the workforce and
encroaching on the autonomy of professionals in inde-
pendent practice and social agencies and serving less
troubled clients through a strategy of preferential selec-
tion. It may be difficult for public officials to document
irregularities in service provision, since most corporate
information is considered proprietary. Corporations en,
joy the liberty ofleaving unprofitable markets in which
event they may dump large numbers of consumers who
must then be cared for by nonprofits or government
agencies.
At the policy level, the implications of corporatiza-
tion are more ominous. Corporations that collude with
lawmakers and bureaucrats are well positioned to lever,
age policy so that it complements their self-interest as
opposed to the public interest. A recent example is the
2003 Medicare Modernization Act, which provided a
windfall for pharmaceutical and managed care compa-
nies at considerable expense to taxpayers (Stoesz,
2005). Thus, the emergence of a human service indus-
trial complex is a direct threat to governmental and
nonprofit providers. For these reasons, corporate invol-
vement in social services cannot be ignored.
Proponents of Corporate Sector Human Services
Adherents of market approaches to social policy point to
the many advantages of corporations in social welfare.
An ineluctable fact is that most Americans obtain goods
and services through markets, except for the poor who
must rely on inferior government provisions, effec-
. tivelysegregating them from the economic mainstream
(Funiciello, 1993). Through access to commercial
financial markets, corporations can readily obtain capi-
tal for program deployment and expansion.
Corporate activity in social services also presents
opportunities for social workers. As government and
nonprofit programs have lagged behind demand for
services, as a result of budget cuts and static charitable
giving, and the corporate service sector expands ac-
cordingly, jobs are increasingly available for social
workers. Anecdotal information indicates that social
workers find the ambiance, salary, and management
accorded by the corporate sector supportive of their
work. Corporations also offer important lessons to so'
cial work managers in nonprofit and governmental
agencies. Innovations in information systems, team,
building, employee ownership, and decentralization are
borrowed from the corporate sector. Similarly, non,
profit managers often seek to augment their agency's
income by engaging in commercial revenue-generating
activities, which are considered tax-exempt so long as
they do not violate the Unrelated Business Income Tax
provisions of the tax code. In recent decades
CONTEXTS/SE1TINGS: CoRPORATE SITTINGS 435
human service administrators have begun to establish
social enterprises as a means to advance social welfare
under commercial auspices. Prominent among these ha s
been asset building, as evident in Michael Sherraden's
idea of Individual Development Accounts (Families in
Society, 2007).
Corporations also present important job opportu-
nities for upwardly mobile social workers. Just as social
workers have moved into the management of nonprofit
and governmental organizations, they could move into
corporate management should they choose to. Finally,
corporations present new opportunities to serve emerg-
ing markets, such as aging baby boomers. Conventional
means for funding new programs mounted by the non-
profit sector require grant applications to foundations
while those initiated by government depend on legisla-
tive action or the approval of public bonds; by contrast,
corporations can generate funding almost instantly from
financial markets. Conventional means of lever aging
funding for social programs have consisted . of laborious
fund-raising campaigns on the part of nonprofit agencies
or bond issues by government that must be approved by
taxpayers, program expansion strategies that are not
only time-consuming but not guaranteed to succeed. By
contrast, commercial providers can quickly secure
capital from private markets based on a wellcrafted
business plan.
In a health and human services market that is in,
creasingly competitive, social workers who ignore the
opportunities attendant with corporate social services
may be doing their clients, themselves, and their pro,
fession a disservice. By way of illustration, since the
1980s, Health Maintenance Organizations (HMOs) re-
organized health and mental health practices in most
regions of the United States. In response to what many
professionals perceived to be abridgments of their
practice prerogatives, many doctors and ancillary
personnel established Individual Practice Associations
(lPAs) to counter HMOs. Between 1990 and 2003, an
increasing number of health and mental health
professionals were no longer practicing under the aegis
of HMOs, but under IP As instead, and their share of
patients in, creased accordingly (U.S. Department of
Commerce, 2(06): Although social work provides the
largest volume of mental health services and at lower
cost than psychiatrists and psychologists, many social
workers in private practice remain vulnerable to the
predations of managed care companies. A social work
IP A would be a means to counter corporate incursions
into the markets served by private practitioners.
Social work's antipathy toward corporate human
service provision is paradoxical insofar as many social
workers are engaged in commercial activity through
 436 CONTEXTS/SETTINGS: CORPORATE
SETTINGS
private practice. The expansion of managed care, often
perceived as occurring at the expense of private practi-
tioners, may account for this. Regardless, corporatiza tion
of human services is a reality with which social work must
contend. Reluctance to take human service cor porations
seriously probably furthers the evolution of a "human
service industrial complex," which manipulates public
policy to the advantage of commercial providers at the
expense of governmental programs and nonprofit agencies.
Moreover, a case could be a made that social
. work's presence in the board rooms of America's human
service corporations might contribute to policies and
practices that are more socially responsible.
REFERENCES
Donahue, J. (1989). The privatization decision. New York: Basic
Books.
Families in Society. (September, 2007) . Working but poor: Next
steps for social work strategies and collaborations. Families in
Society, 88(3) (Special Issue).
Funiciello, T. (1993). Tyranny of kindness. New York: Atlantic
Monthly Press.
Karger, H., & Stoesz, D. (2006). American social welfare policy (5th
ed., Ch. 7). New York: Pearson.
Stoesz, D. (2005). Quixote's ghost: The right, the Liberati, and the future
of social policy (pp, 57-60). New York: Oxford University
Press.
U.S. Department of Commerce. (2006). Statistical abstract of the
United States. Washington, DC: U.S. GPO.
-DAVID STOESZ
FAITH-BASED SETTINGS
ABSTRACT: Religions have traditionally called upon
believers to be generous and assist others in need. Ju daism,
Christianity, Islam, Buddhism, and Hinduism are a few
examples of religions that stress this call. In the United
States, the roots of the current religious system date back to
the 17th century, when those who fled Europe to escape
religious persecution established the first congregations.
However, real faith-based social care developed only after
independence and disestablishment. Today, faith- based
social care is an essential part of the American welfare
system, from the safety net provided by congregations to
the sophisticated" contract ed services provided by the
faith-based social services.
KEY WORDS: organized religion; American welfare
system; charitable choice
Definitions and Meanings
There is inconsistency and strong disagreement about what
constitutes a faith-based organization (FBO).
Such organizations can range from a church's social
ministry to an organization like the YWCA,. whose
original Christian affiliation has long been forsaken. A
commonly accepted definition of an FBO is offered by
Ragan, Montiel, and Wright (2003): " ... an organi zation
that has some degree of connection to an orga nized faith
community. These connections may take any number of
forms, including an organization's found ing; its mission
statement; a shared religious ideology amo ng staff,
volunteers and, or, leadership; conviction that motivates or
guides actions and decisions by staff; and reliance on
financial sources of a religious nature. FBOs mayor may
not have explicit religious content in the programming of
the social services they provide. Faith based organizations
can, in general, be identified as congregation- based,
independent, religiouslyaffiliated, nonprofit, large,
national, faith-affiliated social service providers, and
coalitions or intermediaries, as defined below (p. 23)."
The literature on the extent to which a particular social
service organization is a religious organization is much
more complex. The first serious treatment of the issue was
done by Jeavons (1977) who suggested seven dimensions
for defining an organization as "religious": (a)
organizational self-identity, (b) selection of organi zational
stakeholders (staff, volunteers, funders, and cli ents), (c)
sources of funding, (d) goals, products, and services, (e)
information processing and decision rnak ing (e.g., reliance
on prayer for guidance), (f) development and distribution
of organizational power, and (g) organizational fields
(including program partners). For each dimension, an
organization may be categorized along a scale from least to
most religious. Smith and Sosin (2001) focused on the
ways that service organiza tions are embedded with faith
(that is, how they are connected with denominations or
other religious groups) and the relationship of this
embedding to the organization of service de livery. They
focused on three main dimensions: resource dependency (the
proportion of financing and staff from religious sources),
authority (the bureaucratic or normative control that
religious agencies hold over an organization), and
organizational culture (interactions with religious influences
in relation to secular influences such as professional associ-
ations).Organizations can be placed along a continuum
from high to low coupling in each of these areas.
The most advanced typology of faith- based social
services was offered by Sider and Unruh (2004) who
developed a complex typology of the nature of religion in
social and educational services and programs. The
typology consists of eight levels of religious charac teristics
and four levels of programs. Each possible in teraction (that
is 32 possibilities) is a typology that

then has levels of religiosity within it. This model is
most helpful for advanced scholars and demonstrates
well the complexity of faith issues when applied to
social service organizations. The interested reader may
also look to Goggin and Orth (2002) for a good review
of the topic.
Religious Philosophy of Service
Helping others, especially helping strangers, is
imprinted through a deep process of socialization
(Keith-Lucas, 1972). Religions have traditionally called
upon believers to be generous and assist others in need.
Judaism, Christianity, Islam, Buddhism, and Hinduism
are all but a few examples of the major, world religions
that hold different dogmas, y~t teach their followers to
help
others. . the virtue 'of poverty. Initially, many Buddhists under-
The Jewish tradition distinguishes between values
and rules that define relationships with the Deity and
those that define individual and communal relation ships.
The latter tradition has given rise to the concepts of
Tzedakah, which means justice or charity, Hessed, which
means deeds of love and kindness, including mercy, and
the concept of Tikkun Olam, which stands for social
justice and integrity. These concepts call upon the
believer to feed the hungry, to leave part of the food
production for the local poor to gather, to care for
orphans and widows, to respect and care for elderly
parents, and to treat everyone with dignity. Judaism.
introduced the principle of tithing, where people are
obligated to donate 10% of their wealth to the priests and
charity (Plotinsky, 1995).
Christians are called upon to identify with Jesus and
in doing so, to care for the poor. Jesus told his disciples
that those who feed the hungry and clothe the naked
would be rewarded on judgment day. Jesus said in the
New Testament, "When you did it to one of these, the
poor and dispossessed of his time, the least of my broth-
ers, you did it to me" (Matthew 25:31-46). Another
commonly used Christian concept is agape. Agape love is
valuing, respecting, being willing to assist, and be
committed to the well-being of another person. It ori-
ginates from the understanding of the nature of God as a
merciful and unconditional care provider (KeithLucas,
1989). While there are some variations among the many
Christian denominations, they all have care and concern
for the needy. Some put greater emphasis on the "other
world" and minimize the importance of worldly welfare
while others are more focused on "their world." But in
either case, for all Christians, care for the poor is both a
theological teaching and a practical mandate
(Rauschenbusch, 1907).
Islam, like Judaism and Christianity, places a high
value on charitable acts and giving. The Qur'an
CONTEXTS/SEITlNGS: FAITH-BASED SEITINGS 437
emphasizes the importance of Zakat, which literally
means "to thrive or to be wholesome." In practice, Zakat
is a contribution or tax on property that is earmarked for
the poor, the needy, those in captivity, debtors, travelers
in need, and those who serve Islam (Zayas, 1960). The
Qur'an also calls for the practice of sadaqah, which is a
voluntary giving to those in need. Giving alms to the
needy is one of the five pillars of the Islamic faith; the
Qur'an states that divine punishment and reward are
determined by the extent to which the faithful fulfill
these five principles, Charity and social responsibility in
Islam are moral obligations rooted in the belief that the
world belongs to God and not to people. As such, giving
is a statement about one's belief in God (EI Azayem &
Hedayat-Diba, 1994).
Buddhism is predicated on sympathy to the poor and
took to become-rather than support--beggars, as
begging was considered the breeding ground for virtues
like modesty and appreciation of simplicity. These vir-
tues enabled a life of contemplation, . which was con-
sidered the only justification for human existence.
Those who did not choose this lifestyle Were expected
never to pass a beggar without giving alms and never to
refuse a request for supporting a philanthropic cause
(Conze, 1959). In Buddhism, one who practices charity
and compassion is born to a state that moves him or her
closer to Nirvana since positive acts produce positive
karma. Thus all life is interdependent, and reciprocity is
a central tenet of Buddhist philosophy.
In Hinduism, we find that the concept of nonvio-
lence (ahimsa) is central and is clearly demonstrated in
the classical Hindu text, the Upanishad (Chekki, 1993):
It makes clear references to almsgiving and support of
people in need and also teaches that one who is generous
to others will benefit while others will suffer. The Hin du
religious tradition teaches social harmony and social
order, which is best reflected in collectiverespon sibility
among families, clans, and castes; examples can be seen
in the concept of daana, the act of giving, and daks'ina,
gifts displaying purity and respect. Individual
responsibility to perform actions that will gain merit in
the next life and responsibility for collective welfare
have created the motivation for giving to those in need
(Chatterjee, 1995).
In sum, the tenets of all religions have helped shape
the social values and the institutions that are the foun-
dation of modem social service provisions in both the
secular and religious arenas. Offering service to the
poor, orphans and widows, sick and disabled, prisoners
and captives, travelers, and neighbors in times of calam-
ities is emphasized and fostered in sacred texts. The
438 CONTEXTSjSETIlNGS: FAITH-BASED
SETIlNGS
spirit of faith-based service remains strong among the
modem-day followers of these religious traditions.
Religious teaching alone cannot bring about welfare
activities. Clearly, social welfare values and philosophies
emanated from the many faith traditions. Most religious
teachings encouraged social order and cohesion among
members of society. Social solidarity was perpetuated by
caring for all members of society and showing concern for
the poor. However, the complex link between religion and
social welfare merits careful examination (Cnaan, Boddie,
& Wineburg, 1999; Loewenberg, 1988, Tirrito & Cascio,
2003). Pro-welfare teaching, however, only sets overall
social expectations; it does not create actual social welfare
programs. Furthermore, not all societies' religions have
been active in advocating for and helping the needy and as
such various cultural and social mechanisms play in the
manner in which religion is instrumental in social welfare.
As such, we need to understand how religious teaching was
transformed into massive social welfare programs.
History and Evolution
The early manifestation of social care and support of the
needy is almost singularly religion-based. Ancient Rome
with its public projects and pressure on rich people to feed
the masses and pay for entertainment may have been the
singular most important exception. In most parts of the
world, social care was religionrelated. The Jewish prophets
complained against those who did not support the poor and
disadvantaged, indicating that it was socially expected of
them to do so. The later Jewish text, the Talmud, shows
that care for the poor, the traveler, and the enslaved was
paramount on people's mind and was related to religion.
Troeltsch (1992, p. 80) asserted that "in the early centuries,
charity was directed inward toward creating a haven of
mutual aid within the pagan environment. Later on, in
times of great distress and misery which affected the
masses of people, the Church lifted the burden from the
State onto its shoulders, often creating its own centers of
social service and charity."
The early Christian church was most relevant to the life
of the people as it assisted them with all their life needs.
When the church started to become institutionalized,
especially in the latter part of the first millennium,
monasteries were removed from the public and concen-
trated on sustaining the welfare of their members. At those
times, the priests and nuns were busy tending to themselves
and barely surviving the dangers of famine and war. In
medieval times, churches acted as "patrimony of the poor"
under bishops' supervision. From the 15th century onward,
religious groups received a tax-exempt
status and were able to use land, trees, and water to sustain
hospitals, orphanages, soup kitchens, inns, nursing homes,
and educational institutions. One such example is the
French hospital, The Hotel-Dieu at Beaune, which was
endowed by Philip the Good in 1443 and was only closed
as an operating hospital in the late 20th century
(Hugonett-Berger, 2005).
The roots of current American faith-based social care
go back to the 17th century when those who fled Europe to
escape religious persecution established the first
congregations. Each colony had one established church
and possibly also supported the Church of England.
Following the European model, tax money was used to
erect the building and pay the clergy's salary. Each colony
had one established religious tradition. By law if there
were 10 families interested in the Church of England, this
church was also to be publicly supported (Gough, 1995).
The settlers brought with them the laws of England,
including the Elizabethan Poor Laws of 1601. These laws
stated that the responsibility forthe welfare of an individual
is first and foremost that of the relatives and if they failed,
it is the responsibility of the local authority. This meant
that religious congregations were not highly engaged in
providing social service. One exception was Virginia. In
pre-revolutionary Virginia, many Anglican clergy also
served as municipal poor-law officials, and assumed
responsibility for the old, the sick, the deserted, and the
illegitimate children in their communities. However, these
clergy did so as agents of the local authority and not at the
behest of their churches (Coll, 1969). It was also in
Virginia that the legislature repealed most of the legal
privileges granted to the Anglican Church (including the
collection of taxes for the church) in 1776 (Levy, 1994).
By 1830 all the states had adopted a similar legislation
that disestablished the responsibility of government for
maintaining organized religion and allowing freedom of
worship. This new practice was the precursor of the First
Amendment to the Constitution and the separation of
church and state. Interestingly, disestablishment brought
with it a renewed interest in religion and the number of
congregations grew from fewer than 3,000 in 1780 to
approximately 54,000 in 1820, an increase that even
outstripped the population growth (Miyakawa, 1969).]
Since that time, the United Sates has been-and remains-one
of the most religious countries in the world, with religion
playing an important role in the daily life of its residents
(Finke & Starke, 1992).
The First Amendment, known as the 'Disestablishment
Clause,' is viewed by many as a landmark in which
government, rather than religious organizations, was
expected to meet the needs of all citizens. While the

First Amendment has been subject to numerous inter-
pretations by various Supreme Courts, all courts have
upheld two principles: religious organizations are welcome
to provide any social service they wish for as long as they
do so with their own resources and these services are free to
infuse religious content in the service delivery. However, if
religious services are using public funds for social service
delivery, these publicly funded services are to be free of
religious content and teaching (Dilulio, 2007).
As Leiby (1978) wrote, "religious ideas were the most
important intellectual influence on American welfare
institutions in the nineteenth century" (p. 2). Revivals,
religious camps, and, awakenings were all common in this
era ~f post-disestablishment. The Social Gospel
Movement, part of this religious excitement, sought to
improve the lives of the masses by introducing the
Christian values of just and harmonious living in society
(Curtis, 1991). Religion in America shifted from being the
dictate of the elite into the domain of the members who
started to own and manage their religious communities.
The late 19th century was the era in which religion in
America started to own leisure time and social care. As
Holifield (1994) noted, "In the late nineteenth century,
thousands of congregations were open for worship but also
were available for Sunday school concerts, church socials,
women's meetings, youth groups; girl's guilds, boy's
brigades, sewing circles, benevolent societies, day schools,
temperance societies, athletic clubs, scout troops, and
nameless other activities" (pp, 39-40). Since the early 19th
century, religion, no longer publicly supported, began to
take a more active role as the social center of the
community.
The variety of religions and their fear of one another
made possible the proliferation of religious-social services
from the mid-19th century onward. While Mainline
Protestants used mainstream public services such as public
schools and hospitals, orphanages, soup kitchens, and
public assistance, other religious groups developed parallel
services to "save the souls of their flock." This is how the
rich web of Catholic health, social and human services was
developed (Oates, 1995) and the Jewish as well Methodist,
Episcopalian, Lutheran, and Salvation Army services were
established. The notion of Catholic services for Catholics
and Jewish services for Jews and so forth was fundamental
and seemed the correct way of life.
The first systematic separation from religious-based
social services was the formation of the Charities Orga-
nization Societies (COS). At the end of the 19th century,
religious-based social services in America began to
CoNTEXTS/SETIINGS: FAITH-BASED SETIINGS
439
give way to secular forms of help. The Reverend Samuel
H. Gurteen paved the way by establishing the Buffalo
Charity Organization Society (COS) in 1877 soon to be
followed in all American cities. Although the original
British model was religious-based (Buzelle, 1892;
Schweinitz, 1943), under Gurteen' s leadership, the COS
movement substituted "friendly visitors" for deacons, and
a new scientific quest to eradicate poverty and solve all
social ills. Through their efforts, social services eventually
left their community-religious base for one that was
citywide, temporal, and professional (Tice, 1992), and the
delivery of social services became less arbitrary and more
systematic. The COSs gave rise to the modem social work
profession through the efforts of people like Mary
Richmond who worked for a few COSs and who attempted
to lay a scientific foundation for philanthropy.
Many religious groups became involved in the set-
tlement house movement, either through financial
sponsorship or by providing volunteers. Settlement houses
helped immigrants and indigent people become
self-sufficient and productive citizens. These social ser-
vices brought middle and upper class members of society
to live in poor, usually immigrant, neighborhoods and
model "proper" behavior and values to benefit the needy
neighbors. At the beginning of the 20th century, about half
the settlement houses were sponsored by religious groups
and half were secular in orientation (Evans, 1907).
However, even the flagship of the secular settlement
house, Hull-House in Chicago, was more religious than
usually discussed in social work. texts. For Jane Addams
and many other reformers, Christianity was a religion of
social action and faith that demanded service to the poor
(Garland, 1994). According to Jane Addams, Christian
humanitarianism was taking place "without leaders who
write or philosophize without much speaking, but with a
bent to express in social service and in terms of action the
spirit of Christ. Certain it is that spiritual force is found in
the Settlement movement, and it is also true that this force
must be evoked and must be called into play before the
success of any settlement is assured" (Addams 1910,
p. 124 as quoted in Garland, 1994, p. 81).
The Great Depression brought about a situation in
which most religious-social services depleted their own
sources, their members were in great need, and the new
players with big pockets-federal, state, and local gov-
ernments-became visible. These actors, however, with the
exception of the federal government, acted through the
many existing local religious social services. Mapes
(2004) documented the perceived "right" of religious and
ethnic groups to care for their own
440 CONTEXTS/SETTINGS: FAITIl~BASED
SETTINGS
while being reimbursed by public funds and through
guaranteed referrals from public programs. Faith- based
organizations such as Catholic Charities, Jewish Family
and Children Services, Salvation Army, and Lutheran
Social Services developed massive networks of social
services, many of which received grants or contracts from
various government agencies and cared mostly for their
own members. These services became profes sionalized and
when the government entered the welfare f ield in earnest,
through establishing the federal Social Security system, the
religious organizations started hiring workers with an
MSW degree and positioned themselves 'to provide
professional counseling services. As Mapes (2004 )
demonstrates, these age ncies were the first to offer social
services that were not tangible in nature and they praised
themselves as advanced and professional rather than
bureaucratic and technical, unlike the public services.
Until the late 1950s, many professional social work ers
were employed by the faith- based social services.
However, along with the War on Poverty and the Great
Society programs of the 1960s and the Civil Rights
Movement, many non-sectarian social services w ere
developed and these services cared for people regardless of
their religious background. The many religious social
services were asked by the public authorities to care for
people not of their faith and to offer services in a non-
religious fashion or lose their funding. Thus, since the
1960s, many religious social service organizations started
to care for all needy people regardless of ethnic ity or
religion and hire professional workers based on merit and
not on faith. A minority of religious social ser vices decided
to forgo public funding, rely on private support, and focus
their activities on social services that are heavily religious
in nature and selecting clients who were willing to accept
their faith message.
Alongside the religious social services that are usu ally
staffed by professional workers and are incorpora ted as
tax-exempt entities, a vast amount of social services are
also provided voluntarily and at their own cost by local
religious congregations. There are about 400,000 local
religious congregations in America and about 90% of them
are reported to offer some kind of social program (Cnaan,
Boddie, McGrew, & Kang, 2006). These programs are
often small in scale but their aggregative contribution is
immense. Congregations house the majority of scouts
troops, l Zvstep groups, day-care centers, and food
distribution centers. They are the primary providers of
immediate care for the poorest members of our society and
a large number of them have food programs, clothing
closets, and are involved i n homeless shelters even if not
directly operating one. Many after- school programs are run
by
and housed in local religious congregations. Most
importantly, Cnaan and his colleagues (2006) and
Ammerman (2005) found that the commitment of
congregations to helping people in need is a rooted
American norm. It was the congregations that sus tained the
Civil Rights Movement in the 1960s and many
congregations were the first and most effective to respond
to the devastation left by the Katrina hurricane.
At the dawn of the 21st century, the religious sector, in
many ways, is still the backbone of the American welfare
system: from the safety net services provided by
congregations to the sophisticated contracted services
provided by the faith-based social services for children in
need of child welfare and for seniors in nursing homes. The
role of religion in social service provisions temporarily
diminished with the passage of the Social Security Act of
1935. However, the religious services adapted to the new
environment by developing high quality professionalized
counseling services that are the core of modem- day social
work. It seemed that the federal government was taking
control over the welfare of the American residents. This
impression grew stronger in the 1960s with the War on
Poverty and the Great Society programs under the Kennedy
and Johnson administrations. However, as evidenced by
recent studies, the majority of American religious
congregations.remained active in caring for the needs of
people in the community (Cnaan et al., 2006) and
numerous largescale religious organizations are
contracting with the government and are offering a myriad
of social services.
Positive Attributes of Faith-Based Services
Religious congregations and institutions have numerous
attributes that make them well-positioned to provide
social services. First, organized religion (from local
congregations to national denominations) often fills the
role of intermediary group. It protects the citizen from
the power of government and corporations. Second,
religious institutions are attended and appreciated by
more than half the population and as such are the most
democratic. There is no other community organization
that brings so many people regularly to meet
face-to-face. While most congregations are segregated in
nature, by race, class, and ethnic origin, they allow
minority groups the opportunity to unite and press for
their own interests. Third, religious organizations are
spread around all neighborhoods and do not tend to
concentrate in business centers and in the downtown
areas. Therefore, they are accessible to most people and
are easily noticeable. Fourth, they possess a large pool of
members who can be called upon to assist as volunteers.
Fifth, they have space that is often used

only on weekends and as such is available for service
delivery during weekdays. Sixth, many religious
organizations are small and flexible. They are not bound
by red-tape and can easily experiment with new meth-
ods of care. Finally, the theological teaching of the
world religions is "help thy neighbor." As such, in the
United States, religious congregations and organiza-
tions see helping the needy as a norm. People in need as
well as congregational members accept that helping the
needy is the mission of religious organizations (Dilulio,
2007).
CONTROVERSIES Faith-based social services also
contain a variety of challenges and provoke social
controversies. First, the raison 'cl' etre of religious
organizations is the enhancement and proliferation of
their faith tradition. Many religious organizations,
while providing social services, wish and labor toward
clients' conversion and, at times, may put pressure on
clients in this direction. Second, some religious
organizations view the people in need as "lost souls"
who should seek salvation, which may seem
patronizing and demeaning to the service clients. Third,
religious groups tend to attempt to influence society.
and, as such, are involved in politics. Clergy and other
religious leaders are often active participants in issues
that polarize society. Religious leaders were at the
forefront of the Civil Rights Movement and the
backbone of the Moral Majority movement. There are
religious people on the extreme right and on the extreme
left. Given that half the American society regularly
attends congregations, it is not surprising that these
places and the services they offer are used as political
platforms for various ideological preferences.
Trends
Since the last decade of the 20th century, the trend
toward the strict separation of church and state when it
came to faith-based congregations receiving govern-
ment funding has been reversed. First, the Personal
Responsibility and Work Opportunity Reconciliation
Act of 1996 (P.L. 104-193) passed by a conservative
Congress and signed by President Clinton, included
section 104 also referred to as "Charitable Choice." The
objectives of Charitable Choice are to:(l) encourage
states and counties to increase the participation of
nonprofit organizations in the provision of federally
funded welfare programs, with specific mention of
religion-based organizations; (2) establish eligibility for
religion-based organizations as contractors for service
on the same basis as other organizations; (3) protect the
religious character and employment exemption
CoNTEXTS/SEITINGS: F AITH- BASED. SEITINGS 441
status of participating religion-based organizations; and
(4) safeguard the religious freedom of participants
(Cnaan & Boddie, 2002).
Charitable Choice became central in the 2000 pres-
idential election. Both candidates, Al Gore and George
W. Bush, committed themselves to expand and sustain
this section of the law. Indeed, in his second term in
office, George W. Bush, long before most appointments
were made, announced the creation of the White House
Office of Faith-Based and Community Initiatives. This
office was designed to increase the public role of
religious organizations inthe provision of welfare, to
blur the lines of the church-state separation, and to
encourage all government units to contract out with
religious organizations (Wineburg, 2007). This trend
toward involving the faith-based community in
government programs and legislation has many poten-
tial implications, some of which are still hard to foresee.
It may erode the volunteer and prophetic voice of many
religious groups; it may promote proselytizing it may
lower the standard of professional care; and it may cut
public spending for social care. These provisions have
been, and are still being, challenged in the courts though
they have easily withstood all legal challenges so far
(see http://www.pdp.albany .edu/ About/Programs/
Charitable_Choice.dm). It is not the ideal social ar-
rangement but one that is very popular in the United
States and is gaining popularity.
ROLE OF SOCIAL WORKERS It is imperative for all
social workers to fo llow these developments closely
and make sure that client care and well- being are not
jeopardized. It is unavoidable that many social
services are provided under religious auspices. While
most religionbased social services are well- intended
and provide q uality services, it is the role of social
workers to protect clients' rights and make sure that
no efforts at prosely tizing are taking place and that
clients are treated fairly. Furthermore, social work
and religion are the two ele ments that are most
concerned with the welfare of the needy and
disadvantaged in our society. While the value bases
are not always compatible, the quest for social justice
and welfare of people is a mutual ground. Social
workers should strive to recruit the resources of
religious organizations and congregations to the
benefit of their clients. If clients can benefit from the
resources of a religious organization, the social
worker should recruit these resources; if a religious
group can be harnessed to a local welfare coalition,
the social worker should actively court it. While there
can be many dis agreements and worries about many
religious organiza tions and their political and
religious worldview, in the welfare arena, religious
social services are equally
442 CONTEXTS/SETTINGS: FAITH-BASED SETIINGS
concerned and committed to social justice and to ser ving
the needy. A coalition between the religious social services
and social work is always stronger than each walking
alone.
[See also Faith-Based Agencies and Social Work.]
REFERENCES
Ammerman, N. T. (2005). Pillars of faith: American congregations
and their partners. Berkeley: University of California Press.
Cnaan, R. A., & Boddie, S. C. (2002). Charitable choice and
faith-based welfare: A call for social work. Social Work, 47
247-235.
Cnaan, R. A., Boddie, S. c., McGrew, C. C., & Kang, J. (2006).
The other Philadelphia~tory: How local congregations support
quality of life in urban America. Philadelphia: University of
Pennsylvania Press.
Cnaan, R. A., Boddie, S. c., & Wineburg, R. J. (1999). The newer
deal: Social work and religion in partnership. New York:
Columbia University Press.
Coll, B. D. (1969). Perspectives in public welfare. Washington, DC:
U.S. Social and Rehabilitation Services.
Come, E. (1959). Buddhism: Its essence and development. New
York: Harper & Row.
Curtis, S. A. (1991). A consuming faith: The Social Gospel and
American culture. Baltimore: The Johns Hopkins University
Press.
Gough, D. M. (1995). Christ Church, Philadelphia: The nation's
church in a changing city. Philadelphia: University of Penn-
sylvania Press.
Holifield, E. B. (1994). Toward a history of American con-
gregations. In: J. P. Wind & J. W. Lewis (Eds.), American
Congregations, Vol. ,2. New perspectives in the study of
congregations (pp. 23-53). Chicago: University of Chicago
Press.
Keith-Lucas, A. (1972). Giving and taking help. Chapel Hill:
University of North Carolina Press.
Leiby, J. (1978). A hiswry of social welfare and social work in the
United States. New York: Columbia University Press.
Levy, L. W. (1994). The establishment clause: Religion and the First
Amendment. Chapel Hill: University of North Carolina Press.
Loewenberg, F. M. (1988). Religion and social work practice in
contemporary American society. New York: Columbia Uni-
versity Press.
Miyakawa, T. S. (1969). Protestants and pioneers. Chicago:
University of Chicago Press.
Tirrito, T.,& Cascio, T. (2003). (Eds.). Religious organizations in
community services: A social work perspective. New York:
Springer.
Troeltsch, E. (1992). The social teaching of the Christian churches.
Louisville, KY: Westminster/John Knox Press.
Wineburg, R. J. (2007). Faith based inefficiencies: The follies of
Bush's initiatives. New York: Praeger.
Zayas, F. G. De (1960). The law and philosophy of Zakat.
Damascus, Syria: Al-jadiah Printing Press.
SUGGESTED LINKS
http://www . bama .org
http://www.pdp.albany.edu/About/Programs/Charitable_Choice . cfm
http://www . whitehouse .gov/ government/fhci/
http://www.au.org
-RAM A. CNAAN
lNTERORGANIZA TIONAL CONTEXTS
ABSTRACT: As environmental and organizational in-
fluences drive coalitions, shared service agreements,
mergers and other interorganizational alliances among
health and human service organizations, social workers
are frequently vital contributors. This article contex-
tualizes interorganizational work by reviewing its theor-
etical underpinnings, describing historical development
and discussing issues of language and definition. The wide
range of relationships and corresponding structural
options being implemented are explored. Sector-wide
trends and their implications for interorganizational work
are considered along with key factors for success and the
growing role evaluation plays in promoting positive
impact.
KEY WORDS: association; federation; coalition; col-
laboration; consortium; cooperation; coordination; joint
venture; management service organization; merger;
multi-tenant nonprofit center; network; partnership;
service integration; strategic alliances; strategic
restructuring
The settings in which social workers operate are varied:
public, private, nonprofit, individually focused, com-
munity-based, national, and transnational. Common
among them is the fact that social workers partner with
others to promote societal benefit, and these partner ships
often cross organizational boundaries.
Organizations form partnerships, or alliances, to work
together for agreed-upon purposes, advancing
complementary and common goals. Alliances help or-
ganizations achieve ends that would be more d ifficult to
realize on their own and provide important strategic
options to enhance capacity, operations, services, and
impact.
Theory and Research
The field of interorganizational relations integrates
research from multiple disciplines and viewpoints to
describe how and why alliances work. Foundational
theories drawing on mathematics, economics, sociology,
psychology, and political science, examine alliances
 CONTEXTSjSEITlNGS: INTERORGANlZA TIONAL
CONTEXTS 443
from the perspective of the individual. Among these, social
exchange theory considers how costs and benefits affect
participation (Blau, 1964; Homans, 1958). Rational choice
theory focuses on self-interest and utility, while game theory
illustrates how choices maximize returns (Alter & Hage,
1993). Coalition theory expands investigation, exploring how
individual action impacts collective welfare (Gamson, 1961;
Gentry, 1987; Groennings, Kelley & Leiserson, 1970).
The study of organizations, their contexts, and subsystems
furthers the understanding of alliances. For example,
transorganizational cdevelopment explores how systems of
organizations arrange themselves for effectiveness
(Cummings, 1984); whereas social network analysis examines
how relationships and patterns of connection influence
individuals and organizations (Tichy, Tushman & Fombrun,
1979; Wasserman & Galaskiewicz, 1994). Population-ecology
explains organizational adaptation to environmental
influences (Alter & Hage, 1993), and open systems theory
describes the structure and interdependence of organizational
connections relative to the environment (Wandersman,
Goodman & Butterfoss, 1997). Teamwork, small group
dynamics, and organization development literatures form the
basis for lifecycle models, offering additional insight into
alliance creation, management, performance, and
sustainabilitv.
Prior to the mid-1990s, much literature applied forprofit
dynamics to public and nonprofit alliances until case studies
involving health and human service organizations helped
adapt theory and practice models. Findings from national
studies added new detail about motivations, challenges,
processes, and results to create a more cohesive,
sector-specific body of knowledge about nonprofit alliances
(Bailey & Koney, 2000; Kohm & La Piana, 2003; Yankey,
Jacobus & Wester, 2001).
RATIONALE AND BENEFITS Organizations regularly
exchange and depend on one another for resources and
competencies. Fundamental needs, coupled with a willingness
to align and adapt, drive alliance formation (Alter & Hage,
1993). Six theoretical bases frame alliance rationale and vary
according to the primacy placed on internal capacity building,
environmental influences, or systemic change. Organizations
seeking to build internal capacity by acquiring operational as-
sets or gaining legitimacy with stakeholders align from the
perspectives of resource interdependence or environmental
validity. When challenged by their environments,
organizations respond by seeking operational
efficiency-sharing risks and creating economies of scale and
strategic enhancement-focusing on their missions and
strengthening their competitive positions.
Social responsibility motivates organizations to shape their
environments for large-scale, systemic impact, while domain
influence allows them to coalesce power toward desired
change (Bailey & Koney, 2000).
History and Trends
Circumstances favoring alliances are intensifying as the
nonprofit sector continues to expand. While the pace of
change is more dramatic and the configurations more diverse,
alliances involving health and human service organizations
have deep historical roots.
RESOURCES AND COMPETENCIES As early as the
1880s, philanthropists and local leaders concerned about the
growing number and integrity of benevolent organizations
began creating charitable federations to coordinate
administrative activities for member organizations.
Federations like Denver's Charity Organizations Society
(1887) and the Federation of Jewish Charities in Boston
(1895) centralized fund-raising and administrative support for
member organizations and provided a model for the creation
of today's United Way (United Way of America, 2007).
The impact of early 20th-century living and working
conditions led settlement houses to form alliances with
community groups to promote change around matters of
public welfare. Coalitions championed safer, healthier
neighborhoods, mobilizing improvements in sanitation, public
recreation, and child labor. In a trend that persisted throughout
the 1920s, federations began merging to facilitate more
effective solutions to broad societal concerns. Many mergers,
like that between the Federation for Charity and Philanthropy
and the Cleveland Welfare Council in 1917, integrated
community planning with fund-raising and distribution to
leverage greater impact (Bing, 1938).
A century " after local philanthropists mobilized the first
charitable federations, government, corporate and community
leaders are promoting alliances as a means to achieve greater
social returns on investments (Rosenthal & Mizrahi, 2004).
Heightened organizational scrutiny and demands for
accountability are driving health and human service
organizations to adopt certain for-profit business practices,
while new perspectives on sustainability are moving them to
expand their revenue strategies. Multi-tenant nonprofit centers
are developing and organizations are forming back-office
consolidations to access new technologies, spread
administrative costs, and build infrastructure to improve
effectiveness.
Concurrent social, economic, and demographic trends are
necessitating more flexible and diverse solutions to issues
deemed increasingly complex. Organizations are looking for a
different complement of
444 CoNTEXTS/SETTINGS: INTERORGANIZA TIONAL CONTEXTS
resources, initiating more innovative and inclusive stra-
tegies, and driving comprehensive systems reforms to
address unique community needs while including a wider
range of voices in planning and service delivery. Today's
coalitions continue to champion social change at the same
time that mergers focus more explicitly on strengthening
long-term sustainability.
MULTI, SECTOR RESPONSES Government is increas-
ingly engaging the private sector to discharge its public
responsibilities, and businesses are rapidly entering the
service domain formerly reserved for nonprofit organi-
zations, fostering . more boundary spanning alliances. This
development began after World War II, when the growing
needs of metropolitan centers mobilized
. the formation of public-private partnerships. Coalitions
expanded. Broad-based movements to achieve social and
racial justice combined power and influence for systemic
change. Initiatives like President Johnson's Great Society
in the 1960s and federal efforts to decentralize public
human service delivery stimulated early attempts at
service coordination under President Nixon in the early
1970s. During the 1980s and 1990s, public concerns about
substance abuse, family violence, and child protection,
along with other pervasive health and social issues, fueled
the rise in interdisciplinary and intersectoral alliances to
unite a wider range of strengths around prevention and
family strengthening (Melaville & Blank, 1991; Mulroy,
1997).
Political changes initiated in the 1980s under President
Reagan supported devolution, privatization, and greater
scrutiny in the use of public money for health and welfare.
The government and private foundations began to
encourage and fund consortia, joint ventures, and
integrated service networks. These alliances were designed
to access needed human, financial, and information
resources and reinforce organizational legitimacy and
capability in the increasingly demanding service arena.
This trend continued under President Clinton and President
Bush. At the same time, growing recognition of global
social inequities and the influence of international
non-governmental organizations has supported the
development of transnational alliances to address issues
across cultures and geographies, further expanding the
diversity of alliance options to meet human needs (Carrilio
& Mathiesen, 2006; Ritchie & Eby, 2007; Rodney &
Miller, 2003).
Toward a Common Vocabulary
The field is divided on an overarching term to encompass
the range of interorganizational contexts and activities.
The terms "alliance" and "strategic alliance"
have gained acceptance as broad descriptors. They re-
ference intentional relationships between two or more
organizations to build capabilities and achieve results.
Unlike "partnership," they do not have corresponding legal
definitions and, with few exceptions, are not used to
describe particular interorganiaationalforms,
The major diversion occurs with the continued
application of the term "collaboration" as generic and
inclusive in the literature and, more particularly, its
widespread and interchangeable use in practice. Not all
organizations that align collaborate, and not all alliance
structures are collaboratives. Yet, collaboration is em-
ployed routinely to describe any and all interorganizational
relationships and structures. "Alliance" depicts the range
of interorganizational forms with less ambiguity by
providing a clearer distinction between the umbrella term
and the various types and forms of interorganizational
relationships, collaboration among them.
Continuum of Interdependence
The means and methods through which organizations work
together differ, depending on what the allying
organizations want to accomplish. They can be classified
according to the nature of the. relationship and by its
structure or form. The forms alliances take and the
relationships underlying them are characterized by
progressive degrees of interdependence. They are fre-
quently considered along a continuum and differentiated
across multiple characteristics. Positioning along the
continuum indicates, in part, the extent to which
organizations invest their resources in the collective and
relinquish autonomy in order to accrue benefits.
UNDERSTANDING ALLIANCE RELATIONSHIPS Co-
operation is an informal relationship often characterized by
information sharing. Through coordination, organizations
align efforts to achieve compatible goals. Collaboration is
exemplified by organizational integration for a shared
purpose to which partnering organizations are jointly
accountable.
The most interdependent alliance relationships, which
feature structural unification, combined cultures, and the
greatest degrees of complexity, are variously.categorized
as coadunation (Bailey & Koney, 2000), strategic
restructuring (La Piana, 1999), consolidation (Arsenault,
1998), and merger (Hoskins & Angelica, 2005). The terms
"coadunarion" and "strategic restructuring" are more
precise .because "merger" and "consolidation" also name
particular alliance forms in which two or more
organizations legally combine into one surviving entity.
Organizations become more interconnected as they
move from cooperation to coadunation. They rely more
 CoNTEXTS/SEITINGS: INTERORGANIZATIONAL CoNTEXTS
on each other and the alliance for success. Missions and
people are more interdependent. Financial and oppor-
tunity costs rise, and fear of loss, change, and the un-
known increases. Systems and structures become. more
defined, requiring contracts and the creation of new
legal entities to centralize activities and offset corre-
sponding risks, resulting in greater formality. As inter-
organizational dynamics become more intense and
complex, expectations of relational permanence
increase and process variables, such as trust and equity,
take on more salience. Early establishment of
compatible values and cultures merits higher priority in
negotiations when more integrated operations are
proposed.
DIFFERENTIATING FORMS AND STRUCTURES
Each
~
type of alliance relationship has at least one corre-
sponding structural form that operationalizes it. Struc-
tures range from loosely organized referral
arrangements to formal and fully integrated mergers and
consolidations. Federations, co-locations, consortia,
parent corporations, and other interorganizational
relationships fall in between. Each has distinct
characteristics and patterns of organization appropriate
to its relative degree of integration. Less formal
relationships, like associations and coalitions, may be
managed through membership guidelines and letters of
agreement. More formal relationships, such as joint
ventures and mergers, require changes in bylaws and
corporate structures.
La Plana's (1999) Partnership Matrix classifies
alliance structures along an additional dimension: the
extent to which the alliance is focused administratively
or programmatically. Organizations often consolidate
administrative functions through joint purchase agree-
ments and management service organizations to reduce
costs and create economies of scale. They share space,
technology, financial systems, personnel, and other re-
sources, while often continuing to independently
implement their programs. Alliances with a program
emphasis include co-sponsorships of community
events, research consortia, service networks, and some
joint contracting relationships. Through these alliances,
organizations complement each other's programs,
operate new initiatives, and integrate systems for direct
client and community benefit.
The purpose of the alliance drives its structural ar-
rangement; its structure propels its operations; and the
degree of congruence between its purpose and structure
influences its success. When organizations clearly
define alliance goals before identifying the form the
alliance will take, they can choose the least intensive
type of relationship and simplest structure that will
achieve their desired ends. Alliances often evolve into
more formal arrangements; however, engaging too early
445
unnecessarily complex relationship requires greater
investment and potentially minimizes benefits.
Lifecycles and Stages of Development Alliances
develop through a series of foreseeable stages, each with
its own central issues and dynamic tensions. Lifecycle
models reflect the organic and iterative nature of
alliances with movements forward and backward
affected by internal factors and external circumstances.
Models range from three to seven phases; most commo n
are. four. Success in alliance development depends on
managing core issues, regardless of whether. the stages
feature process descriptors such as formation, imple-
mentation, maintenance and termination (Rosenthal &
Mizrahi, 1994); follow a relationship analogy in which
organizations progress through comparable stages of
courtship, getting serious, commitment and leaving a
legacy (Linden, 2002); or delineate specific tasks such
as mutual exploration and analysis, synthesis and
tentative planning, working committee structure devel-
opment, quick victories, institutional buy-in, work plan
by areas and formalized operational structure
(McLaughlin, 1998).
At the outset, alliance partners focus on assembling the
preliminary information and other resources they n eed
to get established (Bailey & Koney, 2000). They initiate
leadership, engage appropriate members, and confirm
the alliance purpose. Developing a comparative profile
of partnering organizations through side-by-side
analysis (Yankey, Jacobus, & Koney, 2001) is useful in
ascertaining potential synergies, gaps, and distinctive
organizational characteristics that can shape the alliance
and its work.
Ordering establishes structure. Partners define form,
operating agreements, governance, and legal bound-
aries; they articulate strategies and institutionalize
systems and procedures around funding, staffing, tech-
nology, decision making, information dissemination,
and evaluation. Mergers and more formal alliances also
feature a comprehensive interorganizational assessment
called due diligence, a systematic financial and legal
review. Due diligence is an opportunity to confirm
assets and capabilities of potential partners and can
reveal liabilities that might impact the future of the
alliance. Accountants, attorneys, and other professional
consultants may be helpful in these negotiations.
As partners begin perfonning, concentration shifts to
the alliance's work. Implementation plans guide activity
as they employ strategies and focus tasks. Partners link
with stakeholders internally and externally to access
resources, broaden ownership of action and results,
maintain the best structures and systems to support the
work, and strengthen outcomes.
446 CONTEXTSjSETIINGS: INTERORGANIZATIONAL CONTEXTS
Recurring themes include establishing relation, ships and
building trust among partner organizations, promoting
dialogue and effective communication inter, nally and
between individual members and the organizations they
represent, monitoring products and processes in the context of
goals and purpose, soliciting feedback for ongoing
development, and sharing and celebrating successes. Regular
assessments determine when and if the alliance is successful
and whether it terminates or transforms.
In some models, a preparatory phase precedes alliance
development, In most it is implied. This self assessment phase
is an inwardly focused period of deliberation and analysis
involving the organization's Board of Directors and staff. ,It
evaluates organizational readiness for. alliance participation
and defines criteria for potential partnerships, often reviewing
alliance opportunities in the context of the organization's
strategic plan.
PROMOTING AND EVALUATING SUCCESS Alliances
are being created in an environment in which demon, strating
outcomes is paramount to sustaining them. Up-front definition
of alliance goals and measures of efficiency, effectiveness,
and accountability relative to specified results are
instrumental in validating success. Just as organizational
accountability is growing, so is interest in documenting the
added value of working together through intermediate alliance
outcomes and long-term impacts. This means systematically
evaluating alliances, not yet a routine practice.
Some alliances are evaluated through an informal
assessment of the extent to which the initial purpose was met
and the degree to which partners were satisfied with the
process. Common inquiries include whether the alliance
acquired new resources, increased influence with legislators,
or allowed partners to allocate a greater portion of revenues to
direct service, and whether partners perceived the process to
be fair and the means justified by the rewards. These
benchmarks are a good first step in assessing
interorganizational impact.
More comprehensive process benchmarks correspond
with the alliance lifecycle and key success factors. These
include preparation and planning, shared vision and clarity of
purpose, open communication, effective leadership,
involvement of appropriate stake, holders, trust among
members, process equity, resource dedication, and a
supportive environment. Various tools and frameworks
incorporate success factors into assessments of critical
alliance components (Bailey & Koney, 1995b; Borden &
Perkins, 1999; Linden, 2002; Mattessich, Murray-Close, &
Monsey, 2001).
Defining success through logic models and evaluation
plans as part of establishing the alliance helps partners
ascertain whether investments in the joint effort produced
desired results. Setting realistic goals and assessing alliance
strengths and areas for improve, ment throughout the process
enable feedback for midcourse refinements. For example,
alliances formed with efficiency goals may not necessarily
lead to immediate cost savings. Such alliances can impose
new costs or require initial investments, including salary
equity, technology conversions, and merger integration, and it
can take years to achieve economic benefit. Reducing the rate
or pace of cost increases may be a more appropriate interim
financial goal.
It is difficult to directly correlate the establishment and
action of the alliance to broad social and economic impacts
such as reductions in poverty, improvements in health, and the
elimination of disparities. While theories of change help,
appropriate methods and measures are only beginning to be
studied. Broad conceptual frameworks, including assessment
of the nature and dynamics of the social environment, offer
new insights (Mulroy & Austin, 2004). However, more
research is needed to understand what function alliances
themselves serve in mobilizing and addressing systemic
issues so they can be leveraged effectively for maximum
impact. Without this; there maybe a tendency to inaccurately
estimate what it takes to make sustainable changes through
inter-organizational entities, potentially limiting their
influence.
Trends and Implications for Social Work Austin (2000)
calls the 21st century the "age 'of alliances" (p. 1). Despite the
challenges, working together can yield significant benefits to
organizations and com, munities,and social workers can play
both visionary and practical roles in these settings. The
growing realization of issue complexity and focus on impact
is motivating large-scale solutions and systems of care
(FosterFishman, Salem, Allen, & Fahrbach, 2001). Social
workers can utilize their experiences in helping individuals
and families negotiate fragmented service systems and their
knowledge of valuable community resources to inform these
discussions. With information technology as an enabler,
social workers can build traditional and virtual alliances to
facilitate more efficient ways to share knowledge.
Conversely, where information tech, nology, leadership, and
other gaps exist, they can guide organizations to alliances as a
means to enhance capabilities and scale.
Local planning authorities and programs such as the
Empowerment Zones begun under President Clinton are
driving community definition of goals, strategies,
 CoNTEXTS/SETIINGS: INTERORGANIZA TIONAL CoNTEXTS
and measures. Stakeholders investing in successful
outcomes represent multiple perspectives including
businesses, faith groups, and cultural and ethnic com-
munities. Social workers are skilled at bridging differences.
They can help alliances include less-heard voices in their
processes and build consensus across diversity. Social
workers can keep equity and social justice at the center of
dialogue and action, making them vital contributors in
strengthening not only the alliances but also the resultant
public benefit.
With the growth in social entrepreneurship and venture
philanthropy, there is an increasing emphasis on the
application of innovative, business-minded approaches
and strategic investments to support nonprofit missions
and broad social change (Dees, Emerson, & Economy,
2001; Frumkin, 2003). Major financial commitments will
be accompanied by different expectations for process and
results.
Integrating social work skills and values in interor-
ganizational settings can promote connection, commit-
ment, and mutual learning that foster organizational
sustainability and success.
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SUGGESTED LINKS The NonprofitCenters
Network . http://www . nonprofitcenters
.org/index .php
Mandel Center for Nonprofit Organizations Strategic Alliances
Project.
http://www . case .edu/mandelcenter/strategicalliances/ Strategic
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http://surveys . wilder .org/public_cfi/index.php
-KELLY McNALLY KONEY
PRIVATE/IN.DEPENDENT PRACTICE SETIINGS ABSTRACT:
Private independent practice (known historically as private
practice) is a growing segment of the social work profession.
Social workers entering this context are providing a range of
services, including clinical and nonclinical. Major
considerations for establishing, maintaining, and marketing a
successful and ethical private independent practice will be
discussed. Existing tensions and challenges in the social work
profession and in the field of social work education will be
briefly examined. Future directions for private independent
practice of social work will be explored.
KEY WORDS: business; solo practice; group practice;
private practice; independent practice
Private independent practice had its earliest beginnings with
pioneer social workers like Mary Richmond (Barker, 1995;
McLaughlin, 2002; Richmond, 1922). Since that time, and
especially since the mid-1970s, the number of social workers
entering private indepen- . dent practice has grown. The earlier
private practice of social work primarily focused on clinical
work, especially psychotherapy. The contemporary landscape
of private independent practice reflects a myriad of services,
both clinical and nonclinical, depending on individual state
rules and regulations. Clinical work may include such services
as counseling and psychotherapy to individuals, couples,
families, and groups, and clinical supervision of social workers
for licensing, community, and corporate interventions.
Nonclinical work may encompass program development and
evaluation, conflict resolution, mediation, training, and
education. Traditionally, private independent practitioners
have offered their services in a private office setting. Many
now contract with agencies, as well as clients, for the delivery
of services.
Private/independent practice tends to attract social
workers who desire salaries higher than those of their agency
counterparts as well as greater independence
450 CONTEXTS/SETTINGS: PRIVATE/INDEPENDENT PRAcnCE SEITINGS
and flexibility in their work hours, choice of clients, and
approaches to working with clients. Motivation is
considered to be a crucial attribute for successful practice
(Barker, 1992).
The actual number of social workers in private in-
dependent practice is unknown. The Center for Health
Workforce Studies and the NASW Center for W orkforce
Studies (2006) presented findings on a 2004 survey of rv
10,000 licensed social workers. Of those surveyed, 17.5%
identified private practice as their work setting. The largest
percentage of these private practice social workers, nearly
54%, were aged 65 and older. In comparison to other social
service settings, private practitioners had the highest'
salaries (Center for Workforce Studies, 2006;\Whitaker,
Weismiller, & Clark, 2006).
In a NASW Practice Research Network 2004 study of a
representative sample of 2,000 members, it was found that
23% were in private practice only and 18% were in
organizational and private practice settings. Similar to the
earlier-mentioned study, respondents in private practice
reported higher salaries than did those social workers in
organizational settings. On comparing the 2004 study with
an earlier 2002 study, it was found that the number of
private practitioners had increased 3 % (National
Association of Social Workers [NASW], 2005a). From
these studies, it would appear that private independent
practitioners represent a viable and growing sector of the
social work profession. Further evidence of this developing
interest is reflected in the creation and growth of the private
practice specialty section within the National Association
of Social Workers (NASW), which is currently the largest
section within the association (M. Coleman, personal
communication, March 27, 2007).
Prior to engaging in private independent practice, social
workers must meet requirements as set by their respective
state social work laws. State laws vary in terms of
regulations and definitions for private independent practice
(Association of Social Work Boards, 2005). Beyond state
requirements, social workers may pursue additional
clinical credentials and professional development through
the NASW, the American Board of Examiners in Clinical
Social Work, and the Association of Clinical Social Work.
Private independent practice is essentially a business
requiring knowledge and skill in developing and marketing
services as well as managing an office and expenses
(Barker, 1995). Expenses may include office rental,
telephone, telephone answering or voicemail services,
pagers, cell phones, office supplies, health insurance,
self-employment taxes, and malpractice insurance. Rather
than pursuing a solo practice where they
maintain sole responsibility, some social workers prefer
sharing responsibilities through group practice. It is es-
sential to have established relationships with professionals
such as a lawyer, certified public accountant, and
experienced social workers, who can provide periodic
consultation. Knowledge and skill for addressing and
resolving ethical and legal dilemmas, and reducing mal-
practice risks are key considerations (Houston-Vega,
Nuehring, & Daguio, 1997; NASW, 2005b).
Although it is believed that social workers engaging in
their own practice fare better physically and psycho-
logically than do social workers in organizational settings,
there may be stress related to managing a business,
generating referrals, and avoiding ethical, legal, and
malpractice risks (Jayaratne, Davis-Sacks, & Chess, 1991).
The tensions and challenges surrounding the private
independent practice of social work are alive and well and
actually have been in existence since Mary Richmond's
first reference to individual case work (Brown & Barker,
1995; [ayaratne et al., 1991; McLaughlin, 2002;
Richmond, 1922). Social workers engaged in independent
work continue to be criticized for having abandoned the
mission of social work (Specht & Courtney, 1994). Many
private practitioners would argue that they are committed
to social work values, promote social justice, and advocate
on behalf of clients and communities. These controversial
debates exist in the social work profession and in the field
of social work education (Brown & Barker, 1995;
Gibelman, 1999; Jayaratne et al., 1991; McLaughlin,
2002; Strom & Gingerich, 1993). Given the reality that
many graduate social work students plan on working
independently, it creates a critical challenge, obligation,
and opportunity for social work educators to accept some
responsibility for including course content on private
independent practice in the curriculum.
A second notable challenge relates to the diverse terms
and definitions used by state social work boards for the
legal regulation of private independent practice. With the
already existing misperceptions of social work, the lack of
consensus on terms, definitions, and regulations only
contributes to greater confusion for the profession and the
public (Association of Social Work Boards, 2005).
The social work profession is expected to
experience a continued growth in the number of
social workers in private independent practice
(Bureau of Labor Statistics, 2006; Gibelman, 1999).
Future directions will most likely include the
following: greater recognition of the contributions
of private independent practice in the social work
profession; research

efforts to specifically identify the numbers and profiles
of private independent practitioners around the
country; development of additional resource materials
for educating social workers about establishing and
maintaining successful and ethical practices as well as
guidelines for closing and retiring from practice; and
increased attention to and development of courses with
private independent practice content within graduate
social work programs.
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work-Past, present, future. Soda! Work, 44(4), 298-310.
Houston-Vega, M. K., Nuehring, E. M., & Daguio, E. R.
(1997). Prudent practice: A guide for managing malpractice risk.
Washington, DC: NASW Press.
}ayaratne, S., Davis-Sacks, M. L., & Chess, W. A. (1991).
Private practice may be good for your health and wellbeing.
Social Work, 36(3), 224-229.
Mclaughlin, A. M. (2002). Social work's legacy: Irrecon-
cilable differences? Clinical Social Work Journal, 30(2),
187-198.
National Association of Social Workers. [NASW]. (2004).
Clinical soda! workers in private practice: A reference guide.
.Washington, DC: Author.
National Association of Social Workers. [NASW]. (2005a).
Practice Research Network 111 final report, January 2005.
Washington, DC: Author.
National Association of Social Workers. [NASW]. (2005b).
NASW standards for clinical soda! work in soda! work practice.
Washington, DC: Author.
Richmond, M. (1922). What is soda! case work? New York:
Russell Sage Foundation.
Specht, H., & Courtney, M. (1994). Unfaithful angels: How
social work has abandoned its mission. New York: The
Free Press.
CONTINUING EDUCATION 451
Strom, K., & Gingerich, W. (1993). Educating students for the
new market realities Journal of Social Work Education, 29(1),
78-87.
Whitaker, T., We ism iller, T., & Clark, E. (2006). Assuming the
sufficiency of a frontline workforce: A national study of licensed
soda! workers. Executive summary. Washington, DC: National
Association of Social Workers.
FURlHER READ~G
Bent-Goodley, T. B. (2002). Defining and conceptualizing
social work entrepreneurship. Journal of Social Work Educa-
tion, 38(2), 291-302.
Wolfson, E. R. (1999). The fee in social work: Ethical di-
lemmas for practitioners. Social Work, 44(3),269-273.
-SANDRA A. LOPEZ
CONTINUING EDUCATION
ABSTRACT: Continuing education (CE) refers to an
array of opportunities by which professionals can aug-
ment existing knowledge and skills. CE is essential for
professional competence, career development, and
compliance with licensing rules and other regulations.
CE is offered through a variety of auspices, methods,
and venues. Advances in instructional technology and
electronic communication have further expanded
access to CE opportunities. Ongoing challenges in CE
include strategies for assuring quality in CE program-
ming and adequately evaluating skill and knowledge
acquisition.
KEY WORDS: staff development; professional compe-
tence; in-service training; social work education
Continuing education (CE) has been defined as "consistent
participation in educational opportunities beyond the basic,
entry-level professional degree" (National Association of
Social Workers [NASWl, 2002). As such, it builds upon a
foundation of formal education to facilitate lifelong learning.
It can refresh little-used skills and knowledge, it can equip
workers with the abilities necessary for new roles or career
advancement, and it can orient them to new and emerging
theories and practices.
History
The pursuit of educational opportunities to augment existing
knowledge is as old as the profession of social work itself. The
formalization and growth of CE enterprises, however, can be
traced to the 1970s when Title :xx of the Social Security Act
provided for social service training entitlements. It fueled staff
development
452 CONTINUING EDUCATION
activities, such as workshops, conferences, and residen tial
training retreats and institutes (Strom & Green, 1995). The
emphasis and availability of CE foundered in the 1980s ,
due to the erosion of Title XX funding and the difficulty in
making CE financially viable on a feeor tuition- only basis.
The resurgence of CE since the 1990 s can be attributed to
mandatory continuing education requirements associated
with social work credentialing and legal regulation.
Best Practices
CE is both an organizational imperative and an indivi dual
responsibility. Organizations have an interest in staff
development and a responsibility to ensure that employees
comply with agency accreditation standards, licensure
regulations and other professional require ments. In the
form of staff development, agencies assure that, through
CE, workers are compliant with laws and policies, effective
in the provision of services, and equipped to advance the
organization's mission. As such, agencies may sponsor
periodic training on such topics as ethics and risk
management or on universal precautions to prevent the
transmission of disease. To build staff capacity,
organizations may train workers in new treatment
modalities, offer developmental pro grams for new
supervisory personnel, or facilitate men torship and
consulting arrangements for individualized CE (Price,
2005).
Regardless of their agency auspices, individuals pursue
CE for personal interest and growth, to meet licensure
requirements, and to ensure the competence required for
effective and ethical practice (NASW, 1999). Even when
they are partaking in CE to meet external require ments
such as those imposed by licensure boards, social workers
must be responsible and self- directed consumers, selecting
education programs that are congruent with their specific
learning needs (NASW, 2002). Choices about CE are
highly dependent on price, access, and content, as workers
pursue convenient, affordable pro grams on topics that are
personally relevant and provide opportunities for
professional renewal (Daley, 2001). The tax deductible
nature of continuing education may foster selection of
programs in desirable vacation locales, which has the
potential to subjugate knowledge and skill development to
recreational opportunities.
Requirements and Standards
Virtually all of the jurisdictions and orga nizations that
credential, certify, or license social workers, require
evidence of continuing education for renewal (Associa tion
of Social Work Boards, 2006) though each body
sets separate definitions of the hours, content and forms of
study that can qualify for CE standards. For licensure
boards, the number of CE contact hours required an nually
ranges from 10 to 24, depending on locale, and the
definitions of CE include traditional forms of education
such as workshops, seminars, credit- bearing courses,
professional conferences, and certificate pro grams. Most
jurisdictions accept activities such as self directed learning,
online courses, volunteer activities, Internet courses,
videotapes, and workshop, course, or manuscript
preparation, for a portion of the required coil tact hours.
Many regulatory boards also specify that certain content
areas (such as ethics, laws, cultural competence, substance
abuse, or HIV-AIDS) must comprise a portion of the
contact hours for renewal. Some jurisdictions also specify
exclusionary criteriatopics that cannot qualify for CE
requirements for example, job orientation, business or
financial courses, self- improvement programs,
non-interactive electronic or distance education, or courses
that are audited rather than taken for credit.
Auspices
Contemporary CE is developed, organized, and deliv ered
under a variety of auspices, including indepen dent
practitioners, for-profit educational corporations, schools
of social work, training consortia, individual agencies,
professional organizations such as the Council on Social
Work Education and the Nati~nal Associa tion of Social
Workers, and the national and local affiliates of specialty
groups such as the Clinical Social Work Federation and the
Society for Social Work Lead ership in Health Care.
Sponsors such as these deliver a vast array of content
through a variety of instructional methods including
annual conferences, workshops in face-to- face or distance
teleconference formats, Webor CD-RaM-based self- paced
instructional programs, and credit- bearing courses or
certificate programs. Each of these educational strategies
has particular strengths and weaknesses, in cost,
availability, pacing, and suitabil ity for conveying
particular content (Strom-Gottfried, 2006). CE activities
are typically funded by tuition and fees, corporate
sponsorship arrangements, or through foundation or
governmental training grants and con tracts. CE providers
include full-time trainers, social work faculty, seasoned
practitioners, and professionals from other disciplines.
Trends and Challenges
Continuing education in social work is a diverse enter prise.
This diversity has positive connotations for

access, choice, and competition in the effort to enhance
professionals' skills and knowledge. However, the
decentralization, variety, and largely unregulated delivery of
CE raise concerns about quality, relevance, con, sistency, and
the transfer of training to practice. Professional organizations
and regulatory bodies have begun to address quality concerns
by issuing standards on CE delivery (NASW, 2002). Many
entities review and pre, approve individual providers,
workshops, or CE organizations before issuing CE units
(CEUs) or contact hours.
It is unclear, however, how widespread, thorough, and
effective these mechanisms are in assuring quality. The
reliance on credentials, reputations, and recornmendations in
approving corporate and individual pro, viders, and on written
program descriptions for assessing content, may not reflect the
actual delivery of material. A further evaluative concern for
CE lies in the CE recipients themselves. Few CE programs
make use of adequate measures to determine the cornpetencies
resulting from participation in a particular CE event. The
structure of CE makes it difficult to deter, mine whether the
content was appropriate for a particular attendee, properly
integrated with existing knowledge, or applied appropriately
in practice. Contemporary methods of evaluating CE focus on
selfreport, demonstration of attendance, and measures of
participant satisfaction. Concerns about evaluating
comprehension also arise in Web,based or other self, directed
learning methods (Gravois, 2007). The social worker who
passes a post' test after only a cursory review of a text or online
program may he demonstrating knowledge of the content, but
in doing so he or she raises questions about the proper
selection of CE to build on existing abilities.
The next phase in the evolution of continuing professional
education will address these concerns, requiring precisely
drawn objectives, increasing the accountability for delivery of
empirically grounded material, and implementing more
rigorous evaluative methods. Paralleling these structural
trends will be the influence of technologically enabled
delivery mechanisms in the form of online, self-directed and
Web-based learning. CE content will be responsive to
emerging populations and interventions, and address risk man,
agement and other liability concerns through an ex, panded
emphasis on ethics training (ASWB, n.d.). CE is a diverse,
evolving, and essential mechanism for extending social work
education to lifelong learning. Numerous stakeholders, from
regulators, to providers, to end users affect the structure,
content, and delivery of CE programs. Future CE initiatives
must incorporate
CONTINUING EDUCATION 453
longitudinal strategies for empirically demonstrating the
rigor, relevance and retention of the material delivered
(Smith, et al., 2006).
REFERENCES
Association of Social Work Boards. (2006). Continuing educa tion.
Retrieved September 24,2006, from http://www.aswb.
org/educatioruindex.php
Association of Social Work Boards (n.d.). Guide to social work
ethics course development. Retrieved November 30, 2007, from
http://www.aswb.org/ASWBEthicsCourseGuide.pdf Daley, B. J.
(2001). Learning and professional practice: A study of four
professions. Adult Education Quarterly, 52(1),39-53.
Gravois, J. (2007). Illinois questions the ethics of professors who
swiftly aced its ethics quiz. The Chronicle of Higher Education,
1 (2). Retrieved January 15, 2007, from http:// chronicle.com
National Association for Social Workers. (1999). Code of ethics of
the National Association of Social Workers. Washington,
DC:NASW.
National Association for Social Workers. (2002). NASW standards
for continuing professional education. Retrieved September
24,2006, from http://www.socialworkers.org
Price, D. (2005). Continuing medical education, quality
improvement, and organizational change: implications of
recent theories for twenty-first-century CME. Medical Teacher,
27(3), 289-268.
Smith, C. A., Cohen-Callow, A., Dia, D. A., Bliss, D. L., Gantt,
A., Cornelius, L. J. et al. (2006). Staying current in a changing
profession: Evaluating perceived change resulting from
continuing professional education. Journal of Social Work
Education, 42(3),465-482.
Strom-Gottfried, K. J. (2006). Managing human resources. In R.
L. Edwards & J. A. Yankey (Eds.), Effectively managing
nonprofit organizations (pp. 141"-178). Washington DC:
NASW.
Strom, K.J., & Green, R. K. (1995). Continuing education. In R.
L. Edwards (Ed.), Encyclopedia of social work, (19th ed.).
Annapolis, MD: NASW.
SUGGESTED LINKS
Area Health Education Centers.
http://www . nationalahec . org/home/index. asp
Association of Social Work Boards, Social Work Continuing
Education.
http://www .aswb .org/education/index. php
Council on Social Work Education.
http://www.cswe.org/
National Association of Social Workers, NASW Standards for
Continuing Professional Education.
http://www.socialworkers.org/practice/standards/cont.J1r ofessionaC
ed.asp
National Association of Social Workers, NASW Credentialing
Center.
http://www .socialworkers .org/credentials/default . asp
-KIM STROM-GOTTFRIED
454 CONTINUOUS QUALITY IMPROVEMENT
CONTINUOUS QUALITY IMPROVEMENT. See
Management: Quality Assurance.
CONTRACTING OUT OF SOCIAL
SERVICES
ABSTRACT: Contracting out of social services is defined
as the purchase of services by government agencies from
for-profit and nonprofit organizations. It has a long history
beginning with the English Pooi: Law of 1723 and
becoming a major policy during Reagan's administration.
Both the advantages and shortcomings of contracting out
are described and analyzed. The effects on providers'
accountability to government and clients and the
implications \for social work practice and ethics are
discussed. Special emphasis is given to the social workers'
dilemma facing a dual loyalty to contractor-employer on
the one hand and to clients on the other.
KEY WORDS: contracting out; social services; effi-
ciency and effectiveness; competitiveness; measurable
outcomes; accountability; dual loyalty
Contracting out is generally defined as the purchase of
services by government agencies from for-profit and nonprofit
organizations (Demone & Gibelman, 1989). It typically
represents public sector financing of private sector service
delivery (Donahue, 1989), and may assume various forms
ranging from subsidies to purchaseof-service to consumer
vouchers. Contracting out social services has a long history.
The English Poor Law of 1723 allowed local parishes to
contract out relief for the destitute to private providers. In the
United States in the 18th century, local communities
contracted with private individuals to care for their poor, and
in the 19th century the rise of institutional care for the men-
tally ill, the juvenile delinquent, and the physically disabled
was often established by charitable associations with subsidies
from the local government (Katz, 1986). Following the Great
Depression, public subsidies to nonprofit organizations
became quite common (Coughlin, 1965; Kramer, 1994). In the
1960s various social welfare legislations, such as Medicare
and Medicaid, the Economic Opportunity Act, the Model
Cities Act, and Community Development and Housing,
further expanded the use of contracting out. In particular, the
passage of Title XX of the Social Security Act in the
mid-1970s led to a the rapid increase in purchase-ofservice
arrangements with both nonprofit and for-profit social
services (Gilbert, 1983; Wedel, Katz, & Weick, 1979). The
trend has escalated with the Reagan administration's emphasis
on privatization and devolution,
and more recently with the passage of welfare reform in
1996.
Contracting out is the dominant mode of funding and
delivering social services in the United States (Kramer,
1994). About half the revenues of the nonprofit human
services come from government grants (Boris & Steurle,
2006). This strategy is also rapidly expanding in most
postindustrial societies (for example, Deakin, 1996 ;
Gutch, 1992; Kramer, 1994; Lewis, 1996; Seidenstat ,
1999; Yeatman, 1996), reflecting part of a movement
toward privatization and marketization of social services.
Contracting out is viewed as a vehicle to introduce market
forces, especially competition, to the delivery of social
services under the assumption that such forces would lead
to greater effectiveness and efficiency. A s suggested by
Harden (1992, p. 6), the "contract provides a mechanism
by which the supply of private services can be organized
through the market. In doing so, it binds together
individual legal rights and consumer sovereignty." It
highlights the role of the market in determining the
mechanisms of service provision, and the legal right of
consumers to receive services on the one hand, and their
sovereignty and autonomy to choose on the other. In
addition, it describes the division of labor between fundin g
sources, service providers, and consumers of services.
There are several arguments in favor of contracting out.
It is said to increase efficiency and cost effective ness
because governments are usually characterized by high
levels of bureaucracy, red tape, rigid formalization, and
failure to view the client as their primary objective
(Sharkansky, 1989). Contractors are perceived as being
more available, rapid to response, accessible, and bet ter
able to maintain direct relations with the clients (Kramer &
Grossman, 1987; Wedel & Colston, 1988). Contracting out
avoids political pressures that various interest groups exert
on legislators, policy makers, and decision makers at the
federal, state, and local levels. It is believed that transfer of
responsibility for service provision to contractors is based
on considerations of professionalism and expertise. It
encourages competitiveness through a mixed economy,
where various organizations compete for resources,
clients, and provision of services. Competition prevents
monopolies, provides an incentive for efficiency, and
creates opportunities to reduce the cost and price of
services. Contracting out is said to empower clients by
giving them the option to select among a variety of
providers and services. Giving clients a choice alters the
balance of power relations between them and the service
providers. Because contracts can be for specialized
services, they can ensure professionalization, expertise,
and quality. They promote innovation in services by
avoiding the bureaucratic red tape typical of

government, and enhance the evaluation and measurement
of outcomes by contract requirements that service
providers meet clear objectives that can be measured and
assessed. Finally, contracting out is presumed to benefit
from the mobilization of volunteers who bring with them
the spirit and the ideology of altruism and humanitarian
values to help disadvantaged and vulnerable populations
(Schmid, 2003).
Arguments against contracting out emphasize that it
creates a buffer between government and citizens that can
lead to absolving government of its obligations and
responsibilities to citizens-clients. When a buffer is
created, there is a risk that citizens' voices about the quality
and scope of services will 'not be heard by government,
and opposition, will be restrained in order to protect the
interests of the service providers (Schwartz, 2001).
Contracting out is said to produce inequality,
fragmentation, and low-quality services. Knapp,
Robertson, and Thomason (1990, pp. 213-214) argue that
purchase of services has the potential for "fragmentation,
discontinuity, complexity, low-quality outputs, poorly
targeted services, productive inefficiencies, hor izontal and
vertical inequities, wasteful duplication and inappropriate
replication, sectarianism, and paternal ism." There is also a
risk that the contractors will "cream" clients in.order to
meet outcome requirements, which results in further
inequality. In part, the risk arises because contracting out
may emphasize profit over quality through limiting hours
of care, changing care plans, cutting workers' salaries,
limiting the rights of workers, and hiring less-qualified
workers. It may also result in having unreliable contractors
who lack the professional experience and knowledge
needed to provide the required services. Particularly,
private forprofit contractors with the power to penetrate
the market may leave after making their profit (Schmid,
2003).
In addition, it transfers power from government to the
contractors who have greater professional and orga-
nizational knowledge. Governmental agencies become
dependent on the contractors and government loses its
authority and power in matters related to policymaking,
planning and designing services, and effective supervision
of services. Moreover, the transfer of power to service
contractors enables them to act as an interest group and
dictate price policies while making it difficult for
government to impose sanctions for contract fail ures.
Government also finds itself unable to effectively
supervise and control the contractors because it 'becomes
dependent on them to provide the information it needs to
monitor them. Government agencies need to develop
advanced monitoring technologies and advanced
knowledge and skills that require resources not often
available to them. It is also argued that large
CONTRACTING OUT OF SOCIAL SERVICES 455
contractors come to dominate the market, resulting in a
monopoly or cartel, limiting competition, and making the
government as well as the clients highly dependent on
them. Such dominance of the service market forces the exit
and demise of small organizations that may have
operational flexibility, capability of rapid response to the
needs of clients, stable prices, and commit ment to comply
with the expectations of government (leGrand & Bartlett,
1993). Related, contracting is said to reduce organizational
autonomy, increase conforming behavior, and discourage
innovation (Davis-Smith & Hedley, 1993; Deakin, 1996;
Hoyes & Means, 1991). Contractors are more likely to
experience structural isomorphism, a process in which
organizations become similar in their patterns and
structure, and the distinctions among the providers are
blurred (DiMaggio & Anheier, 1990; Hasenfeld & Evans
Powell, 2004; Schmid, 2001). Finally, there is a concern
that nonprofit organizations dependent on government
contracts will be inhibited from engaging in advocacy on
behalf of disadvantaged and vulnerable populations.
Research shows that human service organizations are
unlikely to engage in advocacy, investing minimal re-
sources for such activities (Andrews s, Edwards, 2004;
Child & Gronbjerg, 2007).
Current Issues
Contracting out involves a fundamental shift from citizens
asprincipals and officials as agents to officials as principals
and service providers as agents (Milward & Provan, 2000).
It, therefore, raises the vexing issue of how to make the
service providers accountable to government and
indirectly to citizen-clients (Kettner & Martin, 1998).
According to Donahue (1989), accountability can be
enforced 'when the services to be delivered can be
specified in advance, the performance of the providers,
especially their service outcomes, is readily measured,
unsatisfactory contractors can be readily replaced, and
competition is maintained. In social services, these
conditions seldom prevail. The clients to be served have
diverse characteristics and multiple needs; the services
have intangible elements, such as quality of relations
between staff and clients, that are not readily visible or
measurable; measures of outcomes, let alone service
quality, are particularly problematic; and replacement of
failing service providers is difficult because of the limited
availability of alternative providers. Indeed, government
often resorts to quantitative measures that focus on
processes (for example, number of clients served) or
quantifiable outcomes (for example, number of welfare
recipients off the rolls) rather than on quality of the
services or multiple effects on the clients. By complying
with the
456 CoNTRACTING OUT OF SocIAL SERVICES
evaluation measures set by government, providers may
compromise their values and mission, resulting in goal
displacement (Frumkin & Andre-Clark, 2000).
Challenges and Future Trends Contracting out
has major implications for social work practice because it
may increase inequality in access to social services and to
their commercialization. Although contracts increase the
flow of resources, they may deprive vulnerable and poor
clients from needed services. In addition, the increased
commercialization of social services forces social service
agencies to adopt business like practices that may be
counter to social work values. Under contracting, social
workers often face the dilemma of dual lovalty-e--to the
contractoremployer on the one hand, and to the clients on
the other. Because the best interests of clients are not al-
ways consistent with the interests of the contractor, social
workers are often caught in the middle, and it is not
always clear which one has priority. The current trends
indicate that the process of contracting with private
service providers will continue, that clients may be
compromised, and that efficiency will be given priority
over the values of equality and social solidarity.
Therefore, social workers must not adapt passively to the
changing organizational environment of practice. Rather,
they must reaffirm the values of the profession while
seeking new approaches of working under contractual
arrangements that can still uphold a commitment to the
agency's social mission in a market economy. Under these
conditions, managers of social service organizations need
to guarantee the quality of services provided to their
clients by implementing advanced technologies and
processes of oversight that have n ot been used in the past.
In so doing, they also need to ensure that the quality of
services is not adversely affected by attempts to increase
profits through reductions in human and professional
inputs in the organization. One way of achieving this goal
is to involve the clients in exercising control over
providers, and encourage them to complain when the
organization fails to abide by the terms of the contract.
REFERENCES
Andrews, K. T., & Edwards, B. (2004). Advocacy organiza-
. tions in the US political process. Annual Review of Sociology,
30,479-506.
Boris, E. T., & Steurle, C. E. (2006). Scope and dimensions of the
nonprofit sector In W. W. Powell & R. Steinberg (Eds.) , The
non~profit sector: A research handbook (pp. 66-88). New
Haven, CT: Yale University Press.
Child, C. D., & Gronbjerg, K. A. (2007). Nonprofit advocacy
organizations: Their characteristics and activities. Social
Science Quarterly, 88, 259-281.
Coughlin, B. J. (1965). Church and state in social welfare. New
York: Columbia University Press.
Davis-Smith, J., & Hedley, R. (1993). Volunteering and the contract
culture. Berkhamsted, U.K.: Volunteer Centre.
Deakin, N. (1996). What does contracting do to users? In D. Billis
& M. Harris (Eds.), Voluntary agencies: Challenges of
organization and management. (pp. 113-129). Basingstoke,
U.K.: Macmillan.
Demone, H. W., Jr., & Gibelman, M. (1989). In search of a
theoretical base for the purchase of services In H. W. Demone
Jr. & M. Gibelman (Eds.), Services far sale: Purchasing health
and human services (pp. 5-16). New Brunswick, NJ: Rutgers
University Press.
DiMaggio, P., & Anheier, H. (1990). The sociology ofnonprofit
organizations and sectors. Annual Review of Sociology, 16,
137-159.
Donahue, J. D. (1989). The privatization decision: Public ends,
private means. New York: Basic Books.
Frumkin, P., & Andre-Clark, A. (2000). When missions, markets,
and politics collide: Values and strategy in the nonprofit
human services. Nonprofit and Voluntary Sector QUarterly, 29,
141-163.
Gilbert, N. (1983). Capitalism and the welfare state: Dilemmas of
social benevolence. New Haven, Cf: Yale University Press.
Gutch, R. (1992). Contracting lessons from the United States.
London: National Council for Voluntary Organizations.
Harden, 1. (1992). The contracting state. Buckingham, U.K.:
Open University Press.
Hasenfeld, Y., & Evans Powell, L. (2004). The role of nonprofit
agencies in the provision of welfare-to-work services.
Administration in Social Work, 314, 91-110.
Hoyes, L., & Means, R. (199l).lmplementingthe White Paper on
community care. Bristol, U.K.: School for Advanced Urban
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Katz, M. B. (1986). In the shadow of the poorhouse: A social history
of welfare in America. New York: Basic Books.
Kettner, P., & Martin, L. L. (1998). Accountability in purchase of
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privatization of human services: Policy and practice issues (Vol. 1,
pp. 183-204). New York: Springer.
Knapp, M. Robertson, E., & Thomason, C. (1990). Public money,
voluntary action: Whose welfare? In H. Anheier & W. Seibel
(Eds.), The third sector: Comparative analyses of nonprofit
organizations (pp. 16-40). New York: DeGruyter.
Kramer, R. M., & Grossman, B. (1987). Contracting for social
services: Process management and resource dependencies.
Social Service Review, 61, 32-55.
Kramer, R. (1994). Voluntary agencies and the contract culture:
Dream or nightmare? Social Service Review, 68, 33...,6().
LeGrand, J., & Bartlett, W. (1993). Quasi-markets arul social
policy. Basingstoke, U.K.: Macmillan.
Lewis, J. (1996). What does contracting do to voluntary agencies?
In D. Billis & M. Harris (Eds.), Voluntary agencies:
Challenges of organization and management (pp. 98--112).
Basingstoke, U.K.: Macmillan.
Milward, H. B., & Provan, K. G. (2000). Governing me hollow
state. Journal of Policy Administration Research and Theory,
10,359-379.
 f
Schmid, H. (200l). Evaluating the impact of legal change on
nonprofit and for-profit organizations. Public Management
Review, 3, 167-189.
Schmid, H. (2003). Rethinking the policy of contracting out social
services to non-governmental organizations. Public
Management Review, 5, 307-323.
Schwartz, R. (200l). Managing government-third sector col-
laboration: Accountability, ambiguity and politics. Inter-
national JournaI of Public Policy, 24,1161-1188.
Seidenstat, P. (Ed.). (1999). Contracting out government services.
Westport, Cf: Greenwood.
Sharkansky,1. (1989). Policy making and service delivery on the
margins of the government: The case of contractors. In H. W.
Demone & M. Gibelman (Eds.), Services for sale:
Purchasing health and human services (pp. 81-96). New
Brunswick, N): Rutgers University Press ..
Wedel, K. R., & Colston, S.W. (1988). Performance contracting
in the human services: Issues and suggestions. Administration
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Wedel, K. R., Katz.j., & Weick, A. (Eds.). (1979). Social services by
government contract: A policy analysis. N ew York: Praeger.
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social welfare (2nd ed.). New York: Free Press.
Yeatman, A. (1996). Interpreting contemporary contractualism.
Australian Joumal of Social Issues, 31, 39-54.
FURTHER READING
Brown, D. L., & Moore, M. H. (2001). Accountability, strategy
and international nongovernmental organizations. Nonprofit
and Voluntary Sector Quarterly, 30, 569-587.
SUGGESTED LINKS
Government for sale: An examination of the contracting out of
state and local government services.
http://www .afscme .org/issues/ 10040. cfm
Kuusisto, A. (2005). Contracting-out of welfare services a
challenge for unions. European industrial relations observatory
online.
http://www .eurofound.europa .eu/eiro/2005/03 .
Nightingale, D. S. & Pindus, N. M. (1997). Privatization of public
social services: A background paper.
f http://www . urban. org/publications/407023 .html
Struck, R. ). (2003). Contracting with NGOs for social services.
http://www . urban. org/url. cfm
-HILLEL SCHMID AND YEHESKEL HASENFELD
d NASSA was established in 1942 as a second accrediting
l
-
CORRECTIONS. See Criminal Justice: Courts; Criminal
) Justice: Corrections.
. students, graduates, and employers as the two accrediting
.e
, COST MEASUREMENT. See Management:
d
Financial.
COUNCIL ON SocIAL WORK EDUCATION
457
COUNCIL ON SOCIAL WORK EDUCATION
ABSTRACT: The Council on Social Work Education
(CSWE) provides leadership in social work education
through faculty development, research, and accreditation
of baccalaureate and master's social work programs. As of
October, 2007, 648 social work programs were accredited
by CSWE.These programs represent an estimated 8,000
faculty members and 70,000 updated numbers students at
the baccalaureate and master's levels (CSWE, 2007a).
CSWE promotes continued educational innovation and
relevancy through setting accreditation standards, which
are regularly revised by volunteer representatives from the
social work education and practice community and
approved by the CSWE Board of Directors.
KEY WORDS: accreditation; Council on Social Work
Education (CSWE); curriculum; Educational Policy and
Accreditation Standards (EPAS); social work education
The Council on Social Work Education (CSWE) is a
nonprofit association, which "ensures and enhances the
quality of social work education for professional practice
that promotes individual, family, and community
well-being, and social and economic justice" (CSWE,
2004, p. 1). CSWE accomplishes this mission through
setting standards for accreditation of social work programs,
advancing innovative social work curriculum, promoting
faculty development and research (CSWE, 2004). CSWE
is also recognized by the Council on Higher Education
Accreditation as the sole accrediting body for social work
programs at the baccalaureate and master's levels. As of
October 2007, 648 baccalaureate and master's social work
programs were accredited by CSWE, representing over
8,000 faculty and 70,000 social work students (CSWE,
2007a).
In the first half of the 20th century, CSWE was formed
by the merging of two social work organizations-the
American Association of Schools of Social Work
(AASSW) and the National Association of Schools of
Social Administration (NASSA). The AASSW was created
in 1919 and by 1930 had determined to accredit only
graduate programs in social work (Kendall, 2002). The
body in reaction to the development of the graduate-only
accreditation policy of AASSW (Austin, 1997; Beless,
1995). Difficulties were exacerbated for social work
organizations disagreed over the purpose and means of
preparation for qualified social workers (Beless, 1995).
Continuing and
458 COUNCIL ON SOCIAL WORK EDUCATION
deepening separation between the two accrediting bodies
threatened to divide the field of social work (Austin, 1997;
Kendall, 2002).
In 1945, a Joint Committee for Education in Social
Work ("Joint Committee") was commissioned to address
this division in accreditation. The Joint Committee
included stakeholders in social work education-practice
organizations, accrediting organizations, federal govern-
ment representatives, social service agencies, and private
foundations. The primary work of the Joint Committee was
the commissioning of a comprehensive study of social
work education and curriculum. As a result of the Joint
Committee's study and efforts, the two accrediting orga-
nizations, AASSW and NASSA, merged in 1952 to create
a single accrediting bcdy, the Council on Social Work
Education (CSWE) (Austin, 1997; Kendall, 2002). CSWE
maintained accreditation for the graduate programs in
social work, but only "approved" undergraduate programs
in social work, unti1.1974 when CSWE formed
accreditation standards for baccalaureate programs
(Austin, 1997).
One landmark and controversial decision in the
development of social work curriculum was the decision to
begin formally accrediting baccalaureate social work
programs. The study of social work education conducted
by the Joint Commission in 1945 resulted in
recommendations for social work education at the bac-
calaureate and master's levels. However, when CSWE was
established in 1952, it began formally accrediting only
graduate programs in social work and "approving"
baccalaureate programs. In part, the decision to begin
accrediting only graduate programs stemmed from the
desire in the field to be recognized as a professional
discipline (Austin, 1997). Choosing to begin accrediting
baccalaureate social work programs in 1974 resulted in a
need to critically examine the educational continuum and
especially the purpose for education at each level. The
landmark change resulted in more formal structures for
differentiation of the curriculum at each level and for the
continuum of education (for example Advanced Standing).
A more integrated policy statement, which addressed the
standards for education at the baccalaureate and master's
levels, was issued in 1982 (Frumpkin & Lloyd, 1995).
Role in Development of
Social Work Curriculum
The CSWE Commission on Accreditation (COA) is
charged by the CSWE Board of Directors with the
"authority to accredit, to impose conditional accredited
status, to deny accreditation or to withdraw accreditation of
master's and baccalaureate degree programs in social
work" (CSWE, 2005, p. 8). The Educational Policy
and Accreditation Standards (EP AS) is the document the
COA uses to make accreditation decisions and which
outlines the purpose and requirements for the education of
social work students at the baccalaureate and master's
levels. The EPAS, "promotes academic excellence in
baccalaureate and master's social work education ...
specifies the curricular content and educational context to
prepare students for professional social work practice
(CSWE, 2001, p. 2)." The CSWE bylaws stipulate that the
COA and the Commission on Curriculum and Educational
Innovation (COCEI) will review and revise the EPAS
regularly, to ensure that it is reflective of the current state
of the field (CSWE, 2005). Both COA and eOCEl
commissioners are nominated by the social work
education community and are appointed to their positions
by the CSWE president.
The most recent EPAS was approved by the CSWE
Board of Directors in 2001 after an extensive planning
process; the COCEI and COA are in the revision process
for the EPAS and will be forwarding the proposed
revisions to the CSWE Board of Directors for approval in
2008.
Social Work Curriculum
"The EPAS specifies the curricular content and educa-
tional context to prepare students for professional social
work practice" (CSWE, 2001, p. 2). Past iterations of the
EP AS have included a move toward a less prescriptive
EPAS. The EPAS "permits programs to use timetested and
new models of program design, implementation, and
evaluation" (CSWE, 2001, p. 2), allowing for creativity
and innovation in programs, while maintaining standards
for comparability in the promotion of quality assurance.
The EPAS not only specifies specific content areas for
social work curriculum, but also includes standards for the
entire educational context, including social work faculty,
administration, finances, library, office, and classroom
resources, as well as student rights and
non-discrimination.
Strengthening the Profession
CSWE "ensures and enhances the quality of social work
education for professional practice" not only through the
development of policy and accreditation standards and the
accreditation of social work programs, but also through
providing faculty development opportunities and
promoting research on social work education.
CSWE provides professional development opportu-
nities for social work faculty, administration, and students
through workshops and meetings, including the Annual
Program Meeting (APM), which drew more than 3,000
attendees in 2006. CSWE also provides faculty
development through the publication of the

Journal on Social Work Education, and books and mono-
graphs on issues of concern to the social work
education community (CSWE, n.d.).
The CSWEOffice of Social Work Education and
Research (OSWER) was established in 2004 to fulfill
CSWE's research agenda, assist the CSWE Board of
Directors, commissions, and c ouncils in research and
policy work, and conduct research of interest to the
social work education community. Since its inception
OSWER has assisted in research projects related to the
revisions of EPAS (accreditation quality assurance),
distance education, doctoral education, and Latino/a
faculty and students in social work education, in addition
to managing and reporting 'on the Annual Survey of
Social Work Programs (CSWE, 2006).
Challenges and Opportunities
The current political and educational environment
emphasizes the need for transparency and accountability
for survival. This call for accountability can be seen in
the public sector in initiatives that focus on educa-
tionaloutcomes, institutional, and programmatic com-
parability. In the private sector the continued emphasis
on evaluation is indicative of a focus not only on the
inputs, but also on outputs and outcomes. In order to
I compete in this environment, social work will have to
seriously examine the effectiveness of social work edu-
f cation (Watkins & Pierce, 2005). The draft revised EP
AS developed by the Commission on Curriculum and
Educational Innovation (COCEI) and the Commission
on Accreditation (COA) (disseminated in September
2007), suggests just such a shift in paradigm for social
f work from an inputs model to competencybased
education (CSWE, 2007b).
CSWE is concerned with "ensuring and advancing
the quality of social work education" while also meeting
the workforce demands for trained professional social
workers. Since 2002 the number of CSWE accredited
social work programs has increased by 8% (CSWE,
2007c). Since one of the main reasons that social work
, programs close is due to a lack of resources and funds
(Watkins & Pierce, 2005), a careful balance must be
(
maintained to protect the students enrolled in accredited
.
programs.
: Council on Social Work Education. (2005). Bylaws. Retrieved
Another key area for attention in social work educa-
1 tion is the need to increase diversity in social work
S
programs, students, and faculty. While some gains have
) Annual report 2005-2006. Alexandria, VA: Author.
- been made in increasing diversity in social work pro-
:
S
grams (CSWE, 2007a), further progress is needed .
-
: work education in the United States: 2006: A Summary. Alex-
e CSWE has several initiatives intended to address these
e concerns, including the CSWE Minority Fellowship
. Programs, which have provided scholarship assistance
s to minority doctoral students since the 1970s, and the
e
COUNCIL ON SOCIAL WORK
EDUCATION 459
ongoing work of the CSWE Commission for Diversity
and Social and Economic ]ustice, the Task Force on
Latinos/as in Social Work Education, and the Native
American Task Force (CSWE, 2006).
In addition to the external challenges mentioned
(call for accountability and transparency, maintaining
funding for programs, and diversifying the profession),
internal challenges also threaten to divide the profes-
sion. There is historical basis for the tension between
program levels; as mentioned above, the baccalaureate
and master's levels split very early in the development
of social work education and when they came together
under the auspices of a single accrediting body, only the
master's level was accredited while the baccalaureate
level was "approved" (Austin, 1997). Such devaluing
quite likely only furthered the rift between the two
levels. Recognizing and valuing the education of social
workers at each level is necessary for recruitment and
retention of students and ensuring that educational
content is not repeated in the continuum.
In order to ensure the continued growth and sustain-
ability of social work as a profession, it is imperative
that research, practice, and education be connected and
integrated. Fragmentation in the profession among the
various social work specialty and educational organiza-
tions related to these three components can lead to a
weakened capacity to address the needs of social work
clients over time. The professional associations for
social work are beginning to work together to remedy
this division. It will require the efforts of the whole field
to bring about this systematic coordination of research,
practice, and education for the benefit' of all
constituencies.
REFERENCES
Austin, D. M. (1997). The institutional development of social
work education: The first 100 years and beyond. Journal of
Social Work Education, 33(3), 599-612.
Beless, D. W. (1995). Council on social work education. In
Encyclopedia of social work (19th ed., pp. 632-636).
Washington, DC: NASW Press.
Council on Social Work Education. (n.d.). About CSWE pub-
lications. Retrieved November 8, 2007, from http://www.
cswe.org/CSWE/publications/
Council on Social Work Education. (2001). Educational policy and
accreditation standards. Alexandria, VA: Author.
September 15, 2006, from http://cswe.org/
Council on Social Work Education. (2006). Focusing on our future:
Council on Social Work Education. (2007a). Statistics on social
andria, VA: Author.
Council on Social Work Education. (2007b). Draft Educational
Policy and Accreditation Standards' - 9/24/2007. Retrieved
November 9, 2007, from http://www.cswe.org/NR/
460 COUNCIL ON SOCIAL WORK EDUCATION
rdonlyres/450CmCE-3525-4CE1 -9031-59EA4DC77EDN
O/EP ASDraftSeptember 24 2007Rev 1 0122007 .pdf
Council on Social Work Education. (2007c). 2007 Dashboard
Indicators. Retrieved November 16,2007, from http://www.
cswe.orgfCSWE/research/research/reports/
Frumpkin, M., & Lloyd, G. A. (1995). Social work education.
In Encyclopedia of social work (19th ed., pp. 2238-2246).
Washington, DC: NASW Press.
Kendall, K. A. (2002). Council on social work education: Its
antecedents and first twenty years. Alexandria, VA: Council on
Social Work Education.
Watkins, J. M., & Pierce, D. (2005). Social work education:
A future of strength or peril. Advances in Social Work, 6(1),
17-23.
FURTHER READING
Boehm, W. W. (1959). Objectives of the social work curriculum
of the future. The comprehensive report of the curriculum study
(Vol. 1). New York: Council on Social Work Education.
Hoffman, K. (2006). CSWE and social work education's joint agenda
(Remarks based on the President's Address at the 2006 CSWE
Annual Program Meeting, Chicago, Illinois). Retrieved August
8,2006, ftom http://www.cswe.org
Leighninger, L. (2000). Creating a new profession: The beginnings of
social work education in the United States. Alexandria, VA:
Council on Social Work Education.
United States Department of Labor. (2006). Social workers.
Occupational outlook handbook. Retrieved June 8, 2006, ftom
www.bls.govjoco/ocosnou.htm
SUGGESTED LINKS Council on Social
Work Education. www.cswe.org
Council for Higher Education Accreditation.
http://www .chea. org/default.asp
Education Resources Information Center.
http://www.eric .ed.gov/
National Center for Education Statistics.
http://nces.ed.gov/
-JULIA M. WATKINS AND JESSICA HOLMES
COUPLES
ABSTRACT: This entry discusses the evolution of the
field of couples counseling from an auxiliary service
provided through a variety of professional disciplines
to a well-established field defined by its own
standards, approaches, and a building body of
research. While a few interventions for couples have
been well researched using well- established standards,
many of the interventions used by practitioners still
lack evidence-based research or standard criteria. Also
the research does little to address diversity and the
application of
interventions considering race, ethnicity, and socioeconomic
levels. These concerns require ongoing attention.
KEY WORDS: couples counseling; couples therapy;
marital therapy; couples enrichment programs; evi-
dence-based practice; empirically supported
treatment
Social workers have a long tradition of helping couples work
though the underlying issues of relationship problems. Today,
the field of couples counseling is rapidly growing in scope
and importance. Although divorce rates have been declining
after peaking in the 1970s, the divorce rate in 2005 was still at
48% (Munson & Sutton, 2006). Moreover, the probability of
a first marriage ending within the first 5 years is 20%, with
onethird of marriages ending after 10 years (Kreider & Fields,
2001). At the same time, marriages have been declining and
some observers say that the only reason divorce rates are
declining is that more people are living together with benefit
of marriage. Across the country, rates of cohabitation have
increased, with about 40% of cohabitating unions involving
children. Cohabiting couples contend with similar relation-
ship and family difficulties as do married couples (Bramlett &
Mosher, 2002).
Whether married or cohabitating, affluent or financially
challenged, and across the myriad ethnic/reli-
giousjagejeducational combinations, distress. among couples
exacts a toll on adult and family functioning and often results
in detrimental psychological, physical, and financial
outcomes. Couples seek counseling for help with navigating
relational concerns, including communication difficulties,
power struggles, intimacy and trust issues, extra-relational
involvements, conflicts around roles and values, sexual
concerns, and interpersonal conflicts (Gurman & Fraenkel,
2002). Accordingly, practitioners are called upon to help
alleviate the various interpersonal challenges couples face
through individual and group interventions.
Two prevailing- couples counseling modalities are used in
couples counseling, individual couples' therapy, and
group-based couples' enrichment programs for working with
couples. Each approach has some empirical support along
with challenges and implications for social work practitioners
in the field.
Background
Historically, professional marriage counseling, now more
commonly referred to as couples counseling (the term couples
counseling is more inclusive of unmarried couples and gay and
lesbian couples) developed from an interdisciplinary
perspective involving therapists from

the fields of psychiatry, psychology, clinical social
work, and theology. Social work contributions were
documented in the early work of Mary Richmond in her
1928 book, Concern of. the Community with Marriage.
Broderick and Schrader (1991) outlined the evolution of
couples counseling starting with the earliest stage
(1929-1932) when marriage and pre-marriage counseling
was carried out as an auxiliary function of college
professors, lawyers, social workers, and physicians. Over
the next decade, the American Associ, ation of Marriage
Counselors was established along with professional
standards through meetings, clinical sessions, publications,
research, and a code of ethics for licensing marriage and
family therapists. During the formative stage of
development (196+--:1978), marital therapy merged with
family therapy while the human potential movement, with
its focus on self help groups and church-related marriage
enrichment programs, began to focus on group
interventions for couples who wanted to enrich or improve
their relationship (Broderick & Schrader, 1991). By the end
of this phase, both couples counseling and couples
enrichment programs were well-established practice
methods for counseling couples.
Current Applications
Theorists including Haley (1980), Bowen (1978), Satir
(1964), Minuchin (1974), and others laid the founda tion
that has guided couples therapy, with family sys, terns
theory as a pillar of that foundation. Other significant
approaches include object relations therapy, behavioral
marital therapy, emotionally focused couples therapy,
and insight oriented marital therapy, (Gurman &
Fraenkel, 2002). Among the influential theoretical and
practice approaches, a number of inter, vent ions ha ve
prevailed as contributors to contemporary couples
counseling.
Behavioral Couple Therapy (BCT)
The widely practiced Behavioral Couple Therapy (Di-
midjian, Martell, & Christensen, 2003) is the most
extensively researched couples therapy. The approach is
a skill-based, change-oriented treatment and relies on
two primary components: behavior exchange (BE) and
communication/problem solving training (CPT). In the
early 1990s, Jacobson and Christensen became
concerned about the limits of clinically meaningful
change with what is now referred to as traditional ncr
(TBcr). They observed the tendency of TCBT to work
best with less-distressed, younger, emotionally engaged
couples who were not experiencing concurrent problems
or relationships based on rigidly structured gender roles
(Jacobson & Addis, 1993). In 2000, in an
COUPLES 461
effort to improve the results and extend the long-term
sustainability of TBcr treatment changes, Jacobson,
Christensen, Prince, Cordova, & Eldridge (2000) devel-
oped integrative behavioral couple therapy (mCf),
building on TBq by integrating emotional acceptance.
Through combining emotional acceptance with
behavioral change strategy, the primary goal is to help
the couple better understand and accept each other as
individuals and increase the couples' willingness to
make necessary changes to improve the quality of their
relationship (Dimidjian et al., 2003). On average,
couples participate in approximately 15-26 sessions,
including an initial assessment, one conjoint and two
individual sessions, and a feedback and goal formulation
session. Techniques fall into three categories:
acceptance, tolerance, and change. The techniques used
to facilitate change include
1. Behavior exchange that relies on each person's
commitment to changing themselves in order to
provide pleasure for their partner
2. Communication' that is specific and focused on
minimizing negativity
3. Problem-solving training that encourages partners
to collaborate and accept their role in problems.
EMOTIONALLY FOCUSED THERAPY (EFT) Emo-
tionally Focused Therapy (EFT) (Johnson, Hunsley,
Greenberg, & Schindler, 1999) has its roots in attach-
ment theory, and its methodology is drawn from a blend
of Gestalt and Interactional Systemic Theories, which
emphasize exploring feelings in the "here and now." The
goal of EFT is to bring about change through
restructuring the emotional bond, changing the self
within context of the relationship, supporting fluctua-
tions in the relationship, and evoking emotion between
partners. An integral part of the EFT approach seeks to
heal "attachment injuries"(Naaman, Pappas, Makinen,
Zuccarini, & johnson-Douglas, 2005). ("Attachment
injuries" are the features of trauma-spectrum disorders
that cause conflict and dissatisfaction in intimate
relationships by inhibiting affective communication.)
EFT is grounded in a thorough assessment process that
encourages the therapist to enter the phenomenological
world of the client, identify negative interactional
cycles, and gauge the clients' openness and flexibility in
terms of how likely they are to respond to the therapy.
General principles of EFT focus on:
1. The present experiences of each partner;
2. Primary vulnerable emotions rather than second ary
defensive emotions;
3. The interactive process rather than theproble matic
issues; and
462 COUPLES
4. Newly formed interactions using newly accessed
primary emotions to motivate direct expression of needs,
wants, and new behavior.
INSlGHT~ORIENTED MARITAL THERAPY (lOMT) The
approach of IOMT draws from psychodynamic, experiential,
and cognitive behavioral theories. Its main primary focus is
"affective reconstruction" used to help couples increase their
understanding of each other and gain increased control over
their thoughts and interactions. The approach emphasizes
interpretations of underlying intrapersonal and interpersonal
dynamics that contribute to relationship discord by focusing
on the couple's developmental issues, collusive interactions,
incongruent expectations, and maladaptive relationship rules
(Snyder, Wills, & Grady-Fletcher, 1991; Snyder, Castellani, &
Whisman, 2006). The therapist's role is to help interpret
maladaptive relationship themes in behavior, feelings, and
cognitions and to relate their developmental origin to current
relational fears, dilemmas, and interaction styles.
GOTTMAN METHOD COUPLES THERAPY (GMCT)
Gottman Method Couples Therapy (GMCT) is based on john
Gottman's applied scientific approach to studying the effects
of brief interventions on marital interactions with over 3,000
couples. As a result of his research, he developed the Sound
Marital House (SMH) theory and approach, which aims to
invoke lasting changes by increasing positive affect and de-
creasing negative affect during conflict and nonconflict
interactions (Gottman, 1998). The first three levels of the
Sound Marital House model focus on the "marital friendship";
Love Maps-what each partner knows cognitivelv about the
other's psychological world, Fondness and Admiration, and
Turning Toward versus Away during daily interactions. The
fourth level, Positive Sentiment Override, builds on the
strengths of a strong marital friendship by increasing the
couple's positive interpretations of interactions. This is the
basis for the fifth level, which provides the foundation for
successful repair attempts that regulate conflict. Gottman
defines a repair attempt as anything in which the spouses are
acting as their own therapist to comment on the com-
munication, to support and soothe each other, and to soften
complaints. The final level is focused on Creating Shared
Symbolic Meaning, which involves meshing individual life
dreams, narratives, myths, and metaphors. Gottman's work
established a solid base of evidence about couples through the
development of researchinformed tools for assessment,
diagnosis, and intervention techniques. Many clinicians use
his research to inform their practices with couples.
COUPLES ENRICHMENT PROGRAMS Alongside couples
counseling, a wide range of couples enrichment programs
have emerged. These are brief psychoeducational programs
that promote enhanced communication and relationship skills
in a group format. Initially, the enrichment approach was
focused on marriage and prevention; however, today, a wide
range of couples enrichment programs are conducted for
marriage preparation, interruption of relationship distress, and
divorce prevention. At one point, the differentiation between
couples enrichment and couples counseling was that couples
enrichment was the time-limited and structured approach and
couples counseling was open ended and exploratory.
Currently,. the most empirically supported couples coun-
selingalso is designed to be time limited and structured; many
couples combine the two approaches. Increasingly, some
approaches, like Gottman's Sound Marital House, are
implemented through both couples counseling and educational
programs. The need for brief and dem~nstrably effective
treatment has heavily influenced both cou-: ples counseling
and enrichment programs.
Evidenced-Based Couples Counseling and
Couples Enrichment Practice
The definition of evidence-based practice varies somewhat
among disciplines. The premise that social work practice must
be based on empirically tested and verified knowledge is
widely accepted and endorsed (Rosen, Proctor, & Staudt,
2003). The research on both couples counseling and couples
enrichment programs have been evaluated based on
guidelines for efficacious practices.
EVIDENCE~BASED COUPLES COUNSELING The
American Psychological Association (APA) identifies BCT
as "well established" and EFT as "probably efficacious"
couples therapy interventions meeting basic scientific
standards for evidence-based effectiveness. Byrne, Carr, and
Clark (2004) reviewed 20 outcome studies using BCT and
EFT, both of which are theorybased, manualized treatment
protocols, and empirically supported based on demonstrated
efficacy in treating couples compared to a waiting list in
controlled studies. Thirteen of those 20 studies examined the
efficacy of BCT with couples who were described as
moderately to severely distressed. The duration of treatment
was 8-12 weekly sessions and number of participants ranged
from 5 to 30. Eighty-five percent were married; the remainder
couples were cohabitating. Byrne et al. (2004,
p. 384) report the following summary of BCT findings:
1. BCf-treated couples fare better than 83% of untreated
couples.
2. After treatment, 66% of couples show improvement
based on the reliable change index.
 CoUPLES 463

3. After treatment, 62% fall in the nondistressed working with moderately distressed couples (Wood,
range on psychometric measure of couple distress Crane, Schaalje, & Law, 2005).
and 54% maintain these gains at 6-month to 4-year
follow-ups. EVlDENCE,BASED COUPLES ENRICHMENT PROGRAMS
4. After treatment, 55% show recovery based both on A number of scientific studies have found re-
reliable change index and falling in the nondis- lationship enrichment programs to be effective.
tressed range on psychometric measures of couple Jakubowski, Milne, Brunner, and Miller (2004) ana-
distress. lyzed the existing marriage or coupl es enrichment
5. In the long term, BeT probably leads to no better programs to determine those most efficacious
outcomes than its constituent compo- according to the operational definition of empirically
nents-behavioral exchange training and com- supported treatment (EST) developed through the
munication and problem-solving skills training. American Psy chological Association. Established
6. BCT combined with cognitive therapy techniques EST standards include the randomized select ion of
probably leads to similar outcomes to BCT alone. treatment and control groups, two randomized
7. Integrative couples.therapy (Dirnidjian et a1., control trials conducted by two different research
2003) and insight-oriented marital therapy teams, manualized treatment proto col, and
peer-reviewed publication of results. Based on these
(Snyder & Schneider, 2002) may be more effective
guidelines, Jakubowski et a1. (2004) report on four
than BCT, but the two studies with these findings
couples enrichment programs deemed efficacious.
require replication.
. HOPE,FoCUSED RELATIONSHIP ENRICHMENT This
A study of 130 couples examined the efficacy of approach uses five l- hr psychoeducational groups to
IBCT with TBCT (Christensen, Atkins, Yi, George, & increase the hope couples have in the future of their
Baucom, 2006). Although both treatments produced relationship, increase their sense of agency, and im-
similar levels of clinically significant improvement at prove their skills (Worthington et a1., 1997 ).
2-year posttreatment (69% for IBCT and 60% for Education covers the value of increasing the ratio of
BCT), the couples who stayed together fared better in positiveto-negative interactions, communication
IBCT than in TBCT, as shown through the difference in techniques, self- awareness, conflict resolution, and
satisfaction scores between those couples who stayed mechanisms for increasing intimacy, and
together and those who separated. incorporates an initial and final assessment.
Byrne et a1. (2004) also report on seven studies
using EFT in which couples were described as in the THE PREVENTION AND RELATIONSHIP ENHANCE.
mild-tomoderate range of couple distress. The duration MENT PROGRAM The Prevention and Relationship
of treatment ranged from 8 to 12 weekly sessions. The Enhancement Program-based on 5-6 skills- focused
number of participants ranged from 13 to 34 in each group sessions presented as a weekend retreat-
study. Eighty-three percent were married; the rest were addresses intimacy enhancement, effective conflict
cohabitating. Byrne et a1. (2004, p. 384) indicate that management, sexuality, and partner support
1. After treatment, 73% of couples showed improve- (Halford, Sanders, & Behrens, 2001). The approach
ment based on the reliable change index and 56% incorporates behavioral homework tasks, selection
of these maintain these gains at 4-month to 2-year of behavior change goals, selection of
follow-ups communication goals, an d practice implementing
2. After treatment, 51 % of couples showed recovery communication skills.
based on both the reliable index and fall in the COUPLE COMMUNICA TION PROGRAM This approach
nondistressed range on psychometric measures of consists of four weekly 2-3- hr sessions that address
couple distress, and 53% of them maintain these communication skills training through psycho-
gains at 2-month to 2-year follow-up. education, directed practice, role play, and
3. Adding a brief cognitive therapy component to EFT homework (Butler & Wampler, 1999). Couples
does not enhance its efficacy. participate in ex ercises intended to increase
4. EFT is more effective than problem-solving self-awareness, speaking and listening skills, conflict
therapy and less effective than integrated resolution, and identify different styles of
f systemic therapy but these studies require communication.
replication. RELATIONSHIP ENHANCEMENT Relationship en-
In addition, a study comparing EFT and BCT found hancement approach ranges from all- day sessions to
that EFT has been shown to be superior to BCT in 10-15 2-hr weekly sessions. This approach focuses
on
464 COUPLES
teaching self-disclosure skills and the elimination of blaming
statements. In the weekly sessions, the participants learn nine
skills involving communication, problem solving, and
negotiation.
Two popular approaches to couples enrichment groups
that could not be evaluated because of lack of randomization
and published studies are Imago Therapy (Hendricks, 1998)
and GMCT (Gottman, 1998). Imago therapy lacks systematic
research using acceptable research designs. Gottman,
Schwartz Gottman, & DeClaire (2006) have seven
longitudinal studies of couples using the "Love Lab," a family
research laboratory where couples are screened, interviewed,
and observed in order to determine what, makes relationships
work. Despite the fact that 87% of the 936 couples
participating in Gottman's weekend workshops reported that
they made a major breakthrough on a grid locked conflict in
the 2 days of the workshop, his work lacks published studies
based on randomized control samples to meet the EST
guidelines.
Challenges for the Future
Studies on couples counseling methods show that inter-
ventions are successful in helping couples move toward
improved relationships, and contemporary targets for couple
intervention tend to focus on trust, intimacy, conflict
resolution, attachment, emotion, and acceptance. However,
even the empirically validated approaches may lack
well-established long-term effects, and many relationships fail
despite treatment. Jacobson and Addis (1993) point out that a
challenge of research with couples is what measures are
considered to be reflective of success, especially in cases
when couples choose to or wish to end the relationship.
Research forces uniform criteria, yet practitioners do not treat
couples uniformly. Therefore, inherent in the process of
identifying those practices that have been recognized as
evidence based is the question of who is best served and how
to incorporate approaches that are common and popular, yet
empirically untested. Gurman and Fraenkel (2002) suggest
that "proponents of untested methods have a collective
obligation to provide more than anecdotal evidence of their
efficacy and effectiveness" (p. 244).
Much of the current thrust in couples counseling is toward
an integrative. approach, which allows greater treatment
flexibility and increases treatment applicability. For example,
the combining of couples counseling with other treatment
formats such as individual therapy or the combining of
existing conceptual models of couple treatment (Gurman &
Fraenkel, 2002).
All approaches stress the need for thorough assessment for
domestic violence as well as the complexities
introduced when significant psychopathology or indi vidual
distress is present. Practitioners need to remain aware of the
need for thorough assessment and, when indicated, concurrent
treatment for individuals. In some cases, it may be necessary
to postpone the couple's therapy until treatment of the
individual is established and the partner is stabilized.
Another area for future research is increased attention to
diversity. Both the Gottman method and EFT have been
utilized in work with same sex relationships; however, there is
limited research and literature that addresses the applicability
and accessibility of couples counseling to diverse couples,
especially racially and ethnically diverse couples and couples
of lower socioeconomic levels. Bramlett and Mosher (2002)
report that cohabitation and marriage outcomes are negatively
associated with higher levels of unemployment, lower median
family income, and neighborhoods with relatively higher
number of families living in poverty. Thus, those with
personal and structural factors impacting their relationships
may be the most in: need and yet the least likely to access
couples counseling. Social work practitioners in the field of
couples counseling . should work to increase insights about
interventions with couples who take into account their larger
social context and help to differentiate the usefulness of evi-
dence-based treatments for different populations.
[See also Marriage and Domestic Partners.]
REFERENCES
Bowen, M. (1978). Family therapy in clinical practice. New York:
Jason Aronson.
Bramlett, M., & Mosher, W. (2002). Cohabitation, marriage,
divorce, and remarriage in the United States, National Center
for Health Statistics. Vital and Health Statistics, 23 (22),29-31.
Broderick, C. B., & Schrader, S. S. (1991). The history of
professional marriage and family therapy. In A. S. Gurman &
D. P. Kniskern (Eds.), Handbook of family therapy (Vol. II), New
York: Brunner/Mazel.
Butler, M., & Wampler, K. (1999). A meta-analytic update of
research on the couple communication program. The American
Joumal of Family Therapy, 27,223-237.
Byrne, M., Carr, A., & Clark, M. (2004). The efficacy of
behavioral couples therapy and emotionally focused therapy
for couple distress. Contemporary family therapy, 26, 361-387.
Christensen, A., Atkins, D., Yi, J., George, W., & Baucom, D.
(2006). Couple and individual adjustment for 2 years fol-
lowing a randomized clinical trial comparing traditional
versus integrative behavioral couple therapy. Journal ofCon-
suIting and Clinical Psychology, 74, 1180-1191.
Dimidjlan, S., Martell, C; & Christensen, A. (2003). Integra-
tive behavioral couple therapy. The clinical handbook of
couple's therapy (pp. 251-277). New York: Guilford Press.

Gottman, J. (1998), Marital therapy: A research-based approach:
Clinician's manual. Seattle, W A: The Gottman Institute, Inc.
Gottman, J., Schwartz Gottman, J., & DeClaire, J. (2006). Ten
lessons to transform your marriage: America's love lab experts share
their strategies for strengthening your relationship. New York:
Crown Publishers.
Gurman, AS., & Fraenkel, P. (2002). The history of couple
therapy: A millennial review. Family Process, 41, 199-260.
Haley, J. (1980). Problem-solving therapy. San Francisco, CA:
[ossey-Bass.
Halford, K. W., Sanders, M. R., & Behrens, B. C. (2001).
Can skills training prevent relationship problems in at-risk
couples? Four-year effects of a behavioral relation-' ship
education program. Journal of Family Psychology, 15, 750-768.
Hendricks, H. (1998) Getting the love you want: A guide for
~ Greenberg, L. S., & Johnson, S. M.(1988). EmotionaUy focused
couples. New York: Henry Holt.
Jacobson, N., & Addis, M. (1993). Research on couples and
couple therapy: What do we know? Where are we going?
JourtJal of Consulting and Clinical Psychology, 61, 85-93.
Jacobson, N., Christensen, A., Prince, S. E., Cordova, J., &
Eldridge, K. (2000) Integrative behavioral couple therapy:
An acceptance based, promising new treatment for couple
discord. Journal of Consulting and Clinical Psychology, 68,
351-355.
Jakubowski, S., Milne, E. Brunner, H., & Miller, R. (2004).
A review of empirically supported marital enrichment
programs. Family Relations, 53.5, 528-536.
Johnson, S. M., Hunsley, J., Greenberg, L., & Schindler, D.
(1999). Emotionally focused couples therapy: Status &
challenges. Clinical Psychology: Science & Practice, 6, 67-79.
Kreider, R. M., & Fields, J. M. (2001). Number, timing, and
duration of marriages and divorces: Fall 1996. Retrieved May
2, 2007, from http://www.census.gov/prod/2002pubs/
p70-80.pdf
Minuchin, S. (1974). Families and family therapy. Cambridge, MA:
Harvard University Press.
Munson, M., & Sutton, P. (2006). Births, marriages, divorces, and
deaths: Provisional data for 2005. National Vital Statistics
Reports, 54(20),1-7.
Naaman, S., Pappas, J., Makinen, J., Zuccarini, D., & Johnson-
Douglas, S. (2005). Treating attachment injured couples with
emotionally focused therapy: A case study approach.
Psychiatry: Interpersonal & Biological Processes, 68(1), 55-n
Rosen, A, Proctor, E., & Staudt, M. (2003). Targets of change and
interventions in social work: An empirically based prototype
for developing practice guidelines. Research on Social Work
Practice, 13(2), 208-233.
Satir, V. (1964). Conjoint family therapy. Palo Alto, CA:
Science and Behavior Books.
Snyder, D., Castellani, A, & Whisman M. (2006). Current status
and future directions in couple therapy. Annual Review of
Psychology, 57, 317-344.
Snyder, D., & Schneider, W. (2002) Affective reconstruction:
A pluralistic, developmental approach. I~ A Gurman & N.
Jacobson (Eds.), Clinical handbook of couple therapy (3rd ed., pp.
151-179). New York: Guilford Press.
CRIME AND CRIMINAL BEHAVIOR 465
Snyder, D. K., Wills, R. M., & Grady-Fletcher, A. (1991).
Long-term effectiveness of behavioral versus insightoriented
marital therapy: A four-year follow-up study. Journal of
Consulting and Clinical Psychology, 59, 138-144.
Wood, N., Crane, D. Schaalje, G., & Law, D. (2005). What works
for whom: A meta-analytic review of marital and couples
therapy in reference to marital distress. The Amencan Journal of
Marriage and Family Therapy, 33,273-287.
Worthington, E. L., [r., Hight, T. L., Ripley,J. S., Perrone, K. M.,
Kurusu, T. A., & Jones, D. J. (1997). Strategic hope-focused
relationship-enrichment counseling with individuals. Journal
of Counseling Psychology, 44, 381-389.
FURTHER READING
therapy for couples. New York: Guilford Press.
Johnson, S. (2003). The revolution in couple therapy: A
practitioner-scientist perspective. Journal of Marital and Family
Therapy, 29, 365-384.
SUGGESTED LINKS The Gottman
Institute. http://www.gottman.com!
Center for Emotionally Focused Therapy.
http:// eft. ca
-SUSAN C. HARNDEN
CRIME AND CRIMINAL BEHAVIOR
ABSTRACT: This entry includes contemporary defin-
itions of crime, theoretical ideas about the etiology of
criminal behavior, and information about the methods
used to estimate crime rates in the United States. Key
issues such as disproportionate minority incarceration,
the recent increase in women entering into the crim inal
justice system, and the prevalence of persons with mental
illnesses in the nation's jails and prisons are addressed.
Current controversies and practices such as risk reduction
efforts and rehabilitation strategies are described.
KEY WORDS: crime; criminal behavior; crime meas ures;
reintegration; risk reduction; minority incarcer ation;
women; mental illness
Although crime and criminal behavior are lumped to-
gether here as though they are inseparable concepts, in
fact they are quite different. A crime is a legislatively
defined event, although at times the term is used asa
descriptor for one's dissatisfaction with a particular
behavior or incident, as in "it ought to be a crime to talk
back to one's parent." Local municipalities, every
466 CRIME AND CRIMINAL BEHAVIOR
state legislature, and the federal Congress determine
within their own legal jurisdictions what events will be
considered crimes, what crimes are called, what the
elements of separate crimes are, how they will be cate-
gorized (felony or misdemeanor, major or minor, prop erty
or violent, statutory or common law), and what the range
of punishment for the conviction of a partic ular crime will
be. Certain types of crimes are universal in name and so
found in every state (the "index" violent and property
crimes of murder, robbery, rape, burglary, larceny, and
sodomy-to name a few), while there are other crimes that
exist in one state and even in one town in one state, but not
in another (loitering, urinating in public, vagrancy, certain
sexual behaviors, for example). Even when an event is
defined universally as a crime in almost every jurisdiction
in the United States, the level of severity assigned to and
the stigma associated with the crime itself may vary
significantly (possession of marijuana, for example) leg-
islatively and socially.
Criminal behavior, on the other hand, is behavior that
defies some normative standard in a p articular time and
place and, once displayed, is categorized by associa tion
with the commission of one or more crimes. Crirn inal
behaviors may be associated with psychological
constructs (such as antisocial personality disorder), so-
ciological observations (such as social disorganization
and anomie), economic theories (poverty and un- or
underemployment), religious ideology (moral failings), or
social science perspectives. What is sometimes called
"criminal behavior" is instead criminalized behavior, the
most notable examples being the hypothesis, now in
dispute, of thecriminalization of mental illness (Draine,
Salzer, Culhane, & Hadley, 2002) and the assertions of
racial and ethnic bias in the application of charges to a
particular kind of person. And still at other times, certain
defined groups seek to label some behavior as being
criminal (for example, performing abortions) even though
the event is not a crime.
Social workers' interests and involvement in crime
and criminal behaviors merge in their eff orts to help
people manage their behaviors in successful ways and in
their advocacy for social justice, particularly within the
criminal justice system. These interests will be dis cussed
in detail here.
Historical Background
How crime is reported and criminal behaviors are inter-
preted change with times (Cantor & Lynch, 2000).
Criminal behavior may include individual moral trans-
gressions, the wrongdoings of the community (or the
corporation), the product of social exclusion and pro-
vocation to aggression, the denial of individual human
rights, the work of hatred and evildoers, and so on. Plato
wrote on the themes of crime and punishment and
rehabilitation; so did Kant and Bentham, Nietzsche and
Menninger, to name just a few (Murphy, 1995; Tittle ,
2000). Throughout history, crime and criminal behavior
have drawn the interest of scholars and ordin ary citizens
alike, each wanting to understand better the human
condition that often ends in the perpetration of a crime and
the victimization of a person.
Definitions and Measures of Crime
There is a national interest in tracking the types and
frequencies of crimes committed. Generally speaking,
there are three major sources of crime data: the Uniform
Crime Reports, the National Crime Victimization Sur vey,
and self-report victimization surveys (Cantor & Lynch,
2000; U.S. Department of Justice, 2004). All three
sources are important to consult when wanting to grasp an
overall view of crime in the United States. Each source
has methodological limitations, and some of the data
reported using each method are at best speculative, in part
because of the way the data are reported.
Law enforcement agencies in the United States are
encouraged to voluntarily submit certain types of arrest
data to the Federal Bureau of Investigation, the agency in
charge of compiling and maintaining the annual Uniform
Crime Reports. Data are maintained principally on the
index crimes-those major personal and prop erty crimes
that are believed to be the most common types of crimes
and that are similarly named and catego rized as such in
every state. The participation of some law enforcement
agencies is voluntary, and to compensate for their
nonparticipation or for the submission of incomplete data,
statistics for these jurisdic tions are generated using
formulas designed to produce an estimate of a particular
area's crime rate (U.S. Department of Justice, 2004).
These data from Uniform Crime Reports reflect only
reported crimes; they do not capture the full picture of
U.S. crime rates or patterns. Consequently, two other
methods of crime data are relied on to help do so.
The National Crime Victimization Survey, created to
develop further understanding of criminal victimization,
attempts to gather data about crimes that go unreported,
including information about victims, offenders, and the details
of the crimes committed (U.S. Department of Justice, 2004).
Victims often choose not to report a crime to police for a
variety of reasons, including shame, stigma, fear for their
safety, and their own concerns about or experiences with law
enforcement. Twice yearly Census Bureau personnel
interview 42,000 household members aged 12 and older, for a
total yield of ",150,000 annual interviews

that make up the National Crime Victimization Survey for
each reporting period. Households remain in the sample
for 3 years. In addition to questions about vic timization,
this survey asks about victims' experiences with the
criminal justice system, the self- protective measures they
may have used, and the possibility that the offenders
abused substances. Periodically, other queries are added to
the survey as well.
The development of Self Report instruments and the use
of self-reported data about criminal behaviors and the
commission ofa range of crimes (Thornberry & Krohn,
2000) as well as about victimization (Cantor & Lynch,
2000) started in the 1950s, and the use of these self- report
instruments is subject to continuous refine ment as theories
of the etiology of criminal behavior continue to be tested.
There are various types of crime and victimization
self-report surveys used and types of sampling strategies
employed; consequently, the instru ments and methods
undergo constant scrutiny in terms of their ability to
produce an accurate portrait of victimization in th e United
States (see, for example, Cantor & Lynch, 2000). Thus,
the self-report mechanisms, improving over the years in
terms of internal consistency, reliability, and content
validity, round out the nation's view of crime and criminal
behavior (Thornberry & Krohn, 2000) from the
perspectives of both the criminal and the victim.
Theoretical Perspectives on
the Origins of Criminal Behavior Theories
abound about the origins and causes of criminal behavior
and understandably so: Crime is a central part of everyday
life in the United States. Regardless of whether crime rates
are up or down during any given period, the six o'clock
news carries the day's stories of murder, rape, and pillage.
Thus, questions about etiology persist despite decades of
research into the causes of criminal thinking and behavior.
Tittle (2000) categorizes theories of individual dif-
ferences in criminal behavior into six major themes:
personal defects, learning, strain or deprivation, iden tity,
rational choice, and control/integration. These theories
run the gamut of hypotheses, suggesting biolog ical,
genetic, psychological, or physical causes of crim inal
behavior or a blend of these; but no one theory has
succeeded in adequately pulling together and explain ing
all of the elements of criminal behavior. Other theories
that seek to explain the development of crim inal behavior
focus on the influences of external factors such as those
situated in environment, opportunity, shaming, social
disorganization, and conflict. Again, no one theory is
enough to answer the query: what are the definitive causes
of criminal behavior?
CRIME AND CRIMINAL BEHAVIOR 467
The questions of causation are of interest to criminal
justice scholars, while for soci al workers, the millions of
adults currently living under correctional supervision and
the many thousands of juveniles living under con ditions
of judicially imposed restraint create more im mediate and
pressing questions: How do we predict criminal behavi or?
How do we reduce the risk of crim inal behavior once we
recognize that the risk exists?
Research and Best Practices on
Managing Criminal Behavior
Risk, Resilience, and Protective Factors. The evidence is
building about the risk factors associated with the de-
velopment of criminal behavior. Farrington (1999) cites
many of the risk factors gleaned from the research
evidence, including "hyperactivity-impulsiveness, at .
tention deficit, low intelligence or attainment, con victed
parents or siblings, poor parental supervision, harsh or
erratic discipline, parental conflict, separation or divorce,
low family income, poor housing, large family size,
delinquent friends, attending a high delin quency rate
school, and living in a high crime neighborhood" (p. 157 ).
Childhood sexual abuse and adult victimization,
particularly among women (Greenfeld & Snell, 1999), are
additional risk factors, as are histories of drug and alcohol
abuse. Werner and Smith (1992) report that protective
factors such as "parental compe tence and caregiving style
(particularly the mother's) and a range of sources of
support in the family, neighborhood, school, and
community" (p. 199) helped delinquent children transition
into crime-free adult lives.
Prevention and Risk Reduction. Tonryand Farrington
(1995) classify crime prevention methods into four
categories: those that focus on the identification of risk
and protective factors related to the formation of criminal
thinking and behaviors; those targeting changes in
community institutions, including families, peers, and
organizations; those addressing the everyday
opportunities for crime; and the various criminal justice
system responses, which include efforts to deter, incap-
acitate, and rehabilitate. As these authors point out, while
the "what works" evidence is building in the areas of
prevention and risk reduction, there is still much to be
evaluated.
Reintegration Efforts. The Zl st-century term for re-
habilitation is "reentry," a concept and set of funded
program strategies initiated by the Clinton administra tion
and reformulated by the George W. Bush admin istration
in 2002. In brief, with well over 2 million juveniles and
adults incarcerated in the U nited States, something more
than preventive strategies is needed to stop the
continuation of criminal behaviors and the consequent
flow back into penal institutions
468 CRIME AND QUMINAL BEHAVIOR
(Sabol, Minton, & Harrison, 2007). Helping offenders
reintegrate into the community upon their release from
incarceration is becoming a more evidence-guided en-
deavor, with social workers and other program person-
nel learning from their mistakes and redirecting their
efforts so that specific, tangible services are delivered
that support the offender's life-without-crime once
returned to the community.
The reintegration process starts with a valid assess-
ment of an individual's risks, in this case, for further
criminal behavior and of the individual's criminogenic
needs as well. There are a variety of risk assessment
instruments available to assist with this, such as the
Level of Service Inventory - Revised. Such instruments
are intended to help reintegration specialists design a
program for each offender, based on both the level of
risk the individual presents and the answerable needs he
or she has. Thus, if a high-risk offender has deficits in
cognition or education or job skills, the reintegration
program targets these areas for concentrated interven-
tions. The approach and methods are straightforward:
assess the level of risk posed and respond to it with a
comparable level of intervention. Recent research sug-
gests that doing otherwise may well be harmful to the
ultimate goal of the individual's rehabilitation (see An-
drews & Bonta, 2003; Lowenkamp, Pealer, Smith, &
Latessa, 2006).
Cultural and Special Populations:
Social Justice Issues
Disproportionate Minority Incarceration. No discussion of
crime and criminal behavior would be complete
without at least mentioning the problem of
disproportionate minority arrest and incarceration
rates: the fact that persons of color and ethnic
minorities are arrested and incarcerated at rates much
higher than those of Whites (for an overview of these
issues, see Pewewardy & Severson, 2003). For social
workers, this is a matter of both ethics and advocacy.
In post-Civil War history, this disproportionate
treatment of minorities has been dealt with in at least
three significant ways. First, by alternately blaming
the victim, with suggestions that certain members of
minority groups have genetic or biological
predispositions for criminal behavior. Second, by
lack of or ineffective internal monitoring practices to
ensure a fair and impartial application of the criminal
laws, resulting in racial bias in law enforcement
practices, criminal processing, and judicial pro-
ceedings. And third, by the growth of the prison
industrial complex: a self-perpetuating and often
profit-making system that depends on a steady flow The responsibilities of the criminal justice system in
of prisoners for its continuation (see, for example, terms of working toward a safer society through the
Pewewardy & Severson, 2003).
Women. Since 1995, the rate of women coming
into U.S. jails and prisons has risen considerably
faster than that of men (Harrison & Beck, 2006). The
majority of these women have children who are left
behind when no alternatives for these mothers other
than incarceration are offered. Many of these women
are undereducated. Many are imprisoned for
economically motivated crimes. They bring with
them histories of physical and sexual violence and
victimization and tangible needs that are almost
impossible to meet within the prison environment.
As these women are primary caregivers to their
children, the dilemma is real and these questions
must be asked-how will the development of criminal
thinking and behavior be stopped when parental
incarceration is a risk factor in its development?
What feasible methods of intervention exist to keep
mothers out of the justice system and successful in
their parenting roles? These are areas of particular
importance for social workers to address.
Persons With Mental Illnesses. While the research
methodologies are less than rigorous in this area, by
all anecdotal and investigatory accounts, persons ex-
periencing severe symptoms of mental illness are.
frequently being seen in jails (see, James & Glaze,
2006, and The Criminal Justice Mental Health
Consensus Project at
http://consensusproject.orgf).Infact,itis commonly
believed that the correctional system is the largest
provider of mental health services in the nation. That
is certainly true in large cities, but the evidence
suggests that this is not just an urban problem.
Changes in health-care policy, costs of psychotropic
medications, and long waiting lists to be seen in local
community behavioral health centers are just a few of
the reasons why more persons can expect to be
treated for their mental illnesses in jail than in the
community. Further, law enforcement personnel
know that they can more expediently address the
criminal behavior by transporting the person to jail
rather than by arranging for a mental health
intervention. Across the country, social workers and
other mental health professionals are strategizing to
help divert persons with acute mental illnesses from
the criminal justice system and into a more
responsive mental health system. Some contem-
porary methods of doing so include the use of mental
health courts, crisis response teams, the availability
of social and medical detoxification centers, and the
development of dual diagnosis or co-occurring
disorders programs that include intensive case
Challenges
management services.

provision of law enforcement services, the adjudication
of criminal behaviors, and the punishment of convicted
offenders are expanding every day. At the same time,
the meanings of "safety," "security," "punish ment," and
"rehabilitation"are perhaps as obscure and confusing as
they have ever been. Does being "safe" require the
incarceration of persons not even formally accused of a
crime? Does "security" require the closing of borders
and a heightened level of scrutiny of people who look
different than Americans, how ever that look is defined?
Is there no place in a "rehabilitation" scheme for
temporary relapses and second chances? Should
juveniles who commit serious crimes be tried in adult
criminal courts and sentenced to adult prisons?
These.are burning issues for social workers interfacing
with persons who come into contact with the criminal
justice system in America. Briefly, here are a few of the
tensions that confront every social worker early in the
21st century.
Rehabilitation versus punishment. Rehabilitation and
punishment are not mutually exclusive concepts or
approaches. The evidence is building that in order to
prevent criminal behavior, the risks and needs presented by
the individual must be accurately identified and addressed
for that interdiction to be effective. This fisk and need
process can be accomplished at any point along the
criminal trajectory, even in the confines of a prison, jail, or
detention center.
Life versus Death. Up-to-date information about every
state's and the federal government's stance on the death
penalty, including the number of innocent people freed
from death row in those jurisdictions, can be found at the
nonprofit Death Penalty Informational Center
r
(http://www.deathpenaltyinfo.orgf). Little goes to the heart
of the core social work values like the issue of life and
death.
1
y During its 2007-2008 term, the U.S. Supreme Court
will hear an important death penalty case that raises the
issue of the constitutionality of using lethal injections in
"
the administration of the death penalty. In Baze v. Rees,
e
two Kentucky death row inmates are challenging the use
I
of lethal injection as being in violation of the Eighth
Ia
, Amendment's prohibition against "cruel and unusual
- punishment." While it is not the constitutionality of the
death penalty being argued, allegations of the
experience of pain caused by the lethal injections have
the courts, state legislatures, and the public at large
:
questioning the morality of using this method to effect
s
the sentence of death. Indeed, a number of states have
I
apparently stopped their executions pending the
t
Supreme Court's decision that will most likely be
announced in late spring, 2008 (Greenhouse, 2007). The
Court's review of Baze might be seen as the latest
CRIME AND CRIMINAL BEHAVIOR 469
national expression of uneasiness with the death
penalty.
Retributive versus Restorative Justice. The present day
criminal justice system is largely organized around the
principle of retributive justice: the idea that the person who
has done wrong, that is, broken the law, must be responded
to with an appropriate and commensurate level of
punishment.
An alternative to a system of retribution through
punishment is one that emphasizes restorationrestoring
the persons involved, including the offender and
"victim" and their communities, to their preharm
conditions. Restorative justice (sometimes called trans-
formative justice) 'principles emphasize healing,
wholeness, forgiveness, and the developme nt of
behaviors and attitudes that signify these
states-of-being. In the effort to promote a balanced
response to criminal behavior and harm that results
from it, the work of social workers like Mark Umbreit
(see http://rjp.umn.edu/ index.html), and social
scientists John Braithwaite, Howard Zehr, and Gordon
Bazemore and others is important. Their efforts keep
the philosophical, moral, and normative values that
underlie the concept of restoration alive in the discourse
that occurs in the criminal justice context.
Roles and Implications for Social Work Although
once recognized as an important venue for social work
practice (Pray, 1951), only a very small percentage of
professional social workers are currently working in the
criminal justice system (Chaiklin, 2007; Reamer,
2004). For sure, the many components of the criminal
justice system-law enforcement, victims' rights,
prosecutory and defense organizations, courts,
detention centers, jails, prisons, and probation and pa-
role agencies-are all part of a dynamic, evolving system
where every single subject of concern to social work is
situated. For example, with regard to the aging popu-
lation, the prison systems around the country need help
to plan for their aging prisoners. Another concern
would be the families of those who are incarcerated.
Most prisoners in the nation have children who are left
behind when they are incarcerated. There are civil
rights issues as well: the constitution is a living,
document in every institution in the country. Prisons
also house those with mental health issues who are not
being served by the public or private mental health
system. Many are in jail, and they are remarkably well
cared for despite the fact that they often do not belong
there. Finally, there is the issue of rehabilitation. There
are programs under way around the country that need
the kinds of systems knowledge and understanding-the
person-inenvironment perspective-that only social
work offers.
470 CRIME AND CRIMINAL BEHAVIOR
REFERENCES
Andrews, D. A., & Bonta, J. (2003). The psychology of criminal
conduct (3rd ed.). Cincinnati, OH: Anderson.
. Baze v. Rees, No. 07-5439, 217 S.W.3d 207 (Ky. 2006). Cantor,
D., & Lynch, J. P. (2000, July). Self-report surveys as measures of
crime and criminal victimization. In Measurement and analysis of
crime and justice. CriminalJustice 2000, Vol. 4 (NCJ 182411), (pp,
85-138). Washington, DC: National Institute of Justice, U.S.
Department of Justice.
Chaiklin, H. (2007). Epilogue: Social work and criminal jus. tice?
In D. Springer & A. Roberts (Eds.), Handbook of forensic mental
health with victims and offenders: Assessment, treatment and research
(pp. 573-586). New York: Springer.
Draine, J., Salzer, M. S., Culhane, D. P., & Hadley, T. (2002).
Role of social disadvantage in crime, joblessness, and home-
lessness among persons with serious mental illness. Psychiatric
Services, 53(5), 565-572. \
Farrington.D. P. (1999). A criminological research agenda for the
next millennium. International Journal of Offender Ther apy and
Comparative Criminology, 43(2), 154-167.
Greenfeld, L. A., & Snell, T. L. (1999). Women offenders (NCJ
175688). Washington, DC: Bureau of justice Statistics, U.S.
Department of Justice.
Greenhouse, L. (2007, September 26). Justices to enter the debate
over lethal injection. New York Times. Available at
http://www.nytimes.com/2007 /09 /26/washington/26lethal.
html
Harrison, P. M., & Beck, A. J. (2006). Prisoners in 2005 (NCJ
215092). Washington, DC: Bureau of justice Statistics, U.S.
Department of Justice.
James, D. J., & Glaze, L. E. (2006). Mental health problems of prison
and jail inmates (NCJ 213600). Washington, DC:
Bureau of Justice Statistics, U.S. Department of Justice.
Lowenkamp, C. T., Pealer, J., Smith, P., & Latessa, E. J. (2006).
Adhering to the risk and need principles. Does it matter for
supervision-based programs? Federal Probation, 70(3),3-8.
Murphy, J. G. (1995). Punishment and rehabilitation (3rd ed.).
Belmont, CA: Wadsworth.
Pewewardy, N., & Severson, M. (2003). A threat to liberty:
White privilege and disproportionate minority incarceration.
Journal of Progressive Human Services, 14(2),53-74.
Pray, K. L. M. (1951). Social work in the prison program. In P. W.
Tappan (Ed.), Contemporary corrections (pp. 204210). New
York: McGraw-Hill.
Reamer, F. (2004). Social work and criminal justice: The uneasy
alliance. Social Work, 23(1/2), 213-231.
Sabol, W. J., Minton, T. D., & Harrison, P. M. (2007).
Prison and jail inmates at midyear 2006 (NCJ-217675).
Washington, DC: Bureau of justice Statistics, U.S. Depart-
mentof Justice.
Thornberry, T. P., & Krohn, M. D. (2000, July). The selfreport
method for measuring delinquency and crime. In Measurement
and analysis of crime and justice. Criminal Justice 2000, Vol. 4
(NCJ 182411), (pp. 33-84). Washington, DC:
National Institute of justice, U.S. Department of justice.
Tittle, C. R. (2000, July). Theoretical developments in crim-
inology. In The nature of crime: Continuity and change.
Criminal Justice 2000, Vol. 1 (NCJ 182408), (pp. 51-102).
Washington; DC: National Institute of Justice, U.S. De-
partment of Justice .
Tonry, M., & Farrington, D. (1995). Building a safer society:
Strategic approaches to crime prevention. Chicago: University of
Chicago Press.
U.S. Department of justice. (2004, October). The nation's two
crime measures. Washington, DC: Author. Available at
http://www .ojp.usdoj .gov/bjs/pub/pdf/ntcm.pdf
Werner, E. E., & Smith, R. (1992). Overcoming the odds: High risk
children from birth to adulthood. Ithaca, NY: Cornell University
Press.
FURTHER READING
Bernard, T. J. (1990). Twenty years of testing theories: What have
we learned and why? Journal of Research in Crime and
DeliTUluency, 27(4), 325-347.
-MARGARET E. SEVERSON
CRIMINAL JUSTICE. [This entry contains three sub-
entries: Overview; Criminal Courts; Corrections.]
OVERVIEW
ABSTRACT: The criminal justice system traces its roots to
ancient times. When the 13 original colonies were formed,
they brought many of the laws and legal processes from
England. Traditionally, the criminal justice system is viewed
as including law enforcement, judiciary, and corrections.
However, state legislatures and Congress need to be viewed as
essential components of the criminal justice system, as they
pass laws that influence the other three components. A
number of controversial practices and policies exist within the
criminal justice system. Social work, which has had a long
involvement in the criminal justice system, including
spearheading the creation of the juvenile justice system in the
United States, is involved in all phases of the criminal justice
system.
KEY WORDS: law enforcement; probation; parole; ju-
diciary; corrections; capital punishment; restorative
justice
The criminal justice system traces its roots to the
Sumerian Code and the Code of Hammurabi (Allen &
Simonsen, 2001). When the Ameri can colonies formed,
they transported many criminal laws and practices from
England. Children and adults were dealt with similarly by
the early, fledgling criminal justice system. Child care
advocates from the Progressive Era were able to initiate
some separation of children from adults during

the development of reformatory institutions. In Chicago
in the late 19th century, social workers from Hull-House
provided educational services to youth in detention
centers. These settlement house workers envisioned a
system just for juveniles and collaborated with the
Chicago Bar Association. and the Illinois Conference of
Charities and Corrections to lobby successfully the
Illinois legislature to create the first juvenile court in
1899 (Alexander, 1997). Demonstrating the influence of
the settlement workers at Hull-House, the first juve nile
court was located across the street; the first juvenile
court probation officer was a settlement house worker
from Hull- House (Alexander). In the 1920s settlement
house workers from Cleveland,' Ohio, advocated for
women who were incarcerated at the Ohio Reformatory
for Women, as did other social workers who were ac-
tively involved with discharge planning for adult offen-
ders (Alexander, Butler, & Sias, 1993).
Traditionally, the criminal justice system has been
envisioned as consisting of three components: law
enforcement, judiciary, and corrections. Law enforce-
ment, represented by the police, arrests offenders. The
judiciary tries these offenders and determines whether
they are guilty or not guilty. For those offenders who are
adjudicated guilty, corrections manage them by
probation, incarceration, and parole. Corrections may be
further divided into institution-based (that is, prison or
reformatories) and community-based (that is, probation,
parole, home confinement, and residential program).
Another important component of the criminal jus tice
system is the legislative arena, which includes state
legislatures and Congress. State legislatures and Con-
gress determine behaviors that are criminal in the first
place, and the sentences to be meted out for those found
or pleading guilty. For instance, stalking, computer
solicitation of sex with a minor, viewing child
pornography on the Internet, and racketeering are
relatively new crimes. Legislatures have passed laws
that have created new categories of crime, for example,
related to various forms of sexual assault and drug
possession.
Some laws have been changed to decrease the num-
ber of offenders, such as posse ssion of small amounts of
marijuana and the killing of one's spouse in response to
domestic abuse.
Components of the Criminal Justice System LA W
ENFORCEMENT Police officers, deputies, state
troopers, border patrols, and the FBI make arrests and
initially charge individuals. Most law enforcement offi-
cers see their jobs as to protect and serve the commu-
nity. In June 2000, state and local law enforcement
CRIMINAL JUSTICE:
OVERVIEW 471
departments employed 1,019,496 full-time personnel,
an increase of 11 % from the strength about 5 years
previously (Bureau of Justice Statistics, 2006a). Ac-
cording to the report from the National Center for
Women and Policing (2002), in 2001, women made up
12.7% of sworn officers in departments with more than
100 officers.
In 2005, 55 officers were killed in the line of duty,
46% of whom were women (Federal Bureau ofInvesti-
gation [FBI], 2006a). Additionally, 57,546 officers were
assaulted while doing their jobs (FBI, 2006a).
The best source for determining the number of
crimes in the United States is data collected by the FBI
for the Uniform Crime Reports and the National Crime
Victim Survey (Allen & Simonsen, 2001). These data
tell us whether crime has increased or decreased over
the past year. However, some crimes are not known to
the police or are underreported; some do not have
individual victims; and some victims may not report
crimes, such as domestic assaults.
In 2005, a little more than 14 million arrests were
made by all law enforcement agencies (FBI, 2006b).
About 603,000 were arrests for violent crimes and
1,609,327 were for property crimes (FBI, 2006b). Drug
offenses constituted the most arrests, almost 2 million
(FBI, 2006b). Males accounted for 76% of all arrests, 82
% of the violent crimes, and 68% of the property crimes
(FBI, 2006b). Racially, 70% of all arrests in volved
Whites (FBI, 2006b). Whites also constituted 59% of
arrests for violent crimes and 69% of arrests for property
crimes (FBI, 2006b). African Americans constituted
28% of all arrests in 2005, with 39% of these arrests
involving violent crimes and 29% involving property
crimes. American Indians or Alaskan Natives
constituted 1.3% of all arrests with 1.2% of them ar-
rested for violent crimes and 1.2% of them being
arrested for property crime. Asian or Pacific Islanders
constituted 1.0% of all arrests and 1.1 % of these arrests
were for violent crimes and 1.3% of these arrests were
property crimes (FBI, 2006b). The source for these data
does not reveal or report arrests for Latinos. However, in
many jurisdictions, Latinos are counted within Whites.
JUDICIARY The judiciary consists of the trial process,
which generally involves the judge, prosecutors, de-
fense attorneys, and juries. However, most cases are
decided by plea bargains and only a small number of
cases actually go to trial. Estimates are that more than
90% of cases are decided by plea bargains or nolo con-
tendere, that is, a plea that means that the defendant does
not wish to contest the charges (Lynch, 2003). In 2002,
1,114,000 adults were convicted in federal and
472 OuMINAL JUSfICE: OvERVIEW
state courts for felonies. About 94% of this total were in state
courts and 69% were sentenced to incarceration either in
prison orin the local jails (Bureau of Justice Statistics, 2006b).
The judiciary may decide whether to try a juvenile in
juvenile court or adult court. In some states the legislatures
have taken this decision out of the hands of prosecutors and
judges and mandated that some juveniles and children be tried
as adults as young as 12 years if these children have been
accused of murder or other very serious offenses (Allard &
Young, 2002);
The judiciary is also involved in cases in which a
convicted defendant has filed an appeal for his or her
conviction or sentence. This is. especially so in capital cases
where the death penalty has been imposed. A capital case may
be in state and federal appellate courts for 15-20 years before
a death sentence is actually carried out. Often, the U.S.
Supreme Court is the final court in a death penalty case but the
Court may refuse to intervene and decide a case. As of
January 1, 2007,3,350 persons were on death row, with the
most in California (660), Florida (397), Texas (393), and
Pennsylvania (226) (Death Penalty Information Center,2007).
CORRECTIONS Prisons. At the end of 2005, almost 5
million adult men and women were under the control of
federal, state, and local probation and parole jurisdictions
(Bureau of Justice Statistics, 2006c). Of this total, about
4,162,500 were on probation and about 784,400 were on
parole (Bureau of Justice Statistics, 2006c). In terms of
incarceration, at the end of 2005, 2,193,798 prisoners were
held in federal or state prisons or in local jails (Bureau of
Justice Statistics, 2006d). The incarceration rates for racial
groups were as follows:
African American males, 3,145 per 100,000; Latino males,
1,244 per 100,000; and White males, 471 per 100,000 (Bureau
of Justice Statistics, 2006d). An analysis of trends shows that
incarceration in the United States has increased significantly
since the 1970s.
The Bureau of justice defines probationers as offenders
confined in t~ommunit"f;jnlieu,of mcarceration -" as well as
those all;wed to remain in their homes (often with electronic
monitoring). Parolees are offenders supervised in the
community after serving a prison term. Parole boards decide
whether to release inmates to community-based parole
supervision. The federal government and some states have
abolished parole.
STATE LEGISLATURES AND CONGRESS Legislative Americans are overrepresented among those incarcerated
bodies are often overlooked as part of the criminal justice (Mauer, 2006). Reports have been issued on the high number
system, but they make laws and decide what
criminal conduct is. A few years ago, there was no law
forbidding stalking. A police officer in Ohio was convicted of
multiple counts of stalking-fourth-degree felonies (State v.
Barnhardt, 2006). In addition, laws regarding computer
behaviors have been enacted, and police officers are now on
the lookout for cybersex predators. Also, legislatures have
authorized adult trials for some children who have been
accused of serious crimes, such as school shootings; adult
trials have occurred for children as young as 12 years. Since
the 1980s, Congress has actively persuaded states to reform
some of their laws by tying the receiving of federal funds to
changes in states laws. For example, most states have Megan
laws, which require states to notify neighbors when sex
offenders have moved into their neighborhoods. In addition,
some states have passed laws permitting civil commitment of
sex offenders to prevent these offenders from being released
from prison confinement. Last, some states have passed laws,
such as Three Strikes, permitting the sentencing of felons
who have been convicted three times to receive sentences of
life.
CONTROVERSIES WITHIN THE CRIMINAL JUSTICE
SYSTEM A number of controversies exist within the criminal
justice system in all levels and components. In law
enforcement, the primary criticisms are racial profiling and
police brutality. Studies have been conducted on the extent to
which race is a factor in police stops of minorities, particularly
African Americans, on the streets and on the highways.
Widely publicized, brutal incidents involving African
Americans or people of color and police officers, many of
whom are White, make matters worse. Prominent examples
include. the Rodney King beating by officers in California; the
Abner Louima incident, where a Haitian was sodomized with
a stick while in police custody; the Amadon Dia110 incident,
where Diallo was fired at 41 times and killed; and more
recently, the incident in New York when Sean Bell was shot at
more than 50 times and killed after he and his friends left a
bachelor party. These incidents, and many other incidents that
do not make the news but are known within the African
American community, make it difficult for law enforcement to
establish a collaborative and trusting relationship with the
African American community to address crime in the
community (Alexander, 2005).
Racial and Ethnic Disparities
Exist in the Criminal Justice System African
of African Americans who are
-.-
I CRIMINAL JUSTICE: OVERVIEW
under the control of prisons, probation, and parole
(Mauer). The high number of African Americans in
prisons cannot be viewed in isolation because it is the
judiciary system that sends them to prisons and it is the
law enforcement system, backed sometimes by laws
passed by the legislatures, that initiates an entrance into
the judiciary system.
To illustrate, since the 1980s, differential, and what
some characterize as discriminatory, laws punish posses-
sion of crack cocaine more seriously than possession o f
powder cocaine. Cocaine is an expensive drug, and many
users are actors, actresses, athletes, and business
executives, many of whom are White. Crack cocaine was
developed to make cocaine affordable for poor
people-poor Whites,t-atinos, and African Americ ans.
Crack cocaine is punished more harshly than equal
amounts of powered cocaine. With the help of racial
profiling, a high number of African Americans are
stopped, searched, and arrested for possessing crack
cocaine. Although African Americans have compl ained
since the 1980s, most legislatures have failed to act or
make the punishments more equal.
To illustrate this point, a U.S. District Court Judge,
who was a drug policy adviser to the first President Bush
and who then advocated for tough laws for crack co caine
crimes, stated that "the policy had gone too far and was
undermining faith in the judicial system" (Apuzzo, 2006 ,
p. A7). Trafficking in 500 g of powder cocaine carries a
5-year sentence but it takes only 5 g of crack cocaine to get
a sentence of 5 years-a 100 to 1 disparity. Judge Reggie B .
Walton noted that the crack is an inner city drug and
cocaine is a suburban drug; the differences in punishment
are unconscionable and "contributed to the perception
within minority communities that courts ar e unfair"
(Apuzzo, 2006).
The Federal Sentencing Commission has asked Con-
gress thrice to address the sentencing disparity between
cocaine and crack but it has refused to do so. Congress has
not even been willing to increase the punishment for
cocaine (Apuzzo, 2006), although it proclaimed to have a
war on drugs. This failure to increase the penalty for
cocaine possession may be attributable to race, as it affects
mostly Whites (Alexander, 2005).
Some observers point to the high number of African
Americans involved in drugs, violent crimes, and weap ons
possession, as to why there are disproportionately more
African Americans than Whites in prison. Alex ander
(2005) points out that Whites committed most of the
violent crimes in this country, use the most d rugs, and are
more likely to be arrested for possessing weap ons. The
FBI defines serious crimes or Part 1 crimes as (a) murder
or manslaughter, (b) rape, (c) aggravated assault, (d)
armed robbery, (e) burglary, (f) arson, and
473
(g) theft; violent crimes include the first four. In 2003, 61
% of those arrested for violent crimes were White and
37% were African Americans (The United States
Department of Justice, 2004). Although this pattern has
been shown consistently, many Americans still believe
that African Americans are responsible for the most
serious crimes in the United States. As an illustration,
African Americans constituted about 33% of the persons
arrested for sex crimes, but they are frequently depicted as
the common rapists, which has a long history in the
United States. However, although Whites are more likely
to be arrested for drug crimes and weapons possession,
they do not go to prison in numbers comparable to their
arrests. The same pattern is found among White juveniles
and they too are not committed to juvenile incarceration
proportionately.
It may not be well known that many African
Americans are incarcerated in prisons located in rural
areas, and as a result, their incarceration benefits rural
communities for census purposes and grants obtained at
the expense of urban areas from where most prisoners
come. Stinebrickner-Kauffman (2004) was one of the first
to question the legality of the census bureau count ing
prisoners where they are incarcerated. Alexand er, picking
up on Stinebrickner-Kauffman's argument, explored other
implications of this phenomenon, noting how additional
monies have been used to help rural communities. He
argued that most offenders com mit their crimes in their
communities and in fact have damaged their communities.
Thus, if money is generated from incarceration, then it
should go to the community in which the damage has been
done. In fact, this is the central argument of restorative
justice, which seeks to motivate offenders to repai r the
harm they have done to the community (Alexander, 2006 ).
There is also the issue of the collateral damage done to
the African American community by the
get-tough-on-crime campaigns (Mauer, 2003, 2006 ).
Convictions and imprisonment for a large number of
African Americans carry considerable damage, such as
loss of voting rights and employment discrimination.
Pager (2003) sought to test the impact of an anti-
discrimination law in Wisconsin that banned discrimi-
nation against ex-felons when the conviction s had nothing
to do with a job being sought. She tested for entry- level
jobs requiring only a high school education. On the basis
of a tactic long used to detect housing discrimination by
landlords, Pager gave Whites and African Americans the
same profile of drug convictions and prison sentences. She
then gave another group of Whites and African Americans
no criminal records when they applied for jobs in the city
of Milwaukee. Her dependent variable was whether an
employer
474 CRIMINAL JUSTICE: OVERVIEW
called the applicant offering a job after the interview.
Pager found that 34% of Whites without records re-
ceived callbacks, compared with 17% of Whites with a
criminal record. For African Americans, 14% of those
who had no criminal records received callbacks, com-
pared with 5% of African Americans with criminal
records. Simply, a White man with a criminal record has
a better chance of getting a job than does an African
American man without a criminal record. This
discrimination occurred in a state with protective leg-
islation, which means that discrimination may be worse
in other states without such laws.
Other controversial issues in the criminal justice
system involve sex offenders and especially child mo-
lesters. Indeed, some child sp offenders have killed
children in the process of assaulting and molesting them.
As a . result, there has been an outcry to pass legislation
that protects children. The two most popular laws have
been community notification and restriction of sex
offenders from living too close to schools, playgrounds,
and community centers (Hundley, 2007). Quoting
Allison Taylor, Executive Director of the. Council on
Sex Offender Treatment of the Texas Department of
State Health Services, Hundley reported that sexual
assaults cannot be stopped by passing an ordinance and
there is no evidence that proximity to a school,
playground, or child care center contributed to recidivism
by sex offenders. To date, no study has reported that
these measures effectively protect chil dren. Children are
more likely to be sexually molested by a family member,
a neighbor who is not a convicted child molester, a
teacher, or a coach (Alexander, 2004). Further, the more
popular laws concerning where offenders can live
establish 1,000 feet as the boundary. But no research has
been reported that shows that children are more likely to
be molested within 1,000 feet as opposed to more than
1,000 feet (Alexander, in press-a).
Capital punishment also remains a controversial
issue. Society has endeavored to find the most humane
method of executing prisoners. In these endeavors,
various forms of executions have been tried and subse-
quently . abandoned, including firing squad, hanging,
the gas chamber, and the electric chair. Lethal injection
was believed to be the most humane method of
execution, but even that has come under attack because
of some botched executions in Florida and California,
wherein executioners could not find veins. Moreover,
the U.S. Supreme Court has ruled that executing indi-
viduals who were younger than 18 years at the time they
committed their crimes violated the cruel and unusual
clause of the Eighth Amendment to the U.S. Consti-
tution (Roper v. Simmons, 2005). In addition, the U.S.
Supreme Court ruled that executing someone who is
mentally retarded also violated the prohibition against
cruel and unusual punishment (Atkins v. Virginia, 2002).
Advocates are seeking a further narrowing of capital
punishment by arguing that it is cruel and unusual to
execute individuals who were mentally ill at the time.
they committed their crimes.
Another issue involving capital punishment is. that
many prisoners have been released from death row and
prison because of wrongful convictions. A lot of im petus
to this movement has been generated by the Innocence
Project, headed by Barry Scheck and Peter Neufeld (The
Innocence Project, 2007). This project focuses on using
DNA to prove that. some convicted persons on death row
and in prison were in fact innocent of their crimes. The
Innocence Project has a Web. site where it keeps a
running total of the persons who have been exonerated.
Special issues in criminal justice and law review journals
have been devoted to wrongful convictions (Alexander,
in press-b).
SOCIAL WORKERS' INVOLVEMENT IN THE' CRIMINAL
JUSTICE SYSTEM As social work was emerging as
a-profession in the late 19th and early 20th centuries,
some social workers expressed doubts about workers
being involved in the criminal justice system due to the
lack of self-determination of clients and possible
conflicts with social work values (Alexander, 1997).
Criminal justice is not the most popular area for prac-
tice among social work students and professionals.
Lennon (2005) reported that only 713 (2.7%) of 26,137
undergraduate students were placed in field settings
involving criminal justice and only 798 (2.2%) of
37,052 postgraduate students were placed in field set-
tings involving criminal justice.
Still, social workers occupy a number of positions
inside and related to the criminal justice system. Social
workers are employed as institutional counselors and
juvenile and adult probation and parole officers. One of
the more prominent positions that social workers hold is
victims' advocate in the . legal process. As society
became more responsive to victims and their families, a
number of prosecutors' offices began to employ social
workers to assist and support victims and families in the
courtrooms during trials, at sentencing, and at the time
of parole hearings.
In prisons, social workers are' typically employed in
mental health units to work with inmates with psychia-'
tric problems. In some states, social workers have be-
come prison wardens.
Some social workers are employed by public
defenders offices to work with indigent defendants who
need mental health treatment, substance abuse
treatment, or
~
.
;~
-~:
I CRIMINAL JUSTICE: OVERVIEW
other specialized services. Also, In the area of employee
assistance programs, some social workers have contact with
law enforcement officers and provide counseling to them. The
counseling may help police officers address challenging
issues in their personal lives or their difficulty coping with a
traumatic incident, such as a shooting.
Social workers must address issues of limits of con-
fidentiality with a duty to warn. As an example, the U.S.
Supreme Court case of Jaffee v. Redmond et al. (1996)
involved the issue of whether a social worker's counseling
with an officer was protected as privileged information. In this
case, a police officer shot and killed a man and saw a social
worker to deal with the trauma. The officer was sued by the
family of the deceased, and the plaintiff's lawyer attempted to
get the information from the social worker, setting up a legal
issue for th~ U.S. Supreme Court to decide.
Social workers have been very prominent in-the area of
restorative justice-a growing trend. One Web site reported the
addresses of 86 organizations that embraced some aspects of
restorative justice (Restorative Justice Online, 2005). Within
the School of Social Work at the University of Minnesota,
social workers have established the Center for Restorative
Justice and Mediation. Furthermore, numerous social workers
have written about restorative justice (Adams, 2004; Beck &
Britto, 2006; Burford & Adams, 2004; Gumz, 2004;
Holtquist, 1999; Umbreit, Coates, & Vos, 2004; van Wormer,
2003, 2006).
In conclusion, the criminal justice system has expanded
considerably since the 1970s. The United States incarcerates a
very high number of its citizens, with minorities being
overrepresented in the prison system. Furthermore, the United
States executes more persons than other industrialized
countries do. Social workers played a prominent role in the
creation of the first juvenile court in 1899 and currently act as
victims' advocates with the legal system. Recently, social
workers have played a prominent role in humanizing the
criminal justice system by espousing and embracing
restorative justice.
REFERENCES
Adams, P. (2004). Restorative justice, responsive, regulation, and
democratic governance. Journal of Sociology and Social Welfare,
31 (1),3-5.
Alexander, R., Jr. (1997). Juvenile delinquency and social work
practice. In C. A. McNeece & A. Roberts (Eds.), Social work
policy and practices in the justice system (pp. 181197). Chicago:
Nelson-Hall.
Alexander, R., Jr. (2004). The United States Supreme Court and
civil commitment of sex offenders. Prison Journal, 84, 361-378.
475
Alexander, R., Jr. (2005). Racism, African Americans, and social
justice. Lanham, MD: Rowan & Littlefield.
Alexander, R., Jr. (2006). Restorative justice: Misunderstood and
misapplied. Journal of Policy Practice, 5(1), 67-81.
Alexander, R., Jr. (in press-a). Beyond micro: A macro perspective
of human behavior and the social environment. Newbury,
CA: Sage. .
Alexander, R., Jr. (in press-b). A wrongful conviction from
Georgia. Journal of the Institute of Justice and International
Studies.
Alexander, R., [r., Butler, L., & Sias, P. (1993). Woman offenders
incarcerated at the Ohio penitentiary for men and the Ohio
reformatory for women from 1913-1923. Journal of Sociology
and Social Welfare, 20(3), 61-79.
Allard, P., & Young, M. (2002). Prosecuting juveniles in adult court:
Perspectives for policymakers and practitioners. Washington, DC:
The Sentencing Project.
Allen, H. E., & Simonsen, C. E. (2001). Corrections in America:
An introduction (9th ed.). Upper Saddle River.N]: PrenticeHall.
Apuzzo, M. (2006, November 15). Federal judge decries disparity
in cocaine sentencing. Columbus Dispatch, p. A 7.
Atkins v. Virginia, 536 U.S. 304 (2002).
Beck, E., & Britto, S. (2006). Using feminist methods and
restorative justice to interview capital offenders' family
members. Afflilia: Journal of Women and Social Work, 21 (1),
59-70.
Bureau of Justice Statistics. (2006a). State and local law enforce-
ment statistics. Retrieved December 27, 2006, from 'http://
www.ojp.usdoj.gov/bjs/sandlle.htm#findings
Bureau of Justice Statistics. (2006b). Probation and parole sta-
tistics. Retrieved December 27, 2006, from http://www.ojp.
usdoj .gov /bis/pandp.htm
Bureau of Justice Statistics. (2006c). Prison statistics. Retrieved
December 27, 2006, from http://www.ojp.usdoj.gov/bjs/
prisons.htm
Bureau of Justice Statistics. (2006d). Criminal sentencing statistics.
Retrieved December 27, 2006, from http://www.ojp. usdoj
.gov /bjs/sent.htm
Burford, G., & Adams, P. (2004). Restorative justice, responsive
regulation and social work. Journal of Sociology and Social
Welfare, 31(1), 7-26.
Death Penalty Information Center. (2007). Death row USA.
Washington, DC: Author.
Federal Bureau of Investigation. (2006a). FBI releases 2005
statistics on law enforcement officers killed and assaulted [Press
release]. Washington, DC: Author.
Federal Bureau of Investigation. (2006b). Crime in the United
States, 2005. Retrieved December 31, 2006, from http://
www.fbi.gov/ucr/05cius/arrests/index.html
Gumz, E. J. (2004). American social work, corrections and re-
storative justice: An appraisal. InternationalJ ournal of Offender
Therapy and Comparative Criminology, 48(4), 449-460.
Holtquist, S. E. (1999). Nurturing the seeds of restorative justice.
Journal of Community Practice, 6(2),63-77.
Hundley, W. (2007 November 2007). Cities' residency restric-
tions don't move registered sex offenders. Dallas Morning
News, Retrieved November 13, 2007, from http://www.
476 CRIMINAL JUSTICE: OvERVIEW
dallasnews.com/sharedcontent/dws/news/localnews/storie
s/ 110407 dnmetsexordinance.2cee065.html.
(The) Innocence Project. (2007). The faces of exonerations.
Retrieved November 13, 2007, from http://www.
innocenceproject.org/
Jaffee v, Redmond et al., 518 U.S. 1 (1996).
Lennon, T. M. (2005). Statistics on sociaL work education in the
United States: 2003. Alexandria, V A: Council on Social
Work Education.
Lynch, T. (2003, Fall). The case against plea bargaining.
Regulation, 24-27.
Mauer, M. (2003). Lessons of the get tough movement in the United
States. Washington, DC: The Sentencing Project.
Mauer, M. (2006). Race to incarcerate. New York: New Press.
National Center for Women and Policing. (2002). Equality denied:
The status of women in policing: 2001. Washington, DC: Feminist
Majority Foundatbi ..
Pager, D. (2003). The mark of a criminal record. American
Journal of Sociology, 108,937-975.
Restorative Justice Online. (2005). Restorative justice sites listed
alphabetically. Retrieved November 13, 2007, from http://
www.restorativejustice.org/
Roper v. Simmons, 543 U.S. 551 (2005).
State v. Barnhardt, 2006 Ohio 4531; 2006 Ohio App. LEXIS
4495.
Stinebrickner-Kauffman, T. (2004). Counting matters: Prison
inmates, population bases, and 'one person, one vote'. Vir-
giniaJournal Social Policy and Law, 11, 229-305.
Umbreit, M., Coates, R. B., & Vos, B. (2004). Restorative
justice versus community justice: Clarifying a muddle or
generating confusion? Contemporary Justice Review, 7(1),
81-89.
United States Department of Justice. (2004). Crime in the United
States, 2003. Washington, DC: Author.
van Wormer, K. (2003). Restorative justice: A model for social
work practice with families. Families in Society,
84(3),441-448.
van Wormer, K.(2006). The case for restorative justice: A
crucial adjunct to the social work curriculum. Journal of
Teaching in Social Work, 26(3/4), 57-69.
FURTHER READING
Bureau of Justice Statistics. (2006). Occupational outlook hand-
book, 2006-07 edition. Probation officers and correctional
treatment specialists. Retrieved December 29, 2006, from http://
www.bls.govjoco/ocoszti'i.htm
-RUDOLPH ALEXANDER, JR.
CRIMINAL COURTS
ABSTRACT: This entry on the adult court system in the
United States discusses the foundation, structure, and
authority of courts at federal, state, and local levels. The
role of criminal courts, the nature of an adversarial justice
system, the plea bargaining proces s, and the goals of
sentencing are described. Innovations such as
specialized courts, restorative justice approaches, and
therapeutic jurisprudence are presented. Finally, several social
work roles in the court system are identified.
KEY WORDS: adult courts; criminal courts; restorative
justice; treatment courts
The adult court system in the United States is not one system,
but several, with differing jurisdictions and levels of
authority. The U.S. Constitution and the state constitutions
provide basic principles and procedural safeguards, which
courts must uphold, and describe the various institutions of
government, including the judiciary. The U.S. Congress and
state legislatures decide by statute what constitutes a criminal
offense and the broad parameters for sentences that may be
imposed. Within our common law system, judges make legal
decisions informed by precedent and custom, and in their
specific rulings further add to case law as they create and
modify laws. Thus, when making decisions, judges must
consider consututional mandates, legislative statutes, and
decisions in prior cases (Clear & Cole, 2003).
Local, state, and federal courts have different levels of
authority to hear and resolve certain kinds of cases. The
Judiciary Act of 1789, passed by the Constitutional
Convention, set up a tiered federal court system with higher
and lower courts (Champion, 1998). The u.s. Supreme Court
is the highest court in the land and the last resort for all
appeals. It hears only a fraction of the cases appealed to it,
about 100 of 6,000 appeals per year; less than one-half of
these are criminal cases (Barlow, 2000). Below the U.S.
Supreme Court in the federal system are 12 U.S. Courts of
Appeals (known as circuits) and U.S. District Courts. District
courts hear all cases involving federal criminal offenses as
well as many civil matters.
State courts use different models of court organization.
The most commonly applied model includes, from highest to
lowest, a State Supreme Court, Intermediate Appellate Courts,
courts of general jurisdiction, often called superior or circuit
courts, and courts of limited jurisdiction, such as district or
county courts (Barlow, 2000). Courts of general jurisdiction
typically hear felony trials and conduct felony sentencing
hearings. Felonies are more serious offenses, typically
resulting in sentences of one year or more if incarceration is
ordered. Courts of limited jurisdiction or lower courts
typically handle preliminary hearings, arraignments, and
misdemeanors. Misdemeanors are less serious crimes,
typically resulting in sentences of less than one year if
incarceration is ordered. Preliminary hearings are for
determining whether a person should be

held for trial; the focus is on establishing whether it is
reasonable to think that a crime was committed and that the
suspect did it. An arraignment is a hearing where the
defendant is formally charged and then enters a plea.
Courts of limited jurisdiction also include municipal,
traffic, and justice of the peace courts.
Criminal courts hear matters of criminal law viola tions.
They become engaged around the time criminal charges are
filed and continue through sentencing, other disposition of
the case, such as a probation viola tion hearing or dismissal,
or the appeals process. In our adversarial justice system,
defendants are innocent until proven guilty and have the
right to legal counsel. Those who go to trial must be found
guilty beyond a reasonable doubt, and.the burden of proof
lies with the prosecution. Criminal courts see a tremendous
amount of activity. In 2002, state and federal courts
convicted over 1,114,000 adults on felony charges, with
state courts accounting for 94% of this total (Durose &
Langan, 2004). The majority of felony convictions result
from guilty pleas, and many also through plea bargaining,
where the defense and the prosecution negotiate over
charges and sentences and the defendant pleads guilty in
exchange for leniency. In 2002, only 5% of state felony
convictions resulted from trials (Durose & Langan, 2004).
Goals of sentencing include proportionality-the
punishment should fit the crime, equity-similar offenders
and offenses should be treated the same, and social
debt-consideration of the offender's criminal history (Mays
& Winfree, 2005). In the 1970s a shift away from
indeterminate sentencing began, where judges had more
discretion regarding the sentences offenders would receive,
to determinate sentencing, where the prosecution had more
sentencing discretion. At the same time, the prevailing
public and political focus shifted from a more rehabilitative
view to a more punitive view, and sentencing laws and
structures were created that required harsher sentences be
imposed by the courts, including "three strikes and you're
out" laws (Schiraldi, Colburn, & Lotke, 2004). Significant
disagreement exists among policy makers, criminal justice
officials, scholars, offenders, and the general public over
how well these three goals of sentencing are accomplished
under the prevailing punitive view.
Innovations
Specialized courts were created to respond to defen dants
with persistent social problems that contribute to their
involvement in the criminal justice system. Drug courts
were the first, beginning in 1989 in Florida (National
Criminal Justice Reference Service, 2005). More recently ,
communities are creating mental health
CRIMINAL JUSTICE: CRIMINAL CoURTS
477
courts and domestic violence courts. These courts con nect
defendants with counseling, treatment, and other social
services and encourage them to comply with
recommendations through the use of. incentives (for
example, deferred adjudication) and sanctions (for ex-
ample, jail time) (Griffin, Steadman, & Petrila, 2002).
The first adult gun court began in Providence, Rhode
Island, in 1994; currently there are only a few in the nation
(Post, 2004). Created in an effort to reduce gun violence,
they respond swiftly and severely to cases involving gun
use or possession.
In contrast to an adversarial approach, restorative
justice requires a new way to think about and respond to
criminal behavior. Different models operate throughout
the United States and in several countries, with names
such as victim-offender mediation, circle sentenc ing, and
community reparative boards (Bazemore & Umbreit,
2001). Restorative justice views crime as harm done to
people and communities, and the emphasis in responding
to crime is on repairing the harm (Zehr, 2002). Victims'
needs and perspectives are an integral part of the process.
Offenders are asked for real accountability through
genuine dialogue with victims or community members,
restitution, and community service, and are provided the
opportunity to become reconnected to the community.
Another relatively new way of thinking about the law,
including legal procedures such as court hearings, is
therapeutic jurisprudence. Therapeutic jurisprudence
considers the law's impact on individuals' emotional and
psychological well-being. This way of viewing the law
recognizes that legal rules and procedures, as well as
behaviors by legal actors such as judges, have therapeu tic
and antitherapeutic consequences, and the focus is on
finding ways to increase therapeutic outcomes from the
legal system. Wexler (2007) suggests several useful
examples of what this may look like in practice. Social
workers can contribute to this new emphasis. Therapeutic
jurisprudence has much in common with the value
orientation of the profession and social workers' expertise
in encouraging positive client changes.
Social Work Roles
Social work employment in judicial work is found in
pretrial diversion services, preparation of pre-sentence
investigations, and victim and witness assistance pro-
grams. Pretrial diversion services seek to remove defen-
dants from the criminal justice system and refer them to
community-based services and treatment. These programs
are conducted in probation departments, courthouses, jails,
and independent agencies (Clark & Henry, 2003).
Pre-sentence investigations are conducted to help the
judge decide on the most appropriate
478 CRIMINAL JUSTICE: CRIMINAL COURTS
sentence for the defendant. Probation officers (some of
whom are social workers) prepare written reports based on
an investigation of factors such as the circumstances
surrounding the crime, the offender's background, the
mental health and substance abuse issues, and the
treatment resources available in the community. Vic tim
and witness assistance programs a re conducted primarily
in prosecutors' offices and courthouses. Social workers in
these programs provide a range of services, including
crisis counseling, trauma assessment, referrals to address
immediate needs, orientation to the judicial process, and
assistance in developing victim impact statements
(National Association of Social Workers, 2005).
Although less common, social work~rs are also in-
volved in death and nondeath \penalty mitigation and
restorative justice programs. In capital mitigation work,
social workers gather extensive information and do a
multidimensional assessment to assist the jury in under-
standing the offender so that it may consider life in prison
without parole rather than the death penalty (Schroeder,
2003). Within restorative jus tice programs, social workers
prepare victims and offenders for their meetings with each
other and facilitate victim-offender mediation sessions.
Future Trends and Challenges
Future challenges facing the criminal court system in elude
finding a way to balance the discretion of judges and of
prosecutors, allowing for flexibility in senten cing in order
to appropriately respond to the needs and circumstances of
individual offenders without sacrifi cing the goal of equity
in sentencing. Courts will need to find ways to effectively
respond to the many individuals that come into contact
with the court system with complex needs such as mental
illness, substance abuse, and homelessness. The rising and
substantial financial costs of incar ceration and the human
consequences to families and communities caused by the
high incarceration rates of their members must be
addressed. A more reasonable balance should be found
between securing public safety and incarceration as a
response to criminal behavior. Finally, social workers
should actively engage in the development and evalua tion
of policies arid programs that would support effec tive
prevention efforts and rehabilitative responses to criminal
behavior.
REFERENCES
Barlow, H. D. (2000). Criminal justice in America. Upper Saddle
River, NJ: Prentice-Hall.
Bazemore, G., & Umbreit, M. (200l). A comparison of four
restorative conferencing models (U.S. Department of Justice
Publication No. NCJ 184738). Washington, DC: U.S. Gov-
ernment Printing Office.
Champion, D. J. (1998). Criminal justice in the United States (2nd
ed.). Chicago: Nelson-Hall.
Clark, J., & Henry, D. A. (2003). Pretrial services programming at
the start of the 21 st century: A survey of pretrial services
programs (US. Department of Justice Publication No. NCJ
199773). Washington, DC: U.S. Government Printing Office.
Clear, T. R., & Cole, G. F. (2003). American corrections (6th ed.).
Belmont, CA: Wadsworth[Thomson Learning.
Durose, M. R., & Langan, P. A. (2004). Felony sentences in state
courts, 2002 (US. Department of Justice Publication No. NCJ
206916). Washington, DC: US. Government Printing Office.
Griffin, P. A., Steadman, H. J., & Petrila, J. (2002). The use of
criminal charges and sanctions in mental health courts.
Psychiatric Services, 53(10), 1285-1289.
Mays, G. L., & Winfree, L. T. (2005). Essentials of corrections (3rd
ed.). Belmont, CA: Thomson Wadsworth.
National Association of Social Workers. Victim assistance pro-
grams provide an array of services to crime victims [Online].
Retrieved April 6, 2005, from http://www.naswnys.org/ crime
_ victims/victim_assistance-programs_provLhtm/
National Criminal Justice Reference Service. In the spotlight drug
courts - Summary [Online]. Retrieved April 1, 2005, from
http://www .ncjrs.org/drug courts/surnmary .html/
Post, L. (2004). Gun courts aim to break cycle. The National Law
Journal, 26(39).
Schiraldi, Y., Colburn, J., & Lotke, E. (2004). Three strikes and
you're out: An examination of the impact of strikes laws 10 years
after their enactment. Washington, DC: Justice Policy Institute.
Schroeder, J. (2003). Forging a new prac tice area: Social work's
role in death penalty mitigation investigations. Families in
Society: The Journal of Contemporary Human Services, 84(3),
423-432.
Wexler, D. B. Therapeutic jurisprudence: An overview [Online].
Retrieved March 12, 2007, from http://www.law.arizona. ed~
depts/upr -intj/
Zehr, H. (2002). The little book of restorative justice. Intercourse,
PA: Good Books.
-DIANE S. YOUNG
CORRECTIONS
ABSTRACT: The United States has more than 7 mil lion
adults under correctional supervision, with more than 2
million incarcerated. The history and theories behind
incarceration are described, along with the cur rent jail and
prison inmate populations. Specific prob lems of juveniles
and women are mentioned. Current trends and issues in
corrections are discussed, including community- based
corrections, privatization, faith based programs, and health
care. The roles of social workers in the correctional
system are outlined. Comments are made on the future of
incarceration.

