ENCYCLOPEDIA OF

SOCIAL WORK
\

20TH EDITION
 EDITORIAL BOARD

EDITORS IN CHIEF

Terry Mizrahi, Ph.D., MSW

Professor of Social Wark Hunter
College

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

of Social Wark 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
J ames Midgley, University of California, Berkeley John
G. Orme, University of Tennessee Enola Proctor,
Washingt~n University in St. Louis Frederic G. Reamer,
Rhode Island College Michael So sin, University of
Chicago
 ENCYCLOPEDIA OF

SOCIAL WORK
20TH
EDITION

Terry Mizrahi
Larry E. Davis

Editors in Chief

VOLUME 3
J-R

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OXFORD
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2008
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 ENCYCLOPEDIA OF

SOCIAL WORK
20TH EDITION
JAILS. See Criminal Justice: Corrections.
JAPANESE. See Asian Americans: Japanese.
JEWISH COMMUNAL SERVICES
\
ABSTRACT: The form and character of communal ser-
vices provided under Jewish auspices have been shaped by
religious teachings and traditions. Righteousness is
achieved by fulfilling obligations to those less fortunate or
in need. Acts of tzedakah, translated as justice, are the
hallmark of Jewish philanthropy. The evolution, role,
functions, and organizational structure of services are
reflective of these obligations. While changing funding
patterns and managed care have blurred the sectarian nature
of many communal agencies, these agenci es remain as key
elements in the voluntary social services network of this
country.
KEY WORDS: Charity; Jewish; Nonprofit; Sectarian;
Mutual Aid
Foundation From Scripture and Teachings
The form and character of communal serVices provided
under Jewish auspices have been shaped by religious
teachings and tradition developed over a 4,OOO- year
period. In the Jewish tradition righteousness is achieved by
fulfilling obligations to those less f ortunate or in need. The
evolution, role, functions, and organizational structure of
services are reflective of these obligations, and also of
historic models of Jewish communal organi zation.
Preservation and continuity of Jewish ideals and the Jewish
people are the centerpiece of refugee assis tance programs;
formal and informal education, family services; vocational
programs; services for the frail and elderly; and training for
Jewish communal professionals. While changing funding
patterns and managed ca re have blurred the sectarian nature
of many Jewish communal agencies, these agencies remain
as key elements in the voluntary social services network of
this country (Gelman & Schnall, 1997). Judaism not merely
posited a noble vision of a free, just, and compassionate
society, but also translated this vision in detailed legislation
of
obligatory moral behaviors and acts of loving kindness.
Contemporary Jewish communal service emerges from a
religious and social tradition rooted in Scripture, the
Talmud, and rabbinic dicta. Jewish religious practice is
defined by mitzvoth, which literally mean command ments.
The commandments are broadly separated into those that
are largely ritual and ecclesiastical and those that define a
vast array of social relations, in cluding marriage, economic
pursuits, child rearing, and care for the widow, the orphan,
the poor, and the stranger. Thus, Judaism views personal
charity as motivated by the value of mutual responsibility
and part of a systematic network of social obligati ons,
rather than a voluntary act of kindness (Bernstein, 1965).
As an example, the Bible enjoins that crops forgot ten in
the field or inadvertently left standing after the harvest
remain for poor people. In addition, a corner of a farmer's
field must be purposefully left uncut so that needy people
may glean in private. Such prescriptions stand side by side
with those that require employers to pay workers
punctually and those that restrict creditors in their demands
epistemologies and to collaboOverall, two themes have
Overall, two themes have remained constant over the
years in both religious teaching and practice: First, one who
extends a hand for assistance must never be turned away,
and second, in helping someone else, the benefactor
follows in the paths of righteousness and s anctity that
characterize the Lord. In sum, although numerous Hebrew
terms connote philanthropy and voluntary service, tzeda-
kah, the most popular term used, derives from a word that is
more accurately. translated as justice or righteous giving.
This epitomizes the classic Jewish attitude to ward such an
undertaking (Gelman & Schnall, 1997).
Past and Current History Fundamental
sources regarding personal obligations to needy people
gave rise. to discussions of the organization and structure of
community services. This became especially important as
largely autonomous Jewish communities emerged, first as
part of a centralized monarc hy in ancient Israel and later as
Jews were dispersed throughout the Near East, North
Africa, and Europe. By Tal mudic times (that is, during the
first centuries of the Common Era), Jewish communities
were required to maintain systems of assessment and
collection, with detailed prescriptions for the oversight and
accountability of those who were trustees and
administrators.
1
2 JEWISH COMMUNAL SERVICES
dignity and self-respect of those who were re-
cipients of communal beneficence were given primacy.
Thus, the highest form of tzedakah, according to Mai-
monides (1965), a l Zth-century Jewish philosopher and
jurist, is that which provides poor people with the
wherewithal to become productive and self-s ufficient (for
example, extending loans or providing assistance in finding
ajob or beginning a business). Second is a system of
completely anonymous philanthropy in which nei ther
recipient nor donor can be directly identified. This
approach reduces embarrassment on one side and arro-
gance on the other. Maimonides suggested that the goal is
best facilitated through a central kupah in which the process
of donation is separated from, disbursement.
Given the heavy emphasis in Jewish texts on reli gious
education as equivalent to all other mitzvoth combined, it is
no surprise to find that public education also was an area of
special concern to early Jewish commu nities. Jewish
sources further established the communal obligation to
create local structures of go vernance and to provide for
refugee aid, hospitality for wayfarers, funeral and
bereavement assistance, and mediation of civil and
domestic disputes (Schnall, 1995). The schol arly literature
of the period recorded active debates about public
participation and the scope of the fran chise in communal
decisions, including in the choice of leadership. This
dynamic continues to inform much of what has been
established in the United States over the past 350 years
(Elazar, 1995).
Although rooted in Scripture, the pattern of Jewish
welfare organizations is distinctively different frO"irliltiat'
of other sectarian groups. For the most part, Jewish social
services have developed apart from the synago gue.
Although the beginning of American Jewish phi lanthropy
took place at the synagogue, the sudden and massive influx
of Jewish immigrants created needs for which a synagogue
alone could not provide (Reid & Stimpson, 1987). Jewish
immigrants formed literary societies for recreation and
"landsmanchaften" for mutual aid and self- help. These
organizations facilitated the acculturation of emigres to
their new land and assisted in caring for those in need,
facilitating their independence and self-sufficiency.
It is estimated that 5.2 million Jews currently live in the
United States. Just as their numbers have increased since
the original 23 Jews debarked in New Amsterdam in 1654
with special permission from the Dutch West India
Company, so too has there been growth in the number of
social organizations that provide for heal th, welfare,
recreational, and spiritual needs (Berger, 1980).
Poverty is still a very real problem among Jews.
In New York City, the city with the largest Jewish
population in the United States, 226,000 individuals
have incomes that fall below 150 percent of the federal
poverty standard. The majority of these individuals are
older women and children. One-third of those in need who
are considered to be of working age work full or part-time.
More than half of working-age individuals have no
education beyond the high school level (Metropolitan New
York Coordinating Council on Jewish Poverty, 2004;
Rapfogel, 2004).
The Role of Communal Service
Agencies in the United States According to
Steinitz (1995, 1996), Jewish communal agencies through
much of their history have focused on four primary goals:
a. delivering basic social services to indigent members
of the J~,wish community,
b. resettling refugees and helping Americanize both the
immigrant and the second generations,
c. responding to international crises,
d. fighting anti-Semitism.
However, beginning in the 1960s, changing demo-
graphics, growing identification with the developing state
of Israel, newly established governmental funding streams
designed to expand service options and opportu nities, and
interest in specialized therapeutic interven tions delivered
by highly trained professional personnel led to a reordering
of organizational priorities. The over view provided by
Berger (1980) is enlightening:
These changes not only resulted in the dramatic
expansion of social services provided under Jewish aus-
pices (Blum & Naparstek, 1987; Gibelman, 1995; Smith &
Lipsky, 1993) but also led to a real blurring of what had
been the historical distinction between' sectarian an d
nonsectarian agencies (Levine, 1998; Ortiz, 1995). Jewish
agencies currently exhibit a great degree of auton omy from
religious authority and are largely nonsectarian in client
intake. Many Jewish agencies, particularly in large
metropolitan areas, have high percentages of non Jewish
clients and other service users.
The 1990 and 2001 population surveys produced
disturbing findings of an American Jewish community
with high intermarriage rates and growing levels of
alienation and disengagement, particularl y among the
younger population, from Jewish tradition and commit-
ments. The organized Jewish community, through its
federation network and a growing number of private
foundations, has mobilized to address these continuity
concerns through a dramatic shift in funding priorities
toward Jewish identity building and education services
(Edelsberg, 2004, 2005; Goldman, 2005; Schwager, 2005 ).

The Jewish Federations
The Jewish federations are the central fundraising orga-
nizations within individual Jewish communities, raising
and distributing hundreds of millions of dollars to local
community agencies, Israel, and Jewish communities
around the world. The 155 Jewish community federations
in the United States are autonomous, voluntary
organizations that engage in or provide a series of functions
for communal affiliates that include the following:
• Joint or coordinated annual fundraising
• Endowment development, planned giving, special
and emergency campaigns
• Allocations and central budgeting
• Centralized research and community planning
• Leadership development and training services
• Initiation of new sen>ices
Federations developed in the United States beginning in
Boston in 1895 and currently exist in communities where
there is a significant Jewish presence. The United Jewish
Communities, created in 1999 as a successor organization
to the United Jewish Appeal, Council of Jewish
Federations, and the United Israel Appeal, represents and
serves the local Jewish federations of the United States and
Canada on issues of public social policy, financial resource
development, community building, and Jewish
engagement across North America, Israel, and
internationally.
Jewish agencies increasingly apply for, receive, and use
public funding for the benefit of the Jewish and general
communities. Although one can debate the nature of the
change created by the acceptance of public funds by these
historically sectarian agencies, it is clear that the number of
units of services delivered to the Jewish community, as
well as to the general community, has increased
dramatically as a result of the acceptance of this support
(Solomon, 2005).
On average, federation network agencies receive more
than 40% of their total budget from federal, state, and local
government sources. UJA-Federation of New York, which
conducts the largest federation campaign in the world,
raised mote than $388 million from its annual campaign,
planned giving, endowments, and other sources in 2006
(UJA Federation of New York, 2007).
Communal Services
The following examples of Jewish communal services
agencies are presented to provide a sense of the mission,
scope, and program involvement of such agencies.
International and Refugee Services
The primary mission of the Hebrew Immigrant Aid Society
(HIAS) is to help Jews whose lives and freedom
JEWISH COMMUNAL SERVlCES 3
are endangered. Since 1880, HIAS has been the worldwide
arm of the American Jewish community for rescue,
relocation, family reunification, and resettlement of
refugees and other migrants. Its mission is derived from the
biblical teaching "Kol Yisrael Arevim Ze Bazeh," which
means "all Jews are responsible, one for the other."
During 2004 HIAS resettled 41,445 immigrants,
including 7,565 Jewish refugees from the former Soviet
Union, into communities throughout the United States
(HIAS, 2004). Its 2004 budget exceeded $13 million, with
more than 53% of its funding coming from contracts with
the U.S. government (HIAS, 2006). Since the mid-1970s,
when barriers to immigration were eased in the former
nowledge. Familycentered care, child welfare teams,
rkforce issues, and
ental health, substancement of Jews from the former Soviet
Union to serving a more nonsectarian client base using
money from Jewish funders committed to the Jewish
resettlement tradition. During fiscal 2006 HIAS resettled
1,754 refugees in the United States, 713 from the Former
Soviet Union, 698 from Iran, 241 from Syria, and 102 from
Southeast Asia (HIAS, 2007).
The American Jewish Joint Distribution Committee
was formed by a merger of three agencies in 1914 and
serves as the overseas arm of the American Jewish
community, sponsoring programs of relief, rescue, re-
newal, and helping Israel address its most urgent social
needs. Over the course of its history it has assisted
hundreds of thousands of jews and non-Jews in Europe,
Israel, the former Soviet Union, the Middle East, Asia, and
Africa through humanitarian and development efforts. Its
goal is to develop systematic solutions to social problems
through research and development, pilot demonstration
projects, and strategic interventions working
collaboratively with international organizations such as the
UN, the World Bank, and U.S. Agency for International
Development. For example The Joint provides basic life
sustaining services, including food assistance, medicine,
fuel, and social contact, to the large elderly Jewish
population in the former Soviet Union. It is also involved in
a variety of community-based activities in the former
Soviet Union ranging from educa tional programs for
children, college students, and adults, community outreach
and family camps, to leadership training seminars in Jewish
academic studies in universities (jdc.org).
Community Centers
Jewish community centers (JCC) and Young Men's and
Women's Hebrew Associations provide cultural, re-
creational, educational, and social opportunities for
members of the community. JCCs today are committed
4 JEWISH COMMUNAL SERVICES
to supporting Jewish cultural activities, Jewish identity-
building initiatives, and enabling Jews of all ages and
backgrounds to engage in the joys of Jewish living. Although
under Jewish auspices, these communitybased centers and
their affiliated camps serve populations that are ethnically
diverse, fall along a continuum of religious observance, and
vary by age from early childhood to senior citizens.
Local JCCs are affiliated nationally with the JCC
Association, the successor organization to the Jewish Welfare
Board, which came into being during World War I to provide
welfare, morale, and religious service to men and women in
the armed forces. JCC Association strives to strengthen
Jewish life in North America through research and
publications, human resources development, conferences,
<3irect service and consultation, and special continent-wide
programming. JCCs across the country are known for their
early childhood programs, health and wellness centers, teen
programming, senior adult services, adult Jewish learning,
special needs programming, camping programs, and cultural
enrichment activities. The Association has more than 350
affiliates (JCCA, 2006). Through its Jewish Chaplains
Council (formerly the Jewish Welfare Board), the Association
serves Jews in the armed force of the United States ..
Family Services
Jewish family service (JFS) agencies have been a mainstay of
the Jewish communal network since the 19th century. There
are more than 140 agencies affiliated nationally with the
Association of Jewish Family and Children's Agencies, which
employ trained social workers and other professional
personnel who specialize in clinical work and case
management (Association of Jewish Family and Children's
Agencies [AJFCA], 2006). JFS agencies are recognized for
their clinical expertise and innovative approaches to current
challenging mental health issues (Abramson, 1994). Many of
these agencies provide adoption services, foster care, group
homes for people with developmental disabilities, and
geriatric services under contract with government agencies.'
Services address individual and family concerns, . including
the mental health needs of recent immigrants. JFS agencies
provide the Jewish and non-Jewish communities with high-
quality mental health services sanctioned by the Jewish
community (Abramson, 1994). In 2003, Jewish Family and
Children's Services affiliates spent more than $530 million to
assist a broad range of children, adults, and the elderly
(AJFCA, 2006).
The New York-based Jewish Board of Family and
Children's Services, a UJA-Federation network agency, is one
of the largest nonprofit mental health and social
services organizations in the nation. It serves over 65,000 New
Yorkers annually from all religious, ethnic, and economic
backgrounds through 185 comprehensive community-based
programs, residential facilities, and day treatment centers
(jbfcs.org). This agency has taken a leadership role in
responding to the managed care environment and provides a
highly sophisticated training program for its professional and
line staff.
ospitals and Services for Elderly People
The development of sectarian hospitals, nursing homes, and
specialized geriatric utilities in American communities is a
tradition that dates back to the 19th century. Homes for elderly
people have been the primary source of service to Jewish older
people since the early 20th century. Since the 1930s, Jewish
geriatric facilities and JFS agencies have been innovative in
providing a range of community-based services. According to
Shore (1995/1996); these innovations include the provision of
meals to shut-ins; independent and assisted living
arrangements; and health services and the introduction of
outpatient physical, occupational, and speech therapies. The
Jewish community has also been instrumental in the
development of hospice-based care for patients in the final
stages of terminal illness.
In addition to serving a humanitarian purpose, these
facilities were established to provide kosher food for patients
or residents who observe traditional dietary laws. Although
these facilities have historically received support from
benefactors, self-pay and third party sources, and federation
subsidies, they are predominantly dependent on government
Medicare and Medicaid reimbursement for the services they
provide. The services of these organizations are available to
all people, regardless of race, ethnicity, or religious
identification.
Vocational Services
Jewish vocational services (JVS) agencies were founded by
federations to address specific communal needs in the areas of
employment. "Founded on the concept of 'parnosah,' JVS
agencies had an obligation to help Jews secure a source of
income so they could raise a family, remain independent, live
in dignity, and continue to be a vital and productive part of the
Jewish community" (Miller, 1995/1996, p. 88). They
supplement the efforts of public employment services, with
special assistance being provided to physically and mentally
handicapped individuals and to recent emigres who are in need
of retraining. Services include vocational testing; individual
and group counseling; job placement; educational support;
training programs for people with developmental disabilities,
mental illness, and dual diagnoses; and

economic development services. These programs are
designed to assist individuals in becoming self-sufficient.
FEGS (Federation Employment Guidance Service) in New
York serves more than 100,000 people each year at 300
locations with an annual budget in excess of $200 million
(PEGS, 2005).
Community Relations
Community relations are an integral part of the Jewish
communal service agenda, something that is reflected in
the work of the Anti-Defamation League, the American
Jewish Committee, the American Jewish Con, gress, and
the national and local community relations councils. These
agencies are concerned with issues of church-state
separation, anti-Semitlsm, human and civil rights,
immigration,' equality of women, cultural relations, Jewish
identity and education, and relation, ships among various
religious and ethnic groups. These agencies are also
engaged in advocacy and education for Israel's security and
peace with its neighbors as well as the safety of Jewish
communities worldwide.
Jewish Communal Service Association
The current Jewish Communal Service Association was
originally founded in 1899 as the National Conference of
Jewish Charities and has evolved over the years in terms of
membership and functions. It is the primary professional
association for a wide range of professionals employed in
Jewish communal agencies. It conducts professional
development seminars and workshops and publishes the
Journal of Jewish Communal Service, the leading journal in
the field of Jewish communal services. Affiliated
professional associations include the Association of Jewish
Aging Services, the Association of Jewish Center
Professionals, the Association of Jewish Aging Services,
the North American Associ, ation of Synagogue
Executives, and the World Council of Jewish Communal
Service.
Education for Jewish Communal Service Jewish
communal service is not a unitary profession but a field of
practice bound by a series of shared attributes in which
workers are personally committed and responsible for the
following:
• Developing and deepening Jewish consciousness
based on knowledge and emotional commitment
• Excellence in professional competence, manage,
ment, interpretation, and planning
• Leadership through initiative and service as educators
and models for emulation and inspiration
• Participation of laypeople
• Effective use of human and financial community
resources (Goldman, 2005).
JEWISH COMMUNAL SERVICES 5
The first Jewish school of social work was formally
established in 1913 by the Jewish Settlement, a social
agency affiliated with the Federation of Jewish Char, ities
in Cincinnati. This pioneering institution was abandoned 18
months later because it was unable to attract students. The
New York Kehillah, which opened its offices in the spring
of 1909, organized a school for Jewish communal work in
October 1916. This school closed in its third year, partly
because military conscription for World War I made it
difficult to find students. The Graduate School for Jewish
Social Work, sponsored by the National Conference of
jewish Charities, opened in 1925. It operated until 1940,
when lack of funds caused it to close its doors.
The first attempt to prepare Jewish communal work, ers
in a university setting occurred at Yeshiva University in
1957, with the founding of what was to become the
Wurzweiler School of Social Work. Wurzweiler has
continued to serve the Jewish and general communities in
the preparation of Master's level and doctoral level social.
workers.
There has been a continuing dialogue since the early
1970s as to whether Jewish communal service is a field
(Pins & Ginsburg, 1971), a profession (Reisman, 1972), or
both (Bubis, 1994; Bubis & Reisman, 1995/1996). More
recent writings have provided recommended steps to
develop consensus on the knowledge, values, and skills to
raise Jewish communal service to a professional status
orce issues, and
ealth, substanc North America with programs that
specifically train individuals for careers in Jewish
communal agencies; nine of these are linked to the
Federation Executive Recruitment and Education Program
of the UJc.
Jewish Population Studies
Since the 1960s, Jewish communal organizations have
attempted to better understand their constituencies and their
evolving needs, evaluate their services, and plan for future
service needs through a series of systematic statistical
profiles and local community surveys. The most ambitious
and influential of these surveys is the National Jewish
Population Survey (NJPS), sponsored by the United Jewish
ledge. Familycentered care, child welfare teamNJPS data
NJPS data are the most comprehensive and author'
itative and have the most traction in public discussion and
policy planning. The 2000-2001 Survey shows a U.S.
Jewish population of 5.2 million, a decline from the 5.5
million reported in 1990. Two new population studies
estimate the American Jewish population at over 6 million
(Saxe, Tighe, Phillips, & Kadushin, 2007; Sheshkin &
Dashefsky, 2006).
6 JEWISH COMMUNAL SERVICES

Most significant of all the findings for communal The following are among the most prominent of these
policy makers and educators were data regarding entrepreneurial initiatives:
Jewish identity and engagement in Jewish life and • Taglit-birthright Israel-Inaugurated in 2000,
patterns of intermarriage. The intermarriage rate rose birthright Israel offers a free first-time lfl- day trip
slightly from the record high 1990 leve1. Rates of to Israel for Jews around the world between the
intermarriage have increased by generation, with some ages of 18 and 26. Created by a handful of
87% of those married before 1970 choosing a born or megadonors in the American Jewish community
converted Jew as a marital partner, compared with only with matching support from the federations and
53% of those married between 1996 and 2001 (United the State of Israel, the primary goal is to give
Jewish Communities, 2003). young people their first Israel experience. Over
100,000 young people from 40 countries have
Jewish Identity-Building Initiatives participated in a birthright trip. Research has
The 1990 NJPS made it clear that most Jews in the United ,. - pointed to heightened positive feelings among
States considered themselves well accepted in the general participants toward being Jewish and stronger
society and integrated within a largely secular arena. The commitments to support and be involved with
community would have to prove "worthy" of their support Israel (Saxe et a1., 2004).
by providing initiatives that instill a sense of belonging, • Partnership for Excellence in Jewish Education
affiliation, and inspiration independent from those of their (PEJE)-Launched in 1997, PEJE is a collaborative
ancestors. initiative of major philanthropic donors whose
Against the backdrop of this finding and the alarm- goal is to strengthen the Jewish day school
ing evidence of waning levels of Jewish affiliation and movement by increasing enrollment in Jewish day
dramatic increases in intermarriage rates, the federa- schools in North America. PEJE carries out its
tions declared "Jewish continuity" to be the primary and mission through a Challenge Grant program with
foremost mission of Jewish communal and social schools, advocacy and conferences, and provision
services efforts. The call was to "reinvent" community of expertise to day schools.
and create a strategic vision of Jewish life that ac-
counted for the realities of its constituents, both actual In addition to the Jewish identity issues raised by the
and potentia1. NJPS and other surveys, other issues have become a
In response, throughout the 1990s local Jewish fed- focus of concern and service of Jewish communal
erations, especially those from larger cities with a sub- agencies. These include spousal and child battering;
stantial Jewish population, established continuity substance abuse; the changing role of women; serving
commissions and launched a slew of Jewish identity- intermarried couples; abortion; and serving populations
building initiatives targeting different groups, including at risk, including people with the human immunodefi-
children, teens, young adults, and outreach to the inter- ciency virus (HIV) or acquired immune deficiency
married. These federations undertook to establish goals syndrome (AIDS) (Bayme & Rosen, 1994; Dubin,
and objectives for this mission, with particular focus on 1994; Linzer, 1996; Linzer, Levitz, & Schnall, 1995).
Jewish education, the vitality of the Jewish community Although some of these concerns relate specifically to
including the educational offerings of synagogues and the Jewish community, they are similar, if not identical,
temples, and individual Jewish identity building. Com- to concerns being addressed by other sectarian organ-
munity endowments and other funding sources were izations and by social services agencies in genera1.
created to support new programs of outreach, family
education, professional training, and study or travel to Trends in Jewish Communal Services
Israe1. Collaborations were encouraged between local The future of Jewish communal service in the United
institutions already involved in such activities, and States is intertwined with efforts by Jewish communal
efforts were made to win support from donors and professionals, alongside their volunteer leadership, to
activists for this redirection of communal priorities playa central role in helping shape the Jewish identity
(Dashefsky & Bacon, 1994). and engagement of large number of America's Jews and
Beginning in the mid-1990s and accelerating in the ensure the vitality of its traditional and emerging in-
current decade, new funding partnerships spearheaded stitutions. The contours of American Jewry have been
by leading Jewish philanthropists and family dramatically altered in the last 25 years, with high levels
foundations have emerged to engage unaffiliated and of geographic mobility, significant changes in the
marginally affiliated young Jews in Jewish life through Jewish family, lesser attachment and connectedness to
ambitious and intensive Jewish experiences. Jewish life and full integration within the American

mainstream now the norms for the bulk of American Jewry.
Long-held notions of lifetime Jewish affiliation and
membership, once sin qua non for American Jewry and the
lifeline of its institutions, no longer hold the same meaning and
appeal for younger generation of Jews. However, the most
innovative and far-reaching initiatives to intensify Jewish
connectedness and engagement have been launched outside
the organized Jewish communal agency network. Most
prominent are the roles played by individual
megaphilanthropists and major private foundations that have
created new innovative approaches and launched bold and
ambitious identity-building programs with enormous impact
on Jewish life, particularly for American Jewish youth and
young adults (Bubis, 2005). Their undertakings have reshaped
the comm'unal world. Many of these megafunders and other
Jewish family foundations and independent funders are
affiliated with the Jewish Funders Network, an umbrella
organization dedicated to promote the quality and growth of
philanthropy rooted in Jewish values. This network provides
its members valuable information about philanthropic trends,
offers training in grant making skills and practices, and offers
innovative Matching Grant Initiatives to help foundations
effectively leverage their grant-making.
Simultaneously, there has been a growth of new Jewish
organizations and initiatives dedicated to translating the value
of Tikkun Oram (healing or repairing the world) into action by
mobilizing groups of Jews to provide material aid,
empowerment assistance, and advocacy for oppressed and
beleaguered populations in America and around the
developing world. The American Jewish World Service,
motivated by Judaism's imperative to pursue justice, is
engaged in a wide range of international development projects
in Africa, Asia, and South America. It promotes the values of
global citizenship within the American Jewish community
through strong advocacy and material assistance on behalf of
the endangered tribal populations in Darfur, Sudan.
The Foundation for Jewish Campus Life and local Hillel
chapters organize student missions to respond to natural
disasters in America (for example, rebuilding after Hurricane
Katrina) and to community development challenges in South
America and elsewhere. Avodah, the Jewish Service Corps,
launched in 1998, integrates work for social change, intensive
Jewish learning, and community-building. With programs in
New York, Washington, DC, and Chicago, Avodah provides
young, dedicated Jews internships to work for social change
with disadvantaged communities in inner-city neighborhoods,
within a Jewish framework.
Finally, there has been a proliferation of alternative Jewish
service providers to cater to the particular needs
ThompsonCOMMUNAL SERVICES 7
of specific populations within the Jewish community. From
experimental educational approaches, small and intimate
transdenominational prayer groups, spiritual and learning
retreats to creative outreach initiatives and service programs
for heretofore underserved groups such as special needs
children and adults, gay and lesbian groups, interfaith couples,
Orthodox Jews, young adults, and new immigrants, the Jewish
community has adopted more inclusive and targeted ap-
proaches to respond to the diverse service needs and interests
of American Jewry.
This more diversified landscape of both traditional
communal agencies and a host of new service providers and
funding sources provides a greater variety of opportunities for
professional practice. Many communal service professionals
who start their careers in traditional communal agencies have
later found more challenging opportunities in some of the
newer alternative service models. A growing number of young
professionals seek out these alternate agencies at the outset of
their careers, drawn to their more entrepreneurial approaches
and less bureaucratic organization (Bubis, 2005).
The Jewish community like all ethnic and religious
communities is faced with change. How the Jewish
community deals with issues of choice and diversity as well as
changing demographics are reflected in the organizations that
are created to meet these changes. Lessons learned can serve
as a model for responsive service delivery.
i\cknovvledgunent
I was given assistance by Rebecca Ackerman..
REFERENCES
Abramson, G. (1994). Doing the job in difficult times: An
appreciation of Jewish family service. Journal of Jewish Com-
munal Service, 70, 248-252.
Association of Jewish Family and Children's Agencies. http://
www.ajfca.org.
Bayme, S., & Rosen, G. (1994). The Jewish family and Jewish
continuity. Hoboken, NJ: KT A V.
Berger, G. (1980). The turbulent decades. New York: Conference of
Jewish Communal Service.
Bernstein, P. (1965). Jewish social services. In H. L. Lurie (Ed.),
Encyclopedia of social work (15th ed., pp. 418-428). New York:
National Association of Social Workers.
Blum, A, & Naparstek, A J. (1987). The changing environment
and Jewish communal services. Journal of Jewish Communal
Service, 63, 204-211.
Bubis, G. (1994). Jewish communal service today: Paradoxes and
problems. Journal of Jewish Communal Service, 71,§-12.
Bubis, G. (2005, Fall/Winter). Canons and icons in search of a
Jewish communal service. Journal of Jewish Communal Service,
Vol. 81, Yl, 83-88.
8 JEWISH COMMUNAL SERVICES
Bubis, G., & Reisman.' B. (1995/1996). Jewish communal service
training programs and the federation system. Journal of Jewish
Communal Service, 72, 102-109.
Dashefsky, A., & Bacon, A. (1994). The meaning of Jewish
continuity in the North American community: A preliminary
assessment. Agenda: Jewish Education, 4, 22-28.
Dubin, D. (1994). The liberation of the constituent agency.
Journal of Jewish Communal Service, 70, 226-231.
Edelsberg, e. (2004, Winter). Federation philanthropy for the
future. Journal of Jewish Communal Service, 31-38.
Edelsberg, e. (2005, Fall/Winter). More than money a covenant of
federation philanthropic effectiveness. Journal of Jewish
Communal Service, 107-114.
Elazar, D. (1995). Community and polity. Philadelphia: Jewish
Publication Society.
Federation Employment and Guidance Services. http://www.
fegs.org. \ Reconsidering the size and characteristics of the American Jewish
Gelman, S. R., & Schnall, D. (1997). Jewish communal service. In
R. L. Edwards (Ed.), Encyclopedia of social work (19th ed.,
Supplement, pp. 45-60). Washington, DC:
NASW Press.
Gibelman, M. (1995). Purchasing social services. In R. L.
hen an (Ed.), Encyclopedia of social work: Vo!' 3 (19th ed., pp.
1998-2007). Washington, DC: NASW Press.
Goldman, R. (2005, Fall/Winter). The role of the professional in
developing and shaping Jewish communal policy and
strategies. Journal of JeWish Communal Service, 73-82.
Hebrew Immigration Aid Society [l-IIAS). http://www.hias.
org/news/Statistics/2004USarrivals.html.
IAS. (Fall, 2006). Passages: The magazine of the Hebrew Immigrant
Aid Society, p. 7.
HIAS. (Spring, 2007). Passages: The magazine of the Hebrew
Immigrant Aid Society, p. 5.
Jewish Board Family Children's Services. http://www.jbfcs.org.
Jewish Community Centers Association. http://www.jcca.org.
Levine, E. M. (1998). Church, state and social welfare: Purchase
of service and the sectarian agency. In M. Gibelman & H.
Demone (Eds.), Cases in the privatization of human services:
Perspectives and experiences in contracting (pp. 154-157). New
York: Springer.
Linzer, N. (1996). The Changing Nature of Jewish Identity.
Journal of Jewish Communal Service, 72(3), 142-150.
Linzer, N., Levitz, I., & Schnall, D. (1995). Crisis and continuity:
The Jewish family in the 21st century. Hoboken, NJ: KTAV.
Maimonides, M. (1965). Yad Hahazakah: Hilchot Matanot Le
Aniyim. New York: Monzaim Press.
Metropolitan New York Coordinating Council on Jewish Poverty.
(2004). Jewish poverty in New York City in the 1990's. New York:
Nova Institute.
Miller, A. P. (1995/1996). Jewish vocational service and the
federations. Journal of Jewish Communal Service, 72, 87-90.
Ortiz, L. P. (1995). Sectarian agencies. In R. L. Edwards (Ed.),
Encyclopedia of social work: Vo!' 3 (19th ed., pp. 2109-2116).
Washington, DC: NASW Press.
Pins, A. M., & Ginsburg, L. (1971). New developments in social
work and their impact on Jewish center and communal service
workers. Journal of Jewish Communal Service, 48,60-71.
Rapfogel, W. E. (2004). Combating poverty through action public
policy from the orthodox perspective. Tradition, 38(1),
112-122.
Reid, W. J., & Stimpson, P. K. (1987). Sectarian agencies. In A.
Minahan (Ed-In-Chief), Encyclopedia of social work (18th ed.,
Vol. 2, pp. 545-556). Silver Spring, MD: National Association
of Social Workers.
Reisman, B. (1972). Social work education and Jewish communal
service and JCCs: Time for a change. Journal ofJewish
Communal Service, 48, 384-395.
Saxe, L., Kadushin, e., Hecht, S., Rosen, M. I., Philips, B., &
Kellner, S. (2004). Evaluating birthright Israel: Long-tetm impact
and recent findings. Waltham, MA: Brandeis University,
Maurice and Marilyn COhen Center for Modem Jewish
Studies.
Saxe, L., Tighe, E., Phillips, B., & Kadushin, C. (2007).
population. Waltham, MA: Brandeis University, Steinhardt
Social Research Institute.
Schnall, D. J. (1993). Exploratory notes on employee productivity
and accountability in classic Jewish sources. Journal of Business
Ethics, 12,4.85-491.
Schnall, D. J. (1995). Faithfully occupied with the public need.
Journal of Jewish Communal Service, 71,315-324.
Schwager, S. (2005, Fall/Winter). Assuming Jewish responsibility
in a changing world. Journal of Jewish Communal Service, 29-35.
Sheshkin, I. M., & Dashefsky, A. (2006). Jewish population in the
United States. In D. Singer & L. Grossman (Eds.), American
Jewish year book: The annual record of Jewish dvilization (VoL
106, pp. 133-158). New York: American Jewish Committee.
Shore, H. (1995-1996). Jewish homes and housing for the aging:
Relating to the federation. Journal of Jewish Communal Service,
72, 91-95.
Smith, R., & Lipsky, M. (1993). Nonprofits for hire: The welfare
state in the age of contracting. Cambridge, MA: Harvard
University Press.
Solomon, J. R. (2005, Fall/Winter). jewish foundations: An
introduction. Journal of Jewish Communal Service, 101-105.
Steinitz, L. Y. (1995/1996).!t's all in the family: Jewish family
services and the federation. Journal of Jewish Communal Service,
72, 70-76.
UJA Federation of New York. http://www.ujafedny.org. United
Jewish Communities. (2003). National Jewish Population Survey.
New York: UJe.
FURTHER READING
AmericanJewish year book. (2006). New York: American Jewish
Committee.
Council ofJewish Federations. (1992). National Jewish population
survey. New York: CJF.
Joint Distribution Committee. http://www.jdc.org.
United Jewish Communities. (200l). Nationa!]ewish population
study. New York: UJe.
-SHELDON R. GELMAN,
SAUL ANDRON, AND DAVID J. SCHNALL

JUVENILE DELINQUENCY
ABSTRACT: The article on juvenile delinquency has
three major objectives: First, it defines delinquency and
discusses its measurement and extent. Second, it re views
theory and risk factor data on causes of delin quency.
Third, it discusses current trends in juvenile justice
intervention and delinquency prevention, in cluding social
worker involvement.
KEY WORDS: delinquency; conduct disorder; juvenile
justice; status offender
Juvenile delinquency refers to behavior that violates the
law by persons who are minors, generally under age 18
(Agnew, 2005; Springer, 2006). The FBI, which collects
information on crime annually from police data, classifies
all offenses into Part 1 or "index" of fenses, which include
serious violent or property crimes such as robbery and
arson, and Part 2 offenses, which include some status
offenses-acts that are only illegal for people with the status
of juveniles (U .S. Department of Justice, 2006 onli ne).
Status offenses in the Part 2 category include running
away, violating curfew, and underage drinking. Other
status offenses such as incorrigibility and truancy are
nonindex offenses that are not part of police reports to the
FBI (Agnew, 2005). Status offenders are not now
classified as delinquents in most states but, rather, as
persons in need of supervision (PINS); yet status offenses
are still illegal, and the term "delinquency" is used to refer
to both status and other offenses by juveniles.
The juvenile justice system, including special courts
for juveniles, came into being at the end of the 19 th
century to handle offenses by developmen tally immature
young persons with a less adversarial and less punitive
system and with more concern for rehabilit ation (Agnew,
2005; Siegel, Welsh, & Senna, 2006). The Juvenile Justice
and Delinquency Act of 1974 established many changes in
the juvenile justice system, including
deinstitutionalization of status offenders, and created the
Office for Juvenile Justice and Delinquency Prevention
(OJJDP), which continues to provide national leadership
for the current juvenile justice system.
Behavior that violates the law can also be a compo nent
of conduct disorder, a clinical mental health dis order
involving a pattern of behavior in which the basic rights of
others or societal norms or rules are violated (Henggeler &
Sheidow, 2003; Springer, 2006). Whereas delinquency
can involve a single act, conduct disorder involves a
pattern of antisocial behavior over time. Howev er, in
practice there is a great deal of
JUVENILE
DELINQUENCY 9
overlap in the research literatures. Societal reactions to
delinquency and conduct problems have changed over
time, and debate continues about whether antisocial
adolescents are responsibl e for their own behavior (and
thus need control and punishment, like adults), or are
subject to circumstances, including mental health
disorders, for which they need treatment (Hirschfield et al.,
2006; Mears Daniel, Hay, Gertz, & Mancini, 2007).
Mental health disorders other than conduct disorder are
quite prevalent among juvenile offenders, especially those
in detention. Common cooccurring problems include
attention deficit hyperactivity disorder (ADHD) and
substance abuse disorders. Internalizing probl ems such as
anxiety, trauma, and depression are also
disproportionately present among delinquents compared to
nondelinquents (Cocozza & Skowyra, 2000; Hirschfield et
al., 2006).
Epidemiology
Estimates of the extent of juvenile delinquency come from
two major sources: "official" data from criminal justice
agencies (such as arrest data), and information on
offending and victimization based on self- report. All
sources of data are subject to various biases, and there is
substantial discrepancy between official and self- report
data. Arrest data, for example, only reflect a small
proportion of the delinquent behavior indi cated in
self-report surveys, but include more serious crime.
Self-report data suggest that juvenile offending is fairly
widespread-for example, petty theft, under age alcohol use,
and truancy. For example, about half of high school
seniors report drinking alcohol-a status offense- in the past
30 days (CDC, 2006). Most delinquency is relatively
transient, although large scale surveys suggest that about
6-8% of adolescents are chronic and serious offenders
(Barton, 2006). Generally, data shows that violent crime in
particular is declining (Agnew, 2005). Juvenile arrests
dropped by one third in the decade following 1994 after a
long period of increase. In 2003, juveniles were 26% of the
population, and accounted for 22% of the arrests for index
crimes (Snyder & Sickmund, 2006). Compared with
adults, juveniles are overrepresented in crimes, including
arson, vandalism, burglary, larceny-theft, robber y,
weapons offenses, and liquor law violations, and
underrepresented in the most serious crime categories,
including murder and rape (Barton, 2006).
There are differences by demographic group in arrests
and delinquency. African American youth are more lik ely
to engage in and be arrested for violent delinquency
compared with white youth. Self- report data suggest
smaller race discrepancies than offi cial data. However,
African American youth are
10 JUVENILE DELINQUENCY
disproportionately likely to experience the most restrictive
sanctions, including residential placement (Siegel et al.,
2006; Snyder & Sickmund, 2006). In general, boys start
delinquency earlier in the life course, and persist in having
much higher rates of serious delinquency and conduct
problems than do girls with a ratio of about 4: 1. While
young women are generally less likely to be arrested than
are males, the relative proportion of female delinquency
has been rising (Steffensmeier, Schwartz, Zhong, &
Ackerman, 2005). The percentage of girls arrested as a
proportion of all juvenile arrests rose from 20% in 1980 to
29% in 2003, a trend evident across all offense types,
including violent offenses (Snyder & Sickrnund, f006).
Differences in the prevalence of delinquency by
demographic group are thought to be due mainly to
differential exposure to risk, but there is debate about
whether race and gender differentials also involve bias in
juvenile justice processing (Agnew, 2005; Steffensmeier
etal., 2005).
Etiology
Juvenile delinquency and conduct problems, including
aggression, are predicted by a range of risk factors that are
replicated across many studies (Barton, 2006; Williams et
al., 2004). Individual factors include issues such as
impulsivity, hyperactivity, and difficult temperament, and
also include cognitive and neurological impairments.
Family system variables include family violence, harsh and
abusive parenting, lack of or inconsistent discipline, lack of
support and attachment, and family conflict. School-related
risk factors include early conduct problems in school, lack
of commitment to school and lack of school attainment, and
also ADHD and learning problems. Peer group factors are
the strongest known correlate of delinquent behavior.
Adolescents who spend time with delinquent friends or
those who approve of delinquency are much more likely to
be delinquent (Thornberry & Krohn, 2005). Community
risk factors include chronic violence and disorganization in
the neighborhood.
Criminological theories have employed a wide range of
individual and social or environmental processes to explain
differences in offending (see, for example, Agnew, 2005;
Siegel et al., 2006). A rapidly growing body of research
(also from several longitudinal studies) indicates that
delinquency is determined by multiple factors interacting
across multiple life domains. Development and life course
theori~s now incorporate information about developmental
changes in patterns of risk and delinquency and the impact
of life events, including cumulative adversity (Agnew,
2005; Farrington, 2005; Sampson & Laub, 1997;
Thornberry & Krohn, 2005).
Juvenile Justice Intervention,
Prevention, and Rehabilitation
Juvenile justice interventions involve formal control
through sanctions like juvenile placement and probation, as
well as informal strategies, including prevention and
rehabilitation or treatment. The balance of approaches has
shifted over time. Starting in the 1960s,
deinstitutionalization and diversion of juveniles from legal
proceedings and into prevention programs gained
momentum and an influx of federal funding for diversion
and other rehabilitation programs to improve the system
occurred. From the 1980s funding priorities shifted from
prevention and diversion to the identification of serious and
violent offenders (Siegel et a1., 2006). The shift from
rehabilitative to punitive treatment for delinquents toward
the end of the 20th century occurred in response to rising in
crime rates and pessimism about the impact of
rehabilitation as well as a more conservative mood in the
nation and legal system. The "get tough" approach has
included the use of waivers or transfers to adult courts for
children as young as 10 who committed serious crimes, and
increased use of confinement for serious offenders. Studies
indicate however that this approach has had little effect on
the rate of juvenile crime and may in fact lead to higher
reoffense rates and general maladjustment (Agnew, 2005;
Barton, 2006; Lanctot, Cernkovich, & Giordano, 2007).
Some communities have developed special court
systems such as truancy and drug courts to provide
assistance at early stages of law violation to teens in trouble
with the law to prevent further juvenile justice system
involvement. Identified youth are referred for supportive
and preventive services to prevent further law violation.
Research on the impact of alternative courts is still in its
early stages (Rodriguez & Webb, 2004). Counseling and
other services are integrated with judicial processing.. so
that teens who cooperate with program requirements avoid
more formal justice consequences and punishments. Youth
conferencing and mediation models are also used
increasingly with some promise (Nugent, Williams, &
Umbreit, 2004).
A wide range of other programs and services are
available to address juvenile delinquency, and in many
cases evidence about their effectiveness in deterring
delinquency is incomplete. However, information on a
wide range of promising prevention and intervention
strategies that target precursor behaviors and known risk
factors such as poor school adjustment, aggression, skills
deficits, and ineffective parental management is widely
available (for reviews, see Barton, 2006; Herrenkohl et al.,
2004; Williams et al., 2004). Databases describing
evidence-based programs include the Blueprints Violence
Prevention Program and the

Campbell Collaboration. Some comprehensive pre-
ventive intervention targets communities and schools
(Catalano et al., 1998). Evidence-based interventions for
those already exhibiting delinquency include
ecologically based comprehensive interventions such as
multisystemic treatment (Henggeler, Schoenwald,
Borduin, Rowland, & Cunningham, 1998). Treatment
foster care (Chamberlain, 2002) is effective for youth
needing temporary placement. Much more knowledge
about specific risk factors and effective program models
to combat delinquency and conduct problems have been
produced since the mid-1980s. Although the use of
evidence-based practice methods. and programs is
increasing due in part to demands for accountability in
program funding and reimbursement, challenges re main
in moving research knowledge to practice settings.
These challenges include slow dissemination of
research-based knowledge and organization barriers
such as lack of coordinated systems of care to deliver
programs. More research is needed, too, on interven tions
tailored to specific cultural groups, to address
intervention dropout, and to promote positive youth
development, as well as on deconstructing practices in
common use among social workers (Allen-Meares &
Fraser, 2005; Burns & Hoagwood, 2002).
Social workers address delinquency and its precur-
sors within many agency settings and serve in multiple
roles. Social workers work in the public and not-for-
profit sectors in juvenile offender residential facilities
where they intervene with youth and families. They are
also heavily involved in prevention roles in
communitybased programs, including in schools. They
work with delinquent youth and their families in the
mental health service system. Less frequently, they
work directly in juvenile justice roles such as probation.
In macro practice roles, they contribute to youth
development through community developmental, and
through community action initiatives. Social workers
also conduct research on delinquency, write policy
briefs relevant to juvenile justice policy, and advocate
for improved services and policies for juvenile offenders
and youth at risk.
REFERENCES
Agnew, R. (2005). Juvenile delinquency: Causes and control, (2nd
ed.). Los Angeles, CA: Roxbury.
Allen-Meares, P., & Fraser, M. W. (2005). Intervention with
children and adolescents: New hope and enduring challenges.
In M. W. Fraser (Ed.), Risk and resilience in childhood: An
ecological perspective (2nd ed., pp. 385-402). Washington, DC:
NASW Press.
Barton, W. H. (2006). Juvenile justice policies and programs.
. M. Jenson & M. W. Fraser (Eds.), Social policy for
& families: A risk and resilience perspective (pp. 231264).
Thousand Oaks, CA: Sage.
JUVENIlE DELINQUENCY 11
Bureau of Labor Statistics. (2002). National longitudinal survey of
youth, 1997 cohort, 1997-2001. Chicago, IL: National Opinion
Research Center, University of Chicago (producer).
Columbus, OH: Center for Human Resource Research, Ohio
State University (distributor).
ility to the & Hoagwood, K. (2002). Community treatmentfor youth:
youth: Evidence-based interventions for severe emotional and
behavioral disorders. New York: Oxford University Press.
Catalano, R. F., Arthur, M. W., Hawkins.J. D., Berglund, L., &
Olson, J. J. (1998). Comprehensive community and school
based interventions to prevent antisocial behavior. In R.
Loeber & D. P. Farrington (Eds.), Serious and violent juvenile
offenders: risk factors and successful interventions (pp. 248-283).
Report by the OnDP Study Group, prepared for the Office of
Juvenile Justice and Delinquency Prevention. Thousand Oaks,
WORK. See PCenters for Disease Control and Prevention
Centers for Disease Control and Prevention (CDC, 2006).
Youth Risk Behavior Surveillance-United States, 2005.
Morbidity and Mortality Weekly Report, 55(SS-5), I-lOB.
Chamberlain, P. (2002). Treatment foster care. In B. J. Bums & K.
Hoagwood (Eds.), Community treatment for youth:
Evidence-based interventions for severe emotional and behavioral
disorders. New York: Oxford University Press.
Cocozza, J. J., & Skowyra, K. R. (2000). Youth with mental
health disorders: Issues and emerging responses. Juvenile
Justice, 7(1),3-13.
Farrington, D. P. (Ed.). (2005). Integrated developmental and
life-course theories of offending, Volume 14. New Brunswick, NJ:
Transaction Publishers.
Henggeler, S. W., & Sheidow, A. J. (2003). Conduct disorder and
delinquency. Journal of Marital and Family Therapy,
29(4),505-522.
Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland,
M. D., & Cunningham, P. B. (1998). MuItisystemic treatment of
antisocial behavior in children and adolescents. New York: The
Guilford Press.
Herrenkohl, T. I., Chung, I.-J., & Catalano, R. F. (2004).
Review of Research on predictors of youth violence and
school-based and community based prevention approaches. In
P. Allen-Meares & M. W. Fraser (Eds.), Intervention with
children and adolescents: New hope and enduring challenges [pp.
449-476). Boston, MA: Allyn and Bacon.
Hirschfield, P., Maschi, T., White, H. R., & Traub, L. G. (2006).
Mental health and juvenile arrests: Criminality,
criminalization, or compassion? Criminology, 44(3), 593-630.
Juvenile Justice and Delinquency Prevention Act of 1974, Public
Law No. 93-415 42 u.s.c. 5601 et seq. Online at http://www
.ojjdp.ncjrs.gov /about/jjdpa2002titlev .pdf.
Lanctot, N., Cemkovich, S. A., & Giordano, P. C. (2007).
Delinquent behavior, official delinquency, and gender:
Consequences for adulthood functioning and well-being.
Criminology, 45, 131-157.
Mears Daniel, P., Hay, c., Gertz, M., & Mancini, C. (2007).
Public opinion and the foundation of the Juvenile Court,
Criminology, 45, 233-257.
Nugent, W. R., Williams, M., & Umbreit, M. S. (2004).
Participation in victim offender mediation and the
12 JUVENILE DEUNQUENCY
prevalence of subsequent delinquent behavior: A meta-
analysis. Research on Social Work Practice, 14(6),408-416.
Rodriguez, N., & Webb, V. J. (2004). Multiple measures of
juvenile drug court effectiveness: Results of a quasi-
experimental design. Crime & Delinquency, 50(2), 292-314.
Sampson, R. J., & Laub, J. H. (1997). A life-course theory of
cumulative disadvantage and the stability of delinquency. In
T. P. Thornberry (Ed.), Developmental theories of crime and
delinquency: Advances in criminological theory, Vol. 7 (pp.
133-162). New Brunswick, NJ: Transaction Publishers.
Siegel, L. J., Welsh, B. c, & Senna, J. J. (2006). Juvenile
delinquency: Theory, practice, and law (9th ed.). Belmont, CA:
Thomson Wadsworth.
Snyder, H. N., & Sickmund, M. (2006). Juvenile offenders and
victims: 2006 national report. Washington, DC: U.S. Depart-
ment of Justice, Office of Justice Programs, Office of Juvenile
Justice and Delinquency Prevention.
Springer, D. W. (2006). Treating juvenile delinquents with
conduct disorder, attention-deficit/hyperactivity disorder, and
oppositional defiant disorder. In A. R. Roberts & K. R. Yeager
(Eds.), Foundations of evidence based practice (pp. 231-246).
New York: Oxford University Press.
Steffensmeier, D., Schwartz, J., Zhong, H., & Ackerman, J.
(2005). An assessment of recent trends in girls' violence using
diverse longitudinal sources: Is the gender gap closing?
Criminology, 43(2), 355--406.
n and trry, T. P., & Krohn, M. D. (2005). Applying interactional
theory to the explanation of continuity and change in antisocial
behavior. In D. P. Farrington (Ed.), Integrated developmental &
life-course theories of offending (Vol. 14) (pp. 183-209). New
Brunswick, NJ: Transaction Publishers.
Williams, J. H., Ayers, C. D., Van Darn, R. A., & Arthur, M. W.
(2004). Risk and protective factors in the development of
delinquency and conduct disorder. In M. W. Fraser (Ed.), Risk
and resilience in chi/&wod: An ecological perspective (2nd ed.,
pp. 209-249). Washington, DC: NASW Press.
SUGGESTED LINKS Blueprints for
Violence Prevention. http://www ,colorado,
edu/cspv/blueprints/ Campbell Collaboration.
http://www .campbeUcollaboration. org/
Office of Juvenile Justice and Delinquency Prevention.
http://ojjdp.ncjrs.org/
U.S. Department of Justice, Federal Bureau of Investigation,
Crime in the United States.
http://www2 . fbi .gov/ucr/dus2006/index.html
-CAROLYN SMITH AND JEREMY DARMAN
JUVENILE JUSTICE. [This entry contains two
subentries: Overview; Juvenile and Family Courts.]
OVERVIEW
ABSTRACT: The juvenile justice system was established
with the founding of the Juvenile Court in Chicago in
1900, an institution that spread to all the states in a
short period of time. The history, organization, structure and
operations of the system are described along with its growth
along with increasing Among the key issues examined are:
gender, overrepresent at ion of children of color, placement of
mentally ill and abused or neglected children, human rights
and reintegration of juvenile offenders after their returning
home.
KEY WORDS: history; court processing; disposition and
placement; gender; overrepresentation; social justice
issues
The establishment of the juvenile court in Illinois in 1899 led
to the development of the United States juvenile justice
system, which - was mandated to provide for the processing,
adjudication, and rehabilitation of juveniles charged with
criminal violations, as well as for the care and treatment of
abused and neglected children. Social advocates such as Jane
Addams as well as crusading judges like Ben Lindsey
(Tanenhaus, 2002) established the system, emphasizing care
and treatment rather than punishment and control. The
response to this new social invention was rapid, and the
juvenile court spread throughout the United States in less than
25 years. Since that time it has become a model for the legal
processing of children in much of the developed world.
Although the juvenile court still retains jurisdiction over the
processing of abuse and neglect cases, most of the processing
care and supervision of those cases lie within the child welfare
system while the juvenile justice system focuses primarily on
youth charged with delinquency or status offenses. As of
2002, more than 3.1 million youth were under juvenile court
supervision annually with rv 1.6 million new cases processed
each year (Snyder & Sickmund, 2006).
History
The principles underlying the creation of this social institution
were that children were developmentally immature and
required protection; they weremalleable and could be
habilitated or rehabilitated, and the court should aid children
suffering from a broad range of problems different from
adults. Children were assumed to be dependent, developing
physically and psychologically, in need of care and
hotic drugs in patients ~ith chronic schizophrenia. New
England Journal of Medicine, 353(12), 1209-1223.
Ű
Floersch, ]., & Jenkins, J. (2003). Medication effect
interpretation and tmpact on court procedures, and resulted in
in a theory of state responsibility for children as represented in
the concept of parens patriae.

Prior to the establishment of the juvenile court,
juveniles charged with delinquent acts were p rimarily
tried in the criminal justice system, but even then age
played a role in presumptions of guilt because juveniles
below the age of 14 were presumed not to possess
sufficient criminal responsibility to commit a crime. The
creation of the juvenile co urt altered this pre' sumption in
part, providing almost exclusive jurisdic tion over
individuals below the age of 18 who were charged with
violating criminal laws in most states. Hearings were to
be informal, private, "in the best interest of the child," and
civil rather than criminal. These tenets constituted a
separate system of justice that recognized the differences
between children and
adults (Zimring, 2002). ' processed (Snyder & Sickmund,2006).
State legislation permitted judges to use their discre-
tion in conducting hearing and prescribing inter, ventions.
To meet their statutory goals, the juvenile justice system
employed a range of programs and services-including
prevention, diversion, detention, probation, community
services, and residential treatment (Rosenheim, 2002 ).
For most of the 20th century, judges heard juvenile cases
and then diverted them to community services outside the
court, but substantial numbers were institutionalized'
even for extended periods.
1960-1980. In many communities, the court failed to
meet the goals of its founders to be responsible for the
provision of rehabilitation. Beginning in the 1960s, the
human rights movement influenced developments in
juvenile justice because of growing concern that juveniles
receive due process and protection of their civ il liberties.
Decisions of the Supreme Court in cases such as Kent v.
U.S. 383U.S, 541 (1966), In re Gault 387 U.S.I (1967),
and In re Winship 397 U.S. 352 (1970) led to many new
social policy initiatives to protect children's rights to
challenge arbitrary disposi tions. A series of national
commission reports (Presidential Commission on Law
Enforcement and Criminal Justice and the Task Force on
Juvenile Delinquency and Youth Crime, 1974) had
positive effects, extending human rights along with
policies of decriminalization, de institutionalization, and
diversion. By the 1970s passage of the first federal
juvenile justice legislation, the Juvenile Justice and
Delinquency Act of 1974, funded state efforts to reduce
institutionalization and increase local community- based
programming.
1980-2000. The progress of the 1960s and 1970s was
dramatically reversed in the 1980s and 1990s, with the
passage of federal and state legislation that emphasized
incarceration and punishment, along with withdrawal of
the distinction between juveniles and adults as far as
certain criminal behavior was concerned. As a century
tic drugs in patients ~ith ch13
of the juvenile court was celebrated in 2000, laws and
philosophy had returned to many practices in place before
the invention of the juvenile court. Thousands of
juveniles were held in adult prisons and jails, o ften under
very punitive conditions (Lerman, 2000). Feld (1999 )
argues that judicial, administrative, and legisla tive
decisions transformed the court into a second class
criminal court that did not serve the interests of children.
Much of the transformation appeared to be "justified" by
the increase in juvenile crime between 1985 and 1995
(Bishop, 2000). However, after 1995 there was a dramatic
decline in juvenile crime that continued through 2005 ,
especially serious violent crime, but there has not been a
corresponding reduction in the numbers of juveniles
. Since 2000. Much of the discussion about the juvenile
justice system in the early 21 st century neglects the
changes in the societal context in which it operates.
Garland (200l) and Beckett and Western (2000) point to
the increasing culture of control and the declining
provision of social welfare benefits for the population at
risk for involvement in the justice system. Family struc-
ture has undergone and is undergoing substantial changes
that affect children because single parents are unable to
provide the necessary supervision and support, especially
in critical adolescent years. The increas ing rates of
poverty, the decline of public school education, the lack
of physical and mental health care, and the changing
economic structure in which well- paying blue collar jobs
are unavailable for young adults have had a pronounced
ONS
Medication effect interpretation and t d control but little is
available to prepare the middle- and working- class youth
population for successful adulthood (Osgood, Foster,
Flanagan, & Ruth, 2005; Setterstein, Furstenberg, &
Rumbaut, 2005). All these factors affect juvenile crime in
the society and thereby the operation of the juvenile
justice system.
New England Journal of Medic The
The juvenile justice system is composed of the statutes
and policies as well as organizations charged with re-
sponsibility for the processing of juveniles who violate
state laws and local ordinances (Roberts, 2004). The legal
d~finition of delinquency and crime varies from state to
state as to age of juvenile court jurisdiction and the roles
of the various court officials responsible for the
processing of juveniles into and through the court. The
processing typically includes the following:
1. Arrest and referral of a juvenile to the court for a law
violation; some police may have warning and
diversion alternatives.
14 JUVENILE JUSTICE: OVERVIEW
2. Juvenile court intake includes referral for trial,
diversion of minor offenders, detention, and
preliminary assessment.
3. Filing of a formal petition and deciding to try the
youth in juvenile court or transfer the youth to
adult court for criminal processing.
4. Hearing or trial by the court and determination of
innocence or guilt.
5. Disposition decision making by the judge and
placement in a program for those adjudicated as
delinquent for an indeterminate or specific period
of time, depending upon state laws or judicial
discretion, and release or special sanctions for the
others.
6. Reintegration or reentry programming, which is
formalized as parole, but may also be informally
and unevenly provided;'
Demographics
COURT PROCESSING More than 2.2 million youth
below the age of 18 were arrested in 2003, but only 25 %
were arrested for serious person or property crimes or
"index" crimes as these are defined (Snyder &
Sickrnund, 2006). The remaining offenses were mis-
demeanors, drug offenses, and public order or status
offenses. Juvenile crime increased substantially in the
late 1980s, but by 2003 most violent crime had fallen
below that observed in 1980 (Stahl et al., 2005). Of
those arrested 1.615 million cases were referred to the
juvenile court in 2002. Cases not referred may be
diverted to other agencies, particularly "status offense s;"
those behaviors that are included in the jurisdiction of
the juvenile court in many states but are not classified as
crimes. Status offenses include running away, incor-
rigibility, truancy, and liquor law violations.
ps ty-eight percent of the all cases are formally peti-
tioned and 42% are dismissed or referred to a variety of
social agencies for services. If petitioned 67% can be
expected to be adjudicated delinquent and subsequently
62% are placed on probation and 22% receive an
out-of-the-home placement, most often in a residen tial
institution. Even at the final disposition stage, juvenile
cases are dismissed, and youth are released or given
other sanctions outside the. formal justice system.
Waiver to adult court will result for about 1% of the
cases, but that number declined since 2002 (Bishop,
2000). However, it varies widely among the states re-
flecting the differences in state statutes. Overall, fewer
than 10% of the youth who enter the court ultimately end
up in a correctional institution.
Delinquency case rates overall were 51.6 per 1,000
youth aged 10-17 years in 2002, but there were marked
variations by age from 4.6 per 1,000 for 10-year-old
youth ·to 109.1 per 1,000 for those 17 years old. The
overall rate was far lower than the rate of81.6 in 1994, a
reflection of the decline in crime by juveniles during a
period of substantial population growth (Snyder &
Sickmund, 2006). There are sex differences by age in
that female crime peaks at 16 years while the peak age
for males is 17.
As Table 1 indicates, the largest number of youth
held in custody out of their homes is held in detention.
The rate of 10.2 per 1,000 youth is nearly 3 times the
rate of those in placement following adjudication.
Placement in detention is important because it is pre-
dictive of subsequent adjudication and referral to an
institution. The numbers in detention increased sub-
stantiallyafter 1985, with drug cases explaining most of
the increase (140%). Frequently arrested for drug viola-
tions, African American males are 37% of all detainees
and their detention is a key factor in their overall
disproportionate representation in the juvenile justice
system (Snyder & Sickmund, 2006).
In the decade between 1990 and 2000 formal hand-
ling of juvenile court cases increased from 49.8% to
57.7% (McNeece & Jackson, 2004). Not surprisingly,
there were subsequent increases in adjudications, waiv-
ers, and placements as formalization increased.
DISPOSITIONS On a given day in 2004,96,655 youth
were held in public and private correctional facilities
(Snyder & Sickmund, 2006). Annually more than
145,000 youth adjudicated for delinquency are sent to an
out-of-home placement for a specified period or an
indefinite stay. This is a small percentage of the more
than 2.2 million. youth arrested, and the numbers in
placement declined after 2000, following the increases
in most states during the 1990s when the juvenile crime
rate was substantially higher.
TABLE 1
Youth Population and Processing Rates
NUMBER RATE
Population, 10-17 years 33,352,224
2,202,000 66.2
Juvenile arrests (2004)
Referrals to juvenile 1,620,800 48.8
court-delinquency
Petitions to-juvenile court 934,900 28.1
Detention 339,800 10.2
Adj udications 634,500 19.1
Assigned to probation 385,400 11.6
Placed out of home 144,000 4.3
Waived to adult criminal court 6,900 0.21
Rates are calculated at the numbers per 1,000 youth processed
during the year 2002.

TABLE 2
Delinquency Offense and Placement Profile, 2002
REFERRAL TO COURT
TYPE OF CRIME MALE FEMALE
Person 23% 26%
Property 34 39
Drugs 13 8 uality as 10
Public Order 25 27
Status
From Juvenile Offenders and Victims: 2006 National Report, by Snyder, H. N., and Sickmund, M., 2006, Washington, OC:
OJjDP, Office of Justice Programs, U.S. Department of Justice. Copyright 2006 by the U.S. Department of Justice. Reprinted with
permission.
Females account for 15% of the Juveniles in custody in
public and private facilities, but of that total 40% are
placed for status offenses as their most serious offense. As
Table 2 indicates, male youth in custody have a more
serious crime profile than do females, and they tend to
remain longer in placement. The majority of youth are held
in public facilities, but one-third is placed in private
institutions.
Youth charged with person crimes have a higher
probability of postadjudication placement than those
charged with property or public order crimes. Among the
person crimes, there has been a substantial increase in
processing and institutionalization of juveniles as sexual
offenders for extended periods followed by placement of
their names on a public registry. Zimring (2004) strongly
criticizes the punitiveness of some of these practices.
Although a relatively small percentage of youth are
charged with drug crimes, they are likely to be placed out
of the home because of the lack of drug treatment facilities
in many communities. The profile of offenders in public
versus private facilities does not vary significantly.
Out-of-home placement rose by 44% during the late 1990 s
but since 2000 has declined by 12%, primarily among
property and person offenders. Increases in placement on
probation appear to be the explanation.
Gender
Young females' rising rates of involvement with the
juvenile justice system now receive increased attention.
Their rate of arrest rose to 29% of total juvenile arrests in
2002, and the involvement of young women in certain
crimes (larceny, drugs and simple assault) has risen more
sharply than that of males (Snyder, 2006). Because the
number of male offenders is so much larger, percentage
comparisons are misleading. It is less clear that female
crime has increased commensurate to their involvement in
the justice system, for example, their detention and
placement in residential programs
JUVENILE JUSTICE: OVERVIEW 15
POSTADJUDICATION PLACEMENT
MALE FEMALE PuBLIC PRIVATE
35% 14% 35% 32%
29 12 28 27
12 26 10
10 12 26 20
4 40 3 11
for status offenses, primarily involving family conflict.
The rising rate of their involvement may be partly the
result of changing policies and practices that serve to bring
more young women under the care and control of the
justice system, for example, the r eferral of girls in need of
mental health services to the justice system. It has been
noted that 60-70% of the youth in juvenile justice have a
diagnosable mental health problem with more females
than males so diagnosed (Coalition for Juvenile Justice,
2000; Grisso, 2004).
EVIDENCE~ BASED MODELS OF INTERVENTION Because it
has been shown that there is a wide range of factors that
cause or are associated with delinquency, it is not
surprising that there are many programs for prevention,
early intervention, alternatives to incarcera tion,
community-based intervention, and residential treatment.
Using meta-analysis techniques, Lipsey and Wilson
(1998) found the following characteristics to be associated
with greater effectiveness:
• The integrity of the treatment model implementation.
• Longer duration of treatment produces better results.
• Results from well-established programs exceed new
programs.
• Treatment administered by mental health pro-
fessionals.
• Emphasis on interpersonal skills training.
• Use of the teaching family home methods.
Overall, they found community-based programs to be
more effective than programs in custodial settings, so the
context for the treatment is important. Voluntary
participation was shown to be more effective than that
which is coerced, and there are ways by which volun tary
assent can be achieved. Greenwood (2006) shows that
balanced and restorative justice (BAR}) programs can
integrate restitution and community service by
16 JUVENILE JUSTICE: OVERVIEW
which an offender can repair the harm he or she may
have caused. A report of the U.S. Surgeon General on
Youth Violence (2001) concurs that many programs are
effective with delinquent youth, but they emphasize the
importance of the quality of implementation.
Elliot and his colleagues at the Center for the Study
and Prevention of Youth Violence have developed
"Blueprints" of 10 programs meeting rigorous criteria
that include demonstrated positive outcomes on problem
behavior that persists beyond a youth's involvement in a
program. They can be consulted at www.
colorado.edu/cspu/blueprints for technical assistance
regarding the programs that they regard as effective.
(Michalic, Fagan, Irwin, Ballard, & Elliot, 2002).
Greenwood (2006) has identified a large number of
programs that have been shown to be effective for
working with youth from preschool age through ado-
lescence. For example, the Perry School Pre-School
program was shown to reduce delinquency when the
participants reached adulthood in contrast with a com-
parable control group. Programs targeting the youth and
his or her family have been shown to be effective,
including functional family therapy, multisystemic
therapy, the Seattle Social Development Program, and
Big Brothers/Big Sisters. If cost benefit issues are of
concern, Greenwood (2006) shows that cost-effective
programs ultimately reduce crime..
Because of the lack of systematic evaluation the
effectiveness of most juvenile justice program is un-
known. However, residential programs that include only
delinquent youth are seldom effective in reducing
recidivism. Other popular programs that have been
shown not to be effective include boot camps, substance
abuse programs such as DARE, and "scared straight"
programs.
ocial Justice Issues
Some important social justice issues include overrepre-
sentation of youth of color, prosecution of juveniles as
adults, child welfare and juvenile justice, mental health
of offenders, reintegration, and human rights.
urthREPRESENT A TION OF YOUTH OF COLOR One of the
the most critical issues facing the entire justice sys tem
in the United States in the disproportionate repre-
sentation of persons of color in all phases of the
system, despite the fact that the United States has
ratified the U.N. Convention on the Elimination of all
Forms of Racial Discrimination. The juvenile justice
system is not an exception in that youth of color are
disproportionately represented in all phases of the
justice, child welfare, and public assista nce systems,
particularly African American youth. The Juvenile
Justice
and Delinquency Prevention Act of 1974 was amended
in 1988 to mandate that states who participate in its
programs make "every effort" to achieve proportional
representation of youth of color in the juvenile justice
system. As of 2003, youth of color comprised 36% of
the total juvenile population, but 62 % of those in
detention and 67% of those in other types of residential
facilities. The overrepresentation of youth of color in
the early stages of processing has profound effects,
because if a youth is detained, there is an increased
probability of being found guilty and sentenced to an
out-of-home placement. As youth of color move
through the justice system there are amplification
effects in the subsequent processing that add to the
overrepresentation (Kempf-Leonard & Sontheirner,
1995).
A variety of factors have been identified as causes of
this disproportionality, including:
• Crime rates are higher in neighborhood of high
levels of deterioration and segregation where
youth of color reside and where police are likely to
do more surveillance (Sampson, Morenoff, &
Raudenbush, 2005).
• Juvenile justice agencies treat youth of color more
severely than white youth, particularly early in
processing (Bishop & Frazier, 2000; Bridges &
Steen, 1998).
• Nunn (2002) argues that the oppression of African
American youth (especially males) appears
normal because decision makers have been
socialized to undervalue the lives of these youth.
• Diversion and other alternatives to incarceration
are more available in suburban areas with lower
proportions of youth of color (Sarri, Shook, &
Ward, 2001).
The highest rates of incarceration of youth of color are
found in public residential facilities reaching 90% in
some states (Snyder & Sickmund, 2006). Overall, as of
2004, 754 African American, 496 American Indian/
Native American, 348 Hispanic, 190 white, and 113
Asian youth per 100,000 were incarcerated.
PROSECUTING AND INCARCERATING JUVENILES AS
ADULTS The shift toward the punitive handling of
children and youth in the justice systems is best
exemplified by the increased transfer of juveniles to
adult criminal courts and their subsequent incar-
ceration in adult prisons. During the 1990s, there was
a proliferation of transfer legislation: 44 states and the
District of Columbia enacted at least one change
easing the processing of juveniles as adults (T orbet &
Szymanski, 1998). By the end of the decade, all 50
states permitted the transfer to adult courts. Although

the legislative changes were made to address growing youth
violence, by 2000 the majority of youth sentenced to the
adult system were there for property, drug, and public order
offenses. This legislation also decreased the power of the
juvenile court judge and expanded that of the prosecutor.
This change represented a significant shift in the role of the
judge that had existed since 1900, about when the court was
founded.
There are three procedures by which juveniles are
transferred for trial as adults: judicial discretion, prose-
cutorial discretion, and statutory exclusion of certain youth
from the juvenile court based on offense and age. Some
states do not maintain minimum age limits for trying
juveniles as adults while other states set the lower age limi t
between 10 and 16 years: Some states allow for a case to be
designated for trial in the juvenile court with adult court
rules. The juvenile may receive a "blended sentence" that
permits a youth to remain in the juvenile system, provided
he or she commits no subsequent crime.
Accurate information on the numbers of youth pro-
cessed as adults is not available. Bishop (2000) re viewed a
large number of studies and was unablb to arrive at a sound
estimate. Conservative estimates placed the number
processed under the age of 18 at 200,000 per year, but the
numbers convicted were far smaller (Sickrnund, Snyder, &
Poe-Yamagata, 2000). There has been a decline since 2000
because of the dramatic decline in serious and violent crime
by juveniles, but the amount of t he decline remains
unknown. The U.S. Justice Department reported that as of
2004 there were 2,800 youth under 18 in adult prisons ;
however, this number excludes adults who were sen tenced
as juveniles, often with long sentences, so nationally the
number may well exceed 100,000 individuals (Harrison &
Beck, 2006). In 1997 there were 7,400 juveniles below 18 in
state and federal prisons; so there has been a substantial
decline as of 2004.
Juveniles of color and males are the overwhelm ing
majority of those tried as adults (Bortner, Zatz, & Hawkins,
2000). Most of the youth in adult prisons will be released in
their mid-20, but they will be ill equipped to meet the
demands of society for successful adulthood and parenting
because of the stigma of incarcerati on and because of the
lack of education, health care, and social services while
incarcerated. Moreover, charges of human rights violations
have been and are being made with respect to the conditions
of incarceration (Human Rights Watch, 2005). Studies of
recidivism indicate that juveniles released from adult
facilities have higher rates of recidivism than similar youth
released from juvenile facilities (Bishop & Frazier, 2000;
Fagan, 1996). Thus, the transfer of juvenile s to
JUVENILE JUSTICE: OVERVIEW 17
he adult criminal justice system is counterproductive as a
crime control policy.
CHILD WELFARE AND JUVENILE JUSTICE The juvenile
court serves both abused and neglected children as well as
those charged with delinquency, but it was expected that
the two areas would be separately addressed since child
welfare clients are initially victims of parental abuse or
neglect while juvenile delinquents are viewed as primarily
responsible for their behavior as perpetrators of crime.
to be refined through furth increasingly ambiguous as
studies have shown the "drift" of child welfare clients to
the juvenile justice system (jonson-Reid & Barth, 2000;
Kaufman & Widom, 1999; Smith & Thornberry, 1995). A
large study by Kelly (2002) in the Cook County, Illinois,
juvenile court, observed that more than a third of
maltreated children ended up in the juvenile justice
system as delinquents.
4), New York: Macmillan. and Hispanic youth with
experience in foster care have been shown to be at high risk
for subsequent transfer to the justice system. Although the
numbers of male victims are greater than those of females,
most of those who "drift" to the justice system are reported
to be female, largely for status offenses and property crime.
With a large sample in California, jonson- Reld and Barth
(2000) followed youth from child welfare to entrance into
the California Youth Authority. They observed that if
youth were transferred to probation, the risk for subsequent
transfer to the CY A for a serious felony increased
significantly. Having multiple placements was correlated
with transfer to the justice system.
A recent study in Michigan of adolescents who aged out
of foster care reported several negative outcomes:
homelessness, inadequate education, lack of employ ment,
mental health problems, substance abuse, and experience in
the justice system (Fowler & T oro, 2006). These youth
also reported being physically and sexually abused. To
delineate the process by which child welfare youth "drift"
to the justice system, youth frequently run away from
placements, more often from congregate care than
individual foster care or kin care. Some of these youth may
engage in delinquent behavior as they attem pt to survive
"on the street." When they are apprehended by police, they
may be taken to a detention facility pending a hearing by
the court. Depending upon the outcome of that placement a
juvenile may then be moved to juvenile justice system
through furthhe child welfare system may cease involve-
with the case. Because a youth may be an older adolescent
at this point, there is a tendency to view them more as a
delinquent than a victim of abuse or neglect.
18 JUVENILE JUSTICE: OVERVIEW
MENTAL HEALTH AND JUVENILE COMPETENCY The
collapse of the mental health system serving chil dren
and youth in the 1990s resulted in a gradual move ment
of mentally ill juveniles into the justice system. The
inappropriateness of these placements was exacer bated
by the lack of adequate legislation in many states for the
assessment of competency for trial as a delin quent or as
an adult. Prior to the 1990s, the issues of juvenile
competence were seldom raised, but findings from
research on brain development and developmen tal
maturity, as well as concerns about due process
protection of youth, raised concerns in both the mental
health and legal professions (Scott & Grisso, 1997).
Findings from brain development research are directly
relevant to the criminal justice processing of juveniles
for both the individual's culpability and ability to par-
ticipate effectively in his or her defense. Recent neu-
roimaging studies indicate that the brain, specifically
the pre-frontal lobe (PFC) , continues to grow and
change throughout adolescence and into the 20s. The
PFC controls higher-order cognitive processes, which
include motivation, inhibition, logical decision mak ing,
risk taking, problem solving, planning, emotional
regulation, sexual urges,. and anticipation ~f conse-
quences (Spear, 2000). Past and current trauma and
stress have detrimental effects on adolescent brain
functioning, and delinquent adolescents are signifi-
cantly more at risk for limited cognitive development
(Arnsten & Shansky, 2004).
ugh furth to estimate the number of juveniles with a
diagnosable mental disorder, Grisso (2004) reported that
findings from several studies indicated that 6070% of
juveniles in correctional facilities have at least one
disorder. Relatively few receive professional eva luations
or treatment in most settings. Grisso (2004) suggests
reasons for attention to these youth: (a) agencies have a
ving hope or reasonable expectations, and finding
ng in life apart from mental illness, a concept to be refined
through furthqual protection under the law, including
determination of their competency to partici pate in their
own defense; and (c) protection of the public requires that
juveniles with mental disorders be treated and managed in
ways that maintains protection.
REINTEGRA nON AND AFTERCARE Each year nearly
100,000 juvenile offenders in correctional facilities are
returned to their home communities, and an even lar ger
number are released from probation, but reintegra tion
services are poorly developed and reach a small
proportion of returning youth (Griffin, 2005). In many
states juveniles are released from correctional facilities
under state supervised parole, and so there is little
adaptation to the circumstances of the youth or the
community.
Griffin (2005) describes three court-directed pro grams
for aftercare and reintegration in Pennsylvania, West
Virginia, and Indiana, which offered comprehen sive
services for education, employment, and treatment as
needed along with mentoring and monitoring. Altschuler,
Armstrong, & MacKenzie (1999) developed a model for
intensive aftercare by institutional and parole staff that is
ETRICS
), Educational Measurement (3rd ed., pp. 13-104), New
ork: Macmillan.
being in a correctional program is a life- changing
experience; They present a cognitive behavioral approach
that addresses the individual's environment as well as their
personal characteristics. Their research and that of Barton
(2006) found very low rates of recidivism among youth
who completed programs that promoted competency, a
positive sense of self, and transition programming with
strong social support necessary for the youth to achieve
success and stability.
HUMAN RIGHTS The United States strongly advo cates
for the extension of human rights enforcement
throughout the world, but when it relates directly to the
United States, there is resistance not only to the adop-
tion but also to enforcement of those rights by United
Nations agencies. Nowhere are the principles of human
rights more at risk than in the U.S. processing of juve-
niles in the justice system. The International Conven-
tion on the Rights of the Child has not been ratified and
several of its provisions were ignore d. The United
States has signed and ratified four other conventions,
which are often negated by our practices of processing
juveniles as adults, in the conditions of confinement in
many facilities, in the incarceration of juveniles when
community services would be more effective, and in the
overrepresentation of youth of color in all levels of the
juvenile justice system. The four other con ventions
include the following: Convention on the Elimination of
All Forms of Racism, the Covenant on Civil and
Political Rights, the Convention against Torture, and
the Convention on Human Rights. The relevance and
importance of international law and customs was
acknowledged by Justice Arthur Kennedy of the U.S.
Supreme Court in his decision in the Roper v. Simmons
case 543 U.S., in which the Court acknowledged that the
juvenile death penalty was unconstitutional. In 2005 writing
for the majority Justice Kennedy stated that international law
provided guidance for the Supreme Court because execution
of juveniles was

prohibited in many Western countries many years prior to
2005.·
Human rights conventions set limits on state punishment
and control, specify what is required in legal representation of
children in the justice systems, reject the transferring children
to the adult justice system, mandate states to make "every
effort" to achieve proportional representation of youth of color
in the juvenile justice system, and specify appropriate
conditions of confinement (Sarri & Shook, 2005). Attention to
international law and custom is increasingly recognized in the
United States as are the more humane policies and practices in
other countries (Amnesty International, 1998). Human rights
frameworks provide powerful tools for effecting the
processing of juveniles in the United States. It is probable that
in the near future we will see a challenge to the "life without
parole" sentences of juveniles, using international law as a
conceptual framework for the complaint.
Future Trends and Directions
Greater attention to community-based intervention is essential
if juvenile justice in the United States is to increase in
effectiveness (Tyler, Zeidenberg, & Lotke, 2006). The efforts
of the founders of the juvenile court along with those who
advocated for juvenile rights in the 1960s and 1970s need
reexamination, including the goals of the Juvenile Justice and
Delinquency Prevention Act, which strongly asserted that
juveniles were to be primarily treated in the community.
Moreover, that Act has emphasized priorities to reduce over-
representation of youth of color, achieve gender equity, and
increase community-based intervention. Edelman's
presentation of the four circles for intervention in a
comprehensive approach to youth policy comes the closest to
recognition of the earlier prioritiesreduction of poverty,
universalistic approaches to youth development, education
and after-school programming, and parsimony in punitive
intervention (Edelman, 2002). He argues for approaches that
"do no harm" as a minimum requirement.
Public opinion surveys report that a majority of the public
(91 %) believe that rehabilitative services and treatment for
incarcerated youth can help prevent future crimes (Krisberg &
Marchionna, 2007). The public also think that spending on
rehabilitative services will save tax dollars in the long run.
These attitudes suggest that in the future we may see a return
to the goals of the original juvenile court, as Mears, Hay,
Gertz, and Mancini (2007) suggest. The character of the
justice system is shaped by the attitudes and behavior of local
communities. The newly developing
JUVENILE JUSTICE: OVERVIEW 19
rograms of restorative justice, community service, and
conflict resolution may provide the mechanisms for restoring
community values regarding children and youth.
REFERENCES
Altschuler, D., Armstrong, T., & MacKenzie, D. (1999).
Reintegration, supervised release and intensive aftercare.
Washington, DC: U.S. Department of Justice, Office of Justice
Programs, OJJDP Juvenile Justice Bulletin.
Amnesty International. (1998). Betraying the young: Human rights
violations against children in the U.S. justice system. New York:
Amnesty International.
Arnsten, A., & Shansky, R. (2004). Adolescence: Vulnerable period
for stress-induced prefrontal cortical function. Annals of the New
York Academy of Sciences, 1021 (Adolescent brain development:
Vulnerabilities and opportunities) 143-147.
Barton, W. (2006). Incorporating the strengths perspective into
intensive juvenile aftercare. Western Criminology Review, 7(2)
48-6l.
Beckett, K., & Western, B. (2000). The institutional sources of
incarceration: Deviance, regulation and the transformation of state
policy. Paper presented at the American Criminology Society
Annual Meeting, Toronto, Ontario, Canada.
Bishop, D. (2000). Juvenile offenders in the adult criminal justice
system. In M. Tonry (Ed.), Crime and Justice: A Review of
Research. Chicago: University of Chicago Press.
Bishop, D., & Frazier, C. (2000). Consequences of Transfer. In J.
Fagan & F. Zimring (Eds.), The changing borders of juvenile
justice. (pp. 227-276). Chicago: University of Chicago Press.
Bortner, M., Zatz, M., & Hawkins, D. (2000). Race and transfer:
Empirical research and social context. In J. Fagan & F. Zimring
(Eds.), The changing borders of juvenile justice (pp. 277-320).
Chicago: University of Chicago Press.
Bridges, G. S., & Steen, S. (1998). Racial disparities in official
assessment of juvenile offenders; attributional stereotypes as
mediating mechanisms. American Sociological Review, 63(4),
554-570.
Coalition for Juvenile Justice. (2000). Serving the mental health
needs of young offenders. Washington, DC: Author.
Edelman, P. (2002). American government and the politics of youth.
In M. Rosenheim (Eds.), A century of juvenile justice (pp.
310-339). Chicago: University of Chicago Press.
Fagan, J. (1996). The comparative advantage of juvenile versus
criminal court sanction among adolescent felony offenders. Law
and Society, 18(1), 77-114.
Feld, B. (Ed.). (999). Bad kids: Race and the transformation of the
juvenile court. New York: Oxford University Press.
Fowler, P., & Toro, P. (2006). Youth aging out of foster care in
southeast michigan. Detroit, MI: Dept. of Psychology, Wayne
State University.
Garland, D. (200l). The culture of contra!' Chicago: University of
Chicago Press.
Greenwood, P. (2006). Changing lives: Delinquency prevention as
crime-control policy. Chicago: University of Chicago Press.
20 JUVENILE JUSTICE: OVERVIEW
Griffin, P. (2005). Juvenile court-controUed reentry: Three practice
models. Special Project Bulletin. Pittsburgh, PA: Office of
Juvenile Justice and Delinquency Prevention, National Center
for Juvenile Justice.
Grisso, T. (2004). Double jeopardy: Adolescent offenders with mental
disorders. Chicago: University of Chicago Press.
Harrison, P., & Beck, A (2006). Prisoners in 2005.
Washington, DC: U.S. Dept. of Justice, Bureau of Justice
Statistics. NC] 215092.
Human Rights Watch. (2005). The rest of their lives: Life without
parole for child offenders in the U.S. New York: Human Rights
Watch & Amnesty International.
[onson-Reid, M., & Barth, R. (2000). From treatment report to
juvenile incarceration. The role of child welfare services.
Children and Youth Services Review, 22(7),493-516.
Kaufman, J., & Widom, C. (1999). Childhood victimization,
running away and delinquency. Journal of research in crime and
delinquency, 36(4), 347-370.
Kelly, K. (2002). Abuse/neglect and delinquency: Dually involved
minors in the juvenile court. Paper presented at the American
Society of Criminology Annual Meeting, Chicago.
Kempf-Leonard, K., & Sontheimer, H. (1995). The role of race in
juvenile justice in Pennsylvania. In C. E. Pope & W. H.
Feyerherm (Eds.), Minorities in juvenile justice (pp. 98-128).
Thousand Oaks, CA
Krisberg, B., & Marchionna, S. (2007, February). Attitudes of US
voters toward youth crime and the justice system. Focus. San
Francisco: National Council on Crime and Delinquency.
Lerman, P. (2000). Twentieth century developments in America's
institutional system for youth in trouble. In M. Rosenheim
(Ed.), A Century of Juvenile Justice (pp. 74-110). Chicago:
University of Chicago Press.
Lipsey, M., & Wilson, D. (1998). Effective intervention for
serious delinquency in adolescence and early adulthood. In R.
Loeber & D. Farrington (Eds.), Serious and violent juvenile
offenders. Thousand Oaks, CA: Sage.
McNeece, C. A, & Jackson, S. (2004). Juvenile justice policy:
Current trends and 21st century issues. In A Roberts (Ed.),
Juvenile Justice Sourcebook (pp. 41-68). New York: Oxford
University Press.
y threats, and dc., Gertz, M., & Mancini, C. (2007). Public
opinion and the foundation of the juvenile court. Criminology,
45(1),223-258.
Michalic, S., Fagan, A, Irwin, K., Ballard, D., & Elliot, D. (2002).
Blueprints for violence prevention replications: Factors for
Implementation Success. Boulder, CO: Center for the Study and
Prevention of Violence, Institute of Behavioral Science,
University of Colorado.
Nunn, K. (2002). The child as other: Race and differential
treatment in the juvenile justice system. DePaul Law Review, 51
(Spring), 134-146.
Osgood, D. W., Foster, M., Flanagan, c, & Ruth, G. (2005).
On your own without a net: The transition to adulthood for
vulnerable populations. Chicago: University of Chicago Press.
Roberts, A. R. (2004). Juvenile justice sourcebook. New York:
Oxford University Press.
erventions that appear to be effective. juvenile court.
In M. Rosenheim, F. Zimring, D. Tanenhaus, & B. Dohm
(Eds.), A century of juvenile justice (pp. 341-360). Chicago:
University of Chicago Press.
Sampson, R., Morenoff, J., & Raudenbush, S. (2005). Social
anatomy of racial and ethnic disparities in violence, American
Journal of Public Health, 95(2),224-232.
Sarri, R., & Shook, J. (2005). Human rights and juvenile justice in
the United States: Challenges and opportunities. In M.
Ensalaco & L. Majka (Eds.), Children's human rights (pp.
197-228). New York: Rowman and Littlefield.
Sarri, R., Shook, J., & Ward, G. (200l). Decision making in juvenile
justice: A comparative study of four states. Ann Arbor:
Institute for Social Research, University of Michigan.
Scott, E., & Grisso, T. (1997). The evolutions of the adolescence:
A developmental perspective on juvenile justice. Journal of
Criminal Law and Criminology, 88, 137-138.
Setterstein, R., Furstenberg, F., & Rumbaut, R. (2005). On~it
frontier of young adulthood: Theory, research and public policy.
Chicago: University of Chicago Press.
Sickmund, M., Snyder, H., & Poe-Yamagata (2000). Juvenile
Transfers to Criminal court in the 1990's: Lessons Learned from
Four States. Washington, DC: U.S. Department of Justice
Office of Juvenile Justice and Delinquency Prevention.
Smith, c., & Thornberry, T. P. (1995). The relationship between
childhood maltreatment and adolescent involvement in
delinquency. Criminology, 33(3), 451-481.
Snyder, H. N. (2006). Juvenile Arrests, 2004. Washington, DC:
0JJDP, Office of Justice Programs, U.S. Department of Justice.
Snyder, H. N., & Sickrnund, M. (2006). Juvenile offenders and
victims: 2006 national report. Washington, DC: 0JJDP, Office
ofJustice Programs, U.S. Deptartment of justice.
Spear, L. (2000). The adolescent brain and age-related behavioral
manifestations. Neuroscience Biobehavior, 24, 417-463.
Spencer, M. B., & Jones- Walker, C. (2004). Interventions and
services offered to former juvenile offenders reentering their
communities: An analysis of program effectiveness. Youth
Violence and Juvenile Justice, 2(1), 88-89.
Stahl, A, Puzzanchera, c., Sladky, A, Finnegan, T., Tierney, N., &
Snyder, H. (2005). Juvenile court statistics 2001-2002.
Pittsburgh, PA: National Center for Juvenile Justice.
Tanenhaus, D. (2002). The evolution of the juvenile court in the
early twentieth century. In M. Rosenheim, F. Zimring, D.
Tanenhaus, & B. Dohm (Eds.), A century of juvenile justice (pp.
42-74). Chicago: University of Chicago Press.
Torbet, P., & Szymanski, L. (1998). State legislative responses to
violent juvenile crime: 1996-1997 update. Washington, DC:
0JJDP, Office of Justice Programs, U.S. Department of Justice.
Tyler, J., Zeidenberg, J., & Lotke, E. (2006). Cost effective youth
corrections: The fiscal architecture of rational juvenile justice
systems. Washington, DC: Justice Policy Institute.
U.S. Surgeon General (2001). Delinquency prevention programs that
do not work. Washington, DC: U.S. Department of Health and
Human Services.

Zimring, F. E. (2002). The common thread: Diversion in the
jurisprudence of juvenile courts. In M. Rosenheim, F.
Zimring, D. T anenhaus, & B. Dohrn (Eds.), A century of
juvenile justice (pp. 142-158). Chicago: University of Chicago
Press.
Zimring, F. E. (2004). An American travesty. Chicago: University of
Chicago Press.
FURTHER READING
Andrews, D., Zinger, 1., Hoge, R., & Bonta, J. (1990). Does
correctional treatment work? A clinically relevant and
psychologically informed meta-analysis. Criminology, 28,
369-404.
Pope, c., & Feyerherm, W. H. (1995). Minorities
in juvenile justice. Thousand Oaks, CA: Sage.
-, -ROSEMAR Y C. SARRI
roVENILE AND FAMILY COURTS
ABSTRACT: This section defines and discusses the jur-
isdictions of the juvenile and family courts as well as their
influences on social work practice. The history of the
court, several interpretations of it, as well as various
reform efforts are reviewed. Opportunities for social
workers to be employed by the numerous agencies af-
filiated with the court, as well as several nontraditional
social work roles, are outlined in this section. The final two
parts of the section discuss the major innovations and
primary challenges faced by the contemporary court such
as gender, class, and racial biases in the system, questions
about the effectiveness of the court and associated
programs. Finally, proposals to abolish or reinvent the
juvenile court are presented.
KEY WORDS: juvenile court; family court; court juris-
diction; juvenile delinquency; status offenses; depend-
ency; juvenile drug courts; teen courts; diversion;
deinstitutionalization; decrminalization; juvenile death
penalty; guardians ad litem; court appointed special
advocate
"Invented in 1899 in Illinois, this [the juvenile court ]
American idea has achieved a worldwide popularity larger
than any other Anglo-American innovation" (Zimring,
2005, p. xi). WhHe there are obvious differ ences in the
court from country to country, state to state, and even in
counties of the same state, there is no question the
jurisdiction and power of the court permits social workers
to intervene in the lives of in fants, children, adolescents,
and their families.
The wide reach and multiple functions of juvenile and
family court create the organizational and policy context
for social work practice with children, youth, and
families. The primary purpose of this section is to define
the court's jurisdiction and to illustrate its
JUVENILE JUSTICE: JUVENILE AND FAMILY
COURTS 21
influence on social work practice. This is done by briefly
reviewing the history of the court, its societal role, and
legal jurisdiction. In addition, ongoing themes, issues, and
controversies are identified.
Definition of Juvenile Court
As a major social institution (Vinter, 1967) members of
society have expectations and hopes for the juvenile court:
be a compassionate guardian of wayward children; protect
children from persons and situations deemed unhealthy or
harmful; protect the public from assaults on their person
or property; preserve families; and prevent delinquency,
abuse, and neglect.
There is little consensus on the goals of juvenile court
especially when recognizing that the court in volves itself
in the lives of abandoned, maltreated, and misbehaving
children. It is clear that at least two major challenges face
the court: (a) society has extre mely high expectations for
the court, expecting it to not only prevent bu t resolve very
complex social and individual problems; and (b) many
goals contradict each other and produce a tension that is
difficult to balance, such as the "caring" and "correcting"
thrusts of the court. This struggle, among others, is critical
to the court's history, trends in policy, and everyday social
work practice (Vinter, 1967).
J URISDlCTlON Laws in every state specifically define
the situations and behaviors that fall under the jurisdic tion
of the juvenile court. A youth's age is a primary de limiting
factor. Most states set the upper age limit for delinquency
and dependency at 17, and some states define an age under
which a youth will not be handled as a delinquent (for
example, 10 or 12). Exceptions to jurisdictional limits are
numerous and complex. It is common for the court to
retain jurisdiction until youth reach the age of 21 if they
are in the custody of a court authorized agency.
DELINQUENCY The primary factor that defines court
jurisdiction is situational or behavioral. Costin, Bell, and
Downs (1991) categorize these situations in the following
manner. First, the court has jurisdiction when youth are
alleged delinquents, usually d efined as the violation of
any local, state, or federal law for which an adult can be
prosecuted. There are times when the juvenile court may
relinquish this jurisdiction. When this occurs, jurisdiction
falls to adult criminal court.
IN NEED OF SERVICES? Second, most juvenile courts
have jurisdiction when youth are thought to be in need of
services or supervision. Examples include running away,
truancy, disobedience (also known as ungovernable or
22 JUVENILE JUSTICE: JUVENILE AND FAMILY CoURTS
incorrigible), and curfew violations. These "status
offenses"-behaviors subject to court jurisdiction be cause
of the youth's status as a minor, but for which an adult is
not-are controversial because of their vague ness, their
paternalistic overuse (especially with girls), and that
status offenders were institutionalized with delinquent
youth, even, in some cases, for longer periods of time.
Federal legislation (the Juvenile Justice and Delinquency
Prevention Act) originally passed in 1975 and
reauthorized since has reduced some of the problems
associated with this type of court jurisdiction, but unless
more services are made available to these youth and their
families, there is the real possibility that courts will try to
reestablish their powers over these youth. While
incarcerating status offenders is rarely an effective
solution, parents, judges, and law enforcement officials
are frustrated because many states and commu nities have
not sufficiently invested in alternative programs.
Zimring's (2005) conclusion about this aspect of court
jurisdiction is clear: "The saga of the status offender was
one of the great failings of the interven tionist theory of
juvenile courts" (p. 43).
DEPENDENCY, NEGLECT, AND ABUSE The third
area of juvenile court jurisdiction concerns the quality of
care and protection children receive from their par entts)
or legal custodiants). State laws refer to these youth as
dependent, neglected, or abused children. De pendency
refers to "destitute or abandoned children who are
without adequate means of support and care" whereas
"[nleglect and. abuse pertain to children whose parents or
custodians actively deny proper care or inflict injury"
(Flicker, 1987, p. 239). Neglect is a vague area of
jurisdiction, and even though policies dictate that parents
must have the means to provide care before they can be
considered neglectful, it is easy to see that unless social
workers are aware and sensitive to the myriad cultural
and economic overlays of neglect, the court might
overintervene into families.
The broad conceptualization of the juvenile court
used here is that expansive network of agencies, pro-
grams, roles, policies, and practices that operate to
exercise authority over and deliver services to children,
youth, and families in order to accomplish the goals
described earlier. Functions such as law enforcement,
court intake, pre- and posttrial detention, prosecu tion, the
judiciary, defense, probation, juvenile correc tions, and
parole or aftercare are encompassed by this
conceptualization.
Definition of the Family Court
The difference between the juvenile and family court is
one of breadth of jurisdiction. In addition to jurisdiction
over the traditional matters of the juvenile court, family
courts have jurisdiction over divorce, paternity or child
support, adoption, domestic violence protection orders,
and intrafamily misdemeanors (Rubin, 1991). Case
coordination is the goal of this a pproach, and some
believe that the best of all worlds occurs if the same judge
hears all the different cases for a particular family. Absent
a family court, families' cases could be scattered among
civil, criminal, juvenile, probate, domestic rela tions,
divorce, and traffic courts.
Hurst and Svzrnanski's report (as cited in Gebo, 2005)
indicates that "in 1996, 35 states were either operating or
considering developing family courts" (p. 190). Rubin
(1991) points out that court organization is very complex
and a unified family court is no guarantee of case
coordination. "For example, the circuit court in
Milwaukee, Wisconsin, has jurisdiction over all these
matters. But, adoption proceedings take place in the
probate division; juvenile matters are heard in the
children's division; dissolution, domestic vio lence
protection orders, and paternity or child support are
centered in the family division; and intra- family
misdemeanors are heard in the misdemeanor and traffic
division" (p. 42). Not only are there major structural and
practical obstacles to case coordination, but consolidated
jurisdictions such as that envisioned in family courts,
raise constitutional questions as well (Guggenheim,
1991). Flango (2000) asserts "the in creasing volume and
complexity of family caseloads place significant
constraints on the ability of courts to both address the
needs of families and effectively manage cases" (p. 99).
RESEARCH: OVERVIEW nile Court
Many excellent histories of the juvenile court have been
written (Empey, 1982; Krisberg & Austin, 1993; Mennel,
1973; Platt, 1977, Rosenheim, 2002). The court' s history
can be divided into two major eras, the pre- Gault and
post-Gault periods.
PARENS PATRIAE PHILOSOPHY During the 19th century,
there was an emerging recognition that youth were
developmentally distinct from adults, and their welfare and
misbehaviors required different societal responses. With this
recognition, separate court policies and practices for juveniles
began throughout the country. Illinois is recognized as having
the first juvenile court because that state legislature was the
m evaluations (Unrau, Gabor, & Grinnell, 2006).
Even though all 50 states have established juvenile
courts, they vary by breadth of jurisdiction, loca tion in
state court structure (Sutton, 1985), and in administrative
authority. Nevertheless, the operation

of every juvenile court is premised on a parens patriae
philosophy, an approach to delinquency, which focuses on
why .youth act out and how to rehabilitate them. Any
youthful misbehavior, from skipping school or being idle,
to actual crimes, was a concern of the ju venile court. Court
procedures were informal and law yers and due process
practices common in adult criminal court were less
extensive and formal in juven ile court. For example,
contrary to our current courtroom designs, juvenile judges
frequently sat beside the youth at a table so as to diagnose
the youth's problems.
Historians, sociologists, and others have overlapping
interpretations of why the juvenile court came to be and
what motivated its creators. One of the most fre quently
articulated versions is that the court emerged from the
humanitarian impulses of Progressive Era phi lanthropists,
civic groups, and social workers. Aban doned or destitute
children were in need of care and protection; lawless
youth needed compassionate inter-
. vention separate from adult offenders. Other social
commentators explain, however, that societal elites
created the juvenile court so as to control the lower classes
and emigrants who were a threat to class stability (Platt,
1977). Pointing to current ethnic disproportion aliry in
juvenile institutions, contempora ry critics make similar
arguments that the court is still an instrument of the white,
wealthy class.
Another view of the court's history holds that the court
optimistically institutionalized the Progressive Era's new
scientific determinism: delinquency is not genetic but is
determined by events in a youth's life. This being the case,
individualistic interventions will reverse delinquent habits
and tendencies. Finally, an other version of the motivations
behind the creation and operation of the juvenile cou rt is
that increased migration, urbanization, industrialization,
and compulsory education produced larger and larger
numbers of wayward youth, and a new social mechanism
was needed to help enforce the authority of the
community, families, and the schools (Ferdinand, 1991 ).
The juvenile court, supported by its parens patriae
philosophy, was a practical response to the social
problems of the day.
Whichever interpretation one chooses, it is irrefu table
that social workers were among the early leaders of the
juvenile court movement, as well as being its volunteers
and employees (Costin et al., 1991). Further, Sutton
(1985) makes a strong argument that the crea tion of the
juvenile court and its wide spread adoption by states was
part of the broader charity organization movement.
AFTER IN RE GAULT In the 1960s, as a result of several
Supreme Court rulings (most notably In re Gault
JUVENILE JUSTICE: JUVENILE AND FAMILY COURTS 23
juvenile crime, and
research findings concerning the recidivism of juvenile
justice system "graduates" as well as increasing reports of
inhumane institutional settings, the juvenile court came
under attack and began extending constitutional d ue
process protections to juveniles. In the Gault case, the
Supreme Court ruled that juveniles have the right to be
nder attack in the 1960s for viewing difference tected
against self-incrimination, to confront witnesses, and to
have a written transcript o f the proceedings. The Supreme
Court, as well as many researchers and social
commentators, concluded that notwithstanding the good
intentions of the designers of the juvenile court, treatment
turned out to be worse than punishment in that youth were
frequently sent to decrepit and abusive institutions for
long stays without any social, health or educational
services.
Prior to the Gault ruling, the court intervened based on
its perceptions of juveniles' needs and used "low" levels of
proof (for example, a preponderance of evidence). Several
Supreme Court rulings attempted to focus the juvenile
court on the establishment of "legal guilt" beyond a
reasonable doubt; it banned double jeopardy and gave
juveniles a right to counsel, and essentially "posited a
functional equivalence between criminal trials and
delinquency proceedings" (Feld, 1992, p. 62 ).
Notwithstanding these decisions to increase due process
in the juvenile court, the Supreme Court has also ruled that
juveniles do not have a right to jury trials.
OUTCOME OF "D" REFORMS During 1970s, the "D "
reforms-the diversion of juveniles away from court, the
deinstitutionalization and decriminalization of status offenses,
and the improvement of due process protections-were
implemented because the juvenile - court failed to meet
societal expectations and because juveniles are
stigmatized and allowed to learn from
serious offenders (Blomberg, 1984). There are dis-
agreements about their impact, including unintended
consequences. Practitioners and scholars have raised
questions about the degree to which due process rights
have actually been extended to juveniles. For example,
Feld (1990) estimates that approximately half of the
juveniles appearing in court have the services of legal
counsel.
The U.S. Supreme Court recently issued a ruling on
another "D," the death penalty for juveniles. The case,
Roper v.Simmons, was decided in March 2005 on a slim
majority vote (five justices to four). The National
Association of Social Workers filed an amicus curiae brief
opposing the juvenile death penalty. The Court ruled that
persons who are under the age of
24 JUVENILE JUSTICE: JUVENILE AND FAMILY COURTS
18 when they commit murder will not be subject to the
death penalty.
The performance of juvenile court continues to be
unsatisfactory as both liberals and conservatives con tinue
to propose changes. Recent proposals to reform the
juvenile court are dominated by a conservative agenda
(Krisberg & Austin, 1993), with an emphasis on personal
responsibility (Roberts & Brownell, 1999). This agenda
emphasizes deterrence, accountability, de terminant
sentencing, incarceration, and easier t ransfer to adult
court.
SOCIAL WORK ROLES The jurisdiction and design of the
court create the context for social work practice with
children and youth. Whenever social workers in vestigate
reports of abuse, conduct intake interviews determining
youths' suitability for court or detention, or find
temporary shelter for runaways, they act as agents of the
court and the powers of the court allow them to
intervene.
It is difficult to estimate how many social workers
have jobs that are associated with juvenile or family
courts. Addressing "forensic social work," Roberts and
Brownell (1999) explain "that only 1.2 percent of its
members [NASW] identified themselves as working in
the field of corrections and law enforcement (Gibelman,
1995). However, if social workers providing protective
services for children, adults, and families, as well as other
victim services, were included in the forensic social work
category, this percentage likely would increase" (p. 363 ).
While some of the data is dated, inexact, and anec-
dotal, there is a fair consensus that social work does not
have the presence it once did in the juvenile court (Gumz,
2004). An MSW used to be, but no longer is, a common
prerequisite to become a juvenile probation officer or
counselor.
There are many challenging roles for social workers at
direct service, supervisory, management, or policy levels.
Social workers have traditionally been employed at all
levels of juvenile justice and child welfare agen cies.
Besides the traditional jobs social workers hold in the
court, there are many others that might not ordi narily
come to mind. It is rarely mentioned that social workers
can and do get law degrees, and, therefore, are prepared to
become juvenile judges, prosecutors, or defense
attorneys. Second, community policing, the popular law
enforcement innovation of the day, has distinctive social
work correlates and should not be ruled out as a job
possibility. This approach emphasizes pre vention,
mediation of disputes, and referral to services. Third,
states and communities are trying to remove categorical
barriers to service delivery and
promote "blended" or "wrap- around" services especially
to multiproblem youth. Delinquent youth are a key target
of these efforts and social workers are an excel lent choice
as case coordinators or managers. Fourth, the drug,
alcohol, and mental health problems of delin quent and
dependent youth are well known.iOpportu nities exist for
social workers to design and offer relevant programming
for these issues, either within or adjacent to existing
programs. Finally, since the court remains flawed in
structure, policy, and operation, there is a great need for
social workers to do advocacy work, from inside or
outside, at the case or class level (Ezell, 1994).
CHALLENGES FOR SOCIAL WORKERS Understanding
how the court delegates its authority to social work ers,
thereby facilitating interventions for children and
families, is critical because some argue that the court is
unnecessary and agency interventions are sufficient,
especially in cases of abuse, neglect, and dependency.
Clearly, when the actions of social workers or other
agents of the court place restrictions on a person's
liberty, the court must be involved. Bearrows, Bleich,
and Oshima (1987) suggest other reasons for court
involvement. First, in many cases parents acknowledge
their behavior relating to the care of their child needs to
change. Unfortunately, however, social workers do find
parents who disagree and the coercive powers of court
are necessary to protect children and remedy the
situation. Second, some cases involve temporary or
permanent transfer of care from biological parents to
another party. This alteration of recognized rights and
responsibilities needs to be done in a legal context.
Another reason the juvenile court provides a critical
backdrop to social work is to protect children's interests
when in the custody of state or local agencies. Abuses in
foster or group care occur frequently enough to under-
score the need for the court, independent from the agency,
to continue its interests in protecting children. For
example, Children's Rights, Inc., a legal advocacy
organization for abused and neglected children, is cur-
rently involved in litigation in half a dozen jurisdictions to
force public agencies to improve foster care (2007).
Juvenile Court Innovations
There are several noteworthy court innovations. How ever,
all innovative programs can fall prey to the "pa nacea
phenomenon" (Finckenauer & Gavin, 1999), especially if
program designers and managers fail to implement
evaluative mechanisms. This phenom enon recognizes that
there is no shortage of promising program ideas over
which much excitement is usually generated. Once a
reasonable body of rigorous

evaluations attains critical mass, disenchantment- or maybe
realism-prevails and the search for the next panacea begins.
ALTERNATIVE COURT PROGRAMS Two alternative
court programs became popular in the last decade, teen
courts and drug courts. The teen court innovation relies
on participation of youth as jurors usually to decide
upon dispositions, but sometimes to adjudicate guilt
(Minor, Wells, Soderstrom, Bingham, & Williamson,
1999). This program model embraces several elements :
(a) teach accountability to offenders; (b) educate
offenders and jurors about court processes; and (c) use
peer pressure to change behavior. Typical dispositions
include restitution or community service. Elements of
restorative justice may also be reflected in dispositions
(see later). While some research has been reported in
the literature, the lack of rigor prevents one from
reaching firm conclusions about teen courts (Forgays &
DeMilio, 2005)
Juvenile Drug Courts. Since the mid-1990s, juvenile
drug courts are operating in virtually every state (Butts &
Roman, 2004). These courts are designed to meet offenders'
treatment needs. "Juvenile drug courts ... also focus on family
needs, the influence of negative peers, c~ntinuous supervision
of both juvenile and family, and coordination between the
court, treatment community, and school system" (Applegate &
þ ฃ þ
observed by Sloan and Smykla (2003), however, there is great
variation from one drug court to another in terms of target
population and problems as well as other variables. The
research on drug courts is limited, but to date the findings on
multiple measures of effectiveness have been mixed.
Guardians ad Litem. Federal legislation in the mid-1970s
called for the appointment of guardians ad litem (GAls) for
children on matters of dependency and maltreatment. This
is a person who is charged to represent the child's best
interest in court. Many com munities implemented
programs in which lawyers serve as GAls while others use
volunteers (not necessarily attorneys); the latter are
generally called "court appointed special advocates" or
CASAs. In either case, GALs receive special training and
are to work on cases from the very first court hearing to the
end of the case. This continuity is another benefit of these
programs. Foster care review boards have similar goals but
use a different approach.
The duties of GALs may include case investigation,
monitoring of the case, and making recommenda tions to
the court (Youngclarke, Ramos, & GrangerMerkle, 2004).
Advocating for the child is their sole
JUVENILE JUSTICE: JUVENILE AND FAMILY COURTS 25
responsibility, not speaking for the parentts) or any
agencies. Based on a review of 20 studies, Y oungclarke et
al. (2004) concluded, "that children who have CASA
support do about as well, and in some important ways
better, than those represented solely by an attor ney" (p.
121). They caution readers not to overgener alize the
findings.
RESTORATIVE JUSTICE Many new programs and
practices have been developed based on the concept of
restorative justice (Levrant, Cullen, Fulton, &
Wozniak, 1999). "This concept emphasizes the ele-
ments of restoration and restitution and stresses max-
imum involvement in the justice process" (Gumz, 2004 ,
p. 455). Victim offender reconciliation, mediation, and
group conferencing, among others, are progr ams
springing from the concept. One hallmark of these
programs is creating new opportunities for victims of
crimes and their families to be involved in the justice
process, including face-to- face meetings with
offenders. Other common features include offe nders
providing restitution to victims and the community.
The professional literature includes an increasing
sprinkling of evaluative research on restorative justice
programs. One such study was able to randomly assign
juveniles to traditional probation versus a new model for
probation (Lane, Turner, Fain, & Sehgal, 2005). This
particular "model calls for the state to facilitate a healing
transaction among the offender, victim, and community"
(p. 30). The researchers tracked several outcome measures ,
including recidivism, for over two years and found no
significant differences between the two types of juvenile
probation. As Levrant et al. (1999) warn, proceed with
caution.
CURRENT ISSUES AND CHALLENGES The court is
dynamically connected to other social in stitutions and
society as a whole. Among other things, it responds to
and influences public opinion. At least two social issues
of public concern have a major influence on the court
today: (a) the increased demand for family autonomy
and (b) the perceived increase of youth violence and the
nature of the court's response to it.
Family Autonomy. The first issue is most pertinent when
abuse or neglect is suspected. The driving question is, which
familial acts of omission or commission, and at what levels of
severity constitute grounds for· interventions to protect the
child? At what point does the need to protect children
outweigh respect for family autonomy and reasonable
differences in childrearing practices? These questions have
gained heightened attention when social workers remove
children
26 JUVENILE JUSTICE: JUVENILE AND FAMILY COURTS
from homes in what may be prectpitous conditions.
Conversely, social workers are criticized (even prose-
cuted) for failing to remove children from situations that
later result in serious injury or death of a child. The court
walks a fine line on these difficult issues, and it reacts to
criticism from all sides, frequently revising, and
sometimes overcorrecting, policies and practices. The
balance between over- and underintervening will only get
more precarious as society's ethnic and cultural diversity
increases.
Youth Violence. The second broad social issue to
which the court is reacting is the perceived dramatic
increase in youth violence. As th e court responds to
current criticisms, it is important t~ differentiate be tween
increased media coverage of youth crime and the real
amount of illegal behavior. The trends in the 1980 s
showed an increase in the violence victimization rates for
adolescents,· a small increase in the percentage of youth
involved in serious violent offending, and, finally, a large
increase in adolescent homicide (Elliott, 1994, p. 1 ).
Handguns are the major contributor to the increased
lethality of juvenile crime.
The most recent time period in which data are available
indicates that arrest rates for juveniles for violent crimes
against persons "declined in 2003 for the ninth consecutive
year, falling 48% from its 1994 peak and reaching its
lowest level since at least 1980" (Snyder, 2005, p. 1 ).
Likewise, arrests of juveniles for alleged property crimes
in 2003 achieved their lowest point since mid-1970s
(Snyder, 2005).
Notwithstanding what juvenile arrest data tells us,
public polls show growing concern about youth violence.
Contrary to the vast majority of political and legislative
responses to youth crime, polls demonstrate continuing
support for the juvenile court's rehabilitation goals and
preferences for community-based programming and early
intervention over imprisonment (Haugen, Costello,
Schwartz, Krisberg, & Litsky, 1982; Moon, Sundt, Cullen,
& Wright, 2000; Schwartz, Guo, & Kerbs, 1992).
Coupled with the concern over youth violence is the
argument over the appropriate balance between rehabi-
litation and punishment in the juvenile court. Accord ing to
Feld (1993), the recent trend is to de-emphasize
rehabilitation and increase attention to public safety. These
debates seem to lose sight of the practical reality that all of
these youth, even if temporarily incarcerated in some
faraway rural institution, will return to and live in our
communities. Attention should be on those pro grams,
policies, and services that effectively, efficiently, and
humanely achieve legal conformity. Effective pro-
gramming that reduces the reoccurrence of delinquent or
criminal behavior is fiscally sound policy.
ions. This viewpoint does not ask, however, if its goals
gender, and racial bias. The research record document ing
differential treatment for juveniles of each of these stat uses
is mixed (for example, see Johnson & Scheuble [1991];
Phillips & Dinitz [1982]; Sampson & Laub [1993]; Staples
[1987]). lt is hard to ignore the fact, however, that most, if
not all, juvenile institutions hold a disproportionately high
thnic minorities and
Whether this outcome is the result of discriminatory
practices by court officials or the consequence of a
malfunctioning society, it must be addressed if the concept
of justice is to be associated with the juvenile court.
EFFECTIVENESS OF JUVENILE COURTS While it is nearly
impossible to assess the effectiveness of the juvenile court as
a whole, researchers study various programs and policies to
see how well they work. There is not enough space here to
report on all of this research and fairly represent its findings
and intricate methodologies, but a brief summary is presented.
In a review essay, Gibbons (1999) traced the debate
over the last 50 years surrounding the effectiveness of
treatment programs for delinquents. As he recounts, into
the 1980s the conclusion was "that as far as correc tional
treatment is concerned, nothing works or, at best, not
much works" (p. 275). The research record has grown and
research methodologies are more sophisticated, to a point
where, according to Gibbons, researchers in the late 1980 s
and into the 1990s are more optimistic about the
effectiveness of treatment. Concerning treatment
programs for juvenile offenders, Gibbons says "that we are
now a good deal better off with respect to knowledge
about what works than was true even a decade ago" (p.
280), but "there is much that remains somewhat cloudy"
(p. 283).
The research on the effectiveness of the juvenile court,
while promising, remains inconclusive. Granted, the
interventions are complex, and many studies lack
scientific rigor, but there is little argument that too many
youth handled by the juvenile court eventually reoffend. A
major challenge for the court-its future might depend on
it-is to increase the effectiveness of its programs. Social
workers can and should provide the leadership to insure
that policies and program are informed by evidence and
rigorous evaluation rather than by fear, politics, and
superstition seem to be the primary drivers.
Future Trends and Directions
An obvious conclusion is that the juvenile court has not
satisfied society's expectations. This viewpoint does not
ask, however, if its goals are reasonable. Also, few

argue the funding of the court is adequate. Where does that
leave us, especially since prior reform efforts have been
thwarted or co-opted in some way? We are left with the
immense and complex social problems of delinquency, abuse
and neglect, and the need to reform the juvenile court or start
over with something new.
Recent proposals have been made to abolish juvenile court
jurisdiction over delinquent youth. Feld (1993) argues that
since Gault, the distinctions between the juvenile and criminal
courts have practically disappeared, except for certain
procedural deficiencies, and that handling juveniles in
criminal court makes more sense. He adds that in his proposal,
juveniles would be sentenced differently than adults (that is,
leniently). Even those who disagree with this recommendation
are in agreement that the court punishes but does not treat and
that fewer legal safeguards are available to accused youth than
to adults (Rosenberg, 1993).
Krisberg and Austin (1993) argue that the juvenile court
needs to be "reinvented" by a series of measures. First,
delinquency should be viewed as a public health issue
primarily to encourage prevention, to avoid a moralistic
approach, and to explore environmental, nonpsychological
factors associated with delinquency. Second, juvenile justice
programs and policies need to be based on what is known
about adolescent development. Next, the court must do a
better job protecting the legal rights of youth. Finally, a more
integrated social service delivery system needs to be
developed so that a complete view of a youth's needs is
accomplished and the requisite services are easily accessible
without categorical hurdles.
Restructuring, consolidation, increased funding, or new
social interventions are not likely to solve one of the court's
major problems, however. "For the most part, juvenile courts
are seen as unimportant, low-status enterprises within the
nation's legal system" (Bearrows et a1., 1987, p. 50).lt also
seems to be true that programs for delinquents are low priority
in the social service system when one sees how poorly they
compete for funds against other, sometimes more popular,
client groups.
The juvenile court has been an incredibly resilient social
institution for over 100 years, always criticized, but little
changed. Whatever the future of the juvenile court, its
replacement, or its reinvention, social workers can and should
play major roles shaping and implementing the many facets of
tomorrow's court. They should neither be too optimistic nor
resigned about the probability of change, for those with power
rarely relinquish it easily. In the case of the juvenile court,
judges and prosecutors exercise very broad discretion, and
they will fight to maintain it. Change strategies must take this
into account if there is any chance of
JUVENILE JUSTICE: JUVENILE AND FAMILY COURTS 27
success. One element of the recommended reform strategy is
to endeavor to increase the accountability of judges and
prosecutors for the outcomes of their actions, just as society
wishes youth to be accountable for theirs.
Acknowledgment
While writing this section, a very important social work
educator and researcher passed away. Robert Vinter, Professor
Emeritus at the University of Michigan, died on Christmas
Day, 2006. He made significant research contributions in
juvenile justice, conducting the National Assessment of
Juvenile Corrections among many other publications. The
President's Committee on Juvenile Delinquency, the U.S.
Department of Health and Human Services, as well as the
Department of Justice frequently sought his advice. I dedicate
this entry to the memory of Professor V inter.
ere has beenBearrows, T., Bleich, J., &
Bearrows, T., Bleich, J., & Oshima, M. (1987). The contemporary
mandate. In M. H. Moore (EeL), From children to citizens:
Volume I: The mandate for juvenile justice (pp. 49-95). New York:
Springer-Verlag.
Blomberg, T. G. (1984). Juvenile court and community corrections.
Lanham, MD: University Press of American.
Butts, J. A., & Roman, J. (2004). Juvenile drug courts and teen
substance abuse. Washington, DC: The Urban Institute.
Children's Rights, Inc. (2007). How children's rights improved the
child welfare system and children's lives. Retrieved October
21, 2007, from http://www.childrensrights.org/ si
te/PageServer ?pagename= Issues_FosterCare.
Costin, L. B., Bell, C. J., & Downs, S. W. (1991). Child welfare:
Policies and practice (4th ed.). New York: Longman.
Elliott, D. S. (1994). Youth violence: An overview. Paper presented
to the Carnegie Foundation, New York City, February.
Empey, L. (1982). American delinquency: Its meaning and con-
struction. Homewood, IL: Dorsey Press.
Ezell, M. (1994, January). The advocacy practice of social
workers. Families in Society, 36-46.
Feld, B. F. (1990). The right of counsel in juvenile court:
Fulfilling Gault's promise. Youth Law News, 11(3),20-23.
Feld, B. F. (1992). Criminalizing the juvenile court: A research
agenda for the 1990s. In I. M. Schwartz (Ed.), Juvenile justice
and public policy (pp. 59-88). New York: Lexington Books.
Feld, B. F. (1993 ).Justice for children: The right to counsel and the
juvenile court. Boston: Northeastern University Press.
Ferdinand, T. N. (1991). History overtakes the juvenile justice
system. Crime & Delinquency, 37(2), 204-224.
Finckenauer, J. 0., & Gavin, P. W. (1999). Scared straight:
The panacea phenomenon revisited. Prospect Heights, IL:
Waveland.
Flango, C. R. (2000). Family-focused courts. Journal of the Center
for Families, Children and the Courts, 2, 99-106.
Flicker, B. (1987). A short history of jurisdiction of juvenile and
family matters. In F. X. Hartmann (Ed.), From children
28 JUVENILE JUSTICE: JUVENILE AND FAMILY COURTS
to dtizens: Volume 11: The role of the juvenile court (pp. 229250).
New York: Springer-Verlag.
Forgays, D. K., & DeMilio, L. (2005). Is teen court effective for
repeat offenders? A test of the restorative justice approach.
International Journal of Offender Therapy and Comparative
Criminology, 49(1), 107-118.
Gebo, E. (2005, June). Do family courts administer individualized
justice in delinquency cases? Criminal Justice Policy Review,
16(2), 19Qc...210.
Gibbons, D. C. (1999). Review essay: Changing lawbreakersWhat
have we learned since the 1950s? Crime and Delinquency,
45(2), 272-293.
Guggenheim, M. (1991). Constitutional and due process
concerns: Juvenile and family courts of the future. In M.
Hofford (Ed.), Families in court (pp. 179-188). Reno, NV:
The National Council of Juvenile and Family Court Judges.
Gumz, E. J. (2004). American social work, corrections and
resorative justice: An appraisal. International Journal of
Offender Therapy and Comparative Ciminology, 48(4), 449-460.
Haugen, D., Costello, T., Schwartz, I., Krisberg, B., & Litsky, P.
(1982). Public attitudes toward youth crime. Minneapolis, MN:
Hubert H. Humphrey Institute of Public Affairs.
In re Gault, 387 U.S. 1(1967).
Johnson, D. R., & Scheuble, L. K. (1991). Gender bias in the
disposition of juvenile court referrals: The effects of time and
location. Criminology, 29(4), 677-699.
Krisberg, B., & Austin, J. F. (1993). Reinventing juvenile justice.
Newbury Park, CA: Sage Publications.
Lane, J., Turner, S., Fain, T., & Sehgal, A. (2005). Evaluating an
experimental intensive juvenile probation program:
Supervision and official outcomes. Crime and Delinquency,
51(1),26-52.
Levrant, S., Cullen, F. T., Fulton, B., & Wozniak, J. F. (1999).
Reconsidering resorative justice: The corruption of benevo-
lence revisited? Crime and Delinquency, 45(1), 3-27.
Mennel, R. M. (1973). Thorns and thistles: Juvenile delinquents in
the United States 1825-1940. Hanover, NH: The University
Press of New England.
Minor, K. I., Wells, J. B., Soderstrom, I. R., Bingham, R., &
Williamson, D. (1999). Sentence completion and recidivism
among juveniles referred to teen courts. Crime and
Delinquency, 45(4), 467-480.
Moon, M. M., Sundt, J. L., Cullen, F. T., & Wright, J. P. (2000). Is
child saving dead? Public support for juvenile rehabilitation.
Crime and Delinquency, 46(1),38-60.
Phillips, C. D., & Dinitz, S. (1982). Labeling and juvenile court
dispositions: Official responses to a cohort of violent
juveniles. The Sodological Quarterly, 23, 267-278.
Platt, A. (1977). The child savers: The invention of delinquency (2nd
ed.). Chicago: University of Chicago Press.
Roberts, A. R., & Brownell, P. (1999). A century of forensic
social work: Bridging the past to the present. Social Work,
44(4),359-369.
Rodriguez, N., & Webb, V. J. (2004). Multiple measures of
juvenile drug court effectiveness: Results of a quasi-
experimental design. Crime and Delinquency, 50(2), 292-314.
Roper v. Simmons, 125 S. Ct. 1183 (2005).
Rosenberg, I. M. (1993). Leaving bad enough alone: A response
to the juvenile court abolitionists. Wisconsin Law Review,
163-185.
Rosenheim, M. :IC. (2002). A century of juvenile justice. Chicago:
University of Chicago Press.
Rubin, H. T. (1991). Child and family legal proceedings:
Court structure, statutes, and rules. In M. Hofford (Ed.),
Families in court (pp. 25-62). Reno, NV: The National Council
of Juvenile and Family Court Judges.
Sampson, R. J., & Laub, J. H. (1993). Structural variations in
juvenile court processing: Inequality, the underclass, and
social control. Law & Sodety Review, 27(2), 285-311.
Schwartz, I., Guo, S., & Kerbs, J. (1992). Public attitudes toward
juvenile crime and juvenile justice: Implications for public policy.
Ann Arbor: University of Michigan, Center for the Study of
Youth Policy.
Sloan, J. J., III, & Smykla, J. O. (2003). Juvenile drug courts:
Understanding the importance of dimensional variability.
CriminalJustice Policy Review, 14(3),339-360.
Snyder, H. N. (2005). Juvenile arrests 2003. Juvenile justice
bulletin. Washington, DC: U.S. Department of Justice, Office
of Justice Programs, Office of Juvenile Justice and
Delinquency Prevention.
Staples, W. G. (1987). Law and social control in juvenile justice
dispositions. Journal of Research in Crime and Delinquency,
24(1), 7-22.
Sutton, J. R. (1985). The juvenile court and social welfare:
Dynamics of progressive reform. Law & Society Review,
19(1),107-145.
Vinter, R. D. (1967). The juvenile court as an institution.
In President's Commission on Law Enforcement and Adm-
inistration of Justice, Task Force on Juvenile Delinquency,
Task Force Report: Juvenile Delinquency and Youth Crime:
Report on Juvenile Justice and Consultants' Papers, pp. 84-90.
Youngclarke, D., Ramos, K. D., & Granger-Merkle, L. (2004).
A systematic review of the impact of court appointed special
advocates. Journal of the Center for Families, Children and the
Courts, 5, 109-126.
Zimring, F. E. (2005). American juvenile justice. New York:
Oxford University Press.
FURTHER READING
Austin, J., Elms, W., Krisberg, B., & Steele, P. A. (1991).
Unlocking juvenile corrections: Evaluating the Massachusetts
Department of Youth Services. San Francisco: National Council
on Crime and Delinquency.
Austin, J., Joe, K., Krisberg, B., & Steele, P. A. (1990). The impact
of juvenile court sanctions: A court that works. San Francisco:
National Council on Crime and Delinquency.
Champion, D. J., & Mays, G. L. (1991). Transferringjuveniles to
criminal courts: Trends and implications for criminal justice. New
York: Praeger.
Ezell, M. (1992). Juvenile diversion: The ongoing search for
alternatives. In I. M. Schwartz (Ed.), Juvenile Justice and Public
Policy (pp. 45-58). New York: Lexington Books.

Garcia, P. A. (2001). Unified family courts: Justice delivered.
Chicago: American Bar Association's Office of Justice
Initiatives.
Hasenfeld, Y. (1983). Human service organizations. Englewood .
Cliffs, NJ: Prentice-Hall.
Hasenfeld, Y., & Cheung, P. P. L. (1985). The juvenile court as a
people-processing organization: A political economy
perspective. American Journal of Sociology, 90(4), 801-824.
Lerman, P. (1984). Child welfare, the private sector, and com-
munity-based corrections. Crime and Delinquency, 30, 5-38.
JUVENILE JUSTICE: JUVENILE AND FAMILY COURTS 29
Pettibone,J. M., Swisher, R. G., Weiland, K. H., Wolf, C. E., &
White, J. L. (1981). Major issues in juvenile justice information
and training: Services to children in juvenile courts: The judicial-
executive controversy. Columbus, OH: Academy for Contem-
porary Problems.
Wald, M. (1975). State intervention on behalf of "neglected"
children: A search for realistic standards. Stanford Law Review,
27, pp. 985-1040.
-MARK EZELL
LABOR. See Employment and Unemployment.
LABOR UNIONS. See Unions.
LATINOS AND LATINAS. [This entry contains five
subentries: Overview; Practice Interventions; Cubans;
Mexicans; Puerto Ricans.]
OVERVIEW
ABSTRACT: This entry emphasizes diversity among
Latinos/Hispanics with reference to national origin
group, geographical distribution, language use, racial
identity, family life, sexual orientation, immigration and
immigration status, and socioeconomic circum stances.
It also calls attention to the special dilemmas confronted
by Mexican and Central American immigrants and their
children.
KEY WORDS: Hispanic; Latino; racial identity; His-
panic family; immigration
Introduction
By 2005, Hispanics approached 42 million people,
making them the largest minority population in the
United States. This is a significant increase over the 22
million recorded in 1990 and 35 million recorded in
2000 (Ramirez, 2004). Forty percent of Hispanics were
foreign-born (Fry & Hakimzadeh, 2007), with an esti-
mated 25% of the Hispanic population entering as
unauthorized immigrants since 1990 (Passel, 2006).
Hispanics trace their origins to a large number of
Spanish-speaking nations (Table 1). Those of Mexican
origin comprise about 64% of the aggregate, a percen-
tage that has remained stable over the past decades.
Over 15% of Hispanics trace their origins to Caribbean
countries and another 13% trace their origins to Central
and South American nations. Using 2005 U.S. census
data, the Pew Hispanic Center (PHC) found that 7.2%
identified themselves simply as Hispanic without
naming a country of origin.
It was not until the 1970 census that these disparate
national groups, each with its proud and unique history,
culture, and complexity, began to be treated as a single
31
American community. Prior to 1970, the U.S. census
counted each national group separately. In 1970, the
census made, for the first time, a single count using
categories like "Spanish-surname" or
"Spanish-speaking." In 1980, respondents were allowed
to self-identify in terms of "Hispanic" ethnicity (Grieco
& Cassidy, 2000) and for the first time the groups had a
name. In the 2000 census, the name was expanded to
"Spanish, Hispanic, or Latino" (Ramirez, 2004).
Although many accept a pan-Latino identity, im-
migrants generally identify with their national origin
groups rather than as Hispanic. Among second genera-
tion, the preferred identity often shifts to Hispanic while
among the third generation and the most common
identity accepted is that of "American" (PHC, 2004).
The Cultural Access Group (2007), however, found that
many Latino youth preferred to be identified with their
national origin group.
There are also differences among those that accept a
pan-Hispanic identity. Some do not like to call them-
selves Hispanic since it is not a Spanish word and feels
imposed by American society. Latino is the most
acceptable term today especially among intellectuals
and those committed to the struggle for justice. Since it
is a Spanish word, it also promotes the visibility of
women as it allows for the use ofLatina(s) and Latinots)
(for women and men as individuals and as a collective).
Since both terms are commonly used in research and
everyday interaction, they will be used interchangeably
in this essay. For the present, social workers should
refrain from assuming a pan-Hispanic identity. Cultural
competence requires letting colleagues and clients take
the lead in defining their identity.
THE LATINO DIASPORA The rapid growth in the
Latino population is being felt throughout the United
States. In 1980, 64% lived in just three states: California ,
Texas, and New York. By 2000, Latinos were living in
every state but the location and rate of that growth varied
considerably. Suro and Singer (2002) examined the 100
largest standard metropolitan areas and found that 77%
live in the "Hispanic Heartland" and its "fast growing
hubs," which are located in California, Texas, Arizona,
New Mexico, and Colorado in the Southwest; New
York, New Jersey, and Florida along the east coast; and
Illinois in the Midwest. They. also identify "new Latino
destinations" that have shown a 303 % increase
32 LATINOS AND LA TINAS: OvERVIEW

since 1980, making Hispanics visible throughout the
Southeast, Northeast, Mid-Atlantic, Midwest and Cen tral
states, and Western and Pacific states. "Small Lati no
areas" are visible throughout the nation but have realized
modest growth since 1980.
Diversity in the Hispanic/Latino Population
Hispanics are diverse not only in national origin, identity
preference, and residence but also in language, race,
religion, family life, sexual orientation, modes and time
of immigration, and socioeconomic status.