KEY WORDS: corrections; jail; prison; inmate;
privatization
History
This entry deals with jail and prison programs designed
primarily to incarcerate adult offenders. According to
Sullivan (1990), incarceration was originally a ritual for the
redemption of sin through punishment. The most common
forms of punishments for transgressions of moral codes and
threats to the social order have been death, slavery,
maiming, or the payment of fines. From the Enlightenment
to the late 20th century, the philosophy of utilitarianism
dominated penal reform. Beccaria (1819) decreed that
punishrnent should be prescribed according to the gravity
of the offense, creating a hierarchy of "penalties. Other
reformers, such as John Howard (1791/1973), translated
this theory into specific penal reforms, and it was the
driving force behind American penology from the late 18th
century.
An opposing philosophy was articulated by Kant
(1796/1991) in The Metaphysics of Morals. Punishment
would never be imposed just for the purpose of securing
some extrinsic good such as the deterrence of crime; the
penal code was to be what Kant termed a categorical
imperative. Punishment was imposed because an indi vidual
had committed an offense (Heath, 1963). A case could be
made that. today penology has once rnore shifted from
utilitarianism to retribution, based on the neo-Kantian
principle of "just deserts."
The first American prison (1773) was a converted
copper mine near Simsbury, Connecticut. A few years later
the Quakers created an organization to improve the
situation of convicts by substituting imprisonment in
solitary confinement for physical torture or the death
penalty. The "penitentiary movement" began with the
Walnut Street-jail in 1790, later becoming the
Pennsylvania Prison Society in 1887 (Sullivan, 1990).
John Howard (1726-1790) initiated lay visiting in
England's jails and prisons. The John Howard Society, a
voluntary advocacy and prisoners' rights orga-
.. .nization, was established in England in 1866 and in
Massachusetts in 1889. The Correctional Association of
New York was formed in 1884 and the Prisoner's Aid
Association of Maryland was created in 1869 (Fox, 1983 ).
Professional social work has had a n uneasy relation,
ship with corrections, partly because of the social work
emphasis on self-determination (Fox, 1983). By accepting
employment in an authoritarian setting with nonvoluntary,
unmotivated clients, social workers in correctional settings
were often considered to be ignoring professional values
(Congress, 2007).
CRIMINAL JUSTICE: CoRRECTIONS
479
The ideology, if not the reality, of correctional
rehabilitation in the 1950s was rooted in the practice of
therapeutic treatment, either psychotherapy or some form
of group treatment. By the end of the 1960s, however,
political and social events made rehabilitation in a prison
setting seem impossible (Sullivan, 1990). The 1970 s began
with prison activism and violence on an unprecedented
scale at Soledad, California, and Attica, New York
(Montgomery, 1998). In 1980, 33 inmates were killed in
Santa Fe, New Mexico (Rolland, 1997). A riot at San
Quentin (California) injured 23 inmates and 2 guards in
January 2006; another riot at San Quentin occurred the
following month, injuring 16 inmates (Herel, 2006). That
same month all seven Los Angeles County jails were
locked down because of racial violence, with a riot in one
jail involving 300 inmates (Washington Times, 2006).
Relatively few resources have been directed at improving
these conditions.
Functions of Incarceration
LIBERAL IDEOLOGIES Liberal ideologies assume that
problems in behavior originate in the social environ, ment.
The key to changing offenders is mani pulating their
environments or their psychological consequences
(McNeece & Roberts, 2001). Liberals focus on the
relationship between poverty, racism, and crime, and they
assume that efforts to prevent" crime should be directed at
these conditions. Liberal s also believe that incarceration
should provide treatment to rehabilitate, reeducate, and
reintegrate offenders into society. Some social workers
have been active in the correctional re form movement as a
reaction to the conservative ideologies and punit ive
strategies that began in the 1970s (Treger & Allen, 2007).
CONSERVATIVE IDEOLOGIES Conservatives view in,
adequate control over fundamentally flawed human na ture
as the primary cause of crime (McNeece & Roberts, 2001).
They support the notion of retribution or just deserts
because it serves utilitarian purposes. Punishment is not
only proper, but also necessary, because it rein forces the
social order. Deterrence is an expected out come of
incarceration, because punishing offenders for their
misdeeds will reduce both the probability of their repeating
the act (specific deterrence) and the likelihood of others
committing criminal acts (general deterrence). The
incapacitation function of incarceration reflects a
pessimistic view of human nature: offender s cannot be
rehabilitated, but neither can they commit crimes against
people outside the prison while incarcerated. Thus, harsher
sentences and fewer rehabilitative mea sures are required
(McNeece & Roberts, 2001).
480 CRIMINAL JUSTICE: CORRECfIONS
RADICAL IDEOLOGIES Radical ideologies are based on
the view that crime is an inevitable result of the
capitalist economic system (Gibbons, 1979). According
to Rusche and Kirchheimer (1939), the threat of in-
carceration was an effective capitalist device for con-
trolling the labor supply. Radicals argue that crime
should be substantially affected by changes in the poli-
tical economy. Because of their focus on the social
environment, radicals have devoted little effort to re-
forming correctional programs for individual offenders.
To the extent that reforms actually are adopted, they
only strengthen the ability of the correctional system to
control populations. According to this view, the only
hope for meaningful change is socialism (McNeece &
Roberts, 2001).
Correctional Programs
JAILS Despite being the oldest type of penal institution,
jails have been studied less than prisons have been and
are not always included in a discussion of corrections.
Jails are local institutions, many of which are dirty and
dilapidated and hold only a few prisoners; they are
located in rural areas and were built decades ago. A
smaller number of jails are newer, located in urban
areas, and may hold several thousand inmates. The latter
type of jail currently houses the majority of inmates.
Such disparate groups as people awaiting trial, inmates
serving misdemeanor sentences (generally less than 1
year), mentally ill people, alleged parole and probation
violators, felony prisoners in transit, 'intoxicated people
"drying out," and juveniles may be found in the same jail.
Inmates are disproportionately people of color, poor
people, and disadvantaged people, leading one critic to
refer to the jail as "the ultimate ghetto" of the criminal
justice system (Goldfarb, 1975). Irwin (1985) argued that
jail inmates are people who are not well integrated into
conventional society; have few ties to social networks; and
are perceived by their jailers as irksome, offensive, and
threatening, rather than dangerous.
Jails are administered by the police, usually the county
sheriff. However, a rapidly growing practice is the
contracting of local jail services to private corpora tions. By
1999, the last year national statistics were k ept, there were
almost 14,000 inmates in privately owned or managed jails
(Bureau of Justice Statistics [BJS], 2000). Usually the local
government issues bonds to pay for jail construction costs
and pledges the revenues generated from the lease of the
facility to retire the bonds. Another common practice is the
contracting of jail health care and some social services to
private firms.
At midyear 2005, 747,529 inmates were held in
American jails, a raise by 33,539 from the previous year.
An additional 71,905 offenders were in alternative
programs run by jails, but housed outside the jail (BJS,
2006a). Males were 87.3% of the jail population. Non-
White minorities accounted for 55.7% of jail inmates.
Blacks were almost 5 times, and Hispanics were nearly 3
times more likely than Whites to have been in jail.
Sixty-two percent of those in jail were not convicted of a
crime, but were awaiting court action on a criminal charge.
Sixty-eight percent met the criteria for substance
dependence or abuse.
Jail Conditions. Few attempts have been made to
systematically study jail conditions since 1991, when 136
jails were under a court order to reduce overcrowding, 66 to
provide recreational facilities, 58 to provide medical
services, 50 to provide libraries, 46 to provide more staff ,
and 37 to appropriately classify and separate inmates. Forty
of these largest jails were under court order to improve the
"totality of conditions," including such things as
illuminating fire hazards and providing educational
(Bureau of Justice Statistics, 1992a). Cur rent information
about these conditions is largely anec dotal, but the
hundreds of recent and pending court decisions on jail
conditions would lead one to believe that a severe problem
with overcrowding, sanitation, food, education, social
services, and health care still persists (AELE Legal
Publications Menu, 2006).
Juveniles in Jail. More than 100,000 juveniles were
admitted to adult jails each year during the mid1980s, with
the average daily population varying between 1,500 and
1,700 (Schwartz, 1989). After a spe cific amendment to
federal law to remove juveniles from jail, the average daily
population of juveniles in jail dropped only slightly by
1988, from 1,740 to 1,451 (Bureau of justice Statistics ,
1992a). A recent report by the National Council on Crime
and Delinquency (2006) documented a 208% increase in
the number of youth younger than 18 years serving time in
adult jails between 1990 and 2004, and the average daily
population of juveniles in adult jails has been just over
7,200 since the year 2000.
Women in Jail. The number of women in jails
increased by 8.0% during the year ending June 30, 2005 ,
and the rate of increase of women in jail since 1998 has
averaged 6.2%. The major reason is that more women a re
being arrested. Women's health problems are even less
likely to receive proper attention (McNeece, 1992). The
great majority of women offenders are mothers, and
two-thirds of women in jail have children younger than 18
years (BJS, 1992b). In addition to the trauma of separation
from their children while in jail, women inmates also run
the risk of having their parental rights terminated. Sexual
harassment of female inmates by male guards is another
serious issue

(Amnesty International, 2007). A significant propor tion
of female inmates also have been sexually abused and
struggle with substance abuse and mental health
problems (DeHart, 2004; National Institute of Justice
[NIJl, 2000).
PRISONS The stereotype of the prison as a "big house"
holding 2,000 or 3,000 inmates has never been an
accurate view of the U.S. prison, and it has become
increasingly inaccurate since World War II (Irwin,
1980). Many states have never relied on large institu-
tions to house convicted offenders, preferr ing to use
smaller, decentralized road camps or prison farms.
With more than 2,186,230 of its citizens behind bars,
the United States has the highest rate of incar-
\
ceration in the world (738 per 100,000), more than
either the former Soviet Union (628 per 100,000) or
South Africa (400 per 100,000). The incarceration rate
in Sweden and Switzerland is ",10% the rate in the
United States (Sentencing Project, 2003). There were
1,512,823 inmates in federal and state prisons in
FY2005, in addition to the 819,434 in local jails and
other local alternative jail programs (BJS, 2006a). The
number of prison inmates in custody per 100,000 popu-
lation in 2005 ranged from 153 in Maine to 824 in
Louisiana. States with the largest pri son populations
were Texas (171,338) and California (166,532), with
Florida (87,545) a distant third.
1. Black males had the highest probability of being in
prison (3,145 per 100,000), followed by Hispanic
males (1,244 per 100,000) and White males (471
per 100,000).
2. The number of female inmates continues to rise,
comprising 7.5% of the total state and federal
prison population in FY2005.
3. 68% of state prison inmates did not have a high
school diploma.
4; Just over half (52%) of state prison inmates were
serving time for a violent offense; the others were
in for property (21 %), drug (20%), and public
order (7%) offenses.
5. 80% of state prison inmates have a history of drug
abuse (Mumola, 1999).
6. 16% of state prison inmates have a history of
mental health problems (BJS, 1999).
Trends and Issues in Incarceration
ALTERNATIVES TO INCARCERATION The great
majority of America's 7 million adults who are under
correctional supervision are not incarcerated. The rna-
jority are sentenced to probation within the community
(sometimes called community-based corrections), and
CRIMINAL JUSTICE:
CORRECTIONS 481
most of the others have been released from prison on
parole. The number of adults on probation increased by
400% between 1980 and 2005, and the number on
parole doubled (BJS, 2006c).
PRIV A TIZA TION The prison population explosion,
coupled with increasing demands for cost cutting, has
led to an expansion of privatization. Private for-profit
corporations have a long history of involvement in
providing correctional services, from laundry and food
services, to medical, substance abuse treatment, and
psychiatric services, to complete prison operation. Fee,
ley (2002) presents an interesting history of the entre,
preneurial aspect of corrections. Hallett (2002) argues
that privatization has resulted in a concept of prisoners .
as commodities. Prisoners are no longer profitable only
for their labor, but also for their ability to generate per
diem payments to private organizations that house, feed,
and care for them.
The major incentives are speed and cost. Both
. construction time and costs have been reduced (Joel,
1993). Privately operated prison facilities held 101,228
inmates in FY2005, with the federal system reporting
the largest increase in privatization (BJS, 2006a). The
debate continues over the quality of care arid services in
private prisons and jails, as well as whether they are
actually more cost-effective (Abt Associates, 1998 ).
One concern is that cost savings are realized at the
expense of services (Dolovich, 2005).
FAITH,BASED PROGRAMS The George W. Bush ad,
ministration has strongly supported the provision of
prison services by religious organizations as a way of
reducing recidivism. Governor [eb Bush authorized the
nation's first completely faith, based prison in Florida.
Despite claims of success from the supporters of this
approach, Mears, Roman, Wolff, & Buck (2006) and his
associates did not find that faith, based program out,
comes were any better than other programs. In addition
there is controversy regarding the proper role of
churches and other religious organizations in conduct,
ing public business.
HEAL TH CARE Most correction agencies also con,
tract with private providers for at least some aspects of
inmate health care services (NIC, 2003). Whether public
or private, lack of access to adequate health care remains
a serious problem for many of the nation's jails and
prisons (NIC, 2001). Most of the nation' s inmates arrive
at the prison gate with unmet health needs, and despite
decades of litigation and some improvements in
programs, many of those needs persist throughout their
482 CRIMINAL JUSTICE: CORRECTIONS
sentence. The most serious health crisis in American
prisons is HIV or AIDS. At year-end 2003, 1.9% of all
male prison inmates were HIV -positive, compared with
2.8% of females (BJS, 2005a). Many local jails have
HIV-positive rates of more than 10%. In addition to higher
prevalence rates for other STDs, women inmates also have
special health problems associated with their reproductive
systems. Most pregnancies among female inmates are
classified as "high risk," since ex posure to drugs and
alcohol can lead to fetal health abnormalities.
According to the BJS (2006d), the majority of in-
carcerated inmates in America have a mental illness. The
prevalence of mental disorders among female inmates in
state prisons is an astounding 73%, compared to 55% for
males. Most of these illnesses are treated
psychopharmacologically. Inmates with a nonacute mental
illness generally receive less than an hour per week of
counseling. One of the greatest needs is for separate
housing for mentally ill inmates.
Substance abuse treatment is a major need in prisons
and jails. According toNIJ (2003), the majority of arrestees
are at risk for alcohol or drug dependence, or both, and
three of four convicted jail inmates were involved with
alcohol or drugs at the time of their current offense. If
treatment is not provided during incarceration, the chance
of recidivism remains high; yet our best estimates are that
only about 10% of those needing treatment while
incarcerated actually receive it (Mumola, 1999). The
number of prisoners incarcerated for drug offenses
increased substantially during the 1970s and 1980s, partly
because of harsher drug laws, such as the Rockefeller laws
in New York. Treatment accessibility varies greatly from
state to state and prison to prison, with a few offering a full
range of treatment for addictions, mental health problems,
domestic violence, and educational deficits.
PRISON CONDITIONS Selke (1993 ) maintained that
four overriding features of prison life must be consid ered:
(a) violence, (b) corruption, (c) racism, and (d) boredom.
Violence, always a fact of prison life, has been exacerbated
in recent years because of overcrowding. There were 6,241
allegations of sexual violence in prison and jail reported in
2005, with 38% of allegations involving staff sexual
misconduct; 35%, inmateon-inmate nonconsensual sexual
acts; 17%, staff sexual harassment; and 10%,
inmate-on-inmate abusive sexual contact (BJS, 2006b ).
The number of nonreported incidents is believed to be
much higher.
Corruption has also been a historical problem in closed
prisons as both inmates and staff attempt to
ameliorate the strains of living and working in such an
unpleasant atmosphere. Racism has been a com monly
recognized fact of prison life since the civil rights
movement of the 1960s. According to Irwin (1980), "the
hate and distrust between White and Black prison ers
constitute the most powerful source of divisions" in prison
(p. 183).
Boredom is a reflection of the absence of meaningful
activities for most inmates. Prisoners are confined to their
living and sleeping unit most of the day. Most inmates
who are physically able are required to work, and most are
paid a small hourly wage. Work assignments generally fall
into three categories: operational assignments within the
prison (janitorial, food preparation), community service
(highway clean-up, construction), and prison industries
(producing goods for sale). Even in the best correctional
programs, the routine that pervades prison life compels
some inmates to bizarre and outrageous conduct. Other
serious issues for inmates are the lack of autonomy ove r
one's actions, excessive noise, and lack of privacy.
RECIDIVISM Incarceration is often described as a "re-
volving door." In a study of 380,691 inmates released from
state prisons, BJS (2002) reported that two-thirds were
rearrested within 3 years, and almost half were
reconvicted. McKean and Ransford (2004) recommend
mental health and substance abuse treatrnentveduca tion,
and vocational training in prison as the most cost effective
ways of reducing recidivism. Drug courts, with mandatory
treatment and education programs, have managed to cut
recidivism rates by 31 %.
Social Work and Corrections
According to the Bureau of Labor Statistics (2006), there
are opportunities for correctional social workers in jails,
prisons, and parole or probation agencies. In jails and
prisons, they often assist in classifying inmates' needs,
evaluate their progress, and work with other agencies to
develop parole and release plans. In addition, social
workers provide offenders with coping, anger
management, and drug and sexual abuse counseling and
plan education and training programs to improve
offenders' job skills and employment prospects. Social
workers are usually part of an interdisciplinary team.
Despite many opportunities in corrections, relatively
few social workers choose a career in this field (Gibelman,
2006). This may be due partly to the aversion social
workers have toward working with "mandated" clients in a
coercive system that allows minimal client
self-determination. Also, few graduate programs provide
more than one course in correctional or justice

system social work (McNeece & Roberts, 1997). Students
interested in this field of practice should contact The
National Organization of Forensic Social Work
(http://www .nofsw .org!).
Future of Incarceration
Corrections in the United States is a growth industry.
Prison and jail populations have continued to climb
steadily since the mid-1990s, despite a decline in the rate
of both violent crimes and property crimes (BJS, 2005b).
We have the highest rate of incarceration in the world.
States and communities do not seem to have the capacity
to build jails and prisons fast enough to keep pace with the
growing inmate population. The Violent Crime Control
and Law Enforcement Act of
"
1994 emphasized the construction of new correctional
facilities by providing $9.7 billion for new prisons, boot
camps, and "other alternative correctional facilities that
free traditional prison and jail space for confinementof
violent offenders" (U.S. Department of'justice, 1994 ).
Despite our increasing ability to electronically monitor
offenders with global positioning devices, the states and
the federal government have turned increasingly to the
private sector to build even more jails and prisons, without
answering questions about whether the private sector can
build and operate such facilities more efficiently. Progress
has been made in improving living conditions and the
provision of essential services to inmates, but much
remains to be done.
REFERENCES
Abt Associates, Inc. (1998). Private prisons in the United States.
Cambridge, MA: Author.
Americans for Effective Law Enforcement (AELE). AELE legal
publications menu .. Retrieved December 22, 2006, from
http://www.ae.e.org/law/index.html
Amnesty International. (2007). Women in prison: A fact sheet.
Retrieved May 1, 2007, from http://www.prisonpolicy.org/
scans/women_prison. pdf.
Beccaria, C. (1819). An essay on crimes and punishments (2nd ed.).
Philadelphia: Philip H. Nicklin.
Bureau of Justice Statistics. (1992a). Jail inmates, 1991.
Washington, DC: Author. (NCJ 134726)
Bureau of Justice Statistics. (1992b). Women in jail, 1989.
Washington, DC: Author. (NCJ 134732)
Bureau of justice Statistics. (1999). Mental health and treatment of
inmates and probationers. Washington, DC: Author. (NCJ
174463)
Bureau of Justice Statistics. (2000). Prison and jail inmates at
midyear, 1999. Washington, DC: Author. (NCJ 181643) Bureau of
Justice Statistics. (2002). Reentry trends in the U.S.
Retrieved December 22, 2006, from www.ojp.usdoj.gov/bjs/
reentry/recidivism.htm
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Bureau of Justice Statistics. (2005a). HlV in prisons, 2003.
Retrieved December 22, 2006, from www.ojp.usdoj.gov/
bjs/abstractfhivp03.htin
Bureau of Justice Statistics. (2005b). Prison and jail inmates at
midyear 2004. Washington, DC: Author. (NCJ 208801) Bureau of
Justice Statistics. (2006a). Prison and jail inmates at midyear 2005.
Washington, DC: Author. (NC] 213133)
Bureau of Justice Statistics. (2006b). SeXUf,l1 violence reported by
correctional authorities, 2005 (NCJ 214646). Retrieved De-
cember 22, 2006, from www.ojp.usdog.gov/bjs/abstract/
svrca05.htrn
Bureau of Justice Statistics. (2006c). Sociql statistics briefing room:
COrrectional facts at a glance. Retrieved December 29, 2006,
from http://www.ojp.usdoj.gov/bjs/glance/corr2. htm
Bureau of Justice Statistics. (2006d). Mental health problems of
prison and jail inmates. Washington, DC: Author. (NCJ213600)
Bureau of Labor Statistics, U.S. Department of Labor. (2006).
Occupational outlook handbook. Retrieved December 26, 2006,
from http://www.bls.gov/oco/ocos265.htm
Congress, E. (2007). Ethical practice in forensic social work. In
A. R. Roberts & D. W. Springer (Eds.), Social work in juvenile
and criminal justice settings (3rd ed., pp. 75-86). Springfield, IL:
Charles C. Thomas.
DeHart, D. D. (2004). Pathways to prison: Impact of victimization in
the lives of incarcerated women. Washington, DC: National
Institute of Justice. (NCJ 208383)
Dolovich, S. (2005). State punishment and private prisons.
Duke Law Journal, 55(30), 439.
Feeley, M. M. (2002). Entrepreneurs of punishment: The legacy
of privatization. Punishment and Society, 4(3), 321~344.
Fox, V. (1983). Foreword. InA. R. Roberts (Ed.), SociaIworkin
juvenile and criminal justice settings (pp, ix-xxvii). Springfield,
IL: Charles C. Thomas.
Gibbons; D. (1979). The criminological enterprise. Englewood
Cliffs, NJ: Prentice-Hall ..
Gibelrnan, M. (2006). What social workers do (Znd ed.).
Washington, DC: NASW Press.
Goldfarb, R. (1975). Jails. Garden City, NY: Anchor Books.
Hallett, M. A. (2002). Race, crime, and for-profit imprisonment:
Social disorganization as market opportunity. Punishment and
Society, 4(3),369-393.
Heath, J. (1963). Eighteenth century penal theory. London:
Oxford University Press.
Herel, S. (2006, February 3). San Quentin prison locked down
after 16 hurt in riots. San Francisco Chronicle.
Howard, J. (1973). Prisons and lazarettos. Montclair, N]:
Patterson Smith. (Original work published 1791)
Irwin,]. (1980). Prisons in turmoil. Boston: Little, Brown. Irwin, J.
(1985). The jail. Berkeley: University of California Press.
Joel, D. (1993). The privatization of secure adult prisons: Issues
and evidence. In G. Bowman, S. Hakim, & P. Seidenstat
(Eds.), Privatizing corrections institutions (pp. 51-74). New
Brunswick, NJ: Transaction Books.
484 CRIMINAL JUSTICE: CORRECTIONS
Kant, 1. (1991). The metaphysics of morals. New York:
Cambridge University Press. (Original work published 1796)
McKean, L., & Ransford, C. (2004). Current strategies for reducing
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McN eece, C. (1992). An evaluation of anti-drug abuse act grant-
funded substance abuse treatment programs in Florida. T alla-
hassee: Florida State University, Institute for Health and
Human Services Research.
McNeece, C. A, & Roberts, A. R. (1997). Preface. In C. A.
McNeece & A. R. Roberts (Eds.), Policy and practice in the
justice system (pp. xi-xiii). Chicago; Nelson-Hall,
McNeece, C. A., & Roberts, A. R. (2001). Adult corrections.
In A Gitterman (Ed.), Handbook of social work practice with
vulnerable and resilient populations (pp. 342-366). New York:
Columbia University Press. \ CRISIS INTERVENTIONS
Mears, D., Roman, c., Wolff, A, & Buck, J. (2006). Faith-based
efforts to improve prisoner reentry: Assessing the logic and
evidence. Journal of Crimina/Justice, 34(4), 351-367.
Montgomery, R. (1998). History of correctional violence: An
examination of reported caUSes of prison riots and disturbances.
Alexandria, VA: American Correctional Association.
Mumola, C.']. (1999). Substance abuse and treatment, state and
federal prisoners, 1997. Washington, DC; U.S. Department of
Justice, Bureau of Justice Statistics. (NC] 172871) National
Council on Crime and Delinquency. (2006). Fact sheet: Youth under
age 18 in the adult criminal justice system. Oakland, CA: Author.
National Institute of Corrections, U.S. Department of Justice.
(2001). Correctional health care: Guidelines for the
management of an adequate delivery system. Washington,
DC:NIC.
National Institute of Corrections, U.s. Department of Justice.
(2003, September). Corrections agency collaborations with
public health. Longmont, CO; NIC Information Center.
National Institute of Justice, Office of Justice Programs, U.S.
Department of Justice. (2000, September). Research on women
and girls in the justice system. NIJ; Washington, DC. (NC]
180973)
National Institute of Justice. (2003). 2000 Arrestee drug abuse
monitoring: Annual report. Author; Washington, DC. (NC]
193013)
Rolland, M. (1997). Descent into madness: An inmate's experience
of the New Mexico State Prison riot. Cincinnati, OH; Anderson.
Rusche, G., & Kirchheimer, O. (1939). Punishment and
social structure. New York: Columbia University Press.
Schwartz, I. (1989). (In)justice for juveniles: Rethinking the best
interests of the child. Lexington, MA; Lexington Books.
Selke, W. (1993). Prisons in crisis. Bloomington; Indiana
University Press.
The Sentencing Project. (2003). Comparative international rates of
incarceration: An examination of causes and trends.
Washington, DC.
Sullivan, L. (1990). The prison reform movement: Forlorn hope.
Boston; T wayne.
Treger, H., & Allen, F. (2007). Social work in the justice system;
An overview. In A. R. Roberts & D. W. Springer
(Eds.), Social work in juvenile and criminal justice settings (3rd
ed., pp. 44-52). Springfield, IL: Charles C. Thomas.
Washington Times. (2006, February 10). Jail riots force lockdown.
FURTHER READING
Von Hirsch, A (1976). Doing justice. New York; Hill and Wang.
-Co AARON
McNEECE
ABSTRACT: Crisis intervention has been used to help
millions of at-risk and vulnerable social work clients
throughout the world. Acute crisis- inducing situations
range from the sudden loss of a loved one to a Stage IV
cancer diagnosis to a school shooting spree. Thi s entry
includes definitions and descriptions of crisis theory
and crisis intervention protocols. It traces the historical
background on the development of crisis intervention
programs. The next two sections discuss social work
roles and techniques with persons in crisis, and evi-
dence-based crisis intervention protocols based on the
latest meta-analysis.
KEY WORDS: crisis intervention; acute crisis episodes;
precipitating event; coping; equilibrium; perception
Introduction
We live in an era in which crisis and traumatic-inducing
events have become far too commonplace. Every day,
millions of people are confronted by potentially crisis-
inducing events, which they are not able to resolve on their
own. They often need immediate help from social workers or
other mental health professionals.
Crisis intervention programs begun in the late 1940s and
1950s when the first crisis clinics were opened in Boston;
Elmhurst, New York; and Los Angeles. When individuals
experience an acute crisis episode they can receive rapid
assistance via telephone crisis lines or from health, mental
health, and family counseling facilities. Professional interest
in crisis intervention, crisis management, suicide prevention,
crisis response teams, and disaster mental health has grown
tremendously since the horrific terrorist bombings of the
World Trade Center and Pentagon on September 11, 2001.
"Crisisinducing events and situations can often be critical
turning points in a person's life. They can serve as a challenge
and opportunity for rapid problem resolution

and growth, or as a debilitating event leading to sudden
disequilibrium, failed coping, and dysfunctional beha vior
patterns" (Roberts, 2005, p. 20). Many crises are triggered
by an unpredictable, overwhelming, fear inducing, or
life-threatening event such as terrorism, acute cardiac
arrest, a psychiatric emergency, drug over dose, motor
vehicle crash, child custody battle, cancer diagnosis,
becoming a victim of a violent crime, a community-wide
disaster, or violence at school or in the workplace (Roberts,
2005).
Definitional" Issues
Crisis and crisis intervention are words that have become all
too familiar during the past decades. This entry serves as a
historical perspective and a current practice guideline for
crisis intervention practice. In examining issues of crisis
there are two primary paths that describe crisis
experiences. The first is that a crisis often leads to an
individual's turning point. Another path is a crisis inducing
event that functions as a precipitating event, when it
short-circuits the individual's coping mechanisms.
Whatever the triggering episode, individuals experiencing
crisis events struggle to cope and attain a previously
experienced level of composure and balance in their life.
Therefore, crisis is defined as follows:
An acute disruption of psychological homeostasis
in which one's usual coping mechanisms fail and
there exists evidence of distress and functional
impairment. The subjective reaction to a stressful
life experience that compromises the individual's
stability and ability to cope or function. (Roberts,
2005, p. 779)
The main cause of a crisis is an intensely stressful,
traumatic, or hazardous event, accompanied by two other
conditions: (a) the individual's perception of the event as
the cause of considerable upset or disruption; and (b) the
individual's inability to resolve the disruption by
previously used coping methods. The presence of these
two factors combine with the event to create "an upset in
the steady state of the individual experiencing the crisis."
Although all crisis events are unique to the individual,
there are also similar components within the crisis episode.
Crisis episodes are usually composed of five components:
a hazardous or traumatic event, a vulnerable state, a
precipitating factor, an active crisis state, and the
resolution of the crisis (Roberts, 2005).
Historical Roots of Crisis Intervention
The roots of crisis intervention can be traced back to the
aftermath of the Cocoanut Grove Nightclub fire in
November 1942 in Boston, which caused the death of
CRISIS INTERVENTIONS
485
493 people when the flames spread rapidly throughout the
crowded nightclub. Dr. Eric Lindemann, a community
psychiatrist affiliated with Massachusetts General
Hospital and Harvard Medical School, assessed and
treated 101 survivors and close relatives of the victims of
this tragic fire. Lindemann observed grief that seemed to
be acute at onset, lasting for a brief time period, and
following a predictable sequence of stages. Lindemann
further believed that preventive clinical interventions
prevented psychopathology. In 1948, Lindemann
established the first community mental health clinic for
bereaved disaster victims and their families-the Wellesley
Human Relations Service. Dr. Eric Lindemann is best
known as the founder of preventive crisis psychiatry, also
known as crisis intervention.
Building on his collaboration with Eric Lindemann in
the 1950s, Dr. Caplan (1964) first conceptualized the
significance of life crises among adult psychiatric pa tients,
and concluded that psychiatric patients were unable to
handle crises and developmental transitions, which led to
disorganized thinking and mental illness. Caplan (1964) is
known to have coined the term preventive psychiatry and
psychiatric consultation, which focuses on the importance
of training medical and mental health practitioners to
identify and intervene on behalf of children and
adolescents experiencing critical life transitions, and
accompanying disorganized thinking. The goal is to
minimize psychological maladjustment and promote
positive growth.
Parad and Caplan (1960) in their classic article in Social
Wark examined the fact that a crisis has a peak or a sudden
turning point and as the individual reaches this peak,
tension increases, stimulating the mobiliza tion of the
individual's previously hidden strengths and capacities, or
triggering the individual to attempt to redefine the problem
and to try new coping strategies. They urge timely
intervention by helping individuals to best cope with a
crisis situation. Otherwise, a breaking point results in
severe emotional disorganization and dysfunction-a crisis
state.
Roles, Techniques, and Implications
- for Social Work
Caplan (1964) noted that in a typical crisis state, equi-
librium is usually restored in 4-6 weeks. The person
usually grows from the crisis experience by discovering
new coping skills and resources. In general, crisis inter-
vention researchers are in agreement that some events are
brief and transient, whereas others may last for several
days to several weeks, and as a result of the longer
duration are more likely to have a more severe impact on
the person.
486 OuSIS INTERVENTIONS
. Focusing, also known as actively exploring the
precipitating event or a specific problem, has a long
history in social work practice. Golan (1978) and
Roberts (1990) underscore a key principle in the
beginning phase of crisis intervention, specifically a
focus on the precipitating event or target problem. As
Golan has pointed out, the person in crisis and
professional social worker together select one target
problem on which to focus. The targeted problem and
contractual agreement can serve to keep both the social
worker and the client clearly focused throughout their
work together. As discussed by Golan (1978) the crisis
worker and client should negotiate an agreement on
specific goals and tasks to focus on, and collaborativelv
agreeing on joint activities. She encourages the worker
and client to "be as specific and concrete as possible"
(p. 87). As discussed by Roberts (1990), the crisis
worker is highly active, and helps the client to proceed
through each phase of crisis intervention in a structured
and often sequential fashion. Roberts (1990) further
encourages the crisis worker and the client to jointly
generate alternative strategies and identify a range of
potentially more adaptive coping behaviors.
Crisis Intervention Models and Strategies Several
systematic practice models have been utilized over the
years in crisis intervention work. The current crisis
intervention model builds upon the work of Caplan
(1964), Golan (1978), Parad (1965), Parad and Caplan
(1960), Roberts (1990, 1991, 2000), Roberts and
Dziegielewski (1995). Each of these practice models
has in common efforts to minimize and resolve
immediate problems, emotional conflicts, and distress
experienced through a minimum number of contacts.
Crisis-oriented treatment is by nature timelimited and
goal directed. This stands in stark contrast to traditional
psychotherapeutic approaches, which' may take years
to complete.
Crisis intervenors consistently demonstrate charac-
teristics of hopefulness and acceptance as they under-
take efforts to communicate with persons experiencing
intense emotional .turmoil and threatening situations.
At the same time, social workers are assuring the in-
dividual that he or she can survive this incident, they
should display acceptance and hopefulness in order to
communicate to persons in crisis that their intense
emotional turmoil and threatening situations are not
hopeless, and that in fact they (like others in similar
situations before them) will survive the crisis success-
fully and become better prepared for hazardous life
events in the future.
The Roberts' seven-stage model of crisis interven-
tion builds on and expands upon the earlier three and
four-stage models (Roberts, 1990, 1991, 2005). It has
been utilized in helping persons in acute psychological
crisis, acute situational crisis, and acute stress
disorders. The seven stages are as follows:
1. Plan and conduct a rapid crisis assessment
(including lethality, dangerousness to self or
others, and immediate psychosocial needs).
2. Make psychological contact, establish rapport and
rapidly establish the relationship (conveying
genuine respect for. the client, acceptance,
reassurance, and a nonjudgmental attitude).
3. Examine the dimensions of the problem in order
to define it (including the last straw or precipitat-
ing event).
4. Encourage an exploration of feelings and
emotions.
5. Generate, explore, and assess past coping
attempts.
6. Restore cognitive functioning through implemen-
tation of an action plan.
7. Follow-up and leave the door open for booster
sessions 3 or 6 months later.
Evidence-Based Practice and
Outcome Research
There is an increasing amount of evidence to support
the efficacy of crisis intervention, particularly intensive
home-based family crisis intervention. Systematic re-
view of 36 crisis intervention studies by Roberts and
Everly (2006) statistically demonstrated that intensive
home-based crisis intervention with abusive families
was much more effective than crisis debriefings and
other forms of short-term interventions.
In terms of measuring the effectiveness of in-home
family crisis intervention, also known as family
preservation programs, many of' the studies had
matched comparison groups as well as many hours of
intensive crisis intervention for the experimental
families. The significant finding was that "eight or
more hours of in-home crisis intervention over a one to
three month period consistently had been found to be
highly effective." Multicomponent Critical Incident
Stress Management (CISM), consisting of three or
more intensive sessions of crisis preparation and crisis
intervention with victims of violent crimes and
community disasters, was also found to be effective
(Roberts & Everly, 2006, p. 9). Crisis intervention is
certainly not a panacea, and Roberts and Everly (2006)
pointed out that booster sessions are often necessary
six months to one year after completion of the initial
in-home intensive crisis intervention with abused
children and their parents.

Conclusion
Most clinical social workers would agree that cnsis theory
and the crisis intervention approach provides us eful
guideposts for intervening with all types of acute crisis
episodes. By providing rapid assessments and timely
responses, clinicians can formulate effective and
economically feasible plans for time- limited crisis
intervention.
REFERENCES
Caplan, G. (1964). Principles of preventive psychiatry. New York:
Basic Books.
Golan, N. (1978). Treatment in crisis situations. New York:
The Free Press.
Parad, H. (Ed.). (1965). prisis intervention: Selected readings.
New York: Family Service Association of America.
Parad, H., & Caplan, G. (1960). A framework for studying
families in crisis. Social Work, 5(3), 3-15.
Roberts, A. R. (Ed.). (1990). Crisis intervention handbook (Ist ed.).
Belmont, CA: Wadsworth.
Roberts, A. R. (1991). Conceptualizing crisis theory and the crisis
intervention model. In A. R; Roberts (Ed.), Contemporary
perspeetiveson crisis intervention and prevention (pp. 3-17).
Englewood Cliffs, Nl: Prentice-Hall.
Roberts, A. R. (Ed.). (2000). Crisis intervention handbook:
Assessment, treatment and research (Znd ed.). New .York:
Oxford University Press.
Roberts, A. R. (Ed.). (2005). Bridging the past and present to the
future of crisis intervention and crisis management In Crisis
intervention handbook: Assessment; treatment and research (3rd
ed., pp. 3-34). New York: Oxford University Press.
Roberts, A. R., & Dziegielewski, S. F. (1995). Foundation skills
and applications of crisis intervention and cognitive therapy. In
A. R. Roberts (Ed.), Crisis intervention and time-limited cognitive
treatment (pp. 3-27). Thousand Oaks, CA: Sage.
Roberts, A. R., & Everly, G. S. (2006). A meta-analysis of 36
crisis intervention studies. Brief Treatment and Crisis Inter-
vention: A]oumal of Evidence-Based Practice, 6(1),10--21.
FURTHER READING
Parad, H., & Parad, L. (Eds.). (1990). Crisis intervention, book 2: The
practitioner's sourcebook for brief therapy. Milwaukee, WI:
Family Service of America.
Roberts, A. R. (Ed.). (1995). Crisis intervention and time-limited
cognitive treatment. Thousand Oaks, CA: Sage.
Roberts, A. R. (1996). An overview and the epidemiology of acute
crisis. InA. R. Roberts (Ed.), Crisis management and brief
treatment (pp. 16-33). Chicago: Nelson-Hall.
SUGGESTED LINKS
www.crisisinterventionnetwork.com
http://www.brief-treatment.oupjoumals . org
-ALBERT R. ROBERTS
CuLTURAL COMPITENCE 487
CUBANS. See Latinos and Latinas: Cubans.
CULTURAL COMPETENCE
ABSTRACT: Cultural competence emerged as a con cept
in the 1980s, took form as a set of organizational ,
educational, advocacy, policy, and practice constructs in
the 1990s, and has since matured into a broad rubric that
addresses'social justice and service delivery quality, equity,
access, and efficacy for people and groups of diverse
backgrounds. Cultural competence has become an essential
element of social work at every level of the field, from
direct practice to social policy. The evolu tion of cultural
competence and its role in social work is exami ned and
summarized in this entry.
KEY WORDS: cultural competence; cultural competency;
ethno-cultural competence; social justice; cultural relevance;
cultural awareness; diversity
This entry provides an overview of cultural competence
generally with a particular focus on organizatlons.vsys-
tems, and policy level issues. Cultural competence has
been defined in social work practice as the capacity to
function effectively as a helper in the context of cultural
differences (Cross, 2007). It has also been de fined at the
organizational and systems level as a set of congruent
policies, structures, procedures, and practices that to gether
enable and empower social work service providers to work
effectively in cross-cultural situations (Cross, Bazron,
Dennis, & Issacs, 1989; SAHMSA, 1997).
History
Cultural competence has its roots in a rapidly changing
demographic context, in a shifting political environ ment, in
social advocacy and action (Lum, 2007), as well as in
social justice theory (Van Soest& Garcia, 2003 ), ethnic
sensitivity (Devore & Schlesinger, 1999) and cultural
awareness models (Green, 1999). Cultural competence
emerged as a theoretical construct in the 1980 s and
developed into a generally accepted frame work for
multicultural practice by the late 1990s. " We can trace a
historical progression of related multicultur al themes such
as ethnic sensitivity, cultural awareness, cultural diversity,
and now cultural competence. These concepts are not
mutually exclusive. Rather, cultural competence serves as
a rubric that embraces these areas of concern" (Lum,
2007).
In the 1950s and 1960s the civil rights movement ,
along with the War' on Poverty and the Great Society
policy initiatives, transformed the relationship between
488 CuLTURAL COMPETENCE
social work and people of color in the United States
(Gutierrez, Zuniga, & Lum, 2004; Schram, Soss, &
Fording, 2003). Prior to this period social work was
almost exclusively a profession made up of White
service providers. Services to communities of color, if
available at all, were predominantly aimed at rescuing,
assimilating, or maintaining the status quo. For exam ple,
social work was largely responsible for the assimila-
tionist transracial adoption programs of the 1950s and
1960s that saw thousands of American Indian children
separated from their families without due process or
services ever being offered to families (Mallon &
McCartt Hess, 2005). At the same time, social work
services were virtually unavailable to most African,
Hispanic, or Asian Americans (Karger & Stoesz, 2005).
African Americans in some states were system atically
excluded from aid to families with dependent children
by race-biased eligibility rules (Kiltz & Segal, 2006;
Schram, Soss, & Fording, 2003).
The important results of the 1960s civil rights strug-
gles, policy shifts, and progressive programs were the
educational rights and resources secured by people of
color. Social work education opportunities for people of
color expanded rapidly, from funds channeled through
the National Institute for Mental Health, the Children's
Bureau, and the Indian Health Service, to . mention only
a few. During the 1970s and into the early
1980s an entire generation of social workers of color
entered the field through these opportunities only to find
that even with a formal social work education, they were
ill prepared to practice in their own communities. The
theories, models, and practices learned in the course of
their social work education proved to be ethnocentric. In
addition, many people of color realized that most
mainstream social workers serving communities of color
were using methods and practices in these communities
that were ineffective at best and at worst damaging
(Gutierrez, Zuniga, & Lum 2004; Van Soest & Garcia,
2003).
Young professionals of color began to search for
answers. Many began to formulate new practice models,
advance new theories, advocate for their communities,
and to provide cultural awareness training. Some be-
came the social work educators who would craft a new
framework for practice in a multicultural society. Social
workers of color working as grassroots advocates began
to hold their mainstream collogues accountable through
advocacy for individual clients, or whole communities.
Professional organizations, child advocacy organiza-
tions, and branches of government came under pressure
to address the issues presented by professionals of color,
eventually leading to the development of, or changes in,
standards, codes of ethics, and policies (Lum, 2007).
Literature
Literature by social workers of color began producing
helpful direction on working cross-culturally. At first,
this literature was largely aimed at understanding eth nic
culture, discussing a particular group, their life ways,
and the implications for social work. Journal articles
published in the 1970s were the first to begin to address
these issues. In the early 1980s books began to appear
such as Ethnic Sensitive Social Work Practice by Devore
and Schlesinger (1981) and Cultural Awareness in the
Human Services by Green and Associates (1982). These
were important early works in the evolution of what
would become the encompassing rubric known as
cultural competence. Green and Associates (1982 )
coined the term ethnic competence and was the first to
discuss a theoretical framework for effective cross-cul-
tural practice that was not ethnic group specific. By the
mid-1980s social workers of color were beginning to use
the term cultural competence in training events, confer-
ence presentations, and school of soci al work electives.
In 1988 a series of nonattributed articles on cultural
competence were published in Focal Point. (See Cross,
2007). One of these articles, "What Is a Culturally
Competent Professional," (Cross, 2007) proposes five
conditions for the development of culturally competent
practices. These five conditions-(a) awareness and
acceptance of difference, (b) cultural self-awareness, (c)
understanding the dynamics of difference,(d)
developing cultural knowledge, and (e) adaptation of
practice skills to fit the cultural context of the
client-were largely based on the work of Green and
Associates (1982). They would become central to
uniting several related theories and models under the
rubric of cultural competence.
These articles, written by Cross and Mason
(McManus, 1988), also provided much of the content for
the seminal work "Toward a Culturally Competent
System of Care" (Cross et a1.) published in 1989. This
monograph provides a definition for organizational
cultural competence at the mesolevel and describes a
continuum of competence evidenced by organizations
(Cross et al., 1989). This work is considered the first
systematic treatment of the topic (Lum, 2007). Also in
1989, Penderhughes described culturally competent
practice in her book, Understanding Race, Ethnicity, and
Power: "Cultural Competence demands that clinicians
develop flexibility in thinking and behavior, because
they must learn to adapt professional tasks and work
styles to the values, expectations, and preferences of
specific clients" (Penderhughes, 1989). In Lum's 1997
hallmark work Culturally Competent Practice cultural
competence is conceptualized as a framework for
practice. Lum's first comprehensive treatment of the
..:.:M

subject is followed up with second and third editions. Van
Soest and Garcia (2003) bring cultural compe tence back to
its roots with their social work education text Diversity
Education for Social Justice: Mastering Teaching Skills. In it
they criticize the cultural cornpe tence movement for not
holding social justice as the true compass and declare that
without addressing racism and discrimination there can be
no cultural competence. By the turn of the century, cultural
competence has evolved into "a major subject area for
culturally diverse social work practice and a process of
individual and professional growth" (Lum, 2007).
Policy Developments
During the 1990s, several professional organizations ,
federal agencies, and state governments began to ernbra ce
the principles~f cultural competence as expressed by Cross
et al. (1989). Organizations such as the Child Welfare
League of America developedcomrnittees that drafted
cultural competence position statements, poli des, or
standards. In the field of psychology and coun seling,
organizations such as the American Association for
Counseling and Development identified competen cies for
multicultural counseling (Sue, Arrendondo, & McDavis,
1992). By 1993, the American Psychological Association
had committed itself to multicultural com petence (APA,
1993; Lum, 2007). In the mid~1990s the Substance Abuse
Mental Health Services Administra tion began including
cultural competence as a criterion for grant applications and
in 1997 published its own definition of cultur al competence
based on the work of Cross et al. (1989). In 1995, Mason
published an organizational self- assessment for cultural
competence, further advancing the field.
In 1999 the National Association of Social Workers
(NASW, 2001) adopted language on cultural compe tence
into the NASW Code of Ethics, for the first time making the
delivery of culturally competent services an ethical issue. In
2001, the NASW "Standards for Cultural Competence in
Social Work Practice" adopted a broad meaning of cultural
"to include sociocultural experience of people of different
genders, social class, religious and spiritual beliefs, sexual
orientations, ages, and physical and mental abilities" (Lum,
2007; NASW, 2001). This move formally recognized the
growing pressure from advocates of diverse backgrounds
for the social work field to be competent across a range of
differences, not just ethno-cultural. In so doing, the rubric
of cultural competence gained : momentum, stakeholders,
and allied scholars. At the same time, expan ding the
definition of culture brought debate regarding this
expansion. Ridley (2005) discusses this debate, questioning
the application of the term cultural
CuLTURAL COMPETENCE 489
to other diverse people. Lum (2007) concludes that as long
as advocates for these groups make a case for application of
the cultural competence framework to their experience
there will be broad application.
In 2002; under pressure from advocates of color and
other diverse populations within the social work educa tion
community, the Counsel on Social Work Education
(CSWE) adopted diversity standards that encompass and
advance the established frameworks for culturally com-
petent social work. In addition, the CSWE standards on
social and economic justice further address cultural
diversity, reinforcing the social justice aspect of cul tural
competence. Although not using the term cultural
competence directly, the standards provide clear guidelines
and professional sanction for the growing movement. (See
Educational Policy and Accreditation Standards, 2002.)
CSWE has become one of the leading publishers of cultural
competence literature. With the direct involvement of
diverse social work educators, it has become a key resource
for social work educators to build the depth and breadth of
the cultural competence in professional social work
education.
Controversies
As the cultural competence movement progressed, it
generated confusion regarding its definition and appli-
cation. In part, this is a product of the complexity of the
issues but it is also because many authors have ap proached
the issues from diverse perspectives. Lum (2007) outlines
several levels and dimensions of cultur al competence and
reviews the literature addressing the issue at the micro
(practice), meso (agency), and macro (system) levels.
Miley, O'Melia, and Dubois (1998) also discuss cultural
competence at the practitioner, agency, and community
levels. Cross et al. (1989) discuss how a culturally
competent system requires effective indivi dual
cross-cultural practice and appropriate organiza tional level
values, policies, structures, and programs that are
supported by system-wide policies, regulations, and
funding mechanisms that empower both individual and
agency multicultural service delivery. The National Center
for Cultural and Linguistic Competence at Georgetown
University Child Development Center pro vides several
useful tools for organizational development of cultural
competence (http://gucchd.georgetown.edu . nccc/pa.html).
Nybell and Gray (2004) address the in herent conflictual
nature of achieving cultural compe tence within
organizations. In their study of several organizations they
found that achieving cultural compe tence required a
redistribution of power toward clients, programs, and
communities of color, and in reality most predominantly
mainstream social service agencies are reluctan t to
relinquish control to disenfranchised people.
490 CuLTURAL COMPETENCE
Advancements
Among the works addressing cultural competence at the
level of the professional field are those of Ponterotto,
Casas, Suzuki, and Alexander (1995), Pope-Davis and
Coleman (1997), Fong and Furuto (2001), Fong (2004),
Constantine and Sue (2005), and Orlandi, Weston, and
Epstein (1992). Each of these authors has contributed to
the advancement of cultural competence through
documenting examples of implementation and providing
insights into emerging efforts to advance the cross- cultural
effectiveness of the field. . Further, Straussner (2001) uses
the term ethnocultural competence to describe the complex
contextual issues of cross-cultural practice and provides
insight into the deeper dimensions of effective
cross-cultural practice. Finally, Lum (2007) provides a
comprehensive look into the richness of culturally
competent practice with his framework for culturally
competent practice that poses four levels, each with
generalist and advanced characteristics. The first is
cultural awareness, both personally and professionally, of
diverse people and the oppression that impacts them. The
second is the acquisition of cultural knowledge that
plausibly explains behavior. The third is skill development
based on the awareness and acquired knowledge. The
fourth is inductive learning, which is characterized by
innovation and contribution of new insights to the field
(Lum, 2007).
A significant paradigm shift i s evidenced in these
discussions. Where the early works emphasized under -
standing of specific cultural groups and their values and
lifeways as the unit of study, the most recent works
emphasize culture, culturally based experiences, and
power dynamics as the units of study. This shift is away
from the notion that the practitioner should simply know
about a person's cultural group. The practitioner should
now be able to understand and adapt to the following: the
person's experience of his or her culture, the specific
social and mental health challenges experi enced by people
of any specific group, the dynamics of power differentials,
and identity and oppression and their impact on behavior.
It is the complex interplay between personality and the
sociocultural environment that accounts for human
behavior. In this new paradigm for multicultural practice,
social and economic justice are placed at the forefront of
achieving competence. Lum (2007) states, "The social
context of diversity, racism, sexism, homopho bia,
discrimination, and oppression is with us as we help
people with problems. The message is that these
contextual factors must be confronted and dealt with on a
constant basis." Increasingly, social service systems and
agencies are recognized
as being part of the sociocultural environment. Cultural
competence is not just about the relationship between
worker and client but about creating organizations that are
accountable for ensuring that their services and policy not
only reach diverse populations but are rele vant to their
culturally based needs and to the pursuit of social justice.
Converging Theorie; .
While the concepts foundational to cultural compe tence
anchor the field, new and emerging theories continue to
impact our understanding of cultural com petence. The
theory of sociai constructionism (Norton, 1993) relates to
the process by which "people use the ecology of their
environment to construct meaning for themselves based
on their experiences" (Lum, 2007). Applied to cultural
competence, this theory supports the paradigm that
encourages culture as a unit of study. Identity
development theory (Morton & Atkinson, 1983) also
supports the notion of a complex interplay between
personality and culture both of which are influenced and
shaped by personal experience. Fong and Furuto (2001)
in their work Culturally Competent Practice: Skills,
Interventions, and Evaluations advance several theories of
cultural competent practice in line with the paradigm shift
described earlier. Theories regarding ethnicity, culture,
minority status, social class, and acculturation (Devore &
Schlesinger, 1999; Gordon, 1978; Green, 1999; Inglehart
& Becerra, 1995; Paniagua, 2005) are essential to
culturally diverse practice (see Lum, 2007, pp. 157-182,
for a full discussion).
Implications for Social Work
Cultural competence is an ethical obligation, a profes-
sional standard, a defined practice framework with its own
knowledge base and skill set and established prin ciples for
effective multicultural service delivery at the practice,
agency, and system levels. It is about the complex
interplay between the individual and the en vironment and
the power dynamics associated with be ing different. As
social work struggles to incorporate social justice with
effective practice, it has had to align its institutions,
theories, and helping approaches to respond to the
growing demands of a shifting demo graphic and the
advocates from diverse cultures that have entered and are
now shaping the field.
REFERENCES
American Psychological Association. [APA]. (1993). Guidelines
for providers of psychological services to ethnic, linguistic,
and culturally diverse populations. American Psychologist, 48,
45-48.
,.J
 CuLTURAL DIVERSITY 491

Constantine, M. G., & Sue, D. W. (Eds.). (2005). The American University, Research and Training Center on Family Support
Psychological Association's guidelines on multicultural and Children's Mental Health.
education, training, research, practice, and organizational Miley, K. K., O'Melia, M., & Dubois, B. I. (1998). Generalist social
psychology: Initial development and summary. In M. G. work practice: An empowering approach. Boston: Allyn & Bacon.
Constantine, & D. W. Sue (Eds.), Strategies for building Morton, G., & Atkinson, D. R. (1983). Minority identity
multicultural competence in mental health and educa tional settings development and preference for counselor race. Journal of
(pp. 3-15). Hoboken, NJ: Wiley. Negro Education, 52(2), 156-161.
Council on Social Work Education (CSWE), Commission on National Association of Social Workers. [NASW]. (2001).
Accreditation. (2002). Educational policy and accreditation NASW Standards for cultural competence in social work practice.
standards. Alexandria, VA: Author. http://www.naswdc.org/pub/standards/cultural.htm Norton, D. G.
Cross T. L. (2007, Spring). What is a culturally competent (1993). Diversity, early socialization, and temporal development:
professional? Pathways Practice Digest, pp. 10--11. Portland, The dual perspective revisited. Social Work,38(1),82-90.
OR: National Indian Child Welfare Association. Nybell, L. M., & Gray, S. S. (2004). Race, place, space:
Cross, T. L., Bazron, B. J., Dennis, K. W., & Issacs, M. R. (1989).
Meanings of cultural competence in three child welfare
Toward a culturally competent system of care. Washington, DC:
agencies. Social Work, 49, 17-26.
Georgetown University Child Develop-
Orlandi, M. A, Weston, R., & Epstein, L. G. (Eels.). (1992).
ment Center. \
Cultural competence for evaluators: A guide for alcohol and other
Cross, T. L., & Mason, J. (1988). Services to minority populations:
drug abuse prevention practitioners working with ethnic/racialcom-
Cultural competence continuum. In M. C. McManus, (Ed.),
munities. Rockville, MD: U.S. Department of Health and
Focal point: A national buUetin on family support and children's
Human Services, Office for Substance Abuse Prevention.
mental health, 3(1) pp.1-3. Portland, OR: Portland State
University, Research and Training Center on Family Support Paniagua, F. A (2005). Assessing and treating culturaUy diverse
and Children's Mental Health. clients: A practical guide. Thousand Oaks, CA: Sage.
Devore, W., & Schlesinger, E. G. (1981). Ethnic-sensitive social Penderhughes, E. (1989). Understanding race, ethnicity, a nd power:
work practice. St. Louis, MO: Mosby. The key to efficacy in clinical practice. New York: Free Press.
Ponterotto, J. G., Casas, J. M., Suzuki, L. A., & Alexander, C. M.
Devore, W., & Schlesinger, E. G. (1999). Ethnic-sensitive social
(Eds.). (1995). Handbook of multicultural counseling. Thousands
work practice. New-York: Allyn & Bacon.
Oaks, CA: Sage.
Fong, R. (Ed.'. (2004). Culturally competent practice with immigrant
Pope-Davis, D. B., & Coleman, H. L. K. (Eds.). (1997). Multi-
and refugee children and families. New York: Guilford Press.
cultural counseling competencies: Assessment, education and
Fong, R., & Furuto, S. (Eds.). (2001). CulturaUy competent practice:
training, and supervision. Thousand Oaks, CA: Sage.
SkiUs, interventions, and evaluations. Boston: Allyn &-Bacon.
Ridley, C. R. (2005). Overcoming unintentional racism in counseling
Gordon, M. M. (1978). Human nature, class, and ethnicity. New
and therapy: A practitioner guide to intentional intervention.
York: Oxford University Press.
Thousand Oaks, CA: Sage.
Green, J. W., & Associates. (1982). Cultural awareness in the human
Schram, S. F., Soss, J., & Fording, R. C. (2003). Race and the
s~viC:~J. Englewood Cliffs, NJ: Prentice-Hall.
politics of welfare reform. Ann Arbor: University of Michigan
Green, J. W. (1999). Cultural awareness in the human services: A
Press.
multiethnic approach. Boston: Allyn & Bacon.
Straussner, S. L. A (2001). Ethnocultural issues in substance
Gutierrez, L., Zuniga, M., & Lum, D. (2004). Education for
abuse treatment. In S. L. A. Sttaussner (Ed.), Ethnocultural
multicultural social work practice: Critical viewpoints andfuture
factors in substance a~e treatment (pp. 3-28). New York:
directions. Alexandria, VA: CSWE.
Guilford Press.
Inglehart, A P., & Becerra, R. M. (1995). Social services and the
Sue, D. W., Arrendondo, P., & McDavis, R. J. (1992). Multi-
ethnic community. Boston: Allyn & Bacon.
cultural counseling competencies and standards: A call to the
Karger, H. J., & Stoesz, D. (Eds.). (2005). American social welfare
profession. Journal of Counseling and Development, 70, 477-486.
policy: A pluralistic approach (4th ed.). San Francisco:
Van Soest, D., & Garcia, B. (2003). Diversity education for social
Pearson.
justice: Mastering teaching skiUs. Alexandria, VA: CSWE.
Kiltz, K. M., & Segal, E. A (Eds.). (2006). The promise of welfare
reform: Political rhetoric and the reality of poverty in
the 21st century. New York: Haworth Press. .
Lum, D. (Ed.). (2007). CulturaUy competent practice: A framework for
understanding diverse groups and justice issues (3rd ed.). Belmont,
CA: Thomson Brooks/Cole. - TERRY L. CROSS
Mallon, G. P., & McCartt Hess, P. (2005). Child welfare for the 21st
century: A handbook of practices, policies, and programs. New
York: University Press.
Mason, J; L. (1995). Cultural competence self-assessment ques-
tionnaire: A manual for users. Portland, OR: Portland State CULTURAL DIVERSITY. See Cultural Compe-
tence; Multiculturalism.
492 CuLlURAL INSTITUTIONS AND 11-IE ARTS
eUL TURAL INSTITUTIONS AND
THE ARTS
ABSTRACT: The arts and cultural institutions can be
powerful resources for promoting the development of
individuals and communities. Social work agencies and
cultural institutions share similar goals at the individual
and community levels, such as personal improvement, the
creation of social bonds, expression of communal
meaning, and economic growth. Studies on the use of arts
in social work practice suggest that they can be powerful
tools for intervention. These collaborations were essential
to practice in the social settlements and in economic
policies of the New Deal. Social work practice into the
future can build upon this historical engagement.
KEY WORDS: arts; community institutions; community
organization; clinical social work
Cultural institutions are public social institutions that exist
primarily for the purposes of promoting and orga nizing
cultural production through the arts and human, ities.
These public institutions may be governmental or
nonprofit educational and charitable organizations tha t
may receive funding from public grants or private dona-
tions or fees for services. This perspective would not
include profit-making organizations, such as the popu lar
entertainment industry.
Cultural institutions differ in their structure and
functions depending on whether they involve
objects and collections (for example, museums,
libraries, monuments),
concepts (for example, academic and scientific
associations), or
performances (for example, music, dance, and
theater).
Cultural institutions, such as the churches, local his toric
societies, and other organizations that maintain collections
and educational programs about the Under, ground
Railroad, may engage in several of these activ ities. The
National Park Service lists 20 states that have national .
historic landmarks that combine physical structures,
artifacts, historic documents, and education, al programs
(http://www.nps.gov/nr/travel/underground/ states.htm).
Cultural institutions represent "stores" of culture, and
they are valuable resources for cultural diversity and social
action. Their importance to cultural trans, mission is shared
with other organizations who also do work in cultural
sectors. Many organizations that are not cultural
institutions-such as schools, public social
welfare agencies, or settlement houses-operate cul tural
programs and express and develop cultural values. For
example, many children 'are first exposed to music and fine
arts in schools (McCarthy, 2004, p. 71). Cities sponsor art ,
craft, and ethnic fairs, where cultural activ ities and
products are collected, presented, and sold. Private
corporations collect fine arts and sponsor com munity
cultural events.
Even though their primary function is to represent and
advocate for cultures and focus on cultural produc tion,
cultural institutions collaborate and impact other societal
sectors such as economic, political, and educa tional
organizations. This approach was documented by the Ford
Foundation's 2003 report, "Downside Up," which
described organizations engaged in the arts and community
development (Borrup, 2003). Borrup (2003) cites four
examples of organizations such as Boston's Asian
Community Development Corporation, or Miami's Black
Archives that engage jointly in cultural and communi ty and
economic development.
As engagement by cultural institutions in commu nities
has expanded, stresses and conflicts have emerged. The
first conflict is historically grounded (Price, 1994). Cultural
institutions have historically functioned to demarca te social
classes and represent a homogenized vision of a diverse
society. During the 19th century, many of our major
cultural institutions such as the Chicago Art Institute were
founded to expose middle class people to European art and
to display and legitimize the wealth of the newly rich
(Horowitz, 1976; Strom, 2002). More recent public con-
flicts about museum exhibits, dioramas, gallery exhibi-
tions, or public performances indicate that our public
cultural institutions face many stresses as they represe nt
diverse communities (Aug, 2005; Price, 1994). Strom
(2002) has argued that an eclecticism by museums and
performing arts companies has made them more com-
mercially viable and created a new role as an engine of
economic revitalization. Some institutions, such as the
Ecomuseum, have located their focus on one culture and
one space.
This use of the word culture also reflects an historical
conflict among public cultural institutions. Williams (1983 )
describes that culture is "one of the two or three most
complicated words in the English language." The concept
is powerful for social work, because the plural noun,
cultures, stands in opposition to a dominant and unitary
notion of culture and is foundational to cultural pluralists
and the notion of diversity (Williams, 1983 ).
Multiculturalism was developed in the Roman tic
movement of the 19th century, as an alternative to notions
of one sole view of "civilization." As such, culture is
distributed among all people equally as

opposed to a scarce attribute belonging to an intellectual or
aesthetic elite, as when one is considered "cultured" or
"cultivated" (Williams, 1983, p. 87).
A second source of conflict is endemic to broadening
the focus to new areas of art and engaging complex
communities that disagree about the representation of their
cultural identities. Conflicts involving the engage ment of
cultural institutions in communities are com plex as
Livingston and Beardsley (1991) critica lly documented
their own curation, Hispanic Art in the United States:
Thirty ContemPorary Sculptures. Their exhibit received
popular acclaim, but Hispanic critics emerged who
expressed a "preexisting wide range of opinion and attitude
among-the various groups of Hispanics" (Livingston, &
Beardsley, 1991, p. 112). Agreement did not exist among
Hispanic people, who had an interest in the perception of
Hispanic art by the mainstream, or among Hispanic artists
who were not satisfied by the types of art that wer e
selected. Criticism also came from mainstream
professional colleagues as the exhibition challenged
contemporary perspectives on art and culture (Livingston
& Beardsley, 1991).
A third source of conflict for cultural institutions
concerns the degree that they are valuable for their inherent
effects or extrinsically for the instrumental benefits that
they produce. Yudice (2005) raises con cerns that "culture is
increasingly wielded as a resource for both sociopolitical
and economic amelioration" (Yudice, 2005, p. 11). He
observes that the use of culture has expanded with this new
legitimizing utilitarian strategy. He describes The National
Endowment for the Arts monograph American Canvas,
which points to the new partnerships between arts
organizations and school districts, parks and recreation
departments, convention and visitor bureaus, chambers of
commerce, and a host of social welfare agencies as
demonstrating the utilitarian aspects of the arts in
contemporary society (Yudice, 2005). Reminiscent of th e
use of culture in the cold war, art and culture have been.
posited as engines for economic development by major
foundations, the European Union, World Bank, and the
lnterAmerican Development Bank (Goldbard, 2006).
The conflict between the expedient an d intrinsic quality
of culture is often represented by extremes. At one extreme,
many support arts and culture, because they bring pleasure
and the capacity to captivate. At another extreme are those
who support arts and culture for the economic and social
capital they may bring.
)
The concept of cultural capital offers an alternative
perspective on this conflict by separating the intrinsic and
"
expedient effects by time. Cultural capital con structs
culture as a valued resource that can be stored like other
forms of capital (for example, financial,
i,
, Minneapolis's Walker Art Center, which the
s
CuLTURAL INSTITUTIONS AND THE ARTS
493
physical, human, political, and social capital). As such,
cultural capital can be built or enhanced at one time period,
can appreciate or depreciate over time, and later be
transformed to other forms of capital to facilitate action
(Crowell, 2004; Light, 2004).
These conflicts around representations of culture are
made sharper as cultural organizations engage in com-
merce, contributing to concerns that commercial goals will
drive out artistic vision. Yudice (2005) has de scribed the
"clientalization of culture" as creating a demand for a
specific type of familiar cultural production. Of course,
cultural programs can lose their vision even without
commerce to the inertia that occurs when a participatory
program is repeated over time. For ex ample, current art
programs in schools, harking back to a traditional art form,
and the Mexican sponsorship of murals in the 1920s ands
1930s, often sponsor murals to support a traditional
identity, not as artistic expressions (Yudice, 2(05). When
Livingston and Beardsley surveyed art for their exhibit
(from 1984 to 1987), they found that murals and posters
could no longer be considered a dominant form of
expression among Hispanic artists. Similarly, Hurley and
Trimarco (2004) have documented both praise and
condemnation of vendors of World Trade Center souvenirs
by tourists, police, journalists, and politicians. The
sentiments aroused are familiar to cultural production:
They describe critics as viewing "ground zero as a sacred
space, an area that should be protected from the
contaminating effects of commerce" (Hurley and Trimarco,
2004, p. 51).
Out of these conflicts new forms of cultural organi-
zations have emerged, as shown by the development of the
ecomuseurn movement. This movement is one out come of
the social innovation following the 1968 Paris students '
riots. It was first proposed formally by Riviere, who
defined it as an "interdisciplinary approach that emphasizes
the importance of place" (Fuller, 1991). The ecomuseum
defined itself by focusing on a geo graphic area or the
audience being served; nontraditional collections such as
audiovisual materials, traditional ceremoni es, oral
histories, and social relationships; inven tories of valued
objects without necessarily collecting or possessing them;
educating individuals in archival and museological skills;
and participating in community problem- solving (Fuller,
1991, pp. 330-332). The ecomuseum addresses cultural
relevancy and is organized to be a catalyst for change
(Fuller, 1991). In 2007, there were over 300 ecomuseums
developed with these principles throughout the world
(Outlook on Ecomuseums, 2007).
More traditional and mainstream cultural institu tions
have also broadened their missions and visions to become
more inclusive, one of the most well- known being
494 CuLTURAL INSTITUTIONS AND THE ARTS
director, Kathy Halbreich, describes as a new town
square (Krinke, 2006). It includes collections, classes,
lectures, performances, film, dining, and shopping.
These changes' have focused on new forms of cultural
content such as the exhibition Brave New Worlds,
"which considers the present state of political con-
sciousness, expressed through the questions of how to
live, experience, and dream" and have also crossed
boundaries' between curators, archivists, collectors, re-
searchers, and the public through the active engage-
ment of audiences (Walker Art Center Web site).
Despite the rush to expediency, an important ques-
tion remains: To what degree should the arts and hu-
manities be expedient to other values, such as an
intervention or societal goals and to what degree do
interventions or the achievement of goals depend on the
pleasure and captivation of the participants and the
quality of artistic expression? For example, photovoice
was designed as a form of participatory action research
(Wang, 1999; Wang & Burris, 1997). The results
depend on the photographic images and narrative texts
that describe them. To what extent will interventions be
improved by more skillful photographs and better
narratives? Yudice raises this same issue at a macro
level when cultural production is used as a resource for
capital development and tourism (Yudice, 2005, pp. 4
arid 9 ff).
Cultural Institutions and
the Arts in Social Work
Arts and cultural programming have been an essential
aspect of social work practice since the rise of the social
settlements (Fabricant & Fischer, 2003). The arts and
artistic expression were deeply embedded in the work
of such social settlements as Hull-House and Henry
Street Settlement (Fabricant & Fischer, 2003). These
early arts programs led to the development of
community theaters, such as the Neighborhood
Playhouse in New York, provided arts education for
low-income individuals, and exposed low-income and
immigrant communities to the larger cultural resources
in their communities (Brieland, 1990).
The arts also played a central role in the economic
recovery policies of the New Deal during the 1930s.
Government support for the visual and performing arts
during that era improved the economic position of
artists and contributed to the quality of life in urban and
rural communities. Federal Project One, also known as
the Federal Arts Project (FAP), was one of the
divisions of the Works Progress Administration and
included "Art, Music, Theatre and Writers' Projects."
The FAP created over 5,000 'jobs for artists and pro-
duced over 225,000 works of art (National New Deal
Preservation Association; Yetman, 1967). Artists and
performers were paid for work such as graphic design,
murals in government buildings, local theater perfor-
mances, photography, and other forms of cultural ex-
pression. Unlike comparable art programs in the United
Kingdom and Australia, the FAP was local and
democratic (Gibson, 1997). This level of U.S.
government support for the arts was unprecedented and
has never' been as extensive since (A New Deal for the
Arts, 2007).
The collection of over 2,000 ex-slave narratives
between 1936 and 1938 by the Federal Writer's Project
was a remarkable example of ethnographic research
that itself provides multiple levels of insight about race
relations before and during the Depression.
Lack of extensive documentation and impact re-
search does not mean that cultural interventions are
ineffective. On the contrary, for the last 20 years "cul-
ture wars" have been fought over their imputed effec-
tiveness and as their entanglement in community life
has increased. Cocke (2004) has documented one of the
first skirmishes in the culture wars as the withdrawal in
1984 of the United States from the United Nations
Educational, Scientific and Cultural Organization
(UNESCO); it "sent a clear signal to the International
arts community that we would no longer consider cul-
tural exchange useful to our understanding of others in
the world" (Cocke, 2004, p. 165; Kolin, 1995). Cur-
rently, the arts and humanities are seen as expressions
of interest and as aspects of political struggle (Yudice,
2005). The active engagement of cultural institutions in
community and political life has removed the per-
ception that they are neutral repositories and represen-
tatives of a unitary culture, and they have apparently
removed reticence about their importance.
Research and Measures of Effectiveness
The arts and humanities currently work together with
social policy and social work practice at many different
levels: clinical, group, community, and political. Arts
and culture organizations have claimed both individual
and community-level outcomes. However, much re-
search on the effects of participation in arts and culture
programs has lacked specificity and methodological
rigor (McCarthy, 2004).
The proposed individual benefits from cultural
. participation include cognitive development (such as
improved academic performance,' basic skills and atti-
tudes, and skills that affect the learning process) and
health benefits (such as quality of life, over a variety of
patients, reduced stress, reduced anxiety) (McCarthy,
2004, pp. 6-13). The arts and humanities are also the
basis for expressive therapies used by clinical social

workers. Creative-arts therapies use different art forms
and engages the imagination as part of the individual
change process. They are distinguished by the focus on
the process of creation and the expression of ideas and
feelings through art rather than on the ultimate end
product. These therapies most typically involve the
visual arts, dance, music, theater, or writing. They may
involve various art forms, but all methods are based on
the assumption that engaging in multiple forms of ex-
pression is an essential aspect of intrapersonal change
(Feldman, 2007). Although the effects of expressive
therapies have not been fully investigated, research .
suggests that engaging in creative arts can have a positive
impact on self-concept (Clawson & Coolbaugh, 2001;
Wexler, 2002),\ school performance (Fiske, 1999), and
social skills (Groves & Huber, 2003). A number of
studies on the impact of music therapy in health-care
settings have found that music therapy can be effective in
reducing stress during medical procedures and among
those with chronic conditions (Nickel, Hillecke,
Argestatter, & Volker Bolay, 2005). Emerging research
has also found visual-arts-based therapy ro improve
symproms among cancer patients (Nainis et al., 2006).
Research on drama and dance therapy is less developed
and there have been no consistent findings ro support its
efficacy (Landy, 2006). Emerging research on the impact
of expressive therapies on brain chemistry suggests that
by engaging the right side of the brain, which processes
visual and sensory information, culturally based methods
uniquely assist individuals to cope with emotional
distress (Lusebrink, 2004).
Community-level benefits can include promotion of
social interaction by building trust and social capital
among diverse groups and empowerment of commu-
nities for collective action through the development of
local capacity through leadership and organizational
development. Economic benefits include direct benefits
from the economic activity of the art organization,
indirect benefits such as volunteering and the ability to
attract individuals to an area on the basis of artistic
activity, and public-good benefits such as satisfaction
from knowing that arts exist for ourselves or our chil-
dren even when we do not directly participate
(McCarthy, 2004).
Community organizations have found that arts and
humanities are an effective means to engage commu-
nitiesand "hard to reach" populations, build cohesion,
develop skills and assets, and identify common prob-
lems (Thompson, 1998; Wexler, 2002; Witt & Baker,
1997). For example, murals in Latino and other ethnic
communities are ways of expressing and communicat-
ing community identity and issues. Engaging a local
community in planning and creating a mural can be a
CuLTURAL INSTITUTIONS AND TIlE ARTS 495
mechanism for solidarity and communication. The re-
sulting product is often experienced by community
residents as a local resource (Delgado, 1998).
At the level of political participation, arts and
humanities perform important functions through the
practical development of cultural citizenship. Social
work agencies and cultural institutions both can benefit
from collaboration that facilitate cultural citizenship
(Rosaldo, 1994). In cultural citizenship, the conse-
quences of citizenship, such as the recognition of worth
and access to resources, are accorded to groups unlike
traditional concepts of citizenship where individuals
hold rights. The concept of cultural citizenship has been
applied to racial and ethnic groups, immigrants, groups
who are disabled or infirm, youth, women, and seniors.
Research on the impact of the arts varies in
methodological rigor. Winner and Hetland (2000)
conducted a meta-analysis of cognitive benefits and
found that only 32 of 1,135 studies involved quasi-
experimental designs. McCarthy (2005, pp. 9-20) cites
similar weaknesses in other areas of research. Issues
involving research design may also contribute to re-
search problems. DiMaggio (2002) has identified three
fallacies embedded in cultural policy discourse
regarding the benefits from the arts: fallacies of
treatment (that all arts programs produce the same
effects), homogeneity (that arts programs will have" the
same effects on all participants, across all communities),
and the linearity of effects (that effects are linearly
related to the amount of participation). The
infrastructure from governmental and foundation
funders that has characterized other interventions, such
as drug treatment or mental health services, has lagged
for art and culture organizations. This lack of resource
for research has limited its scope.
Trends and Future Directions
Social work agencies and cultural institutions that are
engaged in communities share similar goals, such as
personal improvement (that is cognitive development,
self-efficacy, learning skills, health), creation of social
bonds, expression of communal meaning, and econom-
ic growth, at. the individual and community levels.
They share similar sensibilities regarding the deep
respect both have for cultural expression and diversity.
They also share similar programmatic activities,
including the recruitment and constitution of groups,
supportive group processes, the management of
conflict, the cultivation and documentation of memory
and translation, and mediation with outside
organizations and other audiences. The potential
benefits of collaboration between these two sectors
seem extensive. Both social welfare and cultural
institutions are also seeking funding from similar
sources: the government, foundations, and
496 CuLTURAL INSTITUTIONS AND THE ARTS
the public. The role of the government as a funder of both
cultural and social welfare institutions is often uncertain
(Koch, 1998). State and city governments are principal
funders of large cultural institutions, and the smaller ones rely
a
on variety of funding sources, including private foundations,
contracts with other organizations such as schools, public
gifts, and ticket sales. Collaboration, joint operating
agreements, and mergers among social service agencies have
been rare, but new collaborative possibilities exist among
cultural and social service institutions. Cultural institutions
can benefit greatly from social work's access to and
knowledge of underrepresented populations. Social work can
benefit from the skills and substantive knowledge of cultural
institutions in the arts and humanities. Social welfare,
agencies have long been criticized for being too oriented to
problems rather than assets and for lacking an expansive
imaginative vision (Addams, 1909). Cultural institutions are
the repositories of cultural capital that is both pleasurable and
captivating. Both institutions would advance by increasing
their shared public creative work. Cultural institutions can
benefit from partnerships with social work researchers who
can apply their skills to evaluate their effectiveness. While
these collaborative advantages may occur in some locations
because of prior personal and institutional relationships, it
seems unlikely that such boundary-spanning activities will
occur spontaneously. Two methods have produced
collaborations in the past: funding sup~ port for infrastructural
development-as has occurred with drug treatment programs-or
joint training programs under the auspices of professional
associations or academic institutions. As common goals and
resource opportunities arise, we may see further collaboration
between these significant societal institutions.
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art practice at the Harlem Hospital Horizon Art Studio. Studies ABSTRACT: This entry defines cultural competence and
in Art Education, 43(4), 339-352. culturally competent practice and focuses on cultural
Yetman, N. R. (1967). The background of the slave narrative
awareness, knowledge acquisition, skill development, and
collection. American Quarterly, 19(3),534-553.
inductive learning as key components. It traces the historical
Yudice, G. (2005). The exp~diency of culture: Uses ofeulture in
the global era. Durham: Duke University Press. development of cultural competence in the disciplines of
psychology and social work, pointing out how cultural
FURrHER READING competence has become a professional standard. Cultural
Arts and community development. Retrieved September 24, 2007, competence has also been recognized on the federal and state
from http://www.communityarts.net/archivefiles/ community health and human services levels. Cultural competence is
_development/index.php viewed on the practitioner, agency, and community levels as
Bennett, T., & Carter,D. (200l). Culture in Australia. Cambridge: well as the micro, meso, and macro dimensions. Among the
Cambridge University Press. implications for practice are the issues of cultural competence
Cruickshank, B. (1994). The will to empower: Technologies of and cultural competencies, the ethics of cultural competence,
citizenship and the War on Poverty. SoCialist Review, 23(4). social context, and biculturation and multiculturalization.
40-58.
Hass, K. A. (1998). Carried to the Wall: American Memory and the
Vietnam Veterans Memorial. Berkeley: University of California
Press.
Karp, I., & Lavine, S. D. (1991). Exhibiting cultures: The poetics arid KEY WORDS: biculturation; cultural awareness; cul tural
politics of museum display. Washington, DC: Smithsonian competence; cultural competencies; cultural identity;
Institution Press. culturally competent practice; culture; ethics; inductive
Killacky, J. (1994, Fall). On cultural citizenship. High Perfor- learning; knowledge acquisition; multicultur alization; skill
mance, 67(14). development; social and economic justice; social context
Linenthal, E. T. (200l). The unfinished bombing: Oklahoma City
in American memory. New York: Oxford University Press.
Miller, T. (2007). Cultural citizenship: Cosmopolitanism, con- Cultural competence has been defined as "a set of congruent
sumerism, and television in a neoliberal age. Philadelphia:
practice skills, behaviors, attitudes, and policies that come
temple University Press.
together in a system, agency, or among professionals and
Reisch, M., & Jarman-Rohde, L. (1998, November). Strengthening
enables that system,agency, or those professionals to work
community advocacy through collaborative cultural activities and
political action. Annual Conference of the Association for effectively in cross-cultural situations. It is the ability to
Research on Nonprofit Organizations and Voluntary Action, demonstrate skills and knowledge which enable a person to
1
Seattle, WA. work effectively across cultures; the ability to provide mental
Smith, T. (200l). The visual arts: Imploding infrastructure, shifting health treatment within the cultural framework of the
J.
frames, uncertain futures. In T. Bennett & D. Carter (Eds.), consumer; the ability to provide effective services to people of
t Culture in Australia (pp. 66-88). Cambridge: a specific cultural background, including one different from
I Cambridge University Press. the provider" (Substance Abuse and Mental Health Services
, Stark, M. G. a. D. (in press). Socio-technologies of assembly:
L Administration, 1997, p. 1). Elsewhere Orlandi (1992, pp.
Sense-making and demonstration in rebuilding lower Man- 3-4) explained cultural competence as "a set of academic and
hattan. In D. Lazer & V. Mayer-Schoenberger (Eds.), Gov- interpersonal skills that allow individuals to increase their
ernance and information: The rewiring of governing and
understanding and appreciation of cultural differences and
deliberation in the 21 st century. New York and Oxford: Oxford
: similarities, within, among and between
n University Press.
498 CuLTURAllY COMPETENT PRACTICE
groups. This requires a willingness and ability to draw
on community-based values, traditions, and customs and
to work with knowledgeable persons of and from the
community in developing focused interventions,
communi, cations, and other supports." As a further step
Lum (1999) coined the term culturaUy competent practice to
integrate cultural competence into social work practice.
Fong and Furuto (200l) and Fong (2004) also adopted
this concept in their books. Thus, culturally competent
practice has become an integral part of diversity and
practice among social work educators and professional
practitioners.
The focus of this entry is to provide an overview of
culturally competent practice, review the history of this
practice model, discuss, different perspectives on this
practice model, and 'specify implications for practice at
all levels. It is hoped that the reader will be motivated to
incorporate culturally competent practice in his or her
helping repertoire.
An Overview of Culturally Competent Practice
Culturally competent practice has focused on the in,
dividual, professional education, practice model, and
system levels. LaFromboise, Coleman, and Gerton
(1993) state that a culturally competent individual
possesses a strong personal identity, has knowledge. of
the beliefs and values of the culture, and displays sensi-
tivity to the affective processes of the culture. Cultural
competence is a part of a continuum of social skill and
personality development. This concept encompasses an
individual's sense of self-sufficiency and ego strength;
cultural identity related to culture of origin and cultural
context; and knowledge, appreciation, and internaliza-
tion of basic beliefs of a culture.
From a practice perspective, cultural competence
may also be understood as the development of academic
and professional expertise and skills in the art of work-
ing with culturally diverse clients. A starting point is the
fostering of cultural awareness. The social worker
becomes culturally effective with the client when the
worker develops cultural awareness through an
exploration of his or her own ethnic identity, cultural
background, and contact with ethnic clients.
Furthermore the social worker must develop a
knowledge acquisition perspective and a set of skills in
order to work with multicultural clients; Knowledge
acquisition provides a body of facts and principles that
serve as guidelines to best assist the problems and
cultural or ethnic dimensions of the particular client.
Skill development applies knowledge acquisition to
actual practice with clients from a culturally competent
perspective. It also addresses the service delivery
structure that ought to be in place for client services.
Finally, culturally competent practice
must constantly uncover new facts about multicultural
clients through ari inductive learning process (Lum,
2007).
How broad an understanding does culturally
competent practice extend itself? Should it be used in a
narrow sense to focus on ethnicity and culture or can it
be applied in a broader sense that may encompass a
general view of culture? Green and Hucles-Sanchez
(1994) suggest that cultural competence should
incorporate differential historical, political,
socioeconomic, psychophysical, spiritual, and
ecological realities, their interaction, and its impacton
individuals or groups. Culture is understood in its
broadest sense to include race, ethnicity, gender, and
sexual orientation and other dimensions of individual or
group experiences that are relevant to their
understanding of the world and of themselves. Here
culturally competent practice must be aware of its
context as far as relevant individual or group
characteristics are concerned and must highlight these
unique differences as culturally appropriate. Adjusting
the dimensions of cultural competence to fit the
worker's and the client's perspectives and viewpoints are
paramount to the helping process.
A Historical Review
of Culturally Competent Practice
The fields of psychology and social work respectively
have contributed much of the pioneering thinking about
cultural competence. The American Psychological
Association (APA) in 1980 adopted a professional
competence practice requirement and recognized
cultural competence as an essential element of
competent practice (AP A, 1980). In 1982 a major
position paper on cross-cultural counseling
competencies advocated that there be specified
multicultural knowledge, awareness, and skill areas in
counseling psychology (Casas, Ponterotto, & Gutierrez,
1986; Ibrahim & Arredondo, 1986). Green (1982) and
Pinderhughes (1989) introduced the concept of cultural
competence to social work. However, Terry Cross in
1989 developed the first full-scale organizational para~
digm on cultural competence and is considered the
father of cultural competence. Cross, a First Nation
Peoples MSW social worker and the executive director
of the National Indian Child Welfare Association, and
others published a monograph (Cross, Bazron, Dennis,
& Isaacs, 1989) formulating six anchor points along a
cultural competence continuum regarding an organiza-
tional system of care, which is considered the first sys-
tematic treatment of cultural competence.
In April 1992 the Association for Multicultural
Counseling and Development (AMCD) was an influ-
ential group, which lobbied for multicultural content,
and the Professional Standards Committee of the
I CuLTURALLY COMPETENT PRACTICE
American Association for Counseling and Develop, ment
proposed 31 multicultural counseling cornpeten cies to the
APA (Sue, Arredondo, & McDavis, 1992). Also in 1992 a
paradigm model of the characteristics of a culturally
competent counselor and the dimensions of cultural
competence was constructed (Sue et al., 1992). By 1993
the APA had committed itself to multicultural competence
(APA, 1993).
On the federal and state levels, cultur al competence has
been recognized as an essential ingredient in the health
and human services arena. The U. S. Public Health Service
Office for Substance Abuse Prevention has published a
series of monographs that integrated cultural competence,
alcohol arid drug abuse treatment programs, and ethnic
groups and community. (Orlandi, Weston, & Epstein,
1992). The Title IV-Echild welfare training grant under
the auspices of the California Social Work Education
Center at the University of California (CalSWEC),
Berkeley (1996) identified 14 cultural competencies
according to population groups, child welfare knowledge,
and practice skills. Such states as California (1997) and
New York (1998) have articulated cultural competence
plans on the state and county levels. California was
i concerned about planning cultu rally competent mental
I
health services, while New York developed cultural
competence performance measures for managed
behavioral health care programs. New Jersey (Adams,
;l
2005) passed a 2005 law requiring physi cians to take
cultural competency training as a part of licensure. The
2005 CalSWEC II Mental Health Initiative identi' fled two
sets of mental health competencies at the foun dational and
,~
advanced levels with sections on culturally and
1 linguistically competent practice competencies in
accordance with the 2004 California Mental Health Ser -
1 vices Act and the 2003 California Mental Health Master
" and development. The client has the task of sorting out his
! Plan: A Vision for California.
~ The National Association of Social Workers (NASW)
i has a section on cultural competence (1.05 a, b, c) in their
NASW 1999 Code of Ethics and issued in 2001 ten
I Standards for Cultural Competence in Social Work Practice
covering ,ethics and values, self-awareness, cross- cultural
, knowledge, cross-cultural skills, service delivery,
t empowerment and advocacy, diverse work, force,
1 professional education, language diversity, and
I
cross-cultural leadership. Thus, there is steady growth in
the development of culturally competent practice.
Different' Perspectives on
Culturally Competent Practice
One might view culturally competent practice based on
levels and dimensions. Miley, O'Melia, and DuBois
(1998) discuss three levels: practitioner, agency, and
community. On the practitioner level, the worker must
499
know about self-awareness in terms of personal values and
cultural heritage, value differences and conflicts regarding
assimilation and cultural pluralism, and awareness of the
cultures of others, especially clients. In terms of agency
level cultural competence, workers should be trained in the
skills necessary for diversitysensitive practice, and
multicultural' awareness and functioning are promoted in
organizational structure and program delivery. For
example, Kaiser Permanente (2004) has published an
educational monograph on cultural competence and has
established Centers of Excellence in Cultural Competence
targeting specific populations, while BlueCross
BlueShield of Florida (2004) has instituted in ternal
diversity training and cultural competence education for
providers. The com, munity level is concerned about the
promotion of a context of pluralism, celebration of
diversity, promo, tion of cross-cultural interaction, and
social justice. Cultural c ompetence in health care services
has sought to provide interpreter services; recruit and
retain minority staff; provide training to increase cultural
awareness, knowledge, and skills; coordinate with trad-
itional healers; use community health workers; incor-
porate culture-specific attitudes and values into health
promotional tools; include family and community
members in health care decision making; locate clinics in
geographic areas that are easily accessible for certain
populations; expand hours of operation; and provide
linguistic competency beyond the clinical encounter to the
appointment desk, advice lines, medical billing, and other
written materials.
Cultural competence can be viewed on the micro,
meso, and macro dimensions. Micro cultural competence
involves the client and the social worker. The client
acquires cultural, competence from personal back ground
or her culture of origin and elements of the dominant
culture to achieve bicultural integra tion and bicultural
competence. Likewise, the worker develops expertise and
skills through education and through working with
culturally diverse clients. Meso cultural competence
addresses the organizational level to determine whether an
organization has a culturally competent system of care.
Cross et al. (1989) create a cultural competence
continuum for an organizational system of care: (a)
cultural destructiveness (attitudes, practices, and policies
that promote the superiority of the dominant cul ture and
attempt to eradicate the inferior and different culture); (b)
cultural incapacity (attitudes, practices, and policies that
adhere to separate but equal treatment and tend toward
segregated institutional practices); (c) cultural blindness
(attitudes, practices, and policies that have an unbiased
500 CuLTURALLY COMPETENT PRACTICE
view of undifferentiated elements ofculture and people
and treat all people as assimilated); (d) culturally open
organization (attitudes, practices, and policies that are
receptive to the improvement of cultural services
through staff hiring practices, training on cultural sen-
sitivity, and minority board representation); (e) cultur-
ally competent agency (attitudes, practices, and policies
that demonstrate respect for different cultures and
people by seeking advice and consultation from ethnic
and racial communities and by being committed to
incorporating these practices into the organization); and
(f) cultural proficiency (attitudes, practices, an d policies
that are sensitive to cultural differences and diversity,
improve cultural quality of services through cultural
research, disseminate research findings, and promote
diverse group cultural relations). A culturally competent
organization and service delivery system should value
diversity, have the capacity for cultural self- assessment,
be conscious of the dynamics of cultural interaction,
institutionalize cultural knowledge, and develop
programs and services that promote diversity between
and within cultures. Macro cultural competence refers to
large system efforts to address cultural competence
issues and programs. On the national level the National
Center for Cultural Competence (NCCC) has been a
leadership force at the Georgetown University Child
Development Center. Its mission is to increase the
capacity of health care programs to design, implement,
and evaluate culturally competent service delivery
systems. The center serves as the clearinghouse for
planning, policy, and programs related to cultural
competence (see http://gucchd.georgetown.edu/nccc/
pa.html).
Implications for Practice
Culturally competent practice is emerging as an inte gral
part of social work practice and education. It offers a
new complementary orientation and standard to cul-
turally.diverse social work practice. Cultural competence is
the subject area that relates to the cultural awareness of
the worker and the client and their mutual backgrounds,
knowledge acquisition about historical oppression, and
related theories of understanding the multiple
dimensions of the human person; skill development to
deal effectively with the needs of the culturally diverse
client; and inductive learning, which heuristically pro-
cesses new information about emerging new popula-
tions .. Cultural competencies involve turning culturally
competent areas and concepts into specific and meas-
urable statements. Leung and Cheung (2001) identify
five clusters of competencies, which are useful in
categorizing: (a) informational competencies (ethnic
differences, family history, minority identity
development);
(b) intellectual competencies (information gathering,
assessment; goal setting); (c) interpersonal
competencies (relationship building, communication
skills); (d) intrapersonal competencies (values and
attitudes; personal qualities and characteristics); and (e)
intervention competencies (family and cultural
expectations, support systems, fa mily acculturation,
termination). In this sense there is a need to develop a
conversation between measure-seeking cultural
competencies and evidence-based practice.
The ethics of cultural Competence reaffirms that social
work ethics has a connection to cultural competence.
Ethics are based on the values that we have as individ-
uals and as professionals, which guide our choices based
on our sense of right and wrong and on ideals such as the
highest good, the promotion of fairness, or the moral
duty and obligation that we have to ourselves, others, our
profession, our community, and to a higher being.
At.times our ethical guidelines force us to make a tragic
moral choice where we must choose the lesser of the two
evils because the two or more available selections are
less than ideal. Along with the cultural competence
components of the NASW Code of Ethics and the Standards
for Cultural. Competence in Social Wark Practice, which were
previously mentioned, are some ethical moral guidelines
and cultural beliefs and practices that comprise an ethical
notion of cultural competence: the acknowledgement of
the importance of culture in people's lives; the respect for
cultural differences; the minimization of any negative
consequences of cultural differences, which ha s a
discriminatory effect on persons or groups; the
assessment of personal cultural values, acknowledging
the existence of a cultural lens that shapes our
interpretations of the world; the understanding and
acknowledgement of the historical relationship between
your own culture and other cultural groups; and the
creation and dissemination of institutional cultural
knowledge, which recognizes and honors diversity
(Lum, 2007, p. 22). The highest ethical value and the
striving goal of the social work profession is social and
economic justice. Social justice governs how social
institutions deal fairly or justly with the social needs of
people as far as opening access to what is good for
individuals and groups. Economic justice encompasses
moral principles of how to design economic institutions,
policies, programs, and practices so that a person can
earn a living, enter into social and economic contracts,
and exchange goods and services in order to produce an
independent material foundation for economic
sustenance. How we articulate and shape our personal
and professional ethics and our sense of social and
economic justice have implications for how we practice
cultural competence.

Social context is an important factor in culturally
competent practice. Contextual social work practice is
concerned with the person and the environment or
situational setting. Lum (2007) discusses personcentered
context and environmental-centered context. The former is
concerned about the unique character istics 'of diverse
people, that is, what makes a person similar to and different
from another person, while the latter explores the social
environmental issues of racism, sexism, homophobia,
discrimination, and oppression. The term context implies
the "joining and weaving together". of textures that are
surrounding or immediately next to parts that create how a
situation, background, or environment is structured or put
together. In social work we discuss the social context in
terms of the person and the environment or the psy-
chosocial perspective. That is, we are concerned about
understanding the important characteristics of the person
and the environment as well as the interaction between the
person and the environment. This is the core meaning of
social context.
Finally there has been a major paradigm shift to
biculturation and multiculturalization. Fong (2001) called for
the recognition of the interracial interblending of cultures
in a single ethnic group and the need for assessments and
interventions to deal with multiethnic identities and the
differing environments of clients. This is a timely shift
away from a static description of various people of color
ethnic groups, particularly as we recognize the multiple
identities of people and the intersecti onality of their
backgrounds (Guadalupe & Lum, 2005). That is, a
growing number of people are multiracial in ethnic identity
and understand themselves along ethnic, gender, social
class, and sexual orientation lines. The question then
becomes: What is the particular set of individual, family,
group multicultural variables that must be identified in
order to understand the client? Can we then make a case for
a broad and new sense of cultural identity? Fong (2001) goes
on to state that values and belief sys tems comprising
traditions and cultural norms are central to understand ing
the ethnic client's functioning.
The starting point is the indigenous culture itself,
particularly the ethnic social environment of the client and
the parallel use of Euro-Arnerican norms as a com plement
to the client's ethnic reality. One might call this a
multicultural social construction approach. That is, to fully
understand and work with a client, the worker must start
with the client's cultural context (the culture of the cl ient
and his or her surrounding environment) and find useful
cultural helping approaches. Next the worker should
identify useful and complementary social work
interventions that support the cultural ones. It is
CuLTURALLY COMPETENT PRACfICE 501
not an either/or approach; rather, it is a both/and, side-
by-side integration of the helping process from both
perspectives.
The particular paradigm model of the preceding shift is
Fong, Boyd, and Browne's (1999) biculturation of
intervention approach. It brings together the client's culture
and world view and the adaptation of Western
interventions. This model incorporates appropriate ethnic
group norms and practices, and supplements them by using
Euro-American practices as well. It is analogous to the
Asian approach of integrating and blending Eastern and
Western medicine where there is a common belief and
practice of using Eastern herbal medicine and Western
medication and surgery. Fong et al. (1999, p. 105) identify
the important values in the ethnic cu lture that can be used to
reinforce therapeutic interventions; chooses a Western
intervention whose theoretical framework and values are
compatible with the ethnic cultural values of the family
client system; analyzes an indigenous intervention familiar
to the ethnic client system in order to discern which tech-
niques can be reinforced and integrated with a Western
intervention; develops a framework and approach that
integrates the values and techniques of the ethnic cul ture
with the Western intervention; and applies the Western
intervention, at the same time explaining to a client family
how the techniques reinforce cultural values and support
indigenous interventions.
In short, culturally competent practice is a healthy and
thriving sibling of competency-based and evidence- based
social work practice. Culturally competent practice will
thrive and grow as social work educators and practitioners
thoughtfully reflect on their theoreti cal knowledge and
practical experiences with ethnic and culturally diverse
clients.
REFERENCES
Adams, D. (2005). Cultural competency now law in New Jersey.
Retrieved from
http://www.ama-assn.org/amednews/2005/
04/25/prl204 25 .htrn
American Psychological Association. (APA) (Educational and
Training Committee of Division 17). (1980, September).
Cross-cultural competencies: A position paper. Paper
presented at the annual meeting of the American
Psychological Association, Montreal, Canada.
American Psychological Association (APA). (1993 ).
Guidelines for providers of psychological services to
ethnic, linguistic, and cultural diverse populations.
American Psychologist, 48, 45-48.
BlueCross BlueShield of Florida. (2004, December 27).
Diversity program. Retrieved from
http://www.bebsfl.com/index. cfm ?secion =&fuseaction
=Careers.diversityProgram California Social Work
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(1996, June). Revised competencies. Berkeley, CA: Author.
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Casas, J. M., Ponterotto, J. G., & Gutierrez, J. M. (1986). An ethical
indictment of counseling research and training: The cross-cultural
perspective. Journal of Counseling and Development, 64, 347-349.
Cross, T L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989).
Toward a culturally competent system of care. Washington, DC:
Georgetown University Child Development Center.
Fong, R. (2001). Culturally competent social work practice:
Past and present. In R. Fong & S. B. C. L. Furuto (Eds.), Culturally
competent practice: Skills, interventions, and evaluations (pp.l-9).
Boston: Allyn & Bacon.
Fong, R. (Ed.). (2004). Culturally competent practice with immigrant
and refugee children and families. New York: Guilford Press.
Fong, R., Boyd, T, & Browne, C\ (1999). The Gandhi technique: A
biculturalization approach for empowering Asian and Pacific
Islander families. Journal of Multicultural Social Work, 7, 95-110.
Fong, R., & Furuto, S. (Eds.). (2001). Culturally competent practice:
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Green, J. W. (1982). Cultural awareness in the human services.
Englewood Cliffs, NJ: Prentice-Hall.
Greene, B., & Hucles-Sanchez, J. (1994). Diversity: Advancing an
inclusive feminist psychology. In J. Worell & N. Johnson (Eds.),
Feminist visions: New directions in educa tion and training for
feminist psychology practice (pp, 173-202). Washington, DC:
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Guadalupe, K. L., & Lum, D. (Eds.). (2005). Multidimensional
contextual practice: Diversity and transcendence. Belmont, CA:
Thomson Brooks/Cole.
Ibrahim, F. A., & Arredondo, P. M. (1986). Ethical standards for
cross-cultural counseling: Counselor preparation, practice,
assessment, and research. Journal of Counseling and Development,
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Kaiser Permanente. (2004, December). Diversity and inclusion.
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workinghere/ diversity .asp
LaFromboise, T, Coleman, H. L. K., & Gerton, J. (1993).
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Leung, P., & Cheung, M. (2001). Competencies in practice
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In R. Fong & S. B. C. L. Furuto (Eds.), Culturally competent
practice: Skills, interventions, and evaluations (pp. 412-425).
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Lum, D. (1999). Culturally competent practice: A framework for
growth and action. Pacific Grove, CA: Brooks/Cole.
Lum, D. (2007). Culturally competent practice: A framework for
understanding diverse groups and justice issues (3rd ed.). Belmont,
CA: Thomson Brooks/Cole.
Miley, K. K., O'Melia, M., & DuBois, B. 1. (1998). Generalist social
work practice: An empowering approach. Boston: Allyn & Bacon.
National Association of Social Workers (NASW). (1999).
NASW code of ethics. Washington, DC: Author.
National Association of Social Workers (NASW). (2001).
N ASW standards for cultural competence in social work practice.
http://www.naswdcorg/pubs/standards/cultural.htm
Orlandi, M. A. (1992). The challenge of evaluating communitybased
prevention programs: A cross-cultural perspective. In M. A.
Orlandi, R. Weston, & L. G. Epstein (Eds.), Cultural competence
for evaluators: A guide for alcohol and other drug abuse prevention
practitioners working with ethnic/ racial communities (pp. 1-22).
Rockville, MD: U.S. Department of Health and Human Services,
Office for Substance Abuse Prevention.
Orlandi, M. A., Weston, R., & Epstein, L. G. (Eds.). (1992).
Cultural competence for evaluators: A guide for alcohol and other
drug abuse prevention practitioners working with ethnic/ racial
communities. Rockville, MD: U.S. Department of Health and
Human Services, Office for Substance Abuse Prevention.
Pinderhughes, E. (1989). Understanding race, ethnicity, and power:
The key to efficacy in clinical practice. New York: Free Press.
Substance Abuse and Mental Health Services Administration. (1997).
Cultural competence guidelines in managed care mental health
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-DOMAN LUM
 ENCYCLOPEDIA OF

SOCIAL WORK
20TH EDITION
 EDITORIAL BOARD

EDITORS IN CHIEF

Terry Mizrahi, Ph.D., MSW

Professor of Social Work Hunter
College

Larry E. Davis, Ph.D., MSW Dean

of Social Work University of Pittsburgh

AREA EDITORS

Paula Allen-Meares, University of Michigan Darlyne

Bailey, University of Minnesota Diana M. DiNitto,
University of Texas at Austin Cynthia Franklin, University of
Texas at Austin Charles D. Garvin, University of Michigan
Lorraine Gutierrez, University of Michigan
Jan L. Hagen, University at Albany, State University of New York Yeheskel
Hasenfeld, University of California, Los Angeles Shanti K. Khinduka,
Washington University in St. Louis Ruth McRoy, University of Texas at
Austin
James Midgley, University of California, Berkeley
John G. Orrne, University of Tennessee
Enola Proctor, Washington University in St. Louis Frederic G.
Reamer, Rhode Island College
Michael Sosin, University of Chicago
 ENCYCLOPEDIA OF

SOCIAL WORK
20TH EDITION

Terry Mizrahi
Larry E. Davis

Editors in Chief

VOLUME 2
D-I

NASW PRESS

OXFORD
UNIVERSITY PRESS

2008
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 ENCYCLOPEDIA OF

SOCIAL WORK
20TH EDITION
DAY CARE. See Adult Day Care; Child Care Services.
DEAFNESS AND HARDNESS OF HEARING
ABSTRACT: Effective social work practice with deaf and
hard-of-hearing people requires a unique, yet diverse,
collection of lmowledge, values, skills, and ethical
considerations. Salient issues among this population are
language, communication, and educational choices,
interpreting, assistive devices, cochlear implants, genetics,
culture, and access to community resources. Competencies at
micro, mezzo, and macro levels with a deaf or hard-of-hearing
population include knowledge of the psychosocial and
developmental aspects of hearing loss, fluency in the national
sign language, and an understanding of deaf cultural values
and norms. In the United States, the use of American Sign
Language (ASL) is the single most distinguishing factor that
identifies deaf people as a linguistic minority group. This entry
presents an overview of the practice competencies and
intervention approaches that should be considered in working
with deaf and hardof-hearing people, their families,
communities, and organizations. It introduces the knowledge
base, diversity in community and cultural orientations, social
constructions, and international perspectives, the latest
research and best practices, interdisciplinary connections,
trends, challenges, and implications for effective social work
practice with this population. An integrative strengths-based
transactional paradigm is suggested.
KEY WORDS: deaf; deaf culture; deaf community; deafhood;
hard of hearing; sign languages
Deaf and hard-of-hearing people represent the wide
heterogeneity of any society in the world, including diversity
in socioeconomic status, race, sexual orientation, ethnicity,
and religious preference. People who are deaf or hard of
hearing are also diverse in terms of decibel loss, identification
with the deaf community, and personal preferences in use of
available technology such as hearing aids, assistive
communication devices, and surgical procedures to improve
hearing through cochlear implants. In spite of the diversity of
individuals within this population, there are distinct
commonalities that justify understanding the deaf and
hard-of-hearing population as a culturally diverse group as
well as a population at risk. A review of the social work
literature reveals that discussions about the deaf and
hard-of-hearing population and the deaf community and
culture are rare.
Definitions and Demographics
The term deaf and hard of hearing replaces terms such as hearing
impaired and is used broadly to identify anyone with a hearing
loss. A person may self-identify as either "deaf" or "hard of
hearing" based on any number of factors, including
educational placement, family background, decibel loss, and
cultural values. A hard-ofhearing person may have a mild to
moderate hearing loss and mayor may not identify with the
Deaf community. "Hard of hearing" may also be the preferred
social identification for individuals with severe to profound
hearing loss, such as late deafened or older adults. The
literature uses the word Deaf with either uppercase spelling or
lowercase spelling, depending on cultural identification. The
lowercase deaf refers to people who identify themselves as
having a moderate to severe hearing loss as measured on an
audiogram and live their lives without much contact with deaf
people who sign. The uppercase Deaf refers to individuals born
deaf or became deaf later in life who use their society's national
sign language and whose primary social networks and
allegiances include the Deaf community (Ladd, 2003). Thus,
deaf and hard-of-hearing people mayor may not affiliate with
Deaf culture, and this affiliation may change through the life
course (Oliva, 2004).
Demographic information on the deaf and hard-ofhearing
population varies according to researcher's definition of deaf
and hard of hearing as well as the sources used. A widely cited
demographic source from the Gallaudet University Research
Institute reveals that 20,292,000 people, or 8.6% of the U.S.
population, are deaf or hard of hearing (Holt & Hotto, 1994).
Of this number, 1.8% are children 3-17 years old, and 29.1 %
are older than 65 years. Researchers should use caution when
reporting demographic data on deaf and hard-of-hearing
people and specify how the terms are defined. The data
available, however, indicate a sizable deaf and hard-of-hearing
population that is often overlooked in research studies, social
programs, and
1
2 DEAFNESS AND HARDNESS OF HEARING
services, and even in the u.s. Census (Disability and the
2000 Census, 2007).
Social Constructions of Deaf People
There are two opposing social constructions of deaf people
that have been the subject of professional debate for
hundreds of years: the medical model and the cul tural
model (Higgins, 1980; Lane, 1999; Padden & Humphries,
1988; Sheridan, 2001; White, 1997). The medical model
has been the dominant paradigm among researchers and
health professionals in Western socie ties. This model
emphasizes the audiologic al aspects of hearing loss,
technical and surgical advances to eradi cate deafness, and
the rehabilitative notion that medi cine and science can
"cure" deafness. It also emphasizes the pathology of
deafness and the deaf person's deficiencies in language a nd
literacy, cognition, mental health, and psychosocial
development. Educational po licies for deaf children have
been rooted in this model, and an oral philosophy in
education, which disavows the use of sign language and
emphasizes mainstream education th rough lip reading and
use of hearing aids and cochlear implants, has dominated
the educational debate for deaf and hard-of- hearing
children. Role models for deaf children are usually hearing
persons or oral deaf adults who do not use sign language.
The medical model has largely been promoted by hearing
professionals (Neisser, 1983) and by the Western belief that
bodily perfection is a virtue (Crittenden, 1993).
The cultural model portrays Deaf people from a
sociocultural and human diversity framework where
deafness is viewed as a human difference and the Deaf
community is seen as a linguistic minority group with a
rich, vibrant culture and sign language. Linguis tic studies
of Stokoe (1960) provided legitimacy to American Sign
Language (ASL) and spawned a p opular and growing field
of sign language studies. More than 35 states recognize
ASL as a language of study in public schools, and many
universities have established depart ments of deaf studies
(http://www.aslta.org/language/ index.html). The cultural
construction is viewed as less oppressive to deaf people,
and, in the social work tradition, emphasizes strengths and
empowerment.
The Deaf Community and Deaf Culture
The most distinguishing characteristic of deaf culture in the
United States is the value placed on ASL and the
acceptance of a set of values, attitudes, and beliefs about
deaf people and the deaf community (Padden &
Humphries, 1988). Deaf people have place d a high value on
educating deaf children at state residential or day schools,
since it is there that a deaf heritage is learned, classroom
teachers use ASL, and there are
deaf adult role models. Approximately 10% of deaf
children have deaf parents. Deaf parents are commonly
pleased with the diagnosis of deafness in their infants, often
puzzling their doctors (Lane, 1993; Schlesinger &
Meadow, 1972). Deaf adoptive parents more often express
a desire to adopt deaf children (White, 2000). One' s hearing
loss is less important than one's attitude of acceptance of
"being deaf in the world" or what Ladd (2003) calls
"deafhood." Certain behaviors such as flicking a light
switch to get one's attention, raising and shaking hands in
the air for applause, and standing at a greater distance when
communicating in ASL are accepted cultural norms. The
intermarriage rate in the deaf community is perhaps the
highest of any disability group, with 85-95% of deaf people
marrying a person who is deaf (Schein, 1989). Formal
organizational structure is also a salient feature of deaf
culture, with an abundant network of local, state, and
international organizations of, by, and for deaf people. As
with any culture, there are material goods that distinguish
deaf culture; these include personal pagers, flashing or
vibrating alarm clocks, baby crier and flashing phone
signalers, strobe smoke detectors and doorbell lights,
teletypewriter devices, and video phones. Deaf culture
includes a rich body of literature, folklore, poetry, theater,
and art, as well as formal sports organizations and events,
such as the "Deaflympics" (http://www.
deaflympics.comJ). In the 21st century, deaf blogs, chat
rooms, videoblogs, and video phones keep the community
connected (Coalition for Critical Inquiry, r etrieved from
http://wwwccigally.info/).
Diversity and Population at Risk
The deaf community is a diverse one representing the
microcosm of the society of which they are a part. The same
is true for hard-of-hearing people. People of color, women,
gays and lesbians, deaf senior citizens, deaf blind people,
and people with disabilities have estab lished separate
formal organizations (http://infotogo.
gallaudet.edu/184.html) to promote equal rights and
empowerment. Members of these groups face double
stigma and marginalization.
The deaf population is considered a "low incidence"
population; therefore, as a group, they are often over looked
in the development of policies, programs, and services
because of communication barriers. The Americans with
Disabilities Act of 1990 empowered deaf and
hard-of-hearing people with equal rights to education,
employment, health, and social services. However, these
hard-earned legal rights and access to these services are still
being challenged in the courts. The National Ass ociation of
the Deaf regularly files lawsuits on behalf of deaf plaintiffs
who are denied sign

language interpreters in health, education, and legal settings,
as well as cases involving police brutality and imprisonment
without sign language interpreters (Estrada, 2006). Deaf and
hard-of-hearing people must educate and advocate for access
to social benefits such as captioned television and films,
emergency telecommunication broadcasts, health and mental
health care, education, and interpreting services on a daily
basis (Sheridan; White, 2006). Deaf people face a higher rate
of unemployment and underemployment and lower incomes
than does the general population (Welsh & Foster, 1991).
In addition to access issues, the history of deaf peo ple is a
story of marginalization, language oppression, diminished
educational choices, discrimination, and devaluation of ASL
(Lane, 1984; VanCleve & Crouch, 1989). Models of culturally
affirmative mental health services are available (Glickman &
Harvey, 1996; Myers, 1995), yet the general health and mental
health disparities among this population are ever present.
There is evidence of higher incidence of physical and sexual
abuse of deaf children (Hamerdinger & Hill, 2006), lack of
access to health care, legal and social services, and vocational
assistance (DuBow, Geer, & Strauss, 1992), and generally
lower educational achievement and literacy rates (Lane, 1999).
International Deaf Community
Deaf communities exist in every country of the world, and each
country has its own sign language, even when the spoken
language is the same, such as in the United States and United
Kingdom. Schein (1989) proposed a theory of deaf community
development and lists three criteria that explain how deaf
communities perpetuate: alienation from the larger hearing
society, affiliation with other deaf people and their
organizations, and sustainability with a critical mass. Most
deaf communities have established local, state, and national
organizations. The World Federation of the Deaf (WFD) is a
nongovernmental international body representing 127 national
deaf associations throughout the world. WFD works to
improve human rights, equal access to information and
services, recognition of national sign languages, and education
of deaf people worldwide. WFD is recognized by and works
closely with the Union Nations to promote the principles of the
Universal Declaration of Human Rights for the 70 million deaf
people in the world (World Federation of the Deaf, 2007).
Thus, deaf communities throughout the world maintain their
existence through a common sign language, a cultural identity,
and an organizational structure that provides social affiliation
and empowerment. Cultural affiliation and identity serve as a
buffer
DEAFNESS AND HARDNESS OF HEARING 3
to a sense of alienation often perpetuated by social exclusion
and reduced access to the goods and services of society.
Advocacy is an ongoing endeavor because deaf people
throughout the world face discrimination, oppression, and
infringement on their human rights.
For deaf people in the developing world, the unem-
ployment rate is 3 times higher than the national average and
only about 20% of deaf children attend school (J outselainen,
1991). In some countries, deaf people are not allowed to get a
driver's license, marry another deaf person, or register to vote
(Joutselainen, 1991). The WFD reports that 80% of the 70
million people in the world live in developing countries, where
their rights to access to communication, use of a national sign
language, equal participation in society, and opportunity to an
education are largely ignored (World Federation of the Deaf,
retrieved from http://www.wfdeaf.org/).
A Model for Social Wark Practice
with Deaf and Hard-of-Hearing People Effective
social work practice with deaf and hard-ofhearing people, their
communities, and organizations involves commitment and
competencies of three dimensions: (a) generalist social work
practice, (b) competencies that qualify them to work with this
unique multicultural population, and (c) a commitment to the
social justice values of the profession, the community they
serve, and theoretical approaches promoting empowerment
and strengths. These three dimensions form an integrative
strengths-based transactional paradigm for social work
practice with deaf and hard-of-hearing people. Originating
from the strengths-based transactional deafness paradigm
proposed by Sheridan (1999) coupled with an integrative
model (Nichols, 1995), this paradigm allows social workers to
synthesize any number of theoretical approaches deemed
appropriate to the cases at hand. This is in keeping with the
social justice values of the profession, the strengths
perspective (Saleebey, 2002), and empowerment. The
population of deaf and hard-of-hearing people is diverse in
racial, ethnic, cultural, gender, and spiritual realities; there-
fore, multicultural competencies are also necessary.
Practitioners should be mindful of audisrn, the individual,
institutional, and metaphysical aspects of oppression that
support the notion of the superiority of people who can hear
(Bauman, 2004). Audism is present in the lives of many deaf
and hard-of-hearing people, their families, and communities
(Bauman, 2004). Application of a strengths approach to
practice that examines the capabilities, resiliencies, resources,
and talents of deaf and hard-of-hearing people may counter
any internalized oppression. Social workers should also be
familiar with the unique biopsychosocial,
4 DEAFNESS AND HARDNESS OF HEARING
cultural, linguistic, and developmental factors. Additionally,
researchers should be mindful of unique communication and
cross-cultural ethics (Pollard, 1992). Social and organizational
policies should take the communication and cultural concerns
of deaf and hard-of-hearing people into consideration,
especially as these relate to access and culturally appropriate
provision of agency services and implications and important
concerns for communication. Agencies would do well to
employ and consult with social workers who are deaf, hard of
hearing, or hearing with the necessary competencies and
qualifications to provide consultation related to the provision
of services to deaf and hardof-hearing people.
To date, the effectiveness of theoretical applications to
assessment and intervention with deaf and hard-ofhearing
people has for the most part not been investigated (Andrews,
Leigh, & Weiner, 2004). Service voids exist because of the
still developing number of practitioners possessing the
competencies necessary for effective practice with this
population. Because of the voids in specialized social work
practice arenas with this population, many social workers find
that they must use a generalist approach allowing for the
application of a variety of social work roles, theories,
assessment, and intervention techniques at multisystem
levels.
The aim of this integrative strengths-based transactional
paradigm is empowerment of deaf and hard-ofhearing people
in systems of all sizes. This approach fits a
person-in-the-environment perspective which values
transactions between individuals and others that enhance
dignity, individuality, self-determination, and social justice.
THEORETICAL CONSIDERA TlONS FOR AN INTEGRA TIVE
ApPROACH The development of social work practice
theories and theories of human behavior and the social
environment occur within sociocultural, political, and
temporal contexts (Sheridan, in press). Social workers
working with deaf and hard-of-hearing people must
critique the contextual utility of these theories for practice
with these populations.
Considering that deaf and hard-of-hearing people may
have fewer opportunities for environmental stimulation
enhancing development (Sheetz, 2001), it is inappropriate to
draw conclusions about successful development based on
comparative observations with hearing people. Like anyone
else with sufficient opporamities for environmental
stimulation, deaf and hardof-hearing people grow to become
fully functioning actualized, healthy adults. These
opportunities include language, communication, information,
physical and
emotional care, appropriate educational placements, ample
opportunities for socialization, and critical attachment
experiences. From an existential perspective, the survival and
transcendence of an often inaccessible and oppressive
environment represent a collective and individual strength of
deaf and hard-of-hearing people (Sher~an, 1995, 2008)
RESEARCH Little empirical research has been con ducted to
explore the biopsychosocial development of deaf persons.
Current longitudinal life course research depic ting, to date,
the experiences and perceptions of the lifeworlJs of deaf
children and adolescents is an attempt in this direction
(Sheridan, 2001, 2008). This research is framed in a
symbolic interactionist and an ecological perspective of
development, wherein the deaf person is observed in the
biopsychosocial and temporal contexts of the environment
in an effort to understand the deaf perspective of self and
others in their lifeworlds (Sheridan, 2008). Naturalistic
research methods (Lincoln & Guba, 1985) give voice to the
developmental perspectives and experiences of deaf and
hard-of-hearing people (Sheridan, 1996, 2001). The study
of Becker (1980) showing the adaptive strengths of older
deaf adults, and the developmental research of Sheridan
(2001, in press) are examples.
A few examples of applications of existing developmental
theories to the experiences of deaf and hard-ofhearing people
are Harvey's use of an ecosystems model to examine critical
points in the life cycle of deaf and hard-of-hearing persons
from birth through old age (Harvey, 2003), applications of
Erikson's psychosocial theory to the development of deaf and
hard-of-hearing people (Schlesinger & Meadow, 1972;
Sheetz, 2001), and psychodynamic applications to assessment
and practice (Cohen, 2000), and identity development
(Glickman, 1996; Holcomb, 1997). Schirmer (2001), Moores
(2001), Sheetz (2001), Marschark (2003), Ronnberg (2003),
and Andrews, Leigh, and Weiner (2004) have reviewed
cognitive correlates and implications of the developing deaf
person important in education and social and psychological
functioning.
Sheridan (1995, 2001) sees Frankl's (1969) existential
logotherapies having potential for understanding the
meanings that deaf and hard-of-hearing people ascribe to
situations in their lives and for understanding and promoting
transcendence over disruptive personal and social conditions.
The symbolic interaction theory of Mead (1934) is useful as a
framework for understanding the development of self
perceptions through interaction with others at various systems
levels.
Research into the practical application and effectiveness
of intervention theories is even more limited.

However, practitioners are increasingly aware of the need to
focus on the impact of the deaf or hard-ofhearing person's
environment as opposed to their personal characteristics
(Sheridan, 2008).
The isolation of deaf people in a larger hearing society is
believed to lead deaf people to respond to an imposed
"outsider" status by forming their own identificational
community (Higgins, 1980). Community membership is
attained through shared experiences, identification with, and
participation in, the activities of other deaf people (Wax, 1997).
Social change occurs through the process of symbolic in-
teraction; as we act upon the interpretations and meanings we
derive from situations, we contribute to the development .. of
our cultures and societies (Sheridan, 2008). Wax (1997)
suggests that social workers working with deaf communities
must adopt "a reconstructionist (Ivey, 1993), or coevolutionary
(Harvey & Dym, 1988) approach whereby practitioners and
community members alike need to minimize assumptions
about each other and negotiate a. consensus of values or
meanings as groundwork for intervention" (p. 683).
An ecosystems approach to assessment and intervention
has been applied to deaf and hard-of-hearing people (Harvey,
2003). Although not empirically based, this model offers an
understanding of development of deaf and hard-of-hearing
people in the context of their ecosystems and discusses
applications for psychotherapeutic interventions.
PRACTICE COMPETENCIES AND INTERVENTION Mental
health and social service professionals must possess a
specialized set of competencies for effective practice with
deaf and hard-of-hearing people (for ex ample, Myers,
1995; Pollard, 1992, 1994; Sheridan, 1988, 1993, 1999).
Individual and collective values of the deaf community
and deaf and hard-of-hearing peo ple and their
organizations and a commitment to an empowering and
participatory approach to practice and self determination
are necessary.
Social workers should be aware of a client's perspective of
self as a deaf person, namely, if they see themselves as a
member of the deaf community or as a person with a disability,
as this has implications for practice. While deaf and
hard-of-hearing people will seek the services of social workers
for any of the same reasons that a hearing person would, their
different self contexts may suggest divergent intervention
strategies. Social workers working with recently deafened
individuals may need to focus on options for education,
communication, including assistive technologies, and
language, family and systems adaptation, and individual
DEAFNESS AND HARDNESS OF HEARING 5
and family emotional responses to the loss of hearing. An
affiliation with the Deaf Community and the facilitation of a
change to a cultural orientation may be considered an option
for intervention (Wax, 1993, 1997). On the other hand, the
social worker assisting an individual who lives within the deaf
community, and who takes being deaf for granted, must be
prepared for cross-cultural practice and communication.
Deaf people are visually oriented rather than auditory
oriented (Christensen & Delgado, 1993; Ladd, 2003; Lane,
Hoffmeister, & Bahan, 1996). This means that visual
communication in the practice relationship, in agency
communications, and in the personal (for example, arts,
recreation, and social relationships) and vocational or
professional lives of deaf people is essential.
Minimum standard competencies for mental health
professionals have been discussed in a number of sources and
include expressive and receptive abilities in the full range of
communication and linguistic competencies used by deaf and
hard-of-hearing people, including ASL and proper utilization
of sign language interpreters. Effective communication may
be the single most important factor for successful social work
practice with this population. There are, however, several
additional critical components, including knowledge of
1. options in educational placement and communication
and implications for the individual and family systems;
2. awareness of normative behaviors, language, and
cognition and implications for culturally affirmative
biopsychosocial mental status assessment and
intervention;
3. psychosocial, identity, developmental, and mul-
tisystemic issues in human behavior and the social
environment across the life cycle;
4. current research;
5. basic audiology (type and degree of hearing loss,
technology, information on cochlear implants, and
implications);
6. significant issues in etiology, onset, and the discovery
that one is deaf or hard of hearing;
7. visual and telecommunication technologies (TTY s,
digital pagers, telecommunication relay services, video
telecommunications technology), and alerting devices;
8. sociocultural realities, social constructions, and
multicultural awareness and values for a diverse deaf
and hard-of-hearing community;
9. strengths and resources of deaf and hard-ofhearing
individuals, families, groups, communities, and
organizations;
6 DEAFNESS AND HARDNESS OF HEARING
10. effective engagement skills such as use of eye contact
and spatial orientation with deaf and hard-of-hearing
people, their families, communities, and organizations;
11. unique social justice issues, including experiences with
oppression, discrimination, and institutional audism;
12. civil rights such as The Rehabilitation Act of 1973, the
Americans with Disabilities Act, and the Individuals
with Disabilities Education Act, 1990;
13. psychosocial dynamics of families with deaf members;
14. awareness of community and professional resources;
and
15. knowledge of the code of ethics of professional sign
language interpreters and their appropriate roles
(Andrews, Leigh, & Weiner, 2004; Levine, 1977; Pollard,
1994; Sheridan, 1988, 1999; Wax, 1997).
Current literature explores psychotherapeutic issues
inherent in working with diverse groups of deaf and
hard-of-hearing people (Glickman & Harvey, 2003; Leigh,
1999). The range, purpose, and settings of social work
practice with deaf and hard-of-hearing people are the same as
they are for anyone else. Exceptions exist in that some
services may be provided in organizations and educational
programs specifically designed and established by or for deaf
and hard-of-hearing people.
Interdisciplinary Connections
Deaf and hard-of-hearing people may have connections to a
variety of professionals throughout their life course, which
may exceed the professional connections of hearing people
(Harvey, 2003). These professionals may include deaf
education teachers, school psychologists, school social
workers, audiologists, sign language interpreters, and speech
therapists, who may be tied to a child or adolescent's
individualized education plan mandated by the Individuals
with Disabilities Education Act. Sign language instructors,
vocational rehabilitation specialists, telecommunications
specialists, and specialized community service providers
working with organizations serving deaf and hard-of-hearing
people may be additional professional resources available.
SERVICES FOR INFANTS, CHILDREN, AND ADULTS
The Federal Newborn Infant Hearing Screening and
Intervention Act of 1999 has allowed for early testing and
identification of deaf and hard-of-hearing infants and
opportunities for early intervention, including
language and communication, and the facilitation of early
parent child attachment. Deaf and hard-of-hearing youth today
have a broader range of postsecondary education options than
ever before; a greater number of deaf and hard-of-hearing
people are attending college, and deaf people are entering a
greater number of professional fields than ever before.
However, data show that large numbers of deaf high school
students do not receive a high school diploma (National Center
for Education Statistics, 1999).
School composition and placement of deaf and
hard-of-hearing youth have changed drastically over the past
30 years. Today, most deaf and hard-of-hearing children
receive at least some of their instruction in the regular
classroom with hearing children (Mitchell & Karchmer,
2006). This has created challenges for the social and
emotional well-being of deaf and hardof-hearing children who
are without a reference group in the mainstream, and whose
school personnel may not be prepared to understand or meet
their educational or communication needs in the classroom.
School social workers can play an important role in a deaf
or hard-of-hearing child's educational programming. The
Individuals with Disabilities Education Act (IDEA) requires
that elementary and secondary schools design an
individualized education plan for deaf and hard-of-hearing
students to meet the child's unique educational and
communication needs. Educational needs of each child are
determined case by case and may include assistive
technologies or sign language interpreters and related services
such as counseling, social work, and psychological services.
On a community level, in a post-September 11 world, it is
imperative that deaf and hard-of-hearing people and their
communities are involved in emergency preparedness plans in
their communities (Sheridan, 2008; White, 2006).
CONSUMER AND SELF-ADVOCACY The Deaf com-
munity takes great pride in the effectiveness of its
self-governed advocacy and community service programs.
These organizations may provide case management and
mental health services, systems advocacy,
telecommunications devices and services, and sign language
interpreting, various prevention and intervention services
(substance abuse, HIV and AIDS, domestic violence), sign
language instruction, education in independent living skills,
social and recreation programs for deaf and hard-of-hearing
youth, technical assistance and consultation, and parent
mentoring. Social workers working with deaf and
hard-of-hearing people should consider these organizations as
a rich source of collaboration.

Social work practice with this population involves several
ethical considerations, including the recognition of the
practice competencies necessary to effective work with deaf
and hard-of-hearing people and the adoption of an
empowering approach to practice. The social work principle
of self-determination is of primary importance when working
with deaf and hard-ofhearing people and their communities.
The cohesive interdependent nature of the Deaf community
demands strict adherence to confidentiality and boundaries.
The social worker should avoid dual roles where additional
professional, volunteer, or social activities in the deaf or
hard-of-hearing community interfere with those of their
consumers.
Social workers should be mindful of their own medical or
cultural perspectives of deaf and hard-of-hearing people,
allowing individuals and families to make informed decisions
about controversial issues such as educational placement,
communication approaches (an emphasis on oral and aural
approaches to communication or visual methods, including
ASL), and cochlear implants.
Most disability groups advocate that integrated
educational programming through architectural and mobility
access is the least restrictive environment for children with
disabilities (Barnartt, 2007). However, because education
depends on effective communication in the classroom and
social environment of the school, mainstreaming can actually
be the most restrictive choice for many deaf and
hard-of-hearing children (Barnartt, 2007; Sheridan, 2008).
Parents need the opportunity to fully explore the implications
of integrated and segregated educational approaches in the
context of their individual child's needs.
Gutman (2002) discusses ethical issues in mental health
practice with deaf and hard-of-hearing consumers. Competing
interests and values of the deaf community and the medical
model construction of a larger hearing society continue to
exist. More people than ever in the United States use ASL.
However, at a time when cochlear implants, molecular
genetics, and other medical advances, and educational reform
continue to strive for a "cure," the deaf community continues
to face an uphill battle to gain control over their "bodies" and
"voices" (Padden & Humphries, 2005) This debate will
continue and social workers will need to be sensitive to the
competing social pressures and ethical dilemmas that they
present for deaf and hard-of-hearing people and their families.
Cochlear implants, the subject of a bioethics debate
between the medical profession and the deaf community,
exemplify the conflict in medical and cultural perspectives of
deaf people. Concern for nonrnalfeasance,
DEAFNESS AND HARDNESS OF HEARING 7
community survival, autonomy, principles of justice, and
individual rights are at the center of this debate (Christensen &
Leigh, 2002). Properly informed social workers can assist their
consumers in making informed decisions about cochlear
implantation.
Current Trends, Challenges,
and Future Directions
The lives of deaf and hard-of-hearing people have changed
rapidly over the past few decades with educational and social
reforms, legislation, technological advances, and scientific
progression. As a result, the deaf community is becoming
increasingly diversified and the community is "faced with new
challenges of self definition and cultural and linguistic
survival" (Sheridan, 2008).
TECHNOLOGIES Deaf and hard-of-hearing people have
access to television and media and take advantage of the
ever-changing technology in the 21st century. T oday's deaf
youth are the first generation of deaf people to grow up with
closed-captioned television and occasional captioning in
movie theatres and at educational events. In addition, the
Internet has made information readily available to deaf and
hard-ofhearing people. Although English-language limitations
have disadvantaged some in this process, increasingly
available person-to-person videophones, video relay
interpreting, and "vlogs" are paving the way for greater access
to communication technology. Telecommunication relay
services, reliance on digital pagers, e-mail, instant messaging,
and video telecommunications have revolutionized
communications for deaf and hard-ofhearing people and
helped to level the playing field accessing educational
opportunities, jobs, and leisure. Social workers should be
mindful of the potential benefits of technology and advocate
for resources that may close the gaps that prevent
economically disadvantaged deaf and hard-of-hearing people
from accessing them.
Role and Implications for Social Work Culturally
competent social workers who are fluent in the national sign
language of their clients are needed around the world to
provide a wide range of services to deaf and hard-of-hearing
people, their families, communities, and organizations. Social
workers should understand the psychosocial and
communication needs of those who are hard of hearing,
elderly, deafblind, and have additional disabilities. Even with
technical advances to reduce communication barriers between
deaf and hearing people, deaf and hard-ofhearing people most
often prefer face-to-face
8 DEAFNESS AND HARDNESS OF HEARING
interactions with competent social workers who can effectively
communicate with them. In some court cases, judges have ruled
in favor of direct communication without the use of interpreters
(Tugg v. Towey, 1994) to communicate with them. Social workers
should adopt an empowering approach to practice with this
population.
Career opportunities exist for social workers with the
necessary competencies to work with deaf and hard-of-hearing
people in any of the earlier-mentioned settings in addition to
medical, social, mental health, and other service arenas.
Specialized training at the undergraduate and graduate level to
work with deaf and hard-of-hearing populations can be found at
several universities, notably Gallaudet University in Washington,
D.C. Social workers and other professionals who are deaf or hard
of hearing are valued employees of these organizations.
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Sheridan, M. (1996). Emerging themes in the study of deaf children.
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Sheridan, M. (2001). Inner lives of deaf children: Interviews and
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Sheridan, M. (2008). Deaf adolescents: Inner lives and lifeworld
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Stokoe, W. (1960). Sign language structure: An outline of the visual
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linguistics, occasional paper no. 8. Washington, DC: Gallaudet
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999-1005 (July 19, 1994).
VanCleve, J., & Crouch, B. (1989). A place of their own.
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Wax, T. (1993). Matchmaking among cultures: Disability culture and
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Welsh, W. A, & Foster, S. B. (1991). Does a college degree influence
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the initial and long term impact of college. Journal of
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White, B. (1997). Permanency planning for deaf children: Con-
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White, B. (2000). This child is mine: Deaf parents and their adopted
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White, B. (2006). Disaster relief for deaf persons: Lessons from
Hurricanes Katrina and Rita. Review of Disability Studies An
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148956-piPK:216618-theSitePK:282699 ,00.html.
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from http://wfdeaf.org.
FURTHER READING
American Sign Language Teacher's Association. ASL as a language.
Retrieved January 2, 2007, from http://www.aslta.
org/language/index.h tml.
Anderson, P. (1987). Networking: The forgotten minority.
Innovations in the habilitation and rehabilitation of deaf
adolescents. In G. B. Anderson & D. Watson (Eds.), Proceedings
of the Second National Conference on the Habilitation and
Rehabilitation of Deaf Adolescents, Afton, Oklahoma.
10 DEAFNESS AND HARDNESS OF HEARING

Christensen, K. (2000). Deafness plus: A multicultural perspec tive. San Gay and Lesbian Association of the Deaf-East.
Diego, CA: DawnSign. http://www.cleafqueer.net/glade/affiliates.htm Hearing
Gallaudet University Library. Deaf-related resources. Frequently Loss Association of America. http://www.shhh.org/
asked questions: Statistics: Deaf population of the United States. Intertribal Deaf Council.
Retrieved January 1, 2007, from http:// library, gallaudet.edu/ http://www.deafnative.com/
dr/faq-s tat ist ics-deaf-us. htrn I. Laurent Clerc National Deaf Education Center.
Guthrnan, D. (1996). An analysis of variables that impact treatment http://clerccenter .gallaudet .edu/
outcomes of chemically dependent deaf and hard of hearing League for the Hard of Hearing.
individuals (doctoral dissertation, University of Minnesota). http://nasponline .org
Dissertation Abstracts International, 56(7A),2638. National Asian Deaf Congress.
Parasnis, 1. (2000). Deaf ethnic-minority students: Diversity and http://nadc-usa.org/
identity (pp. 1-7). Congress CD ROM Proceedings of the 19th National Association of the Deaf.
International Congress on Education of the Deaf and 7th http://nad.org
Asia-Pacific Congress on Deafness. ICED 2000 APCD National Black Deaf Advocates.
Secretariat, Sydney, Australia. Journal of Deaf Studies and Deaf http://nbda.org/
Education, 8(3), 271\290. National Technical Institute for the Deaf.
Rainer, ]., & Altschuler, K. (Eds.). (1966). Comprehensive mental http://rit.edu/NTID
health services of the Deaf. New York State Psychiatric Institute, Rainbow Alliance of the Deaf.
New York: Columbia University Press. http://www.rad.org/
Robinson, L. J. (1978). Sound minds in a soundless world.
Registry for Interpreters for the Deaf.
Washington, DC: U.S. Department of Health, Education and
http://rid.org
Welfare.
Telecommunications for the Deaf, Inc.
Santos, D. (1997). Deafness. In Encyclopedia of social work (19th ed., http://tdi-online.org
pp. 685-704). Washington, DC: NASW Press. World Federation of the Deaf.
Vernon, M. (1971). Current status of counseling with deaf people. In http://wfdeaforg
A. Sussman & L. Stewart (Eds.), Counseling with deaf people. New World Recreation Association of the Deaf/USA.
York: New York University School of Education. http://wrad.org
Videos: For a Deaf Son.
http://www . hera. org/tv/productions/ deafson/ Mr.
Holland's Opus.
SUGGESTED LINKS Abused Deaf Women's http://www.irndb.com/title/ttOI13862/ Sound
Advocacy Services. http://adwas.org/ and Fury.
American Association of the Deaf Blind. http://www . pbs. org/wnet/ soundandfury/
http://aadb.org/ Through Deaf Eyes.
American Deafness and Rehabilitation Association. http://wwwflorentinefilms.org/thefilms/OOfilm.htm
http://adara.org Unheard Voices. http://hearingloss.sidestreetshop.com/
American Society for Deaf Children.
http://www .deafchildren .org/ Association
of Late Deafened Adults. http://www
.alda.org/ -MARTHA A. SHERIDAN AND BARBARA J. \'{!HITE
Children of Deaf Adults.
http://www .coda-international.org/
Deaf, Hard of Hearing and Hearing Social Workers. httl):/
/academic .gallaudet. edu/prof/dhhhswweb. nsf Deaf Latino
Organizations. DEINSTITUTIONALIZA TION
http://www.deafvision.net/aztlan/resources/index . html
Deaflympics. ABSTRACT: The de institutionalization policy sought to
http://www.deaflympics.com/ prevent unnecessary admission and retention in institutions
Deaf Seniors of America.
for six populations: elderly people, children, people with
http://deafseniors.org/
mental illness or developmental disabil ities, criminal
Deaf Woman United.
offenders, and more recently the home less. It also sought to
http://www.dwu.org/
Directory of National Organizations of and for Deaf and Hard of develop community alternatives for housing, treating and
Hearing People. rehabilitating these groups. U.S. institutional populations,
http://clerccenter .gallaudet . edu/info togo/ 184. html however, have increased since the policy's inception by 215% .
Gallaudet University. As implemented, deinstitutionalization initiated a process that
httl):/ /gallaudet .edu involved a societal shift in the type of institutions and

institutional alternatives used to house these groups, often
referred to as transinstitutionalization. This entry considers
how this shift has affected the care and control of such
individuals from political, economic, legal and social
perspectives, as well as suggestions for a truer implementation
of deinstutionalization.
KEY WORDS: community care; deinstitutionalization;
transinsti tu tionaliza tion
Since the early 1950s, stated national policy has come to
reflect a preference for an alternative to institutional placement
as the solution to social problems (Rothman, 1971).
Deinstitutionalization, as the policy has become known,
developed along different lines among populations that were
traditionally subject to care and control in large institutions:
people with mental illness or developmental disabilities,
criminal offenders, children, elderly people, and more
recently, the homeless. This process has also been documented
internationally in Western Europe and Australia among other
countries (Goldman, 1982). As it pertains to each of these
groups in the United States, deinstitutionalization is best
defined by a 1977 U.S. General Accounting Office (GAO)
report as:
the process of (1) preventing both unnecessary ad-
mission to and retention in institutions; (2) finding and
developing appropriate alternatives in the community
for housing, treatment, training, education, and
rehabilitation of persons who do not need to be in
institutions, and (3) improving conditions, care, and
treatment for those who need to have institutional care.
This approach is based on the principle that. .. persons
are entitled to live in the least restrictive environment
necessary and lead lives as normally and
independently as they can. (U.S. GAO, 1977, p. 1)
Although this definition reflects the broad aims (Fakhoury
& Priebe, 2002) of the policy of deinstitutionalization, the
most discernible consequence of it has been the reduction of
the average daily census of a select group of large
institutions-state and county mental hospitals and children's
homes-and the transfer of their resident populations to other
supervised living arrangements. Overall, the resident
populations in institutions have increased rather than
diminished in the United States from 1,887,000 0,052 people
per 100,000 population) in 1960, to 4,059,039 0,442 per
100,000) in 2000 (U.S. Bureau of the Census, 19602000), up
215%. Alternative living arrangements, while sometimes
smaller, often differ little in institutional character. Thus,
many analysts describe the result as transinstitutionalization-a
process that
DEINSTITUTIONALIZA TION 11
involves a societal shift in the type of institutions used to
house dependent and deviant populations. This entry discusses
the deinstirurionalization process and the new structure of
institutional care in the United States that has emerged from it,
as well as suggestions for achieving a truer form of
deinstitutionalization.
Origins of Deinstitutionalization
Critiques of institutional care for dependent and deviant
groups have been common since the last quarter of the 19th
century (Barr, 1992; Deutch, 1948; Goffman, 1961; Maisel,
1946; Ward, 1946). In the 1960s, however, six trends
combined to make deinstitutionalization attractive and
politically feasible: (1) the negative effects of
institutionalization documented by journalists and social
scientists; (2) improvements to institutions (increased staffing,
programming, and upgrading of facilities) leading to the
growing costs of some types of institutional care relative to
alternatives; (3) advances in social, psychological, and
medical sciences that were thought to make the confinement
and isolation functions of the institution obsolete; (4) the
development of the civil rights movement, which emphasized
the protection of individuals' due process rights and the
necessity to approach care and treatment in the least restrictive
manner; (5) the development of an extensive system of public
aid that allowed the maintenance function of institutions
(in-kind room and board) to be replaced by a system of cash
grants to clients; and (6) the development of new institutional
alternatives, relatively less expensive than existing
institutions. The last two developments, in particular, created
state-subsidized markets for local provision of care by the
private sector in single room occupancy hotels, board and care
homes, homeless shelters, nursing homes, group and foster
care settings, private prisons, and general hospitals.
These trends enabled the development of a unique
coalition in support of deinsitutitionalization policy that
spanned the political spectrum. Conservatives supported
deinstitutionalization, viewing it as a means to reduce
institutional censuses, use cheaper institutional placements,
and limit government spending. Liberals championed civil
rights protections and humane community care. The only
opposition came from employee unions affected by job
decreases due to institutional closures. Without significant
political opposition, and with many groups in the political
community viewing deinstitutionalization as a means to
achieve their own ends, the policy gained momentum.
Yet, there are more people in institutions now than at the
outset of the policy's implementation. It is therefore important
to understand how the policy's implementation led to the
abandonment of broader
12 DEINSTlTUTIONALlZA TION
de institutionalization goals for specific groups as well as
the relationship between the aforementioned trends and the
development of new institutional and community-based
alternatives. This entry explores these trends with respect
to six populations: people with mental illness and
developmental disabilities, criminal offenders, children,
elderly, and the homeless.
Deinstitutionalizing Six Populations PEOPLE
WITH MENTAL ILLNESS In 1950, one of the most
prevalent forms of institutionalization (in addition to
criminal incarceration) was the admission to a state or
county mental hospital. These institutions were the most
affected by the de institutionalization movement. Their
census plummeted 90%, from a high of 558,922 in 1955
to a low of 54,826 in 2000 (U.S. Bureau of the Census,
2000). The number of such institutions fell from 310 in
1970 to 222 in 2002 (SAMHSA, 2004b). Although the
resident population fell drastically, admissions to state
and county mental hospitals have increased relative to
the number of resident patients. People with serious
mental illness now evidence a revolving door pattern of
brief hospitalizations and more hospitalizations than in
the past. In 1950 there were 152,186 admissions and
512,501 residents-a ratio of 0.29 admissions for every
resident. By 1991 this ratio had increased to 2.88
admissions for every resident.
This revolving-door pattern also describes the care
provided in nonfederal general hospitals with psychia tric
services. These facilities, along with nursing homes, have
become the new primary service institutions for people
with mental illness (SAMHSA, 2004a). Their resident
population almost doubled in this period, from 17,808 in
1970 to 27,460 in 2002, admissions (techni cally additions)
increased from 478,000 to 877,398, and their admission to
resident ratio increased from 26.84 to 31.95.
Impetus for Deinstitutionalization. Justification for
reducing state mental hospital populations came from
several points of view. Studies that compared short- and
long-term treatment in mental institutions were unable to
demonstrate the effectiveness of the latter, while research
that compared hospital treatment to community treatment
combined with psychoactive medication s supported the
community-based approach. The first major clinical trials
were used to convince the public that psychoactive
medications were a solution to the control of mental health
symptomology, thus serving as justification for trusting
patients outside the confines of mental institutions.
Patients were to use the hospital merely to have their
medication adjusted over a period of time (see
Pasamanick, Scarpitic, & Dinitz, 1967).
The 1962 decision of the U.S. Department of Health ,
Education, and Welfare (DHEW) to make aid available to
former mental patients under the Aid to the Permanently
and Totally Disabled program- now the Supplemental
Security Income (SSl) program of the Socia l Security
Act-provided federal government support to maintain
patients in local com munities and a local economic
stimulus to private entrepreneurs to offer them board and
care. SSI provisions also made such individuals eligible for
Medicaid, allowing states a cost sharing of 50 to 80% for
the medical care of clients transferred to community care
(Harrington, Newcomer, & Estes, 1985) from care
previously provided at state expense in state hospitals.
Perhaps the major factor in the demise of the state a nd
county mental hospital was the new financing scheme
introduced by Medicaid or Title XIX of the Social Security
Act in 1965. It introduced financing for nursing homes that
was a less expensive alternative to the mental hospital.
Before Medicaid, state me ntal hospitals were supported in
full by state general funds. Medicaid allowed states to
receive 50% or more in federal funds for the cost of patient
care by transferring a patient to a nursing home. This
cost-shifting incentive was further enhanced becau se the
cost of patient care in the nursing home was approximately
half that of the state mental hospital. Thus each patient
transferred from a state mental hospital to a nursing home
could be maintained at approximately 75% less cost to the
state. It is estimated that almost three- fifths of the patients
in state hospitals, institutions largely populated by elderly
individuals, were so transferred, their care refocused
around their existing medical conditions and their pre sence
in the mental health system l ost due to the provisions of
nursing home financing that have encour aged such
facilities to underreport psychiatric conditions.
Two additional political processes contributed to the
emptying of state mental hospitals. First, the civil rights
movement put an end to long-term hospitaliza tion by
effectively ceasing indefinite commitments to state mental
hospitals and, second, the restricting of involuntary
detention to brief periods of time. Finally, the key element
in the political support for the state ho spital, which was its
employment function in rural areas lacking alternative job
opportunities, was eroded by the rapid development of state
prisons providing similar employment opportunities.
Alternative Facilities. The major shift in care for
mentally ill adults involved their episodic placement and
long-term relocation or the retargeting of their initial
placements to psychiatric wards of general hos pitals,
nursing homes, and board-and-care facilities.

The latter two settings were often described as the new "back
wards" in the community. Few statistics are available on the
prevalence of mental illness among nursing home patients.
Estimates vary from 30% to more than 85%, with the higher
estimates being more common. One can estimate that 28% of
those in nursing homes have a major mental disorder exclusive
of senile dementia (Rovner, 1990; Linn & Stein, 1981).
Because Medicaid programs disallowed services in nursing
homes considered institutions for mental disease-a
classification made when more than 50% of the patients have
mental illnesses that require inpatient treatment according to
their medical records (jazwieck & Press, 1986)-nursing
facilities became increasingly reluctant to acknowledge their
patients' mental disorders for fear of losing Medicaid support.
This led to an underground system of long-term care for
people with mental illness.
The board-and-care home is a residential facility that
provides 24-hour supervision as a nonmedical facility for
disabled individuals. These facilities are not part of the formal
mental health system, they vary in size from 1 to more than
500 beds, and they are usually financed on a fee-for-service
basis. The disabled individual usually pays for his or her board
and care with a Supplemental Security Income (SSI) check.
Only some states license these homes, and licensing is often
done through the social services rather than the health or
mental health department. This licensing policy takes these
disabled individuals out of the formal mental health arena and
adds them to the underground system of long-term care for
people with mental illness. It is estimated that 300,000 to
400,000 people with serious mental illness live in this system
of care.
The political coalition that engineered the demise of state
mental institutions did not survive to foster and maintain the
development of alternative communitybased care. Once
institutions were closed, conservatives could no longer justify
expenditures for such programs as efforts to reduce excessive
government spending. In the 1970s, between 10% and 30% of
those released from state hospitals went to live in sheltered
living arrangements, including foster or family care homes,
board-and-care homes, supervised hotels, and halfway houses
(Segal & Aviram, 1978), while many returned to live on their
own or with family. Currently a significant segment of new
patients find their way to such facilities, never passing through
the state hospital. However, a large proportion of these
supervised living arrangements are similar to large mental
institutions in character and environment. Those failing with
family supports and living in these types of supervised living
environments end up cycling in and out of general
DEINSTITUTIONALIZA TION 13
hospital psychiatric units, homeless shelters, jail or prison. A
few find their way to a small select group of model programs
that represent show pieces-such as the Village in Los
Angeles-of what community mental health care for individuals
with serious mental illness should be. Such model programs
are well designed to meet the psychosocial needs of the
mentally ill and, while varying tremendously, almost
universally include an emphasis on flexible homelike settings
focused on a vision of recovery that includes a vocational
component and extensive peer and professional supports.
PEOPLE WITH DEVELOPMENTAL DISABILITIES More than 3.6
million noninstitutionalized Americans have either mental
retardation or developmental disabilities. Roughly lout of 10
of them lived in a residential setting in 1998 (348,394). The
number of people with developmental disabilities in public
institutions declined from 149,892 in 1977 to 51,485 in 1999
(National Council of State Legislators, 1998).
People with developmental disabilities were deinsti-
tutionalized to some extent because they lived in the same
state and county mental hospitals as the mentally ill. In 1950,
state and county mental hospitals housed 48,000 people with
developmental disabilities-27% Of all developmentally
disabled residents in public institutions. In 1989 this
population had declined 97%, to only 1,605 individuals, just
1.7% of the developmentally disabled individuals in public
institutions.
Impetus for Deinstitutionalization. The deinstitu-
tionalization of people with developmental disabilities was
prodded by landmark court decisions such as Wyatt v. Stickney
(1972) and Olmstead (1999). The former dealt with the right
to treatment, and decisions related to housing individuals in
the least restrictive environments; the latter required states to
provide communitybased services for people with mental
disabilities if treatment professionals determine that it is
appropriate and the affected individuals do not object to such
placement. Under Olmstead, states are responsible for
community-based placement if they have the available
resources to provide them. States must also demonstrate that
they have a comprehensive, effective working plan, including
timetables and progress reports, for placing qualified people in
less restrictive settings.
The movement of the developmentally disabled into the
community was also fostered by the increasing costs of
improving institutions, combined with the advent of new
technologies, communications, and the concept of
normalization (the treatment of people in an environment most
closely approximating a "normal" situation). Like people with
mental illness, most people with developmental disabilities go
on to live with their
14 DEINSTlTUTlONALlZA TION
families or on their own. However, a significant proportion
reside in smaller community-based facilities, foster homes,
board-and-care homes, and some large group homes that
begin to approximate the formal character that is typical of
many large institutions. The developmentally disabled have
fared much better than the mentally ill in developing and
obtaining the financial support for the community-based
social support services that enable them to maintain stable
community existences. They have had better political appeal,
better lobbies, and more success in appealing to the general
public as being "worthy" of such support than have the
mentally ill.
Alternative Facilities. Between 1970 and 1989 the
number of public residential facilities serving the
developmentally disabled rose from 190 to 1,305. The
resident population of these facilities did not rise in concert
with the number of facilities. Between 1950 and 1967, the
population rose from 176,000 to 193,000, where it peaked .
It then declined to 94,268 by 1989 (U.S. Department of
Commerce, 1992). The decline in publicly operated
facilities has been more than compensated for in the
increase in both the num ber and resident population of
private facilities catering to this population. Such facilities
numbered 10,219 in 1977; in 1989,38,657 facilities
included intermediate care facilities, foster homes, and
group residences that provide 24-hour, 7 -day-a- week
responsibility for room, board, and supervision. The
population of these facilities increased dur ing this same
period from 89,120 to 180,023 (U.S. Department of
Commerce, 1992).
The development of these alternative facilities and
supports for home-based care to avoid institutionalization was
facilitated by the enactment in 1981 of the Home and
Community-Based Services (HCBS) waiver program through
the creation of 1915(c) of the Social Security Act to provide a
community alternative to serving eligible persons in an
institution, defined as a hospital, nursing facility, or
Intermediate Care Facilities for the Mentally Retarded
(ICF-MR). This program assists more than 700,000 older
persons and individuals with disabilities to remain in their
communities and avoid institutionalization. Prior to 1981,
Medicaid expenditures for persons who required longterm
services or supports were essentially available only for
institutional care provided through nursing facilities or
ICF-MR.
By 1986, 51.9% of the beds available in both public and
private facilities were located in facilities where the average
number of residents was no more than 35, indicating that
consistent with deinstitutionalization ideology, small was
considered better. The trend toward smaller residential
placements was further
exemplified in the types of facilities occupied by devel-
opmentally disabled individuals. In 1998, 6% of recipients of
residential services in this population resided in nursing
homes, 32% in intermediate care facilities, and the remainder
(240,321 people) procured residential services through the
Home- and Community-Based Services (HCBS) waiver
program. Furthermore, 54% of the residential settings housed
between one and six people, reflecting a trend in smaller
settings (National Conference of State Legislators, 1998; U.s.
Department of Health and Human Services [USDHHSj,
2004).
CRIMINAL OFFENDERS On December 31,1989,1.6% of the
adult population in the United States was under correctional
supervision (U.S. Department of Commerce, 1992). By
year-end 2005, this proportion had doubled to 3.2%, or 1 of
every 32 adults. State and federal prison authorities had in
custody 1,446,269 inmates-1,259,905 in state and 179,220 in
federal custody. Local jails held 747,529 persons awaiting
trial or serving a sentence at midyear 2005 (Bureau of Justice
Statistics, 2007). State and federal prison populations rose
from 212,953 in 1960 to 1,446,269 in 2005-almost a 700%
increase during the period of deinstitutionalization policy
implementation. Similarly, county jail populations grew
steadily from 158,394 in 1978 to 747,529 in 2005, a 472%
increase in this period (Bureau of Justice Statistics, 1984a,
1984b, 1990a, 1990b, 2006).
Impetus to Expand Institutionalization. The pressure
on the correctional system to confine large num bers of
people has increased dramatically, but is only partially
attributable to increases in drug- related and violent crimes.
While adult drug-related arrests have steadily
increased-from 471,200 in 1980 to 1,654,600 in 2005, up
351 %-violent crime rates increased only 35.3% and total
crime rates only 8% in the decade between 1980 and 1990
and serious violent crime rates have declined since 1993 ,
reaching the lowest level ever in 2005 (21.0 per 1000 )
(Bureau of]ustice Statistics, 2007).
Increased law enforcement accompanied by an ideological
shift emphasizing punishment over rehabilitation seems to
account for some of the increase in the criminal justice
institutionalized population. Significant numbers of offenders
spend less time in prison and receive shorter sentences, but the
number of times they return to custody, through parole
revocations, has increased greatly. Cuts in probation and
parole budgets have confined community-based supervision
to the desk drawer. Like the mentally ill population, the
offender population is increasingly subject to the

revolving-door phenomenon with little effort invested in real
community programming.
The increased focus of the correctional system on anti-drug
enforcement has expanded the containment functions of
correctional institutions. Many would argue that such facilities
have now absorbed substantial numbers of mentally ill
individuals, particularly those with co-morbid substance abuse
problems who find intermittent and lifetime supervision in
prisons and jails. Prisons and jails now house the mentally ill at
50 to 75% less cost than state hospitals. Studies suggest that 6
to 15% of persons in city and county jails and 10 to 15% of
persons in state prisons have severe mental illnesses (Lamb,
1998). It appears that a greater proportion of mentally ill
persons are arrested and convicted, compared with the general
population (Wallace, 2004). Further, there is evidence that the
criminal justice and mental health systems more frequently
serve the same individuals and that community mental health
centers are more frequently becoming the outpatient providers
for individuals with criminal justice involvements (Theriot &
Segal, 2005).
Finally, some recognition needs to be offered to the
industrial function of prisons and jails. These facilities have
replaced state mental hospitals as local industries in rural
communities without employment opportunities. Like the
employees of the state hospitals in the past, their unions have
become major advocates for the expansion of these
institutions. They are among the largest contributors to
political campaigns at all governmental levels. They have
supported tough sentencing laws-such as Proposition 184 (the
Three Strikes law) in California, requiring 5-year en-
hancements for each prior offense in addition to the current
penalty-providing long-term inmates for these facilities.
Alternatives to Institutional Provision. The increase in
the number of individuals in state and federal prisons and
local jails has been matched by an increase in the number of
individuals with probation and parole status. The scale of
community-based supervision of offenders is now greater
than at any other time in history. In 1989 there were
2,520,500 adults on probation in the United States. At
year-end 2005, over 4.9 million adult men and women were
under federal, state, or local probation or parole
jurisdiction, with approximately 4,162,500 on pro bation
and 784,400 on parole. Further, an additional 71,905
persons under jail supervision were serving their sentence
in the community (Bureau of Justice Statistics, 2007 ).
Although this expanded use of community- based
supervision was designed to reduce the potential population
of prisons, the
DEINSTlTUTIONALIZA TION 15
national prison census continues to grow, spawning
controversial measures to finance the construction of new
county jails and state prisons.
CHILDREN Children have been housed in a myriad of group
care settings: the traditional orphan home, children's home,
homes for dependent and neglected children, and more
specialized group care such as homes for unwed mothers,
psychiatric hospitals, residential treatment centers, halfway
houses and even nursing homes and homes for the elderly .
To these are added detention homes for juvenile
delinquents, training schools, and other correctional
institutions as well as noninstitutional settings such as
boarding houses and schools.
The number of children in institutions reached a 50year
low of 70,892 in 1960 (almost a 50% drop from the 1933 high )
and then more than doubled in the 1980s and 1990s, only to
level off at 144,981 in 2000, surpassing its absolute high.
Deinstitutionalization for children, outside of the decline in
state mental hospital residence, was over by 1960, when a
major change occurred in the character of child institutional
care. Facilities went from being organizations focused on the
normalized growth and development of their children to being
residual repositories of the failures of foster family care.
Children's homes became residential treatment centers,
runaway homes, detention facilities, and substance abuse
treatment centers, among others. Of particular note is the
increasing use of residential treatment centers for emotionally
disturbed children and juvenile justice facilities for juvenile
offenders (such as detention centers, reception and diagnostic
centers, training schools, and halfway houses). The capacity of
residential treatment centers for emotionally disturbed
children increased from 5,270 in 1970 to 30,370 in 1998
(Substance Abuse and Mental Health Services Administration,
1998). The population of juvenile justice facilities increased
between 1979 and 2000 from 74,113 to 112,479 (U.S. Office
of Juvenile Justice and Delinquency Prevention, 1990).
Impetus for Deinstitutionalization. In the 1860s, large
numbers of children were transferred from alms houses to
orphanages so as to remove the "deserving poor" child ren
from the contaminating influences of the poorhouse and
increase the likelihood of such children being indentured or
placed-out. The Children's Law of 1875 in New York State ,
and similar laws in other states, prohibited future placement
of children in almshouses. The ranks of orphanages were
swelled by the availability of per- capita state funding in
New York, a system that gave aid according to the numbers
of inmates kept. Many
16 DEINSTITUTIONALIZA TION
superintendents packed their institutions, shed educational and
religious programming, and became fiscally efficient
warehouses for under-serving children waiting to be
indentured. Other small orphanages retained their mission to
"save" the children (Barr, 1992).
Introduced at the 1909 Conference on Dependent Children
in Washington, DC, where President Roosevelt urged that
children not be removed from their homes for the reason of
poverty alone, the new policy of moving children from
institutions to foster family care came to be promoted with
arguments of fiscal efficiency and the notion that social control
would be easier to maintain in the family than in the
institution. It was also believed that children could be
protected from the abuses of institutional settings in these
family environments. The move away from the children's
home (as early as 1910) was attributed to such things as
"hospitalism"-or failure to thrive-and child labor exploitation.
Other abuses notable in the first half of the 20th century
included placement in ever-larger facilities with decreasing
amounts of resources to keep government costs down and the
use of institutionalized children as experimental guinea pigs at
all points in the effort to eradicate diphtheria.
Yet, as children often contributed to their own support in
institutions with their labor in the earlier part of the 20th
century and state subsid ies continued to flow for their support
in children's institutions, the ranks of these organizations
continued to grow until in 1933 their population reached
140,352. Foster care was also growing at a rapid pace during
the 1930s. One may speculate that it was spurred on by the
fiscal incentives associated with providing foster care, much
needed by families during the Great Depression and World
War II.
Alternatives to Institutional Provision. The turn of the
20th century saw a change in viewing children from
property available for exploitation as cheap labor to
human beings whose development would either con-
tribute to society in later life or detract from it. Foster care
is a living arrangement where children reside out side their
own home in a family-like environment un der the case
management and planning responsibility of a state child
welfare agency. The ratio of children in institutions to
foster care declined from a high of 2.15: 1 (3.19 versus
1.48 per thousand children under 18 years of age) in 1923
to 0.97 in 1950. Thus it was in the 1950s that foster care
became the placement of choice and the low eb b for
institutional placement came in the early 1960 s when the
institution to foster care ratio reached .43 (1.1 per
thousand children under 18 years of age). In the 1980s and
1990s, the ratio was again elevated to between 0.5 and 0.6 ,
only to fall off again at the dawn of the 21 st cen tury to 0.39.
Foster care as an alternative to institutional care continued
its growth throughout the 20th century. By 1972 foster care
numbers reached 319,800, by 1983 it dropped to 269,500, but
by 1991 had increased to 429,000 (Tatara, 1992). In 1988,
according to the American Public Welfare Association
(APWA), 71.4% of children living outside their homes in
24-hour supervised residential care were in foster homes;
18.6% were in group homes, residential treatment facilities,
and emergency shelters; and 10% were in other settings (U.S.
House of Representatives, 1992). In 2000, the number of
children in 24-hour care was 562,000, exclusive of those in
homeless shelters and the correctional system.
The expansion of foster care since 1980 has been
accompanied by a national drive to find permanent homes for
foster children. Unfortunately, the effort to find permanent
placement for such children seems to have floundered. Foster
care was plagued by an increase in the "churning" of children
within the system. In 1982, 43% of children in care had
experienced more than one placement; by 1988, 54% had
experienced more than one placement (U .S. House of
Representatives, 1992). Data on entering and leaving the
system can be interpreted to indicate an increase in children's
length of stay in the system. It shows relatively stable numbers
entering and leaving care with a continuing increase in the
population size (Tatara, 1992). Given the revolving-door
phenomenon and the fact that 15% of children entering care in
1988 were reentering the system, it would appear that the
system's focus on reunification might be more disruptive than
helpful. Family reunification is not necessarily a successful
outcome, and as a goal it may compromise a more important
need in the child's life-stability of upbringing. Such stability
was often achieved in the nowabsent children's institutions.
The foster care system is further plagued by administrative
contradictions that serve to disrupt health growth and
development and is characterized by terrible outcomes. For
example, in Missouri, over 50% of foster children do not
graduate high school; upon leaving foster care, over half
become homeless; and 80% of the young women become
pregnant before reaching the age of 21. The more recent use of
kinship foster care has been touted as a possible solution
offering better outcomes. Yet one must wonder whether the
potential of this option is simply a function of selection of
those children with stronger family support systems and thus
better potential outcomes. Since today's institutions are most
often facilities designed to cope with the failures of foster care,
their potential as placements of first resort rather than last
resort is difficult to evaluate. The loss of the children's home
focused on stable

normal growth and development as such a placement option
may have to some extent limited our ability to deal with these
challenges.
ELDERLY PEOPLE In 1900, there were 3.1 million elderly
(65 and older) in the United States, or about 1 in 25
Americans. There were about 122,000 people 85 years old
or older, only a fraction of a percent of the population, and
the average life expectancy was 47 years. By 1994, the
elderly population was 11 times larger than 1900-33.2
million elderly, or 1 in 8 Americans, and 1.2%, and three
million of the population were 85 or older. In 1994, life
expectance in the United States was over 75 years.
Changing demographics have caused changes in
institutional care for older people (Centers foi Disease
Control and Prevention, 2005).
Since the early 1900s there has been a steady growth in the
institutionalization of older people in the United States. The
elderly population residing in groupsettings increased 267%
between 1910 and 1970. In the latter half of the 20th century,
major shifts occurred in the type of group quarters occupied by
the elderly. In 1940, census data showed that 4.1 % of the total
elderly population was institutionalized: 40.5% of these were
in noninstitutional group quarters such as hotels and boarding
houses; 33% were in nursing homes, personal care homes, and
residential homes; and 23% were in mental institutions (Estes
& Harrington, 1981). By 1990, 1,883,178 elderly people, or
5.9% of the elderly population, lived in institutions (Price,
Rirnkunas, & O'Shaughnessy, 1990). Of them, 94% resided in
nursing homes, 5% in other institutional group quarters, and 1
% in psychiatric inpatient services. In 1999, there were 18,000
nursing homes in the United States, housing 1.72 million
residents (1.6 million elderly people) and 1.9 million elderly
were living in institutions generally (approximately 6% of the
population) (Centers for Disease Control and Prevention,
1999).
Impetus to Expand Institutionalization. Three major
federal programs have had a direct effect on the private nursing
home and residential care industry: the Social Security Act of
1935 and the Medicare and Medicaid additions to the Act. The
Social Security Act provided a cash income to retired elderly
people so they could live by themselves and purchase boarding
home care. By the late 1950s, shortages of beds in general
hospitals created pressure to move chronic patients into
nursing homes to make room for acute cases. Medicaid
legislation of 1965 had the most dramatic effect on
institutional care for older people. For low-income individuals
with severe long-term chronic illnesses, nursing-home care
services are primarily available
DEINSTITUTIONALIZA TION 17
through federal and state Medicaid (public assistance)
programs designed for the indigent. In 1987, federal and state
programs paid for 41.4% of all nursing-home care, thus
functioning as a major resource for the private nursing-home
industry (Estes & Harrington, 1981; Gibson, 1980). From its
inception, Medicare has been oriented toward acute care
services. In 1987, Medicare gave 93% of its funds to hospitals
and physicians and only 0.8% to nursing homes.
Deinstitutionalization primarily affected elderly in-
dividuals who were confined to state and county mental
hospitals. They were often moved directly out of hospitals into
nursing homes, or they were not moved at all; the building
names were changed and most of the population stayed in
place. As noted previously, it is estimated that 85% of those 65
and older living in nursing homes have some degree of mental
impairment. Given the large-scale institutional character of
today's nursing homes, emphasis is being placed on the need
for the de institutionalization of nursing home residents and
the provision of more home-based care. This emphasis is
primarily a product of the extensive costs of the Medicare and
Medicaid systems.
Alternative to Institutional Care. As noted above, a drop
in nursing home residents between 1990 and 2000 did occur
(Centers for Disease Control and Prevention, 2005; U.S.
Department of Health and Human Services, 2004). The
USDHHS 1995 survey of nursing homes reported fewer but
larger facilities for nursing care in the United States over a 10
year period and a decline in occupancy rates and in actual
numbers of residents in many cases. This decline was
attributed to more choices for health care among elderly
people, most importantly the provision of home health aides
and home care. In the early 1990s, Medicare became
somewhat less restrictive in eligibility for home health care,
and utilization increased. In response to the dramatic increases
in expenditures, however, Medicare subsequently tightened
eligibility (for example, requiring evidence of actual
rehabilitation following an acute event rather than
maintenance), impacting utilization. Some home and hospice
agencies went out of business. This action occurred in the late
1990s and illustrates the responsiveness of institutional
populations to alternative financial opportunities or changes.
Data from a related National Home and Hospice Care Survey
indicate that the number of home care agencies and clients
increased from 8,000 agencies and 1.3 million clients in 1992
to 13 ,500 agencies and almost 2.5 million patients in 1996.
Once the restrictions went into place, however, the numbers of
both agencies and patients began to decline to 1992 levels
(Centers for Disease Control and Prevention, 2005).
18 DElNSTlTUTIONALlZA TION
HOMELESS PEOPLE The homeless are the un-
accommodated "residual poor people," suffering
multiple handicaps, in need of parens patrie protections
that have evaporated with the advent of deinstitutionalization.
The state of homelessness is that of a veritable sewer leaving
those who enter this state with a single affliction exposed to
multiple afflictions including stress or trauma induced mental
illnesses, AIDS, TB, and substance dependence. The size of
the homeless population in a society is determined by the
availability of low cost housing, the particular individuals that
become homeless by their vulnerabilities to falling into this
sorry state. The current homeless epidemic in the United
States dates from around 1980. In 2007, in a 3-month
emergency, homeless shelters accommodated approximately
750,000 individuals. Given an estimated nightly census of
500,000 homeless in the United States and yearly estimates as
high as 3,000,000, the shelter figure indicates a high turnover
and a cycling through a limited use resource-that is, many
people get to use the available beds whenever they can get
access to them.
Impetus to Expand Institutional Care. The homeless
population is made up of people who live in marginal
accommodations and are vulnerable to structural shifts in
society, the least able to find or afford alternate
accommodations. This population is made up of many who in
the past would have been accommodated in institutions or
whose transitions might have been facilitated by the social
services attached to such institutions. Among the homeless,
33% have serious mental illnesses (Burt, 2000, 25% have
grown up in out of home care, and 74% have substance abuse
disorders. It is estimated that 20 to 60% were
deinstitutionalized (Torrey, 1988) and that risk of premature
death among mid-aged homeless people in U.S. cities is 3-4
times greater than the general population (O'Connell, 2005).
Extensive emergency shelter construction in the late 1980s
and 1990s was precipitated by the local outcry generated in
response to the sorry state of these individuals. There were
approximately 399,800 emergency-shelter and
transitional-housing beds subsidized by HUD during this
period, up about 250% on average in bed numbers in 1996
from the 1985 levels. The homeless to a significant extent are
the victims of de institutionalization. They are periodically
accommodated in homeless shelters that are not the new poor
houses where people previously lived and worked. Such
shelters offer a bed with sometimes early morning or late
evening meals. The shelters are places where people line up
each day to sleep the night, where people sometimes are
limited to a 3 to 4 hour sleep period. Some shelters consider
themselves as transitional and allow longer-term arrangements
(perhaps to a year). The shelters, however, generally provide
emergency
overnight accommodation in what for significant numbers has
become a chronic emergency.
Alternatives to Institutional Care. The alternative to
chronic homelessness (those on the street for more than a year
or with four or more episodes of homelessness), validated as a
cost effective approach, is the development of supported
housing programs. The alternative to homelessness in general
is reinvestment in the development of affordable housing.
The precipitation of the homeless epidemic can be traced
to the change in government policy that moved away from the
development of new affordable housing units to of fering cash
subsidies to individuals in the form of Section 8 housing
vouchers to purchase available housing. Between 1976 and
1982, a 7 -year period, more than 755,000 affordable housing
units were built by the federal government; by comparison,
over the next 20 years only 256,000 units were built. Since
1996, The Department of Housing and Urban Development's
(HUD's) funding for new public housing has been $0, while
over 100,000 units of existing public housing have been lost to
demolition, sale, or other removal from the program rolls,
often precipitated by federal urban renewal efforts. At the
outset of deinsitutionalization, from the early 1960s to
mid-1970s, there was a surplus of affordable housing. In 1970 ,
this amounted to 6.8 million affordable units to accommodate
6.4 million low-income renter households; in 2003 the
combination of lack of investment in new affordable housing
and growth in the number of poor families left a deficit of 7.8
million units.
While a small number of supported housing units have
been developed-1l4,000 nationally in the same period-to
address what has become the new policy of the elimination of
chronic homelessness, these facilities seem only a token
replacement compared to the number of low-cost units that
have disappeared (estimated at 2.3 million between 1973 and
1993). The income supplements necessary to make rents
affordable under Section 8 work well in a real estate market
with a surplus in rental housing. In what has become a very
difficult market, landlords can cherry-pick their tenants and do
not have to cope with federal regulations associated with
renting to a federally subsidized person. Thus, reports across
areas show that between 30% and 75% of new Section 8
recipients returned their vouchers unused. A reinvestment in
affordable housing supply is required.
Evaluating Trends in Deinstitutionalization
At its best, deinstitutionalization has succeeded in promoting
community care that is more humane and effective than care
provided in large institutions. At its worst,
deinstitutionalization is condemned because it

has resulted in both the forced homelessness of former residents
of state institutions and an accumulation of individuals in
community-based facilities that are no better than their
antecedents. Unfortunately, the second situation occurs more
frequently.
For the most part, the problems of deinstitutionalization
derive not from the concept itself but from its naive
implementation. The array of community-based services
necessary to support community care is costly. The political
coalition that had forged the deinstitutionalization movement
never had any objectives in common other than reducing
institutional censuses and so it fell apart. Little attention has been
paid to the fiscal incentives created by different branches of
government for the creation, maintenance, or the abandonment of
different institutional forms. The noble ideas expressed in the
GAO definition with its emphasis on finding and developing
appropriate alternatives in the community for housing, treatment,
training, education, and rehabilitation of persons who do not need
to be in institutions and improving institutional care where
necessary, were realized only in model programs, show pieces
spread throughout the country as tempting examples of what
might be. Fiscal retrenchment of government has left the grand
vision of deinsitiutionalization ominously incomplete, a poorly
designed experiment woefully short of resources. As a result,
many residential community care facilities have abandoned the
"small is beautiful" philosophy that provided a marked contrast to
the operations of large institutions. Capitalizing on economies of
scale, many nursing homes and group homes that cater to various
populations have come to resemble the institutions they were
intended to replace. The term "trans institutionalization" has been
coined to describe this lateral movement of individuals from one
dominant institutional form to another. It also describes the
replacement of one type of institution with another as the primary
service site for new admissions.
There is ample evidence in model programs providing quality
supervised care in homelike settings in the community that de
institutionalization can work. However, insofar as it demands
both the improvement of necessary large institutions and the
provision of community-based care, de institutionalization
remains the expensive creation of a frugal era. It may best be seen
as a process that describes the reorganization of institutional
accommodation in a society so as to control the costs of such
provision for marginal and dependent populations.
[See also Adult Foster Care; Aging: Public Policy Issues and
Trends; Child Welfare Overview; Criminal Justice Overview;
Developmental Disabilities:
DEINSTITUTIONALIZA TION 19
Definitions and Policies; Family Caregiving; Health Care:
Reform Initiatives; Health Services Systems Policy;
Homelessness; Long- Term Care; Managed Care; Mental Health
Overview; Patient Rights; Psychosocial Rehabilitation;
Runaways and Homeless Youths; Settlements and Neighborhood
Centers; Social Security; Social Welfare History; Social Welfare
Policy; Supplemental Security Income.]
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Talbott, J. A. (2004). Deinstitutionalization: Avoiding the disasters of
the past. Psychiatric Services, 55(10), 1112-1115.
U.S. Bureau of the Census. (990). We the Americnn eldeTly. Retrieved
from http://www.census.gov/apsd/wepeople/we-9.pdf.
-STEVEN P. SEG!\L
DELINQUENCY. See Juvenile Delinquency; Juvenile
Justice: Juvenile and Family Courts.
DEMOGRAPHICS
ABSTRACT: This entry provides a brief overview of the field
of social demography, the components of population
change, projections of future population growth,

and recent transformations in population composition
pertaining to age, race, and ethniciry. Trends that shape family
household structure (for example, marriage, divorce,
cohabitation, and nonmarital child bearing) are also
considered, as are trends pertaining to the distribution of
income, wealth and poverty. Population trends given particular
attention include the growth of class-based disparities in
marriage and nonmarital child bearing, the contributions of
immigration to population growth and diversity, and a
disturbing increase over recent decades in the prevalence of
poverty among children of immigrants.
KEY WORDS: demography; components of population
change; population growth; population composition;
population aging; old-age dependency ratio; longev ity;
immigration; single parent households; marriage;
divorce; cohabitation; nonmarital births; teen- aged
births; income distribution; wealth distribution; pov-
erty; child poverty; family household structure
Social demography is concerned with three core characteristics
of human populations-size, territorial distribution and
composition-and the dynamic trends in these characteristics
(Hauser & Duncan, 1959; Winnsborough, 2000). Social
welfare policy is closely linked to the determinants of
population change (fertility, mortality, migration and social
mobility), both as a cause and as a consequence. For this
reason, social demographers and social welfare policy scholars
share a compelling interest in how these determinants are
evolving and in tum reshaping the core characteristics of
populations through an array of observable trends. Trends and
determinants of trends of special interest encompass
population aging and human longevity, reproductive behavior,
the distribution of mortality, social stratification, racial identity
and ascription, family structure, immigration, the distribution
of poverty, social mobility, and the spatial dynamics of
disadvantage (for example, racial segregation, concentrated
poverty, and urban blight). A few of the more dominant
demographic trends that affect social welfare policy will be
highlighted: (l) changes in the size of the population and the
components of population change, (2) population aging and
human longevity, (3) trends pertaining to family household
structure, and (4) trends pertaining to the distribution of
income, wealth and poverty.
Population Size, Racial Composition,
and the Components of Population Change
In 2006, official estimates of the US. population reached the
figure of 300 million, and the current U.S. Census Bureau
interim projections predict that the U.s.
DEMOGRAPHICS 21
population will grow to a total of 420 million persons by the
year 2050 (US. Census Bureau, 2004). Moreover, within a few
years on either side of 2050 the United States will no longer be
a nation comprised of a majority non-Hispanic white
population. Changes in racial and ethnic composition are
particularly relevant from a social welfare policy perspective,
because so much of social welfare policy is influenced by and
affects the racial and ethnic stratification that has
characterized American society from its colonial origins.
Between 1970 and 2000, the overall share of the U.S.
population comprising Native Americans, African Americans,
Latinos, and Asian Americans increased from just under 13%
of the population to over 30% (Hirschman, 2005).
The demographic outcomes described above reflect the
complex interplay between the four components of population
change that determine the size and composition of human
populations: births, deaths, immigration and emigration. The
balance between births and deaths determines the net rate of
natural increase or decrease, while the balance between
immigration (inmigration) and emigration (out-migration)
determines the direction of net migration (Shryock & Siegal,
1976). For example, the 10-fold increase in the size of the
Native American population in the 20th century (from about
250,000 to at least 2.5 million persons) represents an
increasingly favorable balance between births and deaths that
produced a robust rate of natural increase and has led to a
resurgence of Native American identity (U.S. Census Bureau,
2002). In contrast, the increased representation of other
ethnic/racial groups in the national population is largely
attributable to the direct and indirect effects of net
immigration (Hirschman, 2005). Thus, both the size and the
racial composition of the 2050 U.S. population (as well as its
age distribution) will be determined by the natural population
increase/decrease occurring among different ethnic/racial
groups and their net migration flows.
Averaged over all ethnic and racial groups, the current
U.S. Census Bureau projects a gradual increase in the average
number of lifetime births per woman (also referred to as the
TFR or Total Fertility Rate) from 2.05 in 2000 to 2.19 in 2050.
Increased fertility, coupled with continued declines in
mortality, provide the foundation for a modest rate of natural
population growth. In addition, the Census Bureau projects net
immigration flows (both legal and nonlegal immigration) that
average about 900,000 persons between 2000 and 2050
(Hollmann, Mulder, & Kallan, 2000; US. Census Bureau,
2005). As a result, the US. population is predicted to add
another 120 million persons over the 300 million person
landmark achieved in 2006 and be about 25% Hispanic, 15%
African American,
22 DEMOGRAPHICS
8% Asian, and about 50% non-Hispanic white (U.S. Census
Bureau, 2005). Notably, in the absence of recent and new
flows of immigrants, the U.S. population of 2050 would be
smaller than currently predicted, much older and dominantly
non-Hispanic whitewith an array of detrimental consequences
that include economic stagnation.
Population Aging and Human Longevity When
the Social Security Act of 1935 was signed into law, the
average life expectancy was approximately 62 years for
males and 63 years for females (Greville, 1947).
According to the current estimates of the National
Center for Health Statistics, life expectancy is now 75
years for males and just over 80 years for females
(NCHS, 2006b). While these phenomenal gains in life
expectancy have tapered off in recent decades, the
sustained incremental gains that are predicted by most
demographers are one key assumption behind U.S.
Census Bureau projections that predict that the
proportion of the population that is aged 85 years and
older will increase fivefold between 2000 and 2050
(U.S. Census Bureau, 2005).
Two other critical trends that affect the proportion of the
population in the oldest age ranges are fertility and
immigration. That is, to the extent that birth rates in the native
population remain low and immigration policies are more
effective at restricting flows of new immigrants, the
proportion of the population in the old and very oldest age
ranges will be increased well over current projections, even
barring additional gains in life expectancy. That is, because
the age distribution of immigrants in the U.S. is skewed
toward the younger age ranges than the native population and
because the foreign-born fertility rate is higher than that of the
native U.S. population, immigration retards the effects on the
age distribution of population aging among native-born
Americans. Indeed, different assumptions about the complex
interaction between the relative birth rates of the native-born
and foreign-born segments of the population, the size of the
immigrant population and new immigrant flows, and
improvements in longevity among the aged, are reflected in
different projections of the magnitude of one measure of the
age distribution, the old-age dependency ratio. That ratio
represents the size of the population that is aged (either 65 or
85- plus), relative to the size of the population that is in the age
range of the labor force, conventionally expressed as the 15-64
age range. The magnitude of the old-age dependency ratio has
enormous implications for social welfare policy, because this
ratio represents both the relative balance between the
entitlement claims of the aged and the taxes placed on the
labor market earnings of the younger
working age generations. Of equal importance, the oldage
dependency ratio also represents the balance between the
demands for formal and informal care posed by a large aged
population and the formal and informal labor resources
available from younger generations.
Census Bureau "middle range" population projections
predict that changes in the age distribution for the period
between the years 2000 and 2025 increase the old-age
dependency ratio by 58% in the 65+ population and 48% in
the 85+ population. The middle case projection for old-age
dependency ratio by the year 2050 predicts an increase of 77%
for the 65+ population (relative to the 2000 population), and
an increase of 300% for the 85+ population (U.S. Census
Bureau, 2000).
The trends in aging thus affect four domains of social
welfare policy: the solvency of the Social Security and
Medicare social insurance trust funds that are the pillars of
economic and health security for the aged, the structure and
sustainability of the formal long term care system (for
example, community-based care agencies, nursing homes),
the adequacy of family resources that are the core of the
informal long-term care system, and the generational balance
of claims and entitlements to a limited pool of social welfare
resources. There are an array of social welfare policy
implications tied to these trends, the most controversial being
the need to revisit the financing and benefit structures of the
Social Security and Medicare trust funds.
Trends Pertaining to
Family Household Structure
Patterns and trends in the composition of family households
are the consequences of several complex processes: marital
and nonrnarital childbearing, marriage and cohabitation,
marital dissolution through divorce or death, and transitions in
the family life cycle (for example, changes in family
households when adult children leave). Such processes and
their effects on trends in the composition of family households
are critical to social welfare policy for several reasons. For
example, trends in nonmarital childbearing have implications
for the relative risk of child poverty by family household type
and the structure of labor market-based social welfare provi-
sions that favor some family household forms over others. In
this brief summary, only a few of the most relevant social
welfare processes and trends are considered: the prevalence of
family household types that are at highest risk of poverty,
trends in the age and marital/ cohabitation distribution of
childbearing, and trends pertaining to the stability of
two-parent households.
TRENDS IN FAMILY HOUSEHOLD TYPES AT HIGH EST RISK
OF POVERTY Over the last several decades,

a diminishing proportion of children are located in a family
household that includes married parents, while the number of
children in a single-parent household headed by a female has
risen dramatically. For example, between 1970 and 2004, the
percentage of children living with a single parent has more
than doubled-from 12% to 28% (Haskins, 2006). In the United
States as with other developed market economies, women
confront a variety of disadvantages in the labor market and
thus are far less likely than men to earn a solo income
sufficient to keep their families out of poverty. For family
households headed by a single female parent, social welfare
supports are far more critical as a buffer against poverty than
for single male parents (Smeeding & Phillips, 2002). The
poverty rate for family households headed by single female
parents is over 2.5 times that for family households headed by
married parents and well over twice that of single-parent
households headed by males.
The trend toward a higher proportion of family households
that are at risk for poverty due to the disadvantaged status of a
single female parent suggests four basic social policy
alternatives: reducing earnings disparities between men and
women, increasing the income and in-kind subsidies to
economically disadvantaged single-parent families,
discouraging nonmarital childbearing, and pursuing policies
that might promote the formation and stability of two-parent
households. Liberal and progressive social policy advocates
tend to be favorably disposed toward policies that attend to
gender-based labor market disadvantages and increasing
income and in-kind transfer subsidies to low-income single
parent families. Centrist and conservative policy advocates
focus their attention on policy solutions aimed at the control of
reproductive behavior and the promotion of marriage and
marital stability. Since the 1970s, the latter kinds of policies
have been in clear ascendance, culminating in the Personal
Responsibility and Work Opportunity Reconciliation Act
(PRWORA) of 1996 that eliminated AFDC (Aide to Families
with Dependent Children) in favor of the Temporary
Assistance to Needy Families (T AN F) program. Three of the
T ANF's core policy goals (reducing the dependency of needy
parents by promoting job preparation, work and marriage,
preventing out-of-wedlock pregnancies, and encouraging the
formation and maintenance of two-parent families) directly
reflect this centrist/conservative policy agenda (Office of
Families Assistance, 2006). In the light of the T ANF core
goals, it is of particular interest from a policy perspective to
examine recent population trends in non-marital child bearing,
cohabitation, and marriage.
TRENDS IN NONMARlTAL CHILD BEARING Although a
temporary pause in what had been a
DEMOGRAPHICS
23
sustained increase in nonmarital child-bearing coincided with
the passage of T ANF in 1996, since then a sustained increase
in nonmarital child-bearing has resumed. As T ANF entered its
first full decade of implementation, the nonmarital birth rate
had risen to an unprecedented 37% of all births, despite the fact
in the decade subsequent to the implementation of welfare
reform in 1996, welfare participation had declined to its lowest
level since 1962 (NCHS, 2006a).
This suggests that welfare participation itself has little to do
with sustained trends in nonmarital childbearing, either as a
cause or an effect. Notably, most of nonmarital child-bearing
(77%) occurs with women over the age of 20 (NCHS, 2006a).
This implies that delayed marriage in adulthood and the choice
of cohabitation as an alternative to marriage have become
dominant over teenaged sexual activity as the central
explanation for out-of-wedlock child-bearing. Indeed, the
teenaged birth rate has been in continuous decline since the
early 1990s, while over the same period (per Figure 4) the
general out-of-wedlock birth rate has been on the rise.
Teenaged child-bearing has declined from the 50% share in
nonmarital child bearing it held in 1970 to the 23% share in
nonmarital child-bearing it holds today (NCHS, 2000, 2006a ).
Taken together, these findings suggest that the current strategy
of linking the structure of welfare benefits to adolescent
reproductive behavior and postbirth living arrangements is
unlikely to yield the magnitude of benefits envisioned by the T
ANF program's most vociferous proponents.
TRENDS IN COHABITATION, MARRIAGE, AND
DIVORCE As discussed previously, children who live in
households where both parents are married and present have a
far lower probability of poverty than children in families
headed by a single female, although the direct effects of
marriage and the presence of both parents are difficult to
disentangle from a variety of confounding effects (pertaining
to such factors as education, stable employment, and selective
psychological traits). However, progressive as well as
conservative social welfare scholars broadly favor policies that
support the viability of marriage as an institution and the
stability of two-parent households (Haskins, 2006). Indeed,
rates of marital disruption by marriage cohort and the marriage
rates themselves have been moving in unfavorable directions
since the 1960s (Bramlett & Mosher, 2002). To an increasing
extent, cohabitation is being used both as a preliminary step
toward marriage and also a substitute. While in most racial and
ethnic groups three out of four women enter marriage by age
30, roughly one-half of women who eventually enter marriage
at
24 DEMOGRAPHICS
some point during their child-bearing years (conventionally
defined as the 15-44 age range) have also cohabited at least
once either before or subsequent to their first marriage
(Bramlett et al., 2002). As noted in the most recent
comprehensive report on the population dynamics of
cohabitation, marriage, and divorce by the National Center for
Health Statistics, increased rates of cohabitation have largely
offset declines in the marriage rates (see Bramlett et al., 2002,
p. 4). Generally speaking, longer term cohabitations
(particularly those that entail children and parenting
functions) eventually result in marriage. However, what is
most critical from the standpoint of social welfare policy is
that transitions from cohabitation to marriage are greatly
influenced by such contextual factors as the local community
male unemployment rate and thee extent of community pov-
erty (Bramlett et a1., 2002, p. 2). Conversely, high levels of
unemployment and higher levels of community poverty are
more conducive to higher rates of divorce (Bramlett et al.,
2002., p. 20). Broadly speaking, the demographic evidence
from patterns of cohabitation, marriage, and marital
disruption suggests that policies that favor employment
opportunities and lower poverty rates are in effect
pro-marriage as well.
Class Differences
There is an ever-widening income and education gap in
marriage rates and single parenthood between the lower and
higher ends of the socioeconomic hierarchy. While between
1960 and 2000 the likelihood of nonmarital child-bearing
among women in the top quarter of the educational
distribution rose modestly from 4.5% to 7% of all births, for
women in the lowest quarter of the educational distribution,
the incidence of nonrnarital child-bearing increased
dramatically from 14% of all births to 43% (Cherlin, 2005).
As observed by McLanahan (2004), the divergent patterns in
nonrnarital child births by education and income suggest the
emergence of a distinct class-based divide in reproductive
strategies. At the bottom of the income and education
distribution, the reproductive strategy increasingly entails
early child-bearing outside of marriage, seemingly in
response to limited prospects for either a stable marriage or
educational advancement. Among women with more
favorable opportunities for advanced education and high in-
come, a strategy that involves delayed marriage and
childbearing subsequent to high return investments in
education and career has become prevalent (Chetlin, 2005;
McLanahan, 2004). ln the long run, these class-based
differences in reproductive and marriage strategies both
extend and further solidify the already formidable boundaries
of social class.
The Distribution of Income,
Wealth, and Poverty
TRENDS IN HOUSEHOLD INCOME AND THE DIS-
TRIBUTION OF WEALTH Over the nearly four decades
since 1970, the annual median household income (in constant
dollars) has increased from $37.5 thousand per year to $46.3
thousand-a 23.4% increase (DeNavasWalt, Proctor, & Lee,
2006). However, over this same period, income inequality (as
measured by the Gini Coefficient) also increased by 18.2%.
Relative to income, wealth (individual or household net worth
in dollars, and dollar values in real estate, furnishings, and
belongings) has become even more concentrated in the United
States. According to Federal Reserve Board estimates, by
2001 the nation's wealth was distributed in one-third
allotments to each of the following groups: the wealthiest 1 %
of the population, the next wealthiest 9%, and the remaining
90% of the population. Only 3% of wealth is owned by the
least wealthy half of the population (Kennickell, 2003, p. 6).
Race and Gender Differences
Disparities in the racial distribution of wealth are also quite
remarkable, for example, even with dramatic gains in net
worth during the 1990s, the median wealth of African
American households by the end of the decade was only 16%
that of non-Hispanic white households (Kennickell, 2003, p .
48).
Racial and gender disparities persist despite broad
progress. For example, African American households have
just 61 % of the median for non-Hispanic White households,
Hispanic households 71 %, and Native American households
66% of the median income of non-Hispanic white households
(DeNavas-Walt et al., 2006). In terms of gender disparities,
despite a favorable trend since 1980, the earnings ratio of
women by year 2005 remained only 77% that of men
(DeNavas-Walt et al., 2006).
General Poverty Trends. Poverty trends are tracked by
various federal agencies primarily through one measure,
the federal poverty line (FPL). This 40year- old measure,
devised by a Social Security Administration economist, is
based on obsolete assumptions pertaining to the
relationships between food costs, family composition, and
other household expenditures. The FPL does not consider
adjustments for such factors as local variations in food and
housing costs, child care, transportation, or off-setting
in-kind subsidies, and is insensitive to fluctuations and
trends in the severity of poverty. However, the FPL
remains a useful measure for the general interpretation of
trends in absolute poverty.
As measured by the FPL, since 1970 the poverty rate for
the general U.S. population has fluctuated

between 11% and 15% (DeNavas-Walt et al., 2006). The
general poverty rate declined during most of the 1990s to the
11.3% level in 2000, but it has since gradually risen to its
current 12.6% level. This translates to 37 million U.S.
residents in poverty (DeNavasWalt et al., 2006). Of course, the
risk of falling below the FPL is not shared equally.
Race, Class and Gender Differences
There are large variations in poverty rate according to age, sex,
marital status, race, ethnicity, nativity, and geographic
location. The households that are most likely to fall into
poverty are female-headed, single-parent households. In terms
of race and ethnicity, the groups that share a disproportionate
risk of poverty include African Americans (24.7%), Native
Americans (25.3%), and Hispanics (22.0%) (DeNavas-Walt et
al., 2006).
In the last three decades of the 20th century, the aged have
been at no greater risk of poverty than the working age
population. Currently, only 10% of persons over age 65 are
below the FPL (DeNavas-Walt et al., 2006). However, child
poverty trends are somewhat the opposite for the last three
decades.
Trends in Child Poverty. According to the U.S.
Census Bureau's most recent (2005) annual estimates of
poverty in the United States, 17.6% of children (12.9 million
children) in the United States were living below the federal
poverty line, an estimate essentially unchanged from the
previous year (DeNavas-Walt et al., 2006). As shown in the
historic child poverty trends, from the early 1990s through
2000 there was a sustained decrease in the percentage of
children living in poverty, followed by a slight rise that seems
to have peaked during 2004. Two groups that represent a large
share of children in poverty, African Americans and
Hispanics, both benefited from a robust decline in the child
poverty rate during most the 1990s. Other groups with a
historically large share of children in poverty also benefited
from reductions in child poverty during the 1990s: Native
Americans (from 38.0 to 30.7%), Southeast Asians (from 37.4
to 26.8%), and Puerto Ricans (from 41.0 to 32.7%) (Lichter,
Qian, & Crowley, 2005).
In contrast to other groups, since 2000 poverty among
African American children has resurged. In part, this may be a
reflection of recent research findings showing that states with
high proportions of African Americans also have more
punitive T ANF sanction policies (Soss, 2006). Taken as a
whole, however, the general trends in child poverty over the
last 15 years that mark the pre- and post-T ANF periods
provide little compelling evidence to support early fears that T
ANF would plunge more millions of children into poverty, or
the claims of T ANF's most ardent proponents
DEMOGRAPHICS 25
that decreasing welfare participation in favor of low wage
employment functions as an antipoverty policy.
Beneath the historic trends, child poverty is a worrisome
variation with significant social welfare policy implications.
In 1970, both children of native born Americans and the
children of immigrants shared a similar risk of poverty, with
the children of immigrants at a 12 % poverty rate relative to an
overall child poverty rate of 14.9% (U.S. Census Bureau,
2006; Van Hook, Brown, & Kwenda, 2004). As the proportion
of the foreign-born U.S. population increased over the last
decades of the 20th century from under 5% of the popula tion
in 1970 to over 11 % (Hirschman, 2005), so did the poverty
rate of the children of immigrants, peaking in the 1990s at a
33% child poverty rate and then ending the century at 21%
(Van Hook et al., 2004).
In general, the increased share of child poverty among
children of immigrants can be attributed to such factors as
structural changes in the U.S. economy and differences in the
human capital resources of more recent waves of immigrants
compared to earlier waves (Van Hook et al., 2004). However,
it is also the case that social welfare policy has evolved to
become restrictive (and even punitive) toward immigrant
families at a historical point when the structure of the U.S.
economy offers ever more daunting obstacles for the upward
mobility oflow-wage workers. As we are warned by
immigration sociologist Alejandro Portes, in the absence of
significant compensatory investments in the children of
immigrants from the more economically disadvantaged
groups, we are on the path to replicating the tragic national
legacy of racial and ethnic stratification in the generations to
come (Portes, FernandezKelly, & Haller, 2005).
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-GUNNAR ALMGREN
DIAGNOSTIC AND STATISTICAL MANUAL OF
MENTAL DISORDERS
ABSTRACT: The fourth edition of the Diagnostic and
statistical manual of mental disorders Diagnostic and
Statistical Manual of Mental Disorders of the American
Psychiatric Association is referred to as DSM-IV. DSM-IV's
predecessor, DSM-III, differed considerably from the first two
editions. Its innovative incorporation of specified diagnostic
criteria and a multiaxial system for evaluation resulted in its
having a major impact on the field of mental health.
KEY WORDS: criteria set; mental disorder; multiaxial system;
relational disturbances
The fourth edition of the Diagnostic and Statistical Manual of
Mental Disorders of the American Psychiatric Association
(APA, 1994) is referred to as DSM-IV. DSM-IV's
predecessor, DSM-III (APA, 1980), differed considerably
from the first two editions. Its innovative incorporation of
specified diagnostic criteria and a multiaxial system for
evaluation resulted in its having a major impact on the field of
mental health (Spitzer et al., 1980).
DSM-IV contains a classification that lists all the mental
disorders, as well as certain conditions that are not mental
disorders but may be a focus of clinical attention. In addition,
it includes a detailed description of each diagnostic category,
and specified diagnostic criteria for each mental disorder to
help clinicians make reliable diagnoses. The specific
diagnostic categories are grouped into the 17 major classes
listed in Table 1. Each category is assigned a code number
that can be recorded for statistical and record-keeping
purposes.
Work on DSM-IV proceeded in three major phases
(Widger et al., 1990). First, each work group developed
 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS 27
TABLE 1
Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence
Delirium, dementia, and amnestic and other cognitive
disorders
Mental disorders due to a general medical condition not
elsewhere classified
Substance-related disorders
Schizophrenia and other psychotic disorders
Mood disorders
Anxiety disorders
Sornatoforrn disorders
Factitious disorders
Dissociative disorders
Sexual and gender identity disorders
Eating disorders
Sleep disorders
Impulse-control disorders not elsewhere classified
Adjustment disorders
Personality disorders
Other conditions that may be a focus of clinical attention
systematic and comprehensive literature reviews focusing on
the most pertinent issues in their area, to inform their final
decisions and to document the process and the reasons for
those decisions. Second, the John D. and Catherine T.
MacArthur Foundation funded a series of analyses of data
from completed studies or studies in progress to answer
specific nosologic questions. Finally, the National Institute of
Mental Health (NIMH), the National Institute on Drug Abuse
(NIDA), and the National Institute on Alcohol Abuse and
Alcoholism (NIAAA) funded 12 field trials to study the effects
of the changes that were being considered. The literature
review and reports on the data reanalyses and the field trials
were published in a series of volumes called the DSM-IV
Sourcebook (APA, 1994).
Since the next major revision of DSM (DSM- V) will not
be available until 2012 or so, a text revision of the manual,
DSM-IV-TR, was published in 2000 (APA, 2000). The main
goal of DSM-IV-TR was to update the text description of the
disorders, while preserving the diagnostic criteria as they were
developed for DSM-IV. (A handful of the criteria sets were
altered ro correct errors or ambiguities in the DSM-IV criteria,
and some of the diagnostic codes were changed.) The
descriptive text of the manual was revised by Work Groups for
the DSM- IV Text Revision to reflect recent research and
clinical findings. The DSM-IV-TR includes an appendix
(Appendix D) that provides an overview of the important
changes.
In 2002, "A Research Agenda for DSM- V" was published
at the end of a 3-year pre-planning phase for DSM-V. This
volume was an attempt to stimulate
research and discussion in the field in preparation for the
DSM-V revision process that eventually began in 2006. The
volume was prepared under a partnership between the APA
and the NIMH, NIAAA, and NIDA with the goal of providing
direction and potential incentives for research that would yield
an improved scientific basis for future classifications. A Web
site, DSM-V Prelude, was set up to keep the public and
professional communities informed.
In 2006, the APA announced the appointment of Dr. David
Kupfer, Professor and Chair of the Department of Psychiatry
at the University of Pittsburgh Medical Center, as the Chair of
the DSM- V task force. As of this writing, the members of the
task force and work groups have not been announced. Updates
will be posted on www.dsm5.org.
Multiaxial System
An important and unique feature of DSM-IV of special
interest to social workers is the inclusion of a multiaxial
system for evaluation (Williams, Goldman, Gruenberg,
Mezzich, & Skodol, 1990). The system is similar to the one
inaugurated in DSM-III, which incorporated a rnultiaxial
system in which psychological, biological, and social aspects
of an individual's functioning are evaluated and the results
recorded on different axes. The DSM-IV-TR system includes
the five axes listed in Table 2; each axis requires the
evaluation of a different domain of information that may help
the practitioner plan treatment and predict outcome. Axes I
and II contain all the mental disorders, and Axis III lists
general medical conditions. Axis IV provides a checklist for
recording psychosocial and environmental problems that may
affect the diagnosis, treatment planning, and prognosis of an
individual's mental disorders. Finally, Axis V includes a rating
scale to indicate a person's overall level of functioning. The
instructions for making an Axis V (GAF Scale) rating are
explained in DSM-IV-TR.
The use of a multiaxial system facilitates comprehensive
evaluation with attention to different types of disorders,
aspects of the environment, and areas of function that may be
overlooked if the focus were limited to the assessment of a
single presenting problem. Personality disorders and mental
retardation are listed on a separate axis from the other mental
disorders because they tend to be overlooked, in that their
symptoms are generally chronic and stable, relative to the
Axis I disorders.
DSM-IV-TR's multiaxial system emphasizes areas of
information that have traditionally been considered highly
important in social work evaluations: psychosocial and
environmental problems and adaptive
28 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

functioning. It is these areas that are the focus of the
Person-in-Environment System (Karls & Wandrei, 1992,
1994; Williams, Karls, & Wandrei, 1989). The inclusion of
these areas in the official multiaxial evaluation system of
DSM-IV-TR encourages more comprehensive assessment of
an individual than did DSM-I and DSM-ll, which were limited
to brief descriptions of the mental disorders and did not
include diagnostic criteria or a multiaxial system.
Other Important Features
DSM-IV-TR differs in other important ways from earlier
diagnostic schemes. First, it takes a generally atheoretical
approach to the classification of mental disorders, as did
DSM-lIl and DSM-III-R. In other words, it describes the
manifestations of the various mental disorders and only rarely
attempts to account for the causes of the disturbances, unless
the mechanism is included in the definition of the disorder (as
in the disorders that are due to
general medical conditions). This approach permits clinicians
of differing theoretical orientations to use the specified criteria
to make diagnoses while retaining their diverse theories about
the causes of the various disorders.
Second, the inclusion since DSM-III of specified
diagnostic criteria as guides for making a diagnosis has
enhanced the reliability with which a diagnosis can be made
(see, for example, the DSM-IV-TR diagnostic criteria for a
major depressive episode in Table 3).With diagnostic criteria,
clinicians are better able to agree about the presence or
absence of a condition when they evaluate a patient or client.
However, although diagnostic reliability is essential for
effective communication among mental health professionals,
even high reliability does not necessarily indicate high validity
or accuracy of the diagnostic definitions.
A word of caution: As noted in the introduction to
DSM-IV-TR, it is necessary to obtain much more information
beyond a DSM-IV-TR diagnosis before an

TABLE 2 DSM-IV-TR
Multiaxial System
Axis I: Clinical disorders Axis II: Other conditions that may be a focus of clinical attention Mental
Personality disorders retardation
Axis III: General medical conditions
Axis IV: Psychosocial and environmental problems Axis V:
Global assessment of functioning

TABLE 3
The DSM-IV-TR Diagnostic Criteria for a Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at
least one of the symptoms is either (a) depressed mood or (b) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a
general medical condition, or mood-incongruent delusions or hallucinations. (1) Depressed mood most of the day, nearly every day, as indicated by
either subjective report (for example, feels sad or empty) or observation made by others (for example, appears tearful). Note: In children and
adolescents, can be irritable mood. (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
(as indicated by either subjective account or observation made by others). Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected
weight gains. (4) Insomnia or hypersomnia nearly every day.
(5) Psychomotor agitation 0 retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed
down). (6) Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick). (8) Diminished abilityto think or concentrate, or indecisiveness, ready every
day (either by subjective account or as observed by others). (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms do not meet criteria for a Mixed Episode.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are
not due to the direct physiological effects of a substance (for example, a drug of abuse, a medication) or a general medical condition (for example,
hypothyroidism). The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer
than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. Washington, DC: Author (4th ed.) Reprinted by
permission.
 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS 29

adequate treatment plan can be formulated for any individual. TABLE 4

A DSM-IV-TR diagnosis represents only the initial step in a Criteria Sets Included in DSM-lV-TR's Appendix B
comprehensive evaluation that leads to a treatment plan. Of
course, the additional information that is necessary will be Postconcussional disorder Mild
neurocognitive disorder
determined, in part, by the theoretical orientation of the Caffeine withdrawal
clinician and may emphasize the psychological, biological, or Alternative dimensional descriptors for Schizophrenia
social aspects of the functioning of the individual being Postpsychotic depressive disorder of Schizophrenia Simple
evaluated. deteriorative disorder (simple Schizophrenia) Premenstrual
dysphoric disorder
Alternative Criterion B for Dysthymic Disorder
Minor depressive disorder
Cross-Cultural Considerations Recurrent brief depressive disorder
Mixed anxiety-depressive disorder
The issue of cultural considerations in DSM-IlI received even Factitious disorder by proxy
more attention in DSM-IV, supported by the Conference on Dissociative trance disorder
Culture and DSM-IV (Mezzich, Kleinman, Fabrega, & Parron, Binge-eating disorder
1996). The conference specifically addressed needed changes Depressive personality disorder
in the text and criteria that would make them more useful and Passive-aggressive personality disorder (negativistic
personality disorder)
accurate across cultures. In addition, three innovative features Medication-induced Movement Disorders
were included in DSM-IV. First, a new section, describing Neuroleptic-induced Parkinsonism
culturally related features, was added to the text of many Neuroleptic malignant syndrome
disorders that are influenced by cultural factors. Second, Neuroleptic-induced acute dystonia Neuroleptic-induced
descriptions of some "culture-bound syndromes" were added acute akathisia Neuroleptic-induced tardive dyskinesia
Medication-induced postural tremor Medication-induced
as examples in some residual categories (for instance, movement disorder not otherwise
"possession" is listed as an example of a dissociative disorder specified:
not otherwise specified). Third, an outline for cultural Defensive Functioning Scale
formulation and a glossary of culture-bound syndromes were Global Assessment of Relational Functioning (GARF) Scale Social
and Occupational Functioning Assessment Scale
included in Appendix I.
(SOFAS)

From Diagnostic and statistical manual of mental disorders (4th ed.,

pp. 759-815), by American Psychiatric Association, 2000, Washington.
Relational Disturbances DC: Author reprinted with permission.
A frequent criticism of DSM-IlI was that it included only "These categories are included in the "Other Conditions That May
mental disorders that occur in individuals, which restricted its Be a Focus of Clinical Attention" section. Text and research criteria
usefulness in the diagnosis and treatment of problems that sets for these conditions are included here.
occur in the family and other relational units (Wynne, 1987 ).
Early in the development of DSM-IV, the Coalition on Family
Diagnosis was formed by professional groups that deal with
these issues to consider possible changes that might be made in
that worked on the definitions of disorders and the APA
DSM-IV. The result was several new features, including the
DSM- IV Task Force believed that there was sufficient
addition to the section on Other Conditions That May Be a
research and clinical evidence of the validity of each of these
Focus of Clinical Attention of a group of relational problems:
categories to justify their inclusion in the revised manual,
relational problem related to a mental disorder or general
although not as full-fledged disorders and axes. Table 4 lists
medical condition, parentchild relational problem, partner
the categories for which criteria sets are included in
relational problem, and sibling relational problem.
DSM-IV-TR's Appendix B. This appendix contains a number
Furthermore, an optional axis, the Global Assessment of
of proposals for new categories and axes that were suggested
Relational Functioning (GARF) Scale, was inserted in
for possible inclusion in DSM-IY. The DSM-IV Task Force
Appendix B.
and Work Groups subjected each of these proposals to a
careful empirical review, and invited wide commentary from
the field. The task force determined that there was insufficient
Criteria Sets and Axes Provided for Further information to warrant inclusion of these proposals as official
Study (Appendix B) categories or axes in DSM-IV.
During the development of DSM-IV, there were many
proposals for new categories. The advisory committees
30 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS
The items, thresholds, and durations contained in the
research criteria sets were intended to provide a common
language for researchers and clinicians who are interested in
studying these disorders. It is hoped that such research will
help to determine the possible utility of these proposed
categories and will result in refinement of the criteria sets. The
specific thresholds and durations were set by expert consensus
(informed by literature review, data reanalysis, and field trial
results when such information was available) and, as such,
should be considered tentative. It would be highly desirable
for researchers to study alternative items, thresholds, or
durations whenever this is possible.
Also listed are three optional axes that may be useful to
clinicians and researchers.
DSM- IV as an Educational Tool
Certain features of DSM- IV - TR make it useful as a tool for
teaching students about basic psychopathology (Skodol,
Spitzer, & Williams, 1981). Appendix A includes a number of
decision trees for differential diagnosis that can guide a
clinician to follow a series of questions to rule in or out
various disorders. The Glossary of Technical Terms
(Appendix C) defines technical terms that are included in the
diagnostic criteria of DSM-IV-TR. Appendix 0, Highlights of
changes in DSM-IV Text Revision, provides an overview of
the changes made in the descriptive text from DSMIV-TR.
Other useful teaching tools include the DSM-IV-TR
Casebooks (Spitzer, First, Gibbon, & Williams, 2004, 2006;
Spitzer, Gibbon, Skodol, Williams, & First, 2002) and various
study guides (Fauman, 2002).
The text for each specific mental disorder includes
information under each of the following headings: diagnostic
features; subtypes or specifiers; recording procedures;
associated features and disorders; specific culture, age, and
gender features; prevalence; course; familial patters; and
differential diagnosis. Care was taken in the text and criteria
of DSM-IV-TR to avoid the use of such phrases as
"schizophrenic" or "alcoholic" because the classification and
descriptions are of mental disorders that people have, rather
than of the people themselves (Spitzer & Williams, 1979).
Instead, the manual refers to "a person with schizophrenia" or
"individuals with alcohol dependence." This terminology
avoids the mistaken implication that a person with a mental
disorder has only that, and no other important attributes and
roles in life, and that all people with a particular mental
disorder are alike.
In addition, in DSM-IV-TR the individuals evaluated are
not referred to as "patients." During development of DSM-lIl,
it was recognized that the use of this
word might limit the use of the manual by some mental health
professionals, including many social workers, who do not
traditionally refer to their clientele as patients. Finally, in a
further attempt to facilitate the use of DSM-IV-TR by the
various mental health professions, the terms "physician" and
"psychiatrist' are not used. Instead, users are referred to as
clinicians and mental heath professionals.
Importance to Social Work
DSM-III and DSM-III-R have not been without their critics,
even among social workers (Kirk & Kutchins, 1992), and
DSM-IV has been similarly critiqued. However, recognizing
that DSM is still an imperfect system, one must balance the
improvement in mental health practice that it has facilitated
with the possible drawbacks to the system, such as an implied
reification of the diagnostic categories and an increased
number of categories that could potentially become
stigmatizing labels. Despite these potential negatives, the
increasing precision of the classification of mental disorders
has undoubtedly facilitated recent important clinical and
research advances, such as more effective psychotherapeutic
and pharmacological treatments for panic disorder and major
depressive disorder, as well as significant genetic findings,
such as those that are already paving the way to cures for some
general medical disorders. The drawbacks to patients or clients
and mental health professionals, on balance, seem few in
comparison to the potential gains. It is crucial for clinical
social workers to be familiar with the diagnostic criteria and
multiaxial system of DSM-IV-TR because of the manual's
universality as a tool for communication among mental health
professionals, its potential as a basis for research, its
usefulness for teaching psychopathology, and its contribution
to effective evaluation and treatment planning.
In most psychiatric treatment facilities, the language of
DSM- IV - TR is the standard terminology used in diagnostic
case discussions. Therefore, familiarity with DSM-IV -TR is
often required for participation in such discussions. The
specificity of the diagnostic criteria in DSM-IV-TR and the
consequent increase in diagnostic reliability have made it
possible for researchers to select groups of subjects that are
more homogeneous diagnostically. Because many social
variables are influenced by and have an influence on
psychopathology, it is important for researchers in the social
sciences to pay attention to diagnostic variables. Without
doubt, the most significant contribution of DSM-III and
DSMIV is their enhancement of the comprehensiveness of
diagnostic evaluations and the effectiveness of treatment
planning by the inclusion of a multiaxial system and specified
diagnostic criteria that are based in the

most up-to-date empirical research and clinical experience.
The increased reliability and validity with which the various
mental disorders are defined in DSM-IV-TR should result in
more effective treatment planning because they have
promoted the establishment of a clearer relationship between
diagnosis and treatment for many of the categories (Frances et
al., 1991).
It was said that DSM-III was "only one still frame in the
ongoing process of attempting to better understand mental
disorders" (APA, 1980, p. 12). The specificity of DSM- III
encouraged research that has already provided the basis for
many improvements in the classification and definitions of
mental disorders. Presumably, this process will continue as the
improved definitions help professionals develop more
effective treatments. The recent DSMs are seen as major
contributions to the science of mental health and to its practice
worldwide (Spitzer, Williams, & Skodol, 1983). The manuals
have been translated into many languages and are used rou-
tinely by teachers and researchers in other countries. Input
from research with individuals from various social and cultural
backgrounds has increased significantly with each revision of
DSM and will undoubtedly continue to provide information
that will be useful for future revisions of the manual.
REFERENCES
American Psychiatric Association. (1980). Diagnostic and statistical
manual of mental disorders (3rd ed.). Washington, DC:
Author.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC:
Author.
Frances, A., Pincus, H., Davis, W. W., Kline, M., First, M., & Widiger
T. (1991). The DSM-IV field trials: Moving towards an
empirically derived classification. European Psychiatry, 6,
307-314.
Karls, j., & Wandrei, K. (1992). PIE: A new language for social work.
Social Work, 37,80-85.
Karls,]. M., & Wandrei, K. E. (1994). Person in environment system:
The PIE classification system for social functioning problems.
Washington, DC: NASW Press.
Kirk, S. A, & Kutchins, H. (1992). The selling of DSM: The rhetoric of
science in psychiatry. New York: Aldine de Gruyer.
Mezzich,]. E., Kleinman, A, Fabrega, H., & Parron, D. (1996).
Culture and psychiatric diagnosis. Washingron, DC:
American Psychiatric Press.
Skodol, A E., Spitzer, R. L., & Williams, ]. B. W. (1981).
Teaching and learning DSM-lIl. American Journal of Psychiatry,
138, 243-244.
Spitzer, R. L., Williams, ]. B. W., & Skodol, A E. (Eds.). (1983).
International perspectives on DSM-lll. Washington, DC: American
Psychiatric Press.
Spitzer, R. L., Gibbon, M., Skodol, A. E., Williams,]. B. W., & First,
M. B. (2002). DSM-lV-TR casebook. A learning
DIRECT PRACTICE 31
companion to the diagnostic and statistical manual of mental
disorders (4th ed., text rev.). Washington, DC: American
Psychiatric Association.
Spitzer, R. L., First, M. B., Gibbon, M., & Williams,]. B. W. (Eds.).
(2004). Treatment companion to the DSM-lV- TR casebook.
Washington, DC: American Psychiatric Association.
Spitzer, R. L., First, M. B, Williams, ]. B. W., & Gibbon, M. (Eds.).
(2006). DSM-lV- TR casebook, Vol. 2. Experts tell how they treated
their own patients. Washington, DC: American Psychiatric
Association.
Williams,]. B. W., Goldman, H., Gruenberg, A., Mezzich,]. E., &
Skodol, A E. (1990). DSM-IV in progress: The multiaxial system.
Hospital & Community Psychiatry, 41, 181-182.
Williams,]. B. W., Karls,]. M., & Wandrei, K. (1989). Social work
update: The person-in-environment (PIE) system for describing
problems of social functioning. Hospital & Community Psychiatry,
40, 1125-1127.
Wynne, L. C. (1987). A preliminary proposal for strengthening the
rnultiaxial approach of DSM-lll: Possible familyoriented
revisions. In G. L. Tischler (Ed.), Diagnosis and classification in
psychiatry: A critical appraisal of DSM- 11l (pp. 477-488).
Cambridge, England: Cambridge University Press.
FURTHER READING
American Psychiatric Association. (1952). Diagnostic and statistical
manual of mental disorders. Washington, DC: Author.
American Psychiatric Association. (1968). Diagnostic and statistical
manual of mental disorders (2nd ed.). Washington, DC:
Author.
American Psychiatric Association. (1987). Diagnostic and statistical
manual of mental disorders (3rd ed., rev.). Washington, DC:
Author.
Frances, A, Pincus, H. A, Widiger, T. A, Davis, W. W., & First, M.
B. (1990). DSM-V: Work in progress. American Journal of
Psychiatry, 147, 1439-1448.
Kutchins, H., & Kirk, S. A (1987). DSM-1lI and social work
malpractice. Social Work, 32(3), 205-211.
Williams,]. B. W. (1985). The multiaxial system of DSM-llI:
Where did it come from and where should it go? lts origins and
critiques. Archives of General Psychiatry, 42, 175-180.
-]ANET B. W. WILLIAMS
DIRECT PRACTICE
ABSTRACT: Direct practice in social work represents the
micro-level practice environment (individuals, families, and
groups). This encompasses a vast arena of practice as social
workers are employed in many different social service,
educational, health, and mental health settings and serve many
different roles within these settings. What underlies these
various roles and settings is social work's commitment to
bring services to oppressed and vulnerable people and to
improve their quality of life.
32 DIRECT PRACTICE
KEY WORDS: direct practice; strengths-based practice;
evidence-based practice
Direct practice in social work represents the microlevel
practice environment (individuals, families, and groups). This
encompasses a vast arena of practice as social workers are
employed in many different social service, educational,
health, and mental health settings and serve many different
roles within these settings. What underlies these various roles
and settings is social work's commitment to bring services to
oppressed and vulnerable people and to improve their quality
of life.
Although the Council on Social Work Education Policy
and Accreditation Standards (CSWE EPAS, 2004) for "social
work practice" contain many different charges for education
in this area, two main underlying thrusts will be emphasized
here. The first thrust is a focus on the "strengths, capacities,
and resources ~f client systems ... " (CSWE EPAS, 2004, p.
4). Client systems can be defined as individuals, families,
groups, organizations, and communities, and the interaction
between the client system and the broader environment is the
focus of intervention (rather than pathology within the
individual). The second thrust for social work practice is to
identify, analyze, and apply empirically based interventions.
These two major thrusts will be expanded later.
A recent movement in the helping professions focuses on
the strengths of people and their circumstances rather than
individual pathology. Prior to this time, the dominant idealogy
involved the "expert" practitioner diagnosing and determining
what people should do to fix their problems. People were
viewed largely in terms of their weaknesses, limitations, and
problems. Now with strengths-based (Saleeby, 2001) and
resilience (Werner & Smith, 2001) frameworks, the helper, in
collaboration with the client system, identifies and amplifies
existing client system capacities in order to resolve problems
and improving quality of life. Strengths-based approaches can
be viewed as respectful toward and empowering of the
oppressed and vulnerable people to which the field of social
work has been traditionally committed.
Three different approaches can help operationalize a
strengths-based idealogy for foundation-level in direct social
work practice. These include solution-focused brief therapy,
motivational interviewing, and the risk and resilience
framework. Developed by deShazer, Berg, and colleagues
(Cade & O'Hanlon, 1993; De ]ong & Berg, 2001; deShazer,
1998, 1994; de Shazer et al., 1986; O'Hanlon & Weiner-Davis,
1989), solution-focused brief therapy, in addition to a
theoretical basis and philosophy of change, has also
developed a method for using language and specific
techniques to orient clients
toward strengths, even when they find themselves amidst
difficult and painful circumstances or when they are initially
unwilling to make changes. Solution-focused work is geared
toward specific, concrete goals that are achievable within a
brief time frame, making it ideal for use in all types of social
work settings (not just in "therapy" as the title implies), even
those in which the social worker is limited to one client
contact, such as crisis intervention. Indeed, solution-focused
brief therapy has been applied to crisis intervention (Greene,
Lee, & Trask, 2005), school services (Durrant, 1995; Murphy,
1997), and child welfare (Berg & Kelly, 2000; Corcoran,
1999,2002,2004).
A second strengths-based approach for foundation direct
practice, motivational interviewing, is also a brief method that
can be used in all types of settings. Specifically designed for
work with people who are initially unwilling to make changes
(Miller & Rollnick, 2002), motivational interviewing works
with a client's inherent ambivalence toward change. A
by-product of working with oppressed and vulnerable people
is that they often come to social workers because they have
been mandated to do so by the courts or by another external
entity. Like solution-focused brief therapy, it is an approach
that respects the value, dignity, and worth of the individual
with recognition of self-determination; that is, clients should
determine the course of their change. Specific techniques
include listening reflectively, demonstrating empathy, getting
the client to argue for change, exploring the advantages and
disadvantages of change. Also explored are techniques for
handling "resistance," which is defined as a sign that the
practitioner's tactics do not match the client's stage of change
(Miller & Rollnick, 1991). Although designed for people with
substance use disorders, it has been applied to other problems
in which ambivalence about change is paramount (that is,
eating disorders and intimate partner violence) (Killick &
Allen, 1997; Wahab, 2005) and has evidenced effectiveness
with alcohol and drug use problems (Burke, Arkowitz, &
Menchola, 2003; Vasilaki, Hosier, & Cox, 2006).
A third framework, the biopsychosocial risk and resilience
framework captures "the complex interplay of multiple
psychological, social, and biological processes" that result in
the occurrence of emotional or mental disorder (Shirk, Talmi,
& Olds, 2000). The risk and resilience aspect of the framework
considers the balance of risk and protective factors that
interact to determine an individual's propensity toward
resilience, or the ability to function adaptively despite stressful
life events. The strengths perspective underlies the concept of
"resilience" in that resilient people are not only able to survive
and endure but also can triumph over difficult life
circumstances.

Risks, on the other hand, can be understood as "hazards in
the individual or the environment that increase the likelihood
of a problem occurring" (Bogenschneider, 1996). Protective
influences exist in the presence of risk, and involve the
"personal, social, and institutional resources that foster
competence, promote successful development, and thus
decrease the likelihood of engaging in problem behavior"
(Dekovic, 1999). Protective mechanisms may counter-balance
or buffer against risk (Pollard, Hawkins, & Arthur, 1999;
Werner, 2000). Risk and protective influences have been
organized at the micro, mezzo, and macro levels (Corcoran &
Nichols-Casebolt, 2004; Fraser, 2004). This framework fits
well with social work's emphasis on empowerment and the
strengths-based perspective.
The risk and resilience framework has also been
empirically validated. That is, risk and protective factors have
been identified through empirical study, initially in several
groundbreaking longitudinal studies in' which at-risk youth
were followed over time to determine the factors that seemed
to produce adaptation despite the adversity they faced (for
example, Rutter, 1987; Rutter, Maugham, Mortimore, &
Ouston, 1979; Wallerstein, 2005; Werner & Smith, 2001).
(See Garmezy, 1993, for a review.) Other longitudinal and
cross-sectional research has followed, resulting in the
accumulation of a substantial literature.
The risk and resilience framework can provide a the-
oretical basis for social workers to conceptualize at multi-
levels, and assist them in identifying and bolstering strengths,
as well as reducing risk. It can also be used as a practice tool
for goal formulation and intervention at the micro, mezzo, and
macro levels (Corcoran & Nichols-Casebolt, 2004). Although
specific interventions need to be guided by empirical evidence
about what works for whom and in what setting, intervention
goals can be set by examining the risks and protective factors
available in a given situation at the different system levels.
Therefore, the micro, mezzo and macro levels each need to be
considered as potential points of intervention. For example,
goals to reduce the risk of child abuse for a family (a
micro-level risk factor) might include working with families
to identify and address needed parenting skills (micro-level
intervention), community support resources (mezzo-level
intervention), and policies that reduce poverty (macro-level
intervention).
Goal setting for micro risk and protective factors include
interventions that reduce the risks and build on the strengths of
people through enhancing their skills, their access to programs
and services, and the availability of adequate and appropriate
resources and policies. Goal setting for the mezzo risk and
protective factors include micro-level interventions that focus
on
DIRECT PRACTICE 33
changing a person's situation (for example, helping a family
move out of a high-risk neighborhood), mezzolevel strategies
that focus on changing the social environment in which the
person interacts, to macro-level strategies that address
inequalities within the social environment. The macro risk and
protective factors suggest intervention goals that encourage
individuals to advocate on their own behalf, for communities
to address economic and social inadequacies and inequities,
and for macro systems to develop policies that improve
income and reduce discrimination and segregation. Although
social work practitioners may not be experts in implementing
interventions in all system levels, they must be knowledgeable
about the potential range of micro, mezzo, and macro factors
that affect the functioning of individuals and families. And,
more important, they must be committed to assuring that their
assessment and goal setting with the client system consider
each of these levels as a potential target for intervention
(Corcoran & Nichols-Casebolt, 2004).
A third thrust operating in social work practice is
evidence-based practice, which has been defined as the
prioritization of research evidence when social workers
consider how best to help the clients. However, client
preferences and available resources must also be part of the
process of clinical judgment (Gambrill, 2006; Straus,
Richardson, Glasziou, Haynes, 2005). The Council of Social
Work in Education states that direct practice content in
schools of social work should include "identifying, analyzing,
and implementing empirically based interventions designed to
achieve client goals" (CSWE EPAS, 2004, p. 10) The
advantages of relying on empirically based interventions are
several. First and most importantly, individual social work
practitioners, when faced with a particular client problem,
have no need to "reinvent the wheel" when there are already
standardized ways to intervene that are proven to help at least
a percentage of people. Second, social work practitioners and
the agencies in which they work may be held increasingly
accountable for client outcomes, with fee reimbursement for
services dependent on the use of helping methods that
conform to best available evidence. Third, other mental health
professions (that is, medicine and psychology) have increas-
ingly turned to empirically validated treatments. To be
competitive and conversant within the helping professions,
social work, as well, will have to be familiar with interventions
that have empirical validation.
One school of social work, George Warren Brown at
Washington University in St. Louis, has structured its
curriculum around evidence-based practice (Howard,
McMillen, & Pollio, 2003), and almost half (47%) of Masters
in Social Work programs formally endorse the
34 DIRECT PRACTICE
teaching of empirically-supported interventions (ES1)
(Woody, D'Souza, & Dartman, 2006). Empirically supported
interventions as specified by the Division of Clinical
Psychology of the American Psychological Association are
"clearly specified psychological treatments shown to be
efficacious in controlled research" (Chambless & Hollon,
1998, p. 1). Unlike psychology, "no social work organization
has identified specific ESI and training materials that educators
or practitioners should know about" (Woody et al., 2006, p.
477). One reason is that research on treatment of psychosocial
problems has typically been limited to the mental disorders
delineated in the American Psychological Association
Diagnostic and Statistical Manual of Psychiatric Disorders
(American Psychological Association [APA], 2000). Social
workers do not only practice psychotherapy, they are also
engaged in other types of helping relations. Further, social
work, as a profession, has limited buy-in to the DSM system
(Corcoran & Walsh, 2006; Kutchins & Kirk, 1997). On a
positive note, a recent social work publication offered a
systematic review of community practice interventions
(Ohmer & Korr, 2006), and other psychosocial problems of
interest to social workers, such as welfare-to-work programs
(Smedslund et al., 2006); child abuse (Lundahl, Nimer, &
Parsons, 2006), adolescent pregnancy prevention (Corcoran &
Ptllai, 2007a; Scher, Maynard, & Stagner, 2006); and services
for minority youth (Wilson, Lipsey, & Soydan, 2003) have
been subject to systematic review or meta-analysis. Systematic
reviews and meta-analyses systematically synthesize available
research evidence and can be enormously helpful for
researchers, practitioners and policy makers to understand the
status of a particular body of knowledge.
Overall, cognitive-behavioral therapy has emerged as an
empirically supported treatment for many DSMdefined
disorders (Chambless, 2005). Given these findings, it appears
that social work practitioners, particularly those in their
concentration year, should develop knowledge and skills with
cognitive-behavioral methods (see Corcoran, 2006; Lambert
et a1., 2005). As many schools of social work have students
select a field of practice, such as child and family, health,
mental health, gerontology, for their advanced practice,
empirically based interventions in these particular arenas
should also be a focus of direct practice.
Conclusion
This brief entry has covered two major thrusts of direct
practice as articulated by the CSWE EPAS: a
strengths-orientation rather than individual pathology; and
ESI. The main theories and frameworks encompassing these
thrusts include solution-focused therapy,
motivational interviewing, the risk and resilience framework,
and cognitive-behavioral therapy. However, there are some
tensions intrinsic in these selected theories and the aims of
direct practice. For example, the focus of most ESI is on
therapy of DSM defined disorders and some of the
strengths-based methods described (that is, solution-focused
therapy) have not had a great deal of empirical support
(Corcoran & Pillai, 2007b). In resolving these tensions, social
work may be able to forge a unique practice identity
comprising strengthsbased interventions enacted at various
client system levels (individuals, families, groups, and
communities) dealing with the kinds of problems that social
workers typically encounter, such as poverty, health care
disparity, neighborhood and community safety. Research and
the systematic review of research in these areas could be
identified as appropriate for social work, intervention.
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-JACQUELINE CORCORAN
DISABILITY. [This entry contains four subentries:
Overview; Neurocognitive Disabilities; Physical Disabilities;
Psychiatric Disabilities.]
OVERVIEW
ABSTRACT: Characteristics that we contemporarily define
as disabilities have existed in the human popu lation from
earliest recorded history. Societal explan ations for
disability have varied greatly by time and populations in
which disabilities have occurred. At various times in
history, disability has been viewed as a blessing from deity
or the deities, a punishment for sin, or a medical problem.
Social workers have worked with persons with disabilities
from the inception of the profession, and in recent years,
social work has begun to embrace the concept of disability
as diversity and to treat disability as diversity and
welcome disabled persons as fully participating members
of society. Social work has begun welcoming persons with
disabilities as fully participating members of society,
including valuable members of the profession.
KEY WORDS: CSWE; disability; diversity; independent
living; medical model; moral model; NASWj social model
of disability
Introduction
The United Nations estimated that 600 million people live with
disabilities in the world today and that those numbers are
expanding rapidly (World Health Assembly, 2005). At the turn of
the 21st century, the U.S. government estimated approximately 55
million Americans, including 5 million children live with
disabilities. One in five adults and three in four persons aged 80
years and older live with a disability (U.S. Census Bureau, 2000;
Waldrop & Stern, 2003). Historically, disability has been defined
as pathology contained within individuals. However,
contemporary disability
prevalence estimates acknowledge the social and societal
contexts that influence people with atypical characteristics being
considered disabled. As life expectancies increase and with
technological advancements, the numbers and proportions of
people living with disabilities will continue to expand. including
the thousands of wounded service people from the war in Iraq and
Afghanistan.
History
Throughout history, societies have attempted to explain the place
of disability in the social order. Neolithic tribes believed that
disabilities were caused by spirits (Albrecht, 1992) and skull
surgeries performed to release the spirits when the spirits were
believed to be evil. Ancient Greeks believed disabled persons
were not human and that they should be abandoned to die (DePoy
& Gilson, 2004; Plato, 1991). Romans left children with severe
disabilities to die but also provided assistance to persons with
disabilities with expectation that they be appreciative and
complacent (Morris, 1986). Concomitantly, not all disabilities
were problematic, particularly those that did not manifest with
physical differences. For example, Julius Caesar had epilepsy,
known as falling sickness, and claimed that he had visions during
his seizures. In Ancient Asia, disability was viewed similar to
Western culture. Life with disability was viewed as substandard
with people with disabilities often begging for sustenance.
However, because religious vows of poverty were common in
some parts of Asia, this activity may not have been viewed as
negative as in Western culture. Both heroic and malevolent
disabled characters are featured in ancient Asian history (Miles,
2002). Ancient Zoroastrian scripture dating back 2,500 years in
Persia envisioned a perfect world without disabilities.
[udeo-Christian and Muslim histories portray disability
negatively. The Koran displayed the deaf, blind, and "dumb" as
being without understanding. The Old Testament forbade people
with physical atvpicalities and those of short stature from
officiating in temple and priesthood ordinances. In the New
Testament, blindness and other disabilities were believed to be
caused by the sins of disabled people or their parents. Those with
disabilities that we characterize today as mental illness were
thought to be possessed by devils (Mackelprang & Salsgiver,
1999). However, disability was not universally condemned. For
example, both the Koran and the Bible describe a significant
speech impairment Moses lived with that did not disqualify him
from leading the Israelites out of Egypt. The New Testament
portrayed disability as arising from sin and spiritual deficiency.
However, Jesus also displayed compassion for disabled

persons, setting an archetype for subsequent charitable efforts
in Western culture.
In the Middle Ages, disability continued to be explained in
religious and supernatural terms in which disabled persons
were out of harmony with god or the natural order of the
universe. However, although moral explanations prevailed
during the Middle Ages, there was no singular, unifying
perspective (Metzler, 2006). When disability was attributed to
demonic or evil influences, people were ostracized and
sometimes burned at the stake. Concomitantly, many clergy
espoused the belief that people with disabilities provided an
opportunity for the nondisabled to display charity. People with
leprosy were segregated to protect society physically and
spirituallvt ihowever, some also believed lepers' infirmities
help them to progress to salvation faster than others.
The Enlightenment era brought a new emphasis on rational
inquiry that competed with morally based explanations of
disability. As early as 1600, Francis Bacon refuted the idea
that "madness" resulted from moral punishment (DePoy &
Gilson, 2004). Disability from birth was considered a
monstrosity, while disabilities acquired later were considered
natural (DePoy & Gilson, 2004). Those injured in war were
given special consideration and support. In Europe, blind
persons were especially afforded higher status resulting from
the wartime practice in which prisoners of war were blinded
by their captors and allowed to return to their homes. This
practice was considered a humane alternative to execution
while neutralizing the captives' threat to the victors.
The Enlightenment coincided with industrialization and
increased urbanization, all of which influence societal
reactions to disability. As scientific inquiry increasingly
supplanted religious and supernatural explanations of
disability, medical and rational explanations began to
supersede moral explanations of disability. The increased
reliance on medicine brought increased emphasis on curing, or
at least treating, biological inadequacies. Increasingly people's
worth was measured by their ability to work and contribute to
the economy. As contrasted to rural, agrarian societies, in
which family and communities integrated those who were
different, institutions that housed the unproductive, including
people with disabilities, proliferated. The original intent of
some of these organizations may have been to improve the
dysfunctional, and lack of resources often turned into ware-
houses with subhuman conditions (Foucault, 2006).
The 1800s and the Victorian era brought increasing
modernity and scientific advances in architecture,
photography, health, and science. Charles Darwin's
observations challenged perceptions about the nature
DISABILITY: OVERVIEW 37
and development of humanity. Inventions and advances
produced optimism and professionals held great hope that
"deviants" could be molded and changed to be more
acceptable to society (Rothman, 1971). However, as the
century progressed, social Darwinism and eugenics gained
prominence. Darwin observed that biological natural selection
benefited species, whereas, social Darwinists advocated
eugenics, wherein social engineering would discourage
undesirables from reproducing while promoting the
proliferation of desired classes, primarily white, nondisabled,
affluent people (Longmore, 1987; Trattner, 1999; Wiggam,
1924).
The 20th century ushered in an era in which the intellectual
elite advocated for the elimination of the poor, nonproductive,
and undesirable while advocating for the proliferation of those
with desirable traits (Wiggam, 1924). Eugenics provided easy
explanations for society's ills that justified laws forbidding
interracial marriage, mandating sterilization of the disabled,
and led to the proliferation of large institutions with degrading
living conditions (Longmore, 1987; Mackelprang & Salsgiver,
1999).
In the first half of the 20th century, both moral and medical
approaches to explaining disability were firmly entrenched in
Western culture. Disability was shameful and people with
disabilities were isolated. Professionals encouraged parents to
institutionalize their disabled children. People with mental
health disabilities were segregated in mental hospitals. People
with mobility disabilities were denied access to public and
private facilities. The 1924 (1927) U.S. Supreme Court deci-
sion in Buck V5. Bell (274 U.S. 200) legitimized forced
sterilization of disabled persons. Eugenics policies embedded
in western culture also provided impetus for the genocide of
between 75,000 and 200,000 physically and mentally disabled
people in Nazi Germany. Joseph Goebbels, Adolf Hitler's
propaganda minister who was disabled from polio,
nevertheless led the publicity effort portraying disabled
persons as subhuman and incurable, justifying the T 4
program in which their murders were defined as mercy killing
and release by comfortable death.
Eugenics advocates differentiation between conge- . nital
disabilities and acquired disabilities. For example, World War I
produced hundreds of thousands of veterans and civilians with
disabilities in Europe and the United States, and responses to
their needs reinforced and strengthened the concept of the
worthy poor (British Broadcasting Corporation, 1999).
Franklin D. Roosevelt was elected as president of the United
States in spite of polio; however, he went to great lengths to
hide his physical disability from the public. Increased survival
rates of persons born with or acquiring disabilities, public
responsibility to care for veterans disabled
38 DISABILlTI: OVERVIEW
by wars, and technological advances led to increased
awareness and attention to "treat" disabled persons.
In the early decades of the 20th century, disability rights'
seeds were being planted. Longmore (2003) recalls the 1935
"league of the physically handicapped," a small group of
mobility disabled persons and their supporters who protested
against job discrimination against those with disabilities. In the
1940s, such as researchers like Roger Barker and Beatrice
Wright began demonstrating similarities between the
experiences of disabled persons and other disenfranchised
groups. By the 1960s, the tumultuous atmosphere that gave
rise to the civil right movement for women and "minorities"
also gave birth to the disability civil rights movement.
Disability rights' leaders such as Ed Roberts and Judy
Heumann, both polio survivors, contended they were denied
access to education and employment because of societal
barriers, and rejected arguments that they were unemployable
because of their disabilities (Fleisher, & Zames, 2001;
Mackelprang & Salsgiver, 1999; Shapiro, 1994). The
Independent Living movement was founded on the premise
that persons with disabilities are a minority group that lives in
a primarily nondisabled society. The primary problems facing
persons with disabilities are imposed by society rather than
residing within individuals. Since the 1970s, the disability
movement gained momentum and many successes by uniting
people with different types of disabilities and aligning with the
civil rights movement (Fleisher and Zames, 2001).
Disability Policies
Legislation in the last century has had a marked impact on the
lives of people with disabilities. In turn, expanded
opportunities resulting from disability laws have changed
public perceptions of disability and persons with disabilities.
The followings are important disability laws from the last
century.
1917-Smith-Hughes Act: Established FederalState
vocational rehabilitation program for disabled veterans .
1918-Smith-Sears (Soldiers Rehabilitation) Act: Expanded
federal vocational rehabilitation programs to veterans of
World War I
1920-Smith-Fess (Civilian Rehabilitation) Act: Began
vocational rehabilitation for all Americans with
disabilities.
1935 -Made federal vocational rehabilitation programs
permanent. Provided an income maintenance system to
people who were unable to work. Included provisions
for crippled children.
1968-Architectural Barriers Act: Required federally funded
or utilized buildings to be accessible to the
"handicapped."
1973-Rehabilitation Act: Provided protections to people
with disabilities in federally involved programs
including hiring practices, architectural and
transportation barriers, employment, education, and
technology. This law did not apply to nonfederal entities
such as private enterprises. It has been modified and
updated multiple times in the three decades subsequent
to its passage.
1975-Education for All Handicapped Children Act:
Mandated free and appropriate education for children
with disabilities, including services related to the
disability (for example, speech, occupational, physical
therapy).
1978-Rehabilitation Act Amendments: Provided for the
establishment of federally funded Centers for
Independent Living to be directed by people with
disabilities.
1986-Amendments to the Education for All Handicapped
Children Act: Entitled children with disabilities
educational services from birth to six years of age.
1990-Americans with Disabilities Act: Civil rights law that
mandate equal access and nondiscrimination in
employment, public accommodations,
telecommunications, and societal services (for example,
insurance).
1997-Individuals with Disabilities Education Act:
Strengthened the provisions of the Education for All
Handicapped Children Act. This law was further
modified in 2004 with the Individuals with Disabilities
Education Improvement Act aligning IDEA with the No
Child Left Behind Act and increasing equity and
accountability in education for children with disabilities.
Originally, disability legislation targeted war veterans
who were considered worthy of assistance for serving their
country. Over time, legislation has expanded to include all
citizens with disabilities. The most significant disability civil
rights law is the Americans with Disabilities Act (ADA) of
1990 because it expanded the rights of the disabled to all areas
of society whereas previous legislation such as Rehabilitation
Acts applied only to governmental entities and organizations
receiving governmental support. Some disability legislation
such as the Social Security Act and education acts for children
provide entitlements (cash benefits and services) for people
with disabilities. In contrast, legislation such as ADA protect
the rights of people with disabilities but do not provide entitle-
ments or guarantee benefits.
In addition to legislation, disability policy is affected by
the judicial system, particularly in the form of court

decisions. In recent years, U.S. Supreme Court decisions have
limited the scope and protections of the ADA. For example, in
Sutton vs. United Airlines dismissed a disability discrimination
case brought by two sisters for employment discrimination.
The petitioners charged that defendant's policy requiring
20/100 uncorrected vision was discriminatory that excluded
them from employment as airline pilots. Both petitioners had
20/200 vision that was correctable with corrective lenses. The
court ruled that, because their vision was correctable, they
were not covered under ADA, even though the airline's policy
excluded them from employment. On the 'other hand, some
recent decisions have expanded the rights of disabled persons.
Among these is the 1999 Olmstead decision, in which the court
determined that disabled people who are capable should be
allowed to leave institutional care and live in the community.
Disability Language
The practice of combining people with diverse, unusual, or
atypical characteristics as a unified group has been adopted
primarily in the last century. By using tools such as the bell
curve, one can plot normal human characteristics. Being
normal became desirable and those who fall outside the
normal and desired range of mental, physical, cognitive, and
behavioral characteristics have been labeled abnormal and
with terms such as cripple, spastic, invalid, and handicap.
Terms such as differently abled have been used by some in an
attempt to soften the negativity associated with disability.
With the birth of the disability rights movement, the term
disability has become increasingly accepted by disabled
persons and nondisabled persons alike to describe those with
atypical characteristics. Disability rights advocates use terms
such as ableism and disable ism to describe the belief that
people with atypical characteristics are inherently inferior.
Given the traditionally derogatory nature of terms such as
handicap and disability, "person first" language became
widely adopted. Terms such as "person with a disability"
became more acceptable than "disabled person" because of the
belief that disabled persons are not defined by their disability;
rather, disability is a characteristic they live with. However, in
the 21st century, disability advocates and activists are
increasingly eschewing person first language in favor of
disability identity language. They argue that person first
language fosters a belief that disability is inherently
pathological rather than a characteristic of diversity. This
rationale can be illustrated by applying person first language
to other characteristics. African Americans and Caucasians do
not want to be called "persons with
DISABILITY: OVERVIEW 39
blackness," or "persons with whiteness." Women and men do
not want to be called "persons with femaleness" or "persons
with maleness." In the same way, some disabled persons are
embracing disability as a characteristic and identity.
Contemporarily, in 2007, person first language is the common
choice in the United States while in England disability first
language is more common. Use of language will continue to
evolve over time with different countries, languages, and
cultures adopting multiple and, at times, conflicting uses.
In the United States, Deaf culture can be identified by
those who use American Sign Language as their primary
language and method of communication, who identify
Deafness as a cultural characteristic, and identify with other
Deaf people as their primary sources of socialization.
Culturally Deaf persons use language such as Deaf person
with a capital D to connote Deaf culture and deaf person with a
little D to signify deafness as an auditory condition. There
seems to be an evolving trend in which disabled persons who
identify with disability culture eschew person first language
and may be beginning to use capital D Disability to refer to
Disability culture and identity.
Models of DisabiIi ty
Explanations of disability can be divided into three categories:
the moral, medical, and social models. The moral and medical
models define disability as a pathological individual
characteristic. In contrast, the social model defines disability
as a diverse attribute in society. The moral models have
pervaded most societies and cultures while the social model is
gaining increasing recognition. The moral model, which has
been present from antiquity, explains that disability is a result
of sin or is out of order with the natural order of existence.
Disabilities may arise as a result of one's misdeeds or as a
consequence of the sins or errors of one's family. The medical
model regards disability as a defect or sickness that should be
prevented, treated, or cured. The moral and medical models
define disability as shameful and repulsive. Both models are
common contemporarily and are evident throughout society.
In the United States, people with severe disabilities are
routinely forced to live in nursing facilities rather than select a
community residence of their choosing. Contemporary media
portray physical disability as a fate worse than death as
demonstrated by the 2004 Academy Awardwinning picture,
MiHion Dollar Baby, which portrayed the murder of a severely
disabled woman as heroic.
The birth of the disability rights movement in the 1960s
has produced a contrasting approach to disability. The
diversity model of disability (also known as the social model
or disability model) defines disability as a
40 DISABILITY: OVERVIEW
naturally occurring phenomenon that adds to societal
diversity. While acknowledging the impact of impairments
and limitations on individuals, the diversity model of
disability contends that the problems facing disabled persons
arise primarily out of societal attitudes, structures, policies,
and institutions that limit the full participation of disabled
persons in society. Devaluation and discrimination exclude
people with disabilities from reaching their potential.
Problems such as unemployment rates of people with
disability are caused, in part, by social policies such as the loss
of health benefits that exclude them from the workforce.
Disability Theory and Contemporary Practice With the
emergence of the social model of disability, societal
conceptualizations of disability are changing. World Health
Organization [WHO] (1980) published the International
Classification of Impairments, Disabilities, and Health (lCD)
that classified disability, impairment, and handicaps as
internal problems.
Impairment: Any loss or abnormality of psychological,
physiological, or anatomical structure or function.
Disability: Any restriction or lack (resulting from an
impairment) of ability to perform an activity in the
manner or within the range considered normal for a
human being.
Handicap: A disadvantage for a given individual,
resulting from an impairment or disability, that limits or
prevents the fulfillment of a role that is normal,
depending on age, sex, social, and cultural factors, for
that individual.
The Americans with Disabilities Act (1990) also defined
disability internally; however, it acknowledged that people
with disabilities experience pervasive discrimination and lack
of access to society. WHO (2001) began a multinational
process that culminated in the development of the International
Classification of Functioning, Disability and Health (lCF).
While the ICF also attends to internal impairments and
conditions, it also addresses activities and participation as well
as environmental factors impacting disability. Thus, the ICF
acknowledges that disability occurs in context, not as an
exclusively internal pathological condition. From within the
Disability movement and community, a unique disability
perspective has recently developed that addresses disability as
an identity and seeks to understand a culture of disability. This
movement is evident in academia where Disability Studies
programs are proliferating, Disability Studies journals have
been created, and The Society for Disability Studies brings
together disability scholars to discuss and debate Disability
and Disability culture. Fashioned after ethnic and women's
studies, disability studies have become a vital field of study
and a new professional venue.
The emergence of the social model of disability produces
new challenges for human behavior, social, and economic
theorists. Traditional longitudinal theories that explain
behavior over the lifespan have addressed disability as an
impediment to meeting expected tasks or milestones. Social
and economic theorists have approached disability in terms of
the societal costs and social problems wrought by disabilities.
Categorical theories that explain the world according to
attributes such as social class, gender, sexual orientation, or
race and ethnicity have typically eschewed disability.
Disability theory is now being inculcated into a variety of
traditional theoretical approaches to explaining the world and
people in the world (DePoy & Gilson, 2004; Johnson, 2000;
Longmore, 2003; Mackelprang & Salsgiver, 1999; May &
Raske, 2005; McRuer, 2006; Priestly, 2001; Stone, 200S).
Universal design and universal access (UA) are important
components of the disability rights movement. UA proponents
contend that societies have generally been organized around
the majority or those in power. Civil rights and special
protections policies such as affirmative action and reasonable
accommodation have been necessary to provide societal
access to minorities and disadvantaged persons. UA, which
began as an approach to improving disability access, is
applicable to all people, majority and nonrnajoriry. UA
contends that society should be organized to encompass the
diverse range of the population, not developed for the majority
and that the responsibility for promoting diversity rests on
everyone's shoulders. For example curb cuts and electric doors
were originally designed for disabled people but benefit all
people. Similarly, UA contends that other areas of society
such as college admission and job requirements can be
developed in a universally accessible manner rather than
advantaging some groups over others.
Challenges
People with disabilities continue to face discrimination and
lack of access to the full benefits of society. A challenge for
society and for social work is to promote disability rights,
opportunities, and decision making.
Housing: The deinstitutionalization movement that
began in the 1980s has reduced and prevented the
warehousing of thousands; however, challenges remain.
For many, resources did not follow people as they have
left institutions, thus exposing them to higher risk.
Thousands remain institutionalized

unnecessarily despite policies and the Olmstead decision
by the U.S. Supreme Court that mandated states to
discharge eligible people with disabilities into the
community. In addition, adequate housing is in short
supply because of problems such as inaccessible and
unaffordable dwellings. The social work ethical
principles of self-determination and social justice
obligate social workers to assist disabled persons in
living independently to the extent possible. Passage of
legislation such as the 2005 "Money Follows the Person"
will facilitate independence for many disabled persons,
but others will not have the educational or financial
resources to take advantage. As of 2007, 31 states had
demonstration projects to move more than disabled
persons out of the institutions in which they were
warehoused into the community (U.S. Department of
Health and Human Services, 2007).
Income: The unemployment rate of people with disabilities
is double the nondisabled population, and their individual
and family incomes lag far behind. Social policies
discourage disabled people from working including
policies that eliminate health and social benefits for people
with disabilities who are employed. Supplemental Security
Income (SSI) provides disabled beneficiaries a subsistence,
poverty level income. To qualify for Social Security
Disability (SSD) benefits, an individual must have a
substantial work history; thus, many people with
disabilities, especially those born with disabilities, are
unable to qualify.
Health Care: Forty-nine million Americans, including
millions with disabilities, have no health insurance.
Medicare is the primary source of health coverage for
disabled people age 65 and older as well as those under 65
years of age who had a substantial work history prior to
acquiring a disability that prohibits them from working.
Nonelderly Medicare recipients must first receive SSD,
then wait two years before they can receive Medicare.
Medicaid, a federal and state program provides SSI
recipients with health coverage; however, reimbursement
rates limit access to some health services and benefits are
frequently very limited in scope. Some disabled Medicare
and Medicaid recipients do not work to the extent they can
because earning an income would disqualify them from
coverage and their health care needs are such that their
income would not adequately compensate for the lack of
coverage. For example an electric wheelchair can cost as
much as $15,000, more than the annual income of
individuals earning minimum
DISABILITY: OVERVIEW 41
wage. Social policies that expand health care coverage
and end penalties for working are critical to increased
independence, earning potential, and quality of life for
disabled persons.
Independent Living: Traditionally professionals'
relationships with disabled persons have been hierarchal.
Medical professionals prescribe treatments. Social workers
and other human service professionals often work as "case
managers" for persons with disabilities; a term that implies
that clients are cases to be managed. In contrast,
independent living philosophy and centers for independent
living place the participants in control of decisions and
services they receive. While complete autonomy is not
possible in all situations, it is incumbent on social workers
to advocate for self-determination and assume control only
when necessary.
Life and Death: Life and death policies and decisions are
of major importance to persons with disabilities
throughout the lifespan. Groups such as Not Dead Yet
(http://notdeadyetnewscommentary. blogspot.com/)
have been created to illuminate the perception that
people with disabilities are more expendable than
nondisabled persons. Prenatal testing is sometimes
encouraged to ascertain the presence of a disability that
would justify abortion, a practice some disability
advocates consider genocidal (Davis, 2002; Johnson,
2005). Two 1989 "right to die" court cases illustrate the
societal belief that disabled lives are worth less than non-
disabled persons. David Rivlin, a 38-year-old
quadriplegic from Michigan who had been forced to live
in a nursing facility for years sought and received court
sanction to end his life. Similarly, Larry McAfee a
34-year-old quadriplegic from Georgia who had also
been forced to live in nursing facilities also received
sanction to end his life. In both cases, the courts ruled
that the petitioners' conditions were so abhorrent they
should be allowed to die while ignoring the conditions in
which they had been forced to live. Rivlin completed his
suicide; however, independent living advocates
facilitated McAfee's discharge and transition to
community living. A year later he reported he was happy
to be living (Mackelprang & Mackelprang, 2005;
Shapiro, 1994). The public disability rights debate
reached its zenith in 2005 with the public legal battles
between the parents and spouse of Terry Shiavo, a
woman who had been in a persistent vegetative state for
15 years. Shiavo's husband and health providers
eventually prevailed, Shiavc's nutrition and hydration
were
42 DISABILITY: OVERVIEW
discontinued, and she died. This case deeply divided the
country including disability rights advocates, some of
whom argued that Shiavo was murdered because she
was disabled while others disagreed, contending that she
was not conscious. However, though disability rights
proponents disagree over the Shiavo case, all share the
belief that disabled people should have the same life and
death decisions that are afforded nondisabled persons.
Concomitantly, however, extant social and health
policies may consign people with disabilities to
substandard lives. Social workers are responsible for
advocating for universal access and quality of life and
not assume that life with a disability is inferior to life
without a disabilitvlives.
Social Work Implications
The social work profession has a strong history of
responsibility to work with and advocacy for the dis-
advantaged and oppressed in society. Social workers have
worked in the disability arena for as long as the profession has
existed at the micro and macro levels. Some of the earliest
venues of social work practice include institutions for the
"mentally retarded" as well as in mental health/ psychiatric
facilities and community mental health. Because disability
crosses all population groups, social workers in all areas of
practice work with disabled persons. In addition, the
profession is charged to advocate for equity and social justice.
Thus, the profession has a responsibility to advocate for social
policies and practices that provide the same opportunities for
disabled persons as nondisabled persons.
In addition to the profession's commitment to non-
discrimination, and ending oppression, social work is also
committed to diversity. The National Association of Social
Workers (NASW) (2007) states "NASW is committed to
social justice for all. Discrimination and prejudice directed
against any group are damaging to the social, emotional, and
economic well-being of the affected group and of society as a
whole."
In recent years, NASW has begun to recognize disability
as diversity rather than a medical problem or pathology
(Stoessen, 2003).
The Council on Social Work Education (CSWE) began
transforming its approach to disability in the 1990s. Its 1994
accreditation standards defined disability as one aspect of
human diversity. In 1996, CSWE created the Commission on
Disability and Persons with Disabilities to complement its
diversity commissions on race and ethnicity, women, and
sexual orientation. In addition, in 2005 CSWE began seeking
disabled
persons to serve in organizational leadership positions
alongside people from other diverse backgrounds.
Disabled social workers have always been part of the
profession. In recent years, they are gaining recognition as a
part of the diverse tapestry of society. Changes in laws and
social policies, societal attitudes, as well as advances in
technology and access to society are providing disabled
persons new opportunities to participate fully in society.
However, they still face significant social and economic
problems. Social work faces three challenges related to
disability. First, the profession has the responsibility to
provide culturally competent services to disabled clients and
groups. Second, social work's commitment to social justice
compels it to advocate for nondiscriminatory laws, policies,
and practices. Third, social workers need to promote client/
consumer participation at the case, agency, and policy level.
Finally, social work has the responsibility to embrace disabled
persons as a vital part of the profession.
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Davis, L. J. (2002). Bending over backwards: Disability, dismodernism
& other difficult positions. New York: New York University Press.
DePoy, E., & Gilson, S. (2004). Rethinking disability: Principles for
professional and social change. Belmont, CA:
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Fleisher, D. A. & Zames, F. (2001). The disability rights movement:
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Foucault, M. (2006). History of Madness. (2006 English Translation.)
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Johnson, H. M. (2005). Too late to die young: Nearly true tales from a
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Longmore, P. (2003). Why I burned my book and other essays on
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Mackelprang, R. W., & Mackelprang, R. D. (2005). Historical and
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May, G., & Raske, M. (2005). Ending disability discrimination:
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McRuer, R. (2006). Crip theory: Cultural signs of queerness and
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Waldrop, J., & Stern, S. (2003). Disability status: 2000.
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SUGGESTED LINKS
Rehabilitation Research and Training Center on Disability
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www.DisabilityStatistics.org.
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www.census.gov/main/www/cen2000.htm!.
-ROMEl W.
MACKELPRANG
DISABILITY: NEUROCOGNITIVE DISABILITIES 43
NEUROCOGNlTIVE DISABILITIES
ABSTRACT: The multiplicity of disability definitions can be
attributed to the heterogeneity of disability, its rnultifactoral
nature, and its effects across the life span. Of particular concern to
the social work profession are those persons with neurocognitive
disabilities. Neurocognitive disabilities are ones where a problem
with the brain or neural pathways causes a condition (or condi-
tions) that impairs learning or mental/physical functioning or
both. Some examples are intellectual disabilities, autism spectrum
disorders, and savant syndrome. Neurocognitive disabilities are
the most difficult to diagnose often times because of their
invisibility. Providing services for people with neurocognitive
disabilities is very difficult, and people with these disabilities are
among the most vulnerable populations in today's society. This
entry discusses neurocognitive disabilities and current and future
trends in social work disability practice.
KEY WORDS: neurocognitive disability; cognitive disability;
neurological disability; discrimination; disability rights; quality
of adjusted life year measurements; person-centered planning;
constructionist approach to disability; consumer-driven service
delivery; International Classification of Functioning, Disability
and Health; disability demographics
Introduction
Since the mid-1970s, the area of disability practice has evolved
more rapidly than any other social work practice area
(Mackelprang, 2002; Patchner, 2005; Redfoot, 2003). This
evolution can be explained by the rapid growth of scientific
discovery, our understanding of the human body and how it
works, and the disability rights movement. Medical and
technological advances, civil rights, and sociopolitical changes
within society have challenged social work practitioners to be
current and relevant within the field of disability practice.
Historically, social workers have usually followed a medical or
rehabilitative model of practice which has resulted in a
discriminatory and biased approach to disability practice
(Mackelprang, 2002; Patchner, 2005). Our lack of an enlightened
model of practice that does not locate the problem strictly within
the person with a disability has led to an increase in other
personnel, for example, rehabilitation workers and
paraprofessionals, working within the disability practice arena.
Subsequently, there exists no standardized model of disability
practice within the profession of social work (Gilson & DePoy,
2002). When addressing the entire specialty of disability practice,
especially cognitive disabilities, social work practitioners must
take into account this evolving landscape.
44 DISABILITY: NEUROCOGNITIVE DISABILITIES
Definitions
The multiplicity of disability definitions and terms can be
attributed to the heterogeneity of disability, the multifactoral
nature (that is, many contributing factors), including causal
factors, of disabilities, and the effects of disabilities across the
life span on the individual, family, and soc iety. Words such as
neurodevelopmental, developmental delay, cognitive delay,
learning disabilities, sensory integration dysfunction,
physically challenged, sensory impairment, morbidity,
chronic illness, and a host of other terms all fit within the
larger scope of neurological or cognitive disabilities. These
terms are beginning to be used in some service organizations
to let people know who they serve. One example of this is the
Orion Academy: A Unique School for Neurocognitive
Disorders (www, orionacademy.org) in Moraga, California.
Being diagnosed or called a person with a disability does
not make the individual a person with a disability. Disability
today takes on another paradigm, that of functionality within
the workforce and broader society (DeWeaver, 1995;
Patchner, 2005). For example, a person with cerebral palsy
carries a diagnostic label but may not consider himself or
herself a person with a disability because the individual is not
limited in any major life activity such as work. A deaf person
from birth most likely would reject the disability label
altogether. Social workers should be familiar with how
disability definitions can discriminate and prevent persons
from receiving needed health and welfare services.
Some contemporary definitions of disability are as
follows:
Americans with Disabilities Act (1990). An individual with
a disability is defined as a person who
has a physical or mental impairment that substantially
limits a major life activity, or
has a record of such an impairment, or
is regarded as having such an impairment.
Social Security Administration (2007). Disability under
Social Security is based on the inability to work. Under
Social Security rules if individuals cannot do work that
they did before, and if they cannot adjust to other work
because of their medical cond itionts), they are considered
disabled.
The disability must also last or be expected to last for at
least 1 year or to result in death.
International Classification of Functioning, Disabil ity, and
Health (200l). Disability serves as an umbrella term for
impairments, activity limitations, or participa tion
restrictions of the individual.
The Developmental Disabilities Assistance and Bill of
Rights Act (1990). Developmental disability means a
severe, chronic disability of a person 5 years of age or older
that
is attributable to a mental or physical impairment or a
combination of both;
is manifested before the person attains 22 years of age;
is likely to continue indefinitely;
results in substantial functional limitations in three or
more of the following areas of major life activity:
self-care, receptive and expressive language, learning,
mobility, self-direction, capacity for independent living,
and economic selfsufficiency;
reflects the person's need for a combination and
sequence of special, interdisciplinary, or generic care,
treatment, or other services that are lifelong or of
extended duration and are individually planned and
coordinated; except that such term, when applied to
infants and young children, means individuals from birth
to age 5, inclusive, who have substantial developmental
delay or specific congenital or acquired conditions with
a high probability of resulting in developmental
disabilities if services are not provided.
The United Nations Convention on the Rights of Persons
with Disabilities (2007). Disability is an evolving concept
and that disability results from the interaction between
persons with impairments and attitudinal and
environmental barriers that hinder their full and effective
participation in society on an equal basis with others.
Most disabilities have a neurological component, either by
genetics (genes, chromosomes, metabolic) or by injury
(accidents, disease, poisoning). Cognitive disability pertains
to the mental capacity in orientation (time, place, person),
intellect, psychological, memory, sensory integration, and
thought process. Routinely, professionals have utilized
standardized measures of intelligence or IQ range to classify
the level of cognitive deficits, especially with people with
intellectual disabilities (formerly called mental retardation)
(Sulkes, 2003). Such classifications of intelligence were
viewed as difficult to apply meaningfully, restrictive (Slick,
Sherman, & Iverson, 1999), and discriminatory by many in
the disability community and can exacerbate the stigma of
cognitive disability (Corrigan, 2007). One of the reasons that
the term mental retardation was dropped was to get away from
the stigma of the term and its inappropriate shortcuts and
slang, for example, "retarded," "retards," and "tard."
Currently, the International Classification of Functioning,
Disability and Health classifies cognitive deficits by global
mental

functions along a dimensional continuum. These mental
functions include consciousness, orientation, intelligence,
psychosocial, temperament and personality, energy and drive,
and sleep functions (World Health Organization, 200l).
The vast majority of persons with disabilities do not have
cognitive disabilities. Therefore, in this entry, the term
neurocognitive disabilities refers to persons who have both a
neurological disability as well as a cognitive disability. This
may include (but is not limited to) the disabilities of autism,
down syndrome, Fragile X, intellectual disability,
developmental disabilities, learning disabilities, Williams
syndrome, Alzheimer's disease, savant syndrome (formerly
idiot savant), and sensory integration dysfunction .. Persons
with neurocognitive disabilities are the most vulnerable
population in the United States because of their unique needs
in care, self-determination, and self-advocacy (De Weaver,
1995; Patchner, 2005). Most residents of institutions for people
with disabilities are persons with neurocognitive disabilities,
many of whom have behavioral challenges to overcome before
they can successfully integrate in the community. Most civil
rights advances that have assisted persons with disabilities
have been less successful in advancing the quality of life for
those with cognitive deficits (National Association of Social
Workers, 2003b).
Demographics
According to the U.S. Census Bureau's (2006) report
Americans with Disabilities: 2002, data collected from the
Survey of Income and Program Participation show that over
51.2 million (18.1 %) Americans have a disability, of which
32.5 million (11.5%) have a severe disability. The Census
Bureau also notes that more than half of those aged 21-64 had a
job, more than 4 of 10 between the ages 15 and 64 used a
computer at home, and a quarter of those between the ages 25
and 64 had a college degree. The Census Bureau delineates
between severe disabilities and other disabilities and collects
data on mental disabilities for specific age groups. These data
indicate that over 14 million, or 6.4%, of Americans aged 15
years and older have some form of mental disability. Since the
U.S. Census figures on severe disability include those who
have severe physical disabilities with no cognitive impairment,
it is not an accurate measure of those individuals who possess
both neurological and cognitive disabilities.
The National Organization on Disability (2004)
commissioned the Harris Survey of Americans with Dis-
abilities: 2004 and found that 54 million Americans had one or
more disabilities. This report also indicates that
DISABILITY: NEUROCOGNITIVE DISABILITIES 45
Americans with disabilities are at significant disadvantage
when compared with other Americans on 10 indicators. Since
1986, The Harris Survey has indicated slow progress in
improvement of these indicators. Some significant findings
are as follows: 18% go without adequate health care; only
35% of persons with disabilities are employed, and 22% of
them report discrimination; persons with disabilities are 3
times more likely to live in poverty; twice as likely to drop out
of high school; twice as likely to have problems with
transportation; 22% of those employed report job dis-
crimination; and, the severity of disability significantly
increases disadvantages in all areas of life (National
Organization on Disability, 2004).
Owing to population identification and sampling
variability, these reports can be expected to show different
outcomes. However, both surveys show significant economic
and life disadvantages for those with severe disabilities, which
would include those having neurocognitive disabilities. This
would suggest a disparity in health care and social supports for
the most vulnerable population in the United States.
Of particular concern in the United States is the growing
numbers of children diagnosed with the neurocognitive
disability of autism spectrum disorders (ASDs). The U.S.
Centers for Disease Control recently published a report on the
prevalence of ASDs (Rice, 2007). These data, collected from
14 states, showed an increase in ASDs from 1 in 166 in 2000 to
1 in 150 children in 2002. Of particular concern was the
finding that 1 in 104 male children are diagnosed with an
ASD. Furthermore, a child is diagnosed with autism every 20
minutes, and the number of cases has increased IS-fold since
1991 (Autism Speaks, 2007; Graziano, 2002). That year,
companies began putting thimerosal, a mercury-based
preservative, into vaccines given to very young children. This
practice has since stopped; however; many infants and young
children were exposed to thimerosal. Young children now are
vaccinated 23 times before they reach age 5. Scientific and
political battles are now being fought over whether there is a
connection between thimerosal and autism. A recent
government-funded clinical study indicated that thimerosal
did not increase autism numbers. Most recently, the common
flu shot given to pregnant women has come under scrutiny.
Obviously, many questions remain unanswered. Still others
question whether sun block may be blamed for autism. As sun
light assists in producing Vitamin 0, sun block can inhibit its
production. It is hypothesized that the interference in Vitamin
o production could be related to autism increases (see
vitamindcouncil.com). Curiously enough, the Amish, who do
not get vaccinations, flu shots, or use

46 DISABILITY: NEUROCOGNITIVE DISABILITIES
sun block, are not afflicted by autism. Social workers must
follow research in this area to disseminate to their clients and
community.
The World Health Report: 2006 calculates both life
expectancy at birth and healthy life expectancy at birth. This
is in recognition that disability will encompass a portion of the
life span of people around the world. The report shows that in
the United States, life expectancy at birth for males is 75.0 and
for females is 80.0, whereas, healthy life expectancy for males
is 67.2 and for females is 71.3 (World Health Organization,
2006). Most of us can expect disability to occur during some
time in our lives, and for the majority of us this will occur
during our later years (National Association of Social
Workers, 2003a).
Many persons with cognitive disabilities are hidden and
may escape official counts on the number of people in the
population with disabilities. Several reasons for this could be
discrimination toward underserved populations, lack of
information that could mean less funding for governmental
programs, restrictive and changing definitions on
developmental disability, and persons and families who do
not wish to identify the person as having a disability. Social
workers engaged in policy practice need accurate
demographic data in order to clearly represent the number
needing health, social, and public assistance services.
Theory, Research, and Best Practices
Historically, in the area of disability practice, the social
work knowledge base has relied on theoretical applica-
tions such as behaviorism, anatomical knowledge, and,
later, the human genome project that stemmed from
scientific discovery and medicine (Patchner, 2005).
Because of recent advances in science and medicine,
persons with disabilities have greater longevity and a
better quality of life. Undeniably, these advances in
science and medicine have resulted in social work
practice that was medically modeled. As social service
delivery systems matured, social work practice moved
its focus from the medical model to social service de-
livery and rehabilitation model. Until recently, this left
little room for self-determination of the person and
family. During the 1970s and 1980s, with the arrival of
the independent living movement and civil rights
advocacy and legislation, social work disability
practice began to focus on the self- determination of the
person and a constructionist approach to disability
began to emerge (Asch, 2001). This approach to
disability views the interaction between persons with
disabilities and society as dysfunctional. The approach
proposes that it is society's responsibility to fix itself
and not the person (Gilson & DePoy, 2002). The social
work profession
I
I
grapples with both medical progress in identifying and
I
iI
treating disabilities and advocating for a society, through
ongoing progressive change, that respects the
I
self-determination of the person. Most grapple with this
situation by performing the main functions of social work:
helping the person with a disability and their family via direct
!
services and using advocacy to attempt to change policy for
this vulnerable group of people. Many cases are complex, and J
the social worker has to remain flexible and prioritize needs,
which often are clinical first and then policy-changing (see the
j
i
Pediatric Case Example that follows). i
I
PEDIATRIC CASE EXAMPLE Lee Chin is a 2-year-old child
with dual diagnoses of dwarfism and Down syndrome. He
requires a trach and continuous oxygen, and exhibits
I
feeding problems because of difficulty in swallowing. At I
risk for increased respiratory infections due to the trach,
Lee Chin has required numerous hospitalizations. The I
child sits with the support of a brace, exhibits better use of
I
his upper extremities, is alert but severely developmentally
delayed. Family and professional staff have observed Lee
Chin's attempt at speech and minimal use of upper
extremities. The child is currently being treated at a
rehabilitation center, following his most recent
hospitalization.
Lee Chin lives with his parents and 3~year-old brother.
There had been reported domestic stress between the parents,
which resulted in the father disengaging from any caretaker
functions of the child. The family emigrated from Vietnam 2
years ago, and has experienced the additional stress of cultural
assimilation. There exists no extended family support system
and limited ethnic community support. The family has
experienced several significant losses during the past several
years-their son's serious medical problems, strained
relationship between the parents, cultural identification, and
lack of familial network.
Several community- and medical-based agencies are
providing services in the home where Lee Chin receives
ongoing medical care. These services include physical
therapy, skilled nursing, medical social work services, and
early education intervention. Some service providers have
exacerbated family stress by the lack of cultural sensitivity to
the unique needs of this newly immigrant family. Owing to
possible cultural and language barriers, service providers did
not encourage the self-determination of this family in making
informed treatment decisions regarding their son. As a result,
Lee Chin's mother is uneasy in utilizing service providers, and
retreats from available help when she feels threatened,
misunderstood, or pressured into making a decision. An initial
hospital multidisciplinary team

evaluation of Lee Chin was discontinued when the mother
exhibited fear and anxiety regarding the nature of the
evaluation process. In addition, a communication breakdown,
over a difference in treatment goals, between the treating
physician and Lee Chin's mother has further complicated the
treatment plan for the child. An interdisciplinary team, which
included a health insurance case manager, was created. The
interdisciplinary team evaluation focusing on feeding,
speech/augmentative communication, cognitive issues, and
future discharge planning was held at the rehabilitation facility
where Lee Chin has been a patient for the past 2 weeks.
Chaired by the rehabilitation center social worker, the
interdisciplinary team identified the complex psychosocial
needs of Lee Chin and his family. They supported and
partnered with the family during the decision-making process.
Specifically, the mother was given flexibility in scheduling the
skilled nursing services for her child in order to facilitate her
work schedule outside the home, and to maximize her time
with the home health nurse while enhancing her caregiver
role. Discharge planning goals were to provide the medically
necessary amount of skilled home health nursing home-based
medical and community-based services, and parental decision
making. The social worker used a family-centered approach to
facilitate parental decision making regarding the future care of
Lee Chin.
Theory and Research
A dichotomy has evolved where disability practice relies on
both scientific advances for best practice knowledge, as well
as sociopolitical standards which support the person in
determining what best practice is. There exists a constant
struggle to balance scientific and medical advances by
supplying this research knowledge to persons with disabilities
and their families so that they can determine what is useful for
them (Patchner, 2005; Redfoot, 2003; Rose & Moore, 1995).
Perhaps the greatest scientific advances have occurred
during the 13-year period from 1990 to 2003 of the
International Human Genome Sequencing Consortium.
During its initial efforts the entire DNA code for 30,000
human genes was mapped and sequenced. The functions of
half of the discovered genes is now known, and researchers
are continuing their effort in discovering all gene functioning.
Some neurological conditions that have been identified in
recent years include white matter diseases of the brain, cystic
fibrosis, Huntington's disease, early-onset Alzheimer's
disease, and progeria, which is a fatal rare condition
characterized by advanced aging in young children usually by
2 years (see www.progeriaresearch.org). Once genes are
identified, researchers hope to develop treatments to lesson the
DISABILITY: NEUROCOGNITIVE D1SABILITIES 47
disease effects and progression or to directly treat damaged
genes. It is hoped that in the future, many neurocognitive
disabilities will not only be identified by their gene mutations
but will be amenable to effective medical intervention
(National Institutes of Health, 2006).
Identifying the Human Genome has raised many societal
concerns regarding how genetic information will be used in
the future. Some of these concerns deal with the ethical use of
the information and the possibility that persons with such gene
defects will be discriminated against and stigmatized
(National Institutes of Health, 2006). To prevent misuse of
genetic information, NASW (the National Association of
Social Workers) and other organizations have supported the
proposed Genetic Information Nondiscrimination Act (Pace,
2007). This act has received steady support from members of
Congress and is expected to become law. Of additional
concern is how gene identification will be utilized in
calculating Quality of Adjusted Life Year measurements to
determine through microeconomic models person-years lived
by health status. Such estimates are used in cost-effectiveness
analyses to determine the quality of life given a person's health
status against medical treatment options. Such measurements
could adversely affect those with neurocognitive disabilities in
the area of cost control and rationing of health care (Patchner,
2005).
Best Practice
Social workers have a key role to play in the lives of persons
with disabilities and their families. From direct practice to
policy advocacy, the array of opportunities for social workers
in disability practice continues to broaden as many live longer
with chronic disabilities. No longer is disability viewed as a
state experienced by a small percentage of our population.
Intellectual disability alone can account for nearly 3% of the
U.S.'s population (U.S. Census Bureau, 2006).
Best practice dictates an active involvement of the person
with the disability and their family in all life area decisions.
The economic term consumer-driven service delivery
indicatesa shift from a previous supplier-driven model to a
demander-driven model. Persons with disabilities are the
demander of services and, therefore, are the catalyst for what
goods and services they desire and need. The professionals are
the suppliers of services and they no longer direct the care and
services that are to be provided, but are the facilitator in
making sure that the person gets the care and services that they
desire and need.
When an individual has a neurocognitive disability, the
family or a close friend is instrumental in determining what
the person's needs are and in finalizing services with
professionals. The use of person-centered planning
48 DISABILITY: NEUROCOGNITIVE DISABILITIES
in working with persons with cognitive impairments and
their family or friends has been extremely successful both
in Canada (where it was developed) and in the United
States (O'Brien & O'Brien, 2000). When employing this
technique, the person and those close to the person outline
together what is an optimal quality of life for the person. It
begins by identifying the individual's hopes and aspirations
and continues with an action plan to realize these goals.
The person-centered planning process involves modifying
goals, aspirations, and action plans until an optimal quality
of life is achieved for the person (Patchner,2005).
Best practices for professional social workers who work
with persons who have neurocognitive disabilities involve
a thorough understanding of consumer- driven strategies.
These strategies may utilize person- centered planning and
other consumer-driven modalities.
Policy practice is the responsibility of all social
workers. Within the disability specialization, profes sional
social workers partner with or represent the in terests of
persons and families who request assistance in advocating
for policy change. Such activities may in clude advocating
on the local, state, or federal levels for cha nges in fiscal
allocations and services, speaking with legislators or
bureaucrats, gathering data for policy ana lyses, and
performing such analyses, or helping a person navigate the
complex service delivery system. The most effective policy
practice activities involve consumer advocates who,
because of their own experiences, are most knowledgeable
about gaps in services and unmet needs or solutions.
When it comes to best practices, the person and/or
family are usually the "experts." It is the social worker's
responsibility to identify needs, assist in procuring ser-
vices, navigate the maze of services, and promote poli cies
and services to better serve this population.
Future Trends and Practice Implications Future
trends in practice will be affected by cost containment
as well as quality of care concerns. According to Rose
and Moore (1995), cost containment (providerdriven)
and quality of care (consumer-driven) cannot exist
together with a quality outcome as an expectation.
Institutions, government, and social services have at-
tempted to balance both concerns to please both con-
stituent groups. A constant tension will exist unless
policy makers successfully mediate between both
forces (Redfoot, 2003).
New problems for people with neurocognitive dis-
abilities will develop, and social workers will often assist
with these new challenges. For example, as more people
with intellectual disabilities live t o an older age, who will
provide for them as their parents either die or are unable
to care for their offspring anymore? Formerly they were
institutionalized; however, these facilities are being closed,
partly to save state funds but primarily because of the lack
of care and dignity accorded to persons with disabilities.
Social workers can assist by identifying community-based
housing and employment, and where appropriate find them
guardians as well. Social workers can also alert their
legislators that additional funding and adequate housing are
needed for this.
Future Trends
Future practice trends will involve the modification of
current practices such as interdisciplinary practice, re-
storative care, and holistic care to embrace disabilities
across the life span. New specializations will develop in
order to serve a greater heterogeneous population. The
continuum of care will become more identifiable as private
and public agencies may become more specialized.
Technology innovations will allow persons with
disabilities more self-determination and freedom of ex-
pression. And as society becomes more enlightened, we
can expect that universal design (that is, accessibility in all
areas of life for every person) will become commonplace
(Kurtz, Dowrick, Levy, & Batshaw, 1996; National
Association of Social Workers, 2003b).
Newer emerging trends will be controversial and will
require Vigilance by professionals. There will be a growing
number of privatized services and less public services.
Subsequently, because of cost containment priorities, we
can expect a greater use of quality of adjusted life years in
determining who gets what care and services. As cost
containment becomes a pressing issue for government and
industry, rationing of health and welfare service s will
become common. Macroutili tarian approaches to providing
care will spar with rnicroegalitarian approaches. The most
vulnerable population at risk will be those with
neurocognitive disabilities, who can be considered costly
by society's standards (Maramaldi, Berkman, & Barusch,
2005; Patchner, 2005; Sacristan, 2003).
Social Work Practice Implications
There will continue to be a steep educational learning curve
for professional social workers engaged in neuro cognitive
disability practice. Medical and scientific ad vances will
require intensive continuing education. Letting go of the
reigns and encouraging persons to develop and implement
their own plan of care takes experience, acceptance of a
new practice model, and maturity. Being knowledgeable
about privatization of services in order to advocate and
navigate for health and welfare services, housing, and
employment will become an essential skill.

Persons with neurocognitive disabilities could easily fall
through the cracks. Professional social workers who are
knowledgeable about the evolving service environment are
obliged to partner with this population to ensure dignity and
the ability to earn a livelihood both today and in years to
come.
REFERENCES
Asch, A. (2001). Critical race theory, feminism, and disability:
Reflections on social justice and personal identity. Ohio State Law
Journal, 62,1-17.
Autism Speaks. (2007). www.autismspeaks.org
Corrigan, P. W. (2007). How clinical diagnosis might exacerbate the
stigma of mental illness. Social Work, 52, 31--40.
De Weaver, K. L. (1995). Developmental disabilities: Definitions and
policies. InR. L. Edwards et al. (Eds.), The encyclopedia of social
work (19th ed., Vol. 1, pp. 712-720). Washington, DC: NASW
Press.
Gilson, S., & DePoy, E. (2002). Theoretical approaches to disability
content in social work education. Journal of Social Work Education,
38,153-165.
Graziano, A. M. (2002). Developmental disabilities: Introduction to a
diverse field. Boston: Allyn and Bacon.
Kurtz, L., Dowrick, P., Levy, S., & Batshaw, M. (Eds.). (1996).
Handbook of developmental disabilities: Resources for interdis-
ciplinary care. Gaithersburg, MD: Aspen.
Mackelprang, R. W. (2002). Social work practice with persons of
disability. In S. F. Gilson et al. (Eds.), Integrating disability content
in social work education: A curriculum resource (pp. 914).
Alexandria, VA: Council on Social Work Education.
Maramaldi, P., Berkman, B., & Barusch, A. (2005). Assessment and
the ubiquity of culture: Threats to validity in measures of
health-related quality of life. Health and Social \'(1ork, 30, 27-36.
National Association of Social Workers. (2003a). Disabilities.
Washington, DC: NASW Press.
National Association of Social Workers. (2003b). People with
disabilities. In P. L. Delo et al. (Eds.), Social work speaks (6th ed.,
pp. 270-275). Washington, DC: NASW Press.
National Organization on Disability. (2004). Harris survey of
Americans with disabilities: 2004. Washington, DC: Author.
National Institutes of Health. (2006). History of the human genome
project. Atlanta, GA: U.S. Centers for Disease Control.
O'Brien, C. L., & O'Brien, J. (2000). The origins of person centered
planning: A community of practice experience. Syracuse, NY: Center
on Human Policy, Syracuse University.
Pace, P. R. (2007). Mental health parity, Genetics bills backed. NASW
News, 52, p. 1.
Patchner, L. (2005). Social work practice and people with disabilities:
Our future selves. Advances in Social Work, 6, 109-120.
Redfoot, D. (2003). The changing consumer: The social context of
culture change in long-term care. Journal of Social Work in
Long-Term Care, 2, 95-110.
Rice, C. (2007). Prevalence of autism disorders: Autism and
developmental disabilities monitoring network, 14 sites,
DISABILITY: PHYSICAL DISABILITIES 49
United States, 2002. Morbidity and Mortality Weekly Report, 56,
12-28.
Rose, S. M., & Moore, V. L. (1995). Case management. In R. L.
Edwards et al. (Eds.), The encyclopedia of social work (19th ed., Vol.
1, pp. 335-340). Washington, DC: NASW Press.
Sacristan, P. (2003). Problems and solutions in calculating
quality-adjusted life years (QALY s). Health Quality Life
Ourcomes, 1,80.
Slick, D. ]., Sherman, E. M., & Iverson, G. L. (1999). Diagnostic
criteria for malingered neurocognitive dysfunction:
Proposed standards for clinical practice and research. The Clinical
Neuropsychologist, 13,545-561.
Sulkes, S. B. (2003). Mental retardation. In M. H. Beers et al. (Eds.),
The Merck manual of medical information (2nd home ed., pp.
1626-1629). Whitehouse Station, N]: Merck Research
Laboratories.
United Nations. (2007). The convention on the rights of persons with
disabilities. New York, NY: Department of Economic and Social
Affairs, United Nations.
U.S. Census Bureau. (2006). Americans with disabilities: 2002.
Washington, DC: U.S. Government Printing Office.
World Health Organization. (200l). International classification of
functioning, disability and health. Geneva, Switzerland: Author.
World Health Organization. (2006). The world health report: 2006.
Geneva, Switzerland: Author.
SUGGESTED LINKS National Organization on
Disability. www.nod.oTg
International Usability Professionals Association-World Usability
Day.
www.wOTldusabilityday .0Tg
World Health Organization-International Classification of
Functioning, Disability, and Health. www.who.int/classification/icf
Kaiser Family Foundation.
www.kaisemetwoTk.oTg
The Arc.
www.theaTc.org
Consortium for Citizens with Disabilities.
www.c-c-d.oTg
American Association on Intellectual and Developmental Disabilities
(formerly AAMR).
www.aaidd.oTg
Institute for Independent Living.
www.independentliving.oTg/
National Family Caregivers Association.
www.nfcacaTes.org!
-LISA S. PATCHNER AND KEVIN L. DEWEAVER
PHYSICAL DISABILITIES
ABSTRACT: Physical disability is traditionally defined
by society's view of atypical function. The medical
model offers information on factors contributing to
physical disability, including genetics, injury, and
50 DISABILITY: PHYSICAL DISABILITIES
disease. The social model of disability, however, defines the
societal responses, not the physical differences, as disabling.
People with physical disabilities have unique characteristics
and experiences that fall into the broad range of human
diversity. They belong as full participants in society. Social
workers must focus on working in respectful partnerships with
people with physical disabilities to change environments and
attitudes. This will help build a just society that honors
diversity.
This entry addresses multiple factors that cause disability,
from genetics to environment, as viewed through the medical
model. The social model view of "the problem" is offered in
comparison. It also introduces the wide diversity of people
with physical disability. The entry discusses two major
societal responses to physical disability. Environmental
modification is one approach. A more recent approach,
Universal Access, involves upfront design of environments to
meet diverse needs. The final sections explain implications for
social workers and lays groundwork for action. Creating
access and respectful partnerships are foundations of the work
ahead.
It is difficult to define physical disability without situating
the discussion in the model used to view and deal with human
diversity. This discussion is based on the social model of
disability, a view of disability that sees the environment as
disabling, not the individual condition. Discussion of the
medical model is offered as a contrast. (For a more complete
discussion of disability models, see Mackelprang's Disability:
An Overview in this publication.)
KEY WORDS: disability; disability identity; impairment;
models of disability; practice issues; rehabilitation; social
model of disability; teratogens; universal access; universal
design; universal instructional design
Definitions
Knowledge of physical disability is required for competent
social work practice in a diverse world. There are contrasting
definitions based on medical and social models (Mackelprang
& Salsgiver, 1999). Using the medical or deficit model,
impairment is defined as an atypicality of body parts or
function. Examples include arthritis, missing limbs, lung or
heart disease. Physical disability is determined by the actual
impact of those conditions on function. The condition must be
severe enough to limit physical activity before it can be con-
sidered a disability. Conversely, from the social model, an
impairment is viewed as a social construction (Overall, 2006;
Tremain, 2001). Society creates the meaning of the condition,
which may change over
time, and vary from one culture to another. Currently, society
differentiates atypical from typical function. Differences are
noted and labeled. Judgments often follow (Depoy & Gilson,
2004; Reeve, 2002). The social model of disability proposes
that it is the societal response that disables a person with
diverse characteristics.
CAUSES OF PHYSICAL DIFFERENCE From the medical
model, typical development is viewed as the norm (Depoy &
Gilson, 2004). Atypical development is pathological. Causes,
cures, and prevention are key elements in the medical model
(Jakubowicz & Meekosha, 2002). Those who use the medical
model are concerned with the causes of physical disabilities.
Science helps explain the causes of physical difference. These
causes include genetic or chromosomal alterations, en-
vironmental events or exposures, physical trauma throughout
the life span, and disease processes (Conover, 1994; Giavini &
Menegola, 2004; Graziano, 2002; Mackelprang, n.d.;
Penchaszadeh, 2002; Seaver, 2002).
A variety of prenatal factors are linked to disability.
Genetic or chromosomal causes of disability may be due to
hereditary conditions, for example, cystic fibrosis.
Spontaneous chromosomal changes can result in conditions
such as Prader Willi (Graziano, 2002; Wattendorf & Muenke,
2005). Factors that interfere with typical fetal development are
called teratogens.
As many as 60,000 substances have been linked to
alterations in fetal development (Giavini & Menegola, 2004).
In addition, iodine and folic acid deficiencies have been tied
respectively to growth problems and neural tube (brain and
spinal column) atvpicalities (Penchaszadeh, 2002). Also,
maternal use of prescription and nonprescription medications
can lead to alterations in fetal development. Disease during
pregnancy is another trigger for alteration of fetal de-
velopment. Maternal or infant viral exposure put the fetus at
risk. The pregnant mother's external environment also can
affect the fetus. Exposure to radiation can cause physical
damage to the fetus (Graziano, 2002; Ursprung, Howe,
Yochum, & Kettner, 2006). Lead, solvents, and pesticides are
just a few examples of other environmental toxins (Conover,
1994).
In the United States, 85% of disabled persons acquire their
disabilities after birth (Shapiro, 1994). Adult onset diseases
can lead to physical disability in adults. Poorly controlled
diabetes may result in limbamputation. Cancer may reduce
functionality of organs, blood, and bones. The pain and
stiffness of rheumatoid arthritis may lead to physical
disability. HIV and AIDS as well as Alzheimer's disease can
follow pathways of progressive physical deterioration.
Trauma or injury may also cause disabilities throughout the
life span. During the birth

process, injuries to the fetus can be sustained. At any age,
limbs may sustain damage directly, or an injury to the brain or
spinal cord can manifest in paralysis and other limitations in
physical functioning.
Physical disability may be a temporary state for some.
Sprains and fractures are ready examples. Rehabilitation can
promote recovery from injuries and medical incidents such as
strokes (Stucki, Stier-jarrner, Grill, & Melvin, 2005).
Conversely, genetic conditions have lifelong effects.
Age-related disabilities may affect the individual throughout
the remainder of the life course. Aging may be accompanied
by the development of disability, although healthy aging is
becoming more prevalent (NIH, 2007). Health conditions such
as osteoporosis, stroke, heart disease, emphysema, and
chronic obstructive pulmonary disease can become more
prevalent with age. Arthritis is the most prevalent cause of
disability in the United States. Eighty-five percent of those
with arthritis are older than 45 years (AOA, 2007). Advanced
age may also be accompanied by hearing, vision, or tactile
sensitivity losses (Zastrow & Kirst-Ashman, 2007), which add
more challenges to completing tasks of daily living.
PERSONS WITH PHYSICAL DISABILITIES What are the
characteristics of a person with a physical disability? People
with physical disabilities are first and foremost, people. Their
physical difference may be visible, as evidenced by a missing
limb, atypical gait, or use of a wheelchair. It is very possible
for a disability to be invisible, as in some phases of heart or
respiratory conditions, multiple sclerosis, rheumatoid arthritis,
or muscular dystrophy. It is important to note that a number of
physical disabilities simply involve physical differences, such
as an absent limb. In some cases, however, the physical
disability may be accompanied by other disabilities. For
instance, a head injury from a motorcycle accident can result in
physical, psychological, sensory, and cognitive disabilities.
History
People with disabilities have historically been viewed as
needing to be fixed or cured (Mackelprang & Salsgiver, 1999).
Those who need help with tasks of daily living, such as eating,
dressing, and toileting, were seen as abnormal. Some people
with physical disabilities were met with fear and discomfort,
as well as treated as objects of charity (Depoy & Gilson, 2004).
In the past, care in institutions or nursing facilities were often
seen as the only alternatives. Living independently, attending
school (especially higher education), claiming sexuality,
having families and jobs were not viewed as realistic goals. It
is well supported in the literature (for
DISABILITY: PHYSICAL DISABILITIES 51
example, Depoy & Gilson, 2004; Mackelprang & Salsgiver,
1999) that these reactions are tied to the stigma associated
with disability.
The Independent Living movement, which emerged in the
1960s, began to challenge these assumptions (Mackelprang &
Salsgiver, 1999). With accessible housing, schools,
transportation, and businesses, and often the help from
attendants, all people can live in the community. Social roles,
from parent to professional, can be successfully fulfilled with
adequate support and opportunity. The social environment
plays a large role in the extent to which physical difference
will affect an individual's life and life span. How persons with
physical disabilities view themselves is as diverse as the
human experience. Social experiences with family,
neighborhood, and school make a difference (Antle, 2004;
Moore, 1998).
The civil rights movements of the 1960s fueled disability
rights protests and demands for access. Finally, in 1990, The
Americans with Disabilities Act (ADA) affirmed the existing
inequities for citizens with disabilities (Mackelprang &
Salsgiver, 1999). Yet barriers still exist. Lack of financial
resources continue to limit access to full participation in
society. Payment is needed for qualified attendants or
technology to increase access. Poverty is associated with
causes of disability as well as the consequences of disability
(Lustig & Strauser, 2007). Not all people with physical
disabilities are poor (Depoy & Gilson, 2004). Those with
financial resources have somewhat different experiences than
those without, such as increased access to qualified attendants
and technology. Also, persons with coexisting disability,
along with racial, ethnic, gender, and sexual identities, face
further complexities in defining themselves and taking action
(Mpofu & Harley, 2006; Robinson, 1999).
Researchers are asking questions about who people with
disabilities feel connected to, and how persons with
disabilities define themselves (Depoy & Gilson, 2004;
Putnam, 2005). Personal and social identities (culture) for
people with physical disabilities are being explored (Beart,
Hardy, & Buchan, 2005). One strand ofliterature includes
discussion of financial, governmental, and environmental
discrimination. This can impede full participation in society
and contribute to internalized oppression (Galvin, 2005;
Reeve, 2002). Yet high selfesteem and positive outlooks for
persons with disabilities are reported despite negative social
experiences (Putnam, 2005). Many report that they would not
change their circumstances (Hahn & Belt, 2004).
Existence of a shared culture that honors each individual
would offer a community of support for action (Depoy &
Gilson, 2004). But disability cultural
52 DISABILITY: PHYSICAL DISABILITIES
identity is not a clear or universally accepted concept (Depoy
& Gilson; Mackelprang & Salsgiver, 2007).
The social model of disability offers a framework for
changing the environment and bolstering positive identities,
rather than internalizing oppression. Social constructions are
created; therefore they can be recreated in ways that honor
diversity (Galvin, 2005). Social workers have an important
role in working with persons with disabilities to challenge
current social constructions about disability and work in
partnerships to create a new view of disability as a form of
diversity.
FROM ENVIRONMENTAL MODIFICATION TO UNI.
VERSAL ACCESS Western society has generally responded
environmentally to disability in one of two ways. Following
the ADA itJ. 1990, efforts have been made to modify existing
environments to accommodate physical disability.
"Reasonable accommodation"
(http://www.usdoj.gov/crt/ada/q%26aeng02.htm) provides
access by remodeling physical space or providing equipment.
The equipment, called Assistive T echnology, allows access to
an activity or service. This technology ranges from items such
as sponge pencil grips and mechanical reachers to
computerized programs that run a household. The United
Nations, as well as individual countries such as Canada,
United Kingdom, Australia, Spain, Holland, and Sweden,
have implemented laws and policies to address accessibility
for those with disabilities (Sandhu, 2000).
A second approach, Universal Access, offers a proactive
approach. Universal Access involves "upfront" design that
makes environments and services accessible to all. A major
component is Universal Design (UD) that began as an
architectural concept (http://www.design.
ncsu.edu/cud/aboucudprinciples.htm). Ideally, buildings are
constructed and businesses and services are designed around
these principles. UD involves initial inclusion of items such as
automatic doors, curb cuts, levered door handles, wider doors,
and adequate space to accommodate adaptive equipment, such
as wheelchairs. UD benefits students juggling books, parents
with strollers, as well as grocery shoppers with carts or bags of
purchases. All society profits from UD which offers a
framework for designing more inclusive communities
throughout the world (Sandhu, 2000). Environments created
with UD principles require fewer modifications for individual
needs.
Universal Access is not just about making physical
alterations, but also encompasses designing activities that
encourage the participation of as many people as possible (
http://homepage .e ircom.net/ - tippcil/universal jiccess. htm.)
Universal Instructional Design (UID) or Universal Learning
Design (ULD) has been receiving
greater attention in the literature (Curry, 2003; Hackman &
Rauscher, 2004; Johnson, 2004; Lightfoot & Gibson, 2005;
Mino, 2004; Oulett, 2004; Pliner & Johnson, 2004; Scott,
McGuire, & Shaw, 2003). UlD or UDL principles are often
built on UD principles and usually incorporate three core
principles from the Center for Applied Special Technology:
multiples means of representation, multiple means of
expression, and multiple means of engagement (http://www
.cast.org/a bout/index. h tml). These principles are vital in
social justice education which examines power imbalances
present in oppression (Hackman & Rauscher, 2004) and social
work education (Lightfoot & Gibson, 2005).
SOCIAL WORK AND UNIVERSAL ACCESS Universal
Access principles provide guidelines for social workers to
meet the needs of a diverse society. These principles can be
used to work with colleagues with physical disabilities, clients
who use English as their second language, adults with learning
disabilities, or older adults with low vision. Social workers can
apply Universal Access principles before scheduling
community meetings, or developing individual client
activities.
Applying principles of UlD (Alschuler & Mackelprang,
n.d.; Curry, 2003; Hackman & Rauscher, 2004; Johnson, 2004;
Lightfoot & Gibson, 2005; Mino, 2004; Oulett, 2004; Piner &
Johnson, 2004; Scott, McGuire, & Shaw, 2003) to social work
practice improves access to policy development, research, and
direct service. Descriptions of Scott, McGuire, and Shaw's
nine principles of UID are adapted below for social work use.
(a) To meet the needs of a diverse population, select locations
that are served by public transportation, with accessible
entrance, intake or counseling area. Provide clear signage and
pictorial signage. Work or meeting spaces should be
physically accessible. (b) Honor diverse learning styles by
providing activity-based and/or group-based activities. (c)
Offer clear, jargon-free descriptions/depictions of expectations
of participation. (d) Provide information before, during, and
after the session or meeting in a variety of formats so that the
information is perceptible to as many as possible. (e) To
encourage success of all, give individuals early and ongoing
feedback about their participation. Welcome unique outcomes.
Use materials that the client or participant can be most
successful completing, such as materials with diagrams or
pictures in addition to written instructions. (f) Design required
paperwork to be done as efficiently as possible. For example,
post required forms online. Provide a variety of means to
demonstrate or share expertise, such as having participants act
or draw out their suggestions. (g) Arrange

space that will welcome those with sensory disabilities, as well as
sufficient room for those using assistive devices. (h) Build
connections. Get to know participants or clients as unique
persons. Develop ways to share their expertise and gifts with
others. (i) To build feelings of safety and acceptance, use
materials that depict diversity and convey respect. Respectful
language is imperative, such as "Ms. Smith is a wheelchair user or
rider" as opposed to "Ms. Smith is confined to a wheelchair"
(Mackelprang, n.d.). Finally, the social worker must always
anticipate and be ready to make additional individual adjustments
based on specific needs, such as interpreters, special equipment,
attendants, and any necessary Assistive Technology. Universal
Access principles help social workers create a respectful
environment for colleagues, community members, as well as
clients.
BEST PRACTICES Beyond creating access, social workers must
understand societal and individual responses to disability. In the
National Association of Social Work's Code of Ethics, Standard
1.05 Cultural Competence and Social Diversity states: "(c) Social
workers should obtain education about and seek to understand the
nature of social diversity and oppression with respect to race,
ethnicitv, national origin, color, sex, sexual orientation, age,
marital status, political belief, religion, and mental or physical
disability"
(http://www.socialworkers.org/pubs/code/code.asp).Social
workers must acknowledge the identities, cultures, experiences,
insights, and goals of all persons, including persons with physical
disabilities. Social workers must be comfortable with persons
who speak, move, and listen in nontypical ways. Neighbors,
colleagues, and business associates, as well as consumers may
have physical disabilities. Social workers must respect the
self-knowledge, strengths, and capabilities of all people,
including people with disabilities (Beaulaurier & Taylor, 2001;
Gilson, Bricout, & Baskind, 1998). In order to form partnerships
with individuals having disabilities, social workers must listen
respectfully. They should see these individuals as possessing
unique as well as common needs (Gilson et al. 1998).
Barriers to access, ranging from the financial cost of
necessary equipment to social stigma, remain at the core of the
disability experience for many (Mackelprang & Salsgiver, 1999).
Complexities of overlapping identities such as race, gender, and
sexual orientation, as well as disability must be acknowledged
(Robinson, 1999).
Global aging is occurring, with global projections for 700
million citizens over age 65 by 2020 (Ramurti, 2000). Incidence
of disability may increase with age (Zastrow & Kirst-Ashman,
2007). War-related injuries continue, affecting children and
adults (Giorlarni,
DISABILITY: PHYSICAL DISABILITIES
53
Foex, & Little, 1999). War-related disability has severe impact on
small countries engaged in civil war (Giorlarni et aI., 1999).
Technology is improving to increase physical and information
access, but dissemination of information and funding continue to
be obstacles (Sandhu, 2000).
Physical disability traditionally represents society's view of
functional limitations. Use of the medical model offers
descriptions of the many factors that contribute to physical
disability. Rather than viewing these individuals with these
physical differences as "disabled," the social model of disability
focuses on the environment as disabling. Many societies are
recognizing that people with physical disabilities have diverse
characteristics and experiences that fall into the broad range of
human diversity. They belong as full participants in society.
Literature is emerging on the concepts of disability identity and
disability cultural identity. Social workers can help in developing
respectful partnerships with people having physical disabilities to
change environments and attitudes. This will help build a society
that honors diversity.
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-MARY ANN CLUTE
PSYCHIATRIC DISABILITIES
ABSTRACT: The psychosocial catastrophe that accompanies
serious mental illness negatively impacts individual
performance and success in all key life domains. A person
in-environment perspective, and with a traditional and
inherent interest in consumer and community strengths is well
positioned to address psychiatric disabilities. This entry
describes a select set of habilitation and rehabilitation services
that are ideally designed to address the challenges faced by
persons with mental illness. In addition, it is argued that em-
phasis on a recovery model serves as an important framework
for developing effective interventions.
KEY WORDS: mental health; psychiatric disability;
recovery; supported employment; case management;
psychotropic medication; strengths model
Once nearly hidden from view and public consideration,
mental illness is considered a significant social problem
around the globe today. In the United States alone, it has been
estimated that 20% of the population is affected by mental
illness in a given year, with approximately 5.4% of this group
classified as those afflicted by serious mental disorders (U.S.
Surgeon General, 1999). The direct and indirect costs of
mental illness are staggering. More than a decade ago, Rice
and Miller (1996) estimated that the direct costs, or those
expenditures dedicated to treatment and rehabilitation, totaled
$69 billion, while the indirect costs, or losses due to
diminished opportunities and inability to maximize full
potential, surpassed $78 billion. (While many await a new
comprehensive study of the economic impact of mental
illness, given the trends in healthcare spending across the
board, and the growing demand for and use of
pharmaceuticals, it is clear that these costs have risen
significantly [Cunningham, McKenzie, & Taylor, 2006;
Knapp, Mangalore, & Simon, 2004].)
Persons identified as seriously and persistently mentally
ill-and this encompasses categories such as schizophrenia,
bipolar disorder, and major depression-face
DISABILITY: PSYCHIATRIC DISABILITIES 55
particularly daunting personal challenges. As a group, they are
the most costly to treat, commonly receiving specialized
services for years, often in the most intensive and most
expensive settings. Germane to the concept of serious and
persistent mental illness is a consideration of disability.
Disability can be a direct function of the illness process, but it
is also a function of the social sequela that follows. Indeed, in
many ways, serious and persistent mental illness can be
viewed as a psychosocial catastrophe (Spaniol, Gagne, &
Koehler, 2003). From a social work perspective, it is vital to
understand that disability is defined by, and a reflection of,
social processes, as well as the result of personal misfortune.
Accordingly, it is critical that helping endeavors honor the
profession's long-standing person-in-environment perspective.
Historically, those deemed disabled were seen as unable to
perform key social tasks or occupy valued roles. While some
progress has been made, vestiges of this perspective linger to
this day. Although all those deemed disabled deal with stigma,
the general public still largely misunderstands mental illness,
and reacts to this condition with fear. Psychiatric challenges
often remain hidden from view, but when symptoms of illness
become too pronounced to ignore, the impulse to segregate and
exclude can become strong. To be considered mentally
disabled is to be judged against notions of normative social
behavior and functioning. As was true with others who face
more visible challenges, there was a time when no appreciable
consideration was given to the notion that those with serious
mental illnesses could aspire to, and participate in, the
activities and roles that confirm full citizenship.
Deinstitutionalization and the
Emergence of Community-Based Services
A perfect storm of forces converged in earnest during the
middle and late 1960s to provoke a significant depopulation of
psychiatric hospitals. Advances in psychopharmacology, key
legal decisions, fiscal pressures on individual states, the
enactment of Medicaid and Medicare, and a general interest in
human rights and exposes of abuses in institutions (Goffman's
Asylum; Willowbrook) all conspired to create a movement
that has been labeled retroactively as deinstitutionalization
(Foley & Sharfstein, 1983; Rothmann, 1990). Bachrach (1986)
argued that as the seriously mentally ill struggled to find a
foothold in community life and practitioners strived to help
them, the disabilities these individuals faced were displayed in
bold relief. As a result, the Nationallnstitute of Mental Health
unveiled the Communi ty Support Program, recommending
structural and programmatic changes in the delivery of mental
health services. One
56 DISABILITY: PSYCHIATRIC DISABILITIES
critical component of this model-psychosocial rehabilitation
services-underscored that services should go beyond a
medical focus and also direct attention to the disabilities
associated with mental illness (Turner & TenHoor, 1978).
Psychiatric disability can be understood from a range of
perspectives, all having utility in devising the services and
interventions that can be useful to those striving to reach their
full potential. For example, a medical or primary perspective
focuses squarely on the illness process and the immediate
symptoms that are hallmarks of the given condition. A second
level, or functional model, is concerned with the psychosocial
impact of illness. Here, the concern switches to the plethora of
problems of living that arise as a result of illness, and efforts
are made to help individuals in those activities that directly
impact their quality of life. A final perspective targets social
opportunities and legal rights, highlighting the roles of stigma,
discrimination, and rejection as equally disabling (see
Bachrach, 1986; Asch & Mudrick, 1995; Barton, 1999;
Corrigan, 2003; Barusch, 2006).
As the field of psychosocial (or psychiatric) rehabilitation
has evolved, the pessimistic outlook that professional helpers
once shared with the general public about those deemed
seriously and persistently mentally ill has been supplanted
with a more hopeful and optimistic view. In part, this new
perspective was fueled by longitudinal studies that challenged
the dominant belief that the courses of illnesses like
schizophrenia were always chronic and unbending, and
similar reports that suggested that positive outcomes were
possible following diagnosis (Harding, Brooks, Ashikasa,
Strauss, & Breier, 1987a, 1987b; McGlashan, 1988; Harding,
Zubin, & Strauss, 1987; Sullivan, 1994a). These studies have
also been buttressed by accounts of former and current con-
sumers of mental health services who are now living
rewarding lives (Deegan, 2003; Ochocka, Nelson, & [absen,
200S; Schiff, A, 2004; Sullivan, 1994b).
Recovery, Disability, and
Psychosocial Rehabilitation
In response to the available data, the development of more
effective community-based programs, and the voice of the
consumer, the concept of recovery has emerged as a guiding
principle and framework for mental health services. Recovery
has been defined as "a way of living a satisfying, hopeful, and
contributing life even with the limitations caused by illness"
(Anthony, 1993, p. 15). It is also a deeply personal
process-experienced as one strives to live a fulfilling life in
the presence of widespread social stigma and seemingly
endless insults to self-esteem and personal identity. Indeed,
Spanoil (2001) notes, "while the illness
itself can cause a major disruption in a person's life, stigma
and discrimination ... can further disconnect people and
represent serious barriers to recovering" (p. 175).
Although there have been great strides in our understanding of
the social forces that impede. recovery, the reality is that those
with serious mental illnesses "have a unique set of disabilities
that interfere with their life goals" (Corrigan, 2003, p. 347). In
mental health jargon these individuals display both "positive"
and "negative" symptoms. Positive symptoms, or things that
have been added as a result of illness, include visible
symptoms and behaviors that others will view as odd and
disturbing, including hallucinations and other behavioral
idiosyncrasies. Negative symptoms, or things taken away, are
often the focus of habilitation and rehabilitation services.
These are seen in the form of lethargy, difficulties in
interpersonal communication, cognitive deficits and the like.
In combination, these factors impede the ability of people to
flourish in community settings, particularly in the areas of
education, work, independent living, positive leisure, and in
the ability to form and sustain meaningful intimate and
personal relationships. The simplest model used to explain
serious mental illness posits that basic psychobiological
factors may render some persons particularly vulnerable to
mental illness. It is also speculated that these illnesses are
triggered by the stress of life. Certainly, new tools have
increased our understanding of the brain, but our knowledge of
the precise etiology of mental illness is still largely incomplete.
Advances in psychopharmacology continue, and newer
medications have a tendency to produce fewer negative side
effects. Today it is well accepted that medication is an impor-
tant ingredient of effective care, although there are a
significant percentage of individuals who derive little benefit
from their use (see Mellman, Miller, Weissman, Crismon,
Essock, & Marder, 2001; Bentley & Walsh, 2006). When
effective, medication can reduce harmful symptoms, and help
people organize their thoughts. However, medication alone is
not enough to help individuals thrive in personal and
community life (Eack, Newhill, Anderson, & Rotondi, 2007).
As a personal process, recovery may unfold with or
without professional intervention. Recovery may be an
internal process reflecting mood or attitude, or one marked by
observable behavior and achievements. In many ways it is a
subjective process, best understood by the person who is
striving to surmount the devastation caused by mental illness.
Yet, many facing mental illnesses seek, or are directed to,
mental health professionals. Psychiatric rehabilitation services
are designed to deal directly with those life challenges
presented by serious mental illnesses.