LANGUAGE Through its conquests, Spain left behind its

language. Among immigrants, however, the binds to
Spanish have begun to loosen. When Latinos were asked
whether immigrants must speak English to say they are
part of American society, a majority of foreign- and
native-born agreed as did 64% of Latino Republicans and
52% of Latino Democrats (PHC, 2006).
Table 2 shows that Latinos vary in their degree of
Spanish and English language proficiency and that this
varies by national origin group. Almost 60% of Latinos
speak English exclusively or well, while Spanish profi-
ciency is reported by almost 80% (Ramirez, 2004). Fry
and Hakimzadeh (2007) report that although the majority
of foreign-born Latinos speak English well, they are less
likely to speak it well (46%) than do the native- born
(14.8%) Latinos.
Research on Latino youth can help us· assess the
degree to which Latinos are adapting to the United States
(Portes, 2004). The Cultural Access Group (2007 )
surveyed Latino youth in Los Angeles, Miami, and New
York using both quantitative and qualitative methods.
They found the following:
• The great majority felt pride. in being Latino and in
being bilingual. They were family- oriented and,
rather than being called Latino, preferred being
identified with their unique heritage.
• In spite of their pride, most indicated a strong
From A statistical portrait of Hispanics at mid decade, by R. Fry & S.
preference for English. This was less true for youth
Hakimzadeh, 2007, retrieved April 5, 2007, from http://
pewhispanic.org/reports/middecade/. Copyright 2007 by the Pew in Miami, however.
Hispanic Center. Adapted with permission.

TABLE 2
Languages Spoken (5 Years or Older) by Hispanic Origin: 2000 Census
ONLY ENGLISH AT SPANISH AT HOME OR SPANISH AT HOME OR ENGLISH
HOME . ENGLISH "VERY WELL" LESS THAN "VERY wsu,"
Mexican 21.2 35.7 43.1
Puerto Rican 24.6 48.7 26.7
Cuban 13.7 40,4 45.9
Dominican Central 7.1 39.2 53.7
American South 8.5 34.6 56.8
American Spaniard 10.5 41.9 47.8
Other Hispanic 25.3
40.1 34.6
Towl Hispanic 313 38.8 29.8
21.4 37.9 40.6

From We the People: Hispanics in the United States. Census 2000 Special Report, by R. Ramirez, 2004, retrieved April 4, 2007, from
http://www.census.gov/prod/2004pubs/censr.18,pdf. U.S. Census Bureau, Washington, DC.

• Most indicated that their households were
bilingual with a skew toward English in New York
and Miami.
• Most were proficient in speaking but less profi-
cient in reading and writing Spanish. New York
youth were the least proficient.
• Over 70% of youth indicated they spoke Spangl-
ish, a mixture of Spanish and English.
• A clear majority of youth preferred tuning into
English language television and Internet sites and
listening to American music at least most of the
time.
RELIGION Catholicism, another .legacy from Spain;
has been the dominant religion in Latin America.
For Hispanic Americans it is' still the dominant
religion, although how dominant is unclear. Among
recent studies, estimates range from 57% to 70% of
Hispanic Americans being Catholic (Perl, Greely, &
·Gray, 2006; Suro, Escobar, Livingstone, &
Hakimzadeh, 2007). The percentage of Hispanics
identifying as Protestant varies between 20% and
25%, a figure that has been stable since at least 1990
(Keysar, Kosmin, & Mayer, 2001). Between 8% and
13% of people identify with no religion. N
inety-nine percent of all of them identified with a
religion are either Catholic or Protestant, and 39%
of them define themselves as "born again" or
evangelical. The following profiles of religious and
socioeconomic status are drawn from Keysar et al.
and Suro et al.
Catholic Latinos now make up close to a third of all
Catholics in the United States, with more than half
identifying as charismatic. (Charismatics emphasize a
belief in the holy spirit and often participate in ener-
getic services, healing, and speaking in tongues.) T
wothirds are foreign-born and Spanish is their primary
language; 42% have not graduated from high school
and 46% have an annual household income of under
$30,000.
Evangelical Protestants also tend to be foreignborn
but 63% say English is their primary language or that
they are bilingual while 64% have a high school
diploma and 61 % have a household income of over
$30,000.
Mainline Protestants, such as Episcopalians and
Methodists, constitute only about 5% of Latinos. They
are the most likely to be native-born and 45% say
English is their primary language. They have the high-
est socioeconomic standing with 70% having a high
school diploma and 71 % having an annual household
income of over $30,000.
Nonreligious Latinos tend to be younger, male, and
foreign-born. Although the foreign-born are less likely
LATINOS AND LATINAS: OVERVIEW 33
to be a member of a church, believe in God or miracles,
or believe "God helps me" than other Latinos, they are
more likely to do or believe these things than other
Americans. Seventy-six percent of the nonreligious
Latinos had considered themselves Catholic or Protes-
tant in the past. The nonreligious also had the highest
full-time employment level and the lowest level of
unemployment.
RACIAL DIVERSITY In addition to language and reli-
gion, Spain left its mark on the phenotypes of Latin
Americans. Because of Catholicism, both the
indigenous people and the slaves that followed later
were considered souls, that is, full human beings in the
eyes of God; therefore, intermarriage between Spanish
and indigenous or African was common if not
altogether acceptable. Although the Spanish invented a
cumbersome system of racial categories to distinguish
among all possible mixtures, the system eventually fell
apart from it own weight (Wolfe, 1959). An important
element of that system continuing today in that race in
most Latino nations is viewed on a continuum. People
of mixed ancestry are neither White nor non-White.
Thus, most racially mixed people in Spanish speaking
nations think of themselves as White or as some inter-
mediary designation such as mestizo (European or Indi-
genous) or mulatto, trigeno, and moreno (variations on
African or European ancestry). This is in clear contrast
to the common practice in the United States of per-
ceiving individuals as belonging to one race only.
According to the U.S. census, Hispanics are an
ethnic group whose members may be of any race.
Respondents are asked to indicate their Hispanic eth-
nicity and, separately, their race (for example, White or
Black). Given specific choices, Hispanics often mark
"some other race" and write in designators like "Latino"
or "Hispanic" (Logan, 2003; Tafoya, 2003). However,
Tafoya also notes that if not given the option to choose
an alternative racial category, as in the 1990 and2000
supplemental census surveys, Latinos are likely to de-
fine themselves as White as indicated in Table 3 below.
Logan (2003) and Tafoya (2004) have uncovered
interesting differences among Hispanic Hispanics
(HH), Hispanic Blacks (HB), and Hispanic Whites
(HW) as laid out below. We should read these differ-
ences knowing that if not given a choice, many Hispa-
nic Hispanics would call themselves White.
• Hispanic Blacks (HB): 13% of Dominicans, 8% of
Puerto Ricans, and 4% of Central Americans
identify as Black. Although a higher percent
were likely to speak English and have
completed high school, HB had the highest rates
of unemployment and poverty and the lowest
median household
34 LATINOS AND LATINAS: OVERVIEW
TABLE 3
Racial Composition of Hispanic Population in the
United States: 1980-2000
From How race counts for Hispanic Americans, by]. Logan, 2003,
University of Albany, Lewis Mumford Center for Comparative Urban
and Regional Research. Retrieved May 1, 2007, from Educational
Resources Information Center, ED479962, http://
www.eric.ed.gov/ERICDocs/data/ericdocs2sq l!contencstorage_
01/00000 19b/80/1 b/55/bc. pdf.
income. Of the major Hispanic cities, New York .
had the highest percentage of HB.
• Hispanics Whites (HW) had the highest median
household income and the lowest
unemployment and poverty rates. About 85% of
Cuban, 76% of Spanish, and 61 % of South
Americans claimed a White identity. Of the
major metropolitan areas, 86% of Hispanics
living in Miami, 77% living in EI Paso, 64%
living in San Antonio, 57% living in
Albuquerque, and 54% living in Houston iden-
tified as White.
• Hispanic Hispanics (HH) are most likely to be
foreign-born. They had the lowest levels of
education but tended to be in the middle of the
Hispanic distribution when it c ame to median
household income, unemployment, and poverty.
Around 63% of Dominicans, 54% of Central
Americans, 50% of Mexicans, and 43% of
Puerto Ricans identified as HH. Around 54% of
HH lived in Southern California with about 49%
living in New York and Chicago.
Tafoya (2004) hypothesizes that racial identification
among Latinos measures their sense of belonging.
Since race is considered fluid, she believes that the
more Hispanics feel they are part of the United States
the more they are likely to identify as White. It should
not surprise, therefore, that two ma jor predictors of
racial identification are foreign birth and socioeco-
nomic status.
Focusing on racial differences presents a dilemma,
namely, whether Latinos will be allowed to be a multi-
racial group. The same society that invented the term
Latinos may, with its one of two choices racial system,
might as easily separate them .into White and Black
Since Americans think in terms of one of two choices,
the likelihood of imposing racial dichotomies
on Hispanics is real. Rodriguez (1985) pointed out that
Puerto Ricans were being forced into a Black-White
dichotomy in their interactions with other Americans.
Along these lines, Scherer (2003) reports on the con-
sternation experienced by newspapers in telling the
story that Hispanics were now the largest minority. They
reasoned, if Hispanics are Black, should not they be
counted as African Americans rather than as Hispanics?
Thus, many newspapers hedged on proclaiming
Hispanics the largest minority. It is also interesting that
Scherer, along with Logan (2003), uses the term "Black
Hispanics," thus making race more important than
ethnicity.
Racism in the Latino population might also work to
separate out not only "Black" but darker skinned His-
panics. Montalvo (1991) reported that darker Mexican
Americans were acutely aware of their skin color and
the negative influence it played in their lives. Massey
and Denton (1992) found that suburbanization of male
Mexican Americans was associated with higher income,
having a White spouse, and choosing "White" as one's
race. Given the either-or approach to race in the United
States and racism among Latinos, will it be pos sible for
Hispanic Blacks to sustain a Hispanic identity?
DIVERSITY IN FAMILY Hispanic tradition emphasizes a
commitment to strong family attachments or familismo
(Santiago-Rivera, 2003; Vasquez, 2005). Family life
ideals often espouse male-headed,. tightly knit,
extended heterosexual units. According to tradition,
male and female roles are strictly divided and positive
value given to responsible male authority and female
devotion to home, children, and husband. Latino men
aim to be macho, that is, to take on responsibility for
providing financial support and security in return for
extramarital freedoms. Latina mothers respect the
authority of their husbands and work to maintain
emotional balance in the household. Children show
respect for parental authority and abide by the will of
responsible fathers and devoted mothers.
This commitment to family life is seen as a source of
strength by many and there is indeed evidence that
Latinos place more emphasis on family life than non-
Hispanics. They are more likely than other Americans to
live in family households (Ramirez, 2004). Likewise ,
27% of Latinos live in families of more than five people
compared with 10% of White non-Hispanic families
(Fry & Hakimzadeh, 2007). Fertility rates are also
somewhat higher and, following from this, the median
age of Hispanics is 26 compared with 35 for the total
American population (Ramirez).
There is also evidence that family life ideals are not
always reached. There is a great deal of heterogeneity
among Hispanic families, both within and across

Hispanic ethnic groups. The harsh external realities
confronted by many Hispanic families-including
unemployment and poverty, and problems resulting
from unauthorized immigration-often act as a spur to
change. The rise of the women's and the gay and lesbian
movements has also forced the Latino to face some of
the inequalities inherent in traditional family life. As a
result, the modem Hispanic family resembles the
modem non-Hispanic family in many particulars.
Many aspects of contemporary Hispanic family life
do not conform to traditional family ideals. For instance,
in 2005, marriage between Hispanic couples (51%) was
lower than White not-Hispanic couples (57%).
Although the percentage of divorced and separated
people was lower among Hispanics (12%) than white
non-Hispanics (13%), the difference was 'small .
Similarly, although Latinos are more likely than White
non-Hispanics to live in family households, the
percentage of two parent family households is fairly
comparable across both groups (Ramirez, 2004).
Furthermore, the percentage of female single-parent
householder was somewhat higher among Latinas than
in the total American population (Fry & Hakimzadeh,
2007). In terms of children living with parents, White
children are more likely to live with at least one parent
(92.1%) than Hispanic children (85.3%).
HISPANIC INTERMARRIAGE Writings on Hispanic
American families often assume the ethnic homo-
geneity of family life. Yet in the 2000 U.S. census ,
about 27% of those reporting multiple- race identities
were Hispanic children, husbands, or wives (Lee &
Edmonston, 2005). Since 1970, Hispanic to
non-Hispanic marriages have held fairly stable at
around 14%. Puerto Ricans, however, have the
highest intermarriage rates, increasing from 10% in
1970 to 21 % in 2000. Other Hispanics had the
highest out-marriage in 1970 (21 %) but decreased by
1990 to 17%. Lee and EdmOnston (2006) believe
these rates are likely to rise in the future, especially i f
immigration slows. They add that since many
Hispanics define their race as White or Hispanic, the
barrier to out-marriage with non-Hispanic Ameri cans
is lowered.
HISPANIC GAYS AND LESBIANS The intense em phasis
on heterosexual, private family life forced tradi tional
Latinos interested in same sex relations to either
conform to gender role ideals or risk being ostracized
from family (Hidalgo, 1995; Molloy & Mckee-Irwin,
1998; Murray, 1987; Ramos, 2004) as a result, some
Latinos ascribe homosexuality onl y to flamboyant
men and cross-dressing women living on the edges of
LATINOS AND LATINAS: OVERVIEW 35
traditional family life. Gender conforming men and the
women who had sex with them, often abusing them
(Molloy & Mckee-Irwin, 1998; Zamora-Hernandez &
Paterson, 1996), did not think of themselves as homo-
sexuals. Thus, health care services today often use the
term "men who have sex with men" as a way of
respecting traditional thinking.
Although many still adhere to these norms, they are
clearly breaking down especially among educated and
acculturated Latinos. In a survey 0(92 self-identified
Latina lesbians, those with a higher occupational status,
education, and income were committed to a lesbian
identity (Alquijay, 1997). Openly gay and lesbian
Latinos have been out and active since before the
Stonewall uprising of 1968 (Roque-Ramirez, 2005).
They recognize the strong homophobia embedded in
their culture and have organized for change.
The pull of family remains strong among many les-
bians and gays and their families, and so it is a mistake
to assume that Hispanic families will automatically
reject their gay and lesbian children. Bonilla and Porter
(1990) found that Latinos were just as tolerant as Whites
about homosexuality. Marsiglia (1998) notes that many
find supportive families once they come out. As
Zamora-Hernandez and Paterson (1996) suggest, family
ties can be strengthened by promoting the inclusion of
lesbians and gay members.
HISPANICS BEFORE Not all Hispanics are recent im-
migrants and many have a long ancestry in the United
States. Some Hispanic Americans trace their origins
to the colonial southwest where they lived under the
Spanish and Mexican flags, before the area was
incorporated into the United States in 1848. As early
as 1860, laborers from Mexico, Chile, and Peru were
working in the mines and railroads of the West
(Edmonston & Passel, 1994). Immigration from Latin
America rivaled immigration from Europe
throughout the 20th century (Massey, 1995 ).
Immigration before 1966 was domina ted by
Mexicans, Puerto Ricans, and Cubans. The first large
wave came as a result of the Mexican Revolu tion of
1910 (Gibson, 1987) and continued through World
War Ii and the Korean War. Between 1942 and 1964 ,
some 4 million Mexican braceros or legal farm workers
migrated and helped to transform American agriculture
into the industry it is today (Weaver, 2001).
Puerto Rico was annexed by the United States as a
result of the Spanish American War in 1898. Immi grants
were coming by the 1920s but the "Great Migration," of
Puerto Ricans began after World War II (Delgado,
1987). Since the mid-1960s, a "revolving door" or back
and forth migration between the Mainland the Island has
been common.
36 LATINOS AND LATINAS: OVERVIEW
Large waves of Cuban refugees came to the United
States beginning in 1959, when a revolution brought
Fidel Castro to power. The first wave of Cubans tended
to be educated professionals from the upper and middle
classes, but successive waves drew on Cubans of more
modest backgrounds. To help ease their adjustment,
1966 Congressional legislature granted Cuban refugees
$1.2 billion in direct assistance, public assistance,
Medicare, free English classes, scholarships, and low-
interest college loans (Cuban American Adjustment
Act, 1966).
IMMIGRA TION SINCE 1966 Prior to 1966, Latinos who
had the desire and wherewithal could enter the
United States legally. U.S. immigration policy;
which restricted immigration froin other parts of the
world, did not restrict people from the Western
hemisphere. Since that time, Latinos enter under the
same national quota policies as other immigrants.
For this reason, 1966 becomes a pivotal year in the
migration of Latinos.
Latino immigration remained at about 50% of the
total immigration between 1960 and 1990. During this
time, the Mexican American population remained at
about 62% of all Hispanics, while Hispanics from Cen-
tral and South America increased their share of the
Hispanic population. By 1994, about 1 million immi-
grants were entering annually. In 1994, the number of
immigrants began to increase rapidly, spiking at a mil-
lion and a half a. year in 2000 and then declining to early
1990 levels. In 2004, the numbers started to rise again
(Passel & Suro, 2005). Although these data are not
broken down by nation, Passel and Suro (2005) report
that migration out of Mexico followed the same trend
and held relatively steady at around 33% of the overall
migration.
UNAUTHORIZED AND ILLEGAL IMMIGRATION The
history of illegal immigration begins with the end of the
bracero project in 1964 and especially with the enactment
of the Immigration and Naturalization Act of 1986. The
former shut off a legal channel for immigration and the
later led to the requirement of a Permanent Resident or
"green" Card to remain legally in the U. S. Using 2005
census data, researchers (Passel, 2006; Passel & Suro,
2005) estimate that there were nearly 12 million
unauthorized immigrants living in the United States,
most of whom are Latino.
To discourage illegal immigration, Congress enacted
The Immigration Reform and Control Act ORCA) of
1986, which granted amnesty to undocumented immi-
grants who could demonstrate they had lived in the
United States for at least 4 years. Over 92% of those
granted amnesty were Latino. This new policy failed to
stop illegal immigration. In the mid-1990s, the federal
government quintupled border enforcement expendi-
tures and introduced fortified checkpoints, high-tech
surveillance techniques, and increased the number of
border patrol agents (Rubio-Goldsmith, McCormick,
Martinez, & Duarte, 2007). These draconian policies
also failed. Fear of terrorism recently has led to in-
creased crack downs on illegal border. However, the
Immigration Policy Center (2007) reports that 99.8% of
all apprehensions were from people of Mexico and
Central and South America. Increased surveillance
along the Mexico border has also led to the deaths of
many would-be immigrants. Examining corpses found
along the border with Arizona, Rubio-Goldsmith et al.
found that the number of corpses found each year rose
from 14 in 1966 to over 200 in 2005.
SOCIOECONOMIC STATUS On average, there is wide
variation in income and educational attainment among
the different Hispanic subgroups (Table 4). With
regard to median family income, people from Spain do
very well in comparison with the total population, and
those from South America and Cuba do better than all
other Hispanics. Except for Spaniards, however, all
other Hispanics fall significantly below income figures
for the total U.S. population. The median family in-
come for South American Hispanics is, on average,
86% of what is earned by the total population. At the
other extreme, median family income among Domini-
cans is only 57% of the total American population.
In terms of per capita income, we see similar varia-
bility with all Hispanic groups, except Spaniards earn-
ing less than the U.S. population as a whole. Latinas
come closer to male incomes than American women do
.. Mexican women earn on average 87.5% of what
Mexican men earn. Puerto Rican, Cuban, Central
American, and Dominican women earn on average
",83% of what their male peers earn. Non-Hispanic
women earn on average only 73% only of their male
counterparts. One could conjecture that at the lower end
of the income pyramid, the earnings of men and women
become more comparable.
With respect to educational attainment, over 80% of
non-Hispanic Americans complete High School and
24% complete college. Only Spaniards, South
Americans, and Cubans approach or surpass these
achievements. Educational attainment is particularly
problematic for Mexican and Central Americans as
only about 46% have completed high school and less
than 10% college.
Labor force participation measures the proportion of
the population 16 and older that is either employed or
 LATINOS AND LATINAS: OVERVIEW 37

TABLE 4
Income and Education by Hispanic Origin: 2000
MEDIAN FAMILY MEDIAN PER CAPITA EDUCATIONAL ATTAINMENT
INCOME EARNINGS MALE
FEMALE % HS % BA DIPLOMA
DIPLOMA OR OR MORE
Mexican $33,516 23,495 20,556 MORE 7.5
Puerto Rican Cuban $32,791 30,281 25,582 45.8 12.5
Dominican Central $42,642 31,527 26,254 63.3 21.2
American South $28,729 25,106 20,488 62.9 10.9
American Spaniard $34,150 22,423 18,588 51.1 9.5
Other Hispanic $42,824 30,482 24,153 46.0 25.2
All Americans $53,002 39,628 30,874 76.1 29.9
$34,703 27,418 22,106 no 11.2
$50,046 37,057 27,194 60.0 2404
8004
From We the People: Hispanics in the Unitid States. Census 2000 Special Report, by R. Ramirez, R., 2004, retrieved April 4, 2007, from
http://www.census.gov/prod/2004pubs/censr-18.pdf. U.S. Census Bureau, Washington, DC.

TABLE 5 replace the existing population, the economy can only

Labor Force Participation by Hispanic Origin: 2000 grow through immigration (Paral, Siciliano, Johnson,
Ewing, & Chittendon, 2005). In particular, the economy
NATIONAL ORIGIN % LABOR FORCE
is expanding in the low-skilled sectors where the number
GROUPS PARTICIPATION
MEN WOMEN of young, relatively uneducated, native-born Americans
Mexican 71.1 52.0 is declining. Recent unauthorized immigrants from
Puerto Rican 64.3 53.7 Mexico and Central America easily find their niche in
Cuban 62.7 4904
52.9 these less skilled, physically demanding jobs. In 2004,
Dominican Central 64.6
American South 76.0 57.9 immigrants made up more than 25% of all 25- to
American Spaniard 59.1 34-year-old workers with a high school diploma or less.
74.8 55.7
Other Hispanic 69.7 This situation is expected to remain the same through
All Americans 53.3
63.5 2010 (Paral et al., 2005). Many Americans believe that
57.5
70.7
illegal immigrants are taking jobs away from Americans
From We the People: Hispanics in the United States. Census 2000 eager to have them (NPR/Kaiser Family
Special Report, by R. Ramirez, R., 2004, retrieved April 4, 2007, Foundation/Kennedy School, 2004). Far from stealing
from http://www.census.gov/prod/2004pubs/censr-18.pdf. U.S. jobs, a robust U.S. economy now depends on low-wage
Census Bureau, Washington, DC.
foreign immigrants. The healthy economy for Hispanic
workers has been driven largely by the demands of the
construction industry. This industry added almost half a
seeking employment. Hispanic labor force participation million jobs in 2005 and 2006, the majority of them
varies by Hispanic sub-group. Mexican and Central and filled by;:[oreign-born Latinos (PHC, 2007). In addition
South American men participated at a higher rate than to construction, a wide range of service industries
the American population as a whole. Cuban, other looking for cheap labor encourage immigration by
Hispanic, Puerto Rican, and Dominican men partici- Mexican and Central American laborers (Portes,2004).
pated significantly less (see table 5). By 2006, Hispanic
unemployment had reached an historic low of 5.2%,
bringing the gap between Latino and non-Latino un- PROSPECTS FOR THE FUTURE Looked at through the
employment to just 0.06% points (Kochhar, 2006). prism of recent and continuing immigration and low
Kochhar also notes that the foreign-born dominate the skilled, menial employment, these so cioeconomic
labor market gaining about 8 in every 10 jobs landed by data are what might be expected. Although Hispanic
Latinos in 2005-2006. labor force participation is presently good, too many
Labor force growth, which is critical to economic occupations are in the lowest wage brackets, bringing
growth, increases as a function of the number of people the average income for Hispanics as a total
working or seeking work. Since the birth rate among population down. A lack of opportunity,
Americans has remained stable at just enough to discrimination, and diffi culties in educational
advancement suggests that it will
38 LATINOS AND LATINAS: OVERVIEW
be very difficult for low-income, less-educated Latinos to
move ahead.
In our deindustrializing economy upward mobility
increasingly requires educational credentials beyond high
school (Portes, 2004; Raijman & Tienda, 1999).
Today, darker-skinned Hispanics and their children are
more easily stigmatized as "other." Even with educa tion,
their access to American society can feel con strained.
Portes found that two-thirds of Mexican youth reported
experiencing discrimination regardless of how much
education they had.
The intense debate over immigration in America hangs
as a weight on all Hispanics, especially second generation
Hispanics. A study of American attitudes found that 41 %
of nonimmigrant Americans believed that legal
immigration shoulH be decreased (NPR/Kaiser Family
Foundation/Kennedy School, 2004). More than 50%
expressed fear that immigrants were changing American
culture and values for the worse, taking jobs from
Americans, and not paying their fair share of taxes. Even
more negative attitudes are held about illegal immigrants.
In spite of overwhelming contrary evidence, nearly 60% o f
native-born Americans believed that illegal immigration
has hurt the national economy.
Education is central to success in the American
economy and it is education that many Latinos lack. A
large percentage of the most recent immigrants from
Mexico and Central America have less than 9 years of
education (PHC, 2007). Additionally, young immi grants
who have done poorly in school before immigrating have a
higher likelihood of dropping out or even not enrolling
once in the United States (Fry, 2005).
The education of native-born Latinos presents a mixed
picture. On the bright side, native-born Hispa nics are more
likely to complete high school than their immigrant
counterparts. Yet, high school completion rates are
significantly lower for native Hispanics than for native
non-Hispanic Whites. By age 9, Latinos are on average
two grades behind their White peers. Hispanics are also
less likely to attend pre- and nursery school programs. The
majority of Latino youth are enrolled in overcrowded,
underfunded, central city schools. Sixteen percent of the
teachers in such schools are not fully credentialed (PHC,
2002).
At the college level there is an even wider disparity
between Hispanics and Whites (Fry, 2005). Although
native-born Latinos are more likely to go to college than
their foreign peers, native-born Latinos are less likely to
go on to college than their White counterparts (PHC,
2002). Furthermore, the pathways taken suggest their
educational potential will not be fully realized. Many
Latino youth go to community colleges where they are half
as likely to finish their programs as non-Hispanic
Whites. Those who complete college are likely to have
attended an "open door" or other less-selective institu tions
with low BA completion rates (Fry, 2005).
In his longitudinal study of 17 -year-old second-gen-
eration teens, Portes (2004) found that Mexicans had the
lowest educational aspirations. Cubans who attended
Catholic private high schools were the most likely to
aspire (85%) to an advanced degree. Nicaraguan, non-
private school Cubans, and Columbians followed behind.
Only 48% of second generation Mexican aspired to an
advanced degree. By age 24, only 38% of these same
Mexican youth had completed High School, the lowest
rate among second-generation Hispanics. Clearly the
children of poorly educated, unskilled laborers are having
a hard time adapting to the United States.
Portes (2004) concludes that integration into American
society is likely to follow three different paths. For
immigrants with high levels of educationSpaniards, South
Americans,' and Cubans-the future looks bright. Their
children can generally expect to integrate smoothly into
society at the same level as other Americans (Portes,
2004). Hispanics in the middle-Puerto Ricans and
Dominicans-are likely to have a tougher time, but largely
because they are no longer growing as a population, their
children should scratch their way up' using family and
community as resources. For Mexicans and Central
Americans, those with the lowest educational attainment,
the future looks bleak. Children of Mexican and Central
American immigrants must make the leap from the poor
education of their parents to the high school and college
education their parents likely never dreamed of. Some will
overcome' these obstacles and over the generations
manage to work their way up the socioeconomic ladder.
Unless educational attainment can be markedly in creased,
many will fall prey to a lack of resources for positive
development.
IMPLICATIONS FOR PRACTICE In addition to the
educational needs discussed above, we call attention to
child welfare, criminal justice, and mental health needs.
Latino children and their families represent the fastest
growing group in the child welfare system (Rivera, 2002 ).
The percentage of Latino children in foster care in the
United States increased more than double from 8% in 1990
to 17% in 1999 (Gonzalez, 2004). In 2005, 18% of the
children in foster care were Latino. Thirty-five percent of
Latino children placed in foster care are less than 1 year in
age (Community for Hispanic Children and Families,
2004).
Latino youth, with nowhere to go, easily succumb to
the lure of crime, drugs, depression, and suicidal ideation.
Since 1985, Latinos have been the fastest growing

population in the criminal justice system. Incarceration
rates for Latino men are more than double the rates for
White males (Rumbaut, 2005). Latinos are also dispro-
portionately represented in the juvenile justice system
(Building Blocks for Youth Report, 2002).
Although suicide rates are lower for Latino youth, they
are more likely to attempt suicide (Center for Disease
Control and Prevention, 2004) and just as likely to
experience depression as their White nonLatino peers
(Organista, 2000; Zhang & Snowden, 1999). Vega et al.
(1998) found that long-term residence in the United States
significantly increased the likelihood of mental disorders
among adults, with particularly marked increases in
substance abuse. In a study of Mexican, Puerto Rican,
Cuban and "other" Latinos, English-proficient, third
g~neration Latinos had higher rates of psychiatric
disorders (Alegria et al., 2007). The problem of mental
health care is exacerbated since many Latinos seek help in
the general medical sector (Alegria et al., 2007; Vega and
Alegria, 2001). Reasons for this include lack of familiarity
with mental health services and a tendency to sommaticize
emotional and behavioral difficulties.
Policies and programs should aim to enhance educa-
tional and occupational opportunities, especially formiddle
and lower socioeconomic Latinos. Evidence-based
practice (EBP) approaches are promising, especially with
respect to depression and anxiety (Miranda et al., 2005;
Schraufnagel, Wagner, Miranda, & Roy-Byrne, 2006).
However, few EBPs have been developed with Latinos in
mind; clinical trials rarely include Latinos either as
researchers or clients and rarely use outcome measures
relevant to Latinos (National Implementation Research
Network, 2003).
To work, evidence-based approaches should not force
Hispanics to adapt to research protocols, rather they should
be infused with cultural competence. The issues raised in
this entry should help in this regard. In particular, social
workers should avoid stereotyping by recognizing
diversity among Latinos in national origin, language
preference, religion, racial identification, family organi-
zation, sexual orientation, immigration status and gen-
eration, and socioeconomic status. In particular, social
workers should
• support and respect Latino diversity in national
origin, racial identity, religious beliefs, sexual
orientation, time in the United States, and cultural
pride;
• serve Latinos according to their language
preferences;
• recognize the centrality of family as it evolves in
American society;
• build on family and community strengths to promote
achievement for all Latinos.
LATINOS AND LATINAS: OVERVIEW 39
• develop policies and services to fully integrate
unskilled immigrants and their children into
occupational and educational opportunities.
REFERENCES
Alegria, M., Mulvaney-Day, N., Torres, M., Polo, A., Cao, Z., &
Canino, G. (2007). Prevalence of psychiatric disorders across
Latino subgroups in the United States. American Journal of
Public Health, 97, 68-75.
Alquijay, M. A. (1997). The relationship among self-esteem,
acculturation, and lesbian identity formation. In B. Greene
(Ed.), Ethnic and cultural diversity among lexbians and gay men (pp.
249-265). Thousand Oaks, CA: Sage Publications.
Bonilla, G. j., & Porter, j. (1990). A comparison of Latino, Black
and non-Hispanic White attitudes toward homosexuality.
Hispanic Journal of Behavioral Science, 12, 437-452.
Building Blocks for Youth Report. (2002). D6nde Esu! La Justicia?
A Call for Action on Behalf of Latino and Latina Youth in the U.S.
Jusdce System.
Community for Hispanic Children and Families. (2004). Creating
a Latino child welfare agenda: A strategic framework for change.
New York: Author.
Center for Disease Control and Prevention. (2004). Suicide among
Hispanics-United States, 1997-2001. Morbidity and Mortality
Weekly Report, 53, 478-481.
Cuban American Adjustment Act, Pub. L. No. 89-732, 80 Stat.
1161 (1966). Retrieved December 1, 2007, from
http://heinonline.org.
Cultural Access Group. (2007). U.S. Latino youth: A tale of two
cultures. Received via correspondence from Central Access
Group, Figueroa Street, Los Angeles, CA.
Delgado, M. (1987). Puerto Ricans. Encyclopedia of Social Work (18th
ed., Vol. 2, pp. 426-434). Washington, DC: National
Association of Social Workers.
Edmonston, B., and Passel,]. S. (Eds.). (1994). Ethnic demog-
raphy: U.S. immigration and ethnic variations. In Immigration
and ethnicity. Washington, oc: Urban Institute Press.
Fry, R. (2005). The higher dropout rate of foreign born teens: The
role of schooling abroad. Retrieved April 25, 2007, from
http://pewhiSpanic.org/reports/report.php?Report ID=55.
Fry, R., & Hakimzadeh, S. (2007). A statistical portrait of
Hispanics at mid-decade. Retrieved April 5, 2007, from
http://pewhispanic.org/reports/middecade/.
Gibson, G. (1987). Mexican Americans. In Encyclopedia of Social
Work. (18th ed., Vol. 2, pp. 135-148). Washington, DC:
National Association of Social Workers.
Gonzalez, L. P. S. (2004). Five commentaries: Looking to the
future. Commentary 5. Children, Families, and Foster Care, 14,
184-189.
Grieco, E. M., & Cassidy, R.C. (2000). Overview of race and
Hispanic origin. Retrieved May 1, 2007, from http://www.
census.gov/prod/2001 pubs/cenbrOl-l.pdf.
Hidalgo, H. (Ed.). (1995). The norms of conduct in social service
agencies. A threat to the mental health of Puerto Rican
lesbians. In Lesbians of color: Social and human services (pp.
23-42). New York: Haworth.
40 LATINOS AND LATINAS: OVERVIEW
Immigration Policy Center. (2007). The myth of immigrant
criminality and the paradox of assimilation: Incarceration
rates among native- and foreign-born men. Retrieved April 25,
2007, from http://www.ailf.org/ipc/special_report/pr_
feb07.html.
Keysar, A., Kosmin, B. A., & Mayer, E. (2001). Religious
identification among Hispanics in the United States. Unpublished
manuscript, The Graduate Center of the City University of
New York and Brooklyn College, NY. Retrieved May 1,
2007, from http://depthome.brooklyn.cuny.edu/risc/
ARISHispanicfinal%20DecI12002.pdf.
Kochhar, R. (2006, September). Latino Labor Report, 2006:
Strong gains in employment. Retrieved April 25, 2007, from
http://pewhispanic.org/files/reports/70.pdf.
Lee; S. M., & Edmonston, B. (2005, June). New marriages, new
families: U.S. racial and Hispanic intermarriage. Population
Bulletin, 60(2). Retrieved April 25, 2007, from
https://www.prb.org(femplate.cfmlSection=PRB&template=
/Content/ContentGroups/Population_Bulletin/N ew _Marri
ages,_New _Families_ U _S_Racial_and_Hispanic_Inter
marriage.htm.
Logan, J. (2003, July). How race counts for Hispanic Americans.
University of Albany, Lewis Mumford Center for
Comparative Urban and Regional Research. Retrieved
October 30, 2007, from Educational Resources Information
Center, ED479962, http://www.eric.ed.gov/ERICDocs/data/
ericdocs2sql/content_storage_ 01/0000019b/80/1 b/55
/be.pdf.
Marsiglia, F. F. (1998). Homosexuality and Latinos/as: Toward an
integration of identities. Journal of Gay and Lesbian Social
Services, 10(4), 1-18.
Massey, D. S. (1995). The new immigration and ethnicity in the
United States. Population and Development Review,
26(4),631-652.
Massey, D. S., & Denton, N. A. (1992). Racial identity and the
spatial assimilation of Mexicans in the United States. Social
Science Research, 21, 235-260.
Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, W. c., &
LaFromboise, T. (2005). State of the science on psychosocial
interventions for ethnic minorities. Annual Review of Clinical
Psychology, 1, 113-142.
Molloy, S., & McKee-Irwin, R. (1998). Hispanisms and homo-
sexualities. Durham, NC: Duke University Press.
Montalvo, F. F. (1991). Phenotyping, acculturation, and biracial
assimilation of Mexican Americans. In M. Sotomayor (Ed.),
Empowering Hispanic families: A critical issue for the '90s (pp.
97-120). Milwaukee, WI: Family Service of America.
Murray, S. O. (1987). The family as an obstacle to the growth of a
gay subculture in Latin America. In S. O. Murray (Ed.), Male
hamosexuality in Central and South America (pp, 118-129). New
York: Gay Academic Union.
National Implementation Research Network, the Louis de la Parte
Florida Mental Health Institute. (2003). Consensus statement
on evidence based programs and cultural competence. Tampa,
FL. Retrieved April 10, 2007, from: http://www
.epp.networkofcare.org/uploads/Consensus 6230512.pdf.
NPR/Kaiser Family Foundation/Kennedy School, Harvard
University. (2004). Immigration In America Survey 2004.
Retrieved April 27, 2007, from http://www.npr.org/tem
plates/story/story.php ?storyId =4062605.
Organista, K. C. (2000). Cognitive-behavioral group psycho-
therapy with Latinos. In A. Freeman & J. R. White (Eds.),
Handbook of group cognitive behavioral psychotherapy (pp.
281-303). Washington, OC: American Psychological
Association.
Paral, P., Siciliano, D., Johnson, B., Ewing, W., & Chittendon, H.
(2005, November). Economic growth and immigration: . Bridging
the demographic divide. Immigration Policy Center. Retrieved
April 24, 2007, from http://www .ailf.org/ipc/ speciaLreport/2005
_bridging. pdf.
Passel, J. S. (2006). Size and characteristics of the unauthorized .
migrant population in the U.S.: Estimates based on March
2005 Current Population Survey. Retrieved April 25, 2007,
from http://pewhispanic.org/files/reports/61.pdf.
Passel, J. S., & Suro, R. (2005). Rise, peak and decline: Tr~nds in
U.S. immigration 1992-2004. Retrieved April 23, 2007, from
http://pewhispanic.org/files/reports/53 .pdf.
Perl, P., Greely, J. Z., & Gray, M. M. (2006). What proportion of
adult Hispanics are Catholic? A review of survey data and
methodology. Journal for the Scientific Study of Religion, 45,
419-436.
Pew Hispanic Center. (2002). Educational attainment: Better than
meets the eye, but large challenges remain. Retrieved April 22,
2007, from http://pewhispanic.org/factsheets/factsheet.php
?FactsheetlD= 3.
Pew Hispanic Center. (2006, June). Hispanic attitudes toward
leaning English: Fact Sheet. Retrieved April 15, 2007, from
http://pewhispanic.org/files/factsheets/20.pdf.
Pew Hispanic Center. (2007, March). Construction jobs expand
for Latinos despite slump in housing market: Fact sheet.
Retrieved April 25, 2007, from http://pewhispanic.
org/files/factsheets/28. pdf.
Portes, A. (2004, February). The new Latino nation: Imrriigration
and the Hispanic population in the United States. The Center
for Migration and Development: Work!ng Paper 04-02.
Princeton, NJ: Princeton University.
Raijman, R., & Tienda, M. (1999). Immigrants' socioeconomic
progress post-1965: Forging mobility or survival. In C.
Hirschman, P. Kasinitz, & J. De Wind (Eds.), The handbook of
international migration: The American experience (pp. 239-256).
New York: Russell Sage Foundation.
Ramirez, R. R. (2004). We the people: Hispanics in the United
States. Census 2000 Special Report. Retrieved April 4, 2007,
from http://www .census.gov/prod/2004pubs/censr -18.pdf.
Ramos, J. (Ed.). (2004). Compaiieras: Latina Lesbians (An Anthology)
(3rd ed.). Latina Lesbian History Project, New York. New
York: Routledge, Chapman and Hall.
Rivera, H. P. (2002). Developing collaborations between child
welfare agencies and Latino communities. Child Welfare, 81,
371-384.
Roque-Ramirez, H. N. (2005). Latina/Latino Americans. In
GLBTQ: Encyclopedia of gay, lesbian, bisexual, transgender
and queer culture. Retrieved October 29, 2007, from

http://www.glbtq.com/social-sciences/latina_latino_americans
. development of the U.S.-Mexico border region from
html. .
Rodriguez, C. (1985). Puerto Ricans: Born in the USA. Boston:
Unwin Hyman.
Rubio-Goldsmith, R. M., McCormick, M., Martinez, D., &
Duarte; I. M. (2007). A Humanitarian crisis at the border:
New estimates of deaths among unauthorized immigrants.
Immigration Policy Center. Retrieved April 23, 2007, from
http://www.ailf.orgfipc/policybrief/policybrieC020607.shtml .
Rumbaut, R. G. (2005). Turning points in the transition to
adulthood: Determinants of educational attainment, incar-
ceration, and early childbearing among children of immi-
grants. Ethnic and Racial Studies, 28, 1041-1086. .
Santiago-Rivera, A. (2003, February). Latino values and family
transition: Practical considerations for counseling. Counseling
and Human Development, 5, 'pp, 1, 4-18. http://
findarticles.com/p/articles/mi~qa3934/is_200302/aCn919834
2.
Scherer, M. (2003, January/February). Census confusion: Have
Hispanics surpassed Blacks as the largest minority in Amer-
ica? Columbia Journalism Review. Retrieved May 1, 2007, from
http://www.projectrace.com/inthenews/archive/inthenews-On
703 .php.
Schraufnagel, T. J., Wagner, A. W., Miranda, J., & Roy-Byrne, P.
P. (2006). Treating minority patients with depression and
anxiety: What does the evidence tell use? General Hospital
Pyschiatry, 28, 27-36.
Suro, R., & Singer, A. (2002). Latino growth in metropolitan
America: Changing patterns, new locations. The Brookings
Institution, Survey Series, Census 2000. Retrieved April 13,
2007, from http://www.brookings.edu/metro/publications/
surosingerexsum.htm.
Suro, F., Escobar, G., Livingstone, G., & Hakirnzadeh, S. (2007).
Changing faiths: Latinos and the transformation of American
religion. Pew Forum on Religion and Public Life .. Retrieved
May 3, 2007, from http://pewhispanic.orgf reports/report.php
?ReportlD= 75.
Tafoya, S. (2003). Latinos and racial identification in California.
California Counts: Population Trends and Profiles, 4(4), 1-15.
Retrieved May 3, 2007, from http://www.ppic.
org/content/pubs/cacounts/CC _503STCC.pdf.
Tafoya, S. (2004, December). Shades of belonging. Retrieved
May 3, 2007, from http://pewhispanic.org/reports/report.
php?ReportID=35.
U.S. Department of Health and Human Services. (2002).
AFCARS, Report 8. Washington, DC: Author.
Vasquez, C. (2005, Summer). An interview with Dr. Carmen
Vasquez. Salwi Mental, 1(3), pp. 1, 18-22. http://www.
mhnews-latino.org/back_issues/saludsummer 2005 .pdf,
Vega, W., & Alegria, M. (200l). Latino mental health and
treatment in the United States. In M. Aguirre-Melina, C.
Molina, & R. Zambrana (Eds.), Health issues in the Latino
commu7!ity (pp. 179-208). New York: jessey-Bass.
Vega, W. A., Kolody, B., Aguilar-Gaxiola, S., Alderete, E.,
Catalano, R., & Caraveo-Anduaga, J. (1998). Lifetime pre-
valence of DSM-III-R psychiatric disorders among urban and
rural Mexican Americans in California. Archives of General
Psychiatry, 55, 771-778.
LATINOS AND LATINAS:.PRAcrICE INTERVENTIONS 41
Weaver, T. (200l). Time, space and articulation in the economic
1940-2000. Human Organization, 60(2). Retrieved April 24,
2007, from http://findarticles.com/p/articles/
mi_qa3800/is_200107/ai_n8955786.
Wolfe, E. (959). Sons of the shaking earth. Chicago: University of
Chicago Press.
Zamora-Hernandez, C. E., & Patterson, D. G. (1996). Homo-
sexually active Latino men: Issues for social work practice.
Journal of Gay and Lesbian Social Services, 5, 69-92.
Zhang, A. Y., & Snowden, L. R. (1999). Ethnic characteristics of
mental disorders in five U.S. communities. Cultural Diversity &
Ethnic Minority Psychology, 5,134-146.
SUGGESTED LINKS Immigration Policy Center.
http://search.comcast. net/? q=immigration+policy
+center&cat=Web&con=net&x=22&y=7
Pew Hispanic Research Center.
http://pewhispanic . org/
-JOHN F. LONGRES AND EUGENE AISENBERG
PRACTICE INTERVENTIONS
ABSTRACT: Latinos are a heterogeneous and highly
complex population that presents the profession with one
of the greatest challenges in understanding diversity and
what constitutes culturally and linguistically competent
social work interventions. At this point in history, Latinos
are the fastest growing racial and ethnic group in the
United States. This has given rise to strong
anti-immigration sentiment, English only legislation, and
increased discrimination and racism, which Latino'
newcomers must contend with upon arrival in the United
States. Social workers need to work to reduce both
external and internal institutional barriers to service
delivery for Latinos.while responding effectively to their
interpersonal and familial needs.
KEY WORDS: Latinos or Hispanics; health and mental
health services; immigrant services; culturally competent
practice
Hispanics have in common a historical connection with
Spain and the Spanish language, but this connection is
filtered through the proud heritage of separate
heterogeneous nations. It is only as people from these
groups have become part of the U.S. that the need has
arisen for a general term to describe them, as such, we
may be witnessing the emergence of a new ethnic group
unique to the U.S. (Longres, Social Work Encyclopedia,
1995, p. 1214)
42 LATINOS AND LATINAS: PRACTICE INTERVENTIONS
Since the NASW Code of Ethics was revised in 1996,
social workers have had an ethical responsibility to address
diversity and provide clients with culturally competent
services. As the fastest growing racial or ethnic population
in the United States, Latinos are a heterogeneous and
highly complex population that presents the profession
with one of the greatest challenges in understanding
diversity and what constitutes culturally and linguistically
competent social work interventions. Cultural sensitivity
and selfawareness have long been the hallmarks o f social
work practice; essential first steps in developing
relationships with diverse clients. However, the diversity
that exists within the Latino community requires that
Latino and non-Latino social workers gain an appreciation
of the range of experiences that Latino clients bring to the
social work relationship. This range includes varying
geographic and cultural backgrounds, historical and
political experiences, ages and developmental stages,
mental and physical abilities, social and class status,
religious and spiritual beliefs, gender roles and sexual
orientations, and racial and ethnic identities. Under the
umbrella label of Hispanic or Latino are 19 countries of
origin and a global diaspora of the Latino community.
Depending upon the geographic region in which social
workers practice, the majority of Latino clients will be of
Mexican descent as well as of Puerto Rican, Cuban, and
Dominican origin or from any other Central and South
American nation. Furthermore, when Latinos arrive in the
United States is a significant factor in the assessment of
service needs. A majority of the 40 million Latinos
residing in the United States have documented status for
multiple generations. Mexican Americans may have an
ancestry in the United States that dates back over 400
years. Some Mexicans are more identified with indigenous
people than with their Spanish ancestry. Puerto Ricans
have been citizens of the United States since 1917. Cuban
Americans have been refugees since 1959. According to
the Pew Hispanic Center, there have been dramatic shifts
in Latino immigration in recent years. Globalization,
political upheavals, wars, genocide, and famine are fueling
the rise in undocumented Latino immigration to the United
States. This has given rise to strong anti-immig ration
sentiment, English only legislation, and increased dis-
crimination and racism, which Latino newcomers must
contend with upon arrival in the United States. All of these
factors are important aspects for s~cial workers to assess
and address in their work with Latino clients.
Latinos need skilled and knowledgeable social work
interventions that begin with comprehensive histories,
broad assessment of needs, and a plan of action with
immediate and long-range steps. Recent literature
attests to the fact that many contemporary social work
approaches are not as effective with Latino cli ents
(Gonzalez & Gonzalez-Ramos, 2005; Rosenberg,
Gonzalez, & Rosenberg, 2005; Torres & Rivera, 2002).
One example frequently cited is that evidence-based
practice is not the treatment approach of choice for most
Latino clients. Social work practice research is needed to
"understand the ways in which Hispanic culture serves as a
protective factor, and why it seems that accultura tion
places Hispanics at higher risk for mental health
problems" (Gonzalez & Gonzalez-Ramos, 2005, p. 7).
Social workers face the challenge of developing cultu rally
and linguistically effective treatment approaches that meet
the specific needs of specific Latino' clients facing
multiple stressors and environmental problems (Congress
& Kung, 2005). In addition to cornmunijybased
organizations, social workers may need to work out of
storefront churches, bodegas or delis, and beauty parlors
where Latinos tum to natural helpers for immedi ate
assistance on a daily basis (Delgado, 1998).
There are some striking disparities in social service
utilization by Latinos who are overrepresented in criminal
justice, juvenile delinquency, child welfare, and public
welfare programs, but have historically underutilized
conventional health and mental health care services. Some
of this disparity may be attributed to cultural factors such
as discomfort with traditional treatment approaches, but
other institutional barriers such as a lack of understanding
of Latino mental health needs and the lack of bilingual or
bicultural health care providers directly impact on service
utilization. For instance, health and mental health
professionals need to understand and include alternative
help-seeking behaviors that employ espiritistas, santeros,
or curanderos as valid folk medicine resources. In addition,
social workers are becoming more aware of the
interrelationship between family violence, pov erty,
substance use, criminal justice, and child maltreatment;
meaning that you often cannot address one problem
without recognizing the convergence of other stressors and
needs (Ortiz Hendricks & Fong, 2006). However, available
research on child well-being and Latino families is scarce
despite the disproportionate numbers of Latinos receiving
child welfare services. Overall, the Latino child foster care
population has almost doubled from 8% in 1990 to 15% as
of September 2002 (Suleiman, 2003), and even this figure
is considered an underestimate of the number of Latino
children in the system. Latino issues are often ignored
within the context of child welfare policy discussions on
national, state, and local levels, which has resulted in a
tremendous gap in research, policy, and programs that can
effectively address the needs of Latino families and child
well-being.

At the National Congress for Hispanic Mental Health
(2000), it was reported that in a psychiatric
epidemiological study (Vega et al., 1999) conducted with
over 3,000 Mexican Americans in California, Mexican
immigrants had considerably lower lifetime prevalence
rates of major mental disorders than did U.S.-born
Mexican Americans (24.9% versus 48.1 %), which
suggests that the health and mental health well ness of
Hispanics decreases as they acculturate to the U.s. way of
life. This contradicts what most social scientists believe is
healthy about acculturation. In a nationwide study by the
Center for Disease Control (Kann et al., 2000), Latino
youth had proportionately more suicidal ideation and
specific suicidal attempts than Whites or Blacks.
Twenty-three percent of Latinos considered the possibility
of suicide and 10% reported having attempted suicide. In
the same study, less than 9% of Latinos contacted mental
health care specialists, and less than 18% contacted health
care providers. The problem is even more severe for
Mexican immigrants, with less than 5% using mental
health services and less than 11 % using general health
care providers.
A recent study by the New York City Department of
Health and Mental Hygiene (2003) uncovered th e fact that
57% of referrals for outpatient mental health clinic
services for children in the Bronx do not lead to treatment.
The study findings highlighted the severity and
complexity of the mental health problems presented by
children compared with the extended average wait for
services and the attrition rate for children prior to receiving
any treatment or services. This study depicts "a system that
is not meeting the needs of children who are presenting for
outpatient mental health clinic services in the Bronx"
(Engstrom et al., 2003, p. 2). In addition, clinic capacity
was at maximum suggesting the need for expanded mental
health services in the Bronx. Thirty-seven percent of the
clinics participating in this study had clinical staff whose
bilingual ability was inadequate to serve Spanish-speaking
parents and guardians. Although Latinos account for over
13% of the total U.S. population, they comprise only 4.6%
of physicians, 4% of psychologists, 7% of social workers,
and 2.4% of nurses (Institute of Medicine, 2004). "The
majority of psychologists and social workers in the nation,
who are the primary care providers in both the mental
health and substance abuse fields, in 1998, were
non-Hispanic whites, 84% and 65% respectively" (Na-
tional Hispanic-Latino American Agenda Summit
[NHAAS], 2004, p. 7).
Access and barriers to health and mental health care for
Latinos can be examined from three dimen sions: primary
access is defined as having health insurance; secondary
access is defined as having health
LATINOS AND LATINAS: I'RAcrICE INTERVENTIONS 43
insurance but facing institutional and structural barriers;
and tertiary access looks at persons who have health
insurance, make medical appointments but face lin guistic
and cultural barriers to care (Carrillo, Trevino, Betancourt,
& Coustasse, 2001). Social workers need to work to reduce
both external and internal institutional barriers to service
delivery for Latinos. The external barriers that impinge on
utilization of services by Latinos include financial or cost
considerations, lack of health insurance, geographic
location, language accessibility, and the need for culturally
competent services. Racism and ethnic discrimination also
contribute to health care bias at a conscious, unconscious,
individual and institutional level (Geiger, 2003). The
Institute of Medicine (2003) found that health care
practitioners' attitudes, both conscious and unconscious,
including their prejudices, stereotypes, and clinical
uncertainties were major factors contributing to health care
disparities. Latinos have many misconceptions about
help-seeking approaches or a lack of knowledge of the
helping professions. They have traditionally held strong
doubts that health and mental health service s really help
people, and they still fear the stigma and external controls
imposed bythese services. Other risks include socioeco-
nomic factors, lifestyle choices and behaviors, and poor
nutrition. The protective factors include resiliency and
strengths of Latino communities, and the importance of
social relations in maintaining emotional health and
dealing with acculturative stress. When community mental
health services are provided in culturally competent
agencies and by culturally and linguistically competent
professionals, Latinos are more likely to use them and
remain in treatment.
Addressing health and mental health disparities may be
as important to the health and well-being of Latino
communities as treating serious psychiatric dis orders.
Advocacy and empowerment skills in working with Latino
communities are as essential as clinical interventions with
individuals, pairs, families, and groups. Social workers
have a role in increasing diversity within the health and
mental health workforce by recruiting more Latinos and
culturally and linguistically competent health care
providers. It is a national crisis for the Latino community
when there are 29' Hispanic mental health professionals for
every 100,000 Hispanics, and 37% of Hispanics in the"
United States are uninsured (Arias, 2003).
Since Spanish is the single most important unifying
factor among all Latino ethnic groups, social workers need
to look at their own linguistic competencies in this area.
Most Latinos speak Spanish at home, and Spanish is the
most common language spoken by those with limited
English proficiency surpassing the total of
44 LATINOS AND LATINAS: PRACTICE INTERVENTIONS
all other languages combined. "Pressure to implement plans to
boost access to services for Spanish-speaking recipients is
expected soon from the federal government under Executive
Order 13166. The order's purpose, based on Title VI of the
Civil Rights Act of 1964, is to ensure that people with limited
English proficiency receive assistance in a uniform and
consistent manner" (O'Neil, 2003, p. 4). Social agencies will
be required to provide more specialized services for those
with a limited understanding of English. These will include
increased bilingual or bicultural staff, multilingualtelephone
hotlines and clearinghouses, interpreter services, Spanish and
other language Web sites, and translations of hard-copy
materials.
In most major cities of the UniteclStates, Latinos can live
in Spanish-dominant, \ethnic enclaves where they can work,
shop, or go to church and school in predominantly
Spanish-speaking neighborhoods. The news and radio and
television media also cater to a Spanishspeaking population
with Spanish newspapers and programming. Moreover,
Latinos maintain Spanish as a strength and cultural response
to too much "Americanization," and a counterbalance to
oppressive conditions and historical trauma associated with
lifelong experiences of exploitation and colonization both in
the country of origin and in the United States. Social workers
can best help Latino clients by encouraging them to acquire
English language skills while demonstrating respect for the
important role that Spanish plays in their lives. Social workers
working primarily with limited Englishspeaking Latino
clients should feel an obligation to speak Spanish to avoid the
use of interpreters, and to most effectively communicate with
clients ..
The implications of under utilization of health and mental
health services in the face of great need require a
reexamination of professional educational requirements for
health and mental health practitioners along with
reaccreditation and licensing standards that seek to improve
the quality of health and mental health services for all patients.
Social work education and training is needed to prepare social
workers for the growing demands for services among Latinos.
Social work programs and agencies serving predominantly
Spanish-speaking clients need to require curricula that support
culturally competent practice and research with Latinos. They
need to do more to recruit Latinos into BSW, MSW, and PhD
programs, and to require students and staff to speak the
language of their clients. Social work leadership and support
for the areas discussed in this section on intervention with
Latino clients is a necessary and ongoing aspect in the
development of culturally and linguistically competent social
work practice.
REFERENCES
Arias, S. (2003, November 8). Creating culturally competent
mental health systems for Hispanics. Presentation by the
Executive Director, National Association for the Mentally IU, at the
Somas El Futuro Conference, San Juan, Puerto Rico, November
8,2003.
Carrillo, J. E., Trevino, F. M., Betancourt, J. R., & Coustasse, A.
(2001). Latino access to health care: The role of insurance,
managed care, and institutional barriers. In M.
Aguirre-Melina, C. Molina, & R. E. Zambrana (Eds.), Health
issues in the Latino community. San Francisco, CA: jessey-Bass.
Congress, E. P., & Kung, W. W. (2005). Using the culturagram to
assess and empower culturally diverse families. In E. P.
Congress & M. J. Gonzalez (Eds.), Multicultural perspectives in
working with families (2nd ed., pp. 3-21). New York:
Springer.
Delgado, M. (1998). Puerto Rican elders and merchant estab-
lishments: Natural caregiving systems or simply businesses?
In M. Delgado (Ed.], Latino elders and the twenty-first century:
Issues and challenges for culturally competent research and practice
(pp. 33--46). New York: Haworth Press.
Engstrom, M., Harrison, M., Lee, R., McVeigh, K., & Ross, R.
(2003, August). Children's mental health needs assessment in the
Bronx. New York: New York City Department of Health and
Mental Hygiene, Division of Mental Hygiene, Bureau of
Planning Evaluation and Quality Improvement.
Geiger, H. J. (2003). Racial and ethnic disparities in diagnosis and
treatment: A review of the evidence and a consideration of
causes. In B. D. Smedley, A. Y. Stith, & A. R. Nelson (Eds.),
Unequal treatment: Confronting racial and ethnic disparities in
healthcare. Washington, OC: Institute of Medicine, The
National Academy Press.
Gonzalez, M. J., & Gonzalez-Ramos, G. (Eds.). (2005). Mental
health care for new Hispanic immigrants: Innovative approaches in
contemporary clinical practice. New York: The Haworth Social
Work Practice Press (co-published simultaneously in Journal
of Immigrant & Refugee Services, Vol. 3, nos. 1/2,2004).
Institute of Medicine. (2003). Unequal treatment: Confronting racial
and ethnic disparities in healthcare. Washington, OC:
The National Academy Press.
Institute of Medicine. (2004, February). Report urges diversity in
health jobs. Retrieved February 20, 2004, from http://www.
iom.edu. .
Kann, L., Kinchen, S. A., Williams, B. 1., Ross, J. G., Lowry, R.,
Grunbaum, J. A., & Kolbe, L. J. (2000). Youth risk behavior
surveillance-United States, 1999. MMWR, 49(5), pp. 1-32.
National Hispanic-Latino American Agenda Summit (NHAAS).
(2004, July 13). Mental Health Issues Platform and Issues
Committee. Final Committee Report (pp. 1-38). New York:
Author.
O'Neill, J. V. (2003, June). Services in Spanish unavailable to
many: Agencies ill-prepared as population grows. NASW
News, p. 4.
Ortiz Hendricks, C, & Fong, R. (2006). Ethnically sensitive
practice with children and families. In N. Boyd Webb (Ed.),

Working with traumatized youth in child welfare (pp. 135-154).
New York: Guilford Press. 'c
Rosenberg, ]., Gonzalez, M. j, & Rosenberg, S. (2005). Clinical
practice with immigrants and refugees: An ethnographic
multicultural approach. In E. P. Congress & M. ]. Gonzalez
(Eds.), Multicultural perspectives in working with families (2nd ed.,
pp. 145-166). New York: Springer.
Suleiman, L. P. (2003). Hispanic children in foster care: State by state
analysis of 1999 AFCARS data. In Creating a Hispanic child welfare
agenda: A strategic framework for change. Unpublished
manuscript. New York: The Committee for Hispanic Children
& Families.
Torres, ]. B., & Rivera, F. G. (Eds.). (2002). Latino/Hispanic
Liaisons and Visions for Human Behavior in the Social Environment.
New York: The Haworth Social Work Practice Press.
Vega, W. A., Kolody, B., Aguilar-Gaxiola, S., & Catalano, R.
(1999). Gaps in service utilization by Mexian Americans with
mental health problems. The American Journal of Psych iatry,
156,928-934.
-CARMEN ORTIZ HENDRICKS
CuBANS'
ABSTRACT: In 2004, an estimated 1,614,000 individ-
uals of Cuban origin were residing in the United
States, placing Cubans as the third largest Hispanic
ethnic group in the United States, constituting "'-'4%
of the nation's Hispanic population. 84.1% of the
CubanAmerican population is concentrated in four
states:
Florida (67.1%), New Jersey (6.2%), California (5.8%),
and New York (5.0%). Although Cuban immigration to
the United States dates back to the mid1800s, 68.5% of
Cuban Americans are foreign-born and, as a group,
represent a wide spectrum of social realities and
political interests.
KEY WORDS: Cuban; refugee; immigrant; Cuban-
American
In 2004, an estimated 1,614,000 individuals of Cuban
origin were residing in the United States, placing
Cubans as the third largest Hispanic ethnic group in the
United States, comprising "'-'4% of the nation's
Hispanic population. 84.1% of the Cuban American
population is concentrated in four states: Florida (67.1
%), New Jersey (6.2%), California (5.8%), and New
York (5.0%). Although Cuban immigration to the
United States dates back to the mid-1800s, 68.5% of
Cuban Americans are foreign-born and, as a group,
represent a wide spectrum of social realities and politi-
cal interests (U.S. Census Bureau, 2004a, 2004b,
2004c).
LATINOS AND LATINAS: CuBANS 45
History and International Connections
The island of Cuba, 90 miles offthe coast of Florida, has
long been a focus of U.S. economic and political inter-
est. From the early 1880s through the mid-1900s, the
economic and political destiny of Cuba was tied to the
United States. Although the United States had long
developed foreign policy which intentionally manipu-
lated nationalist movements in Cuba advocating libera-
tion from Spain, in 1898 the United States directly
intervened in Cuba's War of Independence by sending
in American naval and military forces and declaring
war on Spain, which quickly culminated in a Spanish
surrender. That same year the Treaty of Paris was
signed between Spain and the United States,
terminating Spain's rights to Cuba and acknowledging
Cuban independence. The United States occupied Cuba
after the war until 1902, during which time it drafted the
Platt Amendment, providing the guideline for future
U.S.-Cuban relations. Despite considerable Cuban re-
sistance, these articles became a part of the 1902 Cuban
Constitution and entitled the United States to intervene
in Cuban affairs to protect U.S. investments and to
establish a military base at Guantanamo. The
amendment was abrogated in 1934, yet the United
States continued to wield economic and political control
of the island nation until 1959.
January 1, 1959, marked the overthrow of Fulgencio
Batista by the Movimiento 26 de Julio, the revolutionary
organization led by Fidel Castro. In the first months and
years of the new government, sweeping changes were
made, including the passage of the Agrarian Reform
Law in May, 1959, which expropriated farm acreage
over ·1,000 acres and forbade foreign land ownership,
the nationalization of U.S.- and foreign-owned proper-
ties, and the resumption of diplomatic relations between
Cuba and the Soviet Union. The United States
responded with similar dramatic actions that included
the imposition of an economic blockade on Cuba, the
severing of diplomatic relations, and the execution of a
U.Sc-supported Cuban exile invasion at the Bay of Pigs.
Prior to the Revolution, the Cuban economy was
highly dependant on its market relationship with the
United States, which accounted for 60% of its exports
and 80% of its imports (Poyo, 1989). The economic
blockade devastated the Cuban economy by freezing all
Cuban bank accounts in the United States and prohi-
biting U.S. citizens from spending money in Cuba or
doing business with any Cuban firm in foreign nations,
U.S. trade with any company that contained Cuban
components, U.S. firms abroad from conducting busi-
ness with Cuba, international financial institutions from
extending credit to Cuba, and foreign nations from
using U.S. dollars with Cuba. The economic
46 LATINOS AND LATINAS: CuBANS
embargo created conditions that required Cuba to re-
structure its economic development and foreign trade
strategy, inevitably leading the nation to form an alli-
ance with the Soviet Union and to become a member of
the Socialist-based Council for Mutual Economic As,
sistance (Nackerud, Springer, Larrison, & Issac, 1999).
U.S. policy toward Cuba continues to be defined by the
embargo, despite periodic initiatives toward improving
relations between the two countries and the collapse of
the Soviet Union in 1991.
Immigration .History and Trends Immigration
to the United States before the Cuban Revolution of 1959
was small, amounting to probably less than 50,000 and
centered in Key West and Ibor Citv/Tarnpa, Florida, and
New York City. This early Cuban immigration established
Tampa as a major center for the Cuban cigar industry and
New York as a hub for Cuban emigre organizing in support
of the indepen-
dence movement (Gallagher, 1980).
. brought 55 young Cubans to their homeland in
The majority of Cuban immigration to the United
States has occurred since the Cuban Revolution of 1959
in waves that have reflected the changing sociopolitical
circumstances and relations between Cuba and the
United States. The first major postrevolutionary wave of
Cuban immigration began in January 1959 and ended in
October 1962 with the Missile Crisis. During the early
revolutionary period, exodus through the U.S. Embassy
and the Santiago de Cuba Consulate could be secured
with little difficulty. However, on January 31, 1961, the
United States broke diplomatic relations with Cuba,
making departure for the States more difficult, except
for children aged 6-16 years. For this group, an
exception was made by the United States that marked
the beginning of a flow of over 14,000 unaccompanied
children into the United States through Operation Pedro
Pan. An estimated 240,285 Cubans immigrated to the
United States during this period (Boswell, 1984;
Masud-Piloto, 1996).
The second wave began with the Missile Crisis and
concluded with the opening of the Port of Camarioca in
September 1965. The Missile Crisis led to a termina tion
of regular flights and communication between Cuba and
the United States. Consequently, most Cubans leaving
for the States after that time traveled by way of a third
country, usually Mexico or Spain, or clandestinely by
boat or plane. Approximately 29,962 Cubans came to
the United States during this period (Boswell, 1984;
Masud-Piloto, 1996).
On September 25,1965, Castro announced that the
Port of Camarioca would be opened to all Cubans in the
United States desiring to pickup any family members
remaining in Cuba who wished to join them stateside,
beginning the third and largest wave of immigration.
Three months later a Memorandum of Understanding
was signed between the Johnson and Castro adminis-
trations, commencing the "freedom flights" or "aerial
bridge" between Varadero Beach and Miami. These
flights continued until April 1973, when the Cuban
government suspended· emigration. An estimated
303,798 Cubans came to the States during this period
(Boswell, 1984; Masud-Piloto, 1996).
The fourth wave stretched from April 1973 to
September 1978. With restrictions on emigration and
without the airlift, the number of Cubans coming to the
United States dropped to ,,-,35,000 during this period.
Most Cubans coming to the United States during this
wave came via Spain, with difficulty and delay (Azicri,
1981-1982; Diaz-Briquetes & Perez, 1981).
The fifth wave, occurring from October 1978 to
April 1980, was closely connected to the Havana dia-
logues. On September 28, 1978, the Cuban government
issued an invitation to Cubans abroad to return to
dialogue with their island nationals. The first dialogue
December 1977 and another 275 over the summers of
1979 and 1980. Three of the major issues addressed in
the dialogue were the status of political prisoners, re-
unification of families, and the opportunity for Cubans
living abroad to visit the island. These talks were
largely responsible for the ability of many Cubans sub,
sequently to return to Cuba for visits and for the release
of many political prisoners. During this stage 16,642
Cubans, mostly former political prisoners and their
immediate family members, immigrated to the United
States (Azicri, 1981-82; Bach, 1987).
The sixth wave of immigration occurred over a
5-month period in 1980, brining more than 125,000
Cubans to the United States. The Cuban economic
slump beginning in the late 1970s and the family ties
rekindled by the return visits of Cubans living abroad
precipitated this exodus. It began with a number of
Cubans approaching the Peruvian Embassy for political
asylum and within a matter of days, a rush on the
embassy ensued. In response, the Cuban government
issued open permission to all those desiring to leave the
island to do so by boat through the Port of Mariel. The
United States was flooded with over 125,000 more
individuals, who were reluctantly accepted. However,
unlike previous waves, refugee status was not
automatic and it was not granted until the 1984 Cuban
Adjustment Act (Pedraza, 1996).
The most recent wave of Cuban immigration,
known as the Balsero (Rafter) Crisis, occurred in 1994. It
was rooted in the economic downturn of the Cuban
economy resulting from the collapse of the Soviet

Union in 1991, the subsequent loss of over $8 billion in annual
Soviet subsidies and the continued financial squeeze of the
blockade, paired with the US. open door policy toward
Cubans. Following a riot in Havana, Fidel Castro gave orders
to border guards not to discourage vessels attempting to leave
Cuba. The new U.S. policy was a departure from the previous
open door policy, as it (a) repealed the Cuban Adjustment Act
of 1966, which granted legal status to Cuban refugees; (b)
limited the annual number of visas for Cuba to a maximum of
20,000; (c) legalized the return of Cubans intercepted at sea;
(d) eliminated the indefinite detention of the more than 28,000
intercepted Cubans that were being held at the U.S. Naval
Base in Guantanamo Bay; (e) put severe restrictions on travel
to Cuba; and (f) prohibited the sending of economic re-
mittances to Cuba (Nackerud et al., 1999).
Community Demographics:
Trends and Directions
As the sociopolitical circumstances of each wave varied, so did
the socioeconomic status of Cubans immigrating during each
period. While the upper class strata of the island population
were overrepresented in the initial waves, each subsequent
wave has reflected a continuation of a downward class trend of
emigres (Pedraza, 1996). As a result of the varied waves of
migration, all sectors of Cuban society are represented in the
United States today.
The majority of Cubans (68.5%) are foreign-born, with a
median age of 40.3 years. Eighty-six percent of Cubans over
the age of 5 report speaking Spanish at. home and 45.9%
indicate that they speak English less than "very well" (US.
Census Bureau, 2004b). Despite the majority immigrant
composition of the Cuban American community, several
socioeconomic indicators suggest that Cuban Americans, as a
group, have achieved considerable structural integration in the
United States. For example, the 2000 Census indicated that
Cubans had a relatively low poverty rate and higher levels of
educational achievement, household income, rates of home
ownership, and political participation when compared with
other Hispanic groups (U .S. Census Bureau, 2004b). More
specifically, among Cubans aged 25 years or older, 62.9% had
completed high school and 21.2% had obtained a Bachelor's
degree or more, in contrast to 52.4 and 10.4%, respectively, for
the Hispanic population as a whole. The median family income
for Cubans in 1999 was $42,642, a figure $8,245 above that of
the Hispanic population, and the poverty rate was 14.6 and
22.6%, respectively, for Cubans and all Hispanics.
Furthermore, Cuban households were more likely to live in
owner-occupied
LATINOS AND LATINAS: CuBANS 47
housing (57.6%) than were Hispanics as a whole (45.7%);
they had the highest rate of naturalization of all Hispanic
groups (41.4%); and they were significantly more likely to
register and tum out to vote than other Hispanics (Jackson,
2003; U.S. Census Bureau, 2004b).
While there is considerable controversy regarding the
extent and factors contributing to Cuban structural
incorporation in the United States, it is certain that these issues
have dominated the literature concerning this immigrant
group. Human capital and selective migration, state support
through the Cuban Refugee Program, the development of an
ethnic economic enclave, and the household organization of
Cubans have all been credited for the relative structural
integration of Cubans (Pedraza-Baily, 1985; Perez, 1986;
Portes & Bach, 1985). Clearly, the open door policy, welcome
reception, and generous supports of the Cuban Refugee
Program offered to previous waves of Cuban immigration
have encouraged Cuban migration to the United States and
subsequent structural incorporation. With the end of Cuban
exceptionalism within US. immigration policy following the
Balsero Crisis, the future of Cuban immigration continues to
be shaped by the socioeconomic and political conditions in
and between
sending and receiving states. '
REFERENCES
Azicri, M. (1981-82). The politics of exile: Trends and dynamics of
political change among Cuban-Americans. CubanStudies/Estudios
Ctibanos, 11/12,55-73.
Bach, R. L. (1987). The Cuban exodus: Political and economic
motivations. In B. B. Levine (Ed.), The Caribbean exodus (pp.
106-130). New York: Praeger.
Boswell, T. D. (1984). The Cuban experience: Culture, images,
and perspectives. Totowa, NJ: Rowman and Allenheld.
Diaz-Briquetes, S., & Perez, L. (1981). Cuba: The demography of a
revolution. Population Bulletin, 36,2-41.
Gallagher, P. L. (1980). The Cuban exile: A social political analysis.
New York: Arno Press.
Jackson, R. A. (2003). Differential influences on Latino electoral
participation. Political Behavior, 25(4),339-366.
Masud-Piloto, F. R. (1996). From welcomed exiles to illegal
immigrants. Lanham, MD: Rowman and Littlefield.
Nackerud, L.. Springer, A., Larrison, c., & Issac, A. (1999).
The end of the Cuban contradiction in U.S. refugee policy.
International Migration Review, 33(1), 176-192.
Pedraza, S. (1996). Cuba's refugees: Manifold migrations. In S.
Pedraza & R. Rumbaut (Eds.), Origins and destinies: Im-
migration, race, ethnicity in America (pp. 263-279). Albany, NY:
Wadsworth.
Pedraza-Baily, S. (1985). Political and economic migrants in
America: Cubans and Mexicans. Austin: University of Texas
Press.
Perez, L. (1986). Immigrant economic adjustment and family
organization: The Cuban success story reexamined. International
Migration Ret1iew, 20( 1), 4-20.
48 LATINOS AND LA TINAS: CuBANS
Portes, A., & Bach, R. L. (1985). Latin journey: Cuban and Mexican
immigrants in the United States. Berkeley, CA: University of
California Press.
Poyo, G. E. (1989). With allandfor the good of all: The emergence of
popular nationalism in the Cuban communities of the United States,
1848-1898. Durham, NC: Duke University Press.
U.S. Census Bureau. (2004a). Table 1.2. Population by sex, age, and
Hispanic origin type: 2004. Retrieved March 27, 2007, from
http://www.census.gov/population/socdemo/hispanic/
ASEC2004/2oo4CPS _tab1.2a.html.
U.S. Census Bureau. (2004b). We the people: Hispanics in the
United States, Census 2000 special reports. (U.S. Census Bureau
CENSR-18). Washington, DC: 'U.S. Department of
Commerce Economics and Statistics Administration.
U.S. Census Bureau. (2004c). Fact sheet United States Census 2000
demographic profile highlights: Selected population group:
Cuban. Retrieved March 27, 2007, from http://factfirider.
census.gov/servlet/SAFFlteratedFactsCevent = &geo_id =
01OO0US&-£eoContext = OlOOOUS&_street = &_county =
&_cityTown = &_state = &_zip = &_lang = en&_sse =
on&ActiveGeoDiv = &_useEV = &pctxt = fph&pgsl =
OlO&_submenuld = factsheec2&ds_name = DEC_20oo_
SAFF&_cLnbr = 403&qr_name = DEC_20oo_SAFF_
RlOlO&reg = DEC~OOO_SAFF _Rl01 0%3A403&_keyword
= &_industry.html.
-MARIA VIDAL DE HAYMES
MEXICANS
ABSTRACT: Mexican origin Hispanics represent (67%)
of an estimated 44.3 million Hispanics. The current U.S .
Census demographic information was used to project
social needs of Mexican-origin Hispanics. An estimated
12 million unauthorized Hispanic origin migrants reside in
the United States. Select provisions of 2007 Proposed
Immigration Reform Act are discussed in context of the
1986 Immigration Reform Act. Key words are defined to
facilitate understanding of issues presented that affect the
well-being of the Mexicanorigin population. Best social
work practices for working with Mexican-origin
Hispanics are proposed in context of issues identified in
the narrative. Future trends are speculative prediction s and
suggestions based on the author's practice experience and
knowledge of the profession.
KEY WORDS: Hispanic or Latinota), Mexican origin;
Mexican American; authorized; unauthorized; docu-
mented; undocumented; Chicanota); other Spanish;
amnesty; 2004 American Community Survey; Treaty of
Guadalupe Hidalgo; bilingual; English only move ment;
Limited English Proficient; No Child Left Be hind Act;
English monolingual; HIV and AIDS;
empowerment perspective; principles of strengths per-
spective; social justice; National Council of La Raza;
Immigration Reform Act; English as a Second language;
case aide model; promotora model; indigenous case aide
Introduction
The U.S. Census Bureau reports an all time high new
population estimate for the U.S. Hispanic population of
44.3 million. The Hispanic population, now largest
minority community (14.8% of total population), grew
faster (3.4%) than the population as a whole (0.3%) during
the period 2005-2006 (U.S. Census Bureau News, 2007).
Persons of Mexican origin constitute largest (66.9%)
number of persons who self-identify as Hispanic or
Latinota). Two in five Hispanics (40%) are recent
immigrants, 52% entered the United States between 1990
and 2002, another 25.6 % came in the 1980s, and the
remainder (22.3%) before 1980 (Ramirez & de la Cruz,
2002). Suro (2006b) found that the number of foreign- born
Mexicans jumped from less than 800,000 in 1970 to more
than 5 million in 1995 and doubled to 11 million in 2005.
The estimated population size and growth rate of
unauthorized persons post 9/11 has heightened protective
national security concerns. The result has been the
initiation and enactment of a series of national and state
policies aimed at restricting the flow and access to
employment and social services for individuals and
families with unauthorized or undocumented members.
One national protective policy example is Public Law
109-367, "The Secure Fence Act of 2006" enacted by the
109th U.S. Congress. The Act aims to strengthen
U.S.-Mexico border security control by increasing border
patrol personnel and adding technical security measures
that includes construction of a fence across the 2,000-mile
border between the United States and Mexico. A similar
protective policy at a state level is Arizona's Proposition
200 enacted in 2004 that requires public employees to
check the legal status of public benefit applicants, with
penalties for failure to verify. Proof of
. citizenship on voter registration is another protective
provision of Proposition 200 (Furman et al., 2007). The
110th Congress in 2007 engaged in heated debate over
proposed Immigration Reform legislation that included
language provisions reminiscent of the Immigration
Reform and Control Act of 1986 enacted during the
Reagan administration. A controversial provision in the
1986 Act, the granting of legal status or "amnesty" to
select groups of unauthorized immigrants met with similar
major resistance in Congressional hearings (see Curiel,
1995, p. 1241, for summary Immigration Reform and
Control Act of 1986). Another controversial

provtsion called for creation of "a temporary guest worker
program" similar to the 1942-1964 "U.S.Mexico Bracero
agricultural worker Agreement." Present day opponents argue
that immigrant laborers take jobs away from U.S. citizens.
Proponents argue that immigrants do labor American workers
will not do.
The dramatic growth rate of this immigrant population
with language challenges (limited English proficiency) and
cultural differences produces public reactions that tend to
polarize legislative leaders and the American public.
Immigration policy has irnplications for social workers who
are charged with theresponsibility for administering and
interpreting eligibility policy for recipients of social services.
Immigration law may present ethical dilemmas for social
workers who may find themselves torn between adhering to a
law that prescribes denying services and their professional
ethical values which mandate the provision of their services to
vulnerable populations (Furman, Langer, Sanchez, & Negi,
2007; NASW Code of Ethics, 1999, p. 27).
The purpose of this entry is to increase knowledge and
understanding about the growing Mexican-origin population
in the United States. The most current U.S. Census
demographic information is used to study population trends in
order to identify social needs of Mexican-origin Hispanics.
The majority of Hispanics or Latinos (60%) are native-born
U.S. citizens. An estimated 12 million non-native born
Hispanics are believed to be residents without legal status.
NASW recognizes the serious problems with U.S.
immigration policy and encourages members to become active
on discussions and advocacy for policy reform to correct
policies such as Arizona's Proposition 200 that require social
workers to report "undocumented" individuals (NASW, Social
Work Speaks, 5th ed., 2000). Although social workers will
likely encounter clients lacking legal immigration status, the
primary focus of this entry is on helping social workers
anticipate other practice challenges given the unprecedented
growth of the Mexican-origin population. The U.S. Census
data do not distinguish documented (or authorized) from
undocumented (or nonauthorized) foreign-born persons of
Mexican origin. The entry ends with a section on Best Practice
principles for effective social work practice with individuals
and families that happen to have a Mexican-origin heritage.
Definitions
The following definitions are terms found in the literature that
provide a context for understanding events or policies
described in this narrative. In most literature sources it was
problematic to distinguish between
LATINOS AND LATINAS: MEXICANS 49
subgroup populations such as authorized or nonauthorized and
the collective Hispanic. or Latino group and subgroups
identified by national or geographic identities such as
Mexican, Puerto Rican, Cuban, and Central or South
American, or other Spanish descent group. This entry focuses
on the Mexican-origin subgroup of Hispanics, which includes
native- and nonnative-born persons of Mexican origin. fu
indicated earlier, the U.S. Census data do not distinguish
documented hom undocumented foreign-born persons of
Mexican origin.
Puerto Ricans are American citizens included in the u.S.
census Hispaniccount if they reside on the U.S. mainland. The
majority of Puerto Ricans on the U.S. mainland live in the
northeastern states. As a result of U.S. involvement in external
politics, immigrant subgroups from Central (Cuba,
Guatemala) and South America (Nicaragua, El Salvador)
entered the United States as refugees and many have become
naturalized citizens (Furman et al., 2007).
Other Spanish is used by the U.S. Census Bureau to group
persons by national origin who chose a generic Hispanic or
Spanish as identifier instead of a national origin identity. Most
Hispanic recent immigrants chose country of origin for
subgroup identifier.
Amnesty: The process of granting legal status with
conditions to unauthorized or undocumented persons who have
resided in the United States for specified time . periods. This is
a controversial provision in immigration language reform that
spells out conditions for eligibility to attain legal status.
Unauthorized Migrant: The U.S. Department of
Commerce language to designate a noncitizen who resides in
the United States without legal status. The undocumented or
unauthorized (used interchangeably) are individuals who may
have entered the country legally as students, guest workers, or
visitors and overstayed their visa time permits. Majority of
unauthorized immigrants entered the country illegally.
Hispanic or Latino( a): This is official inclusive definition
used by the U.S. Office of Management and Budget for
reporting the U.S.' Census population by groups. Hispanics or
Latinola)s are persons who trace their descent from Mexico,
Puerto Rico, Cuba, Central, South America, or other Spanish
cultures. This is an ethnic identification as opposed to a racial
designation. Hispanics do not share a common race, ethnicity,
or ancestry. They may be Black, Asian, White, mixed race, or
of Indigenous, Native American origins (Suro, 2006b).
Mexican American: The terms Mexican origin and
Mexican American are used interchangeably in this narrative
to refer to persons who share a connection to Mexico by birth
or by ancestry. First-generation
50 LATINOS AND LATINAS: MEXICANS
native-born Mexican origin individuals like other chil-
dren of immigrants experience an identity crisis in the
process of forming their American national identity. As
children they learn they are different, not Mexican and
not American. As they become adolescents, in addition
to forming their personal identity separate from their
family they experience conflict with their dual national
heritage. In reaction to dominant societal prejudice,
some may chose to identify as "Spanish," "Hispanic," or
"Latin American" to distance or set themselves apart
from foreign-born Mexicans viewed as an inferior race
by some in the White majority society. Mexican
Americans may experience prejudice from Mexican
nationals who havesuperior knowledge of Mexican
history, culture, and Spanish language proficiency. The
Chicano civil rights movement of the 1960s and 1970s
provided native-born Mexican origin youth a venue to
learn about their indigenous heritage and in the process
found a new identity as Chicanos (males) and Chicanas
(females). There are a number of theories on the origins
of the term Chicano( a). One suggests that it is a
diminutive version of Spanish word Mexicano, which
substitutes "chi" for "Mexi" to differentiate group from
Mexican nationals. Another theory version is that the
word Chicano is derived from an Aztec word meaning
rebel (Rosen, 1974, p. 283). The term Chicanota) has
had a derogatory class meaning for the older Mexican
origin generation. Gutierrez (2005) says that some posit
etymologically that the term is derived from "chiriaco,"
which means "tramp." Youth inverted its derogatory
meaning and embraced it as a badge of ethnic identity
and pride (Gutierrez, 2005). When addressing issues
affecting Mexican origin individuals or families social
work practitioners must take into account the breadth of
diversity found within and between subgroups that
makeup this population and how they are like or
different from the collective Hispanic or Latino
population.
Sociodemographics: Overview
The 2004 American Community Survey (ACS) issued
February 2007 by the US. Census Bureau reports the
estimate population of Hispanics to be 40.5 million or
14.2% of the U.S. household population. Mexican ori-
gin Hispanics (25.9 million) constitute the largest
(64%) Hispanic subgroup (US. Census Bureau, 2007,
p. 2). In 2004, about 1 of every 2 Hispanics lived in two
states: 30% in California and 19% in Texas. The four
states bordering Mexico had highest state percentages
of Hispanics: Arizona (28%), California (35%), Texas
(35%), and New Mexico (43%) (U.S. Census, 2007).
States with fast growth of Hispanics between 2000 and
2005 were North Dakota, Arkansas, South Carolina,
Tennessee, and North Carolina. North Dakota experi-
enced a 62% increase in Hispanics during this 5:year
period (Hakimzadeh, 2006). The bulk of Mexican ori-
gin population lives in the Southwest and the majority
are descendents of former Mexican settlers displaced by
land acquisition as a result of the Mexican American
war that ended with the Treaty of Guadalupe Hidalgo in
1848. In 2002 nearly half of all Hispanics lived in
central cities within a metropolitan area (45.6%) or
outside within a metropolitan area (45.7%), compared
to (21.1%) of non-Hispanic Whites living in central
cities or (56.8%) outside central cities within a metro-
politan area. The percentage of Hispanics living in non
metropolitan areas (8.7%) was smaller when compared
with that (22.1%) for non-Hispanic Whites (Ramirez &
de la Cruz, 2002).
Age: In 2004, Hispanics had a larger proportion of
young and smaller proportion of older population,
compared with the non-Hispanic White population. The
median age for Hispanics was 26.9 years, compared to
40.1 for non-Hispanic Whites. About 1 in 3 Hispanics
was a child (tinder 18 years), compared with 1 in 5 non-
Hispanic Whites. About 5% of Hispanics were 65 years
or older, compared to 15% of non-Hispanic Whites
(US. Census, 2007a). Among Hispanic origin groups,
Mexican origin population with 25.3 median age was
the youngest, compared with 40.6 years median age for
Cubans. A larger proportion (18%) of Cubans were
aged 65 and older, compared to 4.1% for Mexican
origin and 7% or less for other national or regional
self-identified Hispanic subgroups (US. Census,
2007a).
Marriage: In 2004, about one-half of Hispanics,
compared with 57% of non-Hispanic Whites, aged 15
and older were married. A higher number of Hispanics
(35%), compared with non-Hispanic Whites (24%),
were never married. A smaller proportion of Hispanics
(8%), compared with non-Hispanic Whites (11%), were
divorced. About 19% of Hispanic households were
families maintained by a woman with no husband,
compared with 9% of non-Hispanic White households.
About 9% of Mexican households were maintained by a
male householder with no spouse present (US. Census,
2007, p. 8).
Fertility: Pew Hispanic Center (Hakimzadeh, 2006)
indicates that the US. Census Bureau's 2005 American
Community Survey confirms that Hispanic population
growth has been driven primarily by second generation
increases. Over the last 5 years (2000-2005), nativeborn
Hispanics accounted for 62% of the total change in
Hispanic population, while foreign-born Hispanics
represented the remaining 38%. The boom in the sec-
ond generation is attributable to high fertility rates.

In 2004, Hispanics accounted for 1 of every 5 women
giving birth in the United States. Hispanic women had a
higher fertility rate than did non-Hispanic White
women. About 83 of every 1,000 Mexican origin His-
panic women aged 15-50 had given birth in the 12
months prior to the 2004 survey, compared to 50 of
every 1,000 non-Hispanic White women of the same
age range (US. Census Bureau, 2007a, p. 9).
Nativity and Citizenship Status in 2004: Nearly three-
quarters of Hispanics were U.S. citizens, either
through birth (about 61%) or through naturalization
(about 11 %). About 28% of Hispanics were
foreign-born and· had not become citizens. About 61
% of Hispanics of Mexican origin were native-born
and 9% were foreignborn U.S. citizens through
naturalization. Another 31 % of foreign-born were
not citizens (US. Census Bureau, 2007, p. 11). About
42% of foreign-born Mexicans entered the United
States before 1990 or later, 37% between 1990 and
1999, and 21% since 2000 or later (US. Census
Bureau, 2007, p. 13).
Language Issue: Most Americans are surprised to
learn that the U.S. Constitution does not designate an
"official" language. It is obvious English is the US.
common language, but proponents of the "English
only" movement have sought since the 1980s a
constitutional amendment to limit what they consider
"creeping bilingualism" by making English the
official US. Language (Edwards & Curiel, 1989;
Friedman, 1987), The high estimated number of
unauthorized non-English-speaking immigrants and
proposed immigration reform are likely to add
momentum to the "English only" movement and
assure that English proficiency be a requirement for
legal status. Competence in the use of English is
unquestionably essential for success in U.S. society.
Language minority groups want to learn English; the
issue is how best to help them do it (Edwards &
Curiel, 1989). Embodied in social work's
professional Code of Ethics, Edwards and Curiel
(1989) point out, is a commitment to promote social
justice, preserve dignity, expand choice oppor-
tunities and respect for all people. Some Hispanics
speak only English, others only Spanish, and many
are bilingual. In a 2005 Pew analysis of 2000 Census
data, Hakimzadeh (2006) found that 80% of
Hispanics under age 18 spoke English very well,
while 53% over age 18 claimed a similar level of
English proficiency. Among foreign-born Hispanics
older than 18 years, nearly three of-four indicate that
they speak English less than very well. Among
native-born Hispanics aged 5 and older, more than 75%
spoke a language other than English at home and 39%
spoke English well, too. Only 6% of non-Hispanic
Whites speak a language other than English at home. A
proportion of Puerto Ricans
LATINOS AND LATINAS: MEXICANS 51
(30.6%) and 22.9% of Mexican origin persons reported
speaking only English at home (U.S. Census, 2007a, p.
14). Immigrants know that they need to know English
to increase their opportunities for success. The
challenge for the profession is to work with educators
to advocate and support expansion of adult programs
for learning English.
Contemporary Issues
Educational Attainment: A 2002 US; Census Bureau
report indicates that the Hispanic population aged 25
and older were less likely to have graduated from
high school (57%), compared with 89% of
non-Hispanic Whites. More than one-quarter of
Hispanics (27%) had less than a ninth grade
education, compared with 4.0% for non-Hispanic
Whites. Fifty-one percent of Mexican-origin
Hispanics attained a high school diploma. Eleven
percent of Hispanics attained a bachelor's degree or
more, compared with 29% for non-Hispanic Whites.
Among Hispanic subgroups the proportion attaining
a Bachelor's degree ranged from 19% for Cubans,
17.3% for Central and South Americans, and 7.6%
for Mexican origin Hispanics (Ramirez & de la
Cruz, 2002). Hakimzadeh (2006) points out the
importance of distinguishing educational attainment
between native-born and foreign-born Hispanics.
Three out of four native-born Hispanics have
completed high school, compared with less than half
of foreign-born adults. Despite progress in
educational attainment among native-born Hispanic
adults, there remains a challenge to match the 89%
high school graduation rate for non-Hispanic
Whites.
Hispanics for whom English is a second language
have historically had difficulty succeeding in English
monolingual schools. The passage of 1967 Title VII,
Bilingual Education Act, as part of the Elementary and
Secondary Education Act (ESEA), afforded federal
funding for schools to provide a program of instruction
to facilitate learning English by use of the child's
language to limited-English-proficient children from
low-income families. The initial legislative language
allowed for various interpretations to approaches to
what collectively became known as bilingual educa-
tion. The role and purpose of native-language instruc-
tion has remained controversial throughout the almost
40 years of bilingual education in American schools.
Studies of educational outcomes have been problematic
because of the variability of bilingual educational ap-
proaches (Curiel, Rosenthal, & Richek, 1986). As part
of the 2002 reforms, the Bilingual Education Act of
1968 was renamed the English Language Acquisition,
Language Enhancement and Academic Achievement
Act. The new title for "Bilingual Education" in the
52 LATINOS AND LATINAS: MEXICANS
"No Child Left Behind Act" imposes extensive require, ments
for accountability testing that emphasizes English
proficiency, not native language literacy, as the desired
educational outcome.
Poverty: The size of families places strains on family
resources which contribute to the incidence of poverty. In
2002,26.5% of Hispanic family households consisted of five
or more people, compared to 10.8% of nonHispanic
households. Among Hispanic households, Mex ican family
households (30.8%) were most likely to have five or more
persons (Ramirez & de la Cruz, 2002).
In March 2002, 8.4% Mexican origin Hispanics in the
civilian labor force aged 16 and, older were unemployed,
compared with 5.1% non-Hispanic Whites. The median
income for N1exican origin households was 35,000,
compared with 49,000 for non-Hispanic White households.
About 24% of Mexican origin households with mixed age
members were living below the poverty level, compared with
9% of non-Hispanic White households in the 12 months prior
to U.S. Census Community Survey of 2004. The poverty rate
was about 30% for Mexican origin children, compared with
11 % for non' Hispanic children, and 20% for adults aged 65
and older, compared with 7% for non-Hispanic elder adult
Whites (U'S. Census, 2007a, p. 18).
HIVIAlDS: Hispanics in 2004 composed 14% of the U.s.
population and accounted for an estimated 20.4% of new
AIDS cases reported at the end of 2004 (Center for Disease
Control and Prevention [CDC], 2004a). In 2004, an estimated
20.4% of all deaths attributed to AIDS were among Hispanics,
compared with 17.8% in 2002 and 17.6% in 2000. In 2002,
AIDS was the fourth leading cause of death in the United
States for Hispanic men aged 35-44. For men aged 25-34 and
45-54, it was the sixth leading cause of death (Anderson &
Smith, 2005). Disease transmission route for Hispanic males,
in 2004, was primarily by men having sex with men (MSM) in
51.6% of cases and via intravenous drug use in 28.3% of cases
(CDC, 2004b). An estimated 17,780 Hispanic women were
living with AIDS in the United States at the end of 2004.
Heterosexual contact was the primary transmission route for
women in estimated 65% of cases and intravenous drug use in
32.6% of cases (HRSA, 2006). Hispanics tend to be tested late
for HIV and are more likely to have an AIDS diagnosis when
first tested (CDC, 2003).
Best Practices
Social workers have a key role to play in the lives of
Mexican-origin client applicants and their families. From
direct practice to policy advocacy the array of challenges for
social workers serving Mexican-origin
clients or families can be overpowering. Of course, social
workers who know the Mexican or Latino culture and speak
Spanish have an initial advantage in working with Hispanic
clients. All social workers would benefit by becoming familiar
with the "NASW Standards for Cultural Competence in Social
Work Practice" (NASW, 2001). Non-Hispanic English
monolingual social workers conducting initial assessments
need to anticipate variation in client applicants' English profi-
ciency and their ethnic group identification as a function of
time in the United States. In cases in which an interpreter is
used, the social worker is advised to direct questions to the
client and not to the interpreter. The social worker is cautioned
not to use the client's children as interpreters. Information
shared with the social worker is an adult transaction that
violates cultural norms when children are used as interpreters.
Yes, some social workers will be faced with an ethical
dilemma when a Hispanic or Mexican-origin client may
present as applicant without legal resident status. The social
worker is advised to seek supervision or administrative
consultation when agency policy is not clear on appropriate
course of action. Knowing community resources is the
responsibility of social workers. Faith-based organizations
have been known to be a resource for clients who do not
qualify for public services. As indicated earlier, the
Mexican-origin subgroup is composed of 61 % native-born,
9% naturalized, and varying estimates of residents without
legal status. Given these estimate percentages few social
workers will encounter applicants with legal resident status
questions. The question in context of "Best Practices" is, what
do social workers need to know to acquire necessary skills that
will enable them to be competent in promoting the well-being
of Mexican-origin persons? Census data indicators suggest
that a high percentage of Mexicanorigin Hispanics experience
poverty due to limited education and limited English
proficiency. Best practice dictates adoption of an
empowerment perspective where the worker becomes the
learner in a collaborative worker-elient alliance that affirms the
client's rea, lity and builds on the client's strengths and the
worker's knowledge of community resources. Best practice
dictates that social workers develop intervention approaches
based on principles of, the strengths' perspective when
working with minority populations (Saleebey, 2006, pp.
16-20).
Best practice dictates that social workers commit to view
clients as unique beings in the context of their cultural
heritage. Social workers like clients inherit a societal culture
that Helman (1990), a medical anthropologist, portrays as a set
of guidelines (explicit and implicit) that prescribe how to view
and experience

the world emotionally, and how to behave in it. He adds:
"Culture can be seen as an inherited 'lens,' through which
individuals perceive and understand the. world that they
inhabit and learn how to live within it" (Helman, 1990).
Social workers through their education learn the culture
of the profession which prescribes professional behavior
embodied in the "Code of Ethics" that guides
professional practice. Best practice dictates that social
workers commit to learning about their own cultural
heritage to increase their appreciation and understanding
of their clients' culture.
Shaping policy to promote social justice is the
responsibility of all social workers. Best policy prac tices
can be achieved by becoming involved in community
programs that serve the Hispanic community. Social
workers can provide leadership within their own
agencies by serving on agency policy committees.
Outside their agencies, social workers can serve on
agency boards that make policy that affect minority
populations. Social workers needing a powerful ally will
want to partner with The National Council of La Raza to
meet and learn from Hispanic and nonHispanic leaders
from all walks of life about latest research on Hispanics.
Activism can be in the form of writing or making phone
calls to legislative leaders. Even better become a
legislator. An increasing number of social workers have
been elected to public office at all levels of government.
As legislative leaders embodied with social work values
they are more able to influence the direction of social
policy. Social workers can influence future social policy
by actively recruiting minority group members to the
profession and academia.
Future Trends and Practice Implications
The future trends indicate that the Hispanic or Mexica n
origin population will continue to grow. The
unprecedented growth of limited-English-proficient
immigrants suggests that there will be a need for more
bilingual, bicultural social workers in all areas of social
work practice. To succeed in the U.S. economy, new
immigrants will want to learn English. It is almost
certain; the proposed 2007 Immigration Reform Act
will include an English proficient requirement for legal
status consideration. To meet the English proficient
requirement, more adult English as a Second Language
(ESL) education programs will be needed. High fertility
rates for first-generation Hispanics and new immigrants
who want their children to succeed in school will need
transitional bilingual or English enhancement programs
to assure school success. In the future there will be
continued national security concerns which will polarize
communities and legislators on questions raised by
LATINOS AND LATINAS: MEXICANS 53
the presence of an estimated 12 million unauthorized
immigrants.
The Hispanic cultural taboos about discussing hu man
sexuality will contribute to a continued increase in the
incidence of HI V infection and AIDS. In the future
Hispanics will continue to have the second highest
incidence of new cases of AIDS. The rate of HIV/AIDS
infection in Hispanic women will continue to increase.
In the future social workers will provide leadership
needed to develop educational strategies to prevent the
spread of HIVjAIDS. Given the potential market of the
Hispanic population, corporate America increasingly
will include marketing messages in both English and
Spanish. This will add fuel to "English only" pro ponents
who will become more determined in their goal to make
English the official national language. In the future the
Supreme Court will again rule unconstitutional the
"English only" laws. In the future schools of social work
located in areas with high concentration of Hispanics
will place greater emphasis on students acquiring
Spanish language skills. In an effort to meet the
socialization and educational needs of large number of
new immigrants, social work schools will reintroduce
courses in social group work. There will continue to be a
shortage of social work student applicants with bilin gual
and bicultural skills and a shortage of minority faculty
role models.
In the future to meet the growth demands of antici-
pated limited-English-proficient clients, agencies with
only monolingual English social workers wil l be looking
for interpreters or bilingual, bicultural case aides to
assist the social worker. During the 1960s " War on
Poverty" era "para-professional" case aides indigenous
to local neighborhoods were trained to perform case
management type functions. The case aides were usually
women with a high school education who had a history
of community leadership. The case aide model was not
unlike the "promotora" (promoter) model used to pro-
mote public health education in countries with high
concentration of low income indigenous populations.
The promotora,like the case aide, received training and
ongoing close supervision to become a team staff mem-
ber. The professional health care providers (nurseedu-
cators or physicians) partnered with the promotora to
gain community trust. In a "case aide" model, the agency
would be able to serve limited-English-proficient clients
by creating social service care teams composed of one
English monolingual professional social worker teamed
with an indigenous case aide that shares clients' cultural
values and speaks Spanish in addition to English. In the
case aide model the English monolingual social worker
would have a built-in translator and interpreter as case
manager to perform the service plan activities.
54 LATINOS AND LATINAS: MEXICANS
Practice Implications
The practice reality is that the profession will not have
sufficient number of trained professionals who have bilingual
and bicultural skills to meet the needs of the growing
population of Hispanics who will need social services. One
option is to increase recruitment efforts to attract faculty and
students with cultural knowledge and Spanish language
proficiency. A second option is to build in curriculum content,
such as Spanish language courses, to prepare students for
practice interventions with Hispanics. A third option is to train
students to work with case aides who will need supervision.
Given the continued low number of minority doctoral
students, the Council on Social Work Education (CSW~) may
accelerate recruitment of future minority faculty by initiating
a repeat of a 1970s minority faculty training model admi-
nistered by the late Carl Scott. A number of fellow minority
academics, trained as MSW faculty, are now role models for
minority students and the profession.
REFERENCES
Anderson, R. N., & Smith, B. L. (2005). Deaths: Leading causes
for 2002. Nacional Vital Statistical Report. 53:17:51. Table 2.
Available at www.cdc.gov/nchs/data/nvsr/nvsr53_17pdf.
Centers for Disease Control and Prevention [CDC]. (2oo4a).
HN/AIDS surveiUance report. 16:20, Table 10. Available at
http://www.cdc.gov/ .. ./surveillance/resources/reports/ 2004
report.
Centers for Disease Control and Prevention [CDC]. (2004b).
HN/AIDS surveiUance report. 16:21, Table 11. Available at
http://www.cdc.gov /hiv/topics/surveillance/resources/
2004report.
Centers for Disease Control and Prevention [CDC]. (2003).
Late versus early testing of HIV -16 sites, United Status,
2000-2003. MMWR Morbidity & Mortality Weekly Report,
52(25),581-586.
Curiel, H. (1995). Mexican-Americans. In R. L. Edwards & J. G.
Hopps (Eds.), Encyclopedia of social work (19th ed., pp.
1233-1244). Washington, DC: NASW Press.
Curiel, H., Rosenthal, J. A., & Richek, H. G. (1986). Impacts of
bilingual education on secondary school grades, attendance,
retentions and drop-out. Hispanic Journal of Behavioral Sciences,
8(4), 357-367.
Edwards, R. L., & Curiel, H. (1989). Effects of the English-only
movement on bilingual education. Social Work in Education,
12(1),53-66.
Friedman, M. (1987, June 16). Making English official isn't the
answer for America. Wall Street Journal, p. BO.
Furman, R., Langer, C. L., Sanchez, T. W., & Negi, N. J. (2007).
A qualitative study of immigration policy and practice
dilemmas for social work students. Journal of Social Work
Education, 43(1), 133-146.
Gutierrez, R. A. (2005). Mexican-origin people in the United
States. In S. Oboler & D. J. Gonzalez (Eds.), The Oxford
encyclopedia of Latinos and Latinas in the UnitedStates (Vol. 3,
pp. 129-139). New York: OXford University Press.
Hakimzadeh, S. (2006).41.9 million and counting: A statistical
view of Hispanics atmid;decade. Retrieved June 7, 2007, from
http://pewresearch.org.
Helman, C. (1990). Culture, health and illness. Oxford: Butter-
worth-Heinemann.
HRSA. (2006). Hispanics and HN/AlDS in the United States.
Washington, DC: Author.
NASW. (1999). NASW Code of Ethics. Washington, DC:
NASW Press.
NASW. (200l). NASW standards for cultural competence in social
work practice. Retrieved September 24, 2001, from
http://www.socialworkers.org/pubs/standards/curural.htm.
Ramirez, R. R., & de la Cruz, G. P. (2002). The Hispanic
population in the United States: March 2002. Current population
reports, P20-545. Washington, DC: U.S. Census Bureau.
Rosen, G. (1974). The Chicano movement and the politicization
of culture. Ethnicity, 1, 279-293.
Saleebey, D. (2006). The strengths perspective in social work
practice (4th ed.). Boston, MA: Allyn & Bacon, Pearson
Education.
Suro, R. (2006a). The research challenges posed by the Latino
experience. Latino Research Notre Dame, 3(3), 1-16.
Suro, R. (2006b). A developing identity: Hispanics in the United
States. Carnegie Reporter, 3(4), 22-34.
U.S. Census Bureau. (2007a). The American Community Survey-
Hispanics: 2004. Washington, DC: U.S. Department of
Commerce, Economics and Statistics Administration. Re-
trieved June 9,2007, from http://www.census.gov/acs.
U.S. Census Bureau News. (2007, May 17). Minority population
tops 100 million (CB07-70). Retrieved June 8, 2007, from
http://www .census.gov/press-releases/archieves/population.
FURTHER READING
Passel, J. S. (2006). The size and characteristics of the unauthorized
migrant population in the United States: Estimate based on
March 2005 current population survey. Washington, DC: Pew
Hispanic Center.
Stavans, I., & Augenbraum, H. (Eds.). (2005). Encyclopedia Latina:
History, culture, and society in the United States, Vol. 3.
Danbury, CT: Scholastic Library.
U.S. Department of Health & Human Services. (2006). Hispanics
and HN/AIDS in the United States. Washington, DC:
HRSA.
-HERMAN CURIEL
PUERTO RICANS
ABSTRACT: The 2000 census counted 3,406,178 Puerto
Ricans living in the United States, bringing the total for those
living in Puerto Rico and the United States to 7,333,403
million (U.S. Bureau of Census. (2000). Overview of race and
Hispanic origin. We the people: Hispanics in the United
States. Washington, DC:
U.S. Government Printing Office). The label "Puerto

Rican" is not a race but a self- identifier. A Puerto Rican
might be born in Puerto Rico or in the United States
from Puerto Rican parents. A Puerto Rican might be
first-, second-, third-, or even fourth- generation in the
Unites States or 20th-generation in Puerto Rico. As long
as they identify themselves as Puerto Rican, they are
Puerto Rican. The label Puerto Rican has many different
connotations to both Puerto Ricans and non-Puerto
Ricans. For the purpose of this entry, Puerto Ricans,
whether born in Puerto Rico or in the United States, are
defined as a multiracial and multicultural ethnic group
with more than 500 years of history. The discussion in
this entry provides a brief overview; for more in- depth
reviews please see the following references: (Anders on,
R. W. (1965). Party politics in Puerto Rico. Stanmford,
CA: Stanford University Press.; Fitzpatrick, J. P. (1987).
Puerto Rican Americans: The meaning of migra tion to the
mainland (2nd ed.). Englewood Cliffs, NJ:
Prentice-Hall; Lewis, G. K. (1963). Puerto Rico: Free-
dom and power in the Caribbean. New York: Harper &
Row; Morales. (1986). Puerto Rican poverty and migration:
We just have to try elsewhere. New York: Praeger).
KEY WORDS: cultural sensitivity; Hispanics; migra-
tion; Puerto Ricans
Brief Historical Overview
Puerto Rico became a possession of Spain in 1493 when
Christopher Col~mbus landed on the island during his
second voyage to the Americas. At that time its inha-
bitants, the T aino Indians, called the island Boriquen. In
1508 Spain began the colonization of Puerto Rico; Juan
Ponce de Leon was appointed as the first governor of the
island, and the first European settlement on the Island
was called Caparra.
The Spaniards believed that there were substantial
gold deposits in Puerto Rico and the T aino Indians were
forced to work in the mines. Many died in the process,
others fled the island. The existing gold deposits were
quickly depleted, and Spain turned to agriculture, in-
troducing plantations to the island. Slaves were im-
ported from West Africa to work on the plantations.
According to a 1797 census, there were more than
2,000 Indians and thousands of other Puerto Ricans of
partially Indian origin. In 1875, when the abolition of
slavery became effective on the island, more than
30,000 black slaves were freed. Thousands of others-
black and mulatto-lived as free people during the period
of slavery.
Melting Pot
During the 19th century, the Spanish community
increased from continued migration from Spain. In
LATINOS AND LATIN AS: PuERTO RICANS 55
addition, many Spanish loyalists went to Puerto Rico
from Central and South America in the wake of a series
of pro-independence revolutions. The French moved to
the island when the United States purchased Louisiana
and from Haiti when the slaves revolted. In 1840 labor
shortages influenced Chinese workers to move to Cuba
and Puerto Rico. Italians, Corsicans, Lebanese,
Germans, Scots, and Irish also spiced the Puerto Rican
melting pot.
In the 20th century, Puerto -Rico experienced an
influx of people from the United States, political refu-
gees from Cuba, Central and South America, and most
recently, the Dominican Republic. Ethnically, all are
Puerto Ricans; racially the Puerto Rican community
cover the spectrum from White to Black with a larger
in-between category known as triguenos (tan or olive-
skinned people), with some unclear lines dividing these
groups because of racial intermarriage (Table 1).
u.s. Relationships
On July 25, 1898, U.S. troops landed on Puerto Rico' s
south coast in one of the final engagements of the
Spanish-American War. Under the Treaty of Paris of
1899, Puerto Rico was given to the United States by
Spain. During the negotiations for the treaty, no Puerto
Rican was included in the deliberations or even con-
sulted. For 2 years, the island was ruled by the U.S .
military. The Foraker Act of 1900 established a civil
government, with the governor an American appointed
by the U.S. President.
In 1917, with the Jones Act, U.S. citizenship was
conferred to all Puerto Ricans. The conferral of U.s.
citizenship was met with mixed feelings in Puerto Rico.
The Republican Party, which constituted a minority on
the island, welcomed the move because its members
aspired to eventual U.S. statehood. But the majority
Unionist Party favored increased autonomy, and many
TABLE 1
Racial Composition of the Puerto Rican Population in 2005
From Overview of race and Hispanic origin. We the people: Hispanics
in the United States, by U.S. Bureau of Census, 2000, Washington,
oc: U'S. Government Printing Office and http://www.cia/gov/
publications/factbook/geos/rq.html (2007).
56 LATINOS AND LATINAS: PuERTO RICANS
of its members preferred eventual independence. Dur ing
the floor debate in Congress, Resident Commis sioner Luis
Munoz Rivera said that his party sought autonomy, and
that U.S. citizenship conflicted with the long- range goals
of the Puerto Rican people. He asked that a plebiscite be
held to determine whether Puerto Rican desired American
citizenship. The request was denied.
Commonwealth Status
In 1948 Luis Munoz Marin was the first elected gover nor
of Puerto Rico. In 1950 the U.S. Congress author ized
Puerto Rico to draft its own constitution. On July 25 ,
1952, 54 years after American troops landed in Puerto
Rico, the Puerto Rican Commonwealth was inaugurated,
giving the Puerto Rican people the right to elect not only
their own governor but also members of the legislature
and senate. Under this new agree ment, Puerto Rico
acquired a considerable degree of home rule and has
continued to elect its governor and resident commissioner
in Congress (who has a voice but not a vote), and all
member of the insular house and senate. It sets its own
educational policies (with Span ish as the language of
instruction in public schools and, since 1948, with
English as a required second language), determines its
own budget, and amends its own civil and criminal code s.
The Estado Libre Asociado de Puerto Rico (the Puerto
Rican Commonwealth) was described as "a per manent
union between the United States and Puerto Rico on the
basi~ of common citizenship, common defense, common
currency, free market, and a common loyal ty to the value
of democracy," with the U.S. Gov ernment retaining
specifically defined powers "essential to the Union (U.S.
Commission on Civil Rights, 1976, p. 15). In practical
terms, the U.S. government re tained the powers over
military defense and foreign affairs, and federal agencies
(for example the postal service system, and others)
operated as they did in the United States.
Socioeconomic Changes
Whereas the island's political status has remained the
same for the past 55 years, Puerto Rico has undergone
radical economic changes since the end of World War II.
The development strategy of the Puerto Rican leadership
was to industrialize the island by attracting outside capital
with long-term industrial exemptions, lower wages,
governmental low-interest loans, and other types of
incentives.
By the mid- 1950s, manufacturing replaced agricul ture
as the island's principal source of income. As the island
grew increasingly urban, there was also a
shift in living patterns, creating a large urban and
suburban middle-class. Concrete homes replaced wooden
shacks. Miles of new road were built, and factories were
built in fields that once grew sugarcane. Remote areas
were linked to major cities and the rest of the world by
telephones, radios, and televisions. Increasingly, a
considerable segment of the population enjoyed a living
standard comparable to that of the United States and
Western Europe. Advances in pub lic health made
significant inroads in reducing infant mortality and death
from infectious diseases or malnu trition. A population
that once traveled on foot or horseback now traveled on
wheels, as cars clogged new highways. Despite this
progress, however, major problems remained. The debate
continues over the political status of the island and its
relationship to the United States. Although the majority of
voters appears to support the commonwealth status, a
strong minority advocates statehood, and a s maller third
group insists that the island should be independent.
Coupled with this perennial debate over political sta tus
are severe, chronic problems of poverty, unernploy ment,
and underemployment.
Although the industrialization program that was
launched in the 1950s has permitted undeniable im-
provements in the quality of life for thousands of fa milks,
it has been unable to keep pace with the island's growing
needs. A high birthrate and the loss of jobs in agriculture
and, most recently, in industrie s have swelled the ranks of
the unemployed. By 2000 Puerto Rico remained poorer
than Mississippi, the poorest state in the United States,
although it i~ ahead of many underdeveloped nations
(U.S. Bureau of the Census, 2000). Given the poverty ,
unemployment, and underemployment that have affected
the island over the last 50 years, many Puerto Ricans
believe that the sole hope for socioeconomic mobility is to
migrate to the United States. Between 1990 and 2000 ,
more than 1,498,718 million Puerto Ricans left the island
to seek better opportunities in the United States.
Migration to the United States
Puerto Ricans were living in the United States when
Puerto Rico was still a part of the Spanish colonial empire.
During the 1830s, the founding members of a Spanish
benevolent society in New York City included several
Puerto Rican merchants (Fitzpatrick, 1987; Morales ,
1986). By the middle of the 19th century, Puerto Ricans
were engaged in more commerce with the United States
than with Spain, and the sea routes between San Juan and
New York, as well as other sea ports, were well traveled.
In 1898, the Bureau of the Census noted 1,513 Puerto
Ricans on the mainland.
 LATINOS AND LATINAS: PuERTO RICANS
57

Large-scale Puerto Rican migrations to the mainland is a
post-World War II phenomenon. As Fitzpatrick (1987)
indicated:
Puerto Ricans have come for the most part in the first
great airborne migration of people from abroad. They
are decidedly newcomers of the aviation age .... They
are the first to come in large numbers from a different
cultural background, but who are nevertheless citizens
of the United States.
Although in 1940 fewer than 70,000 Puerto Ricans lived in
the United States, there has been a significant increase in the
Puerto Rican population living in the United States since the
1950s (see Table 2).
Reasons for'the Migration
Although economics is almost always a key factor in the
migration of people from their native lands, human mo-
tivation is never that simple or simplistic. Puerto Ricans fled
neither religious nor political persecutiori, but life in the
'island for many young adults, particularly in the rural areas,
may have seemed intolerable during the 1940s and early
1950s. As in the case of many parts of the world, rural Puerto
Rico offered a static environment with few visible avenues for
upward social mobility.
life elsewhere. Thousands of Puerto Rican men and women
served in World War II and later in the Korean Conflict. They
returned home with tales of their travels throughout the world
and in the United States. In other cases Puerto Rican rural
laborers were recruited for seasonal work on U.S. farms and
gained a taste of the United States. Air travel between San Juan
and New York was quick and affordable. In many cases,
migrants first moved from their rural home to the island's cities
and then continue northward to the United States.
The hardships endured by the earliest migrants became
less harsh for the later arrivals, who found relatives and
friends waiting, stores that sold familiar Puerto Rican
products, and even Spanish-language newspapers, radio, and
television programs. Migration became common place, to the
extent that some people made the 3lh-hr flight on a whim or in
reaction to some personal setback. If one can sum motivations,
they could equate with the search for a better life.
ECONOMICS Economics was probably a decisive factor in
the decision to leave the island. Wage levels in the United
States were higher that those in Puerto Rico, and the
opportunities for employment were more numerous and more
varied. Monserrat (1968) indicated:

The size of the Puerto Rican migration varies closely

Modernization with the job opportunities in the United States, i.e,
In the years following World War II, the urban parts of the when job opportunities increase,migration increases;
island began to modernize, offering access to modem homes, when job opportunities decline, migration declines. (p,
cars, and other lures of modem life. T elevision in the 1950s 421)
tempted rural viewers with pictures of
A study conducted by Maldonado (1976), a Puerto Rican
economist, provided support for Monserrat's statement. In her
study, Maldonado found that:
TABLE 2
Number of Puerto Ricans Living in the Unites States Puerto Ricans migrate to the United States primarily
(1950-2000) for economic reasons ... Specifically ... (1) If the job
YEA TOTAL NUMBER BORN IN BORN IN THE
market in the USA is relatively better than inPuerto
R LIVING IN THE PuERTO RICO UNITED STATES Rico; and (2) if the average wage in the USA is higher
UNITED STATES relative to Those in Puerto Rico. (p. 9)
195 301,375 226,11 75,26
0 887,626 0 5
196 1;391,46 615,34 272,27 Search for the "Good Life"
0 3 8 8
2,013,94 581,37 New York City, the first stopping place for millions of
197 810,08
0 5 7 6 immigrants to this country, became the new home for most of
198 2,728,00 1,107,12 906,82 the Puerto Rican migration to the United States. The earliest
From
0 Puerto Ricans0 in the continental
0 5 (Series P-E
United States Puerto Rican migrants settled in East Harlem or £1 Barrio. In
3,406,17
1993 D), by
No U.S. Bureau of Census, 1,282,16
1,445,841953; Puerto Ricans in the
8 1940, about 20% of New York's 61,000 Puerto Ricans lived in
0 0 0
United States (Series PC(2)-lD), by U.S. Bureau of the Census, Manhattan, but the migrants soon began to spread out to the
200 1,771,21 1,634,96
1963; Puerto Ricans in the United States (Series5PC (2) IE), U.S. city's other four boroughs. Although East Harlem was still an
0 3
Bureau of Census, 1973; Characteristics of the population important enclave, by 1970 the thrust of the movement made
(Series PC 80-1CO, by U.S. Bureau of Census (1983); the Bronx the largest Puerto Rican borough, followed by
Characteristic of the population (Series CP2-1-M), by U.S. Brooklyn, Manhattan, Queens, and Staten Island.
Bureau of Census (1993); and Current population survey, 2004,
by U.S. Bureau of Census, 2004, Washington, DC: U.S.
Government Printing Office.
58 LATINOS AND LATINAS: PuERTO RICANS
While Puerto Ricans dispersed among the city's five
boroughs, they were also moving outside of the city to
Connecticut, Illinois, Massachusetts, New Jersey, Penn-
sylvania, and other areas of New York State. In 1940, 90%
of all Puerto Rican migrants lived in New York City; by
1970 only 57 of all Puerto Ricans lived there.
ECONOMICS The search for the good life has been almost
an impossible dream for many. The u.S. experi ence
suggests that immigrants from other countries also began at
the bottom of the ladder and gradually moved up; Puerto
Rican migrants began at the bottom of the ladder and for
the most part have not been able to move up. The economic
situation of Puerto, Ricans has changed little in the last 37
years. Table 3 compares the U.S. general population with
the Puerto Ricans living in the United States on three
variables to illusttate the dis advantaged position of Puerto
Ricans.
By 1990, as the table illustrates, Puerto Rican fa milies
were more than 3 times as likely as non- Puerto Rican
families to fall below the official poverty level. If the
husband is the only employed member of the household,
chances are that the family will be as poor as 86% of al l
Puerto Rican males-those 16 years and older are in the
labor force concentrated in low- paying jobs such as
nontechnical and sales, service occupa tions, precision
production and repair, and operators and laborers.
FEMALE- HEADED FAMILIES Contributing to the
poverty problem among Puerto Ricans in the United States
is the increase in the number of female- headed families.
The increase is the result of a number of factors: (a) an
increase in the number of divorces among Puerto Rican in
the United States; (b) Puerto Rican women (including
teenagers) having children without marrying the fathers;
(c) the abandonment of some women by the father of the
children; and (d) the death of the husband. In addition,
women in the United States often receive lower pay than do
men for the same jobs; consequently lower salaries place
them at greater risk of becoming poor.
TABLE 3
Comparison of the General U.S. Population and Puerto Ricans Living in the United States for Median Income, Poverty,
and Unemployment
2000 1990
PR U.S. GENERAL PR U.S. GENERAL
POPULATION POPULATION POPULATION POPULATION
30,644 $41,994 $8,913 $$36,253
48.2 12 37.5 10.7
13.8 5,4 10.1 8,4
From Characteristics of the population (Series PC80-1-C-1), by U.S. Bureau of Census, 1983 and Characteristics of the population (Series
CP2-1-M), by U.S. Bureau of Census, 1993, Washington, DC: U.S. Government Printing Office.
In 1990, women headed 17% of all families in the
United States, but 43.3% of all Puerto Rican families were
headed by women. Although many of these Puerto Rican
women worked, their salaries are often below or near the
official poverty level (Ll.S. Bureau of the Census, 1993 ).
Forty-two percent of Puerto Rican women 16 years of age
or older were in the labor force, with an unemployment rate
of 8.3% in 1993. That same year, women 16 or older in the
U.S. population constituted 60% of all working women ,
with an unemployment rate of 6.1 %. Seventy percent of all
women in the labor force 16 years of age or older and 76%
of Puerto Rican women in the labor force i n the same age
bracket are in relatively low- paying jobs, as shown in
Table 3.
EDUCA nON Another element linked to future em-
ployability and income is education. According to the
Census Bureau in March 1991, only 24% of the total U.S .
population 25 years and older had completed less than 5
years of school-for Puerto Ricans living in the United
States, the figure is 8.4%, almost 3 times higher. Almost
70% of the general population has completed high school ,
compared with 58% of the Puerto Rican population .
Furthermore, depending on the source used, the drop- out
rate for Puerto Ricans in the United States is alarming,
especially in the high-school grades, ranging from 30% to
80% (Fitzpatrick, 1987; Ford Foundation, 1984 ;
Stevens-Arroyo & Diaz-Ramirez, 1982; U.S. Commission
on Civil Rights, 1978). However, the drop- out rate may be
declining. It was previously estimated that only about 7%
of the Puerto Rican community had attended college, with
1 % graduating. In March 1991, the Census Bureau
indicated that 10.1 % have 4 or more years of college. As
with the general population, Puerto Rican women appear to
be entering and completing college more often than do
Puerto Rican men.
HOUSING AND HEALTH In addition to education,
employment, and income, housing and health are im portant
indicators of the conditions of Puerto Ricans in
1980 VARIABLES
PR U.S. GENERAL
POPULATION POPULATION
$7,629 $23,517 Median income
32.0 9.0 Below the poverty line (in %)
13.8 8,4 Unemployment (in %)

the United States. The availability of good affordable care
continues to be a problem. Most Puerto Ricans continue to
live in the central parts of inner cities in old buildings
where plumbing, heating, and electrical systems are
antiquated. Given the low income of most Puerto Ricans,
these buildings are the poor housing left behind by other
groups. Quoting from an article in a Hartford, Connecticut
newspaper, Morales (1986) noted:
They (Puerto Ricans) live in the ruins of inner cities
... forced to raise their children in housing that is
most uninhabitable, attempting to raise their young
in school systems that reject them, working in jobs
that lead nowhere. (p. 38)
Poverty, poor education, ~nd poor housing also lead to
poor health. Puerto Ricans in the United States die more
often of heart conditions and cancer than do the general
population. Among Hispanic people in the United States,
Puerto Ricans have a higher incidence of strokes and
infant mortality, and lower prenatal care and preventive
health care. In addition to heart diseases and cancer,
injuries, strokes liver diseases, pneumonia, influenza,
diabetes, human immunodeficiency vi rus, and homicides
are the major causes of death among Puerto Ricans in the
United States. In the case of acquired immune deficiency
syndrome (AIDS), the rate for Hispanics in general is 3
times higher than that of non-Hispanic Whites, and among
Puerto Rican born Hispanics is as much as 7 times higher .
Among the risks to health, smoking continues in 43%
of Puerto Rican men, and teenagers of both gen ders
smoke more than either non-Hispanic White or Black
teenagers. Furthermore, Puerto Rican teenagers repor t
heavy drinking of alcoholic beverages more fre quently
than do non-Hispanic Black or White teen agers. Puerto
Ricans and Cubans aged 12-17 in the United States also
report higher rates of cocaine use than do their
non-Hispanic White and Black counterpar ts (Public
Health Service, 2000).
Reaching or achieving a better life has been an
impossible dream for many Puerto Ricans. As Morales
(1986) indicated:
They (Puerto Ricans) brought with them their own
culture and language and a unique history of op-
pression at the hands of the Spanish and U.S. gov-
ernments. As a Multiracial Latino group with U.S.
citizenship, they have entered a competitive system
that pits them against the descendants of black
slaves and European peasants, who have to various
degrees, learned the meaning of ethnic and racial
strife. (p. 18)
LATINOS AND LATlNAS: PuERTO RICANS 59
Return Migration to Puerto Rico
Responding to a variety of forces-from economic
incentives to family personal and triumphs and
tragedies-migration from and to Puerto Rico by Puerto
Ricans has been a complex and dynamic process that
has not been systematically studied.
Migration to the United States appears to have
followed economic trends in the Unites States- for
example, when employment opportunities in the Uni ted
States increase, more people move to the United States,
and when economic conditions and employ ment
opportunities drop, so does migration. Little is
understood, however, about who migrates, when they
migrate, and why they migrate.
After World War II, and until the early part of the
1960s, the U.S. economy was booming, and the mi gration
from Puerto Rico to the United States was high, especially
among three groups of Puerto Ricans: (a) unemployed
low-skilled laborers, (b) unemployed agricultura l
workers, and (c) agricultural contract workers (workers
who were recruited in Puerto Rico to move to farms in the
United States for a limited time with the purpose of
working on these farms). Although economic conditions
in Puerto Rico had improved, sala ries were low and
unemployment continued to be as high as 40%. Most of
the migration, except for the agricultural contract workers,
was concentrated in New York City, but as Morales
(1986) indicated, "we had to try elsewhere (p. 58), and
Puerto Ricans began dispersing over a much wider area of
the United States."
By 1970 the U.S. economy began to decline, and many
jobs for low-skilled laborers began to disappear. Although
unemployment began to rise in Puerto Rico, many people
began to return to the island. According to the 1980
census, 137,474 Puerto Ricans who had been living in the
United States returned, many of them having lived in the
United States for more than 10 years (U.S. Bureau of the
Census, 1983). Fitzpatrick (1987) quoted a study done in
Puerto Rico that indicated "In 1979 there were 83,834
children from the mainland in the schools in Puerto Rico
who did not speak Spanish well enough to be instructed in
Spanish" (p. 22).
Few studies were conducted in the late 1960 s and early
1970s in an effort to understand the return. Stu dies by
Hernandez (1967) and Sandis (1970) indicated that most
Puerto Ricans returning to Puerto Rico were better off
financially than most people living in the island at the time
(Badillo Vega, Morales Rivera, Rodriquez Hernandez, &
Sanchez Benites, 1975; Bonilla & Colon Jordan, 1979;
Cintron & Vales, 1975). By 1980, the picture had changed
and the Puerto
60 LATINOS AND LATINAS: PuERTO RICANS
Ricans returning to Puerto Rico from the United States
appeared to be middle-aged, poor, and oflow education.
Then a new twist developed in migration patterns of
Puerto Rican in the 1980s: The migration of skilled people
such as doctors, lawyers, engineers, and accountants who
could not find employment in Puerto Rico to the United
States from the island (Puerto Rican Planning Board,
1984).
Another factor that appears to have had an impact on
the Puerto Rican migration to and from Puerto Rico to the
United States is the continuing immigration of people to
Puerto Rico from others parts of South America, Central
America, and other areas of the Caribbean. The
immigration laws of Puerto Rico are American laws
enforced by the fed~ral government. Puerto Ricans do not
participate in decisions as to who can or cannot immigrate
to Puerto Rico. After the Castro revolution in Cuba,
hundreds of Cubans moved to Puerto Rico. They moved to
the Island because they spoke the same language, and
shared a similar climate and culture. They entered Puerto
Rico as political refugees. Puerto Ricans were not
consulted nor could did they do anything about the Cuban
immigration to Puerto Rico. More recently, Puerto Rico
has become the permanent home of over 100,000 legal
residents. They moved to Puerto Rico from Argentina,
Colombia, Venezuela, and other counties from other South
American and Central American countries. S ome moved
originally to the United States and, after receiving their
permanent residency, moved to Puerto Rico as they felt
more at home with the culture, lan guage, and climate of
Puerto Rico than the United States mainland. More
recently, thousands of illegal immi grants from the
Dominican Republic cross the Mona Passage to Puerto
Rico each year looking for work. Consequently as the
economic situation in Puerto Rico worsens, and fewer jobs
are available, more Puerto Ricans will leave the island and
those who remain will become a minority group within
their own island.
Social Services and the Puerto Ricans
in the United States
CUL TURAL KNOWLEDGE AND SENSITIVITY Most
social services programs geared to help Puerto Ricans in
the United States have failed a nd will continue to fail as
long as Puerto Ricans continue to be misunderstood,
stereotyped, and disrespected. The failure of social ser vice
providers to acknowledge and value the strengths of the
Puerto Rican family and community has not served Puerto
Ricans in the United States well (Campoa, 1974; Delgado ,
1987; Longres, 1977). Culturally sensitive and culturally
competent workers who understand the language, history,
legal rights, and cultural values are
required to provide the needed, culturally appropriate
interventions to our community.
Social service workers providing services to Puerto
Ricans need to have an understanding of the different
generations of Puerto Ricans living in the United States,
and the degree of assimilation achieved by these dif ferent
cohorts. For example, many workers assume that because
the client is Puerto Rican, he or she speaks, writes, and
reads Spanish, which is not necessarily so. Those Puerto
Rican consumers of social services who are Spanish lan-
guage dominant often do not get the best professional
social services for two reasons: (a) there are few compe-
tent bilingual and bicultural social workers and (b) many
interviews are conducted using interpreters, who are not
effective or who are children of the interviewees. The use
of children to interpret is inappropriate for the purpose of
the interview or the content when the discussion centers
on very personal topics, including sexual content or
intimate issues about the family.
Being a sensitive social worker entails more than just
speaking the language: Understanding the values of the
Puerto Rican culture as perceived by the Puerto Rican
client (whether born in Puerto Rico or in the United
States) and how this guides their behavior and gives
meaning to their life. Social w orkers need to be
professionally trained, culturally sensitive, and compe tent
workers to work with Puerto Ricans clients. Those who
are willing and able to understand the meaning of respecto
(respect) for a Puerto Rican client and how this respect is
manifested by the worker and the client when addressing
one another during an interview is critical. Puerto Ricans
are taught from childhood that when a parent, an elderly
person, or anybody of authority addresses them, they must
look at the floor as a sign of respect. Failure to understand
this behavior has led many social workers to indicate in
their case records that "the client has difficulty in
maintaining eye-to-eye contact."
UNDERSTANDING FAMILY AND COMMUNITY
Understanding the role of the Puerto Rican family in the
daily routine and the significant events in the life of a
Puerto Rican is extremely important. Understanding the
roles of family members, including godparents (padrinos),
is necessary in the assessment of the support system
available to the family. Some Puerto Ricans have referred
to the Puerto Rican family as a blessing and a curse. It is a
blessing because, whether extended or not, the family is
the first support group. It also a curse: although it is nice
to have so many people caring, th ere is also a reciprocal
responsibility of caring for family members and to be
there when needed. Many social workers assume that all
Puerto Ricans have an extended

family ready and available to care for them. This is not
always the case, and the assumption might result in
workers not offering or exploring with Puerto Rican
clients the support or resources needed by them to deal
with their situation.
Finally, the assessment of a Puerto Rican clients is not
complete without understanding the Puerto Rican
community in which the client lives and the support and
resources available in that community that can be tapped
to help the client. What formal systems, such as
community agencies, are available to the client? Is the
client affiliated with any church in their com munity? Are
these institutions culturally sensitive to Puerto Ricans?
What are the informal support systems, such as frien ds,
bodegas (grocery stores), and bota nicas (a neighborhood
store in which herbs, medicinal plants, candles, prayers
books, and statues of saints are sold)?
REFERENCES
Badillo Vega, A., Morales Rivera, Rodriquez Hernandez, &
Sanchez Benites, T. (1975). A note on the return migration to
Puerto Rico, 1970. Proceedings of the American Statistical
Association, 24(2), 267-289.
Bonilla, E., & Colon Jordan, H. (1979). Mama, Borinquen Me
Llama (Mother, Borinquen is calling me). Migration Today,
7(2),7-13.
Campoa, A. (Ed.). (1974). Puerto Rican curriculum development
workshop. New York: Council on Social Work Education.
Cintron, C,, & Vales, P. (1975). Social dynamics of return migration
to Puerto Rico. Rio Piedras, Puerto Rico: Centro de
Investigaciones Sociales, Universidad de Puerto Rico.
Delgado, M. (1987). Puerto Ricans. In Manahan (Ed. in Chief),
Encyclopedia of social work (18th ed., Vol. 2, pp. 426-434).
Silver Spring, MD: National Association of Social Workers.
Fitzpatrick, J. P. (1987). Puerto Rican Americans: The meaning of
migration to the mainland (2nd ed.). Englewood Cliffs, NJ:
Prentice Hall.
Ford Foundation. (1984). Hispanics: Challenges and opportunities.
New York: Author.
Hernandez, A. J. (1967). Return migration to Puerto Rico. Berkeley:
University of California Press.
Longres,]. P. (1977). Minorities: Puerto Ricans. InJ. B. Turner
(Ed. in Chief), Encyclopedia of social work (17th ed., Vol. 2, pp.
973-979). Silver Spring, MD: National Association of Social
Workers.
Maldonado, R. (1976). Why Puerto Ricans migrated to the United
States. Monthly Labor Review, 99(9), 7-10.
Monserrat, J. (1968). Puerto Rican migration: The impact of
future relations. Harvard Law, 32(9), 420-429 (Review).
Morales, J. (1986). Puerto Rican poverty and migration: We just have
to try elsewhere. New York: Praeger.
Public Health Service. (2000). Washington, DC: Department of
Health and Human Services.
LATINOS AND LA TIN AS: PuERTO RICANS 61
Puerto Rican Planning Board. (1984). Caracteristicas de la
poblacion migrante de Puerto Rico 1982-83 (Characteristics of
the migrant population of Puerto Rico, 1982-83). San Juan:
Author.
Sandis, E. E. (1970). Characteristics of Puerto Rican migrants to
and from the United States. International Migration Review, 4(1
I), 22-43.
Stevens-Arroyo, A. M., & Diaz-Rarnirez, A. M. (1982). Puerto
Ricans in the United States: A struggle for identity. In A. G.
Dworkin & R. J. Dworkin (Eds.), The minority report (pp.
235-248). New York: Holt, Rinehart & Winston.
U.S. Bureau of Census. (1983). Characteristics of the Population
(Series PC80-1-CI). Washington, DC: U.S. Government
Printing Office.
U.S. Bureau of Census. (1993). Characteristics of the population
(Series CPZ-I-M). Washington, DC: U.S. Government
Printing Office.
U.S. Bureau of Census. (2000). Overview of race and Hispanic
origin. We the people: Hispanics in the United States. Washington,
DC: U.S. Government Printing Office.
U.S. Commission on Civil Rights. (1976). Washington, DC:
U.S. Government Printing Office.
U.S. Commission on Civil Rights. (1978). Washington, DC:
U.S. Government Printing Office.
FURTHER READING
Morales Carrion, A. (1983). Puerto Rico: A political and cultural
history. New York: Norton.
Maldonado-Denis, M. (1972). Puerto Rico: A Socio-historical
interpretation. New York: Vintage Books.
Public Health Service. (1990). Healthy people 2000: National health
promotion and disease prevention objectives (DHHS Publication
No. PHS 91-50212). Washington, DC: U.S. Government
Printing Office.
Social Security Administration. (1993). Annual statistical sup-
plement, 1993 to the social security bulletin. Washington, DC:
U.S. Government Printing Office.
U.S. Bureau of Census. (1953). Puerto Ricans in the continental
United States (Series poE No. 3D). Washington, DC: U.S.
Government Printing Office.
U.S. Bureau of Census. (1963). Puerto Ricans in the Continental
United States (Series PC (2)-lD). Washington, DC: U.S.
Government Printing Office.
U.S. Bureau of Census. (1973). Puerto Ricans in the United States
(Series PC (2)-lE). Washington, DC: U.S. Government
Printing Office.
U.S. Bureau of Census. (2001). The Hispanic population: Census
2000 brief. Washington, DC: U.S. Government Printing Office.
U.S. Bureau of Census. (2004). We the people: Hispanics in the
United States. Census 2000 special reports. Washington, DC:
U.S. Government Printing Office.
U.S. Bureau of Census. (2005). Current population survey, 2002 to
2004 annual social and economic supplements. Washington, DC:
U.S. Government Printing Office.
-ANGEL P.
CAMPOS
62 LEADERSHIP
LEADERSHIP
ABSTRACT: The concept of leadership has evolved
from focusing on innate abilities, to learned skills, to
recognition that leadership is composed of both skills
and abilities. Recently, theorists and practitioners
have identified core elements of leadership for socia l
work organizations. These elements encourage social
work leaders to understand their organizations as
living systems within an interdependent world and aid
them in connecting humanistic intentions with effects.
Acknowledgement and enactment of these
competencies secure skills of communication and
guidance needed for engagement in dialogue and
action. Social work students and leaders can learn and
hone these qualities in social work programs, 'schools,
and professional development opportunities for
effective leadership in the field.
KEY WORDS: leader; leadership; leadership
competencies; leadership skills; leadership theory;
spirituality; social work managers
Leadership-Historical Background
Leadership theory has developed various paradigms. It
began in the early part of the 20 th century with the trait
approach, which corresponded with the scientific
management school of organizational thought (Taylor,
1911; Holland, 1959, 1962, 1966). This fo cus sought to
discover and describe the elemental characteristics of
leaders and was premised upon the assumption that
leadership is an inherent ability, rather than some thing
that can be learned and honed. Research in the 1940s
by Stogdill and Mann indicated inconsistencies in the
trait approach, although more recent investigation has
demonstrated a link between personality and
leadership, creating renewed interest in traits (Bargal,
2000; Bryman, 1997). The emergence of the human
relations school of management in the 1930s and 1940 s
provided the basis for a study by Bowers and Seashore
(1966) that revealed two basic leadership patterns:
consideration, or concern for reporting employees as
individuals, and initiating structure, or dear delineation of
and monitoring of tasks. Theory "Y" Management through
the 1960s encouraged leaders to balance autonomy with
mutual objective-setting in their organizations, and to
focus on goals, planning, and rational thinking (McGregor,
1960). As broad-spectrum theories broke down in the
1960s across all fields, however, the contingency
leadership approach emerged, which acknowledged the
unfixed face of leadership, primarily dependent upon the
various contexts and situations in which an individual
finds oneself (Fielder, 1967).
During the 1980s, a new leadership approach devel-
oped, which actually consisted of multiple theories. In
general, these theories "revealed a conception of the leader
as someone who defines organizational reality through the
articulation of a vision, which is a reflection of how he or
she defines an organization's mission and the values that
will support it" (Bryman, 1997, p. 280).
A particularly notable new leadership concept was
Bass's (1990) distinction between the transactional and
transformational leadership styles as two ends of a beha-
vioral continuum, rather than as "either/or" types. T rans-
actional leadership involves an exchange relationship
between "leaders" and "followers"; adherence to rules and
standards; actions exerted solely to correct problems; and
a laissez-faire leadership approach. In contrast, a
relationship berweenl'leaders" and "followers" with ac-
tivities such as use of power to serve others, learning from
criticism, open dialogue, shared recognition, and encour-
agement of free thinking characterizes transformational
leadership. T ransformationalleadership builds a sense of
vision, pride, respect, and trust; clearly communicates
high expectations; encourages problem solving; and
explicitly values each individual employee.
Perhaps not too surprisingly, feminist and ethnic
leadership theories also emerged during this time, chal-
lenging the white, male-dominant culture upon which
most organizations had been constructed. Feminist the ory
argued that women tended to lead with a more
cooperative, collaborative, and empathetic style, and that
female leaders often used intuition, in addition to rational
thought, to solve problems (Loden, 1985). Even then,
some scholars suggested that the female leadership
approach was not exclusive to women, but rather offered a
complementary approach to the traditional,
male-constructed model. Afrocentric theory, which
strongly valued interpersonal relationships and
spirituality, conceptualized the leader as one who strives
to encourage and nourish these relationships and the
well-being of people in society. A critique of it was that it
could reduce the efficiency of the organization (Hasenfeld,
1983). Although the leader is greatly respected in
Afrocentric organizations, he or she must also have
believed in transparency, been approachable, and
maintained clear communication (McFarlin, Coster, &
Mogale-Pretorius, 1999).
Over the past 40 years, leadership scholars incorpo-
rated and expanded the female and ethnic approaches to
offer an ecological view of leadership (Wheatley, 1994 ).
Inspired by theory from quantum physics, this holistic
conception ofleadership valued interconnected networks
and fluid information channels, and it recognized that both
the organization and world beyond consist of emerging,
self-organizing structures and

interdependent relationships among individuals from
multiple cultures. Instead of exerting command and
control, leaders are encouraged to make meaning in the
midst of chaos, trusting that organizations will evolve
healthfully and freely if guided with self-consistency and
authenticity.
Most recently, leadership scholars have developed
upon the interconnected, holistic nature of life de scribed
by the ecological approach to articulate a spiri-
tualleadership approach (Heifetz, 1994; Owen, 1999;
Bailey, 1997,2006; Scharmer, 2007). Spirit is separate
from political or religious doctrine, and it serves as the
connecting force throughout all life (Palmer, 1998; Owen,
1999). This approach attends to the health of the
organization and the people within it. Leaders with spirit
recognize, lead from, and cultivate softer process skills and
attributes in their organizations, breathing life and
inspiration into them.
Social Work Leadership: Context and
Development
Over the past century, social work has produced numerous
well-known leaders; many, especially in the profession's
earliest years, however, primarily served as personnel
administrators and facilitators who linked agency boards
and staff members. The field itself has focused more on
developing social work administration and management,
which overlaps with but is different from social work
leadership. This has resulted in a dearth of professional
literature (Brilliant in Patti, 2003; Rank & Hutchison,
2000). Interestingly, Mary Parker Follett, a major
contributor to the scientific management theory, was a
social worker.
In the 1960s, as the Civil Rights movement devel oped,
social work leaders began to challenge biased ser vice
patterns and actively forge new conceptions and processes
in their organizations (Austin, 2000). In 1969, Whitney
Young became the first African American pre sident of
NASW. While social work organizations were some of the
earliest to address institutionalized prejudices, this activity
did not ultimately result in a new definition of social work
leadership. The competing values framework, described
by organizational behaviorist Quinn (1988), provided
guiding principles for social work leaders, which included
maintaining internal stability, developing human
resources, adapting to opportunities and threats in the
environment, and productively and effectively reaching
the organization's goals. Addi tionally, social workers have
looked toward total quality management (TQM), again
developed in the business world, as a preferred leadership
model (Abrahamson, 1996; Reeves & Bednar, 1994;
Boettecher, 1998; Gummer & McCallion, 1995).
LEADERSHIP 63
In short, while also importing theories from other
fields, leadership education in social work has largely
encouraged individuals in these positions to be visionary,
proactive, and responsible for the development of their
organizations. Today, it remains particularly critical that
social work leaders consider how they can help their org-
anizations reach performance goals in all areas of function
in order to improve social work service (Patti, 2000).
As the field of social work continues to evolve, it
becomes more diverse, market driven, and research-
oriented. It has also become more political, with multi ple
social workers in the U.S. Congress, and hundreds serving
across the United States in local and state legislatures.
Nonetheless, today, the field of social work receives little
positive acknowledgment by society, resulting in many
social workers seeing the need to increase its status and
access to power.
Leadership is still not a core component of social work
education, and often, leaders of social work orga nizations
cross over from other disciplines (Patti, 2000) Some
scholars have recommended that the human services field
develop a unique theoretical perspective on leadership that
can be inducted into mainstream management theory and
education, rather than human services simply adopting
models from other fields; others have suggested that social
workers need not hesitate to follow successful leadership
training models from other fields, such as business and
public administration (Drucker, 1993; Patti, 2003;
Perlmutter, 2006; Rank & Hutchison, 2000).
Perlmutter's (2006) interviews of CEO's/executive
directors of social services agencies revealed that many of
these leaders expressed a need for highly developed
analytic skills, commitment to outcome- based practice,
data-driven decision making, and effective oral and written
communication abilities. They noted that these skills are
more often found among MBAs, MP As, and urban
planners, rather than social work graduates. Additionally,
they suggested that social work leaders engage in
preparation that extends beyond the clinical approach and
addresses societal needs. Relatedly, Ezell (1991) found
that advocacy and macro-practice are also core areas of
social work administration that schools of social work
must more deeply address.
A survey of 75 deans and directors for 460 CWSE-
accredited social work programs and 75 executive
directors and presidents of 56 chapters of NASW con-
ducted by Rank and Hutchison (2000) indicated that
leaders in the social work profession tend to distinguish
their leadership from that in other professions because of
five common elements: (a) committing to the NASW Code
of Ethics, (b) maintaining a systemic perspective, (c)
employing a participatory leadership
64 LEADERSHIP
style, (d) advocating altruism, and (e) focusing on the
public image of the profession.
This group of leaders also identified nine leadership
skills specifically necessary for social workers in the 21 st
century, including:
1. Community development, or t he "efforts made by
professional and community residents to enhance the
social b~nds among members of the commu nity,
motivate the citizens for self- help, develop
responsible local leadership, and create or revita lize
local institutions" (Barker in Rank & Hutchison,
2000, pp. 495--496);
2. Communication or interpersonal skills, or "the
verbal and nonverbal exchange of information,
including all the ways in which knowledge is
transmitted and received" (Ibid.). Communica tion
and interpersonal skills also include the ability to
work with others to accomplish specific objectives
through clear speaking and writing, proper allocation
of time and resources, and consideration of diverse
perspectives;
3. Analytic skills, or the "systematic consideration of
anything in its respective parts and their relation ship
to one another" (Ibid., Hardina, 2002);
4. Technological skills, or the ability to apply
knowledge and engage with computers and related
technology (Meenaghan, Gibbons, & McNutt,
2005);
5. Political skills, or the coordination of "efforts to
influence legislation, election of candidates, and
social causes," and "running for elective office,
organizing campaigns in support of other candi dates
or issues, fundraising, and mobilizing voters and
public opinion" (Barker in Rank & Hutchison, 2000,
pp. 495-496); in addition to understanding the
connection between local practice and the global
context (Mary, 1997);
6. Visioning skills, or the ability to conceptualize
objectives for a cohort, instit ution, constituency,
community, employees, or clients, in addition to
expressing this vision through verbal and written
communication (Mizrahi & Rosenthal, 2001);
7. Risk-taking skills, or the attributes that enable a
leader to demonstrate courage when f aced with
confrontation so as to improve the human condi tion
for a cohort, institution, constituency, com munity,
employees, or clients and that engender "tenacity
and courage in employees" (Kets De Vries,
Vringnaud, & Florent-Treacy, 2004, p. 479);
8. Ethical reasoning, or the faithful reference to the
values outlined by the NASW Code of Ethics during
decision making, including integrity, trust,
credibility, and accountability;
9. Cultural competency or diversity, or "the set of
academic and interpers onal skills that allow
individuals to increase their understanding arid
appreciation of cultural differences and simila rities,
within, among, and between groups to reflect the
needs of all ... (i.e., not just the majority cultural
group) with all systems" (Bailey & Aronoff, 2004, p.
136). Garrett et a1. (2001) also outlines cultural
competency skills necessary between supervisors
and supervisees.
Certainly, these abilities-among other general skills, such
as strategic planning and collaboration, which are
necessary for leaders in any field- are critical for leaders
within the social work profession (Mizrahi & Berger,
2005; Mizrahi & Rosenthal, 2001). Yet, to most
effectively develop, use, and sustain these skills and
ourselves as leaders, we must recognize and draw upon
another group of what are frequently referred to as
"softer" skills.
Often defined as process skills, these are
competencies' of "heart and head" that are implicit to our
profession. To most effectively address the numerous
complex challenges facing the organizations of the 21 st
century necessitates that these traits and skills now be
made explicit and publicly reclaimed (Bolman & Deal,
1995; Bailey, 1997; Bailey, 2006). Able to be taught and
learned, this set of core competencies-authentic ity,
humility, empathy, courage and compassion, faith,
patience, and love-composes the essence of life, or "spirit"
(Bailey, 2006). Although rarely discussed in the literature ,
these elements offer a framework within which to support
the nine leadership skills cited above and address the cen-
tral and increasingly complex leadership demands, while
greatly benefiting our organizations. In fact, re cent studies
have shown that organizations that seek to recognize the
spirit and even attempt to align their goa ls with the spirit
outperform those that do not (e.g., Mitroff & Denton in
Pink, 2006). These seven components of spirit encourage
social work leaders to understand their organizations as
living systems within an interconnected world (Mulroy,
2004), rather than as independent entities, and "aid them in
collectively creating systems designed to enhance the
human condition and co-construct cultures of inclusion"
(Bailey, 2006, p. 299).
Leadership Competencies for the 21st Century
1. Authenticity: As noted earlier, the demands on
leaders are increasing in amount and complexity. In
order to meet these demands and maintain
well-being, leaders must take the time to become
fully aware of themselves, continuously assessing

their abilities, values, and areas needing develop-
ment. All leaders are different, and consequently,
when leading authentically and consistently
according to their character, all lead~rs practice
slightly different styles (George, 2003). Through
authentic self-knowledge, leaders develop the
strength to use their abilities to full potential and
with integrity, living what they believe at all times
and through all choices (Bailey, 1997).
2. Humility: A derivative of the word "humus," or
earth, "humility is the understanding of what one
believes in; it is transcending ego to resist the lure of
the trappings of authority" (Bailey, 2006, p. 299 ).
Leadership requires one to be grounded and c entered
in order to comprehend that individuals' inherent
value extends beyond title and place in society.
Humble leaders acknowledge that both criticism as
well as praise are part of the holistic quest for
understanding, and they recognize the unique natu re
of each being and acknowledge the necessity of
everyone in the organization as an important part of
this interconnected web (Freire, 1981).
3. Empathy: Empathy is "the self- knowledge that
comes from being able to 'hold' the perceptions and
the emotions of another" (Bailey, 2006, p. 300 ).
Being empathic requires a mindfulness "unfolding"
and moment-to-moment awareness when leaders
remain grounded and true to themselves, continu-
ously growing personally and professionally, while
at the same time opening their minds and hearts to
learn and know others more deeply (Kabat- Zinn,
2005). Social neuroscience has recently demon-
strated that human beings pos sess mirror neurons,
which recreate in one person's brain the neural
activity that is occurring in another's brain during
focused social exchanges (Goleman, 2006). These
neurons actually help to establish an empathetic
rapport between people that strengthens interac tions
and relationships.
4. Courage and Compassion: While these states of
emotion and action are usually thought of as
separate, the values of courage and compassion
complement and strengthen each other. With both
courage and compassion, leaders can make purpo-
seful, definite, and strategic decisions while at the
same time respecting the joys and struggles of
others. Furthermore, courage and compassion
embolden leaders to embrace the more challenging
paradoxes of life, providing an antidote to the
oftentimes resultant stressors that may show up in
diminished physical health (Sapolsky, 2004 ).
Together, they enable leaders to contemplate
LEADERSHIP 65
possibilities through opposition and appreciate the
bigger picture, the realities of the larger context in
which both strengths and challenges coexist.
5. Faith: As described by Bailey (2006), " the faith of
leadership is about living with uncertainty and
trusting that all that happens serves a higher good;
that there is a lesson to be learned in every pleasure
and every pain" (p. 300). Dispelling pop ular
misconnotations of the word, faith is not contrary to
reason; it does not ignore people and situations that
are dishonest or dangerous; and it does not inhibit
human beings from asking questions and developing
new knowledge. Faith can serve as the origin of
inspiration as well as the energy for continuing
efforts. It encourages leaders to think beyond the
known into the realm of opportunities not yet
conceived. Often, the source of organizations' most
effective vision statements is faith, as visions extend
beyond the present into future possibilities.
Although most organizations develop and tout vision
statements rather easily, faith is one of the most
difficult competencies to maintain because fe ar often
replaces it, especially with constant changes and
ambiguity in the world. While elements of fear will
always be present, leaders must embrace faith and
extend it to the others in their organizations as they
move forward in the complexities of life (Morris,
2007).
6. Patience: The patience of leadership applies to both
self and to others. It is the willingness to attend to the
needs and growth of all by partaking in deep
listening, acknowledging the context and
circumstances of each situation, and cultivating the
capacity to "restore ... and counter the destructive
efforts of power stress" (Boyatzis & McKee, 2005,
p. 72). Patience allows leaders to know how and
when to conserve and to prune, both in their
organizations as well as in their individua l lives,
trusting in the process.
7. Love: In the realm of leadership, the love that one
must nurture and share is best defined as "agape."
Agape goes beyond romantic and familial love; it is
a love for all simply because they exist, regardless of
their identities, actions, or associations (Bailey,
2006). Indeed, agape is the form of love that
engenders freedom (Freire, 1981), as demonstrated
through the lives of people that many consider
heroes. Agape love is the culmination of all of the
core competencies of leaders; it requires that leaders
have invested themselves in the process to live lives
as authentic, humble, empathic, coura geous,
compassionate, faithful, and patient beings.
66 LEADERSHIP
In sum, the spiritual components of leadership find their
roots in social work's earliest theories of expansive,
collective, process-oriented engagement with others.
Collectively, they form the requisite base upon whic h other
critically important areas of knowledge and skills can be
well-honed and most effectively used. Social work
leadership education offers a strong example of
multidisciplinary attention to relationships-between and
among organizations, structures, cultures, and indi vidual
people; yet in the current era of growing accountability
demands and downsizing, it must also consistently focus
on building morale and improving organizational
outcomes (Mizrahi & Berger, 2005; Patti, 2003). There-
fore, social work schools and departments must continue to
develop theories and practices that 'will provide and
support leaders for many yeats to come. Attending to
'leading from the spirit' advances these processes of
creation and resilience while recognizing that there will
always be much to learn about leadership from other fields
and disciplines to enhance our service to the world.
REFERENCES
Abrahamson, E. (1996). Management fashion. Academy of
Management Review, 21 (1),254-285.
Austin, D. M. (2000). Social work and social welfare administration:
A historical perspective. In R. Patti (Ed.), The handbook of social
welfare management (pp. 27-54). California: Sage Publications.
Bailey, D. (2006). Leading from the spirit. In F. Hesselbein & M.
Goldsmith (Eds.), The leader of the future 2: Visions, strategies,
and practices for a new era (pp. 297-302). San Francisco: J ossey -
Bass.
Bailey, D. (1997). Proceedings from: Advanced Leadership Institute
for Catholic Charities Directors. Florida: Franciscan Center.
Bailey, D., & Aronoff, N. (2004). The integration of multicultural
competency and organizational practice in social work education:
Recommendations for the future. In L. Gutierrez, M. Zuniga, & D.
Lum (Eds.), Education for multicultural social work practice:
Critical viewpoints and future directions (pp. 135-144).
Alexandria, VA: CSWE Press.
Bargal, D. (2000). The manager as leader. In R. Patti (Ed.), The
handbook of social welfare management (pp. 303-320). California:
Sage Publications.
Bass, B. M. (1990). From transactional to transformational
leadership: Learning to share the vision, Organizational Dynamics,
18(3), 19-31.
Boettcher, R. E. (1998). A study of quality managed human service
organizations. Administration in Social Work, 22(2), 41-56.
Bolman, L. G., & Deal, T. E. (1995). Leading with soul. San
Francisco: [ossey-Bass.
Bowers, D., & Seashore, S. (1966). Predicting organizational
effectiveness with a four-factor theory ofleadership. Admin-
istrative Science Quarterly, 11, 238-263.
Boyatzis, R. E., & McKee, A (2005). Resonant leadership.
Massachusetts: Harvard Business School Press.
Bryman, A (1997). Leadership in organizations. In S. R. Clegg, C.
Hardy, & W. R. Nord (Eds.), Handbook of organization studies
(pp. 276--292). California: Sage Publications.
Drucker, P. (1993). Managing the non-profit organization: Principles
and practices. New York: Harper Collins.
Ezell, M. (1991). Administrators as advocates. Administration in
Social Work, 15(40), 1-18.
Fielder, F. (1967). A theory of leadership effectiveness. New York:
McGraw-Hill.
Freire, P. (1981). Pedagogy of the oppressed. New York:
Continu~m.
Garrett, M. T. et al. (2001). Multicultural SuperVISION: A paradigm
of cultural responsiveness for supervisors. Journal of Multicultural
Counseling and Development, 29, 147-158.
George, B. (2003). Authentic leadership: Rediscovering the secrets to
creating lasting value. San Francisco: [ossey-Bass.
Goleman, D. (2006). Social inteUigence: The new science of social
relationships. USA: Bantam.
Gummer, B., & McCallion, P. (Eds.). (1995). Total quality
management in the social services. Albany: State University of
New York at Albany.
Hardina, D. (2002). Analytical skills for community organization
practice. New York: Columbia University Press.
Hasenfeld, Y. (1983). Human service organizations. Englewood
Cliffs, NJ: Prentice Hall.
Heifetz, R. A (1994). Leadership without easy answers.
Cambridge, MA: Belknap Press of Harvard University Press.
Holland, J. (1959). A theory of vocational choice. Journal of
Counseling Psychology, 6, 35-45.
Holland, J. (1962). Some explorations of a theory of vocational
choice. Psychological Monographs, 76(26), 1-545.
Holland, J. (1966). The psychology of vocational choice.
Waltham, MA: Blaisdell.
Kabat-Zinn, J. (2005). Coming to our senses: Healing ourselves and
the world through mindfulness. New York: Hyperion.
Kets De Vries, M. F. R., Vringnaud, P., & Florent-Treacy, E. (2004).
The global leadership life inventory. International Journal of
Human Resource Management, 15(3),475-492.
Loden, M. (1985). Feminine leadership, or how to succeed in business
without being one of the boys. New York: Times Books.
Mary, N. L. (1997). Linking social welfare policy and global
problems: Lessons learned from an advanced seminar. Journal of
Social Work Education, 33(3).
McFarlin, D. B., Coster, E. A, & Mogale-Prerorius, C. (1999).
South African management development in the twentyfirst
century: Moving toward an Africanized model. Journal of
Management Development, 18(1),63-78.
McGregor, D. (1960). The human side of enterprise. New York:
McGraw-Hill.
Meenaghan, T. M, Gibbons,W. E., & McNutt, J. G. (2005).
Generalist practice in larger settings: Knowledge and skill con-
cepts. Chicago, IL: Lyceum.
Mizrahi, T., & Rosenthal, B. B. (2001). Complexities of coalition
building: Leaders' successes, strategies, struggles, and solutions.
Social Work, 46(1), 63-78.
 LEGAL SYSTEM 67

Morris, J. (2007). The current leadership crisis and thoughts LEGAL SYSTEM
on solutions. In Mack, T C. (Ed.), Hopes and visions far the
21st century (pp. 250-263). Bethesda, MD: World Future
ABSTRACT: The law is a powerful force in all aspects of
Society.
contemporary American society. The legal system fur-
Owen, H. (1999). The spirit of leadership: Liberating the leader
nishes the context and procedures for the creation and
in each of us. San Francisco: Berrett-Koehler.
Palmer, P. (1998). The courage to teach: Exploring the inner enforcement of laws to resolve disputes, protect rights,
landscape of a teacher's life. San Francisco: jessey-Bass and generally to maintain order. Social workers are
Publishing. expected to understand the basic workings of the legal
Patti, R. (2000). The landscape of social welfare management. system. Knowledge of the legal system provides the
In R. Patti (Ed.), The handbook of social welfare management foundation to support social workers to undertake social
(pp. 3-25). California: Sage Publications. justice initiatives, to give voice to vulnerable client
Patti, R. (2003). Reflections on the state of management in populations, and to work for legal rules tha t support
social work. Administration in Social Wark, 27(2),1-11. good social work practice.
Perlmutter, F. D. (2006). Ensuring social work administration.
Administration in Social Wark, 30(2), 3-10.
KEY WORDS: constitution; federalism; social justice;
Pink, D. H. (2006). A whole new mind. New York: Berkeley
liberty; equality; civil rights; due process; balance of
Publishing Group. \
Quinn, R. E. (1988). Beyond rational management: Mastering powers
the paradoxes and competing demands of high performance.
San Francisco: jessey-Bass.
Rank, M. G., & Hutchison, W. S. (2000). An analysis of Introduction
leadership within the social workprofession.]ournalofSocial The practice of social work is influenced significantly Wark
Education, 36(3), 487-502. by the legal system through statutes, regulations, govReeves, C, & Bednar, D. (1994). Defining
quality: alterna- ernmental oversight, and decisions in court cases. In
tives and implications, Academy of Management Review, 19, addition, social policies are institutionalized, con-
p.419-445. trolled, and sanctioned by legislation at some level
Sapolsky, R. M. (2004). Why zebras don't get ulcers (3rd ed.). of the political system. The social work community
New York: Henry Holt and Company, LLC.
must be proactive so as to assure that legal mandates
Scharmer, O. C. (2007). Theory U: Leading from the future as
it emerges. Cambridge, MA: Society for Organizational support social work values or practice principles and
Learning. reflect the voices of all segments of society. Thus, an
Taylor, F. W. (1911). The principles of scientific management. essential part of the preparation and continuing
New York: Harper & Brothers. -:' education of social workers is learning about the
Wheatley, M. (1994). Leadership and the new science. San American legal system. This knowledge enables social
Francisco: Berrett-Koehler. workers to become engaged in making and reforming
FURTHER READING laws as citizen advocates, elected officials and gov
Fisher, E. A. (2005). Facing the challenges of outcomes ernment employees. Through knowledge of legal systems,
measurement: The role of transformational leadership. social workers become empowered to be activists, influencing
Administration in social wark, 29(4), 35-49. and setting sound and just social policy.
Mizrahi, T, & Berger, C. S. (2001). Effect of a changing health Chapin (2007) defines social policies as the laws, rules,
care environment on social work leaders: Obstacles and and regulations that govern the benefits and services provided
opportunities in hospital social work, Social Work, 46(2),
by governmental and private organizations to assist people in
170-182.
meeting their needs (p. 1). Social work scholars have long
Mulroy, E. A. (2004). Theoretical perspectives on the social
environment to guide management and community prac- understood that the legal system can be an important location
tice: An organization-in-environment approach. Admin- for policy change efforts (Albert, 2000). By their very nature,
istration in Social Wark, 28(1), 77-96. social policies are established and enforced by elements of the
Slavin, S. (Ed.). (1985). An introduction to human services legal system (Madden, 2003). Unfortunately, the legal system
management (2nd ed.). New York: Haworth Press. often is perceived by social workers as an uncomfortable,
adversarial environment to be avoided.
-DARLYNE BAILEY AND KATRINA M. UHLY It is viewed as the province of the rich and powerful, or at
least those with legal representation. However,
knowledge of the legal systems and the process by which
laws. are made opens the field to all who make the investment.
LEARNING DISABILITIES. See Disability: Neu-
rocognitive Disabilities.
68 LEGAL SYSTEM
Sources of American Law
The legal system of a country reflects important cultural
values and moral positions. In American law, liberty and
equality are fundamental values that are operationalized in
the structure and principles of the legal system. Laws may
be made at the federal, state, or local level by legislative
bodies, administrative agencies, and courts. However, any
study of the American legal system must begin with the
U.S. Constitution. Constitutionallaw articulates the
powers of a government and the organization, purpose,
authority, and legal principles that determine the
relationship of the government to the people (Madden,
2003). While there are many sources of American law, the
federal Constitution is the ultimate authority. This is
clearly stated in the Constitution in what is often caned the
Supremacy Clause:
"This Constitution, and the laws of the United States which shall
be made in pursuance thereof; ... shall be the supreme law of
the land; and the judges in every state shall be bound thereby."
(Article VI) .
The Constitution seeks to balance society's need for
order with its desire for liberty. It does this in three
primary ways. First, the Constitution sets up a series of
checks and balances on the three fe deral branches of
government: the executive, legislative, and judicial, so
that no one branch can exceed the powers granted to it
under the Constitution or subjugate the power of the other
branches. Second, the Constitution expressly lim its the
power of the federal government by allocating power
between the states and federal government. Final ly, the
Constitution limits governmental power through the
identification and protection of individual civil and
political rights, primarily found in the first 10 amend-
ments of the Bill of Rights. Each of these constitutional
principles is discussed in more detail here. Together they
form the legal ideals that embody important societal
values and provide structure to the legal system.
The tripartite design of Americ an government is
characterized by a balance of powers built on distrust of a
strong central authority in government. Congress can.
pass a law but it may be subject to a presidential veto or be
overturned by a court. The president can issue an
executive order or an administrative regula tion, but if it is
in violation of Constitutional principles, a court could
overturn it. Courts can invalidate statutes challenged in
legal cases but Congress could revise a law to fix
constitutional problems or to clarify th e workings of the
law.
On the federal level, Congress is authorized to make
all laws necessary and proper to execute its specified
powers. The powers, expressly enumerated in Article 1 ,
Section 8 of the Constitution, include the power to tax and
spend, to regulate interstate commerce, and to
maintain the national defense. Within the limited scope of
its powers, the Constitution preempts any state or local
legislature from establishing laws on subjects the federal
government regulates. For example, a single state could
not negotiate a treaty with a neigh boring country or
establish a tax on the commercial products of other states.
Federalism is a term that describes the relationship of
states to the federal government. It is believed by many
that a strong central government tends to con solidate
power and restrict individual rights. Moreover, in a
diverse country such as the United States, decision making
that is centralized is more removed from the context of
community and may not effectively meet the nee ds of the
local population. On the other hand, decision making that
is too decentralized can result in limited national identity,
widely varying standards, and conflicts between the laws
of various states. Federalism reflects a middle ground in
this continuum, with lim ited powers granted to the federal
government, and local control over such issues as health,
safety, and education. However, the glue that holds the
system together is the requirement that all state and local
laws and the decisions by all cou rts are consistent with
constitutional principles. The 14 th Amendment prohibits
states from making or enforcing any law that violates any
constitutional protections. This means that equal
protection under the law and due process protections, as
well as civil rights and individual liberties, are guaran teed
in every sphere of the American legal system.
The power of these Constitutional protections is also a
check against unbridled democracy. Consider what might
happen if a local town voted to exclude all c itizens of a
particular race or creed from holding public office. Such a
law might pass a democratic vote of the people of the
town, but the Constitution would prohibit this
discriminatory regulation. Judicial review is often the last
line of defense for maintaining consis tent standards across
all levels of the legal system. Similarly, the needs of a
minority population or a nonvoting group (for example,
children, the imprisoned, or persons with cognitive
disabilities) may not be met if the democratic vot e of the
majority is required. Policies to end discrimination or to
guarantee minority rights may not be passed on a popular
vote. Yet a court can require such policies on
constitutional grounds.
The Supreme Court established the doctrine of im plied
powers of the federal government in the case, McCulloch v.
Maryland (17 U.S. 316 [1819]). The doctrine allows
Congress to make laws that are necessary and proper for
carrying out the enumerated functions. In pre- Civil War
America, most federal legis lation involved interstate
commerce. In the 20th century,

the federal government in law enforcement, civil rights
and social services expanded enormously. However, since
conservative President Reagan's administration in the
1980s' congressional actions and Supreme Court rulings
have diminished the role of the federal government in
favor of state decision making.
Although the federal government has limited areas of
power to legislate, many social service initiatives emerge
out of the federal government because of the desire for
national standards combined with the opportunity for
funding programs in all states using the broad federal tax
revenues. The federal government often uses the incentive
of funding to establish standards and programs in each
state. For example, child welfare services had been an area
traditionally reserved for the states. The federal
government, through legislation passed by Congress,
names the Act and the year, provides funding for state
child welfare services. To receive this funding, each state
must abide by the standards tied to the funding, standards
that are developed by the executive branch through the
relevant administrative departments, for example, the
Department of Health and Human Services in the cas e of
child welfare.
The Constitution places limits on the government's
powers to restrict or interfere with individual liberties
known as the Bill of Rights. This includes first amendment
rights such as freedom of speech, freedom of religion, and
add right to bear arms, freedom from un reasonable
searches, among others. The Constitution, abetted by
clarifying decisions of the Supreme Court, establishes
procedural devices to ensure the protection of individual
rights. Before a person's property or liberty may be
restricted by a government action, due process is required.
This means the individual has the right to a fair hearing.
For example, before the government can perform a search
or seizure, or issue a warrant, probable cause must be
established. Similarly, before a public benefit is
terminated, a client has a right to a hearing on the matter.
How Law is Made
Law emerges from legislative, executive, and judicial
branches at the federal, state, and local levels of gov-
ernment. It is important for a social worker to under stand
what issues are decided at what level and by what branch
of government in order to influence the process. Each
branch of government has specific areas of power
although the principle of legislative supremacy holds that
the primary law-making branch is the legislature, while the
judicial executive branches are required to interpret, apply,
and enforce statutes.
The legislative branch has responsibility for estab-
lishing laws through the passage of statutes and
ordinances. In most legislatures, specialized committees
LEGAL SYSTEM 69
study proposals and develop the language of proposed
legislation before voting to move a bill to the whole
legislative body. As part of the committee process,
testimony by experts can provide legislators with the facts
to inform their votes. Much legislation is written in general
language. A statute often authorizes a parti cular
administrative agency to develop regulations that fill in the
details of how a program will operate or how a rule will be
enforced. The courts are often called on to determine if a
particular statute applies to the facts of a case or whether
an administrative regulation exceeds the scope of the
legislation.
The executive branch gives powers to the chief
operating officer of the government. The chief executive,
whether that be a president, governor, or mayor, exercises
powers that include managing the various administrative
agencies that provide government services. While the
executive branch generally develops a budget for the
relevant unit of government, it is up to the legislative
branch to appropriate the funds and come to agreement
with the executive branch concerning revenues and
expenses.
The role of the judiciary includes the interpretation of
statutes, regulations, and procedures through rulings called
case law. Courts are not able to take on legal questions
outside of a legitimate case. In other words, a court must
rule on a specific controversy properly under its
jurisdiction. Federal cases are limited to issues invol ving
federal laws or disputes between parties from different
states (diversity jurisdiction). Federal courts can also rule
on whether a state law or action is Constitutional. The
jurisdiction of a court is established by the federal or state
Constitution and through legislative action. In recent years,
states have passed legislation to establish specialized
courts for difficult social issues such as drug courts and
domestic violence courts where judges and support
personnel are trained to manage the issues of the affected
population. Statutes and actions of the government may be
interpreted by courts if the case raises a challenge to them.
Stability and Change in the Law
Whether a case involves a contract dispute, a criminal
charge, a divorce, or a civil suit, the courts apply the law to
the facts of the case to determine the outcome. At times,
the facts are presented to a jury who, guided by the judge's
explanation of the law, decides the outcome of the case.
Other times, such as in juvenile and family courts, it is the
judge who is the trier of both the facts and the law. The
outcome of most cases, while important to the participants,
has very little lasting significance for the legal system or
the public. Court structure is hierarchical, the lowest level
being the trial
70 LEGAL SYSTEM
courts. For a case to have precedential value, it must be
reviewed by an appellate court.
Most appeals to higher courts involve questions of law
that one side feels have been incorrectly decided at triaL
The appellate process at the federal level and in most state
systems is a tiered system. An appeal to an intermediate
appellate court and subseque ntly to a supreme court is the
usual sequence with the higher courts having the power to
overrule lower court rulings. The U.S. Supreme Court is
the ultimate authority on a legal question while a state
supreme court would be the authority on issues related to
state law, provided they do not violate the Constitution.
Because appellate and supreme courts are deciding issues
of law, their decisions provide guidance as to the validity,
scope, and interpretation of the law. In legal terms, the
principle of stare decisis guides their decisions. Courts are
expected to analyze previous decisions made by courts
within the same jurisdiction to make decisions consistent
with the established law in most cases. At times, courts
will decide that a legal principle must b e overruled or that
the particular facts of a case are somehow different from
established case law and thus should be decided differ-
ently. The process of constructing this argument is the
foundation of legal reasoning: analyzing and distin-
guishing the facts, arguing the relevance of applicable
laws, or contending that the present case is analogous to
another set of cases in order to convince a court to find for
one's client. The public goal is to have like cases decided
alike but the law is a living proce ss, evolving as societal
needs and values change.
Civil and Criminal Law Systems Jurisdiction of
a court is not limited to the location of the case or the
federal or state issue being litigated. Courts are organized
and procedures are specialized to respond to cases
involving civil issues such as lawsuits, family matters,
contract disputes, and the like, and alleged violations of
criminal statutes. In large part, the differences in
procedures reflect a higher level of protection for the
person accused of a crime since a guilty verdict will result
in a sanction imposed by the government such as
imprisonment, probation, or a fine. As noted earlier, our
individual liberties protect us from inappropriate exercise
of governmental powers and so criminal courts have a
higher standard of proof than most civil matters. Criminal
cases must be proven beyond a reasonable doubt while
most civil cases can be won on a preponderance of the
evidence.
The Litigation Process
Litigation begins with the filing of the case with the court
clerk. At this point, an attorney may begin the
discovery process by issuing subpoenas to potential wit-
nesses. A deposition generally occurs in the lawyers'
offices and is the opportunity for the witness, under oath,
to give information likely to be asked in court. Collecting
this information allows the attorneys t o decide whether to
proceed to trial or to seek a settlement of the case. It also
enables the attorneys to prepare the case for triaL During
the pretrial phase, motions may be made by the attorneys
to dismiss or otherwise limit the scope of the case. At tr ial,
the evidence is presented and witnesses are examined and
cross examined. In some cases, the trial is heard in front of
a judge; in other cases, a jury is selected to evaluate the
facts and to apply the law to decide the case. At any time
during the trial, the sides might agree to a settlement or a
judge may decide to dismiss a case or to find for one side.
Once a case has been decided, a party may choose to file
an appeal of the decision if it is felt that the case was
wrongly decided due to an error by the judge in applying
the law.
Social workers play an active role in legal cases
involving clients. They may be asked to serve as wit nesses
in cases such as custody disputes, competency hearings,
civil suits, and even criminal trials. Often social work ers
receive a subpoena to submit records, or to testify in a
deposition or a hearing. Social workers most often appear
as fact witnesses in a case, providing direct information to
the court. In some cases, a social worker who is qualified
may be asked to provide expert testimony to the court
concerning specialized or tech nical knowledge necessary
for understanding the context of the case. Social workers
often assume significant roles to help a client survive and
navigate legal system involvement. These ro les can
include advocacy, education and support (Madden, 1998 ).
In addition to working on the legal cases of individual
clients, social workers assume roles in legal policy
practice. Legal policy is developed in class action lawsuits
and other litigation that affects social policies, as well as
legislative and administrative law settings where new laws
are developed and refined. Social workers can supply
testimony, provide data, assume political roles, and enable
legal policy makers such as judges and l egislators to hear
the stories of clients to influence decisions that affect
clients' lives.
[See also Criminal Justice: Overview; Juvenile Justice:
Overview.]
REFERENCES
Albert, R. (2000). Law and social work practice (Znd ed.).
New York: Springer.
Chapin, R. (2007). Social policy for effective practice: A strengths
approach. New York: McGraw-Hill.

Madden, R. G. (1998). Legal issues in social work, counseling and
mental health: Guidelines for clinical practice. Thousand Oaks,
CA: Sage.
Madden, R. G. (2003). Essential law for social workers. New York:
Columbia University Press.
FURTHER READING
Alexander, R. (2003). Understanding legal concepts that influence
sodal welfare policy and practice. Pacific Grove, CA: Thomson,
Brooks Cole.
Dickson, D. T. (1995). Law in the health and human services.
New York: Free Press.
Reichert, E. (2003). The role of law in social work and human rights.
New York: Columbia University Press.
Salzman, A., & Furman, D. (999). Law in social welfare practice.
Belmont, CA: Wadsworth Group.
Stein, T. J. (2004). The role, of law in social work practice and
administration. New York: Columbia University Press.
SUGGESTED LINK Centerfor Law
and Social Policy. http://www . clasp
.org/
Federal Court Information Documents.
http://www . uscourts .gov/UFC99 . pdf
Find Law.
http://www·findlaw.com/
Jurist Legal Dictionary.
http://jurist.law.pitt.edu/dictionary .htm Internet
Law Library.
http://www.lawguru.com/ilawlib/index .html
Legal Information Institute, Cornell.
http://www.law.comell.edu/
-ROBERT G. MADDEN
LEGISLATIVE ADVOCACY. See Political Inter-
ventions; Political Process; Political Social Work.
LESBIANS. [This entry contains two subentries: Over-
view; Practice Interventions.]
OVERVIEW
ABSTRACT: This entry provides an overview of re search
on lesbians in the United States using an over arching
framework of oppression and empowerment. Historical
and current demographic and cultural infor mation about
lesbians will be reported, along with an analysis of
personal and environmental factors critical to social work
practitioners' ability to enhance the well being of lesbian
individuals, couples, and families.
KEY WORDS: lesbian; oppression; lesbian health; les-
bian sexuality; lesbian policy
LESBIANS: OvERVIEW 71
There are different definitions of the term "lesbian."
Researchers have based definitions on women's (a)
same-sex attractions, (b) same- sex sexual behavior, (c)
same-sex emotional or romantic attachments, (d)
self-proclaimed identity, and/or (e) associatio n with the
larger lesbian community (Parks, Hughes, &
Werkmeister-Rozas, in press). Although some research ers
restrict the term to women who exclusively engage in
sexual and/or romantic relationships with other women,
others include women who have also had sex ual or
romantic relationships with men. Rust (1992) found that
women with similar sexual histories self identified
differently, as lesbian or bisexual, confirming that sexual
identity does not necessarily reflect sexual experience.
Here, the term lesbian includes each of these definitions
(attraction, emotional attachment, sexual behavior,
personal identification, or community identifica tion).
It is challenging to quantify the number of lesbians in
the United States. The 2000 U.S. Census is perhaps the
best national count; yet, it only recognized cohabit ing
couples who self-identified as "unmarried partners."
Nevertheless, 297,061 lesbian couples identified them-
selves. Most of these couples were White (76.6%), with
12.4% Black, 12.7% Hispanic, 1 % Native American, 2.1
% Asian, 4.8% other races, and 2.8% multiracial. The
Census revealed that the average age of American lesbians
is 42.8 years and that almost one-third of les bians had
given birth, with higher rates in rural states. Yet, these
statistics obscure the diversity of lesbian experiences and
identities, especially those who are single and/or do not
disclose their sexual orientation (Brown & Knopp, 2006).
Lesbian Identity Development
Lesbian and gay identity development has been con-
ceptualized primarily through stage models. The earliest
models were specific to gay men or were originally
intended for men but later generalized to lesbians. Cass's
six stage model (1979) was among the most influential ,
underpinning much of the later identity de velopment
theories. During the first stage, identity confusion, a
woman realizes she may differ from the dominant,
heterosexual culture; in identity comparison, she accepts
the possibility that she may be lesbian; and in identity
tolerance, she acknowledges that she is prob ably lesbian
and seeks community with other lesbians. The last three
stages are identity acceptance, in which she accepts
herself as lesbian and identifies with lesbian culture;
identity pride, when she expresses anger with the
dominant, heterosexual culture and may come out to more
people; and identity synthesis, where she fully integrates
her lesbian identity into her life.
72 LESBIANS: OVERVIEW
Later models, including those of Coleman, Troiden, and
Minton and McDonald (cited in Liddle, 2007), each altered
Cass's work somewhat. All models follow the individual
from their initial sense of being different, through
intermediate stages of beginning to understand their
identity, and end with a perception of self wher ein sexual
identity is but one component (Liddle, 2007).
McCarn and Fassinger's model (1996) was a depar ture
from earlier individualistic identity development models.
Drawing from racial/ethnic identity develop ment literature,
they argued that identifying as lesbian involves not only
understanding one's sexuality, but also comfortably
identifying as part of a minority group. These concurrent
processes involve four developmental phases: awareness,
exploration, deepening/commit ment, and
internalization/synthesis. As a lesbian moves through these
phases, her individual and group identi ties may develop at
the same rate, or at different paces- it is possible for a
lesbian to be comfortable in her relationship with a
particular woman (phase three) and simultaneously feel
awkward navigating the lesbian community (phase two).
Unlike earlier models, McCarn and Fassinger do not
believe these phases are linear, but rather see the phases as
a heuristic for describing the dyn amic process of disclosure
and identification lesbians experience throughout their
lives.
Most of these models were developed nearly 30 years
ago, when lesbians and gay men had fewer role models,
less social support, and were still developing a definitio n of
homosexuality based on difference rather than pathology.
Subsequent generations may find these mod els do not
reflect their processes of coming to terms with their
sexuality. Studies of sexual- minority youth have found that
stage theories are more app ropriate to young gay men than
young lesbians, and that contextual in fluences of race,
ethnicity, geographical locale, culture, class, religious
affiliation, and other forces shape the sexual identity
development experiences of youth, especially young
women. Savin-Williams and Diamond (2000) found that
young lesbians were more likely to face sexual identity
development milestones later than young gay men, with the
exception of disclosure. Lesbians were also more likely to
have an emotionally oriented bas is for milestones, as
opposed to a sexually oriented basis for young gay men;
were less likely to have had sex before claiming lesbian
identity; and were more likely to initially identify as
bisexual before identifying as lesbian. All sexual- minority
youth averaged 10 years between first same- sex attraction
(age 10 for girls) and first disclosure.
The achievement of these milestones also differs by
race and ethnicity. Parks, Hughes, and Matthews (2004 )
found that African American and Hispanic
lesbians were likely to take longer than whites between
wondering about their sexual orientation and claiming a
lesbian identity. Lesbians of color also disclosed to fewer
people outside of family than white lesbians.
While identity development theories tend to defin e
sexual orientation as a static and essentialist identity, there
is "proliferating evidence for fluidity, circum stance, and
even choice in same-sex sexuality, particu larly among
women" (Diamond in Parks et al., in press). Rust (1992 )
found that two-thirds of lesbians have some attraction to
men, and 43% have had romantic relationships with men
since identifying as lesbian. Social workers must help
women negotiate their iden tities and be open to redefinition
of identities over time.
History of Oppression and Advocacy
The history of lesbians in the United States is a tale of
oppression, informal and formal organizing, and advo cacy,
shaped by national and regional cultures that have been
heterosexist (assuming that heterosexuality is the normal,
preferred, or only sexual orientation) and homophobic
(treating homosexuality as vile, frighten ing, or
threatening). The telling of this tale is compli cated by the
hidden nature of lesbian lives. The term "lesbian" is recent
(c. 1883), and, given the heterosexis t and homophobic
nature of American history, few his torical figures openly
claimed their sexual orientations. Yet, researchers have
identified some women who lived in emotional and
perhaps physical relationships with other women. This
section will explore the different characteristics of
oppression (Young, 1990) American lesbians have faced
and the methods they have used to fight oppression,
identifying important lesbian figures in American social
welfare history.
Cultural imperialism exists when dominant group
norms render the oppressed group as stereotypical or
invisible. In the mid-1800s, the Cult of True Woman hood
dominated the American cultural landscape, pre scribing
limited, procreative roles for women. Women who
criticized the female role, such as Mary Wollstone craft,
Frances Wright, and Harriet Matineau, were condemned in
1838 by a minister as "only semi- women, mental
hermaphrodites" (Katz, 1983, p. 140). While not
necessarily lesbians, they were characterized as such in an
attempt to denigrate them.
In the later 1800s, young upper-class women at tended
institutions of higher learning and some devel oped
"romantic friendships." Some later created same- sex
households, often called "Boston marriages" because of
their popularity in the Eastern Unite d States. These
relationships were initially ignored or characterized as
harmless. Women working in the new field of social work,
such as settlement house leader

Jane Addams, social reformers Frances Kellor and Mary
Drier, and child welfare advocates Jessica Taft and
Virginia Robinson, all maintained such same-sex rela-
tionships (Messinger, 2006).
Within the next decade, public acceptance of Freu-
dian and sexologists' theories of homosexuality as per-
version or disease decreased the acceptance of romantic
friendships. The characterization of homosexuality as
disease led to the marginalization of lesbians. Upper-
class lesbians responded creatively by establishing lit-
erary societies, women's clubs, and lesbian friendship
circles, while working-class lesbians utilized bars and
speakeasies to connect one another (Messinger, 2006).
During the two world wars, bars continued to be a
central meeting place for lesbians. Yet, bar owners were
routinely harassed and denied liquor licenses, and some
states and localities passed laws forbidding the congre-
gation of homosexuals. Many lesbians served in the
military and worked in factories, but homophobic po-
licies required them to be discreet. Lesbians found
themselves powerless, without the ability to affect pol-
icy change in local law enforcement or the larger arena
of American politics.
In the decade after World War 11, the American
public stopped seeing same-sex behaviors as individual
transgressions and focused more on homosexuality as
an identity (D'Emilio, 1983, p. 4). The American
Psychiatric Association identified homosexuality as a
mental disorder in the first Diagnostic and Statistical Manual
of Mental Disarders (DSM-l) in 1952 (Bayer, 1987). The
McCarthy-driven anticommunist movement emerged
during this time. The House Un-Arnerican Activities
Committee targeted homosexuals as potential com-
munists. "Sexual perverts" were seen as national secur-
ity risks, so the FBI conducted "widespread surveillance
of the gay and lesbian world" (D'Emilio, 1983, p. 124 ).
The majority of state legislatures passed sexual psy-
chopath laws that officially recognized homosexuality
as a socially threatening disease. These institutional
persecutions were mirrored by medical violence, as
doctors tried to cure lesbians and gay men by using
experimental treatments such as psychotherapy, hypno-
sis, castration, hysterectomy, . lobotomy, electroshock,
aversion therapy, and the administration of untested
drugs (p. 18).
A new pro-gay organizing strategy, labeled The
Homophile Movement, emerged as a response to these
oppressive practices. D'Emilio (1983) characterizes the
Homophile Movement as focused predominantly on
helping gay men and lesbians assimilate, rather than
fighting for legal and political change. The first homo-
phile group, the Mattachine Society, worked as a sup-
port group for the concerns and needs of gay people,
LESBIANS: OVERVIEW 73
though it was established and run by gay men. In re-
sponse, Del Martin and Phyllis Lyon and three other
lesbian couples established the Daughters of Bilitis
(OOB) in San Francisco in 1955 (O'Emilio, 1983),
which maintained a focus on the needs and concerns of
lesbians. In 1956, the group began publishing The
Ladder, its magazine for lesbians. .
The Civil Rights Era ushered in bolder activism and
advocacy for lesbians and gay men. Gay men like Frank
Kameny and lesbians such as Barbara Gittings led pick-
eting of the White House, the Pentagon, and all gov-
ernment installations, protesting the treatment of gay
men and lesbians (Faderman, 1991). Organizing and
advocacy among lesbians and gay men emerged in
campuses, small towns, cities, and throughout the
country. This activism came to a head with the
Stonewall Riot in New York City in 1969, when a gay
bar was raided by local police and the patrons-drag
queens, gay men, and some butch lesbians-fought back.
The Gay Liberation era began.
The face of gay organizing also changed in the 1970s
with the emergence of a new group: lesbian feminists- .
-young, college-educated, politically aware, and more
militant and activist organizers. Lesbian femin ist groups
were established because feminist groups were "too
straight and the Gay Liberation Front was too male"
(Sears, 2001, p. 110). Lesbian feminists were involved
in creating battered women's shelters and rape crisis pro-
grams, as well as other social services programs for
women.
Over time, lesbians were excluded from women's
liberation groups, many of which they had helped cre ate.
The exploitation oflesbian activist labor by heterosexual
feminists was most blatant when, in 1970, Betty
Friedan, the executive director of the National Organi-
zation for Women (NOW), urged the defeat of a NOW
resolution supporting lesbian rights, labeling lesbians
"the Lavender Menace" (Messinger, 2006).
Faced with this rejection, some lesbian feminists
founded separatist groups, advocating purposive
separation from men and coed political and social
organizations as a way to evade and overcome
patriarchal institutions. Lesbian feminists created new
lesbian cultures through the establishment of presses for
lesbian literature, magazines, and newsletters; lesbian
communes; women's bookstores; and "women's musi c"
companies and music festivals for lesbian singers and
songwriters (Morris, 1999).
All of this political and social activism coalesced in
the first National March on Washington in October
1979. Planned by representatives of the various seg-
ments of LGBT communities and their allies, more than
100,000 participants attended the March (Messinger,
2006).
74 LESBIANS: OVERVIEW
In the wake of the Match, a new coordinated
political/religious movement began, taking aim at the
gains of the LGBT communities (Gilgoff, 2007). Calling
themselves the "Moral Majority," a coalition of
evangelical, fundamentalist, and conservative Chris tians
organized in late 1979 to bring conservative religious
beliefs into political organizing and advocacy. F oremost
on the agenda of political and social issues was restricting
rights and advances of LGBT populations. While the
Moral Majority was formally disbanded in 1989, it gave
rise to the development of many new religiously oriented
political groups over the next two decades, including the
American Family Association, the American Center for
Law and Justice, the Christian Coalition, the Family
Research Council, Focus on the Family, and the
Traditional Values Coalition.
Gay men and lesbians worked closely ag ain during the
emerging AIDS crisis in the late 1980s and 1990s. Facing
inaction by the federal government, a number of
AIDS~specific voluntary organizations were created by
1982, including the San Francisco AIDS Foundation,
AIDS Project Los Angeles, and Gay Men's Health Crisis.
The continuing fight for LGBT rights and federal
recognition and funding for HIVjAIDS provided the
impetus for the second National March on Washington for
Lesbian and Gay Rights on October 11, 1987. The AIDS
quilt, a memorial to people who had died from the disease,
was displayed on the National Mall that weekend,
covering a space larger than a football field and including
1,920 panels. Two days later, more than 600 LGBT people
were arrested at the largest civil disobedience event ever
held at the U.S. Supreme Court (Messinger, 2006).
While cultural imperialism, marginalization, power-
lessness, violence, and exploitation persist for lesbians in
the United States, lesbian women and organizations have
creatively responded to these challenges through personal
and case advocacy, social support, communication
education, community development, political advocacy,
and social change movements.
Lesbian Relationships and Families
As the 2000 U.S. Census revealed, many American
women are in same-sex relationships, though formal
recognition of these relationships varies across the United
States. As of July 2007, Massachusetts is the only state that
offers same-sex marriage. Civil unions are available in
Vermont, Connecticut, New Hampshire, an d New Jersey,
while same-sex couples can register for domestic
partnerships in California, the District of Columbia,
Hawaii, Maine, Oregon, Washington, and numerous cities
and towns. None of these state or local laws make it
possible for lesbian couples to access
federal- level benefits, such as filing joint tax returns,
social security, or transferring property or money to each
other without tax liability. This is because the federal
Defense of Marriage Act (OOMA) defined marriagefor the
federal government as only the union of a man and a
woman. The law was enacted in 1996 when Hawaii
seemed poised to legalize same-sex marriage; it also
allows states to refuse recognition of same-sex marriages
performed in other states (Messinger, 2006).
Relationship recognition by the state seems more
important to lesbians than gay men. Within the first year
(2004-2005) that marriage was open to same- sex couples
in Massachusetts, 65% of the over 6,100 samesex couples
married were lesbian couples (Greenberger & Neuwahl,
2005). Two-thirds of the Vermont Civil Unions recorded
in 2000-2002 were made by women, with the percentage
of women increasing to 70% in 2003 (State of Vermont ,
2005). Possible reasons for why lesbians seem more
interested in pursuing marriage than gay men include
women's socialization regarding marriage, lesbians' higher
rate of parenthood and desire to legally protect children,
and the higher rate of longterm relationships among
lesbians.
Forming and Developing Relationships Friendship
circles are hallowed within the lesbian community, and
many women describe their chosen families of close
friends and former lovers as their primary support systems.
Being socialized as women to connect emotionally and
value intimacy, it is not unexpected that many lesbians
describe relationships where the lines between friendship
and dating are blurred and romantic attachments develop
quickly (Parks & Humphreys, 2006). Perhaps due to the
lack of legal recognition and social sanction, lesbians may
look within their relationships for support and nurturing at
the exclusion of outside supports. This fusion, although
having protective functions, in the extreme can lead to
enmeshment where partners have difficulty maintaining
unique identities and expressing needs outside the
relationship (Slater, 1995). Nonetheless, studies have also
shown that lesbians are more likely than heterosexual
couples to split household tasks equally, to share decision
making, and to maintain autonomy in their relationships
(Parks & Humphreys, 2006).
Recognizing that society's heterosexist assumptions
and lack of support for sexual minorities place stress upon
lesbians and their relationships, Slater (1995) developed
the Lesbian Family Life Cycle to frame how lesbian
relationships develop across the lifespan, and how they are
both similar to and different from heterosexual
relationships. Slater's stages are similar to most
mainstream relationship models: couple formation,

ongoing couplehood, middle years, generatrviry, and
couples over 65. Lesbian couples, however, move
through these stages differently than heterosexuals, pri-
marily because traditional models assume that couples
marry in their early to mid-20s. In contrast, most lesbian
couples do not settle into long-term relationships until
their late 20s or 30s, and those with children usually
begin this process later, as welL
Parenting
The 2000 Census identified that 34.3% of female cou-
ples had children under 18 in their household, with rates
often much higher for lesbians of color (Cahill, Ellen, &
Tobias, 2002, p. 14). Most lesbians have chil dren
through prior heterosexual relationships, althou gh
growing numbers choose some form of donor
insemination. Lesbian families are also formed through
foster parenting and adopting domestically or
internationally. While lesbian couples may adopt jointly
in a handful of states, in other states one partner adopts
as a single parent and the second partner completes a
second parent adoption (where allowed) after the first
partner's adoption is finalized. To date, only the state of
Florida explicitly prohibits lesbians and gay men from
adopting, while most others do not ask about sexual
orientation but maintain formal or informal policies
prohibiting unmarried or same-sex couples from
adopting. International adoption laws are similarly
disparate. The Convention on Protection of Children and
Co-operation in Respect of Intercountry Adoption
attempts to regulate the conditions under which children
maybe adopted outside their birth country. An important
portion of the Convention is instituting the "best
interests of the child" as a primary criterion for matching
children with adoptive parents. Use of this standard may
eventually influence countries with restrictive adoption
laws to permit adoption by homosexual individuals and
couples (Parks & Humphreys, 2006).
The role equity observed within lesbian couples also
generally carries over to parenting responsibilities. In
most other ways, children of two lesbian parents are
indistinguishable from their counterparts in intact het-
erosexual homes, although they seem to be more toler ant
of difference among their peers, and more protective and
nurturing toward younger children (Pawelski et al.,
2006).
Ironically, society's heterosexist assumptions may
work to benefit single lesbians as they interact with their
children's health care providers, schools, and other
institutions. People will likely assume a lesbian is a
heterosexual single parent. In lesbian couples, the
partner who is not a biological mother may be asked to
prove parental status before being allowed to act in a
LESBIANS: OVERVIEW 75
parental capacity. Regardless of composition, all lesbian
families should use powers of attorney, wills, and guar-
dianship agreements to create a legal framework pro-
tecting their families.
Lesbian Income and Employment
A perception exists that gays and lesbians are wealthier
than the general population. This is because market
research in the 1990s artificially inflated gay and lesbian
income levels and perpetuated the belief that few gays
and lesbians have children. Economist M.V. Lee
Badgett demonstrated that they are far from being an
economically privileged group. Badgett (2001) found
that while individual lesbian's earnings are similar to
heterosexual women's, lesbian couples earn less than
heterosexual couples primarily because men's incomes
tend to be 25-30% higher than women's incomes. In
reality, the estimated average income of individual
lesbians is $35,813 (22% less than gay men).
Each time lesbians meet new people, they face issues
of disclosure. As they consider whether to disclose their
sexual orientation in workplace settings, lesbians must
decide when to come out, who to come out to, and how
to come out. Concerns about firing and harassment are
common. Not being out can be stressful, though, and
people who are out at work report higher satisfaction
and productivity (Human Rights Campaign, 2006).
Lesbians in the United States are not federally pro-
tected as a class from employment discrimination.
Although a 2001 Gallup poll showed the vast: majority
of Americans (85%) believe that lesbians and gay men
deserve equal opportunity in employment (Human
Rights Campaign, 2006), the Employment Non-
Discrimination Act (ENDA) has twice failed to pass
through Congress. ENDA would prohibit employment
discrimination based on sexual orientation and give
lesbians a means of redress if they have experienced
discrimination because of their sexual orientation. De-
spite lack of movement at the federal level, some
progress has been made at state and local levels. By
2006, 17 states, the District of Columbia, and 167 cities
and counties nationwide had enacted employment
protections for lesbians and gay men; 13 states, the
District of Columbia, and 201 cities and counties
provide benefits for domestic partners of public
employees. Despite government hesitance,
nondiscrimination policies and family benefits for
same-sex partners have become common at large cor-
porations. As ofJune 2006,51 % of Fortune 500 compa-
nies offered domestic partner benefits, and 86%
included sexual orientation in their nondiscrimination
policies (Human Rights Campaign, 2006).
Discrimination against gay men and lesbians in em-
ployment has specific implications for members of the
76 LESBIANS: OVERVIEW
U.S. armed forces. When President Clinton signed Don't
Ask, Don't TeU (DADT) in 1993, it was intended as a step
forward from the outright ban on gays and lesbians in the
military. Under the law, gays and lesbians could serve in
the military as long as they did not make their sexual
orientation known to their fellow soldiers, and
commanders were forbidden to ask about soldiers'
orientation. The numbers of soldiers discharged has risen
steadily since DADT was instituted, with women being
disproportionately targeted-accounting for 30% of those
discharged, despite composing only 14% of personnel.
Support is building for repeal of DADT, with a 2003
Gallop Poll reporting that 79% of Americans now favor
allowing gays and lesbians to serve in the armed forces
(Servicemembers Legal Defense Network, 2004).
Health and Mental Health
Research comparing lesbians' health and well-being with
those of heterosexual women has identified im portant
similarities and differences: Lesbians are less likely to
have health insurance, disclose their sexual identity to
health care providers, or utilize preventative health care,
such as pap smears, although those with serious health
problems sought care. Lesbians may be at increased risk
for breast cancer, cervical cancer, uterine cance r, and
endometrial cancer, but it is not understood whether the
increased risk is due to lesbians' less frequent medical
screening and care, lower rates of childbearing, and/or the
stress of living in a homophobic society. In
population-based surveys, lesbians report higher rates of
obesity, smoking, and alcohol and drug use, which leave
them at increased risk for cardiovascular disease, diabetes,
and breast cancer (Ryan & Gruskin,2006).
Lesbians' reluctance to seek health care is under-
standable in light of several studies examining health care
professionals' training and attitudes regarding sexual
minorities. In a national survey, 9 out of 10 lesbian or gay
physicians reported witnessing care of lesbian and gay
patients that was biased in some way (Schatz & O'Hanlon,
as cited in Ryan & Gruskin, 2006). A survey of
Midwestern medical students found that 28% believed
homosexuality to be immoral, and 15% reported negative
feelings toward homosexuals because of AIDS (Klamen,
Grossman, & Kopacz, as cited in Ryan & Gruskin, 2006).
Lesbians commonly report feeling that their health care
provider seemed uncomfortable with them, was unable to
provide information on sexual health outside of the
context of a heterosexual relationship, or did not t ake time
to discuss their unique health needs. Lesbians may want to
consider obtaining medical care through lesbian and gay
health clinics or
women's health clinics that specialize in providing medical
care to sexual minority populations.
Generally, lesbians have similar mental health con-
cerns and strengths as heterosexual women. They do,
however, experience deeper social stigma and stressors
due to society's homophobia and heterosexism. The
pressure of this stigma has been associated with higher
rates of depression, substance abuse, and anxiety than the
general population (Ryan & Gruskin, 2006). Within the
lesbian community, youth and elders are likely to
experience more intense struggles than those experienced
by lesbian women in midlife. Lesbian youth may
experience isolation, rejection, and harassment at school.
When coupled with the emotional upheaval typical of
adolescence, these issues greatly increase youth's risk for
negative outcomes, including leaving school, running
away from home, and attempting suicide. Gay- straight
alliances have been successful in providing lesbian
students with a caring environment to share their concerns,
find friendship, and be accepted for who they are (Ryan &
Gruskin, 2006).
Lesbian elders often face profound isolation with the
loss of their partners and support systems. This is espe-
cially true for women who came of age before lesbians
could be open about their sexuality and who may never
have had the opportunity to form friendships with les bians
other than their partner (Ryan & Gruskin, 2006). A number
of cities with large lesbian populations have established
retirement and assisted living facilities for lesbian elders,
providing community and companionship.
Despite these troubles, the majority oflesbians in all
phases of life do not experience mental health difficul ties
outside the norm for their cohort. On the contrary, lesbians
likely possess the emotional resilience to main tain their
sense of self in a society that acknowledges them
grudgingly, if at all.
While same-sex sexual behaviors are not the only
determinant of sexual identity in lesbians, sexual ex-
pression and sexual health are important components of
lesbians' lives. A recent study of lesbian, bisexual, and
heterosexual women (Nichols, 2005b) revealed that sex
between women lasts longer, is more varied, and in cludes
more sex acts likely to lead to orgasm. Women who have
sex with women are less likely to have sex because their
partner wants it, and more likely to have orgasms during
sex with their partner than are women who have sex with
men, regardless of marital status or length of relationship.
There is a myth that when lesbians decide to begin a
sexual relationship, they naturally know each other's
preferences because they are both women. Lesbians come
to relationships with varied experiences and needs, just as
heterosexual couples do, and it is equally

important for them to spend time in: advance of a sexual
encounter sharing any personal history that an intimate
partner should be aware of.
Another common misperception is that lesbians face
little risk of contracting sexually transmitted diseases ;
many lesbians fail to use safer sex practices for this
reason. While the incidence of STDs among women
who have sex with other women is lower than among
women who have sex with men, there is evidence that
the former group can transmit human papillomavirus,
bacterial vaginosis, and trichomoniasis to one another.
Importantly, since most lesbians have had sex with a
man at some point in their lives, it is possible for them to
contract an STD that they may later pass on to their
female lovers'. It is important for lesbians to negotiate
which safer sex practices they will use. Safer sex
practices for lesbians include using latex or plastic
barriers during oral sex, placing condoms on sex toys,
not sharing sex toys without washing them or changing
the condom, and monogamy (Boston Women's Health
Book Collective, 2005).
The phrase "lesbian bed death" came to prominence
within the lesbian community in the 1980s after several
researchers reported that established lesbian couples
have less frequent genital sexual contact than either gay
male or heterosexual couples. More recently, how ever,
feminist therapists and researchers have questioned this
idea, arguing it arose from heterosexist and
phallocentric assumptions within sex therapy that
pathologized lesbian sexuality. A primary issue is how
sex is defined-limited to genital touching resulting in
orgasm or inclusive of diverse sensual activities?
Nichols (200Sa) reports that women generally require a
longer period of time than men to become sufficiently
aroused for orgasm, and prefer a variety of touching
besides genital contact. She suggests that sex between
women lasts longer than sex between gay male or het-
erosexual couples, and includes a variety of activities
that lead to orgasm. "Lesbian bed death," Nichols con-
cludes, may be simply another myth.
Religion and Spirituality
For many people, spirituality represents their sense of
connection to the universe, nature, and other people, a
sense of wholeness. Religion is a "social vehicle"
(Morrow & Tyson, 2006) through which spirituality can
be channeled. As a social institution, religion has had
great power in shaping social life. Religion is also a tool
through which heterosexism has impacted spiritual
practices. Motivated by heterosexist beliefs, many reli-
gious organizations refuse to sanction same-sex
relationships, ordain lesbians and gay men to the
ministry, or allow clergy to minister to sexual minority
congregants.
LESBIANS: OvERVIEW 77
Religious traditions with strong antigay posmons
include the Roman Catholic Church, Orthodox Judaism,
Islam, the Church of Jesus Christ of Latter- Day Saints
(Mormons), and the Southern Baptist Church. Those
with more accepting practices include the United
Church of Christ, the Episcopal Church, Unity, Quaker
Friends, Reform Judaism, and Unitarian Uni versalists.
The National Baptist Convention, Church of God in
Christ, and African Methodist Episcopal Church have
no formal position on homosexuality, but have been
slow to address issues that are important to lesbians
(Morrow & Tyson, 2006).
Many Christian lesbians have found religious com-
munity within the Universal Fellowship of Metropolitan
Community Church and the Unity Fellowship Church
Movement, two Christian denominations explicitly for
LGBT people. Unless they live ina larger city, lesbians
from other faith traditions may have more difficulty
locating a welcoming religious community. A number
of organizations, including the World Congress of Gay,
Lesbian, Bisexual and Transgender Jews and the Gay
and Lesbian Arabic Society, have established Internet
websites with links to local resources and groups.
Challenges for
Social Work Practice with Lesbians
Social workers, especially lesbian practitioners, face
specific challenges in practice with lesbian individuals,
families, and communities. Lesbian social workers have
to struggle with questions of disclosure in the face of
heterosexism and homophobia, as well as their own
internalized homophobia, in social work practice
settings (Messinger, 2004). Further, lesbian social
workers who provide services to lesbian clients may
need to negotiate multiple relationships with these
clients (for example, professional, social, and personal),
especially when they are in smaller lesbian communities
(Kessler & Waehler, 2005). In negotiating these
challenges, lesbian social workers have little support, as
many cannot identify lesbian professionals to act as
mentors and consultants, and the body of scholarship on
issues facing lesbian practitioners is still small (Van
Voorhis & Wagner, 2001).
It is important for all social workers to work with
lesbians as unique individuals, couples, families, and
communities. Lesbian clients should be able to define
their own interests, strengths, challenges, and needs.
Social workers should also reflect on their biases as they
approach work with lesbian clients and consistently
seek to educate themselves about lesbian identity de-
velopment, lived experiences, cultures, and commu-
nities. Only through this education can social workers
serve lesbian communities and improve lesbian lives.
78 LESBIANS: OVERVIEW
REFERENCES
Badgett, M. V. L. (2001). Money, myths, and change: The economic
lives of lesbians and gay men. Chicago, IL: The University of
Chicago Press.
Bayer, R. (1987). Homosexuality and American Psychiatry: The
politics of diagnosis. Princeton, NJ: Princeton University Press.
Boston Women's Health Book Collective. (2005). Our bodies,
ourselves: A new edition for a new era. New York: Simon and
Schuster.
Brown, M., & Knopp, L. (2006). Places or polygons? Govern-
mentality, scale, and the Census in the Gay and Lesbian Atlas.
Population, Space, and Place, 12,223-242.
Cahill, S., Ellen, M., & Tobias, S. (2002). Family policy: Issues
affecting gay, lesbian, bisexual, and transgendered families. New
York: National Gay and Lesbian Task Force.
Cass, V. (1979). Homosexual identity formation: A theoretical
model. Journal of Homosexuality, 4(3),219-235.
D'Emilio, J. (1983). Sexual politics, sexual communities: The ma~ing
of a hoTnosexual minority in the United States, 19401970.
Chicago, IL: University of Chicago Press.
Faderman, L. (1991). Odd girls and twilight lovers: A history of
lesbian life in twentieth centlfry America. New York: Columbia
University Press.
Gilgoff, D. (2007). The Jesus machine: How James Dobson, Focus
on the Family, and Evangelical America are winning the culture
war. New York: St. Martin's Press.
Greenberger, S. S., & Neuwahl, J. (2005, May 5). Same-sex
marriages slow, studies show. Boston Globe.
Human Rights Campaign. (2006). The state of the workplace for gay,
lesbian, bisexual and transgender Americans 2005-2006.
Washington, DC: Human Rights Campaign Foundation.
Katz, J. N. (1983). Gay/lesbian almanac: A new documentary.
New York: HarperCollins.
Katz, J. N. (1978). Gay American history: Lesbians and gay men in
the U.S.A. New York: Harper and Row.
Kessler, L. E., & Waehler, C. A. (2005). Addressing multiple
relationships between clients and therapists in lesbian, gay,
bisexual, and transgender communities. Professional Psych-
ology: Research and Practice, 36(1), 66-72.
Liddle, B. J. (2007). Mutual bonds: Lesbian women's lives and
communities. In K. J. Bieschke, R. M. Perez, & K. A. DeBord
(Eds.), Handbook of counseling and psychotherapy with lesbian,
gay, bisexual and transgender clients (pp. 51-69). Washington,
DC: American Psychological Association ..
McCarn, S., & Fassinger, R. (1996). Revisioning sexual minority
identity formation: A new model of lesbian identity and its
implications for counseling and research. The Counseling
Psychologist, 24(3), 508--534.
Messinger, L. (2006). An historical perspective. In D. F.
Morrow & L. Messinger (Eds.), Sexual orientation and gender
identity in social work practice (pp. 27-63). New York:
Columbia University Press.
Messinger, L. (2004). Out in the field: Gay and lesbian social
work students in field placement. Journal of Social Work
Education, 40(2/3), 187-204.
Morris, B. J. (1999). Eden built by Eves: The culture of women's
music festivals. Los Angeles, CA: Alyson Books.
Morrow, D., & Tyson, B. (2006). Religion and spirituality. In D.
Morrow & L. Messinger (Eds.), Sexual orientation and gender
expression in social work practice: Working with gay, lesbian,
bisexuall1nd transgender people (pp. 384-404). New York:
Columbia University Press.
Nichols, M. (2005a). Is "lesbian bed death" for real? The Gay &
Lesbian Review, 12(4), 18-20.
Nichols, M. (2005b). Sexual function in lesbians and lesbian
relationships. In 1. Goldstein, C. M. Meston, S. Davis, & M.
Traish (Eds.), Female sexual dysfunction. London:
Parthenon Publishing.
Parks, C. A., Hughes, T. L., & Werkmeister-Rozas, L. (in press).
Defining sexual identity and orientation in research with
lesbians and gay men. InJ. Martin & B. Meezan (Eds.),
Handbook of research with gay, lesbian, bisexual and transgender
populations. Binghamton, NY: Haworth Press.
Parks, c., & Humphreys, N. (2006). Lesbian relationships and
families. In D. Morrow & L. Messinger (Eds.), Sexual orien-
tation and gender expression in social work practice: Working with
gay, lesbian, bisexual and transgender people (pp, 216242).
New York: Columbia University Press.
Parks, C. L., Hughes, T. A., & Matthews, A. K. (2004). Race/
ethnicity and sexual orientation: Intersecting identities.
Cultural Diversity and Ethnic Minority Psychology, 10(3),
241-254. .
Pawelski, J., Perrin, E., Foy, J., Allen, c., Crawford, J., Del
Monte,.M., et al. (2006). The effects of marriage, civil union,
and domestic partnership laws on the health and well-being of
children. Pediatrics, 118(1),349-364.
Rust, P. C. (1992). The politics of sexual identity: Sexual
attraction and behaviour among lesbian and bisexual women.
Social Problems, 39(4), 366-386.
Ryan, c., & Gruskin, E. (2006). Health concerns for lesbians, gay
men, and bisexuals. In D. Morrow & L. Messinger (Eds.),
Sexual orientation and gender expression in social work practice:
Working with gay, lesbian, bisexual and transgender people (pp.
307-342). New York: Columbia University Press.
Savin-Williams, R. c., & Diamond, L. M. (2000). Sexual identity
trajectories among sexual-minority youths: Gender
comparisons. Archives of Sexual Behavior, 29, 419--440.
Sears, J. T. (2001). Rebels, rubyfruits, and rhinestones: Queering
space in the Stonewall South. New Brunswick, NJ: Rutgers
University Press.
Servicemembers Legal Defense Network. (2004). Conduct un-
becoming: Tenth annual report on Don't ask, don't tell, don't
pursue, don't harass. Washington, DC. Available online at
http://www .sldn.org/templates/ dadt/record.html ?section =
22&record = 1411.
Slater, S. (1995). The lesbian family life cycle. New York: The Free
Press.
State of Vermont. (2005). State of Vermont Vital Statistics.
Available online at http://healthvermont.gov/research/
stats/2003 /2003vital.aspx.
Van Voorhis, R., & Wagner, M. (2001). Coverage of gay and
lesbian subject matter in social work journals. Journal of Social
Work Education, 37, 147-159.
Young, 1. M. (1990). Justice and the Politics of Difference. Prince-
ton, NJ: Princeton University Press.

SUGGESTED
LINKS Gay Demographics.
http://www .gaydemographics .org
Gay events timeline: 1970-1999. Sexual Orientation Issues in the
News. http://www.usc.edu/schools/annenberg/asc/projeets/soin/enhan-
dngCurricula/timeline .html
GLBT National Help Center.
http://www.glnh.org/
Human Rights Campaign.
http://www.hrc.org
Lesbian feminist chronology: 1963-1970.
http://www.womeris-studies.ohio-state.edu/araw/chronol.htm Lesbian
Herstory Archives.
http://www .lesbianherstoryarchives .org/
National Center for Lesbian Rights.
http://www.nclrights.org \ identity development, or progression, for lesbians. Phase
National Lesbian and Gay Taskforce.
http://www . thetaskforce .org/
-LORI MESSINGER AND JENNIFER WHEELER BROOKS
PRACTICE INTERVENTIONS
ABSTRACT: This entry will provide an overview of
psychosocial issues and social work intervention rele vant
to working with lesbians. Practice issues related to the
impact of heterosexism, coming out, lesbian iden tity
development, and lesbian couple and family forma tion
will be discussed. Assessment and intervention methods
appropriate for social work practice with les bians will be
addressed.
KEY WORDS: identity development; adolescents; fam-
ilies; diversity; interventions
Lesbians are women whose intimate attractions are to
other women. Lesbians compose rv4-12% of the U.S .
population (Gates & Ost, 2004; Green, 1994; Patterson ,
1995). Some are single, some are in partnered relation-
ships, and many are also parents. Lesbians are impacted
daily by the pervasive social stigma assigned to sexual
minority people. This stigma is made manifest through
homophobia, the fear and hatred of gay and lesbian people,
and heterosexism, the belief in the superiority of a
heterosexual orientation over lesbian and gay orientations
(Morrow, 1996a). The effects of these forms of
oppression permeate virtually all facets of les bian and gay
lives. Yet, many social workers have lim ited preparation
for serving lesbian clients, even though such preparation
is called for in social work education standards (Council
on Social Work Education, 2004).
Lesbian Identity Development Recognizing
and coming to terms with one's identity as lesbian is a
lengthy process. Heterosexism confers legal,
LESBIANS: PRAcncE INTERVENTIONS 79
political, and social privilege on those who identify as
heterosexual and concomitant negation of those who
identify as lesbian or gay. Therefore, to develop a posi tive
lesbian identity, lesbians must engage in the pro cess of
critically examining the effects of heterosexism on their
lives. They must work to dismantle the nega tive
stereotypes and untruths perpetrated against them and seek
to affirm and validate their own existence as lesbian
women.
Numerous models of lesbian identity development
have been proposed (Chapman & Brannock, 1987;
McCarn & Fassinger, 1996; Ponse, 1978; Raphael, 1974 ;
Sophie, 1986), the most recent of which is by McCarn and
Fassinger(1996). Their model proposes four phases o f
one, awareness, relates to a person's increasing awareness
of being different from the dominant heterosexual culture.
One's prior assumptions of heterosexuality are called into
question. There is a growing awareness that
heterosexuality is not universal- that there are other forms
of sexual orientation other than heterosexuality.
Phase two, exploration, involves continued critical
examination of a lesbian identity in relation to pre-
sumptive heterosexuality. Women in this phase may
demonstrate strong feelings for other women. They may
actively pursue knowledge about lesbian and gay people,
and they may nurture their interest in the possibility of
developing group membership with other lesbians ..
In phase three, deepening or commitment, there is a
growing sense of individual identity characterized by
further clarity and self-understanding as lesbian. Crit ical
examination of the effects of heterocentric culture and the
related social oppression of those who identify as lesbian
also occurs. In further describing this phase of
development, McCarn and Fassinger (1996) state, " The
emerging lesbian is likely to recognize her desire for other
women as within herself and, with deepening
self-awareness, will develop sexual clarity and commit-
ment to her self-fulfillment as a sexual being" (p.523).
Phase four is known as internalization or synthesis.
This phase involves a deepening self- acceptance of one's
personal identity as lesbian. A woman in phase four has
clarity and focus about who she is as a lesbian. Her
internal and external expressions of identity are integrated
and she exhibits a synthesis of her sexual identity with the
external world.
Assisting lesbians with moving through the pro cesses
of identity development can be an essential feature of
social work intervention with this popula tion. A
strengths-based perspective is an appropriate intervention
framework, given the oppressive impact
80 LESBIANS: PRACTICE INTERVENTIONS
of heterosexism. Facilitating client understanding that
coming to terms with a lesbian self-identity is a norma-
tive and progressive process can be empowering.
Assisting clients in critically examining the forces of
heterosexism in their own lives is an important step
toward beginning to dismantle its power.
Coming Out
Coming out, or disclosure, is a common issue for many
lesbians seeking social work intervention. Disclosure
may be defined as the acknowledgment of a lesbian (or
gay or bisexual) identity to oneself and then to others.
Disclosure is often positively correlated with
progression through the stages, or phases, of identity
development (Cass, 1979; Kahn,' 1991; Morrow,
1996b). That is, the farther ,Hong a person is in accept-
ing herself as lesbian, the more likely she is to disclose
that identity to others.
Social workers may observe there is a great
variability in the degree of "outness" among lesbians.
Appropriate intervention is individually driven, as each
individual has a right to self-determine her personal
degree of outness. Workers can assist clients with ex-
amining the consequences of disclosure for given
contexts-for example, outness at work or with one's
family of origin. Berzon (2001) suggests there are two
principal reasons for disclosure. The first is the personal
growth that can accompany being honest about oneself,
and the second is the political power in being part of a
visible lesbian or gay community. Berzon states, "The
changes that are needed in social policies and in laws in
order to improve the quality of life for gay people have
come only when there was a political and economic gay
and lesbian constituency that was visible and iden-
tifiable" (2001, p. 28). Other motivating factors for
disclosure include the desire to preserve a sense of
integrity and honesty within oneself and when inter-
acting with others (Harry, 1993), an interest in main-
taining openness and closeness in communicating with
others (Ben-Ari, 1995a; Cramer & Roach, 1998), an
interest in increasing one's self-confidence and in
developing an improved self-image (Rhoads, 1995) ,
and a desire to avoid the social and psychological
effects of secrecy and falsehood (Ben-An, 1995a; Cain ,
1991; Harry, 1993).
Reasons that people give for avoiding coming out
include fear of rejection (Elliott, 1996; Harry, 1993) ,
fear of being physically harmed (Elliott, 1996), fear of
discrimination and harassment (Rhoads, 1995), and a
desire to. protect loved ones from the stress that disclo-
sure may bring (Ben-An, 1995b; Boon & Miller, 1999).
A particularly stressful coming out event for lesbian and
gay people is disclosure to patents (Boon & Miller,
1999). Social workers are prudent to keep in mind that
the greatest predictor of outness among lesbians is their
perception of other people's acceptance of lesbian and
gay people in general (Franke & Leary, 1991). Workers
can help clients assess the potential climate of accep-
tance or rejection of disclosure to others. They can also
help clients develop and rehearse disclosure statements, .
as well as help them formulate responses to potential
rejecting statements. Additionally, they can assist les-
bian' clients considering disclosure and make connec-
tions with affirming community resources, such as
PFLAG (parents, family, and friends, of lesbians and
gays) and to the Human Rights Campaign National
Coming Out Project (Morrow, 2006a).
Lesbian Adolescents
In transitioning from childhood to adulthood, adoles-
cents engage in the task of identity development
(Erikson, 1950, 1963). For lesbian adolescents, the pro-
cess carries added challenges in that their developing
sense of lesbian identity is imbued with stigma. Thus, a
principal task for lesbian adolescents is to adjust to the
social stigma assigned to being lesbian (Hetrick &
Martin, 1987). Their sense of self as lesbians is devel-
oped in the midst of intense social pressure to be het-
erosexual. Lesbian adolescents have few adult rale
models and few social resources to assist them in
developing a positive identity ..
Many lesbian youth go through a questioning period
before arriving at an internal understanding of who they
are as lesbians. Because of the overwhelming social
pressure to be heterosexual, lesbian youth often present a
history of attempts at other-sex relationships prior to
identifying as lesbian (Coleman & Remafedi, 1989).
They may fear that being same-sex identified is
pathological, and they may fear the social repercussions
of being "found out" as lesbian by others. Some may
cope by engaging in .risky behaviors such as sexual
promiscuity, substance abuse, running away, or suicide
(Gonsiorek, 1988; Morrow, 2006b; Proctor & Graze,
1994; Savin-Williams, 1994).
A particular challenge, and risk, for lesbian adoles-
cents is coming out to family. Those who disclose to
families hope for greater honesty, closeness, and sup-
port. Yet, they are also at- risk for rejection and violence
by family members (Teague, 1992). The risk of rejec tion
can be especially high in minority families where being
gay may carry a particularly intense stigma (Newman &
Muzzonigro, 1993). There is some evidence that lesbian
and gay youth who have a close relationship with their
families may be more reluctant to disclose their sexual
orientation because of fear of disappointing their loved
ones (Waldner & Magruder, 1999). Such

youth may experience more internal pressure to try and
meet the heterosexual expectations held by family.
D'Augelli, Hershberger, and Pilkington (1998) found
that, of those lesbian and gay youth who disclose to
families, they are more likely to come out to mothers than
to fathers. In a sample of over 100 lesbian and gay youth
who had disclosed to families, only half the mothers and
siblings were accepting of the news, and that less than 25%
of fathers were accepting. Youth who disclosed their
sexual orientation were at greater risk of violence from
family members. Thus, social workers are prudent to
recognize the potential risks for lesbian youth in coming
out to families.
Social work intervention with lesbian adolescents
includes helping them explore their emerging sexual
identity in a safe and affirming environment. Psychosocial
education related to lesbian identity development, coming
out, and healthy relationship development can be valuable.
Helping lesbian youth recognize, under' stand, and cope
with the effects ofheterosexism can also be beneficial.
Because of the social stress that accorn panies being lesbian
in a heterocentric social culture, assessment of lesbian
youth should include screening for depression, suicide, and
substance abuse. In addition, assessment with lesbian
adolescents should include ex, ploring family supports, as
well as assessing for a history of violence or abuse based
on the adolescent's sexual orientation (Morrow, 2006b).
Lesbian Relationships and Families Heterosexual
culture supplies a bounty of legal, social, and religious
sanctioned rituals to demarcate relation, ship and family
development (Human Rights Cam, paign, 2003; Johnson,
2000; Parks, 1998; Slater & Mencher, 1991). Many of
those rituals, such as legal marriage and two, parent legal
guardianship of children, are not available to lesbian
relationships and families in most states. This lack of social
recognition is note, worthy in that how people view
themselves is influenced, in part, by how they are viewed
by the larger social context in which they exist. To a great
extent, lesbian relationships and families are rendered
socially invisible. Lesbians must learn to build their
relation, ships and families within a culture that denies
their very existence. Partnered relationships are dismissed
as" friendships and lesbian parents are questioned in terms
of who is the "real" mother of a child.
The term, fusion, has been proposed to describe the
nature of some lesbian relationships. Fusion relates to a
deep connection between the members of the couple,
whereby healthy individual boundaries may become
compromised by an overemphasis on the coupled identity,
and individual identity becomes overshadowed
LESBIANS: PRACTICE INTERVENTIONS 81
(Burch, 1985; Krestan & Bepko, 1980; Lowenstein,
1980). A critical examination of the concept of fusion in
more recent years, however, has supported the prem ise
that fusion is a functional adaptation by lesbian couples for
coping with a negating social environment (Laird, 1993 ;
Mencher, 1990; Slater & Mencher, 1991). When
threatened by external forces such as religious and legal
sanctions, a "circling of the wagons" to protect the
integrity of the coupled relationship is a reasonable
adaptation. Whenever the outer world is threatening,
greater energy is directed toward the more validating inner
world of the couple relationship.
Nonetheless, such adaptation may still be stressful for
couples. Social work intervention with couples can include
helping them establish connections with validating
external supports, such as lesbian-affirming social groups,
friendship networks, and faith communities, so that
couples can nurture healthy individual bound aries as well
as preserve the integrity of the coupled relationship.
Evidence also supports that affirmation of lesbian couples
by friends and family helps to reduce characteristics of
fusion and enhance couple satisfaction (Caron & Ulin,
1997; Eldridge & Gilbert, 1990; Parks & Humphreys,
2006).
Researchers have found that lesbians as parents tend to
value the equitable distribution of parenting and household
responsibilities (Patterson, 1995; Sullivan, 1996). This
finding contrasts with traditional heterosexual relationship
patterns in which women are ex, pected to have greater
involvement than men in both parenting and household
responsibilities. Patterson (1995) found this more
equitable distribution of responsibilities was beneficial to
the family adjustment of both parents and children.
Children of lesbian parents tend to fair as well as
children of heterosexual parents in terms of normative
development. In studies of children reared by lesbian
parents compared with children reared by heterosexual
parents, no significant differences were found with re gard
to gender identity (Patterson, 1992), intellectual
development (Flaks, Ficher, Masterpasqua, & Joseph,
1995; Green, Mandel, Hotvedt, Gray, & Smith, 1986),
behavioral problems (Flaks et al., 1995; Lewis, 1980), and
overall psychological adjustment (American
Psychological Association, 2004).
Social work intervention with lesbian families in'
eludes, above all, validation of the family experience.
Similar to any couple, regardless of sexual orientation,
lesbian couples may seek support for coping with the stress
of family life and parenting. In addition, inter' vention with
lesbian families must recognize the impact of
heterosexism on the family. Workers may be called on to
advocate for equitable legal treatment of lesbian
 82 LESBlANS:PRAcnCE INTERVENTIONS
women involved in child custody battles-especially when
the status of their sexual orientation per se is under attack.
Social work advocacy on behalf of legal recognition of
lesbian relationships and lesbian families is critical to
preserving the security and continuity of lesbian fa milies
and their children.
Older lesbians are an especially isolated and closeted
population. They came of age in an era when being gay
was presumed to be mental illness. Institutional set tings,
such as assisted living centers and nursing homes, are
decidedly heterosexist in nature. There is little place for
the recognition of lesbian couples and fa milies, including
the option for lesbian couples to share a room together.
Social work interve~tion in these and
. related medical settings often centers on validation of a
lesbian presence and advocacy for the inclusive and
equitable treatment of lesbians and their families.
Health Issues
Encountering heterosexism and homophobia on a virtu ally
daily basis can have an impact on lesbian health and
well-being. The internalization of social shame related to
being lesbian can be a risk factor for the occurrence of
substance abuse (Bobbe, 2002; Garofalo, Wolf, Kessel ,
Palfrey, & DuRant, 1998), depression (Ryan & Gruskin,
2006), and suicide (Hershberger & D'Augelli, 1995;
Remafedi, Farrow, & Deisher, 1991). Therefore, social
work assessment and intervention with lesbian women
should address these areas of concern.
Health care delivery systems have generally been
perceived as unreceptive to lesbians (Ryan & Gruskin,
2006). Medical forms often exclude the recognition of
lesbian relationships and families. Health care provi ders
presume heterosexuality among women pati ents.
Lesbians may refrain from disclosing their sexual orien-
tation to healthcare providers for fear of being ostra cized
and viewed as deviant. Antigay bias has been found in
both physician (Schatz & O'Hanlan, 1994) and nurse
(Eliason, 1998) attitudes toward lesbian and gay patients.
Lesbians seeking options for parent ing have reported
discrimination from reproductive healthcare providers
(Ryan & Gruskin). Social workers in healthcare settings
can provide diversity training for staff on sexual
orientation topics, and workers can also advocate for
creating more inclusive health care environments (for
example, inclusive medical forms, recognition of
partnered relationships).
Some concerns have been raised regarding a poten tial
higher risk for breast cancer among lesbians in
comparison to heterosexual women. However, research to
date has not supported a higher incidence (Ryan &
Gruskin, 2006). Findings, however, have concluded that
lesbians are less likely to receive preventive healthcare
such as mammograms and gynecological examinations
that can lead to early detection of cancer (Cochran, et al.,
2001).
An important health issue for lesbians is the use of
conversion (also known as reparative) therapy for the
purpose of changing a person's sexual orientati on from
lesbian or gay to heterosexual. Conversion therapies often
occur within the context of socially conservative religious
traditions. Techniques used to try and change sexual
orientation include religious- based shaming, prayer,
exorcism, and punishment-oriented forms of behavior
modification (Ritter & O'Neill, 1989; Tozer &
McClanahan, 1999; White, 1995). Conversion ther apy is
considered an unethical form of practice by a number of
national professional associations, including the National
Association of Social Workers, the American Counseling
Association, the American Psy chological Association,
and the American Medical Association (Haldeman, 1994 ;
Jenkins & Johnston, 2004; Tozer & McClanahan, 1999).
Intervention with lesbian clients seeking to change their
sexual orientation to heterosexual is better focused by
helping them explore and respond to the internal and
external homophobia ~nd heterosexism that creates shame
and guilt surrounding their sexual orientation.
Religion and Spirituality
Intervention with lesbian clients must recognize the
personal and cultural impact of religion and spirituality.
Most Americans are reared with some sort of connec tion
to religious or spiritual ties. As a social institution,
religion has long been a tool of hete rosexism and
oppression against lesbians and gay men (Davidson,
2000; Hilton, 1992; McNeill, 1993; Spong, 1991, 1998 ).
Indeed, the term, "family values," is for many people a
code-phrase representing anti-gay and lesbian social and
political perspectives. Many lesbians struggle with their
sexual minority status in relation to their faith community
teachings on "homosexuality. This struggle can create a
significant amount of distress when lesbians perceive they
have to choose between their sexual orientation and their
religious tradition.
Especially in larger urban settings, lesbian- affirrnative
worship services are available. For those who wish to
maintain ties to lifelong religious denominations while
also challenging the heterosexism within these institu-
tions, social workers can assist them with accessing affir-
mative groups such as Dignity (Catholic), Integrity
(Episcopalian), More Light (Presbyterian), Affirmation
(Mormon, also United Methodist), Friends for Lesbian
and Gay Concerns (Quaker), Seventh Day Adventist

Kinship International (Seventh Day Adventist), the
Work Congress of Gay and Lesbian Jewish
Organizations for Jews (Jewish), and Evangelicals
Concerned (Evangelicals) .
While some lesbians may nurture their spirituality
through more traditional forms of religion, others seek
avenues such as Native American spirituality that his-
torically honors both the feminine and masculine in all
(TaFoya, 1997; Wilson, 1996). In addition, feminist
forms of spirituality are important to many lesbians.
Themes of finding one's personal spiritual voice and of
liberating oneself from patriarchal and heterosexist
forces are common in feminist spirituality (Johnson,
2000).
Social workers must be prepared to recognize and
honor the personal and social influence of religion on
the well-being of lesbian clients. Workers can assist
lesbian clients who wish to explore the impact of reli-
gion as a tool of social injustice. They can also support
lesbian clients by validating their personal religious
narratives and by providing reference lists of affirming
faith communities and of affirming clergy as sources for
pastoral care.
Multicultural and Diversity Considerations
Diversity in the form of sexual orientation is also ac-
companied by diversity across other dimensions of hu-
man expression, including race, ethnicity, gender
expression, socioeconomic class, political perspective,
physical ability, and religion. Lesbians represent a range
of gradations across these representations of diversity.
In addition to navigating a dominant heterocentric
culture that denies their sexuality, lesbians must also
cope with the institutional sexism that comes with their
status as women. Lesbians of color carry the added
challenge of racism. They often encounter racism within
predominately Caucasian lesbian communities and
homophobia within predominately heterosexual com-
munities of color. It is neither fair nor healthy to have to
choose between minority statuses in order to gain socia l
validation and support.
African American and Latino communities-both of
which are dominated by relatively conservative re-
ligious traditions-are often less accepting of a lesbian
orientation in comparison to Anglo communities
(Smith, 1997; Snider, 1996). Asian cultures also view
lesbianism as rejection of the important role of parent-
hood (Chan, 1993). Lesbian youth in ethnic minority
cultures can be especially vulnerable and invisible
(Morrow, 2006b).
Social workers must be mindful of the cumulative
nature of multiple oppressions when serving lesbians.
Garnets and Kimmel (1993) propose a number of
themes from the literature relative to assessment and
LESBIANS: PRACTICE INTERVENTIONS 83
intervention with diverse lesbian and gay client groups,
including recognizing the importance of religion within
respective cultures and its relevance for personal beliefs
about sexuality; understanding the nature and influence
of family structure across diverse communities; and
reconciling the fit for individuals across personal ethni-
city, gender, and sexual orientation.
Social Work Practice Interventions
There are a range of general social work practice meth-
odologies that tend to fit well with assessment and
intervention with lesbians. Cognitive behavioral ap-
proaches (Balsam, Martell, & Safren, 2006; Weersing &
Brent, 2006), motivational interviewing (Harper &
Hardy, 2000; Knight, McGowan, & Dickens, 2006), and
psychoeducation (deGroot, Lloyd, & King, 2003; Gold-
berg, Fristad, & Gavazzi, 1999; Guajardo & Anderson,
2007) have all been identified as effective evidence-
based practice methods across a variety of populations
and problems. Each of these modalities can likely be
utilized with lesbian populations, although further re-
search is needed to substantiate or refute their efficacy
with lesbians in particular. In addition, feminist theore-
tical perspectives (Hyde, 2003; Orme, 2002; Saulnier,
2000) may be useful for helping lesbians critically
examine and respond to the impact of sexism in
combination with heterosexism and other forces such as
racism and able ism. For example, Mercier and Harold
(2003) propose a feminist approach for exploring the
intersection of lesbian mothers and social systems.
An ecological systems perspective (Lum, 2005;
Siporin, 1980; Zastrow & Kirst-Ashman, 2007) can be
useful to assist lesbians in responding to the multisyste-
mic influences of heterosexism in their lives. And
finally, a strengths perspective (Davis, 1993; Greene &
Ephross, 1991; Maton, Schellenback, Leadbetter &
Solarz, 2004) can be useful for engendering personal
power and efficacy in lesbians who, too often, are sys-
tematically disempowered by the impact of internal and
external heterosexism.
Determining the best evidence-based practices for
working with lesbians, however, is still in the beginning
stages. By definition, evidence-based practices rely on
empirical investigations to determine which modalities
work best with specified populations and problems
(Gilgun, 2005). To date, little such research has been
conducted on best-practice methodologies among les-
bian populations. Thus, there is a clear need for re search
that will more accurately determine which practice
interventions work best with lesbian clients addressing
specific life challenges.
A hallmark of social work practice is advocacy for
the rights of socially marginalized groups. In honoring
84 LESBIANS: PRACTICE INTERVENTIONS
this professional value of social justice, soc ial work
intervention must address the personal and systemic
impact of homophobia and heterosexism on the lives of
lesbians. Social workers should seek to validate les bian
individuals, couples, and families and also to pro vide
them services that are equi table to services that are
rendered to presumed heterosexual clients. Institu tional
and political advocacy must address ways to make laws
and social institutions more equitable for lesbians and
other sexual minority groups. And research on
empirical-based intervention methodologies must be
more inclusive of lesbian samples in order to better
determine which intervention methods best serve this
population.
CURRENT CHALLENGES AND CONTROVERSIES The lack of
legal recognition of same-sex relationships remains a
significant challenge impacting lesbians. At the time of
this writing, Massachusetts is the only state in the United
States where marriage between same-sex couples is legal.
Civil unions are recognized in Vermont, Connecticut, Hew
Hampshire, and New Jersey; and domestic partnerships
are recognized in California and Oregon (Human Rights
Campaign, 2007). Yet, numerous other states have enacted
constitutional amendments or state laws that solidify their
resolve to withhold legal recognition of same-sex rela-
tionships. The lack of legal sanctioning for same-sex
relationships further impacts related family issues such as
joint adoption, second-parent adoption, inheritance rights,
and domestic partner insurance benefits.
The absence of federal legislation to prohibit discri-
mination on the basis of sexual orientation is also a
human rights concern for lesbians. For instance, les bians
and gay men continue to be terminated from military
service in the United States solely b ecause of their sexual
orientation. Because of this lack of federal protection,
efforts to prevent discrimination on the basis of sexual
orientation have been piecemeal and inconsistent across
most states and local municipalities. Thus, advocacy for
federal protection against discrimi nation on the basis of
sexual orientation remains a major challenge.
Even in the midst of such legal challenges, however,
the future is encouraging. Many major businesses in the
United States have chosen to offer domestic par tner
benefits-despite the present lack of a federal mandate for
equal inclusion. The Employment Nondiscrimina tion Act
to prevent employment-based discrimination
- because of sexual orientation is moving through Con-
gress. Lesbians are increasingly visibl e in the media and
in the political arena. And, advocacy for equal rights for
all people, including lesbians, grows ever stronger.
REFERENCES
American Psychological Association. (2004). On marriage rights
for same sex couples. Retrieved December 13,2006, from
httpllwww.hrc.org.
Balsam, K. F., Martell, C. R., & Safren, S. A. (2006). Affirmative
cognitive-behavioral therapy with lesbian, gay, and bisexual
people. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally
responsive cognitive-behavioral therapy: Assessment, practice and
supervision. Washington, DC: American Psychological
Association.
Ben-Ari, A. (1995a). The discovery that an offspring is gay:
Parents' gay men's, and lesbians' perspectives. JouTTIilI of
Homosexuality, 30(1), 89-111.
Ben-An, A. (1995b). Coming out: A dialectic of intimacy and
privacy. Families in Society: The Journal of Contemporary Human
Services, 76(5),306-314.
Berzon, B. (200l). Positively gay: New approaches to gay and lesbian
life (3rd ed.). Berkeley, CA: Celestial Arts.
Bobbe, J. (2002). Treatment with lesbian alcoholics: Healing
shame and internalized homophobia for ongoing sobriety.
Health and Social Work, 27(3), 218-222.
Boon, S. D., & Miller, R. J. (1999). Exploring the links between
interpersonal trust and the reasons underlying gay and
bisexual males disclosure of their sexual orientation to their
mothers. Journal of Homosexuality, 37(3),45-68.
Burch, B. (1985). Another perspective on merger in lesbian
relationship. In L. Rosewater & L. Walker (Eds.), Handbook of
feminist therapy: Women's issues in psychotherapy (pp, 232256).
New York: Springer.
Cain, R. (1991). Relational contexts and information management
among gay men. Families in Society, 72,344-352.
Caron, S. L., & Ulin, M. (1997). Closeting and the quality of
lesbian relationships. Families in Society, 78,413-419.
Cass, V. C. (1979). Homosexual identity formation: A theoretical
model. Journal of Homosexuality, 4(3), 219-235.
Chan, C. S. (1993). Issues of identity development among Asian
American lesbian and gay men. In L. D. Garnets & D. C.
Kimmel (Eds.), Psychological perspectives on lesbian and gay
male experiences (pp. 376-387). New York: Columbia
University Press.
Chapman, B. E., & Brannock,J. C. (1987). Proposed model of
lesbian identity development: An empirical examination.
Journal of Homosexuality, 14{3/4), 69-80.
Cochran, S. D., Mays, V. M., Bowen, D., Gage, S., Bybee, D.,
Roberts, S. J., et al. (200l). Cancer-related risk indicators and
preventive screening behaviors among lesbians and bisexual
women. American Journal of Public Health, 91, 591-597.
Coleman, E., & Remafedi, G. (1989). Gay, lesbian, and bisexual
adolescents: A critical challenge to counselors. JouTTIilI of
Counseling and Development, 68(1), 36-40.
Council on Social Work Education. (2004). Educational policy and
accreditation standards. Arlington, VA: Author.
Cramer, D. W., & Roach, A. J. (1998). Coming out to mom and
dad: A study of gay males and their relationships with their
parents. Journal of Homosexua/ity, 15(3/4). 79-91.
D'Augelli, R. R., Hershberger, S. L., & Pilkington, N. W. (1998).
Lesbian, gay, and bisexual youth and their families:

Disclosure of sexual orientation and its consequences.
American Journal of Ortlwpsychiatry, 68(3), 361-371.
Davidson, M. G. (2000). Religion and spirituality. In R. M.
Perez & K. A DeBord (Eds.) , Handbook of counseling and
psychotherapy with lesbian, gay, and bisexual clients (pp.
409-.433). Washington, DC: American Psychological
Association.
Davis, L. V. (1993). Building on women's strengths: A social work
agenda for the twenty-first century. New York: Haworth. deGroot,
L., Lloyd, c., & King, R. (2003). An evaluation of family
psychoeducational programs in community mental health.
Psychiatric RehabilitatianJournal, 27(1), 18-23.
Eldridge, N. S., & Gilbert, L. A. (1990). Correlates of relationship
satisfaction in lesbian couples. Psychology of Women Quarterly,
14,43-62.
Eliason, M. (1998). Correlates of prejudice in nursing students.
Journal of Nursing Education,,37, 27-29.
Elliott, M. (1996). Coming out in the classroom: A return to the
hard place. College English, 58(6), 693-708.
Erikson, E. H. (1950). Childhood and society. New York: Norton.
Erikson, E. H. (1963). Childhood and society (Znd ed.). New York:
Norton.
Flaks, D. K., Ficher, 1., Masterpasqua, R., & Joseph, G. (1995).
Lesbians choosing motherhood: A comparative study of
lesbian and heterosexual parents and their children. Special
issue: Sexual orientation and human development. Devel-
opmentalPsychology, 31,105-114.
Franke, R., & Leary, M. R. (1991). Disclosure of sexual orien-
tation by lesbians and gay men: A comparison of private and
public processes. Journal of Soda! and Clinical Psychology,
10(3),262-269.
Gates, G. J., & Ost, J. (2004). The gay and lesbian atlas.
Washington, DC: The Urban Institute Press.
Garnets, L. D., & Kimmel, D. C. (Eels.). (1993). Psychological
perspectives on lesbian and gay male experiences. New York:
Columbia University Press.
Garofalo, R., Wolf, c, Kessel, S., Palfrey, J., & DuRant, R. H.
(1998). The association between risk behaviors and sexual
orientation among a school-based sample of adolescents.
Pediatrics, 101(5),895-202.
Gilgun, J. F. (2005). The four cornerstones of evidence-based
practice in social work. Research on Sodal Work Practice,
15(1),52--6l.
Goldberg, A J. S., Fristad, M. A, & Gavazzi, S. M. (1999).
Family psychoeducation:. Giving caregivers what they need.
Family Relations, 48(4),411-.417.
Gonsiorek,J. C. (1988). Mental health issues of gay and lesbian
adolescents. Journal of Adolescent Health Care, 9, 114-122.
Green, B. (1994). Lesbian and gay sexual orientations: Impli-
cations for clinical training, practice, and research. In B. Green
& G. M. Herek (Eels.), Psychological perspectives on lesbian and
gay issues, Vo!' I-Lesbian and gay psychology:
Theory, research and clinical applications (pp. 1-24). Thousand
Oaks, CA: Sage.
Green, R., Mandel, J. B., Hotvedt, M. E., Gray, J., & Smith, L.
(1986). Lesbian mothers and their children: A comparison
with solo parent heterosexual mothers and their children.
Archives of Sexual Behavior, 15, 197-184.
LESBIANS: I'RAcrICE INTERVENTIONS 85
Greene, R. R., & Ephross, P. H. (Eds.). (1991). Human behavior
theory and soda! work practice. New York: Aldine de Gruyter.
Guajardo, J. M., & Anderson, T. (2007). An investigation of
psychoeducational interventions about therapy. Psychotherapy
Research, 17(1), 120-127.
Harper, R., & Hardy, S. (2000). An evaluation of motivational
interviewing as a method of intervention with clients in a
probation setting. The British Journal of Soda! Work, 30(3),
393-.400.
Harry, J. (1993). Being out: A general model. Journal of Homo-
sexuality, 26(1),25-39.
Hershberger, S. L., & D'Augelli, A. R. (1995). The impact of
victimization on the mental health and suicidaliry of lesbian,
gay, and bisexual youths. Developmental Psychology, 31, 65-74.
Hetrick, E. S., & Martin, A D. (1987). Developmental issues and
their resolution for gay and lesbian adolescents. Journal of
Homosexuality, 14(1/2), 25-.42.
Hilton, B. (1992). Can homophobia be cured? Nashville, TN:
Abingdon.
Human Rights Campaign. (2003). About us. Retrieved June 30,
2003, from the Human Rights Campaign Web site, http://www
.hrc.org.
Human Rights Campaign. (2007). Working for gay, lesbian,
bisexual, and transgender rights. Retrieved November 10,
2007, from the Human Rights Campaign Web site, www.
hrc.org/issues/parenting.asp.
Hyde, C. A. (2003). Gendered perceptions of community needs
and concerns: An exploratory analysis. Journal of Human
Behavior in the Social Environment, 8(4), 45-65.
Jenkins, D., & Johnston, L. B. (2004). Unethical treatment of gay
and lesbian people with conversion therapy. Families in Society,
85(4), 557-56l.
Johnson, T. (2000). Gay spirituality: The role of gay identity in the
transformation of human consciousness. Los Angeles: Alyson
Books.
Kahn, M. J. (1991). Factors affecting the coming out process for
lesbians. Journal of Homosexuality, 22(3), 47-70.
Knight, K. M., McGowan, L., & Dickens, C. (2006). A systematic
review of motivational interviewing in physical health care
settings. British Journal of Health Psychology, 11 (2),319-332.
Krestan, J., & Bepko, C. (1980). The problem of fusion in the
lesbian relationship. Family Process, 19, 277-289.'
Laird, J. (1993). Lesbian and gay families. In F. Walsh (Ed.),
Normal family processes (2nd ed., pp. 282-328). New York:
Guilford.
Lewis, K. G. (1980). Children oflesbians: Their point of view.
SodaIWork,25,198-203.
Lowenstein, S. F. (1980). Understanding lesbian women. Social
Casework, 61(1), 29-38.
Lum, D. (2005). Cultural competence, practice stages, and client
systems: A case study approach. Belmont, CA: Brooks/ Cole.
Maton, K. 1., Schellenback, C. J., Leadbetter, B. J., & Solarz, A. L.
(Eds.), (2004). Investing in children, youth, families, and
communities: Strengths-based research and policy. Washington,
DC: American Psychological Association.
86 LESBIANS: PRAcrICE INTERVENTIONS
McCarn, S. R., & Fassinger, R. E. (1996). Revisioning sexual
minority identity formation: A new model of lesbian identity
and its implications for counseling and research. The
Counseling Psychologist, 24, 508-534.
McNeill, J. J. (1993). The church and the homosexual (4th ed.).
New York: Beacon.
Mencher, J. (1990). Intimacy in lesbian relationship: A critical
reexaminationoffusion. (Work in progress No. 42). Wel1esley,
MA: Stone Center Working Papers Series.
Mercier, L. R., & Harold, R. D. (2003). A feminist approach to
exploring the intersections of individuals, families, and
communities: An illustration focusing on lesbian mother
research. Journal of Human Behavior in the Social Environment,
7(3/4), 79-95.
Morrow, D. F. (1996a). Heterosexism: Hidden discrimination in
social work education. Journal of Gay and Lesbian Social
Services, 5(4), 1-16. , medicine: Results of a national survey of lesbian, gay, and bisexual
Morrow, D. F. (1996b). Coming out issues for adult lesbians: A
group intervention. Social Work, 41(6),647-656.
Morrow, D. F. (2006a). Coming out as gay, lesbian, bisexual, and
transgender. In D. F. Morrow & L. Messinger (Eds.), Sexual
orientation and gender identity in social work practice (pp.
129-149). New York: Columbia University Press.
Morrow, D. F. (2006b). Gay, lesbian, bisexual, and transgender
adolescents. In D. F. Morrow & L. Messinger (Eds.), Sexual
orientation and gender identity in social work practice (pp. 177-
195). New York: Columbia University Press.
Newman, F. S., & Muzzonlgro, P. G. (1993). The effects of
traditional family values on the coming out process of gay
male adolescents. Adolescence, 28(109), 213-226.
Orme, J. (2002). Social work: Gender, care, and justice. The
British Journal of Social Work, 32(6), 799-814.
Parks, C. A (1998). Lesbian parenthood: A review of the
literature. American Journal of Orthopsychiatry, 68(3), 376-389.
Parks, C. A, & Humphreys, N. A (2006). Lesbian relationships
and families. In D. F. Morrow & L. Messinger (Eds.), Sexual
orientation and gender identity in social work practice (pp,
177-195). New York: Columbia University Press.
Patterson, C. J. (1992). Children of lesbian and gay parents.
Child Development, 63, 1025-1042.
Patterson, C. J. (1995). Families of the lesbian baby boom:
Parents' division of labor and children's adjustment. Devel-
opmental Psychology, 31, 3-11.
Ponse, B. (1978). Identities in the lesbian world. Connecticut:
Greenwood Press.
Proctor, C. D., & Groze, V. K. (1994). Risk factors for suicide
among gay, lesbian, and bisexual youths. Social Work, 39(5),
504-513.
Raphael, S. (1974). Coming out: The emergence of the movement
lesbian. Dissertation Abstracts International, 35/08-A, 5536.
Remafedi, G., Farrow, J. A, & Deisher, R. W. (1991 ).
Risk factors for attempted suicide in gay and
bisexual youth. Pediatrics, 87, 869-875.
Rhoads, R. A (1995). Learning from the coming out experiences
of col1ege males. Joumal of College Student Development,
36(1), 67-74.
Ritter, K. Y., & O'Neill, C. W. (1989). Moving through loss:
The spiritual journey of gay men and lesbian women. Journal
of Counseling and Development, 68,9-15.
Ryan, c., & Gruskin, E. (2006). Health concerns for lesbians,
gay men, and bisexuals. In D. F. Morrow & L. Messinger
(Eds.), Sexual orientation and gender identity in social work
practice (pp. 177-195). New York: Columbia University Press.
Saulnier, C. F. (2000). Incorporating feminist theory into social
work practice: Group work examples. Social Work with Groups,
23(1), 5-29.
Savin-Williams, R. C. (1994). Verbal and physical abuse as
stressors in the lives of lesbian, gay male, and bisexual youths:
Associations with school problems, running away, substance
abuse, prostitution, and suicide. Journal of Consulting and
Clinical Psychology, 62, 261-269.
Schatz, F., & O'Hanlan, K. (1994). Anti-gay discrimination in
physicians. San Francisco: American Association of Physicians
for Human Rights.
Siporin, M. (1980). Ecological systems theory in social work.
Journal of Sociology and Social Welfare, 7(4),507-532.
Slater, S., & Mencher, J. (1991). The lesbian family life cycle:
A contextual approach. American Journal of Orthopsychiatry,
61(3),372-382.
Smith, A (1997). Cultural diversity and the coming-out process:
Implications for clinical practice. In B. Green (Ed.), Ethnic
and cultural diversity among lesbians and gay men (pp, 279-300).
Newbury Park, CA: Sage.
Snider, K. (1996). Race and sexual orientation: The (lm)
possibility of these intersections in educational policy.Harvard
Educational Review, 66,294-302.
Sophie, J. (1986). A critical examination of stage theories of
lesbian identity development. Journal of Homosexuality,
12(2),39-51.
Spong, J. S. (1991). Rescuing the Bible from fundamentalism. San
Francisco: Harper & Row.
Spong, J. S. (1998). Why Christianity must change or die. San
Francisco: Harper.
Su 11 ivan, M. (1996). Rozzie and Harriet? Gender and family
patterns of lesbian coparents. Gender and Society, 10, 747767.
TaFoya, T. (1997). Native gay and lesbian issues: The twospirited.
In B. Green (Ed.), Ethnic and cultural diversity among lesbians
and gay men (Vol. III, pp. 1-10). Thousand Oaks:
Sage.
Teague, J. B. (1992). Issues relating to the treatment of adolescent
lesbians and homosexuals. Journal of Mental Health Counseling,
14(4),422-439.
Tozer, E. E., & McClanahan, M. K. (1999). Treating the purple
menace: Ethical considerations of conversion therapy and
affirmative alternatives. The Counseling Psychologist, 27(5),
722-743.
Waldner, L. K., & Magruder, B. (1999). Coming out to parents:
Perceptions of family relations, perceived resources, and
identity expression as predictors of identity disclosure for gay
and lesbian adolescents. Journal of Homosexuality,
37(2),83-100.
9'
·
Weersing, V. R., & Brent, D. A. (2006). Cognitive-behavioral
therapy for depression in youth. ChilJ. and Adolescent Psychi-
atric Clinics of Narth America, 15(4), 939-957.
White, M. (1995). Stranger at the gate: To be gay and Christian in
America. New York: Plume.
Wilson, A. (1996). How we find ourselves: Identity development and
two-spirit people. Harvard Educational Review, 66(2), 303-317.
Zastrow, c., & Kirst-Ashman, K. K. (2007). Understanding human
behaviar and the social environment (7th ed.). Belmont, CA:
Brooks/Cole.
. around the world, including Great Britain, Wales,
FURTHER READING
Ermer, R. (1999). Gender loving care: A guide to counseling
gender-variant clients. New York: W. W. Norton & Co.
Morrow, D. F. (1993). Social work with gay and lesbian ado-
lescents. Social Wark, 38(6») 655-660.
-DEANA F. MORROW
LIABILITY. See Professional Liability and' Malpractice.
LICENSING
ABSTRACT: Social work regulation protects the public
by establishing the qualifications that a professional
must possess, by establishing a means of holding
professionals accountable, and by having a system
for the public to make complaints against
incompetent or unethical prac titioners and have them
investigated and adjudicated. The profession of
social work is regulated in all 50 states in the United
States, the District of Columbia, Puerto Rico, the
Virgin Islands, and 10 Canadian provinces .
Certification also exists in various specialty areas of
social work practice, as is a function of professional
organizations versus governmental regulatory
agencies.
KEY WORDS: licensing; regulation; certification in so-
cial work; credentialing
Purposes of Licensing and Regulation
The purpose of professional regulation is to protect the
public. Regulation enacted by statute sets the terms for
who can practice a profession and call themselves a
member of it by delineating the needed qualifications and
competencies. The first professions to be regulated were
medicine and dentistry, followed by architecture and
accountancy, all of which became regulated in the late
19th and early 20th centuries when social work was
established as a profession.
LICENSING 8
7
Legal regulation protects the public by setting forth the
qualifications that a professional must possess, by
establishing a means of holding professionals accounta ble,
and having a system for the public to make com plaints
against incompetent or unethical practitioners and have
them investigated and adjudicated. Today social work is
regulated in all 50 states in the United States, the District
of Columbia, Puerto Rico, the Virgin Islands, and 10
Canadian provinces. The trend to regulate social work is
also found in other countries
Australia, and New Zealand.
Definitions
Certification, credentialing, licensure, and registration are
terms that are applied to the regulation of social work in
different jurisdictions. For purposes of regulation, there is
no legal distinction between certification and licensure,
although it is common for "certification" to describe a less
rigorous regulatory structure than "licensure," which
usually refers to a more comprehensive system. These
terms are further confused in their use as part of the title of
a legally regulated social worker, such as Licensed Social
Worker or Certified Social Worker.
The real distinction in legal regulation is between a
practice act, the legislation that defines and regulates
practice and establishes who can call themselves a social
worker, and title protection legislation, which only regulates
what social workers who have met the legal requirements
can call themselves, such as Licensed Social Worker.
Practice acts define the professional activities that can be
performed and require anyone engaging in these activities
to hold a license. Title protection acts are less stringent and
do not prevent others who do not meet the qualifications
from practicing, only from calling themselves by the
regulated title, such as Licensed Independent . Social
Worker.
The term registration, within the United States, is used
to describe a system of voluntary registration with a
governmental authority in order to use a prescribed
restricted title. Michigan was the last state to' have a
system of registration, until it enacted its practice act
licensing law in 2004. Some states, like Louisiana, have a
system of registration for baccalaureate social workers
(BSW).
In Canada, the legal regulation of social work is
referred to as registration. However, these provincial laws
have enacted mandatory registration systems, which
operate in ways very similar to practice act or title
protection models in the United States.
Credential is often used to describe any document that
verifies the qualifications of a social worker. It is
88 LICENSING
the term most often used to refer tovoluntarv recognitions
from professional associations. The Academy of Certified
Social Workers (ACSW), the Qualified Clinical Social
Worker (QCSW), and the Diplomate in Clinical Social
Work (DCSW) are voluntary credentials issued by the
National Association of Social Workers (NASW). The
American Board of Examiners (ABE) in clinical social
work also offers a voluntary credential in advanced
clinical practice, the Board Cer tified Diplomate (BCD).
Credentialing programs are usually operated by private
organizations and serve to promote the profession and the
professional holding them as having demonstrated
knowledge, abilities, and achievement beyond the
minimum competency requirements to become licensed.
" to practice clinical social work. However, the practicalities
Historical Overview
There is no national licensure for any profession. Under
the U.S. Constitution it is a state's right to regulate the
professions practicing within the state. Puerto Rico was
the first U.S. jurisdiction to enact social work regulation,
in 1934. California followed 11 years later, in 1945. Seven
more states enacted legislation to regulate social work in
the 19608 and 14 more got social work laws passed in the
1970s. At first many of these states enacted title protection
and licensed at only one category, typically clinical or
masters degree upon entry. In 1980, NASW developed a
three-tiered model social work law, for bachelors, masters,
and advanced practice categories of licensure. NASW
chapters around the country began to promote the passage
of social work licensing and the majority of social work
licensing laws came into being in the 1980s, when 27
states enacted legislation. By 1992, when Wisconsin
enacted social work licensure, all 50 states, the District of
Columbia, Puerto Rico, and the Virgin Islands regulated
social work. As of 2005, the Association of Social Work
Boards (ASWB) estimated, that there are almost 400,000
licensed social workers practicing in the Uni ted States and
Canada.
Since that time, states have amended their laws to
include multiple categories, BSW, MSW, and cl inical, and
have passed practice acts instead of just title pro tection.
Many exemptions by employment setting were established
in these early licensing laws as part of the political
compromises that needed to be made to achieve
enactment. Jurisdictions have since worked to remove
exemptions so that all social workers, regardless of
practice setting, must be licensed. That remains an uphill
battle. In 1998, ASWB developed a new Model Social Work
Practice Act, which is reviewed and updated annually in
keeping with changes in the social work profession and
within legal professional regulation.
The Act has been used as a resource by a number of social
work licensing boards to update and upgrade their laws.
As jurisdictions enacted these first laws, a hodge podge
of different structures for regulating social work emerged.
The first licensing laws were usually' for social workers
with a master's degree entering the profession right after
graduation, or for clinical licensees who had received a
master's degree and completed two years of supervised
clinical experience. The model law developed and
promulgated by NASW provided a three-tiered licensure
structure: BSW upon graduation; master's social workers
(MSW) upon graduation; and an advanced licensure for
MSW with two years of supervised experience. There was
no distinction made for this category to be strictly a license
of parity with other mental health professions and the need
to qualify for third party reimbursement to achieve this
drove the pursuit of specific clinical social work licensure.
Current Licensure Structure
Today social work has four types of licensure: BSW
(usually upon graduation); MSW (upon graduation,
independent after 2 years of supervised general experi-
ence); and clinical (after 2 years of specific supervised
clinical experience). Most jurisdictions license social
workers at two or more of these categories. According to
ASWB, as of 2006 BSW were legally regulated in 35
states. The same number of states, 35, although not
necessarily the same ones, also regulated MSW. Social
workers practicing independently, but not necessarily as
clinical social workers, were licensed in 23 states, and
clinical social workers were licensed in 45 states. In 2006,
six states had a category of associate licensure for people
who work in the social service field but who do not have a
formal social work degree.
In Canada, all 10 provinces have registration for BSW ,
and 8 provinces register MSW, unusually under the same
registration act and title. Two provinces also license
clinical social workers and one province also registers
social workers for independent practice.
The regulatory trends for social work in both the
United States and Canada are to move from title protection
to a practice act along with title protection, increase the
categories of licensure, and remove exemptions from
licensure so that all social workers, regardless of practice
area or setting, must be licensed. This serves the regulatory
boards' mission of public protection by ensuring that all of
the public is served by social workers who meet minimum
qualifications and standards and are accountable to a
governmental body and therefore indirectly to the public
for their practice.