Anthony (1992) suggests "the clinical practice of
psychiatric rehabilitation, just like its counterpart in
physical rehabilitation, comprises two broad interven tion
strategies: development of client's skills and devel opment
of client's supports" (p. 166). Corrigan (2003) has offered
an integrated model of psychiatric rehabilita tion that
underscores the wide range of life domains that must be
addressed if recovery can be realized. In general, the thrust
of rehabilitation has been strengths-based, and "is positive
in focus, reflecting an individual's possibili ties rather than
his or her limitations" (p. 349).
A staple in specialized mental health rehabilitation
services has been training in a wide range of skills,
including interventions aimed to improve the ability of
people to cope with psychiatric symptoms and stress. The
areas targeted are broad, but often include matters such as
personal hygiene, interpersonal communica tion, and
vocational and independent living skills. In the most
systematic programs, training modules and curriculums are
developed, and the interventions are guided by principles of
social learning (Nemac, McNamara, & Walsh, 1992;
Corrigan, 2003). The persistent criticism of these methods
involves the difficulty consumers have transfe rring skills
learned in structured programs to community living.
Extensions of this approach emphasize the need for a
multifaceted effort that includes the use of actors who
model the target behavior, rehearsal and practice,
homework, and supports in the community (Corrigan,
2003). Unfortunately, many day or partial hospital
programs fall well short of this standard, and fail to
customize interventions to the needs of the individual.
These programs tend to be unstructured, place few demands
on consumers, and are rarely goal-focused.
As consumers have shared their experiences, profes-
sionals have begun to understand the various ways people
have learned to cope with the symptoms of ill ness. Auditory
hallucinations can be particularly vexing to deal with , and
reports of consumers have been vital to developing
strategies to cope with them (Romme & Escher, 1989;
Ritsher, Lucksted, Otilingam, & Grajales, 2004). Equally
important has been individual's ability to recognize signs of
stress and other indications that things are going badly.
Consumers often choose to organize daily life to reduce
stress, pay greater attention to matters like sleep and diet,
consult with professionals or draw support from peers, or
fall back on their spiritual beliefs. While an under standing
of these strategies can guide the development of supportive
services, recovery is a unique process, and professionals
should be cautious when assuming that a tool that helps one
individual will have the same positive effect with another.
DISABILITY: PSYCHIATRIC DISABILITIES 57
In many ways, to experience serious mental illness is to
experience loss. Spanoil, Gagne, and Koehler (2003) note
that what people are recovering from includes the loss of a
sense of self, loss of connectedness, loss of power, loss of
valued social roles, and perhaps the deepest cut of all, the
loss of hope. Recovery is also an interactive process. A key
component of comprehensive rehabilita tion programs is
service designed to increase social sup port. At times, no
professional intervention is needed, as peer support
services and clubhouse models are predi cated on the
philosophy of mutual help (Solomon, 2004; Glynn, Cohen ,
Dixon, and Niv, 2006). At other times, professionals can be
particularly helpful in working wit h families, and in efforts
to create stronger connections with others in the
community. Of particular help to families has been the
work of the National Alliance on Mental Illness (NAMl).
Local NAMI chapters offer support groups for family
members dealing with a loved one who suffers from mental
illness. Primary consumers have also formed
mutual-support and advocacy groups that serve to offer
information and advice to members, as well as impact
public policy and protect individual rights. The relationship
between professional helpers and families caring for a
loved one with mental illness and sometimes between
patients or consumers and their families have been fraught
with tensions and contradic tions at time. In recent decades,
the legacy of theories that b lame families has largely been
shed (Pratt, Gill, Barrett, & Roberts, 1999), and in its place
a partnership model has developed. Families can become
isolated from others due to the time and effort needed to
care for a mentally ill member, and the social st igma that
follows. When support and information are given in
sensitive ways, and families are offered practical advice
and tools that they can use day to day, the primary
consumer benefits as well. Early signs of relapse can be
identified, hospitalization can be avoided, and all parties
begin to view life as more manageable.
For recovery to be realized, however, mental health
consumers must have opportunities to participate in
community life and assume valued social roles. Out reach
case management, partic ularly when guided by the
strengths perspective, highlights resource acquisi tion as
vital to success. The strengths model is predi cated on two
primary assumptions. First, it is argued that individual
behavior is heavily influenced by the resources availa ble to
people. The second principle states that our society, at least
in word if not in deed, values equal access to resources
(Rapp & Chamberlain, 1985). The latter principle flows
directly from the social work's traditional interest in social
justice, a key consideration for people with all forms of
disability, and also calls forth the profession's
long-standing
58 DISABILITY: PSYCHIATRIC DISABILITIES
commitment to advocacy for vulnerable citizens. This is vitally
important given the stigma, segregation, and rejection
experienced by those with mental illnesses.
Outreach case management is a versatile service. (see Rapp &
Goscha, 2004). Outreach case management is not executed
behind a desk or simply by telephone. By working in
environments where consumers live, work, and play, case
managers can help consumers learn and practice skills needed for
successful community living, and increase the odds that skills
learned inprogram are transferred to real-world settings. Case
managers can also help consumers in times of distress, watch for
signs of impending difficulty, and work with them to develop and
execute a plan of action to avoid relapse. With consumers taking
the lead, goal and case planning is at the heart of the case
management process. By breaking larger goals into manageable
steps consumers can learn a problem-solving method that has
utility in other life spheres. Finally, the strengths model
highlights the use of natural community resources as a first
priority. These resources, generally tied directly to
consumer-established goals, also help individuals establish bonds
with others outside the professional community and their current
peer group.
Given the important role of work in people's lives, vocational
rehabilitation has been a central aspect of mental health services
throughout history. Over the past 20 years, the traditional "train,
then place" approach has been rejected in favor of the supported
employment model based on the principle of chooseget-keep.
Here, the consumer's vocational interests are quickly identified,
and job placement occurs as rapidly as possible, rejecting the
notion that a long prevocational training phase is necessary to
prepare people for work. The model is predicated on the
assumption that "all people-regardless of the severity of their
disability-can do meaningful, productive work in normal settings,
if that is what they choose to do, and if they are given the
necessary support" (Anthony & Blanch, 1987, p. 7). Key
principles of the model include a focus on competitive
employment, rapid job search, integration of mental health and
rehabilitation services, consumer choice, and the availability of
time-unlimited individualized support (Bond, 2004; Salyers,
Becker, Drake, Torrey, & Wyzik, 2004). Job coaches, job
sharing, and other innovative methods are used to help people
meet the demands of competitive employment. Extensions of this
model have also been developed in education and independent
living (Rog, 2004). It should be noted that some consumers had
viable career interests before the onset of illness and hope to
resume their chosen profession or training. Like people suffering
from physical challenges, those considered psychiatrically
disabled also long for a chance to realize their potential and
pursue life goals. Legislation such as the Americans with
Disability Act provides a measure of protection against
discriminatory practices. Such legislation, plus advocacy efforts
and changing social mores, can help hold the door open to greater
social opportunities.
From here, well-designed and executed rehabilitation
services, like those described earlier, can provide needed support,
ignite individual strengths, and help consumers learn the skills
needed to exercise their individual rights. However, these
opportunities can be fleeting. The U.S. Surgeon General's report
underscored the persistent gaps in the mental health system (U.S.
Health and Human Services, 1999). Lack of capacity and access
to specialty services leaves consumers in vulnerable situations.
Jails have become defacto hospitals, and professionals are left to
manage ever-growing caseloads. The advances in treatment and
care described above are undermined in a poorly funded treatment
environment. Likewise, changing political winds can emphasize
individual deficiencies as the source of problems like
homelessness, and minimize the role of restricted opportunity and
stigma. This can result in the continued criminal ization of mental
illness and a retreat from the goal of true community integration
for those with these challenges.
Social workers have played and will continue to playa strong
role in the mental health system. Many entry-level professionals
begin their careers as case managers, and social workers are
prominent in the community mental health system in direct
practice roles, as well as in administration and leadership. ln order
to develop effective programs efforts must be extended to
determine best practices and also shape the political and policy
context necessary for success. Thus, from researchers to policy
makers, there are many opportunities for social workers to help
improve the mental health system and help advance the recovery
vrsion.
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Anthony, W., & Blanch, A. (1987). Supported employment for
persons who are psychiatrically disabled: A historical and
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(2),5-23.
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Cunningham, P., McKenzie, K., & Taylor, E. (2006). The struggle to
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journai, 26(4), 368-376.
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Quality of life for persons living with schizophrenia: More than
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impact of the recovery movement on family interventions in
schizophrenia: Opportunities and obstacles. Schizophrenia Bulletin,
32(3), 451-463.
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(1987b). The Vermont longitudinal study of persons with severe
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Salyers, M., Becker, D., Drake, R., Torrey, W., & Wyzik, P. (2004). A
ten-year follow-up of a supported employment program.
Psychiatric Services, 55(3),302-308.
Schiff, A (2004). Recovery and mental illness: Analysis and personal
reflections. Psychiatric Rehabilitation Journal, 27(3), 212-218.
Solomon, P. (2004). Peer support/peer provided services underlying
processes, benefits, and critical ingredients. Psychiatric
Rehabilitation Journal, 27( 4), 392-01.
Spanoil, L. (200l). Recovery from psychiatric disability: Implications
for rehabilitation counseling education. Rehabilitation Education,
15(2), 167-175.
Spaniol, L., Gagne, C, & Koehler, M. (2003). The recovery
framework in rehabilitation and mental health. In D. Moxley & ].
Finch (Eds.), Sourcebook of rehabilitation and mental health IJractice
(pp. 37-50). New York: Kluwer Academic Publishers.
Sullivan, W. P. (1994a). A long and winding road: The process of
recovery from severe mental illness. 1nnovations & Research,
3(3),19-27.
Sullivan, W. P. (1994b). Recovery from schizophrenia: What we can
learn from the developing nations. Innovations & Research,
3(2),7-15.
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Rockville, MD: U.S. Department of Health and
60 DISABILITY: PSYCHIATRIC DISABILITIES
Human Services, Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services, National
Institutes of Health, National Institute of Mental Health.
FURTHER READING
Barton, R. (1999). Psychosocial rehabilitation services in community
support systems: A review of outcomes and policy
recommendations. Psychiatric Services, 50( 4), 525-534.
SUGGESTED LINKS Center for Psychiatric
Rehabilitation http://www . bu.edu/cpr/
Mental Health America
http://www.nmha.org/
Mental Health: A Report of the Surgeon General
http://www . surgeongeneral.gov/library/mentalhealth/home . heml
National Alliance on Mental Illness
http:// www . nami. org/
National Institute of Mental Health
http://www. nimh.nih.gov/ Recovery, Inc.
http://www . recovery-inc. org/
-w. PATRICK
SULLIVAN
DISASTERS
ABSTRACT: Disasters are a form of collective stress posing
an unavoidable threat to people around the world. Disaster
losses result from interactions among the natural, social, and
built environments, which are becoming increasingly
complex. The risk of disaster and people's susceptibility to
damage or harm from disasters is represented with the concept
of vulnerability. Data from the Indian Ocean tsunami,
Hurricane Katrina, and genocide in Darfur, Sudan, show poor
people suffer disproportionately from disasters. Disaster
social work intervenes in the social and built environments to
reduce vulnerability and prevent or reduce long-term social,
health, and mental health problems from disasters.
KEY WORDS: disaster; collective stress; vulnerability;
preparedness; mitigation; response; recovery
People have experienced natural disasters, such as floods,
hurricanes, and earthquakes, for as long as can be
remembered. Disasters from nuclear power stations, toxic
chemicals, and other potentially dangerous technologies have
been added to the calculation of societal risks since the
industrial age. The risk equation has been further complicated
in recent years by the threat
of terrorism, for which the variety of agents and targets areas
cannot always be identified before the event. The increasingly
interdependent nature of our world means that localized
natural or human-made disasters affect people around the
globe.
The concept of vulnerability offers a useful way to
organize knowledge, plan effective responses, and guide
ongoing efforts to reduce the negative consequences of
disasters. Oliver-Smith and Button (2005) define vulnerability
as a ratio of risk to susceptibility. The idea of vulnerability is
grounded in distributive justice (Soliman & Rogge, 2002).
The vulnerability concept was first introduced in the 1970s
(O'Keefe, Westgate, & Wisner, 1976) but has recently
resurfaced as an encompassing idea that is flexible and
capable of integrating the wide spectrum of issues and
challenges involved in reducing the casualties and damage
from disasters (Cutter, 2006; McEntire, 2005; Villagran De
Leon, 2006).
Disaster Definitions, Types, and Effects There
are many definitions of disaster. Frequently cited
definitions view disasters as the prevention of essential
functions (Fritz, 1961), the need to respond with excep-
tional measures (Carter, 1992), collective stress (Barton ,
1969), and crisis situations (Quarantelli, 1998). Accord-
ing to Britton (1987), disasters differ from emergencies
and accidents in two ways: disasters affect many people
at the same time, while the degree of involvement and
disruption is great. Disasters involve significant hard-
ships and losses. Barton's explanation of disasters as
collective stress is the most general, and thus the most
useful, definition for guiding social work theory and
practice. Stress theory classifies consequences according
to disaster type, demands on the system and duration
(Dodds & Nuehring, 1996). These properties fit with
Barton's (1969) typology of collective stress situations
and subsume all types of disaster, including conflict
situations.
Disasters are classified as natural, technological, and
synergistic. Natural disasters are defined by disruptions of
physical agents. Examples of natural disaster include
earthquakes, volcanic eruptions, and tornados (Wijkman &
Timberlake, 1984; Wisner, Blaikie, Cannon, & Davis, 2003).
Technological disasters are defined by harm to people or
damage to property from human-made materials or conditions.
Technological disasters include hazardous material releases,
transportation accidents, civil unrest or riots, and war (Cutter,
1991; Collier & Sambanis, 2003; Peek & Sutton, 2003;
Perrow, 1984). Synergistic disasters are defined as two or
more agents that together produce harm or damage not
possible by anyone of the agents independently. Synergistic
disasters include drought,
I DISASTE
desertification, and famine (Middleton & Thomas, 1997;
Walker, 2005). Particular disasters can involve a mix of these
types, referred to as "complex disasters," which occur most
often in developing parts of the world (Aptekar,1994).
In collaboration with the U.S. Office of Disaster
Assistance and the Belgium government, the World Health
Organization's Centre for Research on the Epidemiology of
Disasters tracks 15 types of disasters with about 50 subtypes,
reporting the time and location of disasters; number of people
killed, injured, and displaced; the estimated cost of damage
and reconstruction; and the amount of aid contributed
(http://www. ern-dat.net/). Using the EM-DAT data,
Guha-Sapir, Hargitt, and Hoyois (2004) summarize 30 years
of the world's disasters and their consequences.
Disaster losses result from interactions among the physical
environment, social and demographic characteristics, and the
buildings, roads, bridges, and other parts of the constructed
environment (Mileti, 1999). These systems and their
interactions are becoming increasingly complex (Gillespie,
Robards, & Cho, 2004). Each year, many people are killed or
injured and many others suffer income and property losses. In
2006, Indonesia had 5,778 persons killed by an earthquake,
while a typhoon and landslide combination in the Philippines
caused 2,511 deaths (Centre for Research on the
Epidemiology of Disasters, 2007). The price tag of disasters
has climbed to staggering heights; the worldwide estimated
annual cost from all types of disaster has increased from about
1.1 billion U.S. dollars in 1960 to over 78.4 billion U.S. dollars
in 2006.
Case Studies of Three Disasters
INDIAN OCEAN TSUNAMI (2004) The Indian Ocean
tsunami of 26 December 2004 was the world's largest natural
disaster in 40 years, unprecedented in both deaths and damage
(U.S. Agency for International Development, 2005). In
response to estimates of 283,000 deaths, 14,000 missing and
1,130,000 displaced across the 14 directly affected countries
(U.S. Geological Survey, 2005), the relief effort included a
major international humanitarian response. While the tsuna-
mi's devastation was not discriminatory, certain groups were
more affected than others. Children were particularly
endangered because of the locations of impact and their
limited ability to survive in the force of the water (Birkmann et
al., 2006; Cosgrave, 2007). Moreover, Oxfam International
(2005) raised concerns regarding the tsunami's impact on
women. In Indonesia, for example, women have had to
assume greater workloads in caring for extended families, and
may be encouraged to marry earlier than in the past because of
a post-tsunami
RS
6
1
gender imbalance. In India, the loss of assets, homes, and
family members have contributed to greater gender inequality
between men and women (T ata Institute of Social Sciences,
2005). Overall, evaluations have highlighted shortcomings in
ensuring participation and consultation with affected
communities, competition between agencies, housing
reconstruction, and exclusion of the most vulnerable sectors of
society, including the aged, women, children, and people with
a disability (Tara Institute of Social Sciences, 2005).
HURRICANE KATRINA (2005) On 29 August 2005,
Hurricane Katrina struck the north-central Gulf Coast of the
United States, resulting in the deaths of more than 1,800
people, the displacement of more than one million and billions
of dollars of damage from a combination of floods and winds.
The majority of those who died from the disaster were elderly
(Knabb, Rhome, & Brown, 2005). Katrina affected 90,000
square miles of land, extending from southern Louisiana to the
Alabama-Florida border. The storm surge destroyed many
towns in the southern states of Louisiana, Mississippi, and
Alabama, and the devastating breaching of levees in New
Orleans resulted in the flooding of 80% of the city. lt is
estimated that the hurricane and the resulting flooding
destroyed more than 300,000 singlefamily homes (U.S. House
of Representatives, 2006).
The cost of repairs for the U.S. government from
Hurricane Katrina has been estimated as of julv 2006 to be
over 107 billion U.S. dollars (Liu, Katz, & Fellowes, 2006).
Private insurance costs are not published. The total economic
impact depends on how long the recovery period persists.
Although the economic losses had a relatively small impact on
the U.S. economy as a whole, the hurricane destruction
devastated many local economies, causing the loss of
thousands of jobs and disrupted oil refining activities in the
Gulf of Mexico for several months (Knabb et al., 2005). As a
result of Hurricane Katrina, the population of New Orleans
was dispersed across the southeast United States and other
parts of the country, and the State of Louisiana experienced a
significant population loss following the hurricane. The
disaster response especially from the Federal government has
been sharply criticized for being slow and ineffective. The
reasons are many, including lack of presidential leadership,
inadequate prevention and preparation by the Federal
Emergency Management Agency (FEMA), extensive
coordination problems between federal, state, and local
response efforts, and an overall lack of capacity of responders
(Basham, 2005). This lack of capacity was made apparent
through media coverage in New Orleans at the Superdome
serving as a shelter, where thousands suffered from lack of
water,
62 DISASTERS
food, space, and restroom facilities. There have been
accusations of blatant racism in the government's response
as well as adamant denials that race played any role at all.
Henkel et al.'s (2006) discussion of institutional
discrimination, subtle biases, and racial mistrust explains
why these issues continue to surface and some fear that it
could happen again.
CIVIL UNREST, WAR, AND GENOCIDE IN DARFUR,
SUDAN (2003 TO PRESENT) Violence in Darfur, Sudan,
has led to a conservative estimate of 200,000 death s (Hagan
& Palloni, 2006) and 2.5 million displacements, including
those living in internal refugee camps and others fleeing to
Chad (Guha-Sapir & Degomme, 2006; Vasagar &
MacAskill, 2005). The citizens of Darfur were pawns in the
Sudanese political peace process, with the [unjaweed, a
Sudanese military group, beginning a full-scale campaign
against them. The conflict has been presented as a war
between the Arab Muslim North and African Animist and
Christian South, but Ylonen (2005) explains how culturally
and regionally political, economic, and social marginaliza-
tion and its effects lead to the conflict. The ]unjaweed has
eradicated whole villages, destroyed wells and fields, and
stolen or ruined anything of value to the people of Darfur.
The affected populations are suffering widespread disease
and starvation, and many humanitarian organizations have
been unable to serve the region because of the ongoing
violence, ineffective security, and lack of access, as the
Sudanese government continues to restrict international aid
efforts. In addition to the government blocking
humanitarian assistance, the [unjaweed have sealed off
displacement camps and refuse to let necessary supplies be
delivered. In Khartoum (the capital of Sudan), aid
provisions are not released to agencies. On the few roads
that exist in Darfur, roadblocks and hijackings occur
regularly. The [unjaweed, together with the Sudanese
military, have continued to systematically commit acts of
mass murder, rape, torture, and mutilation in Darfur
(Cheadle & Prendergast, 2007).
Responses to Disaster
International: Most major disasters are problems of
international magnitude. All nations have hazards, al-
though the range of disasters varies widely in various
parts of the world. The Indian Ocean tsunami directly
affected 14 countries and indirectly impacted many
others. The genocide in Darfur is creating severe refugee
problems in surrounding countries. Oliver-Smith (1994)
notes that the policies and activities of one nation can
increase risk in other nations. However, some progress is
being made by countries working
together to solve mutual concerns and challenges
(Slaughter, 2004) and through dedicated efforts of global
institutions such as the United Nations International
Decade for Natural Disaster Reduction, the Yokohama
Strategy, International Strategy for Disaster Reduction, and
the Hyogo Declaration (Nates & Moyer, 2005).
u.s. Govemment: The terrorist attacks on September 11,
2001, resulted in profound policy changes in the United States.
This led to the creation of a major new agency. The Homeland
Security Act of 2002 and the Homeland Security Presidential
Directive Five, entitled "Management of Domestic Incidents,"
issued in 2003, authorized a radical change in the American
government's approach to disasters. This approach is spelled
out in the National Response Plan (NRP), implemented
through the National Incident Management System (NIMS).
The NRP specifies that extensive training is necessary for
those operating in the system. The NRP is a complex, formal
preparedness, and response plan intended to provide a
comprehensive policy framework for coordinating federal,
state, and local governments, as well as nongovernmental
organizations and private sector resources (U.S. Department of
Homeland Security, 2004). Nongovernmental and voluntary
organizations are directed to collaborate with governmental
first responders at all levels. The American Red Cross and
National Voluntary Organizations Active in Disaster, which
includes 39 national voluntary organizations, are mentioned
explicitly as serving the emergency support function of mass
care, housing, and human services. The NRP/NIMS represents
a topdown management system, centrally coordinated by the
Department of Homeland Security. Adjustments are being
made to the NRP/NIMS as a result of the many problems
surfacing during the government's response to Hurricane
Katrina. Some question the viability of a top-down approach,
arguing that the complex nature of disasters demand a fluid,
open, and adaptive organizational system (Pearce, 2003).
Social Work Roles in Disaster:
Emergency Relief and Reducing Vulnerability The
disaster field is organized overall around a cycle of four
stages: mitigation, preparedness, response, and recovery
(National Governors' Association, 1979). Mitigation and
preparedness take place before disasters strike, and
response and recovery take place after disasters have
happened (Banerjee & Gillespie, 1994). Social workers
have played major roles professionally and as volunteers in
disaster work at the micro and macro levels. Social workers
have traditionally been involved during the response and to
some extent the

recovery period (Zakour, 2006). Gillespie and Banerjee
(1993) argue that effective response requires expanded
involvement of social workers in all four stages.
Rogge (2003) points out that disaster social work is
concerned with intervention in the social and physical
environments of individuals and groups as a means of
preventing serious long-term emotional, spiritual, and mental
health problems after a disaster. Consistent with the complex
nature of disaster, social work deals with problems at the
individual, family, group, organization, community, and
structural or institutional levels (Streeter & Murty, 1996). With
community connections and knowledge of local values and
norms, social workers can be involved with disaster
mitigation, including mobilizing communities to support
land-use planning and management, lobbying for stronger
building codes and standards, expanding the use of disaster
insurance, creating improved disaster warning systems, and
working toward safer infrastructure ("lifelines") to reduce
vulnerability (Mileti, 1999).
Social workers also facilitate access to those in need,
linking vulnerable populations to services and creating
connections across service systems to improve distribution of
resources (Gillespie & Murty, 1994). Some of the earliest
social work research in the disaster field is on organizations
and interorganizational networks (Gillespie, 1988; Gillespie,
1990; Gillespie, Colignon, Banerjee, Murty, & Rogge, 1992;
Gillespie, Sherraden, Streeter, & Zakour, 1986). Zakour and
Gillespie (1999) point out the advantages of linking
government and nonprofit organizations in disaster
preparedness networks, for example, the integration of
government resources with the knowledge of community
needs of local nonprofits.
Social workers are also integral to the disaster prepa-
redness team, as they frequently provide traumatic stress
services. These services include psychological debriefing to
help victims understand typical stress responses, teaching
useful coping mechanisms (Miller, 2003), and coordinating
community resources (G illespie, 1991; Gillespie, Colignon,
Banerjee, Murthy, & Rogge, 1993). After the Oklahoma City
bombing, Callahan (2000) found that debriefing by social
workers helped police and fire fighters process their losses.
Similarly, in Kosovar refugee camps, Drumm, Pittmann, &
Perry (2003) found individual counseling helped refugees
manage stress and emotional problems.
International social work organizations, including The
International Federation of Social Workers and
Commonwealth Organisation for Social Work, played a
central role in the wake of the Indian Ocean tsunami. The
organization launched the Families and Survivors of Tsumani
Project (FAST, http://www.fastproject.
DISASTERS 63
net), which was designed to support the recovery of children,
youth, and families who were impacted by the tsunami.
FAST's goal was to ensure socialemotional support,
advocacy, and planning and capacity building for family and
community recovery.
The most important role for social work in disasters is
reducing community and individual levels of vulnerability.
Recent work on vulnerability focuses on changing the system
(Cutter, 1996), and is highly consistent with social work
values and practice (Gillespie, 2007; McEntire, 2004). These
strategies for changing the system involve (a) using existing
environmental laws to challenge construction and operating
permits, decisions about locating or transporting hazardous
materials, discharge permit violations, and underenforced
statutes, (b) writing new legislation focused on environmental
justice, (c) filing toxic torts where people claim injuries to
their health or property, and (d) mobilizing grass roots
activism focused on systemwide opposition to racism,
poverty, and injustice. In addition to the relevance of social
work, there are good reasons to make use of the vulnerability
perspective. First, there is not much we can do to affect natural
hazards, but we can reduce vulnerabilities. Second,
vulnerability relates to every kind of hazard and disaster.
Third, vulnerability takes into account both positive and
negative features (capabilities or liabilities), thus
incorporating individual and community resiliency. Fourth,
vulnerability is a function of many variables representing
different disciplines. Fifth, levels of vulnerability are
continuously changing and must be periodically reappraised.
Sixth, there are things that can be done during each phase of
disaster to reduce vulnerability. The vulnerability perspective
offers social work a way to build on its roots, contribute
significantly to the disaster field, and reduce the human and
material losses from disaster.
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-DAVID F. GILLESPIE
DISCHARGE PLANNING. See Health Care Social
Work.
DISPARITIES AND INEQUALITIES
ABSTRACT: This entry defines the term disparity as
measurable differences between groups on a number of
indices. The term disparity originated in France in the
Loth century and has been used as a barometer of
66 DISPARITIES AND INEQUALITIES
progress in social justice and equality in the United States.
When disparity is examined across the U.S. population over a
longitudinal period, it is clear that disparities continue to exist
and to distinguish groups by race, income, class, and gender.
African American and Native American populations have
historically ranked higher in prevalence and incidence than
others on most indices of disparity. However, the level of
adverse health and social conditions has declined for all popu-
lation groups in the United States. The disparity indices
include mortality rates, poor health, and disease, absence of
health insurance, accidents, and poverty. Max Weber's theory
of community formation is used in this entry to explain the
continued presence and distribution of disparities. Other
theoretical frameworks are utilized to buttress the major
hypothesis by Weber that social ills tend to result from
structural faults rather than individual choice. Social workers
are seen as being in a position to challenge the structural
origins of disparities as part of their professional commitment
to social justice.
Social workers and political reformers have long sought to
eliminate disparity between racial and ethnic groups in the
United States. To address the challenges posed by the complex
manifestations of inequality in America, disparity must be
examined from a comprehensive perspective. A comparative
examination shows that while tremendous progress has been
made in improving overall health and well-being of all groups,
racial and ethnic disparities persist. No single racial or ethnic
group in the United States is exempt from the problems of
socioeconomic and health disparities. Surprisingly, while
black Americans continue to rank first on almost all disparity
measures, white Americans frequently rank second.
The Concept of Disparity
The term disparity originated in the sixteenth century in France
and literally refers to measurable differences between two or
more objects or people or to an absence of parity or equality
(Encarta, 2007). Disparity has also been used in several
different ways in the context of studying and addressing
demographic inequities in the United States. The National
Cancer Institute (NCI) defined disparity as "inequalities in
health status," measured in terms of frequency, diagnosis,
mortality, and survival rates by race, income, social class, or
ethnicity where these exceed the expected rates for the
population as a whole, or when groups are compared against
the rates found within the Euro-American population (Center
to Reduce Cancer Health Disparities, 2003). In his efforts to
establish federal policy to reduce health disparities, President
Clinton defined
such disparities as "differences in the incidence, prevalence,
mortality, and burden of disease and other adverse health
conditions that exist among specific population groups in the
United States" (National Institute of Health, 2003). This
definition emphasizes the relationship between
socioeconomic status and a variety of disparities in addition to
health.
Recently, the Institute of Medicine (2002) defined
disparity as differences in access as well as actual treatment
between populations where there is no medical or patient
justification for the difference. This emphasis on equitable
access to treatment reflects the 10M's policy proposal for
reducing disparity in prevalence and incidence of health
problems. Despite the ubiquitous application of the term
disparity in federal and academic reports, there is no universal
agreement in the research literature or in the public policy
sector about its operational definition (Atrash & Hunter, 2006;
McGuire et al., 2006). Here, disparity will be defined simply
as measurable differences between groups, thus avoiding limiting
assumptions about the source or nature of the problems to be
examined. Anderson (2002) defines prevalence as a measure
of the number of existing cases or health problems within a
specified population while incidence refers to the number of
new cases or health problems.
Demographic Data on Disparities
As early as the first U.S. Census in 1790, federal reports
chronicled major differences in socioeconomic, political, and
health conditions in the population (U.S. Bureau of the Census,
1975). Early reports showed distinct differences between black
and white Americans on a number of social and health
indicators (U.S. Department of Commerce, 1975). Although
several populations of color have higher than expected fre-
quencies of socioeconomic and health problems, research,
policy, and controversy have centered primarily on inveterate
comparisons between blacks and whites (Atrash & Hunter,
2006; Byrd & Clayton, 2000). Therefore, there is a lack of
comparative data about Native Americans, Latino Americans,
and Asian Americans for major portions of the 19th and 20th
centuries. In addition, the literature created a myth that
Euro-American populations were significantly healthier than
other racial groups. Demographic data reveal that, although,
over time, the overall health, mental health, and
socioeconomic status of Americans has improved, the pattern
of racial and ethnic ran kings on a number of indices has not
changed (U.S. Census Bureau, 2007). No single group in the
United States is exempt from problems created by
socioeconomic and health disparities.

Socioeconomic Disparities
Census data confirm long-standing historical differences in
the economic circumstances of families in the United States
by race, ethnicity, language, and culture (Bureau of the
Census, 1975; Davis & Bent-Goodley, 2004). The most salient
differences are in per capita and familial income levels,
families living below the poverty level, and percent
unemployed. Low rankings on these three indices have
characterized some populations of color for decades and are
linked closely to differences in quality of life, morbidity, and
mortality in these populations compared to other Americans.
PER CAPITA AND MEDIAN FAMILY INCOME Federal
reports identify Latino and African American populations as
having the lowest per capita income in the United States (U.S.
Census Bureau, 2007). However, Taylor and Kalt (2005)
argue that Native Americans on reservations have lower per
capita incomes but are not included in many federal income
studies. In 2004, Latino and African American populations
had per capita income of $9,000 to $11 ,000 less than that of
Asian and Euro-Arnericans. A similar difference Was noted in
2004 for median family income by race and Hispanic origin
(U.S. Census Bureau, 2007).
POVERTY Although there have been significant decreases in
the percentage of families below the poverty level, close to
20% of African and Latino American families continue to live
below this level (U.S. Census Bureau, 2007). Asian and white
families have the lowest rates of family poverty while Native
Americans have the highest rate.
UNEMPLOYMENT Historically, African Americans have
had unemployment rates that are double EuroAmerican rates;
Latino and Asian populations have rates similar to
Euro-Arnericans (U.S. Census Bureau, 2007). In 1992, the
labor force participation rate for whites was the lowest of the
five major racial and ethnic groups, and in 2003 it was fourth
of the five groups. Although labor force participation among
Latinos increased slightly by 2003, there are minimal
differences among racial and ethnic groups in current labor
participation rates.
HEALTH DISPARITIES
Health Insurance. In 2001, Native Americans were the
group most likely to be uninsured (35% lacked health
insurance) (Census Bureau/National Center for Health
Statistics, 2001). Of the five populations for
DISPARITIES AND INEQUALITIES
67
which data were available, four had increases between 1990
and 2004 in the percentage of persons without health
insurance. Only the African American population saw a
decline in the percent of persons without health insurance
(U.S. Census Bureau, 2007).
Life Expectancy. Life expectancy for all groups in the
United States has increased. Though their life expectancy
remains lower than other major population groups, the most
significant increase in life expectancy has been for black
males. Black males born in 2004 could expect to live to 69.5
years compared to 64.5 years for those born in 1990. A white
American female born in 2004 could expect to live 80.8 years,
while a white American male could expect to live 75.7 years.
African American female life expectancy was 76.3, slightly
higher than Euro-Arnerican males. The Census Bureau
reported the combined life expectancy of Asian, Native
American, and Hispanic populations in 1996 as 76.1 for
women and 68.9 for men (National Center for Health
Statistics, 1998; U.S. Department of Commerce, 1998).
Causes of Death. Keppel, Pearcy, and Wagener (2002),
Plepys and Klein (1995), and the National Center for Health
Statistics (2006) examined ageadjusted death rates for seven
selected causes by race and Hispanic origin (see Table 1).
Overall, there were major declines in the death rates per
100,000 population in almost all 11 categories and for almost
all populations. However, patterns varied tremendously. Each
of the five racial/ethnic groups experienced increases in deaths
from diabetes from 1990 through 2004, with African
Americans experiencing the largest increase. Whites
experienced a slight increase in deaths from chronic lower
respiratory diseases, while the rates declined for all other
groups.
Groups. African Americans and Native Americans saw
slight increases in deaths from malignant neoplasms. Two of
the most significant reductions in death rates occurred in the
black population in HIV and homicides (National Center for
Health Statistics, 2006).
Infant and Maternal Mortality. Infant and ma-
ternal mortality rates among racial and ethnic minority
populations remained considerably above the national
mean throughout the 20th century. From 1900 to 2000 ,
infant and maternal mortality rates for all groups of
Americans declined. When infant mortalit y rates are
compared between 1990 and 2003, the ranking by race
and Hispanic origin have not changed (Census Bureau/
National Center for Health Statistics, 2001). African
Americans ranked first with Native Americans second.
The lowest infant mortality rate s were found in Asian
and Pacific Islander populations. There were minimal
differences between Hispanic and Euro- Arnerican
rates.
68
16.
DISPARITIES AND INEQUALITIES

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Their rates are close to one-half the rates of African
Americans and Native Americans.
Deaths from Violence. There are marked differences in
homicides by race and Hispanic origin. By 2004, the rates for
homicides per 100,000 for males and females in every group
had declined from the rates recorded in 1990. The homicide
rate for African Americans in 1990 was 36 per 100,000
population while the rate for the next highest rate was 16 per
100,000 for the Latino population. Rates were 10 per 100,000
for N ative Americans and 5 for Asian Americans. The lowest
homicide rate (4 per 100,000) was for the white population in
1990. By 2004, deaths from homicides had declined for all
populations. However, African Americans continued to rank
first at 20 deaths per 100,000 population. The rate for Latinos
and Native Americans were very similar (7.2 and 7.0).
Homicide rates for Asian Americans (2.5) were the lowest in
2004; rates for the white population were slightly higher at 2.7
per 100,000 (Keppel et al., 2002; National Center for Health
Statistics, 2006; Pearcy & Keppel, 2002; Plepys & Klein,
1995).
Cardiovascular Disease and Stroke. In the United States,
death rates per 100,000 population from cardiovascular
disease are highest among African American males and lowest
among Asian and Pacific Islander American women (342.1
and 96.1, respectively, in 2004). The second highest rate
(268.7 in 2004) was among white males. Rates for African
American women were 236.5 per 100,000 in 2004 (National
Center for Health Statistics, 2006). Rates for all groups were
substantially higher in 1990 with African American male rates
close to 500 and white American males close to 415 per
100,000 population. Although rates declined for all American
populations by 2004, there was no change in the rank order of
frequency by racial group or ethnicity. African Americans
(male and female) and white Americans (male and female) had
the highest rates throughout the 20th century.
Diabetes. Approximately 21 million Americans have
diabetes, while an estimated 6.2 million have the disease but
have not been diagnosed (National Institute of Diabetes and
Digestive and Kidney Diseases, 2005). Overall, close to 7% of
the U.S. population has diabetes with the rates increasing at
approximately 3-5% over the last 5 years (Medical N ews
Today, 2003). Rates are highest (21 %) in the population over
age 60 and among men (10.5%) compared to women (8.8%).
A greater percentage (19%) of Native Americans over age 20
have diabetes while African Americans and Latino Americans
have similar prevalence rates (16% and 15%, respectively).
White populations had the lowest (8%) prevalence rate
DISPARITIES AND INEQUALITIES
69
(National Institute of Diabetes and Digestive and Kidney
Diseases, 2005). However, the incidence rate (26) per 100,000
white youths below age 20 was the highest in the United
States. The lowest incidence rate (16.7) was found in
Asian/pacific Islander youth (Brown, 2007). Death rates from
diabetes increased for all populations from 1990 to 2004.
Rates for African Americans increased from 40 per 100,000
population to 48 while rates for Native Americans increased
from 34 to 39. Death rates from diabetes in Latino populations
increased from 28 to 32 per 100,000 and from 18 to 21 and 14
to 17 for Euro-Americans and Asian Americans, respectively,
from 1990 to 2004 (National Center for Health Statistics,
2006).
HN Infections/AIDS. In the early 1990s, HIV
j AIDS infection rates for African-American populations were
close to 155 per 100,000, far exceeding the rates for all other
U.s. populations. Death rates for H1Vj AIDS varied
considerably in 1990 from 27 per 100,000 in African
American populations to 1.8 for Native Americans. By 2004,
the rate of deaths per 100,000 had declined in four out of the
five population groups. In 2004, the rate for Native Americans
had increased to 2.9 per 100,000 population from 1.8 in 1990.
However, the rate for African American populations remained
the highest at 20A per 100,000, though this was a significant
decline from the 1990s (Keppel et al., 2002; National Center
for Health Statistics, 2006; Plepys & Klein, 1995).
Deaths from Influenza and Pneumonia. Deaths for all
American populations from influenza and pneumonia
declined substantially from 1990 to 2004 (National Center for
Health Statistics, 2006). Rates for Native American
populations declined from 36 per 100,000 to 17 while the rates
for Asian populations declined from 31 to 16 during this
period. Rates per 100,000 for Hispanic and Euro-Americans
declined from 30 and 36 to 17 and 19, respectively. African
Americans had the highest death rates per 100,000 from
influenza and pneumonia in 1990 (39) as well as in 2004 (22).
Changes in Rankings. From 1990 to 2004, mortality rates
ranked by race and Hispanic origin showed minimal changes
(Table 2). Death rates overall and within categories were
highest for the black population at the beginning of the 1990s
and in 2004. The ranking of African American deaths from
suicides declined from fourth to fifth between 1990 and 2004.
Of significance, the death rate for American Indians from
HIVjAIDS increased in rank from fifth to third for this same
period. Rankings for Asian-American populations remained
the most stable during the 14-year span, while the ranking for
white American death rates from accidents increased from
third to second.
70 DISPARITIES AND INEQUALITIES

TABLE 2
Changes in Ranking of Morwlity by Race, Hispanic Origin, and Year

LATINO EURO- AMERICANS ASIAN AMERICAN AFRICAN CAUSES OF

AMERICANS AMERICANS INDIANS AMERICANS MORTALITY
200 1990 2004 1990 2004 1990 2004 1990 2004 1990
3 3 2 2 5 5 4 4 1 1 Heart disease
2 2 4 5 5 4 3 3 1 1 Homicide
2 2 1 1 5 4 3 3 5 4 Suicide
2 2 4 4 3 3 5 5 1 1 Cerebrovascular
disease
4 4 2 2 3 3 5 5 1 1 Malignancy
4 5 1 1 5 4 2 3 3 2 Respiratory disease
4 5 2 2 5 4 3 3 1 1 Influenza
2 2 5 5 3 4 1 1 4 3 Liver diseases
3 3 4 4 5 5 2 2 1 1 Diabetes
2 2 5 3 5 4 3 5 1 1 HI VjA
2 3 4 3 5 5 1 1 3 2 Accidents

MENTAL HEALTH DISPARITIES A series of studies since the
1960s consistently finds minimal, if any, dif ferences in the
incidence and prevalence of mental illness by race and
ethnicity (Fischer, 1969; Neighbors & Lumpkin, 1990;
Robins & Regier, 1991). Recent replications of earlier
studies by Wang et a1. (200S) and Kessler et a1. (200S) also
support this finding. Wang (2006), however, identified
significant differences in service use patterns by race,
ethnicity, gender, and income. NIMH's Five Year Strategic
Plan focuses on eliminating disparities in service (access,
quality, outcomes) by race, color, ethnicity, and culture based
on the relative homogeneity in incidence and prevalence of
mental disorders. NIMH has identified constraints in help
seeking, impediments to access, and poorer outcomes by race,
ethnicity, and social class as important variables. The focus on
service disparities is congruent with the conclusions of the
Surgeon General's Report (U.S. Department of Health and
Human Services, 2001) and the broad tenets of a report by the
Institute of Medicine (2002). Numerous other studies have
documented the barriers to and the differences in the use of
mental health services by race and ethnicity (Abe-Kim et al.,
2007; Alegria et al., 2007; Johnson & Cameron, 2001; Lopez et
al., 2000; Neighbors et aI., 2007; Spencer & Chen, 2004; U.S.
Department of Health and Human Services, 2001; Wang et aI.,
2006).
Theoretical Perspectives
Disparities are complex phenomena and yet, numerous
research studies are yet to identify any single explanation of
the causes of these disparities that have been accepted in the
scientific community or by public policy makers. Although
the causes of disparities are difficult to pinpoint, Weber's
Theory of Community Closure (Neuwirth, 1968) provides an
alternative
meaning and explanation of the disparities that exist that may
be useful for social workers seeking to understand and reform
structural factors.
WEBER'S THEORY OF COMMUNITY CLOSURE Max Weber's
Theory of Community Closure offers a useful explanation
of disparity in the United States. Weber proposed that
human groups compete with each other for limited
resources within the environment. Groups that are able to
gamer or exercise power and control over limited societal
resources to survive, thrive, and reduce their risk of
adverse circumstances-starvation, disease, sickness, early
mortality, or dependence. On the other hand, groups
without power and control of available resources have a
higher risk of these problems. Weber's theoretical
formulation suggests that basic re sources are not only
essential to survival, but also to overall life quality and
satisfaction. Various studies reinforce the Weber ian
perspective. Pratto and Sidanius (1999) identified power
and dominance by elites as the key factors that contribute
to the uneven distribution of opportunity. Conley (1999)
concluded that adverse economic circumstances not only
affect immediate life chances of families of color, they also
have a cumulative adverse effect for generations.
Weber (Neuwirth, 1968) indicated that the quest for
survival and growth propels human groups to act in ways that
increase the probability of obtaining a share of scarce
resources. Weber describes these actions as competition
between groups. Competition between groups requires some
differences in identifiable characteristics. Durkheim (1900)
proposed that in competition for resources, social status,
authority, or power, groups will seize on any personal
characteristic like height, weight, language, culture, skin
color, or clothing to establish a system of favored in-groups
and

l

rejected out-groups, which Weber called negative privileged
status groups.
Once groups are formed, they seek to monopolize
resources as well as the vital processes used to develop, access,
enhance, or protect them for their own group. Weber believed
that once group formation took place, powerful groups closed
or delimited access to outside groups through a process of
community closure. The groups excluded through closure have
a higher than average risk of developing social problems based
on limited access to the needs-meeting social institutions in
their society.
Neuwirth (1968) used Weber's community formation theory to
explain the higher than expected frequency of social ills in
African American communities. Neuwirth explained that, not
only are African American populations provided limited access
to social capital, but that the power of community closure by
the white power structure also limits the ability of outsider
groups to form or maintain their own internal closure.
Disparities arise from a continuous process of exclusion,
delimitation, monopoly of existing resources, and an active
process of limiting excluded groups from developing systems,
infrastructure, and opportunities within their own communities.
In addition to Weber's conceptualization, Green (2003), Byrd
and Clayton (2002), Stone (2006), and Diamond (1997)
provide complementary perspectives. Green (2003) proposes
that health disparities result from an absence of civil rights
enforcement. Green argues that the Civil Rights Act of 1964
outlaws disparate treatment that results in limited access to
health care, poor quality outcomes, and poor health status. Byrd
and Clayton (2002) propose that health disparities result from
two forces. Continued reliance by populations of color on
public sources of health care results in lower quality of health
and numerous health problems. In addition, Byrd and Clayton
suggest that scientific racism is the key factor that causes and
sustains health disparities. Stone (2006) proposes that
disparities result from major gaps in access to quality medical
care. She argues that the gap in access can be measured
quantitatively and if addressed, reduces the extent of
disparities. Stone concludes that the essence of the disparities
problem is political indifference and public misinformation
about the impact of limited access to quality medical care.
Diamond (1997) theorizes that disparities between groups stem
from the interaction of three variables: control of weapons, the
spread of disease, and the production of steel. In essence,
Diamond believes that the greater the extent of inequality
within a society, the greater the chances are that specific groups
that lack access to and control of resources will evidence
disparate life conditions.
DISPARITIES AND INEQUALITIES 71
Trends. These data show clearly that long- standing
differences in life conditions and mortality exist by race,
ethnicity, and culture. Some populations of color
(African Americans, Native Americans, and Mexican
Americans) have consistently been overrepresented on
several indices of disparity; however, the prevalence and
incidence patterns by race and ethnicity are un even. For
example, though the leading causes of death for African
Americans and Euro-Arnericans are simi lar, the rates for
African Americans are usually con siderable higher. In
health and socioeconomic status, African American,
Native American, and Latino populations generally rank
lower than Asian and Euro-Arnericans. Although there
are critical differences in health and mortality associated
with populations of color, lower socioeconomic status
seems to be the most important predictor of disparities in
the 21st century.
Demographic data show progress in improving
Americans' well-being. Disparities are not confined to
populations of color alone, though some (poverty, absence of
health insurance, unemployment, and high mortality rates) are
disproportionate to African, Mexican, Puerto Rican, and
Native American populations, and pose a great challenge to
the field of social work in the 21st century. The United States
has reached a point where structural changes are called for in
order to address the problem of disparity. Innovations in social
work and modem political and societal sensibilities now make
it conceivable that structural shifts can occur because
American scholars now have a much more in-depth
understanding of the pathways to disparity and the role of the
distribution of opportunity and access within our society.
Implications and Roles for Social Work. First, disparities
are ubiquitous social phenomena that occur in all populations
in the United States, not simply along racial, ethnic, or color
lines (Satcher & Pamies, 2006). Actions that focus on only
one segment of the population cannot succeed in eradicating
problems in the structure of social institutions and policies.
Second, the frequency of disparate conditions has declined
considerably in all groups over the past several decades,
although some conditions such as HIVjAIDS and diabetes
continue to increase. Third, although all groups have made
progress, African American and Native American populations
continue to rank higher on negative indices of health and
well-being and lower in income than most other groups.
Fourth, white Americans rank second on a number of
mortality indices and first in suicides. These four patterns
appear consistently across decades with limited variation.
Many of the problems seem to be related, but it is not clear
why,
72 DISPARITIES AND INEQUALITIES
increasing the difficulty in identifying solutions, treatments,
interventions, or prevention.
If one can assume that groups do not willfully choose
disparities, then involuntary forces must be causing both the
development of these problems as well as the distributional
patterns that have been so consistent over many decades.
Disparities occur across racial, cultural, and ethnic lines, but these
factors alone should not be viewed as the single causes. Weber's
(Neuwirth, 1968) work suggests that the underlying causes of
many of these problems are in the societal structures where
access, policy, resource distribution, values, opportunity, and
rights are determined. Weber proposes (Neuwirth, 1968) that
barriers placed before a group increase the group and individual
member's risk of harm, lower achievement, and distress. For
Weber, the issue is structural inequality that bears heavily and
disproportionately on groups that can be identified by some
characteristics such as race, culture, language, region of the
country, gender, sexual preference, disability status, housing,
weight, height, employment status, education, or age. Weber's
theory (Neuwirth, 1968) proposes that discrepancies between
needs and opportunities increase the level of risk for disparities in
one or more of the categories discussed in this entry.
The social work profession does not focus as much on
individual motivation with respect to meeting or ignoring their
health care needs. Rather, they have concentrated on the
prohibitive cost, lack of accessibility, and culturally incompetent
nature of care, which increases the risk of mortality, disability, or
severe illness. They have also fought for over 100 years with
other reformers in the United States to pass legislation that would
provide universal coverage to all citizens regardless of their
personal, group, or regional characteristics. Gil's (1987) work
suggests that the source of major social problems is the policies
formulated and implemented by the powerful. Gil (1987 )
proposes that social workers and other reformers measure their
actions by the extent to which change occurs in the distribution of
rights, resources, and social status.
The key challenge for social work reformers now is how to
make further progress in reducing problems (consistent
disparities in health, employment, income, education, mortality,
and incarceration rates) that appear almost intractable, resistant,
and embedded in the structure, policies, and essential functions of
American society. Social workers can adopt a Weberian approach
to the problem of disparities by looking beyond traditional
limitations and being open to solutions from unexpected sources.
One way that this can be achieved is by demonstrating the
investment value of lessening
disparities for the entire population to current fiscally
conservative audiences and institutions. In this way, the field of
social work can overcome historical limitations and motivate
even unlikely parties to work toward change by taking an
approach that respectfully appeals to logic, emotions, economic
sensibilities, and ethical values.
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-KING DAVIS
DISPLACED PEOPLE
ABSTRACT: Internally displaced people (IDPs)- those
involuntarily uprooted but remaining within their na tion's
borders-now greatly outnumber refugees, who are
similarly uprooted but in their search for refuge cross an
international border. For protection and assistance, IDPs
are dependent on their national governments.
74 DISPLACED PEOPLE

In cases of displacement due to natural disasters or large-scale TABLE 1

development projects, governments may be able and willing to Numbers of Refugees and Asylum Seekers Compared to
help or to invite the international community to assist. People Conflict-Induced lOPs (in millions)
displaced by conflicts are often the most vulnerable, when
REFUGEES AND ASYLUM INTERNALLY DISPLACED
national governments are unwilling or unable to help. The
SEEKERS PEOPLE
global IDP crisis is one that can use the skills of social workers 2001 14.9 25
at all levels. 2002 13 21.8
2003 11.9 23.6
2004 11.5 21.3
KEY WORDS: internally displaced people; displaced people, 2005 21
12
refugees; migration; immigration
u.s. Committee for Refugees and Immigrants (USCR).
Around the globe there are tens of millions of people
displaced within their own countries. They have been forcibly
uprooted from their homes and communities by natural
TABLE 2
disasters, large-scale development projects, civil conflicts,
lOP Estimates by Region (2004)
political oppression, and other human rights violations. This
population is distinguished from other people in migration. REGION COUNTRIES IDPS
Given the needs of internally displaced people, social workers Africa 20 12,100,000
at all levels can be involved in ameliorating this problem. Americas 4 4,000,000
Asia Europe 11 2,800,000
Middle East 10 2,700,000
Total 5 2,100,000
50 23,700,000
Global Displacement
DEFINITIONS People who migrate may either do so Internal Displacement Monitoring Centre (lDMC).
voluntarily-as do most immigrants and migrant workers-or
involuntarily. Chief among those who migrate involuntarily
are refugees and asylum seekers, who cross international
boundaries in search of refuge, and internally displaced people TABLE 3
(lDPs) who have been forcibly uprooted but remain in their lOPs by Country (Dec. 31 , 2005)
own countries. Those displaced by armed conflict are of
Sudan 5,335,000
particular concern. Colombia 2,900.000
Uganda 1,740.500
Congo- Kinshasa 1,664,000
Iraq 1,300,000
Recent trends USCR, World Refugee Survey 2006.
Beginning approximately in the mid-1990s, the numbers of
people worldwide affected by conflict-induced internal
displacement began to grow dramatically, reaching a high of
at the end of 2005 were located in just five countries (see
an estimated 25 million by 2001. During the same period, the
Table 3). In four of those countries (Sudan, Colombia,
number of refugees trended slightly downward. As of 2004,
Uganda, and Iraq), IDPs were at great risk for continued
there were nearly twice as many conflict-induced IDPs around
life-threatening violence (U.S. Committee for Refugees,
the world as there were refugees and asylum seekers (see
2006).
Table 1).

A Vulnerable Population Displacement breaks

Global Statistics
There are conflict-induced IDPs in at least 50 countries around
the world. By region, the largest estimated numbers are in
Africa (see Table 2). At the end of 2004, Africa had more IDPs
than all the world's other regions combined. Among the
African nations, Sudan (Darfur) by itself accounted for a full
20% of the !DPs on the African continent. Approximately half
of IDPs
peoples' links to livelihoods and traditional support
mechanisms. The resulting impoverishment makes IDPs
vulnerable to malnutrition. Vulnerability to disease is
exacerbated by high exposure rates often coupled with lack of
access to adequate health care. In addition, there are
deleterious effects on mental health, particularly the high
incidence of post-traumatic stress disorder.

Women and children, who comprise 70-80% of IDPs, are
at greatest risk. Though reliable and comprehensive statistics
are lacking, many observers believe that sexual violence is a
serious problem for displaced women in a number of
countries (United Nations, 2003). Children are especially
vulnerable since displacement ruptures families, breaks
community structures, destroys traditional norms, and
interrupts or deprives them of education.
Protection and Assistance for IDPs
While IDPs and refugees share the experience of forcible
uprooting and the trauma, impoverishment and peril that
entails, refugees, by virtue of having crossed an international
border, are eligible for international protection under the
United Nations 1951 Refugee Convention. IDPs, however,
are not automatically provided such international protection
and assistance.
National governments are, in the first instance,
responsible for the protection of their own people. However,
not all governments have been able or willing to protect or
assist their own IDPs. In fact, in some of the worst situations,
governments themselves have been complicit in the
displacement (Internal Displacement Monitoring Centre
[lDMC], 2006; U.S. Committee for Refugees, 2006).
The international community is not under the same legal
obligations to assist IDPs as it is with refugees. And when
international humanitarian assistance is available for IDPs, it
requires the invitation or acquiescence of the national
government. In some cases governments refuse such
assistance and in others they are unable to protect
humanitarian relief workers. Even when governments seek or
would welcome assistance, there may be barriers (United
Nations, 2003). Physical barriers include difficult terrain and
bad transportation infrastructure. Among man-made barriers
are closed borders, the front lines of battle, and landmines
(see U.N. reference above). Finally, there may be lack of
resources or poor public awareness owing to limited or no
media coverage; or in cases such as the Darfur crisis, even
extensive media coverage may fail to bring about the
necessary international pressure to minimize hardships.
Evolving International Response
In the late 1980s, the U.N. began to take steps to strengthen
international institutional attention to and assistance for IDPs.
Since 1992, the Secretary-General has had a Representative
for IDPs, who reports to the Commission on Human Rights
and to the General Assembly. In 2002 the Internal
Displacement Unit
DISPLACED PEOPLE 75
was created within the U.N.'s Office for Coordination of
Humanitarian Affairs (OCHA) to address issues of protection
for IDPs and to provide field support as well as
capacity-building and training. This unit, under the direction
of the U.N.'s Emergency Relief Coordinator (ERC) also
coordinates with the Secretary-General's Representative to
develop policy, undertake research, and advocate for lDPs
(United Nations, 2003).
In 1998, the UN. published its Guiding Principles on
Internal Displacement, which includes sections on rights, both
to protection and to humanitarian assistance. While these
principles are not legally binding, they have been effective in
improving assistance to IDPs and have gained authority over
the years. Still, among U.N. and outside actors, the
institutional approach to aiding IDPs has been collaboration,
with no one agency clearly in charge or accountable-an
arrangement found deficient by most evaluations (Cohen,
2006). UNHCR agreed in 2006 to assume some limited re-
sponsibility for IDPs, but gaps, especially for protection,
remain. IDPs are still a good distance from having the degree
of reliability and predictability of the response regime enjoyed
by refugees.
Social Work Role
Among institutions involved in the IDP crisis, there is a clear
sense that psychosocial support is an important element in the
recovery of these often-traumatized people (Internal
Displacement Monitoring Centre [lDMC], 2006).
Psychosocial support is sometimes provided by NGOs or by
local or international organizations, but there has been no
comprehensive or coordinated approach. In June, 2005, the
United Nation's Inter-Agency Standing Committee, which
brings together humanitarian organizations both within and
outside the U.N., established a task force to integrate mental
health issues into emergency settings and develop guidelines.
While there is as yet virtually no attention specifically to
IDPs in social work literature, social work experience with
refugees offers a useful proxy, since IDPs can be thought of as
"internal refugees." A view of IDPs from an ecological
perspective reveals a need for skilled social workers at every
level from micro through meso to macro (Ager, Strang, &
Abebe, 2005; Drumm, Pittman, & Perry, 2003; Nash, Wong
& Trlin, 2006).
Migration has traditionally been viewed as a threestage
process: premigration experiences, transit, and postmigration
resettlement. For IDPs, there may be peril and trauma at every
stage. Notably, while refugees are eventually resettled in safe
places, lOPs may
76 DISPLACED PEOPLE
continue to be in harm's way until armed conflicts are settled, and
some IDPs, for example ethnic minorities, are at risk of remaining
marginalized and oppressed even after peace is attained (IDMC,
2006).
Exposure to violence and extreme stress has long been
associated with refugee mental health problems, particularly
PTSD and depression. Clinical intervention models for
traumatized refugees have increasingly recognized the signal
importance of culturally appropriate needs assessments and
treatment models (Gibson, 2002; Hinton, Pich, Safren, Pollack, &
McNally, 2005; Lacrois, 2002), and emphasized individual and
community resilience (Doran, 2005; Gibson, 2002; Witmer &
Culver, 2001). More fully elaborated treatment models have
integrated family systems approaches with constructivist theory
(Kelley, 1994) or utilized support groups incorporating social
constructivism and the strengths perspective (Nicholson & Kay,
1999).
Especially because the global internal displacement crisis is
still relatively unknown outside the circles of migration
specialists and involved institutions and because the crisis has yet
to be effectively addressed by the international community, social
workers can also playa useful role at the macro level in helping to
develop policy and advocating on behalf of \DPs.
REFERENCES
Ager, A., Strang, A., & Abebe, B. (2005). Conceptualizing
community development for war-affected populations:
Illustrations from Tigray. Community Development Journal,
40(2),158-168.
Cohen, R. (2006). Strengthening proection of IDPs: The UN's role.
Georgetown Journal of International Affairs, 7(1), 101110.
Doron, E. (2005). Working with Lebanese refugees in a community
resilience model. Community Development Journal,
40(2),182-191.
Drumm, R. D., Pittman, S. W., & Perry, S. (2003). Social work
interventions in refugee camps: An ecosystems approach. Journal
of Social Service Research, 30(2), 67-92.
Gibson, E. C. (2002). The impact of political violence: Adaptation
and identity development in Bosnian adolescent refugees. Smith
College Studies in Social Work, 73(1), 29-50.
Hinton, D. c., Pich, v., Safren, S., Pollack, M., & McNally, R.
(2005). Anxiety sensitivity in traumatized Cambodian refugees:
A discriminant function and factor analytic investigation. Behavior
Research and Therapy, 43(12),1631-1643.
Kelley, P. (1994). Integrating systemic and postsystemic approaches
to social work practice with refugee families. Families in Society,
75(9), 541-555.
Lacrois, M. (2002). Refugee claimants and social work practice:
Toward developing a new knowledge base. Canadian Social
Worldournal, 4(1), 85-93.
Nash, M., Wong, J., & Trlin, A. (2006). Civic and social integration:
A new field of social work practice with
immigrants, refugees, and asylum seekers. International Social
Work, 49(3), 345-363.
Nicholson, B., & Kay, 0. (1999). Group treatment of traumatized
Cambodian women: A culture-specific approach. Social Work,
44(5), 470-481.
Norwegian Refugee Council, Internal Displacement Monitoring
Centre. (2006). Internal displacement: Global overview of trends
and developments in 2005. Geneva: Author.
United Nations, Office for the Coordination of Humanitarian Affairs.
(2003). No refuge: The challenge of internal displacement. New
York: Author.
U.S. Committee for Refugees. (2006). World refugee survey 2006.
Washington, DC: Author.
Witmer, T. A. P., & Culver, S. M. (200l). Trauma and resilience
among Bosnian refugee families: A critical review of the
literature. Journal of Social Work Research and Evaluation, 2(2),
173-187.
SUGGESTED LINKS Brookings-SAIS Project on
Internal Displacement. www . brookings. edu
Norwegian Refugee Council's Global \DP Project.
www.internal-displacement.org
UN OCHA, Internal Displacement Unit. www.
reliefweb .int/idp
U.S. Committee for Refugees (USCR).
www. refugees. org
-JUDITH A. WALTER AND FREDERICK L. AHEARN, JR.
DIVORCE
ABSTRACT: This entry presents the demographic trends of
divorce and the social changes that have impacted the divorce
rate. A cultural perspective of divorce is provided by analyzing
divorce in the context of race and gender and across nations.
Current explanatory theories of divorce are described. Research
on the consequences of divorce on adults and children is
presented followed by the practice implications for social
workers. Future directions for policy and research are discussed.
KEY WORDS: divorce rate; divorce probability; divorce laws;
cultural perspectives; gender; race; divorce theories; divorce
recovery; divorce mediation; external stressors; social policy
Although researchers and demographers rnay not always agree on
how to calculate the divorce rate, there seems to be a common
consensus that the divorce rate in the United States hit a peak in
the late 1980s and leveled off in the 1990s. While the rate is
leveling off, the United States still has the highest divorce rate of
any Westernized country. Currently, the rate of divorce is

about 20 per 1,000. Put differently, about 2% of all marriages
end in divorce in a single year (Amato & Irving, 2006).
Considering the probability of divorce across all years of
marriage, about one-half of first marriages and 60% of second
marriages will end in divorce (Cherlin, 1992; Schoen &
Canudas-Rorno, 2006).
Not every couple will have the same risk for divorce.
The divorce rate is higher among the lower socioeconomic
population and among African Americans (Bramlett &
Mosher, 2002; Heaton, 2002; Orbuch, Veroff, Hassan, &
Horrocks, 2002). Furthermore, divorce is more common in
certain regions of the United States than it is in other regions.
In particular, several states in the South have the highest
divorce rates in the country, around 50% higher than the
national average (Karney, Story, & Bradbury, 2005). These
include Alabama, Arkansas, Kentucky, Mississippi,
Tennessee, and West Virginia (National Center for Health
Statistics, 2006). Interestingly, these states also rank near the
bottom of the 50 states in terms of employment rate,
household income, education, and health insurance cov erage
and have some of the highest rates of crime and poverty in the
nation. Hence, a plausible explanation for the high divorce
rate is the amount of chronic stress from economic pressure
that couples face (Conger, Rueter, & Elder, 2003; Karney et
al., 2005). Premarital cohabitation, premarital child-bearing,
age at marriage, education, length of marriage, and the
experience of parental divorce are also factors that are
associated with the likelihood of divorce (Rodrigues, Hall, &
Fincham, 2006).
Partly due to the high divorce rate, at least one-half of all
children will spend at least one-quarter of their lives in
female-headed households (Webb, 2005). Because there is a
higher rate of dissolution of second (and higher-order)
marriages than first marriages, it is very likely that the blended
family will also break up (Amato, 2000). As a result, about
one of every six adults experiences two or more divorces
(Cherlin, 1992) and one of ten children will experience at least
two divorces of their residential parents before reaching the
age of 16 (Hetherington, 1999).
Social Changes and Divorce
During the past 20 years, a number of societal changes have
impacted the divorce rate in the United States. Four will be
mentioned here: (a) the shift in the meaning of marriage, (b)
liberalization of divorce laws, (c) public attitudes toward
divorce, and (d) demographic changes.
SHIFT FROM INSTITUTIONALIZED TO INDIVIDUA.
LIZED MARRIAGES There have been two transitions in the
meaning of marriage during the 20th century. First, there was a
shift from an institutional marriage to
DIVORCE 77
a companionship form of marriage (Burgess & Locke, 1945).
In contrast to the notion of marriage as primarily a
commitment to social obligations of an institution, the
companionate marriage was held together by ties of love,
friendship, and common interest. By the 1980s, the
companionate marriage was considered as an ideal and the
trend toward a greater emphasis on the fulfillment of love and
emotional needs through marriage was further documented by
researchers (Caplow, Bahr, Chadwick, & Williamson, 1982;
Veroff, Douvan, & Kulka, 1981).
Since the mid-1990s, family scholars have identified a
second trend emphasizing an ethic of expressive indivi-
dualism or individual autonomy in marriage (Thornton &
Young-DeMarco, 200l). A shift from a companionate
marriage to an individualized marriage meant that satisfaction
with marriage was based on development of one's own sense
of self and expression of feeling rather than satisfaction
through raising children and playing the role of a spouse. No
longer were spouses willing to stay in a marriage that did not
meet their individual emotional needs. Along with the theme
of individual autonomy in marriage, there has been increased
tolerance toward a diversity of personal and family behaviors
(Thornton & Young-DeMarco, 2001). Thus, trends of
increasing individualization, freedom, and tolerance of
diverse ideas and behaviors, coupled with reduced
commitment to the broader community has had a significant
effect on the stability of marriages (Thornton & Young-
DeMarco, 2001).
THE LIBERALIZATION OF DIVORCE LAWS Laws
governing issues such as the grounds for divorce, spouse
maintenance, property distribution, child support, and child
custody have undergone major changes in every state during
the past few decades (Mahoney, 2006). Although the reforms
in each state addressed the same important topics, there is little
uniformity among the resulting state laws governing the
divorce-related issues (Mahoney, 2006). With the
establishment of no-fault divorce laws, courts could grant
divorces even if one spouse wanted the divorce and the other
did not-a system known as unilateral no-fault divorce. The
assumption underlying unilateral no-fault divorce was that if
one spouse no longer wished to remain in the marriage, then it
was no longer practical to have a marriage (Amato & Irving,
2006).
Social conservatives have criticized no-fault divorce for
promoting a culture of divorce on demand, which they believe
leads to other social problems, such as poverty in
single-parent families. Hence, there are legislative reforms
being proposed in many states that have placed restrictions on
unilateral no-fault divorce
78 DIVORCE
(Weisberg & Appleton, 2002) and a few states have introduced
no-fault divorce only by mutual consent. Some states have
proposed fault-based divorce in cases of abuse, desertion, or
adultery, and other bills have attempted to lengthen the
waiting period prior to divorce or to require marital counseling
before divorce. Most of these attempts at reform have not been
successfully passed (DiFonzo, 1997). However, with the
hopes to discourage divorce, Louisiana, Arizona, and
Arkansas have established a covenant marriage as an option to
a standard marriage (Amato & Irving, 2006; Mahoney, 2006).
If a couple chooses a covenant marriage, they are required to
attend premarital education classes and promise to seek
marital counseling if serious problems arise later. To dissolve
a covenant marriage, one spouse must prove fault or the
couple can obtain a divorce after a 2-year separation
(Thompson & Wyatt, 1999). While there may be some
problems with the no-fault divorce laws, there are conflicting
views on whether the liberalization of divorce laws has
directly increased the demand for divorce (Mahoney, 2006). It
is more likely that the divorce laws are a consequence rather
than a cause of marital breakdown (Amato & Irving, 2006).
PUBLIC ATTITUDES TOWARD DIVORCE During the
1960s and 1970s, public attitudes toward divorce became
more liberal. However, findings from five recent national
surveys (Thornton & Young-DeMarco, 200l) revealed that
since the late 1980s attitudes toward divorce have remained
stable. There has been no dramatic increase in people's
approval of divorce. For example, responses to the statement
"Marriage is a lifetime relationship and should never be ended
except under extreme circumstances" remained very steady
from 1987 through 1992 (Thornton & Young- DeMarco,
2001). In one study with an intergenerational panel, there was
a trend from 1985 to 1993 toward more acceptance of the
possibility that divorce may be the best solution when a couple
cannot work out their marriage problems. However, there was
no consistent trend in the other divorce questions for the
respondents in this data set. Thus, while there have been
modest changes among some portions of the population on
particular issues, there has not been a large or widespread
movement in any particular direction concerning divorce
during the late 1980s and 1990s (Thornton & YoungDeMarco,
2001). The data also reveal some ambivalence about divorce.
Although there is a high level of acceptance of divorce, nearly
half of all Americans believe that divorce should be more
difficult to obtain and a 1998 survey indicates that half of
Americans support covenant marriages as an option for people
who want one (Thornton & Young-DeMarco, 200l).
DEMOGRAPHIC CHANGES AND DIVORCE TRENDS
Despite the numerous demographic changes since mid1990s
(for example, change in age of marriage, number of
remarriages, number of children, and heterogamy), the
probability of divorce and the actual divorce rate have changed
very little. Amato, Johnson, Booth, and Rogers (2003)
analyzed data from two national surveys from 1980 and 2000.
They examined factors indicative of social changes, for
example, increased employment of women, increase in level of
education overall, attitudes and values toward gender roles,
and found that despite changes in these factors, the propensity
to divorce remained the same. Some of these social changes
could increase the divorce proneness: increase in the
proportion of remarried individuals, the increase in
cohabitation prior to marriage, the increase in wives' extended
hours of employment, and the increase in wives' job demands.
But other social changes could offset this trend, namely, the
increase in age at marriage, the decline in the use of public
assistance, the increase in husbands' share of housework, the
increase in decision-making equality, and financial stability.
They concluded that the continuity in the mean level of divorce
probability between 1980 and 2000 was the result of two
opposing trends, with some social forces increasing divorce
proneness and other social forces decreasing divorce
proneness (Amato et al. 2003).
Cultural Perspectives on Divorce DIVORCE IN
THE CONTEXT OF RACE While there are some overall
similarities of factors associated with marital instability among
African American and white American couples, few
significant differences exist. In their longitudinal study on the
early years of marriage, Veroff, Douvan, and Hatchett (1995)
found that among both African American and white American
couples, the wife's extramarital affair, interferences ex,
perienced from wives' friends, and the experience of marital
unhappiness among wives were common cortelares of divorce.
However, there were some differences between the groups
based on cultural factors that go beyond simply race.
Meanings of marital experiences are influenced by factors
connected to the social and cultural context in which the
marriage takes place. Only for African Americans did the
husband's par, ticipation in household tasks reduce the risk of
divorce-the more he participated in household tasks, from both
husbands' and wives' perspectives, the lower the risk for
divorce. In contrast, there was a slight tendency for an
increased risk of divorce when white husbands reported high
participation in the home (Orbuch et aI., 2002). Education
among the African American couples also played an important
role in
f DIVORCE
reducing the risk for divorce. However, this applied to only the
wives-the level of education for African American husbands
seemed to play no role in reducing the risk of divorce. Race
and education were major structural factors that were
associated with the risk for divorce. The finding that race was a
significant predictor of divorce among these couples
highlights the disadvantages experienced by many African
Americans and the blocks to access resources needed for
maintaining marital commitments (Orbuch et aI., 2002).
DIVORCE IN THE CONTEXT OF GENDER Just as the
meanings of marriage and divorce can be influenced by one's
race or ethnicity, it can also be influenced by a person's
gender. In a national longitudinal survey, men and women
differed on their reasons for divorce. Wives were more likely
than husbands to attribute the cause of their divorce to
emotional and relationship issues, personality variables,
drinking, and abusive behavior. Husbands were more likely to
blame external causes and their own negative behaviors for the
divorce. Men were also more likely to report that they were
uncertain about what caused the divorce and women were
more likely the ones to initiate the divorce (Amato & Previti,
2003).
The differences in the economic consequences of divorce
between men and women has been a topic of significant
interest to both researchers and practitioners. There have been
some conflicting findings in the research. While early studies
indicated that mothers fared substantially worse economically
after divorce than did fathers (Weitzman, 1985), more recent
findings indicate that the postdivorce financial circumstances
of fathers and mothers are largely equal in the short term and
neither is particularly worse off than before the divorce
(Braver, Shapiro, & Goodman, 2006). The conflicting findings
may be related to when the research was conducted-the earlier
research was conducted at a time when women's wages were
substantially lower than those of men. However, another
factor that could explain the conflicting results involves how
the postdivorce standard of living of the mother and father are
calculated. According to Braver and his colleagues, what is
often missing from these calculations are the higher taxes on
income of the noncustodial parents and the child expenses paid
by these parents during their visitations. Custodial parents are
often taxed at a more favorable rate than noncustodial parents.
The child support that a custodial parent receives is not taxed,
his or her income is usually taxed at a lower,
head-of-household rate, and the parent takes the children as
exemptions (Braver et aI., 2006). However, other researchers
have argued that even when taxes and
79
voluntary support by the noncustodial parent are taken into
account, the results still are that on average, former husbands
are economically better off following divorce compared with
their former wives (Sayer, 2006).
DIVORCE IN AN INTERNATIONAL CONTEXT Divorce
patterns and practices can vary across nations. The differences
are influenced by factors such as the country's divorce laws,
the level of economic development, values related to
individualism, and gender inequalities. Some trends in divorce
seem to be quite consistent across countries. The liberalization
of divorce laws and an increase in the divorce rate since
mid-1980s seem to be common themes in many Westernized
countries. However, some countries have only recently
legalized divorce. For example, divorce in Argentina was
legalized in 1986 (jelin, 2005). Others have had dramatic
changes to their laws, such as the divorce law in the Czech
Republic, which has new legislation banning divorces within
the first year of marriage and those that would be counter to
the interests of minor children. Only after the interests of
children have been considered can the couple proceed with the
divorce process (Mozny & Katrnak, 2005). In countries that
emphasize collectivism, such as in India, divorce has more
frequently become accepted. However, the divorce rate is still
much lower than in Western societies that emphasize
individualism. Reasons for divorce vary with culture. Among
families in Kenya, a common reason for divorce is infertility
(Mburugu & Adams, 2005). In the Arab regions of Israel,
divorce is an option only in extreme cases that involve
physical violence, emotional abuse, mental illness, and
addiction (Savaya & Cohen, 1998).
Culture also influences how individuals cope with divorce.
Chicana women tend to show higher levels of distress and
reliance on their families than do Anglo or Mexicana women
(Parra, Arkowitz, Hannah, & Vasquez, 1995). African
American working women draw on their cultural and family
networks, religious beliefs, and employment experiences in
order to cope with divorce (Molina, 1999). Women in Hong
Kong utilize both Chinese and Western strategies in order to
cope with divorce (Hung, Kung, & Chan, 2003).
Theorizing About Divorce
Divorce theorists give a great deal of attention to the intra- and
interpersonal dynamics that underlie the process of divorce.
Theories explaining divorce among couples and families
include stress and coping, risk and resilience, cognitive,
cognitive-behavioral, family stress, family systems,
ecological, developmental, symbolic interactionism,
disaffection, social network, and
80 DIVORCE
feminist theories (Fine & Harvey, 2006). However, social
exchange, behavioral, and crisis theories are drawn on most
heavily (Rodrigues et al., 2006) and hold great promise for
future research.
Social exchange theory has a very strong presence in the
divorce literature (Guttman, 1993). Social exchange theorists
claim that individuals remain in relationships because they
perceive doing so as a way to serve their own self-interests,
when all potential profits and costs are considered (White &
Klein, 2002). Relationship dissolution occurs when the costs
of remaining together outweigh the benefits of remaining
together (Clarke-Stewart & Brentano, 2006; White & Klein,
2002). In a similar vein, behavioral theories emphasize the
importance of overt behaviors in marriage; positive behaviors
facilitate marital satisfaction and negative behaviors promote
dissatisfaction with marriage (Rodrigues et a1., 2006).
Crisis theory relies on the notion that marital satisfaction
and stability stem from a couple's ability to handle crises (Hill,
1949; Rodrigues et al., 2006). Crisis theory is based on Hill's
(1949) ABCX model of how couples handle crises. A couple's
ability to handle a crisis (X) depends on the existence of other
stressful life events (A), resources available to the couple (B),
and the family context (C) (Hill, 1949). McCubbin and
Patterson (1982) extended this model and replaced it with the
double-ABCX model. Wiseman's (1975) model of divorce
stems from crisis theory and suggests that individuals go
through five stages during and in the aftermath of divorce:
denial, loss and depression, anger and ambivalence,
reorientation of lifestyle and identity, and acceptance and a
new level of functioning (Guttman, 1993). Karney and
Bradbury (1995) integrated the tenets of crisis theory with
those of social exchange and behavioral theories to form one
comprehensive vulnerability-stressadaptation model that may
hold particular potential for future research (Rodrigues et a1.,
2006).
Attachment theory, which originated with John Bowlby's
(1969, 1973, 1980) description of the relationship between
mothers and infants, and its impact on childhood and adult
development is also used to explain the process of divorce
(Cohen & Finzi, 2005; Rogers, 2004; Todorski, 1995 ).
Existing research shows that individuals with insecure
attachment styles are particularly vulnerable to divorce.
Attachment theory is also used to explain how parents and
children adjust to divorce (Clarke-Stewart & Brentano, 2006).
Some additional models of divorce attempt to
conceptualize divorce as a process that individuals go
through, as well as the types of potential costs and benefits
that individuals experience during divorce. For example,
Kessler's (1975) model of divorce emphasizes the
psychological and emotional transitions that divorcing
individuals endure: disillusionment, erosion, detachment,
physical separation, mourning, second adolescence, and
exploration and hard work (Guttman, 1993). As another
example, Bohannan's (1968) model of divorce emphasizes six
simultaneous divorce processes: the emotional divorce, the
legal divorce, the economic divorce, the co-parental divorce,
the community divorce, and the psychic divorce
(Clarke-Stewart & Brentano, 2006; Guttman, 1993).
Consequences of Divorce
ADUL TS Researchers and practitioners give a great
deal of attention to the consequences of divorce and
the process of recovery. Divorcing and divorced
individuals and parents need to make several
psychological, emotional, legal, and financial
adjustments (Braver et al., 2006; Clarke-Stewart &
Brentano, 2006). On an emotional level, anger,
anxiety, depression, loneliness, and poor physical
health are common reactions (ClarkeStewart &
Brentano, 2006). In general, divorced individuals
tend to report lower levels of emotional well-being
than do married and remarried individuals (Forste &
Heaton, 2004). Men tend to experience more severe
reactions to divorce than do women, but women tend
to take a longer period of time to adjust to divorce
than do men (Clarke-Stewart & Brentano, 2006).
The reestablishment of family and friendship network
boundaries and ties can cause some stress and confusion for
both men and women after a divorce. Participation in
couple-related activities and contact with former inlaws
decline (Clarke-Stewart & Brentano, 2006). Adult friendship
groups evolve and expand to include ties from the workplace,
school, and organizations (Albeck & Kaydar,2002).
Co-parenting is a distressing task for divorcing and
divorced individuals. Legal battles often ensue over child
custody, child visitation, and child support (Braver et al.,
2006). Divorced parents are called on to take on new roles and
develop the capacity to financially and emotionally support
their children separately (Clarke-Stewart & Brentano, 2006).
Competition for intimacy with children sometimes occurs,
and so the establishment of clearly defined parental
relationships is essential (Butler, Mellon, Stroh, & Stern,
1995). The father-child relationship is a particular topic of
concern after divorce. One study indicates that children who
live with their fathers after a divorce retrospectively view their
fathers more favorably than do other children who do not
reside with their fathers after a divorce (Schwartz & Finley,
2005).
The costs and financial consequences of divorce vary
greatly and depend largely on the amount of

conflict between divorcing individuals, as well as existing
assets, debt, and income (Braver et a1., 2006). Spousal support
and property and debt division often requires legal advisement
(Braver et a1., 2006). Divorce has several economic
consequences that are particular challenges for low-income
individuals. Low salaries, unpaid child support payments, and
lack of alimony contribute to the financial troubles that many
experience in the aftermath of divorce (Molina, 1999).
CHILDREN Research shows that children react to parental
divorce in a variety of ways. Child consequences range from
aggression and anger to social difficulty, low self-esteem,
confusion, grief, andguilt (Clarke-Stewart & Brentano, 2006).
Some children have very strong reactions to parental divorce
and experience severe mental health problems or abuse drugs
or alcohol (Clarke-Stewart & Brentano, 2006). Depression is a
common reaction to divorce among children (Oppawsky,
1997; Storks en , Roysamb, Moum, & Tambs, 2005). Anxiety
and school difficulties are also common among children of
recently divorced parents (Storksen et al., 2005). During
divorce, children report feelings of sadness, shock, and anger;
these feelings often decline over time and are replaced with
relief and gladness (Bums & Dunlop, 1999). Sibling ties are
also vulnerable during and after parental divorce. Young
adults with nondivorced parents tend to have closer, more
supportive relationships with their siblings than do young
adults with divorced parents (Milevsky, 2004). For some
children, parental divorce is a positive experience; children in
very dysfunctional families tend to exhibit fewer antisocial
behaviors in the aftermath of a divorce (Strohschein, 2005).
Age is a crucial predictor of a child's reaction to divorce.
Confusion and feelings of abandonment are common among
infants and preschool children because the concept of divorce
is very difficult for them to understand. School-age children
are better able to understand what has happened when a
divorce has occurred, and so confusion is not an issue for
them, but they are very likely to experience anxiety, grief, and
sadness. School-age children often experience academic
difficulties. Young teens react to divorce with a tremendous
amount of shock, anxiety, and disbelief. They are also often
asked to take on extra responsibilities that then encourage
them to have a false sense of maturity. Older adolescents are
struck with divorce at a time when their identities are in
development and, thus, they often experience self-esteem
problems. Behavioral and academic problems are also
common among older teens (Clarke-Stewart & Brentano,
2006).
More research is needed to clarify the impact of divorce on
young adults. A common assumption is
DIVORCE 81
that parental divorce encourages young adults to view their
own romantic relationships differently than they might
otherwise. One recent study suggests that young adults from
both divorced and nondivorced families actually view
romantic relationships similarly (Burgoyne & Hames, 2002).
However, another recent study indicates that communication
and intimacy are obstacles for couples in which adolescent
girls experienced parental divorce (Mullett & Stolberg, 2002).
The Role of the Social Worker
in the Divorce Process
Divorce is inherently an interdisciplinary phenomenon.
Divorcing individuals and their families interact with
psychologists, attorneys, accountants, and other professionals
during the process and aftermath of divorce. Social workers,
however, tend to be responsible for the majority of clinical
services that families utilize. Social workers collaborate with
the other professionals involved in divorce and serve as
therapists, educators, mediators, and advocates.
CLINICAL WORK WITH PARENTS Adults' adjustment to
divorce depends on several factors. Predictors of adjustment
to divorce include access to social support, use of good coping
strategies, financial security, a positive relationship with one's
ex-partner, and a meaningful work situation (Clarke-Stewart
& Brentano, 2006). For many individuals with access to
sufficient social support, divorce can actually be a growth
opportunity (Clarke-Stewart & Brentano).
Psychoeducational programs for divorcing spouses seem
to be an effective approach to help spouses deal with the many
emotional, social, and practical issues during and after the
divorce. Preliminary evidence indicates that mothers'
participation in these programs enhances their
problem-solving skills and facilitates adjustment to divorce
(Zimmerman, Brown, & Portes, 2004). Fathers report that
they particularly appreciate co-parenting skills training, as
well as information about the impact of divorce on children
(Stone, McKenry, & Clark, 1999). However, one study indi-
cates that the effects of divorce education programs do not last
for fathers (Douglas, 2004). More research on the efficacy of
divorce education programs is needed (Whitworth, Capshew,
& Abell, 2002).
Mediation services are available to parents facing a great
deal of conflict during the divorce process. A neutral
individual (for example, a social worker, psychologist, or
attorney) is called upon to mediate between the conflicting
parties and resolve disputes (Sbarra & Emery, 2006).
Participation in mediation
82 DIVORCE
facilitates noncustodial parent contact and involvement with
their children (Dillon & Emery, 1996). The decision about
whether to include children in the mediation process requires
careful thought, however (Gentry, 1997a). Family-oriented
games might facilitate communication between parents and
children during the mediation process (Gentry, 1997b).
CLINICAL WORK WITH CHILDREN A child's adjustment
to divorce will vary depending on several factors including the
child's age, gender, exposure to parental conflict, personality,
access to social support, and cognitive development
(Schwartz, 1993). Additional important influences on a child's
adjustment to divorce include access to the noncustodial
parent, parental adjustment to divorce, conflict between the
parents, family economics, and other stressful life events
(Amato, 1993). Intellectual capacity can serve as a buffer
against the difficulties that many children experience when
their parents divorce (Owusu-Bernpah & Howitt, 2000). Good
communication between divorced parents also facilitates child
adjustment to divorce (Linker, Stolberg, & Green, 1999).
Additional predictors of child adjustment to divorce include
access to social support, financial security, and parental emo-
tional well-being (Clarke-Stewart & Brentano, 2006).
Children in need of professional help or therapy have
several options. Play therapy, for example, can significantly
reduce anxiety as children are dealing with their parents'
divorce (Burroughs, Wagner, &]ohnson, 1997). School-based
supportive programs for children are also very common. The
Divorce Adjustment InventoryRevised (DAI-R) and the
Child's Divorce Adjustment Inventory (COAl) are useful
tools for practitioners interested in assessing family
functioning and child adjustment after divorce (Portes,
Brown, Saylor, & Sekhon, 2005; Portes, Lehman, & Brown,
1999).
SOCIAL WORKERS AND THE LEGAL PROCESS OF
DIVORCE Social workers support individuals, families, and
lawyers in numerous ways during the legal process of divorce.
Divorce coaching is one intervention that professionals, such
as social workers, are increasingly employing to reduce
conflict, promote the well-being of children, and minimize
stress during the divorce process (Portnoy, 2005; 2006). A
divorce coach teaches productive communication skills,
educates about the impact of divorce on children, and helps
manage conflict. Therapy and divorce coaching have very
different goals. Although therapy typically aims to identify
and resolve inner turmoil or mental health problems, the goal
of divorce coaching is to help individuals effectively manage
the divorce process. Divorce coaches are typically licensed
mental health workers
accessible through collaborative law organizations (Portnoy,
2006).
Future Directions for Policy and Research
As mentioned earlier, divorce rates are higher in states where
quality of life is poorer. This suggests that divorce and marital
instability may frequently result from stressors external to
spouses and their relationship, namely factors such as unstable
working conditions, neighborhoods with high crime, poor
education, and low wages (Karney et al., 2005). Yet lawmakers
seem to be overlooking these daily life challenges as
contributors to divorce and marital instability. They seem
intent on promoting marriage as a solution to lifting women
and children out of poverty. The "Healthy Marriage Initiative"
proposed by the Bush administration intends to promote
healthy marriages and fatherhood by providing couples with
information on the value of marriage, marriage-skills
education to reduce conflict and increase happiness and
longevity of their relationships, and reductions in financial
penalties against marriage that were contained in the federal
welfare programs. While there are many positive aspects to
this program in teaching practical skills and providing
counseling to couples who may not otherwise be able to afford
it, it is questionable how effective these programs will be in
curbing the divorce rate. The scientific evidence shows that
marital breakdown and marital distress may be the result of the
chronic stress of poverty. This broader, ecological approach
that focuses on the context of divorce has implications for
social workers and policy makers. Programs aimed at
providing people with a living wage, universal health care, and
quality education for all children may indirectly affect the
quality of marriages and the potential for divorce. If provided
with a social environment that supports the relationship,
couples may be better equipped to maintain their relationships
on their own (Karney et al., 2005).
Another area of reform needs to occur in the legal system.
How couples manage the legal dissolution of their marriages
and postdivorce parenting will impact the postdivorce
adjustment of the former spouses and children. Social workers
can play a critical role in assisting couples through this
process. On another level, they could advocate for a less
adversarial process within our court system.
With nonmarital cohabitation and same-sex couples
(either married or unmarried) becoming more common in the
United States, researchers need to focus on the breakdown and
dissolution of these other types of intimate partnerships. Some
research questions include:
What social supports exist for these partners when their
relationships dissolve? What are the consequences of the
breakup when children are involved? How are these

relationship breakdowns similar or different from di-
vorces? To promote societies that foster the well-being of
all people, the social work profession must be committed to
ensure that families (however they are defined) are valued,
supported, and empowered.
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SUGGESTED LINKS
American Association for Marriage and Family Therapy.
http:// www.aamft.org/index_nm.asp
Americans For Divorce Reform.
http:// www.divorcereform.org/
: Center for Family and Demographic Research.
http:// www.bgsu.edulorganizationslcfdrl
The Coalition for Marriage, Family and Couples Education.
http://www.smaTtmarriages.com/
Divorce Net.
http://www.divorcenet.coml
Medline Plus articles.
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National Marriage Project.
http://marriage.rutgers.edu/rootindex . htm
-KAREN KAYSER AND JESSICA K. M. JOI-INSON
DRUG ABUSE. See Alcohol and Drug Problems:
Overview.
DSM. See Diagnostic and Statistical Manual of Mental Disorders.
DUAL DEGREE PROGRAMS
ABSTRACT: Dual degree programs are growing rapidly
around the country with increasing numbers of univer-
sities offering students an opportunity to earn an M.S.W.
along with another degree. While two degrees offer clear
benefits to the students and provide revenue to
DuAL DEGREE PROGRAMS 85
the institutions, they also raise some issues and concerns about
the "relative worth" of an M.S.W.
KEY WORDS: administration; dual degree; education
Dual degree programs in schools of social work appear to be
proliferating. Although the accrediting body for social work, The
Council on Social Work Education, collects data on dual degree
programs as part of the annual reporting process from schools,
there are some questions about the reliability and
comprehensiveness of these data. Clearly, an up-to-date and
comprehensive database will be extremely valuable in the future
not only for the purposes of counting but also to help
cross-program contacts and conversations. Little information
exists in the professional literature on the effectiveness, functions,
and structures of dual degree social work programs. Available
data tend to be simple counts and configurations of programs, and
even here, what data are obtainable are best estimates. Some in-
formation can be garnered by browsing the Web sites of different
schools and programs, but the information recorded is highly
variable and understandably intended to "sell" the program.
There are, however, considerable differences in how these
programs are administered and how they are defined. There is no
formal or universal definition of what constitutes a dual degree
program, and as a result different universities and programs
appear to use language most consistent with the internal structures
unique to the respective institutions. Thus, it is not uncommon for
terms such as "joint degree," "interdisciplinary program,"
"collaborative degrees," "cooperative degree," and "side-by-side
program" to be used synonymously to what is termed a "dual
degree program" here. In fact, several schools record more than
one of these types of programs. Some schools also list "certificate
programs," such as a certificate in gerontology, nonprofit manage-
ment, or art therapy, as dual degree programs. Still other schools
refer to a combined M.S.W. and Ph.D. program in social work or a
combined B.S.W. and M.S.W. program as a dual degree program.
Although there are commonalities among these programs, there
are also some significant and important differences. To establish
the parameters for this discussion, some definitional distinctions
are provided here. The focus of this entry, however, will be on
those entities defined as dual degree programs because they are
the most predominant programs at the Master's level.
Joint degree programs: These are defined as programs that
eventuate in the receipt of one degree, usually a Ph.D., for
example, in social work and psychology or social work and
sociology. The "joint" comes from
86 DUAL DEGREE PROGRAMS
the fact that the terminal degree is one degree, the Ph.D.
Students in a joint degree program are admitted to both
programs simultaneously; they take course work and
examinations in both programs and presumably write a
dissertation addressing overlapping content. Here, a joint
degree is defined as being between social work and another
discipline, not social work and another professional school.
The rationale is that the terminal degrees in professional
programs are sufficiently different from each other that one
degree is impractical, for example, aJD. (Juris Doctorate) and
Ph.D., or an M.D. and Ph.D. Students in joint Ph.D. and social
work programs typically acquire an M.S.W. degree in the
process.
Interdisciplinary programs: These are defined as
programs that eventuate in one degree and students take
courses in social work ~nd one or more disciplines or
professional schools. However, unlike joint degree programs,
students are admitted only into the social work program, but
are required to take a defined number of credits in the cognate
areas. For example, a student interested in juvenile justice will
take the required course work in the social work program but
may also take classes in a criminal justice program, as well as
sociology and psychology. The required cognate course work
is usually student-specific, may be across one or more
disciplines or professions, and is guided by advising rather
than discipline-specific programmatic requirements.
Typically, such programs eventuate in a Ph.D. Students in
interdisciplinary programs are unlikely to receive the
integrated content in joint programs and may not acquire the
same depth of knowledge and expertise as do
discipline-specific students.
Certificate programs: Cert ifica te programs are courses
of study that eventuate in one degree, typically an M.S.W.,
and a certificate in an area of specialization such gerontology
or school social work. The students are admitted to the social
work program. An identified set of courses and field
practicum are typically required for the certificate. The
coursework and any practicum experience necessary for the
certificate may be within the school or department, or it may
be across schools and departments. Certificate programs are
quite common, and allow students an opportunity to develop
indepth knowledge and expertise in a particular area of
practice without necessarily extending the duration of study.
Many states require certification for practicing in some
contexts, such as schools, hence the popularity of, and often
the need for, certificate programs.
Dual degree programs: These are defined as programs
that eventuate in the receipt of two degrees, for example, an
M.S.W. and J.D., or an M.S.W. and M.P.H. These are
separate and distinct degrees, and the recipients may market
themselves as having both a
social work and a law degree or a social work and public
health degree. To practice as a social worker, the individual
will have to take the relevant licensing examinations in a given
state, and the same holds true for passing the bar examination
in that state in order to practice as a lawyer. Most important, an
individual with a dual degree can practice in either one or both
arenas.
The goal of dual degree programs is to allow students to
acquire greater breadth, depth, and knowledge in two areas.
The assumption would be that individuals thus trained would
not only help themselves, but also help the profession better
integrate and create a synergic relationship with the other
professions and disciplines. Similarly, the corresponding
profession or discipline presumably sees some value in having
students trained in social work. It could also be argued that
dually trained students may be in a position to provide better,
or perhaps qualitatively different, services to clients. For
example, N elson- Becker (2005) found that students from an
M.S.W. and Divinity dual degree program were more likely to
ask clients about their religious views when compared with
students having only an M.S.W.
All dual degree programs typically require admission to
both units. However, some programs require simultaneous
admission prior to matriculation, while others allow for entry
into one or the other program during enrollment in one
program. Still other programs may have separate admission
procedures or application to the dual degree program as
opposed to admission to each unit separately. For the most
part, the different types of entry into dual degree programs are
a function of diverse administrative structures and have little
to do with the common goals of such programs.
Most of the dual degree programs are housed within one
university. The programs are usually across distinctive
schools, colleges, or departments, but they are all a part of the
same institution. A few dual degree programs are coordinated
across universities, and are sometimes referred to as
"cooperative dual degrees." For the most part, such
cross-institutional enterprises are driven by functional needs,
such as the availability of a particular degree and geographic
proximity. There is likely to be considerable variation in the
administrative structures and financial underpinnings among
these different arrangements.
All dual degree programs seem to have the following
common administrative characteristics:
1. They offer two degrees simultaneously.
2. They reduce the time needed to earn the two degrees,
compared with independent enrollment in the two
degree programs.
3. Students are admitted to both programs, thus having to
meet the admission requirements of both programs.
 DUAL DEGREE PROGRAMS 87

4. Students take courses in both programs. TABLE 1

S. They count some subset of coursework typically List of Known Dual Degree Programs at the Master's Level a
toward both degrees.
ASIAN AMERICAN M.S.W. OR M.A.
6. They reduce the cost of education by virtue of a
STUDIES
reduction in terms enrolled. Bioethics M.S.W. or M.B.E. or M.A.
Business M.S.W. or M.B.A.
Dual Degree Programs: Types and Child Development M.S.W. or M.S. or M.A.
Prevalence The program information listed here are Child and Family Law M.S.W. or M.J.
from a survey conducted by the National Association of City and Regional Planning or M.S.W. or M.A.
City Planning Criminology or
Deans and Directors (NADD) in 2005. These data
Criminal M.S.W. or M.S. or M.A.
suggest the existence of a relatively large number of Justice
dual degree programs across a surprisingly wide array of Divinity M.S.W. or M.Div.
schools. Table 1 presents the degrees offered. Education M.S.W. or M.Ed. or Ed.M.
Gerontology M.S.W. or M.S.
In addition to the programs noted in Table 1, the NADD
Government Administration M.S.W. or M.G.A.
data also categorize a few programs that offer an M.S.W. Human Communication M.S.W. or M.A.
degree and a doctoral degree as dual degree programs. For Information Science M.S.W. or M.S.\.
example, programs conferring an M.S.W. and a doctorate in Interdisciplinary Social M.S.W. or M.S.
education (Ed.D.), or an M.S.W. and a Doctor of Ministry Sciences International
(D.Min.), or those that allow students to acquire a Ph.D. in Affairs or International M.S.W. or M.I.A. or M.A.
Studies Jewish Studies
social work along with another discipline, were identified as Jewish Communal Service M.S.W. or M.A. or M.A.J.S.
dual degrees. These programs have been defined as "joint M.S.W. or M.A.
programs" here rather than "dual degree programs" because in or M.A.J.C.S.
the latter category, the student acquires two terminal degrees in Law M.S.W. or J.D.
Marriage and Family M.S.W. or M.S.
two separate disciplines or professions at the same level, that
Nonprofit Organizations M.S.W. or M.N.O.
is, a master's degree. Pan African Studies M.S.W. or M.A.
The data in Table 1 indicate the presence of many dual Public Administration M.S.W. or M.P.A. or M.S.
degree programs. The degrees range from professional schools Public Health M.S.W. or M.P.H.
such as law and divinity, to traditional disciplinary studies Public Policy or Public M.S.W. or M.P.P. or M.S.
Affairs or M.P.A.
such as child development and sociology) to more recent
Sociology M.S.W. or M.A.
developments such as bioethics and pan-African studies. The Special Education M.S.W. or M.S.
most widely cited dual degree programs are with law (M.S.W. Specialized Ministry M.S.W. or M.A.S.M.
and J.D.) and public health (M.S.W. and M.P.H.). Theological Studies or M.S.W. or M.T.S.
What is also of interest is that dual degree programs are Theology
Urban Planning or Urban M.S.W. or M.A. or M.U.P.
offered by both large and small, and private and public or M.S.
and Regional Planning
universities. It is no surprise, perhaps, that large schools in Urban Affairs M.S.W. or M.A.
large universities such as Columbia and the University of Women's Studies or Women M.S.W. or M.A.
Michigan are able to offer dual degree programs. In fact, some and Gender Studies
of these larger schools offer multiple dual degree programs. On "The data presented here are from the NADD Survey conducted in
the other hand, it is interesting to note that a significant number January 2005 and updated in May 2005.
of small private institutions also offer dual degree programs. A
disproportionate number of these smaller programs are housed
in universities with a religious affiliation (for example,
New England School of Law. Such collaborations are not
Augsburg College or College of St. Catherine), and the dual
restricted to private institutions, as demonstrated by the dual
degree programs are mostly with Master's degrees in
degree program between Eastern Washington State University
theological studies, divinity, or pastoral counseling. However,
and Gonzaga University.
a few of these smaller colleges also offer other dual degree
Clearly there are many dual degree programs, but there
programs such as law, and in a number of instances, this is the
are no data on the size of these programs. One can only
result of collaboration between institutions. For example,
assume that the programs exist because of student and faculty
Springfield College offers a dual degree program in
interest. In discussing the value of dual degree engineering
partnership with the Western
programs, Collison (1999) argues that small schools (in this
instance, historically black colleges and universities) "may
hold the key to significantly increasing the number of
under-represented
88 DuAL DEGREE PROGRAMS
engineers" (p. 28). A parallel scenario may be evident in social
work as well, where small schools partner with other schools
and share intellectual and financial resources for the benefit of
the students.
When Does a Dual Degree
Program Make Sense for a Student?
If an individual has specific career goals that can best be
accomplished by the receipt of two degrees, following a dual
degree program will result in greater efficiency and less cost.
Virtually all institutions that offer dual degree programs
emphasize the fact that you get the benefits of two degrees for
one less year (typically). A student interested in child welfare
and law may find it valuable to pursue an M.S.W. along with
JD., which should theoretically provide a broader'set of skills
with which to advocate for children and families. Or a student
whose primary interests lie in working within the Jewish
community may want to consider a dual degree with Jewish
studies or Jewish communal services. A reasonable
assumption is that individuals with dual degrees may not only
have broader job options but also have greater access to and
acceptance into organizations and benefits of each.
Since the primary consumer of a given unit's academic
product is the "home" student, that is the M.S.W. student,
course offerings and activities will be geared to their needs,
not those of the dual degree student. To the extent that this
view is accurate, students in dual degree programs may need
to have a higher degree of flexibility in time and be very well
organized. As such, dual degree programs may work best for
full time students. While many programs allow for part-time
enrollment, the associated costs are often higher and the
program itself longer, thus offsetting to some extent the
inherent benefits. Although virtually all dual degree programs
allow double counting of credits, thereby reducing the time in
the program, it would be incorrect to infer that different
standards apply. Programs expect a candidate to meet the
requirements of both programs. It is also true that the entrance
requirements for an M.S.W. program will be quite different
from those of the partner school, such as the requirements for
a particular GRE score or even the requirement of the GRE
itself.
When Should a School
Offer a Dual Degree Program?
For an institution or school considering the installation of a
dual degree program, the most immediate questions pertain to
the determination of the need for such a program and the
availability of adequate resources. Here the issues range from
salary differentials to job
options, and considerable legwork will need to be done in
order to justify the development of a new program. In the long
run, the marketability of dual degree graduates will impact the
existence of the program. If the external environment is
positive, then internal institutional factors come into play, such
as needed curricular changes, cross-disciplinary connections,
faculty buy in, financial resources, and administrative
structures. Administrators should be prepared to deal with
philosophical differences about purpose as well as differences
in admission requirements and standards (Whiddon, 1990).
For example, there could be significant professional value
conflicts as well as considerable differences in existing codes
of ethics. In those instances where interuniversity colla-
borations are needed, the requisite groundwork necessary will
likely take longer and is likely to be more difficult. For the
most part, the issues that present themselves are surmountable
challenges, but challenges nonetheless.
Do Dual Degree Programs
Add Value or Diminish the Profession?
If there is public professional controversy about the value of
dual degree programs, it is certainly not evident in the
professional literature. The working assumption is that dual
degrees add value to the M.S.W. It is indeed impossible to
argue that a student's intellectual curiosity and professional
goals should somehow be stymied by petty discourse on
diminishing the "inherent" value of an M.S.W.1t is, however, a
nagging concern-or is it?
If an M.S.W. program offers a concentration in social
policy, the assumption is that a graduate would be employable
as a policy analyst. Presumably, so would a student receiving a
Master's in public policy (M.P.P.). The job market may
entertain both degrees as "equal players" (with an emphasis on
may), and this would depend on the organization, its activities,
and its administrators. While bias and perception may also
playa role in a hiring decision of this type, the presence of a
dual degree candidate is much more likely to make the point
moot. What we do not know is whether the M.S.W. enhances
the value of the M.P.P. or whether the M.P.P. adds value to the
M.S.W. From the perspective of the individual, it does not
matter. But, from the perspective of the profession, it may.
The discussion that is not occurring, but should be,
involves the "why" of the apparent proliferation of dual degree
programs. Is the current social environment so complex that a
single Master's degree will no longer suffice? Is the offering of
dual degrees merely a market strategy to increase enrollment?
Are dual degrees a result of financial restructuring within
universities? Are dual degrees a reaction to a marketplace
where M.S.W.s are losing ground to those with other degrees?

Who is initiating the dual degree; is it social work or is it the
other profession? Are dual degrees the best answer to a
changing environment or do we need to reconsider curricular
content?
It is in the best interest of the professions and the academic
environment to have an open discourse. Perhaps the M.S.W. is
simply not enough in an increasingly complicated world;
perhaps the expectations of what an M.S.W. is capable of
doing exceed the realities of practice; and perhaps the
academe and the profession are slowly undermining the
strength and value of the M.S.W. by allocating more resources
to dual degrees-a worthy discussion and debate for the
profession and academia.
DUAL DEGREE PROGRAMS 89
REFERENCES
Collison, M. N. K. (1999). The power of partnerships. Black issues in
highey education. 16, 26-29.
National Association of Deans and Directors. (2005). Dual degree
pTOgram suyvey. Alexandria, V A: Council on Social Work
Education.
Nelson-Becker, H. B. (2005). Does a dual degree make a difference in
social work: An empirical study. Journal of Religion and Spirituality
in Social Woyk: Social Thought, 24, 111-124.
Whiddon, S. (1990). Graduate dual preparation programs in business
and sport management. Journal of Physical Educa tion, Recyeation
and Dance, 61,96-98.
-SRINIKA ]AYARATNE
EAP. See Employee Assistance Programs.
EARNED INCOME TAX CREDIT
ABSTRACT: The federal Earned Income Tax Credit (ElTC)
is a refundable tax credit for working families with low and
moderate incomes. The credit provides a substantial income
supplement to families with children and thus helps families
finance basic necessities or invest in longer-term household
development. In recent years, political support for the EITC
has declined. Social workers should be prepared to advocate
against policy changes that would reduce the impact of the
ElTC Social workers could also support EITC outreach
campaigns and advocate for more and expanded state EITCs.
The federal Earned Income Tax Credit (EITC) is a tax credit
for working families with low and moderate incomes. The
credit is administered by the Internal Revenue Service (IRS);
families receive it by filing their regular tax returns and
completing the seven-line Schedule EIC The EITC is
refundable, which means that eligible individuals and families
receive payments even if they do not owe federal income
taxes. This characteristic is crucial because low-income
families who pay little or no federal income tax do not benefit
from nonrefundable credits. In tax year 2003, over 22 million
tax filers-about 17% of all tax filersclaimed the EITC and
received about $39 billion in benefits (Parisi & Hollenbeck,
n.d.).
History and Structure
The EITC was created in 1975 to offset the burden of payroll
taxes for low-income working people with children (Hotz &
Scholz, 2003). At that time, the credit equaled 10% of earned
income, and the maximum value was $400 (equivalent to
about $1,500 in 2006). From the mid-1980s through the
1990s, there was strong bipartisan support for the EITC, and
major expansions of the credit were enacted in 1986, 1990,
1993, and 2001. These expansions indexed the credit to
inflation, increased benefits (especially for families with
multiple children and later for married couples with children),
created a small credit for childless working families, and
simplified eligibility criteria.
91
ElTC benefits vary with earnings in a somewhat complex
way (Table 1). The credit has a "phase-in range," a "plateau
range," and a "phase-out range." The phase-in range occurs at
low levels of earnings, and the value of the credit increases
with earnings. For example, in the 2006 tax year, working
families with two or more children and earnings at or below
$11,340 were eligible for an EITC equal to 40% of their
earnings. In the plateau range, EITC benefits remain at their
maximum values, despite increases in earnings. For the 2006
tax year, married couples (filing jointly) with two or more
children and earnings between $11,340 and $16,810 were
eligible for the maximum benefit of $4,536. Finally, during
the phase-out range, benefits are reduced and ultimately
eliminated. In 2006, the benefit for married couples with two
or more children was reduced by 21 cents for every dollar of
income earned above $16,810 and was completely phased out
when earnings exceeded $38,348.
EITC-eligible individuals with children may use the
"advance-payment" option to receive a portion of their credits
through their paychecks. In 2006, eligible workers could
receive up to $1,648 in EITC benefits in advance, by
submitting IRS Form W-5 to their employers. This option can
help families smooth consumption and cope with mid-year
budget shortfalls. However, almost all EITC recipients receive
a lump-sum refund after they submit their tax returns. (Hotz &
Scholz, 2003).
Effects on Poverty, Consumption,
Investment, and Employment
As shown above, benefits for families with children can be
substantial. In 2003, the average EITC recipient earned a
credit of $1,788 (Berube, 2006). Spread throughout the year,
the maximum credit for tax year 2006 was equivalent to $87 a
week. Although higherincome families that do not qualify for
any other means-tested assistance may receive the EITC,
working families with children and with incomes just below
the poverty line receive the largest EITC benefit. This
arrangement makes the EITC very effective in reducing
poverty among children. The Center on Budget and Policy
Priorities has shown that the EITC lifts more children out of
poverty than any other public welfare program (Greenstein,
2005).
Evidence from several small studies shows that families
use tax refunds (which may include overwi thholding
92 EARNED INCOME T AX CREDIT
as well as EITC payments) to catch up on bills and to purchase
necessities (Romich & Weisner, 2000; Smeeding, Phillips, &
O'Connor, 2000). Small studies also show that some families
use tax refunds to save, to purchase or repair cars and homes,
to reduce debt, and to pay for education expenses (Beverly,
Romich, & Tescher, 2003; Beverly, Schneider, and Tufano,
2006; Romich & Weisner, 2000; Smeedinget aI., 2000). These
uses of tax refunds may contribute to longer-term household
development. In addition, a fairly large body of research
suggests that the EITC increases employment among single
mothers (for example, see the summary in Hotz & Scholz,
2003).
Advocacy Opportunities
In sum, the federal EITC provides a substantial income
supplement to families with children and thus helps families
finance basic necessities or invest in longerterm household
development. The credit appears to encourage work by single
mothers-an outcome that appeals to proponents of welfare
reform. Because the transfer occurs through the tax system, it
is presumably less stigmatizing than other means-tested
transfers. Finally, the credit may be viewed as an entitlement
because benefits are not subject to time limits. These
characteristics make the EITC a valuable tool for supporting
low-income working families (Beverly, 2002).
Social workers should remain watchful and be prepared to
advocate against policy changes that would reduce the impact
of the EITC. In recent years, however, political support for the
EITC has declined somewhat. An IRS (2002) report estimated
that 27% to 32% of EITC benefits claimed on 1999 tax returns
were erroneous, fueling some existing concerns about EITC
"fraud." Greenstein (2003) and others argue that the IRS
report overestimated the error rate, and tax changes since the
late-1990s have probably decreased the actual error rate. Still,
the IRS has piloted and may expand an EITC
"pre-certification" program, requiring
TABLE 1
2006 Federal Earned Income Tax Credit Parameters
PHASE-OUT RATE PHASE-OUT RANGE
(EARNINGS)
21.06% Married: $16,810-$38,348
Not married: $14,810-$36,348
15.98% Married: $16,810-$34,001
Not married: $14,810-$32,001
7.65% Married: $8,740-$140,120
Not married: $6,740-$12,120
Parisi, M., & Hollenbeck, S., n.d, Indit!idual income tax returns, 2003. Retrieved October 10, 2006, from http://www.irs.gov/pub/irs-soi/
03indtr.pdf
some tax filers to document their eligibility for EITC benefits
in advance (IRS, 2003).
Social workers could also support EITC outreach
campaigns. The best available data suggest that 13 to 18% of
eligible individuals-2.3 to 3.4 million people-did not receive
the credit in 1996 (SBjSE Research, 2002). Because many
social workers are connected to organizations that serve low-
and moderate-income families, they are well-positioned to
participate in and even lead outreach efforts. Research
suggests that eligible Hispanic parents might be especially
unlikely to claim the credit (Phillips, 2001), so outreach to
Hispanic communities seems especially important. The
Center on Budget and Policy Priorities offers an EITC
outreach kit 2007 (http://www.cbpp.org/ eic2007), and
Brooks, Russell, and Fisher (2006) describe and evaluate one
outreach model.
Social workers might advocate for more and expanded
state earned income tax credits. This entry has focused on the
federal EITC, but as of March 2006, 19 states had enacted
state credits. The most likely model simply uses federal EITC
eligibility rules and makes the credit a percentage, say, 10% of
the federal credit. Nagle and Johnson is a great resource for
social workers who want to influence policy. These state
credits typi-
. cally use federal eligibility rules and are usually com. puted as
a percentage of the federal credit (Nagle & Johnson, 2006).
Thus, they are easy to administer. State credits tend to be quite
small, however- sometimes only 4% or 5% of the federal credit
(Nagle & Johnson, 2006). Social workers in states without
credits can work to create state credits, and those in states with
existing credits can advocate for increases. Nagle and Johnson
offer concrete suggestions for designing and enacting state
credits.
Finally, social workers could help create programs and
policies that encourage saving out of tax refunds. Existing
initiatives, which are grounded in the assetbuilding
movement, have allowed refund recipients to
MAXIMUM PHASE-IN PHASE-IN RANGE NUMBER OF
BENEFIT RATE (EARNINGS) CHILDREN
$4,536 40.00% At or below $11,340 Two or more
$2,747 34.00% At or below $8,080 One
$412 7.65% At or below $5,380 None

open low-cost bank accounts with their refunds, encouraged
direct deposit into restricted savings vehicles, and allowed
refund recipients to "split" their refunds, designating some for
savings and some for consumption (Beverly & Dailey, 2003;
Beverly, Romich, & Tescher, 2003; Beverly, Schneider, &
Tufano, 2006).
REFERENCES
Berube, A. (2006). The new safety net: How the tax code helped
low-income working families during the early 2000s. Washington,
DC: Brookings Institution, Metropolitan Policy Program.
Beverly, S. G. (2002). What social workers need to know about the
Earned Income Tax Credit. Social Work, 47(3), 259-266.
Beverly, S. G., & Dailey,C. (2003). Using tax refunds to promote asset
building in low-income households: Program and policy options
(Policy Report). St. Louis, MO: Washington University in St.
Louis, Center for Social Development.
Beverly, S. G., Romich, J. L., & Tescher, J. (2003). Linking tax
refunds and low-cost bank accounts: A social development
strategy for low-income families? Social Development Issues,
25(1/2), 235-246.
Beverly, S. G., Schneider, D., & Tufano, P. (2006). Splitting tax
refunds and building savings: An empirical test. In J. M. Poterba
(Ed.), Tax Policy and the Economy. Cambridge, MA:
National Bureau of Economic Research and MIT Press.
Brooks, F., Russell, n, & Fisher, R. (2006). ACORN's Accelerated
Income Redistribution project: A program evaluation. Research on
Social Work Practice, 16(4), 369-38l.
Greenstein, R. (2003). What is the magnitude of EITC overpayments?
Washington, DC: Center on Budget and Policy Priorities.
Greenstein, R. (2005). The Earned Income Tax Credit: Boosting
employment, aiding the working poor. Washington, DC: Center on
Budget and Policy Priorities.
Hotz, V.J., &Scholz,J. K. (2003). The Earned Income Tax Credit. In
R. A. Moffit (Ed.), Means-tested transfer programs in the United
States. Chicago: The University of Chicago Press.
Internal Revenue Service. (2002). Compliance estimates for Earned
Income Credit claimed on 1999 returns. Washington, DC: Author.
Internal Revenue Service. (2003). EITC reform initiative.
Washington, DC: Author.
Nagle, A., & Johnson, N. (2006). A hand up: How state earned income
tax credits help working families escape poverty in 2006.
Washington, DC: Center on Budget and Policy Priorities.
Parisi, M., & Hollenbeck, S. n.d. Individual income tax returns, 2003.
Retrieved October 10, 2006, from http://www.irs.gov/
pub/irs-soi/03 ind tr. pdf.
Phillips, K. R. (2001). Who knows about the Earned Income Tax Credit.
Washington, DC: Urban Institute.
Romich, J. L., & Weisner, T. (2000). How families view and use the
EITC: Advance payment versus lump sum delivery. National Tax
Journal, 53(4, Part 2),1245-1265.
SB/SE Research. (2002). Participation in the Earned Income Tax
Credit program for tax year 1996. Greensboro, NC: Author.
EATING DISORDERS
93
Smeeding, T. M., Phillips, K. R., & O'Connor, M. (2000). The Earned
Income Tax Credit: Expectation, knowledge, use, and economic
and social mobility. National Tax Journal, 53 (4, Part
2),1187-1209.
-SONDRA G. BEVERLY
EATING DISORDERS
ABSTRACT: Eating disorders involve maladaptive eating
patterns accompanied by a wide range of physical
complications likely to require extensive treatment. In
addition, "eating disorders frequently occur with other mental
disorders such as depression, substance abuse, and anxiety
disorders. The earlier these disorders are diagnosed and
treated, the better the chances are for full recovery" (NIMH,
2002). Early diagnosis is imperative as the National Institute
of Mental Health estimates that the mortality rate for anorexia
is 0.56% per year, one of the highest mortality rates of any
mental illness, including depression (NIMH, 2006). Current
research and treatment options are discussed.
KEY WORDS: eating disorders; anorexia; bulimia; binge
eating; interpersonal therapy; dialectical behavioral
therapy; cognitive behavioral therapy
Introduction
Our understanding of eating disorders has evolved since the
1980s although symptoms have been documented as far back
as the 1400s. They were first recognized in the psychiatric
field in 1952, when Anorexia Nervosa was included in the
DSM-I as a psycho-physiological reaction. The DSM-ll
(1968) identified anorexia under "special symptoms." The
DSM-lll (1980), recognizing differences between "dieters,"
"vomiters and purgers," placed anorexia, pica, and rumination
in a newly designated eating disorders section. Bulimia,
considered a symptom, was classified as "atypical eating
disorder." The DSM-III-R (1987) identified bulimia as an
independent diagnosis and no longer classified eating
disorders under "disorders usually first evident in infancy,
childhood or adolescence." A separate section under adult
disorders was established (Brumberg, 1989, p. 12). The
DSM-IV (1994) expanded to include Eating Disorder Not
Otherwise Specified (EDNOS). The DSM-IV-TR (APA,
2000a), recognized binge eating disorder as a potential
diagnosis needing more research under the section, Criteria
Sets and Axes Provided for Further Study (APA, 2000b).
94 EATING DISORDERS
Overview of Four Eating Disorders
The following is a brief overview of the four current
diagnoses in the DSM-IV-TR (APA, 2000a), including a note
on recent genetic evidence, and key terms used when
discussing behaviors common to eating disorders.
Anorexia Nervosa is identified with refusal to maintain
body weight at or above a minimal weight for age and height,
intense fear of gaining weight, disturbance in body image with
undue influence of body weight, cessation of menstrual cycle
(if previously established), and denial of the seriousness of the
current low body weight (APA, 2000a).
Bulimia Nervosa is identified by recurrent episodes of
binge eating large amounts of food in one time period, feeling
of a lack of control over eating during the episode, and using
recurrent compensatory behaviors to prevent weight gain (that
is, purging by vomiting, laxative abuse, excessive exercising,
etc.) (DSM-IV-TR, 2000).
Eating Disorders Not Otherwise Specified is identified as
the category for disordered eating behaviors not meeting
criteria for any specific Eating Disorder (DSM-IV-TR, 2000).
Binge Eating Disorder is identified as a combination of
symptoms similar to those of Bulimia, excluding recurrent
compensatory behaviors on a regular basis. This potential
disorder is still undergoing rigorous research (DSM-IV-TR,
2000).
Genetic and Emotional Factors
Studies conducted by Kaye, and others, provide new evidence
that anorexia is 56% determined by genetics, enabling a
paradigmatic shift in exploring the etiology of eating disorders
(Davis, 2001; NEDA, 2006). As medical and social science
professionals are seeing more evidence of symptomology
across varied ethnicities, ages, gender, and sexual orientations,
genetics can now be considered alongside psychosocial
factors, providing for enriched understanding and improved
services for persons with eating disorders. Persons with eating
disorders regulate emotional distress with behaviors such as
"restricting" (reducing or eliminating intake of food or liquid),
"purging" (ridding oneself of what has been ingested), and
"binging" (taking in large amounts of food in one sitting).
Often individuals identify "safe and risk foods." A risk food is
likely to be higher in caloric count or possibly associated with
traumatic memories, potentially producing increased anxiety
(Farber, 1997; U.S. Department of Health & Human Services,
n.d.). \Xlhile these eating behaviors initially provide a
semblance of control over emotions, this false sense of control
often perpetuates the cycle, instead of eliminating it (J eppson,
Richards, Hardman, & Granley, 2003).
Statistics and Demographics
The first nationally representative study of eating disorders in
the United States appeared in Biological Psychiatry (2007). The
National Comorbidity Survey Replication (NCS-R)
administered face-to-face surveys to 9,282 U.S.
English-speaking adults, ages 18 and older, between February
2001 and December 2003. Survey results reported the
following: lifetime prevalence of individual eating disorders is
0.6%-4.5%, with anorexia identified in 0.9% of women and
0.3% of men, and bulimia identified in 1.5% of women and
0.5% of men. Men represented approximately one-fourth of
the cases of each disorder. Binge eating is more common than
anorexia or bulimia and is commonly associated with severe
obesity. According to the NCS-R, results of a Harvard study
suggest that binge eating disorder is the most prevalent eating
disorder among both women and men (Hudson, Hiripi, Pope, &
Kessler, 2007). Eating disorders frequently impair the
sufferer's home, work, personal, and social life and substantial
incidents of eating disorders often coexist with other mental
disorders, which remain undiagnosed and untreated. Seventy
percent of those with anorexia nervosa and 75% of those with
bulimia nervosa have another co-existing mental health
diagnosis, including anxiety disorders such as obsessive
compulsive disorder, social phobia and post-traumatic stress
disorder, and mood disorders such as major depression and
bipolar disorder (Arnold & Walsh, 2007). In addition, studies
are beginning to indicate links between sexual orientation and
increased risks for eating disorders. The psychosocial
relationship between sexual orientation and eating disorders is
being explored. Current empirical evidence suggests that
internalized homophobia and sexual orientation concealment
may influence coping skills among those persons who
self-identify as gay, lesbian, bisexual, or transgender, therefore
impacting eating disordered behaviors (Reilly & Rudd, 2006;
Swearingen, 2007; Wichstrom, 2006).
In addition, studies are beginning to indicate sub-
stantiallinks between alternative variables such as race,
ethnicity, culture, age, and gender to eating disorders (Carlat,
Camargo, & Herzog, 1997; Myers, Taub, Morris, & Rothblum,
1999).
Culturally competent care of eating disorders necessitates
the need to replace common myths suggesting that eating
disorders are exclusive to a narrow range of ethnicity, age, and
gender. Although there is evidence to support the propensity
of eating disorders among white, adolescent, and college aged
females, increased empirical studies in the field of eating
disorders is providing evidence supporting cross-ethnic
frequencies in eating disordered behaviors (Franko, 2007;
Franko, Becker,

Thomas, & Herzog, 2007). Research is revealing incidents of
eating disorder presentation among both men and women
(Morgan & Marsh, 2006; StriegelMoore, Garvin, Dohm, et al.,
1999). In addition, eating disorder research is supporting the
presence of eating disorders among elderly people
(Manqweth-Matzek, Rupp, Hausmann, et al., 2006). Elderly
persons are oftentimes adjusting to traumatic life changes and
emotional distress brought upon by deceased spouses,
domestic partners, and family and friends. Behaviors primary
to eating disorders can be used as a means of emotional
regulation, among the elderly similar to persons of younger
age.
Evidence-Based Interventions
Eating disorders are vulnerable to changes in symptoms
throughout treatment. Multidisciplinary team approaches are
considered essential when treating these complex disorders. If
treatment focuses only on symptom management, without
paying attention to the underlying etiology (biopsychosocial
factors), the need for symptomatic behaviors (for example,
substance abuse, starvation, and cutting) will continue to
evolve (Costin, p. xxi, 1999).
There is a variety of treatment interventions typically used
in tandem with one another. Interventions may include
Pharmacological Interventions, Interpersonal Psychotherapy,
Experiential Therapies (for example, Art and Movement
Therapy and Psychodrama), Nutritional Therapy, and
Cognitive Behavioral Therapy (NCCMH, p. 260, 2004).
Dialectical Behavioral Therapy (Safer, Lively, Teich, &
Agras, 2002) focuses on problem-solving, skill building,
identifying where change is needed, and mindfulness training
by developing self-awareness and balancing dichotomous
thinking, thus becoming less judgmental of one's self. Family
therapy (Eisler, Dare, Hodes, et al., 2000) is an essential
component of treatment when working with an eating
disordered child or adolescent.
This select list of treatment options represents only a few
of the most widely used interventions for eating disorders.
While not all of these interventions have been empirically
tested at the present time, the field of eating disorder treatment
is rapidly moving toward evidence-based protocols. All
interventions are designed to restore healthy body perceptions
by attending to distortions in how clients see themselves,
underlying psychological issues, and behaviors required for
healthy physical functioning.
Social Work Practice Approaches
It is vital for social work clinicians to be well trained before
treating a person with an eating disorder. This disorder is
made up of multidimensional symptoms.
EATING DISORDERS
95
Familial and interpersonal factors, the co-occurrence of other
disorders (particularly anxiety and mood disorders), and
suicidal ideation and self-harming behaviors are common.
Villapiano and Goodman (2001) discussed the importance that
clinical "skill, stylized training, and knowledge are essential to
understanding 'effects of starvation, set point theory, body
image, binge eating, means of purging, and medical abnormal-
ities', while simultaneously evaluating clients' thoughts,
behaviors and often shameful, embarrassing, secretive and
guarded feelings and behaviors" (p. 7). By working closely
with a network of professionals, social workers can stay
updated on new treatment interventions, through consultative
activities.
FUTURE RESEARCH Eating disorders research has pre-
dominantly been composed of sample populations limitedto
white female adolescents or college-age women, of upper
economic status and heterosexual orientation. Social work
research is calling for a greater inclusion of variance within
study populations in the field of eating disorders; at present
this is still a very new concept with few studies. Further
empirical studies are needed to explore disparities in persons
with disordered eating behaviors, particularly among
disenfranchised populations. Empirical studies that include
diverse samples will enhance the potential for evidence-based
practice with underserved populations.
NATIONAL ASSOCIATIONS
co National Institute of Mental Health (NIMH)
co Eating Disorders Coalition for Research, Policy & Action
(EDC)
co Anorexia Nervosa and Related Eating Disorders, Inc.
(ANRED)
National Association of Anorexia Nervosa and Associated
Disorders (ANAD)
National Eating Disorders Association (NEDA)
Eating Disorders Awareness and Prevention, Inc.
(EDAP)
Watch Dog (media awareness group: EDAP)
American Anorexia Bulimia Association (AABA)
Academy for Eating Disorders (AED)
[See also Hunger, Nutrition, and Food Programs.)
REFERENCES
APA (American Psychiatric Association). (2000a). Diagnostic and
statistical manual of mental disorders (text revision). Washington,
DC: Author.
APA. (2000b). American Psychiatric Association Work Group on
Eating Disorders. Practice guideline for the treatment of patients
with eating disorders (revision). American JOH111alofPsychiatry,
157(1), 1-39.
96 EATING DISORDERS
Arnold, c., & Walsh, T. (2007). Next to nothing: A firsthand account
of one teenager's experience with an eating disorder. New York:
Oxford University Press.
Brumberg, J. J. (1989). Fasting girls: The history of anorexia nervosa.
Cambridge, MA: Harvard University Press.
Carlat, D., Camargo, c., & Herzog, 0. (1997). Eating Disorders
in Males: A Report on 135 Patients. American Journal of
Psychiatry, 154(8), 1127-1132.
Costin, C. (1999). The eating disorder sourcebook: A comprehensive
guide to the causes, treatments, and prevention of eating disorders
(2nd ed.). Los Angeles: Lowell House.
Davis, C. (2001, February). Addiction and the eating disorders.
[Electronic Version]. Psychiatric Times, 18(2). Retrieved February
16, 2007, from http://www.psychiatric t imes.com/pOl 0259
.html.
Eisler, I., Dare, c., Hodes, M., et al. (2000). Family therapy for
adolescent anorexia nervosa: the result of a controlled comparison
of two family interventions. Journal of Child Psychology Psychiatry,
41, 727-736. [PubMed].
Farber, S. (1997, Spring). Self-medication, traumatic reenactment, and
somatic expression in bulimic and self-mutilating behavior.
Clinical Social Work Jou~l, 25(1), 87-106. Retrieved October
19,2007, from Academic Search Complete database.
Franko, 0. L. (2007, September). Race, ethnicity and eating disorders:
Considerations for DSM-V [Electronic version].
InternationalJournal of Eating Disorders Special Supplement on
Diagnosis and Classification, 40(S3), 31-34.
Franko, D. L., Becker, A E., Thomas, J. J., & Herzog, D. B. (2007,
March). Cross-ethnic differences in eating disorder symptoms and
related distress. InternationalJournal of Eating Disorders, 40(2),
156-164. Retrieved October 18, 2007, from Academic Search
Complete database.
Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007,
February). The prevalence and correlates of eating disorders in the
national comorbidity survey replication. Biological Psychiatry,
61(3),348-358. Retrieved October 18, 2007, from Academic
Search Complete database.
Jeppson, J., Richards, P. S., Hardman, R., & Granley, H. M. (2003,
Summer). Binge and purge processes in bulimia nervosa: A
qualitative investigation. Eating Disorders, 11 (2), 115. Retrieved
October 19, 2007, from Academic Search Complete database.
Manqweth-Matzek, B., Rupp, C. I., Hausmann, A, et al (2006,
November). Never too old for eating disorders or body dissat-
isfaction: A community study of elderly women. International
Journal of Eating Disorders, 39(7), 583-586. Retrieved October
18,2007, from Academic Search Complete database.
Morgan, C. D., & Marsh, C. (2006). Bulimia nervosa in an elderly
male: A case report. International Journal of Eating Disorders,
39(2), 170-171.
Myers, A, Taub, J., Morris, J., & Rothblum, E. (1999). Beauty
mandates and the appearance of obsession: Are lesbian and
bisexual women better off? Journal of Lesbian Studies, 3(4), 15-26.
NCCMH: National Collaborating Centre for Mental Health.
Eating disorders. (2004). Core interventions in the treatment and
management of anorexia nervosa, bulimia nervosa and
related eating disorders. Leicester (UK): British Psychological
Society. Retrieved February 28, 2007, from http://www.
guideline.gov/summary/summary .aspx ?doc_id = 5066.
National Institute of Mental Health. (2002). Eating disorders.
[Electronic Version}. (KEN 98-0047). Retrieved February 16,
2007, from http://nmhicstore.samhsa.gov/publications/all
pubs/ken98-0047/default.asp.
National Institute of Mental Health. (2006). The numbers count:
Mental disorders in america. [Electronic Version]. (NIH Publi-
cation No. 06-4584). Retrieved February 14, 2007 from
http://www . ni mh.n ih.gov /pu b I icat/nu m bers.cfmsliar ing.
NEDA: National Eating Disorder Association. (2006, March 6). News
release: Genetics responsible for more than half of anorexia,
UNC-led study concludes. Retrieved February 14, 2007, from
http://www.edap.org/p.asp?WebPage_ID=886.
Reilly, A., & Rudd, N. (2006, September). Is internalized
homonegativitv related to body image? Family & Consumer
Sciences Research journo], 35(1), 58-73. Retrieved October 18,
2007, from PsyclNFO database.
Safer,D. L., Lively T. J., Teich, C. F, & Agras, W. S. (2002,
September). Predictors of relapse following successful dialectical
behavior therapy for binge eating disorder. InternatiDnal]Durnal
of Eating Disorders, 32(2),155-163.
Striegel-Moore, R. H., Garvin, V., Dohm, FA., et al. (1999).
Psychiatric comorbidity of eating disorders in men: A national
study of hospitalized veterans. International Journal of Eating
Disorders, 25, 399.
Swearingen, C. (2007). The role of internalized homophobia, sexual
orientation concealment and social support in eating disorders and
body image disturbances among lesbian, gay and bisexual
individuals. Dissertation Abstracts International: Sec tion B: The
Sciences and Engineering, 67(10-B), 6079. Retrieved October 18,
2007, from PsyclNFO database.
U.S. Department of Health and Human Services, The Office on
Women's Health. (n.d.) Eating disorders. Retrieved October 18,
2007, from http://wwwAwoman.gov/owh/pub/ fac tsheets/ea
tingd isorders. pdf.
Villapiano, M., & Goodman, L. J. (2001). Eating disovder: Time for
change. Philadelphia: Brunneer-Routledge.
Wichstrom, L. (2006, September). Sexual orientation as a risk factor
for bulimic symptoms. International Journal Df Eating Disorders,
39(6), 448-453. Retrieved October 18, 2007, from PsyclNFO
Database.
FURTHER READING
APA (American Psychiatric Association). (2006). Practice guideline
for the treatment of patients with eating disorders. (3rd ed.).
Washington, DC: Author. Retrieved February 16, 2007, from
http://www.psych.org/psych_pract/treatg/ pg/Ea ting
Disorders3ePG _04- 28-06. pdf.
Burney, J., & Irwin, H. J. (2000, [an.). Shame and guilt in women with
eating-disorder symptomatology. [On-linej.Iosrnal of Clinical
Psychology, 56(1), 51-61. Abstract from:
PubMed - indexed for MEDLINE: PMID Item: 10661368.
National Institute of Mental Health. (2001). Facts about eating
disorders and the search for solutions. [Electronic Version]. (DHHS
Publication No. 01-4901). Retrieved February 14, 2007, from
http://www.nimh.nih.gov/publicat/index.efm.

Safer, D. L., Teich, C. F., & Agras, W. S. (2001, April).
Dialectical behavior therapy for bulimia nervosa. American
Journal of Psychiatry, 158(4),632-634.
Striegal-Moore, R., Wilfley, D., Pike, K., Dohm, F., & Fairburn,
C. (2000). Recurrent binge eating in Black American women.
Archives of Family Medicine, 9, 83-87.
Striegal-Moore, R.,Schreiber, G., Lo, A., Crawford, P.,
Obarzanek, E., & Rodin, ]. (200l). Eating disorder symptoms
in a cohort of 11-16 year old Black and White girls:
The NHLBI Growth and Health Study. IntemationalJournal of
Eating Disorders, 27(1),49-66.
SUGGESTED LINKS NEDA: National Eating
Disorder Association http://tUWW . edap. org/
National Institute of Mental Health
http://www.nimh.nih.gov
Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED)
http://wwtu.anred.com/or
http://www.anred.com/res .html
National Association of Anorexia Nervosa and Associated
Disorders
http://www . anad. org/ site/ anadweb/
National Eating Disorders Association (NEDA)
http://www.edap.org/
Something Fishy Web site: (Resources, recovery information,
cultural issues, and treatment finder)
http://www . some thing-fishy .org/
Eating Disorder Referral and Information Center
http://www.edreferral.com/
-ELIZABETH C. POMEROY AND POLLY Y. BROWNING
ECOLOGICAL FRAMEWORK
ABSTRACT: Used metaphorically, ecological concepts
and principles enable social workers to keep a simul-
taneous focus on people and their environments and their
reciprocal relationships, not only in direct practice with
individuals, families and groups, but also in influencing
organizations and communities and in policy practice.
Ecological concepts emphasize the reciprocity of
person:environment exchanges, in which each shapes and
influences the other over time. Ecological concepts are
reviewed.
KEY WORDS: People:Environment (P:E) fit; abuses of
power; habitat and niche; life course (individual, historical,
and social time); life stressor; stress and coping; resilience;
deep ecology; ecofeminism
A continuing thread in the historical development of social work
has been a dual concern for people and their
ECOLOGICAL FRAMEWORK 97
environments, and the relationship between the two in ways that
gave equal attention to both. Until the 1960s and 1970s and the
advent of systems (Hearn, 1969) and ecological notions (Germain,
1973, 1976, 1978a, 1987b), the profession lacked concepts,
methods, and skills to implement its equal commitment to both
people and their environments. Systems and ecological ideas
provided the profession with an alternative to the medical and
disease metaphor rooted in simple linear etiology. Ecological
ideas came to the fore because ecologists were among the first
system thinkers, and their perspective was systemic; yet, it
avoided the seemingly dehumanizing language of general system
theorists. Coming out of the life science of Biology rather than the
physical science of Physics, ecological ideas were found to be less
abstract and closer to the human experience. Over time the
conceptual framework of the ecological perspective was
elaborated and refined (Germain, 1983, 1985, 1990, 1994;
Germain & Gitterrnan, 1987, 1995) and operationalized by the
Life Model of social work practice (Germain & Gitterman, 1979,
1980, 1996; Gitterrnan, 1996; Gitterrnan & Germain, 1976, in
press).
Used metaphorically, ecological concepts enable social
workers to keep a simultaneous focus on people and their
environments and their reciprocal relationships, not only in direct
practice with individuals, families, and groups, but also in
influencing organizations and communities, and in policy
practice. Ecological concepts emphasize the reciprocity of per-
son-environment exchanges, in which each shapes and influences
the other over time. Ecological thinking recognizes that (a) and (b)
are in a reciprocal relation rather than a linear or unidirectional
one. (A) may act in a way that leads to change in (b), whereupon
that change in (b) leads to change in (a), which in turn affects (b),
thus forming a continuous loop of reciprocal influences over time.
Each element in the loop directly or indirectly influences every
other element. As a consequence, simple linear notions of cause
and effect lose their meaning. Therefore, social workers should
concentrate on helping to change dysfunctional relationships
between people and their environments. We should ask the
questions, "What is going on?" rather than "Why is it going on?"
and "How can the 'what' be changed?" rather than "Who should be
changed (or blamed)?" Werner, Altman, Oxley, and Haggard
(1987) capture the complexity of these reciprocal relationships:
Psychological phenomena are best understood as holistic
events composed of inseparable and mutually defining
psychological processes, physical environments and
social environments, and temporal
98 ECOLOGICAL FRAMEWORK

qualities. There are no separate actors in an event; the Abuses of power by those economically and politically
actions of one person are understood in relation to the advantaged and withholding of power from vulnerable and
actions of other people, and in relation to spatial, marginalized populations lead to poor schools, chronic
situational and temporal circumstances in which the unemployment or underemployment of those whom the
actors are embedded. These different aspects of an schools failed to educate, lack of affordable and safe housing,
event are so intermeshed that understanding one aspect homelessness, inadequate health care, and differential rates of
requires simultaneous inclusion of other aspects in the chronic illness and mortality rates among people of color as
analysis. (p, 244) compared to Whites. Poverty, institutional racism, sexism,
homophobia, and xenophobia are created and maintained
The first part of this entry briefly reviews original ecological
through misuses and abuses of power. Dominant groups also
concepts. The second part briefly introduces newer ecological
exploit the environment by polluting the air, food, water, and
concepts drawn from resilience theory, deep ecology, and
soil. Toxic materials continue to be present in dwellings,
ecofeminism.
schools, and workplaces, especially in poor communities.
Abuses of power reflect destructive relationships between
people and their environment in which the social order permits
Ecological Concepts People:Environment some people to inflict grave, injustice and suffering on others.
(P:E) fit is the actual fit between an individual's or collective
Habitat and niche delineate the nature of the social and
group's needs, aspirations, and capacities and the qualities and
physical environments. Physical habitat may be rural or urban,
operations of their social and physical environments within
and include residential dwellings, physical settings of schools,
particular cultural and historical contexts. (The equation P:E
hospitals, workplaces, religious structures, social agencies,
denoting people:environment relationships uses a colon rather
and transportation systems, and amenities such as parks,
than a hyphen to underscore the transactional nature.) Over the
recreation facilities, entertainment centers, libraries, and
life course, people strive to deal with and improve the level of fit
museums. Human habitats evoke spatial and temporal
with their environments. When a "good" fit evolves between a
behaviors that help shape P:E transactions regulating social
people and their environments, they perceive the availability
distance, intimacy, privacy, and other interpersonal processes
of sufficient personal and environment resources and
in family, group, community, and organizational life. Habitats
experience a condition of adaptedness (Dubos, 1968). When a
may promote or interfere with basic functions of family and
"poor" fit evolves between a people's perceptions of
community life. Habitats that do not support the growth,
environmental resources and their needs, aspirations, and
health, and social functioning of individuals and families, and
capacities, they experience stress. When exchanges over time
do not provide community amenities to an optimum degree,
are generally negative, development, health, and social
are likely to produce isolation, disorientation, and
functioning might be impaired and the environment could be
helplessness.
damaged. How overwhelming and disabling is the stress of
Niche refers to the status occupied by an individual, family,
daily life experienced by people and how effectively they
or group in the social structure of a community. What
manage the associated life tasks will depend largely upon the
constitutes a growth-supporting, healthpromoting human
tetceioed. level of fit between their personal and environmental
niche is defined differently in various societies and in different
resources. When the level of fit is perceived to be unfavorable,
historical eras. In the United States, a set of rights, including
or simply adequate, people, alone or with professional help,
the right to equal opportunity, generally shapes a niche. Yet
may improve the level of fit by adaptive behaviors. Adaptive
millions of children and adults occupy niches that do not
behaviors are active efforts to (a) improve oneself (for
support human needs, rights, and aspirations, often because of
example learn new skills) or (b) influence the environment or
some personal or cultural characteristic such as race, ethnicity,
(c) improve the person:environment transactions.
place of birth, gender, age, sexual orientation, poverty, or
physical or mental states. Stigmatized and destructive niches
designate human beings as "drug addict," "borderline
personality," "person with AIDS," "mentally ill," "welfare
mother," and so on. These niches are shaped and sustained by
society's tolerance of the misuse of power in political, social,
Adaptation is sometimes confused with passive or
and economic structures (Germain & Gitterman, 1987, 1995).
conservative adjustment to the status quo. However, in
the ecological perspective and in life-modeled
practice, adaptation is firmly actionoriented and
change-oriented. Adaptation does not avoid the issues
of conflict and power that are as prominent in nature as
they are in society.

Life course refers to the unique pathways of development
that each human being takes-from conception and birth
through old age- in varied environments and to our infinitely
varied life experiences. In contrast to stage models of
development, which assume a fixed and predictable sequence,
biopsychosocial development is conceived as consisting of
non-uniform, indeterminate pathways within diverse
environments, cultures, and historical eras. Human
development is further placed within the context of individual,
historical and social time. Individual time refers to the
continuity and meaning of individual life experiences, over the
life course. Both are reflected in the life stories that people
construct and tell to others and themselves. The constructing
and sharing of life stories provide meaning and continuity in
life events. Historical time refers to the formative effects of
historical and social change on birth cohorts (segments of the
population born at the same time point) that help account for
generational and age differences in bio-psycho-social
development, opportunities, and social expectations. For
example, cohorts of North American women born between
1990 and 2000 differ-in psychosocial development,
opportunities, expectations of marriage, parenting, and
work-from earlier cohorts.
Finally, social time refers to the timing of individual,
family, and community t~ansitions and life events as
influenced by changing biological, economic, social,
demographic, and cultural factors. Until the 1960s, social time
consisted of sequential "timetables" that prescribed the timing
of certain life transitions: the proper time to enter school, leave
home, marry, have a child, retire. Such timetables are no
longer viable, which is a manifestation of the accelerated rate
of social change (historical time). The early childhood
education movement created a new
group-preschoolers-who attend day care and nursery schools,
Head Start programs, and so on. Elders go back to school for
high school certificates or college degrees, grown children
remain at home after finishing college, some children bear and
rear children, while some adults postpone childbearing until
the last possible moment. Many elders do not regard
themselves as old until their late 70s or 80s. These and other
life transitions are becoming age-independent. In parallel
fashion, the phenomenon of gender crossover has
progressively expanded. Gendered family roles and work roles
have dramatically changed in regard to childrearing, house-
hold management, and careers.
The life stressor, stress, and coping paradigm fits well with
the ecological perspective as it takes into account the
characteristics of the person and the operations of the
environment, as well as the exchanges between
ECOLOGICAL FRAMEWORK 99
them (Lazarus, 1999; Lazarus & Lazarus, 2006). Life stressors,
which are usually externally generated, take the form of a real
or perceived harm or loss, or threat of a future harm or loss (for
example illness, bereavement, job loss, difficult transition,
interpersonal conflict, or countless other painful life events and
traumas). Poverty and oppression create chronic and acute
stressors and make others stressors more difficult to manage.
The resulting stress, which is internally generated, may have
physiological or emotional consequences. Frequently, it has
both. Physiological and emotional stresses are the consequence
of people's intuitive or reasoned appraisal that a difficult life
transition, traumatic life event, environmental or interpersonal
pressure exceeds their perceived available personal and
environmental resources to deal with it. When people appraise
sufficient personal and environmental resources to deal with
life stressors, they experience positive feelings and anticipated
mastery associated with the challenge. In dealing with stress,
people use coping measures to deal with the demands posed by
the life stressorts). Personal resources for coping include
motivation; management of feelings; problem-solving;
flexibility; a hopeful outlook; and an ability to seek
environmental resources and to use them effectively.
Environmental resources include formal service networks such
as public and private agencies and institutions and informal
networks of relatives, friends, neighbors, workrnates, and corel
igionists. Formal and informal networks serve as buffers
against stress. Even the perception of their availability can
make it easier to cope with a life stressor by altering appraisals.
The natural and built physical environments (parks, oceans,
transportation, dwellings) also contribute to physical and
emotional well-being and support coping efforts.
age
Newly Added Ecological Concepts Resilience
is an ecological concept, reflecting complex
person:environment transactions rather than simply
attributes of a person (Gitterrnan, 2001a, 2001b;
Gitterman & Shulman, 2005). Some people do not
succeed in spite of positive personal attributes. Yet, other
people thrive and not simply survive in the face of life's
inhumanities and tragedies. Protective factors (biological,
psychological, or environmental processes) act as a buffer
against life stressors by preventing them, or lessening their
impact, or ameliorating them more quickly. The protective
factors include: (1) temperament; (2) family patterns; (3)
external supports; and (4) environmental resources. (Fraser,
2004; Smith & Carlson, 1997). Temperament includes such
factors as activity level, coping skills, self-esteem, and
attributions. For example, feelings of self-worth emerge from
100 ECOLOGICAL FRAMEWORK
positive intimate relationships, and successful task ac-
complishment (for example academics, sports, music,
employment). In family patterns, a nourishing parentchild
relationship serves as a protective factor in cushioning
dysfunctional family processes as well as in increasing the
child's self-esteem. The presence of a caring adult such as a
grandparent leads to similar outcomes. External support from
a neighbor, parents of peers, teacher, clergy, or social worker
also serve as significant cushioning and protective factors.
Finally, the broader social and physical environment and the
opportunity structure create the conditions that influence all
other factors. When social structures and institutions provide
essential resources and supports, they are critical buffers,
helping people cope with life transitions, environment, and
interpersonal stressors.
The direction of a life trajectory is often determined by
what happens at critical turning points in people's lives rather
than long-standing attributes. Exercising foresight and taking
active steps to cope with environmental challenges are critical
factors. It is important to note that while planning and
foresight are important protective factors, there is always the
simple element of chance, good fortune and misfortune, or
"God's will." While our efforts to be scientific may distance us
from chance or spiritual beliefs and explanations, they may
well enhance our understanding of and feeling for the human
experience. Humor, an additional protective factor, has a
profound impact on everyday interactions (Gitterrnan, 2003).
For poor and oppressed populations, humor and laughter
provide a safety valve for coping with painful realities.
Religious, ethnic and racial humor help a stereotyped group to
vent anger and to dismissively laugh at the dominant culture's
stereotypes. Humor also helps the subtle and less visible
forms of prejudice and discrimination to surface. By making
the less visible more visible, oppression is challenged. To be
able to laugh in the face of adversity and suffering, releases
tension and provides hope.
Deep ecology conceptualizes that all phenomena are
interconnected and interdependent as well as dependent on the
cyclical processes of nature (Greif, 2003; Ungar, 2002).
Living systems are viewed as networks interacting and
intertwined with other systems of networks. Through the
processes of self-regulation and self-organization, new
behaviors, patterns and structures are spontaneously created
and the networks' equilibrium constantly evolves. The
interdependence of networks and the self-correcting feedback
loops allow the living system to adapt to changing conditions
and to survive disturbances. Thus, interdependence of net-
wor1<s, the self-correcting feedback loops, and the cyclical nature
of ecological processes are three basic principles of
deep ecology (Capra, 1996). Since the environment constantly
changes and fluctuates, living organisms must keep
themselves in a flexible state and adapt to changing
conditions. Thus, flexibility is another ecological principle.
However, living organisms have certain "tolerance limits" to
how much change they can manage. If changing conditions go
beyond what a network can deal with, it faces the danger and
threat of collapse and disintegration. Diversity in the system will
increase its potential resilience as stronger parts can replace
the weaker ones. Diversity has the potential to enrich all the
relationships and the system as a whole. However, if the
system is fragmented b)' the differences among the parts and
characterized by prejudice and discrimination, the diversity
may decrease the system's resilience and its chances for
survival.
Ecofeminism (or ecological feminism) challenges the
culture-nature dichotomy and the sexual hierarchy. Western
industrial societies assume the destructive domination of
nature as their right. This destruction reinforces the
subordination of women, long identified with nature. To
ecofeminists, oppression of women and ecological
degradation are intertwined. They both arise from hierarchical,
male domination. For the ecofeminists, social justice cannot
be achieved without the earth's well being. They took up the
cause against toxic waste, animal abuse, deforestation, and
nuclear disarmament. They combined ecology, feminism, and
liberation for all of nature. The adage of "the personal is
political" reflected an effort by feminist scholars to challenge
the dualistic arrangement underlying the sexual hierarchy in
Western views (Mack-Canty, 2004).
IMPLICATIONS FOR SOCIAL WORK PRACTICE AND RESEARCH
The Life Model of Social Work practice operationalizes
the ecological perspective. The purpose of life- modeled
practice is to improve the level of fit between people and their
environments, especially between human needs and
environmental resources. In providing direct services to
individuals, families, and groups, the purpose of social work is
to (a) eliminate, or alleviate life stressors and the associated
stress by helping people to mobilize and draw on personal and
environmental resources for effective coping; and (b)
influence social and physical environmental forces to be
responsive to people's needs. In mediating the exchanges
between people and their environments, social workers
encounter daily the lack of fit between people's needs and the
environment. Thus the purpose of life-modeled practice also
includes professional responsibility for bearing witness
against social inequities and injustice. This is done by
mobilizing community resources to influence quality of life in the
community,

by infLuencing unresponsive organizations to develop responsive
policies and services, and by politically infLuen cing local, state,
and federal legislation and regulations to support social justice.
Naturalistic qualitative methods, widely used in Anthropology
and Biology are compatible with social work's ecological
framework. In naturalistic explorations, the investigator is the
major instrument of study. The social worker skilled in inviting
and exploring clients' stories is a natural investigator into people's
transactions with their social and physical environment.
Constructivist researchers study the personal meanings people
attribute to events in their lives. They believe that human
experience cannot be studied by standing on the outside but can
only be understood as a subjective reality. Subjective data must be
gathered via people's narratives. Naturalistic inquiry is
life-oriented and directed to context as well as people.
Acknowledgment
Carel B. Germain, my dear friend and collaborator for almost
twenty-five years, died in 1995. Professor Germain, an
internationally recognized social work theoretician and historian,
introduced the ecological perspective to the profession she deeply
loved as a viable theoretical metaphor for social work practice
(Germain, 1973).
REFERENCES
Capra, F. (1996). The web of life. New York: Anchor Books. Dubos, R.
(1968). So human an animaL New York: Scribner. Fraser, M. (Eel.).
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-ALEX GITTERMAN AND CAREL B. GERMAIN
ECONOMICS AND SOCIAL WELFARE
ABSTRACT: This article covers basic economic concepts, as
well as their relevance to social welfare policy. It defines
economics, and follows this with discussions of
microeconornic concepts, such as market, demand, supply,
equilibrium price, and market failure. Next, it takes up
discussions of macroeconomic concepts, such as gross
domestic product, aggregate demand, inflation,
unemployment, fiscal policy, taxes, and free trade. As these
economic concepts are discussed, they are related to social
welfare policies, such as Social Security, Unemployment
Insurance, and Temporary Assistance for Needy Families.
KEY WORDS: microeconomics; macroeconomics; social
welfare policy
Introduction
Economics is the social science that deals with the allocation of
scarce resources among competing wants. (Whenever the words
"Economics" or "economists" are mentioned in this article, it
always means mainstream or Neoclassical Economists. These are
the ones whose views, arguably, most influence policy
discussions. See Keen (2002) for a discussion of the Neoclassical
and competing schools of economic thought.) Resources are the
goods and services used in the production of other goods and
services and can be natural or human made (Lewis & Widerquist,
200l). Land, for example, is a natural resource that can be used to
produce food. A computer is a human made resource that, along
with other resources, can be used to produce social services.
Wants or desires refer to things people would like to possess or
consume. To say that wants or desires are competing is to say that
they cannot simultaneously be met. A group of landlords may
want an empty tract of land to be used to support a luxury housing
development, while a group of social workers may want that
same land to be used for a battered women's shelter. Economists
assume that available resources are not plentiful enough to
produce all the goods and services human beings want. This
situation is what economists mean by scarcity, and it is the
defining feature of their discipline.
Scarcity requires all societies to come up with some way of
addressing what economists call "the economic problem." That is,
all societies have to come up with some way of deciding (a) what
will be produced, (b) how output (goods/services) will be
produced, and (c) who will get to receive that output. Economies
are the sets of rules societies develop to address these three
questions. The type of economy that gets the most attention in
Economics is the "mixed economy." In this type of economy,
markets primarily determine what is produced, how output is
produced, and who gets this output. Yet markets receive varying
degrees of "help" from government (Lewis & Widerquist, 2001).
The rest of this entry is a discussion of some basic micro- and
macroeconomic concepts economists have found useful as they
have tried to understand the workings of a mixed economy.
Microeconomic Concepts Microeconomics is the
study of markets for particular goods and services. A market is a
set of potential buyers and sellers of some good or service (from
this point on we'll use the words "good" or "service"
interchangeably) at potential prices (Chambers, 1995; Lewis &
Widerquist, 2001, Nicholson, 1989; Prigoff, 2000). There are a
number of social workers who try to sell their professional
counseling skills to persons in need (or these persons' insurance
companies), and there are a number of people in need looking to
buy the services of social workers at various prices. Thus, we can
talk about there being a market for social work counseling.
Demand is the relationship between the price of a good and
the amount of it consumers are willing to buy (quantity
demanded), all else being equal (Lewis & Widerquist, 2001;
Nicholson, 1989; Prigoff, 2000). The phrase "all else being
equal" simply means that the definition includes the effect of
price, as opposed to other factors, on the quantity demanded.
Economists assume that the relationship between price and
quantity demanded is negative. That is, as the price rises, the
quantity demanded falls, and as the price falls, the quantity
demanded rises.
Supply is the relationship between the price of a good and the
amount of it sellers are willing to sell (quantity supplied), all else
equal (Lewis & Widerquist, 2001; Nicholson, 1989; Prigoff,
2000). Here "all else being equal" should be understood similarly
to the

case regarding demand. Economists assume that price and
quantity demanded are directly related. This means that as
price rises so does quantity demanded, and as price falls, so
does quantity supplied.
The Equilibrium or "Market clearing" price of a good results
from the interaction between supply and demand (Lewis &
Widerquist, 200l). This is the price at which quantity
demanded and quantity supplied are equal. At this price, let us
call it $E, all those willing to buy the good are able to find
someone willing to sell it to them. Thus, the market is said to
"clear," hence the term "market clearing" price. This is also
called the equilibrium price because it is the one the market
tends toward.
To see this, suppose, in a given market, the price of a
service were above $E. Let us call this higher price $A.
Economists tell us that since $A exceeds $E, quantity supplied
would exceed quantity demanded. This means that at $A, at
least some sellers would not be able to find buyers for at least
some of their goods. These sellers would begin lowering their
prices driving $A toward $E. Now suppose, in a given market,
the price of some good were below $E and let us call this price
$B. Since $B is less than $E, quantity demanded would exceed
quantity supplied. Thus, at least some buyers would not be
able to buy the amounts of the good they wanted to at $B, and
they would begin offering higher prices. This would drive $B
toward $E. In short, supply and demand interact in such a way
that no other price is sustainable except the equilibrium price.
Not only do economists think supply and demand actually do
govern market prices but they also think that they should. To
understand why, we need to briefly consider economists'
"philosophical" take on social life. Economists tend to think
that if people can gain from mutually beneficial exchanges,
and these exchanges do not harm anyone else, then no one,
including government, should try to stop them from taking
place (Nicholson, 1989). For example, if at a given price, Jack
is willing to sell social work counseling to J ill and she is
willing to buy it, and, if no one else is harmed by this
exchange, what would be the justification for stopping it from
happening? To the economist, the answer is that nothing
would justify such an intervention. Markets are the
consummate settings within which mutually beneficial
exchanges occur. It is easy to see from this example why
economists tend to like markets so much and tend not to like
government interventions into them.
To see the application of supply and demand analysis to
social welfare policy, consider rent control. Rent control is a
set of policy rules, which tell landlords that they cannot charge
tenants a rent higher than some given amount. Such rules are
often thought of as part of
ECONOMICS AND SOCIAL WELFARE 103
a low income housing policy. Economists are typically critics
of rent control for the reasons having to do with a
straightforward application of supply and demand (Lewis &
Widerquist, 200l).
If landlords are not allowed to raise the rent beyond a
certain level, the rent they are allowed to charge may be set at
less than the equilibrium rent. This will mean that at the
allowed rent, the number of units potential tenants want to rent
(quantity demanded) will exceed the number landlords want to
rent out (quantity supplied). If government were not
"interfering" through rent control laws, this problem could be
solved because landlords would be allowed to raise rents to the
point where the number of units tenants want to rent equaled
the number of units landlords want to rent out. But because
government is interfering through rent control laws, this
process cannot unfold. Thus, a long-term situation develops
wherein the number of units landlords want to rent out, at the
allowed price, is less than the number tenants want to rent.
Economists would call this situation a "shortage" in the rental
housing market.
A social worker might respond by asking, "what's so good
about a situation where the equilibrium rent equalizes quantity
supplied and quantity demanded if some of the people who
don't 'want' to pay the equilibrium rent don't want to because
they're too poor to afford it?" Such a question highlights a key
shortcoming of relying on the market to address the question
of who should get to receive housing. The "market's answer"
is that anyone who is willing to pay the equilibrium price
should get to receive housing because, at this price, tenants
who rent and landlords who rent to them are better off (the
mutual benefit) as a result of this exchange. Rent control rules
block such mutually beneficial exchanges from occurring.
This is why economists tend to dislike such rules.
None of what has been said implies that economists are
necessarily unsympathetic to the plight of those who cannot
afford housing. They just tend to think rent controls laws are
not the best way to address this plight. Those who would
support a low-income housing policy are more likely to
support something like the Section 8 housing policy than rent
control. Section 8 is a program whereby the federal
government pays a portion of the rent for those low to
moderate income tenants who qualify for the program. From
the point of view of beneficiaries of the program, this help
with rent (what economists would call a subsidy) functions
like a decrease in the price of housing, making it easier for
them to afford it. From economists' point of view, this is a
better low-income housing policy than rent control because it
does not directly interfere with the market
104 ECONOMICS AND SOCIAL WELFARE
like rent control does. That is, it does not directly interfere
with mutually beneficial exchanges.
Other policy applications of supply and demand have to
do with the labor market. In this market, workers try to se ll
their labor, employers try to buy it, and the wage is the
price. In the absence of government inter vention, this
market would tend to an equilibrium wage. But because
some are concerned that this equilib rium wage would be
too low, we have minimum and, increasingly, living wage
laws. These laws tell employ ers they cannot pay workers
less than a certain wage (the minimum wage). Contrary to
the position taken by many social workers (NASW, 2006) ,
economists tend not to like minimum wage laws because
they assume that the minimum wage will exceed the
equilibrium wage (Lewis & Widerquist, 200l). Recall that
if this happens, the number of hours workers will want to
sell (work) will exceed the number employers will want to
buy (hire). Economists have a special name for this
situation: unemployment (more will be said about un-
employment later). Thus, as economists see it, a policy
designed to help workers by assuring them high wages
causes some of them to be unemployed. Yet many of these
unemployed workers would be willing to work for a lower
wage and many employers would be willing to hire them at
such a wage if only the government would let the market
settle at this lower wage. Again, none of this implies that
economists are necessarily unsympathetic to the pli ght of
low wage workers. They just tend not to think that
minimum wage laws are the best way to help them (see
Card and Krueger, 1995, for a critique of economists '
standard view of minimum wage laws).
An alternative to the minimum wage proposed by some
economists is a guaranteed or basic income policy (Lewis
& Widerquist, 200l). Such a policy would assure that no
person's income would fall below some mini mum level
whether they worked outside the home or not. Those who
did not work outside the home would receive the minimum
income from government. Those who did work outside the
home would have the mini mum income reduced in such a
way that their net income (earnings from work + what is
left of the minimum) would exceed the level of the
minimum income alone. This could help workers because if
the minimum were set high enough, employers might not
be able to get people to work for them unless they paid a
wage at least as high as this minimum. But notice that the
government would not be directly "forcing" them to pay
this higher wage, as is the case with the minimum wage
policy. This is why economists tend to prefer this
alternative.
Another important microeconomic concept is market
failure. A market failure occurs when (1) market
transactions benefit parties to the transaction but harm or
benefit others not involved in the exchange, (2) when
markets do not form at all or do not form to the extent
necessary for people to enjoy mutual gain from their
formation, (3) sellers or buyers have the power to
individually influence market price, or (4) at least one
participant in a market is not fully informed regarding all
relevant characteristics of the good being traded (Lewis
and Widerquist, 2001).
Market failure type 1 is called an externality. Exter-
nalities can be positive or negative. Positive ones are
benefits to parties not involved in an exchange, while
negative ones are costs to such parties. An externality is an
effect of a market exchange on people who are not a party
to the exchange (Lewis & Widerquist, 2001; Nicholson,
1989). For example, suppose a worker agrees to work for a
company that makes toxic chemicals. An economist would
assume that both the worker and the company benefit from
this exchange (labor is being exchanged for a wage). Yet
people who live near the chemical plant may be harmed by
emissions of the chemical. This may appear to be an issue
of more concern to physicians and environmental health
scientists. Yet social workers often take an interest too
because plants that emit toxic chemicals tend to be found in
low-income areas inhabited mainly by persons of color.
Market failure type 2 is called a public good. A public
good is one, which, if produced, no one can be ex cluded
from enjoying. Child protective service s are a public good.
If someone comes along and protects children from harm
no one who wants children pro tected can be excluded from
enjoying this service. For this reason, a market is not likely
to be a good means of allocating the service, or public
goods in general, because people who would benefit from
the production of such goods have little incentive to pay for
them. If someone cannot be excluded from benefiting from
children being protected whether they pay for the service or
not, why would they pay? This lack of incentive to pay
leads economists to conclude that government is likely to
be more successful at providing public goods than markets
are-governments can force people to pay taxes to finance
the provision of such goods, while private busines ses
cannot. Notice that child protective services are provided
by government, not a child welfare businessperson out to
make a profit. lt is true that government often contracts with
private agencies to carry out its child protective functions.
When this happens, notice that these agencies' work is
financed by government revenues. Agencies that have
contracts with New York's child welfare department do not
charge each New
l

York resident a monthly fee in return for protecting children.
They get money from New York's child welfare department
whose budget comes from government revenues.
Market failure type 3 is called market power. Market power
occurs when businesses or buyers are big enough that their
decisions, alone, regarding how much to sell or buy, affects
market price. A single seller, a monopolist, in a market with
many buyers has market power. So do a few sellers in a market
with many buyers (Lewis & Widerquist, 200l). To economists,
the problem with market power is that it allows sellers to
charge a higher price than would occur in a more competitive
market. If this happens in certain markets, for example, in
health care markets, this could mean trouble for many people.
Health care is, arguably, a human need, and if market power
allows health care providers or health insurance companies to
charge a higher price than the competitive market price, mass
suffering and even death could result.
Market failure type 4 is called imperfect information.
Imperfect information is when one party to a transaction has
information relevant to the transaction that the other party does
not. This allows the more informed party to manipulate the
transaction to disadvantage the other party. Doctors and social
workers are more informed about medicine and social work
intervention than the average patient or client. This means that
an unscrupulous or incompetent doctor or social worker can
manipulate the patient or client to do something that might be
harmful to her or him. The existence of imperfect information
leads economists to often argue for government regulation of
industries in which this problem is endemic. Requiring doctors
and social workers to be licensed to practice are examples of
such regulation.
Macroeconomic Concepts Macroeconomics is
the study of the economy as a whole. Microeconomics focuses
primarily on individual markets, whereas macroeconomics
focuses on all markets that make up an economy, combined.
One of the key concepts in macroeconomics is gross domestic
product (GDP). GOP is the market value (measured in
currency) of all the final goods produced within the borders of
a nation over a year. "Market value" refers to the fact that only
goods bought and sold in markets are included in GDP. "Final
goods" refers to the fact that only goods at the end stage of
production are included in GOP. For example, only the entire
car sold from the showroom floor is part of GOP, not the parts
sold in earlier stages of production (Colander & Gamber,
2002).
ECONOMICS AND SOCIAL WELFARE 105
Other important macroeconomic concepts are aggregate
demand, inflation, and unemployment. Aggregate demand is
the total amount of spending on the goods produced within an
economy. Inflation is the increase in the general price level in
an economy. "General price level" means the prices of all
goods, not just particular ones. Unemployment occurs when
someone is willing and able to work at a given wage but
cannot find anyone to hire her or him to do so. A recession
occurs when GDP declines for six months in a row. Recessions
are also associated with increases in unemployment (Colander
& Gamber, 2002).All this is relevant to a key policy concern of
social workers: whether people have enough income to meet
their needs (NASW, 2006). For example, consider GDP. The
production of more goods means a higher GDP, and, often,
this production requires more people to produce them. If
wages are relatively "decent," the subsequent decline in un-
employment means higher incomes. A GDP decline,
especially if it takes the form of a recession, means fewer job
hires, higher unemployment, and lower income. It also means
the government must payout more money in unemployment
insurance. This is a social program, which, under certain
conditions, provides income to unemployed persons.
What about the relevance of aggregate demand?
Higher aggregate demand, that is more spending on goods
throughout the economy, can mean a higher GDP, leading to
the lower unemployment and higher income referred to in the
previous paragraph. Yet higher aggregate demand does not
necessarily lead to a higher GDP. Instead it may just lead to
higher prices or inflation. Inflation-a decline in the value of
money-is harder on those who live on fixed incomes. An
example would be Temporary Assistance for Needy Families
(T ANF) recipients. T ANF is a social program that provides
benefits to, primarily, single women with young children.
There is currently no federal law that requires T ANF benefits
to increase with inflation. Thus, inflation continues to erode
the value of these benefits year after year.
Monetary policy is the next important macroeconomic
concept to be discussed. Monetary policy is the government's
use of its authority to control a nation's money supply and
interest rates (Colander and Gamber, 2002). Think of the
money supply as the quantity of money "moving through" the
economy as people buy and sell goods. Think of interest rates
as the fees lenders charge people or institutions for the use of
their money. When a person borrows money from a bank, that
person must pay back the amount owed plus an additional
amount called interest. A part of the federal government called
the Federal Reserve Board (the Fed), a
106 ECONOMICS AND SOCIAL WELFARE
bank for the nation's banks, has the authority to tell banks how
much interest they must pay to borrow from each other as well
as how much they must pay to borrow from the Fed. This
influences how much interest the nation's banks charge us to
borrow from them. For example, if the Fed increases interest
rates, making it more expensive for the nation's banks to
borrow from one another as well as from the Fed, these banks
will most likely increase interest rates we have to pay. This
can cause an increase in unemployment and poverty.
To see why, consider the fact that not only do people
borrow money from banks, but businesses do, too. They do so
to increase the scale of their operations, typically hiring more
people as they do so. A Fedinduced higher interest rate 'will
result in businesses borrowing less money, hiring fewer
people than they otherwise would, and, perhaps, a decline in
GOP. As stated earlier, if GOP declines enough, a recession
and higher unemployment would result.
The next major concept to be considered is fiscal policy. It
refers to the tax and spending policies of the government.
Presumably, all social workers know what taxes are and what
government spending is (Colander & Gamber, 2002). At the
federal level, there are taxes on people's incomes, corporate
profits, the purchase of certain types of goods, and a host of
other transactions. There is spending on defense, the federal
court system, various other matters, and social welfare
policies (TANF, housing, etc.). Fiscal policy is often a topic of
heated debate among economists and politicians.
For example, Supply-Side Economists and their, usually,
Republican allies argue that taxes should be kept low. This is
because low taxes allow businesses and the common people to
keep more of their hard earned money. Businesses will use the
greater amount of money they have to make investments in
new plant and equipment as well as new hires. Because they
know that with low taxes they get to keep more of the money
they make, workers will work harder. More investment and
harder work will lead to an increasing GOP. And as stated
earlier, an increasing GOP typically means more job hires and
less unemployment.
Now since taxes are what finance government services,
including social programs, low taxes mean low social
spending, right? Supply-Side Economists have an answer for
this. Low taxes will do so much to stimulate the economy
(increase GOP) that (a) a lot of social services will not be
necessary for such a vibrant working populace and (b) GOP
will grow so much and so many people will be working that
even if people are paying a lower percentage of their incomes
in taxes, the amounts
paid multiplied by the huge number of working people will be
enough to finance any necessary social programs.
Other economists, and their, usually, Democratic allies
contend that this is sheer fantasy. To understand their
counterargument one needs to know what the terms "budget
deficit" and "debt" refer to. A budget deficit is what results
when government revenues are less than government spending
(Colander & Gamber, 2002). Government has to borrow
money to sustain a budget deficit, since this is the only way
that revenues can continue to be less than spending. This is
analogous to a family having to borrow in order for its income
(in most cases, primarily earnings) to stay below its spending.
Debt is what is owed as a result of borrowing to maintain
budget deficits.
Those economists and Democrats who criticize
Supply-Side Economists often argue that supply-side policies
will increase budget deficits. This is because taxes are a large
source of government revenue and lower taxes mean lower
revenue. If spending is not cut enough to compensate for the
lower revenue, a budget deficit will result. Over time, budget
deficits will result in higher debt. Higher debt can be bad for
the economy. This is because government borrows money
from banks just as people and businesses do. When
government borrows, it increases the demand for money. To
get this point, one must think of borrowing money from
someone as "buying" the use of that person's or institution's
money and interest as the "price" one must pay for that use.
When government enters the market to borrow money, it
causes the quantity of money demanded, at the current interest
rate, to exceed the quantity supplied by those who lend money.
Recall from the section on microeconomic concepts, that
when this happens price (in this case, the interest rate lenders
charge) rises. From our discussion of the Fed, we saw that
higher interest can lead to a lower GOP and higher
unemployment. Thus, the critics of supply-side policies are
concerned that such policies may lead to higher unem-
ployment, lower earnings, and higher unemployment
insurance being paid out.
Not only do economists debate the macroeconomic effects
of taxes but they also distinguish among different kinds. The
distinction most relevant here is between progressive taxes
and regressive taxes.
Progressive taxes are those that make up a larger percentage
of larger incomes (Baumol & Blinder, 1991). In theory, the
income tax in the United States is a progressive tax because
the higher one's income, the bigger the percentage of one's
income has to be paid in taxes. In practice, the rich can often
use loopholes to lower their tax bill, resulting in the income
tax being less progressive in reality than it is in theory.