Licensure Requirements
The requirements for licensure are education, super vised
experience, and demonstration of knowledge minimum
competence-by passing an exam, references, and evidence
of good moral character. A BSW or MSW degree is
required for the bachelors and masters categories of
licensure, and a few states also require postgraduate
experience before qualifying for these licenses. An MSW
and a minimum of two years of postgraduate supervised
experience are require d for the independent and clinical
categories of licensure. Some states require more than 2
years of supervised clinical experience, or proof of a
minimum number of hours in a clinical field placement, or
proof of specific clinical coursework, most typica lly
psychopathology.
Generally, after a licensure candidate has sub mitted
documented proof of meeting the board's require ments,
the candidate is approved to take a licensing examination.
Those developed and maintained by ASWB are almost
universally used. There are four categories of
examination, parallel to the categories of licensure. The
Bachelor's and Master's examinations are constructed to
test knowledge upon graduation with a BSW or MSW
degree. The advanced generalist and clinical examinations
are developed for social workers with an MSW. and a
minimum of 2 years' postgraduate experience. For the
clinical examination, this must be specific clinical social
work experience.
The content of each of the four examinations is
determined by a survey, conducted at regular intervals,
usually every 5-10 years, to keep the knowledge tested
current with practice. Social workers are asked to rate a
series of tasks on how frequently they do each one, how
important it is that when they do the task they do it
competently and correctly, and whether it is important to
know how to do it upon entry to practice. The survey is
constructed by a group of social workers who are subject
matter experts. This same group reviews the results and
then from these results and their e xpert opinions
constructs the content outlines for each examination.
The licensure landscape is vast and complex. It is
strongly recommended that social workers become fam-
iliar with the licensing laws in the jurisdictions where they
practice. Social work students should become
knowledgeable about licensure as soon as possible so that
they can plan their education, supervision, and experience
to meet the requirements. Information on the licensure
requirements in each state and pro vince, along with direct
links to the licensing board Web sites, can be found at
http://www.aswb.org, under Licensing Requirements.
LICENSING 89
Functions of Regulatory Boards
Boards that regulate the practice of social work perform
multiple functions, with the protection of public inter est as
the cornerstone. Social work is a professional practice that
affects the public health, safety, and wel fare of the citizens
of the jurisdiction, and the regulatory board has the
statutory power to define and establish the credentials
required for various levels of practice competency, the
ability to issue or deny a professional license, and the
power to investigate allegations of improper practice, and
impose disciplinary sanctions upon a social worker who
violates the statutes of the practice act within the
jurisdiction.
Legislation in each jurisdiction in the United States
and Canada defines the qualifications and educational
requirements for social workers, and specifies the activ-
ities associated with social work practice at the bacca-
laureate, master's, and clinical levels. The requirements
for licensure are specified in each practice act. Exemp-
tions from licensure, generally based o n employment
categories, are also delineated; exemptions are discour-
aged in the ASWB model law , but do continue to exist in
some jurisdictions. The regulations work extends to all
social workers practicing in the jurisdiction, regard less of
the place of actual residency.
Regulatory boards define the scope of practice and
standards for professional conduct for each category of
social work license, thereby defining what unlawful
practice and violation of the code of conduct is. To fulfill
the responsibility of public protection, boards have the
authority to discipline individuals who violate the act or
its rules, including the ability to prohibit these individuals
from threatening the public with harm. Disciplinary
provisions state the grounds for discipl inary actions, the
procedures for the filing and investigation of a complaint,
deciding on the imposition of a disciplinary action, and
application of penalties for the violation. Grounds for
disciplinary procedures may include, but are not limited
to, unprofessional conduct as determined by the board,
practicing outside of the applicable scope of practice,
unlicensed practice, conviction of a felony, or incapacity.
or impairment that prevents the licensee from engaging in
the practice of social work with the reasonable
competence required to protect the public.
Disciplinary regulations also contain the· specific
conditions for imposition of penalties, and establish the
grounds for reinstatement of a license. Penalties may
include the denial of a license (new or renewed), a
monetary fine, restrictions on the license, imposition of
supervised practice by a board- approved practice monitor,
required continuing education, or suspension, probation,
or revocation of the license. Penalties are
90 LICENSING
•
imposed in the majority of disciplinary actions, and each
penalty must state the conditions to be satisfied, and the
specific steps for reinstatement of the license if
applicable.
A licensed social worker who is physically or men-
tally unable to practice safely because of mental illness
or the use or addiction to drugs or alcohol is considered
an impaired professional
Future Directions and Trends Challenges
continue to confront regulatory boards as the practice of
social work evolves.
Electronic Practice
In 2004, a joint task force was ~stablished by the NASW
and the ASWB to develop guidelines for the use of
electronic technologies in social work practice. The l
Ovmember task force studied the issues associated with
the use of emerging electronic means to deliver social
work services and published a guide to best practices
using electronic technology. The NASW and ASWB
Standard for Technology and Social Work Practice may
be obtained from NASW.
Legal regulations vary widely. Some jurisdictions
require social workers who provide any service to any
resident, including doing so by electronic means, to hold
a license for practice in the jurisdiction, while. other
regulatory boards do not address any issues related to
social work practice, record keeping, or trans, mission of
information by electronic means. These complex issues
are the focus of discussion and legislative reform
currently confronting the majority of regulatory boards.
According to ASWB's model law, social work practice
occurs where the client is located and social workers
must be licensed in that jurisdiction. The model act also
provides for notice to the regulatory board of practice on
a temporary basis, such as in cases of emergencies.
Social workers should be cognizant of board
requirements and the risk of practicing without a license
in distant or temporary locations and should check with
the licensing boards in the jurisdictions in question.
Reciprocity
Because regulatory boards function under the authority
of the legislative bodies that govern professional prac-
tice, each jurisdiction in the United States and Canada
creates, enacts, and modifies its own regulatory acts
independent of other states or provinces. Therefore, a
professional license issued in one jurisdiction does not
transfer to another jurisdiction or allow for reciprocity
between jurisdictions. Social workers must currently
apply for and be granted a license to practice in each
state or province individually. The ASWB model law is
used by legislative jurisdictions in reforming and
updating their licensing regulations, and establishes
guidelines that will help move toward greater
unifonnityof social work regulation. In addition, the
Social Work Registry operated by ASWB allows social
workers to place their credentialing information,
including examination test scores, academic transcripts,
supervision, and continuing education documentation,
in a permanent location that each regulatory board may
access to facilitate licensure within its jurisdiction.
Supervision
As the regulation of social work practice evolves, reg-
ulatory boards face the challenge of articulating the
necessary components of supervision for specific levels
of licensure. Supervision has always been addressed in
social work education and practice, but regulatory
boards increasingly are feeling the need to examine and
define what constitutes adequate supervision for a
candidate for licensure. Supervision for the purpose of
qualifying for licensure is one of the last gates through
which a candidate must pass to qualify for a license. The
supervisor is accountable to the regulatory board for the
supervision, practice, and evaluation of the lic ensure
applicant, in addition to being accountable to the
supervisee and the agency. Most regulatory boards have
specific requirements, especially for clinical
supervision-number of hours, qualifications of the
supervisor, individual supervision requirements and
group supervision limits, provisions for supervision by
alternate mental health professions, and if allowed, how
many of the required supervisory hours are permitted to
be provided by other professionals. The trend is for
regulatory boards to strengthen and more closely
specify the qualifications for clinical supervisors. Some
boards have a list of approved clinical supervisors, and
most boards require the supervisor to possess a license
of the same category for which the supervision is being
provided and a minimum number of years of
experience, which are increasing in many jurisdictions
to five. Again, more information about the specific
supervision requirements in each jurisdiction can be
found at www. aswb.org, and standards are available in
the ASWB model law.
An additional challenge for regulatory boards is the
appropriate use of supervision as a disciplinary
measure. Many disciplinary actions involving social
workers who violate practice regulations or standards
include some form of supervision to assist the social
worker in understanding and conforming to practice
standards. The optimum use of supervision for this
purpose continues to be an area of focus of regulatory
boards.

Public Protection
Protection of the public remains the essential function of all
social work regulation. Social work regulations, including
certification and licensure, ensures that minimum .
standards for the practice of social work are established at
the Bachelor's, Master's, and advanced clinical practice
level, and that the requirements for competency are met. In
addition, citizens who receive social work services have a
mechanism to address poor practice by a social worker or
the violation of practice ethics and standards, or practice by
an unlicensed worker. As technology expands and the need
for highly skilled and ethical practitioners grows to meet the
increasing demands of complex social problems, regulatory
boards will evolve with, the profession and continue to
serve the mission of public protection.
\
FURlHER READING
American Association of State Social Work Boards. (1999).
Are we there yet! The first 20 years of an association's visionary
journey. Virginia: Culpeper.
Association of Social Work Boards. (2004). Analysis of the practice
of social work 2003: Final report. Virginia: Culpeper.
Association of Social Work Boards. (2004). The exam "Blue Book."
Virginia: Culpeper.
Association of Social Work Boards. (2007). Manual for new board
members. Virginia: Culpeper. Unpublished Association of Social
Work Boards. (2007). www.aswb.org National Association of
Social Workers. (2000). Code of ethics of the national association of
social workers. Washington, DC:
Author.
Social Work Regulatory Bodies. (1996). The regulations of social
work in Canada: An information sharing newsletter. New-
foundland: Newfoundland Labrador Association of Social
Workers.
Thyer, B. A., & Biggerstaff, M. A. (1989). Professional social work
credentialing and legal regulation. Springfield, IL: Charles C.
Thomas.
-AMANDA DUFFY RANDALL AND DONNA DEANGELIS
LIFE MODEL. See Ecological Framework.
LIFE SPAN. [This entry contains eight subentries:
Overview; Development and Infancy (Birth to Age
. Three); Early Childhood and Preschool; Childhood and
Latency; Young Adulthood; Parenting; Older
Adulthood/Seniors ("Young Old"); Oldest Senior/
Aged-Late ("Old Old").]
OVERVIEW
ABSTRACT: This entry provides an overview of the
lifespan perspective focusing on biological
developments
LIFE SPAN: OVERVIEW 91
and social tasks all of which are embedded in a larger
sociocultural context from birth to old age within diverse
environments, cultures, and historical eras. This section
will also focus on how the life-span perspective succeeds
traditional life course models that assume to be universal,
sequential, and predictable. The life-span perspective of
social work departs from approaches based on traditional
models that are narrow and focuses on personal deficits,
pointing instead to strengths, continued growth, and
environmental resources for individuals, families, groups,
and communities. Finally, this entry will discuss how the
life-span perspective shows great promise for
encompassing theory of human development for the
purpose of expanding knowledge, promoting "best
practice" service delivery, policy regulation and research to
enhance the lives of people with whom social workers
come into contact.
KEY WORDS: life span; human. development; human
diversity; intervention
Theoretical Underpinning
The life-span perspective was a recent development in
human behavior theory in the late 1970s (Baltes, Reese &
Nesselrode, 1977, lerner, 1984, Thomane, 1979). Life-span
theory is based on ongoing transactions between persons
and environments and begins with the premise that
development is lifelong, in which no age period dominates
development. It encompasses a distinctive series of roles
and experiences through which the individual passes as she
or he ages across the life span. Furthermore, it permits
investigation into the impact of various changes on these
patterns. The life-span perspective arose from a confluence
of movements in sociology and psychology in the 1960s
and subsequently came to evolve in social work, anthropol-
ogy, history, and other disciplines (Bengtson, Burgess, &
Parrott, 1997; Marshall, 2000).
Two events seem particularly relevant to the more
recent burgeoning of interest in the life-span perspective:
(a) population demographic changes, with a higher
percentage of elderly members; and (b) the concurrent
emergence of gerontology as a field of specialization in
social work. These events and others have advanced
developmental scholars in recognizing the entire life span
as a scientifically and socially important focus. Its theorists
argue that development occurs at all ages, from infancy to
older adulthood, with specific biological and social tasks at
each stage (Johnson & Matross, 1977; Williams &
Nussbaum, 2001). For example, children during the early
stages of development must deal with developmental tasks
of the attachment process in which
92 LIFE SPAN: OVERVIEW
they strive for positive emotional bonds, as well as motor
skill, language, and moral development. The adolescents
are preoccupied with rapid physical and intellectual
maturation and identity development and turn from their
families of origin to peer groups as their primary frame of
reference. In contrast, older adults endure increased health
risk, make occupational shifts toward retirement, and turn
to personal enjoyment in social activities (Wong, 2000).
As a framework for thinking about the development of
human behavior over time, the life-span perspective has
several advantages over traditional theories of human
development. Historically, traditional life course or stage
model developmental theories have centered on the
"maturational and generational processes driven by
mechanisms of reproduction in natural populations" (0'
Rand & Krecker, 1990, p. 242). These models refer to a
fixed sequence of irreversible stages that assume to be
universal, sequential, and predictable. Furthermore,
traditional stage models overlook the complex interplay of
maturation, individual potential, and resilience, changing
environmental constraints and opportunities. Hence the
models do not incorporate new family forms; gender roles
in family and work life; issues of power, oppression and
poverty; and individual life experiences. In contrast, the
life-span perspective emphasizes that behavior can be
pervasive and rapid at all ages based upon the function of
one's environmental and sociocultural context (Breslow,
1988; Dannefer & Perlmutter, 1990; Germaine, 1987). The
life-span perspective also encourages greater attention to
the impact of historical and social change on human
behavior, which seems particularly important in a rapidly
changing society such as in the United States. Hence, while
traditional conceptualizations provide a way of perceiving
and understanding human beings and their functioning
within the context of their environment, the life-span
perspective offers specific guidelines for pro~ fessional
practice.
An Expanded View of the Life Span
To truly understand the life-span perspective, life span
must be viewed not only as a longitudinal set of stages, but
as a fluid process that is interactive and nonlinear,
characterized by the simultaneous appearance of role gains
and losses, stability, and inconsistency (Hooyman &
Kiyak, 2002; [endrek, 1994). During any of these stages, an
individual's biological development may differ because of
genetic makeup, cultural identification, or the presence of
disease or disability. More recently, the life-span
perspective has also expanded its scope to accommodate
new demographic realities, such as attention to women and
ethnic or racial minorities, which
have been previously ignored (Archer, 1992; Thomas,
Herring, & Horton, 1994). For instance, one promising
outcome of health in later adulthood is social integration in
the form of involvement in multiple roles such as
involvement in the church, community service activities,
and clubs, all which have been positively linked to health
and longevity (Berkman & Breslow, 1983;House, Landis,
& Umberson, 1988). Such multiple role occupancy may be
important at a time when role reduction becomes
increasingly common in American culture (Morgan, 1988).
The life-span perspective is especially important in
viewing women's lives in later life when their age,
education, race or ethnicity, or marital status may have
important repercussions for their health and social
integration. For instance, in most women's lives, social
integration into the larger society has been circumscribed
by the dominance of their family obligations (Hughes &
Gove, 1981). As women become older they are more
susceptible to social and structural isolation, that is,
reduced participation in the workforce, and other
obligatory roles such as mother, wife, or caretaker to other
relatives. These family obligations often diminish their
opportunities for other forms of socialization that do not
conform to their prescribed role (Smith & Moen, 1980).
Race, in particular, for many ethnic minority women
provides another life-span lens in which to view the role of
social integration and health status. For example, among
older ethnic minority women, family responsibilities may
constrain involvement in nonfamily roles and activities
outside of the home. This is often seen in their "forced
kinship care" role, such as a grand mother raising
grandchildren. Kinship care provided by a grandmother
often becomes the only option for the children outside of
the foster care system. Hence, involvement in obligatory
and social health roles during the older adult years may be
conflicting and stressful for ethnic minority women.
Intervention Across the Life Span
The life-span perspective offers an integrated segment of
theory with which to intervene with individuals across the
life span over time. This perspective not only supports
individuals through crises but also enhances one's ability to
deal constructively with life events and transitions.
Life-span development incorporates the concept that
growth and development of the individual is preceded by a
life event (normative transitions, stress encounter or crisis).
It proposes that each person experiences a number of life
transitions in roles or life events that represent a distinct
departure from prior roles and statuses (George, 1996).
One's life span is full of such transitions, which are distinct
and bounded, that is, entering puberty, gaining
employment, retirement,

and so forth, as well as events that represent relatively
abrupt change that may produce serious and longlasting
effects (Settersten & Mayer, 1997).
Attention to intervention throughout the life span has
encouraged a consideration of life events within t he
general concept of a life story in understanding one's
development over the life span. Life stories provide a
context for making meaningful connections among one's
life events and promote coherence to understand ing
individual and family life. The life story is recreated and
revised in an effort to provide life "with a sense of unity
and purpose" (McAdams, 1992, p. 344). In addi tion to
their conceptualization within a life story, life events can
be considered in relation to one's identity. One's persona l
identity then is built upon the sense one can make of one's
own life 'story.
The goal of life-span development interventions are
not to prevent life events, but to enhance the indivi dual's
ability to cope and subsequently grow and develop
(Lazarus & Folkman, 1984). The concept of a life event
refers to changes in an individual's life that are likely to
have an impact on subsequent behavior. Such major
changes can be either negative, such as death of a close
family member, or positive, such as marriage ( Danish and
D'Augelli, 1984) suggest that experience in coping with
life events during the early years leads to effective coping
in later life. Hence, one's experience with similar life
events increases one's competence and awareness to cope
successfully with a wide range of environmental and
social demands throughout the life span. The nature of a
particular life event may vary from stage to stage. In most
cultures there is a normative timetable for major life
events, which include informational norms. Fo r instance,
at the juncture of young adulthood in the life span, one
may be concerned with the following questions: When to
embark upon a career? When to marry? When to purchase
a home? When to raise children? It is important that
individuals be able to co nfront these life events whether
they are normative or not. Social workers can playa vital
role in assisting individuals to acquire the necessary skills,
emotional capacities, and attitudes necessary to suc-
cessfully deal with the life events at various po ints in
development (Germain & Germain, 1996; Hooyman &
Kiyak).
Micro, and Macrolevel Intervention
The life-span perspective shows great promise for en -
compassing the theory of human development for the
purpose of expanding knowledge, while promoting "best
practice" in service delivery, community involve ment,
and research to enhance the lives of people with whom
social workers come into contact (Germain &
LIFE SPAN: OvERVIEW 93
Germain, 1996). Life-span interventions at the micro level
promote successful development and functioning in
human beings by focusing on their unique coping and
adaptive patterns; actual or potential strengths; natural
helping networks, life experiences, and environmental
resources (Maluccio, 2000). In this endeavor, social
workers will need to develop more culturally specific
assessments, intervention strategies, and evaluation
methods across the life span. This perspective in social
work transcends and includes the individual and provides
applicability to the larger context in the amelioration of
conditions that often lead to unhealthy communities as
well as in efforts to create environments that make
behavioral change more durable and transferable
(Mattaini, 1993).
Social Work Implications
The life-span perspective is similar to recent innovations
in social work that highlight the need to promote
competence in development throughout the life span rather
than to remediate problems when they occur at late stages
in the developmental process. Social workers using the
life-span perspective advance the profession's
commitment to human diversity by placing clients in their
own context and then drawing on their strengths as they
manage progression and change [endrek, 1994; Maluccio ,
2000). In other words, the life-span perspec tive recognizes
that developmental trajectories for each individual are
vulnerable to situational, contextual, and experiential
influences. Thus, an individual's developmental path will
be influenced by the particular con- . stellation of life
conditions and experiences that are encountered
throughout the life course. (Germain & Germain, 1996).
Hence, the life-span perspective provides a useful lens
with which to view successful devel opment while pointing
to areas to build strength, continue growth, and identify
environmental resources and participate in social action
(Davison & Neale, 1982). It is important for social workers
to be familiar with the life-span perspective and potential
implications that each developmental stage has for the
client system and practitioner interventions. A social
worker using the life-span perspective must go beyond a
micro context, and view the problem from a broader
perspective that considers macrolevel influences, such as
poverty and access to health insurance and effective care.
For instance, poor nutrition in childhood may predispose a
child to weaker bone structure and result in the
development of osteoporosis in adulthood, thus
accelerating the degenerative process in health outcomes.
However, some life-span factors, which influence health
and well-being, may not be modifiable at the individual
(micro) level. Socioeconomic factors,
94
•
LIFE SPAN: OVERVIEW
including family income, may inhibit access to prevention
resources and quality of care in the early years of the life span,
which in tum may affect disease in later life.
REFERENCES
Archer, J. (1992). Childhood gender roles: Social content and
organization. In H. McGurk (Ed.), Childhood social develop-
ment (pp, 31-62), New Jersey: Erlbuam.
Baltes, P. B., Reese, H. W., Nesserlroade, J. R. (1977). Lifespan
developmental psychology: Introduction to research methods (pp,
10-16). Monterey, CA: Brooks Cole.
Bengtson, V. L., Burgess, E., & Parott, T. M. (1997). Theory,
explanation and a third generation of theoretical development
in social gerontology. Journals of Gerontology, 52B,
S72-S88. ' In W. R. Scott &J. R. Blakem (Eds.), Annual review of sociology
Berkman, L. F., & Breslow, L. (\1983). Health and ways of living:
The Almeda County study. New York: Oxford Press.
Breslow, L. (1988). Possibilities and pitfalls in clinical appli-
cation of cognitive development theory. New Directions for
Child Development, 39, 147-164.
Danish, S. J., & D'Augelli, A. R. (1980). Promoting competence
and enhancing development through life development
intervention. In L. A. Bond & J. C. Rosen (Eds.), Primary
prevention of psychopathology (Vol. 4). (pp, 3083260.
Hanover, NH:University Press of New England.
Dannefer, D., & Perlmutter, M. (1990). Development as a
multidimensional process: Individuals and social constituents.
Human Development, 33, 108-137.
Davison, G. c., & Neale, J. M. (1982). Abnormal psychology.
New York: Wiley.
George, L. K. (1996). Missing links: The case for a social
psychology of the life course. The Gerontologists, 36(2),
248-255.
Germaine, C. B. (1987). Human development in contemporary
environments. Social Services Review, 51,56-64.
Germain, C. B. & Gitterman, A. (1996). The life model of social
work practice: Advances in theory & practice. (2nd ed., pp.
5-23).
Hooyman, N., & Kiyak, A. H. (2002). Social gerontology: A
multidisciplinary approach (6th ed.). Boston, MA: Allyn &
Bacon.
House, J. S., Landis, K. R., & Umberson, D. (1988). Social
relationships and health. Science, 241, 540-545.
Hughes, M., & Gave, W. R. (1981). Living alone, social
integration and mental health. American Journal of Sociology,
87(1), 48-74.
Jendrek, M. P. (1994). Grandparents who parent their grand-
children: Circumstances and decisions. The Gerontologist,
34(2),206-211. .
Johnson, D. W., & Matross, R. (1977). Interpersonal influence in
psychotherapy: A social psychological view. In A. Gurman &
A. Razin (Eds.), Effective psychotherapy (pp. 395-432).
Elmsford, NY: Pergamon.
Maluccio, A. N. (2000). A competence centered perspective on
child welfare. In J. G. Hopps & R. Morris (Eds.), Social work at
the millennium: Critical reflections on the future of the profession
(pp. 160-174). New York: Free Press.
Marshall, L. J. (2000). Toward a life-span perspective on study
of message production. Communication Theory,
188-199.
Mattaini, M. A. (1993). Behavior analysis and community
practice: A review. Research on Social Work Practice,
420-447.
McAdams, D. P. (1992). Unity and purpose in human lives:
The emergence of identity as a life story. In R. A. Zucker, A. I.
Rabin, J. Aronoff, & S. J. Frank (Eds:), Personality structure in
the life course (pp. 67-89). New York: Springer.
Morgan, D. L. (1988). Age differences in social network par-
ticipation. Journal of Gerontology Series B: Social Science 43,
S129.:..s137.
O'Rand, A. M., & Krecker, M. L. (1990). Concepts of the life
cycle: Their history, meanings, and uses in the social sciences.
(Vol. 16, pp. 242-262). Palo Alto, CA: Annual Reviewers.
Settersten, R. A., & Mayer, L. U. (1997). The measurement of
age, age structuring, and the life course. Annual Review of
Sociology, 23, 233-261.
Smith, K. R., & Moen, P. (1980). Passage through midlife:
Women's changing family roles and economic well-being.
Sociological Quarterly, 29, 503~524.
Thomane, H. (1979). The concept of development and life span
developmental psychology. In P. B. Baltes & 0, G. Brim, Jr.
(Eds.), Life span development and behavior (Vol. 2, pp. 287-312).
New York: Academic Press.
Thomas, M. E., Herring, c., & Horton, H. D. (1994). Discrim-
ination over the life course: A synthetic cohort analysis of
earnings differences between black and white males, 1994-
1990. Social Problems, 41 (4),608-628.
Williams, A., & Nussbaum, J. F. (2001). Intergenerational com-
munication across the life span. Mahwah, NJ: Elbaum.
FURTHER READING
Hareven, T. K. (1996). Aging and generation relations over the life
course: A historical and cross-cultural perspective. New York:
Gruyter.
Rosow, I. (1978). What is a cohort and why? Human Development,
21, 65-75.
-LAN! V. JONES
DEVELOPMENT AND INFANCY (BIRTH TO AGE THREE)
ABSTRACT: Infancy and young childhood is characterized by
rapid cognitive, emotional, and physical development. Each year
is marked by specific developmental tasks. Infants need positive
parenting, a safe environment, and attention to their basic
physical needs. A strong bond with caregivers is also necessary,
as this lays the foundation for trust, allowing infants to explore
their world. Many of the risk factors, such as prenatal exposure to
alcohol and drugs, malnutrition, and abuse and neglect, can be
remedied. Interventions such as home visiting, family leave, and
nutrition programs
 LIFE SPAN: DEVELOPMENT AND INFANCY (BIRTH TO AGE THREE)
are inexpensive and effective, and should receive more
attention from social work.
KEyWORDS: infancy; young children; prenatal risk. .
factors; attachment; low birth weight; early
intervention; infant mortality; environmental risk
factors
Infancy and young childhood is one of the most crucial
periods in a child's development. It is a period of rapid
cognitive, emotional, and physical development. There is
a dynamic and continuous interaction between biology
and experience that shapes early human development.
Human relationships are the building blocks of healthy
development, and children are active participants in their
own development (Institute of Medicine, 2004).
"
Related Theory
Several theories inform social work practice with infants
and young children. Charlotte Towles's Common Human
Needs (1987) advanced the principle that beginning at
infancy, all humans have the same basic biological,
psychological, social, and spiritual needs. Piaget's theory
of cognitive development helps explain how infants and
young children develop intelligence through four stages of
adapting, assimilating, and accommodating their
environment (Beillin, 1992; Smith, 1996). Attachment
theory, developed primarily by Bowlby and Ainsworth,
posits that children develop different styles of attachment
based on their interactions with caregivers during infancy
(Bretherton, 1992). Brofenbrenner (1977) developed an
ecological framework for understanding children's
development, arguing that human development takes place
through processes of progressively more complex
reciprocal interactions over time (Brofenbrenner & Evans,
2000; Brofenbrenner & Morris, 1998). Social work
practitioners use these theories as a framework to (a)
integrate knowledge from other disciplines, such as
biology, medi. cine, psychology, and sociology, and to
transfer this knowledge to social work practice; (b)
analyze how social and economic forces impact early
childhood development; and (c) provide an explanation for
the workers' practice decisions. Most important, these
theories help social workers decide what to do (Payne,
2005).
Infants' . Cognitive, Emotional,
and Physical Needs
Sensitivity and responsiveness are most important for
infants and young children's cognitive and emotional
development. Sensitivity refers to how appropriate the
care is to the individual child, and responsiveness has to do
with how adaptive it is to changes in the child's
95
needs (Albers, Riksen-Walraven, & de-Weerth, 2007).
These are attributes both of the caregiver and of the
relationship between the caregiver and child. Parents and
children develop a relationship that is affected by the
child's temperament, parents' own childhood experiences,
the support parents receive, and the family's economic
stability (Waldfogel, 2006).
Developing secure attachments is one of the major
social and emotional developmental tasks for infants, as
secure attachments provide a sense of basic trust, Having a
sense of trust allows children to explore the world around
them and form attachments with others. Children can only
develop secure attachments if their caregivers are both
knowledgeable about their needs and responsive to those
needs (Carlson, Sampson, & Sroufe, 2003; Perry, 2003;
Vasquez & Pitts, 2006; Waldfogel, 2006).
Normal Development
For normal development to occur, infants and young
children need positive parenting, a safe environment, and
attention to their basic physical needs. All children are born
wired for feelings and ready to learn and early relationships
are essential. Each year is marked by specific
developmental tasks (Carter et al., 2005).
BIRTH TO AGE 1 The physical care that caregivers
provide, especially the. extent that caregivers are re-
sponsive and sensitive to children's physical needs,
lays the foundation for their cognitive and emotional
health. Newborns need constant attention, which can
be quite challenging for infants' caregivers. The
physical needs of newborns are fairly simple, in that
they need to be fed and to be kept warm. However,
even these simple needs can become complex.
Mothers' must decide whether to breast-feed, and
caregivers must learn how to keep newborns warm
without smothering them. From birth to age 1,
infants' cognitive development sets the stage for
language development, and they develop bonds of
love and trust (Sohr-Preston & Scaramella, 2006;
Thai & Clancy, 2001).
AGE 1-2 From age 1-2, children become
increasingly aware of themselves and their
surroundings. They develop greater
independence, become more mobile, can
recognize themselves in a mirror, develop the
ability to imitate behavior, form simple phrases
and sentences, and can follow simple directions.
Children are born with much of what they need to
learn language, which is one of their most
important developmental tasks, and much of
language learning is universal. Most children
begin talking between 10 and 15 months, and
their vocabularies grow rapidly from 18 months
onwards. The amount and quality of language
96 LIFE SPAN: DEVELOPMENT AND INFANCY (BIRTH TO AGE THREE)
are exposed to, including singing and playing word
games; enhances language-learning (McMullen &
Saffron, 2004; Suthers, 2001; Waldfogel, 2006).
AGE 2-3 From age 2-3, children experience huge
intellectual, social, and emotional changes to help
explore their world and make sense of it. Toddlers can
follow two or three phrase commands, sort objects by
color and shape, imitate actions of adults and play,
mates, and express a wide range of emotions. Because
of children's growing desire to assert their
independence, this developmental phase if often called
the "terrible twos" (Keenan & Wakschlag, 2000;
Ostrander, 2004).
CHALLENGES OR DILEMMAS Children's early
development depends on the health and well-being of
their parents. Children whose parents' struggle to cope
with their own emotional and - environment concerns
are more likely to experience developmental risk
factors. Such risk factors include low birth weight,
prenatal exposure to alcohol, drugs, and nicotine, abuse
and neglect, which can result in infant -mortality and
Shaken Baby Syndrome, health risk factors, such as
exposure to lead and lack of immunizations, and mal,
nutrition and overfeeding.
Low BIRTH WEIGHT AND SUBSTANCE ABUSE
Low birth weight is one of the leading causes of
neonatal mortality (U .S. Department of Health and
Human Services [USDHHSJ, 2006). Studies have
found a relation, ship between drug use during
pregnancy and premature birth, low birth weight, size
of the infant at birth, and problems with regulation
and alertness. Prenatal expo, sure to drugs can delay
the young child's language development, affect
behavior, and is a significant predictor of aggressive
and delinquent conduct (NIDA, 1999). Though
prenatal exposure to cocaine and to opiates is
associated with premature birth and low birth weight,
such drug exposure is not associated with mental,
motor, or behavioral deficits after controlling for
birth weight at three years of age (Messinger et a1.,
2004). Fetal alcohol syndrome (FAS) results from a
more persistent exposure. The consequences of FAS
range from mild intellectual and behavioral issues to
profound disabilities or premature death. Since
evidence suggests that low birth weight and
behavioral problems can be caused at average levels
of exposure as low as one drink per week, no alcohol
during pregnancy remains the best advice (Nugent,
INFANT& Mazor,
Greene, 1991).
MORTALITY AND HEALTH
DISPARITIES Up until the year 1980, the i~fant
mortality rate had shown a steady decline, from 26.0 per
1,000 live births
in 1960 to 6.8 per 1,000 live births in 2004 (CDC,
2007b). Since 2000, The United States ranked 28th in
the world in infant mortality in 2006 (USDHHS, 2006).
This ranking is due in large parts to racial and ethnic
disparities. Black women have for decades been twice
as likely as White women to give birth to low birth
weight babies (Reichman, 2005). In 2004, the mortality
rate among non-Hispanic Black infants was 14.2 deaths
per 1,000 live births. This is more than twice the rate
among non, Hispanic White infants (5.7 per 1,000 live
births) (USDHHS, 2006). This disparity cannot be
explained by socioeconomic status alone. Other
contributing factors include strenuous working
conditions and toxic exposures (McKinnon, 2003 ),
neighborhood violent crime (Morenoff, 2003),
residential environmental exposures, such as air pollu-
tion (Rogers et a1., 2000), substances in drinking water
(Rodenbeck, Sanderson, & Rene, 2000), and industrial
chemicals (Baibergenova, Kudyakov, Zdeb, &
Carpenter, 2003). Paternal exposure to pesticides, sol ,
vents, and lead in the workplace before contraception
may affect infant health (Trasler & Doersken, 1999).
Black fathers are more likely than Black mothers to be
exposed to toxic substances at work (McKinnon, 2003 ).
The leading causes of infant death include congeni tal
abnormalities, preterm/low birth weight, sudden infant
death syndrome (SIDS), and problems related to
complications of pregnancy (Kung, Hoyert, Xu, &
Murphy, 2007). Infant mortality among African
Americans in 2000 was more than twice the national
average. SIDS death rate among American Indian and
Alaska Natives is 2.3 times the rate of non- Hispanic
White mothers (CDC, 2007a). Low birth rate is asso-
ciated with increased risk in adulthood for cardio-
vascular disease, hypertension, and diabetes, all of
which occur at disproportionate rates among African
Americans, and contribute to lower life expectancies.
The association between birth weight and adult
morbidity remains even when accounting for lifestyle
factors (Barker, 2000).
There is a strong association between maternal
smoking and the increased incidence of SIDS and sleep
apnea. Prenatal exposure to nicotine inflicts lasting
damage that might leave the brain vulnerable to further
injury and addiction upon later use of the drug (Buka,
Shenassa, & Niaura, 2003).
Within the African American community, mater, nal
education and marital status may ultimately influ ence
infant mortality, mediated by biological and
demographic factors, health care, and infant health
status at birth (Sharma, 1998). Although socioeconomic
and behavior factors, including education, mar, ital
status, and substance abuse, may contribute to the
 LIFE SPAN: DEvELOPMENT AND INFANCY (BIRTH TO AGE
THREE) 97
disproportionate numbers of low birth weight African
American infants, these factors do not fully account for
ethnic disparities in adverse birth outcomes. There is now
emerging evidence to suggest that disproportionate rates of
low birth weight infants among African Americans may
result from group differences in exposure or susceptibility
to prenatal stress related to racism and discrimination as
well as from physiological responses to stress (Giscombe &
Lobel, 2005). Despite relatively low incomes, low formal
education, and lack of access to medical care, everyday
pregnancy care may explain why Mexican immigrant
women have positive birth outcomes (Sherraden & Barrera,
1997). African American women have a disproportionately
high rate of low birth weight infants when compared with
EuroAmerican women (Hovert, Freedman, Strobino, &
Guyer, 2001). Although socioeconomic and behavioral
factors contribute to adverse birth outcomes, such factors
as income, education, prenatal care, marital status, and
substance abuse do not fully account for these ethnic
disparities. There is now emerging evidence that the
disproportionate rates of infant mortality, low birth weight,
and preterm delivery in African Americans may result
from group differences in exposure or susceptibility to
prenatal stress, including stress related to racism and
discrimination as well as physiological differences in
physiological responses to stress (Giscombe & Lobel,
2005).
INFANT ABUSE AND NEGLECT More children die
from maltreatment between the ages of 0 and 3
< Widom, 2007). Because major brain development occurs
than during any other time (USDHHS, 2002). There
were 24,900 first confirmed physical abuse reports among
infants in eight states during 1995-1999 in NCANDS-
DCDC, an incidence rate of 2.4 confirmed reports per
1,000 infants. The consequences of maltreatment for
infants and young children can affect a child's development
in ways which may not be recoverable with age
(Scannapieco & Connell-Carrick, 2005). Infants and
toddlers who have been physically abused may exhibit
signs of posttraumatic stress disorder (PTSD) that may be
manifested in both cognitive and behavioral changes,
including problems achieving autonomy, lack of empathic
understanding, and a tendency to engage in more concrete,
rather than imaginary play (Howard, 1996; Perry, 1997,
1999). Though there is a dearth of research on PTSD
among young children, life-threatening trauma, such as
abuse, during the early childhood years may impact the
child's longterm development (Scheeringa, 2004).
Physically, children who are abused may exhibit a failure
to thrive. In more severe cases, physical abuse can cause
developmental delays, retardation, and paralysis (Perry,
1999).
Unpredictable and prolonged stress negatively affects the
infant's developing brain. In toddlerhood, such children
may become aggressive to control the predictability of the
abuse rather than wait for it to happen (Perry, 1997).
Shaken baby syndrome results from vigorously shaking a
baby, and these infants present with seizures, vomiting,
lethargy, drowsiness, and death. Such infants often show
retinal damage and brain injury, and the brain injury can
also result in spinal cord injury, leading to paralysis
(Scannapieco & Connell-Carrick, 2005).
Infants who are neglected may be delayed in their
cognitive development, and may exhibit a failure to thrive
(Barnett, Miller-Perrin, & Perrin, 2005). Such infants are
usually below the 5th percentile of relative growth (Kerr,
Black, & Krishnakurnar, 2000). Chronic neglect can have a
devastating effect on the developing brain, since infants
and young children require a stimulating environment to
foster the development of neural pathways (De Bellis,
2005; Streeck-Fischer & van der Kolk, 2000). Such
children may also fail to develop gross and fine motor
skills. Neglected toddlers tend to be easily frustrated,
impulsive, and be uninterested in play (Erickson &
Egeland, 2002). It should be noted that an infant well cared
for in a dirty home would not exhibit these developmental
delays. While the cognitive deficits of neglected infants
seem to be cumulative, their developmental delays may be
recoverable if identified early enough (Olivan, 2003).
Sexual abuse of infants can be equally devastating,
since children who experience sexual abuse earlier in life
are at greater risk for poor psychological functioning in
adulthood than those maltreated later in life (Kaplow &
over the first 2-3 years of life, the developing brain is
especially vulnerable to the harmful effects of stress and
trauma, such as sexual abuse (Nelson & Carver, 1998; van
der Kolk, 1996). This may affect all their future
relationships, and they may use disassociation as a primary
coping mechanism. (Diseth, 2005; Sar, Akyuz, & Dogan,
2007).
CHILDHOOD DISEASES OR LACK OF IMMUNIZA-
TIONS There are many vaccine-preventable diseases,
which not long ago, disabled and killed millions of
children. These diseases are now uncommon as a result of
the high childhood immunization coverage levels. Since
many of the viruses and bacteria that cause these diseases
are still circulating in the United States, or are only a plane
ride away, it is important that infants and young children
receive recommended immunizations on time. If a child is
not vaccinated and is exposed to a disease germ, the child's
body may not be strong enough to fight the disease. Before
vaccines, many
98 LIFE SPAN: DEVELOPMENT AND INFANCY (BIRTII TO AGE THREE)
children died from diseases that vaccines now prevent,
such as whooping cough, measles, and polio. The same
germs exist today (CDC, 2007c). Many new immigrants
and refugees, including women and young children, are
susceptible to measles, mumps, or rubella and may
benefit from targeted vaccination programs (Davis,
2007). Programs to vaccinate new immigrants may
reduce the number of young children who are exposed to
infectious diseases (CDC, 2007a). Children under the
age of 1 are too young to receive a vaccination and are
among those who would benefit from vaccination
programs that target new immigrants and refugees
(CDC, 2007c).
MALNUTRITION AND OVERFEEDING Ironically,
both malnutrition and overfeeding can be observed
among infants in the United States, both of which have
longterm health consequences. There is no universally
accepted definition of malnutrition, however, the World
Health Organization defines malnutrition as the cellular
imbalance between supply of nutrients and energy and
the body's demand for them to ensure growth,
maintenance, and specific functions (Alberda, Graf, &
McCarger, 2006).
Malnutrition has been described with increasing
frequency in hospitalized and chronically ill children in
the United States, and occurs in as many as 10% of
children in rural areas (Grigsby & Shashidhar, 2006).
Rapid infant weight gain has been associated with
increased risk of being overweight at 4 years of age
(Dennison, Edmunds, Stratton, & Pruzek, 2006). Over-
feeding in infancy could explain in part why childhood
obesity is on the rise (Epps, 2006; Plagemann, 2006;
Rising & Lifshitz, 2005).
LEAD POISONING OR ENVIRONMENTAL RISK
FACTORS Exposure to lead can lead to intellectual and
behavioral deficits in children and hypertension and
kidney disease in adults. Today, ,,-,310,000 children
aged 1-5 years remain at risk for exposure to harmful
lead levels in the United States. Many children, even
those considered at lowest risk, are exposed to some
amounts of lead. Though the percentage of children
aged 1-5 with unsatisfactory blood levels has declined
sharply, blood lead levels remain higher for minority
populations, children from low-income families, and
children who live in older homes (MMWR, 2005).
Researchers have shown that high-risk neighborhoods,
characterized by poverty, high percentages of residents
on public assistance, and multiple or subdivided hous-
ing units, are also neighborhoods with significant
sources of lead toxicity. Children from these neighbor-
hoods are also more likely to be diagnosed with a
learning disability (Margai & Henry, 2003; McLoyd,
1998).Young children who have either emigrated to the
United States with their families or been adopted may be
at increased risk as a result of either pre- or post-
immigration exposure. Children who may be exposed to
lead-containing folk remedies may also be at risk
(Bernard, 2003). While efforts to reduce lead exposure
have resulted in the decline in blood lead levels
(MMWR, 2005), other sources of lead exposure such as
drinking water contaminated during delivery and
exposure to aging buildings remain (Bernard, 2003).
WORKING MOTHERS AND INFANT BONDING
Children who are securely attached to their parents are
more socially competent and get along better with peers
(Allen, Porter, McFarland, McElhaney, & Marsh, 2007;
Lucas-Thompson & Clarke-Stewart, 2007). According
to research, there is a network of behavioral, physiolo-
gical, and neural processes that underlie the psycholo-
gical constructs of attachment theory that is especially
relevantfor the mother-infant bond (Hofer, 200S). As a
result, attachment theory was taken to suggest that
working mothers posed a risk to their children's mental
health. However, research has shown that children with
working mothers (or fathers) can develop secure
attachments to them (Tizard, 1991; Waldfogel, 2006).
Marked changes in the nature, schedule, and amount of
work engaged in by parents of young children make it
increasingly difficult to balance workplace and family
responsibilities (Institute of Medicine, 2004). Mothers
who work full-time during an infant's first year of life
may find it difficult to breast-feed, which can have
adverse effects on a child's health. Mothers' full-time
work after the first year has neutral or positive effects
(Russell, 1999; Tizard, 1991). Ultimately, adequate
care-giving is based on the caregivers' ability to inte-
grate life experiences into the care-giving relationship
(Waldfogel,2006).
FATHERS AND INFANTS Most fathers report being
elated when their infant is born. With the exception of
lactation, there is no evidence that women are bio-
logically predisposed to be better parents than fathers .
(Lamb, 2002), and fathers experience similar changes in
hormonal levels around the time of their infants' birth
(Storey, Walsh, & Quinton, 2000). Some researchers
have found little difference between levels.of maternal
and paternal sensitivity, though fathers' responsiveness
appears to vary according to the degree that they assume
responsibility for infant care (Gervais, 1997; Ninio &
Rinott, 1988) However, there is considerable cultural
variability in how much time fathers spend with infants
(Lamb, 1987; Quinlan & Quinlan, 2007).
 LIFE SPAN: DEvELOPMENT AND INFANCY (BIRW TO AGE THREE)
Implications for Social Work Interventions
that address infants' developmental risk factors are
effective and inexpensive and should receive more
attention from social workers. Research shows - that
short-term interventions with a clear focus appear
to be more effective than long-term broad-based inter-
ventions (van Ijzendoorn, ]uffer, & Duyvesteyn, 1995).
For example, screening low-income pregnant women in a
community setting may be an effective intervention to
prevent FAS, low birth weight, and related conditions
(O'Connor & Whaley, 2003).
Social workers should advocate for the following
interventions to be universally accessible to infants and
their families: prenatal health care, WIC and other nutrition
programs, pre- and perinatal home visitation, early
intervention, and drug and alcohol treatment and tobacco
cessation programs for women who are pregnant. The
Family and Medical Leave Act should be expanded to
include all working parents, and welfare reform's work
requirements for parents of infants should be curtailed.
Studies have shown that extending paid job-protected
maternity leave by 10 weeks reduced postneonatal
mortality, suggesting that infants fare better when mothers
can stay home to care for them during their first weeks of
life (Waldfogel, 2006). In spite of initial concerns
regarding the effect of work requirements as a result of the
passage of the Personal Work and Responsibility act of
1996, research suggests that children whose mothers make
the transition from welfare to work were no healthier than
children with welfare-dependent - caregivers (Slack, Holl,
Yoo, Amsden, Collins, & Bolger, 2007). However,
requiring women to work while pregnant may negatively
affect birth weight, especially for African American
mothers. The effect of job strain on low birth weight of
women who were working during early and late pregnancy
was significantly greater for African Americans than for
European Americans (Oths, Dunn, & Palmer, 2001). While
social workers at the program level may not be able to
affect whether mothers receive maternity leave and other
economic supports, they can provide social support and
encourage mothers to enroll in programs that provide
social support, health services, parenting education, and
other services. Such programs have been demonstrated to
be effective in reducing low birth weight and enhancing the
well-being of infants and young children (DuMont et al., in
press; Olds, 2002).
Trends or Directions
There is little indication that we will see greater public
support for families with infants and young children, in
spite of the research that indicates positive outcomes for
targeted early intervention. For example, despite the
99
benefits associated with the Supplemental Nutrition
Program for Women, Infants, and Children (WI C), over 1
in 4 eligible infants do not receive WIC (Gundersen, 2005).
Young children are more likely to be poor today than 25
years ago, which imposes significant burdens on their
well-being and increases the odds for adverse
developmental outcomes. Ethnically diverse families face
unique challenges as a result of social, political, and
cultural realities that limit families' access to resources and
create additional stressors to families who already are
vulnerable at this critical stage of development. Clearly
more can be done to support families of young children, as
research suggests that such support can promote positive
trends in infants' development.
REFERENCES
Alberda, c., Graf, A., & McCarger, L (2006). Malnutrition:
Etiology, consequence, and assessment of a patient at risk. Best
Practices and Research Clinical Gastroenterology, 29(3), 419-439.
Albers, E. M., Riksen-Walraven, J., & de-Weerth, C. (2007).
Infants, interactions with professional caregivers at 3 and 6
months of age: A longitudinal study. Infant Behavior and
Development, 39(4), 631-640.
Allen, J. P., Porter, M., McFarland, c, McElhaney, K. B., &
Marsh, P. (2007). The relation of attachment security to
adolescents' paternal and peer relationships, depression, and
externalizing behavior. Child Development, 78(4), 1222-1239.
Baibergenova, A., Kudyakov, R., Zeleb, M., & Carpenter, D. O.
(2003). Low birth weight and residential proximity to PCB-
contaminated waste sites. Environmental Health Perspectives,
111(10),1352-1357.
Barker, D. J. P. (2000). In utero programming of cardiovascular
disease. Theriogenology, 53, 555-574.
Barnett, 0., Miller-Perrin, C. L, & Perrin, R. C. (2005).
Family violence across the lifespan; An introduction (2nd ed.).
Thousand Oaks, CA: Sage Publishing.
Beillin, H. (1992). Piaget's enduring contribution to develop-
mental psychology. Developmental Psychology, 28, 191-204.
Bernard, S. (2003). Should the Centers for Disease Control and
Prevention's childhood lead poisoning intervention level be
lowered? American Journal of Public Health, 93(8), 1253-1260.
Bremerton, I. (1992). The origins of attachment theory: John
-Bowlby and Mary Ainsworth. Developmental Psychology, 28,
759-775.
Brofenbrenner, U. (1977). Toward an ecology of human development.
Cambridge, MA: Harvard University Press.
Brofenbrenner, u., & Evans, G. W. (2000).
Developmental science in the 21st century:
Emerging questions, theoretical models,
research designs and empirical findings. Social
Development, 9(1),115-125.
Brofenbrenner, u, & Morris, P. A. (1998). The ecology of
developmental processes. In R. N. Lerner (Ed.), Handbook of
Child Psychology (5th ed., Vol. 1, pp. 993-1028) (W. Damon,
series editor). New York: Wiley.
100 LIFE SPAN: DEVELOPMENT AND INFANCY (BIRTH TO AGE THREE)
Buka, S. L., Shenassa, E. D., Niaura, R. (2003). Elevated risk of
tobacco dependence among offspring of mothers who smoked
during pregnancy: A 30 year prospective study. American Journal
of Psychiatry, 160, 1978-1984.
Carlson, E. A, Sampson, M. C., Sroufe, A L. (2003). lmpli. cations of
attachment theory and research for developmentalbehavioral
pediatrics. Journal of Developmental and Behavioral Pediatrics, 24,
364-369.
Carter, C. S., Ahnert, L., Grossmann, K. E., Hrdy, S. B., Lamb, M. E.,
Porges, S. W., &Sachser, N. (2005). Attachment and Bonding: A
New Synthesis. Cambridge, MA: MIT Press.
Center for Disease Control. (2007a). National Immunization
Program. Retrieved November 16,2007, from http://www.
cdc.gov/nip/diseases/child-vpd.htm#protect.
Center for Disease Control (Office of Minority Health). (2007b). Fact
Sheet: Eliminate disparities in infant mortality. Retrieved
November 16, 2007, from http://www.cdc. gov/omhd/
AMH/factsheets/infant.htm.
Center for Disease Control. (2007c). The importance of childhood
immunizations. Retrieved November 16, 2007, from
http://www.cdc.gov/vaccines/vac-gen/irnportance.htm.
Davis, M. B. (2007). Susceptibility to measles, mumps, and rubella in
newly arrived adult immigrants and refugees. Annals ofIntemal
Medicine, 146(1),20-24.
De Bellis, M. D. (2005). The psychobiology of neglect. Child
Met/treatment, 19(2), 150-1 n.
Dennison, B., Edmunds, L., Stratton, H., & Pruzek, R. (2006).
Rapid infant weight gain predicts childhood overweight. Obesity,
14(3),491-499.
Diseth, T. H. (2005). Dissociation in children and adolescents as
reactions to traurna-c-e.An overview of conceptual issues and
neurobiological factors. Nordic Journal of Psychiatry, 59(2),
79-91.
DuMont, K. A., Mitchell-Herzfeld, S., Greene, R., Lee, E.,
Lowenfels, A, Rodriguez, M., & Dorabawila, V. (in press).
Healthy Families New York (HFNY) randomized trial:
Effects on early child abuse and neglect. Child Abuse &
Negkct. . McLoyd, V. C. (1998). Socioeconomic disadvantage and child
Erickson, M. F., & Egeland, B. (2002). Child neglect, In C. T.
Hendrix, C. Jenny, J. E. B. Myers, L. Berliner, & Briere, J., The
APSAC handbook on child maltreatment (2nd ed., pp. 3-20).
Thousand Oaks, CA: Sage Publications.
Giscombe, C. L., & Lobel, M. (2005). Explaining disproportionately
high rates of adverse birth outcomes among African-Americans:
The impact of stress, racism, and related factors in pregnancy.
Psychological Bulktin, 131 (5),662-683.
Gervais, K. (1997). A study of factors accounting for first-time
fathers' level of caregiving involvement with their newborn
infants. Dissertation Abstracts International, Section B: The
Sciences and Engineering, 57(7-B), 4743.
Grigsby, D., & Shashidhar, H. (2006). Malnutrition. E Medicine.
Retrieved November 16, 2007, from http://www.eme-
dicine.com/ped/topic1360.htm.
Gundersen, C. (2005). A dynamic analysis of the well-being of WIC
recipients and eligible non-recipients. Children and Youth Services
Review, 27(1), 99-114.
Hofer, M. A (2005). Psychobiological roots of early attachment.
Current Directions in Psychological Science, 15 (2), 84-88.
Howard, A C. (1996). Developmental play ages of physically abused
and non abused children. American Journal of Occupational
Therapy, 40 (10), 691-695.
Hoyert, D. L., Freedman, M. A., Strobino, D. M., & Guyer, B.
(2001). Annual summary of vital statistics: 2000. Pediatrics, 108,
1241-1255.
Kaplow, J. B., & Widom, C. S. (2007). Age of onset of child
maltreatment predicts long-term mental health outcomes. Journal
of Abnormal Psychology, 116(1), 176-187.
Keenan, K., & Wakschlag, L. S. (2000). More than the terrible twos:
The nature and severity of behavior problems in clinic-referred
preschool children. Journal of Abnormal Child Psychology, 28(1),
33-46.
Kerr, M. A, Black, M. M., & Krisnakumar, A (2000). Failure to
thrive, maltreatment and the behavior and development of 6-year
old children from low income, urban families:
A cumulative risk modeL Child Abuse and Negkct, 24(5), 587-598.
Kung, H. c., Hoyert; D. L., Xu, J. Q., & Murphy, S. L. (2007).
Estat deaths: Preliminary data for 2005 health Estats,
Hyattsville, MD: US Department of Health and Human
Services, CDC. Retrieved November 16, 2007, from
http://www.
cdc.gov/nchs/products/pubs/pubd/hestats/prelimdeaths05/
prelimdeaths05.htm.
Lamb, M. E. (1987). The father's role: Cross-cultural perspectives.
London: Lawrence Erlbaum Associates.
Lamb, M. (2002). Infant-father attachments and their impact on child
development. In C. Tarnis-Lelvlonda & N. Cabrera (Eds.),
Handbook of father involvement: Multidisciplinary perspectives.
New Jersey: Lawrence Erlbaum Publishers.
Lucas-Thompson, R., & Clarke-Stewart, K. A (2007). Forecasting
friendship: How marital quality, maternal mood, and attachment
security are linked to children's peer re-· lationships. Journal of
Applied Developmental Psychology, 28(5-6),499-514.
Margai, F., & Henry, N. (2003). A community-based assessment of
learning disabilities using environmental and contextual risk
factors. Social Science and Medicine, 56(5), 1073-1085.
development. American Psychologist, 53(2), 185-204.
McMullen, E., & Saffran, J. R. (2004). Music and language:
A developmental comparison, Music Perception, 21 (3), 289-311.
Morbidity and Mortality Weekly Report. (2005, May 27).
Blood kad kvels-United States, 1999-,-2002, 54(20), 513-516.
McKinnon, J. (2003). The Black population in the United States:
March 2002. Current Population Reports, P20-541, Washington,
DC: US Census Bureau.
Morenoff, J. D. (2003). Neighborhood mechanisms and the spatial
dynamics of birth weight. American Journal of Sociology, 108(5),
976-1017.
National Institute on Drug Abuse. (1999). NlDA research priorities
and highlights: Role of research: Fetal and childhood
development. In Drug abuse and addiction research: 25 years of
discovery to advance the health of the public. Bethesda, MD:
Author.
j
 LIFE SPAN: DEvELOPMENT AND INFANCY (BIRTH TO AGE THREE)
National Research Council and Institute of Medicine. (2004).
From neurons to neighborhoods: The science of early child-
hood development. Committee on Integrating the Science
of Early Childhood Development. In J. Shonkoff &
D. Phillips (Eds.), Board on children, youth, and families,
commission on behavioral and social sciences and education. Cowen, D. J., & Decoufle, P. (2000). Association of very
Washington, DC: National Academy Press.
trauma on brain and memory: A view from developmental
..--..-
Nelson, C. A., & Carver, L. J. (1998). The effects of stress and c.·" dioxide and total suspended particulates. American Journal
... ,. .
cognitive neuroscience. Development and Psychopathology,
10(4), 793-809.
N inio, A., & Rinott, N. (1988). Fathers' involvement in the
care of their infants and their attributions of cognitive
competence to infants. Child Development, 59(3), 652-663.
Nugent, K. J., Greene, S. M., & Mazor, K. M. (1991). Neuro-
biological and medical effects of parental alcohol and cig-
arette use: Data from the Dublin Child Development Study.
The Irish Journal of Psychology, 12(2), 153-164~
O'Connor, M., & Whaley, S. (2003). Alcohol use in pregnant
low-income women. Journal of Studies on Alcohol, 64(6),
773-783.
Olds, D. L. (2002). Prenatal and infancy home visiting by
nurses: From trials to community replication. Prevention
Science, 3(3),153-172.
Olivan, G. (2003). Catch-up growth assessment in long-term
physically neglected and emotionally abused preschool age
male children. Child Abuse and Neglect, 27(1), 103-108.
Ostrander, R. (2004). Oppositional defiant disorder and con-
duct disorder. In L. B. Silver & F. M. Kline (Eds.), The
Educator's Guide to Mental Health Issues in the Classroom
(pp. 267-286). Baltimore, MD: Paul H. Brookes Publishing.
Oths, K. S., Dunn, L. L., & Palmer, N. S. (2001). A prospect-
ive study of psychosocial job strain and birth outcomes.
Epidemiology, 12,744-746.
Payne,M.(2005).Modemsocialworktheory(3rded.).Chicago,
IL: Lyceum Press.
Perry, B. (1997). Incubated in terror: Neurodevelopmental
factors in the "cycle of violence," In J. Osofsky (Ed.), Chi!-
dren, youth, and violence: A search for solutions (pp. 124-
148). New York: Guilford Press.
Perry, B. D. (1999). Post-traumatic stress disorders in children
and adolescents. Current Opinions in Pediatrics, 11 (15).
Perry, B. D. (2003). Young children and language. Early Child-
hood Today, 17(5).
Plagemann, A. (2006). Perinatal nutrition and 'hormone-
Hormo-
dependent programming of food intake. Fetal Nutrition and
Postnatal Biology, Hormonal Research, 65 (Suppl. 3), 83-89,
DO I: 10.1159/00081511
Quinlan, R. J., & Quinlan, M. B. (2007). Parenting and cul-
life. Early
tures of risk: A comparative analysis of infidelity, aggression,
and witchcraft. American Anthropologist, 109(1), 164-179. Thai, D. J., & Clancy, B. (2001). Brain development and
Reichman, N. E. (2005). Low birth weight and school readi-
ness. The Future of Children, 15(1),91-116.
Rising, R., & Lifshitz, F. (2005). Relationship between mater-
nal obesity and infant feeding-interactions. Nutrition Jour-
nal, 4(17), DOl: 10.1186/1475-2891-4-17. Retrieved
November 16, 2007, from http://www.nutritionj.com/Motherhood: Meanings, practices and ideologies. Thousand
content/4/1/17.
101
Rodenbeck, S. E., Sanderson, L. M., & Rene; A. (2000).
Maternal exposure to trichloroethylene in drinking water
and birth weight outcomes. Archives of Environmental
Health, 55(3),188-194. C
Rogers, J. F., Thompson, S. J., Addy, C. L., McKeown, R. E.,
low birth weight and exposures to environmental sulfur
of Epidemiology, 151(6),602-613.
Russell, C. M. (1999). A meta- analysis of published research
on the effects of nonmaternal care on child development.
Dissertation Abstracts, International Section A, Humanities and
Social Sciences, 59(9-A), March.
Sar, V., Akyuz, G., & Dogan, O. (2007). Prevalence of disso-
ciative disord~ rs among women in the general population.
Psychiatry Research, 149(1-3), 169-176.
Scannapieco, M., & Connell-Carrick, K. (2005). Understand-
ingchild maltreatment: An ecological and developmental per-
spective. New York: Oxford University Press.
Scheeringa, M. S. (2004). Posttraumatic stress disorder. In
A. Carter & R. DelCarmen-Wiggins (Eds.), Harulbook
of infant, toddler, and preschool mental health assessment
(pp, 377-397). New York: Oxford University Press.
Sharma, R. K. (1998). Causal pathways to infant mortality :
Linking social variables to infant. Journal of Health and Social
Policy, 9(3), 15-28.
Sherraden, M., & Barrera, R. (1997). Culturallv- protective
health practices: Everyday pregnancy care among Mexican
immigrants. Journal of Multicultural Social Work, 6(lf2),
903-115.
Slack, K. S., Holl, J. L., Yoo, J., Amsden, L. B., Collins, E., &
Bolger, K. (2007). Welfare, work, and health care access
predictors of low-income children's physical health out-
comes. Children and Youth Services Review, 29(6), 782--801.
Smith, L. (Ed.). (1996). Critical readings on Piaget. London:
Routledge.
Sohr-Preston, S., & Scaramella, L. V. (2006). Implications of
timing of maternal depressive symptoms for early cognitive
and language development. Clinical Child and Family Psych-
ology Review, 9(1), 65-83.
Streeck-Fischer, A., & van der Kolk, B. A. (2000). Down will
come baby, cradle and all: Diagnostic and therapeutic impli-
cations of chronic trauma on child development. Australian
and New Zealand Journal of Psychiatry, 34(6), 903-918.
Storey, A. E., Walsh, C. J., & Quinton, R. L. (2000).
nal correlates of paternal responsiveness in new and expect-
antfathers. Evolution and Human Behavior, 21(2), 79-95.
Suthers, L. (2001) . Toddler diary: A study of development and
learning through music in the second year of
Childhood Development and Care, 171, 21-32.
language learning: Implications for nonbiologically based
language-learning. Journal of Speech Language Pathology and
Audiology, 25(2), 52-76.
Tizard, B. (1991). Employed mothers and the care of young
children. In E. Lloyd, A. Phoenix, & A. Woolett (Eds.),
Oaks, CA: Sage Publications.
102 LIFE SPAN: DEVELOPMENT AND INFANCY (BIRTH TO AGE THREE)
Trasler, J. M., & Doerksen, T. (1999). Teratogen update:
Paternal exposures-reproductive risks. Teratology, 600),
161-1n.
U.S. Department of Health and Human Services (Administra-
. tion for Children and Families). (2002). Child maltreatment 2000:
Reparts from the States to the National Child Abuse and Neglect
Data Systems. Washington, DC: U.S. Government Printing
Office. Retrieved October 31, 2007, from
http://mchb.hrsa.gov/mchirc/ chusa_ 05/healthstat/infants/
0302Ibw.htm.
U.S. Department of Health and Human Services, Center for
Disease Control (2006). Health, United States, 2006.
Washington, DC: USDHHS, Center for Disease Control,
National Center for Health Statistics, 017~22~1602.Retrieved
October 21, 2007, from http://www.cdc.gov/nchs/
pressroom/06facts/hus06.htm. ' Modifying effects of caregiver, early intervention, and birth
van der Kolk, B. A (1996). The body keeps the score: Approaches
to psychobiology of posttraumatic stress disorder. In B. A van
der Kolk, A. C. McFarlanne, & L. Weisaeth (Eds.), The effects
of overwhelming experiences on mind, body, and society (pp.
214-241). New York: Guilford Press.
van Ijzendoorn, M., Juffer, F., & Duyvesteyn, M. (1995).
Breaking the intergenerational cycle of insecure attachment: A
review of the effects of attachment-based interventions on
maternal sensitivity and infant security. Journal of Child
Psychology, 96(2), 225-248.
Vasquez, E., & Pitts, K. (2006). Red flags during home visitation:
Infants and toddlers. Journal of Community Health
Nursing,23(2), 123-131.
Waldfogel, J. (2006). What children need. Cambridge, MA:
Harvard University Press.
FURTHER READING
Ainsworth, M. (1982). Attachment: Retrospect and prospect.
In C. M. Parkes & J. Stevenson-Hinde (Eds.), The place of
attachment in human behavior (pp. 3-30). New York:
Basic Books.
American Physiological Society. (2006). Prenatal nicotine
exposure ~educes breathing response of newborns. Retrieved
November 16, 2007, from http://www.sciencedaily.com/
releases/2006/04/0604061 0 1419 .htm.
Atella, L., DiPietro, J., Smith, B., & James-Roberts, I. (2003).
More than meets the eye: Parental and infant contributors to
maternal and parental reports of early infant difficulties.
Parenting: Science and Practice, 3(4), 265-284.
Bowlby, J. (1969-1980). Attachment and loss, 3 vols. New York:
Basic Books.
Bowlby, J. (1988). A secure base: Parent-ehildattachment and
healthy human development. New York: Basic Books.
Clark, W. (2001). Residential substance abuse treatment for
pregnant and postpartum women and their children: Treat-
ment and policy. Child Welfare, 80(2), 179-198.
Coles, c., Kable, J., Drews-Botsch, c., & Falek, A
(2000).
Early identification of risk for effects of prenatal alcohol
exposure. Journal of Studies on Alcohol, 61 (4), 607 --Q 16.
Devaney, B., Ellwood, M., & Love, J. (1997). Programs that
mitigate the effects of poverty. The Future of Children, 7(2),
88-112.
Dickson, L., Walker, H., & Fogel, A (1997). The relationship
between smile type and play type during parent-infant play.
Developmental Psychology, 33, 925-933.
Duke Mednews. (2007). Prenatal nicotine primes adolescent
brain for addiction. Retrieved November 16, 2007, from
http://www.dukemednews.org/news/article.php?id=7513.
Dye, J., & Tallese, J. (2006). A child's day: 2003 (Selected
indicators of child weU-being). Current Population Reparts,
P70-109. Washington, DC: U.S. Census Bureau.
Fetal Alcohol Disorders Society. (2007).· Research, information,
support, and communications. Retrieved November 16,2007,
from http://www.faslink.org/.
Frank, D., Jacobs, R., Beeghly, M., Augustyn, M., Bellinger, D.,
Cabral, H., et al. (2002). Level of prenatal cocaine exposure
and scores on the Bayley scales of infant development:
weight. Pediatrics, 110(6), 1143-1152.
Gibson, E., & Pick, A. (2000). An ecological approach to percep-
tualleaming and development. London: Oxford University Press.
Haight, W., & Taylor, E. (2007). Human behaviar for social wark
practice: A developmental-ecological framewark. Chicago:
Lyceum Press.
Hollander, D. (2001). Young mothers' disadvantage, not their age
itself, accounts for their children's educational problems.
Family Planning Perspective, Nov/Dec 2001. Retrieved
November 16, 2007, from http://www.findarticles.com/p/
articles/mi_qa3634/is_200111/ai_n8963093.
Howe, D. (2006). Disabled children, parent-ehild interaction and
attachment. Child and Family Social Wark, 11 (2), 95-106.
Johnson, H., Nusbaum, B., Bejarano, A, & Rosen, T. (1999).
An ecological approach to development in children with
prenatal drug exposure. American Journal of Orthopsychiatry,
69(4),448-456.
Korenbrot, C. c, Wong, S. T., & Stewart, A L. (2005).
Health promotion and psychosocial services and women's
assessments of interpersonal prenatal care in Medicaid
Managed Care. Maternal· and Child Health Journal, 9(2),
135-149.
Lee, B., Mackey, L., & Goergo, R. (2003). The patterns offood
stamps and WIC participation under welfare reform. Children
and Youth Services Review, 25(8),589-610.
Lemons, J., Bauer, C., Oh, W., Korones, S., Papily, L. A., Stoll,
B., et al. (2001). Very low birth weight outcomes of the
National Institute of Child Health and Human Development
Neonatal Research Network, January 1995 through December
1996. Pediatrics, 107(1), e1.
Messinger, D. S., Bauer, C. R., Das, A., Seifer, R., Lester, B. M.,
& Lagasse, L. L. (2004). The Maternal Lifestyle Study:
Cognitive, motor, and behavioral outcomes of
cocaine-exposed and opiate-exposed infants through three
years of age. Pediatrics, 113(6), 1677-1685.
McCarton, c., Brooks-Gunn, J., Wallace, I., Bauer, c., Bennett,
F., Bernbaum, J., et al. (1997). Results at age 8 years of early
intervention for low-birth-weightpremature infants. Journal of
the American Medical Association, 27(2), 126-132.

McCormick, M. (2005). The contribution of low birth weight to
infant mortality and childhood morbidity. The New Eng-
landJournal of Medicine, 312(2), 82-90.
Norbeck, J. S., & Anderson, N. J. (1989). Psychosocial predictors
of pregnancy outcomes in low-income Blacks, Hispanic, and
White women. Nursing Research, 38,204-209.
Queiro-Tajalli, 1. (1989). Hispanic women's perceptions and use
of prenatal health care services. Affilia: Journal of Women and
Social Work, 4(2), 50-72.
Sagrestano, L., Feldman, P., Killingsworth-Rini, c., Woo, G., &
Dunkel-Schetter, C. (1999). Ethnicity and support during
pregnancy. American Journal of Community Psychology, 27,
869-898.
Sidebotham, P., Heron, J., & ALSPAC Study Team (2003).
Child maltreatment in the "children of the nineties": The role
of the child. Child Abuse and Neglect, 27(3),337-352.
Sood, B., Delaney-Black, V., Covington, c., Nordstrom-Klee, B.,
Ager, J., Templin, T., et al. (200l). Prenatal alcohol exposure
and childhood behavior at age 6 to 7 years:
Dose-response effect. Pediatrics, 108(2), e34.
Sroufe, A. (2005). The development of the person: The Minnesota
study of risk and adaptation from birth to adulthood. New York:
Guilford Press.
Strand, P. (2002). Treating antisocial behavior: A context for
substance abuse prevention. Clinical Psychology Review, 22(5),
707-728.
Stratheam, L., Gray, P., O'Callaghan, M.,& Wood, D. (200l).
Childhood neglect and cognitive development in extremely
low birth weight infants: A prospective study. Pediatrics, 108
(1), 142-151.
Towle, C. (1987): Common human needs. Washington, DC:
NASWPress.
U.S. Department of Health and Human Services. (2006).
Child Health, USA 2006, Health Resources and Services
Administration, Maternal and Child Health Bureau, Rockville,
MD: U.S. Department of Health and Human Services.
Retrieved October 31, 2007, from http://www.
mchb.hrsa.gov/chusa_ 06/healthstat/infants/0302lbw .htm.
Windham, A., Rosenberg, L., Fuddy, L., McFarlane, E., & Sia, C.
(2004). Risk of mother-reported child abuse in the first three
years of life. Child Abuse and Neglect, 28(6), 6455-6667.
Winicki, J. (2003). Children in homes below poverty: Changes in
program participation since welfare reform. Children and Youth
Services Review, 25(8), 651-668.
Zeanah, C. (Ed.). (2005). Handbook of infant mental health (2nd
ed.). New York: Guilford Press.
Zeskind, P., & Ramey, C. (1978). Fetal malnutrition: An
experimental study of its consequences. on infant development
in two care-giving environments. Child Development,
49(4),1155.
SUGGESTED LINKS
National Center for Children Exposed to Violence.
http://www.nccev.org/,2007
National Institute of Health, National Institute of Child Health
and Human Development.
http://www . nichd. nih .gov/
LIFE SPAN: EARLY CHILDHOOD AND PRESCHOOL
103
U.S. Department of Health and Human Services. (2007). Families
and children: Infants.
http://www .dhhs .gov/children/index.shtml#babies
-CATHLEEN A. LEWANDOWSKI
EARLY CHILDHOOD AND PRESCHOOL
ABSTRACT: This article focuses on the early childhood
years, from 2 to 5 years of age. There are over 12 million
children in this age range in the United States, many of whom
face a number of challenges. In this article we discuss
cognitive, language, motor, and social development, including
relevant theories and major language and motor
developmental milestones. We also discuss several family and
environmental factors that influence development, including
attachment, parenting, working parents, and poverty.
KEY WORDS: early childhood; preschool; working parents;
child care; poverty; language development; motor
development; cognitive development; social development;
attachment
This article focuses on the early childhood years, also known
as the preschool years, ranging from 2 to 5 years of age.
Children in this age range demonstrate great variability in
every aspect of development. We believe that every child has
the right to develop to his or her fullest potential. Growing up
in a loving, supportive environment that meets children's
emotional and physical needs provides the best beginning for
them. However, some children face environmental and
biological challenges that may interfere with healthy
development. In this article we present demographics for this
age group and then we will discuss the following: cognitive,
language, motor, and social development; attachment;
parenting; and poverty.
Demographics
In 2000, there were almost 12 million 3- to 5-year-old
children in the United States (Kids Count, 2007a; U.S. Census
Bureau, 200l). Children in this age group face a number of
challenges that are becoming more prevalent, including
poverty, language barriers, and obesity. Almost one in five
children under the age of 5 live in poverty, and children in
female-headed households (41 %) are much more likely to be
poor than children living with married couples (6.3%)
(Bishaw & Iceland, 2003). In addition, Blacks and Hispanics
(DeNavas-Walt, Proctor, & Lee, 2006) and children living in
immigrant families are at higher risk of living in poverty.
CurrentI y, one in five American children live in an immigrant
family, increasing their risk of being linguistically
104 LIFE SPAN: EARLY CHILDHOOD AND
PREsCHOOL
isolated in addition to the increased risk of being poor (Kids
Count, 2007b). Finally, obesity is a major health concern in
the United States; in 2003-2004, 13.9% of all 2- to 5-year olds
were overweight (Ogden et al., 2006), which places them at
risk for future obesity and associated health problems.
Development
The early childhood years are a period of rapid development,
particularly in the areas of cognitive, language, motor, and
social abilities. In this section, we will briefly describe
development in each of these areas. Because social workers
may come in contact with children who do not attend school
and, may not receive regular medical attention, we describe
some of the major developmental milestones in language and
motor development so that social workers can recognize
children in need of further developmental assessment.
COGNITIVE Piaget described cognitive development as
progressing through a series of stages, and although it is
unlikely that development is as strongly stage-like as he
described, Piaget has had an enormous impact on our
understanding of cognitive development and the theory has
been supported in research across cultures (Berk, 1994).
According to Piaget, early childhood is characterized by
preoperational thought, which is the transition from the focus
on action and sensorimotor thinking of infancy and the
internalized mental thinking and concrete operations of
school-age children. Development occurs as a process of
interplay between schemes that results in the formation of
new schemes. Preoperational thinking may be reflected in
preschool children's inability to focus on more than one
aspect of a problem at a time or to see another person's
perspective (that is, egocentric thinking). Young children
may also provide too little information when telling a story
and may have trouble telling the difference between
appearances and reality. Although Piaget's description of the
preoperational stage is defined by what children cannot do,
researchers have found that young children are able to
demonstrate the ability to conserve and take others'
perspectives when the tasks are simplified and are age
appropriate (Berk, 1994).
LANGUAGE During early childhood, children's language
development advances rapidly from the nonverbal
communication and one word utterances of infancy, to the
two-word sentences of toddlers, to the rapidly expanding
vocabulary and complex sentence structure of preschoolers.
At 2 years of age, children should have vocabularies of at
least 20 words, use two-word sentences, and follow two-step
commands. At 3 years of
age, children should use three-word or longer sentences, and
know their name, age, and sex. And, at 4 years of age, children
can sing a song and talk about their daily activities and
experiences.
Approximately 4-8% of preschoolers have specific
language impairments (Skau & Cascella, 2006); however by
7-10 years of age, almost three-quarters of children who had
early language delays have caught up, while one-quarter
continue to have language and literacy delays and have poorer
social relationships than same age peers without language
delays (Glogowska, Roulstone, Peters, & Enderby, 2006).
Preschool children who live in homes that provide a poor
linguistic environment and have adolescent mothers who have .
below average language ability are at increased risk of poor
language development (Oxford & Spieker, 2006). However,
the more time parents spend talking to young children the better
their future reading, vocabulary, and math skills (Hirsh-Pasek
& Golinkoff, 2003; Phillips & Adams, 2001), and strategies can
be implemented in preschool programs, such as Head Start, that
improve children's language and literacy development (Wasik,
Bond, & Hindman, 2006).
MOTOR Like language, motor development occurs at very
different speeds for different children. Some young children
are fearless runners and climbers, whereas other children are
much more cautious and tentative. A healthy diet and plenty of
physical activity can help young children develop fine and
gross motor abilities. Preschool age children can be expected
to achieve a number of motor development milestones. At 2
years of age, children should be able to go up and down stairs
one step at a time, kick a ball, stack five or six blocks, and
make horizontal or circular marks with a crayon. At three
years of age, children should be able to jump in place, copy a
circle and a cross, and engage in some selfcare skills (for
example, dressing and feeding). And, at 4 years of age,
children should be able to hop or jump on one foot, ride a
tricycle or bicycle with training wheels, throw a ball overhand,
and draw a person with three parts. Children who do not
appear to be attaining these milestones should be referred for
assessment because early intervention is often successful at
addressing fine and gross motor delays.
SOCIAL Playing with peers contributes to social and
emotional development (Hirsh-Pasek & Golinkoff, 2003).
Preschool children move from engaging in parallel play (that
is, playing beside other children, but not actively interacting
with them) to cooperative play (that is, playing with other
children). According to social learning theory, young children
learn from

observing and interacting with their peers, especially when
behavior is reinforced. This process of modeling can be an
effective component of interventions with young children.
For example, peer-initiation strategies have been found to
increase social interactions for preschool-age children with
autism (DiSalvo & Oswald, 2002).
Attachment
Attachment to caregivers is important for the psychosocial
development of children (Berk, 1994). Insecure
attachment is related to conduct problems and aggressive
behavior, whereas secure attachment is related to good
problem solving ability, self-regulation, and peer relations.
While initial attachment typically develops during infancy,
attachment can continue to develop throughout childhood,
and has an ongoing effect on relationships (Berk, 1994).
Attachment security has a modest effect on peer relations
that is consistent across cultures, suggesting that
attachment is one of many influences on peer relations
(Schneider, Atkinson, & Tardif, 2001). The attachment
paradigm is a promising framework for prevention and
early intervention strategies (Svanberg, 1998).
Parenting
Parents. are the major influence on children's development
(Phillips & Adams, 2001). Both paternal and maternal
involvement is important for . children (Bulanda, 2004;
Shears & Robinson, 2005), and not having a father figure
actively involved is related to negative outcomes (Berk,
2001; Gaunt, 2005). Fathers who are more competent
(Fagan & Barnett, 2003), more educated (Bulanda, 2004),
work fewer hours, believe in equality for men and women,
have at least one son (Bulanda, 2004), and are less
conservative (Gaunt, 2005) are more involved. Among
Hispanic parents, greater involvement during the
preschool years is related to children's school readiness
(Farver, Xu, Eppe, & Lonigan, 2006).
Baumrind (1966) identified three parenting styles: (a)
Permissive parents accept the child's behavior and do not
instill guidelines or rules for behavior. Permissive
parenting is common among parents of preschoolers
(Winsler, Madigan, & Aquilino, 2005), particularly among
Hispanic/Latino parents (De Von FigueroaMoseley,
Ramey, Keltner, & Lanzi, 2006). (b) Authoritative parents
monitor and set limits on behavior; display warmth,
encouragement, and support; and provide reasons for the
standards set, enhancing young children's
self-assertiveness and autonomy. (3) Authoritar ian parents
are controlling and have strict standards that are used to
shape behavior, believing children should
LIFE SPAN: EARLY CHIWHooD AND PREscHOOL 105
obey without asking questions. The authoritarian and
permissive parenting styles are extremes that inadequately
prepare children for interacting with others (Baumrind,
1966).
Authoritative parenting is related to improved outcomes
for children (Amato & Fowler, 2002), including more
healthy adjustment, social support, problemfocused
coping, competence, self-regulation (Amato & Fowler,
2002; Baumrind, 1991; Kauffman et al., 2000; Lamborn,
Mounts, Steinberg, & Dornbusch, 1991; Mcintyre &
Dusek, 1995; Patock-Peckham, Cheong, Balhorn, &
Nagoshi, 2001), and the best social outcomes (Baumrind,
1966; Darling, 1999). Studies with African American and
Chinese children also support the use of the authoritative
parenting style (Chen, Dong, & Zhou, 1997; Pittman &
Chase-Lansdale, 2001; for Chinese children, authoritative
parenting was associated with greater social and school
adjustment' (Chen et al., 1997). Consistent with
authoritative parenting, modem child-directed parenting
focuses on encouraging children to be self-directive,
explore the environment, and make decisions, which is
associated with better developmental outcomes, including
higher cognitive functioning and fewer behavior problems
(Shears & Robinson, 2005). Finally, there is evidence that
parenting styles may be transmitted intergenerationally,
especially for mothers (Belsky, Jaffee, Sligo, Woodward, &
Silva, 2005).
Working Parents
Almost two-thirds (63%) of women with children under
the age of 6 are in the workforce (U.S. Bureau of Labor
Statistics, 2006). Many people believe at-home mothers
raise children better than working mothers (Shpancer,
Melick, Sayre, & Spivey, 2006). Additionally, finding
sufficient quality time with children can be a challenge for
working parents (Booth, Clarke-Stewart, Vandell,
McCartney, & Owen, 2002). However, when working
parents spend quality time with their children, child
development is unlikely to be compromised (Berk, 2001;
Booth et al., 2002).
Finding childcare is a challenge for working parents,
who may rely on relatives, sitters, and daycare (Bromer &
Henly, 2004; Hofferth, 1996; Wolfe & Scrivner, 2004). In
2005, 57% of all children attended centerbased programs
(for example, Head Start, preschools, prekindergarten, and
daycare centers). Poor children were less likely to attend
center-based programs than nonpoor children, Hispanic
children were less likely to attend than Black or White
children, and children of mothers who had less than a high
school education were less likely to attend than those of
mothers with a college degree (U.S. Department of
Education, 2006). In 1997, 22% of children under the age
of 3 with
106 LIFE SPAN: EARLY CHILDHOOD AND PREsCHOOL
employed mothers were in daycare, triple the number
from 1977 (Ehrle, Adams, & Tout, 2001; Phillips & .
Adams, 2001). Daycare use is more prevalent among
White and Black families (Phillips & Adams, 2001);
Hispanic families (Phillips & Adams, 2001) and.low-
income single mothers (Wolfe & Scrivner, 2004) are
more likely to use relative care for their children. High
quality childcare is associated with more positive devel-
opmental outcomes for children, including better voca-
bulary scores, improved school readiness, and more
positive social behavior (Belsky, et al., 2007). In parti-
cular, child outcomes are more positive when poor
children are placed in high quality daycare (Phillips &
Adams, 2001). , rather than a societal failure (Penn, 2005) and there is a
Globally, governments are being pressured to create
childcare policies to meet the needs of the increasing
numbers of parents joining the workforce (Allen, 2003 ).
In Australia and Western Europe, childcare is nationally
regulated and well funded (Berk, 2001), in contrast to
the United States, where means-tested day, care
programs targeting the very poor and tax credits for
childcare expenses are the extent of child care policies
(Allen, 2003; Hofferth, 1996). Although the percentage
of children up to 3 years of age in daycare is similar in
the United States, Sweden, and Japan, Sweden and
Japan have better parental leave policies (Allen, 2003).
In the United States the Family and Medical Leave Act
of 1993 provides for parental leave, but it only applies to
relatively large organizations, does not require paid
leave, and is limited to 12 weeks, whereas Sweden and
Japan provide a partially paid leave for over a year
(Allen, 2003; Phillips & Adams, 2001).
Poverty
There is less tolerance for child poverty in the United
States than in other countries; however, the U.S. poverty
rate for children is high compared with European
countries with higher taxes (Penn, 2005). Living in
persistent poverty and in economically disadvantaged
neighborhoods is related to cognitive, social, emotional,
and school achievement deficits (McLoyd, 1998). For
African American children, higher parental income
during early childhood is related to higher read, ing
scores and fewer behavior problems; in addition,
poverty is associated with parental use of physical pun-
ishment, which in tum is associated with lower voca-
bulary scores (Nievar & Luster, 2006). Among poor
Latino families, socioeconomic status, family size, and
living conditions are related to decreases in children's
social functioning and reading skills (Farver et al.,
2006).
To minimize the negative effects of poverty, parents
in unsafe neighborhoods develop strategies to keep
their children as safe as possible. For example, African
American fathers report using several strat egies to keep
their children safe, including supervising children con,
standy; restricting neighborhood contact; teaching about
home safety, neighborhood survival contacts, and ways
to handle conflict; confronting neighborhood drug
dealers and other troublemakers; and participating in
forms of community activism (Letiecq & Koblinskv,
2004). Social workers need to be aware of the strategies
implemented by parents in poor communities to protect
their children, so that they can provide culturally com-
petent and contextually relevant help.
In the United States, poverty is regarded as a perso nal
shortage of services for poor families with young
children. Head Start is a popular targeted early inter-
vention daycare program that has positive developmental
outcomes for children (De Von Figueroa-Moseley et al.,
2006; Garces, Thomas, & Currie, 2002; Shears &
Robinson, 2005); however, only a limited number of
children are served each year (Garces et al., 2002;
Phillips & Adams, 2001). The Perry Hope Scope project
is another example of an early intervention program for
children 3 to 4 years old that decreased crime later in life
and had other positive outcomes (Schweinhardt, Barnes,
& Weikart, 1993), generating an estimated savings of
$105,126 per child participant in the program (Penn,
2005).
Implications for Social Work
In an ideal world, all children would grow up in loving
and supportive environments. However, not all children
have this experience, and many face challenges that can
interfere with healthy development. There fore, social
workers should be aware of basic developmental
milestones, as described above, so that they can
recognize possible developmental delays and refer for
further assessment and intervention as needed. Early
intervention is most effective so early recognition and
referral is critical. In addition, it is important for social
workers to be aware of issues that face parents, such as
child care and poverty, so that they can advocate for
policy changes that will support families and provide
them with the resources they need to adequately care for
their children.
REFERENCES
Allen, S. F. (2003). Working parents with young children:
Cross-national comparisons of policies and programmes in
three countries. International Journal of Social Welfare, 12,
261-273.
Amato, P. R., & Fowler, F. (2002). Parenting practices, child
adjustment, and family diversity. Journal of Marriage and
Family, 64, 703-716.

Baumrind, D. (1966). Effects of authoritative parental control on
child behavior. Child Development, 37, 887-907.
Baumrind, D. (1991). The influence of parenting style on
adolescent competence and substance use. The Journal of Early
Adolescence, 11 (1), 56-95.
Belsky, J., Jaffee, S. R., Sligo, J., Woodward, L., & Silva, P. A
(2005). Intergenerational transmission of warm-sensitive-
stimulating parenting: A prospective study of mothers and
fathers of 3-year-olds. Child Development, 76,384-396.
Belsky, J., Vandell, D. L., Burchinal, M., Clarke-Stewart, K. A,
McCartney, K., & Owen, M. T. (2007). Are there longterm
effects of early child care? Child Development, 78, 681-701.
Berk, L. E. (1994). Child development (3rd ed.). Boston: Allyn and
Bacon.
Berk, L. E. (2001). Awakeningchildren''s minds: How parents and
teachers can rnak.f a difference. New York: Oxford University
Press.
Bishaw,A, & Iceland, J. (2003, May). Poverty: 1999 (Census 2000
Brief No. C2KBR-19). Washington, DC: US Government
Printing Office.
Booth, C. L., Clarke-Stewart, K. A, Vandell, D. L., . McCartney,
K., & Owen, M. T. (2002). Child-care usage and mother-infant
"quality time." Journal of Marriage and the Family, 64(1), 16-26.
Bromer, J., & Henly, J. R. (2004). Child care as family support:
Caregiving practices across child care providers. Children and
Youth Services Review, 26, 941-964.
Bulanda, R. E. (2004). Paternal involvement with children:
The influence of gender ideologies. Journal of Marriage and
Family, 66(1), 40-45.
Chen, X., Dong, Q., & Zhou, H. (1997)~ Authoritative and
authoritarian parenting practices and social and school per-
formance in Chinese children. International Journal of Be-
havioral Development, 21, 855-874.
Darling, N. (1999). Parenting style and its correlates (Report No.
EDO-PS-99-3). Champaign, IL: ERIC Clearinghouse on
Elementary and Early Childhood Education, University of
Illinois.
De Von Figueroa-Moseley, c, Ramey, C. T., Keltner, B., &
Lanzi, R. G. (2006). Variations in Latino parenting practices
and their effects on child cognitive developmental outcomes.
Hispanic Journal of Behavioral Sciences, 28(1), 102-114.
DeNavas-Walt, c, Proctor, B. D., & Lee, C. H. (2006).
Income, poverty, and health insurance coverage in the United
States: 2005 CU.S. Census Bureau Publication No. P60231).
Washington, DC: U.S. Government Printing Office.
DiSalvo, C. A, & Oswald, D. P. (2002). Peer-mediated inter-
ventions to increase the social interaction of children with
autism: Consideration of peer expectancies. Focus on Autism
and Other Developmental Disabilities, 17, 198-207.
Ehrle, J., Adams, G., & Tout, K. (2001). Who's caring for our
youngest children? Child care patterns of infants and toddlers
(Occasional Paper No. 42). Washington, DC: Urban Institute.
Fagan, J., & Barnett, M. (2003). The relationship between
maternal gatekeeping, paternal competence, mothers'
LIFE SPAN: EARLY CHILDHOOD AND PREsCHOOL 107
attitudes about the father role, and father involvement. Journal
of Family Issues, 24, 1020-1043.
Farver, J. A M., Xu, Y., Eppe, S., & Lonigan, C. J. (2006).
Home environments and young Latino children's school
readiness. Early Childhood Research Quarterly, 21(2), 196-212.
Garces, E., Thomas, D., & Currie, J. (2002). Longer-term effects
of head start. The American Economic Review, 92, 999-1012.
Gaunt, R. (2005). The role of value priorities in paternal and
maternal involvement in child care. Journal of Marriage and
Family, 67, 643-655.
Glogowska, M., Roulstone, S., Peters, T. J., & Enderby, P. (2006).
Early speech- and language-impaired children: linguistic,
literacy, and social outcomes. Developmental Medicine & Child
Neurology, 48, 489-494.
Hirsh-Pasek, K., & Golinkoff, R. M. (2003). Einstein never used
flash cards. Emmaus, PA: Rodale.
Hofferth, S. L. (1996). Child care in the United States today.
The Future of Children, 6( 2), 41--61.
Kaufmann, D., Gesten, E., Lucia, R. C. S., Salcedo, 0.,
Rendina-Gobloff, G., & Gadd, R. (2000). The relationship
between parenting style and children's adjustment: The
parents' perspective. Journal of Child and Family Studies, 9,
231-245.
Kids Count (2007a). 2000 Census data-Age and sex profile for
United States. Retrieved April 27, 2007, from http://
www.kidscount.org.
Kids Count (2007b). One out of five US children is living in an
immigrant family. Data Snapshot, No.4, March. Retrieved April
27, 2007, from http://www.kidscount.org.
Lamborn, S. D., Mounts, N. S., Steinberg, L., & Dornbusch, S. M.
(1991). Patterns of competence and adjustment among
adolescents from authoritative, authoritarian, indulgent, and
neglectful families. Child Development, 62, 1049-1065.
Letiecq, B. L., & Koblinskv, S. A (2004). Parenting in violent
neighborhoods: African American fathers share strategies for
keeping children safe. Journal of Family Issues, 25, 715-734.
Mclntyre, J. G., & Dusek, J. B. (1995). Perceived parental rearing
practices and styles of coping. Journal of Youth and Adolescence,
24, 499-509.
McLoyd, V. C. (1998). Socioeconomic disadvantage and child
development. The American Psychologist, 53, 185-204.
Nievar, M. A, & Luster, T. (2006). Developmental processes in
African American families: An application of McLoyd's
theoretical model. Journal of Marriage and Family, 68, 320-331.
Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A,
Tabak, C. J., & Flegal, K. M. (2006). Prevalence of overweight
and obesity in the United States, 1999-2004.Journal of the
American Medical Association, 295, 1549-1555.
Oxford, M., & Spieker, S. (2006). Preschool language devel-
opment among children of adolescent mothers. Applied
Developmental Psychology, 27, 165-182.
Patock-Peckham, J. A, Cheong, J., Balhom, M. E., & Nagoshi, C.
T. (200l). A social learning perspective: A model of parenting
styles, self-regulation, perceived
108 LIFE SPAN: EARLY CHILDHOOD AND PREsCHOOL
drinking control, and alcohol use and problems. Alcoholism,
Clinical and Experimental Research, 25, 1284-1292.
Penn, H. (2005). Unequal childhoods: Young children's lives in poor
countries. New York: Routledge.
Phillips, D., & Adams, G. (200l). Child care and our youngest
children. The Future of Children, 11 (1), 34-5l.
Pittman, L. D., & Chase-Lansdale, P. L. (200l). African American
adolescent girls in impoverished communities:
Parenting style and adolescent outcomes. Journal of Research on
Adolescence, 11, 199-224.
Schneider, B. H., Atkinson, L., & Tardif, C. (200l). Childparent
attachment and children's peer relations: A quantitative
review. Developmental Psychology, 37, 86-100.
Schweinhart, L. J., Barnes, H. Y., & Weikart, D. P. (1993).
Significant benefits: The high-scope Perry preschool study , through
age 27. Monographs of the High/Scope Educational Research
Foundation, 10. Ypsilanti, MI: High/Scope Press.
Shears, J., & Robinson, J. (2005). Fathering attitudes and
practices: Influences on children's development. Child Care
in Practice, 11 (1),63-79.
Shpancer, N., Melick, K. M., Sayre, P. S., & Spivey, A. T. (2006).
Quality of care attributions to employed versus stayat-home
mothers. Early Child Development and Care, 176, 183-193.
Skau,L., & Cascella, P. W. (2006). Using assistive technology to
foster speech and language skills at home and in preschool.
Teaching Exceptional Children, 38(6), 13-17.
Svanberg, P. O. G. (1998). Attachment, resilience and pre-
vention.Journal of Mental Health, 7, 543-578.
U.S. Bureau of Labor Statistics. (2006). Table 5: Employment status
of the population by sex, marital status, and presence and age of
children 2004-05 annual averages. Washington, DC:
United States Department of Labor.
U.S. Census Bureau. (200l). Age 2000. Retrieved April 27, 2007,
from http://www.census.gov.
U.S. Department of Education, National Center for Education
Statistics. (2006). The condition of education 2006, NCES
2006-071, Washington, DC: U.S. Government Printing
Office.
Wasik, B. A., Bond, M. A., & Hindman, A. (2006). The effects of
a language and literacy intervention on head start children and
teachers. Journal of Educational Psychology, 98,63-74.
Winsler, A., Madigan, A. L., & Aquilino, S. A. (2005). Cor-
respondence between maternal and paternal parenting styles in
early childhood. Early Childhood Research Quarterly, 20(1),
1-12.
Wolfe, B., & Scrivner, S. (2004). Child care use and parental
desire to switch care type amonga low-income population.
Journal of Family and Economic Issues, 25(2), 139-162.
SUGGESTED LINKS The American
Academy of Pediatrics.
http://brightfutures.aap.org/web/ Information
on Head Start.
http://www·acf·hhs.gov/programs/hsb/
The Centers for Disease Control and Prevention (CDC).
http://www.cdc.gov/ncbdddldd/default.htm
The Maternal and Child Health Bureau (MCHB) of the U.S.
Department of Health and Human Services, Health Resources and
Services Administration.
http://mchb.hrsa.gov/
The National Center for Children in Poverty (NCCP) at Columbia
University.
http://www.nccp.org/
-DONNA HARRINGTON AND
KAREN CASTELLANOS-BROWN
CHILDHOOD AND LATINCY
ABSTRACT: School age children are negotiating numerou s
developmental tasks across distinct lines of de velopment.
Social workers recognize that· this development is taking
place within the context of cul ture and systems and are
oriented toward assisting the most vulnerable members of
society. Adverse child hood experiences (ACEs) are
connected to later in life health risk behaviors and serious
medical, mental health, and substance abuse problems. The
social work profession is poised to work comprehensively
in supporting healthy child development and interve ning
when development has been derailed by ACEs. This builds
human capital, which is profitable to society.
KEY WORDS: school age; child development; latency
age; adverse childhood experiences; multiple lines of
development; culture; systems; human capital
School age children of approximately 5-11 years of age
are negotiating numerous developmental tasks across
distinct lines of development. These include cognitive
development (Piaget, 1972), psychosexual development
(Freud & Strachey, 1960), personality development
(Loevinger, 1976), psychosocial development (Erikson,
1959), moral development (Gilligan, 1982; Kohlberg,
1981), emotional and social intelligence (Goleman,
1995, 2006), and multiple other intelligences (Gardner,
1983). Developmental challenges for school age children
include mastering peer relationships and acquiring the
capacity to participate in teamwork (Erikson, 1959).
There is a movement from an ego-centric to a group
orientation (Piaget, 1972), which involves following
group rules (Kohlberg, 1981) and fostering relationships
(Gilligan, 1982). Each of these well-known theorists is
describing different aspects of development, and it
becomes apparent that there are multiple developmental
lines. This points to the fluidity of overall development
while recognizing that developmental stages involved in
each line cannot be skipped. Thus, children must
negotiate developmental stages of increasing complexity
in numerous areas.

Each earlier developmental level provides the platform for
subsequent development, meaning that successful
resolution of one phase is crucial in order to move onto the
next. The child's navigation of these developmen-
. tal stages is not occurring in isolation; development results
from the interplay between the individual child and social,
cultural, and ecological forces (Larkin & Records, 2007;
Wilber, 2000). Social workers have always recognized
that a child's interior development, behaviors, and physical
development arise together with culture and systems,
including all of these aspects in assessment (Larkin, 2005).
Adv~rse Childhood Experiences
Recent prominent research conducted by Kaiser Per,
manente and the Center'S for Disease Control (CDC),
involving a sample of 17,000 middle-class adults, de,
monstrates strong and clear relationships between ad, verse
childhood experiences (ACEs), later in life health risk
behaviors, and serious medical, mental health, and
substance abuse problems (Anda et a1., 1999; Anda et a1.,
2002; Chapman et a1., 2004; Felitti, 2002; Felliti, 2003;
Felitti et a1., 1998). Study participants were given an ACE
Score based on their experience of ten specific ACE
categories falling under two broad categories of abuse and
household dysfunction. In this way, the in' terrelationship
of traumatic occurrences could be mea, sured, while also
correlating ACE scores with social and health
consequences (Dong, Anda, Dube, Giles, & Felitti, 2003;
Dong et a1., 2004; Felitti et a1., 1998; Felliti, 2003).
Cigarette smoking, overeating, intravenous drug use,
sexual risk behaviors, and alcohol abuse and alcoholism
are among the health risk behaviors predicted by ACEs
(Anda et a1., 1999; Dube, Anda, Felitti, Edwards, & Croft,
2002; Dube, Anda, Felitti, Chapman, & Giles, 2003;
Felitti, 2002; Felitti, 2003a, Fellitti, 2003; Williamson,
Thompson, Anda, Dietz, & Felitti, 2002 The likelihood
that someone will begin using drugs, report problems
resulting from drug use, use drugs as a parent, and develop
a drug addiction are all correlated with ACE scores (Dube
et al., 2002; Felliti, 2003).
ACEs lead to a much higher risk of experiencing
depressive disorders later in life (Chapman et a1., 2004),
and higher ACE scores make suicide attempts much more
likely (Dube et a1., 2001). Scores on the mental health
scale of the Medical Outcomes Study 36,item Short, Form
Health Survey decrease as ACE scores in, crease, with
emotionally abusive family environments leading to more
pronounced decreases in mental health scores (Edwards,
Holden, Felitti, & Anda, 2003).
Health risk behaviors also lead to more medical
problems, with various public health implications.
LIFE SPAN: CHILDHOOD AND LATENCY
109
Substance abuse problems, for example, have already been
connected to HIVjAIDS and Hepatitis C (Dube et a1.,
2003). Women's sexual risk behaviors result in infertility,
cervical and vaginal cancers, miscarriages, ectopic
pregnancies, still births, chronic pelvic pain, sexually
transmitted diseases, violence-related trauma, and death.
Pneumonia, ocular infections, neurological damage, low
birth weight, and death area greater danger to the babies
born to these women (Hillis, Anda, Felitti, & Marchbanks,
2001). It is also important to note that ACE scores among
males has been connected with the probability that they
will impregnate a teenager (Anda et a1., 2002; Anda et a1.,
2001, and teenage pregnancy among females increases
along with ACE score (Hillis, Anda, Felitti, Marchbanks, &
Marks, 2004). Obesity, liver disease, cancer, chronic lung
dis, ease, ischemic heart disease, and skeletal fractures are
all correlated with ACE score (Dong, Dube, Felitti, Giles,
& Anda, 2003; Dong et al., 2004; Felittiet a1., 1998;
Williamson et a1., 2002).
Since previous studies tell us that the rate of both
mental illness and substance abuse problems is higher
among homeless people (Bray & Marsden, 1992; Lehman
& Cordray, 1993; National Institute of Drug Abuse, 1993;
Robertson, Zlotnick, & Westerfelt, 1997), and ACEs have
been connected with both mental ill, ness and substance
abuse (Anda et a1., 2002; Chapman et a1., 2004; Dube et
al., 2001; Dube et a1., 2002; Edwards et al., 2003; Felitti ,
2002; Felitti, 2003a; Whitfield, 2005), it is reasonable to
suspect that ACEs are predicting homelessness (Burt,
2001; Larkin & Records, 2007). A connection between the
behaviors of homeless people and ACEs has been
established (Tam, Zlotnick, & Robertson, 2003), and
impaired functioning on the job is related to ACE score
(Anda et a1., 2004). Job market participation among home'
less adults is influenced by substance abuse problems,
which are anteceded by ACEs (Tam et al., 2003). It is also
important to note that approximately three, quarters of
incarcerated people suffer from substance abuse problems
(Delany, Fletcher, & Shields, 2003) and that the criminal
justice system is further challenged by the high incidence
of Hepatitis C (Allen, Rich, Schwartzapfel, & Friedmann,
2003) and behavioral risk factors for HIV infection
(Robillard et a1., 2003). These are all concerns we now
realize are connected with ACEs (Larkin & Records,
2007).
The ACE study researchers suggest that people attempt
to cope with the anger, anxiety, and depression related to
ACEs by engaging in health risk behaviors such as
smoking, alcohol and other drug use, overeating, and
sexual behaviors. Thus, these health risk behaviors are
actually personal solutions that become
110 LIFE SPAN: CHILDHOOD AND LATENCY
serious public health problems, including mental illness,
substance abuse, and a variety of life-threatening
medical issues (Felitti et a1., 1998; Felitti, 2002). The
prospect of identifying and assessing ACEs cuts across
service delivery systems and fields of practice, calling
for strong communication across professions (Felitti et
a1., 1998). ACEs typically result from violent inter-
actions institutionalized within family systems (Larkin
& Records, 2007), and ACE study authors point to the
need to respond with programs preventing and treating
the family dynamics. producing ACEs, supporting
family life and healthy home environments (Felitti et
a1., 1998; Hillis et a1., 2004). Effective prevention and
treatment of ACEs involves a comprehensive approach
that attends to youth development within the context of
culture and systems (Larkin & Records, 2007).
It is important to note that the ACE research has been
primarily documented in medical journals, with
connections now being forged to the social science
literature. Limitations of the ACE research include its
use of retrospective report, the need for an adequate.
conceptual framework, and its lack of connection to the
social science literature.In particular, as the ACE find-
ings become part of our social awareness, there is an
increasing concern of how to effectively prevent and
intervene with ACEs. Social science researchers are
beginning to address these limitations by integrating the
ACE research with the wealth of social science
prevention and intervention research relevant to ACE
outcomes (substance abuse, mental illness, health risk
behaviors, child abuse, etc.) and employing integrative
conceptual frameworks to further ACE informed re-
search across disciplines. An intergenerational perspec-
tive realizes the value of combining intervention and
prevention efforts to effectively respond to ACEs. Since
ACE findings reveal an underlying syndrome at the root
of problems that tend to be addressed by separate service
delivery systems and diverse professions, the emerging
answer to ACEs might be postdisciplinary and
integrative. With a person-in-environment and
intergenerational perspective, the social work profession
is poised to lead this type of comprehensive response to
ACEs.
Child Development and Social Work
Interventions
Social workers are oriented toward assisting the most
vulnerable members of society, advocating for disad-
vantaged populations (National Association of Social
Workers Code of Ethics, 1999). Children's develop-
ment is fragile, and since they are not workforce parti-
cipants and continue to be dependent on adult care,
they lack power in our society. Many children are
further disadvantaged as a result of the oppression ex-
perienced by their parents and cultural, religious, ethnic,
or racial group (Bernard, 2002). Social work has
historically taken a more integrative approach by ~d-
dressing person-environment interactions, drawing on
numerous skills to facilitate healthy personal and social
growth and development in various cultural contexts
across systems (Larkin, 2005). Social workers are
poised to work comprehensively toward the facilitation
of healthy development in children and to intervene
when development has been derailed.
It is important to understand the way in which ACEs
play out in the developing child. ACEs tend to arise
from family system interactions, which take place
within a background of family interpretations and
meanings, and the ACEs also influence family culture.
Families are further impacted by problems in larger
social systems, including war, other acts of social
violence, ecological crises, and economic dysfunctions.
Subcultures and larger cultures are affected by the
family culture, and the family culture is in tum shaped
by subcultural and cultural contexts. For example, ACEs
can be kept hidden by cultural social taboos and a family
culture that demands denial of feelings-the family
culture and the larger culture are mutually influencing
one another, creating these cultural conditions together.
Within this context, the developing child must manage
emotions that may feel overpowering and are frequently
invalidated. The child may begin to develop defense
mechanisms, which shape their behaviors (Larkin &
Records, 2007; Wilber, 2000). ACEs also influence the
brain chemistry of the developing child, again giving
rise to coping behaviors (Felitti, 2003). Alcohol and
other drug use, smoking, overeating, and other health
risk behaviors are strategies young people might adopt
in their attempt to cope if ACEs are not effectively
addressed (Felitti et al., 1998; Felitti, 2002; Felitti,
2003a).
The latency age child of 6-11 years of age is devel-
oping skills and using tools to bring about his or her
new creations. There is a focus on school and
productive activities (Erikson, 1959; Freud & Strachey,
1960). Peers become increasingly important, and
children seek connections with playmates, particularly
same sex peers (Erikson, 1959). This is the c onformist
stage of personality development, where children focus
on group rules and tend to stereotype roles (Loevinger,
1976). One's standing among peers is very important,
and this is a socially decisive age. Feelings of inferiority
and inadequacy may arise if a child feels he/she does
not have the ability to accomplish and produce things or
lacks status among peers (Erikson, 1959). The moral
emphasis is on

interpersonal accord and maintammg social order
(Gilligan, 1982; Kohlberg, 1981). As children increas-
ingly internalize cultural values and beliefs, they also
imitate the behavior of the same-sex parent (Erikson,
1959). The internalization of cultural values and beliefs
involves further development of the . conscience, or
superego (Freud & Strachey, 1960). Cognitivelv, school
age children are learning to use logic and beginning to
develop the ability to take on another person's perspec-
tive (Piaget, 1972). These are among the primary tasks
of some major developmental lines, but children are
developing other multiple intelligences as well, acquir-
ing unique strengths and skills in a variety of areas
ranging from music to language to kinesthetic abilities
(Gardner, 1983). Emotional and social intelligences are
also developing in the context of these childhood re-
lationships (Goleman, 1995, 2006). The concern is . that
ACEs could derail this development, which also
impedes children from moving on to the next stage
(Larkin & Records, 2007).
Mindful that the developing child and his/her beha-
viors arise within the cultural and systemic contexts of
the family, school, and larger structures, social workers
possess the skills to intervene in all of these realms.
Furthermore, social workers often fulfill a unique role
of working across and linking systems (Abramovitz,
1998; Gibelman, 1999; Jacobson, 2001; Johnson, 1999;
Larkin, 2005; Stuart, 1999). This distinctive skill set is
especially helpful in working with children and fa-
milies. Social workers are found in child and family
agencies, schools, mental health settings, substance
abuse prevention and treatment settings, medical set-
tings, and government. Ideally, social workers consider
child and family problems from multiple perspectives
and combine interventions with child and family, school
system, the community, and larger social policies.
Since the school system plays a central role in chil-
dren's lives, social workers are often able to le verage
this connection to effectively intervene with children
and their families. Felitti and colleagues (1998) have
suggested that acknowledging the role of ACEs in
medical problems might enhance the success of health
promotion and disease prevention programs already in
existence. Similarly, educational systems are likely to
increase their efficacy by attending to the prevention
and treatment of ACEs among school age children. In
fact, student outcomes are connected to the crucial role
that school bonding plays in child development and
behaviors (Catalano, Berglund, Lonczak, & Hawkins
2004), and the adoption of health risk behaviors is
related to type of school connectedness (McNeely &
Falci,2004).
LIFE SPAN: CHILDHOOD AND LATENCY 111
Contributions of Healthy Child
Development to Society
Maslow (1968, 1970, 1971) maintains that a hierarchy
of needs exists and that basic needs must be met before
higher level needs can be addressed. He presents five
levels of needs: Physiological needs, safety needs,
love/belonging/social needs, esteem needs, and self-
actualization needs. Physiological needs must be met
first for a person to survive. The examples are breathing,
regulating homeostasis, and having food and water.
Once these needs are met, then safety needs emerge.
These include physical security, employment security,
family security, and security of health. Friendship,
intimacy, and rewarding family relationships are
involved in love/belonging/social needs. Next, esteem
needs emerge, with a need to contribute and feel ac-
cepted. While these first four levels involve some defi-
ciency that must be addressed to feel whole in one's self,
the fifth level, self-actualization, involves reaching
one's full potential through transcending the self.
Maslow found that some of the most thriving and
productive people operated from this level of being,
contributing greatly to society. Thus, helping develop-
ing people to meet their needs, preventing and treating
ACEs, leads to more societal members reaching their
full potential and benefits society as a whole.
Furthermore, building this kind of human capital is
profitable to society. Research has already found that
there are notable returns on every dollar spent on early
intervention programs for disadvantaged children, and
later costs are also decreased. When children do not
have to worry about physiological, safety, and
relational needs, they can focus on the academic ach
ievement that will help them fulfill a role within society
and contribute as adults. Healthy emotional
development plays out in healthier behaviors, reducing
health risks and criminal behaviors.
Thus, the benefits of early childhood interventions
comprise not only the improved life of the individual
served but also the improved lives of other societal
members who benefit from more productive social in-
teractions as well as saving the government the expense
of numerous programs designed to intervene with pro-
blematic adult behavior. Some of these longer-term
expense savings include the costs associated with health
risk behaviors such as substance abuse, health and
mental health costs, criminal justice costs, home less
services, and other programs. Families, schools, and
other systems are all part of human capital development
and it is the early acquisition of skills (upon which later
development builds) that leads to such high returns on
investments in young people (Heckman & Krueger,
2003; Karoly, Kilburn, & Cannon, 2005).
112 LIFE SPAN: QULDHOOD AND LATENCY
REFERENCES
Abramovitz, M. (1998). Social work and social reform: An arena
of struggle. Social Work, 43(6), 512-526.
Allen, S., Rich, J. D., Schwartzapfel, B., & Friedmann, P. (2003).
Hepatitis C among offenders-correctional challenge and
public health opportunity. Federal Probation, 67(2), 22-26.
Anda, R. F., Croft, J. B., Felitti, V. J., Nordenberg, D., Giles, W.
H., & Williamson, D. F., et al. (1999). Adverse childhood
experiences and smoking during adolescence and adulthood.
Journal of the American Medical Association, 282(17),1652-1658.
Anda, R. E, Croft, J. B., Felitti, V. J., Nordenberg, b., Giles, W.
H., & Williamson, D. F., et al. (1999). Adverse childhood
experiences and smoking during adolescence and adulthood.
Journal of the American Medical Association,
282(17),1652-1658. \ household dysfunction, and the risk of attempted suicide
Anda, R. F., Felitti, V. J., Chapman, D. P., Croft, J. B.,
Williamson, D. E, Santelli, J., Dietz, P. M., & Marks, J. S.
(2001). Abused boys, battered mothers, and male involvement
in teen pregnancy. Pediatrics, 107(2), e19.
Anda, R. F., Fleisher, V. 1., Felitti, V. J., Edwards, V. J.,
Whitfield, C. L., & Dube, S. R., et al. (2004). Childhood
abuse, household dysfunction, and indicators of impaired
adult worker performance. The Permanente Journal, 8(1), 30-38.
Anda, R. E, Whitfield, C. L., Felitti, V. J., Chapman, D., Edwards,
V. J., & Dube, S. R., et al. (2002). Adverse childhood
experiences, alcoholic parents, and later risk of alcoholism
and depression. Psychiatric Services, 53(8), 1001-1009.
Bernard, C. (2002). Giving Voice to Experiences: Parental
Maltreatment of Black Children in the Context of Societal
Racism. Child and Family Social Work, 7(4), 239-251.
Bray, R. M., & Marsden, M.E. (1992). Prevalence of use of illicit
drugs, alcohol, and cigarettes among DC metropolitan area
household residents in 1990. The lOath Annual Meeting of the
American Psychological Association, Washington, DC, August
14-18.
Burt, M. (2001). What will it take to end homelessness? Washington,
DC: Urban Institute.
Catalano, R. F., Berglund, M. L., Lonczak, H. S., & Hawkins, J.
D. (2004). Positive youth development in the United States:
Research findings on evaluations of positive youth develop-
ment programs. The Annals of the American Academy of Political
and Social Science, 591, 98-124.
Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R.,
Edwards, V. J., & Anda, R. F. (2004). Adverse childhood
experiences and the risk of depressive disorders in adulthood.
Journal of Affective Disorders, 82(2),217-225.
Delany, P. J., Fletcher, B. W., & Shields,J. J. (2003). Reorgan-
izing care for the substance using offender: The case for
collaboration. Federal Probation, 67(2), 64-68.
Dong, M., Anda, R. E, Dube, S. R., Giles, W. H., & Felitti, V. J.
(2003). The relationship of exposure to childhood sexual
abuse to other forms of abuse, neglect, and household dys-
function during childhood. Child Abuse and Neglect, 27(6),
625-639.
Dong, M., Anda, R. E, Felitti, V.}., Dube, S. R., Williamson, D.
F., & Thompson, T.J., et al. (2004). The interrelatedness of
multiple forms of childhood abuse, neglect, and household
dysfunction. Child Abuse and Neglect, 28(7), 771-784.
Dong, M., Dube, S. R., Felitti, V.J., Giles, W. H., & Anda, R. F.
(2003). Adverse childhood experiences and self-reported liver
disease: New insights into the causal pathway. Archives of
Internal Medicine, 163(16), 1949-1956.
Dong, M., Giles,W. H., Felitti, V. J., Dube, S. R., Williams, J. E.,
& Chapman, D. P., et al. (2004). Insights into causal pathways
for ischemic heart disease: Adverse childhood experiences
study. Circulation, 110(13), 1761-1766.
Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P.,
Williamson, D. F., & Giles, W. H. (2001). Childhood abuse,
throughout the life span: Findings from the Adverse
Childhood Experiences Study. Journal of the American Medical
Association, 286(24),3089-3086.
Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P.; & Giles,
W. H. (2003). Child abuse, neglect, and household
dysfunction and the risk of illicit drug use: The adverse
childhood experiences study. Pediatrics, 111 (3), 564---572.
Dube, S. R., Anda, R. E, Felitti, V. J., Edwards, V. J. & Croft, J. B.
(2002). Adverse childhood experiences and personal alcohol
abuse as an adult. Addictive Behavior, 27(5), 713-725.
Edwards, V. J., Holden, G. W., Felitti, V. J., & Anda, R. F. (2003 ).
Relationship between multiple forms of childhood
maltreatment and adult mental health in community re-
spondents: Results from the adverse childhood experiences
study. American Journal of Psychiatry, 160(8), 1453-1460.
Erikson, E. H. (1959). Identity and the life cycle. Madison, CT:
International Universities Press, Inc.
Felitti, V. J. (2002). Belastungen in der Kindheit and Gesundheit
im Erwchsenenalter, die Verwandlung von Gold in Blei [The
relationship of adverse childhood experiences to adult health:
Turning gold into lead]. Z psychs om Med Psychother,
48(4),359-369.
Felliti, V.I. (2003). The relationship of adult health to adverse
childhood experiences and household dysfunction. Opening
General Session Speech. The 14th National Conference on Child
Abuse and Neglect, Sr. Louis, MO.
Felitti, V. J. (2003a). Ursprungedes Suchrverhaltens-Evidenzen
aus einer Studie zu belastenden Kindheitserfahrungen [The
origins of addiction: Evidence from the adverse childhood
experiences study]. Praxis der Kinderpsychologie und Kinder-
psychiatrie, 52, 547-559.
Felitti, V. J., Anda,R. F., Nordenberg, D., Williamson, D. F.,
Spitz, A. M., & Edwards, V., et al. (1998). Relationship of
childhood abuse and household dysfunction to many of the
leading causes of death in adults. The Adverse Childhood
Experiences (ACE) Study. American Journal of Preventive
Medicine, 14(4),354-364.
Freud, S., & Strachey, J. (1960). The Ego and the Id (The standard
edition of the complete works of Sigmund Freud). New York:
W.W. Norton & Company.
Gibelman, M. (1999). The search for identity: Defining social
work-past, present, and future. Social Work, 44(4), 298-310.
 LIFE SPAN: YOUNG ADULTHOOD 113

Robertson, M. J., Zlotnick, c, & Westerfelt, A (1997). Drug use

Gardner, H. (1983). Frames of mind: The theory of multiple
disorders and treatment contact among homeless adults in
inteUigences. New York: Basic Books.
Alameda County. American Journal of Public Health,
Gilligan, C. (1982). In a different voice: Psychological theory and
87(2),221-228.
women's development. Cambridge, MA: Harvard University
Robillard, A. G., Gallito-Zaparaniuk, P., Arriola, K. J., Kennedy,
Press.
S., Hammett, T., & Braithwaite, R. L. (2003). Partners and
Goleman, D. (1995). Emotional intelligence: Why it can matter more
than IQ. New York: Bantam Books. processes in HIV services for inmates and ex-offenders:
Facilitating collaboration and service delivery. Evaluation
Goleman, D. (2006). Social inteUigence: The new science of human
Review, 27(5),535-562.
relationships. New York: Bantam Dell.
Stuart, P. H. (1999). Linking clients and policy: Social work's
Heckman, J. J., & Krueger, A. B. (Eds.). (2003). Inequality in
distinctive contribution. Social Work, 44(4), 335-347.
America: What role for human capital policies? Cambridge, MA:
Tam, T. W., Zlotnick, c., & Robertson, M. J. (2003). Longi-
The MIT Press.
tudinal perspective: Adverse childhood events, substance
Hillis, S. D., Anda, R. F., Felitti, V. J., & Marchbanks, P. A.
use, and labor force participation among homeless adults.
(2001). Adverse childhood experiences and sexual risk be-
The American Journal of Drug and Alcohol Abuse, 29(4), 829-846.
haviors in women: A retrospective cohort study. Family
Whirfield, C. L. (2005). Mental health. Adverse childhood
Planning Perspectives, 33(5), 206-21 L
experiences increase risk of hallucinations. Medical Letter on
Hillis, S. D., Anda, R. F., FeJitti, V. J., Marchbanks, P. A., &
the CDC & FDA, October 16, 2005; p. 104.
Marks, J. S. (2004). The association between adolescent
pregnancy, long-term psychosocial outcomes, and fetal death. Williamson, D. F., Thompson, T. J., Anda, R. E, Dietz, W. H., &
Felitti, V. J. (2002). Body weight and obesity in adults and
Pediatrics, 113(2),320-327.
self-reported abuse in childhood. International}oumal of Obesity
Jacobson, W. B. (2001). Beyond therapy: Bringing social work
Related Metabolic Disorders, 26(8), 1075-1082.
back to human service reform. Soda! Work, 46(1), 51-61.
Johnson, Y. M. (1999). Indirect work: Social work's uncelebrated Wilber, Ken. (2000). A theory of everything. Boston, MA:
strength. Soda! Work, 44(4), 323-334. Shambhala publications.
Karoly, L. A, Kilburn, M. R., & Cannon, J. S. (2005). Early
childhood interventions: Proven results, future promise. Santa
Monica, CA: RAND Corporation. SUGGESTED LINKS
Kohlberg, L. (1981). The philosophy of moral development: Moral http://www .acestudy .org
stages and the idea of jUstice. San Francisco: Harper & Row. http://www . preventChildabuse .org
Larkin, H. (2005). Social work as an Integral profession. http://www .cots-homeless .org
AQAL: The Journal of Integral Theory and Practice, 1 (2),
320-350. -HEATHER LARKIN

Larkin, H., & Records, J. (2007). Adverse childhood experiences:

Overview, response strategy, and integral theory perspective.
AQAL: The Journal of Integral Theory and Practice.
Lehman, A F., & Cordray, D. S. (1993). Prevalence of alcohol,
drug and mental disorders among the homeless: One more
time. Contemporary Drug Problems, 20(3), 355-383.
Loevinger, J. (1976). Ego development. San Francisco:
[ossey-Bass, Maslow, A (1968). Toward a psychology of being.
New York:
Van Norstrand.
Maslow, A (1970). Motivation and personality. New York:
Harper.
Maslow, A (1971). The further reaches of human nature.
Penguin Books.
McNeely, C., & Falci, C. (2004). School connectedness and the
transition into and out of health-risk behavior among
adolescents: A comparison of social belonging "and teacher
support. Journal of School Health, 74(7), 284-292.
National Association of Social Workers. (1999). Code of ethics.
Washington, DC: NASW Press. "
National Institute of Drug Abuse. (1993). Prevalence of drug use
in the Washington DC, metropolitan area homeless and
transient population: 1991. Washington, DC, metropolitan area
drug study. Washington, DC: U.S. Government Printing Office.
Piaget, J. (1972). The psychology of the child. New York: Basic
Books.
YOUNG ADULTHOOD
ABSTRACT: The development period betweenthe ages of
18-25 is called emerging adulthood. Emerging adult hood
is characterized by transitions through developmen tal
milestones that facilitate an individual's movement into
traditional adulthood roles. During emerging adult hood,
individuals acquire, or at least atte mpt to acquire, the
dimensions of adulthood, for example, economic
independence and residential stability. This entry high-
lights the theoretical foundation of emerging adulthood as
well as current research and future research directions
related to this developmental period.
KEY WORDS: emerging adulthood; developmental tra-
jectories; adulthood; adult roles
Overview
What is emerging adulthood?
The lifespan period commonly referred to as late
adolescence or early adulthood in previous editions of the
NASW Encyclopedia is now conceptualized as emerging
adulthood. The age range along the lifespan
114 LIFE SPAN: YOUNG ADULTHOOD
identifying emerging adulthood is between 18 and 25 years
of age (Barry & Nelson, 2005) but some research has
included the early 30s as part of this span (Arnett, 2003;
Milevsky, 2004; Rindfuss, 1991). Notwithstanding the
slight difference in age range, emerging adulthood is
characterized by transitions marked by developmental
milestones which when ultimately completed enable the
individual to assume adulthood roles with their long-term
consequences, for example, spouse, parent. During
emerging adulthood, individuals acquire, or at least attempt
to acquire, the dimensions of adulthood, for example,
economic independence and residential stability (Schensul
& Burkholder, 2005). When these dimensions are acquired
the individuals are more likely
to view themselves fully as adults. ' The number of individuals marrying in this period has
Developmentally, Arnett'(2000) argues the period is
distinctive demographically, subjectively, and in identity
exploration opportunities from the period immediately
before it (that is, adolescence) and immediately after it (that
is, adulthood). Arnett (1998) defines emerging adulthood
as, "period of development bridging adolescence and
young adulthood, during which young people are no longer
adolescents but have not yet attained full adult status (p,
312).
Emerging adulthood is characterized by specific de-
velopmental tasks, transitions, and criteria signifying an
individual's movement from her/his parental home through
and into her/his own social roles. The tasks, transitions, and
residency changes and opportunities are events that
realistically adolescents cannot avail themselves to (for
example, moving into their own living residences) but are
not expected among those in adult roles (for example,
leaving family in order to volunteer for Peace Corps). For
example, Scharfe and Cole (2006) identify that the
transitions to and from college represent important
milestones to adulthood while other researchers have
identified transitions (for example, joining armed forces)
for emerging adults who do not go on to postsecondary
education. As Arnett states, "emerging adulthood is
distinguished by relative independence from social roles
and from normative expectations" (2000, p. 469).
Significant developmental tasks for this period include
acceptance of responsibility for one's self, making
independent decisions, and establishing one's financial
independence (Arnett, 1998). Researchers identify ro-
mantic relations, employment, education, living ar-
rangements, and substance use as areas frequently explored
and navigated by emerging adults (Arnett, 2000, 2005).
These explorations are also influenced by the originating
family's social and economic status (Berzin, DeMarco,
Shaw, Unick, & Hogan, 2006; Cohen, Kasen, Chen,
Hartmark, & Gordon, 2003;
Milevsky, 2004). Berzin et al. (2006) suggest that suc-
cessful navigation of the transitions and developmental
tasks can be compromised by the lack of resources
available to those emerging adults from backgrounds with
persistent poverty. The period of emerging adulthood is
best viewed as a cultural construction, and the
opportunities for exploration and role development are
reduced or compromised for some in our society due to
institutional and environmental factors.
Demographics
The U.S. Census reports that the number of individuals
between the ages of 18 and 25 represents 10.98% of the
total US. population of 281,421,906 (U.S. Census, 2005).
declined over the past several decades while age of first
marriage has increased. U.S. Census Bureau statistics
indicate that in 1970 the median age of marriage for men
and women was 23.2 and 20.8, respectively. In 2005, the
median age of first marriage for men and womenhas
increased to 27 and 25.5, respectively (US. Census, 2006).
Researchers highlight that the emerging adulthood
period is characterized by significant demographic
variability. While the majority of adolescents of 17 years of
age and under remain in the parental home, are unmarried,
are not parents themselves, and are in school, upon
reaching 18 years of age, the demographics become
increasingly diverse. From postsecondary education, to
employment, to marriage, to parenthood, and residential
status, there is no single demographic variable that can be
consistently predicted regarding emerging adults. As a
group, individuals between the ages of 18 and 25 have the
highest residential mobility of any other age category
(Arnett, 2000). The limits placed on adolescents by parents
are lessened by the legal age of the emerging adult which
thus enables one to participate in activities and behaviors
that facilitate exploration and experimentation.
Similarities exist between Western societies and those
considered traditional relative to the transition between
adolescence and adulthood. However, particularly in
American culture distinctive features are associated with
emerging adulthood while absent in others. Arnett (1998)
posits that (a) lack of gender differentiation, (b) low
importance of role specification, and (c) predominance of
individual .centered transition criteria are unique features
to mainly American culture. Cohen et al. (2003) suggest
that emerging adults must address financial, residential,
romantic, and family formation domains as they transition
through this period. Each domain offers a unique
opportunity for exploration, identity development, and the
establishment
I

of role statuses that may be sustained throughout the
remained of the life course.
The distinguishing characteristic of adulthood is that
one is a self-sufficient person possessing the capa-
. city of consideration of others and avoidance of self-
destructive behavior which may effect others. The tran-
sition to this life-span period can be traversed and
achieved in different paths.· Researchers and scholars
clearly indicate that the period of emerging adulthood is
characterized by marked diversity in experiences,
changes, opportunities, and achievements. In addition
to ·change in marriage rates and age, the labor market
opportunities technological advancements, and globa-
lization present new challenges for the emerging adult
population. . transitions (Matsudaira, 2006), and parental divorce and
A particular challenge for a significant subpopula-
tion of emerging adults is that of incarceration. The
tremendous disparity in incarceration rates between
Blacks and Whites is without question a significant
obstacle for some. Incarceration disrupts transitional
tasks of establishing economic and residential indepen-
dence while long-term serving as continued obstacles in
varying manifestations. The study by Raphael (2006)
regarding incarceration spells and transition to adult-
hood examined four criteria of adult transition. Findings
indicated that incarcerated males scored poorly on all
criteria when compared with nonincarcerated males.
Theory
The theory associated with emerging adulthood being
viewed as a distinctive life-span period was initially put
forth by Arnett (2000, 2003). Using and building upon
classical developmental theories of Erikson, Levinson,
and Keniston, Arnett (2000) articulates that the pro-
longed adolescence period commonly found in indus-
trialized countries offers individuals the chance to delay
adult commitments and responsibilities which in tum
grants opportunities for exploration and experimenta tion
that were only begun in adolescence. The explora tion
and experimentation is often in the areas of work,
relationships, substance use, education, and identity
exploration. These areas cannot be fully explored during
the period of adolescence and when one declares
her/himse1f an adult, continued exploration of these
areas is often viewed as signs of immaturity and not yet
ready for the commitments and responsibilities of
adulthood. Arnett (2003) also theorizes that the term
"youth" is problematic in that its use connotes more with
childhood than the period where the individual is able to
explore avenues that are restricted by virtue of an
adolescent's age and living arrangements.
The conceptualization of emerging adulthood has
been facilitated by changing demographic conditions.
1
LIFE SPAN: YOUNG ADULTIloOD 115
With marriage rates declining and time of marriage and
parenthood increasingly moving toward the third decade
of life, individuals between the ages of 18 and 25 have
multiple opportunities and options available to them to
fully explore and experiment with alternative lifestyles,
personal development, employment, and civic and
social roles, which were not available to their
counterparts in the early and mid-20th century.
Latest Research and Best Practices
A growing body of research involving emerging adult-
hood has included substance use (for example, binge
drinking) (Maggs & Schulenberg, 2004/2005), religion
(Barry & Nelson, 2005), employment and residential
sibling communication (Milevsky, 2004). Milevsky
found that emerging adults who experienced parental
divorce have less communication with their siblings and
perceive less support from those siblings. Maggs and
Schulenberg indicate that it is during this period that
individuals develop lifelong patterns regarding the use
or nonuse of alcohol. Should future empirical research
support this indication, it presents an important
intervention point for those providing services to emer-
ging adults especially in environments such as college
campuses.
A study by Galmbos, Barker, and Krahn (2006)
examines psychological well-being in emerging adults
over a 7 -year period in a school-based community
sample of 920 Canadians. The findings suggest that as
these individuals age, there are noted decreases in
depressive symptomatology, expressive anger, and an
increase in self-esteem. Galabmos et al. indicate
that-these changes are the result of "psychosocial
maturity" (p. 360), which is a critical component in
becoming a productive and active adult.
Diversity and Multicultural Content Although
the extant literature indicates the experiences of
becoming an adult differ by factors such as race (Cohen
et al., 2003), the majority of research efforts into
emerging adulthood contain samples that are over-
whelmingly Caucasian (Cohen et al., 2003; Galmbos et
al., 2006; Lefkowitz, 2005). Extant empirical literature
at this moment is limited in terms of minority group
members. Research into minority group members has
increased recently (Arnett, 2003; Schensul &
Burkholder, 2005). In Arnett's study, a sample size
included 574 participants, of which 81 % are members
of minority groups: 122 African Americans, 96 Latinos ,
and 247 Asian Americans. Results from that study found
that emerging adults from racial/ethnic groups
experience and navigate similar transitions as majority
116 LIFE SPAN: YOUNG ADULTHOOD
emerging adults. Differences were found in transitional
areas of family capacities, norm compliance, and role
transitions. Schensul & Burkholder's sample of was 91 %
African American and Puerto Rican/Latino and :
investigated substance use and its role in creating personal
vulnerabilities, which in tum present significant obstacles in
reaching milestones associated with adulthood.
Nonetheless, additional empirical research examining
emerging adulthood among those from minority groups is
essential.
Barry and Nelson (2005) examined the role of religious
culture in the transition to adulthood among young
emerging adults (18-20 years of age). In this study of 445
undergraduates of which, 89% were of European American
descent, participants were asked to identify spirituality
variables, criteria for adulthood, and whether they had
achieved the criteria for adulthood status. Findings from
that study suggest that religion is an influence on emer ging
adults particularly in the areas of behavior and some of the
criteria recognized as signifying adulthood, for example,
perception of family responsibilities and roles, and
examination of personal beliefs.
Milevsky (2004) posits that further empirical research
is needed into the effects of parental divorce on emerging
adults and their siblings. This study's sam ple also reflects
the trend that emerging adults of color are really not well
represented in empirical research on this subject.
Galmbos et al. (2006) suggest that future research on
emerging adults consider the experiences of these
individuals while in school, particularly the high school
years, and its effect on psychological well-being.
Cohen etal. (2003) suggest that future research on
emerging adults consider the differences in norms and
opportunity structures of individuals in this age group in
order to obtain a fuller picture of the developmental
trajectories and experiences of subgroups (for example,
African Americans) during this life-span period.
Interdisciplinary Connections or
Contributions from Other Disciplines
The overwhelming majority of empirical research on this
topic has been conducted by the disciplines of psychology,
human development, and family studies. Social Work
borrows extensively from these disciplines as they have
from social work. Practice implications, directions for
future research and policy making related Social Work and
social welfare have been affected by the empirical research
of those as well as other disciplines. Social Work's
Person-in-Environment framework contributes to
understanding of the transitional challenges and tasks, thus
clearly integrating the profession and its interdisciplinary
connections.
Role of and Implications for Social Work The
profession of social work has a unique opportunity to
contribute to the knowledge development on emerging
adults through its Person-in-Environment perspective. The
environmental context in which individuals in this age
group transition is fraught with opportunities, challenges,
obstacles, and experiences that may, at times, overwhelm
the individual thus necessitating intervention. Social
workers in assessing individuals in this group can identify
the transitional challenges and obstacles and assist the
individual in adapting to the changes and expectations so
that progress toward the next life-span period, adulthood
can be achieved.
Practice implications abound, especiall y with those
vulnerable population members whose situations are
complicated by internal and external factors. Rising
incarceration rates, increasing HIV/AIDS infections
among some subpopulations of this group, and increasing
reliance on technology will continue to contribute to
psychosocial distress. Awareness of the transitional tasks
and the challenges/obstacles prohibiting success ful
transition will be important areas to highlight and develop
solution strategies.
From a research and scholarship perspective, this area
is fertile with opportunity for social work researchers. The
clear lack of research on the developmental trajectories of
minority group members is but one of several areas that
need further empirical examination. The work of Galmbos
et al. (2006) point to the need to further study the
psychological well-being of emerging adults as it relates
to depression, self-esteem, and expressive anger.
Experiences such as parental divorce, child maltreatment,
and poverty and their effects on emerging adults are areas
in which additional empirical research is needed.
Cohen et al. (2003) indicate that much of the research
on emerging adulthood has focused on status indicators
(for example, marriage) while the role changes (for
example, accepting responsibility, making independent
decisions) important to those in the age group has largely
been ignored. A myriad of research opportunities are open
to social work researchers on this topic, opportunities that
fit well with our focus on the Person-in-Environment and
our historical perspective of life-span development.
REfERENCES
Arnett,].]. (1998). Learning to standalone: The contemporary
American transition to adulthood in cultural and his torical
context. Human Development, 41, 295-315.
Arnett, [. ]. (2000). Emerging adulthood: A theory of devel-
opment from the late teens through the twenties. American
Psychologist, 55(5), 469--480.