Regressive taxes are those that make up a larger percentage of
smaller incomes (Baumol & Blinder, 1991). Social Security, for
example, is financed by a regressive tax.
Social Security is essentially a government retirement pension.
The payrolls of employers are taxed, and since employers'
payrolls are what employees earn, a payroll tax is, in part, a tax on
earnings. This tax is currently 6.2%, meaning that 6.2% of one's
earnings must be turned over to the government to finance Social
Security. However, only earnings up to $97,500 are taxed. This
makes the 6.2% tax regressive because those who make less than
$97,500 pay a larger percentage of their incomes (at least the
earnings part of it) to finance Social Security than those who make
more than $97,000. Many social workers might find this unfair.
On the other hand, Social Security operates so those who earn less
receive a higher percentage of their wages in Social Security
benefits than those who earned more. To some extent, this policy
offsets the regressive nature of the tax (see Social Security Online,
http:// www.socialsecurity.gov.).
The last few concepts to be discussed have to do with global
issues. One of the most important is free trade. Free trade refers to
the ability of persons in different nations to exchange goods with
one another due to there being relatively few barriers to such
exchanges (Colander & Gamber, 2002). To understand what
constitutes barriers to trade one must understand the concepts of
exports and imports. Assume there are two countries A and B.
Exports, from A's perspective, are goods, which persons in A sell
to persons in B. Imports, from A's perspective, are goods persons
in A buy from persons in B (Colander & Gamber, 2002).
One type of barrier to free trade is a Tariff. This is a tax that
importers must pay the government of their nation when they
import goods. Import Quotas are another type of barrier to trade.
These are laws that stipulate that a country cannot import more
than a certain number of goods (Colander & Gamber, 2002). So,
free trade exists when tariffs are low or nonexistent and import
quotas are high (a lot of imports are allowed in) or do not exist.
The more goods a country imports, the more the workers in
that country must compete with workers in the countries the
imports are coming from. Now suppose that the countries the
imports are coming from pay lower wages than the wages paid to
workers in the importing country. This would mean that
businesses in the countries the imports are coming from might be
able to sell the goods being imported for lower prices than
businesses in the importing country charge for these same goods.
This may benefit consumers in the importing country but,
1
ECONOMICS AND SOCIAL WELFARE 107
perhaps, not workers in this country. These workers may face a
higher chance of losing their jobs or being paid lower wages. Job
loss means higher unemployment, perhaps lower self-esteem
(since so many people define their worth by their work outside the
home), higher unemployment insurance payments, and other
consequences of interest to social workers.
A lot of politicians, both Democrats and Republicans, are big
proponents of free trade. When Democrat Bill Clinton was
president, he signed a free trade agreement with Mexico called
the North American Free Trade Agreement (NAFTA). Many
members of his party opposed him, but a lot of Republicans
supported him. Clinton (with a few other Democrats) and
Republicans focused on how the free trade agreement would
benefit consumers in the United States. Opponents focused on
how it would harm workers in the United States (some also
focused on how it would hurt Mexicans). On the basis of what
was said earlier, arguably, both sides may have been right.
Reducing barriers to trade may benefit consumers in importing
countries because, as stated earlier, they may face lower prices for
goods. But reducing these barriers may also hurt workers in
importing countries if job loss results. The question is whether
consumers gain more from free trade than workers lose.
REFERENCES
Baumel, W., & Blinder, A S. (1991). Microeconomics: Principles and
Policy. New York: Harcourt Brace Jovanovich.
Card, D., & Krueger, A B. (1995). Myth and measurement: The new
economics of the minimum wage. Princeton, NJ: Princeton
University Press.
Chambers, E. (1995). Economic Analysis. In L. Beebe, Encyclopedia
of social work (l9th ed.). Washington, DC:
NASW Press.
Colander, D. c., & Gamber, E. N. (2002). Macroeconomics. NJ:
Prentice Hall.
Keen, S. (2002). Debunking economics: The naked emperor of the social
sciences. London: Zed Books.
Lewis, M. A, & Widerquist, K. (200l). Economics for social workers:
The aJ)plication of economic theory to social policy and the human
services. New York: Columbia University Press.
National Association of Social Workers. (2006). Social \Vork Speaks
(7th ed.). Washington, DC: NASW Press.
Nicholson, W. (1989). Microeconomic theory: basic princiJ)/es and
extensions. FL: The Dryden Press.
Prigoff, A (2000). Economics for social workers: Social outcomes of
economic globalization with strategies for community action. CA:
Wadsworth.
Social Security Online. Retrieved September 20, 2007, from
http://www .soc ialsecuri ty .gov.
--MICHAEL A. LE\VIS
1 08 EDUCATION
EDUCATION. See Baccalaureate Social Workers; School
Social Work; Social Work Education:
Overview.
EDUCATION POLICY
ABSTRACT: Educational policy in the United States has
evolved over the last hundred years to address a vast range of
issues, including creating a universal system of primary and
secondary education, trying to ensure equity and access for
students, preparing youth for the workforce, preparing youth
for postsecondary education, improving academic outcomes,
and school safety. This entry summarizes key historical
trends, judicial rulings, and legislative milestones that have
helped form educational policy in the United States. Special
attention is given to current challenges.
KEY WORDS: education; education policy; education equity
Today, the United States public education system includes
programs beginning from early childhood (via early
intervention in special education) through adulthood (adult
education and postsecondary education). While federal
policies related to each segment of this enormous system
exist, most operational control is retained by state and local
authorities. National policy is expressed through legislation,
as well as federal court rulings, which interpret rights related
to the school setting. (Lieberman & McLaughlin, 1982)
History
An educated public was considered a must for democracy by
the founders like Thomas Jefferson, however, a national
system evolved slowly. In 2005, about 88% of all eligible
children attend public schools at some point, with the
remainder attending private schools (NCES, 2006a). Each
state has its own department of education with a school board,
which interprets federal and state policy, sets broad curricular
guidelines, and distributes state and federal funds. Since 1988
the trend has been increasing decentralization to the local
district level. This means that education program
implementation varies not only by state but also by local
district.
EDUCA TED CITIZENRY Massachusetts instituted a
statewide educational system in the mid-1800s, but a national
system did not follow until the turn of the century. Then the
passing of child labor laws and
increasing pressures related to urbanization and immigration
created a demand for more widespread educational
opportunities. Although public high schools existed prior to
1900, only about 6% of the population attended them. By 1929
all states had enacted compulsory attendance laws that
included high school or secondary education (Information
Please, 2006). Most states included kindergarten by the mid
1930s. Compulsory attendance policy, however, still varies by
state with required entry at ages 5 to 7 and allowed exit at ages
16 to 18.
Within this structure, there are a variety of alternatives.
Parents may choose "homeschooling" as an alternative to
attendance at a school. About 1.7% of the eligible population
opts for homeschooling (NCES, 2006b). Alternative public
school settings are also provided in about 39% of school
districts for students at risk of school failure due to behavior,
academic performance, or pregnancy. These are typically high
schools (NCES, 2002). More recently states have begun to
oversee some form of charter schools. These schools receive
public financing but are created and run independently by
outside organizations or individuals (NCES, 2004).
SCHOOL READINESS Publicly funded early childhood
education is largely limited to children from lowincome
families and children with disabilities. In 1965, federal Head
Start legislation provided funds for preschool services for
children from low-income families. Between 44% and 67% of
the eligible preschool population are served (Butler & Gish,
2003). Begun in 1994, the Early Head Start program essen-
tially replicated the Head Start idea for infants and toddlers
from low-income families. It is a smaller discretionary
program estimated to serve only about 3% of the eligible
children (Butler & Gish, 2003). Since 1986, special education
services have included services for very young children under
a broad category called "developmental delay." Eligible
children, aged birth through 4 years, are served if they meet
their state's definition of developmental delay (IDEA lA,
2004). The proportion of this age group that is served ranges
from less than 2% to nearly 7% by state (National Early
Childhood Technical Assistance Center, 2006).
WORKFORCE PREP ARA TION A continued goal of
education is to prepare students for the workforce. Schools
offer technical or vocational programming primarily aimed at
those students who may not be college bound. Vocational
programs in the United States vary from programs fully
integrated with academic curricula

to trammg offered off-site at special schools or at community
workplaces.
Post-secondary education is also a part of the public
education system and can be divided into two categories.
"Adult Education," traced to the Economic Opportunity Act of
1964, was developed to assist young adults who did not
complete high school. Federal funds and policy also support
higher education, including community colleges (usually
two-year programs), and state college and university systems.
Both systems have grown dramatically. Since the late 1960s,
adult education (now under the 1988 Workforce Investment
Act) has grown to include vocational programming, programs
for the elderly (1974), awl literacy programs for families
(Even Start, 1988) and prisoners (1991). Postsecondary
education expanded as initiatives such as the GI bill during the
1940s, and the Higher Education Act in 1965 (reauthorized in
1998) increased federal financial aid to young adults seeking a
college education.
ACCESS AND EQUITY Providing an equitable education
was and remains a major issue facing u.S. public education.
Prior to the 1950s, many children of color and children with
disabilities were forced or coerced into separate schools
according to race (as with African Americans, Native
Americans, and Asians) or language (as with Mexican
American children in states like Texas) or disability. In 1954,
the Brown v. Board of Education Supreme Court case found that
"separate was not equal." The court ruling became federal
policy when the Civil Rights Act of 1964 allowed the federal
government to withhold funds from schools that refused to
desegregate.
Throughout the 1960s and 1970s federal policy con tinued
to develop around issues of access and equity. In 1965 the
Elementary and Secondary Schools Act created federal
funding support (Title 1) to ensure educational equity for poor
children. In 1968, the Bilingual Act was passed to address
segregation resulting from language barriers and created the
English as a Second Language program. In 1972, Title IX
stated that schools must provide equal opportunities
irrespective of gender. In 1975, the Education for All
Handicapped Children Act formally began the special
education system. Children with disabilities were now
educated at regular school sites, but many were still taught in
separate classrooms. After 1986, the notion of "least
restrictive" in the Individuals with Disabilities in Education
Act began to be interpreted under a higher standard of
"inclusion" (that is, the placement of choice is always the
regular class environment unless proved that that is impossible
or harmful).
EDUCATION POLICY
109
FAMILY AND STUDENT RIGHTS Along with equity came
increased attention to the rights of the family and student. One
of the primary policies related to parents' rights is the Family
Educational Rights and Privacy Act (FERPA). This act
protects the privacy of the student's education records and
ensures parental access to their contents. How information is
recorded and shared between professionals within the public
school system and between schools and outside agencies is
heavily influenced by this policy. In addition, several policies
such as the IDEA Improvement Act and the No Child Left
Behind Act emphasize the family's right to information and
appeal regarding special education eligibility and placement,
discipline, and school choice.
National policy on student rights in schools developed
largely through court rulings. Schools must provide for the
safety of their students (Vernonia School District v. Acton,
1995) and maintain order needed for its educational mission
(Hazelwood School District v. Kuhlmeier, 1988). As long as a
student's behavior or belief does not violate these two
principles, the courts have granted limited extensions of
constitutional rights to minors in schools including the right to
express political and religious opinion (Tinker v. Des Moines,
1969; Equal Access Act, 1984), freedom from unlawful search
(In re William G, 1985), and limited due process rights (In re
Gault, 1967).
ACADEMIC ACHIEVEMENT Federal policy has also de-
veloped in response to student achievement. In 1958, the N
ational Defense Education Act was passed to encourage better
academic achievement-particularly in math and science.
Concern continued and, in 1983, the Reagan administration
released the report "A Nation at Risk" resulting in, among
other things, a call for a national accountability system.
Though no policy resulted, the same theme was carried
through the next administration's America 2000 proposal and
finally incorporated into policy in the 1994 Clinton
administration's Educate America Act: Goals 2000. Goals
2000 supplied funding to states for developing assessment
systems, but there were no enforced timelines for
implementation or consequences associated with results. In
2002, this act was replaced by the No Child Left Behind Act
(NCLB). This act laid emphasis on the idea of accountability,
adding timelines and sanctions for not achieving goals (called
adequate yearly progress [A YPJ). Sanctions range from being
listed as a "failing school" and getting technical assistance, to
losing funds, to being closed. The continuing struggle between
state and federal control is evident as states define parameters
and assessment methods for meeting A YP goals.
110 EDUCATION POLICY
SAFETY The safety of students and staff has received a great
deal of federal and state attention since the 1990s. In the mid
1990s [1994], the Safe and Drug Free Schools and
Communities Act (SFDCA) and the Gun Free Schools Act
(GFSA) were passed (both re-authorized as part of NCLB).
The SFDCA provides funds for evidence-based programs
aimed at the prevention of violence and drug use. The GFSA
requires states to enact laws mandating the expulsion of a child
who brings a firearm to school. Further in NCLB, schools must
track and publicize rates of violent acts and drug-related of-
fenses. Parents can transfer (with funds) their children out of
"persistently dangerous" schools (states define "persistently
dangerous") to other schools in the district. Many state policies
go much further to enact so-called zero tolerance disciplinary
regulations related to weapons, substances, and disruptive or
violent behavior.
Student Demographics
Compared to the late 1980s, the public school system serves
students spanning a wider age range, range of ethnic and racial
diversity, and range of disabilities.
AGE Since the late 1970s, the proportion of children in the
United States aged three to five enrolled in public preschools
has tripled to over 60% (NCES, 2006a). Another 1%-3% of
infants and toddlers nationwide are served through various
targeted programs. The proportion of adults over age 70
participating in adult education doubled in the 1990s.
DISABILITY Nearly 13.7% of the student population (ages 3
to 21) receives services for a specific disability: an increase of
nearly 39% since the 1990s. Among children enrolled in
public preschools, 30% had special education needs. African
American students and males have the highest representation
in special education programs.
ETHNICITY AND RACE Forty-three percent of public
education students are part of a racial or ethnic minority group
compared to about 33% in the late 1990s. The proportion of
students of Asian and Hispanic origin is increasing at the
highest rate while the numbers of white students have
declined. English language learner services are provided to
approximately 11 % of the students nationwide-with
percentages being as high as 26% in some states like
California (NCES, 2006a, 2006c).
GENDER The gender composition of K-12 education has not
changed dramatically since the late 1980s, but the number of
women attending postsecondary institutions is rising at a
higher rate than the number of men (NCES, 2006a).
SOCIOECONOMIC DIVERSITY While public education
has always served low-income students, the proportion of
preschool to l Zth-grade students who are poor has increased.
As of 2001,61 % of the students enrolled in the 19,900
pre-kindergarten public school programs were low-income
students. In 2005, about 41 % of all -lth-graders qualified for
free or reduced price lunch (NCES, 2006a).
Challenges and Dilemmas
Because educational achievement is so strongly related to
economic well-being, equal access to effective education is
inherently a social justice issue. Parents have consistently
given the public education system a grade between a "C" and
"B" for the last several years (NCES, 2006a). Poverty at the
family and school level is strongly linked to poor educational
opportunities and outcomes (Barton, 2003; Dahl & Lochner,
2005; NCES, 2006b). African American, Hispanic, and Native
American students lag behind other students on academic tests
and rate of high school graduation (NCES, 2006a). While
special education services have expanded since the late 1970s,
much debate exists on its effectiveness and how it should be
measured (Hanushek, Kain, & Rivkin, 2002; Reynolds &
Wolfe, 1997; U.S. DOE, 2005). Several states report that less
than 50% of students in special education leave school with a
high school diploma (National Center for Special Education
Accountability Monitoring, 2004).
FUNDING The federal government provides only about 8.5%
of the entire public education budget. Many schools still
receive 40% or more of their funds from local property taxes.
This means that a child born in a poor area with low property
values may have reduced educational opportunities. Several
state lawsuits have held that a child's access to equal education
should not depend upon the income of the family or that of the
community (Hadderman, 1999). The debate about an effective
and equitable way of financing schools continues (Crawford,
2004).
DIVERSITY, QUALITY, SCOPE Some researchers suggest
schools perform poorly due to a complex array of issues such
as poor teacher quality, low levels of parent involvement, and
ineffective strategies for teaching a diverse range of students
(Barton, 2003). Recent calls for reform include increasing
cultural competency, better means of assessing outcomes,
improving teacher quality, and removing tracking of lower
achieving classes or schools (Berlak, 2001; Burris & Welner,
2005; Good, Aronson, Inzlicht, 2003; U.S. Department of
Education, 2005). Others suggest that a greater investment in
early childhood education

would improve outcomes (Bamett, 2000; Calman &
Tarr-Whelan, 2005).
COMPETITION Others argue that education can only be
"fixed" by using market forces to force lowperforming
schools to improve. This idea underlies recent federal policy
encouraging charter schools and offering vouchers to allow
some families in low functioning systems to move their
children to better schools. Current research is inconclusive
regarding whether these options have produced or can
produce the desired positive outcomes (Gill, Timpane, Ross &
Brewer, 2001; NCES, 2004).
SAFETY So-called zero tolerance policies are criticized for
uneven and inappropriate application (ABA, 2001; Civil
Rights Project, 2000). Special education policy provides some
extra protection from inappropriate applications of "zero
tolerance" for students with disabilities (IDEA lA, 2004). So
far, federal policy does not limit application of "zero
tolerance" for students without disabilities.
POSTSECONDARY EDUCATION Economic trends in-
creasingly make high school completion a necessary, but
insufficient, educational outcome. Despite improvements in
racial and gender diversity in postsecondary education
(NCES, 2006a), efforts to enhance diversity continue (U.S.
DOE, 2004). Further, entering college does not guarantee
acquisition of academic skills, completion of a degree, or the
interpersonal skills required by employers (American Speech
Language Hearing Association, 2007; Bair, Cook, Baldi,
2006; Casner-Lotto & Barrington, 2006).
International Connections
Research on international educational outcomes ranks the
United States among the lowest in most subjects compared to
other industrialized countries (NCES, 2006a). The structure
and expectations of educational systems in other countries
vary widely, however, making cross-national comparisons
difficult and beyond the scope of a single entry. It is unclear if
or how international models of education will influence
American policy in the future.
Trends and Directions
Education policy still struggles to balance local, state, and
federal funding, control, and accountability. Educators must
also balance attention to the individual with the safety and
education of entire schools. Communities and policy makers
must balance the need for education with competing areas of
need like
EDUCATION POLICY
111
health care. One hundred years later, education policy
continues to address the challenge of providing an effective
and equitable education for all.
REFERENCES
American Bar Association. (2001). Zero tolerance policy. Criminal
Justice Section: Washington, DC. Retrieved January 1, 2007, from
http://www.abanet.org/crimjust/juvjus/zerotolre port.htrnl.
American Speech Language Hearing Association. (2007).
Minority student recruitment, retention and career transition
practices: A review of the literature. Retrieved February 1, 2007,
from http://www.asha.org/about/leadership-projects/ mu I t icu I
tura I/recru i t/I i trev iew .htm.
Bair, J., Cook, A., & Baldi, S. (2006). The literacy of America's college
students. Washington DC: American Institutes for Research.
Barnett, W. (2000). Long-term effects of early childhood programs on
cognitive and school outcomes. The Future of Children, 5, 25-50.
Barton, P. (2003). Parsing the achievement gap. New Jersey:
Education Testing Service.
Berlak, H. (2001). Race and the achievement gap. Rethinking Schools
Online. 15,4. Retrieved January 1, 2007, from http://
www.rethinkingschools.org/archive/15_04/Race 154.shtml.
Brown v. Board of Education of Topeka. (1954).347 U.S. 483. Burris,
C, & Weiner, K. (2005, April). Closing the achievement gap by
detracking. Phi Delta Kappan, 594-598. Retrieved January 15, 2007,
from http://www.pdkintl.org/ kappan/k_ v86/k0504bur.htm.
Butler, A., & Gish, M. (2003). Head Start background and fund ing.
Report for Congress. Retrieved January 1, 2007, from
http://usinfo.sta te.gov /usa/infousa/ educ/files/r 13 0952. pdf.
Caiman, L., & Tan-Whelan, L. (2005, April). Early childhood
education for all. A wise investment. New York, NY: Legal
Momentum.
Carl D. Perkins Vocational and Technical Education Act. (1998).
P L 105-332.
Casner-Lotto, J., & Barrington, L. (2006). Are they really ready to
work? Employers' perspectives on the basic knowledge and applied
skills of new entrants to the 21 st century U.S. workforce. The
Conference Board, Corporate Voices for Working Families,
Partnership for 21st Century Skills, Society for Human Resource
Management.
Civil Rights Act. (1964). PL 88-352.
Civil Rights Project and Advancement Project. (2000, June).
0Pl)ortunities suspended: The devastating consequences of zero
tolerance and school discipline policies. Harvard University.
Retrieved October 1, 2002, from http://www.civilrightspro j ect.
harvard.edu/research/d isci p 1 ine/ opport_suspended. php.
Crawford, C (2004). The critical issue of financing schools.
Delta Kappa Gamma Bulletin, 71 (1), 22-26.
Dahl, G., & Lochner, L. (2005). The impact of family income on child
achievement. (Discussion Paper no. 1305-05). Institute for
Research on Poverty: University of Wisconsin-Madison.
Retrieved January 1, 2007, from http://education.umn.edu/ N
CEO/Onl i ne Pu bs/2005S ta teReport. htrnspart icipati on.
112 EDUCATION POLICY
Economic Opportunity Act. (1964). P.L. 88--452.
Educate America Act: Goals 2000. (1994). P.L. 103-n7 Education of
All Handicapped Children Act. (1973). P.L.
94-142.
Elementary and Secondary Education Act. (1965). P.L. 89-10. Equal
Access Act. (1984). Section 801 of title Vlll of P.L. 98-377.
Family Educational Rights and Privacy Act. (1974). 20 USc. 1232g;
34 CFR Part 99.
Gill, B., Timpanc, P., Ross, K., & Brewer, D. (200l). Rhetoric versus
reality: What we know and what we need to know about school vouchers
and charter schools. Santa Monica, CA: RAND.
Good, o., Aronson, J., & lnzlicht, M. (2003). Improving adolescents'
standardized test performance: An intervention to reduce the
effects of stereotype threat. Journal of Applied Developmental
Psychology, 24(6),645-662.
Gun Free Schools Act. (1994). P;L. 89-10, Title XIV. Hadderman, M.
(1999). Equity and adequacy in educational finance. Eugene, OR: ERIC
Clearinghouse on Educational Management, University of Oregon.
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Hahushek, E., Kain, J., & Rivkin, S. (2002). Inferring program effects
for special populations: Does special education raise achievement
for students with disabilities? The Review of Economics and
Statistics, 84( 4): 584-599.
Hazelwood School District v. Kuhlmeier. (1988). 484 U.S. 260.
Higher Education Act. (1988) P.L. 105-244.
Individuals with Disabilities in Education Act. (1986). PL. 99--457.
Individuals with Disabilities in Education Improvement Act. (2004)
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National Center for Education Statistics. (2002). 2001 "District suTt!ey
of alternative schools and programs." Washington, DC: US
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?sectionID= 1.
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statistics, 2005. Washington, DC: U.S. Department of Education,
Retrieved December 15, 2006, from http://nces.ed. gov
/programs/ d igest/ dO 5.
National Center for Educational Statistics. (2006b). Homeschooling in
the United States: 2003. Washington, DC: U.S.
Department of Education. Retrieved January 1, 2007, from
http://nces.ed .gov /pubs2006/homeschoo l/index.asp
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2003--04. U.S. Department of Education: Washington, DC.
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/pubs2006/20063 07 . pdf.
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Childhood Technical Assistance Center. (2006). State reporting
requirements Part C 2005 tables Retrieved December 15, 2006, from
http://www.necrac.org/ topi cs/ qual i tv / sta te req. aspssta teo
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Reynolds, A., & Wolfe, B. (1997). Special education and school
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http://www.ed.gov/policy/elsec/guid/raising/altassess-Iong.htrnl.
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-MELISSA JONSON-REID
ELDER ABUSE
ABSTRACT: Elder abuse is recognized as a social problem
among the aging population. Intentional abuse, neglect, and
exploitation among the caregivers to frail and isolated
elderly create serious risks. This field has expanded
continuously since the early 1970's. Accurate prevalence
and incidence rates have not been determined. There is a
national system of elder victim protection operating within
each state. The social work profession is legally mandated
to report situations where an elderly person is suspected to
be at risk of abuse. Social workers are involved in all
aspects of elder abuse prevention and intervention services.
KEY WORDS: elder abuse; caregivers; risks; adult pro-
tective services

Background
The field of elder mistreatment, often generalized as elder
abuse, encompasses two conditions. According to the
comprehensive analysis prepared by the National Research
Council (2003), there are important distinctions between
intentional actions that cause harm or create serious risks of
harm by a caregiver and intentional failure by a caregiver to
meet the elder's basic needs or protect them from harm. The
condition of selfneglect occurs from action or inaction by an
individual elder that cannot be attributed to actions of another
person, but may produce harm and risks because of the lack of
self-care. Victimization of elder persons by a stranger falls into
the realm of criminal behavior that is not associated with a
caregiver's action or failure to act. Elder abuse among persons
who reside within institutional care settings is another distinct
form of endangerment that is increasingly addressed separately
from community domestic settings (Frying, Summers, &
Hoffman, 2006).
There is no national consensus over the definition of elder
abuse. Variations in the definitions of elder abuse occur based
on many factors depending on specific application of the
definition. Legalistic definitions flow from the terminology
within statutes. Research definitions are developed in
conjunction with the purpose and study questions directing the
investigation. Policies that govern program design and service
provision often drive definitions based on the specific type of
abuse and the immediate risks the elder faces. Additionally,
there is lack of funding for this type of research, and existing
small sample researches are not generalizable. There is,
however, widespread consensus that the problem creates the
potentiality of harm that can lead to death. Intentional abuse
will continue to increase with the demographic shifts of a
rapidly aging population, and it is of growing concern in the
United States and in other countries (Brownell, 2006). Esti-
mates of elder abuse prevalence and incidence suggest that
between one and two millions of aged persons have been
subject to intentional mistreatment (National Center on Elder
Abuse, 2005). The lack of reliable national epidemiological
studies is a serious limitation in the field. Currently it is
impossible to know how widespread elder abuse is within the
elderly population and speculation about the actual number of
cases emerges from expert opinion.
Risk Factors
Wolf and Pillemer (1989), Pillemer and Finkelhor (1988), and
Blenker, Bloom, and Weber (1974) offer some of the earliest
analyses on elder abuse risks. These
ELDER ABUSE 113
initial projects generated a sufficient number of cases where
the caregiver was not meeting the elder's major needs on
purpose. From these few cases the investigators identified an
aspect of intentionally harmful caregiver behavior toward the
elder. Their work has been expanded in subsequent studies of
the risk associated with elder mistreatment. Repeatedly
confirmed risk factors associated with community-based
domestic elder care settings include living arrangement,
cognitive or physical impairment, mental illness and substance
abuse characteristics among perpetrators, and caregiver social
or emotional or financial dependency on the elderly person. It
has been suggested, but not well validated, that factors of
gender, race, intergenerational family abuse histories, and
many other factors contribute to greater or lesser risk (National
Center on Elder Abuse, 2005). Acierno (2003) provides an
overview of key studies that have elucidated elder
mistreatment risk factors. These represent clusters of risk that
pertain to the elder's condition, specific characteristics of the
harming caregiver, and the historical and current relationship
between them.
Theoretical Frameworks
The pursuit of causal theory to explain elder abuse has relied
on the application of other theoretical areas such as the cycle
of violence, psychopathology, social exchange, and family
stress. In a case-by-case analysis, aspects of different theories
related to intentional harm may seem to apply as reasons for
the elder mistreatment. These theoretical applications are not
satisfactory for explaining elder mistreatment as a growing
social problem among the aged population. More recently, the
Panel to Review Risk and Prevalence of Elder Abuse and
Neglect under the auspices of the National Research Council
(2003) proposes a more detailed model for understanding elder
mistreatment that involves a transactional process unfolding
over time among the elder person, his or her trusted other, and
other interest parties (stakeholders) concerned with his or her
wellbeing in the context of changes in the physical, psycho-
logical, and social circumstances of the several parties as the
result of the elder person's aging process and life course.
Critical concepts in this framework are social embeddedness
between victim and perpetrator, status inequality between
them, power and exchange dynamics in the relationship, and
the outcomes of the relationship transactions. The outcomes of
elder mistreatment may be recurrent, episodic, or
crisis-focused contributing to physical, mental, or social harm.
Application of the sociocultural context of elder
mistreatment has been essential for gaining knowledge about
elder mistreatment among major U.S. minority
114 ELDER ABUSE
groups and contributes to understanding at the internationa l
level. Over time, the exploration of elder abuse among
African American, Hispanic, Asian American, and
American Indian communities in this country has helped to
improve the quality of culturally competent elder abuse
intervention strategies (Rittman, Kuzrneskus, & Flum,
1999). This has increased in accordance with the early
recommendations of Moon and Williams (1993). They
suggest the urgent need for attention to a definition of elder
abuse that is culturally specific for different ethnic groups.
Small sample, descriptive de sign studies have contributed a
beginning clarification of intra- and intergroup similarities
and differences applicable for intervention and prevention
services (Huber, Nelson, Netting, & Borders, 2007).
There is an increasing amount of published informa tion
from research on elder abuse in many different countries
which emphasizes that the sociocultural context of
particular importance is the early stage of research in
developing nations where problem recogni tion and
professional and community concerns have the potential to
influence the development of services. Some of the poorest
regions in India and the smallest countries in Africa are
attempting to build on village or tribal community
resources so as to offer better protection to the most
vulnerable elders. In these efforts ancient values and
traditions of "honoring the elders" are being rekindled with
contemporary community conditions and family
transformations. In 2002, the World Health Organization
sponsored one of the first international projects to define
attitudes and perception of elder abuse involving both
developed and developing nations.
Prevention and Treatment Models
Public adult protective services (APS) are the back bone of
elder mistreatment reporting, investiga tion, and
assessment. The passage of Title XX of the Social Security
Act in 1974 opened a federal funding channel to states for
the development of APS services. Some states capitalized
quickly on tapping into federal resources, while other states
elected not to devote block grant resources for this service
provision.
As states implemented APS, these units were typi cally
located with larger department and divisions ad dressing
aging concerns, public health concerns, and family- focused
social services. By the early 1980 s all states had public
service units that delivered APS. Yet, there has never been
a uniform APS service deliv ery model among states and
there are no uniform definitions of abuse, neglect, or
exploitation. Each state developed statutes tha t broadly
defined the age range and mental and physical disability
status of persons to
be covered as well as defining the conditions of elder abuse,
neglect, and exploitation. With a few excep tions,
professional categories of mandated reporters were
identified and required to report suspected cases of potential
elderly persons thought to be at-risk. For those working as
advocates for greater federal involve ment by way of
legislation and funding, the continued under- funding for
elder abuse compared to child abuse and violence against
women remains a critical concern.
Trends
Elder abuse is an expanding focus of attention and ser vice
delivery expansion. Health care, criminal justice or law
enforcement, and social services systems are all being
required to address the physical, social, and economic risks
that combine to create serious harm to elderly victims.
While APS remain the predominant source of elder victim
reporting, investigation of case detection occurs in diverse
sectors of interaction with aged indivi duals. Because of
multiple risks, the types of harm, and the dimensions of
perpetration, multiple systems must be engaged and their
efforts coordinated. Collaboration occurs through both
formal and informal mechanisms. Number of
multidisciplinary intervention teams working with
individual cases and local as well state level task forces,
coordinating councils, and coalitions to address elder abuse
are increasing (Brandel et al., 2007).
Roles of Social Work
The social work profession does not have proprietary claim
to the prevention or intervention aspects of elder abuse;
however, social workers assume a major role at the micro
and macro levels in all facets of this growing social
calamity. Social workers are the predominant professionals
in APS and provide critical services and help prevent harm
or offer follow-up services to meet the victim- care needs.
They deliver clinical services and help caregiving families
resolve crisis situations. S ome social workers have
contributed extensively to the field through the publication
of case studies documenting the conditions of risks and
harm, the reduction or elimination of these, and the steps
taken for positive resolution or its lack (Dayton, 2005 ).
From these studies the field has identified threads of critical
information about the range of an elder's vulnerabilities, the
relationship structures and functions between victim and
perpetrator, the critical components of case inves tigation
and assessment, and the advocacy processes needed for
policy and program development. Elder abuse prevention
advocacy should involve constant monitoring of caregiver
mistreatment behaviors. Vigi lance is essential by older
people as well as those who provide them with formal
services and are committed to

their overall well-being. Advocacy for more effective
governmental policies, expanded resources for coordinated
comprehensive programs, and community elder safety
education is essential (Huber, Nelson, Netting, & Borders,
2007).
A challenge that social workers face in elder mistreatment
problems relates to the difficulties associated with the
empirical investigation needed to establish a process and
outcome model of best social work practice. Our profession is,
however, beginning to make major strides in anticipatory
preparation to meet the needs of the currently old and the
millions now rapidly aging in our society.
REFERENCES
Acierno, R. (2003). Elder mistreatment; Epidemiological assessment
methodology. In R. J. Bonnie & R. B. Wallace (Eds.), Elder
mistreatment; Abuse, neglect, and exploitation in an aging America.
Washington, DC: The National Academies Press. Committee on
National Statistics, Committee on Law and Justice, Division of
Behavioral and Social Science and Education.
Blenker, M., Bloom, M., & Weber, R. (1974). Protective services for
older people. Findings from the Benjamin Rose Institute Study.
Cleveland, OH; Benjamin Rose Institute.
Brandel, B., Dyer, C. B., Heisler, c., Orr, J. M., Stiegel, L., &
Thomas, R. (2007). Elder abuse detection and intervention: A
collaborative apprDach. New York; Springer.
Brownell, P. (2006). Introduction. In J. Mellor & P. Brownell (Eds.),
Elder abuse and mistreatment: policy, practice, and research. New
York; Haworth Press.
Dayton, C. (2005). Elder abuse; The social worker's perspective.
Clinical Gerontologist, 28, 135-155.
Frying, T., Summers, R., & Hoffman, A. (2006). Definitions and
scope of the problem. In R. W. Summers & A. M. Hoffman (Eds.),
Elder abuse; A public health problem. Washington, DC: American
Public Health Association.
Huber, R., Nelson, H. W., Netting, F. E., & Borders, K. W. (2007).
Elder advocacy: Essential knowledge and skills across settings.
Belmont, CA: Thomson Brooks/Cole.
Moon, A., & Williams, O. (1993). Perception of elder abuse and
help-seeking among African Americans, Caucasian Americans,
and Korean American elderly woman. The Ger ontologist, 33,
386-395.
National Center on Elder Abuse. (2005). Elder abuse prevalence and
incidence. Washington, DC: National Center on Elder Abuse.
National Research Council (Committee on National Statistics,
Committee on Law and Justice, Division of Behavioral and Social
Science and Education). (2003). In R. J. Bonnie & R. B. Wallace
(Eds.), Elder mistreatment; Abuse, neglect, and exploitation in an
aging America .. Washington, DC; The National Academies Press.
Pillemer, K., & Flnkelhor, D. (1988). The prevalence of elder abuse;
A random sample survey. The Gerontologist, 28, 51-57.
EMPLOYEE ASSISTANCE PROGRAMS 115
Rittman, M., Kuzmeskus, L., & Flum, M. (1999). A synthesis of
current knowledge on minority abuse. In T. Tatara (Ed.),
Understanding elder abuse in minority populatiDns. Philadelphia;
Taylor and Francis.
Wolf, R., & Pillemer, K. (1989). Helping elder victims: The reality Df
elder abuse. New York: Columbia University Press.
SUGGESTED LINKS
Elder Abuse and Neglect: In Search of Solutions
www.apa.org/pi/aging/elderabuse
Elder Abuse in the United Kingdom
www.elderabuse.Drg.uk
The National Elder Abuse Incidence Study
www.aDa.gov/factsheets/abuse
Elder Abuse Law
www.elderabuselaw.com
Elder Abuse Prevention
www.oaktrees . ore/elder
Elder Abuse Prevention-Administration on Aging Fact Sheet
www.aoa.gov/factsheets/abuse/html
MEDLINE plus; Elder Abuse
www.nlm.nih.gDv/medlineplus/elderabuse
National Center on Elder Abuse (NCEA)
www.elderabusecenter.Drg
NCPEA Home Page
www.preventelderabuse.org
-ELOISE RATHBONE-McCUAN
ELDERL Y PEOPLE. See Aging: Overview.
ELECTRONIC TECHNOLOGIES. See Social Work
Education: Electronic Technologies; Technology: Overview.
EMPLOYEE ASSISTANCE PROGRAMS
ABSTRACT: Employee assistance programs (EAPs), or
membership assistance programs when sponsored by
unions, are designed to improve worker productivity
and motivation by responding to problems that workers
experience which interfere with job performance and
satisfaction. Now a ubiquitous characteristic of Ameri-
can workplaces, the programs are largely staffed by
social workers. This entry discusses their historic
development, extent, scope, structure, how they are
perceived and utilized by different racial and gender
populations, and the dilemmas and challenges facing
EAPs as they try to define their role, function, and bes t
practices amid emerging trends in the world of work.
116 EMPLOYEE ASSISTANCE PROGRAMS
KEY WORDS: work; occupational social work; alcoholism
and substance abuse; job performance; work/family conflict;
employment; troubled employee; unions
Employee assistance program (EAP), also known as mem-
bership assistance program if sponsored by a union, is a
generic term for services offered in a workplace to workers,
and often their dependents, to solve problems that may
interfere with productivity, job performance, or safety. EAPs
were started after World War II. Earlier, during the depression
of the 1930s, simple industrial processes and excess labor
made workers easily replaceable. Few employers had the
interest or willingness to invest in employees. After World
War II, loss of life reduced the labor supply and a growing
economy and changed production methods increased the
demand for skilled workers. Employees became valued
human capital to be carefully husbanded. Employers became
concerned about productivity as well as retaining workers
uniquely trained for specialized jobs. They began offering
programs to support workers whose performance was
impaired by alcohol abuse.
The passage of the Federal Hughes Act of 1970
(Comprehensive Alcohol Abuse and Alcohol Prevention,
Treatment and Rehabilitation Act; 1970) led to the
organization of the Occupational Alcoholism Branch at the
National Institute on Alcohol Abuse and Alcoholism, which
furthered this trend by encouraging the establishment of
programs at work sites to find, confront, and treat alcoholism.
These efforts began to be called EAPs. While EAPs reduced
alcoholism, worker productivity continued to be impaired
because ending alcohol abuse did not resolve many related
problems that these individuals had. Many EAPs expanded
counseling to other issues, leading to tensions between tradi-
tionalists (who ran programs whose alcohol-focused strategy
came to be known as the "core technology" of EAP services,
and that were often staffed by recovering individuals) and
those whose strategy established a more comprehensive
approach to the individual substance abuser by dealing with
the array of presenting problems that the individual brought to
the EAP (which came to be known as "broad brush" services
and included significant numbers of programs staffed by
social workers) (Kurzrnan, 1993).
EAPs have become ubiquitous in the world of work.
Estimates by the Bureau of Labor Statistics (BLS), based on
their 2006 National Compensation Survey of employees in
private industry in the United States, indicate that 63% of
workers in establishments of 100 or more employees are
covered by EAPs. Similarly, the Federal Occupational Health
supplier reports that 47% of federal government employees
are EAP eligible.
Demographic analysis suggests that those in unionized
workplaces, performing white collar jobs, and earning more
than $15/hr are more likely to be eligible for EAP care than
their non-union, blue collar, less well compensated
counterparts.
All EAPs have certain common characteristics.
They are sponsored under workplace auspices. They are
available to all those in a defined relationship to the
sponsoring auspice, and as a result individuals utilizing the
services experience less stigma than they might experience if
their presenting problem was taken to another delivery
system. All EAPs include a prevention focus since they are
provided under the assumption that assisting employees is
better than firing them. They share the desired outcomes of
promoting productivity, well-being, and job satisfaction
among workers.
There is, however, great variation among EAP models.
The program may be provided internally by an employer or
union with services available at a particular work site, or it
may be run by a vendor hired by the sponsoring auspice with
service delivery offsite. The scope of service can be narrow,
such as a program restricted to problems of substance abuse,
or consist of wide-ranging efforts to cover any presenting
need, for example, marital, family and other interpersonal con-
flict, stress, death and bereavement, crisis and disaster
concerns, family violence, child and eldercare needs, legal
problems, financial concerns, mental or physical health issues,
or the mutual incompatibility presented by work and family
demands. EAPs can report to any of a multitude of sources
including the medical director, the human resource director or,
in a few situations, the CEO. The trend is for EAPs to become
a unit in or be the umbrella department that covers the general
area of health promotion and wellness. Most EAPs encourage
self-referral, but also provide for mandated referral by
supervisors who note deficits in a particular employee's
performance.
Philosophy and Values
Although in theory EAP services are offered to assure worker
productivity as measured by reductions in absenteeism,
tardiness, compensation claims, conflict, and disability and
increased turnover. They also are likely to reflect many other
motives. Employers use EAPs to show their respect for and
commitment to employees. Offering service conveys the
message that employees are a valued resource worthy of
investment. EAPs also provide supervisors with a tool for
dealing with troubled workers and promote the competitive
position of a firm in recruiting by establishing it as the
employer of choice. EAP services can foster compliance with
legislation such as the Drug-Free

Workplace Act. EAP services can protect a company from
precipitous negative response to employee behavior that may
be caused by forestalling ill-considered discharge and
reducing employment litigation. Assisting workers proves a
better strategy than firing them. There are consistent findings
in the best practice literature stressing the importance of top
leadership support as a correlate of effective EAP outcomes.
Roles for Social Workers
Social workers are the dominant profession in EAPs, along
with psychologists, nurses, rehabilitation and other
counselors, as well as recovering individuals. Assessment is
the most basic component, made either in a face-to-face
interview or in a telephonic conversation by a trained
counselor, which is clearly a role for a social worker. Some
EAPs follow assessment by providing limited counseling and
then, if necessary, referral to a community resource. Other
EAPs, most often external, vendor-supplied programs, refer
workers to a therapist identified as part of the behavioral
health managed care benefit. Most EAPs train supervisors in
identification and referral of troubled workers and many
supervisors publicize the EAP service system to all employees
(Hartell et al., 1996). When external vendors are the EAP
supplier, the employer often has an internal employee manage
the vendor relationship and produce evaluative reports on the
value added contribution of the EAP. Although internal EAPs,
especially those tuned in to the culture of the organization,
may engage in advocacy for their clients, external
vendor-supplied EAPs rarely undertake advocacy, reflecting
their tangential relationship to the employing organization.
Current Challenges and Controversies
The utilization of EAP services depends in part on the range
of services offered, the culture of the workplace, the
confidentiality believed to accompany service, and many
other factors. The latest research suggests differential use by
cultural, racial, ethnic, and other populations. The highest
utilization is among white male workers (Hopkins, 1997). The
EAP model does not attract women or ethnic or racial
minorities in equal proportion to white males, perhaps
because the trust a worker needs to share problems with a
supervisor and the comfort the supervisor needs to confront a
worker and suggest or mandate a referral are most likely to
arise when the supervisor resembles the worker, and most
supervisors are white males (Hopkins, 1997). Those
concerned with ethical and social justice issues therefore, see
EAPs as one more way in which the distribution of income in
society favors those who already have
EMPLOYEE ASSISTANCE PROGRAMS
117
as opposed to those who are poor and disadvantaged. Benefits
like EAP care are viewed as income enhancing because the
services EAPs provide have a monetary value that otherwise
would have to be borne by the service recipient or would be
unavailable to the recipient.
Other dilemmas also surround the scope and availability of
EAPs. Should EAPs remain pure to their initial mission of
using constructive confrontation to limit and remedy the abuse
of alcohol and other substances, or should they meet the
challenges of emerging trends in the workplace (for example,
globalization, demographic shifts of the workforce,
privatization), offering services for the range of needs? Can
any program survive, much less grow, when it neglects
changes occurring in its natural environment?
The EAP literature is replete with calls for expansion of
the service model. An Internet search of EAPs and service
delivery netted suggestions for programs, for example, on debt
counseling, health and more general well-being, employee
stress and cardiovascular disease prevention, depression,
Internet assistance for family caregivers of dementia patients,
proactive early intervention and disability management,
organizational assessment and development, marriage and
family counseling to name a select few. Many believe that
EAP survival and best practices warrant an integrated program
that attends to providing care that enhances overall wellness of
the workplace. Under this view, offerings should be attractive
to employers because EAPs can then achieve the greatest
return on investment. EAPs, however, have not undergone the
intensive scrutiny that many other employer-supplied benefits
and social programs undergo (Csiernik, 2005). Only careful
evaluation can make the case for offering EAP services added
value through common workplace interventions such as
family responsive policy.
Careful evaluation might also shed light on two other
classical issues facing EAPs. First, how independent is a
service provider hired or contracted by the employing
organization, and related to that, what level of confidentiality
can the employer-hired EAP service ensure? If the services are
sponsored by a union through a MAP, these questions are
more easily answered since it is in the nature of a union to
protect and represent the interests of the members. But in an
employer-sponsored EAP, the issues are more controversial. It
is here that the significance of having a licensed professional
social worker as the EAP counselor asserts itself. Faced with
the dilemma of loyalty to the individual or the employer, the
social worker can turn to the NASW Code of Ethics for
guidance. The Code of Ethics affirms that the first
responsibility of the professional is to the
118 EMPLOYEE ASSISTANCE PROGRAMS
individual and his or her needs. This suggests that the social
worker becomes the agent, not of the employer, but of the
individual. The employment or vendor contract might well
specify the level of confidentiality that accompanies that agency.
Both these issues require honest and transparent communication
to the parties involved with the EAP so that everyone is aware of
the protections and risks that are inherent to the employer in
offering, and to the employee, in utilizing EAP services. When
transparency and honesty are the hallmarks of an EAP, the trust
necessary to provide effective services is greatly enhanced.
REFERENCES
Csiemik, R. (2005). A review ofEAP Evaluation in the 1990s.
Employee Assistance Quarterly, 19(4),21-37.
Hartell, T. D., Steele, P., French, M., Potter, F., Rodman, N., &
Zarkin, G. (996). Aiding troubled employees: The prevalence,
cost, and characteristics of Employee Assistance Programs in the
United States. American Journal of Public Health, 86( 6),
804-808.
Hopkins, K. (997). Supervisory intervention with troubled workers: A
social identity perspective, Human Relations, 50(0),1215-1237.
Kurzrnan, P. A. (993). Employee Assistance Programs: Toward a
comprehensive service model. In P. A. Kurzrnan, & S. H. Akabas
(Eds.), Work and well-being: The occupational social work
advantage (pp. 26-45). Silver Spring, MD:
NASW Press.
SUGGESTED LINKS Employee Assistance
Professionals Association www.eapassn.org
Employee Assistance Society of North America
www.easna.org
The Society of Human Resource Management
www.shrm.org
-SHEiLA H. AKABAS
EMPLOYMENT AND UNEMPLOYMENT
ABSTRACT: Different types of employment and unemployment
are defined and the measurement of these concepts is illustrated.
Unemployment trends among different groups in the United
States are described and competing theories of the causes of un-
employment are explained. Finally, policies relating to
employment, including those focusing on labor supply, labor
demand, and labor regulation, are discussed.
KEY WORDS: employment; unemployment; labor supply; labor
demand; labor regulation; work
Employment occupies a central place in the history of the social
work profession and how we conceptualize and deal with people,
especially the poor. The relationship of individuals to wage labor
and the social consequences that ensue were at the basis of its
origins. The profession emerged in the United States during the
early 20th century to help individuals and communities cope with
the economic and social changes resulting from urbanization and
industrialization. The promise of jobs in industrializing cities
drew agricultural workers searching for a better life.
Independence from landowners and security from weather-related
hardship inspired many individuals to migrate, leaving the
security of their extended families and communities. In the new
social order of the 20th century, many improved their living
conditions while others faced worse conditions than those they
had left behind (Trattner, 1998).
Perceptions of work and who should be employed define
historic and contemporary views of poverty. In capitalist
societies, wage employment is the primary means whereby
individuals provide for their well-being and that of their families.
The prevalence of wage employment has influenced our
perceptions of the poor since the time of the Elizabethan Poor
Laws in the 1600s. "Deserving" poor were those who were unable
to work, such as children and individuals with disability, while
undeserving poor were those who were able to work but did not.
Popular sentiment required able individuals to work and saw them
as unworthy of charitable assistance (Trattner, 1998). This same
debate surrounded the end of Aid to Families with Dependent
Children (AFDC), a federal entitlement of poor mothers to cash
assistance that had been in existence since the 1930s. Earlier,
mothers were considered "deserving poor" because social norms
did not require that they work. Today, norms have changed:
mothers are expected to work and social welfare programs have
adapted accordingly, including the Temporary Aid to Needy
Families (T ANF), passed in 1996.
Definitions
Numerous terms describe an individual's relationship with the
labor market. Employed and unemployed are terms used to refer to
individuals who are in the labor market. Being in the labor market
means an individual is available to work for pay. Employed
individuals have a formal relationship with an employer and are
compensated for the work they perform. Unemployed individuals
are actively looking for work but are not currently in a contractual
arrangement that provides pay for work. Individuals not actively
looking for work are not in the labor market and are not included
in the calculation of the government unemployment rates.
 EMPLOYMENT AND UNEMPLOYMENT
119

Self-employed individuals fully own the company for which
they work. Work that occurs "off the books" and is not
reported to the Internal Revenue Service is part of the informal
economy and is not included in official employment statistics.
The Bureau of Labor Statistics computes and maintains
records of employment statistics in the United States. The
unemployment rate is the most common statistic discussed in
reference to the topic. This rate is computed by dividing the
number of individuals looking for work by the number of
individuals in the labor force (McEachern, 1988; Bureau of
Labor Statistics, 2007a).
Historical Unemployment Trends Changes in the
unemployment rate reflect changes in the number of people in
the labor force as well as changes in the number of people
working. Over time the unemployment rate of individuals 16
years and older has fluctuated from 3.9% in 1947 to 5.1% in
2005. Since 1947 the unemployment rate has ranged from a
low of 2.9% in 1953 to a high of 9.7% in 1982 (Bureau of
Labor Statistics, 2007a).
Different segments of the population experience different
rates of unemployment. Table 1 depicts differences by race,
ethnicity, and sex for including school-aged labor force
participants (16 years and older) and labor force participants
older than school age (25 years old and older). Except for
Asians, members of minority groups have higher
unemployment rates than whites. Women typically have
slightly higher
unemployment rates than men except for African American
women whose rates are slightly lower than their male
counterparts.
Theoretical Interpretations
of Causes of Unemployment
Theories explaining the causes of unemployment come from
several economic traditions. According to neoclassical
economic theory an economy producing at its potential level of
output will have a natural rate of unemployment. This amount
of unemployment is due to frictional and structural causes.
Frictional unemployment occurs when new jobs become
available and individuals change jobs, because it takes time
for workers to find the right jobs and employers to find the
right worker. Structural unemployment exists because worker
skill (skills mismatch) or location (spatial mismatch) does not
meet the needs of employers. As long as unemployment
remains at the optimal level, no government intervention is
needed. If the unemployment rate is above the natural rate,
supply-side interventions that cut taxes in order to stimulate
private investment are seen as the solution. (McEachern,
1988).
Monetarists see unemployment as a result of the
government's inability to manage the economy. To resolve
unemployment problems, monetarism increases the supply of
money so that investors can spend money on economic
activities that create jobs. Keynesians see unemployment as
cyclical, an inefficiency of the economy occurring when
demand for goods and services decreases. The solution to the
unemployment problem is to increase demand for goods and
services as was done with public works programs during the
Great Depression and the Employment Act of 1946.

TABLE 1
Unemployed Persons by Race, Ethnicity, and
Sex (2005)
MEN WOMEN
Total (16 years and older) 5.1 5.1
White 4.4 4.4
Black or African American 10.5 9.5
Asian 4.0 3.9
Hispanic or Latino 5.4 6.9

Total (25 years and older) 3. 4.2

White 8 3.6
3.4 7.5
o ;
Black or African American
ctl Asian 7.6 3.8
Q)
>- ; Hispanic or Latino 3. 5.8
o 3
FlGURE 1. United States Unemployment Rate (1947-2005). C
\l From Bureau of Labor Statistics, 20073. 4.1
120 EMPLOYMENT AND UNEMPLOYMENT
Classical Marxism argues that high levels of unemployment
increase the power of capital over labor. A large supply of
unemployed workers means employers can keep wages low due
to the competition among workers for scarce jobs (McEachern,
1988).
Policy Options
Like other markets for goods and services, the labor market is
governed by the laws of supply and demand. This section
discusses policies that address labor supply, labor demand,
and regulating the relationship between them
LABOR SUPPLY STRATEGIES The U.S. government has
supported numerous employment training programs over
time. The 1962 Manpower Development and Training Act
(MDT A) provided vocational and onthe-job training, testing,
counseling, job placement services, and living allowances to
unemployed and displaced blue collar workers for new
high-skilled jobs being created by the economy. The Office of
Economic Opportunity (OEO) used community action
agencies to provide employment training and placement
(Janoski, 1990). From 1967 to 1989, the Work Incentive
Program (WIN) required recipients of Aid to Families with
Dependent Children (AFDC) to register for work and training
programs unless they had young children (Bane & Ellwood,
1994).
During the 1970s, the Comprehensive Employment and T
ra ining Program (CET A) decentralized and consolidated
federal and state employment programs, requiring prime
sponsors such as city or county governments to develop
comprehensive "manpower" development policies in their
local areas (Janoski, 1990). In the 1980s, the Job Training and
Partnership Act (JTPA) provided employment training for
impoverished and undereducated adults, youth, and migrant
and seasonal farm workers and gave grants to Native
American tribes to provide similar training. It used Private
Industry Councils (PICs) comprising local business leaders to
plan local employment policy (Guttman, 1983). The Job
Corps Program provided intensive, long term job training and
remedial education programs and job placement assistance for
impoverished youth in a residential setting (GAO, 1995a,
1995b).
The Family Support Act of 1988 created the Job
Opportunities for Basic Skills program (JOBS) to increase the
self-sufficiency of poor mothers who received assistance from
the Aid to Families with Dependent Children (AFDC)
program. Activities under this program included assessment,
basic skills training, job skills training, job development and
job placement (Bane & Ellwood, 1994). In the beginning of
the 21st
century, the Temporary Assistance for Needy Families (T
ANF) program was passed to target this population. T ANF
requires that recipients work as soon as they are able and
allows training only in limited circumstances (U.S. Congress,
Committee on Ways and Means, 1998b; U.S Congress,
Committee on Ways and Means, 2004a)
The Workforce Investment Act of 1998 (Public Law
105-220) repealed the JTPA and sought to coordinate over 60
federal programs through locally controlled workforce
development systems. One-stop service delivery systems
provide public access to different levels of services. The
program prioritizes "core services" such as job readiness,
placement, and retention services that link individuals
immediately to employment. Individuals who are unable to
obtain employment may receive "intensive services" such as
assessment and counseling, and training services. Since its
enactment the WIA has consolidated federal work programs to
44 with increased attention paid to measuring employment
outcomes of participants (GAO, 2003).
Job placement services began with private employment
agencies recruiting workers from Europe and Africa (Janoski,
1990; Martinez, 1976). Although public labor exchanges
began at the state level in the 1890s, numerous Supreme Court
actions discouraged government involvement (Guzda, 1983;
Janoski, 1990). In 1918, President Woodrow Wilson created
the United States Employment Service (USES) with an
executive order. The USES opened employment offices in 40
states and relied on state advisory boards for advice regarding
the operation of these offices. The magnitude of its job
changed over the years, increasing during labor scarcity
(Janoski, 1990; Mucciaroni, 1990).
Under the JTPA, Job Service provided a nationwide
network of over 1,800 offices to help individuals find jobs.
Over time, these services moved from job counseling to a
more self-help approach due to budget cuts. The Workforce
Investment Act of 1998 one-stop-shops provided placement
and information dissemination services.
Although not related to training or placement, the Earned
Income Tax Credit (EITC), at least in theory, affects labor
supply by providing incentives to low wage workers by
increasing their incomes through income tax refunds and
credits. This program is implemented by the Internal Revenue
Service to bring incomes above the poverty threshold
(Levitan, Mangum, & Mangum, 1998).
LABOR DEMAND STRATEGIES Labor demand strategies
encourage employers to hire more workers by

helping them create new jobs, encouraging them to hire
certain workers, and punishing those who discriminate
against certain workers. Some approaches focus on im-
proving private market job opportunities while others rely
on government solutions.
Private market approaches include tax cuts, public
spending, and local economic development. Tax cuts are
seen as a way to shorten the duration of economic
downturns by increasing the amount of money avail able for
consumer spending. This policy option first emerged
during the Kennedy Administration in re sponse to a slow
recovery from the 1960-1961 reces sion. Cutting taxes
continues to be presented as an ideal economic stimulation
policy by conservatives.
As noted earlier, Keynesian policy solutions to the
problem of unemployment involve the federal gov ernment
spending money to stimulate economic activ ity, which in
turn increases job availability. Federal spending on public
works projects during the Great Depression exemplifies
this approach (Mucciaroni, 1990). The Employment Act of
1946 gave the federal government a permanent role in
maintaining employment by requiring the president to
submit an annual economic report to Congress along with
policy solutions that promote employment while
controlling inflation and production. The Full Employment
and Balance Growth Act of 1978 extended this by espous-
ing full employment as a goal and setting specific
unemployment rate targets among other provisions
(Santoni, 1986).
While the Reagan administration left labor demand
policy to private market and local area actions, 37 states
created their own Enterprise zones to stimu late economic
growth and create jobs in poor areas during the 1980s .
Community Development Block Grants fund supportive
housing, public works, and eco nomic development efforts
to create jobs. Enterprise Communities programs and
Empowerment Zones were created by the federal
government under the George H. W. Bush and Clinton
administrations to identify poor communities and use
federal funds to attract and create businesses in order to
create jobs and encourage small business development
(Levitan, Mangum, & Mangum, 1998).
The U.S. Department of Commerce's Economic
Development Administration (EDA) a nd Farmer's Home
Administration (FmHA) provide grants, loans, loan
guarantees, and technical assistance for business
development in areas experiencing business foreclosures
and in low-income rural areas respectively. (FmHA, 1980 ;
GAO, 1997; Levitan et al., 1988; USDA, 1997).
Labor demand can also be increased by creating
incentives for employers to hire individuals typically
EMPLOYMENT AND UNEMPLOYMENT 121
disadvantaged in the hiring process. The Targeted Job Tax
Credit program is an example of this. From 1978 until 1994
it provided federal tax credits to businesses if they hired
hard-to-employ target groups.
Public job creation is another labor demand strategy
used. Faced with record unemployment rates during the
Depression, the federal government imp lemented a number
of public job creation and construction pro grams including
the 1932 Emergency Relief and Con struction Act, the
Civilian Conservation Corps, the Public Works
Administration, the Federal Emergency Relief
Administration (FERA) , the Civil Works Ad ministration,
and the Works Progress Administration (WPA) (Janoski,
1990; Jansson, 1997).
High levels of unemployment during the 1970s brought
about more public job creation programs in cluding the
Emergency Employment Act of 1971, Title II of CE T A,
the 1974 Emergency Unemployment Assistance Act, the
1976 Emergency Jobs Program Extension Act, and, as a
last resort, the Full Employment and Balance Growth Act
of 1978 (Mucciaroni, 1990). These interventions lasted
only a short time due to budget cu ts enacted by the Reagan
administration (J anoski, 1990). As of 2007 , only the
Senior Community Service Program provides part- time
jobs to individuals over 55, with an income of 125% of the
poverty line (Levitan, Mangum, & Mangum, 1998).
Regulatory policies preventing employer discrimina-
tion against workers they view as less desirable can also be
viewed as labor demand policies. The 1963 Equal Pay Act
required that employers pay equal salaries to men and
women undertaking equal work. The Civil Rights Act of
1964 made discrimination based on race, creed, or color
illegal. The 1967 Age Discrimination in Employment Act
made discrimination on the basis of age illegal.
Employment discrimination on the basis of disability was
made illegal by the 1973 Vocational Rehabilitation Act and
the 1990 Americans with Disabilities Act. These acts may
be enforced by lawsuits filed by individuals or the Equal
Employment Opportunity Commission (EEOC) (EEOC,
1998a; Levitan, Mangum, & Mangum, 1998).
REGULATORY LAWS PROTECTING WORKERS Numerous
laws have been enacted to protect workers from common
labor market problems. For example, the Unemployment
Compensation Program, created by the Social Security Act
of 1935 (Public Law 74271), provides income to
individuals who lose their jobs through no fault of their
own. (U.S. Congress, Committee on Ways and Means,
1998d, p. 327). Funded by employer taxes, individuals
receive time-limited as sistance that is a fraction of their
prior wages (U.S.
122 EMPLOYMENT AND UNEMPLOYMENT
Congress, Committee on Ways and Means, 1998d). The Trade
Adjustment Assistance and North American Free Trade
Agreement (NAFT A) Transitional Adjustment Assistance
programs provide some money allowance, employment,
training, job search assistance, and a relocation allowance to
eligible workers (U.S. Congress, Committee on Ways and
Means, 1998a, 1998c).
The health and safety of workers are monitored by the
Occupational Safety and Health Administration (OSHA) or
OSHA-approved state systems (Hartnett, 1996; Mintz, 1984).
The Employee Retirement and Income Security Act (ERISA)
requires that employers insure certain benefits and it regulates
pension administration, disclosure, and reporting. The Family
and Medical Leave Act of 1993 protects workers from losing
their jobs if they need to be absent from work due to family
illness or the birth or adoption of a child. Finally, a federal
minimum wage is assured by the Fair Labor Standards Act.
This was set at $5.85 in July 2007 (Public Law 110-28;
Bureau of National Affairs, 1986; EEOC, 1998b).
REFERENCES
Bane, M. J., & Ellwood, D. T. (1994). Welfare realities: From rhetoric
to reform. Cambridge, MA: Harvard University Press.
Bureau of Labor Statistics. (2007a). Labor Force Statistics from the
Current Population Survey. U.S. Department of Labor, Bureau of
Labor Statistics. Retrieved November 20, 2007, from http://data.
bls.gov/PDQloutside .jsp ?survey= In
Bureau of Labor Statistics. (2007b). Glossary: Unemployment.
U.S. Department of Labor, Bureau of Labor Statistics. Retrieved
November 16, 2007, from http://www.bls.gov/bls/
glossary.htmsl.l
Bureau of National Affairs. (1986). Joint explanatory statement of the
committee of conference on ERISA. In ERISA:
Selected legislative history, 1974-1985. Washington, DC:
Author.
Equal Employment Opportunity Commission. (1998a). Disability
discrimination: Employment discrimination prohibited by the
Americans with Disability Act, Technical Assistance program.
Washington, DC: Author.
Equal Employment Opportunity Commission, Office of Legal
Counsel. (1998b). The Family Medical Leave Act, the Americans
with Disabilities Act, and Title VII of the Civil Rights Act of 1964.
Washington, DC: Author.
Farmers Home Administration (FmHA). (1980). A brief history of
FmHA. Washington, DC: Author.
Government Accounting Office (GAO). (1995a). Multiple employment
and training jJrograms: Major overhaul needed to redlACe costs,
streamline the bureaucracy, and improve reslAlts, testimony of
Clarence Crawford before Committee on Labor and Hllman
Resources. Washington, DC: Author.
Government Accounting Office (GAO). (1995b). Welfare to worf<:
AFDC training jJrogram spends billions, but not well
focused on employment, testimony of Jane L. Ross before the
Committee on Labor and Human Resources, U.S. Senate.
Washington, DC: Author.
Government Accounting Office (GAO). (1997). Rural development:
Availability of capital for agriculture, business & infrastructure.
Washington, DC: Author.
Government Accounting Office (GAO). (2003). Multiple employment
and training programs: Funding and performance measures for major
programs. GAO -03-589. Washington, DC: Author. Retrieved
October 3,2007, from http://www. gao.gov/new. items/d03 589
.pdf.
Guttman, R. (1983). Job Training Partnership Act: New help for the
unemployed. Monthly Labor Review, 106(3), 3-10.
Guzda, A. (1983). The US employment service at 50. Monthly Labor
Review, 106(6), 12-19.
Hartnett, J. (1996). A political history of workplace safety. In OSHA
in the real world. Santa Monica, CA: Merritt Publishing.
Janoski, T. (1990). The political economy of unemployment:
Active labor market jJolicy in \\'lest Gemwny and the Uniteel States.
Berkeley: University of California Press.
Jansson, B. S. (1997). The early states of the New Deal, In The
reluctant welfare state: A history of American social welfare jJolicies.
Pacific Grove, CA: Brooks/Cole Publishing Company.
Levitan, S. A., Mangum, G. L., & Mangum S. L. (1998).
Programs in aid of the poor (7th ed.). Baltimore: Johns Hopkins
University Press.
McEachern, W. A. (1988). Macroeconomics: A contemporary .
introduction. Cinncinnati, OH: South-Western Publishing
Company.
Martinez, T. (1976). The human market place. New Brunswick, NJ:
Transaction Books.
Mintz, B. W. (1984). OSHA: History, law and policy. Washington,
DC: Bureau of National Affairs, Inc.
Mucciaroni, G. (1990). The political failure of employment policy:
1945-1982. Pittsburgh, PA: University of Pittsburgh Press.
Public Law 105-220. (1998). Workforce Inocstmen; Act of 1998, 112
Stat. 936, 105th Retrieved November 10, 2007, from
http://www.usdoj.gov/crt/508/508Iaw.htm!.
Public Law 110-028. (2007). U.S. troop readiness, veterans' care,
Katrina recovery and Iraq accountability act. Retrieved November
11, 2007, from http://www.gpoaccess.gov/plaws/ index.htrnl.
Santoni, G. J. (1986). The Emplo)'ment Act of 1946: Some history notes.
Federal Reserve Bank of Sr. Louis.
Trattner, W. I. (1998). From poor laws to welfare state: A history of
social welfare in America (6th cd.). New York: Simon & Schuster.
U.S. Congress, Committee on \\lays and Means. (1998a).
NAFTA Workers Securit), Act. Green Book, I05th congress.
Washington, DC: U.S. Government Printing Office.
U.S. Congress, Committee on Ways and Means. (l998b).
Temporary assistance for needy families. Green Book, I05th congress.
Washington, DC: U.S. Government Printing Office.
l

u.s. Congress, Committee on Ways and Means. (1998c).
Trade adjustment assistance. Green Book, 105th congress.
Washington, DC: U.S. Government Printing Office.
U.S. Congress, Committee on Ways and Means. (1998d).
Unemployment compensation. Green Book, lOSth congress.
Washington, DC: U.S. Government Printing Office.
U.S. Congress, Committee on Ways and Means. (2004a). Section 7 -
Temporary assistance for needy families (T ANF). Green Book
(pp. 1-98). Retrieved November 10, 2007, from
http://www.gpoaccess.gov/wmprints/green/index.html.
U.S. Congress, Committee on Ways and Means. (2004b).
Section 15- Workforce Investment Act. Green Book. (pp.
118-122). Retrieved November 10, 2007, from http://www.
gpoaccess. gov /wmprin ts/ green/index.h trn I.
U.S. Department of Agriculture. (1997). Business and industry
guaranteed loan program. Washington, DC: U.S. Department of
Agriculture.
FURTHER READING
Government Accounting Office (GAO) (1996). Job Training and
Partnership Act: Long term earnings and employment outcomes
(GAO/HEHS-96-40). Washington, DC: Author.
Rose, D. (1994 ). Twenty-five years later: Where do we stand on
equal employment opportunity law enforcement? In P. Burstein
(Ed.), Equal employment opportunity: Labor market discriminaiton
and public policy. New York: Aldine De Gruyter.
U.S. Congress. (1986). Veterans Readjustment ApPo.intment Au-
thority Extension and Improvements Report, Report (99-627) to
House of Representatives. 99th congress, 2nd session. Washington,
DC: Author.
U.S. Congress. (1986). Veterans Rights Report, Report (99-626) to
House of Representatives. 99th congress, 2nd session. Washington,
DC: Author.
U.S. Department of Labor. (1994). Targeted jobs tax credit program:
Employment inducement or employer windfatl? Washington, DC:
Author.
-MICHELLE LIVERMORE
EMPOWERMENT. See Citizen Participation; Strengths-
Based Framework.
EMPOWERMENT PRACTICE
ABSTRACT: The concept of empowerment has deep roots
in social work practice. Building upon the work of
empowerment theorists of the 1980s and 1990s, the
concept of empowerment has evolved from a philo-
sophical level to practice frameworks and methods.
Substantial research confirms empowerment outcomes
as personal, interpersonal, and sociopolitical. Practice
interventions contain both personal and structural
EMPOWERMENT PRACTICE 123
dimensions and are accomplished through multilevel
interventions. Based on transformation ideology, em-
powerment is a counter to perceived and objective
powerlessness. Social work relationships provide an op-
portunity for experiencing power and collaboration.
Empowerment interventions are often useful with vulnerable
populations, such as women and members of stigmatized
groups.
KEY WORDS: internalized powerlessness; interpersonal
empowerment; learned helplessness; liberation; mas-
tery; multilevel intervention; perceived powerlessness;
personal empowerment; self- efficacy; social justice;
stigmatized groups; sociopolitical empowerment
V ulnerable Populations
Social work has a long history of empowerment traditions
(Simon, 1994) from such sources as social reform movements,
feminism, economic security legislation, settlement house
work, civil rights work, and liberation theology through social
work roles like facilitators, mobilizers, and social reformers.
Barbara Solomon's work (1976) used an empowerment
paradigm to explicate practice in oppressed communities.
Solomon viewed empowerment as the process of a client's
own endeavors to gain resources that will enhance the mastery
of his or her affairs. During the 1980s and 1990s, a substantial
body of research literature from both inside and outside social
work was developed, which conceptualized empowerment as
a three-dimensional construct, geared toward acquisition of
power, both perceived and objective. Subsequently, a
consensus emerged in social work regarding empowerment
processes and outcomes in practice. (For summary of this
literature, see Cox & Parsons, 2000; Parsons, 2002). Torre
(1985), summarized the varied definitions of empowerment as
"a process through which people become strong enough to
participate within, share in the control of, and influence events
and institutions affecting their lives," and that in part,
"empowerment necessitates that people gain particular skills,
knowledge and sufficient power to influence their lives and
the lives of those they care about."
Empowerment outcomes include personal empow-
erment-self-efficacy and perception of the ability to resolve
and influence one's own issues; interpersonal knowledge and
skill acquisition attained through interactions with others that
facilitate overcoming barriers; and sociopolitical actions
influencing societal institutions that can facilitate or impede
self-help and mutual aid efforts. These interacting concepts
influence one another, but act as parts of a whole dynamic of
perceived competency and liberation. Many
124 EMPOWERMENT PRACTICE
frameworks for empowerment-based practice, developed in
the 1990s, capitalize on this convergence of thinking (See
Gutierrez, Parsons, & Cox, 1998 for summary).
Theoretical Considerations
The theoretical foundation of empowerment is transfonnation
from inside oneself, between oneself and others, and in
political liberation. It rests upon the connection of the personal
and the political, and from the notion of learned hopefulness.
Empowerment is viewed as a counter to perceived and
experienced powerlessness, which when internalized, results
in selfblame or surplus powerlessness (Lerner, 1986). This can
create a perception of oneself as helpless to act on one's own
behalf. Membership in stigmatized groups, negative
experience in interactions with the environment, and blocks
from larger environmental systems lead to learned
helplessness, negative self-evaluation, and alienation. Cox
further suggested that powerlessness is caused by economic
insecurity, absence of involvement in political arenas, absence
of access to information, lack of training in critical thought,
physical and emotional stress, learned helplessness, and
emotional and physical attributes that block using available
resources. (For discussion and documentation of these
concepts, see Parsons, 1991, 2002).
Research
Research has confirmed the association between self-efficacy
and self-worth attitudes and actions, both individual and
group, taken to resolve problems (Kieffer, 1984; Kimboko and
Parsons, 1987; Manning, Zirnbalese-Crawford, & Downey,
1994; Parsons, East, & Boesen, 1994, Zimmerman, 1990;
Zimmerman & Rappaport, 1998 ). Action-taking was found to
be a predictor of self-efficacy (Zimmerman et a1., 1992).
Empirical study suggests that an empowerment approach to
the personal and social dysfunction of persons with mental
illness is promising in terms of social functioning and quality
of life outcomes (Kimboko & Parsons, 1987; Manning, 1994;
Manning & Suire, 1996; Paulson, 1991; Rappaport, Reishl, &
Zimmerman, 1992; Segal, Silverman, & Temkin, 1993).
Current research continues to find positive empowerment
outcomes in mental health services (Boyd & Bentley, 2005;
Stromwall, 2003), health services, and in work with women.
Current research also confirms the assumption of association
between social workers' own empowerment in their agencies
and their ability to promote empowerment in clients (Bartle,
Couchonnal, Canda, & Staker, 2002; Leung, 2005). Parsons,
East and Boesen, (1994) evaluated the effects of a praxis
model-action, reflection
and action in an AFDC coalition-and found increased
individual development, reduction of self-blame, and
community participation.
Best Practices
Best practices in empowerment include, at a minimum, both
personal and structural dimensions, and the connection
between them is increasingly implemented through multilevel
empowerment approaches with multi-relationships among
clients and agency staff (Bartle et al., 2002; East, 1999;
McCammon, 2001). Other widely accepted principles of best
practice include problems viewed through sociopolitical
lenses; client experience of power in the helping relationship a
focus on client strengths and self-efficacy, and education
rather than pathology; creation and rejuvenation of informal
social networks; and emphasis on collectivity wherein
support, mutual aid and validation, and promotion of social
justice are primary. In organizations and communities, best
practices include: horizontal decision making structures, an
atmosphere of "community of learners" in the organization,
focus on client need, social justice, and focus on maximized
client participation (Parsons, 2002). Lee (2001), suggests that
if conscientization and praxis are the key elements of
community work, residents and workers alike will experience
self-empowerment.
As a counter to the conditions of powerlessness,
empowerment-based practice has been widely used in work
with vulnerable populations, such as women, nonwhites, and
other diverse populations. Intended to counter the effects of
oppression, it is also particularly beneficial to other
disempowered populations who are members of stigmatized
groups in society, people with mental illnesses, the aged
(Chapin & Cox, 2001), and people with disabilities. In
international social development, empowerment is a
framework of choice due to the political and socioeconomic
conditions in developing countries (Leung, 2005; Yip, 2004 ).
Building on empowerment theories of the 1980s and
1990s, social work has moved the concept of empowerment
from value and philosophical levels to practice principles,
frameworks, and methods. This is accompanied by the
recognition that practice strategies are not
empowerment-oriented simply because of the intention of
either the worker or the agency, but instead must embody the
recognized principles of empowerment practice.
Challenges
In spite of the growth and development in this practice
framework, however, there still remains a healthy skepticism
regarding the reality of transformation as a professional
activity (Pease, 2002), and of public policy sponsorship of
agencies for rearrangements of power

relationships (Jordan, 2004). It can be argued that if
empowerment is indeed a process that one must do to oneself,
undirected by an "expert other," then it may take place more
feasibly and appropriately outside of a professional
relationship between a helping agency and the disempowered.
On the other hand, it is quite possible that a fundamental
reason for the small explosion of empowerment-based
practice in the 1990s was that social work recognized the
futility of some of its traditional methods in the face of the
multi layers of powerlessness found in many social work
clients, so that the necessity of facing the powerlessness issue
in the practice of social work was and is quite glaring.
Another remaining challenge is the structure of financial
renumeration for social services. Funding source structures,
such as third-party reimbursement for a service unit, mitigate
long-term, multilevel, multi-relationships in social service
agencies. Finally, in the age of research-based practice,
empowerment practice faces multiple challenges. One is the
aforementioned dual-focus on both the personal and the
structural or political. Such multilevel interventions are quite
difficult to isolate, unitize, and measure as input variables.
Moreover, measurement of outcomes on multiple levels is a
similarly formidable task. While it is widely agreed that
qualitative research evaluation methods may be wholly
desirable for evaluating empowerment-based practice
(Parsons, 1998), for some funding sources, more traditional
quantitative methodologies are required. And, while Parsons
(1999) and others have attempted to assess both program input
variables and desired empowerment outcome variables, these
multilevel concepts are often confounding for empirical
research design. (See Cox & Parsons, 2000; Parsons, 1999 for
full discussion and literature).
As we continue to experience the exponential growth of
interrelated social problems in our society, social workers will
look toward new and alternative intervention approaches.
Empowerment's potential for both prevention of social
problems and enabling client groups to create their own
solutions to problems will bode well for the continued creation
and usage of empowerment intervention approaches. Lowe
(1997) predicted the use of empowerment approaches in the
creation of a social health model in health care. Likewise,
Gutierrez (1997) prescribed an empowerment-based
"ethno-conscious" approach to practice with communities of
color.
REFERENCES
Bartle, E. E., Couchonnal, G., Canda, E. R., & Staker, M. D. (2002).
Empowerment as a dynamically developing concept for practice:
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EMPOWERMENT PRACTICE 125
Boyd, A. S., & Bentley, K.J. (2005). The relationship between the
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East, J. (1999). An empowerment practice model with low-income
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social work practice: A sourcebook. Pacific Grove, CA:
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Jordan, B. (2004). Emancipatory social work: Opportunity or
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Kieffer, P. C. (1984). Citizen empowerment: A developmental
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Lowe, J. I. (1997). A social-health model: A paradigm for social work
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Manning, S. S., & Suire, B. (1996). Bridges and roadblocks:
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Empowerment in social work practice: A sourcebook. Pacific
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SUGGESTED LINKS
http://www.undefineu.com
httj):/ /www.leadershijmainins).s.com
http://www.empowermenttraining.com
http://www . radpsynet. org/teaching/ gutierrez. html
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http://www . worldbank .org
-RUTH J. PARSONS
EMPOWERMENT ZONE, MICROENTER-
PRISE, AND ASSET BUILDING. See Asset Building.
END-Of-LIFE DECISIONS
ABSTRACT: As medical technology advances producing the
ability to prolong life almost indefinitely, individuals and families
are asked to make increasingly complex choices about what
treatments best correspond to their conceptions of how they wish
to die. These decisions create a need for attention to medical
aspects as well as psychosocial consequences. Social workers
play pivotal roles in ensuring access to needed information and
resources and in safeguarding individuals' rights to
self-determination in end-of-life decisions. This entry discusses
issues related to advance care planning, the process of end-of-life
decision making, and social work roles with individuals, families,
and health care providers.
KEY WORDS: end-of-life; decision making; life-sustain ing
treatments; advance care planning; advance direc tives; living
wills; hospice; palliative care; euthanasia; assisted suicide;
organ donation; terminal illness
Over the past few decades the once taboo subject of death has
entered into the public and private domains of everyday life.
Advances in medical technologies and treatments have been
developed with the ability to prolong life almost indefinitely
through artificial means. One result of these advances is that
human life expectancies have increased. More individuals are
living longer with chronic diseases that potentially cause
debilitation as a result of progression of the condition. During this
progression throughout the aging process individuals and families
may be offered a range of treatments that mayor may not increase
quality or quality of life. A key question then in all of this is when
would the treatments or technologies no longer provide a
meaningful benefit? Ethical dilemmas often arise in

the answer to this question, such as who should make the
decision about when treatment should be halted or does an
individual have a right to refuse treatment. Access to these
tremendous medical advances, such as organ transplants, is a
matter of justice because of the scarcity of some these
resources. Who chooses who lives and who dies? Media
attention surrounding physicianassisted suicide related to the
Oregon's Death with Dignity Act or as espoused and practiced
by Dr. Jack Kevorkian (1990s) and the attention to the Right to
Die case of Terry Schiavo (died in 2005, Florida) have also
thrust death and end-of-life issues and decisions into the fore.
In virtually every practice setting, social workers
encounter individuals and families facing end-of-life
situations. Specific discussion and decision making about
end-of-life treatment occurs in homes, offices, or hospitals,
and with the input of various participants. People may wish to
plan for end-of-life care, before becoming ill, upon initial
diagnosis, or in the chronic stages of a serious life- threatening
illness, through various forms of advance directives.
Regardless of the setting or immediacy of planning need, it
requires a high degree of commitment and competency given
the profound implications of decisions that affect life and
death.
Patient Self-Determination Act
A federal policy intended to promote the use of advance
directives, known as the Patient Self-Determination Act
(PSDA) (Public Law No. 101-508, 1990), became effective
December 1, 1991. The PSDA requires that everyone admitted
to or utilizing health care services that are Medicare and
Medicaid providers, such as hospitals, nursing homes, and
home health agencies, be asked if they have an existing
advance directive and when supplied, it is to be placed in the
medical record. Individuals who do not have an advance
directive must be informed of their right to formulate one.
Education is to be provided to individuals and to the
community-atlarge about advance directives and how to
formulate one.
Advance Care Planning
Advance care planning (ACP) is a broad term used to
encompass discussions about how someone wishes to be cared
for at the end of life. Through ACP, individuals make plans
that shape how decisions should be made about their health
care in the event they become decisionally incapacitated. Open
discussion with family, significant others, and medical
personnel is needed to understand what quality of life means to
individuals. ACP helps individuals prepare for death and gain
some sense of control in ensuring that their death is
END-OF-LIFE DECISIONS 127
consistent with the values by which they lived (Fischer,
Arnold, & Tulsky, 2000).
In ACP, if decisions are made about types of care desired
or not desired when afflicted with a life-threatening or
life-limiting medical condition, these decisions should ideally
be put in writing and shared with others, including family and
physicians. If no written directive is completed, the discussion
itself, referred to as an oral directive, still must be respected by
providers when people are not able to speak for themselves.
A "health care surrogate," "surrogate decisionmaker," or
"health care proxy" is someone who makes a medical decision
on behalf of another (Devettere, 2000). In ACP with healthy
individuals, the focus should be on naming a surrogate
decision maker. Undesirable end-of-life situations, and
preferences based on religious or cultural beliefs should be
discussed. Those who may have "atypical" surrogates, such as
a homosexual couple, are strongly encouraged to make this
designation formal, using a durable power of attorney (see
later). Initiating discussion when individuals are healthy is
encouraged but may be difficult because an impending need
does not exist. However, early dialogue is important so health
care professionals develop an understanding of individuals'
preferences and values for end-of-life care.
When individuals are diagnosed with a serious illness, the
focus may shift to discussion of more specific preferences
regarding life-sustaining treatments and undesirable outcome
states (Fischer, Arnold, & T ulsky, 2000; Teno & Lynn, 1996).
In individuals with a serious illness and limited life
expectancy more specific discussions about prognosis,
treatment options, and likely outcomes are necessary. Future
care plans during the progression of a terminal illness should
be elicited and preferences formally documented and existing
documents should be reviewed for changes in preferences and
updated. Health care professionals need to be aware that some
patients may not want to be involved in decisions and may
defer to the family because of their own family or cultural
norms. They have a responsibility to ask individuals how
much they want to know about their medical diagnosis,
treatment, and prognosis, and who should be involved in the
discussion and decision making.
Advance Directives
The intended goal of advance directives is to maintain the
decisional autonomy of incapacitated individuals (Buchanan
& Brock, 1990; Devettere, 2000). These documents
communicate the individual's wishes to surrogate decision
makers and health care providers who are faced with the task
of making decisions the
128 END-OF-LIFE DECISIONS
individuals would have chosen for themselves at a time when
they are not capable of doing so. All 50 states have passed statutes
protecting the use of advance directives, although the form of
advance directives and regulations regarding their use may vary.
Even though advance directives are acknowledged as an
important way to ensure future wishes are followed, evidence
exists that completion rates are low. Two controversial
assumptions inherent in advance directives are (a) presumption
that the instructional directive will communicate the individual's
wishes in such a way that the surrogate decision maker will make
the same decision as the individual would have made, and (b) that
preferences for end-of-life care will remain stable over time such
that an individual's wishes when incapacitated and in a
life-threatening situation, would be the same as when the
directive was formulated (Ditto, Jacobson, Smucker, Danks, &
Fangerlin, 2006).
Living Wills
The oldest type of advance directive in use is the "living will," a
term coined by Luis Kutner in 1969 (Ditto, 2006). Living wills
are considered "instructional advance directives," which may
specify, or "provide instructions" regarding life-sustaining
treatments an individual wants or does not want to receive. These
older forms are often very informal and ambiguous and are not
legally sanctioned in all states.
Durable Powers of Attorney for Health Care
In a "proxy" directive or durable power of attorney for health
care, individuals name a surrogate decision maker, usually a
family member, who will make decisions should the individual
become incapacitated. These named persons are expected to
assure that directives specified in the document are carried out.
As it is not possible to specify all medical situations that may
occur, surrogates are trusted to use substituted judgment or best
interest standards (see later) to make decisions. Potential
difficulties with these directives are that the named surrogates
may not be aware that they were named or the individuals may
not have discussed their wishes for treatment with them. The
preferred forms of advance directives are those in which a
surrogate decision maker is named and statements of individuals'
wishes are specified. Families find advance directives helpful
when honored by health care professionals because the "burden"
of decision making is removed and when not followed may
become angry (Mick, Medvene, & Strunk, 2003). Social workers
ease the decision making process by assisting health
professionals to validate and support decisions made either in the
advance directive by individuals or by named surrogates.
Focus of End-of-Life Decisions Counseling about
options for care may be held with individuals, families,
significant others including friends and clergy, and various health
care professionals. The discussions cover a range of care options
depending on the individual's specific medical condition and
social circumstances.
Life-Sustaining Treatments
CARDIOPULMONARY RESUSCITATION Among the most
common end-of-life discussions involve the provision of
cardiopulmonary resuscitation (CPR). CPR discussions often
occur when patients are hospitalized with a potentially terminal
or irreversible illness, upon admission to a long-term care
facility, home health care, or in-patient or home hospice or
palliative care. "Do-NotResuscitate" orders are physicians' notes
in patients' medical records that alert providers not to attempt
CPR. Some facilities may refer to these as "ONAR" orders or "Do
Not Attempt Resuscitation." If no orders exist, CPR will be
attempted if a cardiac arrest occurs. The assumption of CPR
treatment is why it is important for providers to discuss this
treatment and for patients to express a choice. If CPR has already
begun, and information about the patient's or family's desire to
refuse CPR is made known, the procedure may be stopped.
MECHANICAL VENTILA nON Ventilators are used to support
breathing temporarily while a patient heals from pneumonia or
some other form of reversible pulmonary illness. Ventilators are
also utilized to assist breathing during surgery when respiration is
depressed because of anesthesia. However, when a patient cannot
breathe without constant ventilator support it is then considered a
life-sustaining treatment and decisions must be made about
continuing it long-term.
ARTIFICIAL NUTRITION AND HYDRATION The purpose of
providing nutrition and hydration through intravenous lines and
tube feeding is to build and support the body as it heals. It is
considered a medical treatment and as such the right to refuse this
treatment exists. When individuals are in irreversible comas or
persistent vegetative states (PVS), decisions about sustenance
through artificial nutrition often become difficult ethical
problems for families and providers alike. In PVS, people are not
considered brain dead as some of the brain stem continues to
function. Sometimes enough of the stem functions enabling them
to live without life-support equipment, such as a ventilator. This
was illustrated in the case of Karen Ann Quinlan who survived 10
years, after the New Jersey Supreme

Court stated it was legally permissible to withdraw her
ventilator, because artificial nutritional support was
maintained.
DIALYSIS Dialysis is a form of renal replacement therapy and
under most circumstances is considered lifesustaining.
Although not a cure, dialysis can lengthen life indefinitely.
When acute renal failure is part of a multi-organ system
decline, dialysis delays the dying process. In those cases,
discussion about whether to initiate dialysis, or have a
short-term trial until further diagnostics can confirm
prognosis, may be held.
Hospice and Palliative Care
When curative or life-sustaining treatments become futile or
are no longer desired, hospice care provides a holistic
approach to comfort care at the end of life. Individuals and
families benefit from the palliative philosophy that addresses
medical needs, such as pain management, as well as
psychological, social, and spiritual needs with the goal of
realizing the best quality of life possible until death.
Euthanasia and Physician-assisted Suicide Passive
euthanasia is withholding or withdrawing lifesustaining
treatment and is legally sanctioned through the enactment of
an individual's advance directive or the decision of a
surrogate. In voluntary active euthanasia and
physician-assisted suicide (PAS) the intention is to hasten or
cause death of a competent person who has consented to the
act. The distinction is in the administration of the means of
death. Euthanasia involves the physician directly
administering a lethal dose of medication causing death. In
PAS, the physician prescribes medication and provides
instruction to patients on how to self-administer the lethal
dose. In 1997, two cases dealing with PAS came before the
U.S. Supreme Court: Washington v. Glucksberg and Quill v.
Vacca (New York). Decisions in both cases were against PAS
but a wide convergence existed among the justices' opinions.
There was agreement on four priniciples:
a. no general right to PAS existed in the Constitution;
b. a reasonable distinction exists between PAS and
withdrawing life-sustaining treatments (as practiced
through advance directives);
c. a fu ture case might establish a precedent for the right to
palliative care and adequate pain control; and
d. individual states are better suited to make policy about
PAS (Arons, 2004).
As of 2007, the only state to have legalized the practice of
physician-assisted suicide is Oregon through the Death with
Dignity Act. The actual numbers of
END-OF-LIFE DECISIONS 129
individuals who requested and completed PAS under the act
have been comparatively few. An attempt was made in 2001
by then U.S. Attorney General John Ashcroft to undermine
Oregon's law, and potentially other states that were pursuing
similar legislation, when an order was issued stating that
physicians would risk losing their licenses to prescribe drugs
listed in the federal Controlled Substances Act if they
prescribed pain medication that was intended to hasten death.
The debate reached the U.S. Supreme Court after several years
of litigation in Oregon, and the ruling issued in 2006 was
against the Ashcroft directive. A majority of the justices found
that it overstepped the bounds of the Attorney General's office,
particularly in trying to regulate medical practice outside of
drug abuse and prevention and for deciding what was in the
public interest without full evaluation of the factors involved
(Bloustein & Sachs, 2006). This was an important decision in
light of other states that have considered or are considering
legislation to legalize physician-assisted suicide.
Organ Donation
At this writing, over 90,000 individuals are waiting for an
organ donor. Organs may come from living donors or from
cadavers. The most common transplants with living donors
are kidney transplants. Before beginning the process with
cadavers, donors must be legally dead; in most cases, "brain
dead." Brain death was defined in the Uniform Determination
of Death Act (UDDA), which was first proposed in 1980 and
approved by numerous medical organizations. It has since
been adopted by a majority of states. According to the UDDA
an individual who is brain dead has sustained either
a. irreversible cessation of circulatory and respiratory
functions, or
b. irreversible cessation of all functions of the entire brain,
including the brain stem (Devettere, 2000).
Discussions with individuals and families about organ
donation often focus on altruistic motives including desire to
leave a legacy or make some "good" come from an
individual's perhaps premature death as well as logistical
aspects of organ procurement and potential delay of funeral
arrangements. Desire for organ donation can be, but is not
typically, specified in an advance directive. While many states
allow individuals to indicate a preference regarding organ
donation on their drivers' licenses, families or surrogates still
need to make the final decision (although the license
indication may guide their decisions). This effort combined
with educational campaigns particularly aimed at culturally
diverse groups have tried to increase the
130 END-OF-LIFE DECISIONS
number of transplants performed and thus lives prolonged.
However, many individuals die while waiting for an organ
donation and maintaining hope and preparing for death at the
same time is a difficult task for these individuals, their
families, and health care professionals (Csikai & Chaitin,
2006).
Process of Decision Making
A hierarchy of standards in end-of-life decision making
exists: the subjective standard, followed by the substituted
judgment standard, and then the best interests' standard
(Buchanan & Brock, 1990; Devettere, 2000).
The Subjective Standard advocates for autonomy and
self-determination of incapacitated individuals by demanding
proof or knowledge of the individuals' actual (subjective)
wishes. A written advance directive is the best proof of
anticipatory wishes of the individual (Miesel, 1989). This
standard was referred to in the case of Nancy Cruzan in which
the State of Missouri requested, "clear and convincing
evidence" of Ms. Cruzan's wishes related to discontinuation of
her feeding tube.
The Substituted Judgment Standard applies when sur-
rogates make medical decisions for incapacitated individuals
on the basis of information previously provided regarding
wishes for or against certain medical treatments. This
knowledge may come from direct discussion or indirect
statements made by the individual. The surrogate is instructed
to choose, as the individual would have if competent.
Sometimes, insufficient evidence exists of what the patient
would have wanted because the individual, when competent,
never expressed her or his viewpoint or expressed contrary or
inconsistent viewpoints in the past. In addition, it is
impossible to apply the substituted judgment standard in
situations where the patient lacked capacity from birth
(Buchanan & Brock, 1990).
The Best Interests Standard applies in cases where
individuals have not executed advance directives, have never
discussed their wishes regarding certain medical treatments,
or have never been considered to have decision making
capacity In enacting this standard the surrogate chooses
treatment believed to be of maximum benefit to the individual
considering all things, not just the outcome of a single
treatment (Devettere, 2000). In this standard, as in others, full
disclosure of medical options, including risks and benefits is
essential in order for a surrogate to decide what is in the
individual's "best interests."
This hierarchy is aimed at protecting individuals' rights to
self-determination since this right of self-determination does
not end when individuals are
no longer decisionally capacitated (Ditto, 2006). It is
incumbent upon surrogates and health care professionals to
uphold this right. However, families may for a number of
reasons act to override individuals' expressed preferences
because of unfamiliarity with these wishes or elements and
conflicts that may have previously existed in their
relationships. Even though advance directives are accepted
and have legal authority, health care providers tend to give in
to the families' choices rather than strictly adhere to these
documents. Agreement among all parties, although not
necessary, is sought (Csikai & Chaitin, 2006).
Social Work Roles
Social workers have vital roles at both micro and macro levels
The primary values of social work provide guidance for social
work practice in end-of-life decisions. Foremost among these
is respect for the dignity and worth of each person. When
individuals are faced with life-threatening health conditions,
social workers have a responsibility to respect and promote
individuals' rights to self-determination. To accomplish this,
ensuring access to accurate, truthful information about
diagnosis, prognosis, and end-of-life care treatment options is
essential so that informed decisions about what course of
action can be made in accordance with individuals' personal
values and wishes for how they want to die.
Recognition of the importance of human relationships is
also central to the process of end-of-life decision making. As
individuals and families interact in the health care system,
relationships are formed with providers who help guide their
medical care. Often as illness progresses, the number of
providers increases as specialists may be consulted. The more
providers, the more complex communication becomes, and
the greater the chance of miscommunication and conflict.
Because end-of-life decisions require synthesis of complex
medical information, in a liaison role, social workers may
coordinate family conferences. The purpose of such
conferences is to ensure an exchange of information between
individuals, families, and the health care team so that
everyone "hears" the same information about diagnosis,
prognosis, and treatment and care options, including risks and
benefits. Conferences are also vehicles to correct
misinformation, discuss patient and family wishes, and make
decisions required for future treatment planning. During these
meetings, social workers can also help health care team
members understand patients' and families' fears, hopes, and
wishes regarding end-of-life care. After the meetings, social
workers assist patients and families to process the in-
formation, facilitate further communication and decisions,
and attend to the feelings associated with such

emotional and sensitive content. At times, the liaison role is
enacted informally with the social worker in a central relationship
facilitating interactions between individuals and their families
and between individuals, families, and medical providers.
Social workers also have advocacy and leadership roles to
play inside their institution and in the community with respect to
issues of social justice. These include inadequate pain
management for minorities and women, rationing of resources to
control costs, and low rates of minority enrollment in hospice.
Social workers should advocate for equal access to end-of-life
care resources and help providers examine their own values and
practices related to these issues. As educators, social workers can
promote adequate understanding of the psychosocial and spiritual
needs of dying individuals and their families. Also, when
possible, social workers should serve on health care ethics
committees (Csikai, 2004; Csikai & Sales, 1998) and participate
in other local, state, and national organizations, task forces, and
committees to promote social justice and safeguard individuals'
rights to self-determination at the end of life (DeSilva & Clark,
2006)
Social workers have a responsibility to be aware of their own
personal values and capabilities regarding end-of-life care.
Continuing education about emerging policies and ethical issues
is imperative. Additionally, social workers must seek
consultation and support when difficult situations arise,
professionally and personally, particularly because working with
dying individuals and their families on an ongoing basis makes
social workers susceptible to compassion fatigue. Appropriate
self-care can enable effective social work practice with people
through what is a critical time in their lives.
REFERENCES
Arons, S. (2004). Current legal issues in end-of-life care. In J. Berzoff
& P. Silverman, (Eds.), Living with dying: A handbook for
end-onife healthcare practitioners (pp. 730-760). New York:
Columbia University Press.
Bloustein, ]., & Sachs, P. (2006). Medill News Service, Retrieved
October 23, 2007, http://docket.medill.north
westem.edu/archives/002179.php
Buchanan, A. E., & Brock, D. W. (1990). Deciding for others:
The ethics of surrogate decision making. New York: Cambridge
University Press.
Csikai, E. L. (2004). Social workers' participation in the resolution of
ethical dilemmas in hospice care. Health & Social Work, 29(1),
67-76.
Csikai, E. L., & Chaitin, E. (2006). Ethics in end-oJ-life decisions in
socia! work practice. Chicago: Lyceum Books
Csikai, E. L., & Sales, E. (1998). The emerging social work role on
hospital ethics committees: A comparison of social worker and
chair perspectives. Social Work, 43(.3),233-242.
END-OF-LIFE DECISIONS 131
DeSilva, E. c., & Clarke, E. J. (Eds.). (2006). End-of-life care.
Social Work Speaks (pp. 129-135).
Devettere, R. J. (2000). Practical decision making in health care ethics:
Concepts and cases (2nd ed.). Washington, DC:
Georgetown University Press.
Ditto, P. H. (2006). Self-determination, substituted judgment, and the
psychology of advance medical decision making. In J. L. Werth,
Jr. & D. Blevins (Eds.), Psychosocial issues near the end of life.
Washington, DC: American Psychological Association.
Ditto, P. H., Jacobson, J. A., Smucker, W. D., Danks, J. H., &
Fagerlin, A. (2006). Context changes choices: A prospective study
of the effects of hospitalization on life-sustaining treatment
preferences. Medical Decision Making, 26( 4), 313-322.
Fischer, G. S., Arnold, R. M., & Tulsky, J. A. (2000). Talking to the
older adult about advance directives. Clinics in Geriatric
Medicine, 16(2),239-254.
Mick, K. A., Medvene, L. J., & Strunk, J. H. (2003). Surrogate
decision making at end of life: Sources of burden and relief.
Joumal of Loss and Trauma, 8, 149-167.
Miesel, A. (1989). The right to die: The law of end-oJ-life deci-
sionmaking. New York: Wiley Law Publications, John Wiley &
Sons.
Teno, J., & Lynn, J. (1996). Putting advance-care planning into
action. Joumal of Clinical Ethics, 7(3), 205-213.
FURTHER READING
Berzoff, J., & Silverman, P. (Eds.). (2004). Living with dying: A
handbook for end-of-life healthcare practitioners. New York:
Columbia University Press.
Hendin, H. (1995). "Selling of death and dignity." Hastings Center
Report, 25(3),19-23. (CPk).
Jansson, B. S., & Dodd, S. J. (2002). Ethical activism: Strategies for
empowering medical social workers. Social Work in Healthcare,
36(1), 11-28. (CPk.)
Mizrahi, T. (1992). The direction of patients' rights in the 1990s:
Proceed with caution, Health and Social Work, 17 (Nov.), 246-252.
Roff, S. (2001). Analyzing end-of-life care legislation: A social work
perspective. Social Work in Health Care, 33(1), 51-68. (CPk.)
Werth, J. L., & Blevins, D. (Eds.). (2006). Psychosocial issues near the
end of life: A resource for professional care providers. Washington,
DC: American Psychological Association.
SUGGESTED LINKS Center to Advance
Palliative Care http://www.capc.org
Caring Connections: for links to state-specific advance directives
(part of the National Hospice and Palliative Care Organization)
http://www.nhpco.org
http://www . caringinfo .org
End-of-life/Palliative Education Resource Center, sponsored by the
Medical College of Wisconsin
http://www.eperc.org
132 END-Of-LIFE DECISIONS

The Hastings Center: a nonpartisan, non-profit bioethics research this human-driven change has occurred from 10 to100 times
institute faster than normal variability. For instance, the IPCC report
www. thehastingscenter. org states that concentrations of carbon dioxide, methane and
National Resource Center on Diversity in End -of-Life Care other greenhouse gases in the atmosphere are at their highest
www.nrcd.com level in at least the last 650,000 years. With this growing
NASW Standards for Social Work Practice in Palliative and awareness of the earth's tenuous ecological and climatic
End-of-Life Care conditions, social work can exercise its traditional
www. naswdc . org/ practice/bereavement/ standards/default. asp Oregon
commitment to environmental concerns and find new ways to
Department of Human Services for information on the Oregon
express and operationalize these concerns in a rapidly chang-
Death with Dignity Act www.oregon.gov/DHS/ph/pas/ors.shon[
ing world. Social work's traditional efforts to address
United Network for Organ Sharing
www. unos. org environmental factors impacting individual and social
well-being, such as settlement house work to improve
sanitation, establish playgrounds and green space, and efforts
-ELLEN L. CSIKAI to eliminate oppressive and dangerous labor practices for
children, are key historical precedents (van Wormer, Besthorn,
& Keefe, 2007).
ENVIRONMENT

ABSTRACT: The earth's climatic and environmental T rends and Direc tions
conditions appear to be going through rapid and dramatic The earth is a living, biological organism made up of a myriad
changes. Social work has traditionally distinguished itself by of interdependent and interconnected parts. Each part of the
claiming a particular focus on person/ environment organism exists in a relative state of equilibrium but all
transactions. The balance between the person and the interact and must, thus, adapt as changes in one part of the
environment has not been easy to maintain-especially with the system impinge upon every other part. Because of the
environmental construct often becoming constricted to small interconnectedness of the earth's complex ecological systems
scale personal space and existing social systems. In the global environmental change is often gradual and almost
context of a growing environmental crisis and international imperceptible until critical thresholds are reached. At these
awareness of the earth's tenuous ecological condition, social tipping points, a far more rapid change of direction often
work can reclaim its traditional commitment to environmental ensues, such as the documented and unprecedented
concerns and find new ways to express and operationalize accelerating rate of the melting Arctic ice sheet. Many of the
these in a rapidly changing world. changes taking place at this moment are most likely
irreversible in any meaningful human time frame
(Worldwatch Institute, 2006). Future climatic changes, many
KEY WORDS: environment; ecology; environmental of which have already been set in motion, are equally
degradation; person/environment; climatic change; deeper unpredictable and may be unstoppable. The impact of global
ecology; ecojustice; ecosocialwork; environmentally sensitive environmental degradation is complex, as it often combines
practice with local ecological as well as social and economic stresses
in unexpected ways. High levels of carbon dioxide emissions
The earth's climatic conditions appear to be changing at an coming from the consumer driven economies of the global
ever increasing pace (Brown, 2006). Since the 1980s, many north are rapidly mixed throughout the atmosphere-severely
indicators of the world's ecological health have precipitously impacting even the poorest nations on the planet. Agribased
worsened, as evinced by increasing levels of carbon dioxide in herbicidal, insecticidal, and synthetic fertilizer pollutants
the atmosphere, higher mean global temperatures, ozone released into the ocean in one location are transported to
depletion, species extinction, deforestation and loss of distant parts of the planet with unpredictable results. Local
biodiversity. The changes measured by these indicators seem and regional ecological problems can create global
to be well beyond any naturally occurring variability that environmental catastrophes.
could have been predicted over the course of the earth's
ancient climatic history (Rornm, 2006). According to a 2007
report by the United Nations Intergovernmental Panel on Social Work's Roles
Climate Change (IPCC) there is widespread evidence of an HISTORY The social work profession has long sought to
anthropogenic or human-driven cause to the earth's dramatic distinguish itself from other helping professions by claiming
climate changes. In some cases, as its particular domain the transactions between persons and
environment (Saleebey, 2001).

However, there remain gaps in the common concep-
tualization of environment in social work theory and
practice. These gaps have sometimes limited the profes-
sion's capacity to envision responses to serious environ-
mental conditions, which, as suggested, are likely to
escalate in severity in the 21 st century.
Some years ago, social work theorist Bartlett (1970) ,
and a bit later Weick (1981) and Germain and Gitterman
(1980) began to recognize that social work's
person-in-environment construct implied a kind of
co-equal synthesis, but as commonly used was plagued by
a problematic ideological oscillation. Social workers often
dichotomized person and environment through the use of
such oppositions as micro/macro practice, direct/policy
practice, and individual/social change. It is not surprising
that the personal dimension of the person-environment
construct came to be emphasized over the environmental
dimension, since much of social work practice is done with
individuals or small social systems. Thus, the environment
itself is typically narrowed in practice to a relatively
small-scale personal space and social systems and is less
about the connection between person and natural
environment and the way humans derive meaning and life
sustaining support from this association (Besthorn and
Canda, 2002).
RELEVANT THEORY Some attempts had been made to
correct this imbalance by emphasizing the importance of
the social context and interrelationships be tween micro
and macro systems, such as the life model, the ecological
perspective, and dynamic systems theory (Robbins,
Chatterjee, & Canda, 2006). Each of these models, to
varying degrees, focuses on the whole-part interaction of
systems and assists the profession in considering a more
holistic framework for understanding the human
condition. They have helped expand professional
conceptualizations of human interaction from earlier
linear, atomistic and mechanical models (van Wormer,
Besthorn, Keefe, 2007). However, most of these
theoretical advances continued to place primary emphasis
on local human systems and consider the larger global
environment only tangentially.
A new generation of social work theorists such as
Besthorn (2002, 2005); Hoff (1998); Rogge (2000); and
Unger (2003) have emphasized the need for social workers
to address the natural environment more explicitly. They
have begun to formulate theoretical perspectives that
provide social work an opportunity to take a fresh look at
its core environmental concerns. They have pointed out
that human problems are compounded and often made
worse when social workers ignore the damage inflicted on
the natural environment by human beings. Human damage
to natural
ENVIRONMENT
133
ecosystems impairs the very life web upon which all life
depends. Additionally, new Internet Web sites by and for
social workers have also been developed in recent years to
help professionals assess their need to consider a deeper
ecological concern (see list following this entry).
The Board of Directors of the National Association of
Social Workers has also taken an important step in ac-
knowledging urgent environmental concerns by proposing
a proactive environmental policy stance (Humphreys &
Rogge, 2004). The International Federation of Social
Workers (IFSW) has also developed a similar statement of
emphasis (http://www.ifsw.org/en/p38000222.html).
These policy proposals suggest human beings are at risk of
life-threatening consequences from unchecked envir-
onmental degradation and the consequences of this de-
gradation will continue for generations to come. The
proposals assert that ecological exploitation violates so cial
work's core commitment to social justice and is a direct
violation of our professional ethics.
CONTRIBUTION FROM OTHER DISCIPLINES Dra-
matic changes in the ecological landscape and in global
consciousness are forcing the world community toward
recognition of the intricate interconnections between
humans and nature and the need for a deeper ecological
worldview (Brown, 2006). The perception is widening
internationally that humanity-its consciousness, its
technology, its definitions of happiness and success, its
economic and social agendas, and its political systems can
no longer be defined in terms which exclude the natural
environment. Many scientific and theoretical disciplines
and cultural traditions are suggesting that the
interdependency between humanity and the natural
environment represents both an aesthetic preference and
biological necessity. For example, emerging work in Eco-
psychology, Environmental Psychology, Environmental
Sociology, Deep Ecology, Ecological Feminism, Social
Ecology, Environmental Ethics, Gaian Theory,the Bio-
philia Hypothesis and Indigenous Ecological Wisdom
(Goldfarb, 2000; Gottlieb, 1996; Wilson, 2002) and eco-
logical insight into the world's major religions such as
Judaism, Hinduism, Buddhism, Christianity, and Islam
demonstrate that human well-being is intricately con-
nected with the well-being of the natural world. The se
disciplines and traditions offer creative responses to the
world's environmental problems as well as innovative
ways of revisioning social work's person-environment
construct that takes into account the essential interrelat-
edness of human beings to the natural world.
SOCIAL JUSTICE ISSUES There is an inherent social
justice logic in an emerging deeper ecological
134 ENVIRONMENT
worldview. Promising new work in social work theory and
practice suggests that struggles against oppressive, systemic
forces that denigrate nature are intertwined with struggles
against all forces that oppress human beings (Van Wonner,
Besthorn, & Keefe, 2007). The oppression that keeps
realization of a dynamic, interdependent human-nature
relationship out of consciousness is connected to other forms
of human oppression, including economic exploitation,
racism, sexism, and patriarchy. For example, as poor
populations around the world stretch the carrying capacity of
their ecological bioregions in order to survive or to fuel first
world economic development, they use up much of their
natural capital and are thereby further impoverished. Though
human oppression and subjugation of nature appear to exist in
separate forms, struggle against anyone in isolation cannot be
effective. This interlocking character of human/environmental
oppression changes the identity of conventional social work
toward a deeper social activism. It encourages social work's
involvement in fostering a radical realignment of the social,
political, economic, and ecological structures and strategies of
modern, industrial society (Besthorn & Canda, 2002).
The traditional commitment of social work is to support
well-being and social justice for everyone-all humans.
Proponents of environmental social work argue that
well-being and justice for all humans can only be achieved by
working for well-being and justice on behalf of all the beings
and sustaining creatures around us (plants and animals), and
the encompassing planetary ecosystem (Besthorn, 2004b;
Humphreys & Rogge, 2004; Rogge, 2000). While it is
important to make human beings the focus of change activity,
this view suggests that it is not reasonable to exclude all other
beings and larger ecosystems that sustain human life.
Exclusion gives rise to a kind of shallow activism, which often
leads to impossible results in that we inadvertently diminish
the sustaining natural environment while trying to help people
live better. In the short term, some people's lives improve
materially, while in the long run, we degrade the world upon
which all depend for survival.
Challenges
Many self-contradictions arise from this limited social
activism. For example, while traveling to conduct home
studies and community outreach, people may be excessively
polluting the air with inefficient gasoline engines. While
lighting agency buildings, staff may be using energy
inefficient bulbs that contribute to a further increase in
greenhouse gases. In spreading pesticides for hygiene in
family service centers, educators may be poisoning children
as they play on the floor. In using computers for information
management,
administrators may cause repetitive motion injuries and
radiation hazards for staff, waste trees by using non-recycled
paper, and pollute the environment with hazardous materials
such as silicon, plastics, and heavy metals. Additionally, new
scholarship is emerging in social work that is addressing the
positive impact that natural settings, domestic animals, and
horticultural practices can have in preventative health
(Besthorn, 2004a; Besthorn & Saleebey, 2003; Unger, 2003).
Roles for Social Work
The primary purpose for teaching theory in social work is to
guide practice. Practitioners often ask: What difference does it
make? A deeper ecological social work can open up
innovative opportunities that emphasize the helpful results of
human-nature harmony. For example, practitioners can revive
a more literal rendering of a long-held social work
commitment to the idea of outdoor relief. Indeed, new
generations of practitioners are beginning to look
outdoors-outside the confines of office and agency in order to
utilize the experiential, imaginative, and consciousness
altering properties of wilderness and natural settings as a way
to help clients realize a deeper sense of interconnectedness
(Bartlett, 2003). The experience of natural places opens people
up to a vivid realization of their practical dependence on
nature, the need for cooperative relations between people for
survival and social enjoyment, and the beauty and profundity
of the ecological life web. Canda (1983) pointed out that when
social workers utilize the therapeutic and inspirational
qualities of nature in practice, they are tapping a resource for
healing that has been addressed in ancient healing protocols
for thousands of years.
One group who may especially benefit from experiences in
nature are children living in urban centers. There is growing
evidence suggesting that helping methods based on the
healing effects of nature have important social and
psychosocial effects on children's development and resilience
(Besthorn, 2004a). This kind of practice does not necessarily
require busing large groups of children to natural preserves or
sending them to Fresh Air Fund camps. It can be as simple as
bringing the natural environment to children through the
introduction of household pets or horticultural in terests in the
environments where the children live. Caring for and playful
interaction with small animals, tending flowers or gardens, or
exploring urban green spaces can facilitate empathetic
capacities and foster responsibility, inner confidence, and
relaxation skills. For instance, introducing a group of children
to the sights, sounds, and tactile sensations of a small farm can
be a moving and lasting experience.

A deeper ecological social work can also lead to innovations
in how human service agencies organize themselves and what
form their policies and programs take. For example, an agency
facility could assess itself for its level of energy efficiency, its
recycling strategies, and the way it affects the natural
surrounding. A guiding question might be: How can the activity
of this agency enrich the beauty of clients' lives as well as the
natural beauty of the neighborhood in which the building is
situated? The Green House Concept (Rabig, Thomas, Kane,
Cutler, & McAlilly, 2006) and Eden Alternative (Thomas, 1996)
in gerontological practice are two examples of how this question
is leading to ecologically friendly facilities and practices.
At the level of macro practice, a deeper ecology alerts social
workers involved with political action, policy formation, and
international social welfare to both questions and to work at
developing solutions that include benefit to both humans and
nonhumans. In social development planning, deep indicators of
social and individual well-being would replace materialistic
standards of increasing consumption with ecocentric standards of
increasing quality of life and ecojustice, which supports the rights
and dignity of all beings. Macro practitioners have the
opportunity to organize against toxic wastes and the
disproportionate siting of polluting factories and depots in poor
and marginalized communities ("environmental racism"),
organize cleanup campaigns, promote alternative transportation
such as safe bicycle routes, plan community gardens, and in
general promote efforts that contribute to the sustainabilitv and
flourishing of all life.
Similar analysis can be applied to social work education to
create a learning atmosphere that is congruent with deeper
ecological sensitivity. Can educators draw on examples from
their personal life style and professional practice to illustrate
deeper ecological awareness and urge that social work's
educational program and curricula operate in environmentally
responsible manners (Kahn & Scher, 2002)? Can they integrate
global events and issues connected with local concerns into
agency and school discussions?
While there is still some debate over the extent of
human-driven climatic change, there is little dispute that humans
are altering the earth's life support system. The rate of
human-driven change is pushing the planet into a far less
supportive state, to the point of ecological and social collapse
(Diamond, 2005). Such large-scale and long-term environmental
changes present major practice and policy challenges for the
social work profession. Social work finds itself at an
environmental crossroads. It can maintain a safe distance outside
the debate over issues of global environmental degradation
ENVIRONMENT 135
or it can begin to forge its own deeper ecological awareness. This
awareness would begin focusing on theoretical formulations and
policy and practice protocols at the local, national, and
international levels to cope with the uncertainty, complexity, and
magnitude of global change. The consequences for society and for
the profession of remaining at a safe distance may be huge. Never
before has an effective multilateral, international, and
interdisciplinary planning for action been more necessary. Social
work can playa major role in deciding between accepting the
challenge to respond in a forthright manner and waiting until a
catastrophic, irreversible change is upon us.
REFERENCES
Bartlett, H. (1970). The common base of social work practice.
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Bartlett, M. (2003). Two movements that have shaped a nation: A
course in the convergence of professional values and
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Besthorn, F. H. (2002). Radical environmentalism and the ecological
self: Rethinking the concept of self-identity for social work
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Besthorn, F. H. (2004a). Beetles, bullfrogs and butterflies:
Contributions of natural environment to childhood development
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handbook of theory, methods and interventions (pp. 106-127).
Thousand Oaks, CA: Sage Publications.
Besthorn, F. H. (2004b). Restorative justice and environmental
restoration- Twin pillars of a just global environmental policy:
Hearing the voice of the victim. Journal of Societal and Social
Policy, 3(2), 33-48.
Besthorn, F. H. (2005). Globalized consumer culture: Its implications
for social justice and practice teaching in social work. Journal of
Practice Teaching in Health and Social Work, 5(3),20-39.
Besthom, F. H., & Canda, E. R. (2002). Revisioning environment:
Deep ecology for education and teaching in social work. Journal of
Teaching in Social Work, 22(1/2), 79-102.
Besthorn, F. H., & Saleebey, D. (2003). Nature, genetics and the
biophilia connection: Exploring linkages with social work values
and practice. Adt'ances in Social Work, 4(1), 1-18.
Brown, L. (2006). Plan B 2.0: Rescuing a jJlanet under stress and a
civilization in trouble. New York: W. W. Norton.
Cauda, E. R. (1983). General implications of shamanism for clinical
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Diamond, ]. (2005). CollajJse: How societies choose to fail or succeed.
New York: Penguin Press.
Germain, C. B., & Gitterrnan, A. (1980). The life model of social work
jJT1!ctice. New York: Columbia University Press.
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Goldfarb, T. D. (Ed.). (2000). Notable selections in environmental
studies (2nd ed.). New York: McGraw-HilI.
Gottlieb, R. S.(Ed.). (1996). This sacred earth: Religion, nature,
environment. New York: Routledge.
Hoff, M. (Ed.). (1998). Sustainable community development:
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Boston: Lewis Publishers.
Humphreys, N., & Rogge, M. E. (2004). Environmental policy. In
National Association of Social Workers, Social Work Speaks: NASW
Policy Statements (2004-2006, 6th ed.). Washington, DC: National
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Kahn, M., & Scher, S. (2002). Infusing content on the physical
environment into the BSW curriculum. The Journal of
Baccalaureate Social Work, 7(2), 1-14.
Rabig, j., Thomas, W., Kane, R. A., Cutler, L. ]., & McAlilly, S.
(2006). Radical. redesign of nursing homes:
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Gerontologist, 46(4),533-539.
Robbins, S., Chatterjee, P., & Canda, E. R. (2006). Contemporary
human behavior theory: A critical perspective for social work (2nd
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Rogge, M. E. (2000). Children poverty, and environmental
degradation: Protecting current and future generations. Social
Development Issues, 22(2/3), 46-53
Romm, ]. (2006). Hell and high water: Global warming-the solution and
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Saleebey, D. (2001). Human behavior and social environments.
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Thomas, W. (1996). Life worth living: How someone you love can still
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MA: VanderWyk & Burnham.
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VanWormer, K., Besthorn, F. H., & Keefe, T. (2007). Human behavior
and the social environment macro level: Groups, communities and
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SUGGESTED LINKS
http://www . ecosocialwork.org/index. html
http://web . utk.edu] -rnetogge]
http://designtrek. ragingweb . com/
http://www.ifsw.org/en/p38000222.html
http:// www.socialworkers . orgjresourcesloossractsloostractsl
environmental.asp
http://www.ipcc.ch/
http:// www . nrdc . org/ globalW arming/default. asp
http://www . epa.gov/climatechange/index .html
http://www.ucsusa.org/ http://unfccc.int/2860.php
http://www.unep.org/
http://www . cep. unt. edu/Comment/elitZHT. html
http://www .deep-ecology .org)
http://www.cehn.org/
-FRED H. BESTHORN
ENVIRONMENTAL JUSTICE
ABSTRACT: The concept of environmental justice gained
currency in the public arena during the latter part of the
20th century. It embodies social work' s
person-in-environment perspective and dedication to
people who are vulnerable, oppressed, and poor. The
pursuit of environmental jus tice engages citizens in local
to international struggles for economic resources, health,
and well-being, and in struggles for political voice and
the realization of civil and human rights.
KEY WORDS: environmental justice; health disparities;
sustainable development; climate justice; precautionary
principle; community-based participatory research
The concept of environmental justice gained currency in the
public arena during the latter part of the 20th century. It embodies
social work's person-inenvironment perspective and dedication to
people who are vulnerable, oppressed, and poor. The pursuit of
environmental justice engages citizens in local to international
struggles for economic resources, health, and well-being, and in
struggles for political voice and the realization of civil and human
rights.
Definitions and Concepts
In the United States, environmental justice has been defined as
"fair treatment and meaningful involvement of all people
regardless of race, ethnicity, income, national origin, or
educational level with respect to the development,
implementation, and enforcement of environmental laws,
regulations, and policies. Fair treatment means that no
population, due to policy or economic disempowerment, is forced
to bear a disproportionate burden of the negative human health or
environmental impacts of pollution or other environmental
consequences resulting from industrial, municipal, and
commercial operations or the execution of

federal, state, local and tribal p rograms and policies."
(United' States Environmental Protection Agency, Office
of Federal Activities, 1998, p. 2). This legal pre scription
integrates environmental justice principles em phasized by
advocacy groups: environmental policy and regulations
should assure that minority and low-income populations
have equal political voice in decision making processes,
equal access to the benefits of, and equal protection from
harm with regard to environmental resources (Bullard,
Mohai, Saha, & Wright, 2007).
Environmental justice is embedded in sustainable
development or sustainability (Gamble & Hoff, 2005).
Shorthand definitions of this complex construct often note
the importance of attending simultaneously to the "three
Es" of equity (social justice), econom y, and environment to
manage world resources for current and future generations
(Rogge, 2000). In the context of sustainability and
environmental justice, Hart (2006) provides useful
definitions of the built environment (that is, buildings,
equipment, infrastructure, informa tion, and technology)
and the natural environment (that is, natural resources
including food, air, water, metals, and energy; ecosystem
services including fertile soil and water filtration; and the
beauty of nature).
Historic and International Context
For many people in the United States, environmental
fairness emerged as a national issue in the late 1970 s with
the controversy over the chemical contamination of Love
Canal, a largely European American, working class
neighborhood in Niagara Falls, New York, parts of which
were built on top of an industrial toxic waste dump (Center
for Health, Environment, and Justice, 2007). With regard to
racial, ethnic, and low income populations, however, the
rise of environmental justice as a national movement is
most often associated with the 1982 unsuccessful battle of
African American residents of Warren County, Alabama,
to prevent the location of a commercial toxic waste dump
in their county. Others note events dating from farm
workers' struggles in the early 1960 s for protection from
pesticides and other labor rights. The 1964 Civil Rights Act
(Title VI) and President W. J. Clinton's 1994 Executive
Order 12898 continue to be anchor points for ongoing
efforts to implement and expand environmental jus tice
legislation at local, state, and national levels (Bullard et al.,
2007). Executive Order 12898, " Federal Action to Address
Environmental Justice in Minority Populations and
Low-Income Populations," requires all federal agencies to
integrate environmental justice into their mission, action
strategies, and research, with an emphasis on
disproportionate health effects from environment- related
exposures (Executive Order
ENVIRONMENTAL JUSTICE
137
No. 12898, 1994). Internationally, initiatives to add ress
synergistic environmental, economic, and social justice
problems, with emphasis on disproportionate threats to
women, children, racial and ethnic minorities, and
low-income populations, are exemplified in the United
Nations Millennium Development Goals and Agenda 21
guidance (Pruss-Ustun & Corvalan, 2006). Many
nongovernmental organizations address environmental
justice in neighborhoods and communities and incre asingly
collaborate regionally, nationally, and inter nationally via
the Internet (Center for Health, Environment, and Justice,
2007; Pesticide Action Network of North America, 2007).
Challenges
Environmental injustice derives from a broad range of
environmental resource depletion and degradation is sues.
Rural, poor communities face the loss of access to water as
public water supplies are privatized, rivers and streams are
redirected to metropolitan areas, or wel1 water is
contaminated by toxic waste dumping (Shiva, 2002 ).
Laborers face low wages and exposure to injury and
hazardous chemicals in under- or unregulated industrial,
commercial, and agricultural workplaces. Global warming
and climate change have generated "climate justice" issues.
These climate-related environ mental justice issues include,
for example, disproportionately high effects on people of
color and low-income from natural- technological disaster
such as Hurricane Katrina in the United States in 2005, and
the loss of Arctic indigenous people's homelands as polar
regions melt (Pastor et al., 2006). Poor communities with
low mobility suffer most in conditions of drought,
desertification, and flood (Rogge, 2000).
Suspected and documented environmental justice
problems include health disparities and the geographic
distribution of environmental hazards. In the United States,
the location of toxic waste processing facilities and dumps
was central to the emergence of the national environmental
justice movement. In 2007, after over 20 years of
controversy and increasingly rigorous re search, evidence
indicates that people of color a nd who have low incomes do
tend to live disproportionately close to industrial and
commercial sources of chemical contamination (Ringquest,
2005). For example, the population of neighborhoods, in
which commercial hazardous waste facilities are located
averages 56% people of color compared with 30% people
of color in neighborhoods with no such facilities. The
neighborhoods also have 1.5 times the poverty rate (18%
vs, 12%). (Bul1ard et al., 2007).
Social workers are familiar with many heal th issues,
such as cancer, infant mortality, and the incidence of
138 ENVIRONMENTAL JUSTICE
HIVjAlDS that have been associated with economic and
social inequity (Gorey, 1995). Factoring in environmental
justice adds new variables, such as multiple and synergistic
effects of chemicals in pollution and in household and
industrial products, to the already complex processes of
identification, assessment, intervention, and evaluation of
health disparities. Models, measures, monitoring techniques,
and analytic capabilities of environmental sources of health
disparities continue to reach new levels of sophistication. The
2003 National Exposure Report, designed to establish a
baseline estimate of human exposure to pollution using a
representative cross-section of U.S. citizens, measured over
100 chemicals including pesticides, dioxins, pthlalates, and
other chemicals associated with adult and childhood cancers:
respiratory and cardiovascular illness, endocrine disruption,
and developmental disabilities (Poppell, 2003).
Accounting for limitations in existing research, there is
evidence that environmental factors contribute to health
disparities. Epidemiological studies have found that
individuals living near hazardous waste sites and industrial
areas have increased risk for certain cancers. There is
evidence that African Americans, Hispanic Americans, and
some Asian American populations have higher rates of certain
cancers associated with environmental hazards
(Morello-Frosch & J esdale, 2006). Epidemiological evidence
suggests that farmers, at risk for exposure to pesticides and
other chemicals, have above average risk for certain cancers;
there has been relatively little study of the health of
farrnworkers and their families with regard to such exposure
(Payne-Sturges & Gilbert, 2006). There is little to no
health-related research in other areas including chemical
exposure in beauty salons, often staffed by women, many of
whom are immigrants (Gorman & O'Connor, 2007).
The National Exposure Report represents advances in
research technology and methods that can better detect what
proportion of health disparities are attributable to
environmental, social, and economic inequities. Another
major advancement is the 2006 World Health Organization
worldwide study of how environmental factors contribute to
over 80 specific diseases and injuries. Significantly, research
suggests that about 25% of the overall global disease burden
and about 33% of the disease burden for children stem from
environmental factors that can be changed (Pruss-Ustun &
Corvalan, 2006).
Roles for Social Work
For social workers, more fully integrating environmental,
social, and economic justice issues means
applying familiar knowledge, skills, and methods to new
substantive areas. It also means learning new applications for
substantive expertise and adhering to the environmental
policy of the major professional organization in the United
States (National Association of Social Workers, 2007). The
pursuit of environmental justice requires seeking out root
causes of environmental inequity and commitment to the right
of all citizens to access environmental "goods" and to be
protected from environmental "bads." It involves developing
expanded, nontraditional interdisciplinary partnerships in
research, policy, and practice arenas. Research on
environmental justice requires multilevel methods that engage
experts in other professions as diverse as microbiology,
geology, entomology, and epidemiology, and in
community-based participatory research, through which
essential alliances with affected citizens are anchored
(Kauffman, 1995; Soobader, Cubbin, Gee, Rosenbaum, &
Laurenson, 2006). Also required is a working knowledge of
the Precautionary Principle (that is, how little harm is
possible?) as an alternative to traditional risk assessment
methods (that is, how much harm is allowable; Myers &
Raffensperger, 2005).
Policy practice and analysis for environmental justice
engages social workers in finding common ground as
advocates and condition-builders with citizens, environmental
engineers, industrial planners, labor unions, and
environmental activists to press for greater institutional
integration of social, economic, and environmental policy that
will protect, benefit, and amplify the political voice of
disenfranchised populations. There are many venues for social
work practitioners across the micro-macro continuum to
engage in environmental justice issues. Clinicians, case
managers, community practitioners, and administrators can
collaborate with individuals, families, groups, organizations,
and communities to exchange information and learn together
about local environmental conditions that affect human
well-being. Social workers in health, mental health, schools,
and other service settings can integrate basic information
about pesticides, pollution, and other chemicals in homes,
yards, and communities, into psychosocial and in-home
assessments. Clinicians who are knowledgeable about
symptoms of chemical contaminant-induced diseases or
developmental disabilities can help client-constituents reduce
exposure to environmental chemical contaminants, and thus
reduce the need to use yet other chemicals, such as
psychotropic medications, to treat them (Hoff & McNutt,
1994; National Association for Social Workers, 2007; Rogge
& Combs-Orrne, 2003). Across the rich spectrum of social
work roles, the best practices of the social work
profession-building relationships

and resources, assessment and intervention, orgamzmg and
problem-solving, celebrating diversity, and fighting
oppression-can be brought to bear to advance environmental
justice and healthy environments for all citizens.
REFERENCES
Bullard, R. D., Mohai, P., Saha, R., & Wright, B. (2007). Toxic wastes
and race at twenty: 1987-2007: Grassroots struggles to disTTWntle
environmental racism in the United States. Cleveland, OH: The
United Church of Christ. Retrieved July 11, 2007, from
http://www.snre.umich.edu/news/newsdocs/ T Ringquest, E. J. (2005). Assessing evidence of environmental
oxic%20Wastes%20and%20Race%20at%20T wenty%20
Rpt%20(2).pdf
Center for Health, Environment, and Justice. (2007). Retrieved July
11, 2007, fromhttp://www.chej.org/
Exec. Order No. 12898, 3 C.F.R. 859 (1995), reprinted as amended in
42 USc. 4321 at 72-73, 1-101, 1-103(a), 3-302 (1994 & Supp. IV
1998).
Gamble, D. N., & Hoff, M. D. (2005). Sustainable community
development. In M. Weil (Ed.), The handbook of community
practice (pp. 169-188). Thousand Oaks, CA: Sage.
Gorey, K. M. (1995). Environmental health: Race and socioeconomic
factors. In R. L. Edwards et al. (Eds.), Encyclopedia of social work
(19th ed., pp. 868-872). Washington, DC:
NASW Press.
Gorman, A, & O'Connor, P. (2007). Glossed over: Health hazards
associated with toxic exposure in nail salons. Missoula, MT:
Women's Voice for the Earth. Retrieved August 20, 2007, from
http://www.womenandenvironment.org/news
reports/issuereports/WVE.N ailSa lon.Report. pdf
Hart, M. (2006). Sustainable measures. Retrieved September 5, 2007,
from http://www.sustainablemeasures.com/
Hoff, M. D., & McNutt, J. G. (Eds.). (1994). The global envir onmental
crisis: Implications for social welfare and social work. Brookfield:
Avebury/Gower House.
Kauffman, S. E. (1995). Conflict and conflict resolution in citizen
participation programs: A case study of the Lipari landfill
superfund site. Journal of Community Practice, 22(2), 33-54.
Morello-Frosch, R., & [esdale, B. M. (2006). Separate and unequal;
Residential segregation and estimated cancer risks associated with
ambient air toxics in U.S. metropolitan areas. Environmental
Health Perspectives, 114(3), 386-393.
Myers, N.]., & Raffensperger, C. (Eds.). (2005). Precautionary tools
for reshaping environmental policy. Cambridge, MA:
MIT Press.
National Association of Social Workers. (2007). Environmental
policy. Social work speaks: NASW polic)' statements (7th ed.).
Washington, DC: National Association of Social Workers.
Pastor, M., Bullard, R. D., Boyce, J. K., Fothergill, A, MorelloFrosch,
R., & Wright, B. (2006). In the wake of the storm:
Environment, disaster and race after Katrina. New York: Russell
Sage Foundation.
Payne-Sturges, D., & Gilbert, C. G. (2006). National environmental
health measures for minority and low-income
EPISTEMOLOGY 139
populations: Tracking social disparities in environmental health.
Environmental Research, 102, 154-171.
Pesticide Action Network of North America. (2007). Retrieved July
11, 2007, from http://www.panna.org/
Poppell, C. (2003). Bearing the burden: Health implications of
environmental pollutants in our bodies. Washington, DC:
Physicians for Social Responsibility.
Pruss-Ustun, A, & Corvalan, C. (2006). Preventing disease through
healthy environments: Toward an estimate of the environmental
burden of disease. Geneva, Switzerland: WHO Press. Retrieved
August 20, 2007, from http://www.who. int/quan t ifying , eh i
mpacts/pu b I i ca tions/prevent ingd isease/ en/index.htrnl
inequities: A meta-analysis. Journal of Policy Analysis and
Management, 24(2), 223-247.
Rogge, M. E. (2000). Social development and the ecological
tradition. Social Development Issues, 22(1), 32-41.
Rogge, M. L, & Cornbs-Orrne, T. (2003). Protecting our future:
Children, environmental policy, and social work. Social Work,
48(4), 439-450.
Shiva, V. (2002). Water wars: Privatization, pollution, and profit.
London: Pluto Press.
Soobader, M., Cubbin, C; Gee, G. c., Rosenbaum, A., & Laurenson,
J. (2006). Levels of analysis for the study of environmental health
disparities. Environmental Research, 102, 172-180.
United States Environmental Protection Agency, Office of Federal
Activities. (1998). Final guidance for incorporating environmental
justice concerns in EPA's NEPA compliance analyses. Washington,
DC: U.S. Government Printing Office.
-MARY E.
ROGGE
EPISTEMOLOGY
ABSTRACT: This entry discusses principal ways in which
knowledge and knowing have been understood within
philosophy, science, and social science, with implications
for contemporary social work practice. Attention is given to
various types of knowledge, its necessary conditions, scope,
and sources. It focuses particularly on how practice wisdom
remains a key source of knowledge for social work theory
and practice, and suggests that greater epistemological
clarity could further competent social work practice in an
increasingly pluralistic world.
KEY WORDS: propositional knowledge; nonpropositional
knowledge; practical knowledge; empirical knowledge;
nonempirical knowledge; a priori; a poster iori; objectivism;
scientific knowledge; contextual knowledge; postmodern or
postmodernist; practice wisdom; evidence-based practice
140 EPISTEMOLOGY
Epistemology refers to various understandings of knowledge
and its study. Beyond general ways of thinking about
knowledge, the term epistemology, derived from the Greek
words episteme (knowledge) and logos (explanation), typically
denotes more formal inquiry into the basic nature of
knowledge and knowing. Inquiry commonly centers on three
matters: (a) types of knowledge, including its essential or
constitutive characteristics; (b) conditions required for
knowledge, including its sources and criteria; and (c) the
scope and limits of knowledge, including its justification and
verification. With respect to these matters we ask such
questions as:
What does it mean to know? How do we know that we know ?
To what extent can we demonstrate our knowing?
Types and Conditions of Knowledge
We may distinguish between at least three principal types of
knowledge: propositional knowledge, nonpropositional
knowledge, and practical knowledge.
Propositional knowledge involves knowing that, and it
stems from a belief about something or someone. A long-held
view of propositional knowledge is that it requires not only
belief, but also the justification of a belief. Hence, a condition
of propositional knowledge is that something is believed, true,
and justified vis-a-vis evidence for its truth. A person may
believe that X is true, but may assert knowledge that X is true
only when this knowledge can be justified. An example of
propositional knowledge is that the earth, on average, is ",-,93
million miles from the sun, which is established beyond
reasonable question by accepted criteria of scientific
justification.
Propositional knowledge may take empirical and
nonempirical forms. Empirical propositional knowledge
results from some kind of sensory or perceptual experience,
such that what one knows cannot be justified through
reasoning or on rational grounds alone, but rather must
involve appeal to one's senses. In other words, one knows by
virtue of one's encounter with, and experience of, someone or
something about which knowledge is being claimed, and one
would not have such knowledge without this encounter or
experience. Empirical propositional knowledge is also termed
a posteriori knowledge, which literally means following from,
and dependent on, experience.
Nonempirical propositional knowledge, on the other hand,
exists prior to and independent of sensory or perceptual
experience. Justifying this type of knowledge-its necessary
condition-requires only that one make use of reason to
demonstrate knowledge. For example, one may know that
mathematical rules prove a theorem with regard to the
hypotenuse of a
2
right triangle (a 2+b =c2) or that the rules of logic hold that if A=B
and B= C then A=C. Nonempirical propositional knowledge is
also termed a priori knowledge, which means prior to, and
independent of, experience. Claims for such knowledge are
increasingly deemed as dubious, especially among scientists
and philosophers, in that it is difficult to provide an example
of knowledge that exists completely independent of the
knower's experience. While it may be possible for one to
conceive of a triangle without ever having seen one, for
example, one knows of mathematical rules by virtue of data
(numbers) that are empirically derived.
Another type of knowledge, nonpropositional knowledge,
involves knowing of something or someone. This type of
knowledge follows explicitly from personal acquaintance
with what is known. Although acquiring this type of
knowledge may include appeal to reason, and often does,
personal acquaintance remains the principal and necessary
means for acquiring it. Nonpropositional knowledge is
indicated by these statements:
"I know of a small bed and breakfast on the coast that is
beautiful and inexpensive" and "I know the city well, having
lived here all of my life."
A third type of knowledge, practical knowledge, involves
knowing how to do something and it stems from performance
or action related to what is known. An example of practical
knowledge is when a person demonstrates how to build a
piece of furniture, or how to administer an assessment for
depression to a client who presents with various problems that
indicate depression-related concerns. Much of social work
involves drawing particularly upon practical knowledge,
along with propositional and nonpropositional knowledge, in
efforts to ameliorate personal, social, structural, and systemic
problems.
There has been long-standing disagreement among
philosophers, scientists, and social scientists over types of
knowledge and the relationship between them. Philosophers
have taken different positions since the 4th century BCE,
when Plato explained knowledge and its essential elements.
Epistemology garnered widespread consideration among
philosophers in the modern period, especially the 17th and
18th centuries, when debates among rationalists and
empiricists took place. These debates centered particularly on
the questions of what constitutes knowing and how
knowledge may be justified, that is, substantiated.
Rationalists, whose noted representatives included Rene
Descartes, Gottfried Leibniz, and Baruch Spinoza, held that
the source of all knowledge in life lies in a priori (nonem-
pirical) reasoning. Empiricists, on the other hand, represented
by John Locke, George Berkeley, and David Hume,
contended that all knowledge is derived from

a posteriori (empirical) reasoning. Generally, the debates over
epistemology have clustered around these two principal foci.
Since the late 18th century, Immanuel Kant and others have
sought rapprochement among these disparate views, arguing
that knowledge finally depends upon both rational processes,
that is, "pure reason" (nonernpirical knowledge), and sensory
perception and experience (empirical knowledge) in
relationship.
Social scientific approaches to knowledge, including those
most closely tied to social work, have typically agreed with
this "both and" approach to knowledge, recognizing its
empirical and nonempirical forms. As social work has
developed as a profession, it has tended to give credibility to
scientific forms of knowledge in particular, especially
empirical knowledge that can be constructed through different
types of social scientific research methods. Nevertheless,
debate continues with respect to the precise roles that different
types of knowledge can and must play in social scientific
inquiry and goals.
Scope and Limits of Knowledge
Most philosophers, scientists, and social scientists agree that
knowledge and the potential for it, while vast and
wide-reaching, is nevertheless limited in scope. We cannot
know everything, nor can we exhaust our knowledge about
anyone thing. Moreover, even if we could accomplish either
of these, we could not verify this accomplishment.
Epistemology has long made use of the term skepticism to
denote the limits of knowledge, with one's degree of
skepticism measured by the extent to which one grants the
existence of knowledge per se. Extreme forms of skepticism
hold that we cannot actually know anything at all, but can only
make informed guesses about knowing anything. All
knowledge, therefore, involves speculation. Other forms of
skepticism grant that while it may be possible to know some
things, we should remain suspicious-skeptical-about what we
think we know and presume to impart.
Closely related to skepticism is the debate between those
espousing objectivism and those embracing postmodern
critiques of objectivism. This debate centers specifically on
the nature of truth, especially universal truths, and their
relationship to knowledge. So-called objectivists claim that
there exists in the world intrinsic truths per se (universal
truths), which can be known objectively by any person given
the right set of circumstances. Typically included in these
circumstances is the ability to reason and make sound
judgments. However, objectivists hold that even if one does
not percei ve or recognize these truths, they continue to exist
and could be known if one's ability for perception or
recognition (reason and judgment) improved.
EPISTEMOLOGY 141
An example of objective truth, some would claim, is the
notion that all people should refrain from taking the life of
another person, in any circumstances. Another example is the
truth that a square has four sides, such that even if a person
could not see a square, touch and feel it, or imagine it, it would
still be true to claim that a square has four sides.
So-called postrnodernists, on the other hand, claim that
there is no such thing as universal truths, but only claims
about truth that, to varying degrees, may be accepted or
denied. While postmodernists are often portrayed as
advocating an "anything goes" position with respect to
knowledge, ethics, or other truth claims-such that nothing can
truly be known or claimed for certain-a more accurate way of
describing the postmodernist position is in terms of the value
placed on humility with respect to what can be known with
complete certainty in any set of circumstances or context. For
postmodernists, a truth claim concerning the duty to refrain
from taking human life, while perhaps true, must nevertheless
be considered in light of the possibility that it is conditioned
on one's view of that truth claim vis-a-vis such variables as
one's context, its operative values and norms, prevailing
worldview, prejudices, and naiveties. For some individuals
and larger societies, it will be true that it is permissible to
terminate a life in particular circumstances, including cases of
severe illness where there is no likelihood for recovery and a
person is suffering (euthanasia), and, in the case of war, when
violence is engaged to achieve a perceived greater good. The
position taken with respect to the scope of knowledge relates
closely to the position taken on objective and postmodem
understandings of truth. In social work, these types of debates
have occurred most often in the form of disagreements over
research methods and how to construct knowledge in practice.
Various positions in the objectivism and postrnodern ism
debates have been taken among social workers. Academic
social workers have tended to champion more objective forms
of knowledge, while practitioners have often allowed more of
a place for postmodern forms of knowledge, particularly those
yielded by practice experience, as they simultaneously
endorse the importance of objective data and claims.
Consequently, current discussion of the scope and limits of
knowledge tends to revolve around the various sources of
knowledge, particularly the knowledge produced and utilized
in social work practice.
Specifically, knowledge may come from such sources as
scientific inquiry, mathematical reasoning, claims about
knowledge that are proffered by historical analysis, religious
belief, aesthetics, political or other
142 EPISTEMOLOGY
culturally mediated and historically contingent forms of
understanding, and various kinds of personal experience.
Such experience includes the cultural, socioeconomic, and
related demographical shapers of the knowledge we consider
and claim. While each of these sources of knowledge may be
said to issue in particular types of knowledge, these types may
be vastly different with regard to what is claimed as justified
true belief. Many social workers, like their colleagues in
related social scientific fields of inquiry and practice (for
example, psychology, sociology, and anthropology),
recognize the importance of maintaining a healthy suspicion
of knowledge precisely because of the significant role that
context plays in what qualifies as belief, truth, justification,
verification, and limits of knowledge. Values, norms, and
what is deemed as rational and true are, to some degree,
context specific. Consequently, social workers tend to focus
intently, though not exclusively, on practical knowledge that
issues from a variety of sources.
Sources of Knowledge
For social workers, principle sources of knowledge that
inform the social work profession's knowledge base include:
science (physical, human, and social): personal experience;
social, cultural and historical context; and practice wisdom.
Scientific knowledge derives from engaging the accepted
methods of various forms of scientific inquiry. Generally
speaking, scientific methods involve the investigation of
certain phenomena that are empirically observed and
quantifiable, such that theories (hypotheses) are formulated
and tested over time (replication) using rational principles in
efforts to substantiate the scientific claims about the
phenomena under investigation. While the accepted methods
of chemistry, sociology, and social work will differ, each of
these fields makes use of the scientific approach to
knowledge.
Personal experience also contributes to social work's
knowledge base, including not only various experiences with
clients in social work practice but also experiences that lie
beyond the professional role. Of particular importance are
how personal experiences inform the social worker's desire
and facility for interpersonal relationships, making
appropriate decisions, exercising sound judgment,
maintaining appropriate boundaries, and cultivating insight
into one's self and story (selfawareness), which includes one's
strengths, weaknesses, and prejudices. Also important are the
values, ethics, and norms of the social work profession along
with those to which the social worker subscribes. These too
influence what counts as knowledge and how this knowledge
gets appropriated. These facets of personal
experience converge to inform the social worker's knowledge
base. Different experiences result in different contents of one's
knowledge base.
Social, cultural, and historical context also serve as sources
of knowledge for social workers. We call this contextual
knowledge. Attention to these sources becomes particularly
crucial in an increasingly pluralistic, multicultural, and
heterogeneous world. At one time, both the objects and
sources of knowledge were considered more or less universal.
Since the second half of the 20th century, however, when
so-called postmodern approaches to epistemology arose,
knowledge has come to be viewed increasingly as
contextualized and particular with respect to its objects,
sources, scope, and the circumstances under which it is
formulated or utilized. What we know relates deeply to what
our dominant culture prizes as knowledge, what our families
of origin and broader communities assume about knowledge,
values, and norms, and also what has qualified historically, in
various contexts, as appropriate and verifiable knowledge.
Evidence-based social work practice, among the most widely
influential practice approaches currently, attempts to take
contextual knowledge seriously while also drawing on the
fruit of scientific inquiry and more objective claims. Rooted in
scientific understandings of knowledge, evidence-based
approaches hold that practice must be guided by the best
evidence (knowledge) gleaned through science and practice
while making this knowledge fit the various contexts of social
work.
Perhaps the most significant source of knowledge for
social work is practice wisdom, which, in a sense, grows out of
the convergence of the other sources of knowledge through the
"doing" of social work. Wisdom is defined in two principle
ways, namely, the sum of knowledge cultivated through time
and experience, and the ability for discernment, particularly
with respect to what is healthy, enriching, and sustaining of
life, human relationships, and community. Practice wisdom
grows out of working with accepted knowledge bases in social
work, on the one hand, including the agreed-upon theories,
models, practice approaches, and evidence (the sum of
knowledge) that have proven effective through widespread
practice over time, while, on the other hand, also employing
the art of discernment for making practice judgments and
decisions. This discernment involves drawing on previous
experiences, self-knowledge, and intuition, along with various
social work knowledge bases, in order to make judgments
about how to proceed in practice. The idea here is that while
accepted norms for practice remain invaluable for the social
work task, so too does the wisdom gleaned through the
interface of what is accepted and what is being newly
experienced in any current episode of

social work. Approaching social work with an intentional
commitment to recognizing the place for practice wisdom,
cultivating it ongoing, while also maintaining an appropriate
place for scientific knowledge, enriches not only the social work
profession but also the populations it serves.
Current Opportunities
Contemporary social work theory and practice will benefit from
greater attention being paid to the relationship between various
types, sources, and criteria for knowledge, such that the field
gains more clarity on the connective role that these may play in
fostering the most sound, competent, and consistent social work
possible. With respect to the concerns raised by advocates for
objective, empiric~l, and scientific knowledge, the social work
profession will benefit from maintaining its close ties to
scientific and empirical inquiry while also considering further
the invaluable roles that nonpropositional knowledge, and
especially practical knowledge (wisdom), play in sound practice.
Although empirical data and scientific inquiry provide much that
is indispensable for knowledge and understanding-including
means for validating observed trends or patterns relating to
human behavior and needs, social norms and customs, and power
structuresempirical and scientific approaches to social work
practice do not provide sufficient means for answering questions
of value and meaning among diverse persons and populations. At
the same time, with respect to the concerns raised by those who
champion the role of practical and nonpropositional knowledge
in social work, the field protects itself from idiosyncratic and
narrow ideology through its continued respect for scientific and
empirical knowledge, and should continue to appeal to this
knowledge in appropriate ways. Social workers and the
populations they serve benefit most when multiple types and
sources of knowledge are considered, advocated, and utilized in
both theory and practice.
Acknowledgment
My sincere thanks to three colleagues for their suggestions on
improving this essay: William Greenway, David F. White, and
Cynthia Franklin.
FURTHER READING
Anderson, H. (1997). Conversation, language, and possibilities:
A posonoclern aJ)proach to theraJ )', New York: BasicBooks.
Berlin, S. B., & Marsh, J. C. (J 993). Infonning practice decisions.
New York: Macmillan.
Bernstein, R. J. (1983). Beyond objectit'ism and realism:
Science, hermeneutics, and praxis. Philadelphia: University of
Pennsylvania Press.
ETHICS AND VALUES 143
Bilson, A. (Ed.). (2004). Evidence-based practice and social work:
International research and policy perspectives. London: Witting &
Birch.
Kirk,S., & Reid, W. (2002). Science and social work practice.
New York: Columbia University Press.
Kuhn, T. S. (1962/1970). The structure of scientific revolutions (2nd
ed.). Chicago: University of Chicago Press.
Mattaini, M. A. (1995). Knowledge for practice. In C. H.
Meyer & M. A. Mattaini (Eds.), The foundations of social work
practice: A graduate text. Washington, DC:
NASW Press.
Meyer, C. H. (1993). Assessment in social work practice. New York:
Columbia University Press.
Payne, M. (2005). Modem social work theory (3rd ed.). Chicago:
Lyceum.
Reamer, F. (1993). The philosophical foundations of social work.
New York: Columbia University Press.
Rosenberg, A. (2008). Philosophy of social science (3rd ed.).
Boulder, CO: Westview Press.
-ALLAN HUGH COLE JR.
ETHICS AND VALUES
ABSTRACT: Social workers' understanding of professional
values and ethics has matured considerably. During the earliest
years of the profession's history, social workers' attention was
focused primarily on cultivating a set of values upon which the
mission of the profession could be based. More recently social
workers' have developed comprehensive ethical standards to
guide practitioners and decision-making frameworks that are
useful when practitioners face difficult ethical dilemmas. T
oday's social workers also have a better understanding of the
relationship between their ethical decisions and potential
malpractice risks.
KEY WORDS: values; ethics; ethical theory; ethical
decision-making; ethical dilemmas; NASW Code of Ethics;
risk management
Ethics and values are at the heart of the social work profession.
Although there has been considerable stability in the core values
of the profession, the day-today ethical issues that social workers
encounter have not remained static. On the contrary, applications
of core values in social work have undergone substantial change
over the years in response to social, political, and economic
developments.
The Evolution of
Social Work Ethics and Values
Social workers' thinking about values and ethics has evolved
during four major periods (Reamer, 1998,
144 ETHICS AND V ALOES
2006a). The first stage, the morality period, began in the late
19th century, when social work was formally intro duced as
a profession. During this period social work was much
more concerned about the morality of the client than about
the morality or ethics of the profes sion or its practitioners.
Over time, particularly during the Settlement House
Movement and Progressive era in the early 20th century ,
social workers' attitudes began to shift from concern about
the morality, or immorality, of the poor to the need for
significant social reform designed to ameliorate a wid e
range of social problems, for example, those related to
housing, health care, sani tation, employment, poverty, and
education. During the Great Depression and New Deal
years, social workers promoted social reforms to address
structural problems.
During the second stage, the values period, concern about
the morality of the client continued to recede. During the
next several decades, especially during the 1960 s and
1970s, a group of social workers engaged in ambitious
attempts to develop a consensus about the profession's core
values (Biestek, 1957; Gordon, 1962; Keith-Lucas, 1977 ;
Levy, 1973, 1976; McDermott, 1975; Pumphrey, 1959 ;
Teicher, 1967; Timms, 1983). It was during this period that
the National Associa tion of Social Workers adopted its first
formal code of ethics (1960).
In addition to exploring the core values of social work,
some of the literature during this period also reflects
practitioners' efforts to examine and clarify the relationship
between their own personal values and the profession's
values (e.g. Hardiman, 1975; Varley, 1968). Not
surprisingly, in the 1960s and 1970s social workers
engaged in complex debates about values concerning the
core constructs of social justice and rights (welfare rights,
clients' rights, prisoners' rights, women's rights, patients'
rights, and so on).
Until the late 1970s, social work focused primarily on
the profession's core values and value base. In the third
stage, the ethical theory and decision-making period, social
work underwent another significant transition in its
concern about values and ethical issues. During the mid
and late 1970s a number of professions (medicine, law ,
business, journalism, engineering, nursing, social work,
criminal justice, and others) beg an to explore ethical issues
in depth (Callahan & Bok, 1980). During this period the
new academic field of applied and pro fessional ethics
emerged. Led especially by develop ments in the bioethics
field, various professions engaged in ambitious attempts t o
identify key ethical dilemmas, formulate ethical
decision-making protocols, and develop guidelines for
ethics consultation. During this period the NASW
EncyclolJedia of Social Work
included, for the first time, an article directly exploring the
relevance of philosophical and ethical concepts to social
work ethics (Reamer, 1987). Unlike social work' s earlier
literature, publications on social work ethics in the 1980 s
began to explore the relevance of moral philosophy and
ethical theory (for example, theor ies of metaethics,
normative ethics, deontology, and utili tarianism) to ethical
dilemmas faced by practitioners.
The most recent stage in the evolution of social work
ethics in the United States, the ethical standards and
risk-management period, reflects the dramatic matur ation of
social workers' understanding of ethical issues. This stage
is characterized by the significant expan sion of ethical
standards to guide practitioners' conduct and by increased
knowledge concerning ethics-related negligence and
professional malpractice. More spe cifically, this period
includes the development of a comprehensive code of
ethics for the profession, the emergence of a significant
body of literature focusing on ethics- related malpractice
and liability risks, and practical risk- management strategies
designed to protect clients and prevent ethics complaints
and ethicsrelated lawsuits (Barker & Branson, 2000;
HoustonVega, Nuehring, & Daguio, 1997; Reamer, 2003 ).
Current thinking about social work ethics and values i s
broad in scope. In general it encompasses three
distinguishable, though related, sets of issues. The first
concerns the nature of the profession's core values and their
relevance to the overall mission, goals, and prio rities of
social work, especially as reflected in the NASW Code of
Ethics (NASW, 1999). The second issue pertains to ethical
dilemmas and decisions that social workers encounter as
they carry out their professional duties and obligations,
particularly their efforts to meet clients' needs a nd protect
them and relevant third parties from harm. The third issue
relates to ethics risk management, that is, practical steps
that social workers can take to protect clients and prevent
ethics-related litigation and ethics complaints filed with
state licensing boards and professional associations.
Value Base of Social Work
The subject of social work values has always been cen tral
to the profession. Values have several important attributes
and perform several important functions: they are
generalized, emotionally charged conceptions of what is
desirable; historically created and derived from experience;
shared by a population or a group within it; and provide the
means for organizing and structuring patterns of behavior
(Williams, 1968). In social work, values have been
important in several key respects, with regard to the nature
of its mission; the relationships that social workers have
with clients,

colleagues, and members of the broader society; the methods of
intervention that social workers use in their work; and the
resolution of ethical dilemmas in practice.
As social work has evolved, it has continually stressed the
need to attend both to the needs of individual clients and to the
ways that the community and society create and respond to those
needs. Thus, there has always been a simultaneous concern in
social work for individual well-being and the environmental
factors that affect it. This unique perspective-which reflects the
evolution of scholarly thinking in the profession about the nature
of its core values and the professional mission based on them-is
stated clearly in the preamble to the NASW Code of Ethics (1999):
The primary mission of the social work profession is to
enhance human well-being and help meet the basic
human needs of all people, with particular attention to the
needs and empowerment of people who are vulnerable,
oppressed, and living in poverty. A historic and defining
feature of social work is the profession's focus on
individual well-being in a social context and the
well-being of society. Fundamental to social work is
attention to the environmental forces that create,
contribute to, and address problems in living ....
The mission of the social work profession is rooted in a
set of core values. These core values, embraced by social
workers throughout the profession's history, are the
foundation of social work's unique purpose and
perspective: service; social justice; dignity and worth of
the person; importance of human relationships; integrity;
and competence. (p. 1)
Social workers' values often shape their professional actions and
ethical decisions. Some moral philosophers argue that
professionals' own moral virtues and character are at the heart of
ethical decisions (MacIntyre, 1984). From the point of view of
virtue ethics, an ethical person has virtuous values and character
traits-such as integrity, truthfulness, generosity, loyalty, sincerity,
kindness, compassion, and trustworthiness-and acts in a manner
consistent with them. These core virtues provide the foundation
that leads to professionals' deep respect for clients' fundamental
right to autonomy and self-determination, commitment to helping
people in need and avoiding harming others, and pursuit of justice
(Beauchamp & Childress, 2001).
Ethical Dilemmas and Decisions
Social workers encounter a wide range of ethical dilemmas.
Ethical dilemmas occur when social workers must
ETHICS AND VALUES 145
choose among conflicting professional values, duties, and rights
that arise sometimes due to their competing obligations to clients,
employers, colleagues, the social work profession, and society at
large. Moral philosophers and ethicists often refer to these
situations as hard cases. These are cases that require a difficult
choice between conflicting duties, or what the philosopher W. D.
Ross (1930) referred to as conflicting prima facie duties-duties
that, when considered by themselves, social workers are inclined
to perform. Eventually, social workers must choose what Ross
called an actual duty from among conflicting prima facie duties.
In social work many ethical decisions are routine, such as
obtaining clients' consent before releasing confidential
information and avoiding sexual contact with clients. These prima
facie duties are clear. In some instances, however, prima facie
duties are unclear and ethical decisions are much more complex
and troubling.
Ethical dilemmas in social work occur in three domains:
relationships with clients in direct-practice settings (individuals,
families, and small groups); social work involving "macro"
practice, such as community practice (community organizing and
advocacy), administration, management, and policy development
and implementation; and relationships among professional
colleagues. Examples of challenging ethical dilemmas include the
following:
It Privacy, confidentiality, and privilegedcommunication: Under
what circumstances do clients forfeit their rights,
particularly if the client threatens to harm himself or others,
has abused or neglected a child or vulnerable adult, or if a
court of law orders social workers to disclose information?
It Client self-determination and professional paternal ism:
What are the limits to clients' right to selfdetermination,
particularly when they engage in self-harming behavior or
threaten others? Is it ever justifiable to lie to clients or
withhold information from them, paternalistically, "for
their own good"?
It Boundaries and dual relationships: How should social workers
handle, for example, personal relationships with former
clients, self-disclosure to clients, bartering for services,
gifts offered by clients, and clients' invitations to attend
lifecvcle events?
It Adhering to laws, policies, and regulations: Is it ethically
permissible for social workers to violate laws, policies, and
regulations that they consider to be unjust or harmful to
clients?
It Whistle-blowing: Under what circumstances are social workers
obligated to disclose ethical misconduct engaged in by
colleagues or agency administrators?
146 ETHICS AND VALUES
Distribution of limited resources: What is the most ethical
way to allocate scarce resources, such as agency funds
or subsidized housing units? Should social workers
distribute resources based on need, the principle of
equality (in the form of a lottery; first-come, first served;
or, when possible, equal shares), affirmative action
criteria, cost-benefit considerations, or clients' ability to
pay?
Conflicts between personal and professional values:
How should social workers resolve clashes between
their deeply held personal beliefs and their professional
duties (for example, with respect to clients' reproductive
rights or end-of-life decisions)?
Ethical Decision Making and Standards Social
workers can use several tools-including codes of ethics,
ethical principles, and ethical theory-to help make ethical
decisions.
CODES OF ETHICS Nearly all professions have devel-
oped codes of ethics to assist practitioners who face
ethical dilemmas; most were developed during the
20th century. Codes of ethics serve several functions
in addition to providing general guidance related to
ethical dilemmas: they also protect the profession
from outside regulation, establish norms related to
the profession's mission and methods, and enunciate
standards that can help adjudicate allegations of
misconduct (Reamer, 2006b).
Until recently, the most visible guides to social workers'
ethical decisions were professional codes of ethics. Social
work has several codes of ethics, including the NASW Code of
Ethics, Code of Ethics of the National Association of Black
Social Workers, Code of Ethics of the Clinical Social Work
Association, and Code of Ethics of the Canadian Association of
Social Workers.
The best-known ethics code to which social workers in the
United States subscribe is the NASW Code of Ethics. The
organization has published several versions of the code,
reflecting changes in the broader culture and in social work
standards. The first NASW code was published in 1960, five
years after the organization was formed. The 1960 Code of
Ethics consisted of a series of proclamations concerning, for
example, every social worker's duty to give precedence to
professional responsibility over personal interests; respect the
privacy of clients; give appropriate professional service in
public emergencies; and contribute knowledge, skills, and
support to programs of human welfare. Brief first-person
statements (such as "1 give precedence to my professional
responsibility over my personal interests" and "1 respect the
privacy of the people 1 serve") were preceded by a preamble
that set forth social workers'
responsibility to uphold humanitarian ideals, maintain and
improve social work service, and develop the philosophy and
skills of the profession. In 1967 a principle pledging
nondiscrimination was added to the proclamations.
However, over time some N ASW members began to
express concern about the code's vagueness, its scope and
usefulness in resolving ethical dilemmas, and its provisions for
handling ethics complaints about practitioners and agencies. In
1977 the NASW Delegate Assembly established a task force to
revise the profession's code of ethics and to enhance its
relevance to practice. The revised code, ratified in 1979, was
much more detailed; it included six sections of brief principles
preceded by a preamble setting forth the general purpose of the
code, the enduring social work values upon which it was based,
and a declaration that the code's principles provide standards
for the enforcement of ethical practices among social workers.
The 1979 code set forth principles related to social workers'
conduct and comportment, and to ethical responsibility to
clients, colleagues, employers and employing organizations,
the social work profession, and society. A number of the code's
principles were concrete and specific (for example, "The social
worker should under no circumstances engage in sexual
activities with clients," and "The social worker should respect
confidences shared by colleagues in the course of their
professional relationships and transactions"), whereas others
were more abstract, asserting ethical ideals (for example, "The
social worker should promote the general welfare of society,"
and "The social worker should uphold and advance the values,
ethics, knowledge, and mission of the profession").
The 1979 code was revised twice. In 1990 several
principles related to solicitation of clients and fee setting were
modified after the Federal Trade Commission (FTC) began an
inquiry in 1986 concerning the possibility that NASW policies
promoted "restraint of trade." As a result of the inquiry,
NASW revised principles in the code in order to remove
prohibitions concerning solicitation of clients from colleagues
or one's agency and to modify wording related to accepting
compensation for making a referral. NASW also entered into a
consent agreement with the FTC concerning the issues raised
by the inquiry.
In 1992 the president of N ASW appointed a national task
force, chaired by this author, to suggest several specific
revisions of the code. In 1993, based on the task force
recommendations, the NASW Delegate Assembly voted to
amend the code to include several new principles related to the
problem of social worker impairment and the problem of
inappropriate

boundaries between social workers and clients, colleagues,
students, and so on.
Because of growing dissatisfaction with the 1979 NASW
code, and because of dramatic developments in the field of
applied and professional ethics since the ratification of the
1979 code, the 1993 NASW Delegate Assembly also passed a
resolution to establish a task force to draft an entirely new
code of ethics for submission to the 1996 Delegate Assembly.
The task force, chaired by this author, was established in an
effort to develop a new code of ethics that would be far more
comprehensive in scope and relevant to contemporary
practice. Since the adoption of the 1979 code, social workers
had developed a much keener grasp of a wide range of ethical
issues facing practitioners, many of which were not addressed
in the NASW code. Moreover, the broader field of applied and
professional ethics, which had begun in the early 1970s, had
matured considerably, resulting in the identification and
greater understanding of novel ethical issues not cited in the
1979 code.
THE CURRENT NASW CODE OF ETHICS The code,
which contains the most comprehensive contemporary
statement of ethical standards in social work, includes
four major sections (see the appendix to this section for
the complete text of the code). The first section,
"Preamble," summarizes the mission and core values of
social work, the first ever sanctioned by NASW for its
code of ethics.
The second section, "Purpose of the NASW Code of
Ethics," provides an overview of the code's main functions
and a brief guide for dealing with ethical issues or dilemmas
in social work practice. The brief guide in this section of the
code to dealing with ethical issues highlights various
resources social workers should consider when faced with
difficult ethical decisions. Such resources include ethical
theory and decision making, social work practice theory and
research, laws, regulations, agency policies, and other
relevant codes of ethics. The guide encourages social workers
to obtain ethics consultation when appropriate, perhaps from
an agency-based or social work organization's ethics com-
mittee, regulatory bodies (for example, a state licensing
board), knowledgeable colleagues, supervisors, or legal
counsel.
An important feature of this section of the code is its
explicit acknowledgment that instances sometimes arise in
social work in which the code's values, principles, and
standards conflict. Moreover, at times the code's provisions
can conflict with agency policies, relevant laws or regulations,
and ethical standards in allied professions (such as
psychology and counseling).
ETHICS AND VALUES 147
The code does not provide a formula for resolving such
conflicts and "does not specify which values, principles, and
standards are most important and ought to outweigh others in
instances when they conflict." (National Association of Social
Workers, 1999:3)
The code's third section, "Ethical Principles," presents six
broad ethical principles that inform social work practice, one
for each of the six core values cited in the preamble. The
principles are presented at a fairly high level of abstraction to
provide a conceptual base for the profession's more specific
ethical standards. The code also includes a brief annotation for
each of the principles.
The code's final section, "Ethical Standards," includes 155
specific ethical standards to guide social workers' conduct and
provide a basis for adjudication of ethics complaints filed
against NASW members. The standards fall into six
categories concerning social workers' ethical responsibilities
to clients, to colleagues, in practice settings, as professionals,
to the profession, and to society at large. The introduction to
this section of the code states explicitly that some standards
are enforceable guidelines for professional conduct and some
are standards to which social workers should aspire.
Furthermore, the code states, "The extent to which each
standard -is enforceable is a matter of professional judgment
to be exercised by those responsible for reviewing alleged
violations of ethical standards" (NASW, 1999:7).
ETHICAL THEORY One key trend in professional edu-
cation and training is to introduce students and practi-
tioners to ethical theories and principles that may help
them analyze and resolve ethical dilemmas (Reamer,
1990). These include theories and principles of what
moral philosophers call metaethics, nonnative ethics, and
practical (or applied) ethics. Briefly, rnetaethics concerns the
meaning of ethical terms or language and the derivation of
ethical principles and guidelines. Typical metaethical
questions concern the meaning of the terms right and wrong
and good and bad. What criteria should we use to judge
whether someone has engaged in unethical conduct? How
should we go about formulating ethical principles to guide
individuals who struggle with moral choices? Normative
ethics attempts to answer the question, "Which general moral
norms for the guidance and evaluation of conduct should we
accept and why?"
In contrast to rnetaethics, which is often abstract,
normative ethics tends to be of special concern to social
workers because of its immediate relevance to practice.
Normative ethics consists of attempts to apply ethical theories
and principles to actual ethical dilemmas.
148 ETHICS AND V AWES
Practical (or applied) ethics is the attempt to apply ethical
norms and theories of normative ethics to specific problems
and contexts, such as professions, organizations, and public
policy. Such guidance is especially useful when social
workers face conflicts among duties they are ordinarily
inclined to perform.
Theories of normative ethics are generally grouped under
two main headings. Deontological theories (from the Greek
deontos, "of the obligatory") are those that claim that certain
actions are inherently right or wrong, or good and bad, without
regard for their consequences. Thus a deontologist might
argue that telling the truth is inherently right, and therefore
social workers should never lie to clients, even if it appears
that lying might be more beneficial to the parties involved.
The same might be said about keeping 'promises made to col-
leagues, upholding contracts with managed care organizations
and insurance companies, obeying a mandatory reporting law,
and so on. For deontologists, rules, rights, and principles are
sacred and inviolable. The ends do not necessarily justify the
means, particularly if they require violating some important
rule, right, principle, or law.
The second major group of theories, teleological theories
(from the Greek teleios, 'brought to its end or purpose'), takes a
different approach to ethical choices. From this point of view,
the rightness of any action is determined by the goodness of its
consequences. T eleologists think it is naive to make ethical
choices without weighing potential consequences. To do
otherwise is to engage in what the philosopher Smart (Smart
& Williams, 1973) referred to as "rule worship." Therefore,
from this perspective (also known as utilitarianism and
consequentialism), the responsible strategy entails an attempt to
anticipate the outcomes of various courses of action and to
weigh their relative merits.
A noteworthy problem with utilitarianism is that different
people are likely to consider different factors and weigh them
differently, as a result of their different life experiences,
values, education, political ideologies, and so on. In addition,
when taken to the extreme, classic utilitarianism can justify
trampling on the rights of a vulnerable minority in order to
benefit the majority.
Two other ethical theories have important implications for
social workers: communitarianism (also known as
community-based theory) and the ethics of care. According to
cornrnunitarianisrn, ethical decisions should be based
primarily on what is best for the community and communal
values (the common good, social goals, and cooperative
virtues) as opposed to individual self-interest. The ethics of
care, in contrast, reflects a collection of moral perspectives
rather than
a single moral principle. This view emphasizes the importance
in ethics and moral decision making of the need to care for,
and willingness to act on behalf of, persons with whom one
has a significant relationship. For social workers this
perspective emphasizes the critical importance of
commitment to their clients.
ETHICAL DECISION MAKING There is no simple, tidy
formula for resolving ethical dilemmas. By definition, ethical
dilemmas are complex. Reasonable, thoughtful social workers
can disagree about the ethical principles and standards that
ought to guide ethical decisions in any given case. But ethicists
generally agree that it is important to approach ethical
decisions systematically, to follow a series of steps to ensure
that all aspects of the ethical dilemma are addressed. By
following a series of clearly formulated steps, social workers
can enhance the quality of the ethical decisions they make and
the likelihood that they will protect clients, third parties, and
themselves. Typically these steps involve: (1) identifying the
ethical issues, including the social work values and conflicting
duties; (2) identifying the individuals, groups, and
organizations likely to be affected by the ethical decision; (3)
tentatively identifying all viable courses of action and the
participants involved in each, along with the potential benefits
and risks for each; (4) thoroughly examining the reasons in
favor of and opposed to each course of action, considering
relevant ethical theories, principles, and guidelines; codes of
ethics and legal principles; social work practice theory and
principles; personal values (including religious, cultural, and
ethnic values and political ideology); consulting with
colleagues and appropriate experts (such as agency staff,
supervisors, agency administrators, agency ethics committee,
attorneys, ethics scholars); making the decision and docu-
menting the decision-making process; and monitoring,
evaluating, and documenting the decision (Congress, 1999;
Linzer, 1999; Loewenberg, Dolgoff, & Harrington, 2004;
Reamer, 2001a, 2006a).
Ethics Enforcement and Risk Management Sometimes
ethics complaints and lawsuits are filed against social
workers. Members of NASW, for example, may be named in
ethics complaints alleging violation of standards in the
association's code of ethics. In addition, social workers can be
named in complaints filed with a state licensing board. Also,
disgruntled parties may file lawsuits against social workers
alleging they were harmed as a result of practitioners' ethics-
related professional negligence (for example, as a result of an
inappropriate dual relationship, incompetent service delivery,
or unauthorized disclosure of confidential

information). Social workers can prevent lawsuits and ethics
complaints by conducting an ethics audit, which is designed to
assess the adequacy of practitioners' and agencies'
ethics-related policies, practices, and procedures (Reamer,
2001 b).
NASW and state licensing boards follow very strict
procedures when they process complaints filed against social
workers to ensure that all parties receive a fair hearing
consistent with due process standards. NASW members who
are named in ethics complaints have the opportunity to testify,
present witnesses, and challenge any evidence that is
presented against them. Using a peer review process, NASW
ethics committees must decide whether there is sufficient
evidence to conclude that a member has violated the NASW
Code of Ethics. NASW may impose sanctions or require
various forms of corrective action when there is evidence of
ethical misconduct, such as suspension from NASW; man-
dated supervision or consultation; censure in the form of a
letter; or instructions to send the complainant a letter of
apology. In some cases the sanction may be publicized.
In contrast to NASW ethics proceedings, state licensing
boards must determine whether social workers have violated
provisions in state licensing laws or regulations. State
licensing boards that find evidence of violation can impose a
range of sanctions or require various forms of corrective
action, such as license suspension or revocation; mandated
supervision, consultation, or continuing education; and
censure in the form of a letter. Some sanctions are publicized,
for example, in local newspapers or the licensing board's Web
site.
Lawsuits filed against social workers alleging ethics-
related negligence are processed according to legal pro-
cedures for civil litigation and related standards of proof
(Reamer, 2003). The process may include subpoenas of
records, depositions, interrogatories, expert witness tes-
timony, and trial before a judge or jury. Most lawsuits are
settled pretrial, often for dollar amounts agreed to by the
parties. Cases that go to trial may result in monetary awards.
In a very small percentage of cases social workers are
indicted on criminal charges that allege ethical misconduct.
Examples include instances when a social worker has
submitted fraudulent bills to clients' insurance companies,
embezzled funds from an employer, or engaged in sexual
misconduct with a client who is a minor.
In some instances social workers involved in ethical
misconduct are impaired. Impairment involves problems in a
social worker's functioning reflected in an inability or
unwillingness to follow professional standards; an inability or
unwillingness to acquire professional skills in order to reach
an acceptable level
ETHICS AND V AWES 149
of competency; and an inability or unwillingness to control
personal stress and emotional problems that interfere with
professional functioning (Reamer). Impairment may involve
failure to provide competent care or violation of the
profession's ethical standards. It may also take such forms as
providing flawed or inferior counseling to a client, sexual
involvement with a client, or failure to carry out professional
duties as a result of substance abuse or mental illness.
It is important for social workers to design ways to prevent
impairment and respond to impaired colleagues. They must be
knowledgeable about the indicators and causes of impairment
so that they can recognize problems that colleagues may be
experiencing. Social workers must also be willing to confront
impaired colleagues, offer assistance and consultation, and, if
necessary, as a last resort, refer the colleague to a supervisor or
local regulatory or disciplinary body.
Social workers who become aware of a colleague's
impairment or unethical conduct may have to make a difficult
ethical decision about whether to "blow the whistle." In these
instances social workers should consult colleagues,
supervisors, ethics experts, and guidelines in the NASW Code
of Ethics (sections 2.09, 2.10, 2.11) for guidance and support.
In an effort to prevent ethical misconduct and enhance
social workers' ethical judgment, NASW chapters and
NASW's national office, state licensing boards, social work
education programs, and continuing education organizations
sponsor ethics education programs throughout the United
States. Many states require licensed social workers to take
continuing education courses on ethics.
The Future of Social Work Ethics
Social workers have been concerned about ethics and values
since the profession began. Social work has a long-standing
history of commitment to issues of social justice and to the
dignified, fair treatment of people in need of assistance.
Although many of the ethical issues of current concern in the
profession have been the focus of attention for decades, others
have emerged only recently. Future changes in the profession
will no doubt lead to new ethical issues and questions.
There is no way to know with certainty what issues are
likely to emerge in the future, but several trends are worth
noting. First, itwill be important for social workers to pay
close attention to ethical issues created by technological
advances that affect the profession. For example,
developments in computer and other electronic technology
will continue to lead to difficult issues related to privacy and
confidentiality. Developments in medical technology will
raise new ethical questions
150 ETHICS AND VALUES
related to the allocation of health care, end-of-life decisions,
and the use of novel medical interventions. In response to
these advances, many social work agencies are forming ethics
committees to consult on difficult decisions, educate staff
about ethical issues, and formulate ethics-related policies
(Reamer, 1987).
A second trend worth observing relates to shifts in
employment patterns among social workers themselves. In
recent years fewer social workers have been entering the
public social service sector that serves particularly vulnerable,
oppressed, and low-income people. This trend raises
important ethical questions about the mission of social work
and its value base. To what extent should social work place
primary emphasis on the poor and oppressed as opposed to
more affluent clients who have ample assets or insurance
coverage to pay for services? What portion of the profession's
resources should be devoted to clinical issues as opposed to
social action, such as advocacy on behalf of the least
advantaged?
In addition, as social work develops new specialties, novel
questions of ethics and values are likely to emerge. For
example, some practitioners are pursuing dual careers as
social workers and as lawyers, clergy, and life coaches. These
combinations pose unique ethical challenges related to
professional-client boundaries, informed consent,
confidentiality, and privacy. Also, as social workers'
involvement in managed care organizations has grown, so too
have ethical issues concerning the allocation of limited health
care resources.
The future of social work cannot be predicted with
precision, but it is certain that ethical and value issues will
continue to permeate the profession. Although some of these
issues will change in response to new trends and
developments, the fundamental issues related to ethics and
values in social work will persist, such as the nature of social
work's core mission and values, the balance between public
and private sector responsibility for social welfare,
practitioners' moral duty to aid those most in need, the nature
and limits of clients' right to confidentiality and self-
determination, and challenges involving the allocation of
limited social services resources. Hence, it will always be
essential for social workers to examine these issues, which in
the end form the very foundation of the profession.
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-FREDERIC G. REAMER
ETHICS IN RESEARCH
ABSTRACT: Social work researchers hold themselves to general
ethical standards for biomedical and social science research and to
the values specific to social work. This article describes (a) the
general ethical principles guiding research involving human
beings, (b) mechanisms for the ethical review of studies involving
human beings, (c) ethical issues in research on vulnerable
populations such as children and adolescents, recipients of care,
and other socially marginalized groups, and (d) plagiarism,
authorship, and conflict of interest. Current topics in the
responsible conduct of research include the use of clinical and
audio or video data, participatory action research, and
Internet-based studies.
KEY WORDS: ethics; research; research ethics; responsible
conduct of research; informed consent; confidentiality; IRB;
vulnerable populations
As research activity in social work has increased, so has attention
to ethics in research. Ethical standards and practices in research
guide the relationship between researcherts) and research
participantf s), guide relationships among researchers and
scholars, guide how researchers relate to the organizations and
communities in which their studies are conducted, and safeguard
the integrity of the scientific enterprise as a whole. Vulnerable
groups in the United States-non-Whites, women, prisoners, and
people with disabilities-have in the past been harmed by
biomedical and social science research. The res])onsible conduct
of research (RCR) considers the ethics of research on many
levelsindividual research participants, researchers, groups and
communities studied, the scientific and scholarly enterprise, and
society as a whole.
ETHICS IN RESEARCH 151
Current standards for RCR trace their origins to the 1947
Code of Nuremberg that emerged from international trials
addressing war crimes committed by the Nazi regime in the
mid-20th century, including crimes carried out in the name of
research (Steneck, 2004; Israel & Hay, 2006). The World Medical
Association's Declaration of Helsinki followed in 1964. In 1979,
based on these codes and in part in reaction to the infamous
Tuskegee Experiment (Jones, 1993), the Report of the National
Commission on the Protection of Human Subjects of Biomedical
and Behavioral Research, known as the Belmont Report, set forth
ethical standards and regulatory mechanisms to be used in all
government-funded research and research settings in the United
States-standards that continue to guide the design and conduct of
research studies in medicine, the social sciences, and the helping
professions. International Ethical Guidelines for Biomedical
Research Involving Human Beings, called "CIOMS" after its
authoring organization, The Council for International
Organizations of Medical Sciences, were adopted in 1982 and
revised in 2002. However, as societies, research funding
mechanisms, and research technologies change, best practices in
the ethics of research and scholarship continually evolve.
Social work research must also reflect the professional and
ethical aims of all social work activities (Antle & Regehr, 2003;
Butler, 2002). Social workers have ethical responsibilities to
clients and others with whom they work, including research
participants; to the practice settings and other organizations in
which they function; to colleagues and to the profession itself; and
to the broader society, commitments that all must be reflected in
the conduct of research.
Beneficence, Justice, and Respect Although there are
differing philosophical bases for research ethics (Christians,
2005; Fuchs & Macrina, 2005; Israel & Hay, 2006; Shamoo &
Resnik, 2003), codes of ethical conduct for research are based on
three major principles: beneficence, justice, and respect. Because
no specific code of conduct can ever address all possible
situations, one must understand the principles that underlie
specific standards of practice (Butler, 2002; Israel & Hay, 2006;
Sieber, 1992; Steneck, 2004). While these principles are widely
accepted, risks and benefits are not always easy to reconcile, and
differences of judgment about the risks and benefits of a study
commonly arise.
Non-malfeasance, or the injunction to do no harm, is
subsumed in the United States under the principle of beneficence.
In some other national and organizational codes, this fourth
principle, also traced to the
152 ETHICS IN RESEARCH
Nuremberg Code, is separately mentioned (Butler, 2002). In
the most infamous example of malfeasance in medical
research in the United States, the Tuskegee experiment, which
ended only in 1972 (Jones, 1993), poor and mostly illiterate
African American sharecroppers with syphilis were studied
without consent, without information about the true nature of
their disease, and without effective treatment even when it
became available-practices that are no longer permissible in
treatment research.
It has been argued that for social work, justice means that
research activities and findings should promote social justice
and equity in society (Antle & Regehr, 2003) and empower
research participants. Justice also drives the relatively recent
requirement of researchers seeking federal funding that
exclusion of participants of either gender or of any racial or
ethnic group must be specifically justified. This measure seeks
to correct past practice in which women and non-Whites were
routinely excluded from medical and other studies, leading to
a systematic lack of data on their health and wellbeing and on
treatments that do and do not work for them.
The Basic Principles of
Research Ethics Defined
Beneficence means that no undue harm shall be done to
research participants and that some demonstrable benefit must
possibly derive from any proposed research, if not to the
research participants themselves then, at least to others like
them in future or to society as a whole. Adherence to this
principle means that any possible risks to research participants
must be anticipated and steps taken to minimize them (see
below). In social work, it means that research must address
goals such as improving social work services, enhancing our
understanding of client problems, and informing the
participants of policies, financing, and regulatory systems that
affect social workers and the people they serve. It also means
that research must be methodologically sound so that any
findings from it will have scientific credibility. The way social
work research is conducted should affirm, respect, and unite
study participants and colleagues and give something back to
those studied.
"Justice in research focuses on the fair distribution of
burden and benefit" (Antle & Regehr, 2003, p. 138), meaning
that all involved, those who are studied and those who do the
studying, are treated with fairness, and this also applies to
traditionally understudied groups and communities. The most
recent Council for International Organizations of Medical
Sciences (CIOMS) guidelines (2002) address this issue as it
relates to
biomedical research in disadvantaged nations and
communities: "the sponsor and the investigator must make
every effort to ensure that the research is responsive to the
health needs and priorities of the population or community in
which it is carried out; and any intervention or product
developed, or knowledge generated, will be made reasonably
available for the benefit of that population or country" (p. 34).
Respect means that the autonomy and self-determination of
those who participate in research must be safe-guarded.
Anyone who is part of a study must consent to .do so
voluntarily and after being fully informed of what will be
required of them, including any risks they might incur during
the conduct of the study or from the dissemination of its
findings. Respect must also be extended to the organizations
and communities in which research is carried out as well as to
all of those involved in the conduct of the research.
Institutional Review Boards
In the United States, the 1979 Belmont Report began a system
of overseeing biomedical and behavioral research: the use of
Institutional Review Boards (IRBs) at all institutions and
organizations that receive any form of government financial
support (Grigsby & Roof, 1993; Shore & West, 2005). Similar
regulatory mechanisms now exist in many other nations as
well (Israel & Hay, 2006). Any social worker who conducts
research with people or who uses information about them that
would otherwise be private must apply to one of these boards
for permission to conduct their research. (What constitutes a
"human subject" in research, what is considered a "no risk" or
"minimal risk" study, and what is acceptable training in
research ethics are all spelled out in federal regulations,
guidelines for IRBs, and the specific policies of each
individual IRB. Who should and must serve on IRB review
panels is also specified in the CIOMS standards and
elsewhere.) Anyone proposing to conduct research under IRB
supervision must document that they have been trained in the
ethical conduct of research with human participants.
Even when the risks of participation in a study are
minimal, as in most social work research, studies must be
conducted in such a way as to minimize risks. However, no
level of risk is acceptable unless there is a real potential for a
study to advance knowledge based on the scientific soundness
of its methodology. There have been specific concerns about
how fairly such bodies may view qualitative, oral history, or
participatory action studies, for example, since IRBs often
appear to be oriented to the value of the experimental and
quantitative methods used in biomedical studies (CSWE,

2007; Lincoln, 2005). The most common IRB feedback to
social work researchers concerns strengthening procedures
(data collection, sample recruitment, data storage) to protect
the autonomy of participants or the confidentiality of data.
Most have concluded that routine outside review of the ethical
safeguards employed in proposed studies involving human
beings is a worthwhile protective mechanism for researcher
and researched alike.
An issue that has been discussed since the original
Belmont Report is the boundary between practice, especially
the evaluation of practice and programs, and research (Grigsby
& Roof, 1993; Shore & West, 2005). Often it is the intent to
publish (suggesting that generalizable knowledge ~ill be
generated from a study and that information about service
recipients will be shared with people not involved in their care)
that differentiates research from practice evaluation and
triggers IRB review.
Code of Ethics Content
on Research and Scholarship
The content in the NASW Code of Ethics (NASW, 1999) that
specifically addresses research ethics is in Section 5.02,
although other sections are relevant as well. These guidelines
are necessary, but not sufficient to ensure that research is
conducted responsibly, and social work researchers commonly
encounter ethical dilemmas in their work (Apgar & Congress,
2005b, p. 73). As Butler (2002) states, "At all stages of the
research process, from inception, resourcing, design,
investigation, and dissemination, social work ... researchers
have a duty to maintain an active, personal and disciplinary
ethical awareness and to take practical and moral respon-
sibility for their work" (p. 245). The Council on Social Work
Education (CSWE) has also developed a national Statement
on Research Integrity in Social Work (2007).
Minimizing Risks to Research Participants Many of the
ethical dilemmas that occur in research stem from the power
differential between researchers and research participants who
are the "objects" of the research (Halse & Honey, 2005).
Involvement in research studies is based in part on the
participants' views of the research enterprise itself as benign
(or nor), which can be influenced by the history that a group or
community has had with biomedical or social research in the
past (Barata, Gucciardi, Ahmad, & Stewart, 2006; Fisher et al,
2002; Martin & Knox, 2000). Cultural competence must
therefore infuse all parts of the research process (Oliver, 2003).
Informed consent. There are two vital dimensions to
informed consent: that research participation is
ETHICS IN RESEARCH
153
voluntary and that consent is given in full knowledge about the
nature of the study and of what will be required of study
participants. Models of consent forms can be obtained from
individual IRBs and from the Web site of the federal Office
for Human Research Protection (OHRP) (see Suggested
Links). The nature, probability, and likely severity of any risks
of research participation should be described (Boothroyd &
Best, 2003). However, initial consent to participate leaves
participants free not to answer specific questions or take part
in specific procedures and to withdraw their consent at any
point in the conduct of the study-rights that must also be made
clear.
Social work research often involves service users, and
assurance must be given to them that declining to participate
in or withdrawing from a study will not compromise the
services or care they are getting in any way. Usually it is
someone other than a treating professional involved in their
care who must request research consent so that the service
user will feel more free to decline. In addition, the practice of
offering research participants some compensation for the time
and effort they contribute to a study is common, and such
rewards must not constitute an undue inducement to volunteer.
Some believe that a cash gift to drug-using study participants,
for example, may be riskier to their well-being than a gift or a
gift certificate, although Festinger et al. (2005) did not find
this to be true. An emerging practice in participant
compensation is offering a lottery award to participants, but
there is debate about its ethical use (Brown, Schonfeld, &
Gordon, 2006). Careful attention to any effects of the power
differential between researcher and potential study par-
ticipants conveys a respect that can actually enhance the data
that is obtained (Sieber, 1992).
Consent forms and the opportunity to discuss research
participation must take into account the language of the
participant and their abilities (for example, any vision
problems affecting the reading of forms, level of literacy).
Hence one area of concern involves how much information to
convey about a study in the consent process. Perhaps to avoid
litigation, the tendency over time has been to give ever more
detailed information, but this trend can result in long and
detailed consent documents that are hard for potential
participants to read and understand. Because peoples'
motivations to enroll or not enroll in a study are complex
(Stone, 2004), how much to say in a consent form as well as
where and how to say it for the most effective communication
is currently being studied and debated (Boothroyd & Best,
2003; Fisher et al., 2002; Lynoe & Hoeyer, 2005).
Confidentiality. Social workers usually know how to
protect the confidentiality of client information and
154 ETHICS IN RESEARCH
therefore understand the need for secure storage of research
data. Identifiable data on research participants, including
signed consent forms and lists linking names to research
codes, must be stored separately from the research data itself,
which is identified only by a code number or pseudonym. Data
stored electronically must also be secure, that is,
password-protected. When and how data will be destroyed
must also be specified.
Although laws vary from state to state, the confidentiality
of data collected by social workers for research rather than for
clinical purposes is less wellprotected. In certain sensitive
areas, such as the mandated reporting of child or elder abuse,
there are clear limits to the confidentiality that a social work
researcher can offer, limits that must be made clear to research
participants. If data on illegal activities, drug use, or other
sensitive information is being collected, it may be desirable to
obtain a Certificate of Confidentiality (Wolf & Zandecki,
2006), although such certificates may not include all relevant
areas like domestic abuse (Hofman, 2004; Wolf & Zandecki,
2006).
The 1996 Health Insurance Portability and Accountability
Act (HIPAA) has imposed some additional regulatory
constraints on research information derived from medical and
other covered settings and from some kinds of patient records.
However, data from affected records can still be used for
research if it is deidentified. A link to further information on
HIPAA and its effects on research activities is given later (see
Suggested Links).
Vulnerable Populations
All negotiations of consent for participation in research
depend on the "presumption of the universalized subject" who
can act freely and rationally in forming a social contract
(Halse & Honey, 2005, p. 2152). While the implications of this
assumption have not been fully addressed, it is well
understood that some potential research participants are
vulnerable in the consent process for a variety of reasons,
many of them of interest to social work researchers. Cognitive
or communicative vulnerability, institutional vulnerability,
deferential vulnerability, medical vulnerability, economic
vulnerability, and social vulnerability must all be considered
(Anderson & Dubois, 2007). CIOMS (2002) guidelines (pp.
49-51) and federal regulations (see the OHRP Web site) also
give special attention to studies involving pregnant women,
fetuses, and neonates.
Children and adolescents are not legally able to represent
themselves in consenting to participation in research,
although the agets) and circumstances, like
being an emancipated minor, at which adolescents are
considered able to consent, vary across jurisdictions. The
consent of a parent or guardian must be sought when children
are to participate in research, unless it can be demonstrated to
an lRB that seeking such consent could in fact endanger the
child, as can be the case, for example, if youth who are gay,
lesbian, bisexual or questioning are to be studied and if they
have not disclosed their sexual identities to their parents for
fear of rejection or abuse. In such cases, a waiver of parental
consent can be granted and an advocate appointed to assist
each participating young person. Children and adolescents
who are wards of the state also present a special circumstance,
and each state has its own method of assisting them with an
advocate for research consent purposes. To respect the
autonomy and dignity of adolescents and older children, it is
desirable also to seek formal assent for research participation
from them and to proceed only if both parental consent and
participant assent are obtained (see the OHRP Web site for
information on involving children and adolescents as
participants in research, including models for assent
documents).
Prisoners, people who live in institutions, or others in need
of services are considered vulnerable in the consent process
either because they may feel undue inducement to enroll in
studies (for example, prisoners may volunteer to demonstrate
good conduct when applying for parole) or because there will
be negative consequences if they decline (Arboleda-Florez,
2005). Anyone who might have diminished capacity to under-
stand what is being asked of them as a research participant or
to make decisions in their own best interest is also considered
vulnerable. This group includes those with some forms of
mental illness, those with intellectual deficits or age-related
cognitive impairments, some who abuse drugs, and some of
those with life-threatening or serious medical illnesses (APA,
2006; Anderson & Dubois, 2007; Boothroyd & Best, 2003;
Fisher et al., 2002; Roberts, 2002). Only when a person has
been legally determined to be incompetent is incapacity to
consent clear-cut, and overprotection can restrict research on
important problems, especially studies in which the
perspectives of those with any of these conditions are
included.
Most people who have disorders or disabilities can, in fact,
consent to participation in research if communication in the
consent process is adapted to their needs, as in reading the
consent form aloud for the visually impaired or
communication in American Sign Language (ASL) for those
who are deaf, although issues of confidentiality can be
magnified in their relatively small social networks (Eckhardt
& Anastas, 2007).
l

Social work research often involves people considered
vulnerable because there may be at risk of painful emotional
reactions consequent to speaking of sensitive personal and
emotional issues (Boothroyd & Best, 2003), such as in
research on those who are bereaved (Stroebe, Stroebe, &
Schut, 2003). When and how to approach such potential
participants must be carefully considered, and it is common to
build in safeguards, as offering referral for professional
assistance to any participant who seems to be distressed. In
these situations, to avoid potential conflicts of interest or dual
roles (Congress, 2001), any assistance offered must be from
an independent source.
Clinical and video or audio elata. Anyone who is observed
or interviewed i~ person can be offered confidentiality
protection but is by definition not anonymous. Similarly,
individual clinical or case study data can include enough detail
that inferred identification of the participants can be made by
someone who may know them; as in case reports used in
education and training, alteration and disguise of selected
information is the usual remedy for this problem. However,
when audiotaped or videotaped information is col\ected, these
data pose special chal\enges in safeguarding participant,
provider, family, and community privacy. Separate and
specific consent to the collection of such data and especially to
any sharing of data in these forms, as in conference
presentations of findings, should be obtained (see APA,
2002,8.03, p. 11 and the OHRP Web site).
Minimizing Risks to
Scholarship and Knowledge Development There is no
benefit to the conduct of social work research unless there is
confidence in the integrity of the profession's
knowledge-generating and dissemination activities as a
whole. The Office of Research Integrity (OR!) describes four
key values in this area: honesty, "conveying information
truthfully and honoring commitments"; accuracy, "reporting
findings precisely and taking care to avoid errors"; efficiency,
"using resources wisely and avoiding waste"; and objectivity,
meaning "letting the facts speak for themselves and avoiding
... bias" (Steneck, 2004, p. 10).
Although there are few well-known examples of
questionable ethical conduct in social work research and
scholarship, the kinds of problems that can arise are known
from related fields (Gibelman & Gelman, 2001). The most
common kinds of research misconduct are the fabrication of
data, the falsification of data, and plagiarism (Gibelman &
Gelman, 2001; Steneck, 2004, p. 21). While the last is known
to occur in social work and in social work education, there is
little or no
1
ETHICS IN RESEARCH
155
systematic information available about plagiarism or the kinds
of sanctions imposed when it occurs. The APA has a very
useful and succinct statement about how to avoid plagiarism: "
... do not present portions of another's work or data as one's
own, even if the other work or data source is cited
occasionally" (APA, 2002, p. 12).
Conflicts of interest. Collaboration is common in social
work research, and people involved in research occupy
different positions and have differing access to power and
resources, differences that occur among those conducting the
research as wel\ as between researchers and participants.
Researchers' sources of funding are coming under increasing
scrutiny for the effects they may have on findings and their
dissemination (Oliver, 2003). In program evaluation, it may be
difficult to draw conclusions that are critical of the agency
studied or that may compromise program funding. Agency
employees who are study informants may be vulnerable to
unintended harms, which must be minimized (Hilton, 2006 ).
Different stakeholders in the research may have conflicting
needs and desires concerning intellectual property,
publication, and the ownership of the data col\ected. Open
discussion of all matters such as the ownership of data,
copyright (as for any data collection instrument developed),
authorship (including those with students), supervision of
findings, and their dissemination is recommended at the
inception of the study and periodically throughout (CSWE,
2007; Macrina, 2005; Netting & Nichols-Casebolt, 1997;
Oliver, 2003; Shamoo & Resnik, 2003; Smith, 2003; Steneck,
2004).
Authorship. Although the principle of not taking credit for
the work of others is clear, there are no social-work specific
guidelines for addressing authorship issues; in fact
considerable variation in beliefs exists even among social
work educators (Apgar & Congress, 2005a; Gibelman &
Gelman, 1999). In addition, there is evidence that many social
work researchers, especially when students, have had adverse
experiences with authorship (Netting & Nichols-Casebolt,
1997). Social workers' beliefs about the weight that should be
given to some tasks when determining authorship credit, such
as data analysis (Apgar & Congress, 2005a), is at variance
with that in other fields (see, for example, chapter 2 in Shamoo
& Resnik, 2003), and more study and discussion of authorship
issues and practices are needed.
Current Issues and Future Trends
in the Responsible Conduct of Research Qualitatit1e
methods. Perhaps because the researcher is seen as an
instrument of the research in qualitative
156 Ennes IN RESEARCH
studies (Haverkamp, 2005), more has recently been published
about ethical dilemmas faced by researchers in this area than in
others. Face-to-face encounters with participants discussing
emotionally laden experiences and prolonged engagement with
them can evoke strong emotional reactions in researchers or even
a conflict between the "helping" and the "studying" roles (see for
example, Davison, 2004). Qualitative researchers have been more
ready than some others to consider power differentials in the
relationships between researchers and study participants; to call
for researcher reflexivity, reciprocity, and participant
empowerment; and to consider the implications of all these
factors for research ethics (Christians, 2005; Haverkamp, 2005;
Lincoln, 2005).
Participatory action research. Social work researchers
concerned with the social justice aims of research are embracing
an investigational model most commonly called participatory
action research (PAR) that seeks maximal power-sharing
between researchers and those being studied, individually and
collectively (see Community-Based Participatory Research). In
PAR procedures and findings are generated collaboratively over
the course of a study, making it difficult to comply with what
IRBs require in an application for approval of a study, since
sampling plans, data-gathering procedures, data analysis plans;
and even the nature of anticipated findings are not
pre-determined. Articulating the risks and benefits of PAR and
explicating how protections can be offered within different
assumptions and procedures are essential (Brydon-Miller,
Greenwood, & Eikeland, 2006; Khanlou & Peter, 2005).
Internet-based studies. Research using the World Wide Web
is becoming more common, and ethical issues in Internet research
is an emerging area of discussion (Buchanan, 2004; Ess & AoIR,
2002; Rhodes, Bowie, & Hergenrather, 2005). Internet research
can involve simply recruiting participants for conventional forms
of data-gathering, analyzing content on existing sites such as chat
rooms, or gathering data via Webbased surveys. Ethnographic and
qualitative research can also be done in cyberspace (Buchanan,
2004). Informed consent can be compromised without faceto-face
interaction, as when a child represents himself or herself as an
adult and parental consent is therefore not obtained. Even special
measures may not ensure anonymity or the privacy of data
collected: "encryption .,. can protect responses to an online
questionnaire but cannot protect the respondent's IP address"
(Rhodes et al., 2005, p. 71), a limitation that must be
acknowledged. In addition, again because there is no face-to-face
interaction, it is difficult to determine if a study has produced
distress in a participant. Doing
Internet-based research therefore requires staying current with
emerging best practices in the ethical conduct of such studies.
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Hilton, T F. (2006). Staff members are human subjects, too.
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Lincoln, Y. S. (2005) Institutional Review Boards (IRBs),
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Oliver, P. (2003). The student's guide to research ethics.
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Shamoo, A E., & Resnik, D. B. (2003). Responsible conduct of
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Shore, N., & West, P. (2005, September 14). Social worker
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158 ETHICS IN RESEARCH
SUGGESTED LINKS
hetj): / / www.socialworkers . org/pubs/ code/default. asp
The National Association of Social Workers' (NASW) Code of
Ethics online. http;//www.socialworkers.org/research/naswResearch/
1006E thies/default. asp
This Web page, developed and maintained by IASWR (the
Institute for the Advancement of Social Work Research) for
NASW, has principles of research ethics, a bibliography, and
links to other useful resources.
http:// cswe. org/home/ ! F inal% 20N ational% 20S tatement%
20-%201-31-2007.pdf
The Council on Social Work Education convened a work group
that developed this CSWE National Statement on Research
Integrity in Social Work.
http://www.dhhs.gov/ohrp
This is the homepage of the Office for Human Research
Protections (OHRP), the federal office that ensures adherence to
federal regulations for the conduct of research studies and for the
Institutional Review Boards that oversee individual studies at a
local level within these guidelines. Online training in research
ethics and information about dealing with vulnerable populations
in research (e.g., children, prisoners) .
http://ori .dhhs .gov/documents/rcrintro. pdf
The Department of Health and Human Services' Office of
Research Integrity has a publication entitled "ORI Introduction to
the Responsible Conduct of Research." The office's newsletter is
also available on their Web site.
http://privacyruleandresearch . nih.gov/pr _02.asp
The 1996 Health Insurance Portability and Accountability Act
(HIPAA) has imposed new restrictions on some research
activities, including clinical and health services research. In-
formation and links to additional topics within this area, including
a summary booklet about the regulations for researchers, are
provided.
http://grants . nih.gov/grants/policy/coc/
This NIH site is the "kiosk," or entry point, for further information
on Certificates of Confidentiality and how to apply for one.
http://www.research.utoronto.ca/ethics/pdf/human/nonspecific/
Intemet%20Research%20Ethics . pdf
In 2002, the Association of Internet Researchers (AoIR)
membership, which is transdisciplinary and international,
approved a set of ethical guidelines for researchers using the
Internet. These are intended to supplement, not supplant, any
profession-specific standards, and the site also includes links to
other useful resources.
http://www.dhhs.gov/ohrp/humansubjects/guidance/belmont.htm This
is the link to a copy of the 1979 Belmont Report codifying ethical
standards for research in the United States.
http://www.cioms.ch/frame-lSuidelines_not._2002.htm
This site contains the complete text of the CIOMS International
Ethical Guide!ines for Biomedical Research Involving I--Iuman Subjects.
httj)://www.hhs.gov/ohrp/references/nurcode.htm
The complete text of the Nuremberg Code can be found here.
http;//www.cirj).org/library/ethies/he!sinki!
This site has the complete text of the 1964 Declaration of Helsinki
as reproduced in the British Medical Journal, No 7070, Volume
313,7 December 1996.
-JEANE W. ANASTAS
EVALUATION. See Program Evaluation; SingleSystem
Designs.
EVIDENCE;BASED PRACTICE
ABSTRACT: Evidence-based practice (EBP) is an edu-
cational and practice paradigm that includes a series of
predetermined steps aimed at helping practitioners and
agency administrators identify, select, and implement
efficacious interventions for clients. This entry identi fies
definitions of EBP and traces the evolution of EBP from its
origins in the medical profession to its current application
in social work. Essential steps in the process of EBP and
challenges associated with applying EBP to social work
practice, education, and research are noted.
KEY WORDS: evidence-based practice; social work
education
Evidence-based practice (EBP) is a five-step process used to
select, deliver, and evaluate individual and social interventions
aimed at preventing or ameliorating client problems and social
conditions. At its most basic level, EBP seeks to systematically
integrate evidence about the efficacy of interventions in clinical
decision-making. Adhering to EBP, however, is a complex
process that requires practitioners to be skilled at posing
practice-relevant questions and proficient at accessing evidence
that answers these questions. Importantly, practitioners must have
the requisite methodological skills to evaluate evidence about the
efficacy of interventions from clinical trials, systematic reviews,
and meta-analyses. Finally, to teach the process of EBP, social
work educators must be competent in tasks associated with
information retrieval and interpretation of evidence.
A recent surge of interest in EBP is raising awareness about
the importance of considering empirical evidence in selecting
interventions among practitioners who may not have considered
such evidence in the past. At the same time, the sudden growth of
EBP gives rise to a cautionary note about the many different ways
that EBP is being defined in published works and taught in the
classroom. A consistent definition of EBP and an

educational commitment to the process steps required in
EBP are critical at this juncture to prevent the misuse or
misunderstanding of this new paradigm.
Definitions and Evolution of EBP
EBP appeared in the medical profession in the 1990s as a
process to help physicians select effective treatments for
their patients. The introduction of EBP in medicine was
viewed by many scholars and practitioners as an effective
way to bring research findings to medical practice
decisions. The rapid diffusion of EBP since then has been
attributed to advances in knowledge about the prevention
and treatment of medial conditions and to economic forces
that emphasize the selection of efficacious treatments as a
strategy to reduce health care costs (Gray,'2001).
The growth of EBP in medicine has also been a product
of an increasingly active and well- informed patient
population. Unlike prior generations, a signifi cant portion
of today's patients are well educated about their medical
problems and demand that they receive the most optimal
treatments for their conditions. The sophistication of
medical consumers has required phy sicians to become
more skilled at evaluating and apply ing evidence to
medical practice decisions (Gambrill, 2006; Gray, 2001 ;
Wennberg, 2002).
Definitions and perceptions of what EBP is- and what it
is not-vary widely. In what is arguably the most wide ly
accepted definition of EBP, Sackett and colleagues
(Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000)
state that EBP is "the integration of best research evidence
with clinical expertise and [client] values" (p. 1). In this
definition, EBP is implied to be a process characterized by
specific steps and actions. In an earlier publication, Sackett,
Richardson, Rosenberg, and Haynes (1997) had defined
EBP as "the conscien tious, explicit, judicious, use of
current best evidence in making decisions abou t the care of
individual [clients]" (p.2).
The introduction of EBP in medicine has created
considerable interest in the process of applying evi dence to
medical practice decision-making. Impor tantly, scholars
also believe that EBP has moved the medical profession
away from its long-standing reliance on authority- based
decision-making processes that fail to adequately consider
empirical evidence (Gambrill, 1999,2005).
Essential Steps of EBP
As the above definitions imply, EBP is both a philoso phy
of practice and a process that implies a series of structured
steps. Sackett et al. (2000) have been cred ited with
developing the five essential steps of EBP.
EVIDENCE-BASED PRAcncE
159
STEP 1: CONVERTING PRACTICE INFORMATION
NEEDS INTO ANSWERABLE QUESTIONS An impor-
tant first step in the process of EBP requires practitioners to
define information needs about a particular client problem.
Sackett et al. (2000) suggest that this information needs to
be framed in the form of answerable questions. Further,
they recommend that questions identify the client
population, intervention type, and anticipated outcomes.
Several scholars have brought elements of this first step
in the EBP process to social wo rk. In an important book on
the subject of EBP, Gibbs (2003) identified a framework
for posing questions that emphasizes the need for
practicality. According to Gibbs, questions must be
client-oriented and they must be specific enough to guide a
search for evidence using electronic resources. Gambrill
(2005) summarized effectively the types of questions that
are generally posed in EBP processes. Her synopsis
includes the following question types: 1) effectiveness, 2 )
prevention, 3) assessment, 4) description,
5) prediction, 6) harm, and 7) cost-benefit.
Framing practice-relevant questions is the founda tion of
the EBP process. Questions must be specific and posed in
terms that lead to a rational search for evi dence. An
illustration of an effectiveness question may be helpful in
understanding the importance of this point. Suppose a
practitioner in a substance abuse pro gram is interested in
knowing whether a cognitivebehavioral intervention is
more effective than a l z- step treatment program for
addressing alcohol abuse in adults. In this case, a logical
practice question might be: Is a structured
cognitive-behavioral intervention more effective than a self- help
program in treating alcohol abuse in adults? In a second
example, suppose practitioners and teachers in a local
elementary school are concerned about the negative effects
of bullying behaviors in the classroom. In this example, a
school social worker might pose a question about the best
way to address aggression. A typical question might be: Is a
universal prevention approach aimed at changing social norms
about aggression more effective than a skills training approach
that seeks to reduce aggression by targeting only high-risk youth?
Posing answerable questions requires precision and
practice. Students and practitioners must be trained to pose
different types of practice- relevant questions and learn
ways to retrieve evidence that is critical in an swering such
questions.
STEP 2: LOCATING EVIDENCE TO ANSWER QUES-
TIONS Step 2 requires practitioners to search for and locate
evidence pertaining to the questions they pose. At least four
sources are available currently to search for empirical
evidence: 1) books and journals,
160 EVIDENCE-BASED PRACTICE
2) systematic reviews organized by client problem or
treatment approach that detail the effects of interventions on
specified outcomes, 3) published "lists" of effective programs
by federal entities and research centers, and 4) practice
guidelines that offer treatment protocols based on empirical
evidence.
Books and Journals. Books and journals represent a
traditional approach to answering practice-relevant questions
identified in step 1. Printed books and journal articles are
readily available and have traditionally been helpful
information sources. However, practitioners must also be
aware of the limitations inherent in books and journals. For
example, there is often a significant time lag between the
submission and subsequent publication of a book or journal
article. Practitioners must also have the skills to identify and
discern published findings that pertain to their questions. This
requires knowing how to select and search appropriate
databases for information. In addition, practitioners must be
trained to recognize that findings reported in book chapters
and other outlets are quite likely not subject to peer review
processes.
A final limitation of books and journals as information
sources relates to the types of articles commonly published in
social work. For example, at least one investigation has
revealed that relatively few intervention outcome studies are
published in social work literature (Rosen, Proctor, & Staudt,
1999). The lack of outcome studies poses a limitation to
practitioners searching for evidence pertaining to the efficacy
of interventions.
Systematic Reviews. Systematic reviews are com-
prehensive evaluations that examine evidence about the
effectiveness of interventions targeted to a range of client
populations and problems. Leadership in dis seminating
knowledge of effective prevention and treatment
approaches through the publication of sys tematic
treatment outcome reviews has come from in ternational
interdisciplinary teams organized under the Campbell
Collaboration (2007, www.carnpbellcolla boration.org)
and the Cochrane Collaboration (2007 ,
www.cochrane.org). Each of these groups disseminates
the results of systematic reviews to inform practi tioners
about the effects of interventions in health, behavioral,
and educational settings. Importantly, systematic reviews
of treatment outcomes are also becoming more available
in social science literature (Vaughn & Howard, 2004).
Lists of Efficacious Programs. A third dissemination
approach has been organized by federal entities and
independent research centers such as the Substance Abuse
and Mental Health Services Administration (SAMHSA) and
the Center for the Study and
Prevention of Violence (CSPV) at the University of Colorado.
For example, SAMHSA (2007, www.rncdel-
prograrns.sarnhsa.gov) publishes a list of efficacious sub-
stance abuse prevention and treatment programs in the
National Registry of Evidence-Based Programs and Practices.
The agency identifies promising, effective, and model
programs on the basis of methodological rigor and client
outcomes. CSPV (2007, http://www.color ado.edu/cspv/)
identifies effective violence prevention programs as part of its
Blueprints for Violence Prevention dissemination effort. At
least one group concerned with the effects of school-based
educational programs for high-risk youth has also published
lists of effective interventions (Collaborative for Academic,
Social, and Emotional Learning, 2003).
In psychology, concern about the failure of many
therapists to use empirically supported treatments led to the
establishment of the American Psychological Association
(APA) Task Force on the Promotion and Dissemination of
Psychological Procedures in 1993 (Barlow, Levitt, & Bufka,
1999). The Task Force was established by the APA Society of
Clinical Psychology (Division 12) to identify efficacious
treatments across a range of mental health disorders and
problems. Task Force members with expertise in diverse
therapeutic approaches and populations developed criteria for
treatments deemed to be well established and empirically
validated and for treatments considered to be probably
efficacious. Well-established treatments were those therapies
that evidenced efficacy in at least two independent and
rigorous experimental studies. Probably efficacious
treatments were therapies in which only one study supported a
treatment's efficacy, or therapies that had been tested by a
single investigator (Task Force on the Promotion and
Dissemination of Psychological Procedures, 1995).
The Task Force recognized randomized clinical trials as
the most rigorous and acceptable method of producing
empirically supported treatments. In lieu of randomized trials,
findings from a large series of single case design experiments
were accepted as criteria. The Task Force initiated a search for
efficacious and probably efficacious treatments in 1993 (Task
Force on the Promotion and Dissemination of Psychological
Procedures, 1995). The subsequent list of efficacious thera-
pies has since been updated twice (Chambless et al., 1996;
Chambless ct al., 1998).
Compilations of effective programs allow practitioners to
access considerable information about the efficacy of
interventions targeted to a wide range of client groups and
problems. Credible lists such as those identified above use
rigorous selection criteria to identify effective programs. For
example, to be included on

the program list compiled by the CSPY at the University of
Colorado, intervention studies must use strong research
designs and demonstrate sustained effects. Replication of
effects is also required to meet criteria for the highest level of
evidence. Similarly, APA criteria clearly identify the levels of
research rigor that are necessary to meet standards for
efficacious or probably efficacious treatments.
Lists of EBPs lead practitioners to potentially effective
interventions. However, such lists cannot simply be accepted
uncritically. In all cases, practitioners should scrutinize the
criteria used to identify effective programs and interventions
when they consider selecting and implementing programs
from lists of EBPs.
Practice Guidelines. Practice guidelines are a fou rth
method of disseminating knowledge of effica cious
interventions to practitioners. Proctor and Rosen (2003 )
defined practice guidelines as "a set of system atically
compiled and organized knowledge statements designed to
enable practitioners to find, se lect, and use appropriately
the interventions that are most effective for a given task" (p.
108). Guidelines offer specific treatment protocols for
practitioners that, when fol lowed, mirror the strategies used
in efficacious interventions with similar ty pes of clients.
Clinical practice guidelines were introduced in medicine
and have recently spread to psychology and social work.
Guidelines in social work have been met with mixed
reaction and their development and application have been
limited to date (see Howard & Jenson, 1999a, 1999b, 2003
and Rosen & Proctor, 2003 for a discussion of practice
guidelines in social work).
Summary. Sources of information and evidence
have proliferated widely in recent years. Practitioners
must possess a range of informat ion retrieval skills to
identify appropriate sources of credible evidence. The
appraisal of such evidence, discussed next, is a critical
next step in the EBP process.
STEPS 3 & 4: ApPRAISING AND ApPLYING EVIDENCE
TO PRACTICE AND POLICY DECISIONS EBP requires
practitioners to use their knowledge of research design and
methodology to evaluate and apply evidence to practice
situations. These steps require familiarity with research
methodology and the ability to draw conclusions about the
utility of information on the basis of levels of evidence. The
scientific community recognizes findings produced by
randomized control1ed trials as the most rigorous and
acceptable level of evidence. However, results from studies
using correlation, single-subject, quasi-experimental,
experimental, and meta-analytic designs must also be
considered and evaluated in steps 3 and 4 (Thyer, 2004).
EVIDENCE- BASED PRACTICE
161
Evaluating the rigor of studies and selecting interventions
that meet high research standards require advanced training in
methodology and intervention research. Unfortunately,
current standards for research training in most Master of
Social Work programs fal1 short of assuring the advanced
skills necessary to critically evaluate the validity and
applicability of research reports. Additional course work in
evaluating evidence should be included in the graduate social
work curriculum.
A second concern in appraising and applying evidence to
practice situations comes from studies suggesting that
practitioners fail to routinely consult research evidence when
selecting interventions. For example, several studies show that
practitioners often choose interventions for reasons other than
empirical evidence (Elliott & Mihalic, 2004; Rosen, Proctor,
MorrowHowel1, & Staudt, 1995). In addition, agency and
organizational policies that limit the choice of intervention
approaches available to practitioners often constrain
practitioners' ability to use EBP.
The flurry of activity associated with EBP is not confined
to selecting and implementing well-tested programs. To
develop new knowledge about the effects of interventions, a
small but increasing number of social work researchers are
testing the effects of interventions across different problem
areas in controlled efficacy trials (Reid & Fortune, 2003). This
is a promising development in view of findings suggesting
there is a dearth of intervention studies in social work (Fraser,
2003; Jenson, 2005; Rosen et al., 1995). More intervention
research by social work investigators is needed to contribute
to the knowledge base of efficacious prevention and treatment
approaches.
STEP 5: EVALUATING THE PROCESS The steps in EBP
appear deceptively simple at first glance. However, the
process of EBP requires knowledge of current literature about
the onset, prevention, and treatment of client or social
problems, the ability to search for relevant information and
data, and skills to evaluate and apply knowledge obtained in
systematic searches. The complexity involved in steps one to
four demands an ongoing evaluation of one's knowledge of
current literature, familiarity with constantly changing
electronic databases, and skills in drawing conclusions based
on methodological rigor.
Gibbs (2003) summarizes effectively the process of EBP:
"Placing the client's benefits first, evidence-based
practitioners adopt a process of lifelong learning that involves
continual1y posing specific questions of direct and practical
importance to clients, searching effectively for the current best
evidence to each question,
162 EVIDENCE-BASED PRACTICE
and taking appropriate action guided by evidence" (p. 6). Most
scholars would agree that the social work profession is in the
beginning stage of implementing the process defined by Gibbs
in practice, and education and research settings.
CHALLENGES AND IMPLlCA TIONS The promotion of
EBP in social work was attributed initially to individual
scholars and small groups of researchers (e.g., Gambrill, 1999,
2003; Howard & Jenson, 1999a; Proctor & Rosen, 2003;
Thyer, 2004). These early efforts were aimed largely at
exposing social workers to definitions of EBP and to
concurrent developments in evidencebased medicine.
Discussion of the process of applying EBP principles to social
work practice and policy soon followed (for example, Eilson,
2005; Gambrill, 2003, 2006; Gibbs, 2003).
A significant number of social work researchers and
educators have since acknowledged the importance of EBP.
Support is evident in the exponential growth in the number of
books and articles on EBP since 2003 (see Gambrill, 2005,
2007; Howard, Himle, Jenson, & Vaughn, in press; Rosenthal,
2004 for reviews). Sessions on EBP have increased
significantly at recent national social work conferences
sponsored by the Society for Social Work and Research and
the Council on Social Work Education. Further, a 2006
University of Texas at Austin symposium on EBP signaled an
increasing recognition of the importance of teaching EBP in
the social work curriculum. The Austin conference led to the
publication of a 2007 special issue of Research on Social Work
Practice that summarized the viewpoints of presenters at the
symposium. Transparency in the use of EBP in practice and
education (Gambrill, in press), steps required to teach EBP
(Mullen, Bellamy, Bledsoe, & Francois, in press), and
structural curricular reforms consistent with EBP (Howard &
Allen-Meares, in press; Jenson, in press) are among the topics
discussed in that issue.
An increase in attention to EBP by social work educators
is indisputable. However, EBP is not without its critics. There
have been voices of skepticism (Taylor & White, 2002) and
even rejection (Webb, 2001) characterized by claims that EBP
offers nothing new to the field. Others point to the lack of an
effective knowledge base for certain client problems and
populations, which hinders the advancement of EBP in the
field.
EBP is at an important turning point in social work.
To some, it reflects a new and revolutionary practice approach
that holds great promise for building stronger bridges between
science and social work (Gambrill, 2007; Jenson, 2005).
Others view EBP as a
repackaged attempt to integrate research and practice that is
fraught with educational and implementation problems
(Webb, 2001). Regardless, the challenges of EBP to social
work education, practice, and research are varied and
complex.
EBP AND SOCIAL WORK EDUCATION
The Challenge of Educational Reform. Rubin and Parrish
(2007) reported that more than 70% of respondents from a
survey of social work educators were in favor of teaching EBP
in the MSW curriculum. Rapp-Paglicci (2007) noted that as
many as 40 social work programs have created classes that
incorporate principles of EBP. At least one school of social
work-the Brown School of Social Work at Washington
University-has identified EBP as the organizational
framework for its graduate curriculum (Edmond, Rochman,
Megivern, Howard, & Williams, 2006; Howard, McMillen, &
Pollio, 2003). Importantly, the Council on Social Work
Education has identified EBP as an important principle in its
educational policy and accreditation documents (Council on
Social Work Education, 2004). These and other examples
illustrate the increasing attention being paid to EBP in the
social work curriculum.
It is also clear, however, that interest in EBP has not yet
resulted in the adoption or implementation of significant
curriculum reform. To illustrate, Woody, D'Souza, and
Dartman (2006) reported less than encouraging findings from
a survey of social work deans and directors examining whether
and how their programs teach empirically supported
interventions. Woody et a1. (2006) noted that, "only 31
programs, less than half, had endorsed teaching specific ESI
[Empirically Supported Interventions] content; still fewer, 26,
had designated courses to teach specific ESI content; and of
the 31 programs that had endorsed teaching ESl, very small
numbers required ESI training materials designed for teaching
students the skills and techniques for implementing the
interventions"
(p.474).
Significant structural and pedagogical changes in social
work education are necessary to teach EBP. For example, a
new generation of students must be exposed to the
complexities involved in posing relevant practice and policy
questions. Students must become experts in information
retrieval and possess the methodological skills necessary to
evaluate and apply evidence. New and innovative teaching
approaches will be required to systematically teach EBP.
Faculty will need to be trained, and in some cases retrained, to
teach EBP. Finally, the appropriate location for teaching the
actual process of EBP must be determined in undergraduate
and graduate curricula.

Teaching the Process of EBP. Above all, EBP is a
process characterized by the five specific steps discussed
above. Thus, a logical assumption is that educators should
focus their efforts on teaching the actual process of conducting
EBP. However, the degree to which faculty members in
schools of social work are teaching the five-step process of
EBP-or simply informing students of effective interventions-
is unclear. Several scholars, most notably Gambrill (2007),
caution that exposing students to only EBPs identified on
compiled lists and national registries is inconsistent with the
fundamental premise of EBP. She accurately notes that a
singular focus on effective interventions, expressed through
commonly used terms such as best practices, is taking focus
away from teaching students the actual process of EBP.
Gambrill (2007) further suggests that emphasizing EBPs at the
cost of understanding the process of EBP is inconsistent with
the original intent of EBP as an approach that fosters
transparency and systematic decision-making with clients.
The importance of teaching students the actual process
steps of EBP cannot be overstated. EBP is a philosophy and an
approach to practice that requires students and practitioners to
understand and apply its essential steps. Teaching students to
identify and use lists of established EBPs to select
interventions is but one small part of the EBP process. As
Gambrill (2007) so eloquently states, the emphasis on EBPs
"ignores the process of EBP that describes skills designed to
help practitioners to integrate external findings with other vital
information (e.g., concerning client characteristics and
circumstances) such as posing well-structured questions, and
ignores the importance of creating tools practitioners need
such as access to high-speed computers with relevant
databases" (p. 430).
Schools of social work must take bold steps to integrate
EBP across the curriculum. Training in EBP occurs
sporadically in most schools, with little consistent application
across key parts of the curriculum. Therefore, discussions
about the best place (e.g., practice or research courses) to teach
the process of EBP in the curriculum are needed. In addition,
new teaching techniques such as problem-based learning that
are compatible with EBP should be examined for applicability
in social work education (Gambrill, in press; Sackett et al.,
2000). Finally, structural changes in long-held traditions such
as advanced standing may need to be considered in the interest
of increasing students' exposure to the complexities of EBP
(Jenson, in press).
EBP AND SOCIAL WORK PRACTICE EBP is receiving
considerable attention from local, state, and federal
EVIDENCE- BASED PRACTICE
163
policy makers and funding sources. State and local systems of
care, private foundations, and federal entities have entered the
debate about the best ways to select and implement effective
interventions for clients and client systems. Agency
administrators and practitioners are working diligently to
understand EBP in an effort to develop competitive research
proposals and implement effective program components.
One significant practice challenge is how to teach
principles of EBP to practitioners and agency administrators.
Community agencies vary widely with respect to their
awareness, understanding, and acceptance of EBP.
Community partnerships and collaborative research projects
such as those being developed at the University of Toronto
(Regehr, Stem, & Shlonksy, 2007) are needed to help
practitioners apply EBP principles in a wide variety of practice
settings. At Toronto, the faculty of social work at the
University of Toronto has created an institute for
evidence-based social work that aims to develop and foster
community collaborations (Regehr et al., 2007). This and
similar models should be further developed and tested.
EBP AND RESEARCH EBP relies on the availability of
accrued knowledge about a range of individual and social
problems. Thus, it is imperative that new knowledge about the
etiology, prevention, and treatment of problems be
consistently developed. In this regard, rigorous research is
needed across many or all substantive areas in social work.
Intervention research to assess the efficacy and effectiveness
of social interventions is particularly lacking. Such studies are
necessary to advance the etiological and intervention
knowledge bases available to practitioners who are interested
in implementing EBP.
The translation of research evidence to practice and policy
is a second important area of research. In many service sectors
there is a considerable lag between the identification of
efficacious treatments and the application of such treatments
to practice and policy. Recently, entities such as the National
Institute of Mental Health have emphasized the importance of
translating research findings to the field (Brekke, Ell, &
Palinkas, 2007). Models for translating research evidence to
practice and policy in health care and adolescent service
sectors have been offered by Gray (2001) and Jenson and
Fraser (2006) respectively.
The careful translation of research into practice is
particularly important in view of the rapid increase in
practices and publications that are promoted as EBP but in
reality fall short of the principles implied in EBP. For
example, the sudden infusion and proliferation of terms that
resemble EBP, but are not EBP, may have an
164 EVIDENCE-BASED PRACTICE
adverse effect on the profession's interest in using EBP to
enhance the connection between science and intervention.
Phrases such as "best practices" and "exemplary programs" are
frequently used for marketing clinical and community
interventions. On closer examination, these terms mayor may not
reflect the underlying processes of EBP. In many cases,
interventions packaged under such names are not based on
empirical evidence and have not been subject to rigorous
evaluation. Promoting untested interventions as evidence-based
promotes a false sense of efficacy, erodes the basic principles of
EBP, and dilutes commonly accepted definitions of EBP used in
medicine and psychology.
Finally, research is needed to systematically assess the effects
of implementing EBP with clients. Embedded in EBP is the
notion tliat client outcomes will be improved significantly by
using EBP. As EBP becomes more widely applied in practice,
studies will be needed to assess the relationship between its use
and client outcomes.
EPB offers the promise of a new approach to social work
education and practice that will dramatically alter the profession
for years to come. The move to EBP as a guiding educational
framework will require schools of social work to include the
essential elements of EBP training (e.g., posing practice-relevant
questions, gaining sophisticated information retrieval skills,
interpreting systematic reviews, applying clinical practice
guidelines, etc.) in graduate courses. In addition, schools of social
work must also assume leadership in assisting communitybased
and human service sectors to understand and apply EBP in
practice and policy settings. The challenge and risk of such
comprehensive change represents an exciting new opportunity in
social work practice and education. The endorsement of EBP is a
risk well worth taking.
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(2006). Integrating evidence-based practice and social work field
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Elliott, D. S., & Mihalic, S. (2004). Issues in disseminating and
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Fraser, M. W. (2003). Intervention research in social work: A basis for
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Gambrill, E. (1999). Evidence-based practice: An alternative to
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Gambrill, E. (2003). Evidence-based practice: Implications for
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Gambrill, E. (2006). Evidence-based practice and policy:
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Gambrill, E. (2007). To be or not to be: Will five-step be used by
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Gambrill, E. (in press). Transparency as the route to
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Gibbs, L. (2003). Evidence-based practice for the helping professions.
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EXPERIMENTAL AND QUASI-ExPERIMENTAL DESIGN
165
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Research in Social Work Practice, 16, 469--479.
-JEFFREY M. JENSON AND MATTI-lEW O. HOWARD
EXPERIMENTAL AND QUASI~
EXPERIMENTAL DESIGN
ABSTRACT: Experimental and quasi-experimental research
provides the foundation for all evidence-based practice systems
that seek to identify and promote the use of social work practices
of demonstrated effectiveness. This reflects the prevailing
perspective that experimental research is the only definitive basis
for claims that certain outcomes can be altered by the
 166 EXPERIMENTAL AND QUASI-ExPERIMENTAL DESIGN
effects of a given intervention. At this point in the
evolution of social work research, however, the body of
work based on experimentation is not extensive. In
response to the challenges of implementing experiments
related to social interventions, researchers have devel oped
new approaches, such as group randomized designs. Also,
newly developed statistical methods may provide ways to
control the selection bias inherent in quasi experimental
designs. This entry explores the central place of
experimental and quasi-experimental designs in social
work research, the challenges of using them, and recent
developments that may expand their use.
KEY WORDS: experimentation; intervention; random-
ization; evidence
The notion of evidence-based practice (EBP) is prem ised
on the availability of strong evidence that a given social
work policy or practice can enhance particular outcomes.
Advocates of EBP have developed systems for as sessing
the strength of evidence by rating the quality of evaluations
on which evidentiary findings are based. Some systems,
such as the one proposed by the National Association of
Public Child Welfare Administrators (APHSA, 2005) ,
have been developed by practitioner- oriented professional
organizations. Other systems, such as the Campbell
Collaboration (2007) and the British Cochrane
Collaboration, on which they are modeled, have designed
processes for researchers to follow in conducting
"systematic reviews" for compiling, rating, and
synthesizing the results of intervention evaluations. In spite
of differ-
. ences in approach and participants, all these EBP sys tems
share a perspective that the strongest evidence of effective
practice can be found in randomized experi mental
evaluations. If a substantial body of such studies does not
exist in an area of practice, quasi- experimental studies are
acceptable as sources of preliminary, but not definitive,
evidence of an intervention's effectiveness.
The primacy of the experimental paradigm in EBP
research and social science research is rooted in broad
acceptance of the fundamental premises and scientific
methods on which it relies. The classic experimental
research design seeks to create a situation in which
researchers can apply counterfactual logic. Specifically, by
randomly selecting two probability samples from a given
population and then intervening with one group, but not the
other, researchers can claim that observed
post-intervention differences are attributable to the in-
tervention. However, establishing the experimental
controls necessary to test social work practices and other
social interventions is challenging and various circum-
stances can threaten the validity of the evaluation.
While a variety of design alternatives exist to deal with
these threats (Campbell & Stanley, 1963), researchers and
cooperating service providers must also deal with ethical
dilemmas, particularly the denial of services to persons
assigned to control groups.
Practical constraints and ethical considerations have
inhibited broad application of experimental re search in
evaluating social work practices; however, these
limitations can be exaggerated, resulting in un derutilization
of experiments. Whether real or per ceived, these
constraints have pushed researchers in two directions. One
is the recent development of group randomized designs as
an alternative to the tra ditional experimental design that is
based on random assignment of individuals within a group to
an intervention or control status (Bloom, Bos & Lee, 1999;
Boruch, 2005). The other direction is the use of
quasi-experimental designs that do not rely on
randomization.
Group-randomized designs offer two enhancements to
designs based on the randomization of individuals in a
group. First, they avoid the denial of potentially beneficial
services to individuals who are members of a group in
which other members do receive the services. Second, they
respond to the need for a research approach that is
appropriate for interventions that require a saturation
approach. This could be because the ap proach to practice
reflects a pronounced difference in philosophy from
prevailing practice in a community or the intervention is
two-staged in its effect. In other words, it first seeks a
change in the group or group context that is deemed
necessary for changes in out comes for individuals.
Although such approaches have not yet been used very
widely, they implicitly entail the challenge of identifying a
population of groups (communities, service systems,
agencies, other formal orga nizations, or informal groups)
and gaining each group's commitment to participate,
regardless of whether it is assigned to an intervention or
control status. In this respect , group randomized designs
merely substitute a different set of problems for those
inherent in individualized designs.
The use of quasi-experimental designs as an alterna tive
to experimental research remains controversial. The most
ardent proponents of quasi-experimental ap proaches argue
that they are, in fact, superior to experi ments in their
underlying logic and in their ability to be actually
implemented (Heckman, 2005). Further, by relying on
powerful multivariate statistical methods to achieve
evaluative controls that are difficult to establish in the field,
they argue that quasi-experimental studies actually offer
stronger evaluative control. Rather than resorting to
statistical controls when experimental field controls fail,
researchers are encouraged to develop a

strong conceptual framework, collect data pertaining to key
constructs in that framework, and use powerful multivariate
analytic techniques to analyze outcomes.
The history of debate on quasi-experimental research extends
from the 1980s. Bolstered by federal legislation that mandated the
use of experimental studies to assess the effectiveness of job
training and welfare-to-work programs, researchers used the
mandate to leverage cooperation from state and local program
managers and staff, and the populations they served. The results
of numerous evaluations conducted throughout the 1980s and
early 1990s led to the pessimistic conclusion that "nothing
works"; however, some researchers argued that weak and poorly
implemented interventions accounted for the results rather than
the intrinsic efficacy of particular approaches (Lattimore & Witte,
1985). This and the inherent challenges of implementing
randomized studies led to the use of quasi-experimental methods,
such as non-equivalent comparison group designs and related
techniques such as propensity score matching (Rosenbaum &
Rubin, 1985). In lieu of randomization, such designs attempt to
observe the counterfactual through the experiences of similar
groups, even though a claim of equivalency of intervention and
comparison groups cannot be made.
According to proponents of experimentation, the fundamental
flaw of quasi-experimental research is apparent in equivocal
findings that emerge from such studies (for example, Fraker &
Maynard, 1987; Grossman & Tierney, 1993). The ambiguity of
the results is rooted in selection bias, the possibility of systematic
differencets) between intervention and comparison groups that is
inherent in comparison-group designs. Critics are not optimistic
about overcoming this problem, even with the use of
sophisticated multivariate models to control for selection bias and
variation in the implementation of interventions. Nevertheless,
even the most ardent proponents of experimental research
(Gueron, 2000), have acknowledged that the need for good
quality evidence dictates flexibility in approaches to evaluating
social interventions.
Given the variety of forces promoting its use, it is likely that
experimentalism will become increasingly prominent in social
work research. As a recent exchange (Littell, 2005; Henggler,
Schoenwald,
EXPERIMENTAL AND QUASI-EXPERIMENTAL DESIGN 167
Borduin, & Swenson 2006) illustrates, however, it is unlikely to
end debates about whether the methods it entails are being
applied appropriately in evaluating social interventions.
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American Public Human Services Association. (2005). Guide for
child welfare administrators on evidence based practice.
Washington, DC.
Bloom, H. S., Bos, J. S., & Lee, S. W. (1999). Using cluster random
assignment to measure program impacts: Statistical implications
for the evaluation of education programs. Evaluation Review, 23,
445--469.
Boruch, R. (Ed.). (2005). Place Randomized Trials: Experimental
tests of public policy. The Annals of the Academy of Political and
Social Science, 599 (May)
Campbell, D. T., & Stanley, J. C. (1963). Experimental and
quasi-experimetuai designs for research. Chicago: Rand McNally.
Campbell Collaboration. (2007). About the Campbell Collabor ation,
Retrieved January 15, 2007, from http://www.camp be
llcollaboration.org/ Abou t.asp
Fraker, T., & Maynard, R. (1987). The adequacy of comparison group
designs for evaluations of employment-related programs. The
Journal of Human Resources, 22 (Spring), 194-227.
Grossman, J., & Tierney, J. P. (1993). The fallibility of comparison
groups. Evaluation Review, 17, 556-57l.
Gueron, J. M. (2000). The politics of random assignment: Imple-
menting studies and impacting policy. MDRC Working Paper on
Research Methodology.
Heckman, J. J. (2005). The Scientific Model of Causality.
Unpublished manuscript (February 23).
Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., & Swenson, C.
C. (2006). Methodological critique and meta-analysis as Trojan
horse. Children and Youth Services Review, 28, 447--457.
Lattimore, P. K., & Witte, A. D. (1985). Programs to aid
ex-offenders: We don't know "nothing works." Monthly Labor
Review, 108(May), 46--48.
Littell, J. H. (2005). Lessons from a systematic review of effects of
multisystemic therapy. Children and Youth Services Review, 27,
445--463.
Rosenbaum, P. R., & Rubin, D. B. (1985). Constructing a control
group using Multivariate Matched Sampling Methods that
incorporate the propensity score. The American Statistician, 39,
33-38.
-CHARLES L. USHER
FAITH,BASED AGENCIES AND
SOCIAL WORK
ABSTRACT: This entry presents the history of faith-based
services, demonstrating that they are a long-standing
component of the U.S. service delivery system. Recently, the
reduction in financial support of some government social
services and growing skepticism about the effectiveness of
government services have led to an expansion in interest and
sometimes in financial support of faith-based services. At
present, faith-based services are delivered in formal agencies
with varying ties to government, and also in many
congregations.
KEY WORDS: faith-based; faith-related; charitable choice;
community-based services; life span services; sectarian;
religious-based services; congregations
Definition of Faith-Based Social Services Faith-based is
a term coined to describe a range of organizations with
religious authority and leadership, religious culture and
practices, or religious sponsorship and resources. In the past,
these organizations were referred to as sectarian,
church-based, and religious or religiousbased (Cnaan,
Wineburg, & Boddie, 1999; Garland, 1998; Netting, 1984).
Faith-based is now used as a relatively inclusive and neutral
term (Vidal, 2001) that, for example, does not include
assumptions about whether public support for the
organizations implies government funding of religion. In some
cases, the term faith-related is used to capture an even larger
group of organizations that can be characterized as being at
least somewhat religious on at least one dimension (Jeavons,
1998; Smith & Sosin, 2001; Wineburg, 2007). Faithbased or
faith-related organizations often are established with strong
religious ties and later lose some of those ties.
Congregations have recently attracted attention as key
faith-based/faith-related social service providers. Other
entities considered to fall under the faith-based category, when
defined broadly, include national networks with affiliation
with denominations, like Catholic Charities, and free standing
religious organizations like Welfare Reform Liaison Project
that have independent status but often have been spun off by
congregations
169
(Vidal, 2001; Wineburg, 2007). For-profit organizations like
Thrivent Financial for Lutherans are gaining prominence in
the faith-based landscape.
Historical Overview
From the 16th century to the present time, faith-based services
have been an important part of the U.S. service delivery
system. Congregations and other religious organizations
provided for the social and spiritual needs of their members,
local constituency, and the broader community. Such
involvement in health and human services by the religious
sector dates back to English Poor Laws in general and
England's Speenharnland Act of 1795 in particular (De
Schweinitz, 1947). For example, in prerevolutionary Virginia,
Anglican church officials were commissioned to care for the
old, the sick, the deserted, and the illegitimate children of their
communities (ColI, 1969). During the colonial era, the
Philadelphia Quakers developed the Friends almshouse for
poor relief (Comptom, 1980), the Episcopalians established
the Boston Episcopal Society (Axinn & Levin, 1992), the
Ursuline Sisters of New Orleans established a home for
children (Reid & Simpson, 1987), and the government used
churches to educate and train Native Americans (Nichols,
1988). Congregations such as the First Baptist Church of
Philadelphia organized the Baptist Orphanage and the
Philadelphia Home for Incurables (Thompson, 1989). Later
these church-based ministries would become independent
social service organizations with social workers and other
professional staff.
At the end of the 19th century, religiously motivated social
services found expression in secular forms of social work.
Most notably, the charity organization movement in the
United States would be adopted by Rev. Samuel H. Gurteen
after his visit to observe the work of Rev. Thomas Chalmers in
Glasgow and London (Leiby, 1984; Lewis, 1966). In 1877,
Gurteen established the Buffalo Charity Organization Society
(COS). Following the European model, the COSs were
originally designed to distribute poverty relief services to
individuals and communities using local churches and their
deacons. The Settlement House Movement also evolved as a
practical expression of faith and a desire to create a more just
and caring society. This movement was inspired by Rev.
Samuel Barnett at Toynbee Hall in England (Addams, 1910).
Shaped by
170 FAITH- BASED AGENCIES AND SOCIAL WORK
her Quaker background and charity work with Rev. Barnett,
Jane Addams founded Chicago's Hull House with Ellen Gates
in 1889. Many religious groups established settlement houses
in the United States-the Salvation Army, the Methodist
Church, and the Presbyterian church. Motivated by religious
convictions, George Edmond Haynes founded the National
Urban League in 1910. These movements, though inspired by
a religious sense of mission, later followed a secular pattern of
service delivery. (For an overview see Cnaan et al., 1999;
Loewenberg, 1988; Netting & Ellor, 2004.)
By the early 20th century, socially oriented and religiously
affiliated agencies delivered many services related to social
work, encompassing employment services and hospital
visitation, joint action with secular agencies such as hospitals
and probation offices, training for volunteers, church
advocacy for social issues and the promotion of voting, social
service experiments such as coffee shops as replacements for
saloons, and research studies of crime and other social
conditions (Johnson, 1930). Services were delivered by
denominations, federated church agencies, and regional and
national religious agencies. The Protestant elite used these
services as institutional resources to exert moral influence
over urban masses (Boyer, 1978). Eventually less overtly
religious organizations came to dominate, including the
Young Men's Christian Association and the Young Women's
Christian Association.
Building on the New Deal legacy of government financing
of services, the 1962, 1976, and 1974 amendments to the
Social Security Act formalized public financing with
nongovernmental social service organizations including
faith-based ones like Catholic Charities (Lynn, 2002). In
many cases, the state and federal government continue to
work in partnership with religious organizations to meet the
demand for local social service. One reason is that social
needs have markedly increased (for example, homelessness
and AIDS) at a time when funding for public welfare has
significantly decreased (Wineburg, 2000, 2004). For example,
over the last 30 years Catholic Charities has received 65% of
its budget from public funding-approximately $2.3 billion
(Anderson, 2000). As the political tide has changed between
the 1980s and 1990s, interest in faith-based organizations has
broadened to include attention to congregations, which
arguably are the most pervasive and community-based type of
faith-based organization.
New Policy Context
Increasing opposition to big government, particularly
spending on social programs as well as opposition to abortion
sparked a new conservative religious
movement in the late 1970s and early 1980s (Wine burg, 2007 ;
Wuthnow, 2004). Opposition to government spending for
social programs gained greater momentum during the Reagan
administration (1981-1989), and faith-based organizations
became viewed as one option for mending the U.S. safety net.
National government administrations, and scholars supporting
social change, came to propose ways of including faith-based
organizations in service delivery. For example, beginning with
the Reagan administration, the failure of the in-
come-maintenance welfare system to solve the problems of
poverty over the 20 years after the launching of the War on
Poverty (Gilens, 1999), coupled with the economic downturn
in the late 1970s and early 1980s (Katz, 2001) led some policy
makers and scholars to look for poverty solutions that
addressed the individual inadequacies and culture of the poor
(Lewis, 1966; Mead, 1986). Faith-based organizations were
viewed as effective agents in helping vulnerable groups to
address attitudinal and skill deficits by building human capital
and assisting with job placement. The term compassionate
conservatism was coined in 1982 when President Reagan said
that "churches and voluntary groups should accept more
responsibility for the needy rather than leaving it to the
bureaucracy." This set the stage for expanding the reach and
responsibility of faith-based organizations that would also be
endorsed by both Bush administrations.
TRANSFORMING INSTITUTIONS Under the Clinton
administration (1993-2001), Congress passed the Personal
Responsibility and Work Opportunity Reconciliation Act of
1996 dismantling 60 years of entitlement programs. This
legislation also boosted efforts to expand privatization and
create market competition among service providers
(Gibelman & Gelman, 2002). Section 104 of this legislation,
also known as the Charitable Choice provision, allowed
pervasively sectarian organizations like congregations to
compete for government contracts. Senator Ashcroft
introduced the Charitable Choice provision with the idea of
placing a larger responsibility of caring for the poor on
faith-based providers. President Clinton advocated for church
involvement with people receiving welfare assistance and
focused on the role of churches in influencing institutions
(Associated Press, 1996). His position also emphasized
extending the type of service choices offered to the poor.
Established by laws during the period of 1996-2000,
Charitable Choice was applied to several programs. These
programs are Temporary Assistance to Needy Families (T
ANF) and the Community Services Block Grant (CSBG)
programs (both overseen by the

Administration for Children and Families at the United States
Department of Health and Human Services [HHS]); programs
for substance abuse and mental health (overseen by the
Substance Abuse and Mental Health Services Administration
[SAMHSA] at HHS); and the Welfare-to-Work program
(overseen by the Department of Labor). Despite such
bipartisan support for Charitable Choice legislation, this
policy was hotly debated among religious leaders.
Conservative religious leaders supported this policy as a
means to expand faithbased services to the poor. On the other
hand, religious liberals feared the potential negative
consequenceschurch and state entanglements, the erosion of
the prophetic voice of the church, and the overestimation of
the capacity of churches to provide services. Many of these
views were also shared by secular opponents of the Charitable
Choice provision. (See john Dilulio's The Godly Republic for a
more detailed discussion of the development of the
Faith-based Initiative and the Charitable Choice legislation.)
TRANSFORMING INDIVIDUALS Embracing the views of
advisors like Marvin Olasky and Stephen Goldsmith,
President George W. Bush (2001-2009) viewed faith as a
missing element in effective social service delivery to
uplift the poor (Stoesz, 2002). In The Tragedy of American
Compassion, Olasky (1992) argued that welfare payments and
bureaucratic support for people who are poor are ineffective,
and religious transformation could bring about greater
responsibility, better discipline, and work ethics among the
poor. However, advancement of the faith-based agenda has
been stalled in the legislative branch under the Bush
administration.
To institutionalize Charitable Choice as a national policy,
President George W. Bush exercised his authority to use
executive orders, regulations, and discretionary grants to
broaden the National Faith-based agenda. The following six
executive orders began to provide infrastructure to facilitate
the funding for faith-based and community-based
organizations: Executive Order 13199 created the White
House Office of Faith-Based & Community Initiatives on
january 29, 2001. Executive Order 13198 created five
Centers for Faith-Based & Community Initiatives on january
29, 2001. Executive Order 13280 created two Centers for
Faith-Based and Community Initiatives on December 12,
2002. Executive Order 13279 requires equal protection for
faith-based and community organizations as of December 12,
2002. Executive Order 13342 created three new Centers for
Faith-Based & Community Initiatives at the Departments of
Commerce and Veterans Affairs and the Small Business
Administration on june 1, 2004. Executive Order 13397
created a new Center for
FAITH-BASED AGENCIES AND SOCIAL WORK
171
Faith-Based & Community Initiatives at the Department of
Homeland Security on March 7, 2006. Overall, these
executive orders established the means to eliminate
regulatory, contracting, and programmatic barriers for the
participation of faith-based and community-based
organizations, to coordinate efforts to include faith-based
organizations, and to design innovative pilot and
demonstration programs to increase participation of
faith-based and community-based organizations in
public-private arrangements (Gibelman & Gelman, 2002;
White House, 200l).
In fiscal year 2002, the administration established a
discretionary grant program called the Compassion Capital
fund (CCF). The first special appropriation of $30 million
established the Demonstration Program. This program was
designed to increase the effectiveness of faith-based and
community organizations to serve those most in need by
providing technical assistance though intermediaries as well
as distributing small grant awards. In the following year, the
Compassion Capital Fund expanded to include a Targeted
CapacityBuilding Program that awards $50,000 to
faith-based and community-based organizations. To date, this
fund has expanded the funding of grants to larger faith-based
organizations such as Neuva Esperanza and Operation
Blessings as well as providing capacity and sub-grants to
smaller faith-based and community-based organizations.
Under CCF, the Cherokee Nation Compassion Project of
Oklahoma received $724,080 in 2004, $965,440 in 2005,
and $965,440 in 2006. This fund has provided incentives for
community and faith-based organizations to spur new types of
partnerships and build local capacity among grassroots
organizations (Reynolds, 2006). Since its inception in 2002,
$264 million has been given to more than 4,500 organizations
including sub-awards from intermediary grantees (Health and
Human Services/ Govnews, 2007). Other feature programs
under the National Faith and Community-based agenda are:
Mentoring Children of Prisoners, Access to Recovery, and
Prisoner Re-Entry Initiative.
Under the Bush administration, congregations are
regarded as one of the central players augmenting
social-service delivery. Those in favor of the Bush admin-
istration faith-based initiative hold several assumptions:
1. Located in communities, congregations are more
responsive, flexible, and less encumbered by
bureaucracy;
2. Congregations are better positioned to recruit and
employ volunteers and therefore provide social services
at a lower cost;
3. Congregation donations that currently support social
services will increase in response to demand for
services;
172 F AITH- BASED AGENCIES AND SOCIAL WORK
4. Legislative reforms related to charitable givmg will
provide incentives to increase giving (Gibelman &
Gelman, 2002; Wineburg, 2007).
Whether or not the assumptions are valid, the over 400,000
U.S. congregations have a pervasive presence in local
communities, particularly those located in urban and rural
areas (Cnaan et al., 1999). Of U.S. residents, 57% of
Americans find their faith to be important to them (Newport,
2006). Republicans are more likely to attend services "almost
every week" (45% compared to 30% for Democrats). When
race is considered, blacks who are Democrats attend church
"almost every week" (65% as compared to 24% of whites who
are Democrats) (Newport, 2005).
Congregations as the New Focus
of Faith-Based Service Delivery Faith-based
services are typically organized in a variety of ways including
informal services offered upon request to more formal mutual
aid and self-help to formal, institutionalized projects and
programs sponsored by congregations as well as nonprofit and
for-profit organizations.
The mandate of many communities of faith gives priority
to feeding the hungry, clothing the poor, and caring for the
sick, widows, and children. Therefore, it is not surprising that
most congregations provide basic needs such as food,
clothing, and emergency financial assistance. Findings from
surveys suggest that from 57% to 92% of congregations
provide some type of social services (Billingsley, 1999;
Chaves, 2004; Cnaan et al., 1999; Cnaan, Boddie, McGrew, &
Kang, 2006; Hodgkinson, Weitzman, & Kirsch, 1988;
Wuthnow, 2004). Most congregations provide short-term
episodic aid such as meals programs, clothing closets, and
services to the homeless; others also provide services
involving youth development, senior services, health,
education, advocacy, community development, and economic
development (Chaves, 2004). Few congregations reportedly
engage in economic development (Billingsley, 1999; Chaves,
2004; Cnaan et al. 1999; Cnaan et al. 2006; Wuthnow, 2004).
Congregations may also provide informal services through
members and clergy support (Cnaan et al., 2006) or provide
space and volunteers to such groups or agencies as Alcoholic
Anonymous, Boy Scouts, Habitat for Humanity, or Amache.
Religious social support and coping assist those confronting
personal and family crisis, illness, disability, chronic pain,
serious accidents, disaster, caregiving, loss of loved ones, and
substance abuse. Congregation members and clergy often
provide the needed affirmations, advice, support, and the
specific actions to address problems and concerns. For
example, black churches have been
found to operate as a therapeutic community that offers mental
health and health resources (see Taylor, Chatters, & Levin,
2004). Congregations have also been found to playa
significant role in preserving cultural and ethnic identity while
assisting immigrants to adapt to U.S. society (Ebaugh &
Chafetz, 2000; Kim, Warner, & Kwon, 200l). With
demographics shifting to increased numbers of Latinos and
more rnultiethnic environments, Latino, Asian, and other
ethnic congregations serve as important resources for
children, youth, seniors, and families (Tirrito & Choi, 2004;
Boddie & Im, 2007).
Congregations also are regarded as a primary source . of
charitable giving. Estimates of the total giving to U.S.
congregations range from $82.83 to $86.28 billion (Brown,
Harris, & Rooney, 2004). Black mega churches like Houston's
Windsor Vilage United Methodist Church allocate over
$500,000 annually for social services (Boddie, 2005). In
Chicago, St. Edmunds Episcopal Church aligned with
businesses, activists, and government agencies to form a
redevelopment corporation that channeled $40 million into the
community. Although congregations like these receive media
attention, these examples are not the norm. The average annual
congregation budget is relatively low. Many congregations
have annual budgets less than $100,000 (Ronsvalle &
Ronsvalle, 2003).
Another way to consider the financial contribution of
congregations is to measure the value of the public goods
produced by congregations-the average financial value of a
congregation-based program. One such measure is called
replacement value for service programs (Cnaan et al. 1999;
Cnaan, Handy, Yancey, & Schneider, 2002; Cnaan et al.,
2006). To calculate this value, respondents were asked to
report their five flagship programs and the total value of their
operating cost including direct and indirect expenses. This
value captured the financial support by the congregation,
in-kind support, value of utilities, estimated value of
congregational space, clergy, staff, and volunteer hours, and
external funding and other income. The findings and
. other from a census of Philadelphia congregations (N = 1,392)
estimate the monthly replacement value for social programs at
$10,076.61 and overall estimated replacement value for
Philadelphia's estimated 2,210 congregations at a quarter of a
billion dollars. One fifth of this amount is provided as cash.
On average these congregation allocated 22.7% of their
annual budget for social services (Cnaan et al., 2006).
Conclusions: Opportunities and Challenges
In this new policy context, social work offers practice
knowledge and skills that are important for the faith-based
context, particularly congregations.

This knowledge and skills are particular ly important as
researchers begin to assess the distinct service niche and
value added of faith-based providers. Recent assessments
of faith-based social service providers typically examine
their capacity, trustworthiness, ef fectiveness, and the
replacement value of programs (Billingsley, 1999; Chaves
& Tsitsos, 2001; Cnaan & Boddie, 2001; Famsley, 2003 ;
Kennedy & Bielefeld, 2003; Monsma, 2004; Monsma &
Mounts, 2002; Owens & Smith, 200S; Reingold, Pirog, &
Brady, 2007; Wuthnow, Hackette, & Hsu, 2003). Primarily,
researchers have quantified the type and number of services
(output) and resources of these services (Billingsley, 1999 ;
Chaves, 2004; Cnaan et al., 2006). Few studies have
focused on outcomes of congregation-based services
(Wuthnow, 2004). Congregations are found to be effec tive
and trustworthy by those clients when they seek help with
emotional and spiritual distress related to financial and
health problems. On the other hand, the good intentions of
faith-based providers often outweigh the financial
resources and administrative expertise (Sinha, 2007). Not
all clients are satisfied with the involvement of churches. In
some cases, low-income residents have greater interest in
partnering wi th church leaders to engage in social change
efforts and less interest in small scale congregation- based
services (Boddie & Smith, 2004). In other cases, the brand
of religion offered will elicit negative responses from those
being served. This was the case for two- thirds of the
homeless people who disliked the sermons and prayers that
were part of services at a faith-based shelter (Sager &
Stephens, 200S). Overall, researchers have concluded that
congregations, like formal agencies that are reli giously
affiliated, are important to the system of p rivate and public
sector social services (Chaves, 2004; Smith & Sosin, 2001;
Wuthnow, 2004). It is possible that social workers will
come to provide more guidance for faith- based providers
that seek to develop staff and volunteer training programs,
advance programmatic efforts to independent
organizations, and evaluate their service outcomes. Social
workers can also assist these providers to balance their dual
identities as religious entities and service providers in this
changing social welfare mix.
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-STEPHANIE BODDIE
FAMILY. [This entry contains two subentries; Overview;
Practice Interventions.]
OVERVIEW
ABSTRACT: Families in almost all societies are viewed
as the basic unit for coordinating personal reproduction
and the redistribution of goals within the larger societal
context of production and exchange. They are vulner-
able to the rapidly changing economics of the environ-
ments in which they live. Universals regarding families
FAMILY: OVERVIEW 175
worldwide include a delay in marriage, an increase in
divorce rates, a decrease in household size and fertility
rates, and nontraditional living arrangements. The most
studied aspect of families continues to be family diversity,
with greater emphasis on an interdisciplinary framework.
There is also a movement toward more effective ways of
treating families. Placing families in an historical context,
this entry discusses evidence based family interventions,
the latest research on fam ilies, family diversity, and
implications for social work practice and education.
KEY WORDS: demographics; interdisciplinarity; best
practices
Introduction
It is generally believed that the family, however it's
defined, has been the foundation of every civilization in
human history. In other words, families in almost all
societies are viewed as the basic unit for coordinating
personal reproduction and redistribution within the larger
societal context of production exchange. It is important to
note, however, that across these basic units are sever al
different types of families. It is critical that these different
types of families be viewed and understood as alternative
family systems, not as a devia tion from some ideal
structure created by groups with different positions or
power in the societal structure (Carter & McGoldrick,
2005). Some of the more prevalent alternative family
systems currently experienced in the United States had its
origin in the destructive impact of European colonization.
The impact of these destructive influences can be se en on
the Native American kinship societies and the family
system and social support networks of the enslaved
Africans (Coontz, 1988; Franklin, 1997; Gutman, 1976 ;
Logan, 2001; Logan, Freeman, & McRoy, 1990; Mintz &
Kellogg, 1988; Stevenson, 1996).
Historical Perspectives on Families
The emergence of the industrial revolution, the influx of
immigrants from Europe, and the westward expan sion
called attention to the influence of ethnic tradi tions and
class relations on family dynamics. It was noted that these
developments led to the emergence of "whiteness" as a
category the European immigrants could use to
differentiate themselves from ethnic groups of color or
other groups near or at the bottom of the economic
hierarchy (J ones, 1997; Roediger, 1988).
The period following the Civil War was marked by
rapid industrialization and urbanization. It was during this
period that American families took on
176 FAMILY: OVERVIEW
characteristics associated with the so-called modern family.
For example, families became smaller, had lower fertility
rates, became less extended and more focused on the nuclear
core; parents became more emotionally involved in rearing
their children; and the separation between home and work
increased. These changes, however, held different meanings
for families, depending on the level of income, ethnicity, and
the country of origin. The divergent and sometimes
contradictory responses of the masses to the impact of
industrialization and urbanization on family organization
eventually led to the production of the six trends associated
with the Industrial Revolution (Coontz, 2000; Katz, Doucet, &
Stern, 1982):
1. The separation of the .. horne and workplace (started
among the working class and among the wage-earning
segment of the business class)
2. The increased nuclearity of household structure (started
among the working class and among the wage-earning
segment of the business class)
3. The decline in marital fertility (started among the
business class, particularly among its least affluent,
most specialized and most mobile sectors)
4. The prolonged residence of children in the home of their
parents (began at about the same time in both working
and business class, though the children of the former
usually went to work and the latter to school)
5. The lengthened period in which husbands and wives live
together after their children have left home (did not
occur until the 20th century and represented a reversal
of 19th century trends)
6. The reintegration of women into productive work,
especially the entry of mothers into paid work outside
the home and the immediate neighborhood (represents a
reversal of 19th century or older trends)
These six trends capture the differences as well as similarities
among American families. They also highlight how life has
changed in one significant way for all families: women of
color no longer have significantly higher rates of labor force
participation than do white women. According to Spain and
Bianchi (1996), a growing number of women from all social
and racial and ethnic groups now combine motherhood with
paid employment, and fewer women are quitting work for
prolonged periods while their children are young.
Overall, this historical overview highlights the diversity
within families as well as the vulnerability of families to the
external forces such as the rapidly changing economics of the
environments in which they live.
Demographics
I t is increasingly evident that the demographic structures of
families in the United States are very diverse. Available
research suggests that this increased diversity seen in the
structure of family life reflects the changing landscape of the
economy and related social factors. The following factors
support this contention (Teachman,2000):
1. That the average family has shown little, if any,
economic progress since the mid-1970s;
2. That the number of American families with poor labor
market skills and little education, which impede
economic growth, is significantly high;
3. That most American families are duel career families out
of necessity. Women in general are now a more critical
source of economic support for their families. Men are
simply no longer the sole wage earners in families.
Families of diverse types, structures, cultural, and ethnic
experiences exist within the above context. This diversity
among families seems to suggest a changing trend in family
demography. For example, it can no longer be assumed that a
family will consist of partners of the opposite sex, and that
women will marry young, bear children, not work outside the
home, and live with the same partners. Instead, evidence
suggests that there has been a retreat from traditional early
marriage, and among some groups, particularly African
Americans, there has been a reversal of a long-time trend of
being married by ages 20-24. African Americans are now
marrying at a much later age (35-39) than are persons of other
ethnic groups. Additionally, African American men and
women spend fewer years in their first marriages and are
slower to remarry than in decades past. It is important to place
this noticeable issue of marriage decline in context, but for
purposes of this discussion the changing family structure will
only be considered from the perspective of the children and
their overall well-being (Taylor, 2000; Taylor, Chatters,
Tucker, & Lewis, 1990). Data still suggest that the number of
children younger than 18 years in the United States living in
poverty continues to increase (Duncan & Brooks-Gunn, 1997;
U.S. Department of Health and Human Service, 1996).
Further, these children are living in female-headed households
where the median income continues to be very low. Research
supports the notion that the economic well-being of children is
linked to family structure. For example, children who live with
a single mother are more likely to live in poverty than are
children who live with two parents. Available evidence
suggest that those children younger than 18 years living in a
mother-headed household are

at a greater risk for a variety of negative outcomes. In other
words, poverty experienced before age 6 is particularly
destructive to positive development. These children
experience behavioral problems, lower cognitive and
academic achievements, and a greater likelihood of
out-of-wedlock pregnancy (Duncan & Brooks-Gunn, 1997). It
is, however, not the intention to oversimplify the complex
dynamics reflected in this proposition. The intent is to
underscore the continuing detrimental impact of poverty on
children's well-being and family structure. There is increasing
consensus that the delay in marriages, the rise in divorce rates,
the rapidly changing economy, and the renegotiation of the
division of economic and household labor are some of the
important factors influencing current family demography.
INTERDISCIPLINARY CONNECTIONS There is an increasing
recognition of the complexity inherent in studying,
researching, and understanding contemporary family life,
In part, this recognition is grounded in the awareness that
there is no one type of family and also that there is no one
way of viewing families. Multiple perspectives on
families are emerging in undergraduate and graduate
programs through the creation of special cou rses to
expose students to inquiry-based learning and methods of
data collec'tion and analysis (Allen, 2001; Allen ,
Floyd-Thomas, & Gillman, 2001). Additionally, scholars
on family life are being encouraged through a variety of
forums to incorporate the issues and practices of other
disciplines in their teaching and research (Le Pore, 2000 ).
Given that many family scholars are inter disciplinary in
their training, it is only natural that linkages would occur
between such disciplines as social work, history,
sociology, religion, and psychology. The bottom line,
however, is that interdisciplinary goes beyond the adding
on approach through a few select readings on families.
Available data suggest that effec tive interdisciplinary
connections for understanding families involve
collaboration, partnerships, and team work (Adams,
2004). With the expanding diversity among families, it is
imperative that family researchers, educators, and
students learn new and expanded meth odologies, both to
understand how one field applies a concept in a different
or similar way to the same situa tion under study. It is this
complimentary relationship between different disciplines
that supports transform ative teaching, learning, and
research.
THEORETICAL PERSPECTIVES No single theory is
preeminent in guiding practice and research on family life
and dynamics. This is especially true when attempt ing to
understand family dynamics with different
FAMILY: OVERVIEW 177
gender, socioeconomic status, sexual orientation, age, and
ethnic racial groups as well as different family types. Theories
that support a better understanding of the interactions are still
being conceptualized.
Queer theory and oppression theory are two theories that
are available for supporting an understanding of
intersectionality. According to Kumashiro (2004), queer
theory focuses on the production of queerness. For example,
he says that something could not be normal (like opposite sex
attraction) if other things were not already abnormal (like
same sex attraction). Therefore, queerness is produced as a
contrast against which normalcy is established. In other
words, queer theory tells us that these standards of normalcy
actually produce queerness. By saying that this is what it
means to be beautiful, we are simultaneously saying that other
images of beauty are pretty queer. Oppression theory flows out
of the type of reasoning undergirding queer theory. Collins
(1990) conceptualizes oppression theory as interlocking
systems of race, class, and gender. She contends that although
these three systems have historically impacted the lives of
African American women, they are not necessarily the most
critical oppressions for other oppressed groups in society. She
believed that research would reveal the particular "matrix of
domination" for other groups in society.
Other perspectives and theoretical approaches fit the
traditional and emergent categories. Most practitioners,
educators, and researchers tend to practice, teach, and do
research based on multiple and interrelated theories. These
theories may be grouped into two broad categories with some
overlap (Compton & Galaway, 1999): prescriptive theories
and descriptive theories. Prescriptive theories are used to
prescribe how problems should be resolved or needs should be
met and are said to operate in concert with underlying de-
scriptive theories. The prescriptive theories are those theories
that include cognitive development theory, ecological
theories, family systems theory, personality theory, risk, and
resilience theory, social exchange theory, social role theory,
and sociological theory. Descriptive theories are bodies of
knowledge and related assumptions about human behavior.
They explain such behavioral phenomena as how individuals
grow and develop the dynamics and causes involved in
organizations and communities. The descriptive theories in-
clude cognitive development theory, Bowenian family theory,
psychodynamic theory, structural family theory, functional
family theory, and general systems theory.
The early 1990s and early 2000s witnessed several new or
emergent theories for working with and understanding
families. These theories and treatment approaches are grouped
under the umbrella of postmodernism, a reaction
178 FAMILY: OVERVIEW
to the widespread belief that the truth could be revealed
through observation and movement. Advancing tech-
nology, globalization, and greater exposure to other
cultures forced the recogniti on that more than one way orientation. Obviously this approach to examining families
exists for viewing and living in the world. Michael
Foucault was a leading proponent in helping to con struct . that families are diverse, that they view and experience
our accepted truths handed down by the various
disciplines: education, literature, religion, psychology,
political science, social work, and medicine. He saw these
constructed truths as principles or stories devel oped by
these disciplines to protect the group's interest and
existence and to subjugate alternative points of view
(Foucault, 1965, 1980). One of the most influen tial
critiques against these so-called truths was the fem inist
critique. As a theory andrherapy, feminist family
treatment gained increased recognition, and issues re lated human, technical, and finan cial resources of the provider.
to gender increased along with the emphasis on
gender-sensitive issues in family treatment, and other
theories continue to emerge world wide (Nicholas &
Schwartz, 2007). In the West, de Shazer (1994) and Berg
(1994), along with O'Hanlan and Weiner-Davis (1989 )
and several others, were developing solution focused
therapy. Meanwhile, White (1995) in Australia and Epston
(1994) in New Zealand were developing narrative therapy .
Interestingly, the emergent theories differed markedly
from the traditional theories in that they were based on
social constructionism, a philosophy that states tha t our
experiences are a function of how we think about them
instead of objective entities (Gergen, 1985). Other theories
for the treatment of families that emerged in 1990 s and
early 2000s included the following:
1. The reflecting team approach (T. Anderson, 1991)
2. The therapeutic conversation model (H. Anderson &
Gooleshin, 1994)
3. The improvisational therapy model (Keeney, 1990)
4. The psychoeducational model (c. Anderson, 1998)
5. The internal family systems model (Schwartz, 1994 )
6. Community family therapy (Rojono, 1997)
The theories and therapies discussed here are not in tended
to be an exhaustive representation of what exist in that
different strategies for working with families are
constantly emerging, which may not be as well recog nized
as those discussed here.
Latest Research and Best Practices
The literature on families suggests that there are multi ple
ways of studying families and that perhaps the most
studied aspects of families continue to be family diversity.
Researchers are examining the compelling
differences within and among families from the per spective
of social stratification such as race and ethni city,
class/socioeconomic status, gender, age, and sexual
will occur until it is a natural recognition
their worlds differently and are treated differently based on
how they are viewed and thought of in the larger societal
context. Coupled with the increasing recogni tion of family
variation and structure is the movement toward more
effective ways of treating families. The most e ffective
ways of treating families are grouped under the umbrella
term of best practices. A "best practice" can be thought of
as a practice that best meets the needs and supports the
healing process of the family being served within the
Further, it is expected that in these instances where family
interventions are based on outcome studies and other
reliable empirical evidence, the "best practice" should be
as close to interventions based on outcome studies or
evidencebased models as circumstances permit.
Evidence-based practices maybe defined as interventions
for which there is consistent scientific evidence showing
that the interventions improve client outcomes. An evi-
dence-based practice has bee n studied using appropriate
scientific methodology and meets the following criteria
(Ganju, 2001):
1. It has been replicated in more than one geographic or
practice setting with consistent results.
2. It has been recognized in scientific journals by one or
more published articles.
3. It is manualized.
4. It produces specific outcomes.
Corcoran (2003) in the first book on this included eight
evidence-based family interventions in her book on clinica l
application of evidence-based family interven tions. These
evidence-based interventions included the following:
Cognitive-behavioral interventions
Behavioral interventions
Multisystemic treatment
Multiple family psychoeducation
Psychoeducation
. Reinforcement training
Solution-focused therapy
Structural family therapy
Despite the usefulness of having available the evi dence that
supports the traditional and emergent the ories that are
available for working with families, the evidenced- based
approach to practice with families is

not without controversy. On the one hand, it is ques-
tionable whether the search for evidence-based inter-
vention is more to satisfy the push of managed care
requirements of accountable practice or to better serve
families. According to Yalom (2002), there is no evi dence
that practitioners' adherence to manuals positively
correlates to recovery consistent in practices.
Diversity and Multicultural Context
The extent or amount of diversity in American families
today is probably no greater than in most periods in the
past. However, what is different today is that so many
different family types have found their voices and are
demanding social recognition and support for their
evidence (Demo, Allen; & Fine, 2000). Although the
professional literature continues to expand on this topic,
there continues to be ambiguity and confusion about the
conceptualization and meaning of diversity (Logan, 2003 ).
However, several lessons about family diversity have
emerged from teaching practice and re search since the
mid-1980s. Perhaps the most important of these lessons is
the need to not allow the racial! ethnic category that a
family occupies to become the defining characteristic in
appreciating the impact of diversity on family life. In
addition to race/ethnicity, attention must be given to the
multiple dimensions of family life, which include the
social context, financial challenges, sexual orientation, and
other important factors that intersect family life.
Despite the expansion of literature on family diversity,
the treatment literature has not kept pace. Addi tionally,
there is still a lack of familiarity with the beliefs and
customs of culturally diverse families, coupled with the
tendency to look for dysfunction. This approach to
understanding diversity has led to errors in clinical
assessment and interventions (Hardy & Laszloffy, 1992;
Kurilla, 1998). Essentially, treatment approaches have not
been expanded or refined to address the diversity that has
been recognized in and across family groups. It is evident
that the available theories continue to emphasize white,
heterosexual, middle income, married couples with
children. This recognition serves to highlight a gap in
teaching, service, and research. Hopefully, this awareness
will serve to encourage experiential learning and research
that will propel the profession toward expanding our
current knowledge base to include fuller explanations of
diverse family life forms and effective culturally
responsive strategies for intervening in diverse family life.
International and Comparative Perspective
As indicated earlier, the world in which all families exist
today is one of economic globalization and rapid
FAMILY: OVERVIEW
179
technological and social change. It is a world of racial,
religious, domestic, and economic violence. It is a world of
involuntary and voluntary migration. It is also a world in
which many people are attempting to resolve conflict and
work for peace and change. Within this context, family
scholars are providing knowledge about families. Despite
the progress being made toward understanding families
within a cultural context, the literature suggests that at
least two examples of truly comparative inter national
family studies exist (Kamerman & Kahn, 1997; Walters,
Warzywoda, & Gurko, 2003). The literature that does exist
identifies several universal issues as well as the apparent
gaps in international family studies.
The first set of issues in international family studies are
regional limitations. It is not surprising that some countries
are more represented by family research and scholarship.
The reasons for their omissions from the literature include
the lack of communication between scholars of the various
countries (Adams, 2004). Although e-mail and the Internet
provide greater access to and information about these
countries, current contacts are limited or nonexistent.
Regional limitation is also impacted by lack of funds to
implement research projects as well as strong conservative
values that do not support value free analysis of families
and family problems.
At least six factors have been identified to support
collaborative cross-cultural family research. These fac tors
include a host coprincipal investigator, clearance from host
country to carry out the research, sensitivity to local
conditions such as wars, ethnic instability, or natural
disasters. Additionally, sampling, translating, and
consideration of the value of the research to the host
country are important. Of equal importance is the need to
engage interviewers who may be found among local
teachers or university students (Adams, 2004).
The gaps in knowledge about the world's families
include groups such as refugees, the oppressed, nomads,
rural residents, poor urbanites, and the very rich. These are
groups that are usually omitted by research designs
because of governmental isolation, inaccessibility, or
social exclusiveness. Among these g roups, the gaps in
knowledge are illustrated by the changing dynamics
surrounding inheritance and property, the varied responses
to child and elders abuse, domestic violence, and hesitancy
in discussing intimate family issues such as marital
satisfaction (Adams, 2004; Logan, 2006).
The universals regarding the world's families include
changes in family patterns such as decreases in house hold
size and fertility rates, increases in divorce, and
nontraditional living arrangements. Much of these changes
are attributed to the increase in women's
180 FAMILY: OVERVIEW
education and employment outside the home (Logan, 2007).
However, it is important to note that these changes have not
resulted in gender equality. It is clear from the literature that
women in the world's nations are still struggling to change the
unequal basis for marriage and divorce, still seeking
legislation to prevent abuse of all kinds, still lack access to
land and financial security, still working to end discrimination
and sexual harassment in the workplace and in educational
settings, and still working to raise men's consciousness about
gender equality (Adams, 2004; Logan, 2007).
TRENDS, CHALLENGES, AND FUTURE DIRECTION
Speculation abounds about what we can expect with
regard to family meaning charge and politics in this
century and beyond. What does seem clear as we move
into the 21st century is that "the family" system has been
or is being transformed globally. Demographers are
recording worldwide the rising rates of divorce and
unwed motherhood, declining birth rates, the feminiza-
tion of poverty, and the increasing number of women
attempting to raise their families without the emotional or
financial support of their children's father. Although the
challenges, debates, and ethical issues are implicit in the
trends that have been addressed throughout this overview
on families, perhaps the most pervasive of the ever
widening scope of challenges and ethical issues are
related to managing mental health care and technology.
Defining families. There is general consensus that
scholars interested in the study of family life must go beyond
the U.S. Bureau of Census' definition of families. However, it
is becoming increasingly clear that we must encourage
families to define themselves. The family definitions of
themselves have implications of how families live their lives
on a day-to-day basis, but also for the type of services
provided, and for financial and policy matters. Finally, the
depth and breadth of the challenges inherent in how
same-gender couples define themselves as family and the
effects of marriages, civil unions, and domestic partnership on
the health and well-being of the children are virtually
unknown to the general public and perhaps to many social
workers (Pawelski et al., 2006). Defining families must also
take into consideration the intersections of race, ethnicity,
class, gender, age, and sexual orientation.
Researching and understanding families. It was very
popular and trendy in the 1990s to forge multidisciplinary
collaborations (researchers from more than one discipline are
involved in a particular field but tend to conduct their work
separately from one another). The language of the 2000s, to
date, has been interdisciplinary collaboration. There is more
dialogue
among researchers, but researchers are holding steadfast to
their root discipline and accompanying methodologies. The
question, therefore, is whether it is possible for researchers to
be transdisciplinary, to let go of d isciplinary root and
boundaries on the questions and concerns about family life
that is informed by knowledge and skills derived from the root
discipline and beyond. This integrative, critical consciousness
about families suggests a parallel to exploring and
understanding the dynamics of family life.
Some scholars and researchers on family life are proposing
a more flexible, postpositivist approach to family research
(Allen, Floyd-Thomas, & Gillman, 200l). This approach
suggests that there are many ways of viewing, knowing, and
understanding families. Similarly, there are a variety of
healthy, adaptive, and successful ways for families to live and
be in the world. Moreover, a more flexible integrative
approach to studying families is needed. Such an approach
would not only address the structural variables that impact
family life, but will also address processes, interactions, and
behaviors within families. Mixed methodologies involving
both quantitative and qualitative methods would be required to
effectively address family life from within as well as
externally.
Role and Implications for Social Work According
to Carter and McGoldrick (2005, p. 1), "we are born into
families. Our first relationships, our first group, our first
experience of the world are with and through our
families." In short, families are at the center of our
existence as individuals and as practitioners, educators,
and researchers.
As a mode of intervention, family-based treatment
approaches have expanded greatly since the mid-1990s.
Practitioners and researchers have confirmed the effectiveness
of treatment when including parents and extended family
members in the helping process. However, opportunities have
been limited not only to institute effective treatment models in
practice settings but to create experiences so as to expand
educators, students, and practitioners' knowledge about
diverse family beliefs and customs. Given the proven
usefulness of ethnographic research and instituting effective
treatment models in practice settings, it is important that
opportunities be made available for exploring and testing new
and expanded ways of working with families and
understanding and appreciating family diversity.
I t is expected that the social work profession would bring
to the forefront explicit statements and discussions regarding
social policy and its effect on families. Current examples of
social policies that impact family functioning and that should
be included in these

discussions are welfare reform, universal health care,
affirmative action, the effect of marriage, civil unions, and
domestic partnering laws on the health and wellbeing of
children, and immigration policies. Additionally, these should
also be included as a part of the required curriculum in schools
of social work. As a profession, we must continue to ask new
and challenging questions about families as well as learn to
suspend the impositions of our beliefs about families in all
their diversities.
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FURTHER READING
Bonnington, S. B., McGrath, P., & Martinek, S. A. (1996).
The fax of the matter: The electronic transfer of confidential
material. Family Journal: Counseling and Therapy for Couples and
families, 4, 155-156.
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-SADYE L. M. LOGAN
PRACTICE INTERVENTIONS
ABSTRACT: This entry traces the historical, conceptual, and
theoretical development of social work practice with families
beginning with the Charity Organization Society and the
Settlement House movement. While social work practice theory
was heavily influenced by psychoanalytic theory beginning in
1920s through the 1950s, emerging theoretical frameworks,
including systems and ecological theory in the 1950s, 1960s, and
1970s, shifted the focus of intervention back to the family. The
proliferation of models for family therapy, family assessment, and
intervention facilitated the development of social work practice
with families. The more recent influence of postmodern
perspectives on direct practice with families is described and
explored.
KEY WORDS: direct practice with families; family therapy;
family practice; social work with families
A History
of Social Work Practice with Families
A family orientation to social work practice has a rich and
enduring legacy within social work history. Beginning in the
early 1880s the Charity Organization Society's (COS) "friendly
visitors" were strongly encouraged to build relationships with
poor urban families to help them cope with the vicissitudes of
living in a society that was adjusting to the impact of the
industrial revolution. During that period many urban families
found themselves coping with an array of problems stemming
from rapid social change. Increasing social problems such as
poverty, immigration, rapid urbanization, illiteracy, disease,
exploited labor, and slum housing were adversely impacting the
lives of individuals and families. In response to the disruption of
family life brought on by these problems, the "friendly visitors"
primarily focused on the provision of in-home concrete services
or "charity." While responding to the basic needs of families, the
orientation of these friendly visitors was that the failure of
families and individuals to cope with the problems of living was
as much due to character defect and/or moral failure as
environmental or societal factors. As such, the "friendly visitors"
acted as role and moral life style models (Collins, Jordan, &
Coleman, 1999).
Mary Richmond, as director of COS, introduced a more
systematic approach for assessing family and individual
problems and emphasized the need for counseling the individuals
within their family context. This was the advent of a "scientific"
approach to providing services to families in need. The friendly
visitor (referred to currently as caseworker) would conduct a
"social investigation" rather than a "moral inventory" of
individuals and families. The friendly visitor was called upon to
develop a more comprehensive set of skills that would not merely
help to understand the individual and their family, but also help to
better determine the services needed.
The beginning of a family orientation to understanding
individual difficulties was articulated by Mary Richmond in her
book Social Diagnosis (1917). While the individual was the focus
of intervention she viewed the family as the focus of assessment,
indicating that one could only understand the individual within
the environment of the family (Nichols & Schwartz, 2006). While
casework services were still delivered to the individual,
understanding the individual with the context of the family
including the family's interest, its

hopes, and ambitions was seen by Richmond as also
necessary (Janzen, Jordan, Harris, & Franklin, 2006).
Though Richmond brought the family to the fore ground of
attention for casework diagnosis, her writing did not
suggest involving family members in interven tion or
change activities. Nonetheless, Richmond's ob servation
regarding the significance of the family laid one of the
cornerstones for a family orientation in social work
practice.
The other cornerstone for a family orientation in social
work was laid by those who were a part of the Settlement
House Movement that began in 1864. Whereas the focus of
the COS was on the individual within the family, the
Settlement House Movement gave attention to the family
within the broader social environment (Hull & Mather,
2006). The Hull House founded by Jane Addams and Ellen
Gates Starr in 1889 viewed family problems as a function
of environmental conditions rather than individual deficits.
Contrary to the "moral treatment" orientation of the friendly
visitors, those within the Settlement House Movement
sought to change those political, economic, societal, local,
and neighborhood conditions that had a deleter ious impact
on family life. As such, this movement shifted the
motivation for practice intervent ions from one of "moral
responsibility" to that of "social responsibility" (Hull &
Mather, 2006). Settlement Houses were often set up in
immigrant neighborhoods and provided a venue for
learning language skills, life skills, and skills that would
help the participants to support their families. Furthermore,
the Settlement Houses provided the oppor tunity for
individuals and families to come together for mutual
support and aid, as they attempted to cope, survive, and
thrive within harsh urban environments.
The Psychoanalytic Movement
and the Resurgence of the Family Orientation Social
work practice became even more focused on the individual
from the early 1920s well into the late 1950s, in large
measure due to the dominant influence of psychoanalytic
thinking with its seductive promise of enhanced
professional status and legitimacy among other helping
professions. Yet in spite of the popularity of Freudian
thought, major social changes such as World Wars I and II,
the Great Depression, the in creased number of immigrants,
and the extreme impact of poverty on family life presented
challenges to those social workers who sought a deeper
understanding of distressed families (Wise, 2005).
The return to the family as a primary focus of atten tion
in direct practice occurred in the 1950s and 1960s. During
this period there was a greater focus on urban American and
the plight of those families that were
FAMILY: PRACTICE
INTERVENTIONS 183
caught in vortex of social disorganization. In addition,
there was much attention on welfare reform with a focus on
those families that seemed to be entrapped in the public
welfare system. These families more often than not were
not only faced with poverty but also with issues of
delinquency, neglect, and severe health pro blems. These
families, referred to as the "multiproblem families,"
garnered the concern of many social scientists
(Horejsi,1981).
This same period also witnessed the emergence of an
interdisciplinary family therapy movement. A rapid
proliferation of family therapy theories and models were
informed by the development of systems, cybernetic, and
ecological systems theories in the 1960s and 1970s. These
new conceptual frameworks shifted the focus from the
individual in the context of the family to the family being
the most salient system of focus (Laird, 1995). Many social
workers were involved in the theo retical development of
models of family therapy, among them, Virginia Satir, Ray
Bardhill, Peggy Papp, Lyn Hoffman, Froma Walsh, Insoo
Kim Berg, Jay Lappin, Richard Stuart, Harry Aponte,
Michael White, Doug Breunlin, Olga Silvertstein, Lois
Braverman, Steve de Shazer, Peggy Penn, Betty Carter,
Braulio Montalvo, and Monica McGoldrick.
The Emergence of Social Work
Practice Models with Families
Social work practice with families then came to repre sent
the joining of a burgeoning interdisciplinary family therapy
movement with a long yet perhaps ambivalent relationship
between the social work profession and the family
(Hartman & Laird, 1983). This union has gen erated family
practice perspectives that are uniquely so cial work.
Ecological and systems theoretical frame works are firmly
grounded in a social work perspective and have infused
concepts from family theory to inform a range of
interventions with a diverse range of families and family
problems (Collins et al., 1999; Constable & Lee, 2004;
Franklin & Jordan, 1999; Helton & Jackson, 1997; Hull &
Mather, 2006; Janzen et al., 2006).
As social work practice with families is now central to
the profession of social work, a distinction is often made
between "family-based" or "family-centered" so cial work
versus "family practice" (Collins et al., 1999; Proctor ,
Davis, & Vosler, 1995; Tracy, 2001). Family-
based/family-centered services encompass a range of
activities: case management, counseling/therapy, edu-
cation, skill building, advocacy, and provision of con crete
services (such as housing, food, and clothing) for families
with problems that threaten their stability (Pecora,
Reed-Ashcraft, & Kirk, 2001). These are often families in
which decisions have been made to place a
184 FAMILY: PRACTICE INTERVENTIONS
child temporarily out of home care. Family-based services
oriented toward child welfare concerns would include
intensive family preservation services, hornebased services
(combining concrete and therapeutic interventions),
permanency planning, and foster care (Pecora et al., 2001).
Family practice on the other hand connotes a more direct
clinical/therapeutic approach to family problems. The family
therapist gives direct attention to family functioning and
patterns of family rules, roles, relationships, and rituals
(Helton & Jackson, 1997) that contribute to the presenting
problem. While there is the perception that family treatment
focuses primarily on family disorganization exclusive of
larger social systems (Proctor et al., 1995), family treatment
approaches that are informed by the social work person in
environment perspective give equal attention to issues with
broader systemic factors impacting family life (Collins et al.,
1999; Constable & Lee, 2004; Franklin & Jordan, 1999; Hull
& Mather, 2006; Janzen et al., 2006).
Many families in distress may be in need of both
family-based services and family practice interventions. The
following family intervention objectives may be appropriate
regardless of the practitioner's orientation or the presenting
family problemts) (Collins et al., 1999). Such family-oriented
intervention objectives would include
To help family members manage daily living activities
and interactions more effectively, thereby decreasing stress
and enhancing family harmony To help families learn
more effective problemsolving skills in order reduce the
number of crisis and manage unavoidable crises more
capably
l!I To help parents develop child management skills
appropriate to the unique needs of each child and
to contribute to the improvement of parent- child
and parent-parent relationships
To help family members learn effective conflict resolution
skills thereby assisting family members to deal with
inevitable moments of stress and disagreement in a more
constructive and growth promoting manner
l!I To help family members communicate indi vidual
wants, needs, and desires as well as feelings of
pain, hurt, and disappointment clearly, correctly,
and honestly, thus increasing the likelihood of
supportive rather than destructive family
interactions
To help family members access concrete and social
resources during periods of stress through promotion of
individual, family, and community networking; and to
develop skills for solving problems
l!I To help families appreciate the unique worth and
potential of each family member, thereby ex-
panding opportunities for growth and develop-
ment (Collins et al., 1999).
Theoretical Perspectives that
Guide Direct Practice with Families
There is no single integrated family therapy practice model
upon which family therapists can rely (Franklin & Jordan,
1999; Nichols & Schwartz, 2006; Sue & Sue, 1999). This
problem is accentuated when therapists deal with ethnic
minority families, even though there have been efforts to
apply various practice models to ethnic minority families
(Ariel, 1999; Boyd-Franklin, 2003; Brown & Shallett, 1997;
DiNicola, 1997; Falicov, 1998; Hong & Ham 2001; Ho,
Rasheed, & Rasheed, 2004; McGoldrick, 1998; McGoldrick,
Giordano, & Pearce, 1996). What is noted in reviewing the
vast family therapy literature is that many concepts that
address the same family phenomenon or processes are
identified by different names within various practice models.
Social work family practice models further derive their
underlying conceptual framework from systems and
ecosystemic theory, family life cycle theory, theories cn
cultural and social diversity, and strength-based and
empowerment theory. Based on these frameworks the
following concepts represent key social work practice
principles with families:
1. The framework for family practice is directed by
thinking "family as context" informed by the belief
systems wherein the family is a special social
environment conceptualized as consisting of multiple
systems.
2. A family is more than the sum of its individual parts, it is
a unique system with particular responsibilities and
functions. It is purposeful and receives input from the
components or members of that system, as well as from
the environment outside the system.
3. A change affects all family members. The family is able
or unable to create a balance between change and
stability.
4. By approaching a complicated family situation from a
systems theory perspective, the practitioner is able to be
somewhat more objective about family issues. Systems
theory allows the practitioner to identify which
problems are more salient than others, providing
direction as to where to begin interventions.
5. Utilizing a multiple systemic perspective for family
assessment and intervention best addresses the complex
needs of many families.

6. Individual member's behaviors are best under stood
as having a circular rather than linear causality.
Behaviors are seen as having multiple interacting
origins, rather than singular causation.
7. Practitioners who see the family context as
interactions of multiple systems between the family
and its social environment will be better able to build
on strengths and resilience in families and promote
family cohesiveness-a notion critical to practice. The
ecosystem perspective because of its "person- in
environment" focus provides a lens in which the
family and family members can be understood
within the context of transactions with a variety of
biological, psychological, life cycle cultural, and
historical environments.
8. Every ethnic minority individual is embedded
simultaneously in at least two systems: that of his
immediate social and physical nurturing environ-
ment and that of the larger major society. The
nurturing environment defines the various ele ments
of each particular culture and it determines an
individual's need and sense of identity.
9. Families from different cultural, racial, ethnic, and
religious groups and representing alternative life
styles may experience the impact of legal, social, and
economic biases and discrimination that may impact
family functioning.
Models of Family Practice
Social worker practitioners use a variety of family ther apy
models in their practice with families; in that family
therapy models differ in their points of emphasis. Ther e
are several ways in which models of family therapies have
been classified. One group has emphasized the
communicative-interactive system within families
(Haley, 1976; Satir, 1967). Another group emphasizes a
structure-functional framework (family-environ ment
transactions and intergenerational dynamic order) re-
presented by Aponte (1994), Kerr and Bowen (1988), and
Minuchin (1974). More recently, some practi tioners of
family therapy have developed postmodern approaches to
therapy (Laird, 1995).
Communica tive- Interactive
Theories and Practice Models
The communicative-interactive practice models devel-
oped and advanced by Haley (1976) and Satir (1988 )
place major emphasis upon the communicative and
interactive process taking place between individual fam ily
members and subsystems within the family. One of the
assumptions of the communicative-interactive
FAMILY: PRAcrlCE INTERVENTIONS 185
model is that family culture is sustained and maintained
through communication and language and (more impor-
tantly) through subjective and everyday interpretations of
behavior. One of the key elements of communication
within families is not just the act of communicating but the
interpretation of communicative events by others and the
interpersonal meanings derived from that inter pretation,
followed by the subsequent response to that interpretation
(Ho, Rasheed, & Rasheed, 2004).
The contributions of the interactional framework to
social work practice center primarily upon changes within
the family unit that are a result of interactions between
members. From this framework, an analysis can be made
in which individual family members act and react to the
actions of others and the interper sonal meanings attached
to these actions. Because the communicative-interacti ve
framework is concerned primarily with change rather than
with stability, the concepts of family equilibrium (status
quo) or family's transaction with the outside world are less
important. The framework, when applied singularly, can
easily shift from one that concentrates upon interactive
processes between system members to one that empha-
sizes intervention methods that focus primarily upon
individual actions or behavior.
Structure-Functional
Theories and Practice Models
Strongly committed to the systems outlook, the structur-
alist position emphasizes the active, organized wholeness
of the family unit. Like the communication theorist, the
structuralist is interested in the components of the sys tem,
how balance or homeostasis is achieved, how the family
feedback mechanism operates, how dysfunctional communication
patterns may develop, and other System factors. Rather than
observe the communicative interaction, and the interpersonal
meanings in a family transaction and what messages members
send back and forth, the structuralist adopts a more holistic view,
observing the activities and functions of the family as a clue to
how the family is organized or structured. The focus here is on
using the content of a transaction in the service of understanding
how the family organizes itself. Structuralists in general are more
concerned with how family members communicate than what
they communicate and the interpretation of that communication.
The study of power games, communication patterns, meaning
systems, or rule processes is only marginally relevant and is
monotheoretical because, in their view, these concepts fail to
explain the complexities of human interactions.
The structure-functional framework primarily de-
veloped and advanced by Bowen (1976) and Minuchin
186 FAMILY: PRACTICE INTERVENTIONS
(1974) was based upon the anthropological and socio-
logical work of Homans (1964), Merton (1957), and
Parson (1951). The internal family system is composed of
individual members who define both the family as a whole
and the various subsystems within the whole, that is, the
conjugal, parent-child, and sibling units. In transacting
with the environment, individual members are viewed
primarily as reactors who are subject to influences and
impingement from the greater social system. The healthy
functioning of an ethnic minority family system can be
measured by its adaptive boundary-maintenance ability
following stressful situations caused by pressures from
transactions with other environmental systems or with
society asa whole (Kerr & Bowen, 1988; Minuchin,
1,974). Hence, therapy as guided by this conceptualiza tion
suggests two levels of intervention: (a) strengthening the
boundary-maintaining ability of the family for adaptive
purposes that serve stability or equilibrium needs and (b)
intervention at the broader societal level to reduce
destructive influences upon families that emanate from the
environment (Aponte & Wohl, 2000; Minuchin, 1974).
Three major models of family therapy derived from
these two perspectives are briefly summarized in the
following sections.
Intergenerational Family Systems
Bowen was trained as a psychoanalyst. He based his
theory on a clinical study of schizophrenia at the Men-
ninger Clinic in the early 1950s and the National Institute
for Mental Health in the early 1960s. Bowen was
impressed with the "emotional stuck togetherness"
(fusion) of family members with schizophrenia.
Bowen (1976). viewed families as open systems whose
members enter and exit over time and thereby alter the
boundaries of the family. Therefore most families are
understood from an intergenerational perspect ive of
interlocking, reciprocal, and repetitive relationships
(Rhodes, 1986). Bowenian family therapy incorporates
important intergenerational processes, allowing family
therapists to explore critical historical events and
intergenerational patterns affecting current family
functioning. Problems related to unresolved family issues
of past generations is conceptualized as hav ing potential
emotional impact (family projection processes) in
subsequent generations and hence can result in problems
in emotional distance (either too much emotional
closeness (fusion) or too little emotional closeness
(emotional cutoff) also resulting in pathological emotional
triangles and poor differentiation of self within the family.
Bowen family theory also conceptualizes family
change in a nonpathological framework as the family
adapts to various stages in the family life cycle such as
marriage, birth of a child, departure of each child,
retirement, aging, and death (Santiago-Rivera, Arredondo,
& Gallardo-Cooper, 2002).
Communications Theory
Theories of communication have been an essential part of
understanding families since the early days of some to the
very first pioneers of family therapy (Duhl, 1989).
Communication theory is rooted in the work of Satir
(1988). She is regarded in the field of family therapy as one
of the founding "grandparents" of the family therapy
movement, as well as being the first female and first social
worker to develop a major model of family therapy. Satir
focused her systems-oriented approach on the
communications patterns within families with the
assumption that there is a unique pattern of communication
within troubled families, as well as a correlation between
self-esteem and communications. The goal is to enhance
self-esteem among family members, as well as to increase
communication and problem-solving skills.
During the course of her career, she experienced a shift
.of emphasis in her philosophy and began to incorporate
existentialist philosophical notions into her already
well-established and well-received family com munication
approach. Her revised family therapy model came to be
known as the human validation process approach (Satir,
Banmen, Gerber, & Gomori, 1991). Satir's revised
approach retained important basic tenets of family
communication among family members and clarity of
roles. However, she also began to incorporate, in a very
significant way, a humanistic focus with a spiritual, though
nonreligious, sensitivity and awareness of human
interconnectedness. The end result of the human validation
model is that it emphasizes the growth potential of all
individuals, and the family's central and critical function of
enhancement of selfesteem of its family members. The end
result is an approach that focuses on facilitation of clear,
direct, and honest communication in the family that will
enhance the self-esteem of individuals in the family.
Structural Family Therapy
Structural family therapy also incorporates a generational
view, focusing on balancing the structure of the family
using direct, concrete, here-and-now approach to problem
solving (Gladding, 2002). Family structure theory focuses
on the family system's structural (contextual) dynamics,
especially the creation, maintenance, and modification of
boundaries, which are rules defining who participates and
how (Minuchin, 1974). The dynamics of the history of the
family (isomorphs) is

manifested in the present and therefore accessible through
interventions in the here and now. Minuchin's approach
emphasizes how stressful contact by the whole family with
extrafamilial forces can produce role confusion and power
conflict within a family. The major subsystems within the
family (spousal, parental, sibling) may need restructuring to
restore healthy boundaries and functional roles.
Minuchin's (1974) concept of different sources of stress
reflecting the family system and its structure and emphasis on
stressful contact of the whole family with extra familial forces
sets him apart from other theorists, whose major concerns are
largely confined to the extended family or the nuclear family
system. By focusing on the extrafamilial forces, Minuchin is
sensitive tothe political, social, and cross-cultural processes of
poverty and discrimination that culturally diverse and socio-
politically oppressed families may experience over time.
Minuchin advocates that family therapists assume the role of
an ombudsman; they can assist the family in reorganizing
various social institutions and structures for its own benefit.
Postmodem Approaches to Direct Practice Newer
formulations of family therapy have been influenced by
postmodern constructivist, narrative, and feminist thought,
and have provided a critique of system-based approaches. The
nature of the critique is that the systems approach represents a
mechanist view of families as an entity to be manipulated and
changed by the "expert" therapist. Such an approach ignores
the impact of the therapist's presence on the family system, the
dynamics of gender, power, and the larger historical and
cultural context in which the family is embedded (Nichols &
Schwartz, 2006). Postmodernists also contend that the
families are the experts of their own lives rather than the
family therapist. As a corrective measure to systems theories,
post modem constructionist and narrative-based approaches
do provide significant insight into understanding families by
giving attention to how family members construct their
intrafamilia1 experiences through language and individual and
family narratives (Ariel, 1999; deShazer, 1998; Freeman &
Combs, 1996; White & Espton, 1990). The narrative emphasis
on "meaning" is further supplemented by a focus on ways in
which broader sociopolitical influences impact family and
individual narratives. Although the postmodern critiques may
address some of the major limitations of family systems
theories, these critiques do not necessitate a rejection of
systems-based theories. The focus of the
communicative-interactive and structural-functional practice
models, within the context of ecological and
FAMILY: PRACTICE INTERVENTIONS 187
critical constructionist metatheories, can provide a framework
for understanding the actual structure of the family and the
narrative meaning and interpretation of that structure by family
members as impacted by ethnic, cultural, historical, economic,
and sociopolitical factors.
Practice Interventions with Families
Direct practice with families involves seven steps. These seven
steps include: engagement, assessment, planning/goal setting,
implementation, evaluation, termination, and follow-up (Hull
& Mather, 2006). As we understand direct practice steps, there
needs to be a distinction made between what the terms
structure, technique, and skill mean. The term structure of
practice refers to the model used by many generalist practi-
tioners in their work with families (Hull & Mather, 2006). A
technique here refers to the specific means or procedures
through which a particular aim mutually agreed upon by
client/family and therapist is implemented and accomplished.
A skill refers to the unique fusion of aptitudes and knowledge
or capabilities essential to performing a professional task or
activity. Unique aptitudes that are part of skill may include a
practitioner's warmth, sensitivity (to own ethnic background,
client's ethnic background and reality, and adaptation of skills
in response to client's ethnic reality), flexibility, positive
regard, and respect for the client/family. Therapists'
capabilities that are part of a skill include therapeutic
procedures responsible for accomplishing a task.
Engagement
The beginning phase of direct practice with families is a
critical period for all families. The reason for this phase of
practice being so important is due to several factors. Many
families tend to utilize helping professionals only if all other
traditional help-seeking attempts have failed. They may have
very little knowledge of what family practice is about. Many
clients may have contacted a social worker or family therapist
only because they are referred by mainstream societal agencies
such as schools, mental and health-care agencies, the courts, or
social service agencies. If this beginning phase of practice is
not "properly" conducted, the first interviews will most likely
be the last time the therapist will have contact with the client or
family. A common pitfall in family therapy is moving through
the engagement process too quickly (Ho, Rasheed, & Rasheed,
2004; Rasheed & Rasheed, 1999). Family practitioners need to
take more time in building these therapeutic relationships.
Trust, respect, genuineness, and integrity are key aspects of
building a clinical relationship
188 FAMILY: PRACTICE INTERVENTIONS
(Franklin, 1994). Therapists are cautioned not to at tempt to
rush through this critical stage of the clinical process for it
may undermine the therapeutic bond. (The engagement
and assessment stages-to be discussed momentarily-are
typically elongated when working with oppressed,
disadvantaged, and culturally diverse families.)
The first step in the clinical relationship is to engage
family/members through the medium of trust, in a teflective
dialogical relationship (Rasheed & Rasheed, 1999). Here the
practitioner listens to their stories and explores the unique
life experiences of each family member as they relate to
(inter and intra) personal problems. With ethically and
culturally diverse families, special attention should be
given to historical trauma and stress resulting from
experiences of various forms of oppression. The family
therapist (especially those not formerly grounded in the
social work perspective of person-in-environment) also
needs to inquire about broader ethnocultural factors, such
as race, social class/caste systems, culture, and gend er, and
their (potential) impact on the family/member's (self and/or
family) narrative as well as their impact on the presenting
problem.
Clinical Assessment
Assessment involves identifying and clarifying the is sues
presented by the family and allowing them to articulate
what they would like to happen in the therapeutic process.
Understanding and assessing the presenting problems of
families requires a broad conceptuallens that includes
multiple levels of assessment. There is especially a unique
constellation of data that needs to be collected in practice
with ethnic minority families in order to "co investigate"
personal, social, and ethnocultural realities in the family's
life space in order. to identify meaningful themes related to
sociopolitical and relational constraints (Rasheed &
Rasheed, 1999). Assessment is a complex process that
involves a bio-psycho-social focus along with an ex-
ploration of the family from the perspective of its
relationship pattern, family roles, rules, and rituals (Hull &
Mather, 2006).
Many sources of information may be used at this stage
including the genogram and eco-rnap. The ecomap
developed and advanced by Hartman (1979) is a useful and
practical technique that visually depicts the family's
relationship with its environment. It identifies and
characterizes the important supportive or conflict laden
connection between the family and the envir onment. It also
identifies emotional and interactive relationships within the
family and its connection with the outside world. The
comprehensive picture of
the family's major themes and patterns identified by an
eco-rnap, in tum, gives direction to the planning process
and keeps both the worker and the family from getting lost
in details. The eco-rnap is a paper-andpencil simu lation of
the family's life space; and it is visual, concrete, and easy
to complete. It is highly relevant for all ethnic minority
families who may be responsive to activity-oriented
processes-especially those targeted at creating a more
enabling niche in the life space of family/members.
Families from diverse ethnic or cultural backgrounds
may especially benefit from the techniques of culture
mapping and genograms (Pendagast & Sherman, 1977).
These two techniques can provide insight into family
members' intergenerational perspective and differing
levels of acculturation. Relevant personal, familial,
community information, and cultural mapping can be
extremely helpful in the assessment of ethnic minority
families that undergo rapid social change and cultura l
transition. Data including the process (and stage) of
cultural adaptation and acculturation level is critical
toward developing culturally relevant and culturally
sensitive interventive goals for family/members. Tech-
niques in data collection with ethnic minorities require
more than the usual question and answer mode of
communication. The use of home visits, family photo-
graphs, published poetry (as well as poetry written by
family members), paintings, and native music can
facilitate interaction and generate meaningful informa tion
(Ho & Settles, 1984).
Planning and Mutual Goal Setting
Goals guide the implementation process. Goals reflect
what changes the family wishes to attain and the steps
needed to make this happen. As such, goals should be
clear, concise, measurable, realistic, and within the
capacity of the family to meet, (Collins et al., 1999). While
the initial goals may be general and abstract, the task of the
therapist is to bring greater specificity to the goal and to
help the family to prioritize their goals. Therapeutic goals
with families can be divided into three categorie s (Falicov,
1998): (a) goals related to situational stress (for example ,
social isolation, poverty, and so on) caused by interface
between the family and the new environment; (b) goal
related to dysfunctional patterns of transaction (for
example, parent-child role reversal, conflictual
child-rearing practice); and (c) goals related to
dysfunctional patterns (for example, family problems such
as developmental impasses, limited range of repetitive
interactional behaviors, and so on). (Goal setting with
ethnic minority families may also require an ecostructural
approach (Aponte, 1979), which, in tum, considers the
"incompleteness" (basic

survival needs) that many ethnic minority families
experience. )
Direct practice with families requires that goals be
problem focused, structured, realistic, concrete, practi cal,
and readily achievable. Minuchin (1967) reaffirms when
patterns of change in the family are out of phase with the
realities of extrafamilial systems, therapy will fail; he
refers to this technique as "probing for flexibility in the
system." Aponte (1979) also emphasizes the need to
formulate therapeutic goals that can produce irn mediate
success (power) in the clients' lives.
Implementation Phase
The implementation phase involves activity directed
toward achieving the previously agreed upon goals. This
stage involves doing the tasks that are necessary to
achieve such goals. As such, honoring the nonhier archical
perspective of the client and worker, this phase involves
work of both the practitioner and the family. A variety of
intervention strategies can be used at the phase of
intervention, such as reframing, enactment, externalizing
the problem, use of metaphor, and teach ing
communications and problem-solving skills.
Evaluation and Termination Phase Evaluation
provides an assessment to determine whether the
implementation phase was successful. It not only
determines what happened but why (Hull & Mather,
2006). It provides better feedback, as to the success. In a
managed care environment and with the emphasis on
evidence-based treatment, this stage is important, as it
provides feedback as to the efficacy of interventive
strategies. Termination is the ending of the relationship
and occurs when the family reaches their goals or when
ongoing progress is no longer desirable or possible.
The termination process should take into considera tion
the family's concept of time and space in a rela tionship.
Some families may never want to end a good relationship
and they learn to respect and love the worker as a member
of their family. It is important that the practitioner be
comfortable with this element of cultural and human
inclusiveness and makes terminat ion a natural and gradual
process.
Developing Trends in
Social Work Practice with Families Roberts and
Yeager (2004) define evidence-based practice as the use
of the best scientific evidence when making a clinical
decision or interventions that seem to work, and also the
evaluation of one's own practice. The increased emphasis
on evidence-based practice along with the advent of
managed care and client rights
FAMILY: PRAcncE INTERVENTIONS 189
has generated the development of brief approaches for
family practice (Franklin & Jordan, 1999). Interventions
that are amenable to measurement approaches and those
that provide support for the efficacy of specific therapeutic
approaches for specific clients are rapidly becoming the
expectation in today's behavio ral manage care
environment (Jordan & Franklin, 2003).
Research in Family Treatment According to
Carlson, Sperry, and Lewis (2005), research on the
outcome of family treatment has identified four factors
that account for change (BIos & Sprenkle, 2001; Lambert,
2003):
1. Client/Extra Therapeutic Factors. These factors include
the client/family's characteristics such as inner strength,
religious faith, and goal directedhess as well as things
outside of the client's control such as social support.
(Forty percent of change is attributed to these factors.)
2. Relationship Factors: These variables are what occur
between the practitioner and the client/family. They
include warmth, respect, empathy, and authenticity.
(Thirty percent of the change is attributed to these
factors.)
3. Model/Technique: These variables are specific to the
different theories of therapy that are employed. (Fifteen
percent of the change is attributed to these factors.)
4. Placebo, Hope, and Expectancy Factor: These variables
are attributed to the presence of the client/ family in
therapy. (Fifteen percent of the change is attributed to
these factors.)
Emerging Trends
Carlson et al. (2005) have identified four areas that will
have future impact on family treatment and will shape the
reality of family treatment in the twenty-first cen tury.
These areas are: the importance of the Human Genome
Project and DNA research, brain research, spirituality, and
attachment theory research.
Conclusion
Social work continues to renew its commitment to practice
with families. This trend has endured many decades,
despite some 40 years of changing and evol ving
theoretical and practice innovations- as well as
withstanding major changes in the epistemological or
paradigmatic practice foundation.
The face of the family has and will continue to change
as well. Family tasks, roles, function, and even the family
life cycle will undoubtedly continue
190 FAMILY: PRACTICE INTERVENTIONS
to endure shifts and modifications in response to our changing
socio-politico-econornic landscape. The ongoing challenge to
direct practice with families is to respond to the changing
family within an ever-evolving society.
Social work's attention to the myriad family forms and
diverse cultures, along with mounting and complex societal
dilemmas facing today's modem family, integrates well with
the postmodemist framework. In that, family practitioners
may want to consider reconceptualizing
ethnic-jcultural-specific educational approaches to family
practice training, in lieu of a cross-cultural! cross-national
training within an anthropological approach to family practice
education. In training social workers to conduct direct practice
with today's diverse family, one may need to consider all of
the subcultural elements that constitute today's family
members, as well as an approach (like that of the
narrative/postmodem ilk) that can better respond/address the
complexities of how family members vary in their individual
experiences of their own societal and subcultural realties.
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-MIKAL N. RASHEED AND ]ANICE MATTHEWS RASHEED
FAMILY CAREGIVING
ABSTRACT: There is growing evidence among social
work researchers and practitioners that family
caregiving in the United States population is
increasing at an unprecedented rate as a result of
various societal issues.
FAMILY CAREGIVING 191
This entry provides a summary of the scholarly literature
regarding elder caregiving trends, demographics, legislation,
challenges, racial and socioeconomic impacts, as well as the
rewards of caregiving. Additionally, the entry provides an
in-depth review of recent empirical findings regarding
evidence-based interventions associated with family
caregiving of older adults.
KEY WORDS: caregiving; elderly; older adults; elder-
care; dependent care; community-based care
In the United States, the tradition of family caregiving or
informal caregiving to older adults is long-standing, and is
broadly defined as unpaid assistance provided by relatives and
friends to an older person who is unable to perform routine
tasks of daily life, such as personal care needs and household
chores (National Alliance for Caregiving & AARP, 2004).
This assistance may take various forms ranging from
performing activities of daily living (ADLS; for example,
bathing and feeding), performing instrumental activities of
daily living (lADLS; for example, shopping and
housekeeping), offering emotional support, and offering
financial support (Whitlatch & Noelker, 1996). Family
members and friends providing or managing care are typically
known as informal caregivers; older adults receiving care are
referred to as care receivers or care recipients (Whitlatch &
Noelker, 1996).
In the past, research on caregiving to older adults has
focused on a single person (that is, a primary caregiver)
believed to have the most responsibility in assisting the older
person, either by performing tasks alone or managing tasks
performed by other care providers. However, a growing body
of evidence documents that other informal providers, typically
labeled secondary caregivers, also assist older adults
(Whitlatch & Noelker, 1996). An updated national profile on
caregivers of frail elders has documented the order of primary
caregivers by relationship to older adults as adult children,
spouses, and other relatives. or friends (Wolf & Kasper, 2006).
Prevalence, Nature and Extent of
Caregiving to Older Adults
In terms of national demographics, findings from a national
study by the National Alliance for Caregiving and the AARP
(2004) found that almost 34 million (16% of the U.S. adult
population) caregivers aged 18 years and older provide
informal care to adults aged 50 years and older. The number of
caregiving hours varies. Based on 2004 U.S. Census Data and
the National Survey of Families and Households approxi-
mately 28.8 million family caregivers were providing an
192 FAMILY CAREGIVING
average of 20 hours of care per week (Arne, 2006). These
hours of care equaled an average 2004 national market
rate of $9.92 per hour for a home health aide. The
prevalence of family caregiving to older adults will
continue to grow significantly in the United States due to
multiple factors, such as an increased life expectancy;
improved medical care and technology; and projected
larger proportions of people aged 65 and older-increasing
from 12.4% in 2005 to 20% in 2030 of the national
population (CDC, 2007; DHHS, 2006). An increased life
expectancy also portends larger proportions of older adults
in the oldest-old group, those aged 85 and older, with high
care needs. Although unprecedented numbers of older
adults will live healthy lives, other less healthy ones will
simultaneously experience chronic diseases (for example,
arthritis and macular degeneration) resulting in disabilities
that accompany the normal aging process as people live
longer. As the percentage of three- and four-generation
families has increased, an anticipated growing number of
"sandwich generation" women and men are
simultaneously caring for aging parents while also raising
children or grandchildren. Addi tionally, the U.S. Bureau
of Labor Statistics projects that baby boomers (those aged
45-54 in 2004) should expect increased health-care
spending as they age seeing that in 2004 those age 55-64
spent $3 ,262 and those 65 and over spent $3,899 (U .S.
Census Bureau, 2006). Other factors, such as shorter
hospital stays, and increased likelihood of being
underinsured or uninsured for longer lengths of time, may
also contribute to placing more demands on family
caregivers to assist older care recipients with chronic
disabilities.
A sole reliance on formal or paid care by frail and
chronically ill older adults is notably low in the United
States, even though it is among the wealthiest nations in
the world. In 1999, approximately 11% (3.7 million) of
older Medicare enrollees with chronic disabilities received
personal care from either a formal source, such as a
professional service provider, or an informal source, such
as a family member or friend (DHHS, 2006). In 2000, a
relatively small number (approximately 1.6 million or
4.5%) of the older adult population, age 65 and over lived
in nursing homes. The relatively low number of older
adults receiving care from formal sources or residing in a
nursing home suggests the homebased care of frail and
chronically ill older Americans may be disproportionately
falling on the shoulders of family members, who are often
ill prepared for or untrained to meet their elders' medical
care needs.
Recent Legislation and Policies
An amendment to the 1965 Older Americans Act, the
National Family Caregiver Support Program, enacted
by the U.S. Congress in 2000, was the first federal law to
acknowledge explicitly the service needs of family
members providing care to older people. This national
program lacks adequate funding, thus leaving gaps in
caregiver services that vary substantially from state to
state, as well as within states (Friss Feinberg, Newman,
Gray, & Kolb, 2004).
Congress enacted the Family and Medical Leave Act
(FMLA) in 1993, another major federal law to support
caregiving families. The FMLA was the first legislation to
offer a protective leave to working caregivers while they
performed both work and family responsibilities.
However, there are three major gaps in the policy's
provisions. First, 40% of the workforce work for
businesses with fewer than 50 employees so their
employers are not required by the FMLA to provide
caregiver leave. Second, most working people cannot
afford to take unpaid leave to provide family care. Thus, as
a stopgap measure, many states have designed and
financed caregiver support services, using both federal and
state funds, to expand family leave benefits, and to offer
respite care or other in-home services to families of
disabled older adults. Third, there is great variability and
inconsistency in the offering of these services be tween and
within states, and thus expanded federal and state
legislation and funding is necessary (Friss Feinberg &
Newman, 2004).
In December 2006, Congress enacted the Lifespan
Respite Care Act (P.L. 109-442). This Act creates grants
for states to recruit and train respite care workers in
addition to volunteers to provide respite care for family
caregivers caring for children or adults with disabilities.
This Act, along with the reauthorization of funds for the
National Family Caregiver Support Program (within
Administration on Aging, P.L. 109-149) expands funding
for services that will specifically assist family members in
their caregiving roles; however, additional legislation is
needed to facilitate evaluation research that develops and
tests model service interventions for caregivers.
Caregiver Stress,
Negative and Positive Outcomes
Family members who provide care to older persons with
chronic or disabling conditions are themselves often at
significant risk of health problems. Long-term care giving
may engender stressors that may place caregivers at risk
for poor physical, emotional and mental well being. The
characteristics of caregiver, characteristics of care
recipient, and the situational context in which the caregiver
renders care to an older person may connote stressors
associated with the caregivers' poor wellbeing. For
instance, being older, female, or a spouse

caregiver and having greater socioeconomic disadvan tage
are specific risk factors associated with higher levels of
subjective burden, depressive symptoms, and lower levels
of physical health in the caregiving role (Pinquart &
Sorensen, 2003, 2007). Characteristics of older adults
receiving care, such as behavior problems in persons
diagnosed with Alzheimer's disease and greater ADL
limitations in frail persons, signify situa tional stressors that
may predispose caregivers to high levels of burden,
impaired emotional health and poor physical well- being.
Furthermore, other situational factors, such as the older
adult's level of cognitive impairments, the amount of care
provided by the caregiver and the duration of caregiving,
are also potential stressors that may be associated with
greater burden and higher levels of depressive symptoms
for care providers. However, as Pinquart and Sorensen
(2003) have noted, these other situational factors and the
greater physical as well as greater cognitive impairments in
older adults are associated inconsistently with bur den and
depressive symptoms. These authors have further
explained these inconsistent findings in the association of
caregiver burden with situational factors as attributed to
different sampling methodologies. That is, the associa tion
between burden and care environmental contextual
measures is strongest in probability samples as compared to
nonprobability samples.
Long-term caregiving may have not only negative
outcomes but also positive ones for persons assisting older
adults (see Picot, Debanne, Namazi, & Wykle, 1997). For
instance, caregivers report positive feelings in providing
care to an older adult family member that may have once
cared for them, such as adult children assisting their elderly
parents. Inconsistent findings exist about the effect that
positive caregiving outcomes may have in mitigating
negative ones. Nonetheless, evidence suggests the positive
and rewarding feelings that persons may have about the
role of caregiver may mediate undesirable effects of care-
giving such as burden and depression (Pinquart and
Sorensen, 2003).
Racial and Socioeconomic
Impacts of Caregiving
Research on the role of race and erhnicity in family
caregiving is receiving increasing attention in light of U.S.
population projections, and because of differential impacts
based on caregivers' ethnicity and race. The ethnic minority
population age 65 and older will increase from 5.7 million
(16.4%) in 2000 to 8.1 million (20.1 %) elderly persons in
2020, with the largest projected increases occurring in the
Hispanic (254%) and Asian and Pacific Islander (208% )
elderly populations
FAMILY CAREGIVING 193
(DHHS, 2006). According to reviews addressing the
current state of ethnic minority caregiving research, race
and ethnicity are factors that may influence care givers'
appraisal of stressful caregiving events; their perception
and use of family support in addition to formal services;
and their use of coping behaviors. Ethnic minority older
adults are more often impoverished and disabled than their
White counterparts, and they rely more heavily on family
members for care. Restricted access of racial and ethnic
minori ty groups to formal care services resulting from
discrimination, whether real or pe rceived, contribute to
service system barriers for both caregiver and care
recipient. Therefore, in an effort to fulfill filial
responsibility and also to meet the needs of older persons,
ethnic minorities caregivers may undertake their care
giving duties with poorer heath status, less reliance on
formal service systems, and greater reliance on religious
coping than White caregivers (see reviews by Aranda &
Knight, 1997; Chadiha, Adams, Biegel, Auslander, &
Gutierrez, 2004; Connell & Gibson, 1997). Additionally,
many ethnic minority caregivers provide care even when it
may negatively affect their financial well-being. Nation-
ally, 22% of African American and 14% of Hispanic
caregivers report experiencing moderate or extreme
financial hardships due to home caregiving (NAC &
AARP, 2004), and smaller samples of African American
family caregivers report not attending to their own health
care needs in order to provide eldercare (Owens-Kane,
2007). Using a metanalysis of over 100 empirical studies,
Pinquart and Sorensen (2005) found ethnic minority
caregivers (Asian American, African American, and
Hispanic American) rendered more care and they held
stronger beliefs of filial responsibility than White
American caregivers did.
Being a member of a certain racial or ethnic group
appears to mitigate risks for some negative outcomes, an
observation that varies among African American, Asian
American, and Hispanic caregivers as compared to White
caregivers. Pinquart and Sorensen (2005) concluded that
African American caregivers reported less caregiver
burden and lower levels of depression symptoms than
White caregivers did; however, Asian American
caregivers reported higher levels of depression symptoms
than Whites did. Furthermore, all three groups of ethnic
minority caregivers experienced worse physical health
than White caregivers. In addition to clarifying the
influential role that ethnicity and race may have on
caregiver outcomes, Pinquart and Sorensen concluded that
other factors, specifically the older adult's illness diagnosis
and sampling methodology, also influenced differences in
caregiver outcomes, such as burden and depression.
194 FAMILY CAREGIYING
There are various explanations for ethnic and racial
differences in caregiving outcomes, such as minority
persons' greater acceptance of caregiving as a normative
experience and perceiving eldercare as a less intrusive
familial role than Whites do (Pinquart & Sorensen, 2005).
Overall, researchers have concluded that more probability
studies using specific theories are required to explain
observed differential effects of caregiving outcomes
among ethnic minority caregivers and White caregivers
(Hargrave, 2006; Pinquart & Sorensen, 2003,2005).
Evidenced-Based Interventions
An evolving body of evidence-based intervention re search
on caregiver outcomes has been catalogued in primary
studies, comprehensive reviews and metaanalysis studies.
Intervention studies vary in their focus on outcomes;
however, a preponderance of caregiver interventions has
aimed to minimize the undesirable effects of care giving
on care providers' psychological, social, emotional, and
physical well-being. An additional goal of the
interventions has been to offer support to caregivers that
facilitates not only their ability to meet individual needs,
but also to meet the needs of the care receiver.
Efforts to characterize caregiver interventions can be
challenging due to a lack of consensus on an optimal
classification system (Biegel, 2006). Schulz (2002) has
proposed a three-dimension taxonomy for characterizing
caregiver interventions. This taxonomy would include (1 )
the "primary entity being targeted" such as the caregiver,
care recipient, and their environmental context; (2) the
"primary functional domain being targeted," such as
increased knowledge and skills of the caregiver; and (3)
"the method of delivery for interventions" ("intensity or
dose;" "delivery mode" at the individual, group or
community level; and "adaptability or controllability of
the intervention by either the interventionist or the study
participant)" (pp. Sl13-S114). Extant literature pinpoints
different types of caregiver interventions. Through an
examination of the effects of 78 caregiver intervention
studies, Sorensen and colleagues (2002) identified six
types of interventions that targeted caregivers and recipi-
ents: (1) psychoeducation; (2) supportive interventions;
(3) respite or adult day care; (4) psychotherapy; (5) care
receiver training, and (6) multicomponent interventions
that combined one or more intervention types.
Approximately half of these studies used a psy-
choeducational model followed second by studies that
used a respite or adult day care model. Multicomponent
interventions designed to address the manifold needs
and challenges of caregivers (Biegel, 2006) ranked third in
this typology (Sorensen et al., 2002).
Besides the different types of interventions, new
technological advancements in telecommunication sys-
tems are setting new trends and contributing to unpre-
cedented innovations in effective supportive caregiver
interventions that include automated telephone sup port
and internet web information to caregivers and care
receivers. Overall, studies of randomized controlled
groups involving mainly caregivers of persons with
dementia document that telephone-based interventions and
internet video-conferencmg interventions are effective in
lowering psychological stress such as depressive
symptoms and anxiety of caregivers (Eisdorfer et al.,
2003; Mahoney,Tarlow, &]ones, 2003; Marziali &
Donahue, 2006; Winter & Gitlin, 2007).
Irrespective of the type or innovation of the inter-
vention, researchers have contended that caregiver in-
terventions should be based in theory and empirical
research results in order to facilitate both replication and
generalizability (Pillemer, Suitor, & Wethington, 2003 ).
Although various theories have been employed in
caregiver intervention studies, dimensions of the stress
process and coping theory, as well as caregiving appraisal
theory, are highly represented in interventions. Use of
these theoretical perspectives in intervention research is
driven undoubtedly by the proliferation of empirical
research on caregiver stress and coping, as well as genuine
concerns on the part of researchers for the well-being of
caregivers and care recipients (George, 1990; Zarit, 1989 ).
In addition to arguments for more theory-driven
interventions, Montgomery (1996) has also argued for
greater "attention to efficacy and feasibility" when in-
vestigating the effects of interventions, given the various
settings in which caregiving occurs (p. SIlO).
Caregiver intervention studies have been weighted
towards those caregivers assisting older persons with
Alzheimer's disease and related forms of dementia (see
reviews by Bourgeois, Schulz, & Burgio, 1996; Brodaty,
Green, & Koschera, 2003; Charlesworth, 2001; Cooke et
al., 2007; Kenner, Burgio, & Schulz, 2000; Pusey &
Richards, 2001; Schulz, 2007; Schulz et al., 2002; T
oseland & Rossiter, 1989). Substantially fewer interven-
tion studies have focused on non-dementia caregivers,
particularly those assisting care recipients reported to have
other types of diagnosis or frail older adults (see
comprehensive reviews by Lui, Ross, & Thompson, 2005 ;
Toseland & Rossiter 1989; Yin, Zhou, & Bashford, 2002 ).
Most caregiver interventions target women rather than
men, which is partly due to the overrepresentation of
women assisting elderly persons. Interventions involving
dyads of the caregiver-care

recipient and both sexes, whether spousal or parentchild, are
rarely conducted (Whitlatch, Judge, Zarit, & Femia, 2006).
The current literature relative to the race and ethnicity of
caregivers indicates that intervention studies have tended
to target White caregivers more than minority caregivers
(see Sorensen et a1., 2002; Toseland & Rossiter, 1989;
Yin et a1., 2002). However, more recent multi- site
intervention trials for caregivers of persons with dementia,
such as Resources for Enhancing Alzheimer's Caregiver
Health (REACH), have placed strong emphasis on the
inclusion of African American and Hispanic caregivers
(Belle et a1., 2003; Burgio, Stevens, Guy, Roth, & Haley,
2003; Gitlin et a1., 2003).
Although findings are not always consistent, extant
evidence of intervention effectiveness is generally positive,
with studies focusing on various outcomes that target different
groups of caregivers reporting small to moderate statistically
significant effects (for example, Belle et a1., 2003; Brodaty et
a1., 2003; Cooke et a1., 2001; Gitlin et a1., 2003; Knight,
Lutzky, & MacofskyUrban, 1993; Pusey & Richards, 2001;
Schulz et a1., 2002; Sorensen et a1., 2002; Toseland &
Rossiter, 1989; Wisniewski et a1., 2003; Yin et a1., 2002).
Using a metaanalysis of 78 caregiver intervention studies,
Sorensen and colleagues (2002) concluded that caregiver
interventions produce statistically significant effect sizes of
0.14 to 0.41 standard deviation units, on average, for such
outcomes as caregiver burden, depression, subjective
well-being, perceived caregiver satisfaction, ability or
knowledge, and care-receiver symptoms. In a different
meta-analysis of psychosocial interventions for caregivers of
persons with dementia, results from 30 studies involving 34
interventions indicated significant benefits in caregiver
psychological distress, caregiver knowledge, any caregiver
outcome measure and patient mood, but no significant
reduction in caregiver burden (Brodaty et a1., 2002).
Statistically significant intervention effects constitute an
important element in evidence-based caregiver interventions.
Still, Schulz and colleagues (2002) ernphasize the importance
of consideration for clinical significance or practical
significance. In a review of 43 studies involving intervention
research, Schulz and colleagues concluded that many studies
with small to moderate statistically significant effects on a
variety of outcomes demonstrated strong clinical significance,
particularly when viewed in a policy, service, and public
health context. Their closing remarks provide a fitting
conclusion for this discussion of caregiver interventions.
Specifically, in reference to searching for both statistically
significant and clinically significant
FAMILY CAREGIVING 195
effects, they state: "Finally, and perhaps most irnportant,
researchers should set as their goal the achievement of reliable
and clinically significant outcomes, preferably in multiple
domains. To the extent that we succeed in achieving this goal,
we will not only solve a vexing social problem but also
advance the field of social/ behavioral intervention research."
(p. 599).
Overall, family caregiving situations are complex and
comprised of varying social, demographic, and environmental
factors that may mediate or moderate outcomes, both negative
and positive, of caring for a frail or older person with a chronic
disability. Evidence suggests caregiving outcomes may also
.be influenced by the national geographic distribution of the
elderly, such as living in urban versus rural communities, or
residing in states with larger versus smaller percentages of
elderly, or residing in communities with adequate elder care
services versus those with inadequate elder care services
(Glasgow, 2000). The role of geographical or community
factors on caregiving outcomes remains a relatively
unexplored area, thus implying need for further basic and
intervention research studies. Caregiver distress may not end
with the placement of an older adult in a nursing home (Schulz
et a1., 2004) or the death of the older adult, thus further
implying future researchers need to consider expanding
effective caregiver interventions beyond the caregiving
experience itself. Current and emerging effective interven-
tions that target ethnic minority caregivers also warrant further
replication and expansion, as most intervention studies have
not included sufficient samples of ethnic minority caregivers.
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FAMILY LIFE EDUCATION
197
National Alliance for Caregiving.
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National Family Caregivers Association.
http://www.nfcacares.org/
Your Aging Parent.
http://youragingparent . com/
-SANDRA OWENS-KANE AND LETHA A. CHADIHA
FAMILY LIFE EDUCATION
ABSTRACT: This entry provides a brief overview of family
life education as a field that provides training in life areas
which impact the well-being of families and individuals. It
focuses on three primary program areas:
Parental education, premarital and marital education, and
adolescent sexuality education. It identifies noted contributors
to the field, as well as evidence-based programs and target
populations. It summarizes how family life education
integrates into the profession of social work as well as how it
is distinct.
KEY WORDS: marital education; parent education; sex
education; life skills training
Family life education (FLE) is a preventive and intervention
venue that facilitates skills and knowledge to strengthen the
well-being of families and individuals. It is relevant to people
across the life span, and interventions are offered in schools,
healthcare facilities, churches, community agencies, and
businesses. FLE programs address developmental tasks and
life issues that require specific knowledge and skills to
navigate. They are instructive in nature, utilizing group, family,
and individual modalities, as well as self-guided curriculum
and the media. Presenters can be teachers, nurses, the clergy,
social workers, psychologists, counselors, or trained program
facilitators. Although FLE encompasses a range of programs,
the most widely uti- . lized are in marital and premarital
education, parent training, and human sexuality, which are the
subjects explored in this chapter.
Developers and Contributors Contributors to the
FLE field identified here have developed prominent
interventions or have been central in research. Thomas
Gordon developed the Parent Effectiveness Training (PET)
program in 1975 (Noller & Taylor, 1989), followed by Don
Dinkmeyer and Gary McKay with the Systematic Training for
Effective Parenting (STEP) program in 1984
(http://www.agsglobe. com). Organizations such as the Child
Welfare League
198 FAMILY LIFE EDUCATION
of America (www.cwla.org) and the National Parenting
Education Network (www.npen.org) have guided the field
of parenting education through sponsored re search,
curriculum development, policy advocacy, and
consultation to child and family service organizati ons and
practitioners.
Miller, Nunnally, and Wackman pioneered evidence-
based marital education with the Couple Communica tion
(CC) Program in 1968. Bernard Guerney developed the
Relationship Enhancement (RE) program in 1977
(Jakubrowski, Milne, Brunner, & Miller, 2004). Markman
and Stanley developed the Prevention and Relationship
Enhancement Program (PREP), (Stanley, Blumberg, &
Markman, 1999).
Contributors from a number of disciplines have guided
FLE intervention with adolescent sexuality and pregnancy
prevention. Some recognized scholars and program
developers are [osefina Card, Michael Carrera, Douglas
Kirby, Jennifer Manlove, Susan Philliber, and Julie
Solomon (http://www.teenpregnancy.org ). Organizations
such as the National Campaign to Prevent Tee n Pregnancy,
the Alan Guttmacher Foundation, and the Annie E. Casey
Foundation are prominent in research, policy development,
and dissemination of essential information.
Applications
Sexuality programs for adolescents have burgeoned with
available federal funding since the early 1990s. Offered as
health education, human development, and family living,
they are a strategy to reduce adolescent risk behaviors that
may lead to SID infection, HIV, or early pregnancy. In
2001 Jindal reported to Congress that there were over 700
adolescent sexuality programs in the United States, in 47%
of urban communities.
Premarital and marital education programs focus on
communication and relationship growth with married
couples and those planning to marry. Examples of widel y
used programs are the PREP (Halford, Sanders, & Behrens,
2001) and the CC Program (Butler & Wampler, 1999).
According to Stanley (2001), by the late 1990s, almost
one-third of marrying couples in the United States received
some form of relationship education. Historically,
recipients of these programs have been primarily
middle-class and white, and most provi ders have been
religious organizations. This trend is being challenged by
critics who question the relevance of traditional FLE
couples education for low-income and minority couples.
Researchers such as Adler- Baeder and Higginbotham
(2004) and DeMaria (2005) encou rage a broader
application that encompasses low income couples, couples
at risk for divorce, and couples who are reparmering and
bringing children from
prior relationships. Others emphasize the need for
intervention at points of major adjustment for couples, such
as those experienced by military families and couples
entering retirement.
Parenting education expands understanding, atti tudes,
knowledge, and skills of parents and their chil dren
(www.npen.org). These programs are increasingly utilized
by child protective services, juvenile justice, and the courts.
Numerous studies (for example, Bryan, DeBord, &
Schrader, 2006; Landy & Menna, 2006) demonstrate
effectiveness in preventing and treating child abuse, school
drop-out, aggressive behavior, juve nile crime, and teen
pregnancy. Programs for adolescent parents that focus on
sexuality, school achievement, and parenting, are provided
in most states and urban school districts.
Change Philosophy and Techniques
The fundamental change philosophy of FLE is that in-
dividuals and families can adapt and cope effectively with
changes and life challenges when they receive es sential
knowledge and skills. This philosophy is empiri cally
supported (for example, Halford et al., 2001) and
corresponds to the change philosophy of social work.
FLE is grounded in the practice theories that guide
social work and related professions. Erikson's theory of
development and Piaget's cognitive- developmental theory
are prominent in parenting education. Behavior al theory is
a foundation of parenting and marital edu cation.
Cognitive-behavioral theory, social learning theory, and
Germain and Gitterman's ecological perspective (1980) are
fundamental in FLE.
Franklin and Corcoran (2000) report in a review of
adolescent pregnancy prevention that research finds
interventions which include actual skills-building stra tegies
with participants to have the best chance for positively
affecting outcomes. Such components as problem- solving
and service learning are increasingly cen tral in FLE
programs.
Evidence-Based Practices and Programs
An abundance of research has been done in all areas of
FLE, resulting in a substa ntial number of programs
qualifying as evidence-based. This is especially the case for
couples' education and sexuality education. Four marital
education programs demonstrated effec tive in improving
communication skills and in relationship satisfaction i n
controlled trials with follow-up assessments of at least six
months: (a) Building Strong and Ready Families (PREP)
(Stanley et al., 1999); (b) RE (Guerney, 1977); (c) The CC
Program (Miller, Nunnally, & Wackman, 1992; (d)
Strategic HopeFocused Enrichmen t (Worthington et al.,
1997).