Arnett, J. J .. (2003). Conceptions of the transition to adulthood
among emerging adults in American ethnic groups. New
Directions for Child and Adolescent Development, LOO, 63-75.
Amett, J. J. (2005). The developmental context of substance use in
emerging adulthood. Journal of Drug Issues, 35(2), 235-253.
Barry, C. M., & Nelson, L. J. (2005). The role of religion in the
transition to adulthood for young emerging adults. Journal of
Youth and Adolescence, 34(4), 245-255.
Berzin, S. c, DeMarco, A. c., Shaw, T. V., Unick, G. J., &
Hogan, S. R. (2006). The effect of parental work history and
public assistance use on the transition to adulthood. Journal of
Sociology and Social Welfare, 33(1), 141-162.
Cohen, P., Kasen, S., Chen, H., Hartmark, C., & Gordon, K.
(2003). Variations in patterns of developmental transitions in
the emerging adulthood period. Developmental Psychology,
39(4),657-669.
Galmbos, N. L., Barker, E. T., & Krahn, H. J. (2006). Depression,
self-esteem, and anger in emerging adulthood: Sevenyear
trajectories. Developmental Psychology, 42(2), 350-365.
Lefkowitz, E. S. (2005). Things have gotten better: Developmental
changes among emerging adults after the transition to
university. Journal of Adolescent Research, 20(1), 40-63.
Maggs, J. L., & Schulenberg, J. E. ,(2004/2005 ). Trajectories of
alcohol use during the transition to adulthood. Alcohol Research
and Health, 28(4), 195-201.
Milevsky, A. (2004). Perceived parental marital satisfaction and
divorce: Effects on sibling relations in emerging adults. Journal
of Divorce & Remarriage, 41(1/2),115-128.
Raphael, S. (2006, May). Early incarceration spells and the transition
to adulthood. Macarthur Foundation Research Network on
Transitions to Adulthood.
Rindfuss, R. R. (1991). The young adult years: Diversity, struc-
tural change, and fertility. Demography, 28(4), 493-512.
Scharfe, E., & Cole, E. (2006). Stability and change of attachment
representations during emerging adulthood: An examination
of mediators and moderators of change. Personal Relationships,
13,363-374.
Schensul, J. J., & Burkholder, G. J. (2005). Vulnerability, social
networks, sites, and selling as predictors of drug use among
urban African American and Puerto Rican emerging adults.
Journal of Drug Issues, 35(2), 379-408.
U.S. Census Bureau (2006, September 21). Estimated median age at
first marriage, by sex: 1890 to the present. Retrieved December 8,
2006, from http://www.census.gov/population/
socdemog/hh-fam/ms2.pdf.
-DA VID MILLER AND SEAN
JOE
PARENTING
ABSTRACT: Parenting is a key part of social work
practice and research, particularly in the child welfare
arena. Despite significant research and theory in other
disciplines about the importance of the parent- child
relationship to the quality of parenting, the focus of
social work appears to lie in narrow goals such as the
LIFE SPAN: PARENTING
117
prevention of abuse and child placement and to employ
interventions that lack significant evidence of effectiveness.
This entry summarizes social work practice and research in
the area of parenting and reviews the state of the art overall in
research and knowledge about parenting.
KEY WORDS: parents; parenting; mothers; fathers;
children; infants; African American parents;
Attachment Theory; sensitivity; responsivity;
authoritative parenting; determinants of parenting
model; child welfare
Parental influences are significant and long-lasting. Parenting
is not only critical to the lives of children and parents; it is the
major way that societies and cultures pass on their traditions
and values and guarantee that future generations are
competent to carry on those traditions and values. It is critical
to society as a whole.
Ogbu (1981) calls attention to cultural differences in
parenting by defining child-rearing as "the process by which
parents ... transmit and ... children acquire the prior existing
competencies required by their social, economic, political,
and other future adult cultural tasks" (p. 418). Cornbs-Orme,
Wilson, Cain, Page, and Kirby (2003) emphasized
context-based parenting: parenting that, given a specific child's
age, developmental needs, special circumstances, culture, and
immediate environment, is optimal for promoting healthy
growth and development.
Demographics of Parenting
Nearly three-fourths of adult females and two-thirds of adult
malesreport having biological children (Child Trends, 2002),
while 45% of female and 38% of male adults currently live
with their biological or adopted children. A biological
relationship is not necessary for parenting, and the changing
demographics of family in this country have led to increasing
diversity in the ties between children and parents. The u.s.
Census Bureau estimates that 6% of children (4.5 million) are
being reared by grandparents, an increase of 30% during the
1990s. In addition, 1 million children in the United States live
with adoptive parents, and 2-4% of American families include
adopted children (U.S. Census; see "Adoption").
Most parenting research has been conducted with mothers,
although there has been increased attention to fathers in recent
years, overall (Marsiglio, Amato, Day, & Lamb, 2000) and in
social work (Greif & Greif, 1997). Research shows that
fathers are important to their children's development and that
they make unique contributions to children's lives (Marsiglio
et al., 2000).
118 LIFE SPAN: PARENTING
Parenting: State of the Knowledge
Social work grows out of the social sciences and draws
much of its foundation knowledge from psychology and
other related disciplines. It is thus important to place social
work's involvement in parenting within that broader scope
of knowledge.
There is no single "theory of parenting," although in the
social work literature social systems theory, Erikson's
stage of generativity, Bronfenbrenner's work on human
development, Vygotsky's theories, and Adlerian theory are
invoked (Heath, 2006). Attachment Theory (Bowlby,
1973) is commonly used to understand the importance of
parenting and is cited in relationship to parents and
children in the child welfare system (for example, Howe,
2000; Page, 1999).
\.
ATTACHMENT THEORY Understanding of the impor-
tance and desirable aspects of parenting grows from
knowledge of what children need to grow and thrive.
Attachment Theory (Bowlby, 1973) explains that in-
fants' attachment behaviors (such as crying) promote
survival by bringing caregivers into close proximity
during times of danger or need. Over time, as
caregivers respond to infants' nee ds, attachment grows
from these transactions (Davies, 1999), and infants
develop models of themselves, others, and the world
that serve as blueprints for future relationships. Infants
whose needs are met consistently develop "internal
working models" of t hemselves as worthy, others as
reliably available, and the world as safe. Infants whose
needs are not met consistently, or who are abused or
neglected, develop anxious attachment styles, built on
mental representa tions that help is not available, the
world is not safe, and they are not worthy of love.
Attachment to a consistent caregiver provides an infant
with feelings of security, and he or she thus feels safe to
explore the environment. In addition, the at tachment
relationship provides a venue for communicating and
expressing feelings. Through the expression of distress and
the calming attention of the caregiver, the infant learns to
manage her own emotions effectively (Davies, 1999), Data
show that secure attachments are associated with children's
greater selfefficacy, social competence, empathy, and
lower levels of anxiety and anger (Weinfield, Sroufe,
Egeland, & Carlson, 1999). As Davies (1999) summarizes,
''. .. the growing evidence of empirical studies points to
quality of attachment as a fundamental mediator of
develop-
ment" (p. 27). . parenting" model (1984), based on Bronfenbrenner' s
PARENTING STYLES Over time, attention to specific
parenting behaviors has given way to a broader focus
on parenting styles or patterns, which consist of
combinations of parenting dimensions that are similar in
meaning and tend to covary. Current research on
parenting, particularly from an Attachment Theory
perspective, often reference sensitivity and responsivity.
Sensitivity and Responsivity. To meet children's
needs, parents first must correctly perceive and interpret
those needs, either by situational context (for example,
the stress of a clinic visit) or by understanding signals (for
example, signs of fatigue). Accurate perceptions of chil-
dren's needs are fundamental to parents' capacities for
sensitive and responsive caregiving, and these percep-
tions are the most consistent predictor of secure attach-
ment (Belsky, 1999). Research consistently shows that
sensitive, responsive parenting is a ssociated with secure
attachment and positive child outcomes (Belsky, 1984).
DiPietro (2000) suggested that the relationships among
nurturing parenting, secure attachment, and positive child
outcomes are mediated through neurophysiologic
processes.' Early brain development proceeds.in response
to experience, and parenting is the most important aspect
of young children's environments. Warm nurturance
appears to provide a buffer against stress when the
hypothalmlc-pitiuitary-adrenal system is developing,
keeping the system in homeostasis and promoting
effective self-regulation. Children who are mistreated or
neglected have chronically high levels of stress hormones
that, through adaptation, may lead to chronic dysregulation
and socioemotional problems that inhibit school
achievement, social relationships, and physical health.
Authoritative, Authoritarian, and Permissive
Parenting. Baumrind (1967) combined dimensions of
parental warmth and demandingness to categorize par ents
as authoritative (high expectations for behavior and
maturity, high levels of warmth and responsiveness),
authoritarian (high expectations, low warmth) or permissive
(low expectations, high warmth). Maccoby and Martin
(1983) later added uninvolved or neglecting (low demands,
low warmth), Although some cultures or contexts (such as
dangerous neighborhoods) may require different parenting
styles (Chao, 2001), parenting marked by warmth, high
expectations, and encouragement of autonomy is
associated with the most successful outcomes for children
(Collins, 2006).
"DETERMINANTS OF PARENTING" MODEL Perhaps the
most influential model for understanding' the con-
tributors to parenting is Belsky's "determinants of
(1986) theory of social ecolo gy. The model explains
that parenting is influenced by characteristics of the
parent, the child, and the social context in which the
parent-child relationship is embedded.

Parent Contributions. Developmental history. It is
widely accepted that parenting behaviors and styles are
transmitted across generations (Belsky, Jaffee, Sligo,
Woodward, & Silva, 2005). Child abuse and . harsh
discipline, for example, are frequently linked to parents'
childhood experiences, and childhood abuse or harsh
parenting is considered to be a risk factor for similar
parenting (Dixon, Browne, & Hamilton, Giachritsis, 2005).
Less research has examined continuity of positive
parenting, but recent evidence suggests that it, too, is
transmitted across generations (Chen & Kaplan, 2001).
However, some parents who were reared poorly are able to
develop resilience that allows them to parent competently
(Travis & Combs-Orme, 2007).
Personality. Parent maturity, positive coping, and
psychological adjustment 'are especially important pre,
dictors of parenting effectiveness (Belsky, 1984; Belsky &
Barends, 2002). Parents who are more intelligent and more
knowledgeable about parenting and children's needs have
more positive interactions with their children (O'Callaghan,
Borkowski, Whitman, Maxwell, & Keogh, 1999).
Kochanska, Aksan, Penney, and Boldt (2007) also found
that parent personality and aspects of socialization buffer
against the negative effects of demo' graphic risk on
parenting behavior.
Mental health. Mental health influences parenting skills
and behaviors. Mowbray, Oyserman, Bybee, and
MacFarlane (2002) summarized research showing mothers
with serious mental illnesses to be less emotionally
available, involved with their children, positive,
encouraging, and sensitive to their children's needs. They
caution, however, that much of that research is based solely
on comparisons of depressed and nondepressed mothers.
Their study of a large urban sample with a variety of
diagnoses demonstrated that effects on parenting may vary
for different diagnostic groups, and that severity of
symptoms and level of community functioning are more
strongly related to parenting than diagnosis.
'Demographic factors. Demographic factors such as
parental age, income, and marital status are associated with
parenting, as they are indicators of the resources available
for parenting (Hubbs-Tait et al., 2006), and the
accumulation of stress related to impoverishment is likely
to interfere with parents' emotional availability to their
children. Older maternal age (up to the early 30s), is related
to more optimal parenting, presumably because of greater
experience, maturity, and knowledge (Bomstein, Putnick,
Suwalsky, & Gini, 2006).
Research on race and culture has generally held white,
middle, class parenting as the norm and ignored effects of
racism, oppression, and socioeconomic discrimination on
parenting and child outcomes (Cain & Combs-Orme,
LIFE SPAN: PARENTING
119
2005; Cochran, 1997). Current research recognizes the
influences of cultural heritage and the environment on
parenting and acknowledges the strengrhs of the African
American family and families of other cultures (Cochran,
1997; Hossain et al., 1999). Carter-Black's (2001) quali-
tative study of two middle-class African American fa,
milies emphasized the dominance of racial heritage over
social class issues on parenting.
Parenting attitudes. Parenting attitudes can be thought
of as preconceptions of desirable parenting behavior, or
generalized models of how parenting should be done
(Page, Cornbs-Orme, & Cain, in press). In the absence of
overt maltreatment, and even with adequate physical care,
negative parenting attitudes may provide early indications
of relationship problems that may lead to abuse, neglect,
poor attachment, and poor child development (Crouch &
Behl, 2001). With notable exceptions, little attention has
been paid to links between parenting attitudes and behavior
(Holden & Buck, 2002). Research does not support Heath's
(2006) statement that "attitudes pre, diet behavior" (p.
757). However, parenting attitudes are believed to make
important contributions to actual behavior (Holden &
Buck, 2002).
Child Contributions. Studies demonstrate a reciprocal
relationship between parenting quality and child
personality and behavior (Crowley & Kazdin, 1998). Child
abuse research shows that child behaviors, particularly
externalizing problems, are independently related to child
abuse potential (Ammerman & Patz, 1996) and severity
(Sprang, Clark, & Bass, 2005). Child temperament, in
particular, has been shown to be related to parenting
behavior (Calkins & Dedmon, 2004).
Environmental Contributions. As Belsky (1984)
originally posited, the quality of parents' interactions with
the wider social environment is an important contributor to
quality of parental care. The accumulation of risk factors
associated with life in impoverished social environments,
including poor family functioning, stressful life events,
maternal psychological distress, and low income, in
particular, presents greater risks to children's development
than do individual indicators (Sameroff & Fiese, 2000).
Poverty has profound effects on the personal and social
resources available to parents to meet their children's needs
(Cain & Combs-Orrne, 2005; Combs-Orme & Cain, 2006).
Whether tangible (child care, financial assistance) or
nontangible (advice, information, sympathy), and whether
from informal (family, friends) or from formal (health care
professionals, teachers) sources, social support is asso-
ciated with more optimal parenting, possibly through
moderation or "buffering" of the effects of stress and
adversity (Cochran & Niego, 2002).
120 LIFE SPAN: PARENTING
Parenting in Social Work
Practice and Research
Perhaps because of social work's deep roots in the child
welfare system (CWS), most attention to parenting is based
on preventing abuse and child placement and restoring a
minimum level of parenting. The literature suggest that
social workers rarely focus on the parentchild relationship
within a theoretically informed assessment and
understanding of attachment issues (Tumey & Tanner,
2001), and it is remarkable how little attention is paid to the
influence of poverty and deprivation on quality of
parenting.
. Across the settings described below, parenting inter.
ventions appear either to focus on correcting specific
excesses or deficits in behavior, or to be delivered in
"psycho-educational" groups, which include both content
and social support elements. Sessions include videotape
instruction, direct observation of parent behavior,
role-play, and feedback. Increasingly, "manualized"
commercial programs are employed, particularly in public
child welfare agencies. (Documentation of social workers'
interventions with clients to improve parenting in
psychotherapeutic or other one-on-one settings is sparse,
although such work undoubtedly occurs.)
CHILD WELFARE SETTINGS Child welfare agencies
are the center of social work's involvement in parent ing,
and many parents in the CWS participate in voluntary or
mandated parenting services (U .S. Depart ment of Health
and Human Services, 2005). In this setting, parents have
usually been reported for child maltreatment, and agencies
seek to "help caregivers provide a minimum sufficient
level of care" (Barth et al., 2005, p. 355).
This narrow focus results from agency missions in the
United States of avoiding child placement and preventing
recurrence of abuse or neglect, of course. Nevertheless,
despite neglect being the most common type of
maltreatment, discipline is usually the targeted parenting
behavior in such programs (Barth et al., 2005). Tumey and
Tanner's (2001) interpretation of neglect as a breakdown in
the parent-child relationship (using Attachment Theory)
would suggest that one reason that neglectful parenting is
so difficult to treat is a failure to address this relationship
dimension.
Following decades of failure of homemaker and in-
tensive family preservation services to document the
parenting services they provide or to demonstrate sub-
stantial effects, Barth et a1. (2005) recently called f or the
extension of evidence-based parent training programs to
parents in the CWS. Ironically, they found that only one
third of parents in the CWS were identified as
having poor parenting skills and that there is a lack of
knowledge about the kinds of parenting problems these
parents experience. Despite the fact that a majority of
parents in the CWS suffer the effects of acute poverty,
poverty is not identified as a parenting problem in Barth et
a1.'s summary of the Department of Health and Human
Services report on child maltreatment.
Barth et a1. (2005) reviewed several training programs
designed for parents of children with behavior problems
that have some empirical documentation of effective ness,
considering the purposes and characteristics of the
programs to determine their usefulness for training parents
in the CWS. Some of those programs have been evaluated
with maltreating parents, but not specifically with parents
in the CWS. They also examined the parent training
programs that are currently widely used in child welfare
agencies, finding little evidence for the effectiveness of
those programs. Their summary emphasizes the critical
need for individual assessments of parenting so that
intervention can target specific deficits in parenting skills.
No mention of parent-child relationship or the challenges
of parenting in poverty are included.
NON-CHILD,WELFARE SETTINGS Social workers
frequently provide classes and groups for mentally ill
(Ackerson, 2003), drug-addicted (Plasse, 2000), and other
parents with problems. In these settings, parents are
assumed to lack appropriate parenting skills, and the focus
is on pathology, often with the goal of assessing the
necessity of terminating parental rights (Ackerson, 2003 ).
Ackerson notes that few "generic" community parenting
programs are equipped to deal with parents who have
serious mental illnesses, and few programs for the
mentally ill target parenting. He asserts that pro grams for
mentally ill parents should involve thorough assessments
of specific functional impairments, competencies, and
parenting knowledge, as well as observation of
parent-child interaction. He does not discuss the
parent-child relationship.
Social workers also frequently work with parents of
children with mental health problems, such as conduct
disorder or other behavior problems. These children are
challenging to care for, and social work interventions are
focused on teaching parents the skills they need to meet
their children's special needs. (See Barth et al., 2005, for a
discussion of these interventions.) For example, Harrison,
Boyle, and Farley (1999) provided 12-week group-based
courses for parents of children referred by mental health
and juvenile court agencies.
Minority Parents. Few parenting services have
been available to meet the specific needs of African
Americans, other minorities, or other cultural groups
(Harachi, Catalano, & Hawkins, 1997), whose
j

parenting occurs in different cultural environments and in
the context of discrimination and limited opportunity.
Recently, interventions have been provided specifically for
African American parents, including groups . that focus on
the unique circumstances of African American parents,
including racial socialization and identity and the
development of bicultural skills (Miller, 1997) and a
strengths-based, Africentric perspective grounded in an
ecological framework (Harvey & Hill, 2004). Farber and
Maharaj (2005) provided a manualized, group-based
psycho-educational program for parents of high-risk
developmentally delayed African American children.
Although evaluations of these parenting interventions
indicated positive outcomes, none included comparison
groups and require replication.
Fathers. Since the niid-1980s, there has been an
increased interest in fathers (Greif & Greif, 1997;
! Marsiglio et a1., 2000), beyond social work's almost
exclusive emphasis on absent fathers and child support
issues. The literature demonstrates social work interest
in low-income fathers (for example, Shears, Summers,
Boller, & Barclay-Mcl.aughlin, 2006), incarcerated
fathers (LaRosa & Rank, 2001), fathers in the CWS
(Tyrer, Chase, Warwick, & Aggleton, 2005), and
fathers caring for children with special needs (Jones &
Neil-Urban, 2003). There is continuing interest in
absent or noncustodial fathers and child support policy
(Carlson, 2006; Mandell & Sharlin, 2006). Curran
(2003) examined fathering programs in the context of
welfare reform and found little evidence of
effectiveness in increasing child support of quality of
fathering.
Published research indicates that social work has gone
beyond describing absent fathers to addressing issues of
fathers' perceptions of their roles and performance in those
roles (Kost, 2001) and involvement with their children
(Carlson, 2006). Lane and Clay (2000) addressed the
service needs of young fathers.
Despite interest in fathers in social work, parenting by
fathers-or "fathering"-is not generally well conceptualized
or placed within a framework or theory about children's
needs, although other disciplines are pursuing that topic
(for example, Brotherson, Dollahite, & Hawkins's 2005
conception of generative fathering and Bradford and
Hawkins's 2006 concept of competent fathering). One
exception in social work is Jones (2005), who provides a
discussion of the role of the father in psychoanalytic theory,
touching on fathers' contemporary roles.
Adolescent Parents. Adolescent parents continue to
be of interest to social workers. (See "Adolescent
Pregnancy.") Many interventions for this group (for
example, Sangalang & Rounds, 2005) not only empha-
size the completion of education and economic
LIFE SPAN: PARENTING
121
independence, as well as contraceptive use to prevent
further pregnancies, but also may provide information
about child development and children's needs. There is
abundant evidence that adolescent parents lack maturity,
knowledge, and skills for parenting and that their social
and environmental circumstances further .complicate their
ability to provide competent care for their children that is
optimal for the children's healthy development (Corcoran,
1998).
Conclusion and Issues for the Future
Social workers have a pivotal role in working with parents
in diverse settings, and they provide the majority of
services to parents in the child welfare system. The
profession needs to address a number of challenges in
order to demonstrate its effectiveness in enhancing
improvement of parenting and thus the lives of the children
touched in this way.
First, social work interventions in parenting are not
making use of a vast, rich literature in other disciplines.
Research in child development and psychology can pro-
vide a theoretical foundation and understanding of the
parenting relationship on child health and development, the
ultimate lens through which parenting is viewed
(Combs-Orme et al., 2003; Davies, 1999; Heath, 2006;
Woodcock, 2003). That research has moved beyond
specific behaviors and parenting skills to affirm the fun-
damental importance of the parent-child relationship and to
measure broader parenting styles. As described earlier,
parenting interventions in American social work are not
embedded in this knowledge and appear to focus narrowly
on such goals as preventing placement. Woodcock's (2003)
discussion of the British system indicates that the child
welfare community there is struggling with these two
different goals: preventing maltreatment and supporting
families.
Second, despite social work's long history and com-
mitment to understanding the impact of poverty, the
profession pays insufficient attention to the effect of
environmental deprivation on parents and their parenting.
Belsky's (1984) model of the determinants of parenting
provides a framework for considering the impact of
poverty and incorporating that understanding into research
and practice with parents, particularly those in the child
welfare system.
Finally, although social workers are delivering par-
enting interventions and often evaluating their efforts,
Barth et a1. (2005) emphasize the poor state of our
knowledge. The more general move toward empirically
based practice surely demands rigorous examination of
this most critical part of social work's mission.
[See also Gay Families and Parenting.]
122 LIFE SPAN: PARENTING
REFERENCES
Ackerson, B. J. (2003). Parents with serious and persistent mental
illness: Issues in assessment and services. Social Work, 48(2),
187-194.
Ammerman, R. T., & Patz, R. J. (1996). Determinants of child
abuse potential: Contribution of parent and child factors.
Journal of Clinical Child Psychology, 25(3), 300-307.
Barth, R. P., Landsverk, J., Chamberlain, P., Reid, J. B., Rolls, J.
A, Hurlburt, M. S., et al. (2005). Parent-training programs in
child welfare services: Planning for a more evidence-based
approach to serving biological parents. Research on Social Work
Practice, 15,353-371.
Baumrind, D. (1967). Child care practices anteceding three
patterns of preschool behavior. Genetic Psychology Mono-
graphs, 75,43-88.
Belsky, J. (1984). The determinants of parenting: A process
model. Child Development, 55(1), 83-96.
Belsky, J. (1999). Interactional and contextual determinants of
attachment security. In J. Cassidy & P. Shaver (Eds.),
Handbook of attachment: Theory, research, and clinical applications
(pp. 249-264). New York: Guilford Press.
Belsky, J., & Barends, N. (2002). Personality and parenting. In M.
H. Bomstein (Ed.), Handbook of parenting, Vol. 3: Being and
becoming a parent (2nd ed., pp. 415--438). Mahwah, NJ:
Erlbaum.
Belsky, J., Jaffee, S. R.; Sligo, J., Woodward, L., & Silva, P. A
(2005). Intergenerational transmission of warm-sensitive-
stimulating parenting: A prospective study of mothers and
fathers of 3-year-olds. Child Development, 76, 384-396.
Bornstein, M. H., Putnick, D. L., Suwalsky, J. T. D., & Gini, M.
(2006). Maternal chronological age, prenatal and perinatal
history, social support, and parenting of infants. Child
Development, 77(4), 875-892,
Bowlby, J. (1973). Attachment (Znd ed.). New York: Basic Books.
Bradford, K., & Hawkins, A J. (2006). Learning competent
fathering: A longitudinal analysis of marital intimacy and
fathering. Fathering, 4(3), 215-234.
Bronfenbrenner, U. (1986). Ecology of the family as a context for
human development: Research perspectives. Developmental
Psychology, 22, 723-742,
Brotherson, S. E., Dollahite, D. c., & Hawkins, A J. (2005).
Generative fathering and the dynamics of connection between
fathers and their children. Fathering, 3(1), 1-28.
Cain, D. S., & Combs-Orme, T. (2005). Family structure effects
on parenting stress and practices in the AfricanAmerican
family. Journal of Sociology and Social Welfare, 32(2), 19--40.
Calkins, A H., & Dedmon, S. E. (2004). Mothers' interactions
with temperamentally frustrated infants. Infant Mental Health
Journal, 25(3),219-239.
Carlson, M. J. (2006). Family structure, father involvement, and
adolescent behavioral outcomes. Journal of Marriage and
Family, 68(1),137-154.
Carter-Black, J. (2001). The myth of "the tangle of pathology":
Resilience strategies employed by middle-class African
American families. Journal of Family Social Work, 6(4), 75-100.
Chao, R. K. (2001). Extending research on the consequences of
parenting style for Chinese American and European
Americans. Child Development, 72, 1832-1843.
Chen, Z. Y., & Kaplan, H. B. (200l).Intergeneral transmission of
constructive parenting. Journal of Marriage and the Family, 63,
17-31.
Child Trends. (2002). Charting Parenthood: A Statistical Portrait
of Fathers and Mothers in America. Washington, DC: Child
Trends; 2002, Retrieved November 28, 2007, from
http://www.childtrendsdatabank.org/.
Cochran, D. L. (1997). African American fathers: A decade
review of the literature. Families in Society: The Journal of
Contemporary Human Services, 78(4), 140-150.
Cochran, M., & Niego, S. (2002). Parenting and social networks.
In M. H. Bomstein (Ed.), Handbook of parenting, Vol. 4: Applied
parenting (2nd ed., pp. 123-148). Mahwah,
NJ: Erlbaum. '
Collins, W. A. (2006). Commentary-Parsing parenting:
Refining models of parental influence during adolescence.
Monographs of the Society for Research in Child Development,
70(4),138-145.
Combs-Orme, T., & Cain, D. S. (2006). The daily lives of poor
infants: Consistent disadvantage. Journal of Children and
Poverty, 12(1), 1-20.
Combs-Orme, T., Wilson, E., Cain, D. S., Page, T., & Kirby, L. D.
(2003). Context-based parenting in infancy. Child and
Adolescent Social Work Journal, 20(6),437--472.
Corcoran, J. (1998). Consequences of adolescent pregnancy/
parenting: A review of the literature. Social Work in Health
Care, 27(2), 49-67.
Crouch, J. L., & Behl, L. E. (2001). Relationships among parental
beliefs in corporal punishment, reported stress, and physical
child abuse potential. Child Abuse and Neglect, 25(3),413--419.
Crowley, M. J., & Kazdin, A E. (1998). Child psychosocial
functioning and parent quality of life among clinically referred
children. Journal of Child and Family Studies, 7, 233-251.
Curran, L. (2003). Social work and fathers: Child support and
fathering programs. Social Work, 48(2), 219-227.
Davies, D. (1999). Child development. A practitioner's guide.
New York: Guilford Press.
DiPietro, J. (2000). Baby and the brain: Advances in child
development. Annual Review of Public Health, 21,455--471.
Dixon, L., Browne, K., & Hamilton-Giachritsis, C. (2005).
Risk factors of parents abused as children: A mediational
analysis of the intergenerational continuity of child mal-
treatment (Part I). Journal of Child Psychology and Psychiatry,
46,47-57.
Farber, M. L. Z., & Maharaj, R. (2005). Empowering high-risk
families of children with disabilities. Research on Social Work
Practice, 15,501-515.
Greif, G. L., & Greif, J. L. (1997). Where are the fathers in social
work literature? Revisiting the question. Families in Society:
The Journal of Contemporary Human Services, 78(4), 433--435.
Harachi, T. W., Catalano, R. F., & Hawkins, J. D. (1997).
Effective recruitment for parenting programs within ethnic

minority communities. Child and Adolescent Social Work Journal,
14(1),23-39.
Harrison, R. S., Boyle, S. W., & Farley, O. W. (1999). Evaluating
the outcomes of family-based intervention for troubled
children: A pretest-posttest study. Research on Social Work
Practice, 9,640-655.
Harvey, A. R., & Hill, R. B. (2004). Africentric Youth and Family
Rites of Passage Program: Promoting resilience among at-risk
African American youths. Social Work, 49(1 ), 65-74.
Heath, H. (2006). Parenting: A relationship-oriented and
competency-based process. Child Welfare, 85(5), 749-766.
Holden, G. W., & Buck, M. J. (2002). Parental attitudes toward
childi:earing. In M. H. Bornstein (Ed.), Handbook of parenting
(2nd ed., pp. 537-562). Mahwah, NJ: Erlbaum.
Hossain, Z., Chew, B., Swilling, S., BrownS., Michaelis, M., &
Philips, S. (1999). Fathers' participation in childcare within
Navajo Indian families. J;arly Child Development and Care,
154,63-74.
Howe, D., Dooley, T., & Hinings, D. (2000). Assessment and
decision-making in a case of child neglect and abuse using an
attachment perspective. Child and Family Social Work,
5,143-155.
Hubbs-Tait, L, Page, M. c, Huey, E. L, Starost, H., Culp, A. M.,
Culp, R. E., et al. (2006). Parenting quality: Confirmation of a
higher-order latent construct with mothers of head start
children. Early Childhood Research Quarterly, 21, 491-506.
Jones, J. B., & Neil-Urban, S. (2003). Father to father: Focus
groups of fathers of children with cancer. Social Work in Health
Care, 37(1), 41-61.
Jones, K. (2005). The role of father in psychoanalytic theory:
Historical and contemporary trends. Smith College Studies in
Social Work, 75(1), 7-28.
Kochanska, G., Aksan, N., Penney, S. J., & Boldt, L J. (2007).
Parental personality as an inner resource that moderates the
impact of ecological adversity on parenting. Journal of Per-
sonality and Social Psychology, 92(1), 136-150.
Kost, K. A. (2001). The function offathers: What poor men say
about fatherhood. Families in Society, 82(5), 499-508.
Lane, T. S., & Clay, C. M. (2000). Meeting the services needs of
young fathers. Child and Adolescent Social Work Journal,
17(1),35-54.
LaRosa, J. J., & Rank, M. G. (2001). Parenting education and
incarcerated fathers. Journal of Family Social Work, 6(3), 15-33.
Maccoby, E. E., & Martin, J. A. (1983). Socialization in the
context of the family: Parent-ehild interaction. In P. H.
Mussen & E. M. Heatherington (Eds.), Handbook of child
psychology, Vol. 4: Socialization, personality, and social devel-
opment (pp. 1-102). New York: Wiley.
Mandell, S., & Sharlin, S. A. (2006). The non-custodial father:
His involvement in his children's lives and the connection
between his role and the ex-wife's, child's and father's
perceptions of that role. Journal of Divorce and Remarriage,
45(1/2), 79-95.
Marsiglio, W., Amato, P., Day, R. D., & Lamb, M. E. (2000).
Scholarship on fatherhood in the 1990s and beyond. Journal of
Marriage and Family, 62, 1173-1191.
LIFE SPAN: PARENTING 123
Miller, D. B. (1997). Parenting against the odds. AfricanAmerican
parents in the child welfare system-A group approach. Social
Work with Groups, 20(1), 5-17~
Mowbray, c., Oyserman, D., Bybee, D., & MacFarlane, P.
(2002). Parenting of mothers with a serious mental illness:
Differential effects of diagnosis, clinical history, and other
mental health variables. Social Work Research, 26(4), 225-240.
O'Callaghan, M. E, Borkowski, J. G., Whitman, T. L, Maxwell,
S. E., & Keogh, D. (1999). A model of adolescent parenting:
The role of cognitive readiness to parent. Journal of Research on
Adolescence, 9(2),203-225.
Ogbu,]. U. (1981). Origins of human competence: A cultural-
ecological perspective. Child Development, 52,413-429.
Page, T. (1999). The attachment partnership as conceptual base
for exploring the impact of child maltreatment. Child and
Adolescent Social Work Journal, 16( 6), 419-437.
Page, T., Cornbs-Orme, T., & Cain, D. S. (2007). New mothers'
psychological experience and behavioral interactions with
their Infants in the first 12 Months. Journal of Child and Family
Studies, 16, 155-167.
Plasse, B. R. (2000). Components of engagement: Women in a
psychoeducational parenting skills group in substance abuse
treatment. Social Work with Groups, 22(4),33-50.
Sameroff, A. J., & Fiese, B. H. (2000). Models of development
and developmental risk. In C. H. Zeanah Jr. (Ed.), Handbook of
infant mental health (2nd ed., pp. 3-19). New York:
Guilford Press.
Sangalang, B. B., & Rounds, K. (2005). Differences in health
behaviors and parenting knowledge between pregnant ado-
lescents and parenting adolescents. Social Work in Health
Care,42(2),1-22.
Shears, J., Summers, J. A., Boller, K., & Barclay-McLaughlin, G.
(2006). Exploring fathering roles in low-income families:
The influence of intergeneral transmission. Families in Society,
87(2),259-268.
Sprang, G., Clark, J. J., & Bass, S. (2005). Factors that contribute
to child maltreatment severity: A multi-method and
multidimensional investigation. Child Abuse and Neglect, 29,
335-350.
Tumey, D., & Tanner, K. (2001). Working with neglected
children and their families. Journal of Social Work Practice,
15(2), 193-204.
Tyrer, P., Chase, E., Warwick, L, & Aggleton, P. (2005).
"Dealing with it": Experiences of young fathers in and leaving
care. British Journal of Social Work, 35(7), 1107-1121.
U.S. Census. Available at http://www.census.gov.
U.S. Department of Health and Human Services. (2005). Child
maltreatment, 2004. Available at http://www.acf.hhs.gov/
programs/cb/stats_research/index.htm#can.
Weinfield, N. S., Sroufe, L. A., Egeland, B., & Carlson, E. A.
(1999). The nature of individual differences in infantcaregiver
attachment. In J. Cassidy & P. R. Shaver (Eds.), Handbook of
attachment: Theory, research, and clinical applications (pp. 68-88).
New York: Guilford Press.
Woodcock, J. (2003). The social work assessment of parenting:
An exploration. British Journal of Social Work, 33, 87-106.
124 LIFE SPAN: PARENTING
Travis, W., & Combs-Orme, T. (2007). Resilient parenting:
Overcoming poor parental bonding. Social Work Research,
31(3), 135-149.
FURTHER READING
Bunting, L., & McAuley, C. (2004). Research review: Teenage
pregnancy and parenthood: The role of fathers. Child and
Family Social Work, 9, 295-303.
Waller, M. A., Brown, B., & Whittle, B. (1999). Mentoring as a
bridge to positive outcomes for teen mothers and their
children. Child and Adolescent Social Work Journal, 16(6),
467-480.
-TERRI COMBS-ORME
OLDER ADm THOOD/SENIORS ("YOUNG OLD")
ABSTRACT: Although the terms "older adult" or "senior
citizen" are commonly defined as individuals 60 years and
above, later adulthood contains various life course phases
and developmental periods. The "young old," defined as
individuals in the age range of 60-75 years, often
experience various health, social, and economic transitions.
As a result, both the individual and family system must
negotiate some of the concomitant changes that accompany
the journey into later life. Therefore, this first decade of
older adulthood is one that can simultaneously be
enjoyable, exciting, demanding, and stressful for the aging
persons and their family.
KEY WORDS: young-old; late life; senior adults
Demographics
As the Baby Boom generation reaches later adulthood, this
group of individuals who were born between 1946 and
1964 are expected to transform this time of life. The large
number of Baby Boomers will require that all sectors of our
society, including government, business/ industry, health
care, and family life, reevaluate the role and status of older
adults within our society. The fol lowing trends within the
young old cohort tell and forecast some of
sociodemographic shifts that are occur ring, or are expected,
as a result of an increase in this population segment:
• In 1900, life expectancy at age 65 was 115 more years
for men and 12.2 years for women. In 2003 ,
65-year-old men were expected to live 16.2 more
years and the same-aged women 19.3 more years
(Federal Interagency Forum on Aging, 2006).
• In 2000,12.4% of the population was at the age of 65
and above. About one-half of all older adults (6.5% of
population) were at 65-74 years of age (U.S. Bureau
of Census, 2001).
• In 2004, 18.1% of individuals aged 65+ were persons
of color: 8.2% were African Americans, 2.9 were
Asian or Pacific Islander, and less than 1 % were
American Indian or Native Alaskan. Persons of
Hispanic origin represented 6.0% of the older
population. Because birthrates are higher in families
of color when compared with Caucas ians, these rates
are expected to increase over the next decades
(Administration on Aging, 2006).
• In 2004, twice as many women aged 65-74 lived
alone (29.4%) as compared to same- aged men
(15.5%) (Federal Interagency Forum on Aging ,
2006).
• The overwhelming majority of men aged 65-74 are
married (79.4%), with the remaining few single
because of divorce (8.7%), being widowed (7.5%) or
never having married (4.4%). Conversely, only about
half of women (56%) are married with the remaining
half being widowed (28.0%), divorced (11.7%) or
never married (3.7%) (Federal Inter agency Forum on
Aging, 2006).
• In 2005, 74.7% of men between the ages 55 and 61
were working, as compared to 62.7% of women. By
ages 65-69, labor force participation rates fell
considerably as only 32.6% of men and 23.7% of
women were still working (Federal Interagency
Forum on Aging, 2006).
These trends are significant for social workers in all
practice settings. Unfortunately, gerontology- focused
social work has lagged behind other pr actice areas as few
students choose aging as a career goal. Until re cently,
educational resources have been lacking to help prepare
students for effective practice in this area (Kropf, 2002 ;
Kropf & Adamek, 2005). However, "as Baby boomers
reach age 65, there will be a greater need for social workers
to use their skills to enhance the quality of life for older
adults and their families and to assist them in navigating
ever-changing and increas ingly complex health, mental
health, social service, and commun ity environments"
(Council on Social Work Education, 2001, p. 1).
Related Theory
The shift from middle to later life is one that often involves
changes for the individual across multiple domains of
functioning (for example, biological, psychological, social,
and spiritual). Various theories have attempted to predict
and explain why some individuals . are able to transition to
later life with greater degrees of adaptation and coping.
Early theorists (for example, Freud, [ung, Erikson) proposed
life stage models that
 LIFE SPAN: OLDER ADULTIIOOD/SENIORS ("YOUNG OLD")
focus on personality development across the life course
(Coleman & O'Hanlon, 2004). As such, later life was
conceptualized as the culmination of a lifetime of both
joyful and painful experiences. Positive outcomes in
later life include an acceptance about one's mortality,
wisdom and perspective, and a sense of connection to
both previous and subsequent cohorts of humankind.
Subsequent theories examined later life as a more
distinct developmental period. One of the early social
gerontology theories was Disengagement Theory
(Cummings & Henry, 1961) which describes later life as
a time of social withdrawal. As aging individuals exit
significant . roles, younger generations are allowed
movement into these social positions. As such, disen-
gagement is functional for both the older individual
and society. \ As previously stated, the majority of both women
Both the research and theory of Disengagement The,
ary sparked controversy and precipitated other research
ventures. Activity Theory proposes that continued in-
volvement in relationships and social roles is critical to a
successful transition into later life (Havighurst,
Neugarten, & Tobin, 1968). Within this perspective, the
key to aging well is to remain socially and physically
active and engaged. Other theories, however, stress the
congruence between previous life functioning and
functioning in later life. Continuity Theory proposes that
the degree, type, and meaning of engagement needs to
remain constant in the transition from mid to late life for
successful adaptation (Atchley, 1989). Similarly, the
Selective Optimization with Compensation Model (Baltes
& Baltes, 1990) stresses the adaptation of the older adult
to substitute similar and pleasurable activities as
physical and cognitive changes occur.
Other contemporary theoretical perspectives inte-
grate the individual and societal dimensions of later life.
Rowe and Kahn (1987, 1997) first proposed the concept
of successful aging, which is defined as remaining
physically and functionally healthy, retaining cognitive
functioning, and being involved with society. More
recently, productive aging has been explored as a
concept that situates the older individual within a
society that either provides or hinders opportun ities for
holding valued social roles (Mitchell, 2006;
Morrow-Howell, Hingerlong, & Sherraden, 2001). In
this perspective, older adults are not viewed as depen-
dent, but as societal members that provide assistance
within social organizations and communities through
paid work and volunteering, as well as within their
families as supporters and care providers.
By tracing the historical progression of theory-
building in aging, it has been found that the trend has
moved from life course theories and models to more
exploration about later life as a distinct social and
J
125
development period. Greater attention to societal in,
volvement is stressed in more contemporary theories. In
addition, more emphasis has been placed on the
responsibility of society to provide greater opportunities
for older adults to retain valued social roles.
Latest Research
As stated, the initial period of older adulthood is one that
involves numerous potential transitions. One of the
major transitions is in labor force participation. Beyond
the obvious financial benefits, employment provides
social network opportunities, intrinsic meaning and re-
wards, and a way to. structure time (Akabas & Gates,
2006). During adulthood, work and employment are
among the most meaningful roles that a person holds.
and men currently leave the labor force between 55 and
70 years of age. Research on employment and retire-
ment trends indicates that many workers use bridging
strategies to move from full-time employment to retire-
ment such as gradually decreasing work hours (Cahill,
Giandrea, & Quinn, 2006). This strategy benefits the
individual worker, who has a greater period to adjust to
postemployment experiences, as well as employers who
retain continuity as workers' exit the workforce.
For some people, retirement may not be an option
because of inadequate financial resources. In particular ,
older women of color who are unmarried are at risk for
living in poverty during later life (Angel, Jimenez, &
Angel, 2007; Kiser & Kendal-Wilson, 2002; Ozawa &
Hong, 2006). These women may need to retain low
wage and physically demanding work as their Social
Security and personal resources (for example, pensions,
savings) are insufficient.
Women also face economic disadvantages because
of caregiving responsibilities for both older and younger
generations. For example, longitudinal research on
mothers of children with and without developmental
disabilities quantified the degree to which a disability
status impacts lifetime income (Parish, Seltzer,
Greenberg, & Floyd, 2004). By mid-life, parents with a
child who had a disability had significantly lower
savings and income levels when compared with parents
who were raising children without disabilities. In
another study on caregiving by MetLife (1999) on
juggling employment and caregiving, an estimate was
that caregivers accrued an average of $566,443 in lost
earnings because of caregiving demands. Clearly,
caregiving includes both expenditures as well as
opportunity costs in evaluating the financial impact on
the individual and family.
For those people that do retire, what opportunities
exist in their postemployment life? For individuals who
enjoy leisure-based activities, later life provides greater
126 LIFE SPAN: OLDER ADULTHOOD/SENIORS ("YOUNG OLD")
time and flexibility to participate in leisure pursuits. As an
example, one study on leisure participation rates from
mid- to later life found that involvement in leisure
activities between these two life course periods remains
fairly stable (Agah, Ahacic, & Parker, 2006). Those
people who enjoyed various hobbies tended to continue
their involvement (for example, reading, gardening). In
addition, certain types of activities (for example, dancing)
increased as people entered later life.
Besides leisure-based activities, postemployment
activities may involve volunteering. In fact, Baby
B60mers are expected to volunteer at greater rates than
their parents' or grandparents' generations (Corporation for
National and Community Services, 2007). In addition, the
types of volunteer activities that Baby Boomers select are
changing from past cohorts. Previously, religious
organizations were primary settings for volunteering
followed by civic or political organizations. Currently,
educational, youth service, and environmental
organizations are selected, indicating the priority areas for
Baby Bodmer volunteers.
Health is a major factor in whether people can be
involved in various activities during later life. Since 1900,
the major causes of death have changed markedly from
acute (for example, pneumonia, influenza, and
tuberculosis) to chronic conditions (for example, heart
disease, cancer, and stroke) (Centers for Disease Control
[CDC], 2004). Furthermore, the five most common
chronic health conditions in later life are the following:
hypertension (49.2%), arthritis (35.9%), cardiac diseases
(20.4%), cancer (19.9%), and diabetes (15.2%). In spite of
these statistics, older adults tend to provide positive
subjective evaluations about 'their health status (Martin,
Schoeni, Freedman, & Andreski, 2007).
While managing these conditions related to their own
aging process, many older adults assume care giving
responsibilities for others. In fact, about half of all
individuals aged 55-64 spend an average of 580 hours per
year caring for family members (Johnson & Schaner,
2005a). While men do assume some of the tasks of care,
the majority of caregiving is provided by women, which
has consequences for their own economic security
(Johnson & Schaner, 2005b). A significant proportion of
these caregivers are caring for their own spouse/partner or
an aged parent. However, care providers may also be
parents of adults with developmental and psychiatric
disabilities who continue with caregiving responsibilities
into their own later life years (Braddock, Emerson, Felce,
& Stanliffe, 2001; Seltzer, Greenberg, Floyd, Pettee, &
Hong, 2001; Smith, 2003). Grandparents also may have
primary responsibility for raising grandchildren. Almost 1
million children live in primary care of their grandparent,
and the majority
of these grandchildren (47.4%) are under 6 years of age
(American Community Survey, 2005a). About 32% of the
custodial grandparents are 60 years of age or beyond
(American Community Survey, 2005b). In determining the
economic contribution of unpaid caregiving, it has been
estimated that people aged 55-75 contributed about $80
billion per year in caring for spouses/partners, older
parents, and their grandchildren (Johnson & Schaner,
2005b).
Best Practices
In light of the various transitions that individuals and
families experience into later life, what interventions
work? This question is an important one as social workers
prepare to practice with increasing numbers of older
clients. In fact, a top priority in social work and aging is the
development and testing of psychosocial interventions for
older adults and their families (MorrowHowell & Burnette,
2001). Additional research on effective intervention
approaches, with specific attention to the particular
contexts and client populations, is necessary to advance
practice with an increasingly older population (Cummings
& Kropf, 2008).
To navigate the possible health and social changes that
occur in later life, various interventions have been proposed
to facilitate effective coping and decisionmaking as people
age. Both group and individual interventions have been
developed to assist mid life and early later life adults set
goals and make decisions about their work/leisure time,
finances, housing and living arrangements, relationships,
and other relevant issues (Bode, deRidder, Kuijer, &
Bensing, 2007; Spira, 2006). Education and training
approaches have also been used to increase self-efficacy or
enhance the sense of empowerment in care provision
(Chadiha, Adams, Biegel, Aslander, & Guterrez, 2004; Cox,
2000) and people who have health or mental health
challenges (DeCoster & George, 2005; Helgeson, Cohen,
Schultz, &, Yasko, 2000; Mohlman, 2004).
Unfortunately, depression may occur as a result of the
more difficult experiences of later life (for example, health
declines, assuming care provision roles for others, or losing
one's spouse or partner). Depression rates are lowest for the
young-old, with 13.1 % having clinically relevant
symptoms between 65 and 69 years of age. For all age
ranges, women have higher rates of depressive symptoms.
Between 65 and 69 years of age, 15.6% of women are
depressed when compared with 9.7% of men. By age 85
and above, approximately 20% have symptoms of
depression: 14.9% of men and 21.9% of women (Federal
Interagency Forum on Aging, 2006). Various psychosocial
interventions have demonstrated efficacy in treating
depression, including reminiscence
 LIFE SPAN: OLDER ADULTHOOD/SENIORS ("YOUNG OLD")
and life review (Bohlmeiger, Smit, & Cuijpers, 2003; Hsieh,
& Wang, 2003), cognitive and behavioral therapies, and
supportive approaches (Cuijpers, 1998; Freudenstein, Jagger,
Arthur, & Donner-Banzoff, 2001).
. Group interventions have been used extensively with older
clients as a way to enhance their support system and to provide
social connection. Support and psychoeducational groups are
the predominant intervention in care, giving, and have been
used with various types of caregiving situations, including
dementia care (Bank, Arguelles, Rubert, Eisdorfer, & Czaja,
2006; Logsdon, McCurry, & Teri, 2006), caring for those who
face a serious illness (Cwikel & Behar, 1999; Manne, Babb,
Pinover, Norwitz, & Ebbert, 2004)1 grandparents who are
raising grandchildren (Burnette, 1998; Kolomer, McCallion, &
Overendyer,\2003), and parents of adults with developmental
disabilities (Botsford & Rule, 2004). Within the group formats,
both information and social support is exchanged among the
members.
As Baby Boomers begin to enter later adulthood, this
generation will transform later life just as they have every
made their mark on every other life stage. This generation is
expected to be healthier, more highly educated, and have
higher expectations than their par' ents or grandparents. Social
workers can be involved with these people between the age of
60 and 75 with their decision making, various transitions, and
with the important family issues that occur as a result of these
changes.
REFERENCES
Administration on Aging. (2006). A statistical profile of older
Americans aged 65+. Retrieved June 6, 2007, from http://
www.aoa.gov!PRESS/fact/pdf/Attachment_1304.pdf.
Agah, N., Ahacic, K., & Parker, M. G. (2006). Continuity of
leisure participation from middle age to old age. Journal of
Gerontology: Sodal Sciences, 618(6), S340--S346.
Akabas, S. H., & Gates, L. B. (2006). Older adults and work in the
21st century. In B. Berkman & S. D'Ambruoso (Eds.),
Handbook of sodal work in health and aging (pp, 181-190). New
York: Oxford University Press.
American Community Survey. (2005a). Grandchildren char,
acteristics, Retrieved November 6, 2007, from http://
facrfinder.census.gov (S 1001).
American Community Survey. (2005b). Grandparents. Retrieved
November 6, 2007, from http://factfinder.census. gov (S
1002).
Angel, ]. L., Jimenez, M. A., & Angel, R. J. (2007). The economic
consequences of widowhood for older minority women.
Geronwlogist, 47(2), 224-234.
Atchley, R. C. (1989). A continuity theory of normal aging.
Gerontologist, 29, 183-190.
Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives
on successful aging: The model of selective optimization with
compensation. In P. B. Baltes & M. M. Baltes
127
(Ed.), Successful aging: Perspectives from the behavioral sciences
(pp. 1-34). Cambridge, UK: Cambridge University Press.
Bank, A. L., Arguelles, S., Rubert. M., Eisdorfer, c., & Czaja, S.
J. (20q6). Value of telephone support groups among ethnically
diverse caregivers of persons with dementia, Gerontologist,
46(1), 134-138.
Bode, c, deRidder, D. T. D., Kuijer, R. G., & Bensing, j M.
(2007). Effects of an intervention promoting proactive coping
competencies in middle and late adulthood. Gerontologist,
47(1), 42-51.
Bohlmeiger, E., Smit, F., & Cuijpers, P. (2003). Effects of
reminiscence and life review on late-life depression:
A meta-analysis. International Journal of Geriatric Psychiatry,
18, 1088-1094.
Botsford, A. L., & Rule, D. (2004). Evaluation of a group
intervention to assist aging parents with permanency planning
for an adult offspring with special needs. Social Work, 49(3);
423-431.
Braddock, D., Emerson, E., Felce, D., & Stanliffe, R. J. (2001).
Living with circumstances of children and adults with mental
retardation and developmental disabilities in the United States,
Canada, England & Wales. Mental Retardation and
Developmental Disabilities Research Reviews, 7(2), 115-121.
Burnette, D. (1998). Grandparents raising grandchildren:
A small-group, school, based intervention. Research on Social
Work Practice, 8(1), 10-18.
Cahill, K. E., Giandrea, M. D., & Quinn, J. F. (2006). Retirement
patterns from career employment. Gerontologist, 46
(4),514-523.
Centers for Disease Control (CDC) (2004). The state of aging and
health in America. Retrieved November 6, 2007, from
http://www.cdc.gov/aging/pdf/State_oCAgin~and_
Health_in_America_2004 .pdf,
Chadiha, L., Adams, P., Biegel, D., Aslander, W., & Guterrez, L.
(2004). Empowering African American women informal
caregivers: A literature synthesis and practice strategies. Social
Work, 49(1), 97-108.
Coleman, P. G., & O'Hanlon, A. (2004). Ageing and develop,
ment: Theories and research. London: Arnold Publishers.
Corporation for National & Community Service. (2007, March).
Keeping baby boomers volunteering: A research brief on
volunteer retention and turnover. Retrieved February 6,2007,
from http://www.nationalservice.gov/pdf/ 07_0307
_boomer_report.pdf.
Council on Social Work Education (CSWE). (2001). Strengthening
the impact of social work to improve the quality of life for older
adults and their families: A blueprint for the new millennium.
Alexandria, VA: Author.
Cox, C. (2000). Empowerment practice: implications for inter-
ventions with African American and Latina custodial
grandmothers. Journal of Mental Health and-aging, 6(4),
385-397.
Cuijpers, P. (1998). Psychological outreach programmes for the
depressed elderly: A meta' analysis of effects and dropout.
International}ournal of Geriatric Psychiatry, 13,41-48.
Cummings, E., & Henry, W. E. (1961). Growing old: The process of
disengagement. New York: Basic Books.
128 LIFE SPAN: OLDER ADULTHOOD/SENIORS ("YOUNG OLD")
Cummings, S. M., & Kropf, N. P. (Eds.). (2008). Handbook of
psychosocial interventions with older adults: Evidence-based
approaches. New York: Haworth Press.
Cwikel, J. G., & Behar, L. (1999). Social work with adult . cancer
patients: A vote-count review of intervention research. Social
Work in Health Care, 29(2),39-67.
DeCoster, V., & George, L. (2005). Empowerment approach for
elders living with diabetes: A pilot study of a communitybased
self-help group. Educational Gerontology, 31(9), 699-713.
Federal Interagency Forum on Aging. (2006). Older American
update 2006: Key indicators of well being. Retrieved May 6,
2007, from http://www.agingstats.gov.
Freudenstein, U., Jagger, C, Arthur, A., & Donner-Banzoff, N.
(2001). Treatments for late life depression in primary care-A
systematic review. Family Practice, 18(3),
321-327. \ Journal of Gerontological Social Work, 36(3/4), 63-79.
Havighurst, R. J., Neugarten, B. L., & Tobin, S. S. (1968).
Disengagement and patterns of aging. In B. L. Neugarten
n ).
(Ed.), Middle age and aging (pp. 161-1 Chicago, IL:
Chicago University Press.
Helgeson, V., Cohen, S., Schultz, R., & Yasko, J. (2000).
Group support interventions for women with breast cancer:
Who benefits from what? Health Psychology, 19(2), 107-114.
Hsieh, H., & Wang, J. (2003). Effect of reminiscence therapy on
depression in older adults: A systematic review. Inter-
national]ournal of Nursing Studies, 40, 335-345.
Johnson, R. W., & Schaner, S. G. (2005a, July). Many older
Americans engage in caregiving aciivities. Perspectives on pro-
ductive aging, Washington, DC: Urban Institute. Retrieved July
1, 2007, from NPK http://www.urban.orgjUploa-
. dedPDF/31120J ... Perspecuves.I.pdf
Johnson, R. W., & Schaner, S. G. (2005b, September). Value of
unpaid activities by older Americans tops $160 billion per
year. Perspectives on productive aging, Washington, DC:
Urban Institute. Retrieved July 1, 2007, from http://
www.urban.org/UploadedPDF/311227_0Ider_americans.pdf.
Kiser, A. J., & Kendal-Wilson, L. (2002). Older homeless women:
Reframing the stereotype of the bag lady. AFFILIA,
17(3),354-370.
Kolomer, S., McCallion, P., & Overendyer, J. (2003). Why
support groups help: Successful interventions for grandparent
caregivers. In B. Hayslip & J. H. Patrick (Eds.), Working with
custodial grandparents (pp, 111-126). New York:
Springer.
Kropf, N. P. (2002). Strategies to increase student interest in
aging. Journal of Gerontological Social Work, 39(1/2), 57-67.
Kropf, N. P., & Adamek, M. (2005). The future of aging in social
work: Everything old is new again. Advances in Social Work,
6(1),121-131.
Logsdon, It G., McCurry, S. M., Teri, L. (2006). Time-limited
support groups for individuals with early stage dementia and
their care partners: Preliminary outcomes from a controlled
clinical trial. Clinical Gerontologist, 30(2), 5-19.
Manne, S., Babb, J., Pinover, W., Norwitz, E., & Ebbert, J. (2004).
Pyschoeducational group intervention for wives of men with
prostate cancer. Psycho-Oncology, 13,37-46.
Martin, L. G., Schoeni, R. F., Freedman, V. A., & Andreski, P.
(2007). Feeling better? Trends in general health status. Journal
of Gerontology: Social Sciences, 62B(1), Sl1-S21.
MetLife. (1999). The MetLife juggling act study: Balancing
caregiving with work and the costs involved. Retrieved June
13, 2007, from http://www.seniorcareconcepts.com/
Insurance_
Guides/Metlife%20Juggling%20Act%20Study.pdf.
Mitchell, K. (2006). Productive aging: The new life stage.
World at Work Journal, 15(1),62-72.
Mohlman, J. (2004). Psychosocial treatment of late-life gener-
alized anxiety disorder: Current status and future directions.
Clinical Psychology Review, 24(2), 149-169.
Morrow-Howell, N., & Burnette, D. (2001). Gerontological
social work research: Current status and future directions.
Morrow-Howell, N., Hingerlong, J., & Sherraden, M. (2001).
Productive aging: Concepts and challenges. Baltimore, MD:
Johns Hopkins University Press.
Ozawa, M. N., & Hong, B. E. (2006). Postretirement earnings
relative to preretirement earnings: Gender and racial differ-
ences. Journal of Gerontological Social Work, 47(3/4), 63--82.
Parish, S. L., Seltzer, M. M., Greenberg, J. S., & Floyd, F. (2004).
Economic implications of caregiving at rnidlife:
Comparing parents with and without children who have
developmental disabilities. Mental Retardation, 42(6), 413-426.
Rowe, J. W., & Kahn, R. L. (1987). Human aging: Usual and
successful. Science, 237, 143-149.
Rowe, J. W., & Kahn, R. L. (1997). Successful aging. Geron-
tologist, 37, 443-440.
Seltzer, J. J., Greenberg, J. S., Floyd, F. J., Pettee, Y., & Hong, J.
(2001). Life course impacts of parenting a child with a
disability. American Journal on Mental Retardation, 106,
265-286.
Smith, G. C. (2003). Patterns and predictors of service use and
unmet needs among aging families of adults with severe
mental illness. Psychiatric Services, 54(6), 871--877.
Spira, M. (2006). Mapping your future-A proactive approach to
aging. Journal of Gerontological Social Work, 47(1/2), 71-87.
U.S. Bureau of Census. (2001). The 65 and older population brief
2000. Retrieved June 6, 2007, from http://www .census. gov
/prod/200 1 pubs/c2kbr01-1 O.pdf.
-NANCY P. KROPF
OLDEST SENIOR/AGED,LATE ("OLD OLD") ABSTRACT:
As a result of rising life expectancies, America's older
population is itself aging. U.S. Census Bureau
projections suggest that by the middle of the 21st
century, more than 40% of Americans aged 65 and older
can expect to live to at least the age of 90. Although the
oldest-old is a diverse population, advanced old age is
associated with a greater risk of experiencing economic
hardship, and disabling illnesses or health conditions,
and social isolation. A growing
 LIFE SPAN: OLDEST SENIOR/AGED-LATE ("OLD
OLD")
public policy challenge will be ensuring the economic
well-being, the health, and the dignity of our very oldest
citizens.
KEY WORDS: oldest-old; very old; advanced old age
Population Trends and the Oldest Old Throughout
the first half of the 20th century, the study of human
development was largely the study of child development.
Growing awareness of the dramatic global growth in the
older population as well as rising life expectancies during
the second half of the century, however, spurred interest in
adult development and the aging experience; this led to the
emergence of the field of social gerontology. Although all
world regions are experiencing an increase in the absolute
and relative size of their older population, substantial
differences exist in the current numbers and expected
growth rates of the older population between
more-developed and less-developed countries. For
example, in 2000, 15.5% of the population of Europe was
aged 65; in contrast, only 2.9% of subSaharan Africa's
population was older than 65 (US. Census Bureau, 2001).
In the United States, the number of older adults increased
more than tenfold throughout the past century. Today, 36.8
million individuals or one in every eight Americans is 65 or
older; by 2030, demographers estimate that 72 million
individuals or one in every five Americans will be among
the ranks of the elderly (US. Census Bureau, 2005).
As the world experiences a growing older population,
many nations, including the United States, are tuming their
attention to understanding the changes occurring within the
older population itself, especially changes in the age
structure of this older population. As a result of rising life
expectancies, the world's older population is itself aging.
Persons aged 80 and older represented 17% of the world's
elderly in 2000; 23% in more-developed countries and 13%
in less-developed countries (US. Census Bureau, 2002).
Historical data underscore the tremendous gains in life
expectancy in the United States. In 1900 the average life
expectancy at birth was only 47 years; by 2003, it reached
74.1 years for men and 80.1 years for women (Federal
Interagency Forum on Aging-Related Statistics [FIFARS],
2006). In fact, the population aged 85 and older is currently
the fastest growing segment of the U.S. older population. In
2005, ",2% of the US. population or 5.1 million Americans
were aged 85 or older; by 2050, the ranks of the oldest old
is projected to increase to almost 5% of the US. population
or about 20.9 million Americans (see Table 1). Currently,
there are about 70,104 centenarians, or individuals aged
100 or older, in the
129
TABLE 1
U.S. Population 85 and Older:
1950-2050 (inmiUions)
1950 0.6
1960 0.9
1970 1.
1980 4
1990 2.2
2000 3.0
2010 4.
2020 3
2030 6.1
2040 7.3
2050 9.6
15.4
Federal Interagency Forum20.9on
Aging-Related Statistics (FlFARS),
2006, http://www.agingstats.gov
United States; and this figure is projected to reach 381,000
by 2030 (Administration on Aging, 2006).
As reflected in Table 1, much of these dramatic age
shifts in the older population will occur during the next
fourto five decades as the baby boomer cohort (individuals
bom between the years of 1946 and 1964) enter their later
years of life. The most rapid increase in the 85-plus
population will occur between 2030 and 2050 as the baby
boomer generation joins the ranks of the very old. The
Census Bureau's population projections suggest that by the
middle of the 21st century, more than 40% of adults aged
65 and older can expect to live to at least the age of 90 (U
.S. Census Bureau, 2005).
Life Course and the Oldest Old
Aging is not only an organic process; it is also a social
process. All societies divide the life span into recognized
stages. These life stages are typically marked by certain
physical, psychological, and/or social milestones; and
privileges, obligations, rights, and roles are assigned
according to culturally shared definitions of periods of life
(Fry & Keith, 1982; Hagestad & Neugarten, 1990). These
socially constructed life stages are not fixed; they have
both expanded and contracted in length and new ones have
emerged in response to broader demographic and social
changes.
Within the United States, the longevity revolution has
also led to a life course revolution (Skolnick, 1991). The
dramatic gains in life expectancies experienced by
American men and women are causing us to rethink what
we mean by "old." In fact, the definition of old age as
beginning at age 65 is a relatively recent phenomenon. In
the early part of the 20th century, as European nations and
the United States formulated their old-age social insurance
programs, the age of 65 was established as the marker of
"normal retirement" and the beginning
130 LIFE SPAN: OLDEST SENIOR/AGED-LATE
("OLD OLD")
of "old age." Today, however, we often do not perceive
healthy, vigorous, and socially engaged individuals in
their 60s and 70s as "elderly." M oreover, one third of
Americans in their 70s identify themselves as being
"middle-aged" (National Council on Aging, 2000).
The democratization of aging- that is, the new reality
that the majority of Americans are attaining old age and
even advanced old age-has led social scientists,
practitioners, and policy makers to differenti ate between
the "young-old" and the "oldest- old." In fact, the term, the
oldest-old, was introduced by Matilda White Riley and
RichardSuzman in a presentation at the 1984 American
Association for the Advancement of Science meeting in
which they strove to draw the scientific community's
attention to this emerging age population. In a specia l
issue of the Milbank Quarterly devoted to the topic of the
oldest-old, Suzman and Riley (1985, p.l77) wrote that it
was "so new a phenomenon that there is little in historical
experience that can help in interpreting it." Yet, they also
predicted that given their rising numbers, the oldest- old
would "no longer remain invisible" in the economy, the
polity, and the health and social service systems.
The Politics of a Long-Lived Society
The aging of the baby boomer generation has focused the
world of public policy on the implications of an increasing
older or long-lived society. The core policy question is
how do we as a society promote the economic well- being,
the health, and the dignity of our very oldest citizens? The
social work profession can contri bute to this national
discussion through the advancement of a social justice
perspective that stresses our societal re sponsibility for
ensuring that all Americans-across all economic
strata-have a positive and secure old age. A key challenge
is helping policy makers understand that the achievement
of a positive and secure old age requires having an
adequate postretirement income, accessible quality health
care, appropriate and affordable housing, strong social
connections or bonds, and a positive sense of self.
Much of the current policy debate centers on the
question of what will be the impact of an increasing
number of oldest-old citizens on our nation's systems of
care such as health care delivery and financing, infor mal
caregiving, and public and pri vate pensions (Gonyea,
2005a). Anticipating that the majority of baby boomers
will live into their 70s, 80s, and even 90s, a number of
policy makers are raising serious con cerns about the
public costs associated with advanced old age. These
concerns about rising public costs are legitimate as
advanced old age is clearly associated with a greater risk
of experiencing economic hardship and
disabling illnesses or health conditions. However, as the
following discussion will highlight, the oldest old is a
diverse population. Many of our country's oldest old are
physically well, economically secure, and have strong
social bonds; this suggests th at the future of the very old,
and of our nation, is by no means bleak. Indeed, as part of
this national discourse, the social work profession can
play an important role in both promoting more accurate
images of advanced old age and educating the public
about the realities of growing old in America today.
The Social World of the Oldest-Old
It is immediately striking that the oldest-old are pre-
dominantly women. In 2005, there was a sex ratio of 46
men per 100 women in the age group of 85 and older
(Administration on Aging, 2006). Although not as rapidly
as the total U.S. population, the nation's older population
is becoming more racially diverse. Cur rently, the vast
majority (87%) of Americans aged 85 and older identify
as non-Hispanic White; however, the percentages of
elders of color and Hispanic origin are projected to
steadily grow throughout the next decades. By 2050, the
proportion of Blacks and Hispanics who are 80 years and
older could increase to approximately one- third (U.S.
Census Bureau, 2005).
Because women have longer life expectancies than
men and also tend to marry men who are older than
themselves, marital status and living arrangements dif fer
considerably by gender in later life. As Table 2 shows ,
58% of men aged 85 and older are married , while only
15% of their female counterparts have spouses. More than
three-quarters (77%) of women aged 85 and older are
widowed compared to only about onethird (35%) of men
aged 85-plus (FIFARS, 2006). Although only about 7%
of the current cohort of oldest old are either divorced or
never married, this figure is projected to rise as future
generations, such as the baby boomers, enter the ranks of
this age group. Because marital status is correlated with a
number of measures of economic, physical, and
emotional well-being in later life, these generational shifts
in marital and
TABLE 2
Marital Status of Americans Aged 85 and Older, by
Gender, in 2005 (percentages)
MARRIED WIDOWED DIVORCED NEVER
MARRIED
Males 58.3 35.1 42 2.4
Females 15.1 77.1 3.2 4.6
Federal Interagency Forum on Aging-Related Statistics (FlFARS),
2006, http://www.agingstats.gov
 LIFE SPAN: OLDEST SENIOR/AGED-LATE ("OLD OLD")
131

divorce patterns may affect the well-being of future additional 2.2 million older adults were classified as near
cohorts of elders. Older married individuals, on average, poor (income between poverty level and 125% of this level
have higher household incomes, better physical and mental (U.S. Census Bureau, 2005). In 2004, 12.6% of the 85-plus
health, and less risk of institutionalization than do their population fell below the poverty line when compared with
nonmarried counterparts. 9.4% of the 65-74 age population and 9.7% of the 75-84
As a result oflonger life expectancy, many of today's age population.
families are multigenerational. Parents and children now The risk of living in poverty in later life, or the
share five or six decades of life, siblings may share eight or economic divide between the "haves" and the "havenots,"
nine decades of life, and the grandparentgrandchild bond varies dramatically by age, gender, and race (Gonyea,
may last three or four decades. There may be both 2005b). The stark reality is that a disproportionate number
potentially positive and negative consequences of more of older Americans living in poverty are women; almost
years of shared living across generations. As Bengston 70% of poor older adults are women, especially women of
(2001) notes, longer years of shared living may offer a color and those older than 85 years and living alone
multigenerationalkinship network to provide family (fitzPatrick & Entmacher, 2000). Life course inequality
continuity and stability across time as well as instrumental affects economic well-being in old age. The cumulative
and elhotional support in times of need. Yet, longer years advantage or disadvantage perspective offers a valuable
of shared living may also mean extended years of lens for. understanding the interactions between individual
caregiving for frail or disabled elders or family conflict. trajectories and structural context or institutional
For instance, an adult daughter in her late 60s may find arrangements in shaping patterns of inequality both within
herself caring for a frail mother in her 90s. and among cohorts over time (Dannefer, 2003; O'Rand,
The gender gap in spouse survivorship also affects 2002). The risk factors for poverty in later life are identical
living arrangements in later life. Older women are at least for both genders: living longer, being widowed, living
twice as likely as older men to live alone. By age 85,6 of alone, an interrupted work history, and a lifetime of
every 10 women live alone, compared with only 3 of 10 working in the lower-wage service and trade occupations.
men (FlFARS, 2006). Older adults generally want to "age Yet, each of these factors is more likely to occur in
in place"-that is, they prefer to stay in their own homes and women's lives. The interactive effects of gender, race, and
communities as they grow older. Older persons typically age on the experience of poverty are highlighted in Table 3;
enter nursing homes when physical or cognitive for example, in 2005, African American women aged
disabilities prevent them from living on their own or being . 75-plus were rv5 times more likely to experience poverty
cared for within the community. Only 1 % of persons aged than were white men aged 75-plus, 28.1 % versus 5.6%
65-74 and slightly less than 5% of persons aged 75-84 (FlFARS, 2006).
resided in nursing homes in 2000; however, this figure
leaps to slightly more than one in five (22%) for persons
aged 85 and older (FlFARS, 2006). Over half of the elderly The Health of the Oldest-Old
residents in nursing homes are 85 years of age and older The image of the very old is often one of frailty. Although
and three quarters are women, most of whom are widowed this is an accurate picture for many on the oldest-old, it is
(Gabrel, 2000). not true for all of the oldest-old. In recent decades,
America's oldest citizens have also

TABLE}
Economic Security and Advanced Old Age Today's
Percentage of Older Americans Living in Poverty, by Age, .
seniors are, in the aggregate, faring better than previous
Gender, Race, and Hispanic Origin, in 2005
generations of older Americans. In 1959, 35%-more than
one of every three elders-lived below the federal poverty
threshold; today, only slightly more than 10% of older
adults are living in poverty (U.S. Census Bureau, 2001;
FlFARS, 2006). The more than threefold decline in poverty
among the older population since the mid-1960s, one of
our nation's greatest public policy achievements, is due
largely to Social Security (Gonyea & Hooyman, 2005). Yet
even with this policy success, rv3.6 million older "Hispamc can be of any race. Federal Interagency Forum on
Americans still fell below the official poverty line in 2003, Aging Related Statistics (FlFARS). 2006. Older Americans 2006:
and an Key Indicators of Well-being, http://www.agingstats.gov
132 LIFE SPAN: OLDEST SENIOR/AGED-LATE
("OLD OLD")
experienced aggregate improvements in their health status
as a result of factors such as advances in medical care,
better living conditions and nutrition, and gains in
educational attainment. Yet, the effects of lifetimes of
cumulative advantage, or disadvantage, means that
individuals reach old age with very different health states
and health trajectories (Himes, 2005). The public health
community has increasingly focused on racial and ethnic
disparities in health status across the life span, including in
old age. Explanations for higher rates of chronic diseases
and mortality among seniors of color include a lifetime of
less access to medical care, inadequate health insurance
coverage, residence in low-income neighborhoods
resulting in greater exposure to environmental pollutants
and toxins, and employment
\
in low-paying occupations that are stressful and often
less safe (Himes, 2005). In terms of self-assessed health
(rated as excellent, very good, good, fair, or poor), for
example, significant differences exist by race and ethnicitv.
Among the 85-plus population, rv67% of nonHispanic
Whites rated their health as good to excellent, compared
with 54% of non-Hispanic Blacks and 51% of Hispanics
(FIFARS, 2006). This race difference in self-perceived
health is important as positive assessments of health are
correlated with lower risks of mortality.
Although chronological age of older adults is an
imperfect indicator of health status given interindividual
variation, rates of chronic disease and disability levels do
rise substantially in advanced old age (SantosEggimann,
2002). As reflected in Table 4, in 2003,82% of Medicare
recipients aged 85 and older had at least two chronic health
conditions, and 33% rated their health as poor (Centers for
Medicare and Medicaid Services, 2003). The most
common chronic health conditions among the elderly were
arthritis, hypertension, heart disease, cancer, diabetes, and
stroke (Center for Disease Control and Prevention, 2007).
Seniors aged 85 and older were also more likely to have
Parkinson's disease, Alzheimer's disease, stroke,
osteoporosis, and a broken hip. These chronic health
conditions can
TABLE 4
Percentage of Medicare Recipients with two or More
Chronic Conditions and Fair or Poor Health
by Age, in 2003
65-74 75-84 85 YEARS
YEARS YEARS AND OLDER
2+ chronic conditions 68 77 82
Fair or poor health 23 25 33
Centers for Medicare and Medicaid. 2003. The Medicare Popula-
tion in 2003: Health Section.
diminish the quality of life for the affected elders and their
families. Often these conditions cause years of pain and
restrict individuals' ability to perform the basic activities of
daily living such as dressing, eating, and bathing. As
reflected in Table 5, only 3% of noninstitutionalized
Americans aged 65-74 reported problems with activities of
daily living; this figure rose dramatically to almost 23% of
community-based Americans aged 85 and older (Center
for Disease Control and Prevention, 2007).
Cognitive impairments, particularly Alzheimer's
disease and other dementias, dramatically compromise the
quality of life of both the affected elder and his or her
family. Although only 1 of every 20 (5.1 %) of the
youngest-old (those 65-69 years) experience either
moderate or severe memory loss, by age 85 almost one out
of every three individuals (31.2 %) was found to have at
least a moderate problem (FIFARS, 2006). Poor cognitive
functioning is a significant risk factor for entering a
nursing home. Higher rates of depression, which is
correlated with poorer physical health, greater functional
limitation, and higher rates of health services utilization,
are also found among the oldest-old. In 2002, 15% of men
and 22% of women aged 85 and older were found to have
clinically relevant depression symptoms (FIFARS, 2006).
Meeting the Challenges of a
Long-Lived Society
The economic and health impacts of a rapidly aging
society have emerged as major public policy issues.
During the next few decades, as the baby boom generation
(who has just started to enter the ranks of America's older
population) becomes our nation's oldest citizens, we will
face considerable challenges related to meeting the
economic, physical, social, cognitive, and mental health
needs of seniors. The social work profession can play a
critical role in identifying, promoting, and implementing
services and programs that promote. the economic
well-being, health, quality of life, and dignity of these
oldest seniors. Moreover, from a social justice
TABLE 5
Percentage of Older Adults Who.Need Help with Activities
of Daily Living, by Age and Gender, in 2003
65-74 75-84 85 YEARS
YEARS YEARS AND OLDER
Total 3.2 6.6 22.6
Male 3.1 5.5 17.3
Femal 3.3 7.3 25.3
e
National Health Interview, 2003.

perspective, the profession must advocate for public
policies that allow all Americans- across gender, race, and
economic strata-to achieve a positive and secure old age.
As a nation, we can help all older Americans live not just
longer but better lives.
REFERENCES
Administration on Aging. (2006). A profile of older Americans:
2006. Retrieved August 3, 2007, from http://www.aoa.gov/
PROF/Statistics/profile/2006/3asp.
Bengston, V. L. (2001). Beyond the nuclear family: The in-
creasing importance of multigenerational bonds. lournal of
Marriage and the Family, 63,1-16.
Center for Disease Control and Prevention. (2007). State of aging
and health in America 2007 [Report]. Retrieved August 7, 2007,
from http://www.ced.gov/aging/pdf/saha_2007.pdf.
Centers for Medicare and Medicaid Services. (2003). The
Medicare population in 2003, Health Section 2. Retrieved August
7, 2007, from http://www.cms.hhs.gov/MCBS/
Downloads/CNP _2003 _dhsec2.pdf.
Dannefer, D. (2003). Cumulative advantage/disadvantage and the
life course: Cross-fertilizing age and social science the-
ory.lournalofGerontology B: Social Sciences, 55, S327-S337.
Federal Interagency Forum on Aging-Related Statistics
[FIFARS]. (2006). Older Americans update 2006: Key indicators
of well--being. Retrieved June 17,2007, from http://www.
agingstats.gov.
fitzPatrick, C. S., & Entmacher, J. (2000). Increasing economic
security for elderly women by improving Sodal Security survivor
benefits. Retrieved October 1, 2005, from http://www.nwlc.
org/pdf/NASIwidows2.pdf. .
Fry, C. L., & Keith, J. (1982). The life course as a cultural unit.
In M. W. Riley, R. P. Abeles, & M. S. Teitelbaum (Eds.),
Aging from birth to death, Vol. 2: Sociotemporal perspectives.
Boulder, CO: Westview Press.
Gabrel, C. S. (2000). Characteristics of elderly nursing home
current residents and discharges: Data from the 1997 National
Nursing Home Survey. Advance Data 312, National Center for
Health Statistics.
Gonyea, J. G. (2005a). The oldest old and a long-lived society:
Challenges for public policy. In R. B. Hudson (Ed.), The new
politics of old age policy. Baltimore, MD: Johns Hopkins
University Press.
Gonyea, J. G. (2005b). The economic well-being of older
Americans and the persistent divide. Public Policy and Aging
Report, 15(2), 1,3-11.
Gonyea, J. G., & Hooyman, N. R. (2005). Reducing poverty
among older women: Social Security reform and gender
equity. Families in Society, 86, 329-337.
Hagestad, G. 0., & Neugarten, B. L. (1990). Age and the life
course. In R. H. Binstock & L. K. George (Eds.), Handbook on
aging and the sodal sciences (3rd ed.). New York:
Academic Press.
Himes, C. L. (2005). Health status in later life. Public Policy and
Aging Report, 15(2), 1, 17-22.
National Council on Aging. (2000). Myths and realities of aging
2000 survey results. Washington, DC: Author.
LONG-TERM CARE 133
O'Rand, A. M. (2002). Cumulative advantage theory in life
course research. Annual Review of Gerontology and Geriatrics,
22,14-20.
Santos-Eggimann, B. (2002). Evolution of the needs of older
persons. Aging Clinical and Experimental Research, 14, 287-292.
Skolnick, A. (1991). Embattled paradise. New York: Basic Books.
Suzman, R., & Riley, M. W. (1985). Introducing the "oldest old."
Milbank Quarterly, 63, 177-186.
U.S. Census Bureau. (2001). International database by age and
region. Retrieved July 2002, from http://www.census.gov/
ipc/www/idb/worldpopinfo.html.
U.S. Census Bureau. (2002). The United States in international
context: 2000. Retrieved August 3,2007, from http://www.
census.gov/prod/2002/pubs/c2kbrO 1-11. pdf.
U.S. Census Bureau. (2005). 65+ in the United States: 2005.
Retrieved August 1, 2007, from http://www.cernus.gov/
prod/2006pubs/p23- 209 .pdf,
-JUDITH G. GONYEA
LOBBYING. See Advocacy; Political Process; Political
Social Work.
LONG,TERM CARE
ABSTRACT: Long-term care (LTC), also called long term
support services, refers to personal care and services for
people of all ages who cannot perform daily activ ities
unaided. This entry reviews trends across LTC
settings-nursing homes, assisted living, and consumers'
own homes, emphasizing efforts since 1990 to downsize
nursing homes and expand community services, while
transforming the remaining nursing home sector into
caring communities with individualized services and im-
proved living conditions. Key themes include sustaining a
frontline work force, developing a cross- disability unified
agenda, defining and assuring quality, and ethical issues in
balancing safety and autonomy. Opportunities for social
work leadership in LTC abound.
KEY WORDS: assisted living; culture change; de-
institutionalization; functional limitations; home care;
housing with services; negotiated risk; nursing homes;
personal care; quality of care; quality of life; safety
In the 21st century, long-term care (LTC) ha s become a
rapidly changing and increasingly important practice area
for social workers. With the influence of the Americans
with Disability Act of 1991, the 1999 Supreme Court
Olmstead decision determining a right
134 LONG-TERM CARE
under that law to care in the most integrated setting, the
presidential New Freedom Initiative for people with
disabilities of 2001, and the subsequent Real Choice
System Change grants to States from the Centers for
Medicare and Medicaid services, polic y and attitudinal
shifts have occurred that emphasize LTC in home and
community-based settings. Along with the impetus to
divert nursing home admissions and encourage relocation
of people of all ages from nursing homes, another
movement has been underway since 1995 to transform
nursing homes into more hospitable living situations with
privacy and individualization of services and routines for
the remaining residents.
Definitions and Principles
\
LTC is commonly defined as personal care and related
health and social services for a sustained period for people
of all ages who cannot perform tasks of daily living
because of a disability or an illness. (The term long- term
supportive services, favored by advocates for younger
persons with disabilities; the new term con notes an
emphasis on personal attendant services and a range of
social supportive services to promote goals of individual
autonomy and community integration.) LTC is
conventionally divided into informal care (that is, care and
assistance provided gratuitously by family and friends)
and formal care (that is, care and assistance provided by
paid individuals and organizations. Decades ago,
researchers established that, far from abandoning elderly
relatives, family members provide the bulk of LTC
services to relatives in the community on an
uncompensated basis. Formal LTC, in turn, may be
provided in a wide variety of settings, including skilled
nursing homes (also known as LTC facilities, assisted
living settings (depending on state licensure pol icies
known by a wide variety of terms, including residential
care facilities, group homes, retirement homes, domi-
ciliary homes, adult foster homes, and board-and-care
homes, to name a few); and in the client's own home. Care
and services provided in the client's own home may be
delivered by home health agencies, personal care agencies,
or by individually employed individuals.
The boundaries between formal. and informal care
have become increasingly muddied since the 1990 s as
more and more state jurisdictions have permitted family
members to be paid for providing services to their
relatives, although at the rate established by the market for
home attendant services rather than at the rate that the
individual might be able to command in the labor force
(Benjamin & Matthias, 2001; Linsk, Keigher,
Simon-Rusinowitz, & England, 1992).
The term long-term care was in use when Medicare and
Medicaid were enacted in 1965. Early on, LTC
referred to health care of sustained duration in contrast to
acute health care provided in hospitals and doctor's offices.
For decades many writers and policy makers used the term
LTC to refer almost exclusively to care in nursing homes.
In current usage, however, LTC would embrace most but
not all services and care received byindividuals in their
own homes. Some homehealth services funded under
Medicare are better understood as short-term skilled
post-acute care designed for short-term rehabilitation and
convalescence. Similarly, some short-term post- acute care
also occurs in nursing homes. With hospitalizations
becoming increasingly shorter, many individuals cannot
immediately return to their homes and they utilize their 20
days of post-hospital care per episode of care in nursing
homes for rehabilitation. (After the 20 days and until the
consumer uses up his or her annual cap of 100 Medicare
days in nursing homes, high copays for the beneficiary
become a deterrent to using Medicare funding streams for
nursing homes.) Not all care in nursing homes is LTC, but
the specifying "sustained period of time" in the definition
is difficult. Ordinarily, care persisting for a month or more
to assist people with functional disabilities is considered to
be LTC.
LTC Consumers and Their Needs
Using LTC is associated with old age. Indeed, under
current patterns those who survive until age 65 have an
almost 50% chance of using LTC in nursing homes before
they die. A long-established axiom ofL TC is that for each
person in a nursing home, about two people with similar
levels of disability and need are receiving help from the
community, largely from unpaid family members, but also
from formal care providers. This statistic has complicated
decades-long efforts to find cost-effective alternatives to
nursing home care; some federal and state officials were
convinced by social research in the 1970s and early 1980s,
including the LTC channeling demonstration, that new,
more desirable LTC programs outside nursing homes will
satisfy a pent-up demand but that the new services will not
displace nursing homes but be a costly add- on for people
who otherwise would have struggled in the community,
albeit with insufficient services. The term woodwark effect is
used as a shorthand term for this phenomenon.
Consumers of LTC in nursing homes are dispropor-
tionately over age 85, never-married or widowed, female,
White, and people with debilitating chronic diseases such
as Alzheimer's disease, Parkinson's dis ease, stroke,
advanced pulmonary disease, and stroke. However, these
risk factors are ubiquitous to predict nursing home use
well for the individual; a very old, White, single woman
with Alzheimer's disease, for
..
example, will not necessarily be in a nursing home; many
such individuals live in other settings.
Old people with disabilities and illnesses are far from
the only LTC consumers. Many children and adults with
mental retardation or developmental disabilities (MR/DD)
use LTC, though the preferred term at present is long-term
support services (LTSS). DD is defined as a lifelong
disability manifesting itself before age 22; some but far
from all people with DD also have MR. Specific DDs
include cerebral palsy, autism spectrum disorders,
spina.bifida, and Down syndrome. Also using LTC are
children and .adults under age 65 with physical
disabilities-these disabilities vary widely in their typical
age of onset and associated limitations; and those in this
category who may use LTC include people with spinal
chord injuries, amputations, birth defects, traumatic brain
injuries, a group that is increasing in size with increased
survival of modem warfare, degenerative neurological
diseases such as multiple sclerosis, Lou Gehrig's Disease
and muscular dystrophy, and HlV-AlDS. Severe and
persistent mental illness would not ordinarily trigger the
need for LTC unless the individual were rendered unable to
function for a long period of time; however, people who
fall into one of the other categories of disability who also
have severe psychiatric disease or substance abuse
problems create challenges for the LTC system.
Payment and Distribution of Expenditures LTC is
funded about half by public dollars and half by private
dollars. The public money comes from Medicaid (the
state-federal program for low-income people), state funds,
and to a lesser extent Veteran's Administration funds,
county or local funds, and funding from federal grant
programs administered by states, for example, through the
Older American's Act programs, rehabilitation service
programs that fund Centers for Independent Living, and
programs through the Department of Education for
cognitive disability. Historically, the vast preponderance of
public money going into LTC was used to finance
institutional care, specifically nursing homes for older
people, and state regional centers and intermediate care
facilities for mental retardation (ICFMRs). Fueled by care
scandals and law suits, downsizing andclosures of state
regional centers and large ICF-MRs began in the 1970s,
and has been completed in some states, though interstate
variation is high (Braddock, Hemp, Parish, & Westrich,
1998). The proportion of public LTC expenditures for older
people in nursing homes varies by state as well; the
majority of money goes to nursing homes but a few states
now spend 50% or more of their LTC resources outside
nursing homes (Kane, Kane, Ladd, & Nielsen, 1998).
The private money funding LTC from users and their
families is usually expended before the public dollars take
effect, especially in nursing homes where a spend-down
process occurs before an individual becomes financially
eligible for Medicaid. Only an infinitesimal amount of
those paying privately for LTC are covered by insurance.
Trends by Service Sector
NURSING HOMES The 1999 nursing home survey
(the most recent data available) indicates that there
were 18,000 nursing homes in the United States ,
housing 1.9 million residents. For the first time
since the periodic surveys began, the 1999 survey
reflected a slight decrease in the proportion of
people using nursing homes. Most nursing homes
are for-profit facilities, and an increasing number
are part of investor-owned or publicly traded
chains. About 20% of nursing homes (accounting
for about 25% of the residents) are non profit, the
majority owned by sectarian or philanthropic
groups, but some publicly owned by states or
counties. The roots of nursing h omes stretch back
to colonial times and include poor house
provisions, boarding homes, and homes for the
aged, the latter an early20th- century charitable
phenomenon for older people. The more modem
health care facilities were developed in the 1950s ,
1960s, and 1970s as response first to federal
construction funds and then to third-party pay ments
under Medicare (for post-acute care) and Med icaid.
They were modeled after hospitals of the day with
double occupancy and sparse living quarters.
Nursing homes have come under severe criticism
because of access problems, high public and private costs,
and, most notably, seemingly intractable quality of care
issues. As a consequence nursing homes are highly
regulated. One of the regulations requires a social work
designee in facilities with 100 or more beds and social
work consultation if the designees do not have social work
education; individual states have gone well beyond these
requirements. The social work role in nursing homes is
evolving and, in practice it varies with the vision and skills
of the director of social work. Social workers in nursing
homes tend to engage in some mix of direct counseling of
families and residents to enhance resident adjustment,
facilitation of admission (including gathering information
about advance directives and end-of-life care preferences)
and discharge, and working with mental health challenges.
Sometimes, the social worker often takes a much broader
responsibility for enhancing psychosocial well-being
through developing and monitoring relevant facility
policies, training facility personnel, and acting as a
member of an interdisciplinary leadership team.
136
•
loNG-TERM CARE
Another important area of practice for social workers
related to nursing homes is in the LTC ombudsman
program, a federally mandated complaint resolution and.
advocacy program for seniors in nursing homes and other
residential care.
The basic federal standards for nursing homes were put
in place in.1987 (Institute of Medicine, 1986 ), but states
have adopted standards for nursing staff-toresident rations
that exceed federal minimums. By 2000, a federally
mandated resident assessment and minimum data system
mandated in 1987, was fully implemented and used to
generate comparative public information on quality
indicators on topics such a proportion of new bedsores,
infections, malnutrition, and other markers of poor quality
(Zimmerman et al., 1995). Quality of life is largely
untapped by such indicators, however, and is generally
considered to be poor in a typical traditional nursing home
because of one-size-fits all care routines, lack of privacy,
and institutional physical surroundings (Wunderlich &
Kohler, 200l). Measures of quality of life for nursing home
residents have become increasingly available, and practice
standards no longer routinely accept proxy respondents
instead of getting feedback directly from nursing home
residents, even those with cognitive impairment (Kane,
2003; Kane et al., 2003).
Since at least 1995, a social movement towards
"culture change" in nursing homes has gathered force,
partly under the aegis of the Pioneer Network in Long-
Term Care (Lustbader, 2000; Lustbader & Williams,
2000). The new approaches include individualized care
and life plans for nursing home residents, creating more
choices for resident by empowering frontline staff (largely
paraprofessional), flattening hierarchies by creating
"universal workers," breaking nursing homes down into
neighborhoods, dramatically increasing the num ber of
single rooms, and remodeling nursing homes so that their
physical exterior and interior designs resemble homes.
Social workers have been heavily engaged in leadership of
this culture change movement. One of the most radical
ideas for nursing home transformation is the small-house
nursing home, including Green Houses ®, a trademarked
term for houses licensed as part of a nursing home that
serve 10 or fewer residents in a normalized living
environment with meals cooked and prepared in
residential kitchens (Kane, Lum, Cutler, Degenholtz, &
Yu, 2007; Rabig, Thomas, Kane, Cutler, & McAlilly,
2006).
ASSISTED LIVING AND RESIDENTIAL CARE As-
sisted living (AL) is a generic term for group residential
settings not licensed or defined as a nursing home that
nonetheless provide assistance with functioning and
routine nursing services for people with disabilitie s. AL
settings are licensed and regulated by states and no
particular federal standards apply. Small group homes and
family care homes are subsets of AL. AL settings reflect
enormous variation within and across states in terms of
physical settings, service patterns, and rules for admission
and retention. In many states, Med icaid waivers cover
services for financially eligible peo ple living in AL
settings, and in that case general quality rules for Medicaid
programs that attach to the federal matching funds are
applicable. AL is a market phenomenon. Since 1990, its
growth was fueled since 1990 by provider investment and
consumer choice, especially for purpose-build apartment
style AL for older people. Simultaneously existing board
and care homes and residential care facilities in many
states have upgraded their service capacity and are now
called AL. The unruly growth of the AL sector has
introduced some confusion into conceptualization of an
LTC continuum, for example, it is unsettled whether fair
housing rules should apply to AL.
PERSONAL CARE AND IN~HoME SERVICES The
bulk of LTC is provided to consumers who live in their
own homes in the community, either alone or with family
members. The bedrock service is personal care-not only to
assist with activities of daily living (that is, personal care
tasks such as bathing, toileting, dressing, transferring from
bed or chair, and mobility) and instrumental activities of
daily living (for example, cooking, cleaning, laundry,
transportation, communication, and business transactions)
in people's 'own homes, but to assist them to conduct
age-appropriate educational, employment, and recreational
activities outside their dwellings. Other LTC
home-and-community-based services (HCBS) (to use a
term in widespread use) include adult day services,
home-delivered meals, durable medical equipment,
emergency alarm systems, assisted transportation, and
home modification. Often the allocation of HCBS services
is overseen by a state and local assessment and case
management program charged with individual-level
advocacy and assistance, and systern-levelqualiry
assurance. In the 1990s and beyond, the trend has been
away from agency provision of in-home and other HCBS
services towards provision by independently employed
workers, who in many instances may be relatives of the
consumer. The National Cash and Counseling
demonstration of the 1990s provided experience with
cashing out Medicaid and Medicaid waivers (at a
discounted amount from the average cost of the in-kind
help) and permitting consumers to develop and draw upon.
their own budgets for services. This approach recognizes
that

LTC is only in part a technical health- related service; it is
also a set of provisions for living that can be managed by
consumers and their agents with information and enhanced
income to defray the additional costs. Many states have
established fiscal intermediary services to manage the
payroll functions on behalf of the LTC consumer.
Themes
LTC WORKFORCE Shortage of professional workers in
LTC (including licensed and registered nurses and qualified
rehabilitation therapists) is a cyclical phenomenon, which has
pertained for about 10 years and is more pronounced in rural
areas. A related and even more pressing problem is
recruiting and retaining a qualified nonprofessional
~orkforce to provide the frontline care. Turnover of
workers in nursing homes and other LTC settings is
extremely high, and often workers at the certified nursin g
assistant and home health aide level leave the LTC
workforce entirely. States have had numerous projects
underway to encourage retention of a well- qualified
workforce for LTC. A national project, Better Jobs Better
Care, operated by the American Associa tion of Homes and
Services for Aging, has provided funding for
demonstrations and statewide coalitions. Better wages and
benefits will be part of the solution, though raising the cost
of LTC; other solutions include developing career ladders,
enhanced training and information systems, and ex panded
more interesting jobs with greater opportu nities. Also given
that recent immigrants, people of color and non- English
speakers are a large part of the LTC labor force in many
geographic areas, provider organizati ons are catapulted
into the need to develop culturally sensitive care settings, to
conduct classes in English as a second language, and to
develop strategies to improve communication among
workers at all levels and between workers and consumers
and their family members.
DEFINING AND ASSURING QUALITY A controversy
remains about the extent to which quality of LTC should.
be defined by process standards (was the care delivered
correctly) or outcome standards, and whether the outcomes
considered should largely focus on absence of negative
events such as falls, bedsores, infections, malnutrition,
decreased functional ability, and increased depression, or
whether the outcomes should include social and
psychological aspects of quality of life.
ETHICS: SAFETY VERSUS AUTONOMY Many of the
ethical issues for practitioners and policy makers in LTC
center on the problem of simultaneously maximizing
LONG-TERM CARE 13 7
a variety of sometimes contradictory goals. In particular,
perceptions of how to promote safety for the LTC con sumer
can end up restricting the choices of the indi vidual, both for
where they will live and how they will be per mitted to live.
The negotiated risk contract, a vehicle by which consumers
or their agent knowingly opt to take risks against the advise
of care providers, is a particularly controversial
development in LTC. Some herald it as a welcome way to
enhance the power of consumers over their own lives,
whereas others see it as a license for providers to offer
substandard care (Jenkens, O'Keeffe, Carder, & Wilson,
2006). Other ethical issues with prac tical import include
dealing with colliding interests of the person needing LTC
and family members, assessment of decision- making
competence, and respecting privacy and confidentiality for
the LTC user.
CROSS, DISABILITY AGENDA People with disabilities
are part of many differ organized groups and may also at
times be beneficiaries of special fund ing at federal or state
levels, say for people with visual impairments or people
with Alzheimer's disease. Finding a common agenda across
age and disability groups has been chal lenging. Many
advocates and self-advocates for people with physical
disabilities argue their case as a civil rights issue, seeking
accommodations for their disabilities so as to participate
fully in society. Many advocates and self advocates for
elderly people with disabilities argue their case as a dearth
of health care services to meet unmet needs. Partly because
of the aging of people with physi cal and intellectual
disabilities, and partly because of federal initiatives under
Real Choice Systems Change grants, older people are
increasingly expecting and receiving the kind of per sonal
care in the community that younger people and their
advocates have demanded. Implementing a unified agenda,
as a collection of essays in a volumes edited by Putnam
shows (Putnam, 2007), means that service providers need
to come together across vastly different service networks
and learn about each other, and also that advocates for older
people need to relinquish some paternalistic attitudes.
Social Work Roles
The social work presence in LTC is ubiquitous in the
system of services, including at the planning and pro gram
level in federal and state governments, as case managers in
LTC programs, as advocates, and as direct workers within
organizations providing services. Social workers, in
conjunction with colleagues in nursing and other
disciplines, have provided leadership to the cul ture change
movement for transforming nursing homes. The
time-honored focus of social work-on the person in his or
her environment-is particularly pertinent
138 LONG-TERM CARE
for LTC for all populations as imaginative thought is given
on how to deliver labor-intensive, sometimes technical
services without compromising and even with enhancing
the individual's quality of life.
REFERENCES
Benjamin, A E., & Matthias, R. E. (200l). Age, consumer
direction, and outcomes of supportive services at home. The
Gerontologist, 41 (5), 632-642.
Braddock, D., Hemp, R., Parish, S., & Westrich, J. (Eds.). (1998).
The state of the states in developmental disabilities, (5th ed.).
Washington, DC: American Association on Mental
Retardation.
Institute of Medicine. (1986). Improving the quality of care in
nursing homes. Washington, 'DC: National Academy Press.
[enkens, R., O'Keeffe, J., Carder, P., & Wilson, K. B. (2006).
Study of negoatiated risk agreements in assisted living (Final
report submitted to OASPE, February 13, 2006, at
http://aspe.hhs.gov/daltcp/reports/2OO6/negrisk.htm).
Research Triangle, NC: RTI International.
Kane, R. A. (2003). Definition, measurement, and correlates of
quality of life in nursing homes: Towards a reasonable
practice, research, and policy agenda. The Gerontologist, 43(2),
28-36.
Kane, R. A, Kling, K. c, Bershadsky, B., Kane, R. L., Giles, K.,
Degenholtz, H. B., et al. (2003). Quality of life measures for
nursing home residents. Journal of Gerontology: Medical Sci-
ences, 58A(3), 240-248.
Kane, R. A., lum, T., Cutler, L. J., Degenholtz, H. B., & Yu, A-C.
(2007). Resident outcomes in small-group-home nursing
homes: A longitudinal evaluation of the initial green house
program. Journal of the American Geriatrics Sodety,
55(6),832-839.
Kane, R. L., Kane, R. A., ladd, R. c., & Nielsen, W. (1998).
Variation in state spending for long-term care: Factors as-
sociated with more balanced systems. Journal of Health Politics,
Policy and law, 23(2),363-390.
Linsk, N. L., Keigher, S. M., Simon-Rusinowitz, L., & England,
E. (1992). Wages for caring: Compensating family care of the
elderly. New York: Praeger.
lustbader, W. (2000). The pioneer challenge: A radical change in
the culture of nursing homes. In L. S. Noelker & Z. Harel
(Eds.), Quality of care and quality of life in nursing homes (pp.
185-203). New York: Springer.
lustbader, W., & Williams, C. C. (2000). Culture change in
long-term care. In B. Berkman (Ed.), Handbook of social
work in health and aging (pp. 645-652). New York: Oxford
University Press.
Putnam, M. (Ed.). (2007). Aging and disability; Crossing network
lines. New York: Springer.
Rabig,J., Thomas, W., Kane, R.A, Cutler, L.J., &McAlilly,S.
(2006). Radical re-design of nursing homes: Applying the
Green House Concept in Tupelo, MS. The Gerontologist,
46(4),543-539.
Wunderlich, G. S., & Kohler, P. O. (Eds.). (200l). Improving the
quality of long-term care. Washington, DC: National Academy
Press.
Zimmerman, D. R., Karon, S. L., Arling, G., Clark, B. R.,
Collins, T., Ross, R., et al. (1995). Development and testing of
nursing home quality indicators. Health Care Financing Review,
16(4), 107-127.
FURTHER READING
Kane, R. A, Kane, R. L., & ladd, R. L. (1998). The heart of
long-term care. New York: Oxford University Press.
Holstein, M. B., & Mitzen, P. B. (Eds.). (200l). Ethics in
community-based elder care. New York: Springer.
Noelker, L. S., & Harel, Z. (Eds.). (2OOl).linkingquality of care and
quality of life. New York: Springer.
Putnam, M. (Ed.). (2007). Aging and disability: Crossing network
lines. New York: Springer.
Weiner, AS., & Ronch, J. L. (Eds.). (2003). Culture change in
long-term care. New York: Haworth Press.
Zimmerman, S., Sloane, P., & Eckert, J. K. (Eds.). (200l).
Assisted living: Needs, practices, and polides in residential care for
the elderly. Baltimore: Johns Hopkins University Press.
SUGGESTED LINKS
Clearing house for the Community living Exchange Collab-
orative.
http://www.hcbs.org/
The Better Jobs/Better Care Website.
http://www.bjbc.org/page.asp?pgid = 39
Pioneer Network in long Term Care.
http;//www.pioneemetwork.net/
Centers for Medicare and Medicaid Services New Freedom
Initiative.
http://www.ems.Ms .gov/NewFreedomlnitiative/O 1_ Overview. asp
Cash and Counseling Program.
http://www .cashandcounseling .org/
-ROSALIE A. KANE
 MACRO SOCIAL WORK PRACTICE
i ABSTRACT: Macro social work practice includes those
activities performed in organizational, community, and
I
, policy arenas. Macro practice has a diverse history that
I' reveals conflicting ideologies and multiple theoretical
perspectives. Programmatic, organizational, commu nity,
and policy dimensions of macro practice under' score the
social work profession's emphasis on using. a person' in'
environment perspective. Thus, social work, ers,
regardless of roles played, are expected to have sensitivity
toward and engage in macro practice activities.
KEY WORDS: organization; community; practice models;
large systems practice; change
Macro social work, sometimes called "community social
work practice" (Austin, Coombs, & Barr, 2005), is so
much a part of all social work practice that it is somewhat
misleading to use the adjective "macro." For a profession
that embraces a person-in-environment perspective,
recognizing the larger arenas in which social work is
practiced, every practitioner must be sensitive to, if not
active in, performing macro roles. Thus, macro is an
important adjective used to describe those aspects of
social work that take one beyond direct or clinical
individual intervention and contextualize practice
regardless of what role is performed (Brody & Nair,
2006).
Definition and Description of Macro Practice Macro
social work includes "efforts within and outside
organizational, community and policy arenas in' tended to
sustain, change, and advocate for quality of life" (Netting,
2005, p. 51). Macro activities are typically performed in
organizations, communities, and policy or decision'
i making arenas. Rothman, Erlich, and Tropman (2001)
1 identify three arenas of intervention: communities,
organizations, and small groups. Small groups are "a
tangible collection of people who can discuss matters
j personally and work together in close association" (p. 13) ,
I often serving as vehicles through which macro activities
take place. They may be ad hoc committees in an
organization, strategic alliances among interdisciplinary
colleagues, coalitions
139
of community agencies, or founders of a budding social
movement. Thus macro social work practice by defini tion
implies working within multiple settings.
The breath of macro social work activities is limit, less
because organizations and communities (both place and
nonplace) are deeply embedded in political systems and
their accompanying ideologies and values. Macro social
work activities, then, include what Jansson (2003) has
called "policy practice" because it is within organizations
and communities that policies are imple mented. Macro
practice involves playing roles that include planning,
policy analysis, program coordina tion, community
organizing, and managing and admin istering
organizations (Netting, Kettner, & McMurtry, 2008).
Given this diversity of roles, Brueggemann (2006 )
includes topics such as social change processes,
community development and organization, leader' ship,
organizational and programmatic development, policy
advocacy, and international social wo rk in the practice of
macro social work. It is important to note that some
practitioners will move in out of these var ious roles and
activities, whereas others have positions that focus on
macro roles full time (Starr, Mizrahi, & Gurzinsky, 1999).
Historical Development
Macro social work has deep roots, both in the history of
the profession as well as in the larger society. Feminist
historians have identified women's organizing efforts that
preceded the development of the profession as those of
benevolence, reform, and rights (Skocpol, 1992). Often
beginning in sewing circles and cent so cieties in the late
1700s, it was acceptable for women to work through
religious structures to form missionary societies and
orphanages. These were early macro organizin g activities,
based on identifying needs and found, ing organizations to
address those needs. In the 1800s reformers created
organizations for causes such as abol ishing slavery or
eliminating brothels, followed by the mid 1800 s in which
women's rights organizers emerged as a third tradition.
Each of these traditions brought different assumptions and
strategies to the macro en, terprise; benevolent women
worked within the system to effect change, whereas
reformers and activists worked both inside and outsid e
existing structures (McCarthy, 2003; Scott, 1993).
140 MACRO SOCIAL WORK PRACTICE
Immigration, industrialization, and rapid population
growth led to concentrated urban areas in the 1800s,
accompanied by rising crime, unemployment, and poverty.
Early helping efforts were driven by conflicting
ideologies, some of which were judgmental and others
were more progressive. Schneider and Lester (2001)
identify "three separate and distinct social work move-
ments [that emerged] in the last 20 years of the 19th
century, [each with] a different perspective about wealth
and poverty as well as the responsibilities one owed to the
other and to the developing social systems" (p. 10). Charity
organizations focused on community justice, settlement
houses focused on social justice, and the third movement
out of the University of Pennsylvania Wharton School
focused on distributive justice (p. 10).
As the profession developed in the early 1900s, a
long-standing tension emerged as well. Called by dif ferent
names-clinical vs. community culture, cause vs. function,
or direct service vs, social welfare-"an endu ring tension
within social work between its social change and its
individual-family change dimensions" (Austin et al., 2005 ,
p. 11) has persisted. These tensions are highlighted by
Reisch and Andrews (2002) in The Road Not Taken.
Focusing on radical social work as an alternative approach,
they give "voice to the effects of nonmainstream social
service and social work organizations on the creation of
U.S. social welfare and the emergence of social work
theories and methods" (p. ix), revealing a complex array of
strongly held beliefs about the targetls) of change, ranging
from social reform within the system to direct assaults on
societal structures.
In the early 1900s, multiple preexisting traditions
converged as the profession emerged, reflecting differe nt
beliefs about the nature of the profession, its underlying
philosophy, and the methods used to carry out strongly
held assumptions, around which there is continuing
disagreement. Given that histories are filtered through
different lenses, some voices are more privileged than
others. For example, feminist historians, advocates, and
radical social workers felt the need to write their own
histories so that alternative voices are heard. Tensions
among strongly held beliefs about what actions are
necessary in order to do social work were divergent in the
beginning of the profession, just as they are divergent
today (Netting, 2005).
Similarly, Reamer (1993) identifies five areas about
which philosophical assumptions have influenced the
profession's development and its macro models of inter-
vention: (a) the goals of government, (b) rights of citizens
in relation to the state, (c) the obligations of the state
toward its citizens, (d) the nature of political or civil
liberty, and (e) the nature of social justice (p. 2).
Historically, these philosophical assumptions have framed
different views of social work macro practice, and have
resulted in value choices, dilemmas, and ques tions. For
example, are the goals of government to maintain the status
quo or to work for change? Which groups of citizens and
what needs receive priority? Should service delivery be
centralized or decentralized? Should planning occur from
the top or from the grassroots? Should consumer-directed
care be instituted or is more professional oversight needed?
Can social programs be built on the principle of social and
economic justice? In organizational arenas, each
organization's basic assumptions, underlying values, and
artifacts reveal competing values (Cameron & Quinn,
1999) such as seeking standardization versus celebrating
differences; or designing programs to address current
needs or advocating for change in the basic structure of ser-
vice provision (Netting & O'Connor, 2003). In planned
change processes, macro practitioners often struggle when
working inside the system is seen as "sell ing out" and when
it is more appropriate to advocate for change from a
position outside the targeted system (Netring et al., 2008 ).
Choices among values undergird every aspect of macro
work, whether it is which problems are privileged, which
group is targeted, or what type of intervention is selected.
The self-aware practitioner will be cognizant of the
assumptions and values that guide those choices and their
potential consequences.
In the latter part of the 1960s, the number of courses in
community organization increased in schools of so cial
work, fueled by an intentional effort on the part of the
Council on Social Work Education (CSWE) to promote
teaching in this area. However, a decade latter momentum
began to wane. In 1976 the inaugural issue of
Administration in Social Work appeared, and in 1980 over
30 macro educators participated in an informal session at
the annual program meeting of CSWE, vowing to have a
CO Symposium at the 1981 annual meeting.
Roberts-Det.Iennaro (2002) has written a history of key
events from 1960 to 1992 that influenced the development
of the Association for Community Organization and Social
Administration (ACOSA), as a structure for so cial workers
interested in macro practice. This association developed
out of the symposium sessions, and by 1987 a set of bylaws
was approved, a steering committee was formed, and a
membership organization formed to serve as an incubator
for persons interested in promoting, integrating, and
advocating for macro curriculum in social work programs.
Today ACOSA sponsors The Journal of Community
Practice, an interdisciplinary journal devoted to
revitalizing research about, theory construction in, and
teaching of macro practice.