More than 20 adolescent sexuality programs are identified
as effective among four nationally recognized lists (Advocates
for Youth, 2003; Kirby, 2001; Manlove et al., 2002; Solomon
& Card, 2004). Five programs are included in all four: (a)
Becoming a Responsible Teen; (b) Making Proud Choices; (c)
Safer Choices; (d) Teen Outreach; (e) Children's Aid Society
Carrera Program (Harris, 2006).
A number of parenting education programs are cate-
gorized as promising, but only a few have conducted the
randomized studies that qualify them as evidence-based. Two
models that demonstrated effective in several domains are (a)
the Parent Management Training (PMT) model (Valdez,
Carlson, & Zanger, 2004) and (b) Nurse Home Visitation
Model. (MacMillan & Wathen, 2005).
Distinctiveness and
Integration in Social Work
FLE is well-defined in several ways. Foremost is that FLE
primarily uses adult learning techniques to guide format and
presentation. FLE interventions are generally quite structured
and often presented in a class-like format. They are instructive
and generally guided by a prescribed curriculum. Although
FLE addresses areas of concern to social work, it represents a
variety of professions in context and perspective.
Like social work, FLE is conducted in individual, couple,
family, and group formats. It uses an ecosystem approach and
a strengths perspective. FLE is grounded in theories central to
social work and focuses on problem-solving and improving
skills. Overall, FLE complements and extends social work
treatment. The profession has utilized FLE as an integrated
service and as adjunct intervention throughout its history.
Considering the current increase in FLE programs and the
expanding role of social workers in the new century, this is a
partnership likely to endure.
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200 FAMILY LIFE EDUCATION

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Worthington, E. L., ]r., Hight, T. L., Ripley, ]. S., Perone, K. M., Youth. www.advocatesforyouth.org
Kurusu, T. A, & Jones, D.]. (1997). Strategic hope-focused Annie E. Casey Foundation.
relationship-enrichment counseling with individuals. Journal of www.annieecaseyfoundation.org
Counseling Psychology, 44, 381-389. California Evidence-Based Clearinghouse for Child Welfare.
www.cachildwelfareclearinghouse.org
Child Welfare League of America.
FURTIIER READING www.cwla.org
Allen, K. R. (2000). A conscious and inclusive family studies. Couple Communication Program.
Journal of Marriage and the Family, 62, 4-17. www.couplecommunication.com
Bandura, A. (1999). Social cognitive theory of personality. In D. National Campaign to Prevent Teen Pregnancy. www.
Cervone & Y. Shoda (Eds.), The coherence of personality. New teenpregnancy . org
York: Guilford Press. National Extension Parent Education Model.
Bayse, D. j., Allgood, S. M., & Van Wyk, P. H. (1991). Family life www.ksu.edu
education: An effective tool for prisoner rehabilitation. Family PET: Parent Effectiveness Training.
Relations, 40(3), 254-25(. www.gordontraining.com
Brubaker, T. H., & Roberto, K. A (1993). Family life education for Parenting Institute of North Carolina.
the later years. Family Relations, 42, 212-22l. www.theparentinginstitute.org
Dian, R. M., Devaney, B., McConnell, S., Ford, M., Hill, H., & PREP: Prevention and Relationship Enhancement Program.
Winston, P. (2002). Helping unwed parents build strong and www.prepinc.com
healthy marriages: A conceptual Framework for interventions. STEP: Systematic Training for Effective Parenting.
Final report. Retrieved January 28, 2007, from http://www. www.agsglobe.com
buildingsrrongfamilies. info/publications/Framework/helping
unwed. pdf
Drummer, A R., Coleman, M., & Cable, S. (2003). Military families -MARY BETH HARRIS
under stress: Implications for family life education. Family
Relations, 52, 279-287.
Halford, W. K. (2004). The future of couple relationship education:
Suggestions on how it can make a difference. Family Relations, FAMILY-ORIENTED CORRECTIONS. See Criminal
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Justice: Corrections.
Harris, M. B., & Franklin, C. (2003). Effectiveness of a cognitive
behavioral group Intervention with Mexican American adolescent
mothers. Social Work Research, 17(2), 71-83.
Miller, B. C. (1998). Families matter: A research synthesis of family FAMILY PRESERVATION AND
influences on Adolescent pregnancy. Washington, DC: HOME,BASED SERVICES
National Campaign to Prevent Teen Pregnancy.
Miller, S., Nunnally, E. W., & Wackman, D. B. (1992). Couple ABSTRACT: The history and development of family
communication. 1. Talking together. Minneapolis, MN: Inter- preservation as a home-based service in social work
personal Communications Program.
practice is traced, current research is reviewed, and
Kazdin, A E., Siegel, T. c., & Bass, D. (1992). Cognitive
future practice trends and challenges are outlined in
problem-solving skills training and parent management training in
this entry. Family preservation services are described
the treatment of antisocial behavior in children. Journal of
Consulting and Clinical Psychology, 60,733-747. in terms of a philosophy of practice as well as a
McDermott, D. (2006). Thinking mindfully about parenting and specified service model.
parenting education. Child Welfare, 85(5), 741-748.
Melton, G. B., & Thompson, R. A (2002). Toward a childcentered, KEY WORDS: child welfare; family preservation;
neighborhood-based Protection system: A report of the consortium homebased services
on children, families, and the law. Westport, CT:
Praeger.
Philliber, S., Brooks, L., Lehrer, L. P., Oakley, M., & Waggoner, S. Background and History
(2003). Outcomes of teen parenting programs in New Mexico. The term family preservation refers to a philosophy as well as a
Adolescence, 38(151), 535-553.
particular model of service delivery that underscores the
Powell, L. H., & Cassidy, D. (2001). Family life education: An
importance of restoring families to safe levels of functioning.
introduction. Mountain View, CA: Mayfield Publishing.
The premise underlying family preservation is that the
Wiley, A. R., & Ebata, A. (2004). Reaching American families:
Making diversity real in family life education. Family Relations, physical, social, psychological, and emotional needs of adults
53, 273-280. and children are best met

when familial relationships are preserved (Grigsby, 1993 ;
Maluccio, Krieger, & Pine, 1991; Maybanks & Bryce,
1979; Pecora, 1991). As a service model, family
preservation programs share common features including
intensive services deli vered over a relatively short period of
time, individualized to a family's needs, and offered in the
family's home and community (Cole & Duva, 1990; Fein &
Staff, 1993; Maluccio et al., 1991; Pecora, 1991; Tracy ,
Haapala, Kinney, & Pecora, 1991; Walton, Fraser, Lewis ,
Pecora, & Walton, 1993). Family preservation philosophy
and services can be applied to many types of families:
biological, blended, kinship (composed of both extended
biological and nonbiological members), or families joined
through adoption.
The service orientation of family preservation can be
traced to the roots of social work. Serving families in their
communities was a trademark philosophy of the "friendly
visiting" workers of the Charitable Organization Societi es
of the early 1900s. One of the earliest documented family
preservation programs, the St. Paul Family- Centered
Project, established in 1949 provided intensive services to
families facing multiple problems. The stimulus for the
continued development of fa mily preservation arose from
dissatisfaction with conven tional child welfare services that
characterized the 1960s and 1970s. During this time period ,
attention shifted to research regarding the negative
outcomes for children who experienced unending term s in
care. Studies supported that large numbers of children were
removed from their homes and placed in foster care for long
periods of time; that these children experienced multiple
moves; and that some never returned home. These lengthy,
unstable separations had long-lasting det rimental effects on
the well-being of children (Knitzer & Allen, 1978;
Weinstein,1960).
Throughout the 1970s, a number of preventive ser vices
programs were implemented (for example, see Jones,
Neuman, & Shyne,1976), and the concept of home- based
services as an alternative to placement arose (Maybanks &
Bryce1979). Among the most notable models created was
the Homebuilders Program in Washington State, which
began in 1974 as an alterna tive to foster care and
psychiatric hospitalization. At about the same time, another
model of home-based services, Families Inc., was founded
in Iowa as an alternative to out-of- home care for
adolescents (Nelson & Landsman, 1992).
Increasing concerns about the growing number of
children in foster care prompted the passage of the
Adoption Assistance and Child Welfare Act (AACW A) of
1980 (P.L. 96-272). This legislation focused on new
provisions and requirements for agencies to prevent
FAMILY PREsERVATION AND HOME-BASED
SERVICES 201
the unnecessary separation of children from parents. This
legislation was a step toward recognizing the value of
supportive services to prevent the potentially harmful
effects of separation. Among other things, it called for
reasonable efforts to be made to either prevent removal or
support timely reunification. Subsequently, during the
1980s there was an increase in the Child Welfare League of
America's published standards for supportive services to
families. At the same time, family preservation programs
were growing in number, the number of children in
out-of-home placement was declining substantially from a
half a million children in care to about 225,000 children .
Recognizing the growing support for these services and
their potential for preventing placement, substantial federal
funds, about 93 million over a 5-year period, were allocated
to states to continue developing family preservation and
support programs under the Family Support and
Preservation Act (1993).
Unfortunately, in some instances, family preserva tion
services were applied inappropriately with families who
were not in a position to be maintained safely together. As a
result, media stories of children who suffered serious and
sometimes fatal injuries appeared. Critics attacked family
preservation services as preser ving families at the expense
of child safety. Since the 1990s, one response to these
criticisms has been less focused on intensive service
models and more focused on integration of
"family-centered" practice, a service deliver y process that
considers each family's unique strengths and needs, across
all child welfare services. The Adoption and Safe Families
Act (ASFA), enacted in 1997, while supportive of family
preservation, placed heavy emphasis on safety and timely
permanence for children through alternatives such as
adoption and kinship care. ASFA clearly indicated that
child safety and permanence were paramount. For example,
this legislation included specific circumstances believed to
be so unsafe that reasonable efforts t o support family
preservation and reunification could be bypassed, such as
in the case of parents with prior convictions of crimes
against children. This gave child welfare agencies and the
courts the power to move forward with permanency
planning more quickly for children in these situations.
Moreover, this legislation outlined specific timelines for
returning children home or filing to terminate par ental
rights. Over the past several years, the number of children
in out-of-home care has once again risen . According to an
annual report published by the Administration for Children
and Families, the number of children in foster care on the
last day of federal fiscal year 2005 was estimated to be
513,000.
202 FAMILY PREsERVATION AND HOME-BASED
SERVICES
Theory, Value Base, and
Essential Program Elements
Various theories have guided the development and practice
of family preservation services. These include crisis
intervention theory, family systems theory, social learning
theory, and ecological theory (Barth, 1991). Attachment
theory and functional theory have also been considered
relevant to family preservation services (Grigsby, 1993 ).
Other approaches have been applied too, including brief
solution-focused and multisystem therapy (Berg, 1991 ;
Henggeler, Melton, & Smith, 1993), and there is more
focused, explicit discussion of the place of theory in these
services, as well as some efforts at cross- training
(Friedman, 1993).
In addition to guiding theories, family preservation
programs generally share an explicit value base includ ing:
families should be maintained together whenever possible;
children need continuity and stability in their lives; and
separation has detrimental effects on both adults and
children. This value base is exp ressed in service delivery
models that capitalize on strengths of the family, mobilize
formal and informal supports, and provide a variety of
concrete and clinical services to meet individual family
needs. (Cole & Duva, 1990; Fein & Staff, 1993; Fraser et
al., 1996; Staff & Fein, 1994; Tracyet al., 1991).
While models vary in typology, most include in ten-
siVe,itiIhe.~limited services delivered in the family home
oi"<t~rlit;~ity. The amount of time spent during the initial
start of services is critical in establishing rapport and trust
with a family who might otherwise be resistant to, or lack
confidence about, the possibility of change. Caseloads are
typically small so that t he worker can be easily accessible to
the family, often available 24 hr a day for emergencies and
crisis intervention. The period of time for service delivery
varies from 1 month to several months depending on the
model, and is time limited in order to restore family
functioning as soon as possible. Cross-cutting elements of
successful programs include providing services in the home
where skill building can be directly applied, the ability to
respond to crises, the use of community resources and
concrete services, and the empowering approach to family
intervention (Fraser, Nelson, & Rivard, 1997).
Demographics
Family preservation programs have been primarily asso-
ciated with serving maltreated children as an alter native to
out-of-home placement. This ser vice model has been also
applied to avert foster and adoptive placement disruptions
(Barth, 1991; Berry, Propp, & Martens, 2007) and to
reunify children with their families (Maluccio et al., 1991 ;
Walton, Fraser, Lewis,
Pecora, & Walton, 1993). Family preservation ser vices
have also been utilized in other child- serving systems such
as mental health and juvenile justice (Henggeler et al.,
1993), as well as in the area of family development helping
low-income families improve functioning and achieve
economic independence (Deutelbaum, 1992).
Berry (2005) points out, there is not a "typical" family
that characterizes service recipients. However, families
most likely to be referred frequently share "common risk
factors and vulnerabilities." Shared characteri stics,
identified by Berry, generally include single parenthood
(usually families headed by single mothers), poverty,
parenting limitations or deficits, educational and/or
behavioral problems of children (including delinquency),
and varying degrees of difficulty with mental health and
substance abuse problems.
Family Diversity
Family preservation as a philosophy has always consid ered
the family's culture and lifestyle as important to
engagement and goal setting (Jones, 1989). Family
preservation models emphasize the importance of un-
derstanding a family's story and utilizing their unique
strengths and abilities, some of which may rest in their
ethnic and/or cultural traditions. Family preservation
workers must be knowledgeable about families from
different cultures and racial or ethnic groups, and with
different sexual orientations, in terms of family struc ture
and boundaries, help-seeking behaviors, level of
acculturation, and child- rearing and parenting skills
(Hodges, 1991).
Practitioners and researchers have examined the use of
family preservation services by different cultural groups
(Gray & Nybell, 1990; Mannes, 1990), but more work
remains to be done. Because family preservation services
are consistent with empowerment-based prac tice, those
practice principles and techniques hold promise for a wide
range of families facing possible discrimination. In one
study of family preservation ser vices, children of color
were significantly more likely to remain at home than were
white non-Hispanic children (Fraser et al., 1997). Although
the sample size in this study was small, this finding
suggests that these services may be a viable alternative to
out-of-home placement for children of color. A more recent
study specific to family preservation services for
African-American families revealed that services also
resulted in significant improvement in child well- being
(Nelson, 2003). Further research is critical given that
minority families have not been the focus of family
preservation services (Denby, Curtis, & Alford, 1998).
Family preservation as a philosophy and model of service
delivery also has

an international context. For example, Holt Inter national
reports a growing trend toward irnplementa tion of family
preservation services, most recently in Vietnam. Family
preservation services provided through Holt-Vie tnam
include "counseling, training, educational support and/or
small economic grants to assist families who have requested
placement of their child in an institution, or to families
whose children are already institutionalized, in order to aid
in their reunification" (see Holt International website). Also,
the Australian Institute of Family Studies indicates a
growing trend toward ensuring that "Indigenous child
welfare policy," traditionally focused on child protec-
. tion, is redesigned to include a focus on family preser-
vation. Family preservation is of particular importance to
indigenous families given the "high value placed on family
and extended family" and the disproportionate placement
rates of these children in the United States, as well as in
Canada, New Zealand, and Australia (Libesman,2004).
There is also growing body of international research on
family preservation programs. For example, a study in the
Netherlands revealed that the Families First program, a
family preservation services model that originated in the
United States, resulted in improve ments in child behavior
and family functioning, as well as a reduced likelihood of
out-of-horne placement (Veerman, de Kemp, ten Brink,
Slot, & Scholte, 2003). Likewise, in England, the
implementation of intensive family preservation services
with families with children with "serious" behavior
problems resulted in both reductions in behavior issues and
a reduced likelihood of out-of-home care (Biehal, 2005).
What Works in Family Preservation:
Latest Research and Best Practices
When family preservation programs were first intro duced,
they were enthusiastically viewed as a way to reduce
out-of-home placements. The mixed results of statewide
evaluations of family preservation services, however, have
tempered this enthusiasm. Research reviews have shown
that children who receive family preservation services are
placed about as often as children in control or comparison
groups who did not receive such services, that the effects of
family preservation services are often not long lasting, and
that determining reduction in negative outcomes, such as
subsequent child maltreatment, is problematic
(Bagdasaryan, 2005; Pecora, 1991; USDHHS, 2001; Wells
& Biegel, 1992).
. Researchers have suggested that a number of elements
of family preservation services appear linked to the success
of services including the client- worker relationship, family
level of participation, and number
FAMILY PRESERVATION AND HOME~BASED
SERVICES 203
of contacts between the family and the worker (Littell &
Schuerman, 2002). Concrete services, such as cloth ing,
furniture, supplies, and housing assistance to families with
economic problems, have been associated with a reduced
risk of subsequent maltreatment (Ryan & Schuerman,
2004).
A review of 27 studies of family preservation pro grams
by Dagenais, Begin, Bouchard, and Fortin (2004) revealed
that family preservation programs focused on specific
target problems, particularly delinquency and chil d
behavior problems, were observed to yield better results
than programs serving a wider range of families
experiencing different problems. For exam ple, types of
family problems, such as child neglect, have been less
amenable to family preservation (Fraser et al., 1997 ).
Parental drug or alcohol addiction poses a particular
challenge to successful outcomes following family
preservation services (Potocky & McDonald, 1996). Also,
more recent research suggests that follow- up with families
through the provision of "aftercare" services is a critical
factor in sustaining positive outcomes and the continued
success of families (Bagdasaryan, 2005).
In 2006, the National Family Preservation Network ,
which supports family preservation research, reported,
"Five comparison group studies ( two published since
2002) demonstrated the effectiveness of high- fidelity
Intensive Family Preservation Services programs." An
evaluation in 2006 by the Washington State Institute for
Public Policy specifically noted that outcomes for intensive
family preservation programs that adhere to the
Homebuilders Model included a substantial de crease in
both out-of-home placements and subsequent maltreatment
reports. Evidence from an experimental study of the
Families First model implemented i n Utah revealed
positive results for families in reducing child behavior
problems and improving parental effective ness, compared
to families who did not receive the service (Lewis, 2005).
Other research challenges include accurately mea suring
risk of placement; matching families to appro priate
services; and utilizing indicators other than placement as
measures of program effectiveness. Addi tionally, as
evidence-based practice techniques are established, these
techniques, including specifying population s for services,
identifying target problems, and high fidelity to a treatment
model, should find their way into family preservation
programs (Jacobs, 2001).
Current Challenges
The renewed focus on family preservation as a preferred
service orientation in public child welfare in the 1980 s was
undermined subsequently by public concern over a
204 FAMILY PRESERvATION AND HOME,BASED SERVICES
small number of cases in which children were harmed.
Since the return to policies that give priority to child safety
over family preservation, however, the number of children
entering out-of-horne placement has risen (see
Administration for Children and Families AFCARS
Reports at http://www.acf.hhs.gov/programs/cb/systems/
afcars/about.htm). Additionally, in 2000, the U.S.
Department of Health and Human Services instituted an
ongoing review process focused on child and family
outcomes and compliance with the Adoption and Safe
Family Act (1997). Although some states met some of the
review standards, no state met all of the established
thresholds for the seven federal standards. One out, come is
specifically related to family preservation, "Children are
safely maintained in their homes whenever possible and
appropriate." Upon initial review, child welfare agencies
nationwide were expected to have a minimum of 90% of
their cases in compliance with this standard and 95% at
subsequent reviews. All states fell short of meeting this
goal during the initial review with reports that only about
one-sixth have met the goal in subsequent reviews (see full
report
http://www.acf.hhs.gov/programs/cb/cwmonitoring/
index.htm). Given this, it is likely that the importance and
usefulness of family preservation services will be revisited
once again.
Future Practice Directions and
Implications for Social Work
Much of what has come to be known in social work as
"family-centered practice" was first embodied in the
family preservation movement. This includes forming a
partnership with the family to assess strengths as well as
needs and jointly developing a comprehensive flexible
treatment plan. These programs have helped broaden the
definition of family by including extended family
members and natural helping networks. Many family
preservation programs now work closely with community
groups, neighborhood, and natural helping networks as a
means of fostering healthy communities. One of the more
recent family-centered models in child welfare
practice-Family Group Decision Making, also referred to
as Family Group Conferencing-makes use of a principle
central to family preservation services, the ability of the
family to make decisions regarding child safety (Burford &
Hudson, 2000; Connolly & McKenzie, 1999). In addition,
the use of concurrent case planning has meant that even
while family preservation services are being delivered,
"concurrent" planning continues for other forms of
permanence for the child and family, either through
kinship care or adoption.
Family preservation programs have reinvigorated the
traditional role of home visiting within the social work
profession, as a model of service delivery, based on the
advantages of providing services to clients in their "natural
environments." The renewed emphasis on home-based
versus agency-based services stems from many sources,
including changes in funding streams and efforts to serve
clients directly in their ecological contexts. For example,
the President's New Freedom Commission on Mental
Health (2003) set forth the need for community-based
services with the goal to make mental health care
consumer and family driven. Building upon the long
tradition of home visiting in social work, social workers in
many practice settings work with clients across the life
span in their homes including: early childhood intervention
programs; school social work; placement prevention and
family reunification programs in child welfare; community
mental health services to children, adults, and their
families; programs for court-involved youth; community
support programs for older adults; adult protective
services; and hospice care.
at
REFERENCES
Bagdasaryan, S. (2005). Evaluating family preservation services:
Reframing the question of effectiveness. Children and Youth
Services Review 27(6), 615-635.
Barth, R. (1991). Adoption preservation services. In E. Tracy, D.
Haapala, ]. Kinney, & P. Pecora (Eds.), Intensive family
preservation services: An instructional sourcebook (pp. 237249).
Cleveland: Mandel School of Applied Social Sci ences, Case
Western Reserve University.
Berg, 1. (1991). Family preservation: A brief therapy workbook.
London: BT Press.
Berry, M. (2005). Overview of family preservation. In G. Mallon &
P. Hess (Eds.), Child welfare for the 21st century: A handbook of
practices, policies, and programs (pp. 319-334). New York:
Columbia University.
Berry, M., Propp,]., & Martens, P. (2007). The use of intensive
family preservation services with adoptive families. Child and
Family Social Work, 12(1),43-53.
Biehal, N. (2005). Working with adolescents at risk of out of home
care: The effectiveness of specialist teams. Children and Youth
Services Review, 27(9), 1045-1059.
Burford, G., & Hudson, ]. (Eds.). (2000). Family group confer-
encing: New directions in community-centered child and family
practice. New York: Aldine de Gruyter.
Cole, E., & Duva,]. (1990). Family Presevation: An orientation for
administrators and practitioners. Washington, DC: Child Welfare
League of America.
Connolly, M., & McKenzie, M. (1999). Effective participatory
practice: Family group conferencing in child protection. New
York: Aldine de Gruyter,
Dagenais, C, Begin, ]., Bouchard, C, & Fortin, D. (2004).
Impact of intensive family support programs: A synthesis of

PRACTICE
maintained a dual focus on both the personal matters of a
client and issues of social justice. Yet there still were
concerns about the level of education required of un-
dergraduate and graduate students of social work and how
to make distinctions between undergraduate education
versus graduate content. Prior to the formation of national
educational standards for social work, only person s
holding a master's degree were considered professional
social workers. Case workers who did not hold this degree
were labeled nonprofessionals. This distinction promoted a
sense of inferiority among members of the latter group,
many of whom performed valuable case work activities for
public and private agencies. This dilemma, along with a
forecasted social worker shortage, prompted the NASW
and CSWE to support the institution of a bachelor degree
in social work and to develop educational content for thi s
degree using a generalist perspective (Brieland, 1995).
CSWE published its first educational standards for
baccalaureate degree programs in 1974. An incon sistency
in how generalist practice was being taught in classrooms
was quickly identified, however. Ripple (1974) reported
that some schools taught generalist practice as a
rnultimethod approach involving the mastery of specific
methods or treatment modalities that could be used in
specific or specialized client settings. Others taught
generalist practice from a more skills oriented perspective,
to produce a "utility worker" (p. 28) who understood the
elements of human behavior, social situations, and
resource acquisition, and had sound communication,
observational, and problemsolving skills that could be
used across multiple settings or problem areas. By the
mid-1980s, and after a second iteration of the CSWE
standards, the profession finally arrived at clearer
consensus about what generalist practice entailed and
where it should be placed in the cu rriculum. This milestone
was authenticated by the first entry on the generalist
perspective in the 18th edition of the Encyclopedia of social
work.
Sheafor and Landon (1987) described the history and
evolution of the generalist perspective. Their entry
included discussion about the generalist framework as a
valid practice orientation and foundation for specializa-
tion, specification of the generic foundation knowledge
that all social workers need, and prerequisite practice
principles upon which generalist and specialist practice
rest. One of the major contributions of this entry is found in
their description of the components of generalist practice.
The first component involved a perspective that assists a
social worker to envision "all possibilities for intervention"
when approaching a practice situation (p. 666). The second
component consisted of a requisite knowledge of four
theoretical
GENERALIST AND ADVANCED GENERALIST
263
approaches to inform generalist practice, including the
systems framework, the structural framework, the
ecological framework, and the social learning frame work.
The third component of generalist practice, the planned
change process, included classical steps of the helping
process: (a) intake and engagement, (b) assessment, (c)
planning and contracting, (d) intervention, (e) monitoring
and evaluation, and (f) termination, as well as a description
of essential activities required to execute the tasks of the
planned change process. The features of the planned
change process represent a classical model of the helping
process that is still taught in classrooms today. Sheafor and
Landon close their entry by stating that the future of the
generalist perspective should include "its refinement into a
solid conceptual framework" addressing the "appropriate
breadth and depth for each level of generalist practice" (p.
668).
Refining the Generalist Framework
Sheafor moved forward with colleagues to refine the
conceptualization of generalist social work practice. Their
work is featured in Milford redefined: A model of initial and
advanced generalist social work (Schatz et a1., 1990), a
qualitative report on the Delphi Study, which involved 42
authors and educators from schools of social work across
the nation. The proposed model that emerged from the
Delphi Study contained three distinct levels of learning: a
generic foundation, content for initial generalist practice,
and advanced generalist practice. The generic foundation
was visioned to support the education and development of
initial generalist education, and eventually, advanced
generalist education, including specializations in practice.
It rested on a liberal arts base, the biological and social
sciences, basic understanding of the
person-in-environment paradigm, basic knowledge of the
profession and its role and sanction in society, basic
communication and helping skills, ethnic or diversity
sensitivity, and basic understanding of problem resolution,
the process of change, and human relationships.
The initial generalist perspective included knowl edge
of sociobehavioral and ecosystems concepts, the
ideologies of democracy, humanism, and empowerment,
methods of social intervention that were "open" or not
highly defined by either theory or precise method, forms
of direct and indirect interventions, a client centered,
problem-focused approach, and research to inform
practice. Initial generalist content also included
knowledge gain in specific competencies. These initial
competencies included being able to engage in interper-
sonal helping, managing the change process, using multi-
level intervention modes with individuals, families,
groups, communities and institutions, being able to
264 GENERALIST AND ADVANCED GENERALIST
PRACTICE
perform varied practice roles (for example, broker,
advocate, mediator, educator, social actionist, and
clinician), being able to assess and examine one's own
practice, and knowing how to function within a social
agency (Schatz, et al., 1990).
Advanced generalist content reflected greater breadth
and depth of social work knowledge, values and the
application of generalist practice methods in both direct
and indirect services. The advanced gener alist was
expected to function more. independently in practice
situations and demonstrate increased skills in indirect
practice, including supervision, administration, social
policy, research and evaluation. Advanced gen eralists were
expected to conduct an eclectic practice and synthesize and
refine knowledge and competencies gained at the generic
and initial generalist levels. This conceptual model also
reflected that specialist practice could occur at either the
initial generalist or advanced generalist level of practice
(Schatz et al., 1990).
The Delphi Study helped to forge a conceptual model
and pedagogical foundation for generalist and advanced
generalist practice at a time when more clarity about the
content of social work knowledge was needed. The results
helped to create a template for social work education that
resembled a continuum of learning. It left room for
specialization at both initial and advanced levels and
seemed to address longstanding needs for a systematic
approach to formal preparation of social workers for
practice in diverse settings. Although the authors of Milford
redefined acknowledge that the model they described did not
seamlessly match the NASW's classification system for
BSW and MSW education and experience at that time, it
was anticipated that a level of agreement between the
education and professional communities over the
definitions of initial generalist and advanced generalist
could be resolved over time.
Generalist practice currently is defined similarly by
authors of widely adopted social work practice texts
(DuBois & Miley, 2005; johnson & Yanca, 2007; Kirst-
Ashman & Hull, 2006; Landon & Feit, 1999; Pilonis, 2007;
Poulin, 2005; Suppes & Wells, 2003; Turner, 2005). The
authors' definitions of general practice, by and large,
converge on the concepts of systems, multip le methods,
problem solving, and partnership with client. The
definitions emphasize the purpose and values of social
work, the various roles or capacities in which social
workers serve, and the use of a planned change process to
address social problems and restore social functioning.
These concepts are similar to those found in Bartlett's
working definition and the "stuff of practice" to which
Gordon (1962) referred to over half a century ago. These
descriptions also align with the
most current definition of generalist practice published by
the Association of Baccalaureate Program Directors (BPD)
(2007). The BPD defines generalist practice as follows:
Generalist social work practitioners work with
individuals, families, groups, communities, and or-
ganizations in a variety of social work and host
settings. Generalist practitioners view clients and
client systems from a strengths perspective in order
to recognize, support, and build upon the innate
capabilities of all human beings. They use a profes-
sional problem solving process to engage, assess,
broker services, advocate, counsel, educate, and or-
ganize with and on behalf of client and client sys-
tems. In addition, generalist practitioners engage in
community and organizational development.
Finally, generalist practitioners evaluate service
outcomes in order to continually improve the
provision and quality of services most appropriate to
client needs. Generalist social work practice is
guided by the NASW Code of Ethics and is
committed to improving the well being of
individuals, families, groups, communities and
organizations and furthering the goals of social
justice.
Debate About the
Advanced Generalist Framework
In 1984, the generalist model became the preferred
framework for baccalaureate social wor k education, and
was deemed analogous to the foundation year of the
master's degree by CSWE (Landon, 1995). The last year of
a master's degree program was reserved for build ing
knowledge and skills in advanced forms of practice. Soon
thereafter, Hernandez, jorgensen, judd, Gould, and Parsons
(1985) described the development of an ad vanced
generalist curriculum designed to prepare social workers as
"social problem specialists." These authors viewed their
curriculum as an answer to the call for a new type o f social
worker, one equipped to respond to the growing
complexities of social problems, as defined in the 1960 s
and 1970s. The authors sought to develop a curriculum that
integrated elements of "a broad range of interventive
techniques across micro and ma cro systems based on the
specific needs of a problem situation" (p. 30). The
curriculum emphasized six professional roles for advanced
generalists-conferee, enabler, broker, mediator, advocate
and guardian-to address needs across five client
systems-individual, family, small group, organization, and
community. This conceptual framework also integrated
concepts of empowerment and social competency, viewing
people as fundamentally healthy and able to meet the
demands of their
 GENERALIST AND ADVANCED GENERALIST PRACTICE
social environments. It viewed social work students as
capable of fulfilling various roles and intervening in a
manner that placed the focus of intervention on the desired
outcome, as opposed to the stated problem (Parsons,
Jorgensen, & Hernandez, 1994). This model attempted to
address the merits of specialist versus gen eralist content at . synonymous with that of an advanced generalist. First,
the graduate level and was an exem plar of how to
configure advanced generalist content during the last year
of graduate education.
Gibbs, Locke, and Lohman (1990) attempted to
address the debate about advanced generalist practice by
reframing baccalaureate and master's educational content
as a continuum of learning, where workers take on
progressively challenging roles and content through the
last year of graduate education. Similar to Hernandez et al.
(1985), these authors agreed that social workers needed to
be equipped for situations for which insufficient
knowledge existed. They argued that a curriculum that
promotes generalist practice at all level s supports work in
traditionally unserved areas, such as rural and small town
communities and communities that have limited
resources. The authors argued that the depth and breadth
of advanced social work practice allowed the practitioner
greater latitude to address such conditions and also
equipped them to engage in "higher level organizational
positions ... and independent practice" (p. 236).
The conceptual models presented by Hernandez et al.
(1985), Parsons et al. (1994), and Gibbs et al. (1990) were depth, breadth, and specificity, and support the program's
intended to respond to increasingly com plex practice
settings and practice situations where access to resources
and specialists was limited. They also attempted to
address how advanced forms of social work practice could
be conducted without resorting to specialties or tracks that
encourage narrow theoretical perspectives about personal
and social problems. These models provided a
counterargument for debates in the profession about the
merits of preparing social workers for generalist versus
specialist practice. Brieland and Korr (2000 ) programs (serving 300 or more MSW students) featured
characterized these debates as representa tive of the "sharp
division" between parties that viewed specialization "as
inevitable and desirable," and others who were concerned
about fragmentation of services and "the need to bring institutional, organization, and community levels, pol icy
fragmented resources together to meet the needs ... of the
whole person" (p. 130).
Maguire (2002) has proposed a contemporary
approach to advanced clinical practice that shares many of
the principles of advanced generalist practice. Similar to
Hernandez et al., Gibbs et al., and Parsons et al., he
believes that it is not enough for an advanced practitioner
to use just a basic generalist approach to clients. Nor is it
suitable to view every case through the lens of a narrowly
defined theoretical orientation.
J
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l
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265
Rather, it is both logical and appropriate for an advanced
practitioner to maintain a generalist, systemsoriented
perspective in order to adequately respond to complex
practice situations. Maguire states that the viewpoint of a
highly skilled clinical social worker is
they share the same systems-oriented base. They apply
"higher levels of knowledge, skills and expertise," re-
cognize the effects of the "interacting social environ-
ment," employ strategies that build from "broad to
specific methods," utilize "rigorous practice research as a
basis for practice," and use "a variety of major, vali dated
theories and subsequent inter ventionist methods drawn
from commonly accepted human behavioral per spectives"
(pp. 36-37). Maguire encourages clinical social workers
to think like an advanced generalist because "no single
theory adequately explains human behavior except those
that rely upon a broad systemic orientation" (p. 40). He
provides a convincing argument that integrating a
systemic, generalist perspective with appropriate clinical
strategies is a form of ad vanced generalist practice that
more fully equips clinical social work to address diverse
forms of human need in increasingly complex
environments.
Currently, CSWE (2003) does not specify the con tent
of advanced curriculum. It only states that ad vanced
content should "build from the foundation ... in greater
conception of advanced practice" (p. 36). This policy has
its advantages and disadvantages. It is advantageous in that
it has given programs leverage to develop conceptual
frameworks for teaching advanced conte nt that responds to
regional need and postmodernist perspectives. In the
2003-2004 academic year, 25 of the 144 master' s degree
programs accredited by CSWE declared that their
"primary" concentration was advanced generalist (2004 ).
A cursory visit to the websites of programs with the largest
advanced generalist content in transcultural perspectives,
practice designed to address regional needs, practice with a
range of diverse and vulnerable populations , leadership at
development and analysis, and multilevel practice. The
Council's stance on advanced content curriculum is
disadvantageous, though, in that the development of a
more unified conceptualization of advanced generalist
practice had been stunted; and has not expanded much
beyond the integrative models proposed in the early 1990s .
Landon (1995) acknowledged that the generalist
perspective was "embedded in the profession, both in
practice and education," but she warned that "the per-
ception that generalist programming is for bachelor's
266 GENERALIST AND ADVANCED GENERALIST PRACTICE
level education only must be put to rest." She urged the
profession to explore how the generalist perspective could be
integrated further into advanced generalist content, by
principally exploring the various levels and competencies of
generalist practice (p. 1106).
No substantial discourse about a more unified con-
ceptualization of advanced generalist practice has taken place
since Landon published her entry on generalist and advanced
generalist practice in 1995. A recent review of Social Work
Abstracts revealed no articles that specifically focused on
refined conceptualizations of the advanced generalist
perspective, although a number of articles do discuss
implications for advanced generalist practice in schools,
groups, health care, rural settings, and with older adults. The
absence of a visible and contemporary discussion about
advanced generalist practice signals that current discussions
may be restricted to programs that offer advanced generalist
content, and that these discussions are not being shared in the
literature. Nevertheless, Landon's challenge to study the
differences between levels and competencies in generalist
practice is being addressed at present through current debates
about EBP.
The EBP Movement
The term evidence-based practice (EBP) entered the national
discourse of social work practice and social work education
almost one decade ago and has implications for social work
practice and how to prepare students for generalist practice
and advanced generalist practice. These implications are
primarily related to the value orientations of social workers,
the identification and implementation of best practices in the
field, and measuring the effects and outcomes of
interventions. Gibbs (2003) states using EBP requires a
practitioner to take three essential elements into consideration,
the practitioner's individual expertise, the client's values and
expectations about the intervention, and the best external
evidence available about a condition or situation. EBP is
considered both a philosophy and a process (Gambrill, 2005).
The philosophy ofEBP in social work calls into question the
evidentiary nature of social work interventions, using a
process of critical appraisal of current research about a given
intervention. Its process involves specific steps a practitioner
should take to evaluate the efficacy and effectiveness of an
intervention before using it in a client situation. The EBP
process includes five steps. First, a practitioner must
formulate an answerable question related to the client
situation at hand. Second, the practitioner must engage in an
efficient strategy for locating evidence that will help answer
the questions posed. The "hierarchy" of credible sources of
evidence includes (in descending order) randomized
controlled trials (RCTs), systematic reviews and meta
analyses of RCTs, well-controlled quasi experimental studies,
pretest posttest studies, case studies, observational studies, and
descriptive reports and qualitative studies. Third, the
practitioner is expected to conduct a critical appraisal of the
evidence for its validity, objectivity, effect size, and
usefulness. Fourth, the practitioner must determine if the
evidence can be applied to the client situation, and apprise the
client of the findings, taking into consideration the client's
values and preferences in making a practice decision. Finally,
the practitioners must evaluate the "effectiveness and
efficiency" of this process, as a means of improving it
(Gambrill, 2005; Rubin & Parrish, 2007). The benefits of
using an EBP approach are threefold. First, it helps the
practitioner determine the outcomes, as well as the benefits
and risks associated with an intervention. Second, EBP helps
the practitioner keep abreast about best practices in the field.
Third, it encourages ethical practice. The philosophy and
process of EBP is not restricted to micro-level interventions
with individuals; it is also applicable to mezzo and macro
practice situations (Howard, McMillen, & Pollio, 2003).
Gibbs (2003) has also demonstrated how EBP can be used in
social work classrooms to support adherence to the CSWE
educational policy and accreditation standards for diversity,
and promote the use of a strengths-based orientation in
practice.
EBP currently is being embraced by segments of the social
work practice and social work education communities for
several reasons. First, it emphasizes the use of scientific
evidence to guide decision making in practice. Second, it
encourages rigorous, critical thinking, and inquiry about
practice interventions. Third, it addresses current demands for
accountability, benchmarks, and outcomes for social work
practice and education. Fourth, it holds promise for enhancing
the credibility of the profession. Fifth, EBP supports the
ethical standards of research and evaluation in the Code of
Ethics (Gambrill, 2003; Howard et al., 2003; NASW, 1999).
EBP is not without its critics. Gibbs and Gambrill (2002)
identified 27 objections to EBP. They propose that these
objections are based on ignorance about EBP or one of a series
of arguments either appealing to tradition, an ad hominem
basis (appealing to personal considerations rather than to logic
or reason), confusion and disagreement about educational
practices, ethical grounds, and philosophy. The authors
provide cogent and persuasive counterarguments to each of
the 27 objections, concluding that they "have not yet heard an
objection to EBP based on concerns about clients" (p. 471).
These authors' counterarguments are not intended to quell
criticisms of EBP, as much as to demonstrate what EBP has to
offer

the profession. Gibbs and Gambrill state that "criticism is
essential to the growth of knowledge" (p. 458). Criti cism,
objections, and counterargument to objecti ons can lead to
insights that can feasibly reduce barriers to adopt ing EBP
principles, address skepticism about the rigorous
evidentiary standards ofEBP, enhance the way in which
EBP is taught, and identify other forms of critical inquiry
that can be brought to bear in making well- informed
decisions about the effects of interventions by generalist
and advanced generalist practitioners. EBP is a response to
three essential questions posed by the Campbell Col-
laboration that should concern social work (Ameri can
Institutes for Research, 2007): What helps? What harms?
Based on what evidence? Incorporating the principles of EBP
into generalist arid advanced generalist practice
curriculums could help to strengthen this content and
produce new models for addressin g the complexities and
ambiguities of modem day practice settings, using a
continuum of multilevel, multimethod approaches.
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-VIRGINIA RONDERO HERNANDEZ
GENETICS
ABSTRACT: The recent explosion of genetic know-
ledge that was a product of the Human Genome
Project has extraordinary implications for social
workers and their client population. It is imperative
that social workers recognize how vital their role is in
helping clients come to terms with being at risk for a
genetic condition or facing the uncertainty of a genetic
diagnosis in the family. Understanding the
psychosocial and ethical implications of genetic
testing is important for all social workers, no matter
where they are practicing. Social workers must take
an active part in ensuring that clients are protected
against genetic discrimination and learn more about
basic genetics and genetic resources.
KEY WORDS: genetics; genetic counseling; genetic
testing; human genome project
Background
The Human Genome Project began in 1990 when the National
Institutes of Health and the Department of Energy and their
international partners joined forces to decipher the massive
amount of information contained in the human genome, which
includes the entire DNA necessary to build a human being.
The Human Genome Project had as its primary goal the
sequencing of the human genome. Ahead of schedule, the
Human Genome Project was completed in 2003 (Collins,
2003).
With the genome now sequenced, scientists are beginning to
study the structure and function of the human genome and the
activity of genes, for example, how they can be turned on or
off in different types of cells and in response to different
stimuli. One interesting finding of the Human Genome Project
is that all individuals are 99.9% the same with respect to their
DNA sequence (Venter et a1., 2001).
Also, with the completion of the human genome sequence,
it has been found that every disease has a genetic component.
As predictive genetic testing becomes available for common
diseases such as cancer and diabetes, it is imperative that
social workers begin incorporating genetic thinking and
genetic principles in their practices.
Emerging advances in the science of genetics (the study of
single genes and their effects) and genomics (the study of the
functions and interaction of all the genes in the human body)
identify not only thousands of rare disorders but also define
genetic components of common diseases such as Alzheimer's,
cancer, mental illness, diabetes, heart disease, and autism. It is
thought that all diseases, with the possible exception of
trauma, are a result of the interaction of one's genes and the
environment (Guttmacher & Collins, 2002).
Genes are pieces of DNA, part of a code that makes us who
we are. Each human cell contains approximately
20,000-30,000 genes. The human genome, which is the total
genetic material within a cell, is packaged into larger units
known as chromosomes. Human cells contain two sets of
chromosomes, one set inherited from each parent. Each cell
contains 23 pairs of chromosomes, totaling 46 chromosomes.
The 23rd pair consists of the sex chromosomes X and Y.
Females have two X chromosomes, and males have an X and a
Y chromosome. Each chromosome contains thousands of
genes that control the body's development, growth, and
chemical reactions. In addition to determining such features as
eye and hair color, genes can influence the development of
diseases and the transmission of diseases from parent to child
(Genetic Alliance, 2006).
There are three main types of genetic disorders: single
gene disorders, which can be dominant (e.g., Huntington
disease) or recessive (e.g., sickle cell disease); multifactorial
disorders, which involve the interaction of many genes or the
combination of environmental and genetic factors (e.g., some
cancers and heart disease); and chromosomal disorders (e.g.,
Down syndrome), which result from an excess or deficiency
or rearrangement of chromosomes within a package of genes.
Differences in the sequence of DNA among individuals
are known as genetic variation. Understanding

the clinical significance of genetic variation is a com-
plicated process. However, new technologies are lead ing
to faster and more accurate detection of genetic variants.
Examining how a particular gene is spelled in an individual
can lead to finer diagnosis and more appropriate treatment.
The National Human Genome Research Instit ute (NHGRI)
supports the dissemination of genome information to the
public and health professionals. Pharmacogenomics is a
recent development of tailoring of drugs for patients on an
individual basis. Although individual differences in
response to drugs can result from effects of age, disease, or
drug interactions, genetic factors are being found to influ-
ence both the efficacy of a drug and possible adverse
reactions (Weinshilboum, 2003).
GENETIC TESTING AND SCREENING Genetic testing is
becoming an integral part of health care. These tests can
often diagnose genetic conditions, predict the risk of
diseases in the future, guide treatment decisions, and
influence reproductive decisions.
Genetic research has enabled the use of genetic tests for
genes associated with a disease or the risk of a disease.
Genetic testing involves the examination of an individual's
DNA found in blood or other tissues for an abnormality
linked to a disease or condition. If a risk is identified by test
results, that knowledge may lead to early intervention and
prevention of the disease. In some cases, it can alert an
individual to personal risks or risks to offspring. However,
often the availability of the genetic test is not followed by
developed treatments.
Genetic tests analyze chromosomes, genes, or gene
products such as proteins and enzymes to detect a var iation
related to a genetic disorder. They include the following
types:
1. Diagnostic Testing: Confirms or rules out a known or
suspected genetic disorder. One example of the use of
diagnostic testing is its use in diagnosis of cystic fibrosis
in a child who is showing some symptoms of that
pulmonary genetic disease.
2. Prenatal Testing: Determines whether or not a fetus is
affected by a genetic condition when pregnancy is at
increased risk because of maternal age or family
history. An example of prenatal testing because of
advanced maternal age is for Down syndrome.
Prenatal testing may be done when there is a family
history of carriers of the TaySachs gene or certain
forms of dwarfism.
3. Predictive or Presymptomatic Testing: Identifies
individuals at risk of getting a disease prior to the onset
of symptoms. Can identify mutations (genetic changes)
that increase a person's risk of
GENITICS 269
developing genetic conditions such as certain types
of cancer. However, although a particular gene
combination may be identified with cer tainty, these
tests cannot predict whether or not the disorder will
ever be manifested, with the possible exception of
identifying a late-onset condition such as Huntington
disease.
4. Newborn Screening: Detects disorders that need
immediate intervention such as PKU or phenylke-
tonuria. Affected infants lack a critical enzyme that
helps them metabolize phenylalanine, an amino acid
contained in food. Without that enzyme, the baby
becomes severely mentally retarded. With the proper
diet, the child develops normally. Today, PKU testing is
considered a model procedure for preventive health.
5. Carrier Screening: Detects healthy carriers of recessive
disorders such as sickle cell anemia, cystic fibrosis, and
Tay-Sachs disease. This type of testing is often offered
to persons who have a family history of a genetic
disorder and to people in ethnic populations with an
increased risk of certain genetic conditions.
6. Pre implantation Genetic Testing: Diagnoses embryos to
determine whether they have an altered gene for a
particular genetic disorder before implanting them in the
uterus.
GENETIC COUNSELING Genetic counseling is a process
of giving information about genetic risks, testing, and
diagnosis. Genetic counselors, usually with at least 2
years of graduate training, discuss avail able options
with the individual or couple, providing counseling
services and referrals to educational and support
services (National Society of Genetic Counselors).
They take a comprehensive family history and analyze
inheritance patterns, calculate risks of recurrence, and
provide information about genetic testing. They h elp
patients understand the significance of genetic disorders in
the context of personal, cultural, and famil ial situations
and provide supportive counseling services. In addition,
they serve as a central resource of information about
genetic disorders for other healthcare professionals,
families, and the general public.
Indications for referrals to genetic counselors include
advanced maternal age, a family history of a g enetic
disorder, and a suspected diagnosis of a genetic condition.
CHALLENGES OF GENETIC TESTING Along with the
powerful new tools of genomics, there has been re-
newed emphasis on the ethical, legal, and social impli-
cations (ELSI) of this new science and its recent
270 GENETICS

developments in research and genetic testing. A program coverage for treatment. The third involves access.
known as the ELSI program was established at the Members of minority groups and impoverished people
National Institutes of Health and continues to playa central may not have access to genetic testing.
role in encouraging society to be sensitive to the social, Genetic testing of children is a major ethical issue.
legal, and ethical issues of knowledge gained from Minors often do not have the opportunity to make
genomic research and testing (Andrews, Mehlman, & decisions about whether or not to be tested. Sometimes
Rothstein, 2002a). Questions need to be asked about how adults want their children tested for all the wrong reasons.
genetic information should be interpreted and used. Who In 1997, the advisory committee of the N ational Human
should have access to it? How can individuals be protected Genome Research Institute stated that genetic testing of
from genetic discrimination based on the misuse of their children for adult onset disease should not be undertaken
genetic information? How will the study of genomics unless the child would gain a direct medical benefit that
affect society's ideas about race and ethnicity? would be lost if the child waited until adulthood to have the
Attention to ethical issues evoked by genetic testing test.
has not kept pace with biotechnological developments. Currently, the only protection from genetic discri-
Advantages of genetic testing, such as facilitating choices mination based on genetic test results is a patchwork' of
about family planning, preventive life-style measures, or state and federal regulations. The passage of the Health
increased surveillance, must be balanced against the risk Insurance Portability and Accountability Act (HIPAA) in
of genetic discrimination in employment, life and health 1996 put some restrictions on predictive genetic test results
insurance, adoption, and society in general. being considered a preexisting condition. However, HIPAA
Among the many ethical issues brought on by does not apply to those individuals not covered by an
advancements of genetic testing are the following employer's policy. HIPAA would not prevent an entire
(NASW, 2003a, 2003b): group from being denied coverage or being charged higher
1. Equitable access to genetic services such as testing rates due to the genetic condition of one or more of its
and financial coverage for testing and treatment members. Only the federal government is prohibited from
2. Privacy and confidentiality of individual genetic using genetic information for employment hiring and firing.
information, particularly in relation to insurance and Scientific studies reveal that many potential subjects
employment for genetic research are fearful that their genetic
3. Self-determination, including allowing an indivi dual information could be used against them and
to select or refuse genetic testing and treatment . therefore are not participating in research (Andrews,
4. The right to know or to refuse to know genetic Mehlman, & Rothstein, 2002b). Others who may benefit
information from genetic testing are not taking the tests for fear that
5. Informed consent in making decisions with regard to their genetic information could be used against them and
genetic testing and research, based on a clear their families. If they are found to be at risk for a genetic
understanding of the risks and benefits disease, they are afraid that they will lose their job or their
6. Voluntary genetic testing and treatment insurance. Some individuals pay for genetic testing when
7. Appropriateauthority for genetic decision making on possible in order to protect personal genetic information
behalf of children and impaired adults and avoid inclusion of that information in their medical
8. Protection of the rights of those living with a record.
genetically determined condition In order to be able to make an informed decision to
9. Definition of what is "normal," for example, for the have a genetic test, an individual must have access to
deaf and dwarf communities and their right to choose current, accurate information. This information includes
a child like themselves protection of confidentiality under federal and state law;
strengths and limitations of the genetic test; availability of
prevention, treatment, and cure; and risks of
stigmatization, discrimination, and psychological stress
POLICY AND LEGAL ISSUES At least three possibili-
(NASW, 2006). Pretest and posttest genetic counseling of
ties for genetic discrimination arise regarding all genet ic
individuals and families regarding the medical
testing: The first is societal. Individuals may be
significance of test results is best done by the health-care
stigmatized or labeled if they are found to be susceptible to
professional such as the genetic counselor. However, there
a disease like cancer or if they have a potential disability.
is currently a potentially harmful trend for individuals to
A second possibility for genetic discrimination is
order genetic tests over the telephone or Internet, using
financial. A person may be turned down by an employer
genetic home testing kits. Risks
because he or she may cost the company too much money
in insurance costs, or be denied insurance

include inappropriate test utilization, misinterpretation of
test results, and no follow-up counseling.
Another issue regarding testing of children is whether
or not children should be tested before they are adopted.
The results of the test may influence the perspective
adoptive parents, but it also may label a child
unnecessarily. However, it is important that adop tive
parents have as much medical history as possible about the
birth parents.
Research is needed by social workers and other mental
health professionals on the psychosocial, cultur al,
economic, and ethical implications of genetics on
individuals, families, and society. How do people react to
learning of their genetic risk status? How do they make
decisions about genetic testing and research participation?
How does genetic information affect the diverse cultural
and ethnic groups within our society? Social workers are
well suited to observe the impact of genetic information on
individuals, families, and society, in addition to helping
lessen the stress and support for informed decision making.
THE ROLES OF SOCIAL WORKERS Social workers need to
recognize how vital they are to helping clients come to
terms with genetic diagnoses and to become more
sensitive to clients' genetic concerns about them selves
and their families. For over 40 years, the profession of
social work has recognized the importance of genetics in
relation to social work practice and education (Schild,
1966; Schultz, 1966; Weiss, 1976). Now social workers
play an increasingly prominent role in addressing the
changing psychosocial needs of individuals and families
affected by genetic disorders or with genetic concerns.
Direct Practice
Social workers need to start incorporating genetic
information in family histories; know how and when to
make referrals to genetic counselors; and understand the
psychological, ethical, and social implications of being at
risk for a genetic condition or of having an affected family
member. This is true wherever they practice. Individuals
are now confronting new experiences such as learning that
one carries a gene that increases the likelihood of illness
decades hence or how to cope during pregnancy with the
prenatal diagnosis of a serious defect in one's unborn child.
Increasingly, clients will seek the help of social workers in
making genetic decisions and choices that may affect
themselves and their families. Clients who are attempting
to adjust to a genetic diagnosis, deciding whether or not to
take genetic tests, or are feeling damaged by being labeled
a carrier of altered genes or passing on a genetic condition
to offspring will often need the
GENETICS 271
help of a social worker. Social workers can identify people
who are at risk and provide crisis intervention and
supportive individual, couple, or family counseling, in
addition to providing referrals to support networks
(Weissman, 2004).
Social workers should understand how social, beha-
vioral, cultural, economic, and environmental factors
interact with genetic factors to influence health. A family
history is essential in determining a genetic diag nosis and
in predicting how family members may be affected in the
future. Social workers can become more knowledgeable
about indications for genetic testing and referrals. This
includes work in the adoption process, placing the best
interests of the child first. Before a child is placed for
adoption, any known medical information should be given
to the potential adoptive couple on the genetic risks of the
child. Then the adoptive family is better prepared to decide
whether they can face stigmatization associated with a
genetic history, such as bipolar illness, mental retardation,
or physical deformities. In addition, genetic background
information may be helpful to the child in later years.
Social work intervention facilitates the identification of
persons who need medical referral or genetic counsel ing
services and should include initiating referrals. Genetic
resources have increased rapidly during the past decade,
and social workers need to know where to refer their
clients who have genetic conditions or concerns about
being at risk for one. They may refer their clients to
medical geneticists or genetic counselors (Lapham, 2004 ).
Medical geneticists are MDs, PhDs, or MD- PhDs with
specialized training in diagnosis of genetic disorders, and
genetic counselors, with a master's degree in genetic
counseling and board certified, provide evaluations and
counseling related to genetic issues.
IIi. addition to being skilled in finding resources for
their clients, social workers are well suited to work as part
of a multidisciplinary team in sharing its expertise with
individuals and families with genetic disorders. All of the
team members must be attuned to the emo tional and social
needs of individuals with genetic conditions. Social
workers can establish bridges between their clients and
health professionals such as genetic counselors and
primary care physicians. Social workers can also create lay
advocacy groups, help with bereavement issues, and
explore with clients the emotional effects the clients and
family members may experience as a result of receiving
genetic information.
Advocacy and Policy Intervention
The ethical principles and standards of the social work
profession are relevant to the integration of genetics and
social work practice. It is important for social
272 GENETICS
workers to protect the rights of their clients to make decisions
with regard to genetic testing and participation in genetic
research based on a clear understanding of risks and benefits.
Genetic testing and treatment must be done on a voluntary
basis, and social workers can make certain that their clients
exercise their rights in knowing or not knowing their genetic
information. They also can see to it that there is appropriate
authority for genetic decision making on behalf of children
and impaired adults. The rights of clients now living with
genetically determined conditions that are threatened by new
reproductive procedures need to be protected by social
workers.
How genetic information can be beneficial and how it can
be misused determines the potential role of the social worker
in understanding and advocating for legislation prohibiting
genetic discrimination and preventing inappropriate
disclosure of genetic information. Social workers can take an
active part in ensuring that clients are protected against genetic
discrimination in areas such as health and life insurance,
employment, education, and adoption by advocating for state
and federal legislation that opposes genetic discrimination.
Social workers need to be active participants in the process of
developing public policy to define access and funding for
genetic services and to safeguard the privacy and
confidentiality of genetic information (Smith, 2004).
Cultural Issues
In order to be most effective in their work with genetically
affected or concerned clients, social workers must identify
their own values and beliefs related to human reproduction,
medical interventions, and the value of life with major
disabilities. Clients may come from a wide variety of religious
and cultural backgrounds that differ from those of the social
worker. Self-awareness is particularly important in helping a
client with the decision-making process in genetics.
Clients' use of genetic information and services may
depend on their traditions, values, cultural background,
religious and health beliefs, and economic situations. The
social worker should be aware of these cultural and social
background factors in working with individuals and families
in the genetic decision-making process and in assessing with
them the results and implications of genetic testing (NASW,
2001).
Rapid advances in the science of genetics and genomics
have made it imperative that social workers help their clients
understand and cope with the impact of genetic information on
themselves and their families. In the past, genetics has dealt
with rare, single gene disorders. Now more common diseases,
including heart
disease, diabetes, cancer, and mental and behavioral disorders
are being found to have a genetic component. With predictive
genetic testing becoming available for these common
diseases, an increasing number of healthy individuals will
seek counseling. Commercial marketing of genetic tests via
the Internet might mean the lack of face-to-face genetic
counseling. There is also the risk of creating designer gene
children, seeking perfection and labeling those with genetic
disabilities. Although potential benefits are derived from new
genetic technology, such as adapting medicines to individual
needs, social workers need to protect the medical privacy of
clients who have genetic predispositions to certain illnesses
and support the uniqueness of the individual, regardless of
one's genetic makeup.
REFERENCES
Andrews, L. B., Mehlman, M. ]., & Rothstein, M. A. (2002a).
Genetics: Ethics, law and policy (pp. 79-81). St. Paul, MN:
West Group.
Andrews, L. B., Mehlman, M. j., & Rothstein, M. A. (2002b).
Genetics: Ethics, law and policy (pp. 84-144). St. Paul, MN:
West Group.
Collins, F. S. (2003). A brief primer on genetic testing: World
Economic Forum. National Institutes of Health, National Genome
Research Institute. Retrieved March 21, 2004, from http://www
.genome.gov /10506784
Genetic Alliance. (2006). Understanding genetics: A guide for
patients and health professionals. Retrieved from http://
www.geneticalllancc.org
Guttmacher, A., & Collins, F. S. (2002). Genomic medicine:
A primer. New England Joumal of Medicine, 347,1512-1513.
Lapham, V. (2004). Resources and referrals in genetics for social
work practitioners. In Intersections in Practice:
NASW Specialty Practice Sections Annual Bulletin, volume 3.
NASW Press.
National Association of Social Workers (NASW). (200l).
NASW standards for cultural competence in social work practice.
Washington, DC: NASW Press.
National Association of Social Workers (NASW). (2003a).
NASW standards for integrating genetics in social work practice.
Washington, DC: NASW Press.
National Association of Social Workers (NASW). (2003b).
Genetics. In Social work speaks: National Association of Social
Workers policy statements, 2003-2006 (orh ed.). Washington, DC:
NASW Press.
National Association of Social Workers (2006). Social Work Speaks.
Washington, DC: NASW Press.
National Society of Genetic Counselors. Retrieved from http://www
.nsgc.org
Schild, S. (1966). The challenging opportunity for social workers in
genetics. Social Work, II, 22-28.
Schultz, A. (1966). The impact of genetic disorders. Social Work, II,
29-34.
Smith, M.]. W. (October 2004). Genetics and genetic testing:
Policy implications. Intersections in practice. Washington,
DC:NASW.
 GESTALT THERAPY 273

Venter, J. C; Adams, M. D., Myers, E. W., et al. (200l). The sequence effectiveness and potential for Gestalt therapy's status as an
of the human genome. Science, 291, 1304-1351. evidence-based practice is framed in relation to recent
Weinshilboum, R. (2003). Inheritance and drug response. overviews of empirical research and to what is needed in the
Genomic medicine (eds. Guttmacher, A., Collins, F.e, Drazen, future for further research. While the current literature in
J.M.), 41-50. social work does not reflect a strong emphasis on Gestalt, we
Weiss, J. O. (1976). Social work and genetic counseling. Social Work
emphasize some of the philosophical and ethical
in Health Care, 2, 5-12.
compatibilities between these approaches.
Weissman, N. (2004). The psychological impact of genetic testing. In
Intersections in Practice: NASW Specialty Practice Sections Annual
Bulletin, volume 3: NASW Press.
KEY WORDS: Gestalt therapy; psychotherapy; organ ism;
FURTHER READING boundary; contact; environment; social work, rele vance
Genetic Alliance. (2006) Understanding Genetics: A guide for
to; field theory
patients and health professionals. http://www.genetical liance.org

Definition
SUGGESTED LINKS National Human Genome Gestalt therapy is a process psychotherapy aimed at en-
Research Institute. www.genome.gov
hancing a person's contact, or state of being fully present and
National Library of Medicine's Genetics Home Reference. www.
aware, with oneself and the environment. Through awareness
ghr.nlm.nih.gov
and spontaneous and genuine dialogue between client and
National Coalition of Health Professional Education in Genetics
(NCHPEG). social worker, obstacles to contact are explored in the present
www.nchpeg.org therapeutic relationship.
National Society of Genetic Counselors.
www.nsgc.org
History and Current Development
Howard University Medical Center, National Human Genome
Center.
Gestalt therapy is celebrating over 50 years of existence,
www.genomecenter.howard.edu/intro.htm marking the publication of its first comprehensive text,
American College of Medical Genetics. Gestalt Therapy: Excitement and Growth in the Human
www.acmg.net Personality (Perls, Hefferline, & Goodman, 1951/1994), and
March of Dimes. the birth of the first professional training group, the New York
www.modimes.org Institute for Gestalt Therapy in 1952, founded by Fritz and
Gene Tests. Laura Perls.
www.genetests.org The origins of Gestalt are in psychoanalysis, especially
Office of Rare Diseases, NIH. Wilhelm Reich's body work and work on resistance and Otto
www.rarediseases.info . nih.gov
Rank's emphasis on the "here and now." Other sources include
Consumer organizations include:
the existentialist philosophy of Martin Buber and Paul Tillich,
Genetic Alliance.
www.geneticalliance.org the experimental psychology of Franz Brentano (the whole is
National Organization for Rare Disorders (NORD). www. greater than the sum of its parts), and the organismic theory of
rarediseases. org Kurt Goldstein (see, e.g., Brentano, 1874/1999; Goldstein,
National Alliance for the Mentally Ill (NAMI). 1939/1999).
www.nami.org As of 2007, there are 177 Gestalt institutes and training
organizations worldwide, with 25 in the United States (see
www.gestalttheory.net/info/gpass.html). There are 4,000
-JOAN O. WEISS subscribers to The International Gestalt Journal (J. Wysong,
Personal' communication, March 20, 2007), and the Gestalt
Network lists a broad range of practitioners across disciplines
GERONTOLOGY. See Aging: Overview. in the United States (see www.gestalttherapy.net/welcom
e/index.html). There are three major English-language
journals-The International Gestalt Journal, Gestalt Review,
GESTAL T THERAPY and the British Gestalt Journal. Listings of events and
programs, publications, and audiovisuals are updated on the
ABSTRACT: The entry defines Gestalt therapy, includ ing
Gestalt Therapy Page Web Site (see
brief history, major influences, contributors, and current www.gestalt.org/contents. html).
status of Gestalt therapy in terms of member ships and
journals. Key concepts are outlined, and the
274 GESfALT THERAPY
Key Concepts
The concepts of Gestalt issue from the core idea that the
organism continually strives to attain a balance that is
disturbed by needs and regained by gratifying those needs.
Gestalt therapy involves a process of heightened
awareness so that a person's natural functioning can
reinstate itself. Gestalt aims to enhance personal growth
through its persistent focus on the present, its expansion of
self-awareness, and its delegation of responsibility for who
one is and what one does. Key concepts include
1. Organism/Environment Field. A field perspective
focuses on what is internal and what is external.
Thinking centered on the contact boundary sees both the
self's needs or experiences and the environment's
demands. The self is conceived as midway between the
organism and the environment.
2. Selfas Process, Function, and Boundary Event. The self
is the capacity of the organism to make contact with its
environment-spontaneously, deliberately, and
creatively. The function of the self is to contact the
environment (called the "how" of human nature).
3. Experience of Contact and Withdrawal from Contact.
The self is always involved in a process of contact
with and withdrawal from the environment. This
process unfolds over time and is innately healthy.
4. Impediments to Healthy Contact. These include un-
finished business, incomplete gestalts, boundary
disturbances, immature life scripts, irrational/invalid
beliefs, and self-fragmentation.
5. Becoming Aware of Impediments. This occurs within the
client-therapist relation and affords the opportunity for
movement toward intuitively responsible functioning.
Effectiveness and Potential for
Evidence-Based Status
Several recent reviews discuss research related to Gestalt
outcomes, process, and techniques.
A meta-analysis of primary studies by the Centre for
Clinical Effectiveness (2001) compared Gestalt therapy to
no treatment, and another treatment approach identified
seven studies in the period 1990-2001. Assessing
outcomes such as emotional arousal, depression, anxiety,
symptom distress, and body image, six of the seven studies
reported that Gestalt therapy resulted in greater increased
positive outcomes when measured against comparators.
One study reported no significant differences between
approaches. Strumpfel's (2004) recent overview of
empirical research on Gestalt therapy summarized the
findings of over 60 process and clinical evaluation studies,
the latter involving data on
approximately 1500 Gestalt clients. Gestalt therapy was
generally found to be as effective as comparators, and
despite the fact that it is not symptom oriented, as is
cognitive-behavioral therapy, a number of samples
revealed the two therapies to be equally effective.
Gestalt therapy, given its global application as a change
process, affecting thought, emotion, and experiencing (a
person's total "being") through physical and verbal
interventions, does not lend itself easily to meas urement
given its multitude of interacting dependent variables and
diversity of application. However, work by Lesonsky,
Kaplan, and Kaplan (1986) constitutes an exemplary
attempt to define, operationalize, and test selected Gestalt
therapy formulations of the change process. The
researchers note the challenge of systematic observation
and study of processes, as opposed to discrete events,
since, within a Gestalt framework, functioning is
appreciated as "ongoing, constantly changing, and
holistically organized" (Lesonsky et al., 1986, p. 48).
Efforts such as these provide a basis for establishing
empirical support by studying specific components of the
process or selected techniques.
Relation to Social Work Practice
A review of Social Work Abstracts for a 20 year period
from 1973 through 1993 results in the identification of 10
articles related to Gestalt therapy in professional social
work journals. Early work includes that of Paul (1973),
who provides an overview of Gestalt theory and techniques
related to social work practice, emphasizing client
responsibility and development of self-support, and Hale
(1978), who provides an excellent review of useful Gestalt
concepts and techniques. Scanlon (1980) provides a very
good overview of six basic Gestalt ideas relevant to
insight-oriented social work. From 1994 to 2006,
according to Social Work Abstracts, no articles have been
published related to Gestalt therapy; how ever, four articles
that were cited related to Emotion Focused Therapy (EFT),
which helps individuals deal with unfinished business from
a Gestalt perspective.
The core values and basic concepts of social work and
Gestalt therapy significantly overlap. Both models reflect
an ability to be adapted to systems of various sizes, and
both include concepts that cut across work with
individuals, couples, families, groups, organizations, and
even communities. Gestalt's emphasis on growth and
maturation finds a parallel in social work's emphasis on
ecological or life development across systems (Germain &
Gitterman, 1980). Gestalt's goal of movement from
other/environment support to selfsupport is mirrored in the
classic work of Perlman (1951) who emphasized social
work's mission to foster

independence and concern that workers do not take over
what clients can do for themselves.
A long-held concept of social work is working with the
person in their environment. Parlett (1997), dis cussing
Gestalt and field theory, argues that lives and collective
systems intertwine and must be considered as a unified
field. The reality of the environment and its impact on the
functioning of individuals in their situations is paramount
in social work practice. Social work's emphasis on the
uniqueness of the individual, unconditional
self-acceptance, and nonjudgmental attitude is mirrored in
Gestalt therapy. The importance of the worker-client
relationship in social work is paramount and harks back to
early social work models such as functional and the
problem-solving process models of direct practice. In the
context of the helping relationship in social work, the roles
include listening, teaching, and fosters effective and
responsible functioning in individuals or in systems for the
benefit of persons in the system.
Contemporary work is needed to combine Gestalt's rich
theory and process with empirically tested cognitive
behavioral techniques in order to move from awareness of
needed change to new growth-producing behaviors.
REFERENCES
Brentano, F. (1999). Psychology from an empirical perspective. In D.
Moss (Eel.), Humanistic and tTanspersonal psychology: A
historical and biographical sourcebook. London:
Greenwood. (Original work published 1874).
Centre for Clinical Effectiveness. (2001). Is Gestalt therapy more
effective than other therapeutic approaches? Melbourne: Southern
Health/Monash Institute of Health Services Research.
Germain, C. B., & Gitterrnan, A. (1980). The life model of social work
practice. New York: Columbia University Press.
Goldstein, K. (1999). The organism: A holistic approach to biology
from pathological data in man. New York: Zone Books. (Original
work published 1939).
Hale, B. J. (1978). Gestalt techniques in marriage counseling.
Social Casework, 59(7), 428-433.
Lesonsky, E. M., Kaplan, M. L., & Kaplan, N. R. (1986).
Operationalizing Gestalt therapy's processes of experiential
organization. Psychotherapy, 23(1),41-49.
Parlett, M. (1997). The unified field in practice. Gestalt Review, 1 (1),
10-33.
Paul, L. L. (1973). The relevance of Gestalt therapy for social work.
Clinical Social Work Joumal, 1(2),94-99.
Perlman, H. H. (1951). Are we creating dependency? Minnesota
Welfare, 6(12), 4-13.
Perls, F. S., Hefferline, R., & Goodman, P. (1951). Gestalt therapy:
Excitement and growth in the human personality. New York: Julian
(Revised edition in 1994).
Striimpfel, U. (2004). Research on Gestalt therapy. International
Gestaltlournal, 27(1), 9-54.
GLOBALIZATION
275
FURTHER READING
Perls, F. S. (1988). Gestalt therapy verbatim. Highland, NY:
Center for Gestalt Development, 1988.
Polster, E., & Polster, M. (1973). Gestalt therapy integrated:
Contours of theory and practice. New York: Brunner-Mazel.
Woldt, A. L., & Toman, S. M. (2005). Gestalt therapy: History,
theory, and practice. Thousand Oaks, CA: Sage Publications.
SUGGESTED LINKS The Gestalt Therapy
Page. http://www.gestalt.org/contents.html The
Gestalt Therapy Network.
http://www.gestalttherapy.net/welcome/index . html
Links to Gestalt Psychotherapy Associations and Institutes, Gestalt
Psychotherapy Journals, and Gestalt Psychotherapy Discussion Lists
and Boards.
http://www.gestalttheory.net/info/gpass .html
-CLAYTON SHORKEY AND MICHAEL UEBEL
GLOBALIZATION
ABSTRACT: Globalization is the key social, economic,
political, and cultural process of our time. This e ntry
defines globalization, summarizes its complex and con-
tradictory correlates and consequences, and offers, from a
social work point of view, a balanced assessment of this
powerful multidimensional process that is sweeping
contemporary world.
KEY WORDS: poverty; economic and social development;
international social welfare; social justice
GlObalization is a dominant theme of our time. It is the
most significant economic, political, sociological, cul tural,
and technological process in the world today (Friedman,
2005; Giddens, 2003; Wolf, 2004). The core of this
process consists of the creation and consciousness of
global interdependencies and exchanges. (Steger, 2003).
The cross-border flow of information, ideas, knowledge,
technology, capital, labor, artifacts, and cultural norms and
values are the essence of this process. (Kaplinsky, 2005 ).
Driven by economic and political liberalization that
followed the collapse of communism in the 1980s, it is
buttressed by the breakthroughs in information and
communications technology that has successively brought
us such transforming revolutions as the fax, the email, the
internet, and the mobile phone in the late 20 th and early
21st centuries. (Fukada-Parr, 2003).
276 GLOBALIZATION
Features of Contemporary Globalization Globalization
is not an entirely new process. The crossborder march of the
Greek and Roman Empires, and the spread of the Chinese,
Indian, and Mayan civilizations can plausibly be seen as
earlier incarnations of globalization. But while the processes
of cultural exchanges, transnational trade, intercontinental
travel, and diffusion and adoption of new worldviews,
technologies, languages, and legal systems are not of recent
vintage, globalization today is more than simply a con-
tinuation of an ancient phenomenon.
Contemporary globalization has a number of special
characteristics. First is its scale and scope: with the robust
involvement of Brazil, Russia, India, and China and of the
nations of the former Soviet block, a majority of the worlds'
people is now engaged in the global economy. Second is its
speed: ideas, technology, currency, and people can now move
with swiftness undreamed of before, and innovation can now
be disseminated at breakneck pace. Third, contemporary
globalization has broken the old international division of
labor: unlike the previous era, the developing countries now
produce and export not just raw materials and commodities,
but also manufactured goods that are imported by higher
income countries. Fourth, international trade now
encompasses services which, like manufacturing, can be
unbundled so that some parts can be shifted elsewhere through
the process of outsourcing and offshoring. Fifth, research and
development (R&D), are now intrinsic to the process of
globalization so that some of the world's largest corporations
are now opening up their R&D departments in low income
countries. And, sixth, there is now a growing
internationalization of talent, that is reflected, for example, in
the visible prominence of Asian engineers in Silicon Valley,
but also in the hiring of European and North American CEOs
by several major Asian corporations. (Bemanke, 2006;
Chanda, 2007; Collier, 2007; Meredith, 2007).
Contemporary globalization has broken the boundaries
between politics, culture, technology, finance, na tional
security, and ecology. It has also broken the walls between
countries, markets, and disciplines. (Friedman, 2000, 2005). It
has created a global economy, given rise to powerful
multinational corporations, led to the formation of new global
governance structures and new forms and areas of
international law, and created and made us aware of such
problems as cross-border migration and displacement of
people, global warming, international terrorism, money
laundering, international trafficking in women and children,
spread of deadly infectious diseases such as HIVjAIDS,
Ebola, and SARS, and the seemingly unstoppable and thriving
business of drug trade.
Globalization affects not just the economic and political
arenas, but also everyday life, including entertainment,
culinary tastes, preferred medical treatments, even the
institutions of marriage and family, and our traditional ways
and cultures. Globalization, thus, is hardly a matter of choice.
It is, as Giddens (2003) remarks, how we live today. Although
globalization may be "the defining trend in the world today"
(Fukada-Parr, 2003, p. 168), it remains one of the most
controversial and disputed topics in the social sciences.
The Liabilities of Globalization
There is little doubt that globalization has created new
asymmetries of power, possessions, and privileges. It has
disrupted traditional cultures and ways of interacting. It has
given rise to new uncertainties and vulnerabilities. It has
generated new angst and anxiety about loss of employment
and declining wages (Bowles et al, 2007a; Bowles et al.
2007b).
At times, globalization has served as a conduit to push
forward the neoliberal agenda that stresses fiscal discipline,
reduction of social spending, downsizing of government,
lowering of taxation, liberalization of finance and trade,
adjustment of national currencies and competitive exchange
rates, privatization of state enterprises, deregulation of the
economy, and protection of private property rights. (Steger,
2003, p. 4). The legitimacy of international financial
institutions such as the World Bank, the International
Monetary Fund, and the World Trade organization has come
into question as many of their policies have benefited the
well-off disproportionately, neglected concern for the
environment, human rights, and social justice, shown little
regard for employment creation, expansion or improvement of
health, educational, or social services, or for progressive land
reform, and their decision-making process has been lacking
openness and transparency (Kaplinsky, 2005; Steger, 2003;
Stiglitz, 2002; The World Commission on the Social
Dimension of Globalization, 2004; United Nations,
Department of Economic and Social Affairs, 2005; United
Nations Development Programme, 2005).
As Midgley (2004) notes, social work authors have
generally underscored the negative consequences of
globalization, which are typically said to include the shrinking
of the welfare state, the diminution of the role and power of
national governments vis-a-vis multinational corporations, the
destruction of indigenous cultures as a result of the
homogenizing effect of globalization, the weakening of trade
unions and workers' rights, the enactment of regressive modes
of taxation, the commodification of social relations, the
ascendancy

of managerialism, and the acceptance and pursuit of the
cult of consumption (Dominelli, 2004; Ferguson,
Lavalette, & Whitmore, 2005; Prigoff, 2000).
Benefits of Globalization
Proponents of economic globalization argue that (a)
foreign trade contributes to economic growth and (b)
economic growth is a necessary condition for the
alleviation of poverty. Countries that have been open to
foreign trade have done economically better than those
that have discouraged it. On the other hand, countries that
have not been able to integrate with the global economy
continue to stagnate or even deteriorate (Sachs, 2005 ).
Champions of globalization like Bhagwati (2004),
Meredith (2007), and Wolf (2004) assert that
globalization, instead of being a cause of poverty, is its
"only feasible cure."
Globalization has also helped raise the wages of
workers in developing countries. Furthermore, it has given
rise to the phenomenon of diaspora philanthropy, which
constitutes an economic plus for developing countries.
Beyond its benefits in the economic realm, globali-
zation has promoted a process of cultural enrichment,
exchange, and pluralism by reducing cultural and in-
tellectual isolation. It has served as a means to bridge the
knowledge gap between people in the economically and
scientifically advanced nations and those not yet there.
Without globalization, there would have been no success
in the war against smallpox and polio, no worldwide
campaign for vaccination and immunization, no progress
in the fight against malaria, no unified voice against child
labor, no global call for women's equality, no international
advocacy of human rights, no environmental movement,
and no network of nongovernmental organizations.
Globalization has spread the ideas of democracy,
diversity, open societies, justice for ethnic and other
minorities, and human rights and human security. In this
sense, globalization has really advanced the social agenda
(Bhagwati, 2004).
Toward a Balanced Assessment
Social work authors have more often than not seen only the
baneful _ correlates of globalization (Dominelli, 2004 ;
Ferguson, Lavalette, & Whitemore, 2005). Given the
accomplishments as well as limitations of this worldwide
phenomenon, it is necessary to attempt a more nuanced
understanding of globalization. The following
observations are offered in that spirit.
First, poverty is a global problem, and if we want to
combat it, we have to create wealth. Redistribution of
deprivation will not eradicate poverty. It is now
GLOBALIZATION 277
common knowledge that free trade, adequate physical
infrastructure, technological progress, individual entre-
preneurship, a people's "adaptive efficiency," and
growth-promoting public policies are necessary for creat-
ing wealth. It is hard to find a country today that has
flourished economically without participating in the global
economy (Bhagwati, 2004; Sachs, 2005).
Second, economic globalization is a necessary but not a
sufficient condition for reducing poverty. Globalization
must be judged not simply in terms of economic growth
but also in terms of its implications for social and
economic justice. Any verdict on globalization must
include its distributional impact and its consequences for
equity and fairness. A strong safety net must be in place to
assist those negatively affected by globalization.
Third, we in social work are apt to see the glass as half
empty. This spurs us to action and advocacy. In the
process, we sometimes overlook or underestimate hu man
triumphs. It is no exaggeration to say that poverty in the
world has declined faster in the last twenty years than in
the previous two hundred. The economic prosperity
brought about by globalization has contributed to rise in
life expectancy and reduction of hunger, child labor, infant
mortality, and fertility rates (Bhagwati, 2004; Wolf, 2004 ).
Fourth, globalization is an uneven process. Its results
have diverged markedly across countries. Asia seems to
have gained, while sub-Saharan Africa and Central As ia
have not fared well. For example, most Asian countries
have seen a rise in their Human Development Index (HDI),
which is a composite measure of human well-being that
goes beyond income, and includes health and education as
part of the barometer to gauge the progress of nations.
However, twelve sub-Saharan countries and six countries
in the former Soviet Union have suffered a reversal in their
HDI (Human Development Report, 2005).
Fifth, it is now abundantly clear that social factors are
as crucial to the well-being of societies as economic
factors. Economic growth without social equity and social
justice cannot be called development. (The International
Bank for Reconstruction and Development/The World
Bank, 2006). It simply ignites social unrest and int ergroup
distrust. There is ample evidence that such factors as
provision of child vaccination, education of the girl child,
participation of women in the labor force, and the general
population's opportunity to be involved in local
government is all positively associated with increased
standards of living.
Sixth, globalization is a complex process. Its conse-
quences can be highly contradictory (Friedman, 2000;
278 GLOBALIZATION
Chanda, 2007). It can spread AIDS as well as lifesaving
technologies. It can promote economic growth and accentuate
economic disparities. It can contribute to environmental
disasters as well as environmental improvement. It can
engender both clashes of culture as well as their synthesis. It
has both benign and baneful correlates and consequences. It
defies simple summations and easy, facile conclusions. Both
its promise and peril seem to be greatly exaggerated. While it
has not benefited everyone, and its rewards have been
distributed unequally, it would be rash to brand it as genocidal
or a new evil and sulkily retreat, even if it were possible, into
the cocoon of cultural and economic protectionism.
Finally, globalization is not an automatic or monolithic
process. Its course, contours, and consequences are affected
by agency, interest, and resistance. (Guillen, 2001). Thus the
challenge for social workers is to advocate and work toward a
process of globalization that has a strong social dimension;
that is fair, inclusive, and participatory; that respects human
dignity and human rights; that is democratically governed;
and that offers tangible benefits to all people in all countries
and not just the fortunate few. Such a shift of perspective was
called "globalization from below" by a recent ILO report (The
World Commission on the Social Dimension of Globalization,
2004). Such globalization is accountable to people. It works
toward sustainable development. It supports economic
growth, environmental protection, and social development
and social justice at every level whether it is local, national,
regional, or global. Such globalization is consonant with the
values of social work and will deserve social workers'
discriminating support.
Implications for Social Work
It is important for social workers to keep an open mind toward
this complex, dynamic and multidimensional process, which
has a bewildering array of contradictory as well as unintended
and unanticipated outcomes. As Harold Wilensky and Charles
Lebeaux in their classic work, Industrial Society and Social
Welfare (1958), remind us, transformative social processes are
often greeted with horror and dismay. The first phase of the
industrial revolution was blamed by many philosophers and
social reformers of that era for the "impoverishment in social
living" as well as community disorganization and
disintegration, and for worsening the plight of the poor. Yet it
world appear to be intellectually irresponsible to consider
industrial revolution as an unalloyed catastrophe today.
Similarly, to regard globalization as an unadulterated blessing
or an unmitigated disaster, to condemn it wholesale or to
celebrate it uncritically, misses the point. Empirical evidence
does not provide a clear, unequivocal verdict on its overall
impact (Chanda, 2007). One must, therefore, settle for a
highly qualified, circumspect, nuanced, and tentative
judgment on its overall impact.
REFERENCES
Bernanke, B. (2006). Global economic integration: What's new and
what's not? Remarks by Chairman Ben S. Bemanke at the Federal
Reserve Bank of Kansas City's Thirtieth Annual Economic
Symposium (pp. 1-8.), Jackson Hole, Wyoming, August 25, 2006.
http://www.federalreserve.gov/boarddocs/ speeches/2006/200608
25 /defaul t.h tm
Berger, P. L., & Huntington, S. M. (2002). Many globalizations:
Cultural diversity in the contemporary world. New York:
Oxford University Press.
Bhagwati, J. (2004). In defense of globalization, New York:
Oxford University Press.
Bowles, P., Veltmeyer, H., Cornelissen, S., lnvernizzi, N., & Tang,
K., Eds. (2007a). National perspectives on globalization. New
York: Palgrave Macmillan.
Bowles, P., Veltmeyer, H., Cornelissen, S., lnvernizzi, N., & Tang,
K., Eds. (2007b). Regional perspectives on globalization. New
York: Palgrave Macmillan.
Chanda, N. (2007b). Bound together: How traders, preachers,
adventurers, and wamors shaped globalization. New Haven, CT:
Yale University Press.
Collier, P. (2007). The bottom billion: Why the poorest countries are
failing and what can be done about it. New York: Oxford
University Press. .
Dominelli, L. (2004). Social work: Theory and practice for a changing
profession. Cambridge, UK: Polity Press.
Ferguson, 1., Lavalette, M., & Whitemore, E. (Eds.). (2005).
Globalization, global justice and social work. Abingdon, UK:
Routledge.
Friedman, T. L. (2000). The lexus and the olive tree. New York:
Knopf Publishing Group.
Friedman, T. L. (2005). The world is flat. A brief history of the
twenty-first century. New York: Farrar, Straus and Giroux.
Fukada-Parr. S. (2003). New threats to human security in the era of
globalization. Journal of Human Development, 4(2).
Giddens, A. (2003). Runaway world. How globalization is reshaping
our lives (3rd ed.) New York: Routledge.
Kaplinskv, R. (2005). Globalization, poverty and inequality:
Between a rock and a hard place. Cambridge, UK: Polity Press.
Meredith, R. (2007). The elephant and the dragon: The rise of India and
China and what it means for an of tIS. New York:
W.W. Norton & Co.
Midgley, J. (2.004). The complexities of globalization: Challenges to
social work. In N. T. Tan & A. Rowlands (Eds.), Social work
around the world III (pp. 13-29). Berne, Switzerland: IFSW Press,
International Federation of Social Workers.
Prigoff, A. (2000). Economics for social workers: Social outcomes of
economic globalization with strategies for community action.
California: Wadsworth/Thomson Learning.
Sachs, J. D. (2005). The end of poverty: Economic possibilities for our
time. New York: The Penguin Press.

Steger, M. B. (2003). Globalization: A very short introduction.
New York: Oxford University Press.
Stiglitz,]. E. (2002). Globalization and its discontents. New York:
W.W. Norton.
The International Bank for Reconstruction and Development/
The World Bank (2006). World developmetn report, equity and
devlopment. Washington, DC: The World Bank and Oxford
University Press.
The World Commission on the Social Dimension of Global-
ization. (2004). A fair globalization: Creating opportunities for
all. Geneva: International Labour Office.
United Nations, Department of Economic & Social Affairs.
(2005). Report on the World Social Situation, the inequality
predicament. New York: Author.
United Nations Development Programme. (2005). Human
development report. New.York: Oxford University Press.
Wilensky, H" & Lebeaux, C. (1958). Industrial society and social
welfare. New York: Russell Sage.
Wolf, M. W. (2004). Why globalization works. New Haven, CT:
Yale University Press.
-SHANT! K. KHINDUKA
GRIEF COUNSELING. See Bereavement Practice.
GROUP DYNAMICS
ABSTRACT: This entry is an overview of group dynam-
ics relevant for group work practice. The history of
small group theory and group dynamics is described.
The bulk of the entry is dedicated to discussing four
main areas of group dynamics: communication and
interaction, interpersonal attraction and cohesion, so-
cial integration (power, influence, norms, roles, status),
and group development. How these might vary
according to gender, race, ethnicity, and culture is
included. The entry ends with a discussion of trends
and needs for further research.
; KEY WORDS: group dynamics; small group theory; group
.
process; group structure
Since the earliest days of the profession, social workers have
studied small groups, the face-to-face "primary group"
I its relationship with other groups and larger institutions
, (Cooley, 1909), whether in the form of the first socializing
:1 group called the family or in smal1 groups assembled for a
purpose, such as in adult education and in the recreation
:
movement. The study and use of small group dynamics
s continued through the decades and is now a fundamental part
I of the education of social group workers. This entry describes
r. group dynamics important for group work practice. We first
r
clarify terms related to
GROUP DYNAMICS 279
group dynamics, outline its history, and then present four
general areas of group dynamics. How group dynamics may
vary due to gender, race, and ethnicity is considered
throughout. This entry is limited in both scope and depth and
readers are encouraged to review the materials cited
throughout the entry and listed in Further Reading.
Clarification of Terms
The small group is "a number of persons gathered together on
the basis of some common purpose and forming a
recognizable unit" (Northen, 1976, p. 117). The definition of
"small" rests on the ability "of members to identify themselves
as members, to engage in interaction, and to exchange
thoughts and feelings among themselves though verbal,
nonverbal, and written communication processes" (Toseland
& Rivas, 2005, p. 12). The emphasis is on "formed" groups
whose purpose is to either meet socioemotional needs
("treatment" groups) or accomplishing goals ("task groups")
not linked to the socioemotional needs of group members
(Toseland & Rivas, 2005).
The terms perspective, framework, or theory are often used
interchangeably in the group literature. An example of a
foundational perspective in the study and practice of small
groups is the social systems perspective. It has been so well
studied that there have been different schools represented by
Parsons and Shils (1951), Bales (1950), Homans (1950),
Olmsted (1959), and Hare and colleagues (Hare, Borgatta, &
Bales, 1955). Examples of small group theories include field
theory (Lewin, 1951), social exchange theory (Thibaut &
Kel1ey, 1959; Homans, 1974), and psychodynamic theory
applied to groups (Freud, 1922; Redl, 1942, 1944). Per-
spectives or theories often determine the type and character of
the group dynamics included. For example, a particular theory
may emphasize roles or may include a particular model of
group development in its formulation.
We define group dynamics as the internal and external
forces that affect processes and outcomes in groups (Gazda,
Ginter, & Horne, 2001; Forsyth, 2006; Yalorn, 1995). There
are two main elements to this definition. First, it is a "field of
inquiry" (Cartwright & Zander, 1968, p. 7), which involves
constructing and testing theories through rigorous empirical
research. The other element is the content of group dynamics,
the external and internal forces that affect processes and
outcomes of groups. External forces refer to the factors
outside of the group that may affect its performance, such as
(Cartwright & Zander, 1968). The impact of the external
environment of the group has been discussed in the literature
(Hasenfeld, 1974; Glasser & Garvin, 1976), but infrequently
empirically
280 GROUP DYNAMICS
studied. These forces also include what individual group
members bring into the group from the social environment
(Toseland, Jones, & Gellis, 2004).
Internal forces include group structures and group
processes. Group structure is "an identifiable arrangement
of elements at a given point in time. In a group, the
structure contains elements that are interactive in nature or
are products of interaction" (Rose, 1998, p. 369 ).
Structures are the "snapshot of the group, from which
inferences can be drawn about relationships in the group"
(Garvin, 1987, p. 690). Examples include norms, rank,
status, and patterns of interpersonal communication and
relations among members. Whereas the focus of structure
is on the pattern or relationship between units, the
emphasis of group process "is on changes occurring in
group conditions" (Garvin, 1985, p. 204). It may be
considered a "motion picture of the group, in which a
sequence of events is examined" (Garvin, 1987, p. 690).
Examples include role differentiation, which refers to the
evolution of the role structure in a group, and
communication-interaction. These internal forces affect
both how the group functions
( " ") dh.d (" ")
processes an ow It pro uces outcomes.
There is substantial literature on how structures and
processes affect the performance of treatment groups
(Burlingame, Fuhriman, & Johnson, 2004). As helping
professionals, social workers should be concerned with
group dynamics that affect processes and outcomes and
that are measurable and changeable.
Thus, group dynamics is both a field of study and the
actual moving and movable forces that are studied, which
consist of group structures and processes. It is what group
workers see, study, and manipulate in their groups.
History of Group Dynamics
The study of groups and group dynamics began in the late
19th and early 20th century in sociology and psychology.
Although the roots lay in the 1800s, it was not until the
1940s and 1950sthat the study of groups developed
substantially. Initiated largely by Kurt Lewin in the late
1930s (Lewin, Lippitt, & White, 1939), researchers began
to examine group processes producing classic studies and
books, such as Lewin's (1951) group dynamics text,
French and Raven's (1959/1968) study on social power,
Bales' (1950) system of Interaction Process Analysis,
Moreno's (1951) sociometry, and the first editions of
readings by Cartwright and Zander (1953) and Hare et al.,
(1955).
Social work with groups both influenced and was
influenced by the development of group dynamics during
this period. In writing about the historical origins of group
dynamics, Cartwright and Zander (1968)
placed social group work (the term that social workers
have utilized to refer to their practice with groups) at the
head of the professional table, noting the important works
of Busch (1934), Coyle (1930), and Wilson and Ryland
(1949). In addition, Wilbur Newstetter's (Newstetter &
Feldstein, 1930; Newstetter, Feldstein, & Newcomb,
1938) contributions were notable. His research
incorporated "experimental sociology" (Newstetter et al.,
1938, p. 9) and contributed to the knowledge of the
dynamics of groups, leadership, and the behavior of boys
in summer camps. His work was hailed as "the first publi c
presentation of the theoretical operation of a group"
(Wilson, 1976, p. 20).
In the late 1950s and 1960s, interest in the group as a
system had waned and research generally focused on
intrapersonal events or processes that mediated re sponses
to social situations (Steiner, 1974). Some of the reasons for
this shift include the influence of psychology to focus on
individuals, the difficulty with undertaking group studies,
and an increased interest in experiential group activity
rather than research (Gazda et al., 2001; Steiner, 1974). As
Steiner 0974, p. 105) noted, "Work on group processes did
not cease during the 60's but enthusiasm declined."
In the 1970s the study of the group as a whole
re-emerged (Steiner, 1974). Over the 1980s and 1990s,
group dynamics continued to be studied, and today is
experiencing a revival. "Many of the pragmatic, meth-
odological, and statistical difficulties that thwarted group
research in the 1950s and 1960s were either ameliorated or
largely overcome" (Johnson & Johnson, 2006, p. 39).
There is renewed interest in studying the group as a whole
(for example, social identity approach and intergroup
relations, Abrams, Hogg, Hinkle, & Otten, 2005; Hogg &
Williams, 2000) and there are new books or editions about
group theory and group dynamics (Agazarian, 1997;
Arrow, McGrath, & Berdahl, 2000; Forsyth, 2006; Poole
& Hollingshead, 2005).
Areas of Group Dynamics
We describe four areas in group dynamics (adapted from
Toseland et al., 2004): 0) communication and interaction,
(2) interpersonal attraction and cohesion, (3) social
integration (power, influence, norms, roles, sta tus), and
(4) group development. These group structures and
processes are not mutually exclusive "and each influences
how the other is expressed in groups. For example, power
and influence may affect communication structures. This
discussion is brief and selective; readers should consult
other sources for more information about these four areas
and others not included here such as leadership, intergroup
relations, conflict,

and decision making (Forsyth, 2006; Garvin, 1997 ;
Johnson & Johnson, 2006; Toseland & Rivas, 2005;
Zastrow, 2006). In each area below, we introduce the
subject and note how it is relevant for social group work
practice. We also include ways in which these areas of
group dynamics have been measured.
COMMUNICA TION AND INTERACTION
Communication processes and interaction patterns have
been fundamental aspects in the study of group dynamics
throughout the history of group dynamics (for example,
Bales, 1950; Hare, Borgatta, & Bales, 1965; Hare, 1983).
Communication and interaction have been ex amined in two
categories, content and form (Hare, 1976). With respect
tocontent, there are two types of interaction in groups, task
interaction where group members engage in the work of the
group, and socioemotional interaction that describes how
members interact in relationship to one another, often in
emotional ways. Its form includes interaction rate, such as
frequency of interactions, and communication net works or
the patterns of interactions. This discussion emphasizes the
form of communication and interaction.
Communication may be viewed as a proces s occurring
between group members and between members and the
worker. Group communication has been defined as "a
message sent by a group member to one or more receivers
with the conscious intent of affecting the receivers'
behavior" (Johnson & Johnson, 2006, p. 133). Commu-
nication may be verbal (face-to- face or via audio or video
transmission, such as telephone or internet voice chat),
nonverbal (face-to-face or video transmission), or virtual
(text-based, such as internet chat rooms). Effective com-
munication occurs among group members "when the
receivers interpret the sender's message in the same way the
sender intended it" (Johnson & Johnson, 2006, p. 133).
Communication problems may arise in groups because
messages are not encoded, transmitted, or deco ded
effectively. Thus, messages may be misunderstood,
misinterpreted, or misperceived due to a number of influ-
ences that can be interrelated.
An area in which much theoretical and empirical work
has been done is in understanding interaction patterns, or
communication networks. The patterns re present the
acceptable paths of communication among members of a
group; who is permitted to communicate, to what extent,
and to whom. There are many possible interaction patterns,
but four include the maypole (worker is central and
communication is from worker to member and from
member to worker), round robin (each member takes a turn
communicating), hot seat (extended back and forth
1 between worker and member),
GROUP DYNAMICS 281
and free floating (all members take responsibility for
communicating) (Toseland et a1., 2004). Group centered
(that is, decentralized) patterns are considered the most
desirable in treatment groups and are often desirable in task
groups. However, when routine deci sions must be made
quickly, workers may prefer leader centered (that is,
centralized) interaction patterns as more efficient (T
oseland et a1., 2004).
Group communication and interaction may be eval-
uated using a range of measurement instruments includ ing
the SYstematic Multiple Level Observation of Groups
(SYMLOG) (Bales, Cohen, & Williamson, 1979; Hare,
2005; Polley, Hare, & Stone, 1988), the Hill Interaction
Matrix (Hill, 1977), and the Group Therapy Interaction
Chronogram (Cox, 1973; Reder, 1978).
INTERPERSONAL ATTRACTION AND COHESION
People often join and remain in groups due to inter personal
attraction and cohesion, areas which have received much
attention (Burlingame, Fuhriman, & Johnson, 2001, 2002;
Cartwright, 1968; Dion, 2000; Lott & Lott, 1965;
Newcomb, 1960; Schachter, Ellerston, McBride, &
Gregory, 1968). Interpersonal attraction is an element of
cohesion and helps build cohesion, but is only a part of
cohesion. Studies of interpersonal attraction, or
"interpersonal sentiment" (Nixon, 1979, p. 86) build on
Jacob Moreno's (1978) work in sociometry, a research
technique that uses mathematics and diagrams to depict
interpersonal attraction in groups. A number of factors
contribute to attraction in groups. These include proximity
(simply meeting together may build attraction), homophily
(the degree of similarity of group members), comple-
mentarity (the degree to which others complement our
personal characteristics), compatibility in expectations,
acceptance and approval, and positive reci procity (when
liking is met with liking in return) (Forsyth, 2006; Toseland
et al., 2004).
Interpersonal attraction is an important foundation for
cohesion in groups. Cohesion has been defined in many
ways, reflecting "the complexity inherent in the conce pt
itself" (Forsyth, 2006, p. 143). Cohesion may be
conceptualized as having four dimensions: attraction, unity,
shared commitment to tasks (Forsyth, 2006), and
therapeutic relationship (Burlingame et a1., 2001,2002), all
of which may develop and change ov er time. Cohesion in
all its dimensions is essential for effective and helpful
group work. Cohesive groups provide acceptance and
support for group members, willingness to express feelings,
willingness to listen, ability to use feedback, and
willingness to take responsibility
282 GROUP DYNAMICS
for group functioning (Burlingame et al., 2001; Toseland &
Rivas, 2005). On the other hand, highly cohesive groups can
have detrimental effects in the form of groupthink (Janis,
1982), "a strong concurrenceseeking tendency that interferes
with effective group decision making" (Forsyth, 2006, p. 46),
and the strengthening of disruptive group norms.
With the rich literature on attraction and cohesion, there
are many ways to measure these aspects of group dynamics.
Examples include the Group Cohesion Questionnaire (van
Andel, Erdman, Karsdorp, Appels, & Trijsburg, 2003), the
Group Attitude Scale (Evans, 1982, 1984; Evans & Jarvis,
1986), Perceived Cohesion Scale (Chin, Salisbury, Pearson, &
Stollak, 1999; Bollen & Hoyle, 1990), the Harvard
Community Health Plan Group Cohesion Scale (Budman et
al., 1987), the Group Cohesion Scale (Treadwell, Lavertue,
Kumar, & Veeraraghavan, 2001), and Yalorn's cohesion scale
(Lieberman, Yalom, & Miles, 1973; Yalom, 1995).
SOCIAL INTEGRATION: POWER, INFLUENCE, NORMS,
ROLES, AND STATUS Social integration has been de fined
as "how members fit together and are accepted in a group"
(Toseland et al., 2004, p. 18). We add that it includes
social control, defined as "The process by which the
individual manipulates the behavior of others or by which
group members bring pressure on the individual" (Hare,
1976, p. 20). Through social interaction, group members
and leaders use power and influence to effec t social
control and social integration that result in the
development and enforcement of norms, roles, and
statuses in groups.
Power, or social power, "is the (a) the potentiality (b) for
inducing forces (c) in other persons (d) toward acting or
changing in a given direction" (Lippitt, Polansky, & Rosen,
1952, p. 236). It is the potential or capacity to influence
others, whereas social influence is viewed as the "processes
that change the thoughts, feelings, or behaviors of another
person" (Forsyth, 2006, p. 206). Thus, power is considered
the potential to influence but the process and result of
changing another person is considered influence. Power and
authority in a group may be affected by group factors. For
example, the power of leaders tends to be more evident in the
first stage of group development, group members tend to obey
directives in groups where there are clear superior-subordinate
hierarchies, members may feel obliged to comply based on the
requirements of their role in the group (Forsyth, 2006).
There are five main bases of power that group workers
may use to influence (French & Raven, 1959/1968: (a) reward
power (control distribution of rewards), (b) coercive power
(capacity to threat or punish),
(c) legitimate power (derived from authorized position, role,
or duty), (d) referent power (influence based on admired or
respected qualities), and (e) expert power (influence based on
superior skills and expertise). Power is important in helping
guide groups to optimal functioning. However, power
exercised by legitimate authorities can result in harmful
outcomes as evident in the experiments on obedience by
Milgram (1963) in which participants obeyed authorities
despite being given information that their actions caused
harm.
Social influence in groups often occurs to achieve
conformity, which is "behavior in accordance with the
standards and beliefs (including norms) of a group" (Crosbie,
1975, p. 431). Workers may influence by virtue of their power
bases and thus achieve conformity, but the use of social
influence occurs when the majority of the members influence
a smaller subgroup or the minority members successfully
convert the majority (Forsyth, 2006). Classic studies have
demonstrated how individuals and subgroups conformed their
opinions under pressure from the majority (Sherif & Murphy,
1936; Newcomb, 1943) even when some knew the opinions
were erroneous (Asch, 1952, 1955). On the other hand,
research has also demonstrated how minority opinions can be
influential in changing majority group opinion (Forsyth,
2006, pp. 220-226). Conformity rates vary across cultures
(collectivist societies yield to majority influence more often
than individualistic societies) and sexes (in face-to-face
groups, women conform more than men and may use it to
increase harmony) (Forsyth, 2006).
Norms, roles and status are essential components in the
process of social influence. Power and influence are often
expressed in the establishment and enforcement of norms,
roles, and status. In addition, they affect how and to whom
power and influence are exercised. Without norms, roles, and
status structures, the process of social integration would not be
possible.
Norms are "rules of behavior, proper ways of acting,
which have been accepted as legitimate by members of a
group. Norms specify the kinds of behavior that are expected
of group members" (Hare, 1976, P: 19). Norms can be explicit
and overt, as demonstrated by verbal or written agreement, or
implicit and covert, which will not be formally discussed, but
will be acted upon nonetheless. They can be prescriptive or
proscriptive in ways that identify preferable and prohibited
behaviors, respectively (Forsyth, 2006). Although the worker,
drawing on his or her power bases, may initially outline them,
norms develop through group interaction (Hare, 1976). Thus,
they will change based on the interaction as group members
engage in the process of influence (described earlier) and as
roles and

statuses take shape. Group members' expectations based
on race and ethnicity are influential in norm develop ment.
For example, some group members' cultures may
proscribe emotional expression, confrontation, or
speaking before elders (DeLucia-Waack & Donigian,
2003).
Roles are "shared expectations about the functions of
individuals in the group" (Toseland & Rivas, 2005, p. 80).
Roles help define the expected behavior of individuals
within the group and thus are related to norms. They are
shared expectations and thus roles are both a dopted and
given by group members as members interact with each
other in a process called role differentiation. In a classic
conceptualization of group roles, Benne & Sheats (1948)
noted that there are task roles, related to the work of the
group (for example, recorder, opinion giver),
socioemotional or relationship roles, related to the
interpersonal and emotional needs of the group (for
example, encourager, gate keeper), and individual roles
that attend to individual needs rather than the group's (for
example, dominator, recognition seeker). As a part of the
process of role differentiation, task and socioemotional
roles are distributed in most groups; rarely does one
person fill both the relational and task roles (Forsyth,
2006). Problems arise when the re is role collision (overlap
in roles), role incompatibility, role confusion (Hare, 1976,
pp. 148-150), and when roles are assigned due to stereo-
typing or out of problematic relations among members
(for example, scapegoating). Workers should strive to
provide an equitable distribution of task and socioemo-
tional roles among the group and prevent the develop ment
of problematic roles. Workers may need to help group
members separate expectations regarding trad itional roles
(that is, being a "man" or "woman ") from being assertive,
emotional expressive, or from issues of sexual orientation
(Garvin, 1987).
f Status (or status structure, status network) is defined as
"an evaluation and ranking of each member's position in
the group relative to all other members" (Toseland &
f Rivas, 2005, p. 81). While roles state the expected
behavior from individuals in groups, status creates the
hierarchical order of roles. Status evalua tions are made in
the early stages of group development, and only become
'
i stable when the members agree with those evaluations
(Crosbie, 1975). Status in groups develops and changes
through a process of status differentiation that is influenced
by a number of dynamic factors including group
composition, power, influence, and roles. Studies have
shown that higher status members contribute more in
'
i terms of length and frequency of talking and speak more to
the group, whereas lower status members speak more to
1
individuals or speak
GROUP DYNAMICS 283
up the hierarchical ladder (Bales, 1999). In addition, low
status members are more likely to depart from group
norms as they have little to lose by deviating unless they
have hopes of gaining a higher status (Toseland & Rivas,
2005). Another concern occurs during status generalization,
when members or workers unfairly allow sex, race, age, or
ethnicity to influence the determination of status (Forsyth,
2006). Group members may accord women and
minorities less status. On the other hand, some racial or
ethnic groups may accord more status to certain persons,
such as older persons. Given the potential positive and
negative effects of social integration and social control,
workers should examine and attend to these structures and
processes within their groups.
Social integration may be measured in various ways.
Power and influence can be measured using the social
power scale (Frost & Stahelski, 1988). Lieberman and his
colleagues developed an assessment of group norms
(Lieberman et a1., 1973; Lieberman, Golant, & Altman,
2004). Status in groups can be measured with a simple
measure of power and status that asks: "rank every
member in the group (self excluded) on a scale of 1 to N -1
(group size minus self) on power (how much influence he
or she has over you) and on prestige (what is his or her
social worth to you in the group)" (Crosbie, 1979, p. 115.
In addition, the SYMLOG instrument can be used to
evaluate roles, norms, and dominance and submission in a
group (Bales et a1., 1979; Hare, 2005; Polley et a1.,
1988).
GROUP DEVELOPMENT All groups move through stages
of development through their life span. Around the same
time, Sarri and Galinsky (1964) and Garland, J ones, and
Kolodny (1965) introduced the concept of stages of group
development to social workers. Helen Northen (1969)
was the first to dedicate a book to conceptualizing theory
and practice according to the stages of group
development. Northen defined a stage as "a differentiable
period or a discernible degree in the process of
development, growth, or change. A phase differs from a
stage only in that it is presumed to be recurrent; in the
literature these terms tend to be used interchangeably"
(1969, p. 49). A group's dynamics (its patterns of
communication and social interaction, cohesion, social
integration, and social control) changes over time. In
addition, member needs are different over time.
Knowledge about how groups develop is valuable in that
it helps workers "understand many group events, even
troubling ones, as necessary to the evolution of the group.
Such events can also be anticipated so that the practitioner
can devise, or help the group to devise, means of coping
with them" (Garvin, 1987, p. 692).
284 GROUP DYNAMICS
Although there is a consensus that groups go through
stages of development, there are different views about how
groups develop and what occurs in each stage. There are
sequential stage models and cyclical models, and
variations related to brief and openmembership groups
(that is, members often enter and leave) and in women's
groups. We will briefly discuss these models and
variations.
Sequential stage models have been the most com mon
model of group development presented in the literature,
with stages ranging from three to nine. Five stages are the
most common (for example, Garland et a1., 1965;
Hartford, 1971; Tuckman, 1965). Instead of presenting
one particular model, we review common themes across
models using the generic stage titles "beginnings,"
"middles," and "endings" (Toseland & Rivas, 2005).
Beginnings consist of planning and convening the group.
This stage is marked by higher levels of worker activity
and relatively low levels of member interaction and
guarded exchanges. There is often tension within the
group. Members may think they want to be a part of the
group while maintaining their autonomy
(approach-avoidance). In the process of social interaction,
and as norms, roles, and statuses are defined and explored
(that is, social integration occurs), conflict emerges among
members. This conflict is an expected and healthy part of a
group's development. Indeed, "low levels of conflict in a
group can be an indication ... that the group members are
simply uninvolved, unmotivated, and bored" (Forsyth,
2006, p. 148). Once the feelings and issues associated with
the beginning stage are resolved, the group moves into the
middle stage where most of the group's work is achieved.
The conflicts and questioning that occurred in the first
stage leads to established patterns of inter action. There is
growth in cohesion and unity, social integration develops,
and more trust is visible and communication occurs. These
structures and processes provide the climate for task
achievement. Endings are characterized by completion of
tasks, termination of roles, and reduction of dependency.
There are also cyclical models that posit that issues
related to particular stages may recur at any stage of a
group's development. An early example of a repeating
cycle model is that of Bales' (1950) who postulated that
groups go through a rhythm (to establish an equilibrium)
in which the group moves from dealing with tasks to
managing socioemotional matters to enhance interpersonal
relationships. A more recent example is Worshel's model
(1994) consisting of six stages through which groups
cycle.
A variation occurs in short-term, single-session, and
open-membership groups. These groups often
remain at the beginning stage of development (Galinsky &
Schopler, 1989). In addition, there isa four-stage relational
model developed for women's groups (Schiller, 1995,
1997). This model takes into account "the centrality of
connection and affiliation for women, women's needs for a
felt sense of safety in a group, and women's different
relationship to power and to conflict" (Schiller, 1997, p. 4 ).
Instruments to determine the stages of group devel-
opment include the Group Development Process Analysis
Measures (Beck, Dugo, Eng, & Lewis, 1986; Lewis, Beck,
Dugo, & Eng, 2000), the Group Development Observation
Form (Bordia, DiFonzo, & Chang, 1999) and the Group
Development Questionnaire (Wheelan & Hochberger,
1996).
Implications for the Future
This entry has described a selection of group dynamics
relevant for practice. The history of group dynamics was
presented, followed by a discussion of four areas of group
dynamics. In addition, how areas may vary according to
gender, race, ethnicity, and culture was highlighted.
The future looks bright for the study of group
dynamics. Social group workers can look forward to
utilizing knowledge that is based on research and theories,
which more fully understand and replicate the conditions
of groups they work with. New strategies in research can
measure and predict the changes that occur in these
dynamic groups. There are approaches for measuring both
the structures and processes within groups and there are
statistical methods that can account for the temporal and
contextual dynamics associated with groups, such as
growth curve analysis (Brossart, Patton, & Wood, 1998;
Kivlighan & Lilly, 1997) and hierarchical linear modeling
(Kivlighan & Tarrant, 2001, p. 227; Shechtman, 2003).
These advances should be applied to relatively
under-researched areas, such as group development
models derived mostly from relatively unstructured an-
ecdotal observations. How these developmental stages
relate to brief, open-ended groups and across different
demographic groups (for example, defined by age, race,
and ethnicity) is a question with implications for prac tice.
Another rich area for study is how group dynamics relates
to virtual groups. Finally, we need rigorous,
practice-suitable (that is, easy to use and score) instru-
ments for measuring the presence and character of group
structures and processes in group. Several reports
(Macgowan, 2003, 2006, 2008; Rose, 1984) have
described how workers can use information about group
structures and processes to inform strategies for improving
the quality of their group work.
r
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Yalom, I. D. (1995). The theory and practice of group psychotherapy
(4th ed.). New York: Basic Books.
Zastrow, C. (2006). Social work with groups: A comprehensive
workbook (6th ed.). Belmont, CA: Thomson.
FURTHER READING
Lippitt, R. (1981). Retrospective reflections on group work and
group dynamics. Social Work with Groups, 4(3/4), 9-19.
-MARK]. MACGOWAN
GROUPS
ABSTRACT: This overview highlights the current status of
group practice, examines the conceptual frameworks for
working with groups, reviews the status of group work
practice research, and identifies challenges for practice.
The discussion examines how the numerous frameworks in
social work with groups are joined by adherence to a
systemic perspective, an understanding of group dynam ics,
common intervention concepts, and processes im portant to
a sequence of intervention. Although recent studies on
social group work are characterized by in creasing attention
to design, data collection, and analy sis, research is still at a
formative stage. The discussion of challenges points to
areas that are of special importance in current and future
practice, including diversity in
288 GROUPS
composition, a commitment to attaining social justice,
changing membership, involuntary membership, new
professional roles, and use of technology.
KEY WORDS: group work; group therapy; group com-
position; group diversity; group research; group worker;
group practice; evaluation of group work
Group Practice Overview
This entry offers a critical appraisal of the current status of
group practice theory and outcomes in social work. The
focus is on direct practice with client groups, but the
concepts and issues addressed are also pertinent to work
with organizational and community groups. Iden tifying
concepts and values critical to social work with groups
provides a framework for assessing current prac tice, as
does the examination of practice outcomes, evaluation
issues, and emerging challenges.
Range of Group Practice
All social workers are involved in groups. They may
facilitate treatment groups, support groups, educational
groups, social goals groups, work groups, or recreational
groups. They may serve as leaders or members of multi-
disciplinary teams, task forces, an d committees. They may
consult with community action groups, self- help groups,
or advocacy groups. For social workers, group practice is
essential and ubiquitous, yet it appears in so many forms
that it almost defies definition. The the ories, skills, and
values important to group practice are applied in all arenas
of social work, from services to individuals and families to
the planning, development, and management of human
services. Group practice in social work today is perhaps
best characterized by its breadth, which spans purposes,
populations, practice settings, practitioners' roles, and
practice approaches.
The following examples illustrate the range and
variety of groups in social work practice:
Psychiatric inpatients meet daily for an hour to d iscuss
interpersonal issues that they face within and outside
the hospital.
Adult residents of a shelter for homeless families gather
twice a week to consider problems of living together
in the shelter.
Parents meet in an open-ended group in a hosp ital
neonatal intensive care unit to gain support and
information and share ways of coping.
A multiracial group of student leaders explores ways to
deal with escalating racial tensions at a high school.
A court-ordered group for abusive spouses mee ts
weekly to learn more acceptable ways to express
anger and to develop relationship skills.
Elderly residents of a retirement community meet at a
community center to share memories, support each
other, and socialize.
A group of foster children meets every other week to
participate in activities and discuss issues.
A group of social workers and other professionals meet
as a team with a family to develop a plan for a cancer
patient's release from a hospital.
A group of community residents meets with a social
worker to plan a way of stopping the city from closing
down a park in their neighborhood. Persons recently
diagnosed with HIV disease meet on the phone to share
experiences and learn new skills.
A child welfare unit in a Department of Social Service
meets to develop new channels to report suspected
abuse.
1
A social worker is active in each of these groups as a
facilitator, therapist, staff resource, or consultant. Broadly
speaking, social work practice with groups re fers to the
!
application of group concepts and practice principles
within the context of social work values to achieve J
individual, group, and social goals.
Why Use Groups?
COMMONALITY OF MEMBERS Sharing a group experience
with others who have similar interests and goals can be
helpful. Members may find relief in knowing others have
faced the same difficulties or discover ful fillment in
sharing common experiences and interests. Many people
find it easier to talk about conce rns with those whose lives
are similar and gain hope through hearing about the
success of others. Bonds among members can dilute
power differences that may create tensions and barriers to
open communication in indi vidual relationships.
Members can also increase their influence on the
environment when they organize to advocate for common
concerns.
CREATIVE AND PROBLEM~SOL VING POTENTIAL Groups
provide an arena in which members can ex change ideas
and opinions, review the problems they face, engage in
new experiences, and develop new ap proaches. As
members form relationships with each other, their varied
perspectives enable them to re- create aspects of the world
outside the group and' to use the group as a proving
ground for testing new behaviors, attitudes , and ideas.
Groups, including team members from a variety of
disciplines, can work out solutions that may never develop
from individual conferences or be accepted if offered by a
social worker alone. Group techniques, such as
role-playing, structured exercises,

games, art, and drama, can be used in combination with
discussion to generate ideas and action, promote members'
growth and social change, and resolve problems.
SMALL-GROUP FORCES Groups are a natural context for
many daily activities, and they exert a tremendous influence
on the way individuals think, feel, and act. (These influences
are discussed in detail in the article on Group Dynamics in this
Encyclopedia)
CONVENIENCE Groups are often the most convenient way
to provide services or make decisions that involve a number of
people. Individuals may have similar needs for information or
support; they may have common concerns, share similar
interests, or already be in a natural neighborhood or work
group. Meeting with these individuals in a group may be the
most productive way to convey information, stimulate
questions, offer support, bring pressure on people in power,
and develop solutions. Although effective group services
require planning, follow-up, and conferences outside group
meetings, results of studies comparing the relative efficiency
of individual and group treatment support the cost-effec ti
veness of groups (T oseland & Siporin, 1986). Studies of the
comparative effectiveness of individual and group treatments
do not allocate superiority to one or the other (Burlingame,
MacKenzie, & Strauss, 2004).
Growth of Group Treatment
During the 1940s, closer association with psychoanalytically
oriented caseworkers, as well as the desire of group workers
for acceptance by the social work profession, led to the
increased use of groups for treatment purposes. Social group
workers began to work in a variety of settings, such as mental
hospitals, child guidance clinics, prisons, children's
institutions, public assistance agencies, and schools. The
broad, ambitious aims of improving society through group
participation were tempered by a concern for treating
individuals in groups with a focus on personal adjustment,
insight, and self-understanding.
The writings of Coyle (1948), Konopka (1949), and RedI
and Wineman (1952) contributed greatly to the development
of the treatment approach and reflected an increasing
integration of social science materials in group work
1 methodology. However, social group work retained some of
its earlier functions of responding to both individual and
social circumstances as it branched into these new arenas.
"
Textbooks on social group work practice were applicable to a
5 range of group activities with clients (Phillips, 1957; Wilson &
. Ryland, 1949). The American Association of Group Workers,
t formed in 1946, was part of the National Conference on Social
e
p Work and published a statement defining the function
3,
GROUPS 289
of the group worker as an enabler who used both group
interaction and program activities to contribute to individual
growth and the achievement of goals (Coyle, 1959).
MODEL DEVELOPMENT From the late 1950s to the early
1970s, group work theorists drew on the professional values
of social work, practice wisdom developed over the years, and
the growing body of social science knowledge about groups to
identify the common tasks that social workers must perform in
their work with groups. A number of different conceptions of
group work emerged, however, during this era and others are
still being created. It appears likely that current practitioners
draw upon several of these in order to attain different sets of
group goals and meet the needs of different kinds of group
members. In the years since the early days of group work, a
virtual explosion of perspectives, including interactionist,
solution focused, psychodynamic, humanistic,
socioeducational, growth, mainstream, empowerment, and
cognitive behavioral approaches, has expanded these basic
frameworks. See the article "Group Work" in this
Encyclopedia for more details on group work models.
Conceptualizing Social Work Practice
with Groups
Since the early 1980s, numerous works offering approaches to
group practice have been published (Brown, 1986, 1991;
Garvin, 1997; Garvin, Gutierrez, & Galinsky, 2004; Glassman
& Kates, 1990; Henry, 1992; Northen and Kurland, 2001 ;
Rose, 1998:
Shulman, 1999; Sundel et al., 1985; Toseland & Rivas, 2005).
The continuing expansion and refinement of conceptual
frameworks for both general practice and practice with
specific populations are reflected in special issues of Social
Work with Groups on topics such as work with the poor and
oppressed, disabled members, the frail elderly, multifamily
groups, violence, health care patients, children, and
adolescence and on various issues in gender and cultural
diversity. However different the frameworks may seem, they
offer a core set of interlocking values and concepts that give
group work its unique identity and integrity as a social work
method. The myriad of frameworks in social work with
groups are joined by adherence to (1) a systemic perspective,
(2) an understanding of group dynamics. (3) common
concepts of intervention, (4) processes important to a
sequence of intervention, and (5) striving for evidence of
effectiveness.
SYSTEMIC PERSPECTIVE Social work practice with
groups is guided by a view of groups as social systems.
290 GROUPS
Other theoretical perspectives, such as psychoanalytic
theory, existential theory, learning theory, field theory,
and social exchange theory have variously influenced the
development of group work models, but all the major
formulations of group work rely on concepts from social
systems theory to describe group functioning (Galinsky &
Schopler, 1989b; Toseland & Rivas, 2005.) More details
on a systems perspective for work with groups may be
found in the articles on Group Dy~ namics and Group
Wark: Overview in this Encyclopedia.
CONCEPTS OF INTERVENTION Social workers vary
widely in their orientations and the frameworks they use
to highlight different aspects of practice with groups.
Some theoretical concepts of practice empha size
planning and analysis; others focus on the worker's
engagement in group process; and some others empha size
approaches of a particular manualized curriculum. In all
cases, however, group practitioners share a com mon
appreciation of the power of the group as a med ium of
service and a common set of group concepts that alert
them to the types of interventions in which they must
engage.
One of the distinguishing features of social work
group practice is the widespread commitment to inter-
vention at the individual, group, and environmental
levels. Individual interventions with members may take
place within the context of the group or beyond the
confines of the meeting. They involve the practitioner's
use of the professional helping relation ship and an array
of techniques designed to facilitate members' relation-
ships and achievement of individual goals. Group
interventions represent the core of the practitioner's
specialized skills and are derived from a knowledge of
group theory and a systems perspective. They are aimed
at helping the group become a unit for help, support, and
the accomplishment of tasks. The practitioner uses group
structure and group processes to promote group
development and to ensure that both task and main-
tenance functions are adequately performed. Environ-
mental interventions involve attempts to engage key
individuals and systems in the group's environment,
which can provide the assistance and linkages needed to
support and promote individual and group perform ance.
An important process in this regard is "boundary
spanning", in which workers help members and groups
interact with other systems as needed to attain goals.
Conceptions of the group as the means and context for
service and as a mutual aid system are also ess ential to
social work practice with groups. Viewing the group as
both a means and a context alerts the practitioner to the
dual role of the group as the major vehicle for service and
as the setting in which service takes place.
As the means for service, group forces are channeled to
promote the development of a climate and relation ships
that will optimally help members to clarify and carry out
their work together. As a context for service, the worker
recognizes that every action reverberates throughout th e
life of the group; even when the worker is interacting with
an individual member, other mem bers perceive and are
affected by whatever takes plate in the group (T oseland,
Jones, & Gellis, 2004)
Groups become a system of mutual aid as members
form reciprocal helping relationships with each other. As
members work on common problems and make
supportive comments, they become committed to help ing
each other. The group practitioner encourages and
promotes group conditions conducive to sharing and
problem solving, and helps members form relationships
with each other that are direct, purposeful, and invested
with feeling. Through the give and take of these rela-
tionships, each member is strengthened and becomes a
part of the productive totality that is the grou p (Gitterman
& Shulman, 1985/1986; Schwartz, 1961, 1971; Steinberg ,
2004).
Intervention Processes
As the social worker guides the group over the course of
its development, critical intervention processes include
composition, assessment, goal setting and contracting,
programming, clarification of processes that are occur-
ring, and evaluation and ending. Although many of these
activities are ongoing throughout the life of the group,
some are more prominent at particular stages of
development This topic is discussed in the article "Group
Work" in this Encyclopedia. Guidelines for intervention
are based on social work values, group work practice
theory, group work research, practice wisdom, and
perspectives and research from the social sciences and
group approaches in related professional fields.
COMPOSITION This process refers to the selection and
modification of the membership of the group system.
Regardless of whether the social worker can influence the
group's composition through the choice of members, it is
important to examine the size of the group and members'
attributes, such as race, gender, and ability to perform
maintenance and task functions. The determi nation of
which attributes are critical will vary with the purpose of
the group and the needs for group development. In any
group, members should have some basis of commonality,
so they will be comfortable sharing their interests and
concerns and have some interest in work ing together.
Members should also vary enough in their behavior and
abilities to ensure a breadth of perspective
I
I and capability for solving problems. When the group's
composition is judged to be a problem, the worker will
need to consider when and how to intervene to make the
group worke (Garvin, 1997; Yalom & Leszcz, 2005).
ASSESSMENT In group practice, assessment requires
ongoing attention to how the group system is evolving,
progress toward individual and group goals, and members'
performance and support outside the group. Frameworks
I, for general practice with individuals, families, organiza-
I
i
tions, and communities, as well as more specialized areas
of practice, are available to guide assessment at the in-
dividual and environmental levels. Furthermore, tools for
assessing group performance along dimensions, such as
cohesion, goal clarity, interpersonal attraction, commu-
nication structures, participation, normative processes,
problem solving, conflict resolution, member engage ment,
and group development are available for eva luating the
progress of the group and the need for interv ention
(Garvin, 1997; Macgowan, 2000; Rose, 1998; Toseland &
Rivas, 2005). Particular emphasis should be given to the
capacity of the group to operate as a mutual aid system and
effective problem solving unit to help it fulfill the
agreed-on purposes.
GOAL SETTING AND CONTRACTING The interrelated
concepts of goal setting and contracting guide intervention.
Goals are the ends that members pursue individually and as
a group. Goals are formulated through a process of finding
a common ground among the various expectations of the
members, the agency, and the social worker. A working
consensus on goals is sought and provides a standard by
which progress in the group is measured. Goals may range
from individual treatment objectives, such as a decrease in
violent behavior; to group conditions, such as emotional
and information sharing; to group products such as new
rules governing visitation in a residential center or a team
decision regarding a policy in a community mental health
program (Kivligham, ]anquet, Hardie, & Francis, 1993;
Schopler, Galinsky & Alicke, 1985; T os eland & Rivas,
2005).
Through the contracting process, the worker and
members come to terms about the goals the group will
pursue; the procedures that will structure their work
together; their respective roles; and working arrange ments
such as time, place, and cost. In short-t erm groups,
contracting may be brief. In longer- term groups and
open-ended groups, the contract may be continu ally
renegotiated as the group develops. Participation in
contracting is important, even when members' choices are
constricted in involuntary groups in which members are
required to attend or in groups in which mem bers have
limited abilities (Garvin, 1997; Northen &
GROUPS 291
Kurland, 2001). By engaging the members as fully as
possible in contract negotiations, the social worker affirms
their right to self-determination and provides an
opportunity for them to become full partners in the group.
PROGRAMMING The planned use of action-oriented
experiences to facilitate the group's work together is a
clearly distinguishing feature of social work group practice.
In addition to discussion, content from games, play,
structured exercises, role-playing, art, drama, guided
imagery, cooking, hobbies, and other forms of creative
self-expression are used to build group bonds and enhance
the potential of the group to achieve group tasks and
individual and social change. The use of verbal and
nonverbal programs to facilitate the work of the gr oup has
been a hallmark of social work practice with groups since
its use in the settlement house movement (Malekoff, 1997 ;
Middleman, 1980; Northen & Kurland, 2001). Because
frameworks for using program activities and analyzing their
consequences have been such an important part of group
work, social workers are in the vanguard of creative
programming and often adapt techniques from other group
approaches (for example, psychodrama and social skills
training) to augment the capabilities of groups. Manuals
created by group workers typically incorporate
recommended program activities that promote conditions,
such as relaxation and mental imagery (Galinsky, Terzian,
& Fraser, 2006).
EVALUA TION AND ENDING Throughout the life of the
group, evaluation is a crit ical task for the worker. Although
the worker guides the group in ensuring that the appraisal of
group functioning and achievement takes place, all
members of the group partake in the evaluation, As the
group comes to an end, the worker's task is to help m embers
examine their accomplishments, review their experience
together, and prepare for the future. When stated goals have
been achieved, the work er helps the group to consider ways
to maintain the individual or social changes. In
circumstances in which t he goal is prevention or support, the
worker seeks to have the conditions that reduce risk or
produce support also maintained. When particular goals
have not been" reached, the worker helps members affirm
what has been accomplished, examine why the goals were
not realized, and consider alternative ways to attain their
goals.
In addition to the activities surrounding evaluation
during the final phases of the group's life, the practitioner
helps the members with other facets of the process of
ending. Because termination often arouses deep feelings in
members, the worker helps the
292 GROUPS
members express and integrate positive and negative
emotions. If the worker has served primarily in a facilitative
role, it may be necessary for him or her to be directive when
the group has particular difficulty ending. Referral to other
services may be in order when the group ends prematurely or
individual members need continued support, or goals have not
been reached.
Group Practice Outcomes
Research that examines processes and outcomes and builds a
theoretical foundation based on empirical data is critical for
the development of group practice. Moreover, in an era of
limited resources and demands for accountability, the
credibility of group practice rests heavily on research
competence. The growing volume of research literature
indicates an increase in systematic approaches to evaluating
group processes and outcomes. Furthermore, social work
researchers are identifying methodological problems and
research issues that create barriers to evaluating group practice
and are testing the validity of conceptual frameworks.
TRENDS IN GROUP PRACTICE RESEARCH The progress in
evaluating the outcomes of group practi ce can be traced in
a number of comprehensive literature reviews. The
reviews of social work research on group practice include
a two-decade comparison of group work research and
knowledge (Feldman, 1986); an assessment of research
reported in Social Work with Groups and at the annual
symposia of the Association for the Advancement of Social
Work with Groups (Rothman & Fike, 1987); an analysis of
trends in social group work methodology, theory, and program
development (Tolman & Molidor, 1994); and a summary
including articles from group psychotherapy research (Garvin,
2005). While not social workers, Burlingame, Mackenzie, and
Strauss (2004), included the work of some social workers, and
have produced one of the most comprehensive compilations of
the effectiveness of group work with people with a variety of
concerns. Their paper also presents an excellent discussion of
research on the relationship between group processes and
outcomes.
Critical analyses of research related to specific
areas of group prac tice address such topics as when to
recommend group treatment (T oseland & Siporin,
1986); groups for substance abuse (Weiss, Jaffee, & de
Menil, 2004); groups for support of people with cancer
(Campbell, Phaneuf, & Deane, 2004); groups for
people with depression (Chen, Jordan, & Thompson,
2006; McDermut, Miller, & Brown, 2001); groups for
offenders (Morgan & Flora, 2002); support groups
(Schopler & Galinsky, 1993); groups for batterers
(Carney & Buttell, 2006), groups for people with
social phobia (Coles &
Hart, 2005), psychodynamic groups for survivors of child-
hood sexual abuse (Callahan, Price, & Hilsenroth, 2004),
groups for clients with dual diagnoses (DiNitto, Webb, &
Rubin, 2002), bereavement groups (Stoddart & Burke, 2002),
and groups for families of children experiencing problems
(Ruffolo, Kuhn, & Evans, 2006).
Other reviews of group practice that exemplify systematic
research procedures include group training for parents of
adolescents (Coren & Barlow, 2005) and social skills training
for adolescents (Ang & Hughes, 2002). These are summaries
of studies that have given careful attention to accepted
research procedures. The studies vary in their approach to
design and measurement, but they all contribute in a careful
and replicable way to the study of group practice.
In general, the reports of research on group practice
document the effectiveness and the efficiency of group
services for meeting the needs of a broad array of populations.
These studies provide an important base for further inquiry.
They also point to factors that limit replication and
generalization and call for research approaches that address
the methodological and practical problems that complicate the
empirical study of complex group interactions.
More Rigorous Approaches
Research on social work practice since the mid-1980s has
been characterized by increasing attention to design, data
collection, and analysis. Although experimental methods are
often precluded because of ethical issues and practical
problems, a few researchers are using random assignment to
treatment and control conditions, whereas others are exploring
alternative approaches to control, such as comparisons with
people on waiting lists or with persons in individual treatment.
A movement to develop evidence-based practice in group
work is gaining momentum (Macgowan, 2006). Such practice
incorporates four stages: (1) formulate an answerable practice
question; (2) search for evidence; (3) critically review the
evidence; and (4) apply the evidence and evaluate outcomes.
As the amount and quality of group work research advances, a
firm base for evidence-based practice will be developed.
FORMATIVE STAGE OF RESEARCH Although the studies
cited represent encouraging trends in group practice
research, the general overviews suggest that research
related to group practice is at a formative stage,
characterized by the independent examination of diffuse
research questions. They also reveal a host of
methodological problems and research inadequacies,
such as vague operational definitions, the use of small
samples, the insufficient description of methodology,

the lack of controls, and the failure to note methodological
deficiencies and research issues. The conclusions of many
studies rest on the subjective observations of group leaders
about group processes and outcomes. Although these group
descriptions can be helpful to practitioners who are working
with similar populations and problems, they are limited in the
conclusions that can be drawn. They may serve as exemplars
of creative, responsive practice, but they do not address the
relationship of interventions to the outcomes achieved or
provide a basis for independent assessment and the replication
of results.
REQUIREMENTS FOR FUTURE RESEARCH To de-
monstrate the effectiveness of social work practice with
groups and to develop the theoretical and empirical base for
practice, a more rigorous approach to research is required.
General guidelines for evaluating social work outcomes
(Thyer, 1991), as well as more specific directives for group
work research (Macgowan, in press), are available. A recent
discussion by Brower, Arndt, and Ketterhagen (2004)
indicates solutions to group work research design problems.
Magen (2004) offers many ideas on measurement of group
processes and outcomes; and Gant (2004) has discussed how
to resolve issues in the evaluation of group work.
Recommendations offered by these authors to increase the
rigor and utility of group practice research include the
following:
III Using measures with documented reliability and
validity that are relevant to the problems addressed
Selecting designs appropriate to the research questions that
ensure the measurement of relevant individual
attributes, individual-group interactions, group
conditions, and interventions
Measuring relevant variables at baseline before
treatment begins and at follow-up periods
III Developing new measures relevant to the pro-
blems addressed
Developing manuals
Designing means to monitor treatment fidelity
Developing practice principles derived from research
findings
More emphasis must be placed on developing programs of
research that examine the effectiveness of interventions under
various conditions and link process to outcome. To give a
more complete picture and to capture all aspects of the group
work experience, qualitative as well as quantitative means of
analysis should be used. Furthermore, group researchers and
practitioners must form collaborative relationships to build a
more scientific basis for practice (Galinsky, Turnbull, Meglin,
& Wilner, 1993) and must include group members in the
evaluation process.
GROUPS 293
Challenges for Group Practice
The opportunities and challenges that come with the
emergence of an increasingly complex society and the
changes in social service and health care payments have
created an unprecedented demand for group work expertise.
To be responsive to this demand, social workers must expand
their conceptual frameworks and develop their research
programs. In developing theory and evaluating practice, social
workers must give particular attention to current and emerging
practice conditions. They must be prepared to work
responsively with groups that have a diverse composition in
terms of such identity aspects as culture, gender, and sexual
orientation. They must know how to respond to changing
membership; and involuntary members must adapt to new
professional roles and must become proficient in the use of
new technology.
DIVERSITY AND COMPOSITION Group workers have
long acknowledged the impact of racial, ethnic, gender,
economic, and sexual orientation, and other cultural factors in
practice, but emphasis on the theme of diversity has increased
since the 1980s. In addition, group workers have sought to
understand how group work practice can be a socially just one
that contributes to a more socially just society.
Current demographics related to the increasing diversity of
the population indicate that social workers can anticipate that
such diversity will be the norm, rather than the exception, in
future group practice. A surge of publications in the 1980s and
early 1990s, including two special issues of Social Work with
Groups (Chau, 1990a; Davis, 1984), focused on multiracial,
multicultural practice. A number of authors have begun to
formulate at a conceptual level the special requirements of such
group practice (Brown & Mistry, 2005; Chau, 1990b; Davis,
Galinsky & Schopler, 1995; Hogg, Abrams, & Otten, 2004;
Rodenborg & Huynh, 2006). The increasing recognition of the
contribution of diversity to effective group outcomes is coupled
with an increased emphasis on empowerment approaches and
renewed attention to social action. Continuing focus on the
development and evaluation of interventions that recognize and
build on the contributions of diverse members is essential for
group services to be responsive and . effective.
CHANGING MEMBERSHIP Membership changes over the
course of the group are becoming common in group practice.
Open-ended groups, such as support groups, inpatient therapy
groups, and interdisciplinary teams, are designed to make
services available on a continuous basis to clients and to
organizations. Although the
294 GROUPS
pattern of change will vary from daily to weekly to
monthly or longer, adaptation to change is a constant factor
in these groups and provides a challenge to the group
leader and the members. These groups are resili ent, and
some last for many years. However, changing membership
alters the typical course of group development and requires
new approaches to intervention that facilitate transitions
for the entry and exit of members. The study of
development in open-ended groups has established that
these groups move beyond a formative stage; this has
suggested that group development varies, depending on
the frequency and extent of the change in membership, and
has identified interventions that can offset the disruptive
effects of change (Galinsky & Schopler, 1985, 1987,
1989a; Schopler & Galinsky, 1984, 1990; Schuh, 2004;
Yalom & Leszcz, 2005).
INVOLUNTARY MEMBERSHIP With the increase in societal
problems related to abuse and neglect, domes tic violence,
chemical dependence, sexual offenses, delinquency, and
youth gangs, social workers can ex pect to serve a growing
number of involuntary group members. Legal mandates or
external pressure by family, friends, or other authorities
for individuals to attend groups related to their problems
are likely to increase.
Although some authors have addressed the unique
demands of group practice with involuntary clients, the
dominant models of practice assume that members'
participation is voluntary. Toseland and Rivas (2005), and
Rooney and Chovanec (2004) stress the importance of
creating opportunities for choice when working with
involuntary clients and offer other useful guidelines for
structuring interventions. Increased theoretical and
research attention is needed to give direction to practice
with those clients who do not become involved in group
work services of their own volition.
NEW PROFESSIONAL ROLES The self-help and support
group movements that began in the 1970 s and the
increasing pressures for interdisciplinary collabora tion in
treatment teams, action initiatives, and organi zational
functioning, have expanded the conception of the social
worker's role in the group (Kurtz, 2004; Segal, this
volume). Social workers are frequently called on to train
volunteers or paraprofessionals as group leaders, provide
consultation to self-help groups, and play key roles in
multidisciplinary groups. Conceptual frameworks must be
developed to identify additional consultation and training
roles and to highlight the member and leadership roles of
social workers in collaborative professional relationships.
USE OF TECHNOLOGY Technology is having a substantial
impact on group practice. Audiovisual equip ment is used
in training and education, in organizatio nal functioning, in
group programming, and in the evaluation of outcomes.
Telephone conferences bring indivi duals with common
concerns together to share those concerns, address
questions, and build supportive rela tionships (Meier,
2004), They are also a common meet ing ground for
professional task groups and organizations located in
different sites.
Computer networks create groups that can respond to
individual concerns and address societal problems at any
hour of the day (Smokowski, Galinsky, & Harlow, 2001).
In addition, computer-assisted technology to facilitate the
decision making of both local groups and geographically
separated members, called group support systems, is
available (Jessup, Connolly, & Tansik, 1990; Mennecke,
Hoffer, & Wynne, 1992).
These technological developments dramatically alter
the character of group interaction, which has long been
based on the assumption of face-to-face interchanges.
They can make group services more accessible to
individuals who are homebound, are geographically
separated from the group, or who wish to remain anon-
ymous, and they can enhance organizational operations
(Meier, 2004; Weinberg, Schmale, & Uken, 1995). The
lack of visual or voice cues, however, may require changes
in the approach to assessment and intervention. Social
workers must be trained in the use of these tech nologies,
and conceptual frameworks must be adapted to reflect the
factors that influence these new forms of practice.
Contribution
This review of current group practice indicates that social
workers have been skillful and innovative in their response
to the demands of practice. Groups have been used to meet
a wide variety of individual and societal needs, and as
these needs have changed, new forms of practice have
emerged. The theoretical underpinnings of group practice
have continued to develop through practice wisdom and
research findings. Because of the power inherent in groups
as a context for practice and a force for action, group
approaches are central to social work and have enormous
potential for promoting the achievement of individual and
social goals.
Acknowledgment
The authors wish to acknowledge that this article was
adapted from an article in the 19th Edition of this
encyclopedia co-authored by ] anice H. Schopler and
Maeda]. Galinsky.

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GROUP WORK
Stein, L., Rothman. B., & Nakanishi, M. (1993). The telephone group:
Accessing group service to the homebound. Social Work with ABSTRACT: This entry begins with a brief history of group
Groups. 16(1-2),203-215. work in the United States. Next, there is a description of
the wide range of treatment and task groups used by
social workers. This is followed by a discussion of group
dynamics, diversity and social justice issues. Then, there
is a brief overview of the developmental stages that
groups go through and widely used

practice models. The chapter concludes with a brief review
of the evidence base for the effectiveness of group work
practice.
KEY WORDS: group work; group dynamics; group de-
velopment; history of group work; task groups; treat-
ment groups; evidenced-based group work
Along with casework and community organization, group
work is one of the three major modalities of social work
practice. Group work can be defined as goal directed
activity that brings together people for a com mon purpose
or goal. Group work is aimed at m eeting members'
socioemotional needs and accomplishing tasks. Group
work mav'be directed at individual mem bers, the group as a
whole, or the environment in which the group works.
Groups are found in almost all settings where social work is
practiced.
The Historic Roots of Group Work
Unlike casework that came about in England and the
United States as a part of the charity house movement in the
late 1800s, group work grew up mostly in settle ment
houses. While charity organizations were focused
primarily on identifying the worthy poor and determin ing
who should receive aid, settlement houses focused on
socializing new citizens to democratic values and the
American way of life. It gave ordinary citizens the
opportunities for education, recreation, social su pport, and
community involvement. Historically, group work focused
on enlightened collective action and demo cratic
participation (Follett, 1926; Slavson, 1939). The contrast
between casework and group work can be seen in the early
writing of Mary Richmond who in 1917 wrote the first
textbook on social casework called Social Diagnosis
(Richmond, 1917). Richmond used legalistic proceedings
to carefully study and diagnose the needs of the poor in
order to determine if they were worthy of aid. In contrast,
the first book written about group work by Grace Coyle
Social Processes in Organized Groups (1930) focused on the
processes that occurred during group meetings. The early
history of group work focused heavily on adult education,
social action, social justice, and social change (Coyle,
1935, 1938). This was in part due to the Great Depression
and the emphasis on the struggle for workers' rights and the
unions that were forming during the 1920s and the 1930s.
Gradually, during the 1940s and 1950s, group work
began to be used more frequently to provide therapy in
child guidance clinics and inpatient and outpatient mental
health settings.
Fritz Redl (1944) and Giesela Konopka (1949) helped
make group services an integral part of child
GROUP WORK 299
guidance clinics. The interest in groups for therapy was also
spurred on by psychoanalysis and ego psychol ogy
(Schilder, 1937; Slavson, 1940; Wender, 1936) and the
severe shortage of trained workers to deal with the mentally
disabled war veterans returning from World War II
(Trecker, 1956). Gradually, group workers who had their
roots in many different disciplines such as adult education
and recreation, began to align them selves with social work.
The American Association of Group Workers, formed in
1946, was a part of the National Conference on Social
Work, but it was not until 1955 that group workers formally
joined with other social workers to form the National
Association of Social Work.
During the 1960s and 1970s interest in group work
declined somewhat because there was a movement away
from specializations in casework, group work, and
community organization to a curriculum in schools of
social work that emphasized generic social work prac tice.
Although generic social work practice was supposed to
emphasize casework, group work, and community orga-
nization, in practice, casework became the dominant mode
of intervention. To increase awareness of the im portance of
group work, in 1978 social workers came together to
establish the journal Social Work with Groups, and in 1979
group workers throughout the United States and Canada
came together for the First Annual Sympo sium for the
Advancement of Group Work, and this Annual Symposium
has grown into an international organization, with chapters
throughout the world.
The Range of Group Work Practice
Today, group work is practiced with a wide range of
groups. Two major types of groups can be distinguished in
group work practice: treatment groups and task groups.
Treatment groups are focused on the needs of individual
members whereas task groups are focused on the task or the
work to be accomplished. Treatment groups can be
distinguished from task groups because their focus is
always on the needs of the members of the group. In
contrast, the work of task groups mayor may not affect the
members of the group themselves. The work of task groups
is focused on a goal or an objective that goes beyond the
members of the group. According to Toseland and Riv as
(2005) there are five broad types of treatment groups: (1 )
support groups; (2) educational groups, (3) growth groups ,
(4) therapy groups, and (5) socialization, recreation, and
activity groups.
There are also three main types of task groups: those
that meet client needs, those that meet organizational
needs, and those that meet community needs. Groups that
meet member needs include teams, treatment con ferences,
and staff development groups. Task groups
300 GROUP WORK
that meet organizational needs include (1) committees, (2)
cabinets, and (3) boards of directors. Task groups that meet
community needs include (l) social action groups, (2)
coalitions, and (3) delegate councils.
Diversity and Social Justice
in Group Work Practice
When social workers hear the word "diversity" with regard to
group work, they may think of a mixed group of Black and
White Americans. Diversity, however, comprises not just
racial differences, but ethnic, gender, sexual, age, intellectual,
and physical diversity among othe-rs. It is important to
understand how diversity influences group cohesiveness and
the effectiveness of group work practice. Indeed, the essence
of group work is to create an environment that is sensitive to
and respectful of all differences, and help individuals thrive
within that group environment (Fluhr, 2004). Gender, race,
disability status, and other forms of diversity have a profound
effect on group processes (Brown & Mistry, 1994; Davis &
Proctor, 1989; Garvin & Reed, 1983). Groups are a
microcosm of the wider society and any group process will
replicate the sociopolitical status and power relationships
evident in the relevant society (Brown & Mistry, 1994).
There is an ongoing discussion in group work literature
regarding the advantages of groups that are homogenous
versus those that are heterogeneous. Some support the idea
that a group's composition should be homogenous (Richards,
Burlingame, & Fuhriman, 1990; Tajfel & Turner, 1986)
especially when group tasks are associated with issues
relevant to the particular groups' common characteristic. For
example, there is evidence that samesex groups are
advantageous for women, when the group task relates to
personal identity, social oppression, and empowerment
(Brown & Mistry, 1994). Similarly, groups designed to meet
the needs of people who are lesbian, gay, or transgendered do
not afford the benefits of group membership to "out-group"
members.
The use of homogenous groups in agencies, treatment
centers, and counseling centers has been endorsed because it
is believed that sameness will expedite treatment. That is,
group cohesion will be fostered more quickly and the group
bond will be stronger if the group members have more in
common (Fluhr, 2004). Kruglankski et a1. (2002) suggest the
commonality of experience will allow for shared opinions and
therefore a more satisfying group experience. Social identity
theory supports this point of view (Perrone, 2000) because it
posits that people classify themselves and others into various
social categories (e.g., racial, gender, and age cohorts) as part
of the process of social identification (Tajfel & Turner, 1986).
The sharing of common
characteristics facilitates a perceived sense of oneness with a
group of people.
Similar to same-sex groups, an ethnic- or racespecific
group is often preferred by members and is more productive
when issues of racial identity, racism, and culture are central
to the task (Brown & Mistry, 1994; Davis, 1979, 1984). The
concept of "support" is sometimes emphasized as a reason for
employing racially homogeneous groups (Boyd-Franklin,
1991; Brayboy, 1971, 1974; Curtis & Hodge, 1994; Davis,
1979, 1984; Denton, 1990; Fenster & Fenster,
1998;Frances-Spence, 1994; Jones & Hodges, 2001; McKay,
Gonzales, Quintana, Kim, & Abdul-Adil, 1999). These
authors suggest that self-disclosure in situations of trust and
mutual support is beneficial to group members with
homogeneous backgrounds, and this need for support is one
reason many Black men and women prefer a racially
homogenous form of group treatment.
Perhaps the most convincing argument for the use of
homogenous groups concerns the empirically supported idea
that the structurally determined oppression of racism, sexism,
and homophobia are replicated as a powerful dynamic in
small groups of mixed membership (Brown & Mistry, 1994).
Few would question the salience of race in the therapeutic
relationship and indeed, literature exists which addresses its
importance (Banks, 1971; Beckett, 1980; Dana, 1981; Davis,
1984; Goodman, 1969; Green, 1982; Sue, 1977, 1981).
Clearly, people enter groups with their own personal and
social frame of reference and as such, bring their experiences
with racism, sexism, and homophobia with them into the
group experience. The group worker's responsibility is to
understand the way in which larger society is an "in-group"
experience, and, at the same time, work to counteract the
replication of social oppression and facilitate the
empowerment of all group members (Brown & Mistry, 2005).
Although there is empirical evidence for the use of
homogenous groups in certain situations, heterogeneous
groups are much more representative of the reality
experienced by practitioners working in the field. Fluhr
(2004) states, "[ejmbedded in social work ethics is a
dedication to serve a multitude of people from every
background, life experience, developmental stage and value
structure. This service is expected to be delivered without bias
and without judgment .... Group work with a heterogeneous
membership embraces that code of ethics and promotes its
realization" (p. 39).
Multiethnic groups are increasingly common as ethnic
diversity widens in American cities. School social workers,
particularly those in urban areas, see the changing
multicultural face of America firsthand and must strive to
encourage acceptance of differences so that

bridges can be built between multiple cultures, languages,
and worldviews. Making connections across multiple
worldviews involves considerations of dimensions such as
individualism-collectivism, masculinity-femininity,
power-distance, and uncertainty-avoidance (Hofstede,
1980). Perhaps the most salient issue for group workers is
to become aware of their own issues with sexism,
homophobia, and racism. The dynamics, which often occur
between members and workers of heterogeneous groups,
include the deep-rooted feelings and reactions to these
issues. Anti-oppressive practice demands not only specific
actions toward equalizing the power and position of group
members, but "constant awareness and vigilance to ensure
a consistent' approach to all aspects of the group work
process" (Brown & Mistry, 2005, p. 140).
Social justice is an ideal condition in which all
members of a society have the same basic rights, protec-
tion, opportunities, obligations, and social benefits
(Barker, 1995). One of the principles upon which group
work as a method rests is its conviction that group work
can and should prepare individuals for democratic par-
ticipation in their communities (Breton, 2004). Groups
geared toward social action (i.e., collective action directed
toward a shared goal) demonstrate the way in which social
justice is operationalized.
In recent years there has been a resurgence of inter est in
social action group work. Such work couples internal
group processes of empowerment with an external agenda
of collective social action. In social action groups, the
learning goals as well as the learning tools employed are
creative and flexible. For example, participants with an
interest in social justice typically desire to be challenged
about their own biases. Thus, goals might include a
thorough examination of personal resistance, being
critiqued on communication skills, and learning how to
educate others about prejudice. Some of the techniques
used to promote social change include experiential
learning (for example, cultural tour of a city or cultural
immersion experiences), readings, dialogue, and the use of
media images. The learning that takes place in action
groups typically extends beyond the group itself to the
creation of agendas and plans for promoting social change
in the larger community.
Linking personal change with social change is clearly
part of the process in a social action group. However, a
common misconception is the belief that engaging in
social change cannot lead to personal healing and that
personal healing cannot lead to social change (see Breton,
2006). Donaldson (2004) and others, however, make it
clear that therapeutic benefits can be gained, including
increased self-esteem, self-efficacy, and confidence. There
is little research documenting the
GROUP WORK 301
therapeutic effects of social action groups. However, there
is consensus regarding the idea that an empowerment
approach to social work practice is both a "clinical and
community oriented approach" (Lee, 2001, p. 30).
A focus on diversity in group work is becoming
increasingly salient in the United States, especially in
urban centers. Decisions about group composition (for
example, homogeneous versus heterogeneous
membership) should be made based on the purpose of the
group, its goals, and the skill of the workerfs). Likewise,
the number, race, and sex of group leaders should be
carefully considered. More than one group leader may be
recommended in certain situations (for example, when
social modeling is being used as a group learning
technique). Group workers should expect that members
seeking treatment will enter groups unequal in power, both
structurally' and interpersonally (Brown & Mistry, 1994)
and overt and subtle forms of oppression will call for
different responses from minority versus majority group
leaders (p. 143).
Social action group work is a vehicle through which
diversity is recognized and valued. For the worker, the
emphasis is on the understanding and use of group
processes and the ways members help one another to
accomplish the purposes of the group (Abels & Garvin,
2005). Positive group processes have the potential to effect
social change. Understanding the occurrence and use of
differences within groups is the cornerstone of effecting
such change.
The Phases of Group Development
No matter what type of group is used in practice, groups go
through a series of developmental steps or phases during
their lives. These steps can be divided into planning,
beginning, middle, and ending phases. The first step in
planning a group is to develop the group's purpose. The
group leader needs to think carefully about the goals of the
group and its intended purpose. In the planning phase, the
worker also needs to consider the best sponsor for the
group, and which members should attend. Although the
workers may think of their own agency or organization as
the most likely sponsor for the group, there are times when
they may want to think of a different sponsor, or having
joint sponsors. For example, if a worker is trying to reach
out to a group of . African-Americans, a church in an
African-American community or a community center
located near where the members live may be the best
sponsor. Once a sponsor is identified, the worker can go
about recruiting members, carefully considering the
composition of the group and how the members will fit
together. As members are selected they can be oriented to
the purpose of the group and contracted for the duration and
nature of their
302 GROUP WORK
participation in the group. The planning phase should also
take into consideration practical issues such as where the
group will meet and any resources the group will need to
conduct its meetings.
The beginning phase of group activity is often char-
acterized by tentativeness as members get to know each other
and begin to work together. The worker's job is to help
members to learn about one another and begin to work
together on shared goals. There is a period of assessment
when the needs of members, the tasks to be accomplished,
and the goals of the group are decided upon. As the beginning
phase progresses and norms begin to be established, some
group theorists suggest that there is a period of conflict when
members test norms or challenge the existing status q1)O.
Garland, Jones, and Kolodny (1976), for example, suggested
that after a preaffiliation phase there is a stage of power and
control when members vie for their place in a group, and chal-
lenge initial norms. The beginning phase is also characterized
by assessment when the worker and the members decide upon
the needs of the group and its members and formulate goals to
be accomplished in later sessions.
The middle phase of group work is a time when the
majority of the work of the group gets accomplished. During
the middle phase the worker structures the group's work,
making sure that individual and group goals are the focus of
the work. One of the worker's major tasks is to involve and
empower members so that they feel a part of the group and
their psychosocial needs and task needs are being met. The
worker also engages reluctant and resistant group members so
that they take part in the life of the group. During the middle
phase the worker also monitors and evaluates the group's
progress, trying to help the group accomplish individual and
group goals while keeping in mind the overall goals of the
sponsoring organization.
The ending phase of group work is the time to consolidate
the work of the group. Members should be helped to finish
their work on goals set earlier. The ending phase is also a time
to help members maintain and generalize the changes they
have already made and to plan for the future. Endings should
help members plan for independent functioning when they
leave the group. Referrals to additional services or resources
may be made, and members should be helped to consider
obstacles that may interfere with goal achievement once the
group breaks up. Ending sessions are also a time to help
members with any feelings they have about ending their
participation in a group, and to recount and take stock of what
they have achieved and what has been accomplished in the
group.
In task groups, ending meetings start by making sure there
is an agenda and the group keeps to it. The group
worker's job is to make sure that members keep to thJorker to ernp. topic. In
such groups, the worker may be a member, thd,sh and pursue chair, or a staff
member assigned to the group. EadV994, 1995, ] member should be given
the opportunity to speak, bU~l997-1998), at the same time, the worker has to
consider the tim~any group we for each topic, and limit the time that any one
membe~e empowerm can speak on the topic. The worker should
summarizeials model. T frequently and try to summarize each topic as it i~ a
task group discussed. If more time is needed, the worker can notEelping
rnernb, that and at the end of the agenda for the meeting~'Pression, imp
discuss with the members the need to return to certainn also help if points
during the next meeting. The worker should alsq The remedi make sure that
any assignments to be completed b1nctioning of i members after a meeting
are clear and consider formin~ted by Vinter subgroups to do some of the
work between rneetingi principles ( that can then be reported to the larger
group the nexlychology. Thi time everyone meets. In the ending phase of
task groupjg members w the major tasks are to review the decisions and
plans fQ\d restore thei: action, and to make sure that there is a plan for
follO'ie worker as ar through so that members know their role in helping t~d
set up the n solve the problem or accomplish the task after tharn new ways
group ends. The ending of task group meetings is als9cusing on pre a time
for self-critique when the members of the groufnter, 1985), s discuss what
was done well and what needs to be irsk-centered sc proved or done
differently the next time (Schwar:pdel ernphasiz 2002). This can be done
collectively, by asking eacltivity to solve member what he or she did well
and would like tl The reciproc improve on the next time. bmbers with sc
bmbers find
Models of Group Work leds and that
In 1962, Papell and Rothman described three historie group is on r cally
relevant models of group work practice that anerapeutic env: still relevant
today. These models include (1) the sociEa whole to ad goals model, (2) the
remedial model, and (3) the recir only to foste procal model. In addition to
these three models a ta'tole to achie, group model can be added. ,9 ncy and the
I
The social goals model is focused on social respon mbers' needs sibility,
social action, and informed democratic partie: neers of the pation. It is used
in community development agencje, .lman (1994 community centers, and
youth organizations for r,k; tp work prac purpose of introducing members to
democratic valu:
and empowering them to achieve goals set by then Blending selves rather
than by the worker. At its core is the vaku 1980 Papell c of social justice
where members take on the respone.am model of bility for changing
oppressive social structures for thements of thr own betterment and for the
welfare of the larger conunstrearn moe munity. The leader is available to
help empower merr common goe bers and to guide them as they take the
necessary stepup structure to help themselves and to change the systems th:rs
as the grouj affect their daily lives. Some of the early pioneersjr mainstream
the social goals model such as Klein (1953, 1970, 197~n elements: ( and
Tropp (1968, 1976), emphasized the autonon1untary associ of the members
of the group and the need for t~ion, and ind
I

iernhers keep to therorker to empower members so that they could estabay be a
member, th~sh and pursue their own goals. More recently, Breton to the group.
Each1994, 1995, 1999), Lee (1991), Nosko and Breton tunity to speak ,
butl997-1998), and Pernell (1986) are some of the o consider the tim~any group
workers who have made contributions to 1at any one membe~e empowerment
strategies embodied in the social -r should summariztbals model. The social
goals model can also be seen each topic as it is a task group model because
although its focus in on :he worker can noteelping members of the group, the
goals of reducing :la for the rneetingrpression, improving social justice, and
empowerment
to return to certairm also help individuals who are not part of the group. e
worker should alsc The remedial model is focused on restoring the :0 be
completed bjnctioning of individual group members. First promul.nd consider
forminsted by Vinter (1967) the remedial model grew out of ( between meetingie
principles of deviance, social role theory, and ego irger group the nexychologv.
The focus of the remedial model is on helpphase of task groupg members with
problems to change their behavior
cisions and plans fCAd restore their functioning. The remedial model views ~ is
a plan for follo',e worker as an expert who helps to structure the group .ir role in
helping tsd set up the necessary conditions so that members can
the task after tharn new ways of behaving and coping with problems. oup
meetings is alsscusing on problem solving (Sundel, Glasser, Sarri, & .ernbers of
the groutnter, 1985), social learning theory (Rose, 1998), and hat needs to be
irnsk-centered social work (Garvin, 1997), the remedial .ext time (Schwanodel
emphasizes structured, time limited, goal directed 'ely, by asking eacltivity to
solve specific problems.
and would like tl The reciprocal model focuses on the interaction of embers with
society. The worker is a mediator helping embers find common ground between
their own Work .eds and that of the larger society. The emphasis in cribed three
historie group is on mutual aid, and for the worker to foster a Irk practice that
arerapeutic environment in the group to help the group nclude (1) the socir.,
whole to achieve its objectives. The worker's role is el, and (3) the reci- only to
foster mutual aid and to help the group as a
three models a tat ole to achieve its goals but also for the sponsoring
\'3 ncv and the larger social environment to better meet ed on
social respon mbers' needs. Schwartz (1976) was one of the early I democratic
partie: 'leers of the reciprocal model, but Gitterman and velopment agencie,
:lman (1994) are also known for this approach to rganizations for tit rp work
practice.
o democratic valu.
goals set by ther Blending Group Work Practice Models
t its core is the va]; 1980 Papell and Rothman (1980) proposed a main Ike on the
respon().~am model of group work practice that incorporated II structures for
theernents of three previously described models. The 'e of the larger
cOlT:linstream model that they proposed was characterized help empower merr
common goals, mutual aid, and the creation of a e the necessary ste[.)Up
structure that increased the autonomy of mernse the systems th2rs as the group
developed. Allisi (2001) pointed out he early pioneers ~lt mainstream group
work models included five com1 (1953,1970, 1972)n elements: (1) a
commitment to democratic values, sized the autonomluntary association,
collective decision making and .d the need for thion, and individual liberty and
freedom with the
GROUP WORK 303
responsibility to promote the common good, (2) a focus on the
welfare of the individual group member and the society as a
whole, (3) an emphasis on program activities that take into
consideration the needs, aspirations, and interests of
members, (4) an emphasis on small group processes as the
medium through which the group operates and achieves its
goals, and (5) the worker as a guide working with rather than
for the members of the group.
Because social workers work with task groups as well as
treatment groups, the task group model can be added to the
thr~e historically relevant models and the main-stream model
described by Pappell and Rothman. In the task group model the
focus is on problem solving, making decisions, and achieving
mutually agreed-on goals based on a shared understanding of
the problem or task facing the group. The major distinction
between treatment and task groups is the focus of the work.
Unlike treatment groups where the members are the primary
target of the work of the group, the primary target of a task
group's work is a larger constituency outside the group who will
be affected by the group's work. The goal of the task group
model is to help members work effectively and efficiently
together on the tasks facing the group. In a classic text I van
Steiner (1972) made the point that actual productivity in solving
a problem equals potential productivity minus process losses.
This way of thinking about task groups has been followed up by
more recent writers such as Richard Hackman (2002). Thus, the
main thrust of the task group model is to help members to work
together in a cooperative fashion so that process losses from a
lack of cohesion and disagreements about goals will not
interfere with the productivity of the group. The core values of
the task group model are a creation of shared purpose and
meaning. Although there is room for individual initiative,
creativity, and input, and all opinions are welcome and valued,
the focus is on collective choice of the solution to the problem,
based on a sharing of all relevant information. Therefore, the
leader is a facilitator of group processes helping the group make
the best use of the contributions of individual members. The
group facilitator strives to maintain and enhance interpersonal,
intergroup, and interorganizational relationships. The facilitator
is always striving to point out' the value of an individual's input
to the group process and at the same time the collective wisdom
of the group. The facilitator strives for collaborative interaction
that builds consensus and produces meaningful outcomes
endorsed and shared by all members of the group. The
facilitator tries to set aside his or her own personal opinions,
supporting instead the group's right to make its own choices
about how to solve the problem
304 GROUP WORK
or complete the task facing the group. In The Skilled
FacilitatOT, Schwarz (2002) discusses the unilateral control
model and the give-up-control model as two models of
group facilitation that do not work over the long run.
Instead, he suggests the mutual learning model. In this
model each member of the group has information and
perspectives that should be respected. Each member of the
group may see things that others do not. In fact, I may be
contributing to the problem and not seeing it or knowing it.
My feelings or positions may be getting in the way.
Therefore, differences of opinion should be viewed as
opportunities for learning.
Schwarz (2002) suggests testing assumptions and
inferences, sharing all relevant information, giving ex-
amples and defining terms to clarify what an individual
group member is saying, explaining the reasoning and
intent behind information or opinions, combining ad-
vocacy with inquiry by explaining your position and the
reasoning you used to get there while at the same time
asking others about their point of view and inviting others
to ask questions about your point of view. Schwarz (2002)
also advocates focusing on interests, not posi tions, jointly
defining the approach to the problem or task, discussing
any uri-discussible or taboo subjects, discussing next steps
and ways to test any disagreements in members' positions,
and using a decision making rule that generates consensus
building and the commitment needed to solve the problem
or get the task accomplished. The goal in thes e steps is to
reduce process losses by helping everyone's opinions to be
heard and valued and to get members to listen to each
others' points of view. Then what follows is working out
disagreements by testing assumptions, or collecting
additional data, and coming up with decision rules that will
generate consensus and help everyone feel that they had a
part in coming up with the solution or contributing to the
accomplishment of the task facing the group.
Recent Practice Models
Despite the focus on a single mainstream model of group
work practice, there remain several distinct ap proaches to
group work practice within the current literature. Breton
(2006) and Knight (2006), for example, continue to
champion the social goals model and social action in
groups. Similarly, there continues to be a strong emphasis
on the reciprocal model of group work and its focus on
mutual aid for vulnerable yet resilient populations
(Shulman & Gitterman, 2005). Perhaps the greatest growth
in group work models, however, has come in the area of
remedial models of group work practice, particularly those
that are focused on cognitive behavior therapy in groups.
For example, White and Freeman (2000) focus on the use
of
cognitive-behavioral therapy for a variety of different
problems and populations. Similarly, Bieling, McCabe,
and Antony (2006) focus on the general principles and
practice of cognitive-behavioral therapy in groups. Both
books then go on to describe the use of cognitive behavior
therapy for specific types of problems. There has also been
a recent focus on group work with specific
sub-populations. For example, Malekoff (2004) has
prepared a book on group work with adolescents and
Salmon and Graziano (2004) have focused on group work
with the aging. In the task group arena there has been an
increased attention given to team work prac tice and the
facilitation of task groups (see for example, Levi, 2007;
Schwarz, 2002).
Technological Innovations
in Group Work Practice
In recent years there has been a growing interest in the use
of technology to enable individuals to meet together in
virtual groups when they are unable to meet in person.
There are many reasons why people may not be able to
meet face-to-face in groups. A lack of transportation or
living in a remote location may make it impossible for
members to join a group. Members with debilitating
illnesses, or those caring for someone with a severe illness
may not be able to leave their home in order to attend a
group meeting. There may also not be enough members
with rare diseases to form a group in a small geographic
area. There are also some individuals who simply prefer
not to attend face-to-face groups because it is too
time-consuming, or because they are shy or find
face-to-face meetings stigmatizing.
The two most common forms of virtual groups are
telephone groups and internet groups. Telephone groups
are made possible through teleconferencing equipment.
Although still relatively expensive the cost of telephone
conferencing has gone down in recent years with the use of
voice-over internet providers. It is also possible for social
service agencies to purchase the equipment to enable them
to conduct telephone groups at low cost. Contrary to what
might be expected, there is a high level of self-disclosure
in telephone groups, possibly because of the lack of verbal
cues to distract members from the central focus of the
group (McKenna & Green, 2002). We have found that
members can stay on the telephone for one to one and a
half hours without getting fatigued and that they enjoy the
benefit from the experience (Smith & T oseland, 2006; T
oseland, N accarrato, & Wray, in press).
Internet groups have also become much more popular
in recent years. Communication in interne t groups may be
synchronous or asynchronous, that is, members may all be
present and communicating at

the same time, or members may log on to sites that allow
them to communicate with each other over an extended
period of time. According to Santhiveeran (1998), there
are fourforms of internet groups: (1) chat rooms where
members communicate at the same time for a designated
period of time, (2) bulletin boards where members can post
messages, (3) e-mail generally between two or a few
members, and (4) list-serves which go out to many
members. Like telephone groups, internet groups offer
support and education to members who may not want to
attend in-person groups, or who may be unable to attend
them. They offer a kind of anonymity similar to telephone
groups but they may particularly appeal to those who enjoy
written communication or who value 24-hour access.
There has not been a great deal of research on the
effectiveness of telephone or internet groups, and we are
aware of no comparisons of the effectiveness of the two
modalities. More research will be needed as they grow in
popularity in future.
There are also software programs for facilitating
decision making in task groups. Multiattribute Utility
Analysis (MAU) is a decision making approach that has
members of the task group decide on the attributes of a
problem, the utility function associated with each attribute,
and the weight that should be assigned to each problem
attribute. Using a statistical procedure called multiple
regression, a worker using MAU can compute the weights
and the functional forms that the group members appear to
be using to make their judgments about the cases under
review. For more about approach see Jessup and Valacich
(1993), Toseland and Rivas (2005), or Reagan- Cirincione
(1994)
The Future of Group Work Practice:
Evidence-based Approaches
About twenty years ago Feldman (1987) did a review of
two decades of social work research. This was followed in
1994 by an article by Tolman and Molidor (1994) that
examined a decade of group work research. Both these
articles concluded that there was increasing but limited
evidence for the effectiveness of social work with groups.
However, Brower, Arndt, and Ketterhagen (2004), Garvin
(2001), and Hoyle, Georgesen, and Webster (2001) were
more positive as they found that group work research is
increasing. Unfortunately, there have not been any new
systematic reviews of group work in social work literature
in recent years. A more recent review of group counseling
literature (Burlingame, Fuhriman, & Johnson, 2004)
revealed that there is some limited evidence for the
effectiveness of group counseling with certain specific
problems. This evidence is largely limited to social- skills,
cognitivebehavioral and psychoeducational group
approaches,
GROUP WORK 305
although interpersonal group work approaches have shown
some effectiveness (Burlingame et aI., 2004). There is also
a chapter by Gant (2004) on the evaluation of social group
work effectiveness that attempts to look at some of the
recent outcome-related studies, but this chapter is a
selected review of the contents of specific journals, not a
comprehensive review of the recent outcome literature on
social group work. Overall, it appears that the situation has
not changed.appreciably in recent years. Although there
has been a recent push within social work to increase the
use of evidenced-based practice (see, for example, Roberts
& Yeager, 2006), there is still not a great deal of knowledge
about the effectiveness of group work practice within
social work. Therefore, in future, more attention should be
paid to examining the outcomes of group work practice.
There is even a striking lack of knowledge about the
therapeutic factors that make group work effective. Many
of the group work studies that have been conducted have
looked at outcomes for individual members, but there has
been little effort to look at the therapeutic factors that have
made these outcomes possible. We know very little, for
example, about what makes for effective leaders, or what
types of group dynamics lead to more effective outcomes.
These studies are difficult to conduct because they require
multiple groups led by multiple leaders and measures of
group processes as well as group outcomes. Still, to
advance the field in future years, these are the types of
studies that are needed.
A Research Agenda for Group Work
As we move forward in the 21st century, there should be a
dual focus on evidence-based practice approaches, and
more studies focused on the group work processes that help
us to achieve desired outcomes. Over the yeats, there has
been a focus on evidence-based practices for a few mental
health disorders such as depression, and for other problems
such as men who use violence, chronic health conditions
such as cancer, and the stress associated with caregiving.
Typically, however, there is very little emphasis on the fact
that these problems are addressed in groups. The emphasis
is on the techniques or the curriculum used to address the
problems rather than the group processes that occurred
while the problems were being addressed. Thus, one
research agenda for the future is making sure that group
processes are described even when the intervention focus is
on a particular mental or physical health problem. Instead
of focusing on the notion of individual treatment within a
group context, more weight should be given to group
processes and the group context and how these can be used
to help individual members and the group as a whole to
achieve its goals. There is also a need for more
306 GROUP WORK
studies on the group work processes that lead to successful
outcomes. Although there have been a few articles on the
group processes that can lead to detrimental or favorable
outcomes in groups (Bedner & Kaul, 1994; Smkowoski, Rose,
& Bacallao; 2001; Smkowoski, Rose, Todar, & Reardon,
1999), additional work that identifies helpful and detrimental
group processes would be welcome. To this end it would be
helpful to have additional measures of group process that
would allow us to quickly assess the dynamics of a group as it
unfolds. Magen (2004) identifies some measurement issues
and measures, but additional work is needed in this area as
well.
We also need to continue to focus on the power of groups
to address specific problems and to address the effectiveness
of these efforts using randomized controlled designs that can
add to the evidence-based effectiveness of group work
practice for specific mental health, social, and health
problems. Although there is a growing base of studies on
groups for specific problems (see Biding, McCabe, & Antony,
2006; Garvin, Gutierrez, & Galinsky, 2004) there is still much
more that can be done in social work. For example, the book
by Biding and collegues is not focused on social work groups.
Finally, additional research is needed on virtual groups such
as those conducted by telephone, over the internet, and
through videoconferencing, because these media will become
more popular as technology progresses and more and more
work is done through the internet. These groups are receiving
additional attention in the literature (Meier, 2004; Smith &
Toseland, 2006), but more work is needed.
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-RONALD W. TOSELAND AND HEATHER HORTON
HAITIAN AMERICANS
ABSTRACT: Haitians constitute a visible segment of
American society, with a population close to 1
million. Many experience a great deal of difficulty
adjusting to a different culture and language, as well
as to the realities of a new labor market.
Consequently, they endure stress and
dysfunctionality, and are referred to counseling and
social work services. This entry discusses important
elements of Haitian culture, such as religion and
family structure, that Haitian immigrants bring with
them to the United States. It argues that an
understanding of how these elements affect Haitian
Americans' lives is critical to delivering social work
services.
KEY WORDS: Haitian settlement patterns; religion;
family structure; attitudes toward social work
providers; successful treatment for Haitians
Haitian immigrants constitute a very visible segment of
contemporary American society. This visibility is be cause
they have been steadily migrating in significant numbers to
the United States since the late 1950s and early 1960s, soon
after Francois Duvalier ("Papa Doc") became president of
Haiti. The political repression that characterized the
Duvalier period forced large numbers of Haitians to seek
refuge in the United States. Sustained political oppression,
economic hardship, and lack of opportunity continued to
drive Haitian immigrants out of their homeland throughout
the 1970s, 1980s, and 1990s (Zephir, 1996, 2001). The
combinationof factors led Haitians to cross the Caribbean
Sea, by plane or by boat, legally or illegally, in order to
reach the shores of America, the perceived land of opportu-
nity, to begin new lives. The removal of President Aristide
in February 2004 exacerbated an already de plorable
situation, and Haitians continue to disembark on the shores
of America, particularly the shores of South Florida. An
examination of the records of the Census Bureau as well as
those of the Immigration and Naturalization Ser vice allows
for reasonable inferences about the size of the Haitian
population residing in the United States. There is good
reason to believe that the Haitian diaspora, which includes
documented and undocumented immigrants, exceeds
850,000, and according to community leaders may be close
to 1 million (Zephir, 2004).
309
History and Demography
Haitian immigrants come from all sectors of Haitian
society. The immigrants who came under the Francois
Duvalier regime from the late 1950s through the early
1970s were primarily professionals. It is reported that by
1970, 80% of Haiti's qualified professionals-doctors,
lawyers, teachers, engineers, and public administratorsleft
the country and relocated to places like New York and
Montreal (Heinl, Heinl, & Heinl, 1996, p. 612). Papa Doc's
death on April 21 , 1971, did not bring an end to
Duvalierism, as his 19-year old son, Jean-Claude Duvalier,
succeeded him as president for life. The young president
was more concerned about the interests of the local
bourgeoisie and business people, who enriched themselves
and enjoyed all the luxuries of modern life (Arthur & Dash,
1999). In consequence, the gulf between the haves and the
have-nets widened. In the face of absolute misery,
complete neglect, and even persecution by Baby Doc's
government, increasing numbers of poor Haitians decided
to take their chances and embark on a risky journey across
the straits of Florida. Thus as early as 1972, the
phenomenon of the Haitian boat people started, which
persists well into the present day. The saga of Haitians
landing on Florida beaches has been well documented in
the U.S. media. In fact, as this article was being written,
television stations reported that a boat carrying 100
Haitians reached Hallandale Beach, Florida, on March 28 ,
2007.
Haitian immigrants have settled primarily in the
Northeast region, Southern Florida, and the state of
Illinois. New York State, in particular, has the oldest and
most diverse concentration of this ethnic population,
estimated at 400,000 people, including the nonimmigrant
and undocumented entrants, as well as the legal population
who do not fill out the census form (Zephir, 2004). The
majority of the New York State Haitian population resides
in New York City. In more recent times, from the
mid-1980s to the present, Southern Florida has been
receiving the largest numbers of the new arrivals,
particularly the cities of Miami, Fort Lauderdale, and West
Palm Beach. Based on informa tion published by the U.S.
Census Bureau (2000) and reported in an article published
in the Miami Herald (August 7, 2001), the legal Haitian
population in the state of Florida is about 270,000, but
when one factors in the illegal population that number
increases (Zephir, 2004). The state of Massachusetts
follows with an
310 HAITIAN AMERICANS
estimated number of 75,000 Haitians, of which rv45,000
reside in the city of Boston. The state of New Jersey is
home to almost 40,000 Haitians, concentrated mostly in
the city of Newark. In addition, Pennsylvania
(Philadelphia) and Connecticut are included in the
Northeast areas where a significant number of Haitians are
found. Illinois is also the place of settle ment of another
30,000 Haitians, of whom more than half have established
their residency in the city of Chicago.
In their ethnic communities, Haitian immigrants have
managed to re-create the cultural habits of their homeland,
and have to a great extent transplanted key elements of
Haitian culture in their new environments, from religion,
family structure; to importance attached to work and
education. An understanding of how these elements affect
Haitians' lives in the United States is critical in the
delivery of social-work related services.
Religion
Haiti is predominantly a Catholic country, where at least
80% of the population practices this religion in herited
from the French colonizers. Sixteen percent of the
population is Protestant. In addition to being Catholic or
Protestant, a significant portion of the population are
Vodou believers and practitioners. In fact, there is a
popular saying that claims that 100% of the Haitian people
serve the Vodou spirits, known as lwas, which are
considered guardian angels or protectors. Vodou (also
spelled Voodoo, Vaudou, Vodu, or Vodun) is a religion
that Haitians inherited from the African slaves who were
brought to the French colony of SaintDomingue. One of
the major aspects of this religion is its healing function
(Zephir, 2004). "It is a system of beliefs and practices that
gives meanings to life: it uplifts the spirits of the
down-trodden who experience life's misfortunes ... and
relates the profane world of humans to that of
incommensurable mythological divine entities, called
lwas, who govern the cosmos" (Desmangles 1992, pp.
2-3). This fundamental belief in the lwas explains to a
great extent why Haitians, in general, are very reluctant to
seek the help of social work or mental health providers.
They prefer to go to a Vodou priest (or oungan) or a Vodou
priestess (or manbo), who can heal their suffering.
Oungans and manbos use the basements of their homes as
sanctuaries or temples for worship, or rent spaces from
large apartment houses to conduct their ministries (Zephir,
1994). They are well known throughout the Haitian
communities. The best known of Haitian manbos is
undoubtedly Mama Lola, who resides in Brooklyn, New
York. She is regarded as a healer who performs
"treatments" for those in need (Brown, 2001). As
Desrosiers and St. Fleurose (2002)
note, Vodou priests and priestesses are the conduits to the
lwas, and as such they possess the knowledge of the
tradition. In Haitian tradition, misfortune, such as an
untimely death, divorce, illness, or loss of jobs can be seen
as a neglect of the lwas. Therefore, Haitians seek to remedy
their misfortunes by seeking the assistance of their Vodou
priests, in whom many place a greater trust than in modern
American. intervention techniques, such as counseling or
psychotherapy.
There is a tendency to believe that Vodou practice is
more widely spread among Haitians of lower socio-
economic status who are less educated. However, one needs
to be aware that some members of the so-called higher
echelons of society may be practitioners of both Vodou and
Catholicism, but would only admit to their Catholic
adherence (Brown, 2001). Among Catholic parishioners
there is also the strong belief that prayers can help one
overcome difficulty, and that suffering from whatever
sources-marital or parental abuse, poor health, depression,
financial and familial problems-is a necessary component of
human existence, one that guarantees a special place in
Heaven. Therefore, many believe it might not be very useful
to seek help from social work or mental health providers. In
short, even when Haitian immigrants, irrespective of social
class, are compelled by someone in a position of authority to
go to a counselor, a social worker, or a psychologist, they'
do so with skepticism. Let us not forget that in Haiti,
Haitians are not usually accustomed to seeking these types
of services, again preferring to look for advice and
interventions from spiritual healers, be they Vodou priests,
Catholic priests, or Protestant pastors. Consequently, in the
United States, they continue their habi ts of consulting these
homeland providers, who transplant their services in their
new places of resettlement (Zephir, 2004).
Another factor that prevents a great number of Haitians
from going to a social worker is that they perceive these
individuals as representing the U.S. authorities. The fact
that many Haitians are, indeed, illegal residents causes
them to live in constant fear of deportation. Therefore, they
have no desire to register their presence with a government
agency, as they are not convinced that these agencies
operate on the principle of confidentiality and are not there
to report them to Immigration Services.
Family Structure
The Haitian family structure tends to be hierarchical, like
most West Indian families (Gopaul-Mcl-licol, 1993;
Zephir, 200l). It can be best characterized in terms of a
vertical entity in which the younger members (children)
are subordinate to the old, and where men

are expected to be heads of the family and primarily
responsible for the economic welfare of the household.
Although Haitian women are accustomed to working outside
of the home and contributing to the revenue of the household,
their primary responsibilities still include child-rearing and
housekeeping matters. Indeed, it is the woman who is
supposed to take care of the home, and as the mother, she is
definitely the nurturant and caring figure. Moreover, her duties
include taking care of her husband, attending to his food,
clothing, laundry, and other basic needs. As a result of this
arrangement, women are expected to accept their husbands'
authority and final word on all major decisions (Zephir, 2001,
p. 130).
A great deal of the' information presented here is based on
participant observations and extensive interviews I conducted
with hundreds of Haitian immigrants over a period of ten years
(1994-2004), in New York, Boston, Miami; and Chicago.
Generally speaking, family problems tend to stay and be
dealt with within the family. Haitians do not believe it is the
role of "strangers"-individuals or institutions that report to
federal, state, or city government-to tell them what to do. This
is why Haitian parents are not particularly keen on attending
parent-teacher conferences and responding to notices that ask
them to come to the school to discuss their children's
problems. Similarly, Haitian women rarely admit to being
abused by their husbands. Some tend to believe that they have
been "bad" by perhaps failing to attend to their husbands'
needs. Others simply find excuses for their husbands by
commenting on the difficulties of their jobs or the pressure
they might be experiencing as a result of too many
responsibilities in their attempt to provide for their wives,
children, and extended family members, some of whom reside
in Haiti. Therefore, as "good" wives, their duty is to help their
husbands by not getting them into trouble with the
"authorities" for reporting their abuse. Moreover, Haitian
wives may think they need to be strong for their children who
need their fathers. Many genuinely believe that it is their
mission on earth to live a life of sacrifice and pain, and that by
relying on their faith, life becomes more bearable and the
future a bit brighter. In instances of abuse, religion once more
can provide some comfort, and these women consult regularly
their manbos, and/or go to church with great devotion, saying
special prayers to the Virgin Mary or particular saints.
Haitian men show the greatest reluctance to admitting that
they have a problem (Desrosiers & St. Fleurose, 2002). Illness
is perceived by them to be a weakness, which undermines their
principal role of providers. For them, denial is the best remedy
to the problem. Even
HAITIAN AMERICANS 311
when they become dysfunctional and cannot perform at work
or at home, they attribute their dysfunctionality to
"supernatural causes," such as a jealous co-worker, an inlaw, a
neighbor, or a former political enemy who wishes to cause
them harm by placing a hex on them. Therefore, they try to
immunize themselves from these spe lis by going to their
oungans who can give them some potion or "medicine" to
make them stronger.
Haitian American parents do not dwell on issues of
depression, unhappiness, disappointment, discouragement,
anxiety, and stress. Even when they experience such
symptoms, they want to fulfill their' respective duties to their
families; they want to work and function normally. Most
important, they want to care for their children and afford them
the best possible education. The concern to ensure that their
offspring are successful explains in part why mothers stay in
abusive relationships and hide the sins of their husbands. They
do not want to cause embarrassment to their children, who
might suffer from the break-up of their parents. As for the
fathers, they want to remain in control and convey an image of
inexhaustible strength. In short, going to a social worker or a
mental health practitioner is an admission of weakness that is
unacceptable to a Haitian American parent. This is
undoubtedly the greatest challenge that social workers face
when it comes to the Haitian immigrant population.
Implications for Social Work
Social work providers need to understand first and foremost
that Haitian Americans who are referred to them either by a
regular physician, a place of employment, or perhaps the
court, arrive in their offices with a great deal of reluctance and
suspicion. At the outset, Haitians exhibit a great deal of
mistrust toward these providers who, they believe, do not
understand anything about their value system. Therefore,
winning the trust of the Haitian client must be the first obstacle
to overcome. In order to do so, the social worker needs to
acknowledge the role of religion in Haitian lives, and mention
that their regular spiritual healers probably do not disapprove
of them seeking the assistance of American providers to help
them overcome problems caused by life. in America. They
might also want to explain to their clients that they too want to
make them stronger, so that they can continue to perform
successfully all their duties to their families, and be sheltered
from whatever harm their "enemies" might want to cause
them. Once trust is gained, the social worker needs to accept
the various reasons the client provides to explain his or her
problems, and acknowledge their validity. The therapist needs
to present himself or herself as an ally to clients, one who can
offer additional remedies to their difficulties
312 HAITIAN AMERICANS
because he or she comes from the vantage point of knowing
the American system. Since Haitian immigrants now live in
America, the help of American allies-or people with great
familiarity with the American system-is a desirable thing that
has added benefits. It is fair to assume that, while in the care of
a social worker or a therapist, Haitians continue to consult
their oungans and manbos, Catholic priests, or Protestant
pastors for these very same problems. Therefore, it is critical
for social workers operating within the American system to
highlight the additional benefits they can offer, which make
them worthy of the trust the client places in them and of the
time this client spends with them.
REFERENCES
Arthur, c., & Dash. M. ]. (1999). Libete: A Haiti Anthology.
Princeton, N]: Markus Wiener.
Brown, K. M. (200l). Mama Lola: A Vodou Priestess in Brooklyn
(Znd ed.). Berkeley: University of California Press.
Desrnangles, L. (1992). The faces of God. Chapel Hill: University of
North Carolina Press.
Desrosiers, A., & St. Fleurose, S. (2002). Treating Haitian parents:
Key cultural aspects. American Journal of Psychotherapy, 56(4),
508-521.
Gopaul-McNicol, S. A. (1993). Working with West lndianfamilies.
New York: Guilford Press.
Heinl, R. D., Heinl, N. G., & Heinl, M. (1996). Written in Blood: The
story of the Haitian People, 1492-1995. Lanham, MD: University
Press of America.
Zephir, F. (1996). Haitian immigrants in Black America: A socio-
logical and sociolinguistic portrait. Westport, CT: Bergin &
Garvey.
Zephir, F. (2001). Trends in ethnic identification among second-
generation Haitian immigrants in New York City. Westport, CT:
Bergin & Garvey.
Zephir, F. (2004). The Haitian Americans. Westport, CT:
Greenwood Press.
SUGGESTED LINKS
Asosyasyon Fanrn Ayisyen nan Boston (Association of Haitian
Women in Boston, also known as AF AB)
http://www .afab-kafanm. org
Center for Community Health Education and Research (CCHER, in
Boston)
http://www.ccher.org
Fanm Ayisyen Nan Miyami (Haitian Women of Miami, also known
as FANM)
http://www.fanm.org
Haitian American Community Association (HACA, in Chicago)
http://hacachicago . com
Haitian Centers Council (in New York)
http://www .hccinc .org
National Coalition for Haitian Rights (CCHR, in New York)
http://www.nchr.org
-FLORE ZEPHIR
HARASSMENT. See Sexual Harassment.
HARM REDUCTION
ABSTRACT: Harm reduction is a helping strategy that
attempts to alleviate the social, legal, and medical con-
sequences associated with unmanaged addiction, and in so
doing, limit the harms, such as infectious disease (HIV,
hepatitis), violence, criminal activity, and early death, without
necessarily attempting to "cure" the addiction. While
abstinence may be an ideal outcome from a harm reduction
standpoint, abstinence is viewed as only one of several means
of improving a person's life. Harm reduction strategies are
I
well known in the U.S. through methadone maintenance and
syringe-exchange programs, and are increasingly relied on in
the treatment of co-existing disorders.
KEY WORDS: harm reduction; addiction treatment; client
self-determination; co-existing disorders; assertive
community treatment; drug policy
Harm reduction is a helping strategy that suggests the most
pragmatic way to engage people in positive change is to focus
on making risky behaviors less risky, without necessarily
insisting that the behavior be changed. Instead of demanding
abstinence from a person who is injecting illegal drugs, a harm
reduction strategist would offer various means to reduce the
risks of potential harms, such as homelessness, contracting
HIVjAIDS, injection abscesses, legal consequences, or
whatever is of concern to the person. Abstinence may be part
of that choice, but is not a requirement for engaging with the
person. Needle-exchange and methadone maintenance
programs exemplify the principles of harm reduction in the
United States (van Wormer & Davis, 2008).
Harm reduction strategies developed from grassroots
movements in England and the Netherlands during the 1980s
to combat the alarming spread of AIDS. In the Netherlands,
drug addicts using syringes formed a]unkie bond (Junkie
League) to represent the interests of addicts to government
officials and raise issues such as distributing methadone and
free sterile syringes, police policies, and housing problems.
These efforts led to the opening of the first syringe exchange
program in Amsterdam in 1984. Since then, policies in the
Netherlands, England, Canada, Australia, and other countries
have been revised to reflect the goal of "normalization," that
is, improving the addict's ability to function in society instead
of punishing addicts for their inability to maintain abstinence
(Miller & Carroll, 2006).
t
I HARM REDUCTION
Harm reduction strategies are based on the follow ing
assumptions (Marlatt, 1998): (l) society has never been free
of high risk behaviors, thus it is impractical to base
intervention solely on abstinence from these behaviors; (2 )
many strategies help to improve function ing, and should be
available as choices to all persons wanting to change; (3) a
public health approach, reducing stigma, is pref erable to
the moral/criminal and disease models of addiction; (4 )
low-threshold access to services (outreach with no
requirements of giving up the behavior) is more effective in
engaging many people than high- threshold approaches
(abstinence from the risky behavior is required for
admission to services); and (5) the primary focus of
concern is what needs to be done to reduce harm and
suffering for both the individual and society.
Syringe exchange programs (SEPs) to prevent the
spread of HIV/AIDS and other blood-borne infections are
one of the most well-researched harm reduction programs
in the United States, and at the same time, politically
controversial. According to the Centers for Disease Control
(CDC, 2005), and the National Insti tutes of Health (Health
and Human Services, 1998) reports to Congress, ensuring
that injection drug users have access to sterile syringes is
one of the most effective strategies for reducing the risk of
these infections by 30% or more and other risk behaviors
by as high as 80%. In addition, SEPs are cost effective :
preventing one HIV infection by SEPs costs $4,000 to
$12,000 compared to an estimated $190,000 in medical
costs for a person infected with HIV (CDC, 2005). In spite
of the evidence and the determination of Secretary of
Health and Human Services Donna Shalala in 1997 that
such programs reduce the transmission of HIV and do not
encourage the use of illegal drugs, Congress has refused to
fund SEPs, although the United States is one of the largest
funders of AIDS prevention in the world.
Harm reduction practices are not limited to the
substance abuse field. For example, in pathological
gambling, serious inquiries have risen about the efficacy of
offering "controlled gambling," as a treatment op tion, in
the light of a study that found some gamblers can eliminate
the harms of their excessive gambling by controlling the
amount of money bet, and the amount of time spent
gambling (Ladouceur, 2005). Although the results were
preliminary, the author noted that none of the participants
would have been willing to engage in treatment if the
requirement had been absti nence. Another experiment in
harm reduction practices found that manipulating the
sensory features of video poker machines to no sound and
slow speeds (instead of clanging bells and whistles and
high speed spinning reels) reduced the risk of abuse by
pathological
313
gamblers, while having minimal effects on the behavior of
non-pathological gamblers (Loba, Stewart, Klein, &
Blackburn, 2002).
Harm reduction in the mental health field has developed
primarily in the treatment of co-existing dis orders. An
example of harm reduction practices is the assertive
community treatment (ACf) model, which was developed
in response to the plight of severely mentally ill persons
(who often had substance use disorders) who were
discharged from hospitals in the 1970s. This is a harm
reduction model that advocates flexible methods; gradual
progress toward rehabilitation, not cure; client-
empowerment; and client-centered goals. Essential fea tures
of the ACf program include a multidisciplinary team
approach; community outreach; the integration of services
such as housing, addiction treatment, and mental health
services; and individualized, time-unlimited ser vices.
(Marx, Test & Stein, 1973).
ACf programs can be found throughout the United
States, Canada, U.K., and Australia. An example of how
the ACf program can work is found in the awardwinnin g
Pathways to Housing program, New York (Psy chiatric
Services, 2005). Based on the idea that housing is a right ,
not a "reward" for compliant behavior, Path ways seeks to
help the most vulnerable clients: people who have lived on
the street a long time, have psychiatric and addiction
disorders, and other health problems and hardships. The
program offers them immediate, perma nent housing, and
uses ACf teams to address mental health and addiction
problems. Decision-making author ity and charting the path
to a better life is in the hands of the clients
Challenges and Future Trends
The harm reduction approach engenders considerable
controversy, even in countries where there is a long standing
tradition of tolerance for an individual's beha vior. It has
been criticized as a dangerous approach that makes it easier
for addicts to keep on being addicted by furnishing shelter,
food, clean needles, and a potent excuse to continue the
addiction. Many established treatment centers in the United
States impose a highthreshold goal of "abstinence- only,"
based on the belief that alcohol and drug addiction are
progressive, fatal "diseases" that never get better once you
have them. Harm reduction proponents counter with the
argument that a majority of people with alcohol, tobacco, or
drug problems recover with no formal treatment; that a
choice of goals tends to result in greater treatment retention
and the recruitment of a broader range of people with
problems; and when given a choice, people tend to choose
the goal that is most appropriate for the severity of their
problems (Miller & Carroll, 2006).
314 HARM REDUCTION
In national and international policy debates, harm
reduction advocates have challenged the existing pol icy in
several areas. On the international level, harm reduction
advocates demand that instead of measuring the success of
various drug policies by changes in use rates, countries
should measure the change in rates of death, disease, crime
costs, and environmental damage (Roberts,
Bewley-Taylor, & Trace, 2006). In the Uni ted States, harm
reduction proponents have vigorously protested inequities
in the availability of resources for treatment, and the extent
to which addicts are penalized, jailed, and punis hed
through policies shaped by federal and state governments'
"war on drugs." Under the George W. Bush administration,
the funding priorities continue to support the "war," not
treatment, with 65% spent on interdiction (supply control )
and 35% on treatment and prevention.
Roles of Social Workers
In their steadfast insistence that people are capable of
making an informed choice in their own best interest, and
that it is a person's right to be provided choices, harm
reduction proponents mirror the social w ork values of
honoring people's dignity and self-determination. Be cause
harm reduction philosophy departs from traditional
treatment practices in the United States by including more
options than abstinence, it challenges us to research and
identify the best empirically based practices and advocate
these. In the case of programs such as SEDs, evidence is
clearly not enough and social justice advocacy is needed to
continue to educate and inform the public, members of
Congress, and law enforcement about the i mportance of
access to sterile syringes. Ideally, the results of research
and advocacy efforts would be the availability of a
multifaceted approach at all levels of care, which couples
research and practice and is based on evidence, not politics
or tradition.
REFERENCES
Centers for Disease Control. (2005). Syringe exchange programs.
Retrieved February 2007 from http://www.cdc.gov/idu/facts/
AED _IDU _SYR.pdf
Health and Human Services. (998). Needle exchange programs:
Part of a comprehensive HIV prevention plan. Retrieved from
http://www .hhs.gov /news/press/ 1998pres/9804 20b.html
Ladouceur, R. (2005). Controlled gambling for pathological
gamblers. Journal of Gambling Studies, 210),51-59.
Loba, P., Stewart, S. H., Klein, R. M., & Blackburn, J. R. (2002).
Manipulations of the features of standard video lottery
terminal (VLT) games: Effects in pathological and
non-pathological gamblers. Journal of Gambling Studies,
17(4),297-320.
Marlatt, G. A (998). Harm reduction: Pragmatic strategies for
managing high-risk behaviors. New York: Guilford Press.
Marx, A J., Test, M. A, Stein, L. 1. (973). Extrohospital
management of severe mental illness, feasibility and effects of
social functioning, Archives of General Psychiatry, 29, 505-511.
Miller, W. R. & Carroll, K. M. (2006). Rethinking substance abuse:
What the science shows. New York: Guilford Press.
Psychiatric Services. (2005).2005 American Psychiatric Associ-
ation Gold Award: Providing housing first and recovery services for
homeless adults with severe mental illness. Retrieved January 6,
2007, from http://www.psychservices.psychia tryonl
ine.org/cgi/ con tent/full/ 56/10/1303
Roberts, M., Bewley-Tayler, D., & Trace, M. (2006). Monitor ing
drug policy outcomes: The measurement of drug-related harm.
Beckley Foundation Drug Policy Programme. Retrieved
January 10, 2007, from http://www.idpc.info/docs/Beckley
Foundation Report , 09. pdf
Van Wormer, K. & Davis, 0. R. (2008). Addiction treatment:
A strengths perspective.Thomson/Brooks/Cole.
- DIANE RAE DAVIS
HATE CRIMES
ABSTRACT: Hate crimes and their traumatic repercus-
sions are an important. area for social worker interven tion.
This entry will examine how hate crimes are defined and
handled, and the difficulties inherent in categorizing and
responding to them. Collection of hate
. crime statistics and hate crime-relat ed legislation are
reviewed. The entry will also examine how social work ers
can help victims and perpetrators and influence how
society conceptualizes and prevents hate crimes and their
consequences.
KEY WORDS: hate crime; bias crimes; social work
interventions; policy; victims
Violence motivated by hate has been part of the fabric of
human culture since the beginning of time (Jenness &
Grattet, 200I). The modern conceptualiza tion of hate
crimes is traceable to the civil rights move ment of the
1960s and war protest movements of the late 20 th century
(Jenness & Grattet, 2001). Since 1993, a few
overwhelmingly tragic cases of hate motivated. violence
have captured the public's attention so much that the 1990 s
have been referred to as the "decade of hate- or at least of
hate crimes" (Rovella, 1994, p. AI). Hate crimes and their
traumatic repercussions are an important area for social
worker intervention. Work with the individuals,
communities, and societies affected by hate crimes is an
integral part of the profession's ethical responsibility to
work for social justice and to prevent domination of,
exploitation of, and discrimination against persons and
groups based on

"race, ethnicity, national origin, color, sex, sexual or-
ientation, age, marital status, political belief, religion, or
mental or physical disability" (NASW, 1999, p. 27).
This entry will first examine how hate crimes are
defined and handled, and the difficulties inherent in
categorizing and responding to them. It will also exam ine
how social workers can help victims and perpetra tors and
influence how society conceptualizes and prevents hate
crimes and their consequences.
Hate crime effects extend far beyond their direct
victims. Through the widespread creation of fear, these
crimes make everyone feel vulnerable, particularly those
with similar demographic characteristics as the victims. In
their most extreme form, hate crimes attempt to ex-
terminate a segment of'the population (Powers, 2002 ).
Beyond the devastating psychological impact, hate crimes
and crimes committed en masse or in the extreme can lead
to mass violence. Most 20th- century genocides or ethnic
cleansings against groups such as Armenians, Jews, and
Bosnians began with individuals or small groups taking
actions against populations that began small and grew
exponentially (Powers, 2002). This may lead to
retaliation, counter-retaliation, social unrest, and poten-
tially civil war. These dangers to individuals, families,
groups, communities, and society led to increased pe-
nalties assigned for hate-related crimes in the United
States (ADL, 1999).
Under federal law, a crime motivated, in whole or in
part, by the victim's actual or perceived race, color,
religion, national origin, ethnicity, gender, disability, or
sexual orientation is a "hate crime" (Krouse & Beaver,
2006). Investigation, prosecution, and adjudi cation of
hate - crimes mostly rest at the state level. Forty- three
states and the District of Columbia have specific hate
crime statutes. These statutes generally follow the
Anti-Defamation League penalty enhance ment strategy,
which allows for a more serious sentence to be prescribed
to those who chose the victims of their crimes based on
the race, religion, national origin, sexual orientation, or
gender of the victim, or on the offender's perception of
such (Wallace, 2006).
All states have legislation that allows some prosecu-
tion of hate crimes (Wallace, 2006). The federal gov-
ernment's involvement is limited to jurisdiction over hate
crimes affecting federally protected rights such as voting,
nationwide hate crime reporting, regulating inter- agency
cooperation in hate crime investigations, and funding hat e
crimes prevention among populations such as juveniles
and members of the armed services. Despite efforts in
recent years by members such as Senator Edward M.
Kennedy (D-MA) and Congressman John Conyers
(D-MI) to expand the federal government's jurisdic tion
over hate crimes with legislation
HATE CRIMES 315
such as the Local Law Enforcement Act of 2005 and other
similar bills, legislation has not been enacted to expand
the federal government's jurisdiction in this area. This
legislation's opponents argue that hate crimes are best
handled at the state and local levels, that the constitutional
rationale for such federal legis lation is weak, and that
such legislation would be more symbolic than effective
(Krouse & Beaver, 2006).
The U.S. Department of Justice records hate crime
statistics using two distinct methods. The FBI's Uni form
Crime Reporting (UCR) program publishes hate crimes as
reported by state and local law enforcement agencies. The
Bureau of justice Statistics (BJS) gathers data about crime
victims through the National Crime Victimization
Survey. Less than half of the crimes de scribed to the BJS
by victims as hate-related have been reported to law
enforcement agencies. The BJS annual numbers are nine
times higher than the FBI's statistics. This significant
discrepancy suggests that the UCR ser iously underreports
incidents of hate crimes (Krouse & Beaver, 2006).
Reasons for the FBI's underreporting of hate crimes
include victims' fear of retribution against themselves,
their family, or other group members; disagreements
about whether violent crimes against women should be
considered hate crimes (Gross, 1999; McPhail & DeNitto,
2005); difficulty in defining how much hate must be
present for an act to be classified as a hate crime
(McPhail, 2000); and victims' unwillingness to "out "
themselves as a member of a stigmatized group
(Swigonski, Mama, & Ward, 2006).
Social workers are in a key position to educate, help
prevent, and ameliorate the devastating consequences of
hate crimes from a variet y of positions. They interact with
those directly affected by hate crimes: victims, per-
petrators, and family members. They also assist commu-
nities to prevent or handle instances of hate crimes and
advocate for stronger hate crime-related public policies.
Many hate crime victims experience a series of attacks
rather than a single episode (Barnes & Ephross, 1994).
They feel overwhelmed, angry, fearful, and sad, and may
make significant life changes in the wake of the hate
crime. Some may suffer from post-traumatic stress
syndrome (PTSS). Effective services to these indi viduals
include intensive, short-term interventions best suited to
their intense emotional reactions (Barnes & Ephross,
1994). Group services provide a supportive and
therapeutic environment with others who have had si milar
experiences. As compared to victims of similar attacks
not motivated by hate, hate crime victims are less likely to
experience reduced self-esteem or to blame themselves
for the crime and wonder if they should or could have
behaved differently (Barnes & Ephross, 1994). In addition
to helping individuals, social workers
316 HATE CRIMES
also intervene in systems: schools, cornmuruties, and
organizations that have experienced instances of hate crimes.
Although victims understandably receive the most attention,
hate crime perpetrators also require sustained interventions to
control hateful actions. Research on the perpetrators of these
crimes suggests they may be thrill-seekers, or they may be
responding to a triggering incident, a delusion, or a hate group
(Levin & McDevitt, 2002). While few hate crimes are directly
linked to hate groups, such groups do create all. atmosphere
conducive to hate crimes (Jacobs & Potter, 1998). In this realm,
counseling and violence prevention programs can be effective
alternatives to prison environments, which can magnify feelings
of hate and bias. As schools have experienced escalating
violence, they have been receptive to innovative programs in
violence reduction and prevention. In fact, many schools have a
violence reduction or prevention program in place, focusing on
skill building and sometimes individual counseling (Astor et al.,
1998). School social workers working in concert with community
groups could provide a natural linkage to effectively prevent,
reduce, or manage violence.
Social workers also play important roles in helping
communities deal with violence and hate crimes. Social workers
can combine direct service with community mobilization to help
communities deal with the consequences of hate. Community
members can work to act, unite, support victims, obtain accurate
information, refrain from responding to hate with hate, lobby
community leaders, and teach and practice tolerance (SPLC,
1999), all actions congruent with social work values and skills.
REFERENCES
Anti- Defamation League. (1999). Hate crimes laws introduction.
Retrieved November 15, 2007, from http://www.adl.org/
99hatecrime/inrro.asp
Astor, R. A, Behre, W. j., Wallace, ]. M., & Fravil, K. A (1998).
School social workers and school violence: Personal safety,
training, and violence programs. Social Work, 43, 223-232.
Barnes, A, & Ephross, P. H. (1994). The impact of hate violence on
victims: Emotional and behavioral responses to attacks. Social
Work, 39, 247-25l.
Gross, E. (1999). Hate crimes are a feminist concern. Affilia,
14,141-143.
]acobs,]. B., & Potter, K. (1998). Hate crimes: Criminal law and
identity politics. New York: Oxford University Press.
Jenness, Y., & Grattet, R. (2001). Making hate a crime: From social
movement to law enforcement. New York: Russell Sage.
Krouse, W. ]., & Beaver, ]. C. (2006). Hate crime legislation in the
109th Congress. Washington, DC: Congressional Research
Service.
Levin, ]., & McDevitt,]. (2002). Hate crimes revisited: America's war
against those tuho are different. Boulder, CO: Westview Press.
McPhail, B. A (2000). Hating hate: Policy implications of hate crime
legislation. Social Service Review, 74, 635-653.
McPhail, B. A, & DeNitto, D. M. (2005). Prosecutorial perspectives
on gender-bias hate crimes. Violence Against Women, 11(9),
1162-1185.
National Association of Social Workers. (1999). Code of Ethics.
Washington, DC: Author.
Powers, S. (2002). A problem from Hell: America and the age of
genocide. New York: Basic Books.
Rovella, D. E. (1994). Attack on hate crime is enhanced.
National Law Journal, August, AI.
Southern Poverty Law Center. (1999) . Ten ways to fight hate:
A community response guide. Montgomery, AL: Author.
Swigonski, M. E., Mama, R. S., & Ward, K. (Eds.). (2006).
From hate crimes to human rights: A tribute to Matthew Shepard.
New York: Haworth Press.
Wallace, P. S.,]r. (2006). Hate crimes: Legalissues. Washington, DC:
Congressional Research Service.
SUGGESTED
LINKS Anti-Defamation League
http://www.ad!. org/99hatecrime/intro .asp FBI
Uniform Crime Reporting
http://wwwfbi.gov/ucr/ucr.htm
Matthew Shepard Foundation
http://www . matthewshepard.org/
National Coalition for the Homeless http://www .
nationalhomeless .org/hatecrimes/ Southern
Poverty Law Center
htt!):/ /www.splcenter.org/
-NANCY A. HUMPHREYS AND SHANNON R. LANE
HEALTH CARE. [This entry contains two subentries:
Overview; Practice Interventions.]
OVERVIEW
ABSTRACT: This entry provides all. overview of the state of
health care in the United States. Service delivery problems such
as access and affordability issues are examined, and health care
disparities and the populations affected are identified. A
discussion of two primary government sponsored health care
programs-Title XVIII (Medicare) and Title XIX (Medicaid)-are
reviewed along with other health care programs and major
existing service delivery systems. Ethical conflicts in providing
health care, and new directions and challenges are discussed,
along with future roles for social workers.

KEY WORDS: health care affordability; health care access;
health care disparities; Medicare; Medicaid; managed
care; interdisciplinary care; collaborative med ical care;
bioethics
Health care in the United States is in the forefront of national
debates that highlight the problems and the costs of providing
even the most basic of services equitably across all
populations of people. The United States spends a larger share
of its gross domestic product (GDP) on health care than any
other major industrialized country. Approximately 16% of the
nation's GDP was spent on health care in 2004 (Kaiser Family
Foundation, 2006). Despite these growing expenditures, the
United States is the only industrialized country without
national health insurance. The high expenditures do not
guarantee equal access to health care; in fact, there are
significant disparities by race, gender, and income levels in
terms of health care quality and access (Agency for Healthcare
Research and Quality [AHRQ], 2006). A survey conduc ted by
the Commonwealth Fund Commission on a High Performance
Health System reported that 48% of adults in middle income
families had serious problems paying for health care and
health insurance. Even households with incomes of $50,000 or
higher reported serious medical bill problems (Roszak, 2006).
National attention is focused on what to do about how to
improve accessibility and affordability of health care in this
country. This question is one that the United States has
struggled over the years to resolve.
Health Care Affordability
Health care affordability is both a societal (macro level) issue
affecting government and systems and a personal (micro
level) issue that affects individuals and families (Chernew,
Hirth, & Cutler, 2003). From a macro perspective, recent
health care spending has risen at a rate that exceeds other
economic sectors. There has been a national focus to contain
health care costs with a vision on how to allocate scarce
resources and still meet the most critical health care needs
(AHRQ, 2006).
Others contend that the issue is less about affordability and
more about how society values health care and whether we are
willing to spend more on it. Chernew et a1. (2003) observed
that, in the past, overall income growth was substantial enough
to allow growth in non-heath care spending by the public and
private sectors even with the growing share of GDP spent on
health care. Their economic model suggests that real health
care spending increases one or two percentage points faster
than real GDP and is predicted to be affordable for most
citizens through 2039 and beyond. The authors are quick to
point out however
HEALTH CARE: OVERVIEW
317
that what is affordable on the average may not be affordable to
all segments of society. Increases in health care costs will
affect health insurance coverage and contribute to problems in
accessing care.
In 2004, per capita health care costs were estimated to be
about $6,300 (Centers for Medicare and Medicaid Services,
2006a), with projections that this cost will increase to about
$12,300 per capita in 2015 (Citizen's Health Care Working
Group, 2006). As health costs rise, the number of uninsured
individuals continues to grow. It is estimated that over 46.6
million people in the United States had no health insurance at
any time in 2005 (DeNavas-Walt, Proctor, & Lee, 2006), and
29 million have been uninsured for more than a year (Cohen &
Martinez, 2005).
There are many reasons for an increase in uninsured
Americans. For nonelderly individuals and families, health
insurance coverage is obtained primarily through employers.
The decline in economic conditions has resulted in more
individuals being unemployed or underemployed Each
employment change has the potential to affect health
insurance benefits. Even in times of employment, individuals
may find that health care benefits are beyond their economic
reach. In challenging economic times, employers drop health
insurance coverage as a benefit or shift costs to their
employees. Only two-thirds of American workers are offered
health insurance by their employers (National Center for
Health Statistics, 2004) and when offered, it is often cost
prohibitive to purchase. It is estimated that 20% of employed
workers cannot afford the health insurance offered by their
employers. An average annual premium costs $9,068 for
family coverage and 27% of this cost is passed on to the
employee (Mitka, 2004).
While the offering of health benefits has remained fairly
constant in large firms of 200 or more employees, firms with
less than 200 workers are less likely to offer health insurance.
Since 2000, there has been a 9% point drop in the number of
small firms tha t offer health benefits (Kaiser Family
Foundation, 2006). People are at risk for becoming uninsured
during life transitions. Circumstances such as no longer being
considered a dependent on a parent's policy, transition from
student to ,employee, retiring before age 65, or losing a spouse
through divorce or death place people at risk for losing' their
health insurance. For individuals dependent on
government-sponsored health insurance, budget deficits at the
federal, state, and local levels result in reductions in coverage
affecting families in or near poverty. Figures indicate that 10.5
million persons who were at or below the poverty level were
not eligible for government sponsored insurance (Robert Wood
Johnson Foundation, 2004).
318 HEALTIl CARE: OVERVIEW
Affordability of prescription drugs is another health care
problem facing Americans. Prescription drug costs have risen
rapidly in the last decade since the mid1990s. A growing
population of people (estimated at 16.6 million in 2004) was
unable to afford their prescribed medication, which leads to
prescription noncompliance or the inability to take medication
as directed by their physician (Kennedy, Coyne, & Sclar,
2004). Persons in poor health and the uninsured are at
particular risk for prescription noncompliance. Prescription
noncompliance due to cost occurs more frequently for
women, working age adults, racial and ethnic minorities,
Medicaid and Medicare beneficiaries, and heavier medical
care users.
Accessibility of Health Care
The u.s. Institute of Medicine (10M) defines access as "the
timely use of personal health services to achieve the best
possible outcome" (Millman, 1993). It requires an adequate
supply of health services to cover basic needs. Indicators of
accessibility often include such factors as the number of
doctors, hospital beds per capita, and costs to the individual.
However, another wide range of factors includes geography
and environment, social and cultural influences, financial and
insurance barriers, organizational and systemic barriers,
efficiency and effectiveness, and inequity in service
availability (Gulliford et al., 2002). Access to even basic
health care services in this country is uneven.
Access is also uneven in rural areas because hospitals,
clinics, and public health facilities are in short supply
(Berkowitz, 2004). Where health care facilities exist, the
availability of physicians, nurses, social workers, and other
medical personnel to staff the facilities is problematic.
Transportation and access problems exist for both patients and
staff. Funding is scarce and access to grant funding is often
limited.
Unequal access to health care affects women, particularly
those who earn less, lack health insurance, and have limited
employment opportunities (Anderson & Keegan, 2004).
Uninsured women often delay or forgo health care, which can
lead to more serious health concerns. Mann, Hudman,
Salganicoff, and Folsom (2002) reported that low-income,
uninsured women are 2.5 times more likely to report a delay in
attending to their health care needs than low-income women
having government sponsored or private health insurance.
The lack of health insurance affects other populations as
well. About 80% of the uninsured were in working families.
Of this employed group, 20 million persons who were
uninsured had full-time jobs, and 6 million had part-time jobs
(U.S. Census Bureau, 2002). In relation to race, 52% of the
uninsured were non-Hispanic Whites; however, Hispanics
and African Americans
were more likely to be uninsured than non-Hispanic Whites.
The nonelderly age group is the most likely to experience
being uninsured with 49.6% of 18-24-year olds falling in this
category and 32.7% of 25-44-year olds having no insurance.
More than 3 million adults in the 55-64 age range lack health
insurance. The youngest population is also vulnerable, with
8.5 million children under age 18 uninsured (Mc Lellan,
2003).
The uninsured lack a consistent source of medical care and
rely on emergency services for treatment. The uninsured are
four times more likely to use emergency care than are insured
individuals (T unzi, 2004), but receive fewer diagnostics and
treatment services, and less follow-up care. In 2001,
uncompensated health care amounted to $35 billion dollars
(10M, 2003).
The Institute of Medicine (2002) reports that the uninsured
have worse clinical outcomes for health and lack access to
preventative services and screenings. The lack of health
insurance results in higher rates of morbidity and mortality.
Consequences of receiving inadequate care including fewer
diagnostic and treatment services and a lack of access to
medications and follow-up medical appointments.
Health Care Disparities
Disparities in health care exist in the United States and are
often framed through two different perspectives. One
perspective is the disease focus, which measures disparities in
terms of disease prevalence and morbidity factors. The second
perspective is the population health perspective, which uses an
ecological model and incorporates all circumstances that
influence health, emphasizing the interacting factors that exist
at both individual and community levels (Kumanyika &
Morssink, 2006). There are several defini tions of health
disparities as well. The 10M defines a disparity as a difference
in treatment provided to members of different racial or ethnic
groups that is not justified by the underlying health condition
or treatment preferences of the patient (10M, 2002). While this
definition provides a starting point to recognize and address
disparities, differences in treatment have also been
documented to occur based on gender, socioeconomic,
geographical, and other factors. A broader definition of health
disparities incorporates differences based on these factors.
Healthy People 2010 developed such a definition-differences
in disease prevalence or treatment by sex, race, or ethnicity,
educational attainment, income, sexual orientation, or
geographical location (U.S. Department of Health and Human
Services, 2000).
Federal recognition of health disparities occurred as early
as 1979 when the Surgeon General's report on health
promotion and disease prevention included

health priorities. This report led the u.s. Department of
Health and Human Services to publish federal guidelines in
the spring of 1980. Fifteen strategic areas and targets for
intervention were identified (U. S. Department of Health and
Human Services, 2000). This initiative became the model for
the Healthy People 2000 campaign that identified the
reduction of health disparities as a main objective. Despite a
focus on reducing health disparities, by the end of the 1990s,
the data showed that while disparities had been reduced,
significant gaps in health care remained. These data provided
the impetus for the next initiative, and in January 2000,
Healthy People 2010 was launched; eliminating health
disparities was one of its two major goals.
Despite federal efforts.idisparities continue to exist.
The largest disparities in quality care and access occurred
among low-income people regardless of race and gender. A
2002 Institute of Medicine (lOM, 2002) report also indicated
that significant disparities remained for lower income
populations in relation to access and use of health care
services (Swift, 2002) and a 2003 10M report identified that
disparities in health outcomes exist among minorities
(Smedley, Stith, & Nelson, 2003). The 2005 National
Healthcare Disparities Report revealed that while racial
disparities in quality of care and access to care were
narrowing, these disparities still exist, particularly for
Hispanic populations (Hand, Chesley, Ho, & Clancy, 2006).
To reduce remaining disparities, the 10M calls for the
development and dissemination of evidence-based clinical
practice guidelines, which encourage consistent, quality
health care, and a move toward preventative care provided by
multidisciplinary teams. An increase in the number of
minority health professionals to more closely compare with
the changing demographic characteristics of the U.S.
population is also recommended (Sullivan Commission,
2007).
Two Major Policies
The two main acts that provide government sponsored support
for health care are Title XVIII and Title XIX of the Social
Security Act, originally administered by the Department of
Health, Education, and Welfare, now called the Department of
Health and Human Services.
MEDICARE Title XVIII of the Social Security Act was
enacted in 1965 to specifically address the medical care needs
of the elderly and disabled. Referred to as Health Insurance
for the Aged and Disabled, or Medicare, this program
establishes health insurance for aged persons over the age of
65 and eligible disabled individuals. It is an offshoot of a
group of social insurance programs
I
HEALTH CARE: OVERVIEW
319
legislated by the Social Security Act called Old Age,
Survivors, Disability and Health Insurance (OASDHI, with
the HI standing for Medicare). While the original Social
Security Act was enacted in 1935, the Health Insurance
component was the last to be added. In 1973, eligibility was
extended to persons entitled to Social Security or Railroad
Retirement disability cash benefits for 24 months, persons
with end-stage renal disease, and other non-covered aged
persons who elect to pay a premium for Medicare coverage.
The program currently covers 95% of the aged population and
also persons who receive Social Security Disability benefits
(Hoffman, Klees, & Curtis, 2000).
There are several components of Medicare. Employees
and employers must pay into Part A or Hospital Insurance
through a payroll tax. Medicare A provides coverage for the
first 60 days of hospital stays, 20 days of skilled nursing care,
skilled home health care services, and hospice care. Some
services require a co-insurance payment. Workers having
retired at age 65 and having accrued 40 quarters of
employment and their spouses are eligible for Medicare after
they sign up for the program. Retired workers with less
quarters accrued can receive Medicare for a fee (Gorin &
Moniz, 2003).
Medicare Part B is voluntary and beneficiaries contribute
by paying a monthly premium. It provides coverage for
medical services, diagnostic testing, outpatient medical,
hospital rehabilitation and mental health care services,
ambulatory surgery, some home health care not covered under
Medicare A and durable medical equipment. In 2005, about
95% of the nation's older population and the chronically
disabled were covered by Medicare. Part A covered 42 million
enrollees and Part B covered 40 million enrollees (Centers for
Medicare and Medicaid Services, 2006).
Medicare C is the Medicare + Choice program, established
by Public Law 105-33 in 1997. This program is provided
through the private sector and has a variety of plan options.
These plans may include coordinated care plans, including
health maintenance organizations (HMOs), provider
sponsored organizations (PSOs), preferred provider
organizations (PPOs), and other certified, coordinated private
health care plans. Certain fee for service (FFS) plans that
allow beneficiaries to select certain private providers are also
available under Medicare Part C. Another option under
Medicare Care medical savings account (MSA) plans after a
deductible is met. Medicare deposits money into an account on
an annual basis, and the beneficiary uses the money in the
account to pay for medical expenses (Hoffman, Klees, &
Curtis, 2000). All Medicare + Choice plans must provide the
basic Medicare benefit package excluding hospice care. Plans
may offer additional services.
320 HEALTH CARE: OVERVIEW
Medicare Part D is the new, voluntary prescription drug
plan that went into effect January 1, 2006, as authorized by
the Medicare Modernization Act. The plan entitles
enrollees to lower-cost prescription dr ugs. Medicare
recipients who did not enroll in the program by May 15 may
face penalties (i.e., higher premiums). Recipients generally
choose from between 20 and 60 plans approved by
individual states and offered by private providers. Each
plan has a different formulary, monthly premium, and
deductibles. Persons who are receiving drug coverage
through other private insurance such as an employer's
retirement benefit can opt out of the plan. Even with Part D
coverage, gaps still exist. The plan pays up to $2,250
annually. Recipients pay for costs exceeding that cap until
the costs reach $3,600 (some higher premium plans do
provide coverage for the gap). At $3,600 catastrophic
coverage kicks in, and Medicare will pay for 95% of
remaining costs. Despite the drug coverage offered, there
are problems with the Part D enrollment process.
Enrollment information is difficult to find, particularly for
individuals who have limited access to Web site
information. In addition, confusion abounds in the sheer
number of available choices, and formularies may change,
leaving enrollees paying higher costs than they expected.
MEDICAID Title XIX of the Social Security Act estab-
lished a program of health assistance for the poor, which is
commonly referred to as Medicaid. Prior to its enactment in
1965, health care services for the poor were provided
piecemeal through an arrangement of services offered by
state and local programs, charities, and hospitals (Provost &
Hughes, 2000). Modeled on the 1960 Kerr- Mills Act,
Medical Assistance for the Aged, and the Social Security
Amendments of 1950, it was designed as a cooperative
program funded jointly by the federal and state
governments, including the District of Columbia and the
U.S. Territories (Provost & Hughes, 2000).lt is an
entitlement program that pays for medical care for certain
individuals and families that have low income and limited
resources (Hoffman Klees, & Curtis, 2000; Rowland and
Garfield, 2000). Its particular emphasis is on dependent
children and their mothers, pregna nt women, the disabled,
and older persons. Using broad federally established
regulations, each state shapes and administers its own
Medicaid program and develops its own standards. These
standards include eligibility requirements (resource and
assets tests), type, amount, duration, and scope of services,
and rate of payment for services, which creates variability
in Medicaid policies throughout the country. However,
states are required to provide medical coverage for particu-
lar individuals who receive federally assisted income
maintenance payments and for related groups who are not
receiving cash payments.
Medicaid was never designed to provide medical
assistance to all poor persons. States must cover certain
categories of people but have discretion in whether to cover
other groups. States may also develop state- only programs
that provide medical assistance for designated poor persons
who do not qualify for Medicaid. There is great variability
across the country in these optional programs (Hoffman,
Klees, & Curtis, 2000). A "medically needy" option allows
states to cover persons to qualify for medical assist ance
through a "spend down" process in which medical
expenditures must exceed assets owned by the individual.
The Personal Responsibility and Work Opportunity Act
of 1996 (Public Law 104-193) introduced restrictive
changes to eligibility standards for Sup plemental Security
Income (SSI) coverage. SSI is a federal welfare program
for persons with chronic health and mental health con-
ditions and for the disabled. The law imposed restrictions
on SSI eligibility among legal resident aliens and other
qualified aliens who entered the United States on or after
August 22, 1996. The law requires a five- year waiting
period before these individuals can be eligible for SSI
unless states opt to provide Medicaid coverage for them.
Emergency services continue to be mandato ry for these
groups
To address the lack of health insurance for uninsured
children, the Balanced Budget Act of 1997 authorized Title
XXI of the Social Security Act. Title XXI, known as the
State Children's Health Insurance Program (SCHIP),
expanded Medicaid eligibility to include low- income
children whose family's income exceeds Medicaid
eligibility requirements. SCHIP is currently under
legislative review and is targeted to be eliminated.
OTHER HEALTH CARE PROGRAMS While Medicare
and Medicaid are two of the largest government spon sored
programs, there are some other significant programs that
provide health care in America. Five such programs are
Veteran's Health Care, Indian Health Services, cor rectional
facilities health care, public health, and long term care.
VETERAN'S HEALTH CARE Health care for veterans is
provided by the Veteran's Health Administration under the
Department of Veteran's Affairs. Services are provided
primarily to veterans with service con nected disabilities
and who are poor. Care is also avail able for progressive
conditions that stem from a service disability. Eligibility
does vary from site to site (U.S. Department of Veterans
Affairs, 2007; Corder 1998).
I

The Veteran's Health Administration is an integra ted
health care system composed of hospitals, nurs ing homes,
ambulatory care clinics, domicilliaries, and readjustment
counseling centers. Services are structured through the use
of Veterans Integrated Service Net works. The size of these
networks are variable including the type and range of
medical facilities. The networks also contract with the
private sector for some services.
The challenges inherent within the Veteran's Health
Administration is that the focus of care tends to be long
term oriented without an orientation to preventive care.
This orientation often clashes with the overall preventive
managed care focus within the rest of society. Services
provided under this structure are costly and inpatient care
facilities have low occupancy rates and h igher than
average length of stays, which add to the expense of
service delivery. There are close links with university
medical schools, which provide high caliber faculty and
residents to care for the veterans, but these arrangements
are costly.
Case management is a model that has been inte grated
into veteran's health care as well as the use of ambulatory
surgery centers to shift the provision of care away from
hospitals. Patients are followed by primary care providers
and these providers interact with dieti cians, social
workers, pharmacists, psychologists, psy chiatrists, and
other health care disciplines to provide comprehensive
care. While these types of services em phasize more of a
community model of care, veterans report that
coordination of care and communication could be
improved (Parchman, Hitchcock Noel, & Lee, 2005).
Future trends will be directed at providing quality care to
our veterans using less expensive models of care. In
particular, there is a shift to ambulatory and community
oriented care with an emphasis on ongoing monitoring to
evaluate the health of veterans with a goal of improving
their quality of life (Kazis et al., 2004).
INDIAN HEALTH SERVICES Health services for American
Indians and Alaskan Natives has been a federal
responsibility since the early 19th century through
treaties formed between the federal government and
various tribes. The Department of the Interior was re-
sponsible for providing these services until 1955 when
the responsibility was transferred to the Department of
Health, Education, and Welfare as the Division of Indian
Health. It has since been renamed the Indian Health
Service, and it is a national program for federally
recognized Indian tribes (Brenneman, G., Rhoades,
Everett, & Chilton, 2006).
Indian Health Services (HIS) is composed of a com-
prehensive network of 33 hospitals, 54 health centers, 38
health stations, and 34 urban Indian health projects
HEALTH CARE: OVERVIEW 321
located in 35 states and provides care for 1.9 million
Indians from 561 federally recognized tribes. With a
budget of $3.1 billion, services include dentistry, nutri tion,
community health, sanitation, injury prevention, and
institutional environmental services. More than 55% of
Native Americans rely on IHS for their health care needs
(Indian Health Services, 2007a & b). Only 28% have
private health insurance (Roberts, 2000).
IHS is divided into two components. One component
is direct care. This care is pr ovided at an IHS facility.
These facilities are located on reservations and include
pharmacological, dental, mental health, and vision care in
addition to medical services. Another component is
contracted health services that are provided by a non IHS
facility or provider. Native Americans require a referral to
be able to receive services by a non-IHS facility or
provider.
A series of legislative mandates have attempted to
improve health services for Indians. The Synder Act of
1921 established the first fe deral authorized expenditures
for health care services for members of federally recog-
nized tribes. In 1975 the Indian Self- Determination and
Education Assistance Act was enacted, which pro vided
tribes the option of managing their own health care
services and programs. In 1976, the Indian Health Care
Improvement Act was approved, which mandated that the
federal government grant more resources to the Indian
Health Services to enable the program provide adequate
heath care (Guiden & Johnson, 2000; Roberts, 2003).
Despite these mandates, health care among Indian
tribes remains inadequate. The congressional appro-
priations that fund Indian Health Services have not kept
pace with the needs of the Native American population.
There is a lack of coordination between IHS and non- IHS
providers, often resulting in poor care. Also, insufficient
funding results in the rationing of health care services for
Native Americans and Alaskan Natives (Roberts, 2000).
HEALTH CARE IN CORRECTIONAL FACILITIES In the
landmark case of Estelle v. Gamble (429 US97 [1976]), the
United States Supreme Court ruled that indifference to the
health care needs of inmates was a violation of the Eighth
Amendment of the Constitution. This ruling established
health care as a constitutional right of correctional facility
inmates. At the time that the courts made this ruling,
organized medicine became involved in correctional
health care. The American Medical Association
conducted a survey of health services in jails throughout
the country and found substandard care abounded in
correctional facilities. Through a grant received from the
Law
322 HEALTH CARE: OVERVIEW
Enforcement Assistance Administration, correctional health
services standards were developed and a pilot project began to
accredit health programs through state medical associations.
Eventually the National Commission on Correctional Health
Care was developed and this group continues to update
standards for health services in jails, prisons, and juvenile
facilities (Thorburn, 1995).
While the 1970s can be viewed as a time period in which
health services improved in correctional facilities, national
public policy decisions in the 1980s created setbacks in this
area. As crime became a national focus, there was more
reliance on incarceration as the primary sanction for the
conviction of criminal offenses. At the same time, the
National Drug Control Strategy mandated lengthy prison
sentences for drug convictions. These factors created a
swelling of the prison population. As the prison population
rose in numbers, health care facilities were inadequate to take
care of the increased demands. The population in correctional
facilities changed with the addition of a growing number of
drug offenders, incarcerated females, and a correctional
population that is aging in place. These changes drastically
affected the health care needs of correctional facilities.
Specifically, the prevalence of HIV infection among state
prison inmates has increased, and the median incidence of
AIDS among the prison population is 10 times higher than
among the general population. To address this increase, there
is a need for HIV prevention efforts including efforts to
prevent disease transmission. Measures to prevent the spread
of the disease include condom distribution, mandatory testing,
and voluntary testing, and these measures are viewed as
controversial (National Commission on Correctional Health
Care, 2007).
Also, with the increase of an aging population, the
incidence of chronic illnesses has risen along with more
susceptibility to infectious diseases. As this aging prison
population continues to becomes frailer, different health
programs are needed to respond to these health concerns
(National Commission on Correctional Health Care, 2007).
The increase in the female prison population mandates that
different health services be offered to this population. Special
health care services such as regular gynecologic and prenatal
care are required to meet the medical needs of women. In
addition, the monitoring of high risk pregnancies is at a rise
due to such factors as drug use by the mothers in the early
stages of pregnancy.
Challenges in the future for correctional facilities center
on providing services for a population of inmates susceptible
to infectious diseases, working with increased numbers of
female inmates, and responding to an aging population.
Responding to the rising cost of health care in correctional
facilities while mandating
strong public health practices are a necessity both from a
humane perspective and for the protection of the larger
community (National Commission on Correctional Health
Care, 2007).
Public Health
The aim of public health is to protect and improve community
health through education, healthy lifestyle advocacy, and to
promote research on disease and injury prevention. The focus
is on the health protection of entire populations located in
neighborhoods, communities, states, and countries through the
prevention of health problems from happening or reoccurring.
The Centers for Disease Control and Prevention (2007)
identify the 10 essential public health services as:
Monitor health status to identify community health
problems
Diagnose and investigate health problems and health
hazards in the community
Inform, educate, and empower people about health
issues
Mobilize community partnerships to identify and solve
health problems
Develop policies and plans that support individual and
community health efforts
Enforce laws and regulations that protect health and
insure safety
Link people to needed personal health services and
assure the provision of health care when otherwise
unavailable
Assure a competent public health and personal health
care workforce
Evaluate effectiveness, accessibility, and quality of
personal and population-based health services
Research for new insights and innovative solutions to
health problems (p. 1)
The frontline of public health services are state and local
health departments that implement programs to mitigate
problems and promote prevention programs at the community
level. At the federal level, the United States Public Health
Service, administered by the Surgeon General, the U.S.
Department of Health and Human Services, and the Centers
for Disease Control and Prevention lead the country on public
health initiatives nationally and internationally.
One such initiative is Healthy People 2010, which is a set
of national goals developed by the U.S. Department of Health
and Human Services. The goals are directed to improve the
health of the country by reducing health threats that could be
prevented. Local, state, and national public health officials
work to meet and exceed these goals through health
interventions and policy

development. The Healthy People 2010 initiative is based on
10 leading health indicators that were selected because they
have the potential to motivate action, have available data to
measure progress, and because they are deemed important as
public health issues. The 10 leading health indicators are:
physical activity, overweight and obesity, tobacco use,
substance abuse, responsible sexual behavior, mental health,
injury and violence, environmental quality, immunization, and
access to health care (U.S. Department of Health and Human
Services, 2007a).
In addition to the Healthy People 2010 initiatives, the
Office of the Surgeon General has named five public health
priorities: disease prevention, eliminating health disparities,
public health preparedness, improving health literacy, and
organ donation (U.S. Department of Health and Human
Services, 2007b). Special attention is being given to
preparedness activities in response to a national pandemic and
preparedness in response to terrorist attacks.
Long Term Care
Long term care covers an array of services provided over a
period of time to individuals of any age with chronic
conditions and functional limitations. Services provided range
from minimal personal assistance with activities to total care.
Many settings are used to provide long term care such as
nursing homes, clinics, community based services, assisted
living centers, residential care facilities, group homes, and
personal homes.
In 2006, approximately 9 million people over the age of 65
needed long term care By 2020, as the aging population
increases, 12 million older adults will need long term care
(U.S. Department of Health and Human Services, 2007c). It is
estimated that 70% of the elderly are cared for at home by
family and friends as informal caregivers. Of those elders
entering the nursing home, about 10% will remain in nursing
homes for five years or more (U.S. Department of Health and
Human Services, 2007 c). Long term care is not just for older
adults. About 40% of people receiving long term care are
adults between the ages of 18 and 64 (Federal Long Term Care
Insurance Program, 2007).
Long term care is paid for in a variety of ways.
Medicare pays for long term care only if there is a skilled need
and only for short periods of time. Care must be provided in a
skilled nursing facility or through home health care .if the
individual is home bound. Some Medicare Advantage Plans
will pay for limited skilled nursing facility and home care if
the care is medically necessary. Medicaid pays for some long
term care services at home and in the community and
Institutional Medicaid will pay for custodial care or
non-skilled care
HEALTH CARE: OVER VIEW 323
such as assistance with bathing, dressing, and meals within
nursing home facilities. Coverage varies from state to state and
eligibility is based on income and personal resources.
Individuals may also pay privately for long term care services
and there are long term care insurance policies that will
provide coverage for care, although terms vary with each
insurance plan.
The national focus on long term care centers on both
quality of care and affordability of services. In 1997, the
federal government passed regulations on nursing home
reform that were intended to enhance quality of life for
residents. While some improvements were made with these
regulations, more work is needed to improve care in nursing
home settings. Nursing home care is expensive, averaging
about $4,000 for a one month stay in a facility. Increased
access to home and community based services and an
emphasis on keeping people in the community longer would
reduce the expense of long term care and enhance quality of
life for individuals (Institute of Medicine, 2007).
Models of Health Care Service Delivery
The emphasis on service delivery in the United States has
historically been individualistic with a fee-forservice structure
(Gorin & Moniz, 2003). Physicians see patients in private
offices and bill the patient for services rendered. Hospital care
is arranged by the physician; however, hospitals operate
independently from the physician. Private insurers offer
coverage through an indemnity model, where the insured pays
a premium to health insurance companies, and are reimbursed
for the cost of services. These types of plans can be expensive
and are believed by some to promote inefficiency since
physicians and consumers have little incentive to control
health care use and costs (Starr, 1982). To control health care
services use and costs, insurers have increased co-pay and
deductible requirements, which the insured must pay
out-of-pocket.
HEALTH MAINTENANCE ORGANIZATIONS In an
attempt to contain rising health care costs, the Nixon
administration encouraged development of health
maintenance organizations (HMOs) as an alternative to
traditional fee-for-service plans. Under the HMO structure,
prepaid group practices provide participants (members)
comprehensive health care coverage and prevention services
for an annual fee. In earlier models, physicians worked
exclusively for the HMO. The HMO Act of 1973 further
promoted the development of HMOs by overturning state laws
that restricted prepaid group practices or practices in which the
cost of care is paid for in advance of service delivery. The act
also
324 HEALTH CARE: OVERVIEW
subsidized HMO start ups and required employers with 25 or
more workers to offer an HMO option of health insurance
(Gorin & Moniz, 2003).
MANAGED CARE In response to the success of the HMO
model in lowering costs for the individual con sumer and
in providing less-expensive health care options for
businesses and organizations (Luft, 1978), the 1980 s saw
the introduction of more managed care arrangements.
Managed care plans (including HMOs) attempt to
control costs through the development of prearranged
agreements with physicians, medical ser vices, and
hospitals who form a network of providers that can be
used to receive medical care. Employers pay managed
care companies a fixed' amount for the con tract or
prearranged agreement. Employees buy into the plan at
costs typically lower than fee-for- service plans.
Consumers who use physicians and services outside of
the plan pay more for these services. Managed care
options are available for Medicare and Medicaid recip-
ients as well.
Service Delivery Options. Another service delivery
model that emerged in the 1980s was the preferred provider
organization (PPO). The PPO is a combination of a
fee-for-service plan and an HMO plan. The consumer may
receive health care from a network of providers for a small fee
in addition to premiums paid for by the consumer. If health
care is received from a nonnetwork provider, the charge for
services is higher. Most PPOs require the consumer to choose
a primary health care provider who oversees services.
Another model is the Point of Service (POS) Plan, where
the consumer has a primary care doctor who refers to other
members in the POS for additional services needed by the
consumer. Providers outside the POS can be used if the
physician makes a referral to these specialists; however, there
may be an additional fee to the consumer for the use of
nonnetwork providers.
Recently, Health Savings Accounts (HSAs) have emerged
as what some believe to be a lower cost alternative to other
health care arrangements. Pre-tax dollars are placed into an
account to be used for medical expenses. The consumer
chooses the provider and expenses are paid through this
tax-free HSA account. Contributions remain in the tax
deferred account and can be used to pay for future expenses.
Money left in the account can be used for retirement expenses
after age 65, much like a tax free retirement savings account.
These types of consumer directed health plans are designed to
enable consumers to manage their health care, support
informed choice between the consumer and the provider, and
provide financial incentives to the consumer to control
expenses (Rosenthal, Hsuan, &
Milstein, 2005). As the United States struggles with the rising
cost of health care, the trend over the last three decades has
been to develop service delivery systems that are less costly
for the consumer, government payers, and employers. While
the majority of these managed care arrangements are viewed
as more efficient, criticism has emerged related to the loss of
quality and effectiveness in health care services provided
through these arrangements (Scandlen, 2001).
Ethical Issues
Rationing health care is at the forefront of public discussions,
and some contend that health care rationing already exists
(Sabin, 2000). Three primary factors contribute to this
discourse. First, as the cost of health care rises and resources
diminish, the average consumer finds it difficult to pay for
basic care. Providers are forced to subsidize the cost of care,
which can be financially prohibitive. Second is that
technological advances have led to an increase in the ability to
treat life-threatening illnesses and accidents that were
previously impossible to survive. The third is an increased life
span. Discussions are emerging about how to limit health care
interventions. Some propose the development of priorities that
can be used as guidelines to limit care and medical inter-
ventions (O'Donnel, Smyth, & Frampton, 2005). Others
suggest honoring advance directives and respecting people's
wishes in terminal conditions (Galambos, 1998). It is also
suggested that by limiting the amount of health care available
to individuals, rationing will occur, and in some cases, must
occur to control health care costs (Aaron, 2005). Still others
advocate that health care is a basic right and there should be a
minimum level of health care for all individuals (Galambos,
2006; 10M, 2004). Americans will need to determine whether
each citizen is entitled to some access to health care and what,
if any, limits will be placed on services.
In addition to rationing, ethical concerns have emerged
related to equity in access to health care and outcomes related
to that care. Equal access and equal outcomes are discussed in
terms of horizontal and vertical equity (Rice & Smith, 2001).
Horizontal equity pertains to equal treatment of equals and
what factors society will use to define who and what is equal.
Vertical equity refers to equal health outcomes. As Healthy
People 2010 continues to define ideal health outcomes for this
country, the issue of how to treat unequal factors and how to
distribute resources in a just and fair way will continue to
appear in the national debate.
Future Directions and Trends
There is increasing national recognition that this country's
medical system is fragmented, overburdened, and

underfunded. Emergency rooms are increasingly being
used as the primary source of health care for the unin sured,
and hospitals are overwhelmed from the demands of
providing care to an increasingly aging population (Perry,
2006). There is a lack of available beds for hospital
admissions in certain areas, and in other areas, the emphasis
on cost containment has left many beds empty in health
care facilities. There is a movement to discharge patients
quicker and sicker in response to the Diagnostic Related
Group's (DRG's) legislation, passed during the Reagan
administration, which standardizes the amount of time
individuals should stay in hospitals according to specific
diagnoses. The DRG has contrib uted to a shift in care being
assumed by long term care facilities and home health care
agencies. Future direc tions in health care primarily focus on
controlling health care expenditures, reducing health
disparities, and increasing access to health care. The
national debate on the develo pment of a single payor
system or some type of national health insurance is in the
forefront of discussions occurring in Congress and in the
campaigns of 2008 Presidential candidates.
Institute of Medicine Recommendations. To address
the growing problems in America's health care de livery
system, the 10M (200l) advocates reinventing the
system from one that is devoted to the treatment of acute
episodic care needs to one capable of handling chronic
health conditions and promoting wellness. Six areas
targeted for improvement include patient safety, service
effectiveness, patient-centered care, timely treatment,
efficiency of operations, and equitable care for all
populations of people regardless of personal
characteristics.
The 10M also identified several factors that must exist
in the reinvented system: (a) evidence- based care; (b)
effective and efficient use of information technol ogy; (c) an
emphasis on quality improvement through the alignment of
payment policies with quality care; (d) workforce
preparation including an emphasis on interdisciplinary care
that utilizes an evidence-based approach.
Responding to the devastation that a lack of health
insurance places on the system and individuals, the 10 M
(2004) calls for all U.S. citizens to have some for m of
health insurance by 2010, including universal, continuous
coverage that is affordable and sustainable. Rather than
recommending one specific plan, various approaches are
recommended to achieve these recommendations.
LOWER COST OPTIONS Communities are developing
strategies to provide health care resources for the grow ing
uninsured in this country. One such approach is to use
current safety net systems in place for the uninsured, such
as inpatient and emergency department services,
HEALTH CARE: OVERVIEW 325
to enroll them in these services that will provide a basic
minimum level of care, while emphasizing preventative
and primary care. Another approach is to organize donated
care initiatives in the community in which health care
providers see patients on a pro bono basis. A third approach
is providing discounted care to the uninsured. Participating
safety net and private provi ders supply health care services
at discounted rates, an approach that has attracted the
working uninsured (Taylor, Cunningham, & McKenzie,
2006). A final approach is the development oflimited
benefit programs in which employers offer small group
limited benefit products through local insurers that are in
compliance with state laws (Taylor et a1., 2006). In rural
communities, telemedicine can be used to address
accessibility issues and to deliver needed care while
reducing expenditures in providing that care (Demiris,
Parker Oliver, & Courtney, 2006).
COORDINATED MODEL OF CARE To address the
fragmentation of health care service delivery, recommen-
dations on how to improve care focus on the develop ment
of a better coordinated model of care. One proposed
approach is to develop a case management system that
focuses on a joint approach to service delivery between
health and social services, and employs a stronger bio-
psychosocial paradigm to health care. Case finding isa part
of this model to identify consumers at risk. Once
consumers are identified, intensive care coordination is
offered, including a patient-centered assessment, empha sis
on proactive, preventative care and self management,
coordination of the treatment of chronic health condi tions,
and the provision of ongoing support and advocacy
(Adams, 2006). Another approach is reorganizing the
delivery system to expand multispecialty group practices
(Crosson, 2005). This movement is aimed at improving the
coordination of care, disseminating knowledge and skills to
support outcome measurement and evidence based
medicine, and making effective use of technology . It is
believed that this type of model leads to better out comes
and will increase both the efficiency and effective ness of
health care services (Crosson, 2005).
COLLABORA TION MODEL A trend in providing health
care services in rural areas is the use o f a collaboration
model of care, interdisciplinary and interorganizational in
nature. This model emphasizes the enhancement of
communication and the development of partnerships and
communication between community- based agencies and
the health care service delivery system such as a
partnership with senior services and public health. These
models may be organized differently and run the gamut of
formal partnerships to participation in community
326 HEALTH CARE: OVERVIEW
coalitions to the development of regional relationships
with local health departments (Berkowitz, 2004).
There are also movements to modernize long term care
services that emphasize partnerships among consu mers,
health care providers, and payers. An expansion of
community based services that promote wellness, enhance
individual autonomy, and incorporate a bio-
psychosocialcultural model of care will move long term
care into the 21st century (lOM, 2007).
Roles for Social Workers
The 10M recommendations and movement toward a model
that emphasizes the coordination of health and social
services provide the impetus for social workers to become
more involved in evolving health care struc tures beyond
the traditional settings. Social wo rk roles may include
planning new service structures, advocating for fair and
equitable health care policies, and conducting research to
identify the best models of care. Social work ers will need to
be versed in evidence-based practice and culturally
competent care and position themselves to be leaders and
active participants in health care administra tion and on
interdisciplinary health care teams. The discipline of social
work has much to offer the team in its movement toward
providing a patient-centered, com munity involved
approach to health care.
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U.S. Department of Health ami Human Services. (2007b).
Office of the Surgeon General: Public health priorities. Retrieved
July 13, 2007, from http://www.surgeongeneral.gov/ pub I ichea I
thpriori ties. h tml
U.S. Department of Health and Human Services. (2007c).
Long tenn care. Retrieved July 13, 2007, from http://www.
medicare.gov/Long Term Care/Static/Home.asp
U.S. Department of Veterans Affairs. (2007). VA health care
eligibility and enrollment. Retrieved July 16, 2007, from http://
www.va.gov /heal theligibili ty
FURTHER READING
Abramson, J. S., & Mizrahi, T. (2003). Understanding collaboration
between social workers and physicians: Application of a typology.
Social Work in Health Care, 37(2), npa.
Anderson, S. G., Halter, A. P., & Gryzlak, B. M. (2004).
Difficulties after leaving T ANF: Inner city women talk about
reasons for returning to welfare. Social Work, 49(2), 185-194.
Institute of Medicine. (2002, March). Unequal treatment: What health
care providers need to know about racial and ethnic disparities in
health care. Retrieved February 23, 2007, from
http:/www.iom.edu/objectJile/Master/4/1 75 /Dispartieshc
providers8pg FINAL.pdf
Mizrahi, T., & Berger, C. S. (2005). Leadership among social workers
in health care: A longitudinal study of hospital social work
directors over time. Health and Social Work, 30(2),155-165.
SUGGESTED LINKS Agency for Healthcare
Research and Quality http://www.ahrq.gov
Brookings Institution
http://www . brookings .eu
Citizen's Health Care Working Group
http://www .citizenshealthcare .gov Health
Care Financing Administration
http://www.hcfa.gov
Healthy People 2010
http:// www.health.gov/healthyjJeople/
Institute of Medicine http://www.iom.edu
Kaiser Family Foundation
httjJ://www.kfforg
Maternal and Child Health Policy Research Center
http://www . mchpolicy. org
National Center for Policy Analysis
http://www.ncjJa.org
National Health Law Program
http://www . healthlaw. org
Urban Institute
http://www.urban.org
-COLLEEN GALAMBOS
PRACTICE INTERVENTIONS
ABSTRACT: Social work in health care emerged with
immigration and urbanization associated with industri-
alization, and the resultant shift from physician visits to the
patient's home and workplace to hospital- centered care. This
change is alleged to have resulted in a loss of the doctor's
perspective of the psychosocial influ ences on physical health.
Originally, some nurses were assigned the function of
addressing this loss. But even tually, the function became
recognized as that of a social worker. From its beginni ngs in
the general hospital setting in the late 1800s, social work in
health care, that is, medical social work, has expanded into
multiple settings of health care, and the role of the social
worker from being a nurse to requiring a Master's Degree in
Social Work (MSW) from a university. How ever, the broad
function of social work in health care

remains much the same, that is, "to remove the obstacles in the
patient's surroundings or in his mental attitude that interfere
with successful treatment, thus freeing him to aid in his own
recovery" (Cannon, 1923. p 15). Health care social workers are
trained to work across the range of "methods," that is, work
with individuals, small groups, and communities (social work
"methods" are called "casework", "group work" and
"community organization"). They work to assist the patient,
using a broad range of interventions, including, when
indicated, speaking on behalf of the client (advocacy), helping
clients to assert themselves, to modify undesirable behaviors,
to link with needed resources, to face their challenges, to cope
with crises, to develop improved' understanding of their
healthrelated thought processes and habits, to build needed self
confidence to do what is required to help themselves deal with
their health problem, to gain insight and support from others
who are in a similar situation, to gain strength from humor, or
from a supportive environment, and through spiritual
experience, and from practicing tasks that are needed to deal
with their health-related problems or from joining forces with
others in the community to modify it in the interest of
improved health status for all, or to gradually restore a sense of
stability and normalcy after a traumatic experience. Most
important of all, perhaps, is the . "helping relationship"
between client and social worker, which needs to be one of
total understanding and acceptance of the client as a person. A
sizable portion of the U.S. population lacks financial access to
health care, where health care is regarded as a privilege rather
than a right, as it is seen in all other industrial nations (except
South Africa). Current trends in the U.S. health care system
reflect efforts to control rising health care costs without
dealing with the "real problems," which are: (1) the lack of a
single-payer health care system and: (2) the lack of focus on
"public health."
KEY WORDS: psychosocial; biopsychosocial
Overview
Health care social workers provide services across the
continuum of care and in various settings. Social workers are
present in public health, acute and chronic care settings, long
term care, rehabilitation, and hospice. They provide a range of
services to patients and families, including health education,
crisis intervention, supportive counseling, and case
management. They also perform group, community, advocacy
and management functions. In response to critical incidents
that are both
HEALTH CARE: PRACTICE INTERVENTIONS 329
global and national, health care social workers are in-
creasingly trained to provide interventions to prepare for and
respond to traumatic events and disasters.
Social workers implement intervention and treatment
plans that promote client well-being and a continuum of care.
Planning shall be based on a comprehensive, culturally
competent assessment with interdisciplinary input. The
function, basis, flexibility, and scope of social work
intervention in health care is described in NASW standards for
social work practice in health care (2007): "The 'client' of the
social work intervention may be an individual, all or part of a
family or any other small group of people, or another larger
sector of the community or society-such as the people in a
neighborhood, a population of people concemed with a
particular health problem, all residents of a treatment center,
rehabilitation center, or halfway house, or all patients in a day
treatment, day care, or other outpatient program. The client is
the person or group that requests and, or, will benefit from the
social work intervention.
Intervention and treatment plans are steps identified by the
health care social worker in collaboration with the client and
with other members of the team, to achieve the objectives
identified during assessment. Health care social workers adapt
practice techniques to best meet client needs within their
health care setting to work effectively with individuals across
their lifespan, across different ethnicities, cultures, religions,
socioeconomic and educational backgrounds, and across the
range of mental health and disability conditions."
HISTORICAL BACKGROUND Social work first emerged in the
United States around the late 1800s, when its early
practitioners were engaged in home visiting to address the
problems of individual families, providing direct casework
services. They also focused on early community organization
and advocacy efforts to address the health-related problems of
workplace hazards, poverty, overcrowding, lack of proper
water and sewage systems that accompanied urbanization,
immigration, industrialization, and ignorance or lack of
acceptance of the dawning germ theory of disease (Cowles,
2003, p. 87).
The specialty field of "medical social work" began with
the emergence of the general hospital. It is traced to 1905,
when Richard C. Cabot, M.D., Chief of the Massachusetts
General Hospital Internal Medicine Clinic, appointed a nurse,
Gamet 1. Pelton, to fill the first hospital social work position.
Ida Cannon, who soon replaced Pelton, wrote a book about her
experiences (Cannon, 1923). Cannon claimed that
330 HEALTH CARE: PRACTICE INTERVENTIONS
social work in hospitals evolved as a result of the shift of
medical practice from being centered in the com munity,
where the physicians had been in touch with the patient's
home and workplace, to the hospital, resulting in the
physician's loss of perspective of the bio-psycho-social
context of the patient's health prob lems. As Ida Cannon
stated, "The social worker seeks to remove those obstacles
in the patient's surroundings or in his mental attitude that
interfere with successful treatment, thus freeing him to aid
i~ his own recovery" (Cannon, 1923, p.l5).
Over the years since then, medical social work has
gradually extended from general hospitals into specialty
hospitals, as well as other community based programssuch
as public health agencies, neighborhood primary care
clinics, group medical practices, family medical prac tice
residency programs, health maintenance organiza tions,
employee assistance programs, suicide prevention
programs, school and college based health clinics, emer-
gency rooms, and free clinics. Furthermore, medical social
workers are now employed in home health care agencies,
hospice programs, rehabilitation programs, nursing
homes, and other residential care facilities.
Settings Across the Care Continuum
To some extent, the "settings" of medical social work
intervention, that is, (1) public health, (2) primary care
(out-patient care), (3) hospital care, (4) home care, (5 )
nursing home or other residential care facility, and (6 )
hospice care, reflect the stages of development of the
health problem. The associated role of the social worker
can move from (a) helping to promote health and prevent
the onset and development of health problems to (b)
enhancing the cure process and helping health and other
associated human problems from further compounding to
(c) maximizing comfort and function when health
problems have become chronic or terminal, and preventing
"secondary disabilities," that is, undesir able "side effects"
of the health problem. Sometimes this is referred to as the
"continuum of health care"-from prevention and health
promotion to curing of already developed health problems to
caring for patients with chronic and terminal health
problems.
Currently, the role of the social worker also extends to
community-based programs, such as public health
agencies, neighborhood primary care clinics, group
medical practices, health maintenance organizations,
employee assistance programs, suicide prevention pro-
grams, school and college-based health clinics, emer gency
rooms, and free clinics. In addition, currently, medical
social workers are employed in home health-care
agencies, hospice programs, rehabilitation programs,
nursing homes and other residential care facilities.
Since early 2000 the National Associat ion of Social
Workers (NASW) has established credentials for social
workers, depending on their field of practice and quali-
fications. The credential for social work in health care is
entitled "Certified Social Worker in Health Care"
(CSWHC). The requirements relate to professional
association membership, academic degree in social work,
credentials of the school from which the degree was
earned, and post degree relevant practice experience.
METHODS Intervention methods of social work in
health care, as in other fields of social work practice,
include the range of micro (mezzo) and macro level
interventions, including casework, group work, com-
munity organization, and administration and manage-
ment, depending on such variables as whether the
"client" is an individual, couple, small group, all or part
of a community, or an organization, as well as the
practice setting, the location of the problem and its
solution, available resources, and the training and
function of the social worker.
Social Work Interventi ons
Social work intervention may occur at any stage of the
helping process. By "intervention" we refer to what the
social worker does in an effort to address the client's
health-related psychosocial problems and needs. However,
the intervention may involve variations in any stage of the
helping process, such as "how" the social worker (1)
engages the client, (2) collects the data, (3) assesses
relevant information, (4) plans the intervention, (5 )
conducts the treatment or intervention, (6) evaluates the
intervention effect, or later (7) terminates the relationship
with the client. The client may be impacted by his or her
interaction with the social worker, not only by what the
social worker intended to do to help the client, but also by
what actually happens at any stage of the helping
relationship.
Kerson (1997) has identified the following social work
interventions in health care: advocacy, assertive ness
training, behavior modification, caring confrontation, care
management, cognitive-behavioral therapy, concrete
services (for example, community resource linkage), crisis
intervention, critical incident stress de briefing, education
and information, ego-building oriented casework, family
therapy, grief counseling, group therapy, humor, milieu
therapy, modeling, psychoanalysis, relaxation therapy,
reminiscence therapy, skills training, solution-focused
therapy, spiritual beliefs exploration, supportive
counseling, supportive environment development, and
task-oriented counseling.
The latest Standards for Social Work Practice in Health
Care (2000) defines 'Intervention or Treatment Plans'

as "Strategies to address needs identified in the assess-
ment: information, referral, and education; individual,
family, or group counseling; vocational, educational, and
supportive counseling; psycho-educational support
groups; financial counseling; case management; discharge
planning; interdisciplinary care planning and
collaboration; client and systems advocacy; and identi-
fication of goals and objectives."
A review of social work in health care journals (Social
Work in Health Care, 2007; Health and Social Work ,
(2003); National Association of Social Workers, (2003 ))
over the past few years finds continued use of many
traditional social work interventions, but with some ap-
parent variations, for example, from work with groups of
individuals to groups of fcimilies; various combinations of
modalities; assistance with decision making concerning
matters such as advance directives; use of story-telling to
engage "hard to reach" clients; therapy with groups of
clients whose health is impacted by a common source of
personal stress; from "cure" efforts to "harm reduction";
from acute to chronic disease-management; and to ad-
dressing communities with high rates of certain health
problems; crisis intervention with individual and com-
munity victims of terrorism; and outreach to newly diag-
nosed groups of people to offer counseling and support.
Two challenges the social worker faces are finding
affordable resources for clients without health insurance to
cover those needs, or personal resources to afford them;
and brief contacts with clients, making it difficult to
accomplish all that the social worker sees is needed.
ORGANIZATION AND FINANCING OF HEALTH CARE:
CURRENT TRENDS
1. Increased cost of health care since 2000, in spite of
the introduction of "managed care" in 1983.
2. Continued shortened hospital stays with focus on
rapid discharge planning.
3. Reduction in tax funding for public health programs
and services (Garrett, 2000) right at the time when the
nation is threatened with terrorism, bird flu, HIV and
AIDS, as well as nationwide epidemics of depression
and obesity with secondary Type II diabetes, heart
disease, and functional impairment.
4. The obesity epidemic, coronary artery disease,
depression, and Type II diabetes are sometimes
interdependent, and may reflect such conditions as
lack of education about nutrition and preparation of
healthy meals at low cost, lack of regulation of the
commercial food industry which promotes a lot of
"junk," lack of regular physical exercise, a lack of
social supports, and a generalized sense of
powerlessness.
HEALTH CARE: PRACTICE INTERVENTIONS 331
5. Growing awareness of the need for more health
promotion and disease prevention programs to
address population-wide, health-related conditions
and associated behavior.
6. There is also increased longevity with associated
increase in age-related chronic health conditions, at
the same time that many traditional family caregivers
work outside the home.
7. Increasing numbers of immigrants (especially
Mexican), and changing demographics, which
require increased recognition of the importance of
culturally appropriate social worker interventions to
enhance their effectiveness.
8. Increased participation of social workers on bioethics
committees to make hard decisions concerning
medical interventions to prolong life.
9. Less extensive or prolonged counseling and more
"solution-focused therapy" and evidence-based
practice as well as linkage of the client with
coordinated community-based services and re-
sources, referred to as "case (or care) management."
10. Growing awareness of the need for more health-
promotion and disease-prevention programs to
address population-wide health-related conditions
and associated behavior.
11. Developing public awareness of the greater
efficiency and cost savings of a single-payer health
care financing system, such as the Medicare system,
and, alternatively, the inefficiency of multiple,
profit-oriented, health insurance company payers,
each with multi-million dollar executives whose
salaries and bonuses are financed through the cost of
health care. In addition, the public is also develop ing
awareness of the relationship between the price of
pharmaceuticals and the entertainment and gift
expenses of those companies in their product
promotion efforts to health care providers. Finally,
one wonders why the very same medications
manufactured in the United States are sold in most
foreign countries, including Mexico and Canada, for
a fraction of their purchase price in the United States
(www, pnhp.org).
12. A currently expanding grassroots movement
throughout the United States to develop a tax-
supported, single-payer health insurance plan, as
many working class citizens find themselves
unemployed as a result of their former company
employers no longer being able to compete with the
lower cost of products manufactured in other
industrial nations, where health care is financed
through pooled payroll taxes rather than by the
employer (http://www.pnhp.org).Anincrease in
primary and ambulatory care neighborhood-clinics
332 HEALTH CARE: PRACTICE INTERVENTIONS
funded by the federal government and, or, staffed by
volunteer medical and ancillary health care professionals,
such as nurses, social workers, and dietitians, for people
with no health insurance, many of whom relied most of their
lives on factory work, and now lack the education and skills
to obtain other kinds of employment, and who now manifest
a variety of health problems, mental and physical, often
associated with prolonged unemployment and "giving up"
(www.pnhp.org). (Note: the author works in such a clinic.)
13. Increased community-centered medical care in
hospital-affiliated medical group practices.
REFERENCES
Cannon, I. M. (1923). Social work in hospitals. New York:
Russell Sage, p. 15.
Cowles, L. A. F. (2003). Social work in the health field: A care
perspective. Binghamton, NY: Haworth Press.
Garrett, L. (2000). Betrayal of trust: The collapse of global public health.
New York: The Hyperion Press.
Kerson, T. S. (1997). Social work in health settings: Practice in context
(2nd ed.). Binghamton, New York: The Haworth Press.
FURTHER READING
Health Care Social Work. (2007). Credentials. http://www. soc ia I
workers .org/ c red en t i a Is/de fa u It. asp
Health United States. Health Care Expenditures. National Center for
Health Statistics. Health United States, p. 10, 2003. Hyattsville,
Md.
Johnson, J. L., & Grant, G., Jr. Medical social work (casebook series).
Boston: Allyn & Bacon.
National Center for Health Statistics. Health, United States, 2003
(Table 111, p. 305). Washington, DC: U.S. Government Printing
Office.
Poland, B. D., Green, L. W., & Rootrnan, I. (Ed.). (2000).
Settings for health promotion: Linking theory and practice. Thousand
Oaks, CA. Sage.
Raphael, D. (Ed.). (2004). Social Determinants of Health: Canadian
Perspecrioes. Ontario: Canadian Scholars Press.
SUGGESTED LINKS
A comprehensive nine-page list of Web sites for social workers in
health care.
http://www . library . wisc . edu/libraries/SOC 1AL WO RK/health
care.html
Physicians for a National Health Program
http:www.jmhp.org
A history of early social work in health care; Massachusetts General
Hospital Social Work
http:// mghsocialwork. org/his tory .html Health
Insurance Coverage 2005. Highlights.
httj)://www.U.S. Census.Gov
-LOIS F. COWLES
HEALTH CARE FINANCING
ABSTRACT: The U.S. health care system is a pluralistic,
market-based approach that incorporates various public and
private payers and providers. Passage of Medicare and Medicaid,
combined with rapid advances in technology and an aging
population, has contributed to rising health care costs that
typically increase faster than general inflation. This entry will
review health care financing, exploring where the money is spent,
who pays for health care, what the reimbursement mechanisms for
providers are, and some issues central to the discussion of reform
of health care financing. To effectively advocate health care
reform, social workers must understand health care financing.
KEY WORDS: government insurance programs; cost-
containment; private insurance; reimbursement mechanisms;
health care spending
Background
The U.S. health care system is a pluralistic, marketbased approach
that combines a variety of public and private payers and
providers. Passage of federal Medicare and Medicaid in 1965,
combined with rapid advances in technology and an aging
population, have contributed to rising health care costs that
typically increase faster than general inflation. Various strategies
to curb spending include fiscal controls (for example, spending
thresholds and fee setting), utilization review initiatives (for
example, peer review and prospective and retrospective case
reviews), reimbursement mechanisms (for example, fixed
reimbursement and capitation) and service delivery strategies (for
example, managed care and case management), which have
produced only short-term success. Managed care initiatives had
the most dramatic impact during the 1980s and 1990s, slowing the
rate of growth from double-digit inflation to about 5%. Health
care costs are again escalating so rapidly that two-thirds of
Americans are worried about their ability to cover health care
costs (Helman, Greenwald & Associates, & Fronstin, 2006). In the
early part of the 20th century, health care expenditures were
almost 5% of the GOP. This grew to 7% by 1970 ($73.1 billion).
Since 2001, health care inflation has been 2-5 times greater than
general inflation. In 2005, the United States spent over $2 trillion
on health care, consuming 16% of the GOP. The 2016 projection
is $4.1 trillion or 19.6% of the GOP. While actual dollars present
one snapshot of health expenditures, growth rates provide further
information about the impact of health expenditures on the
economy.
 HEALTH CARE FINANCING
333

According to data from the National Health Expenditures Data
(2007), health care growth rates have been steadily declining,
down from 9.1 % in 2002 to 6.8% in 2006 and are projected
to be relatively stable at 6.9% through 2016. However, this
rate of growth still outpaces general inflation, resulting in
escalating GOP consumption.
National health care spending may be divided into two
main categories: out-of-pocket expenses (that is, paid by the
consumer) and third-party payments (that is, paid for or
reimbursed by public and private payers). The latter accounted
for 86.4% of spending in 2001, rising to 87.5% by 2005. It is
projected to reach 89.3% by 2016 (over $2 trillion). Public
and private spending levels are almost equal, with public
spending only slightly more. In 2005, public spending
accounted for 52.1 % of third-party payments and is expected
to increase to 54.5% by 2016 in response to the addition of
Medicare Part 0 (prescription drug coverage) and the aging
baby-boomer population.
Where Does the Money Go?
Health care spending may also be divided into the categories
of health services and supplies and investment (Hunt &
Knickman, 2005; National Health Expenditure Data, 2007).
Health services and supplies include hospital care,
professional care (that is, physician and clinical services, other
professional services, dental services, and other personal
health care), nursing home and home health care, retail outlet
sales of medical products (that is, prescription drugs and other
durable and non-durable medical products), program
administration and net costs of private health insurance, and
government public health activities. Health services and
supplies is the largest category,
accounting for over 93% of health care spending (see Table
1); this figure is expected to hold stable through 2015.
Personal health care is the largest national expenditure
(83.3%-84.3%), with hospital care plus professional services
totaling almost two-thirds of national health spending and
three-fourths of personal health care spending. While still a
relatively small percentage of national spending, home health
care is the fastest growing arena, projected to reach double-
digit growth in 2005.
Who Pays for Health Care?
To facilitate discussion of who pays for health care, several
terms need to be defined:
Cost-sharing = the portion of health care expenses paid
by third parties and out-of-pocket
Premiums = the amount beneficiaries (consumers)
pay to purchase health insurance
Deductible = spending threshold paid by the
beneficiary (consumer) prior to benefits starting
Co-payment = fixed amount a beneficiary (consumer)
pays for a service
Co-insurance = index of consumer costs to price of
care using a percentage of costs
Tiered cost-sharing = escalating cost at fixed levels at
point of access or type of service'
Risk pool = insurance enrolls a large enough
population so that the costs for high-end users are
offset by larger numbers of low-end users
Government Funding
The public sector is the largest payer of health care services,
accounting for 45% ($902.7 billion) of national health care
costs in 2005. The largest federal programs

TABLE 1
National Health Expenditures in 5-Year Increments: 2001-2015
TYPE OF EXPENDITURE 2001 2006 2011 2015"
($ BILLION) ($ BILLION) ($ BILLION) ($ BILLION)
National Health Expenditures 1,469.6 2,122.5 2,966.4 3,874.6
Health services and supplies 1,376.2 1,987.7 2,778.1 3,869.9
Personal health care 1,239.0 1,769.2 2,472.6 3,449.4
Hospital care 451.4 651.8 922.3 1,287.8
Professional services 465.3 662.8 918.9 1,253.2
Nursing home & home health Retail 133.7 179.4 239.2 322.0
outlet sales-med. products 188.5 275.2 392.1 586.4
Program adm. & net cost pvt, insurance 90.4 156.8 217.9 295.7
Government public health activities 46.8 61.7 87.6 124.8
Investments 93.4 134.8 188.3 267.0

National Health Expenditures Data, by Centers for Medicare & Medicaid Services, 2007, Retrieved July S, 2007, from www.crns.hhs. govIN a
tionalHeal thExpendData.
"Projections for 2016 are not reported to produce equal size categories for easier review.
334 HEALTH CARE FINANCING

are Medicare and Medicaid. Other major programs include the
State Children's Health Insurance Program (SCHIP),
TRICARE (formerly CHAMPUS for military personnel and
their families), Indian Health Service, Veteran's
Administration, and the Public Health Service. The federal
government also assumes responsibility for a variety of other
programs, including the Federal Employees Health Benefits
Program, Workman's Compensation, and Programs of
All-inclusive Care for the Elderly (PACE) (Centers for
Medicare & Medicaid Services, 2007a, 2007b).
At the state level, Medicaid is the largest program.
Other programs with shared federal financing are SCHIP,
Maternal and Infant Support Programs, and PACE. States may
offer coverage for specialized populations (for example,
Healthy New York is a risk pool for small business and
self-employed residents), license health care providers, and
provide oversight for insurance programs and nursing homes.
State and local governments financially support mental health
services, hospitals, and clinics. Given space limitations,
financial data will only be presented for the top three most
costly programs: Medicare, Medicaid, and SCHIP .
Medicare is administered by CMS and covers most health
care costs for the elderly and the disabled. It is divided into
four parts (A-D); Table 2 provides a brief summary of the
program, including reimbursement approaches (discussed
later). Low-income beneficiaries, called dual enrollees, can
apply for assistance with costsharing through their state
Medicaid program (Centers for Medicare & Medicaid
Services, 2007a; Prescription Drug Coverage: Basic
Information, 2007).
In 2006, the net outlay for Medicare totaled $329.9 billion
and was projected to climb to $698 billion by 2017, assuming
a 7.1% average annual growth rate (Fact Sheet for CBOs,
2007). Spending by program was Part A = 45%, Part B = 43%,
and Part C = 12%. Part D growth saw a 4% increase in
payments to prescription drug plans with a commensurate
decrease in low-income subsidies available through Medicaid.
The distribution will shift by 2017, with Part D increasing to
18% and Part B and Part A dropping by 4%-5%, respectively.
Medicaid targets health care coverage for lowincome
individuals who meet state eligibility requirements based on
elaborate formulas using income and

. TABLE 2
Summary of Medicare Coverage
REIMBURSEMENT COST-SHARING BENEFIT COVERAGE MEDICARE
OPTIONS
Fee-for-service No premium (unless Entitlement if Medically necessary Part A: Traditional
Fixed reimbursement ineligible) eligible institutional and Medicare
Deductible Ineligible can home care
Tiered co-payments enroll but pay
premium
Fee-far-service Tiered monthly Optional enrollment Physician, Part B:
Fixed reimbursement premium community-based Traditional
Deductible care, preventive Medicare
Tiered co-payments or
co-insurance
Capitation Set or tiered premium Must enroIl in Managed care Part C: Medicare
Fixed reimbursement (managed care & Part A & B (HMO, PPO, POS) Advantage
Fee-far-service (POS or Part B) Innovative
PPO out of network) Deductible comprehensive
Fixed or tiered coverage
co-payments
Co-insurance
(if out of network)
Fee-for-service Premium if not Must enroll in Prescription coverage Part D: Prescription
Fixed reimbursement included in insurance Part A & B for traditional Coverage
Annual deductible or in Part C medicare or insur-
Tiered co-pays Must enroll with ance without pre-
Tiered co-insurance approved Part D scription coverage
far unique and highly provider
expensive drugs

asset levels. The programs tend to serve single- parent
families, disabled individuals, the elderly, and the blind.
While states have some flexibility in program design, they
must meet minimum federal standards set by CMS to
qualify for federal cost-sharing . The Congressional Budget
Office (Fact Sheet for CBO ... , 2007) categor izes federal
Medicaid expenditures into costs for direct benefits, which
includes acute service programs (that is, fee-for- service,
managed care, and Medicare premiums) and long-term
care, and three indirect categories, in cluding a
disproportionate share, which is a compensa tion to
hospitals that treat a large share of low- income patients,
vaccines for children and administration pay ments for
hospitals, vaccines for children, and admin istration.
Medicaid is the largest payer of long- term care services
across all payer groups.
In 2006, the federal government spent $180.6 billion for
Medicaid. Benefit payments totaled $160.9 billion or 89%
of total spending: 66% for acute services and 34% to
long-term care. Indirect costs totaled $19.7 billion, with a
fairly even distribution between disproportionate share
payments to hospitals and administration (44% and 47% ,
respectively) and 9% for vaccines. Federal Medicaid
spending was proj ected to increase to $417.1 billion by
2017, assuming an 8% average annual growth. Payments
for benefits would increase to 92%, with mini mal
distribution changes across categories except for a 2%
increase to long-term care. The biggest change is projected
to occur in the indirect payments, with an 11 % shift from
disproportionate share to hospitals to administrative costs
(Fact Sheet for CBO, 2007), adding to the fiscal crunch for
hospitals.
The State Children's Health Insurance Program (SCHIP)
was created through the Balanced Budget Act of 1997 as Title
XXI to reduce the number of uninsured children by extending
eligibility to those in low-income families who do not qualify
for Medicaid. Like Medicaid, SCHIP is state administered
with state or federal cost-sharing. There are no premiums or
copayments; however, many states are assuming responsi-
bility for expanded coverage by instituting a tiered premium
formula. Funds are capped at $5 billion nationwide and each
state receives an allotted amount using an elaborate formula
based on the state's lowincome rates, low-income uninsured
children rates, and wages. State monies can be redistributed to
other states if unused.
SCHIP is up for reauthorization in 2007. SCHIP' s
success is undisputed. In 2005, it covered 6 million children
(Lambrew, 2007). An additional 28 million children
enrolled in Medicaid who were identified dur ing SCHIP
screening, producing a $6.8 million increase
HEALTH CARE FINANCING
335
in Medicaid spending. Between 1997 and 2005, the num ber
of uninsured children dropped by 7.4%, but 9 million
children remain uninsured. To maintain the program,
SCHIP net spending would increase by $28.4 million ,
assuming program funding rules, including eligibility
criteria, do not change (Fact Sheet for CBO, 2007).
Private Payers
Private pay includes private third-party payers (insur ance
companies and other plans) and consumers' outof- pocket
expenses, mostly related to cost-sharing with third- party
payers. In 2001, private pay accounted for $808.4 billion
(55% of national health expenditures) and was projected to
increase to over $2 trillion by 2016, a 4% decrease over
2001 levels. In 2001, private, third-party paym ents totaled
$608.4 billion and are projected to increase to over $1.5
trillion by 2016, holding steady at 41 % of national health
expenditures. Private health insurance typically accounts
for about 45%-48% of all third-party payments (National
Health Expenditure Data, 2007). Out-of-pocket expenses
in 2001 were $200 billion (14% of national expenditures )
and are expected to increase to $440.8 billion by 2016, a
3% decrease over 2001 levels ( National Health
Expenditure Data).
Consumer costs for private, third-party payment plans
vary according to the type of coverage (for exam ple,
individual or family), scope and depth of covered services,
cost-sharing requirements, and system for reimbursement
(for example, managed care or indem nity). Private
insurance for specialty services such as dental, long- term
care, and vision care can be pur chased to supplement
general medical coverage since these services are often
excluded from insurance plans.
Since the turn of the 20th century, private insurance has
grown significantly. Private insurance emerged dur ing the
Great Depression as a strategy to protect con sumers from
health care costs. Prior to the Depression, individuals paid
out-of-pocket, which was feasible giv en that medical
practice was far less technologic al than it is today. The
American Hospital Association advocated private health
insurance; and the Supreme Court's decision to allow
fringe benefits to be included in collective bargaining also
spurred its growth. Private health insurance can be grouped
into two categories: private group plans and private
non-group plans.
Private group insurance: Employers are the largest
purchasers of private group insurance; they are the
second-largest payer of health care costs, behind public
payers. In 2003, 63.8% of the non-elderly (19--04-years
old) were enrolled in private group coverage versus only
3.5% in private non-group coverage, 13.6% had public
336 HEALTH CARE FINANCING
coverage, and 19.2% were uninsured (Bernard & Banthin,
2006).
Since 2000, employer-based health plan premiums have
increased 87% while general inflation increased by only 18%
and wages rose only 20% (Employee Health Benefits, 2007).
In 2006 alone, employers experienced a premium increase that
was twice the rate of inflation (The Impact of Rising Costs,
2007). Employers have initiated a variety of strategies to
decrease the financial burden of health benefits (Employee
Health Benefits, 2007; The Impact of Rising Costs, 2007).
Between 2000 and 2006, the number of employers offering
health care benefits dropped by 10% (from 70% to 60%
respectively); only 47% of small employers provided
coverage in 2006. Employers have passed' on higher
premiums, deductibles, and co-pays to their employees, or
have restricted the benefits within the plans they offer (Goff,
2004; Robinson, 2002; Tu & Ginsburg, 2007). One study
(Facts on the Cost of Health Care, 2007) reported that
employees' average contribution for premiums increased by
143% and out-of-pocket expenses increased by 115%. The use
of tiered cost-sharing has expanded, applying it to points of
access (for example, HMO versus PPO premiums), types of
services (for example, generic versus name-brand drugs), and
providers utilized (for example, low- versus high-cost
providers). Finally, to reduce premium costs, employers have
introduced more restrictive options that tout lower premium
costs but greater out of pocket expenses for utilization, such as
consumer-driven health plans (see later).
Other employer approaches restrict the availability of
coverage by offering only less costly plans such as HMOs or
eroding the breadth of coverage (that is, what is covered) or
both. Family coverage has specifically been under attack, with
25% of employers reporting the use of incentives, such as
flexible benefit credits, to encourage opting out of family
coverage; 10% use disincentives (for example, 10% surcharge
if the spouse does not enroll in his or her own employer's
health plan); 9% eliminated eligibility for the spouse if em-
ployed by a company offering health benefits. Some
employers have introduced tiered benefits fixed to the number
of dependents covered within the plan (Goff, 2004). Not only
have these strategies contributed to the growing numbers of
uninsured, but families also report forgoing living expenses
and other necessities to cover health care costs.
Private non-group insurance is predicted to grow as
employers eliminate or reduce coverage for health benefits.
Private non-group plans generally cost more than group plans
and provide less coverage. Premiums
increase as one grows older or develops medical conditions;
deductibles are also higher. Private, non-group plans are less
likely to have out-of-pocket spending limits below $2,000 for
catastrophic coverage. Ultimately, enrollees spend more of
their family income on health care expenses (Collins, Kriss,
Davis, Doty, & Holmgren, 2006). According to Gabel, Dhont,
Whitmore, and Pickreign (2002), 63% of health expenses for
individuals with private non-group coverage are reimbursed
versus 75% for those with group coverage.
The increased financial burden of private non-group plans
does not translate into better coverage. Benefits within
individual plans tend to be- more limited, with greater
restriction for accessing services (for example, pre-condition
waiting periods). Many who are classified as "underinsured"
fall within this market. Adults purchasing these non-group
plans tend to rate their satisfaction lower than group-plan
enrollees (Collins et al., 2006).
President Bush has been pressing to increase private
non-group purchases, particularly by the uninsured, by
offering tax-credits or state grants (Gabel et al., 2002; Swartz,
2002). There is growing concern about focused expansion in
this segment of the market. On average, a tax-credit of$l,OOO
would cover only 42% of the health costs for individual
coverage. For someone 55 years old, out-of-pocket expenses
would consume 17% of their income, which can compromise
an individual's or a family's ability to sustain their present
quality of life (Gabel et al., 2002). Another concern is the
adverse selection by insurance companies to steer away
potentially high-consuming enrollees.
MediGap policies are a private non-group plan linked to
Medicare to offset out-of-pocket expenses for beneficiaries.
All plans conform to 12 standard levels of coverage, with
improved cost-sharing and wider scopes of coverage as one
moves from plan A-L. These are individual plans only-there
are no family plans-and they cannot be used with Part C.
Individuals must be enrolled in Part A and Part B to purchase a
MediGap plan. Many believe MediGap will pay for services
not covered under Medicare. While the more expensive plans
may cover limited additional services, the plans will typically
only cover the cost-sharing for approved Medicare services.
Consumer driven health plans (CDHP) emerged in
response to the managed care backlash. Rather than directly
manage service access and flow (for example, supply-side
strategies), consumers have more choice but are held
financially accountable for their choices (demand-side
strategies) (Davis, 2004; Employee Benefit

Research Institute, 2006; Fuchs & Potetz, 2007; Goff,
2004; Robinson, 2002; Tu & Ginsburg, 2007). In the past,
insurance coverage often distorted or obscured the real cost
of services to the consumer, so there was no incentive to
make more cost-effective choices. The the ory behind
CDHPs is to increase the consumers' financial stake in their
"choices," which will encourage them to make more
cost-conscious decisions (Davis, 2004, 2007; Goff, 2004 ;
Zuckerman & McFeeters, 2006). For the consumer to
effectively evaluate options, clear and timely 'information
on cost and quality must be available in user- friendly
formats.
While the number of individuals enrolled in medical
savings accounts (MSAs) is small (about 3.2 million), they
are gaining momentum with enrollees tripling in one year
with CDHPs accounting for 23% of all new enrollees in the
private market; of new enrollees in MSAs, 60% are with
private, group plans (Fuchs & Potetz, 2007; Goff, 2004). To
qualify, the plan must provide general medical benefits;
establish a minimum annual deductible (for example,
$1,100 individual or $2,200 family) that applies to
allowable, covered bene fits; and provide catastrophic
coverage that begins when a spending thresho ld has been
reached (for example, $5,500 individual or $11,000
family). Some services may be excluded from the
deductible, called "safe har bor" services (for example,
specific preventive services). The deductible can apply to
the family or to each family member. Catastrophic
coverage is subject to the insurer's definition of medical
necessity and approved types and levels of care. CDHPs
can be paired with different service delivery structures,
including HMOs, but they are easiest to pair with PPO and
indemnity models because of the structural flexibility for
consumer choice. CDHPs also work well with personal
health care spending accounts.
How Are Health Care Services
and Providers Reimbursed?
Just as the sources of money come from a complex system,
the distribution of these dollars to health care providers is
equally complex. Reimbursement can be divided into three
general types: fee-for-services, fixed reimbursement, and
capitation.
Fee-for-service was the traditional way in which
providers were reimbursed. Providers set their rates, and
payers paid them. Within hospitals, the fee-for-service rate is
referred to as the "per diem" cost. If a consumer has private
insurance, the insurer assumes the largest portion of the cost
(for example, 80%), with consumers paying a smaller
co-insurance (for example, 20%). The setting of rates,
particularly within hospitals, often entails
HEALTH CARE FINANCING
337
lengthy and intense negotiations between third-party
payers and providers.
Fee-for-service reimbursement was cited as a major
cause of spiraling health care costs beginning in the 1960 s
since the incentive for providers was to increase their rates
and provide more services. Consumers were shielded from
the actual costs of care be cause their responsibility rested
only with what they had to payout of their own pockets,
including a co-insurance or co-payment. Third party payers
attempted to control the growth of spending by
implementing spending caps and setting standard re-
imbursement rates fixed to an average community rate,
called the "usual and customary" fee.
Fixed-reimbursement was the next wave of reim-
bursement strategies beginning in the 1980s. Prospective rates
for services related to an event of care were established rather
than retrospective rates based on each service provided during
care (for example, $1,200 for a simple broken leg).
Fixed-reimbursements were typically attached to a locus of
care, such as inpatient (hospital) or out-patient settings.
Medicare's Diagnosis Related Groups (DRG) for hospital
services led the way, soon followed by the Resource-Based
Relative Value Scale (RBRVS) for physician services.
Medicaid and private, third-party payers quickly followed
suit, often borrowing the payment scales set by Medicare.
Fixed-reimbursement, in the form of a negotiated; discounted
fee schedule, has been used with two managed care options for
physician services: preferred provider organizations and point
of service plans.
Another form of fixed-reimbursement is package pricing
strategies. When a specific medical situation requires
extensive or comprehensive services that span in- patient
and out-patient settings, traditional fixed reimbursement
approaches may not provide sufficient reimbursement to
make care financially feasible. The providers and
third-party payers negotiate a rate that covers all services
within an event of care. For example, a package- price for a
transplant would include pretransplant assessment and
care, in-patient transplant care, and post-tran splant
follow-up for a set period of time (for example, one year).
Two distinctive features of fixed reimbursement
markedly changed the landscape of health care finan cing.
First, for the first time, the payer of services (the purchaser)
set prices rather than the provider of services (the supplier).
Second, prices were developed using an elaborate formula
that took into consideration some of the following: costs of
care, intensity of care required, provider skill- level
required, type of facility in which care was provided, and
geographic variations that can
338 HEALTH CARE FINANCING
influence costs. This was a significant departure from the
historical approach of prices set by market or political forces
(Hunt & Knickman, 2005).
Capitation is a radically different form of reimbursement
that is used by health maintenance organizations. Rather than
fixing rates to an event of care, the provider receives a set
amount of money annually to cover care for each enrollee
regardless of how often or where the enrollee accesses care
during the year. A primary care provider serves as a
gatekeeper to ensure comprehensive and efficient service
delivery. Providers who spend more than the allowance lose
money; those who spend less keep the unused funds. The
entire system of capitation is based on having a large enough
risk pool of enrollees, with sufficient numbers of low-end
users to offset the high-end users. Presumably, providers have
the incentive to emphasize prevention and early diagnosis and
intervention. Capitation shifts some of the risk of costs of care
to providers since they have limited funds from which to draw
reimbursement for services.
Future Directions and Challenges
Health care financing is a complex system of revenue sources
and reimbursement patterns. As the United States looks to the
future, health care cost-containment continues to be a priority.
Several relevant health care financing issues are critical to
discussions of health care reform. First, in spite of spiraling
health care costs, consumer satisfaction has declined. Data
from the Health Confidence Survey (Helman, et al., 2006)
reveals a 22% increase between 1998 and 2006 in consumers
who were extremely dissatisfied, and a 19% increase in
dissatisfaction from 2005 to 2006. The environment is ripe for
change, with 55% of consumers rating decelerating the growth
of health care costs as a top priority for Congress and 48%
indicating concern over Medicare's ability to pay for health
care in the future as their second priority.
Second, the use of "supply-side" versus "demandside"
strategies to stem health care costs is still an area of debate.
Demand-side strategies focus on changing consumers'
behaviors, such as the use of cost-sharing strategies with
CDHPs. Proponents of this approach suggest that costs will
not be contained until consumers' behavior changes and that
will not happen until consumers are held responsible for their
decisions. However, studies have shown that cost-sharing
strategies reduce not only unnecessary care but also necessary
and effective care (Robinson, 2002). Cost sharing has a
differential impact on choices based on one's financial
situation or the status of their medical situation (for example,
high-end users will not be affected by
cost-sharing since they will quickly meet thresholds regardless
of the efficiency of providers selected). Consumers' decisions
are predicated on timely and understandable information,
which is presently limited.
Rather than a focus on consumers, many believe that
supply-side strategies controlled by providers who focus on
health care delivery hold the most promise in managing costs
(Davis, 2007). They include comprehensive service delivery
systems characteristic of managed care, case management
programs, and provider "pay-for-performance" incentives
based on cost and quality.
Third, the issue of adverse selection (for example,
accepting or rejecting individuals because of their health
status) continues to be a concern since the most recent
approaches to health care financing stress demand-side
strategies. However, there is growing evidence that these
approaches promote risk selection with payers. Those who are
wealthy or healthy (or both) are more likely to enroll in CDHP
formats while those who are poor or have higher health care
utilization patterns (for example, elderly, chronically ill, or
disabled) are more likely to enroll in comprehensive programs
that limit cost-sharing. As the case-mix in the comprehensive
models shift to higher-end users, premiums will dramatically
increase, placing many consumers outside their ability to
afford insurance.
Fourth, there is a positive relationship between rising
health care costs and the growing numbers of uninsured and
underinsured. The number of uninsured is at 47 million, a 7
million increase over the past 5 years (The Impact of Rising
Costs, 2007). Pressure from all sectors continues to focus on
decreasing costs, forcing more people into the ranks of the
uninsured or underinsured, who have similar problems with
access, cost, and quality (Schoen, Doty, Collins, & Holmgren,
2005). Medicare is introducing tiered approaches that increase
consumer out-of-pocket expenses. If given the option,
beneficiaries may opt out of coverage, such as Part B.
Medicaid programs are facing pressure to cut costs as federal
cost-sharing is slated to decline, resulting in tighter eligibility
criteria. Employers are dropping health benefits or seriously
curtailing coverage, particularly family coverage. This forces
women and children into uninsured or underinsured categories
at higher rates. Addressing the needs of the uninsured or
underinsured will become a top priority in addressing cost-
containment.
Fifth, proposals for universal health insurance are
returning to the political landscape in 2007 since their failure
in 1994 under President Clinton (Mizrahi, 1997). There is
increasing momentum to reform the system, given the
increasing costs and percentage of the GNP

while the number of under- and uninsured Americans is
also increasing. The debate is around who is responsible.
The question is whether the government or the market place
can solve the issue of health care coverage that lowers
costs, lessens health disparities, provides quality and
comprehensive care, and improves the health status of
Ameri~ans.
Implications for Social Work
To effectively advocate for health care reform, social
workers must have an understanding of health care
financing. We must be able to talk the language of
economics as well as social justice.
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health care and insurance premiums among the nonelderly
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Collins, S. R., Kriss, J. L., Davis, K., Dory, M. M., & Holmgren, A. L.
(2006). Squeezed: Why rising exposure to health care costs threatens
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al thfund.org/pu bl ica tions/pu bl ica tions_show. htm?doc_id =
235864
Davis, K. (2007). Paying for care episodes and care coordination
[Electronic Version]. The New England Journal of Medicine, 356,
1166-1168. Retrieved March 21, 2007, from
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Employee Benefit Research Institute. (2006). The 2nd annual
EBRI/Commonwealth Fund consumerism in health care survey,
2006: Early experience with high-deductible and consumer-driven
health plans. Retrieved June 28, 2007, from www.ebri.org/ pub
lica tions/ib/index.cfm ?fa = ibDisp&con ten Ud = 3769
Employee Health Benefits: 2006 Annual Survey. (2007). Retrieved
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Facts on the Cost of Health Care. (2007). National coalition on health
care. Retrieved June 21, 2007, from www.nchc. orgs/facts/
costs.shtml
Fuchs, B., & Potetz, L. (2007). The fundamentals of health savings
accounts and high-deductible health plans: National health policy
forum. Retrieved June 15, 2007, from www. nhpf.org/pdfs_bp/BP
_HSAs&HDHPs_Fundame ntals_ 04- 232007.pdf
Gabel, J., Dhont, K., Whitmore, H., & Pickreign, J. (2002).
Individual insurance: How much financial protection does it
provide? [Electronic Version]. Health Affairs, Suppl. Web
Exclusives, W182-W184. Retrieved June 28, 2007, from
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cgi/reprint/hlthaff.w2.172v1
Goff, V. (2004). Consumer cost sharing in private health insurance: On
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Helman, R., Greenwald, M., Associates, G., & Fronstin, P. (2006).
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Hunt, K. A., & Knickrnan, J. R. (Eds.). (2005). Financing for health
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Mizrahi, T. (1997). Health care: Policy development. In R. L.
Edwards (Ed.), Encyclopedia of social work (19th ed.-1997
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Robinson, J. C. (2002). Renewed emphasis on consumer cost sharing
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Change. Retrieved June 28, 2007, from www.hschange.
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Facts on the Cost of Health Care. (2007). Health insurance costs.
Retrieved June 21, 2007, from www.nchc.org/facts/
cost.shtml
Woolhandler, S., & Himmelstein, D. U. (2002). Paying for
national health insurance-And not getting it [Electronic
Version]. Health Affairs, 21, 88-Q8. Retrieved May 18, 2007,
from www.pubmed.com
-CANDYCE S. BERGER
HEALTH CARE REFORM
ABSTRACT: This entry presents an overview of national
health care reform in the United States from its introduction
into the public policy agenda at the tum of the 20th century
through policy debates and legislative proposals more than a
century later. Specifically, it concentrates on the programs
and strategies to obtain universal coverage for health and
mental health services for all Americans at the national level,
with limited success. It ends with the prospects for future
passage. Special emphasis is laid on the roles of social
workers and their professional organizations during this
period.
KEY WORDS: health care reform; health insurance;
managed care; Medicaid; Medicare; single-payer system;
health policy; health financing
Introduction
Proposals for a national health care program to ensure
universal coverage for all Americans have been on the public
agenda in one form or another for more than a century.
Various policy debates and the social work roles since the
inception are presented here, with an emphasis on the current
policies and programs since President Clinton's
comprehensive proposal was defeated in 1994. This is
described in more detail in the 19th edition (Mizrahi, 1995,
1997).
Health Care Reform: 1900-1935
The key organizational advocates for medical insurance in the
early years of the 20th century were the National
Civic Federation (NCF), an organization compnsing major
business corporations, and the American Association for
Labor Legislation (AALL). The AALL organized the social
insurance movement, holding its first conference in 1907. By
1912 it proposed a model bill to institute health coverage for
workers and attempted to mobilize constituencies toward a
compulsory, government-sponsored system of health
insurance for the United States adapted from those programs
developed in Germany and England (Lubove, 1968).
Opposition to government-sponsored health care was
always present. The strength, pervasiveness, 'and diversity of
the opponents depended on the type of reform that was
proposed and the era in which it was presented. Organized
physician groups have always opposed a universal compulsory
plan, although they supported coverage for medical
disabilities and illness in these early years of the 20th century
(Anderson, 1968). Additionally, the American Federation of
Labor opposed government-sponsored compulsory health
insurance, believing that it would weaken the union's role in
securing social benefits for its members. Private insurance
companies were among the strongest opponents of national
health care reform, and they, along with big business,
mainstream unions, and organized medicine, defeated all
attempts at national legislation then.
Throughout the 1920s, there was little publicly visible
activity for comprehensive programs to cover the financing
and delivery of personal health care. Those groups that were
vocal supported the development of private, voluntary health
programs (Hirshfield, 1970), but even those proposals were
not acted upon by Congress.
The AALL reformers shifted their goals and strategies by
calling for the expansion of health facilities and increased
expenditures for health care for specific populations. One of
the first pieces of federal legislation passed in 1921 was the
Sheppard-Towner Act. It provided state health departments
with funds for maternal and child health programs, and was
the only healthrelated program included in the Social Security
Act of 1935 (Anderson, 1968).
The major privately funded policy initiative in the 1920s
was the Committee on the Costs of Medical Care (CCMC).
Formed in 1927, it was composed of a voluntary, diverse
group of people including social workers and others who were
closely aligned with social work. However, the CCMC split
over the ways to achieve universal, comprehensive health
care. The majority of CCMC members proposed voluntary
health insurance (Moore, 1933), while a minority of them
condemned all health insurance recommendations (Anderson,
1968; Falk, 1973).

During the Great Depression, some individual hos pitals
and the American Hospital Association began to expand
private health insurance. Ultimately, Blue Cross was
formed to ensure hospital reimbursement for patient
services, which staved offogovernment-sponsored com-
pulsory health insurance (Anderson, 1968; Law, 1976 ).
Eventually, the American Medical Association (A MA)
supported the concept of voluntary hospital insurance, as
well as voluntary insurance for physicians' services in
hospitals known as Blue Shield.
Social Work Roles
The emerging social work profession in the early 20 th
century participated in critical debates on social insur ance.
Social workers began to write and speak about health
reform as early as 1888. Discussions and debates appeared
all employed people and their dependents with
in the proceedings of the National Conference
of Charities and Correction (NCCC). Rabinow's (1916 )
Standards of Health Insurance served as a model for all
progressive discussions in public and private forums for
several decades. However, as in the general society, there
were ideological divisions within the profession about the
methods of health care financing and delivery.
The NCCC, whose name was changed in 1919 to the
National Conference of Social Work (NCSW), attempted to
reach a middle ground by educating the public on the he alth
care needs of the citizenry, while remaining loyal to
political leaders. In the 1920s, as social work sought to
institutionalize itself as a profes sion, it invested itself in the
less controversial areas of public health and the protection
of women and children (Chambers, 1963).
Health Care Reform: 1935-1960
The rise of private for-profit and nonprofit (voluntary)
health insurance and, to a lesser degree, the develop ment of
alternative medical group practices in some parts of the
country (known as "prepaid cooperative practices" or
"capitation" models) diverted the move ment for
government-funded, universal healthinsur ance. President
Franklin Delano Roosevelt established the Committee on
Economic Security in 1933, headed by Secretary of
Education Frances Perkins, a social worker. However, no
health care proposals were sub mitted to Congress for
inclusion in the Social Security Act of 1935 because of
political opposition (Falk, 1973).
The final Social Security legislation did include several
health care-related programs including Title V- maternal
and child health and welfare and the crippled children's
program; Title VI-the first permanent authorization for
public health grants to states and for intramural research in
the public health service; and Title VII- an authorization to
continue a
HEALTH CARE REFORM
341
national study on medical care. This kept a federal foot in
the door for public financing and development of health
care programs in the future.
The first major bill for a national health care program
was introduced in Congress in 1939 by Senator Robert
Wagner. Physician and hospital groups waged a heavily
financed campaign, which led to its defeat. Another
important bill that was first introduced in Congress in 1943
served as the foundation for national health debates for the
next 50 years. That bill, which became known as the
Wagner-Murray-Dingell bill, was strongly supported by
President Harry S. Truman in his National Health Program
messages of1945, 1947, and 1949.
A revised bill that Senator Wagner introduced in 1947
advocated a national compulsory health program covering
comprehensive benefits, various reimbursement mechan-
isms to providers. The bill's main features were later
adopted in the Medicare and Medicaid legislation in 1966 .
It had the active support of social work organiza tions,
consumer groups, unions, and some physician groups.
In 1952, President Truman established the Commis sion
on the Health Needs of the Nation. With 58% of Americans
covered by some type of private health in surance at that
time, the majority on the commission believed that the
source of financing for health care should be voluntary.
However, a minority on the Commission believed that the
Commission's recommenda tions did not go far enough
(Anderson, 1968).
In addition, during this era, Republican Senator Robert
Taft produced his own bill to provide federal support to
states for medical and hospital care for needy p ersons and
related public health programs (Clark & Clark, 1947).
Although the Taft bill did not pass, the 1950 amendments
to the Social Security Act permitted federal funds to be
used by state public assistance agen cies for the direct
payment of physicians and others who rendered care to the
poor. During the Eisenhower administration of the 1950s ,
there was little presidential leadership for comprehensive
health insurance legislation (Falk, 1973).
As the Kennedy-Johnson era began in 1961, the
Medical Assistance Act, also known as the Kerr- Mills bill,
was passed. With the support of the AMA, it was the first
time that the federal government recognized the poor by
expanding the public assistance section of the Social
Security Act for those aged 65 and over (Anderson, 1968 ).
Social Work Roles
The leaders of the social work profession remained divided
on how pervasive and radical social reform
342 HEALTH CARE REFORM
should be with respect to income redistribution, universality,
equity, individual responsibility, linkage with work, and
governmental contributions. In the 1930s, the Social Security
Act became the predominant model for health care reform,
and this approach was supported by most social workers and
their organizations, including the American Association of
Social Workers. Some social work organizations supported a
publicly financed health insurance program. However, social
workers and social reformers in the White House, including
Harry Hopkins and Frances Perkins, rejected social health
insurance as too controversial.
Throughout the 1940s and 1950s, social workers
continued to be part of the national movement toward
comprehensive health insurance. In 1955, the American
Association of Social Workers and six other separate social
work groups merged to form the National Association of
Social Workers (NASW). Although this consolidation gave a
more powerful voice to the profession, NASW had to mediate
disparate philosophies of various groups and strategies for
achieving health care reform. This mediator role was evident
in the debates held in 1956 at NASW's first Delegate
Assembly, a meeting of elected member representatives who
set the national organization's policy. They called for a
national health program to ensure full health care to all
individuals using an incremental approach (NASW, 1959).
Health Care Reform: 1961-1992
During the Kennedy and Johnson administrations, a
nonmeans-tested set of benefits for older Americans under the
Old Age and Survivor Disability Insurance (Social Security)
gained favor. The King-Anderson[avits bill was introduced in
1961. The first White House Conference on Aging held earlier
that year was unequivocal in its support for such legislation.
The opponents of the King-Anderson-Javits bill were the
American Hospital Association (AHA), AMA, business
groups, and the Health Insurance Association of America
(HIAA). However, there were splits in the opposition's ranks
that eventually paved the way for politically acceptable
compromises.
In July 1965, after years of intense campaigning and
negotiating, President Johnson signed into law the Health
Insurance for the Aged Act. This act created Medicare (Title
XVIII) of the Social Security Act, which provided health
benefits for the aged. Medicaid (Title XIX) was also passed,
which provided separate means-tested medical care for poor
and medically indigent people channeled through the states.
There were victories and disappointments for both sides.
From the perspective of those who were seeking a universal
comprehensive health plan, Medicare
established the principle of nonrneans-tested universal
coverage for a population with uniform benefits. lts
supporters assumed Medicare would open the door to a
similar approach for the rest of the population in the future.
For the first time, Medicare and Medicaid also provided for
greater involvement by the federal government in the
regulation of hospital, physician, and nursing home policies
and practices.
On the other hand, Medicare and Medicaid also stemmed
the tide that was moving toward universal national health
coverage. Medicare preserved the current system of private
insurance patterns, and provided relief for insurance
companies' difficult and expensive insurance obligations. No
providers were required to accept Medicaid or Medicare
patients, and physicians were able to charge additional fees to
Medicare recipients.
In 1971, in the face of dramatically rising costs, President
Richard M. Nixon presented his version of national health
insurance, as well as proposals for health maintenance
organizations and health manpower. After his reelection in
1972, Nixon introduced the Comprehensive Health Insurance
Program (CHIP). It included three components: one for
working Americans, one for poor and unemployed people,
and one for continuation of Medicare. It can only be specu-
lated how much the resignation of President Nixon in 1974
played a role in the demise of almost all major health
insurance measures. The one exception was the passage of the
Nixon-supported Health Maintenance Organization Act of
1973. This law helped change the direction of the private
health care delivery system to one based on what became
known years later as "managed care."
During the Ford and Carter administrations, little was
done on health reform. With the election of President Reagan
in 1980, a conservative social agenda reversed the trend
toward expanded entitlements and citizen rights. It called for
cutbacks in social programs, and it promoted an ideology of
individualism and personal responsibility, the elimination of
many entitlements, and privatization of health care insurance.
Beginning with the 41st President G. H. W. Bush in the
late 1980s, the public national health care debate resurfaced
(Families USA Foundation, 1991). A variety of approaches to
health care reform were published in prestigious medical
journals (Enthoven, Kronick, & Writing Committee of the
Working Group on Program Design, 1989; Himmelstein &
Woolhandler, 1989). The Canadian health care plan began
attracting serious attention based on its principles of
universality, portability, comprehensiveness, public,
nonprofit administration, and freedom of choice of providers
(Mizrahi, Fasano, & Dooha, 1993).

In the late 1980s, Massachusetts became the first state
to pass a referendum declaring health care a right, and
several candidates for public office made health care a
major issue.
Social Work Roles
Beginning in the 1960s, social workers and NASW in
particular, became extremely active in health care re form
in the political arena. They were part of the major health
reform coalitions, including the Health Security Action
Council. By 1975, the NASW Delegate Assem bly passed
a policy statement on national health. It cal led for a
universal comprehensive national health care system. In
1979, the NASW Delegate Assembly passed a more
elaborate version of a policy statement on national health.
A small group of social workers and other progres sive
groups supported a bill known as the U.S. Health Service
Act, introduced by Congressman Ron Dellums, a social
worker, in 1981 and reintroduced every year since, most
recently by Congresswoman Barbara Lee, the successor to
Rep. Dellums (Lee, 2006). Under this plan modeled after
the British health care system, the government would
establish a full range of facilities and services
administered directly by elected officials and community
health boards and indirectly by district, regional, and
national health boards. This radical reform bill kept the
debate on national health care alive.
Health Care Reform: 1992-1996
With the election of President Clinton in 1992, hun dreds
of health-related bills were introduced in the 102 nd
Congress, and almost every interest group be came
involved in the health care issue (Families USA
Foundation, 1993; Mizrahi, 1992). President Clinton
made health care his highest domestic priority. During his
first two years in office, Clinton appointed his wife,
Hillary Rodham Clinton, to head a national Health Car e
Task Force. It produced a complex plan for health care
reform. In contrast to both the single-payer ap proach and
the private insurance and physician plans, Clinton's Health
Security Act built on what was known as "managed
competition" (The President's H ealth Security Plan,
1993).
There were reasons to be cautiously optimistic about
the prospects for passage of comprehensive health care
reform in 1994. First, due to divisions among physicians ,
the AMA no longer wielded the power it once did.
Second, consumers openly expressed dissatisfaction with
the American health care system, and active grassroots
and professional reform efforts were under way (Priest,
1994). Third, there was major presidential support.
HEALTH CARE REFORM 343
However, as in previous decades, opposition to uni-
versal health care surfaced (Moniz & Gorin, 2007). The
Health Insurance Association of America (HIAA), the
AMA, the pharmaceutical, high-technology health
equipment, and health care service industries all sup ported
plans that maintained their power and financial position
(Skocpol, 1996). Small business groups also opposed
fundamental reform.
President Clinton's Health Security Act (S. 1757 and
H.R. 3600) faced opposition from both the Right and the
Left. Many conservatives feared that if enacted, the Act
would resurrect the Democrats' image as advo cates for the
middle class. Interest groups spent more than $10 million
to influence the outcome of that public policy issue in the
early 1990s (Moniz & Gorin, 2007, p. 52; Podhorzer,
1995).
Liberal groups commended the Clinton proposal for its
support of universal coverage and extensive health and
mental health benefits, and for allowing states to create
their own plans, including single- payer systems.
However, they criticized it for preserving the employ-
ment-based system and maintaining a role for private
insurers. Social workers criticized it for not including
language to ensure a comprehensive role for social
workers in the delivery of health and mental heal th care
(Johnson & Broder, 1996).
Despite the fact that the Democrats controlled
Congress, the Clinton plan failed without coming to a
vote. With the election of the conservative Republican
majority to the 104th Congress, reform took on a different
meaning and direction. It meant lowering expectations
about government's responsibility to meet human needs
and increasing personal responsibility. With their
leadership, corporate-dominated, for- profit managed care
has burgeoned since 1994 (Salmon, 1995).
Social Work Roles
In the late 1980s, NASW invested its resources and
expertise to develop a comprehensive national health plan,
together with a complete cost analysis. This plan was
placed in the Congressional Record on May, 22 1990, by
Senator Daniel K. Inouye, who also introduced NASW's
bill, the National Health Care Act, in the House in 1992
and in the Senate in 1993. In addition to proposing its own
bill, NASW provided leadership to several coalitions that
supported a single-payer model. NASW also partic ipated
in some broader and more diverse coalitions, including the
Health Care Reform Project whose goals were compatible
with NASW's plan. NASW also expressed support for the
Health Security Act and worked with the Clinton
administration to promote universal coverage.
344 HEALTH CARE REFORM
The 1990 and 1993 NASW Delegate Assemblies made
the passage of health care reform one of their highest
policy priorities. They passed a revised policy statement
on national health care to reflect the pro posed NASW
health care plan (NASW, 1994).
Health Care Reform: 1996-2007
Since the failure of President Clinton's health proposal,
there has not been a major credible movement for a
national program of universal health coverage. Instead, in
the remainder of his administration, President Clinton
supported expanding health coverage legislation for chil-
dren and Medicare coverage. And under President G. W.
Bush's administration, prescription drug coverage was
added to Medicare, while Bush proposed c uts in Medicaid
and encouraged private market-place solutions such as
Health Savings Accounts. As the 2008 presidential
election unfolds, some form of health care reform ap pears
to be gaining momentum, with very different models put
forth by Republicans and Democrats.
PORTABILITY At the end of the 104th Congress in 1996,
a modest bipartisan health insurance proposal, the Health
Insurance Reform Act (P.L. 104-191) was sponsored by
Senators Edward Kennedy of Massachusetts, a liberal
Democrat and longtime proponent of universal federal
health insurance, and Nancy Landon Kassebaum of
Kansas, a moderate Republican. It allowed workers to
maintain health insurance coverage if they changed or lost
their jobs (known as "portability"), and it barred insurance
companies from denying coverage to people who had
preexisting medical conditions. It also made it easier for
self-employed workers to afford their own insurance by
increasing the share they could deduct from
HEAL TH SAVINGS ACCOUNTS In recent years,
conservatives have continued to promote HSAs as "an
alternative to traditional health insurance" (U.S.
Department of the Treasury, 2005). Like their "precursor"
medical savings accounts, HSAs are rooted in the
assumption that "third-party" payers, which give indi-
viduals relatively unlimited access to healt h care, have
played a key role in driving up health care costs (Fuchs &
James, 2005).
To create an HSA, an individual must buy a high
deductible (or "catastrophic") health plan, which re quires
consumers to assume responsibility for at least the first
$1,050 and families at least the first $2,100 (2006 figures)
in medical expenses (Ll.S. Department of the Treasury,
2005). Individuals and employers can defray these costs
by contributing, on a pretax basis, to a health savings
account; these funds are not ta xable if withdrawn for
medical purposes. HSAs will most likely appeal to
relatively young, healthy individuals, as well as
upper-income people seeking to take advantage of the
investment and tax benefits associated with these accounts
(Moniz & Gorin, 2007).
Supporters of HSAs, and other forms of "consumer-
directed" health care, believe that by forcing individuals to
become careful shoppers, high deductible plans will lower
costs and expand coverage (Moniz & Gorin, 2007).
However, since 78% of all expenditures (both indivi dual
and family) are over the deductible, this is unlikely
(Blumberg & Burman, 2004). It also seems unlikely that
HSAs will reduce the uninsured population (Fronstin &
Collins, 2006). Gruber (2006) estimated that President
Bush's HSA proposals could induce some employers to
stop offering coverage to their workers and actually
increase the uninsured population by 600,000.