Theoretical and Empirical
Foundations for Macro Practice
Multiple theories are often used to understand the
macro aspects of social work practice. Often used to
describe and analyze macro arenas is social systems
theory. In systems theory there are many parts of any
unit of analysis (whether they are groups,
organizations, communities). These units can be
understood as interconnected components engaged in
an interactive process with their environments-as
resources enter the system (inputs), as these resources
are processed (throughputs), and as something new
emerges (outputs). Outcomes are actual quality of life
changes that accompany outputs. For example, human
service organizations attract funding, legitimacy, staff,
clients, and a variety of other input's with the intent of
performing interventions that will make a difference in
the interactive process.
Warren (1978), now a classic in the community
literature, built on the prevailing notions of systems
theory at the time and viewed communities as systems
nested within systems (groups within organizations,
organizations within communities, and others) He dis-
tinguished between internal and external patterns and
between vertical and horizontal community linkages.
Vertical linkages connect individuals, groups, and or-
ganizations within a community; whereas horizontal
linkages transcend community boundaries, connecting
the community to units within the larger environment.
Closely related to systems theories are human ecol-
ogy theories that also examine structural patterns and
relationships within place-based communities.
Emanating from the 1930s work of Robert E. Park at
the University of Chicago, today ecological theories
focus on resident characteristics (for example, master
statuses such as race, age, gender), the use of physical
space (for example, land use, housing), and the social
structures within communities. Communities are seen
as highly interdependent, teeming with changing rela-
tionships among populations of people and organiza-
tions. Human ecologists are particularly concerned
about how place-based communities deal with
processes of competition, centralization, concentration,
integration, and succession (Netting et al., 2008).
Equally important to a focus on space, structure,
function, and relationships among systems are issues of
how people behave in communities; therefore human
behavior theories help macro practitioners recognize
why people act as they do in large systems. Organiza-
tional and community behavior dispels any myths that
macro practice is not "direct" practice because there is
ongoing interaction among people; it is just more com-
plicated because it is not always one-on-one (Netting
~
.
MACRO SOCIAL WORK PRAcrICE 141
et al., 2008). Similarly, power dependency theory, con-
flict theory, and resource mobilization theories are
helpful in understanding the power and politics of
community settings (Hardina, 2002).
Hasenfeld (2000) reveals how multiple organiza-
tional theories are used to guide managerial and admin-
istrative roles in macro practice. Recognizing that
human service organizations are "inherently indetermi-
nate and fraught with ambiguities" (p. 90), Hasenfeld
identifies nine administrative tasks (achieving goals;
managing people; being efficient; mobilizing resources;
founding and surviving; institutionalizing practices; in-
tegrating culture; deconstructing knowledge, power and
control; and promoting social change) and theories used
to perform these tasks. Macro practitioners have drawn
theoretical principles from various schools of thought,
everything from classical bureaucratic to post-modern
and critical theories (Netting et al., 2008). There is,
however, a continual need to recognize that many
theories used by managers and administrators have not
been empirically -tested. Organizational culture theory
holds great promise in this regard because of the
extensive studies conducted by Cameron and Quinn
(1999).
In the last decade concerns have raged about
evidence-based practice (EBP) in clinical social work
and its importance. The debates stem from a number of
macro forces that swept the United States in the 1990s
when a push for accountability led to federal legislation
(Kettner, Moroney, & Martin, 1999), energizing calls
for outcomes-based or performance measurement
(Moxley & Maneia, 2001), for evidence-based
management (Rousseau, 2006), for evidence-based
community practice (Ohmer & Korr, 2006), and for
evidence-based policy (Gambrill, 2006).
EBP is viewed as having three. componentsresearch,
practitioner expertise or practice wisdom, and client
values. Evidence-based macro practice, then, relies on
the use of research conducted in a particular arena, the
expertise of the practitioner, and the values of multiple
stakeholders. This interplay of factors is complicated by
an ongoing debate on what constitutes good science
(Woody, D'Souza, & Dartman, 2006). For example, a
meta-analyses of the empirically based literature on
community practice revealed 58 studies, of which 20
were evaluations of actual interventions. Results
indicated that practitioners are able to mobilize
participates to engage in change and to positively en-
hance their interpersonal and political skills, but it is
much more difficult to address complex physical,
social, and economic problems in poor communities.
Thus, the ability to engage and mobilize needs to be
accompanied by enhanced efforts at capacity building.
142 MACRO SOCIAL WORK PRAcrICE
More research on community interventions, using more
sophisticated research methodologies, is needed (Ohmer &
Korr, 2006). Similarly, case studies and program evaluations
are published in the organizational literature (Mulroy, 2004b),
but as helpful as these are, they are not generalizable. Macro
practitioners need to be aware of the debate on what
constitutes "evidence" and the privileging of different types of
evidence (Netting & O'Connor, forthcoming) as well as where
to locate the latest research in outlets such as the Journal of
Community Practice, Administration in Social Work, Families
in Society, Nonprofit and Voluntary Sector Quarterly, and
Nonprofit Management and Leadership.
Current Modes and
Patterns of MAcro Practice
Since macro practice includes work across programs,
organizations, communities, and policies, there are over-
lapping and different knowledge bases that inform current
modes and patterns of activities. Social workers draw from
related fields such as sociology, psychology, public admin-
istration, health administration, business, management,
political science, and others on an ongoing basis. This move
toward a more multidisciplinary and interdisciplinary focus is
relevant to knowledge dissemination (Gutierrez, Butterfield,
Alvarez, & Moxley, 2006).
At the programmatic level, designing effectiveness"based
programs is a current mode of macro activity. Kettner et a1.
(1999) and Pawlak and Vinter (2004) provide guidelines for
how to develop valuable human service programs. Similarly,
the use of logic models to identify inputs needed, intervention
strategies, outputs, and outcomes reinforce the importance of
accountability and systematic data collection in program
development and implementation. At the organizational level,
core skills needed to engage in social work administration and
management include "leadership, planning, programming,
financial management, accounting, operations, MIS, personnel
management, grantsmanship and fund-raising, program
evaluation, coordination, marketing, computer literacy,
technical writing and oral communication and supervision"
(Raymond, Teare, & Atherton, 1996, as cited in Barak, Travis,
& Bess, 2004). Mulroy (2004a) underscores the importance of
these skills in her work on theoretical perspectives in human
service organizations.
In terms of community practice, in recent years there has
been a resurgence of community building, an emphasis on
partnerships and collaboration, a focus on capacity building
and the importance of sustainability, and a release from
geographically bound definitions of community into virtual
communities of identification made possible by technology.
Practice models are
updated periodically and include locality development or
neighborhood and community organizing, organizing
functional communities, community social and economic
development, social planning, program development and
community liaisoning, political and social action, coalitions,
social movements, or social reform (Hardina, 2002; Kettner et
al., 1999; Rothman, et al., 2001; Weil, 2004; Weil & Gamble,
1995). Strengths, empowerment, and resiliency perspectives
are also used to guide contemporary macro practice, as well as
planned change models relevant to organization and
community change (Netting et al., 2008).
At the policy level macro practitioners have a variety of
analysis models that focus on different aspects of policy.
Gilbert & Terrell (2005) provide three major and interrelated
types of policy analysis: (a) process, (b) product, and (c)
performance (implementation and impact). Process
frameworks "focus on the dynamics of policy formulation
with regard to sociopolitical and technical-methodological
variables" (p. 15). A process approach may examine the
planning (or lack thereof) of a policy or policies, the
decision-making and political processes in the formulation,
development, and movement toward becoming a product.
Product frameworks focus on the results of the planning
process-on what is produced as a result of "a set of policy
choices" (p, 16). Thus, a product model examines policy
content or issues embedded within the policy, as units of
analysis. Performance is "concerned with the description and
evaluation of the programmatic outcomes of policy choices"
(p. 16) and research methodologies are used to determine if
policy implementation works. Two types of questions are
typically asked in performance analysis:
"First, how well is the program carried out] Second, what is its
impact?" (Gilbert & Terrell, 2005, p. 16). The first question
deals with monitoring the process of implementation
(formative evaluation) and the second question deals with
evaluating program outcomes (summative evaluation)
(Hoeffer, 2005).
Trends and Future Directions
Since social workers perform such diverse roles, there is a
tendency to dichotomize micro and macro practice, yet all
accredited schools of social work require that macro content
be part of their curriculum (Austin et al., 2005). Certainly,
depending on the school one attends, there may be
specializations or concentrations that allow students to hone
certain skill sets more than others, but all social workers are
educated in macro content, just as all social workers study
direct practice. In practice, it is often in performing direct
practice roles with multiple individuals where patterns of need
begin to emerge or where policy implementation is
recognized
J

as problematic. The nature of the change needed may
lead to an organizational, community, or policy inter-
vention. At this point, the direct practitioner may identify
the needed change and pursue it with the help of others or
they may alert other practitioners who are in a position to
pursue change. The point is that all social workers are
engaged in recognizing the macro nature of their work,
just as practitioners who do not provide direct service
must recognize the impact their work has on individuals,
families, and groups.
The recognition that social workers are macro change
agents may be evident in the field, but there are persistent
challenges facing both educators and practitioners. As
social workers move into nontraditional jobs in which
their titles are policy analysts, coordinators, supervisors,
information systems analysts, and a host of others their
identities as social workers may be somewhat muted. For
practitioners in some states, clinical licensing laws may
not include roles for persons who perform other than
clinical tasks. These . same requirements may influence
the concentration or specialization that social work
students chose in their programs of study. These and other
challenges are part of the ongoing professional dialogue.
REFERENCES
Austin, M. j., Coombs, M., & Barr, B. (2005). Communitycentered
clinical practice: Is the integration of micro and macro social
work practice possible? Journal of Community Practice,
13(4),9-30.
Barak, M. E. M., Travis, D., & Bess, G. (2004). Exploring
managers' and administrators' retrospective perceptions of
their MSW field work experience: A national study. Ad-
ministration in Social Work, 28(1), 21-44.
Brody, R., & Nair, M. D. (2006). Macro practice: A generalist
approach (Sth ed.). Wheaton, IL: Gregory Publishing.
Brueggemann, W. G. (2006). The practice of macro social work (3rd
ed.). Stamford, CT: Brooks/Cole.
Cameron, K. S., & Quinn, R. E. (1999). Diagnosing and changing
organizational culture: Based on the competing values framework.
Reading, MA: Addison Wesley Longman, Inc.
Gambrill, E. (2006). Evidence-based practice and policy:
Choices ahead. Research on Social Work Research, 16(3),
338--357.
Gilbert, N., & Terrell, P. (2005). Dimensions of social welfare policy
(6th ed.). Boston, MA: Allyn & Bacon.
Gutierrez, L. M., Butterfield, A. K., Alvarez, A. R., & Moxley, D.
P. (2006). Research for community practice. Journal of
Community Practice, 14(4), 1-3.
Hardina, D. (2002). Analytical skills for community organization
practice. New York: Columbia University Press.
Hasenfeld, Y. (2000). Social welfare administration and
organizational theory. In R. [. Patti, The handbook of social
welfare management (pp. 89-112). Thousand Oaks, CA:
Sage.
MACRO SOCIAL WORK PRACTICE 143
Jansson, B. (2003). Becoming an effective policy advocate: From
policy practice to social justice (4th ed.). Pacific Grove, CA:
Brooks/Cole.
Hoeffer, R. (2005). Cutting edge social policy research. Binghamton,
NY: Haworth Press.
Kettner, P. M., Moroney, R. M., & Martin, L. L. (1999).
Designing and managing programs: An effectiveness~based ap-
proach (2nd ed.). Thousand Oaks, CA: Sage.
McCarthy, K. D. (2003). American creed: Philanthropy and the rise of
civiL soceity 1700-1865. Chicago: University of Chicago Press.
Moxley, D. P., & Maneia, R. W. (2001). Expanding the conceptual
basis of outcomes and their use in the human services. Families
in Society, 82, 569-577.
Mulroy, E. A. (2004a). Theoretical perspectives on the social
environment to guide management and community practice:
An organization-in-environment approach. Adminis~ tration in
Social Work, 28(1), 77-97.
Mulroy, E. A. (2004b). University civic engagement with
community-based organizations: Dispersed or coordinated
models? Journal of Community Practice, 12(3/4),35-52.
Netting, F. E. (2005). The future of macro social work .
Advances in Social Work, 6(1),51-59.
Netting, F. E., Kettner, P. M., & McMurtry, S. L. (2008). Social
work macro practice (4th ed.). Boston: Allyn & Bacon.
Netting, F. E., & O'Connor, M. K. (2003). Organization practice.
Boston: Allyn & Bacon.
Netting, F. E., & O'Connor, M. K. (Forthcoming). Recognizing the
need for evidence-based practices in organizational and
community settings. Journal of Empirical Social Work Practice.
Ohmer, M. L., & Korr, W. S. (2006). The effectiveness of
community practice interventions: A review of the . literature.
Research on Social Work Practice, 16(2),132-145.
Pawlak, E. j., & Vinter, R. D. (2004). Designing and planning
programs for nonprofit and government organizations. Indian-
apolis, IN: Wiley.
Roberts-DeGennaro, M. (2002). History of ACOSA: Chronology
of evolving structure and key events from the 1960s to 1992.
Retrieved October 2, 2007, from http://www.acosa.
org/history .htrnl.
Reisch, M., & Andrews,]. (2002). The road not taken: A history of
radical social work in the United States. Philadelphia, PA:
Brunner-Routledge.
Rothman.j., Erlich,]. L., & Tropman.]. E. (200l). Strategies of
community intervention (6th ed.). Itasca, IL: F. E. Peacock.
Rousseau, D. M. (2006). Is there such a thing as "evidence-
based management?" Academy of Management Review, 31, x~~' .~~' •
256--269.
Schneider, R. L., & Lester, L. (2001). Social work advocacy: A new
framework for action. Belmont, CA: Brooks/Cole.
Scott, A. F. (1993). Natural allies: Women's associations in American
history. Chicago: University of Chicago Press.
Skocpol, T. (1992). Protecting soldiers and mothers. Cambridge,
MA: Harvard University Press.
Starr, R., Mizrahi, T., & Gurzinsky, E. (1999). Where have all the
organizers gone? A study of Hunter CO & P Alumni. Journal of
Community Practice, 6(3), 23-48.
144 MACRO SOCIAL WORK PRACTICE
Warren, R. L. (1978). The community in America (3rd ed.).
Chicago: Rand McNally.
Weil, M. (Ed.). (2004). The handbook of community practice.
Thousand Oaks, CA: Sage.
Weil, M., & Gamble, D. N. (1995). Community practice models.
In The encyclopedia of socioi work 09th ed., Vol. 1: pp. 577-'-593).
Washington, DC: National Association of Social Workers.
Woody, J. D., D'Souza, H. j., & Dartman, R. (2006). Do master's
in social work programs teach empirically supported
interventions? A survey of deans and directors. Research on
Social Work, 16(5),469-479.
-FLORENCE ELLEN NETTING
MALPRACTICE. See Professional Liability and Malpractice.
MANAGED CARE
ABSTRACT: Since the mid-1980s, managed care has been
one approach used to address the economic crisis in the
American health-care system. This entry overviews managed
care from the perspective of policy, procedure, practice, and
system. Specifically, emphasis is given to understanding the
emergence and history of managed- care, multiple definitions,
how it works, and examples of managed care plans, key
legislation, existing research, its future, and implications for
social-work practitioners.
KEY WORDS: managed care; health-care reform; capi-
tated; cost-effectiveness; cost-containment; beneficiaries
Emergence of Managed Care Throughout U.S.
history, the costs of health care have always been
"managed"-in one way or another. In post-Civil War days,
health care was bartered for in chickens, farm labor, or the
most basic of wages. Care was "managed" one-on-one, which
we now call "feefor-service" where the patient or insurer pays
each time a service is provided. Fast-forward to contemporary
times where the concern of managing health-care costs has
caused much debate among the public and policy makers.
Among the concerns are health-care spending accounting for
about 19% of the total expenditures at the state and federal
levels and is the second fastest growing component of the
federal budget, overshadowed only by the growth in public
debt (Karger & Stoesz, 2006). Health-care costs are higher in -
the United States than in any other industrialized nation
and health spending in the United States was, as of 2002,14%
(compared with Canada at 9.1 %). The most stunning
expenditures since the mid-1970s are those associated with
hospital care (31 %), physician services (22%), and
prescription drugs (11%). Hospital care costs reached $401
billion in 1999, up from $28 billion in 1970, with nearly 60%
of hospital costs going to wages and caregiver benefits. The
cost for physician services rose by almost 1,800% between
1970 and 1999, with a 300% increase between 1980 and 1990
alone. Pharmaceutical expenditures went from $5.5 billion in
1970 to $101 billion by 1999, a 1,800% increase (Karger &
Stoesz, 2006).
Given these facts, how does a society manage rising
health-care costs? Early attempts at addressing these issues
were met with two strategies: (a) cut the costs for
governmental health programs and (b) lower overall medical
costs. This was the birth of the health care reform movement
and its controversial offspring, "managed care" (Lightbum &
Schamess, 1998).
Definitions
The language used to describe managed care is derived from
the field of business and economics. For example, insurer or
employer becomes payer, clinician or therapist becomes
provider, and patient or client becomes member or enrollee or
beneficiary (Spitz, 1996). Managed care has come to be
synonymous with costcontainment and the mechanism to
address spiraling health-care costs. Using the most generic
definition, managed care refers to "the organization of
networks of providers (doctors, clinics, hospitals) into a
system that is cost-effective. Institutions or individual health-
care providers who are in managed care systems agree to set
fees for each service or flat payments per patient." (Karger &
Stoesz, 2006). Criticism of the fee-forservice model included
the view that clinical services were open-ended, therapist
driven, nonmeasureable, and subjectively delivered (Corcoran
& Vandiver, 1996). It emphasized providing sickness care
after patients got sick. Proponents of managed care point to an
impetus for prevention.
Managed care is also public policy, such as the Health
Maintenance Act of 1973. It is a procedure, such as when
intake workers prospectively screen each case for "medical
necessity" of a service. It is a practice setting or approach. An
example would be a provider employed by a Preferred
Provider Organization (PPO) providing an 8-week smoking
cessation program for members enrolled in a health
maintenance organization (HMO). PPOs refer to a network of
providers who remain in private practice and receive payment
on a fee-for-service basis (Moniz & Gorin, 2007). Managed

care plans can also be seen in the behavioral health care
field. Managed behavioral health care refers to plans
that specifically target mental health and substance
abuse services (Moniz & Gorin). These plans are
usually structured as "carve outs," which are devoted
exclusively to mental health and chemical dependency
issues for a defined population.
History of Managed Care
Sickness coverage has been on the minds of labor and
national leaders since health care benefits were added to
employment as part of collective bargaining between
employee and employer during World War II. How-
ever, since the mid~1980s, federal legislation has ·fo~
cused on costs.
The evolution of man 'aged care was influenced by
the following key legislation:
• 1965-Titles XVIII and XIX of the Social Security
Act: This act established Medicare, which
provides health coverage for workers who have
become elderly or disabled and Medicaid, which
covers care for very low-income Americans and is
a federal-state partnership.
• 1973-Health Maintenance Organization Act of
1973: This act required businesses with 25 or more
employees to provide optional HMO coverage to
their employees and was mainly enacted to
promote the development of HMOs.
• 1981-0mnibus Budget and Reconciliation Act of
1981: This act permitted state-level experi-
mentation with Medicaid managed care by
allowing states to seek federal waivers in place of
their fee-for-service coverage.
• 1982-The Tax Equity and Fiscal Responsibility
Act of 1982: This act paved the way for HMOs to
enroll Medicare beneficiaries; it had capitated
funding based on the idea that financial incentives
for prepaid plans would counter the excessive
costs and utilization of medical services under
Medicare and Medicaid.
• 1983-Deficit Reduction Act of 1983: This act
ushered in a prospective pricing system known as
Diagnostic Related Groups (DRGs), which were
federally mandated payment systems designed to
control costs by using a payment system in which
the hospital receives a particular amount for
certain diagnoses, regardless of services provided.
• 1997-Balanced Budget Act of 1997: This act
expanded Medicare beneficiaries (for example
low-income women, children, and elderly) with
the introduction of Medicare Part C (also known as
Medicare + Choice), in which beneficiaries
MANAGED CARE
145
were encouraged to enroll in managed care health
plans.
• 2003-Medicare Prescription Drug, Improvement,
and Modernization Act of 2003: This act changed
Medicare + Choice to Medicare Advantage, which
now required beneficiaries to join a private health
plan in order to receive prescription drug coverage
(Brill & Levine, 2001).
In the 1980s, federal and state governments looked
at how private insurance was seemingly benefiting from
cost cutting strategies (for example, restricting
reimbursement) and followed suit. Medicaid and Med-
icare policy makers promoted managed care because
they expected that capitation, competition, and parti-
cipation of mainstream, commercial HMOs would
expand access, save money, and improve care. By 1998,
there were 346 Medicare HMOs with 6 million enrol-
lees. However, by 2003, there were only 179 Medicare
HMOs and rv 1 million Medicare enrollees had been
dropped because of low reimbursement rates (Karger &
Stoesz, 2006). HMOs across the nation eventually ex-
ited the traditional Medicare managed care market after
3-5 years (Sparer, 2003), citing low reimbursement
rates, burdensome bureaucratic oversight, and lack of
familiarity with the high needs of enrollees.
By 1997, there was a total of more than 17 million
individuals enrolled in the Medicaid managed care
programs, up from 750,000 in 1983 (Moniz & Gorin,
2007). As of 2004, states like Tennessee have enrolled
100 percent of their Medicaid population into managed
care plans (Centers for Medicare and Medicaid Ser-
vices, 2004, as noted in Moniz & Gorin, 2007, p. 118).
Managed Care Organization and Practice
One common feature of managed care is "cost contain-
ment," also known as "capitated care." Capitation is the
method of payment in which the provider is paid a fixed
amount for each person served regardless of the actual
number or nature of services delivered (Karger &
Stoesz, 2006). For example, under traditional Medicare,
health-care providers bill the government for services
they perform-known as "fee-for-service." But with
"Medicare Advantage" managed care, insurers get a set
amount per person-known as "capitated," which the
insurers reimburse the providers or organizations that
provided the care.
Capitation is a way of controlling costs for care and
may be operationalized in two ways: provider-based
and organization-based. The provider-based capitation
approach assigns a consumer to a provider who receives
a flat payment for services provided. In return for this
per capita payment, the provider assumes the obligation
146 MANAGED CARE
to provide all services required by plan members.
Organization-based capitation, in contrast, begins with a
provider group or an independent practitioner group,
deciding on a group contract under an arrangement in
which the distribution of services is rest ricted to the
capitated budget.
In essence, capitation programs provide all the ser vices
to a group at, say, $3,000 per person/annum. The financial
goal is for the average to be less than $3,000, so that the
remainder becomes profit for the managed care program.
Profit may be realized in the form of reinvestment into the
organization in terms of new services. In one behavioral
health-care organization, the agency reinvested its
"profits" into developing con, sumer run recovery services,
which were not paid for by traditional funding
mechanisms.
Some examples of managed care plans are HMOs,
which are a prepaid or capitated insurance plan, in which
individuals or employers pay a. fixed monthly fee for
services. PPOs are a type of managed care where by an
employer or insurance company contracts with a selected
group of providers for services at pre, established
reimbursement rates. Consumers have the choice of who to
contact for the services. If a physician or provider is not on
the provider list, higher expenses to the patient will result.
Point-of-service plans provide financial incentives to
members who elect to have their treatment services
provided by "preferred providers." Preferred providers
refers to "in-network" providers whose services carry
higher rates of reimbursement than if the consumer chose
to see someone out-of-network. Carve-out plans are
specialized health- care plans devoted exclusively to
mental health and chemical dependency issues. In
exchange for a negotiated pay' ment, carve-outs overse e
the behavioral health care and treatment of a defined
population.
CHALLENGES Research on whether managed care has
contained costs while maintaining access and quality has
been challenging for many reasons: the variety and rapid
change of plans and manag ement techniques, heterogeneity
of the fee-for-service systems, spillover effect from
managed care to fee-for-service programs, uncertainty
about the appropriate level of analysis, the confounding
influence of differences in benefit packages of managed
care and fee-for-service programs, and the possibility of
temporal effects in managed care performance, either a
longer-term negative dose effect or positive organizational
learning (Leff et al., 2005). Additionally, providers find
themselves challenged by is sues of limited access to certain
patient groups, fixed number of patient visits, and having to
tum away patients who do meet the eligibility criteria or
whose
reimbursement rate is so low that they are seen as a
financial liability.
Despite these challenges, new findings provide a
picture of how managed care is or is not impacting health,
care outcomes. Results of three large-scale studies
essentially reported "no differences" between fee,
for-service models compared with capitated or prepaid
managed care programs or other HMO model on the
following variables: access for substance abuse clients
(Bigelow, McFarland, McCamant, Deck, & Gabriel, 2004),
measures of satisfaction, use and quality of services,
symptoms and functioning for clients with serious mental
illness (L"Mfet al., 2005), and medical costs and improved
treatment outcomes for specialty alcohol and drug
treatment (Pollen, Freeborn, Lynch, Mullooly, &
Dickinson, 2006). Two other studies reported no differ-
ences in case management activities (Hromco, Moore &
Nikkel, 2003), nor differences in beneficiaries enrolled in a
HMO compared with regular Medicare managed care
(Wooldridge et al., 2001). However, earlier research does
confirm that managed care achieved cost savings as much
as 30-40% through the cost-control strategy of substituting
less expensive out patient care for inpatient care (Zuvekas,
Rupp, & Norquist, 2007). While these findings suggest
managed care has neither been overwhelmingly helpful or
hurtful, research continues to be limited in terms of
determining whether it improves the quality of care.
TRENDS AND FUTURE DIRECTIONS By 2015, man-
aged care will likely undergo significant changes. From a
policy perspective, the new 110th Congress already has '
plans to overhaul Medicare managed care in two areas:
reimbursement rates to health insurance companies that run
Medicare's managed care programs (that is, specifi cally the
Medicare Advantage) and the insurers slush fund, also
known as the regional stabilization fund, which ensures tha t
certain managed care companies, like PPOs, offer their
services widely. Behind this effort is a newly appointed
independent panel, the Medicare Payment Advisory
Commission. The topic of universal health care is back on
the national table with Massachuset ts and California leading
the way.
At a policy level, the future of managed care will be
influenced by a new generation of employers, insurers,
politicians, consumers, and voters who are working to
eliminate managed care procedures that promoted price
discrimination for reasons of health or job status. For
example, bipartisan efforts to introduce a patients' bill of
rights legislation can be found in initiatives such as the
Bipartisan Patient Protection Act of 2001 and a latter
version that gives individuals the right to hold their HMO's
accountable if poor medical decisions

results in injury (Moniz & Gorin, 2007). Until govern-
mental system change occurs, provider organizations will
continue with cost-containment strategies but with a mix
of fee-for-service and capitated pricing arrangements.
These organizations will work in tandem with a
multidisciplinary group of consumers, corporate benefit
managers, health care consultants, and pharmacy benefit
managers to develop toolkits to help employers select and
purchase a variety of health and mental health services
(Substance Abuse and Mental Health Services
Administration [SAMHSA], 2005).
At a practice level, the f uture of managed care will be
influenced by consumer and provider groups. Specifically,
consumer groups are working on federal legislation to
balance the decision making power of managed care
organizations in areas of provider choice, treat ment
options, and ability to sue HMOs for denial of care.
Providers are increasingly developing providersponsored
(that is therapist-owned) plans that have the competitive
strategy of managed care but with a more consumer
friendly approach and less dictation by insurers. Further,
the principles undergirding managed care are slowly being
embraced by a new generation of workforce professionals
who are open to the notion that services should be
collaborative, patient directed, and relatively brief so as to
encourage people to return to their lives as quickly as
possible, and evidence-based with measurable outcomes.
Managed care has helped cement the idea that services
must be evidence-based and clinicians are accountable for
showing improvement by means other than opinions or
observations.
Implications for Social Work
WHAT SOCIAL WORKERS AS PRACTITIONERS HAVE TO KNow
AND Do The implications for social work to influence the
future of managed care are enormous. Barusch (2006)
identifies several macro level roles in which social work can
shape the next generation of managed care policies,
procedures, and practices. These are (a) negotiating and
monitoring of each states contracts with providers, (b)
ensuring that the needs of consumers are addressed in these
processes, (c) advocating services to address the needs of
Medicaid beneficiaries, and (d) increasing the voice of
Medicaid recipients in decisions related to managed care-for
example, consumer surveys, grievance procedures, hotlines,
and consumer representation on advisory boards, such as
Medicaid ombudsman programs.
Overall, social workers have the skills to influence th e
debate on managed care, particularly if issues of lack of
access to health care or discrimination based on illness
severity are perceived as social justice issues. Social
workers need to help ensure that patients make informed
choices
~-
MANAGED CARE 147
when selecting a managed care plan. The National Asso-
ciation of Social Workers has developed a policy state-
ment on managed care to serve as a guide for the
profession in working as practitioners and advocates
(2006).
Being with managed care since mid- 1980s, can we say
it has worked? Did it achieve the goals of cost containment
and effectiveness, quality assurance and integrated care?
The answers to these questions are varied. In some
settings, managed care jump-started a whole new way of
how services could be delivered, choice was offered, and
care was provided. In other settings, managed care plans
were flawed, punitive, confusing, and proved the detriment
of individuals enrolled in its system.
Managed care has arisen to a large extent because s uch
essential services as health and mental health have been
bought and sold in the marketplace. What must accompany
any future change in managed care is how to improve
access and affordable and quality care for consumers. In
other words, how should we truly "manage" their care?
The only solution as a rising tide of prominent voices
suggests (Moniz & Gorin, 2007) is comprehensive,
universal health and mental health coverage based on
health care as a right not a commodity.
REFERENCES
Barusch, A. (2006). FouiuIations of social policy (2nd ed.).
Belmont, CA: Thomson Brooks/Cole.
Bigelow, D., McFarland, B., McCamant, L., Deck, D., & Gabriel,
R. (2004). Effect of managed care on access to mental health
services among Medicaid enrollees receiving substance
treatment. Psychiatric Services, 55(7), 775-779.
Bril1, N., & Levine, J. (2001). Working with people (7th ed.).
Boston, MA: Al1yn & Bacon.
. Corcoran, K., & Vandiver, V. (1996). Maneuvering the maze of
managed care. New York, NY: Free Press.
Hromco, J., Moore, M., & Nikkel, R. (2003). How managed care
has affected mental health case management activities,
caseload and tenure. Community Mental Healthloumal,
39(6),501-509.
Karger, H., & Stoesz, D. (2006). American Sodal Welfare Policy
(Srh ed.). Boston, MA: Pearson/Allyn & Bacon.
Lightburn, A., & Schamess, G. (Eds.), Humane managed care.
NASW Press, 1998.
Leff, H., Wieman, D., McFarland, B., Morrissey,J., Rothbard, A.,
Shern, D., et al. (2005). Assessment of Medicaid managed
behavioral health care for persons with serious mental illness.
Psychiatric Services, 56(10), 1245-1253.
Moniz, c., & Gorin, S. (2007). Health and mental health care
policy (2nd ed.). Boston, MA: Pearson.
NASW. (2006). Managed care. Social work speaks (6th ed.).
NASWPress.
Pol1en, M., Freeborn, D., Lynch, F., Mullooly,J., & Dickinson, D.
(2006). Medical cost-Offset following treatment referral for
alcohol and other drug use disorders in a group model
148 MANAGED CARE
HMO. Journal of Behavioral Health Services & Research,
33(3),335-346.
Sparer, M. (2003). Managed long-term care: Limits and lessons.
Journal of Aging and Health, 15(1),269-291.
Spitz, H. (1996). Group psychotherapy and managed mental health
care: A clinical guide for providers. New York: Brunner/Maze!'
Substance Abuse and Mental Health Services Administration,
U.S. Department of Health and Human Services. (2005).
Transforming mental health care in America. Federal action
agenda, First steps, DHHS Pub.No SMA-05-4060. Rockville,
MD: Author.
Wooldridge, J., Brown, R., Foster, L., Hoag, S., Irvin, c., Kane,
R., et a!' (2001). Social health maintenance organizations:
Transition into Medicare±Choice. Mathematica Policy Research,
Washington, DC: MPR.
Zuvekas, S., Rupp, A., & Norquist, G. (2007). Cost shifting under
managed behavioral health care. Psychiatric Services,
58(1),100-108.
SUGGESTED LINKS U.S. Health Care
Financing Administration. www.hcfa.gov
Kaiser Family Foundation Commission on Medicaid and the
Uninsured.
www.kff·org
Medicare Payment Advisory Commission.
http://www.medpac.gov
-VIKKI L. VANDIVER
MANAGEMENT. [This entry contains six subentries:
Overview; Practice Interventions; Financial; Human
Resources; Quality Assurance; Volunteers.]
OVERVIEW
ABSTRACT: This entry provides a broad introduction to
management or administration, one of the methods of practice
employed by social workers to achieve professional and
organizational objectives. The contributions of management
to the human services, the history administration as a practice
in social work, and the evolution of education for management
are traced. Management is defined and the roles and functions
performed by practitioners are addressed as well as the
theoretical perspectives they draw upon in the performance of
their craft. Finally, major issues and likely future
developments in this field are reviewed.
KEY WORDS: management; administration; management
roles and functions; organization theory; history of
management; education for management in social work;
management labor force demographics
The terms management and administration will be used
interchangeably here. Managers at all levels are key
players who implement and even/at times shape the intent of
human service policies formulated by public (for example,
congress, state legislators) and private (for example, boards)
governing bodies. Such policies typically set forth broad
goals, populations to be served, programs to be delivered, and
funding and accountability arrangements, but it is the job of
the manager and the staff to translate these directives into
programs and services that are competently and fairly
administered to intended consumers.
Managers also inform and influence the policy for-
mulation process (Ezell, 2001). Policy makers rely on
feedback from administrators who are close to the com-
munities and persons to be served. Managers participate in the
policy process by advocating for changes that will correct
flaws in authorizing policies; identifying unmet needs and
emerging social problems; and representing the interests of
groups that are underserved or disenfranchised. Increasingly,
managers, especially those at executive levels, participate in
the policy process through special interest associations (for
example, welfare directors, community mental health
associations, and so on).
Even as managers are responsible for implementing and
shaping social policy, they also playa vital role in networking
with other agencies serving a common clientele. Human
services "systems" are complex and decentralized, with
multiple funding sources and lines of accountability that pose
potential barriers to consumers. Increasingly, managers act as
systems "engineers," seeking multiagencysolutions to such
problems as service fragmentation, eligibility barriers, and
lack of interagency coordination. In: virtually all human
fields, for example, child welfare, mental health, health, there
is a continuing search for collaborative modes that enable
consumers to more easily access services and allow agencies
to share and exchange information and resources (Alter,
2000).
For at least the last 40 years, human services agencies have
been under increasing pressure to account for how they
expend public and private funds and with what effects. These
expectations have been articulated in federal, state, and local
policies and in the nonprofit sector. Managers at all levels of
human service agencies are responsible for seeing that their
organizations have the necessary political, fiscal, and human
resources to achieve agency goals and objectives. Bringing all
these elements together to create and sustain high-performing
agencies requires consummate leadership.
Social Workers in Management: Demographics Although
there have been intermittent studies of social workers in the
human services management labor force

over the 30 years (Chess, Norlin et a1. 1987; Gibelman and
Schervish 1993; Stamm, 1969), more research is needed to
learn about the number of all social workers in
management (including those not in NASW and those who
are unlicensed), the types and levels of management
responsibility they hold, changes in their gender and ethnic
characteristics of over time, career transition paths, and
educational and experience characteristics. These and
related data would be the most useful to the profession in
planning for the recruitment and development of social
work managers and for tracking the leadership position of
the profession in the human services.
A recent study by the National Association of Social
Work (NASW) Center for Workforce Studies and the
Center for Health 'Workforce Studies provides the most
recent demographic information about social work
managers (Whitaker, We ism iller, & Clark, 2006a); This
study examined the personal attributes and professional
activities of a national sample of licensed social workers,
found that 69% of the respondents devoted at least some
time to administration/ management. Twenty-seven
percent of the respondents spent 20 h or more each week in
management-related functions, including 7% who were
primarily engaged in supervision.
This study may understate the number of professional
social workers in administration since it is likely that some
social work managers, especially those at higher levels, do
not have clinical licenses because they began in their
profession before licensing was widespread or their current
jobs do not require that kind of certification. Nonetheless,
it appears that a significant minority of social workers,
conservatively 25% or so, are mainly involved in
management roles in human service agencies. Clearly, the
profession is a significant source of management labor
force in the human services.
While the distribution of social work managers across
of types of agencies and fields of practice is not well
documented, we know from the workforce study that 66%
of the respondents worked in private agencies including
nonprofit and for profit, while 33% were employed in
public agencies at all levels of government (Whitaker et al.,
2006a). These findings are close to the results of a 2000
survey of members of the National Network of Social
Work Managers (NNSWM); which showed that 74% of its
members were employed in nonprofit and for-profit
sectors, 26% in public agencies.
Social work managers work in a wide variety of
program areas including child welfare (43.8%) and mental
health (39.1%) services, adolescents (32%), aging (21.1
%), and community development (20.5%).
MANAGEMENT: OVERVIEW
149
Although the number of women in social work far
exceeds the number of men, they appear to be under-
represented in the ranks of management. The study of
licensed social workers indicated that men were more
likely than women to be spending any of their time in
administration (76-66%) and supervision (66-56% )
(Whitaker et al., 2006a). In the 1991 survey of NASW
members a significantly higher proportion of males
(32.7%) than females (18.7%) reported their primary job
functions as management and supervision (Gibelman &
Schervish, 1993). A more recent survey of National
Network of Social Work Managers members (Bess, 2000)
indicates that women are substantially less represented in
the membership of that organization than their number in
the profession would suggest.
There also appears to be continuing discrepancy
between the salaries of men and women across all types of
jobs in social work including management. Data from the
study of licensed social workers and a study of NASW
members in one state indicate that men make substantially
more than women in all kinds of fulltime jobs (Koeske &
Krowinski, 2004; Whitaker, Weismiller, & Clark, 2006b.
The reasons for gender disparities in the representation
and. income of men and women in management are
complex, but probably still involve some combination of
early career choices, gender stereotyping, and hiring
discrimination (Austin, 1995). These disparities are
persistent and troublesome in a profession committed to
fairness and the elimination of sexism.
The representation of ethnic and racial minorities in
human services management is also a continuing concern,
given that agencies serve a large and growing number of
people of color. Evidence from a multisite study of public
welfare agencies with a sample of over 1,900 respondents
revealed that European American men occupied 40% of all
administrative jobs and 21 % of all supervisory jobs, but
comprised only 15.7% of the sample. European American
men and women were more likely to hold high-stat us
agency jobs than their minority counterparts (McNeely,
Sapp, & Dailey, 1998). Although public policies regarding
equal opportunity and affirmative action and a growing
awareness of the need to have a minority leadership that
more nearly reflects the communities being served appears
to have intensified awareness of need to recruit and
develop minority workers for management responsibi-
lities, the relatively small percentage of such professionals
in social work is a continuing constraint on this effort.
Additionally, as Mor Barak (2000) has pointed out, the
challenge for human service agencies with a diverse work
force is to see that such workers are fully included so that
their talents are fully developed and utilized.
150 MANAGEMENT: OVERVIEW
Administrative Roles and Functions Human
service management or administration is a multifaceted
practice and process that is primarily concerned with
developing and implementing programs and services for
consumers that will change the status, social conditions,
and behaviors or skills of individuals, families, and/or
community groups. To achieve this objective, managers
engage in a broad array of functions and roles that require
political, analytic, interpersonal, and leadership skills.
ROLES AND FUNCTIONS Managerial roles have been
variously defined (Austin & Kruzich, 2004; Mintzberg,
1973; Patti, 1977) but the framework suggested by
Menefee (2001) is useful because it is grew out of an
\
empirical examination of the actual roles of social work
managers. According to Menefee, managers enact the
following roles:
1. Communicator: Exchanging information with
stakeholders within and outside of the organization to
keep them informed on matters pertinent to common
interests and concerns. This role is instrumental in the
performance of all the roles that follow.
2, Boundary Spanner: Creating and sustaining relationships
with stakeholders in the task environment to build
collaborative arrangements and strategically position
the agency to be influential in key decision forums.
3. Futurist-Innovator: Understanding and adapting to
changes in the social, economic, political,
demographic, and technological environments that
pose threats and opportunities and planning to
anticipate and shape new opportunities.
4. Organizer: Devising agency structures and work
processes that define the distribution of authority and
responsibility; enable coordination of activities and
accountability; planning for, resourcing, and
implementing programs to implement agency mission
and goals; and recruiting, training, and evaluating staff
so to acquire/develop the skills necessary to
competently implement services.
5. Resource Administrator: Acquiring and managing the
human, financial, technological, and physical resources
necessary to carry out agency programs effectively and
efficiently. This role involves a wide array of tasks
including marketing, fundraising, contracting,
financial planning, budgeting and reporting, and
accounting for agency performance.
6. Evaluator: Assessing community need for agency
programs, and monitoring program quality and service
outcomes using a variety of research and information
technologies.
7. Policy Practitioner: Interpreting governmental policies
arid regulations pertaining to agency operations,
providing feedback on the efficacy of policy, and
influencing policy decision makers.
8. Advocate: Fostering an awareness of emerging
problems, unmet needs; working to organize com-
munity action systems to present grievances or press
for change; and lobbying. for new or amended
legislation.
9. Supervisor: Directing, advising, and evaluating
immediate subordinates to improve their performance;
assigning work, devising efficient work processes, and
creating a supportive work climate that is conducive to
staff learning and job satisfaction.
10. Facilitator: Enhancing commitment to agency mission
and values by promoting an agency culture that
encourages participation, collaboration, mutual
support, individual development,. and effective
performance.
11. Team Builder-Leader: Organizing committees, co-
alitions, and work groups both in and out of the agency
and providing leadership to enable effective group
processes that will lead to task accomplishment.
While managerial behavior can be disaggregated for
purposes of discussion, in practice, managers are typi cally
performing at least several roles in any particular context
(Menefee, 2001). In most administrative pro jects or
strategies, these roles are nested such that the performance
of one is complemented by others in a kind of behavioral
configuration. For example, the role of communicator is
essential to the effective performance o f most other roles.
The evaluator and resource administrator roles are
organically related because the decisions required to plan
and allocate resources depend on the information
generated through assessment and evaluation.
LEVELS OF MANAGEMENT RESPONSIBILITY Man-
agement roles become more or less salient under
different circumstances or contingencies. One important
contingency is the organizational level at which the
manager is practicing (Thompson, 1967). Organizations
generally have at least three leve ls of management
authority and responsibility: executive or institutional,
middle or program management, and supervisory
management. The division of labor between
management levels tends to become more sharply
defined as an organization becomes larger and more
complex (Menefee, 2001).
At the executive or institutional level are persons who
carry overall responsibility for directing and
 MANAGEMENT: OVERVIEW
151

coordinating the activities of entire organization or a major common contributions are as facilitators and team
portion thereof, for example, a division, a regional office, builders. In many agencies, they will serve as members or
and so on. Typical titles for managers at this level include chairs of standing or ad hoc committees addressing issues
chief executive officer (CEO), chief operating officer such as quality assurance, personnel grievances, and
(COO) director, associate director, and division manager. budget planning and reorganization.
These managers are likely be most heavily involved in
roles focusing on boundary spanning, innovation, policy
Organizational Theory
practice, advocacy, resource administration, facilitation, and
Theories regarding the key variables associated orga-
team building. They will also perform other roles, but these
nizational performance have developed over the past
are likely to be central their job responsibilities.
century or so in response to changing political and
The middle management or program level of management
economic realties. These explanatory systems are rooted
includes persons who have responsibility for directing a
in different disciplinary traditions and professions (for
major subunit of an agency such as a department, bureau,
example, sociology, psychology, political science, eco-
or program. Persons at this level are often referred to as
nomics, public administration, and business administra-
departmentmanager, program director, bureau chief,
tion) and tend to focus on selected conditions and
section chief. Highly salient roles at this level of
processes to explain, predict, and change organizational
management are organizing, administering resources, and
behavior. These perspectives tend to be seen as competing
evaluation. Team building and facilitating with supervisory
explanations, prescriptions, and/or ideologies and values
staff under their direction or with peers in other department
for understanding and shaping organizational behavior
or agencies are also likely to be an important role. Middle
(Quinn, 1988).
managers are often experts in programs/services they
Management practitioners draw (implicitly or expli-
administer and will often be called upon for advocacy and
citly) upon multiple theoretical perspectives for insight
policy changing activities.
into and guidance for how to deal with various challenges
The supervisory or technical level of management is in the
(Hasenfeld, 2000). What follows are brief sum maries of
closest proximity to the front-line, serviceproviding staff.
the five perspectives that inform human services
Often referred to as supervisor, coordinator, team leader, or
management. These perspectives neither ex haust all those
project manager, they are usually responsible for seeing
that are applicable to management, nor do they address all
that the smallest work units in the organization operate
the variations and subschools embedded in each. The
efficiently and effectively. Key roles at this level include
reader is advised to refer to more detailed treatments
supervisor, facilitator, and team builder within their respective
(Scott & Davis, 2007).
units. Where they are delegated responsibility for planni ng
and . allocating resources, supervisors may also organize
and administer resources. The evaluator role will come into RATIONAL STRUCTURAL PERSPECTIVE The rational
play in assessing the performance of direct service staff.
structural perspective has its roots in the work of
Super-. visory managers arguably exert the most important
early-20th-century scientific and administrative
influence on how front-line staff perform because they management theorists such as Frederick Taylor, Henri
shape the day-to-day working conditions and climate in Fayol, and others and the scholarship of sociologist Max
their work units.
Weber (Shafritz, 1978), all of whom were concerned
Managers at all levels are assisted in their line re-
with how rational structures and processes may produce
sponsibilities (that is, those that involve the direction and
greater efficiency, productivity, and goal accomplish-
implementation of the agency's programs) by staff
ment. Out of this tradition emerged such concepts as
personneL Depending on their areas of expertise, staff hierarchy of authority, unity of command, division of
personnel provide information and supportive services to labor and specialization, defined jobs with performance
line personnel in the performance of all the roles discussed
standards, and systematic selection and training for jobs
here in areas like human resources, development (that is,
and rewards based on performance. These approaches to
fundraising) planning, information systems, financial
organization and management were thought to be
management, research, and evaluation.
preferable to all other forms and universally applicable
Employees without management portfolios (for ex- across all organizations. Following World War II opera-
ample, service providers and technical support staff) also tion research, management science, and systems engi-
participate in the managerial processes. Their most
neering, all built on the assumptions of this earlier work
and systems theory (see later).
The rational structural perspective has been widely
criticized for inattention to how the external environment
152 MANAGEMENT: OVERVIEW
impinges on organizations (closed system thinking),
mechanistic assumptions regarding worker compliance
with superiors directives, the potential of cent ralized
authority to suppress initiative and creativity, the failure to
deal with other than economic sources of motivation, and
the influence of social and group pro cesses on worker
behavior (Scott & Davis, 2007). Later management
theorists argued that rational approaches to management
were necessarily preferable in all types of organizations
under all circumstances (Simon, 1978). Centralization of
authority, tightly drawn rules and the like may have
deleterious effects on the motivation of employees.
Further, in the human services, application of this
perspective is thought to be limited because of the
multiple and sometimes conflicting goals and indeter-
minate technologies found \ in many agencies, th us
making it impossible to assume that all organizational
actions are directed at a single overriding purpose
(Hasenfeld, 2000).
Still, this model of organization and management,
with many recent adaptations to the allow for worker
participation, supportive work environments, and re-
sponsiveness to external influences, continues to exert an
influence on how human service agency are managed.
HUMAN RESOURCESjRELA TIONS PERSPECTIVE The
work of early human relation researchers such as Elton
Mayo and Frederick Roethlisberger (Shafritz &
Whtbeck, 1978), though also principally concerned with
increasing productivity, drew attention to the social and
psychological factors that influence the motivation and
performance of workers in industrial settings. Among
their cardinal contributions to under standing worker
performance were the impact of infor mal groups and
intergroup relations on organi zational climate and
performance norms; the recognition that workers were
motivated by social and psychological incentives as
well as economic ones; and the recogni tion that
leadership which attend to social factors was less
hierarchical and provided oppo rtunities for workers to
participate in decisions, would increase job satisfac tion,
and promote worker productivity. The social and
behavioral aspects of management were further ex-
plored and elaborated by prominent theorists like Mary
Follett (whose career had involved settlement work),
and some years later by behavioral scientists such as
Abraham Maslow, Warren Bennis, and Rensis Likert
(Natemeyer, 1978), who argued for a more complex
view of motivation, supportive work environments, and
democratic leadership to develop a better fit be tween the
needs of workers and those of the organization (Scott &
Davis, 2007).
This model of management and organization was
widely embraced in the human services (Patti, 1983 ).
Indeed, an examination of the roles perfor med by social
work managers presented earlier, suggests that practice is
heavily oriented to creating positive work environ ments
that stress teamwork, communication, support, and
personnel development. Social work manage ment
scholars tend to stress the r elationships between
democratic leadership, supportive work environments,
autonomy and discretion and worker satisfaction, em-
powerment, and commitment (Vinocur-Kaplan, 2000 ).
There is some evidence to suggest that these factors
contribute to greater servi ce effectiveness (Glisson,
1998), but additional research is needed to establish a firm
causal connection between management practices,
organizational conditions, and service outcomes.
The human relations perspective largely focuses on
conditions within organizations that motivate workers to
perform better, but it gives little attention to politi cal and
economic realities such as poorly conceived social
policies, inconsistent and inadequate funding, and
institutional constraints that have direct and indir ect
effects on working conditions and worker morale
(Hasenfeld,2000).
OPEN SYSTEMS PERSPECTIVE The open systems per-
spective, developed largely after World War II, became
an increasingly influential approach to understanding
organizations in the latter half of the 20 th century and
remains an important perspective today. In this
perspective, both internal and external factors and their
interaction to understanding organizational beha vior are
dealt with. Subsystems within organizations are seen as
in a continuous, dynamic interaction such that changes
in any part of the organization will affect changes in
others. But unlike the mostly closed systems thinking of
the rational structural and human relation schools, this
perspective views organizations as inter acting with their
environment to acquire resources (for example,
personnel, money, materials, ideas, technol ogy) and
transforming them into products or services that are then
exported to communities where they contribute to the
maintenance of societal in stitutions. The dependence on
external sources of support requires that organizations
adapt to developments in their environments (for
example, changing policies, new markets, demographic
and technological trends) by aligning their goals,
structures, and internal processes with contingent
environmental conditions (Schmid, 2000; Scott &
Davis, 2007).
Critics of open systems theory have argued that some
organizations do not have highly interdepen dent
subsystems, but rather are "loosely coupled" with

autonomous or at least minimally interactive subsys tems.
Others argue that open system thinking supposes a degree
of complementarily between elements within the
organization and between the organization and the
external environment that does not account for con flict,
inertia, and informal goals pursued by system par ticipants
(Hasenfeld, 2000; Schmid, 2000).
The open systems perspective has very much shaped
management in the human services. Managers give a
great deal of attention to anticipating and adapting to
trends in the environment; responding to changes in
market conditions; and developing teamwork and
cooperation between program elements to encourage
mutual adjustments.
POLITICAL AND INSTITUTIONAL PERSPECTIVES In the
political-economic perspective, organizational en-
vironments are composed of self-interested coalitions
who seek the resources needed to promote their res-
pective goals and purposes, rather than coordinated
systems working toward superordinate goals (Pfeffer,
1978). These groups coexist within the formal structure
of the organization, but their goals and priorities may
diverge from those formally promulgated. Groups
pursue power to impose or protect their interests.
Interest groups develop around fun ction, location,
status, profession, ideology, gender, or race in different
combinations. In the interplay between these groups,
negotiated orders and coalitions emerge that shape the
strategic direction of the organization. Dominant
coalitions change from time to time in response to
changing internal and external conditions (Gummer,
1990).
Organizations rely on their task environments for the
legitimacy, information, and financial resources needed
to establish and maintain their domains. This
fundamental need necessarily places the organization
into interdependent relations with other organi zations. To
manage these relations, organizations engage in multiple
negotiated exchanges with providers of re sources. In
these exchanges, the parties seek to influ ence each other
in ways that fit their respective interests. To better
manage their task environments, organizations often
employ a variety of strategies to protect against threats
and enhance their power positions. These include
competition, bargaining, cooptation, and coalition (Alter,
2000; Schmid, 2000).
The political perspective has bee n criticized for its
preoccupation with power as the principle driver of
internal and external organizational dynamics. Collective
action can also be based on mutual trust, shared values,
tradition, and sacrifice. Still, over the last quarter century
the environments of human service agencies have
become more complex, uncertain, and competitive, and
MANAGEMENT:OVER~EW 153
the struggle for resources ever more difficult. This com-
plexity has been mirrored within organizations that are
increasingly characterized by multiple programs serving
different client groups, a multi professional and diverse
workforce, and competing ideologies about how best to
deal with social problems (Gummer, 1990). In these
contexts, managers who assume that these many inter ests
will find an easy accommodation with formal authority
and strive for a common purpose may miss a key dynamic
of organizational behavior. The policy practice,
advocacy, boundary spanning roles, discussed previously,
are the principal means that managers use to address
external political processes that impact their agencies.
The facilitator and team- building roles are instrumental in
bringing together people with diverse. agendas so that
energy and talent can be focused on delivering effective
services to consumers.
Organization-environment relations may also be
examined from the perspective of institutional theory,
which argues that organizations achieve legitimacy and
support by aligning their structures and processes with
widely accepted beliefs and ideologies promulgated by
powerful institutions. These beliefs may be in the form of
governmental laws and regulations, for example,
appropriate certifications for staff; accountability re-
quirements, values, and expectations, for example, ways
of relating to other organizations; and ideas about how to
understand and interpret information, for example, the
causes of social problems. Human service agencies that
successfully incorporate these institutionalized beliefs
(often referred to as "rationalized myths") increase . their
prospects for survival and resource acquisition
irrespective of the effectiveness of core service tech-
nologies. While there is evidence to support the insti-
tutional perspective, there is debate over whether agencies
passively adapt to external expectations or actively
participate in fashioning and promoting their adoption
(Hasenfeld, 2000; Schmid, 2000). In either case,
managers must attend to ideas and expectations in the
intuitional environment lest they put their agencies at risk.
Many of the same roles used to address the political
environment are also applicable in finding an
accommodation with institutional expectations.
In the last quarter century, there has been a growing
interest in both the popular and the scholarly literatures in
the place of culture as a determinate of behavior in
organizations (Glisson, 2000; Morgan, 1998). Organi-
zational cultures are composed of shared values and
beliefs, norms, and assumptions that may be deeply
rooted in structures and processes of organization and in
the expectations and behaviors of groups and indivi duals.
Although all organizations have cultures, they vary in a
number of respects including the extent to
154 MANAGEMENT: OVERVIEW
which they are monolithic or fragmented, well articu lated
or inchoate, enabling or constraining (Scott & Davis,
2007). Cultures also vary in their substantive values and
beliefs regarding matters such as relations among
colleagues (for example, competition versus co operation),
responsibilities to consumers (for example, uniform
versus individualized), approaches to problem solving
(for example, innovative versus rule bound). Ma nagement
theorists who advance the cultural per spective argue that
the more pervasive, well developed, and reinforced the
cultures or subcultures are in an organization (that is, the
"stronger the culture"), the more patterned and predictable
employee behavior will be. Cultures are also reinforced
by selecting employees whose values appear consonant
with those of the organization, and by training
and'supervising-socializing new recruits to "the way
things are done."
The culture perspective has been widel y embraced
because it appears to offer a management strategy for
building commitment to organizational goals and in-
spiring employees to pursue those goals. "T ransforma-
tional" leadership is considered by many to be the key to
building strong cultures tha t raise the performance levels
of organization (Bargal, 2000; Bass, 1985). In this view ,
culture is significantly shaped by leaders· who
persuasively model desired behavior, focus on indica tors
of process or performance that are important to agency
success, perpetuate agency myths and folklore, and
recognize and reward employee actions that exem plify
key values.
While transformational leadership shows promise as a
means for mobilizing human service agencies toward goal
achievement, there is not much evid ence in the human
services that leaders with this behavior profile in fact
produce these results. Glisson's (1989) research
demonstrated that agency leaders, with characteristics
similar to those described earlier, contributed to higher
employee satisfaction and commitment and Latting's
study suggested a relationship between leaders support for
learning and innovation and the quality of service to
clients. There is also theoretical and anecdotal support
that this approach builds high-performance cultures in
social agencies (Dym & Hutson, 2005). But the paucity of
research on leadership in the human services leaves
uncertainty about the relative contributions of leader
behavior as compared to other factors such a
environmental forces, agency history, and characteris tics
of employees. More research on leadership and
organizational performance is needed.
Social Workers in Management: A Brief History Social
workers have been administrators for as long social work
has been an organized profession. In
the late-19th and early-20th centuries, as voluntary social
agencies emerged as major providers of services to the
poor, social workers began to assume positions of
leadership in these agencies. Charity organization
societies (COS), closely aligned with the emerging
profession, looked to experienced social workers to
administer their agencies. Mary Richmond, an iconic
figure in the field, though mostly remembered for her
contributions to the theory and practice of social case-
work, was for many years an executive dir ector of COS
agencies in Baltimore and Philadelphia. Jane Addams,
who achieved international renown for her work on
poverty and peace, was the founder and long-time ex-
ecutive of Hull House, a social settlement in Chicago.
Social workers were also instrumental in the initia tion and
management of other earlv-Zuth- centurv social agencies
in child welfare, mental health, and health and youth
programs (Austin, 2000).
As state and local public welfare agencies were es-
tablished to deal with widespread poverty and unem-
ployment in the Great Depression in the 1930s, social
workers were recruited into this sector as front- line
workers, supervisors, and administrators. Although so cial
workers were never the predominate sou rce of labor in
these agencies, until the 1960s social case work was
considered an important method for delivering services,
arid trained social workers played a key role in super-
vising and managing these programs.
The quarter century after World War II witnessed a
major expansion of federal and state funding for social
services. This occurred in a number of fields including
public welfare, community action agencies for the poor,
community mental health services, child welfare, and job
training programs. The growth of the human ser vices
sector provided many social workers with manage ment
opportunities. A survey of NASW members in 1969
indicated that 50% of the respondents were en gaged in
administrative roles, a substantial increase from earlier
surveys (Stamm, 1969). Increased involve ment of social
workers in management was accompa nied by attention to
the quality of the preparation they brought to these
responsibilities. Federallyfunded projects in the 1970 s
aimed at upgrading the education of social workers in
management stimulated schools of social work to develop
curricula in this area, and in a few years the number of
schools with management programs increased from 19 to
at least 35 (Patti, 1983).
During the 1980s and 1990s, partly in response to the
dramatic increase in spending for human services in the
preceding decades, and the conservative critique of the
welfare state, federal, state, and local govern ments
accelerated the practice of outsourcing human service
programs to nonprofit and for-profit agencies.

Contracting for services, privatizing responsibility for
social programs was seen by many officials as a more
efficient and flexible way to deliver human services
(Austin, 2000).
In the for-profit arena, programs for alcoholism and
drug dependence, nursing homes, and home health care
expanded significantly. Increased government funding for
nonprofits in child welfare, mental health, and other fields Bess, 2004; Patti, 2003). Macro specializations seek to
increased both the size and complexity of such agencies
and the skills needed to administer them. During this
period, social workers in both management and direct
service gravitated to private agencies (non profit and for
profit) and away from public domain. By 1991, '-"like financial management, information technology,
three-fifths of NASW's members were employed in
nonprofit or for-profit settings (Gibelman & Schervish,
1993). This 'trend has accelerated since that time.
CHALLENGES In this last decade, there has been an
extension and intensification of these developments, but
several additional trends have made the management of speculation that graduates of management education in
human services agencies even more challenging. Among
these is the growth of managed care networks to control
costs and make more efficient use of resources; increased
efforts by agencies serving common clientele to form
collaborative arrangements to share information and
resources; the merger and consolidation of small agencies
into larger ones; the growing stress on demonstrating the
efficacy of programs and services to consumers and
fenders; and the incorporation of rapidly developing
information technology into decision-making practices at
direct service and management levels (Martin, 2000).
Each of these developments requires correspondingly in public and business administration, and others with an
more skill and expertise of managers while maintaining
core social work values and principles.
Social Work Education for Management Observers
have questioned whether social work education has kept
pace with the need for more and better trained social
workers in management (Austin, 2000; Patti, 2003;
Perlmutter, 2006). While most schools now have a
curriculum specialty in macro practice, many of which
include planning and community organization as well as
management, the number of students enrolled in
administration or management specializations in schools
of social work in recent years is about 1000 or 3% of total
enrollments, a figure that has actually declined over the
past 25 years (Ezell, Chernesky, & Healy, 2004). The
small number of graduates is clearly not enough to fill the
available management jobs in human services. A recent
study of managers in the National Network of Social Work
MANAGEMENT: OVERVIEW 155
Managers (NNSWM) found that less than 20% of those
who participated in the survey came out of macro
specializations (Mor Barak, Davis, & Bess, 2004).
Moreover, concerns have been raised about whether
most schools of social work provide the curricular depth
and teaching resources necessary to adequately prepare
students for management careers (Mor Barak, Davis, &
prepare for several kinds of practice such as planning,
policy practice, community organization as well as
management. While these are cognate areas of practice,
in-depth coverage in essential management subjects
personnel management, marketing, fundraising, and board
development is not possible in programs with a 1 year
curriculum in administration.
Field education, where much of the socialization to the
managerial craft takes place, is also a continuing concern
(Mor Barak, Davis, & Bess, 2004). The quality of
preparation issue no doubt contributes to the longstanding
social work may not be widely perceived as a preferred
source of management talent and organizational leadership
in the human services (Hoefer, 2003; Wuenschel, 2006).
As more and more graduates in business, public
administration, and nonprofit management programs enter
the human services arena, there is a concern tha t the
perspective and leadership of social workers may be in the
decline.
The management job market continues to be filled with
a mix of persons including clinical workers pro moted
through the ranks, persons with educational backgrounds
assortment of professional and undergraduate degrees.
There is no definitive data on the education background of
human services managers, but there is anecdotal evidence
that the percentage of social workers at mi ddle and upper
levels of administration, especially in the public social
services, has declined in recent years (Perlmutter, 2006).
Trends and Future Directions
For the foreseeable future social work managers will
operate in an increasingly competitive, privatized, di verse,
technology-rich, outcomes-oriented environment. Public
and private agencies will compete with one another for
funding, for consumers, and for influence. Agencies that
fare well in this environment will require good information
about demographic, economic, and political changes so
that they can anticipate and plan strategically for the
future. Marketing, advocacy, entrepreneurial initiative,
and the ability to demonstrate effective performance will
enable agencies to
156 MANAGEMENT: OVERVIEW
seize opporturuties and acquire the resources they need to
prosper. In the struggle to be competitive, managers will
be challenged to maintain a strong moral and ethical
compass so that doing well also means doing good.
Closely connected to the competition is privatiza tion.
Currently; especially at the highest levels of public policy,
privatizing human services is advocated as a way to
constrain the growth of public bureaucracies, and as a
springboard to lower cost, greater efficiency, consumer
choice, and effectiveness. There are reasons to be con-
cerned with the unfettered development of privatiza tion in
the human services (Gibelman, 2000), but conventional
policy wisdom is that publics are better served when
private, for-profit, nonprofit, and faithba sed agencies are
delivering- social services. For public agency managers
this will mean an even greater role in developing
community agency capabilities, setting rea listic goals,
and developing performance contracts that hold private
agencies fiscally and programmatically ac countable.
Private agency managers will be pressed to make good on
contractual commitments by managing public monies
responsibly and maintaining efficient operations.
Managing multiple grants and contracts, as is now the
norm for most private agencies, will require
administrators to balance competing interests and build
internal cohesion in loosely coupled organizations.
Diversity will be a continuing challenge for human
service agencies. As the population of the United States
becomes more pluralistic, agencies will face a continuing
need to adopt policies and practices that are sensitive to
the needs diverse groups. This will require that agencies
listen to and involve consumers and community
representatives in their decision processe s and monitor
their service technologies to ensure that they are suited to
clients' cultural values and sen sibilities. An important
requisite of cultural compe tence will be the ability to staff
agencies at all levels with persons whose training and life
experience enable them to relate effectively to clients
from different cultures.
While many agencies have made strides in recruit-
ment, persons of color continue to be underrepresented
and the agency work force is less diverse than the
populations they serve. The NASW Workforce Study
(Whitaker et al., 2006a) shows that 86% of licensed social
workers in the United States are white, non Hispanics (p.
9), while Blacks and Hispanics are only 7% and 4% ,
respectively. The challenge for both schools of social
work and human service agencies is to bring more people
of color into the profession and to develop inclusive
agency cultures that support and value diversity.
Information technology is advancing at a rapid rate
and has begun to significantly impact human se rvices.
Managers, planners, and other macro practitioners in-
creasingly rely on this technology to operate organiza tions
effectively (Martin, 2000; Schoech, 1999; Zhang &
Guiterrez, 2007). The Internet provides ready access to
information on community needs, new service technol-
ogies, and industry-wide performance standards that will
be useful in monitoring the task environment and plan ning
for improved services. Computers have, and will
increasingly become a valuable resource to service pro-
viders, offering case-specific information on clients
served by other agencies or programs, suggesting inter-
ventions that may be appropriate in particular types of
cases, and directing clients to community services and
self-help resources (Schoech, Basham, & Fluke, 2006).
Managers will have to become more sophisticated about
the use of information technology and how it can be
seamlessly woven into agency decision- making practices.
For the past several decades, there has been mounting
interest in seeing that consumers of human service
agencies are served effectively. Federal, state, and local
public authorities as well as foundations are increasingly
insistent that agencies demonstrate the effectiveness of
their programs. Social work and other human service
professions widely recognize that in order to meet external
I
expectations and continuously improve on service
performance, agencies need to systematically evaluate
their practice. The empirically based practice movement
(EPB) (Schoech, Basham, & Fluke, 2006), the growing use
of performance contracting, and the deployment of
information systems that measure outcomes as well as
processes, are all indicators of this trend. As agencies are
better able to track the results of their programs,
administrators will be called upon to create the conditions
and processes needed to support these practices.
Finally, the human service administrator is directly or
indirectly involved in making com plex decisions effecting
the lives and prospects of consumers and staff (Hasenfeld,
1992; Patti, 1983; Reamer, 2000). For this reason, his/ her
values and ethics are constantly being brought into play in
decision making. In the future, these decisions will
become even more challenging in the face of limited
resources, activated constituencies, and increased
knowledge. These issues are typically complex and
ambiguous, and often involve conflicting values. The
consequences of one or another choice are not alwa ys
clear in advance. For these reasons, man agers will
increasingly need to refine their skills in ethical reasoning
and be clear about their own ethical principles in order to
work through these dilemmas (Lewis, 1987; Reamer ,
2000).

REFERENCES
Alter, C. F. (2000). Interorganizational collaboration in the task
environment. In R.]. Patti (Eel.), The handbook of social welfare
administration (pp. 283-302). Thousand Oaks, CA:
Sage Publications.
Austin, D. (1995). Management: Overview. In R. Edwards (Ed.),
Encyclopedia of sodal work (pp. 1642-1658). Washington,
DC: NASW.
Austin, D. M. (2000). Social work and social welfare administration.
In R. ]. Patti (Ed.), Handbook of sodal welfare administration (pp.
27-54). Thousand Oaks, CA: Sage Publications.
Austin, M. ]., & Kruzich,]. M. (2004). Assessing recent textbooks
and case books in human service administration: Implications and
future directions. Administration in Sodal Work, 28(1), 115-129.
Bargal, D. (2000). The manl\ger as leader. In R. Patti (Ed.), The
handbook of social welfare management. Thousand Oaks, CA:
Sage Publications.
Bass, B. (1985). Leadership and performance beyond expectations.
New York: Free Press.
Bess, G. (2000). National Network of Social Work Managers
membership survey. Chico, CA: NNSWM.
Chess, W. A, Norlin,]. M., &]ayaratne. S. D. (1987). Social work
administration: Alive, happy and prospering. Administraton in
Social Work, 11 (2),67-77.
Dym, B., & Hutson, H. (2005). Leadership in non profit organ-
izations. Thousand Oaks, CA: Sage Publications.
Ezell, M. (2001). Advocacy in the human services. Belmont, CA:
Brooks/Cole.
Ezell, M., Chernesky, R. H., & Healy, L. M. (2004). The learning
climate for administration students. Administration in Social Work,
28(1), 57-76.
Gibelman, M. (2000). Structural and fiscal characteristics of social
service agencies. In R. Patti (Ed.), The handbook of social welfare
management (pp. 113-132). Thousand Oaks, CA: Sage
Publications.
Gibelman, M., & Schervish, P. H. (1993). Who are we!: The social
work labor force as reflected in the NASW membership.
Washington, DC: NASW.
Glisson, C. (1989). The effect of leadership on workers in human
service organizations. Administration in Social Work,
13(3/4),21-37.
Glisson, C. (2000). Organizational climate and culture. In R. ]. Patti
(Ed.), Handbook of social welfare administration (pp. 195-218).
Thousand Oaks, CA: Sage Publications.
Glisson, c., & Hemmelgarn, A (1998). The effects of organizational
climate and interorganizational coordination on the quality and
outcome of children service systems. Child Abuse and Neglect,
22(5), 410-421.
Gummer, B. (1990). The politics of social administration:
Managing organizational politics in social agencies. Englewood
Cliffs, N]: Prentice Hall.
Hasenfeld, Y. (1992). The nature of human service organizations.
Human services as complex organizations (pp, 3-23). Newbury
Park, CA: Sage Publications.
Hasenfeld, Y. (2000). Social welfare administration and organ-
izational theory. In R. ]. Patti (Ed.), The handbook of social
MANAGEMENT: OVERVIEW 157
welfare management (pp. 89-112). Thousand Oaks, CA:
Sage Publications.
Hoefer, R. (2003). Administrative skills and degrees: The "Best
Place" debate rages on. Administration in Social Work,
27(1),25-46.
Koeske, G., & Krowinski, W. (2004). Gender-based salary inequity
in social work: Mediators of gender's effect on salary. Social Work,
49(2), 309-317.
Lewis, H. (1987). Ethics and the managing of service effectiveness in
social welfare. In R. Patti,]. Poertner, & C. A Rapp (Eds.),
Managing for service effectiveness in sodal welfare organizations
(pp. 271-284). New York: Haworth Press.
Marrin, L. L. (2000). The environmental context of social welfare
administration. In R. ]. Patti (Ed.), Handbook of social welfare
administration. Thousand Oaks, CA: Sage Publications.
McNeely, R. L., Sapp, M., & Dailey, A. (1998). Ethniciry, gender,
earnings, occupational rank and job satisfaction in public social
services: What do workers say? In A. Daley (Ed.), Workplace
diversity issues and perspectives (pp. 144165). Washington, DC:
NASW Press.
Menefee, D. (2001). What managers do and why they do it. In R.
Patti (Ed.), Handbook of sodal welfare management. Thousand
Oaks, CA: Sage Publications.
Mintzberg, H. (1973). The nature of managerial work.
New York: Harper and Row.
Mor Barak, M. E. (2000). The inclusive workplace: An ecosystems
approach to diversity management. Social Work, 45(1),339-353.
Mor Barak, M., Davis, D., & Bess, G. (2004). Exploring manager's
and administrator's rettospective perceptions of their MSW field
experience: A national study. ASW, 28(1), 21-44.
Morgan, G. (1998). Images of organization. Thousand Oaks, CA:
Sage Publications.
Natemeyer, W. E. (1978). Classics of organizational behavior.
Oak Park, IL: Moore Publishing Co.
Patti, R.]. (1977). Patterns of management activity in social welfare
agencies. Administration in Social Work, 1 (1), 5-18.
Patti, R. ]. (1983). Sodal welfare administration: Managing social
programs in a developmental context. Englewood Cliffs, N]:
Prentice Hall.
Patti, R.]. (2003). Reflections on the state of management in social
work. Administration in Social Work, 27(2), 1-11.
Perlmutter, F. (2006). Ensuring social work administration.
ASW, 30(2), 3-10.
Pfeffer, J-, & Salancik, G. R. (1978). The external control of
organizations. New York: Harper and Row.
Quinn, R. (1988). Beyond rational management: Mastering the
paradoxes and competing demands of high performance. San
Francisco, CA: [ossey-Bass.
Reamer, F. G. (2000). Adminitrative ethics. In R. ]. Patti (Ed.), The
handbook of sodal welfare management (pp. 6988). Thousand
Oaks, CA: Sage Publications.
Schmid, H. (2000). Agency-environment relations: Understanding
task environments. In R.]. Patti (Ed.), The handbook of social
welfare management (pp. 133-154). Thousand Oaks, CA: Sage
Publications.
Schoech, D. (1999). Human services technology. New York:
Haworth Press.
158 MANAGEMENT: OVERVIEW
Schoech, D., Basham, R., & Fluke, ]. (2006). A technology
enhanced EBP model. Journal of evidenced based social work,
3(3/4),55-72.
Scott, W., & Davis, G. F. (2007). Organizations; Rational, natural
and open systems. Upper Saddle River, N]: Prentice Hall.
Shafritz,]. (1978). Classics of organization theory. Oak Park, IL:
Moore Publishing Co.
Simon, H. A. (1978). Administrative behavior. New York: Free
Press.
Stamm, A. ]. (969). NASW membership: Characteristics,
deployment, and salaries. Personnel Information, 12,34-45.
Thompson, ]. D. (1967). Organizations in action. New York:
McGraw Hill.
Vinocur-Kaplan, D. & Bogin, D. (2000). Motivating work
performance in the social services. In R. ]. Patti (Ed.), The
handbook of social welfare manpgement (pp. 169-193). Thou-
sand Oaks, CA: Sage Publications.
Whitaker, T, Weismiller, T., & Clark, E. (2006a). Supplement w
the national study of licensed social workers. Washington,
DC:NASW.
Whitaker, T, Weismiller, T, & Clark, E. (2006b). Assuring the
sufficiency of a front line workforce: Executive Summary.
Washington, DC: NASW.
Wuenschel, P. (2006). The diminishing role of social work
administrators in social service agencies: Issues for consid-
eration. Administration in Social Work, 30(4), 5-18.
Zhang, W., & Guiterrez, O. (2007). Information technology
acceptance in the social services sector: an exploration. Social
Work, 52(3),221-229.
-RINo]. PATTI
PRACTICE INTERVENTIONS
ABSTRACT: This entry reviews major intraorganiza-
tional and extraorganizational management strategies
found in the prescriptive as well as empirically based
literature that promote organizational effectiveness and
responsiveness to clients. Obtaining support and
stakeholder management constitute two majo r areas for
extra organizational practices.
Among the most often discussed targets for intraor-
ganizational management interventions are leadership
practices, board practices, organizational culture, orga-
nizational structure, and worker attitudes.
KEY WORDS: organizational effectiveness; manage ment
practices; social services; intraorganizational practices;
extraorganizational practices
Introduction
T oday's social service organizations are facing a twofold
challenge of having to deliver quality servic es to their
clients and to continuously adapt to an ever- changing
external environment. Major internal and external
challenges require that social work managers create and
sustain internal systems and develop strategies to increase
organizational effectiveness and to maintain their client
focus. Because organizational context has been shown to
be related to organizational effective ness, the major task
for social work managers is to shape and influence the
work environment to make it conducive to the effic ient
delivery of services to clients. Additionally, as external
relations are becoming increasingly important, social
work managers must learn to manage the environment to
diversify funding resources, nurture collaborations with
other organizations, stre ngthen organizational legitimacy,
and increase stakeholder involvement.
Theoretical Perspectives
on Organizational Effectiveness
The major approaches to organizational effectiveness
include emphasis on goal attainment, system- resource
enhancement, improving organizational reputation, and
addressing the interests of multiple constituencies
(Forbes, 1998). Reviews of the literature re veal that
organizational effectiveness of social service organiza-
tions has been assessed using all of these four ap proaches.
It can be examined with numerous criteria used as its
indicators, including client outcomes, service quality,
service coordination, degree of goal attain ment, service
comprehensiveness, service coverage, worker and client
satisfaction, response to clients' needs, external
adaptation (system openness and com munity interaction),
ability to acquire resources, and maximization of retu rns
over the long term. Unfortunately, there is no unified
agreement as to what criteria are the best for assessing
effectiveness. In fact, quite often the criteria used to
measure effectiveness in hu man services are conflicting
and contentious.
In order to promote. effectiveness, organizational
processes should support strong internal operations as
well as develop useful linkages with the external
environment (Ridley & Mendoza, 1993). Thus, this
review focuses on extraorganizational as well as intra-
organizational management practices designed to im-
prove an organization's effectiveness.
Extraorganizational Management Strategies
Management practices focusing on obtaining external
support and managing stakeholders are most often dis-
cussed in the literature on effectiveness.
OBTAINING SUPPORT In order to be effective, any
organization first has to survive, which requires obtain ing
resources. A number of strategies for obtaining and
managing the external environment and gaining

resources include: diversification of funding, seeking new
revenue sources, creative fundraising, cutting costs,
taking an active part in the process during which the
funders' demands and expectations are formulated, and
effective lobbying. It is also important to involve im-
portant decision makers in the organization's activities by
inviting them to serve on the board or committees
(Herman & Renz, 1998; Patti, 1987). Furthermore, Meier
(1993) argues that engaging geographically dispersed,
diverse, multiple, and mobilizable interest groups should
help an organization obtain resources and autonomy more
easily.
Using effective marketing strategies also helps social
service organizations develop new and important sup port
and become more responsive to stakeholders' needs.
Marketing strategies such as competitive analy sis,
positioning analysis (trying to learn about the target
audiences' perceptions of the organization), using dif-
ferent types of market segmentation beyond just demo-
graphy, testing new programs before making major
investments, and experimentation (exploring numer ous
alternatives) can be used to achieve those goals
(Andreasen, Goodstein, & Wilson, 2005). When creating
their marketing strategies practitioners have to make sure
to include all clients groups, not just selected few that tend
to attract resources. Schmid (2002) sug gested that in high
uncertainty environments, social service managers should
seek to negotiate with competitors, ensure steady resourc e
flow, map the external environment, and form
partnerships with other organi zations. Ridley and
Mendoza (1993) similarly proposed that effective
organizations develop moderately perme able boundaries,
which allow enough necessary inputs and outputs to be
obtained and dispersed. They also stressed the importance
of a boundary spanning role or the organization's ability to
sense and deal with changes in the external and internal
environments. One way to increase sensitivity is to
implement proactive organiza tional strategies oriented
toward exerting influence on and changing the external
environment. Implementing proactive organizational
strategies oriented toward ex erting influence on and
changing the external environ ment in which the
organization operates would be one way to increase
sensitivity. Additionally, having a worthwhile and
attractive mission statement will attract support from
variety of stakeholder groups. Finally, public relations
campaigns, educational initia tives, and favorable media
coverage can be used to increase organizational
effectiveness.
STAKEHOLDER-ORIENTED MANAGEMENT
PRAC. TICES The multiple constituency approach
defines organizational effectiveness as the extent to which
MANAGEMENT: PRAcrICE
INTERVENDONS 159
organizations are responsive to the needs of multiple
stakeholders (Herman & Rem, 1998). In order to be
perceived as effective, social service organizations should
continuously seek to identify relevant stakeholders, assess
their needs and expectations, prioritize issues in the light
of demands created by external and internal influences,
and decide which areas of need should be addressed.
These tasks can achieved by creating formal and
informal mechanisms for cultivating open and productive
external relationships with a variety of stakeholders,
including oversight authorities (execu tive, judicial, and
legislative), funders, partners and competitors, the board
of directors, and client groups. Managers of social service
organizations should identify each o f their constituent
groups and then carefully explore their interests and
needs. They should understand each group's needs, and
then develop strategies for addressing the needs of the
most important constituent groups.
Clients can be reached via organiza tional reports, data
sheets, community outreach activities (e.g., focus groups,
public forums), and newsletters. Additionally, members of
the board of directors can be very instru mental in
conveying opinions from the communities they represent
to the management.
In his ARC (Availability Responsiveness and Con-
tinuity) organizational intervention model, Glisson (2002 )
suggested that stakeholder involvement may be improved
by creating teams of direct-service provi ders and
community opinion leaders and invi ting them to
collaborate in identifying and addressing the most
pressing work-related issues and barriers existing in the
community. Additionally, he proposed partici patory
decision making to be important for organiza tional
effectiveness and suggested th at by giving the service
providers and community leaders opportunities to provide
input regarding organizational administrative decisions
would influence how services are provided.
Client satisfaction, needs assessment, and other types
of surveys can be used to learn about stakeholders' needs
and their perceptions of service effectiveness (Herman &
Renz, 1998). Holding focus groups and forums, and
inviting selected groups of clients and sup porters to
formal conferences helps to obtain useful information
regarding the stakeholders' needs. Finally, participatory
action research initiatives would increase stakeholder
participation in program design, implemen tation, and
evaluation, which could yield better service outcomes
(Balaswamy & Dabelko, 2002). Stakeholders can serve on
planning committees or task groups that are designed to
create new programs and evaluate existing ones. Some
organizations can also increase
160 MANAGEMENT: PRACTICE
INTERVENTIONS

client participation in program design and implementation
by hiring former clients to deliver services.
Intraorganizational Management Interventions The
context of management practices of service organizations
is important to its effectiveness. Among the most often
discussed targets for management interventions are
leadership practices, board practices, organizational
culture, organizational structure, and worker attitudes.
LEADERSHIP PRACTICES Organizational effectiveness
is directly related to the effectiveness of its leader ship.
While the list of desirable leadership practices and
qualities is very long, among the most emphasized qua-
lities of an effective leader are' commitment to mission,
effective goal setting, ability to cope with external and
internal pressures, effective interpersonal skills, leading
change, leading people, charisma and inspiration, building
partnerships, and sharing leadership by empowering teams
and individuals to undertake some lea dership tasks
(Corrigan, Lickey, Campion, & Rashid, 2000).
Additionally, providing feedback to employees about their
performance, providing rewards and incentives, clarifying
the outcomes, identifying tasks that are central for
achieving the outcomes, involving others in decision
making, delegating authority, decentralizing management,
and allowing employees job discretion and autonomy
constitute the effectiveness-oriented lea dership practices
(Patti, 1987; Schmid, 2002).
One very useful model for understanding managerial
and leadership practices in connection to organizational
effectiveness is the Competing Values Framework (Quinn,
1988). This model is created around two dimensions
representing competing orientations in organizations:
flexibility-eontrol and internalexternal. The intersection of
those two dimensions creates four quadrants of
organizational activity, each of which is important for
overall organizational effectiveness. According to this
model, in order for an organization to perform well, social
service managers should use four basic sets of skills:
boundary spanning, human relations, coordinating, and
directing. The Competing Values Framework can be used
to identify leadership skills needed in each of the four
quadrants.
In order to change or choose the most appropriate
leadership style, one would want to first identify her/his
own leadership style; then identify behaviors of the new
style and try modeling them; reflect on efforts to im prove;
and practice the new behaviors. Yet another approach to
match leadership style to situations is to make changes
within an organization to make the current leadership style
more effective (for example,
scheduling more time for decision making would allow for
consulting the employees on an issue) (Brody, 2000;
Seltzer, 1989).
BOARD PRACTICES Strong link exists between board
effectiveness and organizational effectiveness (Green &
Griesinger, 1996). Effective boards have been shown to be
involved in strategic planning (short term and long term),
policy formulation, program evaluation and monitoring,
resource development (personal contributions, fundraising
efforts, and human resource development), and financial
planning (review of financial statements, fiscal and
entrepreneurial responsibilities) (Green & Griesinger,
1995).
Intentional efforts to improve board effectiveness are
believed to lead to improvements in the board's
management and governance responsibilities, which, in
turn, are believed to increase organizational effectivenes s.
Among the commonly recommended intentional board
improvement practices are creating a common vision
among board members, involving them in strategic
planning process, providing various training interventions
(related to decision making, role clarifica tion, board
structure and processes, and so on), board self-evaluation,
restructuring the board, increasing board diversity,
constructive use of board meeting time, and setting
specific tasks for members (Brudney & Murray, 1998;
Herman & Rem, 2000). The key to success of those
interventions is to involve the board in setting the goals for
itself, identifying the strategies for achiev ing those goals,
and creating the measures to monitor its progress. To
ensure the sustainability of those interventions, co ntinuous
board development activities should be built into the
board's ongoing work, including board performance
evaluations, feedback, and planning (Holland & Jackson,
1998).
ORGANIZATIONAL CULTURE Organizational culture
is believed to be related to organizational effectiveness.
More specifically, such culture aspects as consistency
(strong cultures that are highly consistent, coordinated,
and integrated), adaptability (responsiveness to changing
conditions), individual development and support, and clear
purpose of mission contribute to organizational
effectiveness (Denison & Mishra, 1995; Hemmelgarn,
Glisson, & James, 2006). Empowerment, team orientation,
capability development, agreement, coordination and
integration, creating change, customer focus,
organizational learning, strategic direction and intent,
goals and objectives, and vision are among the cultural
dimensions have been shown to be related to different
indices of effectiveness.

CREA TlNG A CLIENT ,ORIENTED CULTURE Orga-
nizations can become more client oriented by developing
cultures that stress service quality, customer involvement,
and responsiveness to client needs (Moore & Kelly, 1996).
Additionally, customer service issues should be integrated
into training and other human resource functions to help
front-line workers understand the consumers' experiences.
Following a consumer-oriented mission is yet another way
to become more responsive to clients needs (Band, 1991).
Empowerment practices require that organizations
involve program beneficiaries and employees in organi-
zational decision making. A desired result of such ef forts is
the creation of practices and services that meet clients'
needs and increase employee commitment to the
organization. Hardina (2005) suggested a number of
strategies for increasing empowerment among clients and
employees. Client involvement in organizational decision
making can be increased by including them on the board,
task groups, and advisory panels. Employee
empowerment, on the other hand, can be achieved by
providing employee support systems, developing peer
supervision, providing professional development oppor-
tunities in relation to the employees' interests, and
providing training opportunities (Gutierrez, GlenMaye, &
DeLois, 1995).
CULTURE CHANGE STRATEGIES To improve the
cultures of their organizations, social service managers can
employ a number of organizational change strategies.
They should invite employee participation and
involvement and make sure that all employees have a
complete understanding of the core organizational va lues.
While infusion of new values requires much time and
effort, it can be achieved when leaders serve asrole models
and demonstrate positive attitudes, employees are
motivated and inspired to serve their clients, and
appropriate infrastructures are put in place to support
organizational effectiveness (Schein, 1985; Trice & Beyer,
1993).
Cummings and Huse (1989) suggested that values can
be changed or infused through a new vision or mission
statement. Effectiveness-oriented management requires
that managers relate service quality and client outcome to a
broader purpose (Patti, 1987). Additionally, values can be
infused through a number of management (unctions. The
primary mechanisms that offer the greatest potential for
reinforcing aspects of culture are attention (leaders
communicate their priorities and values by their choice of
things to ask about, measure, comment on, praise, and
criticize), reaction to crises (the leader's response to crisis
can send a strong message about values and assumptions),
role modeling
MANAGEMENT: PRACTICE
INTERVENTIONS 161
(communicating values and expectations by their own
actions), and allocation of rewards (the criteria used for
allocating rewards signal what is valued by the organi-
zation) (Patti, 1987; Yukl, 1998). Finally; because new
employees learn about organizational culture via obser-
vation, personal experiences, role modeling, and more
formalized training, informal and formal socialization
tactics should make it clear what values are important for
the organization.
ORGANIZA TlONAL STRUCTURE Organizations cre-
ate structures to facilitate decision making, divide labor
into certain tasks, coordinate tasks, and direct the flow of
information, resources, authority, and decisions across
organizational structural divisions and deliver services.
There are a number of structural changes needed for an
organization to become more effective. More specifically,
open communication, increased participation in decision
making, and emphasis on delegation of responsibility and
authority to clients and other program beneficiaries are
among organizational characteristics that are believed to
contribute to organizational effectiveness (Schmid, 2002).
Ready access to important information, participatory
organizational culture, and assignment of decision- making
responsibilities to employees at all levels, strong support
from supervisors, organizational changes from below as
well as from the upper levels, and shared leadership and
responsibility also constitute components of effective
organizational structures. Finally, effective organiza tions
have structures that welcome technological inno vation and
make their implementation fast and easy.
Establishing structures that place clients and other
program beneficiaries in decision-making roles and in-
crease their participation in the organization's activities is
critical for effective service provision. Having worker-
initiated meetings where chairing responsibility is shared
and clients are welcome to participate would encourage
shared leadership. A team approach to problem solving
and decision making, creation of task forces and action
groups, and reevaluation of roles and responsibilities are
examples of actions that would promote redistribution of
authority and power. Board committees, task teams, and
advisory groups can also serve as ways to involve clients
and other program beneficiaries into organizational
decision making. Among other actions that can increase
participation are having a board that is representative of a
community in terms of race, gender, and income;
providing trainings and workshops on decision making;
and obtaining support for consumer inclusion in decision
making from all organizational constituency groups
(Hardina, Middleton, Montana, & Simpson, 2007).
162 MANAGEMENT: PRACTICE INTERVENTIONS
EMPLOYEE ATTITUDES, MOTIVATION, AND SKILLS
Employee attitudes, motivation, and skills can serve as
barriers or resources to empowering clients and to overall
performance. Effective social service agencies have
employees who are satisfied with their jobs, committed to
the organization, and highly motivated (Marchiori &
Henkin, 2004; McNeese-Smith & Crook, 2003).
Additionally, the importance of having a diverse staff
(with regard to professional background and experiences,
race, national origin, age, religion, sexual orientation and
other aspects) to organizational effectiveness cannot be
underestimated.
Employee empowerment strategies are believed to be
effective in affecting employee attitudes and motiva tions.
Examples of those strategies are: increasing sal aries and
employee benefits (for example, flextime, job sharing,
working from home, and so on), providing development
opportunities that match individual employee interests,
and providing rewards (recognition, praise, bonuses,
promotion, thank-you notes, taking employees to lunch,
and so on). Employee attitudes and motivation can also be
improved by enriching their jobs. This can be done by
allowing them more freedom in deciding how to
accomplish the tasks given to them, providing feedback
about their progress, providing more autonomy, and
redesigning the job in such a way that the tasks are
significant and require use of a variety of skills.
Additionally, because employees who believe in the
mission of their organization are more likely to perform
well on tasks that they believe are related t o mission
accomplishment, relating their work to the mission of an
organization is important for organizational effectiveness
(Rainey & Steinbauer, 1999). Petter, Byrnes, Choi, Fegan,
and Miller (2002) identified a number of conditions that
should lead employees to empowerment when fulfilled:
granting employees power; involving them in decision
making; increasing information about organization's
vision, mission, and goals; allowing more autonomy;
encouraging creativity and initiative; allowing employees
more responsibility in evaluating their own performance;
and providing opportunities for professional development.
REFERENCES
Andreasen, A. R., Goodstein, R. C., & Wilson, J. W. (2005).
Transferring "Marketing knowledge" to the Nonprofit sector.
California Management Review, 47(4), 46-67.
Balaswamy, S., & Dabelko, H. I. (2002). Using a stakeholder
participatory model in a community-wide service needs
assessment of elderly residents: A case study. Journal of
Community Practice, 10(1),55-70.
Band, W. A. (1991). Creating value for customers: Designing and
implementing a total corporate strategy. New York: John Wiley
and Sons.
Brody, R. (2000). Effectively Managing Human Service Organ-
izations. Thousand Oaks, CA: Sage Publications.
Brudney, J. L., & Murray, V. (1998). Do intentional efforts to
improve board really work? The views of nonprofit CEOs.
Nonprofit Management and Leadership, 8(4), 333-348.
Corrigan, P. W., Lickey, S. E., Campion, J., & Rashid, F. (2000).
Mental health team leadership and consumer satisfaction and
quality of life. Psychiatric Services, 51 (6), 781--785.
Cummings, T. G., & Huse, E. F. (1989). Organizational development
and change. Saint Paul, MN: West Publishing.
Denison, D. R., & Mishra, A. K. (1995). Toward a theory of
organizational culture and effectiveness. Organizational Science,
6(2), 204-222.
Forbes, D. P. (1998). Measuring the unmeasurable: Empirical studies
of nonprofit organization effectiveness from 1977 to 1997.
Nonprofit and Voluntary Sector Quarterly, 27(2), 183-202.
Glisson, C. (2002). The organizational context of children's mental
health services. Clinical Child and Family Psychology Review,
5(4), 233--253.
Green, J. c., & Griesinger, D. W. (1995). Board performance and
organizational effectiveness in nonprofit social services
organizations. Nonprofit Management and Leadership, 6(4),
381-402.
Grusky, 0., & Tierney, K. (1992). Evaluating the effectiveness of
countywide mental health care systems. In Y. Hasenfeld (Ed.),
Human services as complex organizations. Newbury Park, CA:
Sage Publications.
Gutierrez, L., GlenMaye, L., & DeLois, K. (1995). The organ-
izational context of empowerment practice: Implications for
social work administration. Social Work, 40(2), 249-258.
Hardina, D. (2005). Ten characteristics of empowermentoriented
social service organizations. Administration in Social Work, 29(3),
23-42.
Hardina, D., Middleton, J., Montana, S., & Simpson, R. A. (2007).
An empowering approach to managing social service
organizations. New York: Springer Publishing Company.
Hemmelgarn, A. L., Glisson, c., & James, L. R. (2006).
Organizational Culture and Climate: Implications for Services
and Interventions Research. Clinical Psychology:
Science and Practice 13(1), 73-89.
Herman, R. D., & Renz, D. O. (1998). Nonprofit organizational
effectiveness: Contrasts between especially effective and less
effective local nonprofit organizations. Nonprofit Management
and Leadership, 9,23--38.
Herman, R. D., & Renz, D. O. (2000). Board practices of especially
effective and less effective local nonprofit organizations.
American Review of Public Administration, 30(2), 146-159.
Holland, T. P., & Jackson, D. K. (1998). Strengthening board
performance: Finding lessons from demonstration projects.
Nonprofit Management and Leadership, 9(2), 121-134.
Marchiori, D. M., & Henkin, A. B. (2004). Organizational
commitment of a health profession faculty: dimensions, correlates
and conditions. Medical Teacher, 26(4),353-358.
McNeese-Smith, D. K., & Crook, M. (2003). Nursing values and a
changing nurse workforce: Values, age, and job stages. Journal of
Nursing Administration, 33(5), 260-270.

Meier, K. J. (1993). Politics and bureaucracy. Pacific Grove, CA:
Brooks/Cole.
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.
Moore, S. T., & Kelly, M. J. (1996). Quality now: Moving human
services organizations toward a consumer orienta tion to service
quality. Social Work, 41(1), 33-40.
Patti, R. J. (1987). Managing for service effectiveness in social
welfare organizations. Social Work, SeptemberOctober, 377-381.
Petter, J., Byrnes, P., Choi, D. L., Fegan, F., & Miller, R. (2002).
Dimensions and patterns in employee empower ment:
Assessing what matters to street-level bureaucrats. Journal of
Public· Administration Research and Theory, 12,
377-401. ~
Quinn, R. E. (1988). Beyond rational management: Mastering the
paradoxes and competing demands of high performance. San
Francisco, CA: jessey-Bass.
Rainey, H. G., & Steinbauer, P. (1999). Galloping elephants:
Developing elements of a theory of effective government
organizations. Journal of Public Administration Research and
Theory, 9(1), 1-32.
Ridley, C. R., & Mendoza, D. W. (1993). Putting organizational
effectiveness into practice: The preeminent consult ation task.
Journal of Counseling and Development, November! December,
72,168-177.
Schein, E. (1985). Organizational culture and leadership. San
Francisco, CA: [ossey-Bass.
Schmid, H. (2002). Relationships between organizational
properties and organizational effectiveness in three types of
nonprofit human service organizations. Public Personnel
Management, 31(3), 377-395.
Seltzer, J. (1989). Developing an effective leadership style. In L.
E. Miller (Ed.), Managing human service organizations. New
York: Quorum Books.
Trice, H. M., & Beyer, J. M. (1993). The cultures of work
organizations. Englewood Cliffs, NJ: Prentice Hall.
Yuki, G. (1998). Leadership in organizations. Upper Saddle River,
NJ: Prentice Hall.
-KRISTINA JASKYTE
FINANCIAL
ABSTRACT: There has been a quiet revolution in fi-
nancial management practice in social agencies in re cent
decades, symbolized by the transition from fund to
enterprise accounting and i ncreasing recognition of the
"third sector" of the social economy. The traditional
voluntary agency model of donations has been joined by
grants, performance contracts, "managed care," and an
array of other options, and traditional voluntary
agency-based and public agency practice now exist
alongside corporate for-profit service delivery and various
forms of private practice. Social enterprise and
entrepreneurship are a common theme in all this
MANAGEMENT: FINANCIAL
163
diversity, as social agencies must aggressively seek out
financial support. In this environment, two models of
budgeting, termed "common-pool" and social enterprise
budgeting, have emerged.
KEY WORDS: budget; financial management; managed
care; private practice; social agency; social enterprise;
social entrepreneurship
Introduction: The Quiet
Revolution in Financial Management Financial
management refers to management decision making and
direction in social agencies concerned with identifying,
locating, collecting and using money, time, and other
fungible scarce resources with which to enable the
delivery of organized programs of social service as well as
appropriate accountability for these activities. The term
fungible refers to (physical or symbolic) objects capable
of being exchanged, traded, or substituted for other things.
Given the largely intangible nature of most social services,
the exchange of symbolic objects (professional advice an d
guidance in exchange for a client's account of personal
troubles, problems, or conflicts) constitutes one such
fungible exchange. Precise measurement may be difficult
but the very existence of social work for more than a
century on the basis of external support attests interest in
the issue. The central problem of principal- agent theory is
how the principal can assure that the agent will act in the
best interest of the principal.
The topic embraces aspects of public and non profit
accounting, including managerial, financial and cost
accounting, fundraising, grants management, in vestment
strategies, budgeting, managed care and other service
contracting issues, nonprofit economics, and assorted
other concerns unique to social service de livery. It is,
along with human resources (or human capital)
management, one of two major means- or
resource-oriented concerns of social administration.
Accumulated changes over the past three decades in
the role of financial management in social work 'practice
have been very dramatic; in fact, they have brought about
nothing less than a quiet revolution in social agency
financial management practice and theory. Per haps most
visible to the majority of social workers are changes
related to the spread of managed health and mental health
care. As various sources have noted (Franklin, 2001 ;
Lohmann & Lohmann, 2002; Sowers & Ellis, 2001),
managed care has largely obliter ated what once was a
clear line of demarcation between administrative decision
making on financial matters and the resource- directing
decisions of therapists, counselors,
164 MANAGEMENT: FINANCIAL
case managers, and other direct service social workers
who previously could practice with little regard for direct
fiduciary concerns. The term fiduciary is used in the
broadest sense here to connote those who must be con-
cerned with the handling of other people's financial
resources. When case managers, therapists, or group
workers are hired explicitly to address client financial
concerns and interests, given quotas for billable hours,
and are asked to solicit donations or write grants to
develop or continue their practice activities, their ac tions
are explicitly involved in the financial manage ment
system. Austin and Hopkins (2004) provide a very
succinct summary of the changes in social work practice
that have brought direct practice into this mode.
Changes in managed care are only part of a much
larger and more complex and fundamental set of trans-
formations in the financing of social work practice in the
recent decades. While most social workers are aware of
the continuous daily manifestations of thes e
developments-dealing with the details of public and
foundation grants, client-paid fees, state contracts,
insurance reimbursements, individual dona tions, liability
issues or other financial instruments, and
intermediaries-the full extent of this transfo rmation in the
social economy of social work practice may not yet be
clear.
This quiet revolution in social work financing has
worked itself out slowly over several decades, mostly by
adding entirely new layers of possibility to the original
donation-based "gift economy," which formed the fi-
nancial undercarriage of social work pr actice prior to the
New Deal in the United States in the 1930s. Each of these
add-ons left many aspects of the older systems largely
intact, transformed others, and in a few cases added
entirely new financial arrangements and possibi lities,
notably those associated with managed care. This is truly a
record of accumulating complexity. While this revolution
is fairly complete with respect to changes in the
underlying accounting and reporting infrastructure, it is
only moderately underway in such areas as mea sured
outcomes and performance management. It is important to
trace in broad strokes the key transitions of this financial
revolution which has moved the social agency from the
benevolent donative enterprise of the 1890 s to the
contemporary, multifunded social enter prise and private
practitioner as a "social entrepreneur."
Voluntary Social Agencies
In most large urban communities in the United States,
remnants of the original class of what were once known as
"voluntary social agencies" remain intact, do ing business
much as agencies like them have for more than a hundred
years. Since the 1980s, these older
donor-supported agencies have been joined by newer
gift-based charitable agencies, largely eschewing gov-
ernment grants and contracts for practical, i deological,
and other reasons. As financial instrumentalities, these
organizations are the original source of the term "social
agency," a reference to the legal and management
doctrines of principal-agent theory, and their legal-
financial position as agent s of their donors and grantors.
As stewards of donations and gifts from others, these are
service operations supported financially by common
resource pools. Even today, their financial arrange ments
are much like the original charity organization societies ,
settlement houses, and other voluntary social agencies out
of which professional social work arose.
These voluntary agencies deal with hard- core issues of
poverty, social dependency, social care, and other social.
problems including homelessness, substa nce abuse, and
short-term relief from poverty and hunger. Most are small
and community based, with limited professional staff and
ample opportunities for volunteers and nonprofessionals.
Some (for example, religious missions. and some
faith-based providers) have arms- length relationships at
best with the contempor ary social work profession,
whereas others are' fully staffed by professional BSW or
MSW social workers. Regardless of these permutations,
the financial model of voluntary social agencies remain s
primarily a concern for periodically refreshing through
gifts and donations, and even subscriptions and
memberships, common re. source pools that are
subsequently "spent down" to
support operations. Agencies like the American Red Cross
and Salvation Army are exemplars of this type of
voluntary agency. Most of the contemporary social
agency community, however, has shifted to other revenue
models.
Toward Social Enterprise
Over time, some of the oldest and best known of these
voluntary social agencies have taken quite differ ent and
distinct financial paths that have led them far beyond the
donation-based common resource pools of the traditional
voluntary agencies. Some,' in cluding numerous urban
YMCAs and Good Will Industries, recognized their
changing economic position and began taking
quasi-commercial paths (sometimes amidst significant
controversy) and transforming them selves into service
businesses long before the term "social enterprises" arose
to describe them. In this vein, a social enterprise c an be
defined as "a business with primarily social objectives
whose surpluses are principally reinvested for that
purpose in the business or in the community, rather than
being driven by the need to maximize profit for share
holders"

(http://www.res.bham.ac.uk/information/entrepreneur~
ship/Resources/Resources.htm, January 12,2007).
. This is not primarily a matter of ideology or intent but
of financial arrangements: With little shift in mean ing, the
definition above could be fitted to an entire class of social
work social enterprises: a mission oriented,
nonprofit-distributing social agency using a variety of
capital acquisition strategies, including donations a nd
gifts, grants, and various types of sales of its services to
underwrite its current operations and gen erate surpluses
for reinvestment in the organization and the community it
serves. Adoption of a fundamental entrepreneurial stance
is perhaps the key characteristic driving the
transformation of social agencies; the en trepreneurial
stance is most often embraced not out of a desire to "make
money" 'but to survive in order to provide services that
meet client needs.
Many revenue-driven social agencies, especially those
nonprofits driven by circumstance into aggres sively
seeking funding (activity that fully fits the ordin ary
business meaning of capital), now qualify as social
enterprises in this sense, quite independent of any re sidual
"antibusiness" or "anticapitalist" outlook on the part of
managers, boards, or the social workers employed there.
Despite this slow, organic rise of entrepreneurship in
social service, many in social work are still deeply
wedded to a major, but quite obsolete, categoric al
distinction-grounded in the Victorian idealism of the
original charity organization society and settlement house
movements, but subsequently rendered irrelevant by the
development of the U.S. social economy between morally
elevated nonprofit/charitable "social service" and morally
debased "for-profit" business. When looking at the
financial base of social agen cies, such a distinction has
been rendered largely meaningless by changes in the
larger social economy.
Events across a broad front have acted to strongly
undermine the once-meaningful difference between
charitable nonprofit organizations and for-profit busi ness
enterprises from the development of nonprofit enterprise
accounting, to the shift from grants to per formance
contracts, all of the associated focus on out come
measurement, and the growth of more robust forms of
professionalism in social work. In an age of managed care,
all social workers have to some degree become social
entrepreneurs, and all "social agencies'; have become less
agents of their donors and more independent social
enterprises in their own right.
The implications of this for financial management of
nonprofit social agencies have been little short of
revolutionary. As a pair of accounting authorities noted
recently, "There are only two fundamental differences
MANAGEMENT: FINANCIAL
165
between for-profit and nonprofit organizations. First,
for-profit businesses have transactions with shareholders,
whereas nonprofit organizations do not. Second, nonprofit
organizations can receive contributed capital which
businesses do not" (Anthony & Young, 2005, p. 468). In
the rhetoric of enterprise, "contributed capital" means
gifts, grants, and donations-the hallmark of the revenue
base of voluntary social agencies. In social enterprise,
such contributed capital functions along with other
revenues from fees, earned income from investments,
capitation payments, and an increasingly wide variety of
other revenue sources.
Orphans of Public Policy
The. rise of enterprise in social agencies is also evident in
a different group of agencies, where risks associated with
limited, uncertain, and insecure financial bases have given
rise to yet another form of social enterprise. It is worth
noting also that in the uncertain environment of the
contemporary social agency, managing substantial risk is
one of the essential characteristics. Such risk management
is also a characteristic often integrally tied to notions of
enterprise and entrepreneurship. Thus, in one more sense,
social agency managers are entrepreneurs.
This group of social agencies includes community
action agencies, community mental health centers,
housing bodies, and local and regional aging agencies and
many other community-based housing and socia l service
agencies established during and after the Great Society
period of the Johnson Administration in the 1960s. The
common trait here is that these social agen cies were
created or reformed in response to one or more federal
policy initiatives, which were subsequently abandoned by
public authorities in the subsequent more conservative
Federal administrations, and either "de funded" or
survived with inadequate funding with more restrictions
and documentation required. Others, in cluding
community mental health centers and local aging
agencies, have. been transformed (in some cases, several
times) by shifting financial and program priorities.
More than a few of these community-based service
providers did not survive changes in their original or
subsequent missions, while others including hospices and
Head Start programs have been able through orga nized
effort to establish newer and more-or- less reliable federal
and state revenue streams through Title XX of the Social
Security Act, revenue sharing, social service block grants,
Medicare, Medicaid, and other federal programs. Some of
the agencies in this category re sponded to the loss of their
public funding sources by moving into full social
entrepreneurial mode as
166 MANAGEMENT: FINANCIAL
reflected by the literature on "grantsmanship," "defund-
ing," "decentralization," and related topics, repurposing
themselves as necessary often using classic goal displa-
cement maneuvers like those described by David Sill's
(Columbia University, Bureau of Applied Social Re-
search, & Sills, 1957) classic study and more recent work
on that topic.
The Chronically Underfunded Agency
A distinct subset of this group founds its way to social
enterprise by a slightly different route. The central
financial fact of life for this group of organizations is that
while their tax-exempt status still allows donations and
their discovery of at least limited public funding at least
allows them to survive, neither revenue source has been
adequate to robust pursuit of the missions these
organizations set for themselves, and additional funding is
deemed desirable or necessary. This puts many of these
organizations in a limited entrepreneurial mode. United
Way funding, or independent donations, or a narrow
spectrum of public allocation or contracts al lows them to
survive financially, but they can thrive only by leveraging
the funding they already have to secure additional
support. And, that pursuit requires them to become more
entrepreneurial. This group includes a su bstantial number
of "multifunded" nonprofit human services, whose
executive and/or boards have elected to pursue mixed
revenue strategies combining gifts and donations, grants,
fee-based services (perhaps including sliding scale fees
and offering what are, in effect, discounted and pro- bono
services).
"The Third Sector"
These are just a few of the many pathways that have
brought large numbers of social agencies into increas ingly
entrepreneurial positions. During the 1980 s some
underlying coherence arose out of the sheer variety of
these voluntary, quasipublic, contract-based, entrepre-
neurial, multifunded, and other nonprofit agencies
through the growing popularity of what h as been called
the "third sector" concept. The underlying idea that much
contemporary social service is not quite govern mental in
auspice, and not profit oriented, places it squarely in this
other realm of the third sector. Basic to the concept of an
identifiable third sector-and human services subsector- in
the United States is the notion of a common, legal
"nondistribution" constraint against distributing profits to
shareholders or owners shared by all of them. A national
classification scheme, the Natio nal Taxonomy of Exempt
Entities (NTEE), has gained acceptance with diverse
national associations like the United Way of America and
authoritative bodies like the Internal Revenue Service
(IRS) and the National Accounting Standards Board
(NASB).· Organizations like the Foundation Center,
National Center for Charitable Statistics (NCCS) and
Guidestar (www.guidestar.org), and a growing body of
researchers use this concept to advantage. [ournals like
Administration in Social Work, the Journal of Community
Practice, Nonprofit ana Voluntary Sector Quarterly,
Nonprofit Management ana Leadership, and Voluntas have
all published studies based on this third sector organizing.
rubric.
The concept of a third sector juxtaposed against "state"
(government) and "market" (corporations) leads rather
easily to a view more expansive than simply taxexempt
service delivery organizations. The European Union has
stepped into the breach and revitalized an older
concept-the social economy, which in the American
context refers to public charities, foundations,
cooperatives, and financial "mutuals" like credit unions
and housing funds (Lohmann, 2007).
"For,Profit" Corporations
Even as the concept of the third sector was coming into
widespread use, social work has also become increas ingly
established in conventional, profit- distributing
corporations providing health and mental health care in
nursing homes, children's services, and several other
arenas. The growth of licensure- based private practice is
one of the many dynamics that have subtly worked to
weaken the older, Victorian linkage of "social agency"
with high moral purpose, and allow for the practice of
social work in purely commercial settings . Social work
activity today is often carried out to serve the corporate
bottom lines. The discussion of social agency enterprise as
the basis of the quiet revolution in financial manage ment is
largely limited to nonprofit auspices and not primarily
concerned with either profit-taking or capitalism per se.
Public Social Agency
The last major category of contemporary social services
organizations (what are conventionally thought of as
"social . agencies") from a financial management
perspective are those public agencies, primarily in state
and local governments, with a smattering of federal and
local public agencies with human service missions as well.
A few (FEMA comes to mind) conduct their own service
delivery operations. The rest have, in one of the
fundamental dynamics of the quiet revolution in financial
management, undergone a series of dramatic
transformations within the larger political economy.
Today, many public agencies only pursue their legisla-
tively sanctioned missions indirectly through a va riety of
contracting, insurance, managed care, and other

fiduciary arrangements. In many respects, the shift away
from public social service grants and toward public
contracting and performance management closely parallels
conventional government purchase of other goods and
services from individual entrepreneurs, group practices
(like many law firms), and corporations: This has brought
fundamental changes in the public social agency financial
model of practice. Notably, an entire class of public agency
social workers is now engaged in contract management.
Multiple Forms of
Private and Independent Practice Relatively large
numbers of social workers, otherwise employed for
nonprofit, private, or even public agencies, supplement
their individual incomes "moonlight, ing" as entrepreneurs
(widely known as social work "consultants") to nursing
homes and an array of other service providers. Among the
most difficult phenomena to describe and conceptualize are
the bewildering array of financial arrangements associated
with the growth of private practice of social work. While it
is tempting to think of private practice as something akin to
opening a law firm, dentist's or optometrist's office, or a
pharmacy, or clinic, such organized commercial social
work firms or "companies" are still few and far between.
Much of contemporary . private practice in social work
consists of individual enterprise: joining an existing
medical or psychiatric specialty practice or a multidisci-
plinary/multiprofessional group practice, moonlighting as
a nursing home consultant, and so on. Undoubtedly, there
are free-standing social work group practices, but many
private social work practitioners are associated with
medical clinics and centers, where the private practice of
social work is enabled by assorted consulting contracts,
fee-based service delivery,insurance reimbursements, and
other financial arrangements.
Financial Management
A growing body of knowledge of financial management
practice exists, but not always in the traditional forms one
familiar with the social work knowledge base might expect.
Discussions of cost measurement for purposes of fee
collection began to appear in child welfare and family
service agencies and journals during the 1950s, a trend
indicative of the (now largely collapsed) effort to build
knowledge of financial management of human services
within the knowledge base of the profession and social
agencies (Fitzdale, 1957; Hill & Ormsby, 1953; Hofstein,
1955). Vinter and Kish (1985), whose first author was well
known as a scholar of group practice, represents the most
mature expression of this approach. Little similar work, in
which authors pursue
MANAGEMENT: FINANCIAL
167
tight integration of financial insights with social work
practice theory, can be found in the past two decades.
The more common approach has been to adapt financial
insights from business and public adrninistration to the
challenges of the social agency. Such efforts have been
carried out by a relatively small group of researchers in
social work education and practice. Eric Lindeman's (1936)
study of Wealth and culture: A study of one hundred
foundations and community trusts and their operations during
the decade 1921-1930 is a largely forgotten, but paradigm
example of this approach (see also Lauffer, 1986; Otten,
1977).
NONPROFIT FINANCIAL MANAGEMENT Recently,
any unique understanding of social agencies is more likely
to have been folded into a broader and quite robust
nonprofit financial management through the vehicle of the
third, or nonprofit sector. Within that larger arena, the
financial management knowledge base is currently
expanding quite rapidly even as fewer social workers are
contributing to it (see Colvin, 2005; Young, 2007). There
are, as always, a number of exceptions and special cases,
including Robert Elkin (University of Maryland), Dennis
Young (Case Western, Georgia State University), and
Michael, Sherraden (Washington University). Their
contributions,however, have been little noted and even less
understood in contemporary social work (Young &
Foundation Center, 2006; Sherraden, 1991; Sherraden,
2005; Sherraden, Sanders & Sherraden, 2004 ).
NONPROFIT ACCOUNTING As a key component of
this, the nonprofit accounting literature is already fairly
substantial and growing (Anthony & Breitner, 2006;
ASAE, 2000). Entirely new accounting specialty
literatures are appearing in topics such as the measurement
of fiscal distress (Greenlee & T russel, 2000; Trussel,
2002), social accounting (Mook, Quarter, & Richmond,
2007; Quarter, Mook, & Richmond, 2003), and
performance management (Clark, DeSeve, Johnson, &
USCoM, 1985; Martin & Kettner, 1996; Olve, Roy, &
Wetter, 1999).
NONPROFIT ECONOMICS Since recognition of non-
profit economics as a disciplinary specialty in the 1980s,
the microeconomics of the firm has moved well beyond the
earlier, speculative work of such pioneers as Kenneth,
Boulding (Boulding, 1967, 1973, 1981; Boulding & Pfaff,
1972; Boulding, Pfaff, & Horvath, 1972; Boulding, Pfaff,
& Pfaff, 1973), and Mancur Olson (1971). Today, a robust
nonprofit economics has emerged {Ben-Ner,
1987,1990,1993,1994; Hansmann, 1980, 1981, 1987;
Speckbacker, 2002; Steinberg, 1987,
168 MANAGEMENT: FINANCIAL
1990,1994; as well as Young, 1983, 1987, 1998,2007).
This is based on, and closely related to, developments
in nonprofit law (Brody, 2005; Fremont-Smith, 2004;
Hopkins, 2003, 2005, 2008; Oleck & Stewart, 1995)
and fundraising (Greenlee & Keating, 2004; Lindahl &
Conley, 2002; Kelly, 1998; Zack, 2003).
ENTERPRISE BUDGET THEORY One of the several
interrelated topics in which the quiet revolution in
social agency financial management has had a
profound impact is budgeting. In social agencies as
in households, governments, and businesses, a
budget is a list of planned revenues and
expenditures. Budgeting is the process of preparing
such a list and planning those same revenues and
expenditures. The key features of an en-
terprise-oriented approach to-budgeting have grown
up in social agency practice over the past 40 years,
joining but in no way replacing the earlier approach
that we denote as "common-pool budgeting."
Balancing Budgets
In all nonprofit and public settings, budget decision
makers in social agencies have no legitimate reason to
maximize financial profits or even to seek the maxi-
mum amount of revenue possible. In any given instance
(an agency with its mission, a single program, or even
an objective, all of which constitute objects for these
purposes), social agency budgeting only requires
enough resources to achieve the stated purposes in
order to "balance" the budget or to "break even"
(Lohmann, 1980).
There are three essential characteristics that define
every social work budget, whether for an agency, a
private practice, or a program conducted by an indivi-
dual, group, organization, or community:
1. A defined or established objective (for example, a
mission, program, service, department, or the
efforts of a single worker or objective)
2. A plan for expending the resources necessary to
achieve that objective (anticipated expenditures or
costs)
3. A coordinated plan estimating the resources to be
obtained on behalf of the same object (anticipated
revenues)
The underlying assumption is that you cannot achieve
any worthwhile objective or purpose without an
expenditure of resources, and you cannot expend what
you do not have. Thus, budget objects generally involve
soine combination of group or organization, and its
mission or purpose, together with resources, personnel,
and organization. Object as a financial entity is a
recursive concept in which any object
may consist of other, nested objects, which in tum
consist of additional objects, and may itself be part of
other objects.
The object (or entity) on which any budget is based
involves a coordination of mission or purpose with a
plan for anticipated revenues and anticipated expendi-
tures. In those cases where resources are not already
known or secured, this is the social enterprise assumption. A
related consideration termed the full-budget assumption is
that it is normally best to provide a complete plan for all
the necessary revenues and expenses of any given
budget object. This will normally yield an "all funds"
budget that is a complete reflection of the effort neces-
sary to obtain a mission or object.
Despite these assumptions, not all contemporary
social work budgets for all budget entities are expected
to break even in the sense of listing- anticipated expen-
ditures and revenues that exactly match. Certainly, the
"balanced" budget projecting revenues that exactly
match or balance anticipated expenditures remain the
semiofficial requirement of every agency budget-
especially those submitted to external grant authorities
like United Ways, grantors, and contracting agencies.
Yet such balance is only one of the three possible
conditions for particular budget objects in contem-
porary social enterprises for which it is conceptually
possible to budget.
In the contemporary social agency, some budget
objects (or "entities" or "centers") are designed or in-
tended to generate surpluses. Because they can, or be-
cause the activities involved are not central to the
agency mission, or for other reasons, such budget ob-
jects can be designated as revenue centers (sometimes
also known, colloquially, as profit centers even when
there are only allocable surpluses but no actual distri-
butable profits involved). For example, a social agency
with its own fundraising _ department will ordinarily
budget this unit as a "revenue object." Who, after all,
would want a fundraising department that costs more
than it brings in, or even just supports itself?
Likewise, cost centers or cost objects reflect
missioncritical activities that must be carried out despite
their inability to generate any (or sufficient) offsetting
revenues. Agencies do not ordinarily do food or
emergency disaster relief distributions for the revenue
surpluses they will produce. Many of the most
meaningful aspects of social work involve budget
objects that always cost more than they produce in
revenue, a reality that is deeply imbedded in social work
practice wisdom. Sliding scale fees, for example,
represent a related (and not always successful) budget
usage of cost centers. Cost centers an essential part of
social agency budgeting. Yet, it was the insight that
some types of

surplus-producing acnvmes (revenue centers sometimes
also termed "cash cows") can be used to offset the
negative balances of cost objects that is the definitive
budget characteristic of contemporary social agency
enterprise budgeting.
Common Pool and Enterprise Budgets
The variety of the financial arrangements and possibi-
lities in contemporary social agencies is truly daunting.
From a budget standpoint, however, this array of com-
plexity can be reduced to two principal budget objects.
The traditional grant- and allocation-funded activities
of one or more cost centers are most often budgeted as
what we term common-pool distributions. A known and
fixed (at least for the budget period) amount of re-
sources are reserved or dedicated for a specific purpose
(or set of purposes) for which costs have been esti-
mated. Large donations or program grants in nonprofit
agencies and annual appropriations in public agencies
are grounded in the essential characteristics of such
common-pool budgeting. The amount of available re-
sources is known in advance and will remain largely
constant throughout the budget period. That is, adjust-
ments are always possible, but unusual. Carrying out
the program tends only to decrease the common
resource pool throughout the budget period. This means
that item 3· in the list earlier is ordinarily only a periodic
and vestigial activity in common-pool budgeting, and
primary attention is on items 1 and 2.
In contrast, in the enterprise budget situation in all
fee-based services as well as rnultifunded agencies
wherein the very acts of service that cause the expend-
iture of resources are also acts that generate revenues
and therefore modify the total of available resources.
Enterprise budgeting must be concerned with all the
three items in the list. In addition, some calculation
protocols like break-even analysis or microeconomics
are necessary to predict the relation between variable
revenues and expenditures. Further, while cash flow
considerations can be important in both types of bud-
geting, they are much more important in the enterprise
budget, since funds are constantly coming in as well as
going out, and the concern for cash flow and accounts
~.-- receivable (monies earned but not yet received) be-
-
comes active considerations.
Another of the key differences is that while the
budgeted reserve in any grant-funded operation is merely
the amount remaining unexpended at any given time,
the budget reserve of an enterprise operation is a highly
complex, dynamic, and uncertain calculation. It must
take into account not only what is collected and
expended, but also what has been earned but not yet
received (accounts receivable) and also what everyone
MANAGEMENT: FINANCIAL 169
involved is doing. And all of that fluctuates with the
passage of time.
Time, Events, and Activities
By convention, budget planning generally occurs within
a fiscal year framework. For the common-pool budget
this is a necessity to periodically restock the pool with
resources, since this does not occur spontaneously. In
enterprise budget planning, the fiscal year becomes
something of an anachronism, a mere convention be-
cause of the assumption that the social agency is an
ongoing enterprise. A fiscal year for these purposes is
any regular, 12-month period coordinated with the
end-of-year closing processes of accounting and IRS
and other state and corporate reporting requirements. A
major part of what gives a current budget context and
meaning typically is comparison-notably with last
year's figures and next year's projections.
Such comparison gives rise to two of the essential
elements of enterprise budget theory.
Base and Increment
The most basic budget problem that arises in the devel-
opment of a common-pool budget is. that the estimates
of anticipated revenues and expenditures involved can
be extremely complex to derive and subject to change
even as they are developed. For budget purposes, base
refers both to the amount of revenue that can be taken
for granted or assumed available for the budget period
and to the amount received last year. (These are often,
for all practical purposes, one and the same.) Base is
thus a historical measure of projected financial position
at the beginning of a new budget period. It is, in this
respect, a measure of position, akin in some respects to
the balance sheet. Increment in tum is a measure of
activity and change in position, related conceptually to
the income and expense and cash flow statements (both
of which are process reports).
The more frequently these calculations must be
repeated in the rolling enterprise budget the more diffi-
cult this problem of calculation becomes.
For many, the concepts of base and increment offer
critical aids to calculation.
Budget . Triptychs
The generic time frame of past, present, and future
suggests a perspective longer than the current fiscal year
that is very useful in enterprise budgeting: Last Year,
This Year, and Next Year. Patterns from other previous
years set the base and may offer additional useful in-
formation, and the current year's actions will have im-
plications into the future. In some cases, it may be
helpful to project further than 1 year into the future,
170 MANAGEMENT: FINANCIAL
but the budget triptych, of past, present, and future, is in most
instances the minimum time frame for successful budgeting.
Identifying a set of budget objects-an entity or whole and the
assorted revenue and cost centers associated with it-can
establish a framework for bringing together the disparate
perspectives of various common-pool and enterprise budget
centers. The familiar events and activities framework of PERT
and the familiar logic of base and increment within the budget
triptych of last year, this year, and next year offer the
fundamental frame of reference for budgeting in virtually all
types of social agencies.
The Recurrent Cost Problem
One of the most consistent errors associated with the
application of base and increment in budgeting is the failure to
take into account the recurring nature of some costs. For
example, adding a new permanent staff position will not only
incur an increment in the next budget cycle, but that additional
cost will henceforth be part of all future base budgets. The
recurrent cost fallacy arises often in social agency budgeting,
as one-time provision (such as grant funds or a one-time gift)
is made for what will be an ongoing added cost to the base
budget without consideration of the ongoing future
obligations this represents. Without sufficient attention to this
problem, social agency budgets can easily become
unmanageable.
REFERENCES
American Society of Association Executives (ASAE). (2000).
Operating ratio report: v. Washington, DC: Author.
Anthony, R. N., & Breitner, L. P. (2006). Essentials of accounting.
Upper Saddle River, NJ: Pearson Prentice Hall.
Anthony, R. N., & Young, D. W. (1999). Management control in
nonprofit organizations. Boston, MA: Irwin/McGraw-Hill.
Anthony, R. N., & Young, D. W. (2005). Financial accounting and
financial management. In R. D. Herman (Ed.), The Jossey-Bass
handbook of nonprofit leadership and management (pp. 466-512).
San Francisco, CA: [ossey-Bass.
Austin, M. J., & Hopkins, K. M. (2004). Supervision as collab-
oration in the human services: BuiWing a learning culture.
Thousand Oaks, CA: Sage.
Ben-Ner, A (1987). Producer Cooperatives: Why Do They Exist
in Capitalist Economies? In W. W. Powell (Ed.), The nonprofit
sector: A research handbook (pp. 434-450). New Haven, Cf:
Yale University Press.
Ben-Ner, A, & Gui, B. (1993). The Nonprofit sector in the mixed
economy. Ann Arbor, MI: University of Michigan Press.
Ben-Ner, A, & Hoomissen, T. V. (1990). The growth of the
nonprofit sector in the 1980's: facts and interpretation.
Nonprofit Management & Leadership, 1 (2),99-116.
Ben-Ner, A, & Hoomissen, T. V. (1994). The governance of
nonprofit organizations: law and public policy. Nonprofit
Management & Leadership, 4(4),393-414.
Boulding, K. (1967). The boundaries of social policy. Social
Work, 12(1), 1-11.
Boulding, K. (1973). The economy of love and fear: A preface to
grants economics. Belmont, CA: Wadsworth.
Boulding, K. (1981). A preface to grants economics: The economy of
love and fear. New York: Praeger.
Boulding, K. E., & Pfaff, M. (Eds.). (1972). Redistribution to the
rich and the poor: The grants economics of income distribution.
Belmont, CA: Wadsworth.
Boulding, K. E., Pfaff, M., & Horvath, J. (1972). Grants eco-
nomics: A simple introduction. American Economist, 16(1),
19-35.
Boulding, K. E., Pfaff, M., & Pfaff, A. (1973). Transfer in an
urbanized economy: Theory and effects of the grants economy.
Belmont, CA: Wadsworth.
Brody, E.(2005). The pioneer revisits her classic-Book review of
Marion R. Fremont-Smith, Governing Nonprofit
Organizations, Federal and State Law and Regulation
Nonprofit Management & Leadership, 16(2), 113.
Clark, T. N., DeSeve, G. E., Johnson, J. c, & United States
Conference of Mayors. (1985). Financial handbookfor mayors
and city managers. Van nostrand reinhold/council on municipal
performance series. New York: Van Nostrand Reinhold.
Columbia University, Bureau of Applied Social Research, & Sills,
D. L. (1957). The volunteers, means and ends in a national
organization; a report. Glencoe, IL: Free Press.
Colvin,G. L. (2005). Fiscal sponsorship: 6 ways to do it right (3rd
ed.). San Francisco, 'CA: San Francisco Study Center.
Fitzdale, R. (1957). A new look at fee charging. Social Casework,
38, 63-69.
Franklin, C. (2001). Coming to terms with the business of direct
practice. Research on social work practice, 11 (2), 235-244.
Fremont-Smith, M. R. (2004). Governing nonprofit organizations:
Federal and state law and regulation. Cambridge, MA:
Belknap Press of Harvard University Press.
Greenlee, J. S., & Keating, E. K. (2004). Accounting for
membership revenues and fundraising costs. Nonprofit Man-
agement & Leadership, 15(2),251-258.
Greenlee, J. S., & Trussel, J. M. (2000). Predicting the financial
vulnerability of charitable organizations. Nonprofit
Management and Leadership, 11(2), 199-210.
Hansmann, H. B. (1980). The role of nonprofit enterprise. Yale
Law Journal, 89(5),835-901.
Hansmann, H. B. (1981). Reforming nonprofit corporation law.
University of Pennsylvania Law Review, 129(3), 500-563.
Hansmann, H. (1987). Economic theories of nonprofit organ-
ization. In W. W. Powell (Ed.), The nonprofit sector: A research
handbook (pp. 27-42). New Haven, CT: Yale University Press.
Hill, J. G., & Ormsby, R. (1953). Cost analysis method for casework
agencies. Philadelphia, PA: Family Service Association of
Philadelphia.
Hofstein, S. (1955). Fee payment in social work counseling.
Social Casework, 36(7).
Hopkins, B. R. (2003 ). The law of intermediate sanctions: A guide
for nonprofits. Hoboken, NJ: J. Wiley & Sons.

Hopkins, B. R. (2005). Starting and managing a nonprofit organ-
ization: A legal guide (4th ed.). Hoboken, Nj.john Wiley &
Sons.
Hopkins, B. R. (2008). IRS audits of tax-exempt organizations:
Policies, practices, and procedures. Hoboken, NJ: John Wiley &
Sons.
Kelly, K. S. (1998). Effective fund-raising management. Mahwah, NJ:
Erlbaum.
Lauffer, A. (1986). To market, to market: a nuts and bolts
approach to strategic planning in human service organizations.
Administration in Social Work, 10(4),31-39.
Lindahl, W., & Conley, A. (2002). Literature review: philan-
thropic fundraising. Nonprofit Management and Leadership,
13(1),91-112.
Lindeman, E. (1936). Wealth & culture, a study of one hundred
foundations and community trusts and their operations during the
decade 1921-1930; w{th 8 charts, 3 graphs, and fuU statistical
tables. New York: Harcourt Brace.
Lohmann, R. A. (1980). Budget-making, financial management
and human services administration. In S. Slavin & F.
Perlmutter (Ed.), Leadership in social administration.
Philadelphia, PA: Temple University Press.
Lohmann, R. A. (2007). Charity, philanthropy, public service or
enterprise: what are the big questions of nonprofit man-
agement? Public Administration Review, 67(3), 437-444.
Lohmann, R. A., & Lohmann, N. L. (1997). Management:
Cost measurement. In R. Edwards (Ed.), Encyclopedia of social
work (1997 Supplement, pp. 214--229). Washington, DC:
National Association of Social Workers.
Lohmann, R. A., & Lohmann, N. (2002). Social administration.
New York: Columbia University Press.
Martin, L. L., & Kettner, P. M. (1996). Measuring the performance of
human services programs. Thousand Oaks, CA: Sage.
Mook, L., Quarter, J., & Richmond, B. J. (2007). What counts:
Social accounting for nonprofits and cooperatives. London:
Sigel Press.
aleck, H. L., & Stewart, M. E. (1995). Nonprofit corporations,
organizations, and associations. Englewood Cliffs, NJ: Prentice
Hall.
Olson, M. (1971). The logic of collective action; public goods and
the theory of groups. Harvard economic studies, v. 124.
Cambridge, MA: Harvard University Press.
Olve, N.-G., Roy,J., & Wetter, M. (1999). Performance drivers:
A practical guide to using the balanced scorecard. Chichester, NY:
John Wiley.
Otten, G. L. (1977). Zero-based budgeting: implications for social
services? Administration in Social Work, 1(4),369-378.
Powell, W. W., & Steinberg, R. (2006). The nonprofit sector: A
research handbook (2nd ed.). New Haven, CT: Yale University
Press.
Quarter, J., Mook, L., & Richmond, B. J. (2003). What counts:
Social accounting for nonprofits and cooperatives. Upper Saddle
River, NJ: Prentice Hall.
Sherraden, M. S., Sanders, C. K., & Sherraden, M. W. (2004).
Kitchen capitalism: Microenterprise in low-income households.
Albany, NY: State University of New York Press.
Sherraden, M. W. (1991). Assets and the poor: A new American
welfare policy. Armonk, NY: M.E. Sharpe.
MANAGEMENT: FINANCIAL 171
Sherraden, M. W. (2005). Inclusion in the American dream:
Assets, poverty, and public policy. Ne'w York: Oxford University
Press.
Sowers, K. M., & Ellis, R. A. (2001). Steering currents for the
future of social work. Research in social work practice, 1 I (2),
245-253.
Speckbacher, G. (2003). The economics of performance man-
agement in nonprofit organizations. Nonprofit Management and
Leadership, 13(3), 267-281.
Speckbacher, G. (2008). Nonprofit versus corporate governance:
An economic approach. Nonprofit Management & Leadership,
18(3).
Steinberg, R. (1987). Nonprofit organizations and the market.
In W. W. Powell (Ed.), The nonprofit sector: A research
handbook. New Haven, Cf: Yale University Press.
Steinberg, R. (1990). Profits and incentive compensation in
nonprofit firms. Nonprofit Management & Leadership, 1(2),
137-152.
Steinberg, R. (1994). Governmental policies and the nonprofit
sector. Nonprofit Management & Leadership, 5(1),99-108.
Trussel, J. M. (2002). Revisiting the prediction of financial
vulnerability. Nonprofit Management and Leadership, 13(1),
17-32.
Vinter, R., & Kish, R. (1985). Budgeting in not-for-profit organ-
izations. New York: Free Press.
Young, D. R. (1983). If not for profit, for what? A behavioral theory of
the nonprofit sector based on entrepreneurship. Lexington, MA:
Lexington Books.
Young, D.R. (1987). Executive leadership in nonprofit organ-
izations. In W. W. Powell (Ed.), The nonprofit sector: A research
handbook. New Haven, CT: Yale University Press.
Young, D. R. (1998). Commercialism in nonprofit social service
associations: Its character, significance, and rationale. Journal
of Policy Analysis & Management, 17(2), 278-297.
Young, D. R. (2007). Financing nonprofits: Putting theory into
practice. Lanham, MD: AltaMira Press.
Young, D. R., & Foundation Center. (2006). Wise decisionmaking
in uncertain times: Using nonprofit resources effectively. New York:
Foundation Center.
Young, D. R., & Steinberg, R. (1995). Economics for nanprofit
managers. New York: Foundation Center.
Zack, G. M. (2003). Fraud and abuse in nonprofit organizations: A
guide to prevention and detection. Hoboken, NJ: John Wiley.
FURTHER READING
Berger, S. H. (2003). Understanding nonprofit financial statements.
Washington, DC: BoardSource.
Blazek, J. (1996). Financial planning for nonprofit organizations.
Nonprofit law, finance, and management series. New York:
John Wiley.
Blazek, J. (2001). 990 handbook: A line-by-line approach. Nonprofit
law, finance, and management series. New York: John Wiley.
Braswell, R., Fortin, K., & Osteryoung, J. S. (1984). Financial
management for not-for-profit organizations. New York: John
Wiley.
Briiliant, E. (1990). The united way: The dilemmas of organized
charity. New York: Columbia University Press.
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172 MANAGEMENT: FINANCIAL
Bryce, H. J. (1992). Financial and strategic management for nonprofit
organizations. Englewood Cliffs, NJ: Prentice Hall.
Capros, P., & Meulders, D. (Eds.). (1997). Budgetary policy
modelling: Public expenditures. Routledge new inter national
studies in economic rnodelli~g. London, New York:
Routledge.
Coe, C. K. (2007). Governmental and nonprofit financial man-
agement. Vienna, VA: Management Concepts.
Connors, T. D., & Callaghan, C. T. (1982). Financial management
for nonprofit organizations. N ew York: American Management
Association.
De Marco, M., Salvo V., & Lanzani, W. (1999). Balanced
scorecard, dalla teoria alIa pratica: Metodi e strumenti per orien-
tare le iniziative aziendali al raggiungimento dei risultati strategid.
Milano, Italy: FrancoAngeli.
Elkin, R. (1985). Paying the piper and calling the tune: Ac-
countability in the human services. Administration in Sodal
Work, 9(2), 1-13.
Elkin, R., & Molitor, M. (1985). A conceptual framework for
selecting management indicators in nonprofit organizations.
Administratiori in Sodal Work, 9(4), 13-23.
Feit, M. D., & Li, P. (1998). Financial management in human
services. Haworth health and social policy. New York: Haworth
Press.
Gambino, A. J., & Reardon, T. (1981). Finandal planning and
evaluation for the nonprofit organization. New York: National
Association of Accountants.
Gelles, E. (1998). Fund raising. In J. S. Ott (Ed.), Understanding
nonprofit organizations: Governance, leadership and management
(pp. 175-181). Denver, CO: Westview.
Gronbjerg, K. A. (1993). Understanding nonprofit funding: Managing
revenues in sodal services and community development
organizations. San Francisco, CA: jessey-Bass.
Grenbjerg, K. (1991). Managing grants and contracts: The case of
four nonprofit social service organizations. Nonprofit and
Voluntary Sector Quarterly, 20(1), 5-24.
Hackshaw, J. O. F., & Robertshaw, N. (1988). Teaching fiscal
management: A live case approach. Administration in Sodal
Work, 12(1), 13-24.
Hairston, C. F. (1985). Costing nonprofit services: Developments,
problems, and issues. Administration in Social Work, 9(1),47-55.
Hairston, C. F. (1985). Using ratio analysis for financial ac-
countability. Sodal Casework, 66(2), 76-82.
Kaplan, R. S., & Norton, D. P. (1996). The balanced scorecard:
Translating strategy into action. Boston, MA: Harvard Busi-
ness School Press.
Lang, A. S. (1995). A practical guide to nonprofit financial man-
agement. Gaithersburg, MD: Aspen Publishers.
Lang, A. S. (2001). Checks & balances: The board member's guide to
nonprofit financial audits. Washington, DC: National Center for
Nonprofit Boards.
Lang, A. S., & Rocha, L. A. (2000). How to read nonprofit financial
statements:Washington, DC: American Society of Association
Executives.
Lohmann, R. A. (1995). Financial management. In R. Edwards
(Ed.), Encyclopedia of social work (Vol. 2, pp. 1028-1036).
Washington, DC: National Association of Social Workers.
Lynch, T. D., & Martin, L. L. (1996). Handbook of comparative
public budgeting and financial management. New York: Marcel
Dekker.
Maddox, D. C. (1999). Budgetingfor not-for-profit organizations.
Wiley nonprofit law, finance, and management series. New York:
Wiley.
Martin, L. L. (1997). Outcome budgeting: A new entrepreneurial
approach to budgeting. Journal of Public Budgeting, Accounting
and Finandal Management, 9(1), 108-126.
Mayers, R. S. (1989). Financial management for nonprofit human
service agencies: Text, cases, readings. Springfield, IL: Charles
C. Thomas.
McMillan, E. J. (1999). Essential financial considerations for not-
for-profit organizations: A guide for non-accounting executives.
ASAE financial management series. Washington, DC: American
Society of Association Executives.
Meyer, D. R., & Sherraden, M. W. (1985). Toward improved
financial planning: Further applications of break even analysis
in not for profit organizations. Administration in Social Work,
9(3), 57-68.
Miller, G. J. (1996). GOvernment financial management theory.
New York: Marcel Dekker.
Mook, L., Sousa.j., Elgie, S., & Quarter.]. (2004). Accounting for
the value of volunteer contributions. Nonprofit Management &
Leadership, 15(4),401-416.
Neumann, B. R., et al. (1984). Financial management: Concepts and
applications for health care providers. Denver, CO:
National Health Publishers.
Nilsen, H. J., Damerow, P., & Englund, R. K. (1994). Archaic
bookkeeping: Early writing and techniques of economic admin-
istration in the ancient near east (Paul Larsen, Trans.). Chicago,
IL: University of Chicago Press.
Nitterhouse, D. (1997). Financial management and accountability
in small, religiously affiliated nonprofit organizations.
Nonprofit and Voluntary Sector Quarterly, 26 (Supplement):
S101-5123.
Perlmutter, F. D. (1988). Alternative federated funds: Resourcing
for change. Administration in Social Work, 12(2), 95-108.
Perlmutter, F. D. (1997). From welfare to work: Corporate initiatives
and welfare reform. New York: Oxford University Press.
Perlmutter, F. D., & Adams, C. T. (1990). The voluntary sector
and for-profit ventures: The transformation of American
social welfare? Administration in Sociol Work, 14(1), 1-13.
Practitioners Publishing Company. (1994). Guide to preparing
nonprofit financial statements: v. Fort Worth, TX: Author.
. Practitioners Publishing Company. (1994). Nonprofit financial
statement, illustrations and trends: 'l1 (looseleaf). Fort Worth,
TX:Author.
Practitioners Publishing Company. (1995). Ppc's TWnprofit
bookkeepers guide: v. Fort Worth, TX: Author.
Practitioners Publishing Company. (1995). Ppc's nonprofit finandal
and accounting manual: v. Fort Worth, TX:
Author.
Rabin, J., & Lynch, T. D. (1996). Handbook of public budgeting and
financial management. New York: Marcel Dekker.
1

Raynard, P. (1998). Coming together a review of contemporary
approaches to social accounting, auditing and reporting in
non-profit organisations. Journal of Business Ethics, 17(13),
1471-1479.
Rosenberg, G. (1980). Concepts in the financial management of
hospital social work departments. Social Work in Health
Care,5(3),287-303.
Ross, C., & Joelson, J. B. (1986). Holding accountability systems
accountable: Is what's good for the goose good for the gander?
Journal of Applied Social Sciences, 10(2), 156175.
Salamon, L M. (1999). America's nonprofit sector: A primer.
New York: Foundation Center.
Schraff, C. R., Mays, R. H., & Steinberg, R. E. (1989). RCRA and
superfund : a practice guide with forms. Colorado Springs, Colo.:
Shepard's/McGraw-Hill.
Simon, J., Dale, H., & Chisholm, L (2006). The federal tax .
treatment of charitable organizations. In W. W; Powell & R.
Steinberg (Eds.), The nonprofit sector: A research handbook (pp.
267-306). New Haven, CT: Yale University Press.
Smith, G. S. (1999). Accounting for libraries and other not,for, profit
organizations. Chicago, IL: American Library Association.
Smith, S. R., & Lipsky, M. (1992). Nonprofits for hire: The welfare
state in the age of contracting. Cambridge, MA: Harvard
University Press.
Steinberg, R. (2004). The economics of nonprofit enterprises.
Northampton, MA: Edward Elgar.
Sumariwalla, R. D. (1974). Accounting and financial reporting: A
guide for united ways and not-for,profit human service organ-
izations. Alexandria, VA: United Way of America.
Tuckman, H., & Chang, C. (1991). A methodology for measuring
the financial vulnerability of charitable nonprofit
organizations. Nonprofit and Voluntary Sector Quarterly,
20(4),445-460.
Wernet, S. P., Hulseman, F. S., Merkel, L A., McMahon, A.,
Clevenger, D., Coletta, A., & Leeds, V. (1992). The fee-for-
service schedule: A new formula. Families in Society, 73(2),
109-115.
Zeichner, S. (1987). Social work as a preparation for health care
administration special issue: Social workers in health care
management: The move to leadership. Social Work in Health
Care, 12(3), 129-142.
Zelman, W. N., DelPizzo, L E., & Sorenson, J. E. (1987). In
pursuit of survival: Managing revenues. Journal of Mental
Health Administration, 14( 2), 44-51.
-ROGER A. LOHMANN AND NANCY LOHMANN
HUMAN RESOURCES
ABSTRACT: Social work organizations depend on a well,
trained and responsive workforce to provide qual, ity
services. Human resource management (HRM) re fers to
the design of formal systems that ensure effective and
efficient use of human talent, and serves as a vehicle to
accomplish organizational goals. Effective HRM requires
applying the same person-in-environment
MANAGEMENT: HUMAN REsOURCES
173
value orientation that guides client services to man aging
human resources. Considering the complexity of HRM, we
have developed an organizing framework focused on
employee development, organizational effectiveness, and
cross-cutting HRM issues. In today's economic, legal,
cultural and technological environment that emphasizes
accountability, effective manage, ment of human talent is
critical.
Background
To provide high quality services to their clients, social
work organizations depend on a well-trained, dedicated,
responsive and flexible workforce. Previously known as
personnel management (Pecora, 1995), this area has
expanded to human resource management (HRM) . This
aspect of social service administration is responsi ble for its
contribution to fairness, equity, maximization of personnel
potential, and enhancement of client services. Effective
HRM practices are essential for building high performance
teams, managing creative professionals, and promoting
diversity as a contributor to organizational innovation (de
Leede & Looise, 2005). The trend in recent decades toward
increased account, ability requires social work
organizations to closely align their HRM practices with
their mission statement and strategic goals.
To meet these challenges, it is necessary for social
work organizations to engage in strategic human resource
management (SRHM). Recruitment and selection
approaches must be cutting edge, career development
opportunities must be tailored to individual employees,
work assignments must maximize workplace flexibility,
and policies must be equitable, rewarding superior
performers and holding marginal employees accountable.
Ultimately, HRM practices must be designed to promote
the goals and values of the organization (Pynes, 2004),
while also adhering to state and Federal regulations.
Definitions
Human Resource Management (HRM) refers to the design
of formal systems in an organization to ensure the effective
and efficient use of human talent to ac complish
organizational goals (Mathis & Jackson, 2006, p. 1). HRM
serves as a vehicle for organizations to support and
develop their workforce, and includes several functions
such as determining the scope of employees' duties,
training and development, compensatory policies, and
employee-employer relations.
In Ll.Si-based social service organizations, HRM
practices offer a range of supportive services geared
toward developing front-line workers, supervisors, and
 174 MANAGEMENT: HUMAN REsoURCES
•

administrators alike in the provision of quality services. performance. At this point, degrees earned and certificates
Many HRM practices in social work organizations are obtained need to be verified. A clean criminal check and
being carried out through the supervision of the staff. This drug test are also sometimes required before
is due to the central role of supervision within the . employment is conferred.
profession, including developing and training of HRM is responsible for training interviewers (and even
employees, their promotion, performance reviews and those who "informally" interact with candidates) about
conflict management (Mor Barak, Travis, Pyun, & appropriate agency-policy and employment law guidelines
Xie,2007). for asking and responding to questions during the
Current trends in HRM reflect an expanded focus on recruitment and interview process (that is, marital status,
Strategic Human Resource Management (SHRM). SHRM age, and race/ethnicity cannot be asked). Lastly, once an
refers to the alignment of human resource man agement applicant has been selected for a position, other applicants
practices with the organization's strategic ob jectives and need to be notified and thanked for their interest in the
organizational performance (Schuler & Jackson, 2005). position, and the actual hiring process can commence.
With current globalization trends (Mor Barak, 2005), there A major part of the recruitment, selection, and hir ing
is also a growing emphasis on International Human \ process involves compliance with Federal and EEOC
Resource Management (IHRM). IHRM refers to human statutes, laws, and regulations. (Perlmutter, Bailey, &
resource practices within a multicultural, multinational Netting, 2001). Table 1 depicts several Federal laws that
organizational affect the selection and hiring processli]; It is thus essential
. context (Schuler & Jackson, 2005). that HRM practices are based on a knowledge and
understanding of legal regulations related to recruiting,
Organizing Framework selecting, and hiring employees.
Considering the complexity of HRM, we have developed
an organizing conceptual framework that includes various
HRM practices: (1) employee development, (2) OVERSEEING COMPENSATION, BENEFITS AND
organizational effectiveness, and (3) cross-cutting. PER. FORMANCE EVALUATIONS In HRM,
considerable attention is devoted to providing
Employee Development HRM Practices compensation and benefits as well as conducting
RECRUITING, SELECTING AND HIRING performance evaluations. With regard to compensation
EMPLOYEES In a social service environment, frontline and benefits, creating fair and equitable policies can be a
employees and supervisors are the heart of the service challenge for HRM. Compensation and merit system
delivery system and are vital to organizational policies aid in this challenge. Kettner (2002) has
effectiveness. The process of recruiting, selecting, and specifically advised that organizations base compensation
hiring employees is a key aspect of HRM (Kettner, 2002 ). on the following factors: intricacy of the job, significance
As a first step, HRM practices involve developing job of the job for organizational effectiveness, type of
descriptions that detail the set of desired knowledge,skills, responsibilities involved in carrying out job duties (for
minimum qualifications, and experience of potential example, supervision and administrative duties), skills and
applicants, and also contain a clear description of the tasks knowledgelevel required, and the organization's financial
to be performed. As this information is summarized into a stability.
job announcement, the Human Resource (HR) Manager In the same vein, Kettner (2002) also advocated for
can determine how to publicize the position's availability formal (for example, consistent policies) designations of
to attract a broad, diverse, and qualified pool of applicants. benefit systems, including merit increase, paid time off,
Applicants are screened using an assessment matrix to health insurance, retirement contributions, work place
score resumes, employment applications, letters of flexibility, and other accrued and employmentbased
reference, and other documents (for example, licenses and entitlement benefits.
degrees) that attest to the applicant's qualifications for the Performance evaluations and work appraisals offer
position. Those that score well are scheduled for occasions for employees to learn about their employer's
interviews where sometimes staff at all levels, including assessment of their work-related contribution and perfor-
managers, supervisors, frontline workers, and support mance. One aspect of HRM practices that provides a
staff members, advise on the fit of the applicant to the job, foundation for performance evaluation involves setting
as well as to the organization. Applicants that appea r performance goals between the supervisor and supervisee.
promising are asked to provide additional references, as Establishment of basic expectations at the beginning of the
needed, which help attest to their skills and employment cycle regarding an employee's performance
should be set forth initially upon hiring and at
predetermined intervals. During an employee's tenure,
 MANAGEMENT: HUMAN REsoURCES
175

TABLE 1
Federal Laws and Regulations Pertinent to HRM Practices
The Equal Pay Act of 1963 (Pub. L. 88-38), a part of the Fair Labor Standards Act of 1938, prohibits sex-based wage
discrimination between men and women in the same establishment who are performing under similar working conditions.
The Age Discrimination in Employment Act of 1967 (Pub. L. 90-202), amended by The Older Workers Benefit Protection Act (Pub. L.
101-433) prohibits employment discrimination against persons 40 years of age or older and prohibits discrimination against
older workers in all employee benefits except when age-based reductions in employee benefit plans are justified by
significant cost considerations.
The Pregnancy Discrimination Act of 1973 (29 C.F.R Part 1604) is an amendment to Title VII of the Civil Rights Act of 1964 that
prohibits discrimination on the basis of pregnancy, childbirth, or related medical conditions, which constitute unlawful sex
discrimination.
The Equal Employment Opportunity Commission's (EEOC) Uniform Guidelines on Employee Selection Procedures published in the
Federal register, p.38290, on August 25, 1978 prohibits employers from ascertaining information about protected class
information, such as race, color, sex, age, disability, marital status, children and child bearing.
The Immigration Reform and Control Act, 1986 - Public Law 99-603 requires all employers to verify proof of identity and
employment eligibility through proper identification.
The Title VII ofCivilRights Act (Pub. L. 88-352) (TitleVII) and The Civil Rights Act of 1991 (Pub. L. 102...,.166) prohibits
employment discriminatiori based on race, national origin, sex, or religion.
The Americans with Disabilities Act of 1990 (Pub. L. 101-336) prohibits private employers, state and local governments,
employment agencies and labor unions from discriminating against qualified individuals based on ability in employment
related to such processes as the selection, hiring, firing, advancement, compensation, and job training of employees.
The Family and Medical Leave Act of 1993, enforced by the Department of Labor, offers employees the opportunity to take up to
12 work weeks of leave during any 12-month period for the birth or adoption (or placement) of a child; the care for the
newborn child, spouse, or parent with a serious health condition; and to tend to a serious personal health condition. During
this time period, an employer must maintain the employee's existing level of health coverage and at the end of the leave an
employer must take an employee back into the same or an equivalent job.
For more information refer to the following: The U.S. Equal Employment Opportunity Commission (EEOC). Laws, Regulations and
Policy Guidance. Retrieved June 5, 2006, from http://www.eeoc.gov/policy/and the U.S. Department of Labor - Office of the Assistant
Secretary for Policy. (2005). Employment Law Guide. Retrieved June 4, 2006, from http://www.doLgov/compliance/guide/index.htm
Few studies have explored the effects of these programs and they were mostly based on employee self-assessment of the outcomes. For
an example, see Eaton, S.c. (2003). If You Can Use Them: Flexibility Policies, Organizational Commitment, and Perceived
Performance. Industrial Relations, 42, 2, 145-167.

these performance goals should be reassessed and renego-
tiated to create optimal worker effectiveness and productivity
as well as service quality (Lal.iberte, Hewitt, & Larson, 2005)
as situations and assumptions change.
TRAINING AND DEVELOPING EMPLOYEES HRM
practices geared toward organizational effectiveness often
focus on the training and development of employees. These
types of HRM practices afford organizations opportunities to
build employee confidence and skills in carrying out job
duties (Laliberte et a1., 2005). Kettner (2002) defined training
and development as follows (p. 301):
• Training: "knowledge or skill building activities that are
designated to engage the employee to improve
performance on the job"
• Development: "refers to learning experiences designated
to enhance both personal and professional growth but
are not necessarily related to the job"
HRM practices focused on training and developing employees
offer supportive, educational, and practical assistance so that
employees are equipped to effectively perform
their jobs (Hewitt, Larson, O'Nell, & Sauer, J.K., 2005). For
new employees, supportive HRM practices can involve
welcoming, socializing and orienting to organizational
policies and practices. However, in the orientation process,
organizations must develop HRM practices considering an
employee's learning capacity and ability to retain new
information as well as the need for ongoing support (even
after the formal orientation process) (Kettner, 2002).
Employee development involves engagement in learning
opportunities that contribute to personal and professional
growth that mayor may not be directly related to one's job
responsibilities (Kettner, 2002). Laliberte et a1. (2005) thus
recommended that employee development be viewed as a
reward and growth opportunity rather than as a mandatory
requirement.
Organizational Effectiveness HRM Practices
RETAINING AND ENGAGING EMPLOYEES Employee
retention and engagement continue to emerge as hot button
issues for social service organizations. This can be attributed
to trends of elevated rates of turnover among social service
workers (The Annie E. Casey
176 MANAGEMENT: HUMAN RESOURCES
Foundation, 2003; United States General Accounting Office
(GAO), 2003). Accordingly, human resource administrators
and managers have been at the forefront of developing and
implementing solutions to reduce' turnover and increase
employee engagement, which, in due course, can impact
organizational effectiveness.
One major component of retention and engagement
orientated HRM practices involves motivating employees
(Laliberte et al., 2005). As employees are both intrinsically
and extrinsically motivated in their jobs, they are more likely
stay in their jobs and be engaged in their work. Intrinsic
motivation refers to a desire to work for its own sake, either
out of a sense of enjoyment or obligation. In contrast, extrinsic
motivation refers to a desire to work for external benefits such
as rewards and recognition (Cameron & Pierce, 2002).
Contrary to a popular assumption about employees in social
services, those who choose to work in public service also
wish to feel valued extrinsically for their work (Travis, 2007).
Thus, human resource managers who work to appeal to
employees' intrinsic and extrinsic motivation can impact
worker outcomes, such as commitment and turnover (Firth,
Mellor, Moore, & Loquet, 2004).
To effectively retain workers, organizations must also
have an understanding of those factors that contribute to
employees staying in their jobs and giving the organization
their all, as well as what factors cause them to leave (Mor
Barak, Levin, Nissly, & Lane, 2006). As examples,
researchers have demonstrated that a host of factors serve as
antecedents to employee retention and engagement. These
antecedents include the following: diversity
characteristics-including visible diversity (such as gender,
ethnicity, and age) and invisible diversity (such as education,
tenure, and position); organizational climate (such as
perceptions of fairness in procedures and compensation,
organizational inclusion-exclusion, stress, and social
support); and individual affective outcomes (such as
well-being, organizational commitment and job satisfaction)
(Mor Barak et al., 2006). Organizations should consider
developing monitoring and assessment systems to gain a
perspective on these types of factors from the employee's
experience.
Overall, ongoing assessment and monitoring may provide
opportunities for organizations to develop innovative policies
and practices to retain desirable employees and keep them
fully involved in work and organizational activities. For
example, employee feedback on organizational processes can
help work organizations gauge employee engagement in
work-related tasks and organizational activities.
FOSTERING QUALITY, PRODUCTIVITY AND INNOV
A TION There is growing evidence that effective
HRM practices are important predictors of service ef-
fectiveness and quality, organizational performance, and
innovation. Patti's (1987) classic work on "service
effectiveness" encapsulates aspects of service quality in social
work organizations. He characterized service effectiveness as
having three outcomes: the organization's ability to generate
desired changes in its clients, the organization's success in
delivering quality service, and the client's level of satisfaction.
In this conceptualization, service effectiveness relates to the
ability to impact clients rather than accomplishing the delivery
of the service.
Some studies have demonstrated that specific HR
practices, such as HR planning, profit sharing and re-
sults-oriented incentive systems, promote organizational
performance; other studies indicate that it is the combination
of several HR practices, rather than a specific practice, that
affects performance (Bae & Lawler, 2000; Guthrie, 2001).
Recent research also indicates that HR practices contribute to
organizational innovations (Shipton, Fay, West, Patterson, &
Birdi, 2005; Shipton, West, Dawson, Birdi, & Patterson,
2006). As employees engage in learning and development
processes, they are exposed to different experiences and
points of view. This makes individuals more willing to
examine their own perspectives and avoid being locked into
rigid mental models. For example, de Leede and Looise
(2005) offer an integrative model of HRM and innovation that
involves the strategic contribution of HRM to organizational
innovation and the focus of innovation as a dynamic part of
organizational processes. The authors framed their HRM
innovation model to focus on the adoption of organizational
strategies for developing HRM practices with the explicit
outcome of innovation.
Applying these principles to social work organizations,
one can conclude that HRM practices that provide on-the-job
training opportunities can expose workers to new practice
models. Such training can introduce new research and
promote the use of innovative and evidence-based practices.
ADDRESSING WORK-RELATED CONCERNS, CON-
FLICTS, AND PROBLEMATIC EVENTS Inevitably, due to
the socio-cultural, political, and environmental context within
which social work organizations operate, HRM often
addresses work-related concerns, internal conflicts, legal
issues, and other problematic events (Kettner, 2002;
Perlmutter et al., 2001).
Given their responsibility for oversight of their sub-
ordinates' performance, supervisors are often the first to
determine that an employee is not functioning up to par
(Hopkins & Austin, 2004).

HRM practices could aid supervisors in identifying and
assisting employees to improve their performance in
alignment with organizational expectations. As an initial
step in identifying employee problems, supervisors or
HRM staff should attempt to understand and identify the
type of employee problem (Hopkins & Austin, 2004). For
example, employee problems related to attitudes toward
work (that is, job dissatisfaction or lack of organizational
commitment) may suggest a different type of HRM
intervention than those for problems that are external to the
work environment, such as distraction associated with
family-related concerns. As another example, employee
problems could constitute undesirable workplace
behaviors, such as job neglect or a lack of engagement in
work activities. Neglect involves any elem~ nt of not
working, including spending less time at work, coming to
work late, making errors, and working slowly (Kidwell &
Robie, 2003). Determining the type of problem c an assist
supervisors and HRM managers, enabling them to decide
upon appropriate actions that may range from
development of an improvement program for the
employee to termination of employment in the interest of
optimal organizational effectiveness.
To address employee performance problems (regard-
less of type) Hopkins and Austin (2004) offer a continuum
of interventions that can assist supervisors or be
incorporated into HRM practices: .
• Create a work environment that supports employees
in seeking help;
• Provide opportunities to listen and talk through
problems;
• Help them make suggestions or give advice;
• Document performance issuers),
• Coach and invest in worker development to improve
performance;
• Refer workers to resources that will help them
address problems; and
• Take disciplinary action or terminate employees
when necessary.
Addressing legal issues is a complex priority area for
HRM. For that reason, hiring and terminating employees,
providing personal leave, and addressing workplace
harassment and violence fall within the realm of fed eral
and other legal mandates that HRM must comply with and
be capable of handling. In the termination process, HRM
i I{; needs to be familiar with appropriate steps to protect
organizations from a wrongful discharge suit, which
employees can file on the basis that their termination
violated federal antidiscrimination policies or written or
implied contractual agreements. At the organizational
level, awareness of the termination
MANAGEMENT: HUMAN REsOURCES
177
process also influences current employees and may create
fears that the organizational environment could similarly
adversely fuel perceptions that their perform ance and
organizational effectiveness is substandard. Though
professionalism governs employee improvement and
termination processes, the reality of an em ployee's abrupt
departure requires that decisions of this nature be guided
by HRM practices that are fair and protect employees'
confidentiality. Perlmutter, Bailey, and Netting (2001 )
recommend that organization and HRM systems offer
formal mechanisms to evaluate employees, avoid
discriminatory statements, and provide confidential
procedures to terminate employees. HRM should take a
lead role in working with managers and supervisors so that
they do not discriminate against others, with particular
attention to those employees in a protected class (for
example, older adults and minorities) (Perlmutter et al.,
2001). This may mean providing information on the lega l
regulations, providing educational and informational
sessions to managers and supervisors, and enforcing
disciplinary actions when needed. Lastly, HRM practices
could be beneficial in providing guidelines to managers
and supervisors in conducting terminations in ways that
prevent missteps, and therefore, create opportunities for
limited legal battles later on.
Cross-cutting HRM Practices
PROVIDING EFFECTIVE SUPERVISION In a social
service setting, supervision plays an instrumental role in
HRM practices (Kettner, 2002). Supervisors are often
expected to have an integral role in, solely or
collaboratively, fulfilling HRM practices related to
employee development and organizational
effectiveness. Supervisors are often key players in
many of the followin g previously discussed tasks, such
as:
• selecting and hiring new employees;
• training and developing employees;
• conducting performance evaluations;
• retaining and engaging employees;
• addressing concerns and problematic events; and
• implementing innovative practices.
. The relationship between supervision and employee
development as well as organizational effectiveness helps
to jointly optimize worker and client outcomes. Research
conducted by Mor Barak and colleagues (Mor Barak et al.,
2007; Mor Barak, Nissly, & Levin, 2001; Mor Barak,
Nissly, Levin, & Lane, 2006) underscore the importance
of supervision to worker outcomes. In a meta-analysis of
the impact of supervision in child welfare, social work,
and mental health settings, three di stinct dimensions of
supervision emerged
178 MANAGEMENT: HUMAN REsOURCES
( emotional and social support, task assistance, and
interpersonal supervisory relationship) (Mor Barak et al.,
2007). Each of these dimensions is uniquely related to
increasing beneficial worker outcomes (such as job
satisfaction, organizational commitment, and worker
effectiveness) and decreasing non-beneficial outcomes (f or
example, turnover and job stress). Emo tional and social
support refers to employee perceptions of a supervisor's
ability to provide support, respond to emotional needs and
help deal with job-related stress. Task assistance involves
employee perceptions of level of supportive supervision
directly related to job func tioning, and supervisor's ability
to provide tangible, work-related supports. Lastly,
interpersonal supervisory relationship involves the
perceptions of the quality of working relationship with
supervisors, and satisfaction with supervision.
CREATING A DIVERSE AND INCLUSIVE WORK-
PLACE This area has been a major priority of social work
administration. The demographic changes in the American
population, coupled with civil rights legisla tion and
affirmative action programs, have created an
unprecedented diversity in the American work force, and
have made diversity management a central issue in HRM
(Cox, 2001; Mathis & Jackson, 2006; Mor Barak, 2000 ).
There is accumulating evidence indicating that, although
present in greater numbers, people from di verse
backgrounds are more likely to be excluded from
information networks and decision- making processes in
organizations, both formal and informal. The issue of
diversity and inclusion takes on special urgency within
social work organizations. Women and racial and eth nic
minorities are disproportionately represented among the
clients of social work agencies as well as in their staff (Mor
Barak, Findler, & Wind, 200l).The extent to which workers
from diverse backgrounds feel included in the organization
may have a direct bearing on their job satisfaction and
commitment and will influence the quality of services
provided, as well as the workers' physical health, mental
health and social functioning.
The current focus on diversity management is quite
different from equal rights legislation and from affirma tive
action programs. The latter are about trying to achieve
equality of opportunities by focusing on specific groups
and righting past wrongs. Diversity efforts focus on
managing and handling the diverse workforce to give the
organization a strategic advantage in delivering services to
clients. These three approaches may be viewed as a
continuum: (a) equal employment opport unity (EEO)
legislation means that it is against the law to discriminate:
(b) affirmative action programs (AAP)
mean that companies need to take positive steps to ensure
equal opportunities; and (c) diversity manage ment is
proactive and aimed at promotin g a diverse and
heterogeneous workforce (Mor Barak, 2005).
To address these challenges, HR managers must focus
their efforts on creating an inclusive work envir onment that
welcomes diversity and celebrates inter personal
differences. An inclusive workpla ce is an organization that
is "not only accepting and utilizing the diversity of its own
workforce but is also active in the community, participates
in state and Federal programs to include population groups
such as immigrants, women, and the working poor , and
collaborates across cultural and national boundaries with a
focus on mutual interests" (Mor Barak, 2005, p. 225). In
the process of implementing inclusive organizational
practices, HR managers need to overcome barriers such as
crosscultural misunderstandings, mistrust of those who are
different, and intergroup conflicts.
Trends and Future Directions OPTIMIZING
OPPORTUNITIES FOR WORK,LIFE BALANCE AND
WORK FLEXIBILITY In recent years corporate leaders,
policy makers and researchers have realized that balancing
the often conflicting demands of work and family life is a
challenge that requires innovative initiatives that could
benefit workers, families, and work organization. Gender
role expectations spilled over into the workplace and were
the basis for its prevailing practices that assumed total
separation between work and family life. Employers
expected employees to completely devote their work time
to their jobs during rigid specified hours (the conventional
"nine-to-five"), premising that someone else (typically the
wife) would attend to family matters during work hours.
The American workforce has changed dramatically
over the past several decades. More women, members of
racial and, or, ethnic minority groups and workers. whose
lifestyles, belief systems, values and other intrin sic and
extrinsic qualities are different from the corpo rate
"mainstream" have entered the workforce (Cox, 2001; Mor
Barak, 2005). The increasingly diverse work force of today
challenges corporate America to embrace diversity as a
necessary strategy for maintaining a healthy bottom line
and to support employees in balan cing work and family
obligations. This is particularly true for the social work
workforce that is composed of diverse racial, ethnic, and
cultural groups and includes a large proportion of women.
To address these changing needs and to attract and
retain talent, a trend has emerged in recent years char-
acterized by more and more work organizations offering

workplace flexibility options. These flexibility options
include scheduling of full-time work hours (including flextime,
compressed work week); amount of time working (including
part time, part year); and with multiple points of entry and
reentry over the course of a career. These are hailed as
progressive solutions for balancing work and life, as well as
for increasing productivity (Hill, Hawkins, Ferris, &
Weitzman, 2001; Hill, Jackson, & Martinengo, 2006).
The problem is that for the most part, these programs have
not been subjected to systematic scientific inquiry and their
true benefits and limitations, such as "flexible work space"
options, could literally mean that workers do not have desks at
work. and are expected to entirely work from home, not
always the best arrangement for those with \people at home.
There is some initial evidence that these Workplace Flexibility
Arrangements could reduce stress and improve productivity,
and limited data on their effectiveness (Eaton, 2003;
Martinez-Sanchez, Vela-Jimenez, de Luis-Carnicer,
perez-Perez,2007).
In summary, the social, legal and cultural environment in
which social work organizations operate and function is
increasingly complex, and requires the same person in
environment value orientation that these organizations place
on providing competent quality services to their beneficiaries.
Effective and strategic HRM practices are central to
supporting organizations and their employees in all aspects of
organizational functioning, . including legal compliance to
policies and practices that promote fairness and social just ice.
As HRM embarks on creating and implementing employee
development and organizational practices, it must also
consider cross-cutting issues such as providing effective
supervision, diversity and inclusion, and workfamily balance
and flexibility. Aligned with the mission of social work,
through HRM practices these organizations may be more able
to meet the needs of their employees, which in tum, can help
foster optimal client outcomes.
REFERENCES
Bae, J., & Lawler, J. J. (2000). Organizational and human resource
management strategies in Korea. Academy of Management J
oumal, 43, 502-517.
Cameron, J., & Pierce, W. D. (2002). Rewards and intrinsic
motivation: Resolving the controversy. Westport, CO: Bergin &
Garvey.
Cox, T. (2001). Creating the multicultural organization: A strategy
for capturing the power of diversity (1 st ed.). San Francisco:
Jessey-Bass.
de Leede, J., & Looise, J. K. (2005). Innovation and HRM:
Towards an integrated framework. Creativity and Innovation
Management, 14(2), 108-117.
MANAGEMENT: HUMAN REsOURCES
179
Eaton, S. C. (2003). If you can use them: Flexibility policies,
organizational commitment, and perceived performance,
Industrial Relations, 42(2), 145-167.
Firth, L., Mellor, D. J., Moore, K. A., & Loquet, C. (2004).
How can managers reduce employee intention to quit? Journal
of Managerial Psychology, 19(1/2), 170-187.
Guthrie, J. P. (200l). High-involvement work practices, turnover,
and productivity: Evidence from New Zealand. Academy of
Management Journal, 44(1),180-190.
Hewitt, A. S., Larson, S. A., O'Nell, S. N., & Sauer, J. K. (2005)
Orientation, socialization, networking, and profes-
sionalization. In S. A. Larson & A. S. Hewitt (Eds.), Staff
recruitment, retention, & training strategies for community human
services organizations (pp. 105-124). Baltimore, MD:
Paul H. Brookes.
Hill, E. J., Hawkins, A. J., Ferris, M., & Weitzman, M. (200l).
Finding an extra day a week: The positive influence of
perceived job flexibility on work and family life balance.
Family Relations, 50(1), 49-58.
Hill, E. J., Jackson, A. D., & Martinengo, G. (2006). Twenty years
of work and family at international business machines
corporation. American Behavioral Sdentist, 49(9), 1165-1183.
Hopkins, K. M., & Austin, M. J. (2004). Coaching employees
with performance problems. In M. J. Austin & K. M. Hopkins
(Eds.), Supervision as collaboration in the human services:
Building a learning culture (pp. 215-226). Thousand Oaks, CA:
Sage.
Kettner, P. M. (2002). Achieving excellence in the management of
human service organizations. Boston: Allyn and Bacon.
Kidwell, R. E., & Robie, C. (2003). Withholding effort in
organizations: Toward development and validation of a
measure. Journal of Business and Psychology, 17(4), 537-561.
Laliberte, T. L., Hewitt, A. S., & Larson, S. A. (2005). Staff
motivation and retention. In S. A. Larson & A. S. Hewitt
(Eds.), Staff recruitment, retention, & training strategies for
community human services organizations (pp. 197-214).
Baltimore, MD: Brookes.
Martinez-Sanchez, A., Vela-Jimenez, M. J., de Luis-Camicer, P.,
& Perez-Perez, M. (2007) Managerial perceptions of
workplace flexibility and firm performance. International
Journal of Operations & Production Management 27( 7), 714.
Mathis, R. L., & Jackson, J. H. (2006). Human resource
management: essential perspectives (4th ed.). Mason, OH:
Thomson Business and Economics.
Mor Barak, M. E. (2000). The inclusive workplace: An ecosystem
approach to diversity management. Social Work, 45(4),339.
Mor Barak, M. E. (2005). Managing diversity: Toward a globally
inclusive workplace. Thousand Oaks, CA: Sage.
Mor Barak, M. E., Findler, L., & Wind, L. H. (200l). Diversity,
inclusion, and commitment in organizations: International
explorations. Journal of Behavioral and Applied Management,
2(2), 72-91.
Mor Barak, M. E., Levin, A., Nissly, J. A., & Lane, C. J. (2006).
Why do they leave? Modeling child welfare workers' turnover
intentions. Children and Youth Services Review, 28(5),548-577.
180 MANAGEMENT: HUMAN REsOURCES
Mor Barak, M. E., Nissly, J. A., & Levin, A. (200l). Antecedents
to retention and turnover among child welfare, social work,
and other human service employees: What can we learn from
past research? A review and rnetanalysis. Social Service
Review, 625-661.
Mor Barak,M.E., Travis, D.J.,Pyun, H., &Xie, B. (2007). The
impact of supervision on worker outcomes in child welfare,
social work and mental health settings: A state of the art
review and meta-analysis. University of Southern California.
(submitted for publication).
Patti, R. (1987). Managing for service effectiveness in social
welfare: Toward a performance model. Administration in Social
Work, 11 (3/4), 7~21.
Pecora, P. J. (1995). Personnel management. In R. L. Edwards
(Ed.), Encyclopedia of Social work (19th ed., pp. 1828-1836).
Washington, DC: National Associatio~ of Social Workers.
Perlmutter, F. D., Bailey, D., & Netting, F. E. (2001). Managing
human resources in the human services: Supervisory challenges.
New York: Oxford University Press.
Pynes, J. (2004). Human resources management for public and
nonprofit organizations. San Francisco, CA: jessey-Bass.
Schuler, R: S., & Jackson, S. E. (2005). A quarter-century review
of human resource management in the US: The growth in
importance of the international perspective. Management
Revue, 16(1), 11-35.
Shipton, H., Fay, D., West, M., Patterson, M., & Birdi, K. (2005).
Managing people to promote innovation. Creativity and
Innovation Management, 14(2), 118-128.
Shipton, H., West, M. A., Dawson, J., Birdi, K., & Patterson, M.
(2006). HRM as a predictor of innovation. Human Resource
Management Journal, 16(1), 3-27.
The Annie E. Casey Foundation. (2003). The unsolved challenge
of system reform: The condition of the frontline human
services workforce. Retrieved July 24, 2006, from http://www
.aecf.org/initiatives/hswi/report_rev. pdf.
Travis, D. (2007). Is doing good enough? A path analytic model
of intrinsic job satisfaction among human service. workers.
Journal of Workplace Behavioral Health, 22(1), 13-32.
United States General Accounting Office (GAO). (2003).
HHS Could Play a Greater Role in Helping Child Welfare
Agencies Recruit and Retain Staff (GAO-03-357). Retrieved
May 2005, from http://www.gao.gov/new.items/d03357.pdf.
FURTHER READING
Armstrong, M. (1996). A handbook of personnel management
practice (6th ed.). London: Kogan Page.
Armstrong, M. (2000). The name has changed but has the game
remained the same? Employee Relations, 22(6), 576-593.
Austin, M. J., & Hopkins, K. M. (2004). Supervision as collab-
oration in the human services: Building a learning culture:
Thousand Oaks, CA: Sage.
BusinessWeek. (2006). Flextime: Honing the balance. Retrieved
June 5, 2006, from http://www.businessweek.com/
magazine/content/06 _50/b40 13007 .htm.
Eaton, S. C. (2003). If you can use them: Flexibility policies,
organizational commitment, and perceived performance.
IndustrialRelations, 42(2), 145-167.
Guest, D. (1987). Human resource management and industrial
relations. Journal of Management Studies, 24(5),503-521.
Hope-Hailey, V., Gratton, L.,McGovern, P., Stiles, P., & Truss,
C. (1997). A chameleon function? HRM in the '90s. Human
Resource Management Journal, 7(3),5-18.
Kadushin, A., & Harkness, D. (2002). Supervision in social work
(4th ed.). New York: Columbia University Press.
Larson, S. A., & Hewitt, A. S. (2005). Staff recruitment, retention,
& training strategies for community human services organ-
izations. Baltimore, MD: Paul H. Brookes.
Mor Barak, M. E., Cherin, D. A., & Berkman, S. (1998).
Organizational and personal dimensions in diversity climate:
Ethnic and gender differences in employee perceptions. The
Journal of Applied Behavioral Science, 34(1), 82-104.
Mor Barak, M. E., Findler, L., & Wind, L. H. (2003). Cross-
cultural aspects of diversity and well-being in the workplace:
An international perspective. Journal of Social Work Research
and Evaluation, 4(2),145-169.
Mor Barak, M. E., & Levin, A. (2002). Outside of the corporate
mainstream and excluded from the work community: A study
of diversity, job satisfaction and well-being. Community, Work
& Family, 5(2), 133-157.
Patti, R. J. (2000). The handbook of social welfare management.
Thousand Oaks, CA: Sage.
Storey, J. (1993). The take-up of human resource management by
mainstream companies: Key lessons from research.
International Journal of Human Resource Management, 4(3),
529-553.
-MICHALLE E. MaR BARAK
AND DNIKA JONES TRAVIS
QUALITY ASSURANCE
ABSTRACT: Quality assurance (QA) is a widely accepted
management function that is intended to ensure that services
provided to consumers meet agreed upon standards. Standards
come from professional organizations, evidence- based
practices, and public policies that specify outcomes for
consumers. QA systems consist of measurement, comparison
of findings to standards, and feedback to practitioners and
managers. There is emerging but limited research that
indicates that QA can be an effective strategy for improving
outcomes for consumers.
KEY WORDS: service standards; measurement; consumer
outcomes; feedback
Quality assurance (QA) is a widely accepted management
function. In its simplest form it is a set of activities that intend to
ensure that services provided to consumers meet certain
standards. The concepts and methods of QA are also referred to as
quality improvement (QI), continuous quality improvement
(CQI), quality management, or total quality management (TQM).

These terms are often used interchangeably. However, Ql
does tend to emphasize improvement over simple
assurance while CQI adds the idea that improving services
is a continuous process. TQM is a broader concept but
includes QAas a key concept.
The Roots of QA in
Management and Health Care
Some of the basic ideas of quality management can be
traced back to Taylor (1911) in his seminal work The
principles of scientific management. He proposed that there was
one "best" or most efficient way to produce a product and
that this could be determined using scientific methods.
Once the most efficient or least cost way was determined
workers would repeat the process and the enterprise would
be more productive (that is, producing more at less cost).
Maintaining the established process as intended is a basic
QA tenant that grew in prominence during the Second
World War.
Juran (1979) and Deming (1986) became the modem
creators of quality management with a shift from Taylor's
goal of efficiency to quality. Deming's Out of the crisis
(1986) became widely popular and marketed as TQM. One
of his basic principles is "The consumer is the most
important part of the production line" (p. 5). He defined
quality as meeting the needs of the consumer. Coming
from the business and particularly the manufacturing sector
the application ofTQM to human services and social work
agencies was controversial. While in the business sector
customer satisfaction produces revenue, some questioned
application of this idea in social services (Gummer &
McCallion, 1995).
Social services were also influenced by the QI move-
ment in health care. This dates back to Florence Night-
ingale's work to improve care to British soldiers in the 19th
century (Lohr & Brook, 1984) and becoming public health
policy in the United States with P.L. 92-603 in 1972 that
mandated professional standards review organizations
(PSROs):
The legislation mandated that PSROs should assure
that services provided and paid for by the Medicare,
Medicaid, and Maternal and Child Health programs
were medically necessary and of a quality that met
locally determined professional standards, and that
they were provided at the most economical level
consistent with quality of care. (p. 11)
Coulton (1982) explored implications of this policy for
social work that were predictive of what was to come in the
literature and the field. For example, a search of Social
Work Abstracts in February 2007 using QA as the search
term found 206 items with over half from the fields of
health and substance abuse.
MANAGEMENT: QUALITY ASSURANCE
181
STANDARDS OF QUALITY AND CONSUMER OUT.
COMES The definition of QA includes the meeting of
standards. One source of standards is professional asso-
ciations. This type of standard is implied by the PSROs of
the 1972 legislation. Standards for social services have
been developed by such organizations as the National
Association of Social Workers (NASW), Child Welfare
League of America, Council on Accreditation, and the
Joint Commission on Accreditation of Healthcare
Organizations. These standards are typically derived
through a consensus of professionals in a given field and
primarily involve service delivery elements such as
qualifications of staff, case loads, and what are thought to
be important service processes. For example, NASW has
practice standards for 14 areas, including substance use
disorders, child welfare, health care,. and school social
work (NASW, 2007).
Some standards are very specific. For example, the
Council on Accreditation standards for domestic violence
services includes 18 topics (Council on Accreditation,
2006). One of these is safety assessment and planning
where the standard is:
Within 24 hr or the first working day after initiation of
services, survivors receive an initial assessment of
1. Immediate needs, including medical and dental
care, legal assistance, food, shelter, and
clothing; arid
2. Safety and risk factors for the survivor, the
survivor's children, and any other involved
family members. (Council on Accreditation,
2006)
While Coulton's (1982) work identified outcomes for
clients as an element of QA, this idea has been con-
troversial and has only recently become a source for
standards. The developing importance of outcomes
coincides with the emphasis on evidence-based practice
(Gambrilll, 1999; McNeese & Thyer, 2004), the social
work management literature (Patti, 2000, 1985; Poertner &
Rapp, 2007; Rapp & Poertner, 1992, 1988), and public
policy. The Adoption and Safe Families Act of 1997 is just
one example of a policy that establishes outcomes (safety
and permanency) as the central focus of child welfare.
Advocates of evidence-based practices and consumer
outcome management also view their efforts as an
application of the NASW Code of Ethics (1999) value of
service and competency. Consequently, many QA systems
now include outcomes for consumers as a key element.
ASSURANCE IS NOT A GUARANTY It is useful to
think of assurance not as a guaranty but as increasing the
probability that the social work transaction will
182 MANAGEMENT: QUAlITY ASSURANG:E
achieve intended results with consumers. Consequently
many authors prefer other terms such as QI. Clients or
consumers achieve results through their interactions with
social workers. Given the variety of people and the com-
plex problems that social workers serve as well as the
research base for the effectiveness of our helping strate-
gies, guarantees are problematic. For example, a child
protection service worker would have difficulty guaran-
teeing that their judgment about the safety of a child would
not lead to another incidence of abuse. Similarly, a mental
health worker providing medication skills train ing to a
consumer would be on shaky ground guarantee ing that all
of the consumers receiving this training would
subsequently comply with their medication regimen.
Elements of.a QA System
QA systems are complex. However, they primarily con sist
of 'measurement, comparison of findings to stan dards, and
feedback to practitioners and managers. Various authors
expand on these elements differently and implem entation
varies widely across fields of prac tice and organizations. A
variety of approaches can be found in works by Bashshur
(2003), Magura (2000), and Yeaman, Craine, Gorsek, and
Corrigan (2000).
MEASUREMENT AND COMPARISON TO
STANDARDS Measurement and comparison to standards
are inseparable since standards dictate what is to be
measured as well as performance targets (Bashur, 2003 ).
For an administrator to know if individual or
organizational practices meet standards there must be
measurement of the practices that are identified by the
standard. This is similar to the long social work tradition of
supervisory review of case records. The standard directs
what the supervisory looks for in the record. For example,
a standard may require that a large percentage of consu-
mers state their goals for the service transaction.
Measurement involves case review to find evidence that
this occurred,' record the findings, and aggregating the
results by caseload or program.
In addition to measuring desired practices, m any QA
systems now include measures of consumer out comes.
Public policy is increasingly specifying the de sired
outcomes of social services. For example, the Adoption
and Safe Families Act (1997) now requires measurement
of child outcomes. The emphasis on evidence- based
practices and managing for consumer outcomes also
emphasizes the measurement of consu mer outcomes
(Poertner & Rapp, 2007).
Once data is collected on both outcomes and prac tices,
the relationship between them is examined. Using the
previous example, research may have estab lished that
when workers include consumers' goals in
case plans results for consumers improve. In this case, the
QA system measures workers inclusion of consumer goals
and consumer outcomes. The relationship between the two
is then examined.
FEEDBACK Knowing the proportion of consumers who
have achieved intended results and the proportion of
workers who included consumers' goals in their work is
meaningless unless these data are put to work. This is a
complex area that most writers on QA, including those
referenced here, discuss extensively.
An important aspect of the use of QA data is rewarding
staff for good results and practices as well as developing
strategies to improve results. A positive and . rewarding
organizational culture is important for this to occur. Alvero,
Bucklin, and Austin (2001) provide a good review of the
conditions for the effective use of feedback in organizations.
Effectiveness of QA
Management techniques ought to be held to the same
standard as direct social work practices in terms of
demonstrating their effectiveness. Unfortunately there is
little research on the effectiveness of QA systems. The
work of Yeaman, Craine, Gorsek, and Corrigan (2000) is
one of the few studies of QI and it demonstrated positive
effects with a program for adults with severe mental
illness.
Some researchers in the field of health regularly review
studies on the effects of organizational interventions on
practice and outcomes. While they are yet to review QI,
reviews of audit and feedback, similar to QA, exist. A
recent review of the audit and feedback research by
[amtvedt, Young, Kristoffersen, O'Brien, and Oxman
(2006) found that it can be effective in improving
professional practice. The effects of audit and feedback on
practice tend to be small to moderate. Effects are likely to
be greatest where measurement shows a large discrepancy
between practice and standards In other words the greater
the divergence between practice and standards the more
likely that audit and feedback will have a positive effect.
Implications for Practitioners and Managers
In the ideal agency QA is an unobtrusive system of data
collection that is used to reward staff, assure that ser vices
are delivered as intended, and produc e positive outcomes
for consumers. When QA systems are less than ideal they
consume a large number of hours of worker time for data
collection that might be better used with clients; much
meaningless data is collected and feedback is often used to
punish staff. The challenge for the social administrator is to
design the QA

system to meet the ideal. This includes developing a
consensus among staffs and agency constituents on desired
outcomes, locating and implementing evidence-based
practices, using data collection instruments that are part of
practice rather than an added burden, and using data to reward
and energize staff. The work of Alvero et al. (2001) and
Poertner and Rapp (2007) are useful for developing such
systems.
REFERENCES
Adoption and Safe Families Act of 1997, Pub. L. No. 105-89,
42 USC 1305,111 Stat 2115 (1997).
Alvero, A M., Bucklin, B. R., & Austin, J. (2001). An
objective review of the effectiveness and essential
characteristics of performance feedback in organizational
settings (1985-1998). Journal of Organizational Behavior
Management, 21 (1),3-29.
Bashur, R. (2003). An introduction to quality assurance in health
care. New York: Oxford University Press.
Coulton, C. J. (1982). Quality assurance for social services
programs: Lessons from health care. Social Work, 27(5),
397-402.
Council on Accreditation. (2006). Accreditation standards:
domestic violence services. Retrieved February 5, 2007,
from http://www .coastandards.org/standards. php ?nav
View= private&section_id= 58.
Deming, W. E. (1986). Out of the crisis. Cambridge, MA:
Massachusetts Institute of Technology.
Gambrilll, E. (1999). Evidence-based practice: An alternative
to authority-based practice; Families in Society, 80(4),
341-350.
Gummer, B., & McCallion, P. (1995). Total quality manage-
ment in the social service: Theory and practice. Albany, NY:
State University of New York.
jarntvedt, G., Young, J. M., Kristoffersen, D. T., O'Brien, M.
A, & Oxman, A D. (2006). Audit and feedback. Cochrane
Effective Practice and Organisation of Care Group, 4,
Retrieved November 27,2006, from Cochrane Database of
Systematic Reviews.
Juran, J. M. (1979). Quality control handbook (3rd ed.). New
York: McGraw-Hill.
Lohr, K. N., & Brook, R. H. (1984). Quality assurance in
medicine: Experience in the public sector. Santa Monica, CA:
Rand Corporation.
Magura, S. (2000). Program quality in substance dependency
treatment. Substance Use & Misuse, 35, 1617-1627.
McNeese, C. A, & Thyer, B. A, (2004). Evidence-based
practice and social work. Journal of Evidence-based Social
Work, 1(1),5-23.
National Association of Social Workers. (1999). Code of ethics
of the national association of social workers [Online].
Available at www.socialworkers.org/pubs/code.
National Association of Social Workers. (2007). Professional
standards [Online]. Available at www.helpstartshere.org/
Professional_Standards.
Patti, R. J. (1985). In search of purpose for social welfare
administration. Administration in Social Work, 9(3), 1-14.
MANAGEMENT: VOLUNTEERS
183
Patti, R. J. (2000). The landscape of social welfare manage-
ment. In R. J. Patti (Ed.), The handbook of social welfare
management (pp, 3-25). Thousand Oaks, CA: Sage Publi-
cations, Inc.
Poettner, J., & Rapp, C. A (2007). Textbook of social adminis-
tration: The consumer-centered approach. Binghamton, NY:
The Haworth Press, Inc.
Rapp, C. A, & Poertner, J. (1988). Moving clients center stage
through the use of client outcomes. In R. J. Patti, J. Poertner, &
C. A Rapp (Eds.), Managing for service effectiveness in social
welfare organizations (pp. 23-38). New York: The Haworth
Press.
Rapp, C. A, & Poertner, J. (1992). Social administration: A
client centered approach. New York: Longman.
Taylor, F. W. (1911). The principles of scientific management.
New York: W.W. Norton.
Yeaman, c, Craine, W. H., Gorsek, J., & Corrigan, P. W.
(2000). Performance improvement teams for better
psychiatric rehabilitation. Administration Policy in Mental
Health, 27(3),113-117.
-JOHN POERTNER
VOLUNTEERS
ABSTRACT: Volunteer activity is linked to the concept of
American democracy; it is also the source of early social work
in the nineteenth century. Volunteering is action taken by
personal choice and generally without expectation of pay; it
takes many forms. In 2006, it represented over 8 billion hours
of organization-related service in the United States. There are
costs as well as benefits in volunteering. In the human
services, volunteers have a variety of roles from serving on
leadership Boards to providing direct service; tension may
exist between professional staff and volunteers, and volunteer
management is important for effective use of volunteers.
KEyWORDS: volunteers; human services; volunteerism;
voluntary action; social work history
Background
Volunteering has been part of American life since colonial
times. In the early days of the Republic volunteer assistance
and mutual aid were often necessary and formal voluntary
associations soon emerged (Bremner, 1988; T rattner, 1999).
By the 1840s, Alexis de T ocqueville had described America
as a nation of joiners, thus helping to articulate the enduring
concept of a democratic nation linked to voluntary activity.
Social science study of volunteers is relatively new (Karl,
1998); research emerged after World War II and has
flourished since the 1970s, along with increased interest in the
concept of the civil society globally (Brilliant, 1995).
184 MANAGEMENT: VOLUNTEERS
Among scholars there is no real consensus about
why people volunteer individually or collectively, and
there are varied views of the scope of volunteering and
its rewards. Volunteer activity is often described as
action taken by personal choice and without pay or
"compensation." Still under the Fair Labor Standards
Act (1985) individuals may be considered volunteers if
they perform service for "civic, charitable, or humani-
tarian reasons" and are paid "expenses, reasonable ben-
efits, or a nominal fee" (Jennifer & Block, 2005).
Corporations also encourage employee volunteering.
Numerous studies point to the impact of collectivities
and community norms on volunteer action, including
variations among ethnic communities (Eckstein, 2001).
An NASW Policy Statement recognizes volunteers as
"an integral part of and ... resource of our human service
programs," providing they have adequate skills, are
appropriately used and supervised (NASW, 2007).
Individuals volunteer for a variety of motives and it
has been argued that these may be related to a conti-
nuum of volunteer roles and activities. Thus, "purist
volunteering" is defined as being of high cost to the
volunteer with little or no personal benefit, or, at the
other end, it may involve little personal cost and con-
siderable gain (Cnaan, Handy, & Wadsworth, 1996).
Most volunteers are not paid; others like Peace Corp
volunteers (overseas) or VISTA and Ameri-Corps vo-
lunteers in this country receive some financial support.
However, rewards may be of many kinds other than
financial: these include high status and networking
opportunities (social capital) from serving on Boards of
major institutions, such as hospitals, museums, pro-
minent social service agencies, or federated fund raising
organizations like a local United Way. Volunteers may
also develop marketable skills and self confidence,
along with the satisfaction of a job well done. Recent
findings suggest that volunteers, particularly older vo-
lunteers, gain health benefits from their activity (Cor-
poration for National & Community Service, 2007b).
The Bureau of Labor Statistics (2007) determined
that in the period from September 2005 to September
2006,61.2 million Americans over age 16 volunteered
at least once, for a total of 8.1 billion hours of formal
volunteer service in or through organizations; more than
5.3 million also volunteer informally in their com-
munities. The highest percentage of volunteers was
described as falling between 35 and 44 years old (a
31.2% participation rate); in comparison, 23.8 % of
those 65 years old and over volunteered, and 26.4% of
individuals between 16 and 19 years of age. Overall
more females (30.1 %) volunteered in comparison with
males (23.0%). A higher percentage of volunteers were
white (28.3%) followed by Black/African-Americans
(19.2%), Asian (18.5%), and Hispanic/Latinos (13.9%).
Social Workers are active volunteers and they mobilize
in times of disaster, such after Hurricane Katrina; in
fact, social workers "make up more than 40 percent of
Red Cross mental health volunteers" (NASW,2005).
Volunteers are a significant part of social work his-
tory. The first social workers are generally considered
to have been the "friendly visitors" in
nineteenth-century charities, notably in the charity
organization societies, paralleled by "residents" and
members of the settlement movement in the same
period (Lubove, 1969). With the professionalization of
social work and voluntary agencies in the early 20th
century, volunteers received less favorable attention.
More recently (and after the Reagan era), social
workers are facing increased voluntary involvement in
social welfare; still, tensions between staff and
volunteers continue to exist (Netting, Nelson, Borders,
& Huber, 2004).
Volunteer Settings and Services
Statistics bear out the importance of volunteers for
social service: high percentages of volunteers are in
religious settings (35.3 % ), educational or youth
services (27.0%), and 7.9% in hospitals or health
settings. The percentage of volunteers in social or
community service organizations in 2006 was 13.1 %,
up from 9.9% in 1989 (Corporation for National &
Community Service, 2007a). Among the activities
listed by all volunteers, the most common is fundraising
or selling items to make money; preparing, distribut ing
and serving food, engaging in "general labor," and
tutoring or teaching follow. A well-respected coalition
group, Independent Sector, estimates the national
average monetary value of volunteering to be equal to
$18.77 an hour (Corporation for National &
Community Service, 2007a). This dollar value may not
adequately reflect the significance of volunteer
leadership in governance for Boards and advisory
councils in the voluntary sector; volunteers also serve in
numerous public-related bodies, like mental health
councils, authorities, and federal advisory agencies or
civic commissions (Brilliant, 2000). The benefits of
volunteering for individuals needs further study
(Hodgkinson, 2004.) However, volunteers report
enhanced self-esteem; and they appear to gain satisfac-
tion from activities which enable them to give back to
their community. Like membership more generally,
volunteering contributes to social capital (Putnam, R.
D., 1995; Rotolo, T., 1999), and is empowering to the
individual who volunteers. (Mayer, Fracastoro, and
McNary, 2007; Still, less well analyzed is social
movement participation as a form of volunteering.

Challenges
There are issues that are problematic for social welfare
volunteering. First, and not fully explained, is a decline in
the 2006 formal volunteer rate (26.7%) compared with the
higher rate (28.8%) in each of the preceding 3 years
(2003, 2004, 2005); the biggest decline was among
teenagers (Bureau of Labor Statistics, 2007). One
explanation relates to volunteer attrition after 2005; one
out of three volunteers did not continue in 2006 at least in
part because they were not managed well (Corporation for
National & Community Service, 2007a).
Second, the nature of volunteering has chaD8td.
Experts suggest that there is a strong increase in "episo-
dic" volunteering, that is, volunteering which is short
term, often project oriented, and noncontinuous (Hustinx
& Lammertyn, 2003; Macduff, 2005). Third, satisfaction
in volunteering and volunteer retention appear to be
related to defined tasks and role definition, as well as
management practices and training. In addition to
recruitment, an Urban Institute study indicates that
management programs. for volunteers should include:
appropriate supervision, liability coverage and insurance
protection, screening for suitable volunteers, written
policies and job descriptions, recognition ceremonies,
measurement of impact (evaluation), development
opportunities, and training for staff working with
volunteers (Hager and Brudney, 2004). This study also
suggests the importance of an organizational culture that
supports volunteers. However, many' smaller orga-
nizations do not have the necessary resources and even
larger ones may not do an adequate job.
Fourth, of specific interest to social work, is the profile
of volunteers, who survey data characterize as better
educated, more religious and of higher income than
nonvolunteers (Weitzman, ]alandoni, Lampkin and
Pollak, 2002). Still, the reason individuals most often give
to explain their volunteering is that they were asked
(Hodgkinson, 2004). This raises questions about opening
up new routes to volunteering and diversity among
volunteers. Enhancing the volunteer pool might also help
alleviate the potential shortage of volunteers already
reported by some organizations. More effective use of
volunteer service bureaus (either affiliated with a local
United Way or free-standing) co uld be one way to reach
out to people not already connected to any volunteer
activity, along with increased media notice of volunteer
opportunities in the community. Also helpful would be
greater agency outreach to specific population groups,
such as teenagers, recent retirees, and racial and ethnic
groups, through social clubs and churches. Future trends
include a focus on involving the next generation of
retirees in new
MANAGEMENT: VOLUNTEERS 185
community activities, and targeted efforts aimed at en-
gaging more low-income, disadvantaged teenagers in
volunteering and civil society activities. In addition,
virtual volunteering, or e-volunteering, and crossnational
volunteering are growing in significance and popularity in
an age of globalization.
REFERENCES
Bremner, R. H. (1988). American philanthropy (Znd ed.).
Chicago, IL: University of Chicago Press.
Brilliant, E. L. (1995). Voluntarism. In R. L. Edwards (Eds.),
Encyclopedia of social wark (19th ed., vol. 3, pp. 2469-2482).
Washington, DC: NASW Press.
Brilliant, E. L. (2000). Private charity and public inquiry: A history
of the Filer and Peterson Commissions. Bloomington and
Indianapolis, IN: Indiana University Press.
Bureau of Labor Statistics, Department of Labor. (2007).
News. Volunteering in the United States, 2006. Released
January 10, 2007. Retrieved from http://www.bls.gov/cps/.
Cnaan, R. A., Handy, F., & Wadsworth, M. (1996). Defining who
is a volunteer: Conceptual and empirical considerations.
Nonprofit and Voluntary Sector Quarterly, 25(3), 364-383.
Corporation for National & Community Service (2007a).
Volunteering in America 2007: State trends and rankings in civic
life. Retrieved from http://www.nationalservice.gov/
about/volunteering/index.asp.
Corporation for National & Community Service (2oo7b).
Volunteering produces health benefits (new report shows
helping others improves your wellbeing and longevity). Press
Release by the Corporation for National & Community
Service. Retrieved, May 07, 2007, from http://www .cns. gov
/about/newsroom/releases_detail.asp ?tbLpr_id =687.
Eckstein, S. (200l). Community as gift giving: Collectivist roots
of volunteerism. American Sociological Review, 66(6), 829-851.
Hager, M. A., & Brudney, J. L. (June 2004). Volunteer management
practices and retention of volunteers. Management Capacity Study
Series. Washington, DC: The Urban Institute.
Hodgkinson, V. (2004). Volunteering. In D. Burlingame (Ed.),
Philanthropy in America: A comprehensive historical encyclope-
dia (vol. 2, pp. 494-499). Santa Barbara, CA: ABC-CLIO, Inc.
Hustinx, L., & Lammertyn, F. (2003). Collective and reflective
styles of volunteering: A sociological modernization
perspective. Voluntas: International}oumal of Voluntary and
Nonprofit Organizations, 14(2), 167-187.
Jenner & Block. (December 2005). Client advisory: DOL clarifies
definition of volunteer under FLSA. Labor and Employment
Practice.
Karl, B. D. (1998). Volunteers and professionals: Many histories,
many meanings. In W. W. Powell & E. S. Clemens (Eds.),
Private action and the public good (pp. 245-257). New Haven,
CT: Yale University Press.
Lubove, R. (1969). The professional altruist: The emergence of social
wark as a career, 1880-1930. New York: Atheneum.
186 MANAGEMENT: VOLUNTEERS
Macduff, N. (2005). Societal changes and the rise of the episodic
volunteer. In J. Brudney (Ed.), Emerging areas of volunteering.
ARNOV A Occasional Paper Series, 1 (2). Indianapolis, IN:
ARNOVA.
Mayer, B. W., Fraccastoro, K. A., and McNary, (2007). The
relationship between organizational-based self-esteem and
various factors motivating volunteers. Nonprofit and Voluntary
Sector Quarterly, 36(2), 327-340.
NASW. (2005, September 6). Social workers mobilize in wake of
Hurricane Katrina. Retrieved from http://www.naswdc.
org/pressroom/2005/090605.asp.
NASW. (2007). Volunteers and social service systems. Social
Work Abstracts. Retrieved from www.naswdc.org/resources/
abstracts/abstracts/volunteers. asp
Netting, F. E., Nelson, H. W., Borders, K., & Huber, R. (2004).
Volunteer and staff relationships: Implications for social work
administration. Administration in Social Work, 28(3/4), 69-89.
Putnam, R. D. (1995). Bowling alone: America's declining social
capital. Journal of Democracy, 6, 65-78.
Rotolo, T. (1999). Trends in voluntary association participation.
Nonprofit and Voluntary Sector Quarterly, 28(2),199-212.
T rattner, W. 1. (1999). From poor law to welfare state: A history of
social welfare in America (6th ed.). New York: The Free Press.
Weitzman, M. S., Jalandoni, N. T., Lampkin, L. M., & Pollak, T.
S. (2002). The new nonprofit almanac and desk reference: The
essential facts and figures for manageres, re,searchers, and volunteers.
San Francisco, CA: [ossey-Bass.
FURTHER READING
Chinman, M. J., & Wandersman, A. (1999). The benefits and
costs of volunteering in community organizations: Review
and practical implications. Nonprofit and Voluntary Sector
Quarterly, 28(1), 46-64.
Ishan, J., Kolodinsky,J., & Kimberly, G. (2006). The effects of
volunteering for nonprofit organizations on social capital
formation: Evidence from a statewide survey. Nonprofit and
Voluntary Sector Quarterly, 35(3), 367-383.
Osttrower, F. (2007). Nonprofit governance in the United States:
Findings on performance and accountability. Retrieved from
http://www .urban.org/url.cfm?lD=411479.
Skocpol, T., & Fiorina, M. P. (Eds.). (1999). Civic engagement and
American democracy. Washington, DC: Brookings Institution
Press and Russell Sage Foundation.
Tocqueville, A. de (1969). Democracy in America (G. Lawrence,
Trans.). New York: Anchor Books.
-ELEANOR L. BRILLIANT.
MARRIAGE AND DOMESTIC PARTNERS
ABSTRACT: This entry briefly covers the history,
demographics, research, clinical practice, diversity, debates,
and trends surrounding marriage and domestic partnership in
the United States.
Who marries and why, when, and at what rate people
marry is covered, as are some of the statistics behind
alternatives to traditional marriage, such as cohabitation,
domestic partnership, and civil unions. It is beyond the scope
of this entry to discuss in detail relationship dissolution and
divorce, although information is provided insomuch as it
relates to marriage and domestic partnership.
KEY WORDS: marriage; domestic partnership; civil unions;
same-sex marriage; couple therapy; cohabitation; divorce
The ability to form close relationships with others is a crucial
component of life span development. In fact, an inability to do
so may be considered partial criteria for some types of mental
disorders (see American Psychiatric Association, 2000).
Psychologist Erik Erikson theorized that young adults must
master intimacy over isolation if they are to move
successfully through his proposed stages of psychosocial
development (Erikson, 1980). Apart from these theoretical
obligations, much of global society sanctions the forming of
close relationships that it deems appropriate. Proms,
engagements, weddings, and anniversary celebrations serve
to socially reinforce (usually heterosexual) couplings and the
norms surrounding acceptable relationships.
Marriage is the legal, and most often consensual, joining
of two persons of the opposite sex, and more recently (albeit
geographically limited) of the same sex as well. Domestic
partnership can refer to any unrelated persons 18 years of age
or older living together for a minimum specified period of
time and in a financially interdependent relationship. Both
unmarried heterosexual couples and same-sex couples can
apply for domestic partner status in those jurisdictions and
companies that recognize it. However, such distinction still
falls short of the 1,138 federal benefits and protections
afforded to legally married couples (U.S. General Accounting
Office, 1997, 2004). For example, access to a partner's Social
Security benefits, Medicaid and Medicare benefits, and
veterans' pensions, and the exemption from gift and estate tax
liabilities are just a few of the laws mentioned in the U.S.
Code that are affected by marital status. Only marriage offers
couples such entitlements; civil unions, a proposed substitute
for same-sex marriage and available in only a handful of
states, afford no federal benefits and protections.
I
1
HISTORY Following an extensive survey of marriage
definitions across time and cultures, Coontz (2005)
summarizes what many definitions of marriage share: the
ascription of rights and responsibilities within the

immediate and extended families and society, and the
generational transmission of inheritance.
THEORY Traditional marriage (referred to by some as
institutional marriage) has been defined by strict gender
roles in which the husband meets the family's financial
needs while the wife fulfills its social and emotional needs.
More egalitarian and less role limiting is companionship
marriage in which friendship and role sharing take center
stage (Steinmetz, Clavan, & Stein, 1990).
Wilcox and Nock (2006) refer to this power-sharing
model as companionate marriage. A departure from this
view is the equity model, in which women are less
concerned with equality than equity. An equitable di vision
of labor may follow along traditional gender lines, but it is
seen as acceptable by women who perceive their domestic
orientation as innate. This differs from institutional
marriage, which Wileox and Nock define as one valued for
its moral and religious underpinnings and the normative
support the couple receives. Last, feminist theory views
marriage as the result of gender socialization, traditional
gender norms, and social pressure to conform to those
norms (Schwartz & Scott, 2000), a theory that loosely
resembles Wilcox and Nock's gender model of marriage.
u.s. PERSPECTIVE In a survey of more than 2,000
Americans (Patterson & Kim, 1991),36% indicated love as the
reason they married. Lagging behind were compa-
nionship/fear of aging alone (14%), desire to have children
(12%), sex (10%), happiness (9%), money (5%), and habit or
convenience (5%). However, these figures belie the trend of
decreasing rates of marriage and increasing rates of divorce.
Amato, Booth, johnson, and Rogers (2007) propose two
models to explain the increase in marital instability. First,
marital expectations have increased while divorce barriers
have decreased. In the second model, marital expectations
have not changed, but marital quality has declined overall.
Traditional marriage has until recently been limited to
the legal, and in most cases religious, union of one man
and one woman. In 2004, the Commonwealth of
Massachusetts, following the Supreme judicial Court's
finding unconstitutional the limiting of marriage to
heterosexual couples, challenged this definition by issu ing
licenses to same-sex partners wishing to marry (Goodridge
v. Department of Public Health, 2004). Similarly, Vermont,
Connecticut, and New jersey passed civil union legislation
recognizing same-sex couples in their respective states.
Despite this progress, all but four states and the District of
Columbia have instituted laws
I
i
J ..
.
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":.
MARRIAGE AND DoMESTIC PARTNERS
187
or constitutional amendments against same-sex unions.
These initiatives go above and beyond the preexisting
Defense of Marriage Act (DOMA) of 1996, which allows
states to not recognize same-sex unions granted by any
other state.
INTERNATIONAL PERSPECTIVE North American and
European societies permit individual selection of marital
partners, compared with most other societies in which
future spouses are chosen by the family (Georgas, 2006 ).
Whom one can marry (endogamy) and cannot marry
(exogamy) varies to some extent across cultures. For
example in some societies, upon her husband's death, a
wife may be expected to marry his brother (endogamy)
while in almost all societies, marrying her own brother
would be widely prohibited (Georgas, 2006).
Much of international, particularly Western, so ciety's
understanding of marriage has come under scrutiny in
recent years, with more countries broadening their legal
protection and benefits to include same-sex partners. The
Netherlands, Belgium, Spain, Canada, and South Africa
now permit same-sex marriage nationwide. The United
Kingdom offers civil partnerships, stopping just short of
using the term "marriage." Many countries in Africa and
the Middle East, however, still consider same-sex sexual
behavior a crime punishable by law.
Demographics
Few would argue that the face of marriage, divorce, and
cohabitation has changed in recent years. However, the
interpretation of those statistics as being for the better or
worse remains subjective. What is certain is that the rush
to marry has slowed (U.S. Census Bureau, 2004b), those
choosing cohabitation have found an alternative path to
partnership (U.S. Census Bureau, 2000), and the
percentage of persons who have ever divorced has
increased (U.S. Census Bureau, 2006) as the barriers to
divorce have diminished.
PREV ALENCE AND INCIDENCE Slightly more than
half (52.6%) of persons 15 years of age and older in 2006
reported being currently married and 2.1 % separated.
Nearly one-third (29.4%) identified as never married, with
6% and 9.8% currently widowed and divorced,
respectively. Compared with the overall percentage, more
Asians (60.1%) and Whites (56.4%) were married than
Blacks (32.4%) and Hispanics (50.7%; U.S. Census
Bureau, 2006). Trends over the last 10 years show a
decline in marriage from 56.9% in 1996 and an increase in
the percentages of persons never married, up from 27.5% ,
and divorced, up from 8.9% (U.S. Census Bureau, 1996).
188 MARRIAGE AND DoMESTIC PARTNERS
By definition, persons in same-sex and other unmar-
ried domestic partnerships are counted among the never
married. Unmarried couples are accounted for only if
they live in the same household. In 2000 (U.S. Census
Bureau, 2000), there were more than 5 million
unmarried couples living together; 12.6% of those were
identified as same-sex couple households (slightly more
than half were male-male couples). According to the
National Center for Health Statistics (NCHS, 2006) of
the Centers for Disease Control, individuals married at a
rate of 7.5 per 1,000 people in 2005, down from 8.8 per
1,000 in 1996 (NCHS, 1999). Likewise, the rate of
divorces dropped from 4.3 per 1,000 in 1996 (NCHS,
1999) to 3.6 in 2005 (NCHS, 2006).
MARIT AL AGE AND DURATION The age at which
individuals marry for the first time continues to rise. In
1983, men entered their first marriage at age 25.4 and
women at 22.8. Twenty years later, those ages jumped to
27.1 and 25.3, respectively (U.S. Census Bureau,
2004b).
Although 96.1 % of the men who married for the first
time between 1955 and 1959 made it to their fifth
wedding anniversary, only 90.1% of men married for
the first time between 1990 and 1994 made it. Even
fewer women saw their fifth anniversary: 94% married
between 1955 and 1959 compared with 86.9% between
1990 and 1994. First marriages that end in divorce do so
after a median of 8.2 years for men and 7.9 years for
women. Second marriages that end in divorce endure
only slightly longer: 9.2 years among men and 8.1 years
among women (Kreider, 2005).
Latest Research and Best Practices
Work with couples can be divided into two realms:
prevention before problems begin and intervention after
problems have appeared. Although prevention can be
considered an intervention in itself, it is meant here in
terms of its temporal relationship to the onset of couple
difficulties.
INTERDISCIPLINARY CONNECTIONS AND
CONTRI. BUTIONS Interpretations of prevention and
intervention in couple therapy can vary across
disciplines. Couple therapy, the specialty of marriage
and family therapists, is also practiced by professionals
in other fields, including social work, psychology,
counseling, and nursing. The social work perspective on
working with couples is similar to its
person-in-environment approach with other systems
(Williams, Karls, & Wandrei, 1994). Social workers
recognize simultaneously the needs of each individual
within the couple dyad as well as the couple as a unit.
From a systems
perspective, each partner is a subsystem within the
couple system, just as the couple is a subsystem within
the larger society. Ecologically speaking, social workers
assess and establish goals and objectives for improving
the fit between couple and environment through colla-
boration with the couple.
PREVENTION With the growing visibility of alterna-
tive relationships, many clinicians and scholars recog-
nize the appropriateness of referring to intimate
relationships inclusively as "couples" rather than using
the more limiting "marriages" (Gurman & Jacobson,
1995). Yet, much of the literature focuses still on the
marital dyad. Nowhere is that more apparent than in the
prevention efforts that typically surround premar ital
education and counseling. Initiatives aimed at pre-
venting destructive marital pattems take on various
forms, from informal to formal and from traditional to
contemporary. In a random household survey of four
mid-American states, premarital education was asso-
ciated with greater marital satisfaction and spousal
commitment and lower odds of divorce (Stanley,
Amato, Johnson, & Markman, 2006). Cordova et a1.
(2005) developed the Marriage Checkup (which
incorporates motivational interviewing) for at-risk
couples and found that participants fared better than
their control group counterparts. Even mindfulness
meditation has found its way into the realm of
relationship .enhancement (Carson, Carson, Gil, &
Baucom, 2004).
One well-known model is the skills-based Preven-
tion and Relationship Enhancement Program (PREP).
PREP involves six 2-2.5-hr sessions delivered weekly
or condensed into a weekend and addresses such skill-
building areas as communication and problem solving
(Floyd, Markman, Kelly, Blumberg, & Stanley, 1995).
Extensive research (see "Suggested Links" below for
PREP resources) has demonstrated PREP's
effectiveness across delivery settings and disciplines.
INTERVENTION Three couple therapies whose effec-
tiveness is widely published are behavioral couple
therapy (BCT), cognitive behavioral couple therapy
(CBCT), and emotionally focused couple therapy
(EFCf; Christensen & Heavey, 1999). In their review of
the literature, Christensen and Heavey indicated that
none of these is better than another and instead point to
the possibilities in matching couples to the most ap-
propriate treatment. A meta-analysis by Wood, Crane,
Schaalje, and Law (2005), however, found EFCf
significantly more effective than behavior marital
therapy (that is, BCf) in treating moderate levels of
marital distress. Integrative behavioral couple therapy
(lBCf) is a relatively newer treatment that combines
BCf with a
 MARRIAGE AND DoMESTIC PARTNERS 189

component of emotional acceptance (that is, helping PHYSICAL AND MENTAL ABILITY The lack of
couples accept in each other what they cannot change). autonomy in decision making may be one of the greatest
mCf was shown to be similar to BCf at posttreatment obstacles to marriage, if not partnership, for persons
(Christensen et a1., 2004) and at 2-year follow- up with disabilities. The inability of an individual deemed
(Christensen, Atkins, Yi, Baucom, & George, 2006) in incompetent to provide consent, or guardians who do
treating marital distress. not grant consent, can prevent those with physical or
mental disabilities from marrying. The high prevalence
Diversity and Vulnerable Populations Cultural of partner violence against persons with disabilities can
expectations and societal limitations affect one's also make this decision very difficult for the individual
decision and ability to partner and/or marry. Aside from with the disability and, if relevant, his or her guardian
the legal implications of same-sex partnerships for (Jordan & Dunlap, 2001).
lesbians and gay men, other (but not necessarily mu-
tually exclusive) populations experience their own ex- CLASS Persons living in poverty or at the margins have
presslOOSohir\d challenges to partnership and particularly been the target of an institutionalized mar-
marriage. riage push. The Welfare Reform Act of 1996 and subse-
RACE AND ETHNICITY 'The availability of mates, quent Reauthorization in 2006 included funds allocated
cultural norms, and filial responsibility to parents affect for the Healthy Marriage Initiative, which seeks to pro-
partnerships and marriages among populations of color. mote marriage as a means of shrinking the welfare rolls
For example, the disproportionately high rates of incar- (Administration for Children and Families, 2007). The
ceration and homicide and low rate of sustainable em- success of such programs remains to be seen, as early
ployment among African American males limits viable reports show that more than half of cohabiting relation-
partner selection for women (Bonhomme, 2006). The ships among poor women end by the fifth year, leaving
probability of Latinas marrying is less than that for White fewer than half of these relationships surviving or tran-
woman but more than that for African American women; sitioning to marriage (Lichter, Qian, & Mellott, 2006),
comparatively, it is higher among non-· U.S.-born than
U.S.-born Latinas (Lloyd, 2006). Some Asian cultures, Debates Including
even when exposed to Western cultures, continue to Ethical Issues and Dilemmas
value filial responsibility. Aging Chinese American and The prevailing debate in the United States at this time
Japanese American parents are more likely than their regarding partnership and marriage is that of same-sex
White counterparts to live with their adult children, marriage. In 2004, President George W. Bush called for
particularly those adult children who are or have ever the Constitution to be amended, once and for all,
been married (Kamo & Zhou, 1994). defining marriage as between one man and one woman,
Antimiscegenation laws, which existed through the fearing that DOMA may one day be overturned.
first two-thirds of the 20th century, prohibited inter racial Traditional definitions of marriage reach from the
marriages between Whites and either Blacks or Asians local to the national levels, including the U.S. Census
(Trask & Koivunen, 2007). Since the repealing of these Bureau's tabulation of marriages as those comprised of a
laws, racial heterogamy increased between 1980 and husband and a wife (U.S. Census Bureau, 2004a).
2000, as did the marital quality of these relationships However, these exclusionary definitions no longer
(Amato et a1., 2007). Interracial marriage is more likely apply to nearly 6 million couples and families across the
between White and non-White groups than between two United
non-White groups. However, Whites and African States (U.S. C~nsus Bureau, 2005). .
Americans have the lowest rates of interracial marriages; The National Association of Social Workers'
American Indians are among the groups with the highest (NASW) Code of Ethics (1996) calls on social workers to
rates (Lee & Edmonston, 2005). "prevent and eliminate domination of, exploitation of,
and discrimination against any person, group, or class
AGE Karasik and Hamon (2007) aptly point out that on the basis of race, ethnicity, national origin, color,
marrying in later life is subject to social and cultural sex, sexual orientation, age, marital status, polit ical
norms. Because women typically outlive men, yet are belief, religion, or mental or physical disability" (§ 6.04
expected to seek out mates their own age or older, there Social and Political Action). Social workers who
is a paucity of available partners. This, coupled with support the extension of marriage to same-sex couples
society's discomfort with sexuality among elderly indi- see this issue as fully within the bounds of social justice
viduals, makes for an environment that denies, if not as spelled out by the Code. Social workers who oppose
discourages, elder partnering. same-sex marriage-nearly 30% in one study (Green ,
2005) believed that state laws regarding
•
190 MARRIAGE AND DOMESTIC PAR1NERS
consensual behavior among gay men and lesbians should
not be loosened-may not view the lack of such legislation
as discriminatory.
Trends and Directions
The proportion of those who have ever cohabited has
increased over the years, from 33% in 1987 to 45% in 1995,
the greatest increase being among Whites and among
high-school graduates (Bumpass & Lu, 2000). The
proportion of premarital cohabitation has likewise
increased, up from 16% in 1980 to 41 % by century's end
(Amato et al., 2007). Marital breakups rose in the decades
spanning the 1950s through the 1970s but leveled off into
the 1980s. The probability that ,a second marriage would
break up, however, continued to increase through the
1980s, even though the likelihood of remarriage' decreased
over the years (Bramlett & Mosher, 2002).
According to a public opinion poll conducted in July
2006 by The Pew Forum on Religion and Public Life
(PFRPL, 2006), 35% of Americans favor same-sex
marriage, while 56% oppose it. A May 2006 Gallup Poll
(2007) reported slightly higher favorabilitv, with between
39% and 42% in favor and between 56% and 58% in
opposition. Favorability has ebbed and flowed in recent
years, reaching a high of 39% in March 2006 following a
low of 29% in August 2004 (PFRPL, 2006). Opposition is
strongest among those 65 years of age and older and among
conservative Republicans. Civil unions, which provide
legal recognition and some of the same rights afforded to
married couples, however, have gained acceptance among
the majority (54%; PFRPL, 2006).
Between the year 2000, when Vermont enacted this
country's first same-sex civil union legislation, and 2003,
6,683 civil unions had been established (Vermont
Department of Health, 2005). There has been a steady
decline in the rate of civil unions performed over the 4-year
period; however, this may be more of a leveling off than a
sign of diminishing interest. Since then, Massachusetts has
become the' first state to permit same-sex marriage. So far,
about 8,500 lesbian and gay couples have taken advantage
of this legalization (Massllqualitv.org).
Implications for Social Work
Social work is a profession that easily adapts to the
changing environment. Judging by the trends and di-
rections discussed above, social work's ability to respond
to the transformation of marriage and domestic partnership
is indispensable. By virtue of their required education and
training, professional values and ethics, and regulated
practice standards, social workers are aptly qualified to
engage in intervention with couples.
Indeed, social workers provide the majority of mental
health services in the United States.
Social workers are in an ideal position to work with all
types of couple relationships, especially those comprising
individuals from traditionally underserved populations.
Working with the partner dyad to decrease destructive
patterns and enhance healthy interactions is just one level of
intervention. With an emphasis on social justice, social work
seeks to dismantle prejudice and discrimination against
those couples whose legal options have been traditionally
limited, for example, same-sex and mentally challenged
couples. Furthermore, social workers are called on to
advocate for couples whose access to and benefits of
domestic partnership and marriage have been negatively
impacted by racial, economic, age, and gender inequality.
Understanding the intersection of political, social, and
economic realities at the various concentric proximities to
the couple will serve social work well, as marriage . and
domestic partnerships undergo continuous reshaping and
redefinition in the future.
[See also Couples.]
REFERENCES
Administration for Children and Families. (2007). The healthy
marriage initiative (HMl): General information. Retrieved April
11, 2007, from http://www.acf.dhhs.gov/healthymar
riage/about/mission.html.
Amato, P. R., Booth, A., Johnson, D. R., & Rogers, S. ]. . (2007).
Alone together: How marriage in America is changing.
Cambridge, MA: Harvard University Press.
American Psychiatric Association. (2000). Diagnostic and stat-
istical manual of mental disorders (4th ed., Text Revision).
Washington, DC: Author.
Bonhomme,]. (2006). African-American males in the United
States prison system: Impact on family and community. 'The
Journal of Men's Health & Gender, 3(3), 223-226.
Bramlett, M. D., & Mosher, W. D. (2002). Cohabitation, marriage,
divorce, and remarriage in the United States (DHHS Publication
No. PHS 2002-1998). Washington, DC: U.S. Government
Printing Office.
Bumpass, L., & Lu, H.-H. (2000). Trends in cohabitation and
implications for children's family contexts in the United
States. Population Studies, 54, 29-41.
Carson,]. W., Carson, K. M., Gil, K. M., & Baucom, D. H. (2004).
Mindfulness-based relationship enhancement. Behavior
Therapy, 35, 471-494.
Christensen, A., Atkins, D. C, Berns, S., Wheeler,]., Baucom, D.
H., & Simpson, L. E. (2004). Traditional versus integrative
behavioral couple therapy for significantly and chronically
distressed married couples. Journal of Consulting and Clinical
Psychology, 72(2), 176-191.
Christensen, A., Atkins, 0. C, Yi, j., Baucom, D. H., & George, W.
H. (2006). Couple and individual adjustment for 2 years
following a randomized clinical trial comparing

traditional versus integrative behavioral couple therapv.Jour-
nal of Consulting and Clinical Psychology, 74( 6), 1180--1191.
Christensen, A., & Heavey, C. L. (1999). Interventions for
couples. Annual Review of Psychology, 50, 165-190.
Coontz, S. (2005). Marriage, a history: From obedience to intimacy or
how love conquered marriage. New York: Viking.
Cordova, J. V., Scott, R. L., Dorian, M., Mirgain, S., Yaeger, D.,
& Groot, A. (2005). The Marriage Checkup: An indicated
preventive intervention for treatment-avoidant couples at risk
for marital deterioration. Behavior Therapy, 36, 301309.
Erikson, E. H. (1980). Identity and the life cycle. New York:
Norton.
Floyd, F. J., Markman, H. J., Kelly, S., Blumberg, S. L., &
Stanley, S. M. (1995). Preventive intervention and relationship
enhancement. In N. S. jacobson & A. S. Gurman (Eds.),
Clinical handbook of> couple therapy (pp, 212-226). New York:
The Guilford Press.
The Gallup Poll. (2007). Homosexual relations. Retrieved April 15,
2007, from http://www.galluppoll.com/content/default.
aspx?ci= 1651&pg= 1.
Georgas, J. (2006). Families and family change. In J. Georgas, J.
W. Berry, F. J. R. van de Vijver, C. Kagircibasi, & Y. H.
Poortinga (Eds.), Families across culture: A 30-nation psychologi-
cal study (pp. 3-50). New York: Cambridge University Press.
Goodridge v. Department of Public Health, 440 Mass. 309; 798
N.E.2d 941 (2003).
Green, R. (2005). The use of bidimensional scales to assess social
workers' attitudes toward lesbians and gay men. Social Work
Research, 29(1), 57-60.
Gutman, A. S., & Jacobson, N. S. (1995). Therapy with couples: A
coming of age. In N. S. Jacobson & A. S. Gurman (Eds.),
Clinical handbook of couple therapy (pp. 1-6). New York: The
Guilford Press.
Jordan, B., & Dunlap, G. (2001). Construction of adulthood and
disability. Mental Retardation, 39(4), 286-296.
Kamo, Y., & Zhou, M. (1994). Living arrangements of elderly
Chinese and Japanese in the United States. Journal of Marriage
and the Family, 56, 544-558.
Karasik, R. J., & Hamon, R. R. (2007). Cultural diversity and
aging families. In B. S. Trask & R. R. Hamon (Eds.), Cultural
diversity and families: Expanding perspectives (pp. 136-153).
Thousand Oaks, CA: Sage.
Kreider, R. M. (2005). Number, timing, and duration of marriages and
divorces: 2001 (Current Population Reports, P70-97).
Washington, DC: U.S. Census Bureau.
Lee, S. M., & Edmonston, B. (2005). New marriages, new
families: U.S. racial and Hispanic intermarriage. Population
Bulletin, 60(2), 3-36.
Lichter.D, T., Qian, Z., & Mellott, L. M. (2006). Marriage or
dissolution? Union transitions among poor cohabiting
women. Demography, 43(2), 223-240.
Lloyd, K. M. (2006). Latinas' transition to first marriage:
An examination of four theoretical perspectives. Journal of
Marriage and Family, 68(4), 993-1014.
MassEquality.org. (n.d.), The history of marriage equality in
t:.
' Massachusetts. Retrieved April 14, 2007, from http://www. mas
sequaliry.org/background/,
MARRIAGE AND DoMESTIC PARTNERS 191
National Association of Social Workers. (n.d.). Did you know?
Facts about the profession. Washington, DC: Author.
National Association of Social Workers (NASW). (1996).
Code of ethics. Washington, DC: Author.
National Center for Health Statistics (NCHS). (1999). Births,
marriages, divorces, and deaths: Provisional data for 1998.
Hyattsville, MD:Public Health Service. Retrieved April 4,
2007, from http://www.cdc.gov/nchs/data/nvsr/nvsr47/
nvs4L21.pdf.
National Center for Health Statistics (NCHS). (2006). Births,
marriages, divorces, and deaths: Provisional data for 2005.
Hyattsville, MD: Public Health Service. Retrieved April 4,
2007, from http://www.cdc.gov/nchs/data/nvsr/nvsr54/
nvsr54_20.pdf.
Patterson, J., & Kim, P. (1991). The day America told the truth:
What people really believe about everything that really matters. New
York: Prentice Hall.
The Pew Forum on Religion & Public Life. (2006). Pragmatic
Americans liberal and conservative on social issues. Retrieved
April 12, 2007, from http://pewforum.org/docs/index.php?
DocID=150.
Schwartz, M. A., & Scott, B. M. (2000). Marriages and families:
Diversity and change (3rd ed.). Upper Saddle River, NJ:
Prentice Hall.
Stanley, S. M., Amato, P. R., Johnson, C. A., & Markman, H.
J. (2006). Premarital education, marital quality, and marital
stability: Findings from a large, random household survey.
Journal of Family Psychology, 20(1), 117-126.
Steinmetz, S. K., Clavan, S., & Stein, K. F. (1990). Marriage and
family realities: Historical and contemporary perspectives. New
York: Harper & Row.
Trask, B. S., & Koivunen, J. M. (2007). Trends in marriage and
cohabitation. In B. S. Trask & R. R. Hamon (Eds.), Cultural
diversity and families: Expanding perspectives (pp. 80-99).
Thousand Oaks, CA: Sage.
U.S. Census Bureau. (1996). Marital status and living arrangements:
March 1996. Retrieved April 4, 2007, from http://
www.census.gov/prod/3/98pubs/p20-496u.pdf.
U.S. Census Bureau. (2000). pen. Unmarried-partner households
by sex of partners [7]-Universe: Households. Retrieved April 5,
2007, from http://factfinder.census.gov/.
U.S. Census Bureau. (2004a). Current Population Survey (CPS):
Definitions and explanations. Retrieved April 13, 2007, from
http://www .census.gov/population/www/cps/cpsdef.html.
U.S. Census Bureau. (2004b). Table MS-2. Estimated median age at
first marriage, by sex: 1890 to present. Retrieved April 5, 2007,
from http://www.census.gov/population/socdemo/
hh-fam/tabMS-2.pdf.
U.S. Census Bureau. (2005).2005 American CommunirySurvey:
Households and families. Retrieved April 13, 2007, from
http://factfinder.census.gov/servlet/Dataset MainPageServlet
?_program = ACS&_submenuId =datasets_ 2&_lang=en.
U.S. Census Bureau. (2006). America's families and living
arrangements: 2006. Retrieved April 4, 2007, from http://www
.census.gov /popu lation/www/socdemo/hh-fam/
cps2006.html.
U.S. General Accounting Office. (1997). Defense of Marriage Act
(GAO/OGC-97-16). Washington, DC: Author.
192 MARluAOE AND DoMESTIC PARTNERS
u.s. General Accounting Office. (2004). Defense of Marriage Act:
Update to the prior report (GAO-04-353R). Washington, DC:
Author.
Vermont Department of Health. (2005). Vemiont vital statistics.
Retrieved April 12, 2007, from http://healthvermont.gov/
research/stats/vital_stats.aspx.
Wilcox, W. B., & Nock, S. L. (2006). What's love got to do with
it? Equality, equity, commitment and women's marital quality.
Social Forces, 84(3), 1321-1345.
Williams, J. B., Karls, J. M., & Wandrei, K. E. (1994). The
person-in-environment (PIE) system for describing problems
of social functioning. Hospital & Community Psychiatry,
40(11),1125-1127.
Wood, N. D., Crane, D. R., Schaalje, G. B., & Law, D. D. (2005).
What works for whom: A meta-analytic review of marital and
couples therapy in reference to marital distress. The American
Journal of Family Therapy, 33, 273-287.
SUGGESTED LINKS Human Rights
Campaign. http://www.hrc.org/
National Center for Health Statistics.
http://www.cdc.gov/nchs/nvss.htm The
National Marriage Project.
http://maTTiage.rutgers.edu/ .
Preventio~ and Relationship Enhancement Program.
http://prepinc.com/index.asp
United Nations Statistics Division.
http://unstats . un.org/unsd/default.
U.S. Census Bureau.
http://www . census .gov/
-ELAINE M. MACCIO
MATERNAL AND CHILD HEALTH
ABSTRACT: Social reform efforts of the settlement house
movement have provided, in part, the foundation for
today's Maternal and Child Health Bureau's policies,
programs, and services. Planning, implementing, and
evaluating policies and programs that affect the health and
well-being of mothers and children require a
multidisciplinary approach. Social workers, whose skills
encompass direct services, advocacy, planning and
research, community development, and administration,
have a critical role to play in improving the health
outcomes of maternal and child populations.
KEY WORDS: infant mortality; health; women;
mothers; child welfare
Historical Background
During the settlement house movement of the 1890s, social
workers labored to improve the health and welfare of the
individuals in the communities where the
settlement houses were located. In 1893, for example, Jane
Addams organized a medical dispensary at the Hull House
settlement. That same year the first milk station was
established in New York City. A short time later, social
reformers in Boston and Kentucky acted to improve the
health of pregnant women by expanding prenatal care to
include assessment of social and environmental conditions.
Working collaboratively with midwives, social workers
visited the homes of pregnant women and assessed
physical, social, and environmental conditions so as to
assure that the women and their soon-to-be-born infants
would have the safe, clean homes needed to reduce their
health risks (Schild & Sable, 2006). Social work reform
efforts were pivotal to developing maternal and child
health as a core component of community public health
practice.
Federal and State Legislation
Founded in 1904 by Florence Kelly and Lillian Wald, the
National Child Labor Committee (NCLC) directed its
efforts to monitoring the effects of child labor on the health
and development of children. The NCLC played a pivotal
role in the first White House Conference on Children,
which was held in 1909. One of the consequences of the
White House Conference was Congress' establishment of
the Children's Bureau in 1912. The creation of the
Children's Bureau served to legitimate the federal
government's responsibility for the health and well-being
of all American children.
The Act establishing the Children's Bureau mandated it
to investigate and report all matters pertaining to the
welfare of children. Foremost among the problems it dealt
with were those related to the health of children. As the
Children's Bureau evolved, it came to be seen as the natural
agency to be entrusted with the administration and
coordination of programs related to maternal and child
welfare. The close ties between the Children's Bureau and
professional social work were profound; in fact, the first
five chiefs of the Bureau were social workers: Julia
Lathrop, Grace Abbot, Katherine Lenroot, Katherine
Oettinger, and Martha May Elliot, who was also a
pediatrician.
During this same time period, in 1908 the first Bureau
of Child Hygiene was established in New York city by Dr.
Josephine Baker. By 1923, Child Hygiene bureaus had
been established in all states. The Child Hygiene bureaus
were typically responsible for disease prevention and
education; they developed programs on the day-today
basics of hygiene for immigrants living in slum
neighborhoods, trained young girls on the basics of infant
care so they could better care for their siblings while their
mothers worked, and created policies that would impact
maternal and infant mortality (Parry, 2006).
;
'-
Several factors came together in the early 1920s that led
to the enactment of new federal maternal and child health
legislation. Research conducted by officials at the
Children's Bureau, the identification of maternal and child
health problems, legislative advocacy calling for the
development of new policies to solve the problems
identified, and a series of legislative reviews of the Bu-
reau's research findings prompted Congressmen Morris
Sheppard of Texas and Horace Towner of Iowa to draft the
Maternity and Infancy Act, which later became the
Sheppard Towner Act of 1921. In effect from 1921 to
1929, the Sheppard Towner Act authorized grants-inaid to
states for the promotion of maternal and child health
programs (Copeland, 2005; [aros & Evans, 1995; Schild &
Sable, 2006). The legislation was controversial; critics
viewed it as ail intrusion on the family, which they believe
was not to be regulated by government, and as a precursor
to socialized medicine. The Children's Bureau in general
and Sheppard Towner in particular provoked major
opposition for the American Medical Association (Golden
and Markel, 2007).
Although the Sheppard Towner Act did not survive a
second reauthorization, the debates on the need to respond
to the welfare of children and maternal health remained
strong (Lesser, 1985; Markel & Golden, 2005). The Act
initiated discussions on several initiatives-federal funding
for child health, encouraging mothers to seek early care for
children-that were deemed valuable to retain. Yet, another
outcome of the Act was the creation of programs for
children that were divided by those needing government
assistance (welfare) and those who were capable of paying
(fee-forservice) (Markel & Golden, 2005). Perhaps it was
this mentality that allowed the Title V program to emerge
as more successful than the Sheppard Act. The Sheppard
Towner Act was the forerunner to Title V, the maternal and
child health service provisions of the Social Security Act of
1935. Much of the discussion around the development of
Title V was based on the emerging philosophy that the
welfare of children was critical. This stemmed from the
national concern of children as laborers and the need to
protect them. Title V represented a multidisciplinary
perspective that childhood was a time of growth and
development and that children should not be exploited as
cheap laborers or young adults (Lesser, 1985)~
Additionally, there was growing concern about the need to
reduce the infant mortality rate (Markel & Golden, 2005).
The Title V program delineated services and policies that
reflected the varying needs of the population. It was
encapsulated into the overarching policy initiative Social
Security, which was seen as necessary in addressing the
economic security of U.S. citizens. Addressing the needs
MATERNAL AND CHILD HEALlH 193
of children, an unprotected and vulnerable group, was seen
as crucial aspect of this economic security.
Title V established the federal government's role for
providing and regulating comprehensive maternal and
child health services, and included several programs:
Maternal and Child Health (MCH) Services, Crippled
Children Services, Child Welfare Services, and Vocational
Rehabilitation Services (Jaros & Evans, 1995; Schild &
Sable, 2006). States were given the authority to establish
their own maternal and child health programs, but these
programs were subject to the approval of a federal board of
maternity and infant hygiene. Social workers from the
Children's Bureau contributed to the inclusion of Title V in
the Social Security Act of 1935, and were involved, as
well, in planning responses to other health and social
services needs, such as the Emergency Maternity and
Infant Care Program that existed from 1943 to 1948 to
provide services to the wives and infants of service men
(Copeland, 2005).
The Title V legislation was formulated in response to
pressure from various social, political, and health interest
groups. It identified public funds for comprehensive health
care for handicapped children, delineated the federal
government's leadership role, and provided direction for
the development of federal and state administrative
structures to implement maternal and child health services.
Perhaps most important, it signaled the central,
instrumental role of social work in maternal and child
health services. Title V remains the primary legislative
expression of the country's commitment to health care for
maternal and child populations (Jaros & Evans, 1995;
Moniz & Gorin, 2007).
Title V has undergone several amendments since its
original enactment in 1935. In 1981 seven categorical
programs were consolidated into a Maternal and Child
Health Services Block Grant program. The Maternal and
Child Health Bureau (MCHB) administers these block
grants to states for the primary purposes of reducing infant
mortality and increasing women's access to prenatal care.
As with the Children's Bureau, social workers have been an
integral part of the MCHB, where the establishment of a
position of Chief Social Work Officer cemented the close
ties between public health and social work. Edith M. Baker
(1935-1955), Virginia Insley (1955-1980), and Juanita
Evans (19802000) have all served as the MCHB's chief
social work officer (Schild & Sable, 2006).
The Omnibus Budget Reconciliation Act (OBRA) of
1989 changed the provisions of the MCH Block Grant
program. The 1989 OBRA mandates that states provide
specific percentages of their funds to children's primary
prevention services, Children with Special Health Care
Needs (the former Crippled Children's
194 MATERNAL AND CHILD HEALTH
Services) programs, and administration. In addition, it
directed states to expand maternal and infant home visiting
programs and enhance rural projects for mothers and
children. It also required states to use any remaining block
grant funds on Special Projects of Regional and National
Significance (SPRANS). Finally, the Act required states to
coordinate their Title V programs with their Medi~aid
programs, a mandate that structurally facil itated initiatives
between maternal and child health and social work
services (Moniz & Gorin, 2007; Schild & Sable, 2006).
Contemporary MCH Issues
The MCHB continues to support the rights of all ma ternal
and child populations to grow and develop to their full
potential (Maternal and Child Health Bureau, 2003). As
the Bureau has evolved over the years, a holistic view of
these populations' physical, psychological, and social
needs has gained prominence. Consistent with this
perspective, the Bureau promotes a society that facilitates
the birth of children who are wanted, provides quality care
for optimal health, and nurtures children with the love and
sensitivity to assure they mature into healthy and
productive adults. In January 2000, President Clinton
unveiled a l.O-vear, $110 billion initiative designed to
improve the affordability of-and access to health insurance
(MCH Alert, 24 January 2000). Today, MCHB's broader
holistic approach emphasizes equal access to health care
in a supportive, culturally competent, family-sensitive,
community environment (Maternal and Child Health
Bureau, 2000).
Maternal and child health services have historically
focused on infants, children, and their mothers. However,
as the MCHB's approach has evolved and expanded to
incorporate an ecological systems perspec tive, attention
has focused on the larger context of families,
communities, and societies where mothers, inf ants, and
children live. The ecological systems perspec tive
recognizes that families are confronted with many
bio-psycho-social issues that affect their health status. In
keeping with its mission, the MCHB seeks to foster an
infrastructure that assures access to and availability of
quality MCH services and develops knowledge and hu-
man resources to ensure continued improvements in the
health, safety, and psychological well-being of maternal
and child populations. To meet these critical chal lenges,
the Bureau administers seven major programs (Maternal
and Child Health Bureau, 2003).
Future Challenges and Trends
A critical and evolving challenge for the MCHB is the
impact of the human papillomavirus (HPV) on women and
infant health. Approximately 10 of the
30 identified genital HPV strains can lead to cervical
cancer, genital warts, or, in some cases, respiratory tract
warts in children. It is the most common STD, with
approximately 20 million individuals currently infected
and 6.2 million new individuals infected each year. It is
estimated that half of all those infected are adolescents and
young adults between the ages of 15 and 24 (Centers for
Disease Control and Prevention, 2006). In 2006, the Food
and Drug Administration (FDA) licensed the first vacc ine
to prevent cervical cancer and gynecological diseases
caused by certain strains of genital HPV. The Advisory
Committee on Immunization Practices (ACIP)
recommends the use of this vaccine by females from 9 to
26 years (Henry J. Kaiser Family Foundation, 2007).
The expanded role of MCHB requires educators,
practitioners, researchers, and policy makers to design
interventions that are systemic and multileveled. The
social ecological model provides the appropriate frame-
work for this approach. This model recognizes the inter-
connectedness of individuals with their environment and
provides a framework for addressing and intervening at the
individual, interpersonal; organizational, community, and
policy level (Bronfrenbrenner, 1979). A paradigm shift
from focusing on changing individual health behavior to
examining how those behaviors are influenced and
impacted by culture, values, policies, and social and
community norms is required for effective intervention.
The health care issues affecting women and chil dren are
numerous and complex. Therefore, it is critical that
MCHB policies, services, and research reflect this
interconnectedness by intervening at all levels.
The Role of Social Work
in the Matemal and Child Health Arena Social
workers' roles in maternal and child health services are
broad and diverse. The holistic view of MCHB is highly
compatible with social work's person-inenvironment
orientation. As the scope of MCH services has evolved,
expanded, and changed to improve the health status of
women and children, the need for social workers' diverse
skills has become ever more important. As noted above,
social work leadership has been critical in MCH at federal
and state levels.
Today, social workers can be found engaged in the
design, development, implementation, and evaluation of
the policies, programs, and services created to im prove the
health outcomes of maternal and child populations.
Moreover, as funding agencies continue to call for greater
coordination, collaboration, and heightened evaluation,
and accountability, MCH programs andservices will
become even more reliant on social workers' expertise.

Social work skills in direct practice, advocacy, plan-
ning and evaluation, community organization, admin-
istration, and coalition building are all applicable to the
maternal and child health arena. To intervene effectively,
the needs of maternal and child populations must be
assessed from an ecological systems perspective that takes
into account not just physical health, but also emotional
well-being, family strengths and needs, and community
resources and problems. Just as in the past, the social work
profession is uniquely qualified to playa leadership role in
the MCH field, and the ongoing involvement of social
workers will continue to shape MCH policy, programs, and
services for future generations.
REFERENCES
Bronfrenbrenner, U. (1979). The ecology of human development.
Cambridge, MA: Harvard University Press.
Centers for Disease Control and Prevention, U.S. Department of
Health and Human Services. (2006, August). HPV and HPV
vacdne. Retrieved January 31,2007, from http://www.
cdc.gov/std/HPV/STD Fact-HPV.
Copeland, V. C (2005). Physicians and social workers: Col-
laborating for 100 years. Bulletin: Allegheny County Medical
Society,94,380-385.
Golden, J., & Markel, H. (2007). A historically based thought
experiment: Meeting new challenges for children's health and
well being. Health Affairs, 26(2), 445-449.
Henry, J. Kaiser Family Foundation. (2007, January). HPV
vacdne: Implementation and jinandng· policy. Retrieved January
31,2007, from www.kff.org.
Jaros, K. J., & Evans, J. C (1995). Maternal and child health.
In R. L. Edwards (Ed.ein-chlef), The encyclopedia of social work
(19th ed., pp.1683-1689). Washington, DC: National
Association of Social Workers.
Lesser, A. J. (1985). Public health then and now: The origin and
development of maternal and child health programs in the
United States. American Journal of Public Health,75(6), 590-598.
Markel, H., & Golden, J. (2005). Successes and missed oppor-
tunities in protecting our children's health: Critical junctures in
the history of children's health policy in the United States.
Pediatrics, 115, 1129-1133.
Maternal and Child Health Bureau, Health Resources and
Services Administration, U.S. Department of Health and
Human Services. (2000, September). The maternal and child
health bureau. Retrieved January 31, 2007, from http://www.
mchb.hrsa.gov.
Maternal and Child Health Bureau, Health Resources and
Services Administration, U.S. Department of Health and
Human Services. (2003, December). Maternal and child health
bureau: Strategic plan: FY 2003-2007. Retrieved January 31,
2007, from http://www.mchb.hrsa.gov/about/
stratplanuf-O'i.htm.
Moniz, C, & Gorin, S. (2007). Health and mental health care policy
(2nded.). New York: Allyn and Bacon.
MEDIA CAMPAIGNS 195
Parry, M. S. (2006). Voices from the past: Sara Josephine Baker
(1873-1945). American Journal of Public Health, 96, 618-62l.
Schild, D., & Sable, M. (2006). Public health and social work.
In S. Gehlert & T. A. Brown (Eds.), Handbook of health and
soda! work (pp. 70-122). Hoboken, NJ: John Wiley & Sons.
-VALIRE CARR COPELAND AND BRENDA N. HENRY
MEDIA CAMPAIGNS
ABSTRACT: Significant advances in media variety
and public access to information have blurred the
lines between journalism, advertising, public
relations, marketing, and other media industries. M
a result of media proliferation, social sector
professionals have more opportunities- as well as
more competition-to gain public attention and
support for the issues and services they advocate. In
addition, the expansion of the Inter net through
citizen journalism, viral marketing, social
networking, and other "new media" strategies has
forever changed mass communication campaigns.
This entry explores different types of media
campaigns, new promotional tools, and
implications for social
KEY WORDS: social policy;workers.
social environments; jour-
nalism; marketing; public relations
The Role of Media in Society
The first decade of the 21st century brought many advances
in the complexity of, and access to, media. The lines
between print, broadcast, and online media have been
blurred. The complementary disciplines of marketing,
journalism, public relations, public affairs, fundraising, and
advertising are further aligned as professionals in each
field use the same tools and tactics to communicate with
and influence their respective audiences. All this occurs in
a fiercely competitive marketplace.
The media are chroniclers of society. Although
Americans depend on different media channels for in-
formation, entertainment, and even social interaction, some
forms of media touch nearly everyone every
day-economically, socially, or politically. What we hear,
read, and see can affect the way we vote and the way we
spend our money. Information from media sources can
influence the way we eat, talk, work, study, and relax
(Biagi, 1988).
The mass media of decades past were defined largely
by large circulation publications, network television, and
widespread radio syndication. Today, the proliferation of
targeted, niche, and grassroots media outlets-in print,
broadcast, and online formats-has
196 MEDIA CAMPAICiNS
created an environment defined by customization and
segmentation.
The Internet was introduced in the mid~1990s, but it
is clearly the key media innovation of the early 21 st
century. It is an amalgamation of its predecessors
(newspapers and magazines were introduced in the 18 th
and 19th centuries; radio and television came in the 20 th
century), but operates at more than three times their
speed. It has changed the very definition of a media
company (Klaassen, 2007).
Whatever their cause, product, service, candidate, or
issue-those individuals who are responsible for
persuading large groups of people to do, buy, or support
things and ideas on behalf of organizations have many
more ways to get their messages out, but also more
competition for the public's attention and interest (Cut lip,
Center, & Broom, 2000).
Social Advocacy and the Media
The goal of any media campaign is to get the attention of
target public, to stimulate interest in the content of a
message, to build desire and intention to act on the
message, and to direct acti on of those who behave
consistently with the message.
Human services professionals have always known
that to achieve greater public understanding and sup port
for their work it is important that they engage in the
public communication process. Educating the public,
opinion leaders, and policy makers about the nature,
extent, and causes of existing social, medical, and men tal
health problems, for example, c an lead to action that
remedies some of these situations (Brawley, 1995). Be-
cause media outlets are key conduits to many different
audiences, media campaigns can help organizations sus-
tain focused attention on campaign goals and outcomes.
Ten years ago, developing a media campaign to
promote a product, service, or issue would have been
limited to outreach with television, radio, and print news
outlets, advertising in the same media if funds allowed,
and targeted e-mail that led people to a Web site for
information. Now, the most basic media campaigns are
just as likely to include "social media" strategies as they
are to include contacts with tradi tional media. Social
media describe the online tech nologies and practices that
people use to share opinions, insights, experiences, and
perspectives. These include blogs, webcasts, search
engines, podcasts, vlogs, RSS feeds, wikis, viral e- mail
marketing, and Web sites such as YouTube, MySpace,
and Facebook (Fielding, 2007).
Business communicators are respondin g to this new
reality with sophisticated multimedia campaigns that
leverage the strengths of each medium, but are
consistent in message and personality-or brand. Si milarly,
nonprofit leaders are finding that they need to use the
same tactics to successfu lly engage the general public in
work that benefits society, to attract new sup porters and
donors, to convince lawmakers and employ ers to create
environments conducive to social change, and to educate
clients about services and resources that can improve their
quality of life (Hand, 2005).
Despite the significant expansion of communication
channels, there is no substitute for a compelling message- a
fact that still challenges many nonprofit media campaign
planners, Because social service agencies often d eal with
intangibles, many people regard these organizations as
existing for "the other fellow." To succeed, these
organizations must educate the public not only about their
programs but also about the larger impact of poverty,
mental health, crime and cor rection, child welfare, aging
issues, and addictions. Planned, consistent
communications are required to both break through the
media clutter, and overcome the public
. apathy and stigma often associated with human services
work (Cutlip et a1., 2000).
Types of Media Campaigns
Different disciplines use online, print, and broadcast
media to get their messages to targeted public. Although
the tools are often the same, the purposes may vary.
Branding campaigns introduce innovative new prod-
ucts or services to the marketplace and reinforce a
company's leadership in an industry.
Corporate social responsibility campaigns marry the
philanthropic interests of a business with existing non-
profit services or causes to benefit a community of people.
Marketing campaigns increase sales, or create envir-
onments conducive to sales, of products or services.
Political or Public Affairs campaigns advocate for
causes or candidates to achieve political or governmen tal
goals.
Public Relations campaigns raise awareness about
issues or seek to improve perceptions about organiza tions
and groups.
PublIcity campaigns create buzz for entertainment
offerings, special events, or celebrities and personalities.
Historically Important Media Campaigns Some of
the most widely recognized media campaigns are geared
toward public health issues. This "cause marketing"
consists of using the skills of advertising to effect social
change, to benefit individuals or society at large (Earle,
2000). For example, some of these campaigns have
informed and encouraged people to:

• avoid or discontinue risky practices such as
smoking, drug abuse, or unprotected sex
• discontinue antisocial actions such as littering or
being careless with campfires
• seek counseling for destructive behavior such as
compulsive gambling or spousal abuse
• take preventative measures such as getting
inoculated, reducing cholesterol intake, or fasten-
ing a safety belt
• seek out and use information about various
diseases
• reexamine personal attitudes toward issues such as
race and sexual preference
• identify and take action against inhumane or
discriminatory practices
• organize, join, or giv'e financial support to groups
that benefit society
• become involved in community activities such as
mentoring and monitoring neighborhood crime
Here are a few examples of such efforts:
Antipollution (1970s). In the annals of advertising his-
tory, few advertisement campaigns stick in as many
minds as the "Crying Indian" television commercials
of the 1960s and 197 Os. See the Ad Council campaign
archives: http://www .adcouncil.org/default.aspx lid
= 132. Antismoking (1980s). Public education efforts
which began 30 years ago with national and state
government funding, later received millions of dollars
from tobacco settlement lawsuits for youth prevention
programs. The Journal of the American Medical Association
(JAMA) recently analyzed the impact of such cam-
paigns. http://jama.ama-assn.org/cgi/content/abstract/
279/10/772.
Breast Cancer (1990s). Led by organizations such as
the American Cancer Society, the Susan B. Komen
Breast Cancer Foundation, Avon, and the National
Cancer Institute as well as grassroots survivors and
advocates, the fight to increase research funding and
to build awareness about screening and treatment to
prevent avoidable deaths from breast cancer has been
a remarkable movement within the United States and
throughout the world. The Centers for Disease
Control chronicles these efforts: www.cdc.gov.
One Campaign to End Poverty (2000s). Irish rock star
Bono (lead singer for the group U2) parlayed his many
connections in the entertainment industry to raise
awareness and funds-from individuals, corpor ations,
and governments-to fight the emergency of global
AIDS and extreme poverty. The ONE Campaign
leverages all facets of the media world to push social
change (www.one.org).
MEDIA CAMPAIGNS
197
Evidence of Media Campaign Efficacy
In this era of sophisticated online media and data me-
tries, most national media campaigns-whether they are
designed to create revenue, elect politicians or change
public behavior-are frequently measured by their
sponsoring organizations. Additionally, independent
research on the impact of many of these campaigns can
be found online through groups such as Jupiter
Research, Pew Research Center for People and the
Press, Forrester Research, the Public Relations Society
of America and the American Association of Advertis-
ing Agencies.
Implications for Social Work
Since the 1960s, the National Association of Social
Workers has used various media channels to promote
critical social issues and the profession of social work.
Activities have included work with Hollywood produ-
cers and writers, outreach to national and local news
reporters and editors, and public service advertising on
radio and television. Despite these early efforts, the
profession has continued to fight inaccurate public per-
ceptions of the range, impact, and value of social work
interventions.
In 2004, the National Association of Social Workers
began the most aggressive media campaign in its history
in order to clarify information about the roles and
contributions of social workers in practice, re search,
policy, and education. It also seeks to educ ate the public
about the wide variety of social work services available
to individuals and families in need, from all walks oflife.
The award-winning "Social Workers: Help Starts Here"
campaign is successfully shaping new per ceptions and
support for the social work profession (Clark &
Woods-Waller, 2006). One bit of proof is the steady
increase in searches for social workers on the campaign's
Web site, www.HelpStartsHere.orgj another is the
expanding range of requests for social work experts from
journalists and other media professionals. To date, this
multiyear, multimedia campaign has been funded by
more than 70 schools of social work and more than
40,000 social workers.
REFERENCES
Biagi, S. (1988). Media/impact: Introduction to mass media (pp. 3-4).
Florence, ICY: Wadsworth.
Brawley, E. A. (1995). Human services and the media: Developing
partnerships for change (p. 53). Newark, N]: Harwood Aca-
demic Publishers.
Clark, E., & Woods-Waller, G. (2006). Improving the profession.
Changing perceptions. Social work in the USA. Sodal work.
Making a world of difference. International Federation of Social
Workers.
198 MEDIA CAMPAIGNS
Cutlip, S. M., Center, A. H., & Broom, G. M. (2000). Effective public
relations (p. 251). Upper Saddle River, NJ: Prentice Hall.
Earle, R. (2000). The art of cause marketing: How to use advertising to
change personal behavior and puMc policy (pp, 3, 66-71,
160,223-227, 245). Columbus, OH: McGraw-HilL Fielding, M.
(2007, April 15). The new tools of the trade:
Shift in technology control demands new marketing skills.
Marketing News, pp. H-14.
Fielding, M. (2007, March 15). Eliminate waste: Determine which
media channels truly engage customers. Marketing News, pp.
10-12.
Hand, M. (2005, August 22). Branding charity: Nonprofits are
borrowing tactics from consumer marketers. PRWeek, pp. 18-25.
Klaassen, A. (2007, May 7). Tracking web traffic: Upstarts trump
titans. Advertising Age,\p. 20.
FURTHER READING
Amis, R. (2007, May). You can't ignore social media. Public
Relations Tactics, pp. 10,22.
Chabria, A. (2005). Communication when it matters: Cause
branding. PR Week: Cause Survey 2005, pp. 18-25.
Garfield, B. (2007, March). The post advertising age: Chaos scenario
2.0. Advertising Age, pp. 1, 12-14.
SUGGESTED LINKS
Discovering the Activation Point: Smart Strategies to Make People
Act, 2006.
www __ activationpoint.org
Pew Research Center on People and the Press.
www.pewresearch.org
The State of the News Media: An Annual Report of American
Journalism, 2007.
www.stateofthe media.org/2007Iindex.asp
-GAIL WOODS-WALLER
MEDIATION. See Conflict Resolution.
MEDICAID AND MEDICARE
ABSTRACT: In 1965, Titles XVIII and XIX of the Social
Security Act were passed creating Medicare and Medicaid
and laying the foundation for U.S. health pol icy. Medicare
was originally created to meet the specific medical needs of
the elderly. Currently, however, indi viduals with end stage
renal disease, amyotrophic lateral sclerosis, and other
disabilities may also receive Medi care. Medicaid was
established to provide a basic level of medical care to
specific categories of people who are poor, including
pregnant women, children, and the aged. This entry
includes a brief explanation of Medicaid and Medicare and
a discussion of current legislative issues.
KEY WORDS: Medicaid; Medicare; health policy; public
health insurance
In 1965, Titles XVIII and XIX of the Social Security Act
were passed creating Medicare and Medicaid and laying
the foundation for U. S. health policy. Medicare was
created to meet the specific medical needs of the elderly.
Medicaid was established to provide a basic level of
medical care to specific categories of people who are poor.
This entry includes a brief explanation of Medicaid and
Medicare and a discussion of current legislative issues.
Medicaid
Medicaid finances health and long-term care services for
more than 55 million low-income Americans, which makes
it the nation's largest public health insur ance program as of
2003. In 2003, health services were provided through
Medicaid for 8 million people with disabilities, 6 million
senior citizens, 14 million adults (mainly low- income
working parents), and 27 million children. In 2004, total
Medicaid spending was $288 billion, with more than half
(59%) of the expenditures attributable to acute care
services. Long-term care services accounted for another
39% of spending. Furthermore, 70% of all Medicaid
spending for acute care and long-term care was attributable
to 3.6% of all Medicaid enrollees. Medicaid funds half of
the long-term care provided to Americans and 60% of
nursing home care. Although the elderly and the disabled
consume the largest proportion of Medicaid dollars, many
lowincome families also use Medicaid as a usual source of
health-care coverage. Two-thirds of low-income fa milies
were enrolled in the Medicaid program in 2004 (Kaiser
Commission on Medicaid and the Uninsured, 2006).
Although these children must be provided with
. Early and Periodic Screening, Diagnostic, and Treat ment
(EPSDT) services, only a small percentage actu ally
receives these preventive services. Furthermore, 60% of
children in managed Medicaid programs do not receive
any EPSDT services (U.S. General Accounting Offic e,
200l).
Medicaid is jointly funded by federal and state gov-
ernments. Federal matching funds are made available to
states to aid in covering the costs of health-care services
for eligible persons. In 2004, the federal government
financed 57% of all Medicaid spending. However, the
federal contribution given to each state ranges between
50% and 76% and is determined using a formula that
compares the state's per capita income with the na tional
average (Kaiser Commission on Medicaid & the
Uninsured, 2006). States with higher per capita income
levels are reimbursed for a smaller share of their

Medicaid costs than states with lower per capita income
levels. Funds for Medicaid are taken from state and
federal tax revenues.
The administration of Medicaid is the responsibility
of each state despite the fact that federal funds are used
for the program. Each state Medicaid plan outlines (a)
eligibility criteria, (b) covered health services, including
type, duration, and amount, and (c) payment rates for
services, using broad national guidelines established by
federal regulations, policies, and statutes. Because state
Medicaid policies are complex and vary greatly from
state to state, a person can be eligible for Medicaid in
one state and ineligible in another. Furthermore, certain
services may be covered by Medicaid in one state and
not covered by a nearby state. States also have much
discretion in identifying \categories of eligible indivi-
duals beyond those mandated for coverage by the
federal government (Hoffman, Klees, & Curtis, 2005).
To receive federal Medicaid matching funds, states
must cover certain categories oflow-income individuals
(for specific state income guidelines, see http://www.
cms.hhs.gov /MedicaidEligibilityJ), including (a) fa-
milies who meet the states' Aid to Families with De-
pendent Children (also known as AFDC) eligibility
requirements (in effect since July 16, 1996); (b) chil dren
aged 6-19 with family income up to 100% of the federal
poverty level; (c) pregnant women and their children
below age 6 whose family income is at or below 133%
of the federal poverty level; and in many states, (d)
Supplemental Security Income (SS1) recipients.
Individuals meeting these eligibility criteria are known
as categorically needy (Centers for Medicare & Medi-
caid, 2006a).
States also have the option of extending eligibility to
those defined as medically needy. These individuals do
not qualify as categorically needy because they have too
much income and, in some cases, too many resources,
such as savings. Medically needy categories include, but
are not limited to, (a) legal guardians or relatives living
with, and caring for, children, (b) blind persons, and (c)
aged persons. States with medically needy programs
must provide coverage for pregnant women through a
60-day postpartum period, children under 18, and
certain newborns for a year. Thirty-four states and the
District of Columbia have medically needy Medicaid
programs. States can also choose to provide eligibility to
special groups not covered in the previous categories,
such as (a) Medicare beneficiaries below 100% of the
poverty level. These individuals are known as dual
eligibles because they are eligible for both Medicare and
Medicaid; (b) individuals diagnosed with Tuberculosis;
and (c) women with cervical and breast cancer (Centers
for Medicare & Medicaid,
MEDICAID AND MEDICARE
199
2006a; Hoffman et al., 2005). In general, individuals
must be American citizens to qualify for Medicaid.
Undocumented aliens are not eligible for Medicaid.
Legal immigrants, who entered the United States after
August 22, 1996, with the exception of children and
pregnant women, must wait 5 years and meet the criteria
for "qualified alien" status to be eligible for Medicaid
benefits. States have the option to determine Medicaid
coverage for legal immigrants who entered the country
before August 22, 1996, or meet the 5-year rule.
However, in the case of emergencies, both legal
immigrants and undocumented aliens must be treated
until they are stabilized (Centers for Medicare &
Medicaid, 2007).
The health services covered by state Medicaid pro-
grams extend beyond the services covered by Medicare
and most private health insurance policies. Federal law
mandates that certain services be covered; however,
states get to determine the scope, duration, and amount
of mandated services that they provide. The following
services are mandated for Medicaid eligibility groups
that are classified as categorically needy (unless such
service provision has been waived by the Centers for
Medicare and Medicaid under the 1115 section of the
Medicaid law): inpatient hospital care; outpatient hos-
pital care; laboratory and X-ray services; pediatric and
family nurse practitioner services; nursing home ser-
vices; early and periodic screening, diagnosis and treat-
ment for children under the age of 21; family planning
services and supplies; physicians' services; medical and
surgical dental services; home health-care services for
Medicaid enrollees entitled to nursing home care; preg-
nancy-related services and services for conditions (for
example, gestational diabetes) that may complicate
pregnancy, nurse midwife services; and 60-day postpar-
tum pregnancy services. States that include the medi-
cally needy under their Medicaid plans need to offer the
following services: prenatal and delivery services; post-
partum pregnancy services for enrollees under the age of
18 who are entitled to institutional and ambulatory
services; and home health services to enrollees who are
entitled to receive nursing home services (Centers for
Medicare & Medicaid, 2006a).
Medicare
Medicare is the largest public payer of health-care ser-
vices. In 2004, Medicare expenditures represented 17%
of total national health-care expenditures and 12% of the
federal budget, which amounts to $295 billion in
Medicare disbursements to providers. Of these expen-
ditures, 39% were inpatient hospital services charges ,
26% were payments to physicians and suppliers, and
less than 10% were home health-care and skilled
200 MEDICAID AND MEDICARE
nursing facility charges. Medicare spending is highly
concentrated with 7% of Medicare enrollees accounting
for more than half of all Medicare spending in 2004. In
2005, Medicare provided health-care coverage to 42
million elderly and disabled individuals (Hoffman et al.,
2005).
Unlike Medicaid, Medicare is administered by the
federal government through the Centers for Medicare
and Medicaid (formerly the Health Care Financing
Administration). Funding is provided through a combi-
nation of the general funds of the federal government,
payroll taxes, and beneficiary premiums. Traditional
Medicare consists of two primary parts: hospital insur-
ance (Medicare, Part A) and supplemental medical
insurance (Medicare, Part B). Medicare Advantage
(Medicare, Part C) was e~tablished as part of the
Balanced Budget Act of 1997. Medicare participants
must be enrolled in Parts A and B in order to enroll in
Part C. In 2006, the Medicare Prescription Drug Plan
(Medicare, Part D) was established as part of the Med-
icare Prescription Drug, Improvement and Moderniza-
tion Act of 2003, Public Law 108-173. All financial
operations for Medicare are handled through two trust
funds: (a) the Health Insurance fund for Part Aj and (b)
the Supplemental Medical Insurance fund for Parts
Band D (Hoffman et al., 2005). These trust funds cannot
be used for any other purposes.
American citizens and permanent residents are
usually eligible for Medicare under one of the following
conditions: (a) they reach age 65 and they or their
spouses have contributed payroll taxes to Social Secur-
ity for 40 quarters (10years)j (b) they are under 65 years
of age and have received Social Security Disability In-
come or Railroad Retirement Board Disability
payments for 24 months: or, (c) they are diagnosed with
end-stage renal disease, requiring dialysis or kidney
transplant; or (d) they are diagnosed with amyotrophic
lateral sclerosis (Lou Gehrig's disease). In certain cases,
ineligible individuals (that is, individuals with no labor
force attachment) can pay a premium to enroll in
Medicare Part A, which then makes them eligible for
Parts B, C, and D.
Medicare Part A: Generally, individuals who are
eligible for Medicare benefits are automatically en-
rolled in Part A without paying a premium. In 2007 ,
ineligible individuals will pay a monthly premium of
up to $410 to enroll and individuals who worked less
than 10 years will pay a premium of $226 (Medicare :
The Official U.S. Government Site for People with
Medicare, 2006). Medicare Part A is almost entirely
financed by a 1.45% tax on earnings paid by the
employee as well as a matching portion paid by the
employer for each employee for a total tax of2.9%
(Hoffman et al., 2005). Self- employed individuals
pay a 2.9% tax.
Medicare Part A provides substantial coverage for
medically necessary inpatient hospital care. In 2007,
Medicare will pay all costs incurred for the first 60 days
of inpatient care after a $992 deductible is met. From
Days 61 to 90, beneficiaries pay a co-insurance of $248
per day. Once individuals reach the 90th day of inpatient
care, they become eligible to use their lifetime reserve
days (Days 91-150) with a co-insurance of $496 per
day. The 60 lifetime reserve days that each individual
receives are nonrenewable, meaning that they can be
used only once in a lifetime. Medicare Part A also
provides limited coverage for skilled nursing care
(excluding long-term care and custodial care). The first
20 days of this care is paid for in full, and in 2007,
beneficiaries will pay a co-insurance of $124 per day for
Days 21-100 of skilled nursing facility care (Medi care:
The Official U.S. Government Site for People with
Medicare, 2006).
Medicare Part B is available to American citizens
and permanent residents who are eligible for Part A.
Part B coverage is optional and beneficiaries are
required to pay a monthly premium to enroll in Part
B. To avoid penalties for late enrollment, individuals
are encouraged to enroll in Part B during the special
enrollment period when they first become eligible for
Part A. In 2007, the standard monthly premium for
Part B is $93.50. However, as part of President Bush' s
2007 fiscal year budget, the current law was changed
to require higher-income beneficiaries to pay higher
Part B premiums. In 2007, benef iciaries who file an
individual federal tax return and report incomes of
more than $80,000, or married couples who file a tax
return and report more than $160,000 as income will
pay higher premiums. Part B is also funded by
contributions from the general f und of the U.S.
Treasury, which is the largest source of Part B
income since beneficiary pre miums are set at a level.
to cover 25% of the average expenditures for elderly
enrollees (Hoffman et al., 2005 j Centers for Medicare
and Medicaid, 2006b).
Medicare Part B helps cover the costs of doctors'
services and outpatient care. It also covers some other
medical services that are not covered under Medicare
Part A, such as physical and occupational therapies and
home health care. Some supplies that are medically
necessary are also covered. In 2007, beneficiaries are
responsible for a yearly deductible of $131. Once this
deductible is met, they are responsible for 20% of the
Medicare approved rate for the health-care services
rendered.
Medicare Part C, also known as Medicare Advan-
tage, allows beneficiaries who are enrolled in
Medicare Parts A and B to choose to receive their
health care through a wide variety of health plans,
including

managed care, private fee-for-service plans, and Medicare
medical savings accounts. In 2006, a new regional
Medicare Advantage program began. Health plans that
wish to participate must serve all beneficiaries within their
identified Medicare Advantage region. Medicare
Advantage programs provide all the services included in
Parts A and B as well as other services (that is, preventive
care, dental care, and hearing aides) (Hoffman et al., 2005)
. coverage. These recent changes could create financial
. Medicare Part D provides prescription drug coverage
f~r Medicare beneficiaries who choose a prescription drug
plan and pay a monthly premium to participate in the
program. Since its inception in January 2006, 90% of
Medicare beneficiaries have enrolled in Part D. Enrollment
in Part D is voluntary, except for individuals who are
eligible for both Medicare and Medicaid who are
automatically enrolled in a drug plan if they do not choose
one on their own. However, if beneficiaries do not have a
drug plan that is equal to the standard Medicare Drug
benefit, they will face a penalty equal to 1 % of the national
average monthly premium for every month that they delay
enrollment. Part D is financed through beneficiary
premiums, which cover 24.5% of the cost of the standard
Medicare drug benefit, state contributions, and general
revenues for the
U. S. Treasury.
The drug benefit is delivered through two types of
private plans: (a) Medicare Advantage plans (that is,
managed care plans) that cover prescription drugs and
other Medicare benefits; and (b) stand-alone prescription
drug plans offered to beneficiaries in the traditional
Medicare fee-for-service program. In 2006, the typical
Medicare drug plan required a $250 yearly deductible and a
co-insurance of 25% after the deductible and up to the
coverage limit of $2,250. Once this cover limit is reached,
beneficiaries have a gap in coverage (known as the donut
hole) and must pay 100% of their drug costs. Once their
out-of-pocket spending reaches $3,600, the plan will cover
95% of their drug costs for the remainder of the year. The
Medicare approved prescription drug plans vary in benefits
offered, covered drugs, and utilization review
requirements, such as quantity limits and prior approval
(The Henry J. Kaiser Family Foundation, 2006).
Current Legislative Issues
Despite the success of Medicaid and Medicare in providing
health-care services to our nation's most underserved and
vulnerable populations, the current focus of legislation
pertaining to Medicaid and Medicare policy is to contain
and reduce health-care costs in these safety net programs.
Both the Deficit Reduction Act of 2005 and the President's
Fiscal Year 2007 budget
MEDICAID AND MEDICARE 201
demonstrate the current administration's attempts to shift
the costs of these public health insurance programs away
from government and businesses and on to individual
consumers by (a) giving states flexibility to limit Medicaid
benefits and impose premiums and cost sharing; (b)
mandating higher premium costs for higherincome
Medicare Part B beneficiaries; and (c) requiring significant
out-of-pocket costs for Medicare prescription drug
barriers for all public health insurance beneficiaries that
will make it more difficult to obtain and keep their
health-care coverage. Going forward it will be important to
monitor and evaluate the impact of these changes on the
vulnerable populations that both of these programs serve
(Families USA, 2006).
REFERENCES
Centers for Medicare & Medicaid, U.S. Department of Health and
Human Services. (2007). Medicaid eligibility. Retrieved
November 15, 2007, from http://www.cms.hhs.gov/
MedicaidEligibility/
Centers for Medicare & Medicaid, U.S. Department of Health and
Human Services. (2006a). The Medicaid program. Publication
No. CMS-ll024-05. Washington, DC: Author.
Centers for Medicare & Medicaid, U. S. Department of Health and
Human Services. (2006b). Medicare & You 2007. Publication
No. 10050. Baltimore, MD: Author.
Families USA. (2006). President Bush's fiscal year 2007 budget:
Analysis of key health care provisions. Washington, DC:
Author.
Hoffman, E., Klees, B., & Curtis, C. (2005). Brief summaries of
Medicare & Medicaid: Title XVIII and TitleXVIIIl of the Social
Security Act. Baltimore, MD: Centers for Medicare and
Medicaid.
Kaiser Commission on Medicaid and the Uninsured. (2006).
Medicaid facts: The Medicaid program at a glance. Washington,
DC: The Henry J. Kaiser Family Foundation.
Medicare: The Official U.S. Government Site for People with
Medicare. (2006). Premium and cost information for 2007.
Retrieved December 18, 2006, from http://www.medicare.
gov/MedicareEligibility/Home.asp?dest = NA V I Home I
GeneralEnrollment I PremiumCostInfo#TabTop
The Henry J. Kaiser Family Foundation. (2006). Medicare: The
Medicare prescription drug benefit. Washington, DC: Author.
U.S. General Accounting Office. (200l). Medicaid: Stronger efforts
need to ensure children's access to health screening services.
Washington, DC: Author.
FURTHER READING
Centers for Medicare & Medicaid, U.S. Department of Health and
Human Services. (2004). CMS legislative summary:
Summary of H.R. 1 Medicare prescription drug, improvement and
modernization act of 2003, Public Law 108-173. Baltimore, MD:
Author.
The Henry J. Kaiser Family Foundation. (2005). Medicare Chart
Book 2005. Washington, DC: Author.
 202 MEDICAID AND MEDICARE
Oliver, T., Lee, P., & Lipton, H. (2004). A political history of
Medicare and prescription drug coverage. The Milbank
Quarterly, 82, 283-354.
SUGGESTED LINKS The Centers for
Medicare and Medicaid. http://www . ems
.hhs/gov
Families USA: The Voice for Health Care Consumers.
http://www .familiesusa. org
The Henry J. Kaiser Family Foundation.
http://www.kff·org
Medicare: The Official Government Site for People with
Medicare.
http://www .medicare .gov
Social Security Administration (Medicare Prescription Drug
Coverage). ' Morbidity
http://www .ssa.gov/prescriptionhelp/
-VICTORIA M. RIZZO
MEDICAL ILLNESS
ABSTRACT: The distribution of illness and its impact are not
random occurrences. Social workers can prevent illness
through education and behavioral change as well as mitigate
its impact once it does occur, and social workers should be
knowledgeable about illness and the heaith status of the
people with whom they work. As advocates for our clients, it
is important that we pursue policies and programs that address
the inadequacies and injustices in health care. To accomplish
this, we must be prepared with the necessary knowledge.
. KEY WORDS: Health; Morbidity.Mortality; Chronic Disease;
Injury
Every person is affected by illness at one time or another
across their lifespan. The nature of illnesses varies, and each
person's response is uniquely individual. Illness can range
from being symptom free to creating mild discomfort to being
life threatening. One's response to illness is shaped by race,
ethnicity, gender, age, socioeconomic status, and previous
experiences, including their family's response to illness.
Nature of Illness
The leading causes of death in the United States have
remained relatively consistent over time. According to the
Centers for Disease Control and Prevention (CDC), the 15
leading causes of death in 2004 were diseases of the heart,
malignant neoplasms, cerebrovascular disease, chronic lower
respiratory diseases, accidents or unintentional injuries,
diabetes mellitus,
Alzheimer's disease, influenza and pneumonia, nephri-
tis,septicemia, suicide, chronic liver disease, essential
hypertension, Parkinson's disease, and homicide (Minifio
AM, 2007). What is most significant about this list is the
overwhelming predominance of chronic illnesses. Health care
delivery must now focus on individuals and families as they
adjust to the biopsychosocial consequences of living with
chronic diseases-oftentimes more than one. Acute contagious
diseases have largely been replaced by debilitating-physically,
emotionally or mentally, and spiritually-chronic disorders. A
health care system should be designed to focus equally on pre-
vention and care of those with chronic disorders.
The most commonly quoted definition of health is that
formalized by the World Health Organization (WHO) over half
a century ago: "A complete state of physical, mental, and social
well-being, and not merely the absence of disease or infirmity."
Several other generally accepted definitions of the noun
"health" exist. Bircher (2005) defines health as "a dynamic
state of well-being characterized by a physical and mental
potential, which satisfies the demands of life commensurate
with age, culture, and personal responsibility," while Saracchi
(Ustun & Jakob, 2005) defines health as "a condition of well
being, free of disease or infirmity, and a basic and universal
human right." For the purpose of this entry we can consider
someone who has not achieved this level of health as
experiencing an illness.
In 2007 the National Center for Health Statistics published
the, "Summary Health Statistics for u.s. Adults: National
Health Interview Survey, 2005." This report summarizes the
health status for noninstitutionalized adults above 18 years in
the United States. It is important to understand the incidence
or prevalence data for the major illness categories in order to
understand the impact of medical illness and chronic condi-
tions. Incidence is the number of new cases of a condition,
symptom, death, or injury that arise during a specific period of
time, such as in a year. It is often expressed as a percentage of
a population (for example, 25% of Americans were diagnosed
with the flu in 2002). Incidence shows the likelihood that a
person in that population will be affected by the condition.
(A.D.A.M. Medical Encyclopedia, MedLine Plus).
MAJOR CAUSES OF ILLNESS AND DISABILITY The
causes of illness and disability reflect the increasing
significance of chronic diseases. More than 90 million
Americans live with at least one chronic disease. Chronic
diseases account for 70% of all U.S. deaths and 75% of health
care costs. Chronic disease including

heart disease, cancer, and lung diseases account for one'
third of the years of potential life lost before age 65
(http://www .cdc.gov /nccdphp/burdenbook2004).
Heart disease is the major cause of disability and
death for American adults. Over 26 million Americans
have been diagnosed with 'heart disease. Another 7
million have been diagnosed with coronary heart
disease. Hypertension has been diagnosed in 48 million
people. One, third of African Americans above 18 have
hypertension. Heart disease accounts for 28% of all U.S .
deaths. There is a body of research that has de'
monstrated that psychosocial factors are significant in
the development, maintenance and progression of all
forms of heart disease (American Heart Association,
2007). Cancer represents the next most significant cause
of illness and deatlt in the United States for the adult
population. It was estimated that in 2006, there would be
1.4 million new cancers diagnosed. For men, over
720,000 have been diagnosed with cancer-33% of the
prostate, 13% of the lung and 10% of the colon and
rectum. 680,000 women have been diagnosed with
cancer-31 % breast, 12% lung and 11% colon and
rectum. Women have a 1 in 3 lifetime probability of
developing cancer, while men have a 1 in 2 life' time
probability of developing cancer. Cancer accounts for
22.7% of adult American deaths.
Ofthe major lung disorders, the most common is
Chronic Obstructive Pulmonary Disorder (COPD).
COPD is often referred to as emphysema or chronic
bronchitis. More than 12 million Americans have been
diagnosed with COPD and another 12 million have it but
do not know it. COPD represents the fourth leading
cause of death and the second leading cause of disability
among the adult population (www.nhlbi.nih.gov).
Chronic illnesses impact the workplace and employ'
ees ability to carry out their jobs. COPD is associated
with the most lost days followed by those diagnosed
with migraine, arthritis, ulcer, and cancer. Workers with
diabetes are three times more likely to be limited in the
work they can do then those without diabetes. Almost 25
million American workers are diagnosed with hyper,
tension. Twenty-six million American workers annually
experience a mental health or substance abuse problem.
This exacts both a financial and human toll that social
workers could impact through mitigating the conse-
quences of these diagnoses (National Health Interview
Survey 2005).
_ In 2002, 148,000 Americans died from injuriesboth
accidental and intentional. Injury is the lead, ing cause
of death and injury for children and young adults.
Homicide is the second leading cause of death for
people ages 15-24 and the leading cause of death for
African American males ages 15-34. Almost
MEDICAL ILLNESS
203
30 million Americans are treated for injuries in emer-
gency rooms, representing 37% of all emergency room
visits. It is estimated that 1.5 million Americans
annually survive a traumatic head injury.
Another significant source of disability is mental
health and substance abuse problems. Estimates of the
incidence of mental illness are less exact than some of
the previous number cited. Epidemiological studies
suggest that 30% of the American population have a
mental health or substance abuse disorder each year. It is
estimated that only 1 out of 2 persons with a serious
mental illnesses will seek treatment. Between 10% and
20% of submitted medical claims are for mental health
or substance abuse treatment. This is a signifi cant when
one considers how many people either do not have
coverage for mental health services and/or would not
submit a claim due to the stigma still existing around
these services. It is important to understand that the
majority of mental health concerns today are treated by
primary care practitioners rather than mental health
professionals (U.S. Department of Health and Human
Services).
Since 1980 the CDC has collected stated based
information on a wide range of behaviors that affect
health status. These include, but are not limited to, lack
of physical activity, being overweight, not using seat,
belts, using tobacco and alcohol, engaging in unsafe
sexual activity, and not utilizing preventive health care
services (Behavioral Risk Factor Surveillance System
Survey Data). This is an area in which social work can
work toward an expanded significant role.
Trends
NEW TECHNOLOGY The explosion of health
information available online can be a positive resource
that improves an individual's level of health literacy.
Unfortunately, while much online information is from
reliable sources, the public is also bombarded with
information that is not factual or based in science. It is
imperative that the public be given the tools to help
distinguish between the legitimate and illegitimate
sources of information. People can make informed
health care decisions as long as they are given accurate
information upon which to base a decision.
There is another important way in which the com-
puter is being utilized in health care. Increasingly, there
are individuals living with chronic illness who reside in
rural and remote communities. This is true in the Uni ted
States as well as throughout the world (World Health
Organization). In addition, there are countless people
who are elderly or disabled and are home bound.
Through the availability of "e-medicine," many of these
people can have access to health care services without
204 MEDICAL ILLNESS
having to leave their home. Depending on the specific
situation, these services can include the remote mon itoring
of vital signs, transmitting EKGs, or simply reminding
someone to take their medications or do their "finger sticks
for diabetes." To be effective, the technology must be
relatively simple to operate with low costs for set up and
maintenance. Insurance companies must also appropriately
reimburse health care professionals for these
non-face-to-face services. Although in its infancy now, the
e-health movement has the potential for having a profound
impact on those who most need health care services.
COMMUNITY Focus Health care services are increas-
ingly being provided in the community. The goal is to
provide services in the least \ restricti ve and least ex-
pensive setting. Community settings are often more
accessible than large institutional setting s such as
hospitals. Social work services must be structured in a way
that is aligned with new reality. Therefore, social workers
must have the flexibility to work with clients in the
community settings in which they are receiving their care.
Po PULA nON MANAGEMENT Much of the focus of
health care has moved beyond the individual to popula tion
management. Population could be defined by diagnosis,
age, gender, ethnicityl race, or geography. Social workers
are in a unique position to make a difference utili zing their
knowledge about health combined with their knowledge
and skills in the areas of community organization and
group dynamics.
Implications for Social Workers
Social workers must understand medical illness and its
impact regardless of their practice setting. Invariably,
clients will raise issues and concerns either about health
conditions or the health care delivery system and social
workers must be prepared to address these concerns. This
is particularly important as we often work with those
individuals at the lower end of the socioeconomic
spectrum and those who have been traditionally mar-
ginalized by our society as they are disproportionately
affected by all of the major disease categories and ex-
perience more severe consequences and negative out-
comes. Social workers must align themselves with
communities to ensure that there are adequate quality
health care services available. They must be involved in
the development of culturally appropriate population
health information as well as intervention tools to ad dress
both health promotion as well as specific inter ventions.
Health promotion, behavior change, and
disease management are areas in which social work can
playa major role and make a significant difference in the
lives of millions of people. Opportunities will exist for
interventions at both the micro and macro levels. The
profession of social work is uniquely qualified through its
knowledge, values and skills to assume very significant
roles in the new health care delivery paradigm. Social
workers in leadership positions must vigorously highlight
and celebrate the contributions social workers make in the
areas of health promotion, behavior change, and disease
management.
REFERENCES
American Heart Association. "Heart Disease and Stroke
Statistics-2007 Update." Retrieved June 1, 2007, from
http://www.americanheart.org/presenter .jhtml?identifier=
3018163.
Bircher, J. (2005). Towards a dynamic definition of health and
disease. Medicine, health care and philosophy. Retrieved June 1,
2007, from http://www.springerlink.com/content/
p44k13j1316g618uj.
Pleis, J. R., & Lethbridge-Cejku, M. (2007). Summary health
u.s.
statistics for adults: National Health Interview Survey, 2005.
Hyattsville, MD: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, Na-
tional Center for Health Statistics. Retrieved June 1, 2007,
from www.cdc.gov/nchs/data/series/sr_l0/srl 0_23 2.pdf.
U.S. Department of Health and Human Services. Mental Health: A
Report of the Surgeon General-Executive Summary. Rockville,
MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration,
Center for Mental Health Services, National Institutes of
Health, National Institute of Mental Health, 1999. Retrieved
June 1, 2007, from http://mentalhealth.samhsa.gov
/features/surgeongeneralreport/home.asp.
Ustun, B., & Jakob, R. (2005). Re-defining "health."
Bulletin of the World Health Organization. Retrieved June 1,
2007, from http://www.who.int/bulletin/bulletin_board/83/
ustunllOSI/en.
World Health Organization Global Observatory for eHealth.
"Building Foundations for eHealth 2007" Retrieved June 1,
2007, from http://www.who.int/goe/enf)
FURTHER READING
Awofeso, N. (2006). Re-defining "health."Bulletin of the World
Health Organization. Retrieved June 1, 2007, from http://
www.who.int/bulletin/bulletin_board/83/ustunll0Sl/en.
Minino, A. M., Heron, M., Smith, B., & Kochanek, K. (2007).
Deaths: Final data for 2004. National Vital Statistics Reports.
Hyatsville, MD: National Center for Health Statistics. Re-
trieved June 1, 2007, from http://www.cdc.gov/nchs/prod-
ucts/pubs/pubd/hestats/finaldeaths04/finaldeaths04 .htm.
SUGGESTED LINKS
Centers for Disease Control and Prevention's National Center for
Health Statistics
www.cdc.gov

Kaiser Family Foundation
www.statehealthfacrs .org
National Association of Social Workers Standards for Social
Work Practice in Health Care Settings
http://www.socialworkers.org/practice/standards/NASWHealth-
CareStandards .pdf
National Association of Social Workers Standards for Cultural
Competence in Social Work Practice
http://www .~ocialworkers .org/practice/standards/NASWCultural
Standards .pdf
National Health Interview Survey, 2005
www.cdc.gov/nchs/data/series/sr_1O/srl0_232.pdf
-CHARLES L. ROBBINS
MEDICARE See Medicaid and Medicare.
MEDICATIO~. See Psychotropic Medications.
MEN. [This entry contains three subentries: Overview;
Health· and Mental Health Care; Practice Interventions.]
OVERVIEW
ABSTRACT: Growing up a male comes with challenges
that can influence the quality and length of one's life.
Attention is directed to gender role socialization that can
result in gender-related physical, social, and mental health
problems that can be exacerbated by poverty, ethniciry,
advanced age, and minority group back ground.
Understanding how men can cope with their problems, as
well as reasons for their failure to utilize community
resources, should be of concern to social workers. A
balanced approach in the portrayal of men, and the
creation of effective interventions that reach and assist
men, seem consistent with social work values.
KEY WORDS: intimate violence; minority group males;
male coping strategies; fathers
Masculinity
GENDER ROLE IDENTITY Levant et al. (2003) sug gest
that a gender role identity paradigm, wher eby gender roles
are seen to develop as a result of the psychological need to
have a sex-appropriate gender role identity, fails to
account for the formation of gender roles. Rather, there is
a newer psychological approach that emphasizes a gender
role strain paradigm-a social constructionist
perspective-to explain gender role formation. In this view,
"prevailing gender ideologies, which vary according to
psychological, historical, and political contexts, serve to
influence parents, teachers, and peers, who, in turn,
socialize
MEN: OVERVIEW 205
children according to the prevailing gender role ideol-
ogies" (Levant et al., p. 91). Generally, traditional gender
role socialization emphasizes patriarchal norms requiring
males to adopt dominant and aggressive be haviors and to
function in the public sphere (Levant, 1996). Given a
social constructionist perspective, there is no constant
standard for masculinity; rather, "there are 'masculinities'
that vary according to the social context" (Levant et al., p.
92).
Burns and Ward (2005), discussing men's confor mity
to traditional masculinity, indicate that male gen der norms
are learned via socialization. Three such sets of norms,
according to Thompson and Pleck (1986), include
toughness, success-status, and antifeminity, Mahalik,
Good, and Carlson (2003) have discussed different forms
of culturally derived "masculin e scripts" that are instilled
in early ages and carried out over the majority of a
lifetime. Each ideology has adverse physi cal,
psychological, and social consequences that present
particular challenges for social workers. Pleck, Sonen-
stein, and Ku (1993) found that the endorsement of
traditional masculinity was characteristic of those who
were younger, single, African American, and with low er
levels of educational expectations, greater church
participation, and living in the South. Thus, the devel-
opment of traditional masculinities includes considera-
tions of age, race, ethnicity, socioeconomic status, and
geographic background, among others.
Should men violate gender role norms: a "discre pancy
strain" may result in problematic or risky behaviors and /or
health problems. Levant (1996) has suggested that males
conforming to traditional male norms have difficulties
with emotional self-awareness, empathy, and expressivity,
adversely affecting emotional functioning and resulting in
alexithymia (the inability to verbalize feelings). Levant et
al. (2003) reviewed studies supporting a conclusion that
differences in the ability to express emotions and feelings
between males and females evolve from young age as a
result of the socialization process. From an ap plied
perspective, traditional gender role socialization
"embedded in a culture's child rearing practices and
prevailing norms concerning gendered behavior"
(Cochran, 2005, p. 649) can lead to a reluctance to seek
help from health and social service profes sionals. The
socialization of males also leads to difficulties in the
self-identification of problems and the communica tion of
emotional feelings to others (including those from
informal or formal support systems).
EARLY CHALLENGES FACING MALES Becoming
and being a man is not as easy today as it had been in the
past when traditional gender role norms and
206 MEN: OVERVIEW
expectations were less complex. In the past, males were
raised to be self-reliant, tough, aggressive, and stoi c. The
norm was that "big boys don't cry," and in certain cultures
and social classes, such norms were strongly supported by
family members and the community. Pollack (2001) has
written about pressures on boys to conform to masculine
expectations, despite confusion and fears, so as to prevent
their shame, embarrassment, and ostracism. This may be
especially true for young minority group males (often from
impoverished backgrounds) who have higher school
dropout rates and are overrepresented in prisons, detention
centers, in probation and parole systems, and are more
likely to face violent death (Cose, 1995). The remnants of
early gender role socialization can adversely affect male
college students as well. Kimmel'(2004) suggests that there
is a "crisis" concerning men in higher education. "A
dramatic decline in enrollments relative to women; an
equally dramatic convergence in test scores, especially in
the sciences; and the daily barrage of accounts of sexual
assault, harassment, violence, and other beha vioral
problems add to an apparently serious social problem" (p.
97) for younger men in particular.
Problems and Issues
HEALTH Courtenay (2003) pointed out that for allIS
leading causes of death (except Alzheimer's disease), in
. every age group, men and boys have higher death rates
than women and girls. Men are more likely than women
to suffer from cardiovascular diseases, 7 of the top 10
infectious diseases, and death from cancer. Men, more
so than women, meet the criteria for psychiatric diag-
noses. Men also have higher rates of substance- related
disorders, sexual disorders, and are at greater risk for
schizophrenia, and their suicide rate is 4-12 times high er
than for females (Courtenay, 2003). So, too, men have
been found to have memory loss, sexually trans mitted
diseases, and physiological challenges to their immune
functioning (Adler, Patterson, & Grant, 2002).
Being male results in particular health concerns and
problems due to aging. Prostate and testicular cancers, as
well as nongender specific. types, have reached epi demic
proportions for males. One of five men develops prostate
cancer and, at age 75, men are dying at twice the rate as
that of women. The cancer death rate for African American
men is twice that for Caucasian men (Men's Health
Network, 2000). In facing nongender specific problems,
there are differences in men's responses to the problem as
well as in their help-seeking behavior. For example, Lund
(2001) has edited a book, Men Coping with Grief, which
discusses social losses, past abuse, and aging, as well as
interventions for grieving men.
The results of some of men's problems do not surface
for many years. Military combat veterans may become
victims of posttraumatic stress disorder (PTSD) decades
after the event (Aging Today, 1991-1992). There has been
attention given to men who have been victims of early
forms of violence either experienced or observed. Lisak
(2001) has identified such "trauma" to include not only
combat, but also having been sexually abused in
childhood, witnessing parental violence, or having been
exposed to physical aggression and abuse. Events
associated with the aging process (for example, retiremen t,
bereavement) can lead to delayed PTSD.
LOSSES AND VULNERABILITY Whether related to
coping or life style, males have been found more likely
than females to be victimized and murdered, to com-
plete suicide attempts, to become substance abusers, to
be homeless, to be victims of work- related injuries and
illness, to suffer heart attacks, and to have fatal car
accidents (Farrell, 1993). While males are commonly
discussed as family abusers, they can also be the
victims of domestic abuse. Dutton and Nicholls (2005 )
have explored abuse of men by women in intimate
relations. Langhinrichsen-Rohling and Vivian (1994 )
found that 61 % of the husbands and 64% of the wives
were classified as aggressive; 36% of husbands and
53% of the wives were classified as severely
aggressive. O'Leary et al. (1989) found that, of 272
couples planning to marry, 44% of women compared
with 31% of men had been physically violent toward
their partners. After assessing several large- scale
studies, Kessler, Molnar, Feurer, and Appelbaum
(2001) concluded that female violence rates are as high
as, or higher, than male violence rates in intimate
relationships. Decades ago, Steinmetz (1977-1978 )
wrote of the "The Battered Husband Syndrome" and,
more recently, Pritchard (2001) has written about t he
abuse of husbands and Nicolls and Dutton (2001) have
discussed the abuse of male intimates by women.
Similar to heterosexual violence, violence against
homosexuals can be perpetu ated by domestic partners,
as well as others. In seeking companionship, lo nely
men may become high risk for physical or financial
victimization (Kosberg, 1998).
Men who face major disruptions to their lives from the
loss of a wife or a significant other (that is, divorce,
institutionalization, death) can be especially vulnerab le.
Some men are without necessary skills to manage their
own domestic affairs (that is, cooking, shopping) or to
continue social relationships. For many men, the spouse
had also been a "confidant," or best friend, compounding
the loss. There can be many consequences of such losses
for men that include problematic bereavement, physical
and mental health problems,

and premature death (McIntosh, Pearson, & Lebowitz,
1997). For men socialized to be self-sufficient and
strong, some life changes adversely affect their self-
concepts. These changes can include losses of physical
functioning, employment, or independence that lead to
loss of role and status. For example, the aging process
can adversely affect some men's sexual performance
that impacts their self-concepts (and possibly also their
spouses or partners).
CAREGIVING Although traditionally a female role,
increasing attention has been given to males as family
caregivers and increasingly males are taking on respon-
sibilities for spouses, children, challenged relatives, or
dependent elderly parents (Kramer & Thompson,
2002). It is no longer uncommon to hear of men staying
at home to raise their children, especially if the wife is
the major wage earner for the family. Some husbands
provide care to ill wives or children. Older husbands
provide long-term care to their wives, and sons provide
care to their siblings or mothers who suffer from physi-
cal, mental health, or cognitive problems (Harris, 2002).
In addition, some grandfathers are actively involved in
assisting their wives in raising grandchildren (Bullock,
2005). There is evidence that male caregivers (that is,
husbands, sons) experience similar levels of burden and
depression as found for females; yet, these males are
less likely to admit their problems and seek assistance
(Yee & Schulz, 2000). Older fathers who take on new or
additional caregiving responsibilities for specially
challenged adult children, when. wives become
incapacitated or die, have been found to have similar
low levels of morale, depressive symptoms, and
subjective burdens as caregiving mothers (Essex,
Seltzer,& Krauss, 2002).
Men of Color
LENGTH AND QUALITY OF LIFE There are special
problems facing minority group males, both native and
foreign born. Such groups of men are often raised in
traditional cultures where male dominance in the family
is normative (for example, Hispanic, African American,
Native American). The nature of one's upbringing has
profound implications on the quality and length of one's
life. Consider the fact that most of those in prisons,
detention centers, and in probation and parole systems
are male, poor, illiterate, and people of color; about 50%
~ are African Americans, 15-20% are Latino, and 1% (a
.
~-
disproportionate percentage) are Native Americans
(Kupers, 2001). Minority group males maybe high risk
for other adversities such as prostate cancer, diabetes,
violence, and homelessness (Davis, 1999). The
introductory chapter of the book
MEN: OvERVIEW
207
Social Wark Practice with African American Males, by
Rasheed and Rasheed (1999), presents a summary of
social statistics that begs for professional and societal
concern and action, and Allen-Meares and Burman
(1995) have appealed for widespread social work action
on behalf of "endangered" African American men: Yet,
Kosberg (2005) has suggested that problems faced by
males from minority group backgrounds "are not
necessarily a result of one's race or ethnicity, but rather
are due to poverty, discrimination, and societal
inequalities in educational, social, and health care
systems" (pp.17-18).
There are differences in health and longevity be-
tween and within racial and ethnic groups of men and
women. For example, African American men die seven
years younger than European American men (DHHS,
2000). Unintentional injuries are the second cause of
death for Native American men, surpassing cancer,
which is the second leading cause of death among
non-Native American men (Collins, Hall, & Neuhaus,
1999). The death rate for HIV is highest for African
Americans and Latinos-it is the third and fourth leading
killer, respectively, of these men. African American
men are nearly six times more likely than European
American men to die from AIDS. Similarly, homicide
ranks among the five leading causes of death only for
Latino and African American men-not for men of oth~r
ethnic groups. Compared to European American men,
African American men experience earlier onset of heart
disease, more severe heart disease, and higher rates of
complications due to heart disease-which is the leading
cause of death for men (Barnett et al., 2001).
UTILIZATION OF PHYSICAL AND MENTAL
HEALTH SERVICES Health care usage is also related
to ethnicity, and Courtenay (2002) points out that
Latino and African American men are significantly less
likely than European American men to see a physician
regularly. Ethnicity is also associated with a patient's
treatment, patient satisfaction, and use of health care
resources. For example, Borowsky et al. (2000) found
that mental health clinicians are less likely to correctly
diagnose mental health problems of African Americans
and Latinos. Blendon, Aiken, Freeman, and Corey
(1989) found African Americans to be more dissatisfied
with their care by doctors and in hospitals than were
European Americans. Williams (2003) concluded that
minority men and women, compared with Whites, re-
ceive less intensive and poorer-quality medical care for
a broad range of medical conditions. Within ethnic
groups, Courtenay (2002) suggests that males utilize
services significantly less often than do females.
Indeed, Solis, Marks, Garcia, and Shelton (1990) found
that twice as many Mexican American men as Mexican
208 MEN: OVERVIEW
American women report having no regular place to get
health care and 1.5 times more women than men report
having had a routine physical examination within the
previous two years.
HETEROGENEITY OF MINORITY GROUP MALES
Writing about interventions with males from minority
groups, Brooks and Good (2001) have emphasized the
need for sensitivity to their special backgrounds that have
influenced their socialization process; such things as
racism, poverty, and social pressures. Caldwell and White
(2001) caution against generaliza tions that fail to
acknowledge differences in the backgrounds and
experiences of African American fflen by socioeco nomic
status and geographic locations. In a study of the meaning
of manhood to African America men, Hammond and
Mattis (2005) found that these men perceived
responsibility-accountability to be the most endorsed
category; yet, they emphasized that their par ticipants came
from relatively affluent backgrounds. In discussing
Hispanic males, Casas, Turner, and Ruiz de Esparza (200l )
refer to the machismo upbringing of these males and the
need to provide them with both culturally and
gender-sensitive attention that takes into account their
heterogeneity. Sue (2001) believes that Asian American
males conform to'different male stan dards (such as
deference and respect); yet, it is necessary to also consider
the specific cultural backgrounds of these men and their
degree of acculturation. As hetero geneity exists within all
ethnic and racial groups, the need for cultural sensitivity
includes the consideration of gender as well as cultural
background.
Coping Mechanisms
STRATEGIES Men are more likely to utilize stress-
reducing strategies, whereas women are more likely to
have psychological attributes that help them reduce their
life stresses. Faced with normal life span and
gender-specific challenges, men can respond in both
constructive and destructive ways. Some will seek to
understand the problem and engage in problem solving
leading to constructive and realistic changes in perso nal
expectations and behavior. Personal strategies will be
facilitated by the existence, and use, of supportive
informal support systems (Hatch, 2000). In a study of
university students, Day and Livingstone (2003) found
men were less likely to interpret scenarios to be stressfu l
than did women, but also they were less likely to tum to
their partner or friends to seek emotional support.
Courtenay (2003) indicates that "Men and boys ... have
fewer, less intimate friendships, and they are less likely to
have a close confidant, particularly someone other than a
spouse" (p. 5).
Maladaptive Coping. Faced with problems, some men
either engage in dangerous efforts to deny problems or engage
in coping mechanisms that exacerbate their situations. Men
are more likely than women to use avoidant coping strategies
such as denial, distraction, and increased alcohol
consumption, and are less likely to acknowledge their need for
assistance (Courtenay, 2003). In addition, Courtenay
concludes from his review of research and practice findings
that faced with stress, men have greater cardiovascular
reactivity, and higher levels of anxiety, depression,
psychological stress, and maladaptive coping patterns. While
excessive substance use might be normal for some men, others
might increase, or begin, the use of such Substances to deal
with their problems. Some men might tum to violence as the
way by which they deal with their problems or as a way by
which to reassert their masculinity to themselves and others. It
is possible that such violence might be targeted on those who
are perceived to be the cause of their problems or those who
are vulnerable to be treated as a scapegoat (that is, a wife,
child, or elderly parent).
Although it is popularly believed that men are less
likely to experience mental he alth problems, there is
reason to question such assumptions. For example, it is
possible that a portion of men who are seen in substance
abuse treatment settings have received a "substance
abuse" primary diagnosis when, in fact, they turned to
substances as a coping mechanism for emotional pro-
blems. Depression might result in a man's suicide
(McIntosh, Pearson, & Lebowitz, 1997), and surveys that
seek mental health differences between men and women
will obviously exclude men who have com mitted suicide.
Also, the fact that men are likely to deny the existence of
emotional problems, or fail to seek and use available
mental health resources, leads to the underreporting of
their mental health problems. The U.S. government,
realizing that some men believe that "real men do not
admit problems or seek help," has published literature
(NIMH, 2003) that describes de pression for men, provides
hotline phone numbers and information on available
resources, and includes state ments from men in different
walks of life who were depressed and successfully sought
needed interventions.
Social Work Perspectives PORTRAYAL
OF MEN Given the fact that most of the social work
professionals are women and more women than men use
social services, it is not surprising that attention to the
needs of males in the field of social work can be
characterized as either "limited" or "biased" (Kosberg,
2002), with the exception of attention to veterans or gays .
Generally, the majority of attention

to males has been limited to those who are delinquent,
deviant, absent fathers, or abusers. Such a biased por trayal
of men precludes a more balanced perspective that is
commonly used for other groups. Further, there appears to
be a propensity in social work literature and curriculum to
use gender as a euphemism for "female issues," rather than
to provide a discussion of both males and females.
Limiting attention to a biased sample of males sends a
distorted message to social work students and to social
work practitioners. There seems too little attention is being
given to males who are undergoing personal or
interpersonal challenges that result from life course
transitions, such as marriage or divorce, parenthood,
employment or unemployment, aging and retirement,
illness anddisability, caregiving and dependency, and
losses and deaths, among other life events.
The inclusion of men in social work literature seems
reserved for those who are in treatment programs and those
incarcerated, hospitalized, or institutionalized. Books that
have been written or edited by social workers that provide
a balanced treatment of men generally come from
countries other than the United States. Examples include
Working with Men in the HumanServices (Pease &
Camilleri, 2001), Understanding Gender and Culture in the
Helping Process (Rabin, 2005), and Men and Social Work:
Theories and Practices (Christie, 2001). In the United
States, Glicken (2005), a social worker, has recently
published Working with Troubled Men, and Moore and
Stratton (the latter being a social worker) authored a book
on Resilient Widowers in 2002.
Taking fatherhood as an example, Strug and Wilmore-
Schaeffer (2003) have written about the lack of attention to
fathers in social work literature and that professionals need
more information on fathers so as to better assist them.
Greif and Greif (1997) ask "Where are the fathers in social
work literature?" and yet found, from their comparison of
discussions of fathers in professional literature seven years
apart, that they were less likely to be discussed as
perpetrators of abuse, missing from the family, and
embattled single fathers raising their children alone.
However, the authors do conclude that fathers who are gay
or who are married continue to be ignored in the literature.
A growing literature focuses on the rights and re-
sponsibilities of unwed fathers (Laakso &Adams, 2006;
Carlson & McLanahan, 2004). British social worker Brid
Featherstone (2003) writes that fathers . are still often
depicted in child welfare as potential threats rather than
resources for their children. The biased or limited attention
to normative life cycle challenges for men-such as
fatherhood-can lead to a false conclusion that they and
t.: their problems are not worthy of
MEN: OVERVIEW 209
professional attention or that they are always the source of
problems for others.
HELP,SEEKING BEHAVIOR Social workers should be
aware of the reasons why men underutilize community
resources (Cochran, 2005). They are less likely to
admit having problems, engage in help- seeking
behavior, participate in certain forms of therapies, and
remain in treatment as a result of their self- perceptions,
how they believe others see them, and the
characteristics of community resources that include
female staff and clients or patients in such settings
(Addis & Mahalik, 2003). In a study of men in Florida ,
Berger, Levant, McMillan, Kelleher, and Sellers
(2005) found that the desire to seek needed help was
inversely related to their adherence to traditional
masculine ideology. Addis and Mahalik explain that
the differences in professional help seeking between
men and women results from men's gender- role
socialization and the masculine ideol ogy emphasizing
self-reliance, toughness, and emotional control. The
authors identify different methods by which innovative
interventions can be developed to encourage
help-seeking behavior by men.
BARRIERS TO SERVICE USE A number of organiza-
tional barriers to the use of needed community . re-
sources by men have been identified. T udiver and
Talbot (1999) have discussed barriers for men in med-
ical settings to include long waiting periods, limited
hours of operation, and the need to publicly d isclose
the reason for the visit to a receptionist or assistant. Xu
and Borders (2003) found that "waiting times of 30
minutes or longer in a physician's office sharply
reduced the likelihood of a man's having visited a
doctor" (p. 1077), causing Kosberg (2005) to reply :
"There is no reason to believe that this would not be
true in an office of a psychologist, social worker, or
nurse" (p. 23). A report published by the International
Longevity Center (2004) indicated that the
accoutrements in clinical settings (such as magazines,
artwork, and furniture) make a man feel welcome or
not.
Men's under-utilization of community resources,
especially in the mental health field, has led to efforts to
better understand why this occurs. Cochran (2005) has
discussed the need for evidence-based assessments of men
that include attention to their gender role socialization that
influences their help-seeking behavior and their reactions
to therapeutic interventions that conflict with their values
and preferences. Focusing on the under-utilization of
needed community resources by men, Rochlen and Hoyer
(2005) have discussed the need for "social marketing" of
mental health resources that is based upon attention to the
210 MEN: OvERVIEW
congruity between the characteristics of resources and
male perceptions of normative roles and values. Thus,
there is a need to consider the "goodness of fit" between
characteristics of community resources and the needs and
expectations of men. Rochlen and Hoyer point o ut that
researchers must accurately measure and com municate
the unique perspectives of men, but "it will be equally
critical that mental health providers moni tor their own
biases toward and preconceptions about men" (2005, p .
682).
PROFESSIONAL DISCRIMINATION Indeed, there may be
biases against male clients and patients by those in
helping professions, including medicine, social work,
and psychology. Such possible sexism (against males)
can well be exacerbated by \ the existence of ageism
(against older men) or racism (against minority group
men). Elderkin-Thompson and Waitzkin (1999) have
identified gender biases in medical care that adversely
impact both men and women. Focusing upon male
patients, Williams (2003) reports that men coming to
emergency rooms with depressive symptoms (seen to be
inconsistent with gender norms) are more likely to be
hospitalized and that men with antisocial behavior or
substance abuse problems are less likely to be hospi-
talized. Williams also found that health care providers
spend less time with men, provide them with fewer
services and less health information, less advice, and are
less likely to talk about the need to change behaviors to
improve health. Unknown is whether or not such
gender-associated discrepancies also exist within the
social service sector.
Wisch and Mahalik (1999) discuss the possibility of
bias against male clients and patients by male profes -
sionals, and suggest that a male therapist's diagnosis and
prognosis are related to his empathy and comfort with a
male client. This, in turn, is related to the client's sexual
orientation and emotional expressiveness and the
therapist's own gender role conflict. Brooks (1998) has
discussed the nuances of both female and male therapists
with men, concluding that both need empathy and a sense
of responsibility and commitment. Johnson (2001) has
written about female therapists with male clients; Scher
(2001) has discussed male therapists with male clients. It
has been found that female physicians give more time to a
patient and engage in more positive discussions,
partnership-building, question- asking, and information
giving (Rater, Lipkin, & Korsgaard, 1991). Such
"patient-centered" propensi ties better facilitate a
relationship with male patients or clients (especially older
ones) who are reluctant to verbalize their health concerns
and abide by medical advice. It is believed that social
work needs
to give more attention to issues raised by those in
medicine and psychology.
CONTEMPORARY CHALLENGES Cose (1995) suggests
there are reasons for believing that males in contem-
porary society are "beleaguered" in their efforts to un-
derstand their roles in a changing society. Indeed, as a
result of the success of the women's movement, Amer-
ican society is moving toward greater gender equity in
the home, workplace, political arena, and throughout
daily life. While males brought up by "enlightened"
parents will embrace gender equity, a culture gap exists
between those men with traditional gender role socia-
lization and the values of contemporary society. Such
men can include those raised in other countries, where
male dominance was the norm; others can include
native-born American men raised by traditional male
norms. The potential challenges facing such men can be
great. In the first instance, traditional men may face
"attacks to their masculinity" in ways that challenge their
dominance in marriage and the family, their leadership in
business and government, and their tendency for
"hiding" personal feelings or problems from themselves
and others. Wade and Brittan-Powell (2001) found that
adherence to a masculine ideology and dependence upon
male reference groups related to negative attitudes
toward racial diversity and women's equality.
Other challenges facing contemporary men include
increases in the average age of marriage for men, the
number of divorces, and the number of remarriag es, but
also the number of men who never marry (Kreider, 2005 ).
Consequences of such trends can lead to poten tial
problems for men and the need for social work
interventions. Although the exact numbers are un known,
there would appear to be an increasing number of gay men
in heterosexual marriages (Caldwell, 2004; Higgins ,
2002). Whether or not they became aware of their
homosexuality before or after their marriage, these men
(and their wives and children) also can benefit from social
work guidance.
Advocacy for the Future
Whereas women have greatly benefited from the suc-
cessful (and needed) advocacy of feminists (and the
"women's movement"), there has not been, until quite
recently, such organizational efforts on behalf of men (see
Suggested Links). Currently, the majority of such
advocacy efforts focus upon men's health, urging men to
pay greater attention to unhealthy lifestyles and to seek
regular health care check-ups as well as seek pro fessional
assistance when a problem occurs. Advocacy efforts ar e
also directed to encourage health care
1

systems to create more responsive and effective services. for
men.
In nonhealth areas, there are number of men's orga-
nizations that champion the rights of fathers and husbands, as
well as challenge existing sexism and discriminatory policies.
Perhaps the most influential applied organization focusing
upon men's issues is the American Psychological
Association's Division 51: Society for the Psychological
Study of Men and Masculinity. This 1,000-member division
seeks to advance knowledge of the critical issues facing men
and improving clinical services for them.
It should be pointed out that the two major social work
organizations, the National Association of Social Workers
(NASW) and the Coun~il on Social Work Education (CSWE),
have been somewhat slow to focus on the problems of males
in their organizational structures. NASW does have national
committees on women's issues and on lesbians, gays,
bisexuals, and transgender issues. The CSWE has
commissions on the role and status of women and on sexual
orientation and gender expressions (formerly the Commission
on Gay Men and Lesbian Women), and CSWE devoted a
special section in the Journal of Social Work Education to "The
Status of Women in Social Work Education." There are
journals that focus upon women's issues (Affilia, Journal of
Feminist Family Therapy, as well as a proposed Journal of
Feminist Social Work).
"Social work has been a woman's profession. The vast
majority of social workers have been and are women" (Weick,
2000, p. 395). Understandably, NASW effectively advocates
for affirmative action for women as a result of past
inequalities against them, and current ones as well. Yet, social
work efforts to challenge inequalities against women can be
accomplished without minimizing attention to men's problems
in the classroom, in scholarship, or in professional practice.
This would deny those men facing personal problems the
benefits of social workers' concern, attention, and skills. Such
omission would be unfair and unfortunate. In the name of
social justice and professional equity, it is believed that social
work attention to the needs of men should be no more, but
certainly no less, than for the needs of women.
There are many potential challenges faced by men in
contemporary American society and, thus, there is a need for
social workers to have the necessary understanding, skills, and
commitments for working with and for men in an effective
and sympathetic manner. The result should lead to efforts that
more effectively reach and serve men. In doing this, the
profession will not only better assist men facing challenges in
their daily lives, but will also help their spouses, partners,
families, and others in society.
MEN: OvERVIEW 211
REFERENCES
Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the
contexts of help seeking. American Psychologist, 58(1), 5-14.
Adler, K. A, Patterson, T. L., & Grant, I. (2002). Physiological
challenges associated with caregiving among men. In B. J.
Kramer & E. H. Thompson, Jr. (Eds.), Men as caregivers:
Theory, research, & service implications (pp. 127-150). New
York: Springer Publishing Company.
Aging Today. (1991{1992, 8 December/January). Research
highlights: Older men.
Allen-Meares, P., & Burman, S. (1995). The endangerment of
African American men: An appeal for social work action.
SociaIVVork,40(2),268-274.
Barnett, E., Casper, M. L., Halverson, J. A., Elmes, G. A, Braham,
V. E., Majeed, Z. A., et al. (2001). Men and. heart disease: An
atlas of radal and ethnic disparities in mortality (Ist ed.).
Morgantown, WV: West Virginia University, Office for
Social Environment and Health Research.
Berger, J. M., Levant, R., McMillan, K. K., Kelleher, W., &
Sellers, A. (2005). Impact of gender role conflict, traditional
masculinity ideology, Alexithymia, and age on men's attitudes
toward psychological help seeking. Psychology of Men &
Masculinity, 6(1), 73-78.
Blendon, R. J., Aiken, L. H., Freeman, H. E., & Corey, C. R.
(1989). Access to medical care for Black and White Ameri-
cans: A matter of continuing concern. Journal of the American
Medical Association, 261 (2), 278-281.
Borowsky, S. J., Rubenstein, L. V., Meredith, L. S., Camp, P.,
[ackson-Triche, M., & Wells, K. B. (2000). Who is at risk of
non-detection of mental health problems in primary care?
Journal of General Internal Medicine, 15(6),381-388.
Brooks, G. R. (1998). A new psychotherapy for traditional men.
San Francisco: [ossey-Bass.
Brooks, G. R., & Good, G.E. (Eds.). (2001). The new handbook of
psychotherapy and counseling with men: A comprehensive guide to
settings, problems, and. treatment approaches, Vols. I & II. San
Francisco: [ossey-Bass.
Bullock, K. (2005). Grandfathers and the impact of raising
grandchildren. Journal of Sociology and. Social. VVelfare,
32(1),43-59.
Bums, S. M., & Ward, A Z. (2005). Men's conformity to
traditional masculinity and relationship satisfaction. Psych-
ology of Men & Masculinity, 6(4), 254-263.
Caldwell, J. (2004). Gay men: Straight lives. Advocate, 924, 55-57.
Caldwell, L. D., & White, J. L. (2001). African-centered
therapeutic and counseling interventions for African American
males. In G. R. Brooks & G. E. Good (Eds.), The new handbook
of psychotherapy and. counseling with men: A comprehensive guide
to settings, problems, and. treatment approaches (Vol. 2, pp.
737-753). San Francisco: jessey-Bass.
Carlson, M., & Mclanahan, S. (2004). Involvement by young,
unmarried fathers before and after their baby's birth. The
Prevention Researcher, 11, 14-17.
Casas, J. M., Turner, J. A, & Ruiz de Esparza, C. A. (2001).
Machismo revisited in a time of crisis: Implications for un-
derstanding and counseling Hispanic men. In G. R. Brooks &
212 MEN: OVERVIEW
G. E. Good (Eds.), The new handbook of psychotherapy and
counseling with men: A comprehensive guide to settings, problems,
and treatment approaches (VoL 2, pp. 754-779). San Francisco:
[ossey-Bass.
Christie, A. (Ed.). (2001). Men and social work: Theories and
practices. Hampshire, UK: Palgrave.
Cochran, S. V. (2005). Evidence-based assessment with men.
Journal of Clinical Psychology, 61(6), 649-660.
Collins, K. S., Hall, A., & Neuhaus, C. (1999). U.S. minority health: A
chartbook. New York: The Commonwealth Fund.
Cose, E. (1995). A man's world: How real is male privilege-How high
is the price? New York: Harperf.ollins.
Courtenay, W. H. (2002). A global perspective on the field of men's
health. International]ournal of Men's Health, 1, 1-13.
Courtenay, W. H. (2003). Key determinants of the health and
well-being of men and boys. International Journal of Men's Health,
2(1), 1-30.
Davis, L. E. (Ed.). (1999); Working with African American males.
Thousand Oaks, CA: Sage Publications.
Day, A. L., & Livingstone, H. A. (2003). Gender differences in
perceptions of stressors and utilization of social support among
university students. Canadian Journal of Behavioural Sdence,
35(2), 73-83.
Department of Health and Human Services. (2000). Deaths:
Final data for 1998 (DHHS Publication No. [PHS] 20001120).
National Vital Statistics Reports, 48(11). Hyattsville, MD:
National Center for Health Statistics.
Dutton, D. G., & Nicholls, T. L. (2005). The gender paradigm in
domestic violence research and theory: Part I-The conflict of
theory and data. Aggression and Violent Behavior, 10,680-714.
Elderkin-Thompson, V., & Waitzkin, H. (1999). Differences in
clinical communication by gender. Journal of General Internal
Medidne, 14, 112-12l.
Essex, E. L., Seltzer, M. M., & Krauss, M. W. (2002). Fathers as
caregivers for adult children with mental retardation. In B. J.
Kramer & E. H. Thompson, Jr. (Eds.), Men as caregivers: Theory,
research, and service implications (pp. 250268). New York:
Springer Publishing Company.
. Farrell, W. (1993). The myth of male power. New York: Berkley
Books.
Featherstone, B. (2003). Taking fathers seriously. British Journal of
Social Work, 33, 239-254.
Glicken, M. D. (2005). Working with troubled men: A contemporary
practitioner's guide. Mahwah, NJ: Lawrence Erlbaum Associates,
Publishers.
Greif, G. L., & J. L. Greif (1997). Where are the fathers in social work
literature? Revisiting the question. Families in Society, 78(4),
433--435.
Hammond, W. P., & Mattis, J. S. (2005). Being a man about it:
Manhood meaning among African American men. Psychology of
Men & Masculinity, 6(2), 114-126.
Harris, P. B. (2002). The voices of husbands and sons caring for a
family member with dementia. In B. J. Kramer & E. H. Thompson
Jr. (Eds.), Men as caregivers: Theory, research, and service
implications (pp, 213-233). New York: Springer Publishing
Company.
Hatch, L. R. (2000). Beyond gender differences: Adaptation to aging in
life course perspective. Amityville, NY: Baywood Publishing
Company, Inc.
Higgins, D. J. (2002). Gay men from heterosexual marriages:
Attitudes, behaviors, childhood experiences, and reasons for
marriage. Journal of Homosexuality, 42(4), 15-34.
International Longevity Center-USA. (2004). Promoting men's
health: Addressing barriers to healthy lifestyle & preventive health
care. New York: ILC-USA.
Johnson, N. G. (2001). Women helping men: Strengths of and barriers
to women therapists working with men clients. In G. R. Brooks &
G. E. Good (Eds.), The new handbook of psychotherapy and
counseling with men: A comprehensive guide. to settings, problems,
and treatment approaches (Vol. 2, pp. 696-718). San Francisco:
jessey-Bass.
Kessler, R. c., Molnar, 1. E., Feurer,1. D., & Appelbaum, M. (2001).
Patterns and mental health predictors of domestic violence in the
United States: Results from the National comorbidity survey.
International Journal of Law and Psychiatry 24, 487-508.
Kimmel, M. (2004). Afterword. In G. E. Kellom (Ed.), Developing
effective programs and services for college men (pp, 97-100). San
Francisco: [ossey-Bass.
Kosberg, J. 1. (1998). The abuse of elderly men. Journal of Elder
Abuse & Neglect, 9(3), 69-88.
Kosberg, J. 1. (2002). Heterosexual males: A group forgotten by the
profession of social work. Journal of Sociology and Social Welfare,
23(3), 51-70.
Kosberg, J. 1. (2005). Meeting the needs of older men: Challenges for
those in helping professions. Journal of Sociology and Social
Welfare, 32(1), 9-3l.
Kramer, B. J., & Thompson, E. H., Jr. (Eds.). (2002). Men as
caregivers: Theory, research, & service implications. New York:
Springer Publishing Company.
Kreider, R. M. (2005). Number, timing, and duration of marriages and
divorces: 2001. Washington, DC: U.S. Department of Commerce,
Economics and Statistics Administration, U.S. Census Bureau.
Kupers, T. A. (2001), Psychotherapy with men in prisons. In G. R.
Brooks & G. E. Good (Eds.), The new handbook of psychotherapy
and counseling with men: A comprehensive guide to settings,
problems, and treatment approaches (Vol. 1, pp. 170-184). San
Francisco: jessey-Bass.
Laakso, J., & Adams, S. (2006). Non-custodial fathers' involvement
with their children: A right or privilege? Families in Society, 87,
85-93.
Langhinrichsen-Rohling, J., & Vivian, D. (1994). The correlated of
spouses' incongruent reports of marital aggression. Journal of
Family Violence, 9, 265-283.
Levant, R. F. (1996). The new psychology of men. Professional
Psychology, 27, 259-265.
Levant, R. F., Richmond, K., Majors, R. G., Enclan, J. E., Rossello, J.
M., et al. (2003). A multicultural investigation of masculinity
ideology and Alexithyrnia. Psychology of Men & Masculinity,
4(2), 91-99.
Lisak, D. (2001). Male survivors of trauma. In G. R. Brooks & G. E.
Good (Eds.), The new handbook of psychotherapy and

counseling with men (Vol. 1, pp. 263-277). San Francisco:
Jossey-Bass.
Lund, D. A. (Ed.). (2001). Men coping with grief. Amityville, NY:
Baywood Publishing Company, Inc;
Mahalik, J. R., Good, G. E., & Carlson, M. (2003). Masculinity,
scripts, presenting concerns, and help seeking: Implications
for practice and training. Professional Psychology:
Research and Practice, 34(2), 123-13l.
McIntosh, J. L., Pearson, J. L., & Lebowitz, B. D. (1997).
Mental disorders of elderly men. In J. I. Kosberg & L. W.
Kaye (Eds.), Elderly men: Special problems & professional
responsibilities (pp. 193-215). New York: Springer.
Men's Health Network (Online). (2000). Retrieved June 16, 2006,
from http://www.menshealthnetworknet.org.
Moore, A. J., & Stratton, D. C. (2002). Resilient widowers:
Older. men speak for themselves. New'York: Springer.
National Institute of Mental Health. (2003). Men and depression.
National Institute of Health Publication No. OJ--4972.
Nicolls, T. L., & Dutton, D. G. (2001). Abuse committed by
women against male intimates. In B. J. Brothers (Ed.), The
abuse of men: Trauma begets trauma (pp. 41-57). New York:
The Haworth Press.
O'leary, K. D., Barling, J ., Arias, I., Rosenbaum, A., Malone, J.,
& Tyree, A. (1989). Prevalence and stability of physical
aggression between spouses: A longitudinal analysis. Journal
of Consulting and Clinical Psychology 57, 263-268.
Pease, B., & Camilleri, P. (Ed.). (2001). Working with men in the
human services. Sydney, Australia: Allen & Unwin.
Pleck, J. H., Sonenstein, F. L., & Ku, L. C. (1993). Masculinity
ideology and its correlates. In S. Oskamp & M. Costanzo
(Eds.), Gender issues in social psychology (pp. 85-110). Newbury
Park, CA: Sage.
Pollack, W. (2001). Inside the world of boys: Behind the mask of
masculinity. In T. F. Cohen (Ed.), Men and masculinity (pp.
70-77). Belmont, CA: Wadsworth.
Pritchard, J. (2001). Male victims of elder abuse: Their experiences
and needs. London: Jessica Kingsley Publishers.
Rabin, C. L. (Ed.). (2005). Understanding gender and culture in the
helping process: Practitioners' narratives from global perspectives.
Belmont, CA: Wadsworth.
Rasheed, J. M., & Rasheed, M. N. (1999). Social work practice with
African American men. Thousand Oaks, CA: Sage Publications,
Inc.
Rochlen, A. B., & Hoyer, W. D. (2005). Marketing mental health
to men: Theoretical and practical considerations. Journal of
Clinical Psychology, 61 (6), 675-684.
Roter, D., Lipkin, M., & Korsgaard, A. (1991). Sex differences in
'patients' and physicians' communication during primary care
medical visits. Medical Care, 29(11), 1083-1093;
Scher, M. (2001). Male therapist, male Client. In G. R. Brooks &
G. E. Good (Eds.), The new handbook of psychotherapy and
counseling with men: A comprehensive guide to settings, problems,
and treatment approaches (Vol. 2, pp. 719-733). San Francisco:
[ossey-Bass.
Solis, J. M., Marks, G., Garcia, M., & Shelton, D. (1990).
Acculturation, access to care, and use of preventive services
MEN: OVERVIEW 213
by Hispanics. Findings from HHANES 1982-84. American
Journal of Public Health, 80 (Supplement), 11-19.
Steinmetz, S. K. (1977-70). The battered husband syndrome.
Victimology, 2, 499.
Strug, D., & Wilmore-Schaeffer (2003). Fathers in the social work
literature: Policy and practice implications. Families in Society,
84(4), 503-511.
Sue, D. (2001). Asian American masculinity and therapy: The
concept of masculinity in Asian American males. In G. R.
Brooks & G. E. Good (Eds.), The new handbook of psychotherapy
and counseling with men: A comprehensive guide to settings,
problems, and treatment approaches, Vol. 2 (pp. 780-795). San
Francisco: [ossey-Bass.
Thompson, E. H., Jr., & Pleck, J. H. (1986). The structure of male
role norms. American Behavioral Scientist, 29,531-543.
Tudiver, F., & Talbot, Y. (1999). Why don't men seek help?
Family physicians' perspectives on help-seeking behavior in
men. Journal of Family Practice, 48(1), 47-52.
Wade, J. c., & Brittan-Powell, C. (2001). Men's attitudes toward
race and gender equity: The importance of masculinity
ideology, gender-related traits, and reference group identify
dependence. Psychology of Men & Masculinity, 2(1), 42-50.
Weick, A. (2000). Hidden voices. Social Work 45(5), 395-402.
Williams, D. R. (2003). The health of men: Structured in-
equalities and opportunities. Public Health Matters. American
Journal of Public Health, 93(5), 724--731.
Wisch, A. F., & Mahalik, J. R. (1999). Male therapists' clinical
bias: Influence of client gender role & therapist gender role
conflict. Journal of Counseling Psychology, 46(1),51-60.
Xu, K. T., & Borders, T. F. (2003). Gender, health, & physician
visits among adults in the United States. American Journal of
Public Health, 93(7), 1076-1078.
Yee. J. L., & Schulz, R. (2000). Gender differences in psychiatric
morbidity among family caregivers: A review and analysis.
The Gerontologist, 40(2), 147-164.
FURTHER READING
Abreau, J. M., Goodyear, R. K., Campos, A., & Newcomb, M. D.
(2000). Ethnic belonging and traditional masculinity ideology
among African Americans, European Americans, and Latinos.
Psychology of Men & Masculinity, 1,75-86.
Brothers, B. J. (Ed.). (2001). The abuse of men: Trauma begets
trauma. New York: The Haworth Press, Inc.
Curran, L. (2003). Social work and fathers: Child support and
fathering programs. Social Work, 48(2), 219-227.
Greif, G. L., & Bailey, C. (1990). Where are the fathers in social
work literature? Families in Society, 71,88-92.
Mansfield, A. K., Addis, M. E., & Courtenay, W. (2005).
Measurement of men's help seeking: Development and
evaluation of the Barriers to Help Seeking Scale. Psychology of
Men & Masculinity, 6(2), 95-108.
McCarthy, J., & Holliday, E. L. (2004). Help-seeking and
counseling within a traditional male gender role: An exam-
ination from a multicultural perspective. Journal of Counseling
& Development, 82, 25-30.
214 MEN: OvERVIEW
Moller-Leirnkuhler, A. M. (2002). Barriers to help-seeking by men:
A review of sociocultural and clinical literature with particular
reference to depression. Journal of Affective Disorders, 71, 1-9.
Murstein, B. I., & Fontaine, P. A. (1993). The public's knowledge
about psychologists and other mental health professionals.
American Psychologist, 48, 839-843.
Pleck,]. H. (1981). The myth of masculinity. Cambridge, MA:
MIT Press.
Rugel, R. P. (1997). Husband focused marital therapy: An approach
to dealing with marital distress. Springfield, IL: Charles C.
Thomas.
Scher, M., Stevens, M., Good, G., & Elchenfield, G. (Eds.). (1987).
Handbook of counseling and psychotherapy with men. Newbury
Park, CA: Sage.
Sommers, C. H. (2000). The war againSt boys. New York:
Touchstone.
SUGGESTED LINKS
American Psychological Association's Division 51: Society for the
Psychological Study of Men and Masculinity.
www.apa.org/divisions/divS1.html
American Men's Studies Association.
http://mensstwlies .org/
Concerned Black Men's National Organization.
http://www . cbmnational.org/
Department of Health and Human Services' (HHS) Web site on The
National Women's Health Information Center.
http://wwwAwoman.gov/mens/ devoted to men's health.
Gerontological Society of America's special interest group on "Men's
Issues".
ethompson@holycross.edu
International Society for Men's Health & Gender in Vienna, Austria.
www:ismh.org
Men's Health Initiative, Morehouse University's School of Medicine.
www.msm.edu/ncpc
Men's Health Network in the U.S.
www.menshealthnetwork.org
National Institutes of Health, Men's Health Issues section of Medline
Plus.
http://www . nlm. nih .gov/medlineplus/menshealthissues .html
National Institutes of Health, Men's Health Information.
http://health . nih .gov/ search .asp/2S
National Institute of Mental Health's initiative on men's depression.
http://menanddepression : nimh. nih .gov/default .asp
Office of Men's Health.
www.menshealthoffice.info , which advocates for the creation of such
an Office that "mirrors" the existing Office of Women's Health in
HHS.
U.S. Census Bureau.
WWW.census,gov, 2005, American Community Survey.
-JORDAN I. KOSBERG AND JAMES "IKE" ADAMS
HEALTH AND MENTAL HEALTH CARE
Introduction
Health care in general is a complex interplay among
biological, physiological, psychological and social sys-
tems. Men's health incorporates all of them in the context
of what maleness and manhood mean in the social setting
and to individuals within these set tings. Stereotypes
defining manliness historically shaped the environment
of men's health care. Over the past fifty years, social and
technological advances have led to reassessments of the
boundaries of masculinity and femininity and
consequently the issues of health for men and women.
Men's health issues and services have emerged as unique
areas of practice, not only due to biological imperatives
but also due to the social and psychological realities men
face. Professional social work practice with and for men's
health requires knowledge in these areas and the ability to
access and mobilize resources within and across systems.
Helping men to understand the factors that affect their
health, to develop interventions that maximize health and
to create systems that sustain health are all within the
repertoire of professional practice.
The Status of Men's Health
Health is more than the absence of disease; it is also the
ability to attain and maintain optimal functioning in
physical and mental capacities (variant of the World
Health Organization's Definition of Health). Assessing
optimal functioning requires both objective and sub-
jective measurements. Biological and physiological
markers are commonly employed to assess health status
and serve as proxies for well-being. A myriad of labora-
tory tests and diagnostic devices allow medical profes-
sionals to evaluate the conditio n of the human body. This
information is used to detect diseases or other anomalies
and to plot courses of intervention. The utility of these
diagnostic measures is irrefutable and social work
professionals should be familiar with the measures
associated with their areas of practice. These measures,
however, do not provide an objective defini tion of health
but rather point to the possible presence or absence of a
given pathogen or disorder. Therefore, social work
practice in health (and, in this context, s pecifically men's
health) must consider the subjective and social contexts
in which health is defined and manifest.
The 19th edition of the Encyclopedia of Social Work has
summarized health status for men (and women) in several key
indicators. It concludes that the basis for men's health
differentials was the result

of more risk factors with less health care. Additionally,
the lack of public attention to the need for a specific
agenda of men's health care and the stereorvpic views held
about men's health, all converged to create an
environment in which men are predisposed to poorer
health outcomes. Many of the circumstances noted then
still plague men's health care.
While advances in the biological sciences have greatly
informed our understanding of many diseases, this has not
resulted in uniform practices or outcomes in men's health
or well-being. Disparities in health outcomes between
men and women and within sectors of male populations
continue to underscore the need for more work in this
area.
Data from the National Center for Health Statistics
(Centers for Disease Cohtrol and Prevention, 2007) show
that 11 % of men over the age of 18 are in fair or poor
health compared to 13% of women in the same age group ,
yet men continue to die at a slightl y higher rate .than
females. The leading two causes of death for men and
women are heart disease and cancer. The third leading
cause for men is accidents, while for women it is stroke.
The similarities and differ ences underscore a pattern
emerging over the past 30 years, which has seen a
narrowing of the gender gap in life expectancies between
men and women, yet retention of many of the biological,
hormonal, and lifestyle factors that differentiate morbidity
and mortality outcomes along gender lines (Glaser, 2006 ).
For example, in 2004, men's ambulatory visits for office-
based physician care numbered 375.3 million, com pared
to 535.5 million for women. The persistent nature of these
disparities in health outcomes and uti lization practices
points to the continued need for gender specific
explorations and interventions (CDC, 2007).
Priority Areas: Men's Health
While women's health care has been frequently linked to
obstetrical and gynecological care, men's h~ alth has
lacked a similar focus. Lichtenberg (l995) points out in
the 19th edition of the Encyclopedia of Social Work that
men's health has been significantly shaped by evolving
definitions of maleness and masculinity. The same social
conditions that have resulted in increased attention to
women's control of their reproductive rights have not
produced the same "liberating" experiences for men.
Social work in men's health requires knowledge of the
significant health issues unique to men and the
psychosocial and cultural factors that influence health
service utilization and outcomes by men.
MEN: HEAL1H AND MENTAL HEALTH CARE
215
Cardiovascular disease: This includes a number of
diseases and syndromes associated with the heart and
systems carrying bodily fluids and nutrients to and away
from the heart and other vital organs of the body.
Commonly identified diseases associated with cardio-
vascular disorders include heart attack, hypertension and
stroke. Cardiovascular disease (CVD) is the num ber one
killer of men in the United States. Many life style and
hereditary factors have been associated with CVD,
including diet (especially th ose high in fats), lack of
exercise and stress (Widlansky, Sesso, Rexrode, Manson,
& Gaziano, 2004).
Prostate Cancer: Prostate cancer is among the most
treatable forms of cancer, yet the key to success, as with
many other cancers, is early detection and a ppropriate
intervention. Engaging men in regular prostate screen ings
has been difficult as many men are averse to the
(perceived or real) physical discomforts and social stig ma
of the digital exam. Blood screening techniques have
greatly enhanced providers' ability to detect ab normalities
indicative of prostatic cancer, and lessened the
apprehension of many potential patients. Even with
technological advances, critical barriers to improving
screening exist. Deibert et al. (2007) identified older age ,
poorer (English) language literacy and lower edu cational
level as critical factors associated with lower knowledge
of the disease.
" Obesity and diabetes: Diabetes Type II, also com-
monly called "adult on-set" (although it is not limited to
adults), is highly correlated with being overweight and, or,
obese. With approximately 70% of men over the age of 20
in the United States being overweight, diabetes is a
significant health concern for men (www.
cdc.gov/nchs/fastats/mens_health.htm). In addition to the
complications associated with obesity, diabetes ac counts
for many annual amputations of limbs, and is a significant
cause of blindness. Diabetes is unique among the diseases
that affect men and women in that it is both preventable
and treatable to a large extent through lifestyle changes
such as diet and exercise. Translating this information into
practice has proved to be significantly difficult. Diet and
exercise are among the many socially and culturally
linked practices that social workers must consider i n their
work with and assessment of diabetics and those at risk for
diabetes. Developing interventions that help men to assess
their dietary needs and practices and realistically assess
their exercise regimen would be areas to which social
work professionals could contribute.
Erectile Dysfunction: Maleness and manhood have
often been linked to sexual capabilities and stereotypes.
Inability to attain or maintain an erection has been the
216 MEN: HEALlli AND MENTAL HEALlli CARE
basis for social, emotional, and psychological distress
for many men. Emerging scientific evidence and
significant media attention have highlighted the
prevalence of erectile dysfunction (ED) and shed light
on the biological and physiological origins of the
dysfunction. In addition to the significant personal
andsocial stigma associated with ED, there is growing
evidence to suggest that it could be a warning sign for
cardiovascular disease and is possibly more common
among men with diabetes (Bauer, 2006; Parker-Pope,
2007; Shirl, Ansari, & Hassani, 2006).
Mental Health: The mental health needs of men are
as varied as the sources of mental distress. However,
among the most common complaints and concerns
associated with men's health are stress, anxiety, and
depression. Smith, Robertson and Houghton (2006 )
identified male socialization \ processes, the stigma of
needing help, and unawareness of or lack of interest in
counseling sessions as leading causes for men's avoid-
ance of mental health counseling. These fact ors are
arguably linked to male role socialization and cultural
influences. Being able to intervene with men on issues
of mental health and mental health counseling would
necessarily require the professional to understand these
facets of the man's worldview.
Alcohol and other drugs: Alcohol and other sub-
'Stance use vary significantly across the U.S. male
landscape. Social, cultural, and developmental factors,
along with mental health and hereditary determinants,
have all been shown to correlate to some degree with
substance use or abuse. The exact relationship is not
well understood and many contradictory findings have
been presented in the literature. Among the many
compelling hypotheses regarding male substance use
are those that suggest male privilege, negotiating the
emotional hazards of being male in contemporary so-
ciety and development factors, each contributing in
unique ways (Capraro, 2000).
Sexually transmitted infections (STI): Many cultu-
rally and stereo typically reinforced views of manhood
are defined by sexual prowess. The sexual capacity of
men has long been a source of mythical and sociological
importance. Infections and diseases associated with the
sexual activities of men (and women) have been high-
lighted over the past 25 years. In. large part, the HIV /
AIDS pandemic has provided the platform for this more
fluid discussion of human sexual expressions and dis-
eases. While HIV and AIDS are- significant health
threats, they are not the only, or the most common,
sexually transmitted infections. Syphilis, gonorrhea,
Chlamydia, and Human Papaloma Virus (HPV, which
causes genital warts and is linked to increased rates of
cervical and possibly rectal cancers) are all common
sexually transmitted diseases.
The etiologies of most of these infections have been
well documented, yet preventing them in the U.S.
cultural milieu has been difficult. The cultura l and value
driven discussions of sex and sexuality have greatly
influenced the ways in which prevention and treatment
of STl's have occurred.
Disparities among men: While many of the health
disorders discussed here affect all men, epidemio logical
evidence is clear that certain groups are overrepresented
in many areas. Latino, Black and African American
men (compared to White, non-Hispanic men) are
disproportionately represented in mortality/ and
morbidity outcomes in several key areas, including
HIV, AIDS, prostrate cancer, diabetes, and hyperten-
sion. Limited evidence exists to conclude that bio-
physiological differences between non-White and
White men account for significant disparities. More
plausible, and more evidenced in the recent studies are
links among poverty, discrimination, incarceration, and
racial segregation and negative health outcomes
(Adimora & Schoenbach, 2005). Such contributing
factors should focus our attentions on contextual inter-
ventions rather than focusing solely on individualistic
models of behavioral change.
Emerging areas: New and emergent areas for
prevention and intervention include eating disorders,
testicular cancer, rectal cancer and rectal screening, and
intimate partner violence. These areas present new
topics or new opportunities for social work to develop
capacities for service provision targeting men's health.
SOCIAL WORKER'S ROLES Men's health is not
simply a matter of gender roles or genital functioning.
In order for social workers to provide beneficial
services, professionals must be equipped to access,
mobilize, and utilize resources at multiple systems
levels. Information and knowledge are necessary
resources, but they will not produce the changes needed
to improve men's health. Interventions and services tha t
incorporate the social and cultural needs of men and
address the issues of a rapidly changing technology base
will have to be designed. Social work practice in the
area of men's health is not yet a well-defined area of
social work specialization, but the unique needs of men,
and the social milieu in which these needs are presented
warrant such an inclusion.
Informatics and other public domains - Social
workers' ability to reach clients in diverse settings is
important for developing intervention avenues.
Technologies have emerged that allow patients and
clients to access information as readily as providers.
Swift access to information does not assure accurate
information retrievalor utilization, so providers must be
familiar with

many information retrieval resources and technologies,
and be able to help clients evaluate the merits and benefits
of information being accessed on line.
Examples of useful men's health information links
include the following: www.malehealth.co.uk, www.
malehealthcenter.com, www.menshealthnetwork.org, and
many others.
Basch et al. (2006) have demonstrated a beneficial
outcome for colorectal screening among minority men
through the use of tailored telephone outreach. This and
similar technologies allow access to potential eli ents and
patients who might otherwise avoid h ealth care settings or
information sources.
Work place practices: Aoun and Johnson (2002) have
documented a significant increase in provider visits
among men engaged'in a workplace project aimed at
promoting health through diabetes education and
screening. Findings of this nature point to the potential
benefits of linking health promotion efforts to work
environments. By extension, including men's health care
in other institutional settings (that is, schools) might also
provide an important conduit by whic h men could access
information and services specific to their health care
needs.
Policy level interventions: Health care utilization is
arguably an individual behavioral activity; however,
many social factors influence the actual ability for one to
choose freely (for example, income, literacy, etc). The
high cost of health care in the United States makes access
to services a privilege unattainable to many men and
women, especially those of color. Social work inter-
ventions in the service of men's health would necessa rily
include policy interventions that seek to mitigate the
effects of income and social inequities. Having uni versal
health care as a guaranteed right is one solution that has
faced many obstacles in U.S. policy arenas. Until health is
a guaranteed right for all in the United States, social work
professionals must work with in local and national
decision-making arenas to assure that vulnerable groups,
including men, have access to needed medical and
pharmacological resources.
Social justice agenda: Social work has a historical link
to issues of social equity and social justice. Practi cing in
the area of men's health is another opportunity for social
work to demonstrate its commitment to equi table practice
and service delivery. The roles of s ocial discrimination,
social injustice, inequalities in income and access to
services, all play critical roles in men's health outcomes.
REFERENCES
Adimora, A A, & Schoenbach, V. J. (2005). Social context,
sexual networks, and racial disparities in rates of sexually
MEN: PRAcncE INTERVENTIONS 217
transmitted infections. Journal of Infectious Diseases, 191,
Sl15-S122.
Aoun, S., & Johnson, L. (2002). Men's health promotion by
general practitioners in a workplace setting. Australian
Journal of Rural Health, 10(6),268-272.
Basch, C. E., Wolf, R. L., Brouse, C. H., Shmukler, C.,
Neugut, A, DeCarlo, L. T., et al. (2006). Telephone
outreach to increase colorectal cancer screening in an urban
minority population. American Journal of Public Health,
96(12), 2246--2253.
Bauer, J. (2006). Erectile dysfunction can signal impending
heart disease. RN, 69(5).
Capraro, R. L. (2000). Why college men drink: Alcohol,
adventure, and the paradox of masculinity. Journal of
American College Health, 48(6), 307-315.
Centers for Disease Control and Prevention (CDC). (2007).
National Center for Health Statistics. Men's health. www.
cdc.govfnchsffastatsfmens_health.htm.
Deibert, C. M., Maliski, S., Kwan, L., Fink, A, Connor, S.
E., & Litwin, M. S. (2007). Prostate cancer knowledge
among low income minority men. The Journal of Urology,
177(5), 1851-1855.
Parker-Pope, T. (2007). A surprising risk factor for heart dis-
ease in men. WaU Street}ournal (Eastern Edition), 249(41).
Shiri, R., Ansari, M., & Hassani, K. F. (2006). Association
between comorbidity and erectile dysfunction in patients
with diabetes. International Journal of Impotence Research,
18(4),348-353.
Smith, J. M., Robertson, S., & Houghton, B. (2006). Phys-
ician's views on men's mental health and the role of coun-
selling services-a pilot study. Counselling & Psychotherapy
Research, 6(4), 258-263.
Widlansky, M. E., Sesso, H. D., Rexrode, K. M., Manson, J.
E., & Gaziano, J. M. (2004). Body mass index and total and
cardiovascular mortality in men with a history of car-
diovascular disease. Archives of 1nternal Medicine, 164(21),
2326--2332.
-DARRELL P. WHEELER
PRACTICE INTERVENTIONS
ABSTRACT: A consistent theme for the majority of
men in the United States remains the code of man-
hood. Men are expected by society to be stoic in the
face of danger and to play out, in all aspects of life,
the idea of the rugged individual going it alone, even
in the face of a quickly changing world. While social
work theorists and practitioners talk about male
aggression, sexuality, intimacy, depression, anxiety,
addiction, ageing, and work-related concerns, most
men are less likely to view these as problems. If they
do enter into counseling or treatment, they are less
likely to remain for any length of time. Faced with
these issues, practitioners are challenged to find ways
of engaging men, and forming successful
collaboration and mean' ingful outcomes.
218 MEN: PRAcrICE INTERVENTIONS
KEY WORDS: men; masculinity; social construction;
gender diversity
Manliness and the Unlikelihood of Seeking Help The
traditional code of masculinity is a primary reason why
most men do not 'seek help or fail to remain in counseling.
Brooks (1998) describes men's view of the therapist's
office as not a "place of understanding and compassion,
[but] a place to experience hostile rejec tion, shame, and
alienation" (p. xii ). Good, Dell, and Mintz (1989) found
that men's conception of what it means to be a "man" was
strongly correlated with their reluctance to engage in
clinical services. The more stoic and self- reliant, the less
likely men are to seek counseling. Addis and Mahalik
(2003) found that the majority of men involved in some
form of clinical treatment had been mandated or coerced
into attending counseling sessions.
Men's attitudes and the process of most clinical
practices converge to discourage men from reaching out for
assistance. For the most part, traditional models of clinical
social work practice require the client to take a passive
position in relationship to the worker. That is, the clinical
practitioner takes the position of expert and expects the
"clients" to talk openly and intimately' about their life,
including their past, and to share their "feelings." Not
participating in this way is interpreted as being "resistant"
or "not ready" for treatment. The traditional models of
practice requiring self-revealing talk and openness have
been viewed by Heesacker and Prichard (1992) as a
"feminine" style of relating that does not recognize that
men rarely participate in this type of conversation with
others, including their spouse. Given that "traditional"
male values require men to adhere to the code that "real
men" deny vulnerability; are occupied with work, status,
control, and achievement; are required to be forceful,
aggressive, and to reject femininity; it is without question
that typical forms of counseling would not fit these
expectations (Brooks, 1998; Doyle, 1995).
Obviously, there are degrees of adherence to these
codes of masculinity. With most men, there is some level
of tension between the code of interpersonal control and
dominance and the requirements of entering into a
traditional counseling situation. To be seen as not
competent or to be seen as vulnerable is a precar ious
position for most men. Entering into a client role and
"needing help" is not a comfortable position. Many men
either refuse to consider counseling or once involved
attempt to maintain some form of control and competency.
If this is challenged in any way, the "help" is interpreted as
a threat and demeaning. The man
himself is supposed to be the problem solver and the one
who fixes what is broken. These few examples of the
complexity of the issue facing practitioners when
attempting to work with men are daunting and uncom-
fortable for both the man and the practitioner. Brooks
(1998) considers this description to be similar to other
recognized diversity issues needing attention in prac tice.
He states that "to some extent, psychotherapy with
traditional men is always a form of cross-cultural coun-
seling" (Brooks, 1998, p.65). The focus then shifts to how
to alter the traditional structure and process of counseling
to better match the life experiences of men.
Gender Sensitive Practice
Allan and Gordon (1990) note that it is important for
practitioners to be "gender-sensitive and aware of their
own biases if they are to work with men successfully" (p.
132). This sounds strange when we consider the issues of
women and race as prominent issues that have been the
focus of diversity in practice. Men are not considered a
"diversity" issue given that they are not oppressed within
society as are other groups. Yet, men have a very unique
set of standards they must learn, meet and maintain to be a
"man" in American society. This unique set of standards or
codes is usually viewed and described from the
perspective of those who take the brunt, at times, of men's
insensitivity, stoicism, anger, control, and unavailability.
The result is viewing men in negative ways without
realizing that these actions have a cost for the man as well
as others. Men must maintain this code or feel ashamed,
either in their own eyes or in the eyes of others, both men
and women.
Gender identity is socially constructed. Masculinity
and femininity are socially created definitions that are
continually being invented through language within a
culture. Our ideas of what is masculine and feminine
emerge from how a culture continually creates meaning
about people and activities. Thus what it means to be a
man or woman is not found in nature but is socially created
(Gergen, 1999). Men's socially constructed identity is
supported and imposed by a society that still demands that
men be men in particular ways. Men who are very
different are often seen as "wimps" and weaklings. Many
older men, if asked, will remember that on the back of
comic books many years ago, there was always an
advertisement that centered around a weak ling getting
pushed around on the beach and his girl taken away by the
stronger man. Then, with the help of the Charles Atlas
muscle building program, he returns to knock out the guy
and get b~ck the girl. The girl looks very proud to be with
him, too. Men do not just walk away from this s ocially
constructed identity. Most do not realize that it is socially
constructed and

supported. It just feels "right" and the way men
"should" be in this world.
Male-Oriented Approaches to Practice Various
authors and practitioners have described models of
practice with men. Brooks (1998) suggests an
approach that encourages gender awareness and
involvement with other men in groups. It is a tradi-
tional approach that looks into assumed gender
specific "psychic pain" caused by the repression of
fear and rage according to the code. Levant (1990)
focused on practice with men, based on men learning
new social skills. Allan and Gordon (1990) focused on
psychoeducational techniques that taught men about
the problems created in their life by living according
to the male code.
The primary focus of most traditional interventions
is on addressing the consequences of the "male code" or
gender role analysis on men's relationships and their
own sense of worth and value (Englar-Carlson, 2006;
I
Merhrn- & Pasick, 1990). They follow the feminist,
gender-focused interventions proposed for women,
where the social construction of femininity is often
challenged as a central part of treatment. O'Neil (2006)
uses in his practice with men the basic assumption that
"men usually need to understand how their family of
origin, their gender role socialization, and any gender
role traumas have affected their growth. and problem
solving" (p. 260). For men, the impact of the "code" of
masculinity on a man's position in terms of
relationships, as husband, father, and friend, and in
terms of age-related changes from youth to elderly, and
in terms of occupational success in life, are potential
targets of intervention. This approach applies to a wide
range of diverse groups of men. While there are unique
and compelling differences as a result of diver, sity and
marginalization of many men not a part of the white
heterosexual dominant group, the idea of dissect ing the
code has been viewed as an essential part of
intervention. Men who are members of marginalized
and oppressed groups require dissecting oppression and
the trauma experienced as a result.
Variation in Masculinities
Diversity exists for men in many forms: socioeco-
nomics, race, ability, religion, age, geography, educa-
tion, and sexual preference. Most male-focused
research has been with middle-class white males. There
is obviously a different experience between a white coal
miner in Appalachia and a black taxi driver in Queens,
New York. Even though all are affected by a code of
masculinity, the manner in which this has been con-
veyed and demonstrated is varied, as are issues of
MEN: PRAcncE INTERVENTIONS 219
oppression and racism (Levant, Majors, & Kelly, 1998).
Little is understood about how diverse groups manage
the expectations of "masculinity" in their specific
culture (Liu, 2002). It is important that practitioners
recognize the potential variations in the code of
masculinity and how this is expressed by a particular
client within particular diverse contexts.
Franklin (1999) described the experience of African
American men in terms of invisibility. He described the
African American man as encountering racism that
undermines his very sense of self and worth as a person
and as a man. Each particular man is acted upon by the
general society as if invisible is a viable being. Rasheed
and Rasheed (1999) stated that what is needed is "a
wider set of lenses for practice strategies that use
schema that encompass the realities of African
American men. These new lenses also need to be able to
search for the strengths and positive attributes of Black
men" (p. 6). They call for a dialogical or collaborative
relationship during intervention. They suggest a
collegial relationship where the client becomes a
"partner with the practitioner .in exploring different and
more empowering ways of being and ways of being
masculine" (p. 56). The focus of intervention is the
development of a new personal narrative that recog-
nizes not only the personal but also the sociopolitical
context of oppression and racism and its impact on the
individual African American male's own personal story.
The intention is to rewrite this personal narrative
outside the dominant narrative that contains the de-
grading and demeaning attitudes of the racism. This
calls for practitioners to be conversant in critical con-
structivist theory (Sexton & Griffin, 1997; Witkin,
1995) and narrative theory (White & Epston, 1990).
Latino men represent a wide range of cultures shar-
ing a common language. Latino men are identified with
the word "machismo," which comes from "macho," the
Spanish word for man, and connotes an exaggerated
presentation of power and strength associated with
being a "man" in our society, as well as domination and
providing for the family. Pleck, Sonenstein, and Ku
(1993) and Torres, Solberg, and Carlstrom (2002),
however, found that there is diversity within Latino
men in there expression of masculinity; generalized
assigning of "machismo" attitudes to Latino men is not
appropriate. Lum (2007) does not mention the idea of
"machismo" in the third edition of Culturally Com,
petent Practice with Latino families. Liu (2002) found
that 'Asian' (representing various groups) expressed the
traditional code of masculinity. For both Latino and
Asian men, the issue is the degree of inclusion in
society and the impact of oppression that needs to be
recognized and addressed by the practitioner.
220 MEN: PRACTICE INTERVENTIONS
. Duran and Duran (1995) relate the failure of wes-
tern-based therapies applied to First Nations Peoples.
They suggest that First Nations Peoples identify with the
land or region in which they live. The authors assert that
these individuals have a "profound sense of
intergenerational grief about the historical past [and] that
these feelings of unexpressed rage, grief, and dis trust are
... expressed in symptoms" (Duran & Duran, 1995, p. O.
For these reasons, as well as oppression and
discrimination, traditional therapies often do not work.
For example, alcohol "is sometimes personified by
Indians as a spirit entity with its own consciousness, and
the patient may converse with the spirit to avoid or escape
its influence ... this conversational effort [discouraged as
an hallucination by traditional thera pists] is therapeutic
for Indians" (Duran & Duran, 1995, p. 2). These
significant issues must be understood b y practitioners if
any effort is to be successful with men from First Nations
Peoples.
Gay men are another group who live in the shadow of
heterosexual masculinity, even though most adhere to the
same ideas as heterosexual men except for sexual
preference (Haldeman, 2005, 2006). Even though the
stereotype of the gay male is one of flamboyant
femininity, most often gay men are socialized as are
heterosexual males with the same code of masculinity. For
gay men, this can be a particularly difficult challenge as
they are growing up and with intimate same sex
relationships.
The unique experiences of growing up gay in a
heterosexual and homophobic world where men are
required to hide their identity become a focus of inter-
ventions. Importantly, as with other di verse groups,
personal experiences of oppression and trauma must be
appreciated and addressed in the intervention. The manner
in which most oppressed groups are invisible to the
dominant groups becomes an issue in itself. Haldeman
(2006) describes the media "mainstreaming gays" as an
issue for some in that it "threatens our uniqueness,
jeopardizes the individuality that we so cherish, and
invites dangerous backlash" (p. 307). Some issues, like
coming out, are unique to younger gay teens and older gay
men who can feel rejection by younger men.
Heterophobia is an issue facing some gay men. As a result
of early and continuous trauma and invisibility from the
heterosexual community, gay men often be come fearful
of being with or around heterosexual men and this must be
addressed (Haldeman, 2006).
Challenging the Male Deficit Approaches
The basic premise of traditional male-oriented ap proaches
described briefly, even with the approaches addressing
diverse groups of men, is traditional in that
men are seen as damaged and misguided by their socia-
lization into the code of masculinity. The intervention
becomes a process of confronting men with their deficits,
the mythology of the masculinity code, in order to help
them change their behavior.
Lee, Sebold, and Uken (2003) have demonstrated an
alternative strengths-based and solution- focused approach
that engages the unresponsive and defen sive male client.
Working with men in domestic violence situations, they
focus on men becoming responsible for the solution rather
than responsible for the problem. Rather than focusing on
individual pathology or the code of masculinity, treatment
focuses on what the client can do differently. Lee et a1 .
(2003) state that "by not focusing on participants '
responsibility for problems and deficits, we are able to
direct all therapeutic energy toward supporting
participants' responsibility for building solutions" (p. 13 ).
If men in general are avoiding being seen as incompetent
and vulnerable, confrontation and fo cusing on what they
are doing wrong or badly is not conducive to retaining the
men's participation in treatment. Giving men the
responsible position of finding a solution to domestic
violence relies on their capacity to solve problems and is
one of the values of the code. It is a matter of working with
the man's code as a potential strength rather than working
against the code and attempting to change it. The research
results have demonstrated very low recid ivism rates and
high levels of completion of the program (Lee et al.,
2003).
Conclusion
The code of masculinity needs to be understood, as does
every manner of diversity in social work practice.
Practitioners need to appreciate that the code of mas-
culinity prevents many men from seeking assistance and
from remaining in a situation that is a threat to their
masculine esteem. Finding ways to acknowledge these
values is important to initiating and sustaining
interventions. The code of masculinity is the center piece
of treatment in many traditional models of practice with
men. It is assumed that the code of mas culinity is one of
the causes of the problem and must therefore be addressed
for the treatment to succeed. An alternative approach uses
men's strengths and possibilities by actually engaging
men's masculinity code that designates them as problem
solvers and action oriented. The strengths and
solution-focused perspective provides such an alternative
approach. The oppression experienced by men of diverse
and marginalized populations is also recogniz ed as a
significant element of working with these particular men
and needs to be understood by social workers.

REFERENCES
Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the
context of help-seeking. American Psychologist, 58, 5-14.
Allan, J. A, & Gordon, S. (1990). Creating a framework for
change. In R. L. Meth & R. S. Pasick (Eds.), Men in therapy:
The challenge of change (pp. 131-151). New York: Guilford
Press.
Brooks, G. R. (1998). A new psychotherapy fOT traditional men.
San Francisco, CA: [ossey-Bass.
Doyle, J. A (1995) The male experience (3rd ed.). Dubuque, IA:
W.C. Brown.
Duran, E. E., & Duran, B. (1995). Native American postcolonial
psychology. Albany, NY: State University of New York
(SUNY) Press, Reviewed in Journal of Third World Studies,
LookSmart. Retrieved December 17, 2006 from http://www.
findarticles.com/p/articles/mi_qa3821'/is_200210/ai_n9115
936/print. \ ends. New York: Norton.
Englar-Carlson, M. (2006). Masculine norms and the therapy
process. In M. Englar-Carlson & M. A Stevens (Eds.), In the
room with men: A casebook of therapeutic change.
Washington,.DC: American Psychological Association.
Franklin, A J. (1999). Invisibility syndrome and racial identity
development in psychotherapy and counseling African
American men. The Counseling Psychologist, 27, 761-793.
Gergen, K. J. (1999). An invitation to social construction. Thousand
Oaks, CA: Sage.
Good, G. E., Dell, D. M., & Mintz, L. B. (1989). Male role and
gender role conflict: Relations to help seeking in men. Journal
of Counseling Psychology, 36, 295-300.
Haldeman, D. C. (2005). Psychotherapy with gay and bisexual
men. In G. E. Good & G. R. Brooks (Eds.), The new handbook of
psychotherapy and counseling with men (pp. 369-383). San
Francisco, CA: jessey-Bass.
Haldeman, D. C. (2006). Queer eye on the straight guy: A case of
gay male heterophobia. In M. Englar-Carlson & M. A Stevens
(Eds.), In·the room with men: A casebook of therapeutic change.
Washington, DC: American Psychological Association.
Heesacker, M., & Prichard, S. (1992). In a different voice,
revisited: Men, women, and emotion. Journal of Mental Health
Counseling, 14,274-290.
Lee, M. Y., Sebold, J., & Uken, A. (2003). Solution-focused
treatment of domestic violence offenders. New York: Guilford
Press.
Levant, R. E (1990). Psychoeducational services designed for
men: A psychoeducational approach. Psychotherapy, 27,
309-315.
Levant, R. E, Majors, R. G., & Kelly, M. L. (1998). Masculinity
ideology among African American and European American
women and men in different regions of the United States.
Cultural Diversity and Mental Health, 4, 227-236.
Liu, W. M. (2002). Exploring lives of Asian American men:
Racial identity, male role norms, gender role conflict, and
prejudicial attitudes. Psychology 'of Men and Masculinity, 3,
107-118.
Lum, D. (2007). Culturally competent practice (3rd ed.).
Belmont, CA: Thomson.
MENTAL HEALTH: OvERVIEW 221
Methm,R. L., & Pasick, R. L. (Eds.). (1990). Men in therapy:
The chaUenge of change. New York: Guilford Press.
Pleck,J. H., Sonenstein, E L., & Ku, L. C. (1993). Masculinity
ideology and its correlates. In S. Oskamp & M. Constanzo
(Eds.), Gender issues in social psychology (pp. 85-110). New-
bury Park, CA: Sage.
Rasheed, J. M., & Rasheed, M. N. (1999). Social work practice with
African American men: The invisible presence. Thousand Oaks,
CA: Sage.
Sexton, T. L., & Griffin, B. L. (Eds.). (1997). Constructivist
thinking in counseling practice, research, and training. New Y
ork: Teachers College Press.
Torres, J. B., Solberg, S. H., & Carlstrom, A H. (2002). The myth
of sameness among Latino men and their machismo.
American Journal of Orthopsychiatry, 72, 163-181.
White, M., & Epston, D. (1990). Narrative means w therapeutic
Witkin, L. (1995). Family Social work: A critical constructionist
perspective. Journal of Family Social WOTk, 1, 33-45.
FURTIIER READING
Archetti, E. P. (1999). Masculinities: Football, polo and the tango in
Argentina. Oxford: Berg.
Buchbinder, D. (1994). Masculinities and identities. Melbourne:
Melbourne University Press.
Chemin, J. N., & Johnson, M. R. (2003). Affirmative psychotherapy
and counseling fOT lesbians and gay men. Thousand Oaks, CA:
Sage.
Connell, R. W. (1995). Masculinities. Cambridge, UK: Polity. De
[ong, P., & Berg, I. K. (2002). InterviewingfOT solutions (Znd
ed.). Pacific Grove, CA: Brooks/Cole. .
Englar-Carlson, M., & Stevens, M. A (Eds.). (2006). In the room
with men: A casebook for therapeutic change. Washington, DC:
American Psychological Association.
Good, G. E., & Brooks, G. R. (Eds.). (2005). The new handbook of
psychotherapy and counseling with men. San Francisco, CA:
Wiley.
Saleebey, D. (Ed.). (2006). The strengths perspective in social wOTk
practice (4th ed.). Boston: Allyn & Bacon.
-ROBERT BLUNDO
MENTAL HEALTH. [This entry contains two suben-
tries: Overview; Practice Interventions.]
OVERVIEW
ABSTRACT: Mental illnesses are very common; more than
one-quarter of people will develop a mental illness during
their lifetime. Mental illnesses are associated with substantial
disability in work, relationships, and physical health, and have
been clearly established as one of the leading causes of
disability in the developing, as well as the industrialized
world. Mental disorders are common in every service sector
important to social workers, and affect outcomes in every
service sector.
 222 MENTAL HEALTH: OVERVIEW
Mental disorders are strongly associated with poverty
worldwide, and are common and often unrecognized in the
general health sector, child welfare, and criminal justice
settings, among others. Basic information about mental
health is thus important to all social workers. Information
about classification systems and major categories of mental
illnesses, including depression, anxiety, psychotic
disorders, and substance abuse disorders,
v is presented. The service system for
mental disorders is badly
underdeveloped, and most people
who need treat- . ment do not
receive it. There is an increasing
body of" evidence demonstrating
effective treatments, and policy is
moving toward requiring that
treatments offered be evidence
based.
KEY WORDS: This is health;
mental a period ofrecovery
disability; a great model;
explosion of knowledge
evidence-based practices about
mental health, and we can expect
Rare is the family that will be free from an encounter
considerable advances in th~
with mental disorders. Gro Harlem Brundtland, Dir-
coming years.
ector General of the World Health Organization
(1998-2003 )
Mental Illnesses Are Common
and Are Very Disabling
Mental illnesses are very common. More than 25% of
people will develop one or more mental disorders during
their lifetime (Almeida-Filho et al., 1997; Andrews, Peters,
Guzman, & Bird, 2001; Fichter et al., 1996; Kessler et al.,
1994; World Health Organization, 2001a). This is true in
the developing world, as well as nations with postindustrial
economies; indeed, recent estimates suggest that
depression is more common in developing nations with
high levels of social adversity (BhagwanjeevParekh,
Paruk, Petersen, & Subedar, 1998; Cheng & Hsu, 1992;
Hollifield, Katon, & Morojele, 1994; Husain, Chaudhry,
Afridi, Tomenson, & Creed, 2007; Scholte et al., 2004;
Vinck, Pham, Stover, & Weinstein, 2007; WHO World
Mental Health Survey Consortium, 2004).
Not only are mental disorders very common, they also
greatly affect the people who experience them. Mental
illness is among the leading causes of disability in the
industrialized world; within some populations, such as 15
to 44-year-olds, mental disorders rank first among all
illnesses in causes of disability (Murray & Lopez, 1996;
President's New Freedom Commission on Mental Health,
2003; Ustun, Ayuso-Mateos, Chatterji, Mathers, &
Murray, 2004). Depression is expected to be the leading
cause of disability worldwide by 2020
(World Health Organization and World Bank, 1996). The
absolute burden of mental illness is similar in the
developing and the industrialized world; in the developing
world the overall burden of mental illness is propor-
tionately lower only because of the comparatively high
burden of infectious diseases (World Health Organization,
2001). Mental illnesses cause disability across a wide
variety of domains, and, as described below, affect
vocational, social, and physical functioning.
DISABiLITIES IN WORK AND SOCIAL
FUNCTIONING People with mental illnesses are less
likely to be employed, and are more likely to miss work.
Eighty percent of people with schizophrenia do not return
to the workforce after their diagnosis (Anthony & Jansen,
1984; Marwaha & Johnson, 2004; Mechanic, Bilder, &
McAlpine, 2002). Mood and anxiety disorders are
considered to be among the most costly disorders for
employers, as they are associated with many lost work
days as well as reduced performance at work (Druss,
Rosenheck, & Sledge, 2000; Stewart, Ricci, Chee, Hahn,
& Morganstein, 2003). People with psychotic disorders
report serious disruptions in their social networks, and
often have a limited social safety net (Mueser &Tarrier,
1998; Robinson, Woerner, McMenirnan, Mendelowitz, &
Bilder, 2004). Mood and anxiety disorders are often
accompanied by serious disruptions in close relationships,
and relationship problems are considered by some theorists
to be elemental in the cause and maintenance of these
disorders (Hirschfeld et al., 2000; Judd et al., 2000;
Klerman, Weissman, Rounsaville, & Chvron, 1984;
Sullivan, 1953, 1956).
HEALTH-RELATED DISABILITIES People with mental
illnesses are substantially more likely to have chronic and
debilitating physical illnesses. Effects of mental illness on
length oflife are especially well documented for people
with schizophrenia, whose life expectancies are 20%
shorter than for those without schizophrenia (Newman &
Bland, 1991). Mood and anxiety disorders are associated
with higher rates of coronary artery disease, diabetes,
hypertension, and even arthritis (Barth, Schumacher, &
Herrmann-Lingen; 2004; Glassman & Shapiro, 1998;
Katon, Lin, & Kroenke, 2007; Marder et al., 2004;
Newman & Bland, 1991). Mental illness negatively affects
management of these illnesses, as well as their
development (for example, Kronish et al., 2006). There is
strong preliminary evidence that psychosocial factors
associated with mental disorders, such as stress and
negative life events, contribute directly to the underlying
physiological processes that cause both acute and chronic
diseases (Cohen et al., 1998; Cohen, Tyrrell, & Smith,
1991;

Kiecolt-Glazer, McGuire, Robles, & Glaser, 2002;
Schiepers, Wichers, & Maes, 2005) ..
CONCLUSION Mental disorders occur so frequently, and
are the source of so much disability, that all social workers
need to be concerned with them.
Mental Illnesses Affect Every
Service Sector Important to Social Workers Social
work is one of the largest mental health professions
(Gibelman & Schervish, 1995; Robiner, 2006), and many
social workers work in mental health settings. However,
social workers in every service sector will encounter people
with mental illnesses, and the course and outcome of
services across these sectors can be greatly affected by
mental illness. Some examples are described in the
following sections.
MENTAL ILLNESS AND POVERTY Lower incomes are
associated with mental illness worldwide (Gresenz, Sturm,
& Tang, 2001; Institute of Medicine, 2001a, 2001b ;
Mangalore, Knapp, & Jenkins, 2007). It is likely that
effects are reciprocal; having a serious mental ill ness is
known to affect the ability to work and is very likely to
cause downward social mobility, in addition, the
substantial stresses associated with poverty are likely
culprits in causing or exacerbating mental illness. Workers
in any part of the social welfare system are likely to work
directly with people whose life situations are complicated
by mental illness, and mental ill ness may negatively affect
the success of the services received. For example, poor
maternal mental health is associated with greater need for
income supports (Romero, Chavkin, Wise, Smith, & Wood,
2002), as well poorer employment outcomes (Horwitz &
Kerker, 2001). Social workers have a special role to play in
providing needed advocacy; recent accounts have
suggested that lowincome people are vulnerable to labor
exploitation that could be a cause of depression (Francoeur,
Copley, & Miller, 1997; Lipscomb et al., 2007).
MENTAL ILLNESS AND THE GENERAL MEDICAL
SECTOR Social workers in the medical sector will fre-
quently encounter people with mental illnesses. People
hospitalized with major medical conditions often have
mental illnesses, and when they do, they are not always
recognized or appropriately treated. The presence of a
mental disorder can greatly affect treatment outcome for
chronic physical disorders (Katon et al., 2007; Proctor et
al., 2003). Depression is one of the most common problems
seen by primary care doctors, with 5-10% of all visits to
primary care doctors being depression related (Brody et al.,
1995; Kessler. Cleary, & Burke, 1985;
MENTAL HEALTH: OvERVIEW
223
Schulberg, Saul, & McClelland, 1985). People with
depression and anxiety are more likely to go to their
primary care doctor than to a mental health specialist
(Wang et al., 2006), and symptom severity is similar to that
of people who present for care in the specialty mental
health sector (Gaynes et al., 2007). Service models that
integrate care for depression along with primary care are
still underutilized, and social workers play an important
role in integrated care settings.
MENT AL ILLNESS AND THE CRIMINAL J USTlCE
SYSTEM Prevalence of mental illness in prisons is high
worldwide (World Health Organization and Interna tional
Committee of the Red Cross, n.d.). In the United States,
between 6% and 15% of people in jails and prisons are
severely. mentally ill, and this number has increased
rapidly in recent years. It is believed that loss of psychiatric
inpatient beds, coupled with inadequate community
supports and lack of access to treatment, has contributed to
the "criminalization" of mental illness (Lamb, Weinb erger,
& Gross, 2004). Mental health courts and jail diversion
programs, which specialize in identifying people with
mental illness and providing appropriate treatment options,
are gaining popularity and are showing promising results
(Moore & Hiday, 2006; Steadman & Naples, 2005).
Intensive, team-based treatment models for people with
chronic mental illnesses can also be helpful (Lurigio &
Fallon, 2007). For these programs to be successful, law
enforcement and legal personnel must have adequate
mental health knowledge. Social workers are again in a
unique position to bridge service sectors and advocate for
human rights in this important and growing problem area.
MENTAL ILLNESS AND CHILD WELFARE Mental
illness is very common, and often unrecognized, in fa milies
that are referred for child protective services (Burnes et al.,
2004; Clausen, Landsverk, Ganger, Chadwick, &
Litrownik, 1998), and recent studies show that identifying
and addressing mental health issues improves children's
outcomes (Glisson & Green, 2006). Substance use is a very
common cause of the need for child protective services
(Barth, Gibbons, & Shenyang, 2006; Forrester & Harwin,
2006; Semidei, Feig-Radel, & Nolan, 2001), and is highly
comorbid with other mental illnesses. Basic understan ding
of mental health issues is urgent for social workers who
work in this profession.
CONCLUSION The high prevalence of mental illness
across service sectors crucial to social work underscores
the importance of basic information about mental health for
all social workers.
224 MENTAL HEALTH: OVERVIEW
What Are Mental Illnesses?
The Medical Model and Its Critics
Great strides have been made in characterizing mental
illness and in developing treatments that alleviate
symptoms, and in recent decades, the pace of progress has
accelerated. Nonetheless, we do not currently know the
cause of any mental illness. The absence of defini tive
information leaves open questions about the basic nature of
mental illness.
THE MEDICAL MODEL The medical model has been the
dominant framework for understanding mental illness for a
number of years, and has provided the conceptual
framework that undergirds many recent knowledge
advances (Mowbray & Holter, 2002). The medical model
holds that m~ntal disorders are physical illnesses
originating in the brain, which in tum affect behavior,
emotions, and functioning. The basic framework of the
medical model is supported by a substantial body of
research that clearly demonstrates neurologic al involvement
in mental illnesses. Pharmacological agents that act on
neurotransmitter systems have well- . proven effectiveness
for reducing symptoms of major medical disorders, and
brain imaging studies are begin ning to document consistent
differences in the neuroanatomy and brain functioning of
people with and without mental disorders.
It is abundantly clear that mental illness is not only
physiological,but is affected by social, contextual, and
cultural factors, and the medical model is more properl y
termed the "biopsychosocial mode1." Recent work has
emphasized integrative neurophysiology, which ac-
knowledges the connections between the mind and the
body, and a general recognition that treating the mind and
the body as separate is unproductive, a no tion that has
characterized much western thought since Descartes, . and
is unlikely to help us continue to ad vance our knowledge in
this field (Mental Health: A report of the Surgeon General,
1999; World Health Organization, 200l).
Movement toward a more integrative approach has
been driven in part by influential commentary on the
shortcomings of the medical mode1. These are of di verse
origins, and some are briefly reviewed in the following
sections.
THE ANTIPSYCHlATRY MOVEMENT The 1960s and
1970s saw the rise of an influential group of critiques who
directly criticized psychiatry and the medical model.
Thomas Szasz and RD Laing are among the best- known
authors associated with arguments that mental illness is a
label applied by society to suppress noncon formity to
societal values (Laing, 1960; Szasz, 1960). Ken Kesey's
1962 novel One Flew Over the Cuckoo's Nest is a compelling
fictionalized account of the misuse of the men tal health
system to suppress challenges to authority. In a related
vein, in the influential feminist work Women and Madness,
Phyllis Chesler (1972) argued that mental health
professionals pathologized women's reasonable responses
to the constraints of female social roles, and that this served
primarily to maintain a male-domin ated power structure.
Serious problems with institution alized inpatient care for
people with severe mental disorders were also subjected to
scrutiny. The influential sociologist Er ving Goffman wrote
eloquently about the dehumanizing effects of institutional
treatment (Goffman, 1961, 1963), and these effects which
were powerfully documented in Frederick Wiseman's film
Tiuicui Follies (1967).
The more radical elements of the antipsyc hiatry
movement continue to reject the disease model of mental
illness (for example, Szasz, 1997). However, the
antipsychiatry movement may be best understood as a
series of powerful and influential critiques of both real and
possible misuses of the way th e mental health system cares
for vulnerable members of the society. These critiques
ultimately strengthened advocacy ef forts that have
advanced the field, and have real pro mise to improve care
for people with mental illnesses.
THE RECOVERY MOVEMENT The medical model has
also been, and continues to be, criticized for its poten tial to
create a mechanistic emphasis on symptoms and the
physical, and a concomitant neglect of the broader human
needs of the people experiencing mental illness.
"Recovery" can be seen as a broad orientation to mental
health and mental health services that stresses opti mism,
personal empowerment, and a deep commitment to
accepting people for who they are. The recovery movement
gathered momentum when evidence became available that
the diagnosis of a chronic mental disorder was not a life
sentence to ever-worsening func tioning, but that for many
people symptoms remitted, and work and social lives were
restored in meaningful ways (Harding, Strauss, & Zubin,
1992). These findings were buttressed by influential
personal accounts of recovery from mental illness (for
example, Deegan, 1988). Groundbreaking work in
rehabilitation strategies for people with severe mental
illnesses also made important contributions (Anthony,
1993). Grassroots consumer and family organizations, such
as the influential National Association for the Mentally III
(NAMI), have embraced the recovery philosophy.
Although some observers are pessimistic about the
compatibility of a recovery orientation and the medic al
model (Carpenter, 2002), others have begun to note that

empowerment and recovery can work hand in hand with
traditional medical treatment and a disease frame work
(Prince & Segal, 2005).
CONCLUSION There is reason to be optimistic that new
approaches will more fully integrate care for the person
along with the symptoms, and more fully embrace the
philosophy that a holistic approach to the person is the best
method to advance care. Social work is a natural meeting
place of these approaches, and the long history of
ecological approaches in social work provides a natural
avenue for a leadership role in integrating care for the
whole person.
Categories of Mental Illnesses
All social workers will en 'Counter people with mental
illness, and it is useful to understand the major s ystems of
classification, as well as basic information about some of
the most prevalent categories of mental illness.
CLASSIFlCgTION SYSTEMS The Diagnostic and
Statistical Manual of Mental Disorders, currently in its
fourth major revision (DSM-IV-TR, American Psychiatric
Association, 2004), is the primary classification system
used in the United States. Its development has paral leled
and influenced the International Classification of Diseases
(lCD-10), which is maintained by the World Health
Organization. There is also a comprehensive Chinese
system that conforms in many ways to the lCD, but also
has important, culturally specific departures (Chen, 2002 ;
Lee, 2001), and there are some efforts to tailor the ICD so
that it is culturally appropriate for Latin American
countries (Berganza, Mezzich, & Jorge, 2002). These
systems were developed in response to the need for
reliable and accurate reporting of epidemiology and
effective treatment for mental illnesses. In the absence of
definitive knowledge about the causes of illness, they
consist of carefully described symptom clusters.
The DSM is currently undergoing a major research-
driven revision, which is expected to be released in 2011;
the ICD is scheduled to undergo its next major update in
2014 (Kupfer, First, & Regier, 2002). Regular reports and
white papers are appearing on the DSM-V project Web
site, http://dsm5.org/whitepapers.cfm. Preliminary reports
state that changes to the DSM in this revision may be
major.
The DSM is structured along five axes, and thor ough
assessments include information on each axis. The axes
include Axis I: Clinical disorders (major mental disorders,
developmental disorders, and learning disorders), Axis II:
Underlying pervasive or personality disorders, including
mental retardation, Axis III:
MENTAL HEALTH: OVERVIEW
225
Medical conditions and physical disorders, Axis IV:
Psychosocial and environmental factors contributing to the
disorder, and Axis V: Global assessment of functioning
(rated from 0 to 100).
Mental disorders are very heterogeneous, and the
DSM-IV-TR lists 297 disorders. Clinical training is
considered essential for the appropriate application of the
DSM; a useful short guide for people with clin ical training
is provided by Zimmerman (1994). Basic familiarity with
some of the most common categories of illnesses is. useful
to social workers, as they are likely to enc ounter people
with mental disorders in many lines of work of importance
to social workers. Four common categories of disorders
are briefly summarized and referenced in the following
sections. Excellent information can be found on the NIMH
Web site, as well as other patient-oriented sources of
information on the Web.
DEPRESSION AND OTHER MOOD DISORDERS De-
pression is characterized by persistent sadness, pessi mism,
difficultly concentrating, and changes in sleep and
appetite. It is often accompanied by persistent physical
symptoms such as headaches, digestive pro blems, and
pain. It affects about 9% of the American population in any
given year, and it is estimated to be one of the most
disabling and costly of the mental disorders. It is twice as
common in women as in men. Depression is one of the
most treatable disorders, but most people with depression
do not access treatment. Best practices for depression
treatment include a combination of talk therapy and
medication therapy. Cognitive behavioral therapy and
interpersonal therapy are well established as effective
psychosocial therapies for depression. Medication
guidelines are also well accepted, and have been recently
summarized by the World Federation of Societies for
Biological Psychiatry (Bauer et al., 2007).
ANXIETY DISORDERS Anxiety disorders are the most
common mental disorders; recent estimates of preva lence
in the United States document that they affect 18% of
adults annually. They include such diverse categories as
panic disorder, obsessive compulsive disorder, and
posttraumatic stress disorder, and may prove to be more
etiologically heterogeneous than depressive disorders.
They are characterized by the experience of significant and
upsetting worry, fearfulness, or unwanted upsetting
thoughts that can come to dominate many aspects of their
behavior. Best treatment practices include medication
along with a talk therapy. Antidepressant medications have
been shown to be effective in treating many kinds of
anxiety, and antianxiety
226 MENTAL HEALTH: OVERVIEW
medications such as the benzodiazepines are also useful in
controlling symptoms.
SCHIZOPHRENIA AND RELATED PSYCHOTIC DIS-
ORDERS Psychotic disorders are characterized by signifi-
cant problems with reality testing. People with psychotic
disorders experience "positive symptoms" including hal-
lucinations (perceiving things that are not there) and
delusions (persistent but potentially possible false beliefs, for
example, that one is being followed by the FBI). People with
psychotic disorders can also be characterized by notably flat
affect and difficulty or lack of interest in sustaining activity
and significant problems with decision making; these are
called "negative symptoms." Schizophrenia and
schizoaffective disorder (schizophre-
\
nia accompanied by significant mood disorder sympto-
matology) are the most chronic and disabling forms of
psychotic illnesses; other psychotic illnesses include schi-
zophreniforrn disorder, delusional disorder, and brief psy-
chotic disorders. Schizophrenia affects about 1 % of people
worldwide. There are a variety of medications that can be
effective; they tend to have high side-effect profiles and must
be carefully monitored. People who have responded well to
medication can also benefit from psychosocial treatments
and rehabilitation activities, such as supported employment.
SUBSTANCE-USE DISORDERS Substance abuse is a state
in which use of psychoactive substances causes detriments to
health or functioning. Substance use disorders are among the
most common and costly mental health problems. In
addition, they are highly comorbid with other mental
disorders; it is commonly believed that people with mood or
psychotic disorders may use substances to "self-medicate."
Pharmacologic agents tend to be substance specific, and
some are very effective. Psychosocial treatments for
substance use are also effective, sometimes particularly in
combination with medications. The amount of time spent in
treatment is highly predictive of successful outcome, and
treatment dropout is a significant problem. The value of
integrated care for people with co-occurring substance use
and mental disorders is well established (Drake & Mueser,
2000; Drake, Mueser, Brunette, & McHugo, 2004), although
rarely available (Harris & Edlund, 2005).
The Mental Health Service System
Access to mental health care is a major problem worldwide.
The World Health Organization 2001 report states that
one-third of countries have no specific mental health
program, and another third allocate less that 1 % of their
public health budget to mental health. Even countries with
established mental health systems do not
provide access to care uniformly across geographical regions,
with urban areas being greatly favored over rural areas
worldwide (WHO, 200la, 2001b, 2004).
Most people who need mental health care do not get it. In
the 12 months preceding surveys conducted by the World
Health Organization, and in the United States (Wang et al.,
2005; WHO World Mental Health Survey Consortium, 2004)
35-50% of cases judged to be serious in developed nations,
and 75-85% of such cases in less-developed nations received
no treatment.
In the United States, the situation is complicated by a
system that is highly fragmented. Regier et aL (1993), who
described the "de facto mental health system," note that
services can be sought in the specialty mental health sector, the
general medical sector, the social service sector (including the
justice system as well as charitable and educational
institutions), or the volun- . tary sector (self-help and other
voluntary groups). Financing and regulation across the different
systems are complex, and mostly nonoverlapping (Mental
Health: A report of the Surgeon General, 1999). Although the
federal government plays a role in financing mental health care,
states and municipalities contribute substantially to funding,
and differ greatly in the types and quality of services available
(Sturm, Ringel, &' Andreyeva, 2003). There can be substantial
restrictions on access across service sectors. Among the most
serious difficulties is the separation of services for drug and
alcohol abuse from services for mental health disorders.
Despite the high likelihood of the co-occurrence of these
disorders (Regier et al., 1990), and strong and consistent
evidence that integrated treatment is more successful than
separate treatment (Drake & Mueser, 2000; Drake et al., 2004;
Herman et al., 2000), the history of separate funding,
long-standing turf battles between the two communities, and
the involvement of the criminal justice system in substance use
problems make integrated care impossible for many consumers
who would benefit from it.
Culture and Mental Illness
Culture is important to every aspect of mental illness,
including the expression and interpretation of symptoms, help
seeking, and the appropriateness and possibly the effectiveness
of the treatment approach. Thepersonal, interpersonal, and
social responses to distress, as well as the role of the personal,
interpersonal, and social in determining what causes distress,
are important components of the understanding of mental
illness, as well as appropriate responses to mental illness
(Fabrega, 1989, 1995; Kleinman, 1988; Lopez & Guamaccia,
2000).
Recent data suggest that there may be cultural differences
in the prevalence of mood and anxiety
1

disorders both internationally and within subcultures of
particular nations, and that differences among cultural
groups may not always be in the expected direction.
People in China have consistently been shown to have a
smaller risk of experiencing a mood or anxiety dis order
(Shen et al., 2006). Although some reviews suggest that
the prevalence of mental illness is similar among racial
subgroups in the United States (Miranda, Lawson,
Escobar, & NIMH Affective Disorders Workgroup,
2002), recent evidence from rigorous epidemiological
studies shows that African Americans and Hispanics
are less likely to experience depression, generalized
anxiety disorder, and social phobia, than non-Hispanic
whites, and that lower risk was more pronounced
among lower-income members of these groups
(Breslau, Kendler,' Aguilar-Gaxiola, Su, & Kessler,
2005; Breslau et al., 2006). The lower preva lence of
these disorders occurs despite the fact that African
Americans experience considerable social adversity,
particularly in the form of the pronounced racism in
American society (for example, Clark, Anderson,
Clark, & Williams, 1999; Williams & WilliamsMorris,
2000), and despite the strong associations between
income and mental disorder shown in a variety of
studies, some of which are cited above.
There is no question that, in the United States, there
are considerable treatment disparities. African
Americans, Native Americans, and Latino Americans
with mental illnesses are substantially less likely to
receive care for them and are more likely to leave care
prematurely (Mental Health: A report of the Surgeon
General, 1999, 2001; Snowden, 2003). Bias in the
mental health system and poverty both appear to con-
tribute to low levels of service use (Dana, 2002;Hollar,
2001; Snowden, 2003). Clients from ethnic minority
groups will usually receive services from someone who
is not of their own race, and may have concerns about
the relevance of the help offered; strong clinical skills
are needed to alleviate fears (Proctor & Davis, 1994).
Cultural competence is becoming an expected stan-
dard, and a variety of models for training cultural com-
petence are now available. Evidence about their
effectiveness is preliminary, but suggests that clinicians
are satisfied with training, and that their sensitivity to
other cultures may increase in a nonlinear fashion
(Bhui, Warfa, Edonya, McKenzi, & Bhugra, 2007;
Bourjolly et al., 2005; Stanhope, Solomon, Pernell-Ar-
nold, Sands, & Bourjolly, 2005).
The Importance of Evidence-Based Practices The
mental health practice field is rapidly moving toward
insisting on the quality and accountability that can be
expected from evidence-based practices. We
MENTAL HEALTH: OVERVIEW
227
have accumulated a great deal of knowledge about
treating mental illnesses, and there is great interest in
providing mental health consumers with proven prac-
tices. The importance of applying this evidence base has
long been noted in social work (see, for example,
Rosen, 2003; Rosen & Proctor, 2003; Rosen, Proctor, &
Staudt, 2003), and has gained national attention; the
President's New Freedom Commission on Mental
Health (2003) is one among many calls for the imple-
mentation of evidence-based practices in mental health.
The Institute of Medicine (2001a, 2006) has noted
that practices known to be effective are not consistently
available, and this has been echoed by other authors
(Beinecke, 2005; Drake et al., 2001). Despite the pro-
mise of evidence-based practice, there are legitimate
obstacles to its implementation, and a number of
authors have enumerated the complexities and difficul-
ties of translating research findings into daily practice
activities (Glasgow & Emmons, 2007; Green &
Glasgow, 2006; Jenson, 2005; Webb, 2001). The evi-
dence base tends to be disease specific, but many people
seen in actual practices have complex groupings of
comorbid disorders. Assessment techniques used in re-
search studies to document the presence of the specific
syndrome under study are not practical for community
settings, and thus even the decision for how to match
the treatment to the client is difficult in real practice
settings.
Problems with dissemination may be exacerbated by
the fact that university treatment researchers are simply
not close enough to the ground, and may unwittingly
design treatments that cannot be adapted to meet the
practical realities of community mental health treatment
settings (Addis & Krasnow, 2000; Addis & Waltz,
2002; Carroll & Nuro, 2002; Chorpita, 2002). Social
work researchers, with their long tradition of academic/
community partnerships, are in a strong position to
contribute to "practice-based evidence" that will ulti-
mately create an evidence base that can be applied to
more fully realize the promise of quality services.
Implications for Social Work Educators
The field of mental health is a fast-moving target, and
social workers must advocate for models of education
that will keep them up to date in their practices, and that
will prepare new generations for social workers with the
best possible knowledge base to alleviate suffer ing. We
are in a good position to establish "communities of
practice" with the agencies that sponsor our field
education, and continue to make social work curricula
more fully based in practice-relevant research (Howard,
McMillen, & Pollio, 2003).
228 MENTAL HEALTH: OVERVIEW
REFERENCES
Addis, M. E., & Krasnow, A. D. (2000). A national survey of
practicing psychologists' attitudes towards psychotherapy
treatment manuals. Journal of Consulting and Clinical Psychology,
68, 331-339.
Addis, M. E., & Waltz, J. (2002). Implicit and untested as-
sumptions about the role of psychotherapy treatment manuals
in evidence-based mental health practice. Clinical Psychology:
Science and Practice, 9(4), 421-424.
Alrneida-Filho, M., Mari J. de, J., Coutinho, E., Franca, J. F.,
Fernandes, J., Andreoli, S. B., et a1. (1997). Brazilian
multicentric study of psychiatric morbidity. Methodological
features and prevalence estimates. British Journal of Psychiatry,
171,524-529.
American Psychiatric Association. (2004). Diagnostic and stat-
isticalmanual of mental disorders DSM-N-TR (4th ed.). Arlington,
VA: American Psychiatric Publishing.
Andrews, G., Peters, L, Guzman, A-M., & Bird, K. (2001).
Prevalence, co morbidity , . disability and service utilization:
Overview of the Australian National Mental Health Survey.
British Journal of Psychiatry, 178, 145-153.
Anthony, W. A. (1993). Recovery from mental illness: The
guiding vision of the mental health service system of the
1990s. Psychological Rehabilitation Journal, 16, 11-24.
Anthony, W. A, & Jansen, M. A (1984). Predicting the vocational
capacity of the chronically mentally ill: Research and policy
implications. American Psychologist, 39, 537-544.
Barth, J., Schumacher, M., & Herrmann-Lingen, C. (2004).
Depression as a risk factor. for mortality in patients with
coronary heart disease: A meta-analysis. Psychosomatic
Medicine, 66(6), 802-813.
Barth, R. P., Gibbons, c., & Shenyang, G. (2006). Substance
abuse treatment and the recurrence of maltreatment among
caregivers with children living at home: A propensity score
analysis. Journal of Substance Abuse Treatment, 30, 93-104.
Bauer, M., Bschor, T., Pfennig, P., Whybrow, P. C., Angst, J.,
Versiani, M., et a1. (2007). World federation of societies of
biological psychiatry (WFSBP) guidelines for biological
treatment of unipolar depressive disorders in primary care. The
World Journal of Biological Psychiatry, 8(2), 67-104.
Beinecke, R. H. (2005). Implementation of evidence based mental
health practice in England. International Journal of Mental
Health, 33, 64-79.
Berganza, C. E., Mezzich, J. E., & Jorge, M. R. (2002). Latin .
American Guide for Psychiatric Disorders (GLDP). Psycho-
pathology, 35(2-3),185-190.
Bhagwanjee, A, Parekh, A., Paruk, z., Petersen, 1., & Subedar, H.
(1998). Prevalence of minor psychiatric disorders in an adult
African rural community in South Africa. Psychological
Medicine, 28(5), 1137-1147.
Bhui, K., Warfa, N., Edonya, P., McKenzi, K., & Bhugra, D.
(2007). Cultural competence in mental health care: A review
of model evaluations. BMC Health Services Research, 7, 15.
Bourjolly, J. N., Sands, R. G., Solomon, P., Stanhope, V.,
Pernell-Arnold, A, & Finley, L (2005). The journey toward
intercultural sensitivity: A non-linear process. Journal of
Multicultural Social Work, 14(3-4),41-62.
Breslau, J., Aguilar-Gaxiola, S., Kendler, K. S., Su, M., Williams,
D., & Kessler, R. C. (2006). Specifying raceethnic differences
in risk for psychiatric disorder in a US national sample.
Psychological Medicine, 36(1),57-68.
Breslau, J., Kendler, K. S., Aguilar-Gaxiola, S., Su, M., &
Kessler, R. C. (2005). Lifetime prevalence and persistence of
psychiatric disorders across ethnic groups in the United States.
Psychological Medicine, 35, 317-327.
Brody, D. S., Thompson, T. L, Larson, D. B., Ford, D. E., Katon,
W. J., & Magruder, K. M. (1995). Recognizing and managing
depression in primary care. General Hospital Psychiatry,
17,93-107.
Burnes, B. J., Phillips, S. D., Wagner, H. R., Barth, R. P., Kolko,
D. J., Campbell, Y., et a1. (2004). Journal of the American
Academy of Child Psychiatry, 43(8), 960-970.
Carpenter, J. (2002). Mental health recovery paradigm: Impli-
cations for social work. Health and Social Work, 27(2), 86--94.
Carroll, C. M., & Nuro, K. F. (2002). One size cannot fit all: A
stage model for psychotherapy manual development. Clinical
Psychology: Science and Practice, 9(4), 396-406.
Chen, Y. F. (2002). Chinese classification of mental disorders
(CCMD-3): Towards integration in international classifica-
tion. Psychopathology, 35(2-3), 171-175.
Cheng, T. A, & Hsu, M. (1992). A community study of mental
disorders among four aboriginal groups in Taiwan.
Psychological Medicine, 22(1), 255-263.
Chesler, P. (1972). Women and Madness. New York:
Doubleday.
Chorpita, B. F. (2002). Treatment manuals for the real world:
Where do we build them? Clinical Psychology: Science and
Practice, 9(4), 431-438.
Clark, R., Anderson, N. B., Clark, V. R., & Williams, D. R.
(1999). Racism as a stressor for African Americans: A
biopsychosocial model. American Psychologist, 54, 805-816.
Clausen, J. M., Landsverk, J., Ganger, W., Chadwick, D., &
Litrownik, A (1998). Mental health problems of children in
foster care. Journal of Child and Family Studies, 7(3), 283-296.
Cohen, S., Frank, E., Doyle, J. W., Skoner, D. P., Rabin, B. S., &
Gwaltney, J. M. (1998). Types of stressors that increase
susceptibility to the common cold in healthy adults. Health
Psychology, 17(3),214-223.
Cohen, S., Tyrrell, D. A, & Smith, A P. (1991). Psychological
stress and susceptibility to the common cold. New England
[oumal of Medicine, 325(9), 606--612.
Dana, R. H. (2002). Mental health services for African
Americans: A cultural/racial perspective. Cultural Diversity and
Ethnic Minority Psychology, 8(1), 3-18.
Deegan, P. E. (1988). Recovery: The lived experience of
rehabilitation. Psychiatric Rehabilitation Journal, 11, 11-19.
Drake, R. E., Goldman, H. H., Leff, S., Lehman, A. F., Dixon, L,
Mueser, K. T., et al. (2001). Implementing evidence-based
practice in routine mental health settings. Psychiatric
Services,52,179-182.
Drake, R. E., & Mueser, K. T. (2000). Psychosocial approaches to
dual diagnosis. Schizophrenia Bulletin, 26(1), 105-118.
Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J:
(2004). A review of treatments for people with severe

mental illnesses and co-occurring substance use disorders.
Psychiatric Rehabilitation Journal, 27 ( 4 ), 360-374.
Druss, B. G., Rosenheck, R. A., & Sledge, W. H. (2000). Health
and disability costs of depressive illness in a major US
corporation. American Journal of Psychiatry, 157, 1274-1278.
Fabrega, H. Jr. (1989). Cultural relativism and psychiatric illness.
Journal of Nervous and Mental Disease, 177(7), 415-425.
Fabrega, H., Jr. (1995). Cultural challenges to the psychiatric
enterprise. Comprehensive Psychiatry, 36( 5), 377-383.
Fichter, M. M., Narrow, W. E., Roper, M. T., Rehm, J., Elton, M.,
Rae, D. S., et al. (1996). Prevalence of mental illness in
Germany and the United States. Comparison of the upper
Bavarian Study and the epidemiologic catchment area
program. Journal of Nervous and Mental Disease,
184(10),598-606. ' International Journal of Psychiatry in Medicine, 24(2), 179-188.
Forrester, D., & Harwin, J. (2006). Parental substance misuse and
child care social work: Findings from the first stage of a study
of 100 families. Child and Family Social Work, 11, 325-335.
Francoeur, R. B., Copley,C. K., & Miller, P. J. (1997). The
challenge to meet the mental health and biopsychosocial needs
of the poor: Expanded roles for hospital social workers in a
changing healthcare environment. Social Work Health Care,
26(2), 1-13.
Gaynes, B. N., Rush, A. J., Trivedi, M. H., Wisniewski, S. R.,
Balasubramani, G. K., Spencer, D. C., et al. (2007). Major
depression symptoms in primary care and psychiatric settings:
A cross-sectional analysis. Annals of Family Medicine, 5(2),
126-134.
Gibelman, M., & Schervish, P. (1995). Practice areas and setting
of social workers in metal health. Psychiatric Services, 46,1237.
Glasgow, R. E., & Emmons, K. M. (2007). How can we increase
translation of research into practice? Types of evidence
needed. Annual Review of Public Health, 28, 413-433.
Glassman, A. H., & Shapiro, P. A. (1998). Depression and the
course of coronary artery disease. American Journal of Psych-
iatry, 155(1),4-11.
Glisson, c., & Green, P. (2006). The role of specialty mental
health care in predicting child welfare and juvenile justice
out-of-home placements. Research on Social Work Practice, 16,
480-490.
Goffman, E. (1961). Asylums: Essays on the social situation of mental
patients and other inmates. New York: Doubleday.
Goffman, E. (1963). Stigma: Notes on the management of spoiled
identity. New York: Prentice-Hall.
Green, L. W., & Glasgow, R. E. (2006). Evaluating the relevance,
generalization, and applicability of research: Issues in external
validation and translation methodology. Evaluation & the
Health Professions, 29(1), 126-153.
Gresenz, C. R., Sturm, R., & Tang, L. (2001). Income and mental
health: Unraveling community and individual level
relationships. Journal of Mental Health Policy and Economics,
4(4),197-203.
Harding, C., Strauss, J. S., & Zubin, J. (1992). Chronicity in
schizophrenia: Revisited. British Journal of Psychiatry, 161,
27-37.
MENTAL HEALTH: OVERVIEW 229
Harris, K. M., & Edlund, M. J. (2005). Use of mental health care
and substance abuse treatment among adults with cooccurring
disorders. Psychiatric Services, 56(8), 954-959.
Herman, S. E., Frank, K. A., Mowbray, C. T., Ribisl, K. M.,
Davidson, W. S. 11., BootsMiller, B., et al. (2000). Longitu-
dinal effects of integrated treatment on alcohol use for persons
with serious mental illness and substance use disorder. Journal
of Mental Health Administration, 27(3), 286-302.
Hirschfeld, R. M., Montgomery, S. A., Keller, M. B., Kasper, S.,
Schatzberg, A. F., Moller, H. J., et al. (2000). Social
functioning in depression: A review. Journal of Clinical
Psychiatry, 51, 123-133.
Hollifield, M., Katon, W., & Morojele, N. (1994). Anxiety and
depression in an outpatient clinic in Lesotho, Africa.
Hollar, M. C. (2001). The impact of racism on the delivery of
health care and mental health services. Psychiatric Quarterly,
72(4),337-345.
Horwitz, S. M., & Kerker, B. D. (2001). Impediments to
employment under welfare reform: The importance of physical
health and psychosocial characteristics. Women Health,
32(1-2),101-117.
Howard, M. 0., McMillen, C. J., & Pollio, D. E. (2003).
Teaching evidence-based practice: Toward a new paradigm for
social education. Research on Social Work Practice, 13(2),
234-259.
Husain, N., Chaudhry, I. B., Afridi, M. A., Tomenson, B., &
Creed, F. (2007). Life stress and depression in a tribal area of
Pakistan. British Journal of Psychiatry, 190,36-41.
Institute of Medicine. (2001a). Crossing the quality chasm: A new
health system for the 21st century. Washington, DC:
National Academy Press.
Institute of Medicine. (2001b). Neurological, psychiatric and
developmental disorders: Meeting the challenge in the developing
world. Washington, DC: National Academy Press.
Institute of Medicine Committee on Crossing the Quality Chasm:
Adaptation to Mental Health and Addictive Services. (2006).
Improving the quality of care for mental and substance use
conditions. Washington, DC: National Academy Press.
Jenson, J. M. (2005). Connecting science to intervention:
Advances, challenges, and the promise of evidence-based
practice. Social Work Research, 29(3),131-135.
Judd, L. L., Akiskal, H. S., Zeller, P. J., Paulus, M., Leon, A. c,
Maser, J. D., Endicott, J., Coryell, W., Kunovac, J. L., Mueller,
T. I., Rice, J. P., & Keller, M. B. (2000). Psychosocial
disability during the long-term course of unipolar major
depressive disorder. Archives of General Psychiatry, 57
(4),381-382,
Katon, W., Lin, E. H., & Kroenke, K. (2007). The association of
depression and anxiety with medical symptom burden in
patients with chronic medical illness. General Hospital
Psychiatry, 29(2), 147-155.
Kesey, K. (1962). One flew over the cuckoo's nest. New York:
Viking.
230 MENTAL HEALTH: OVERVIEW
Kessler, L. G., Cleary, P. D., & Burke, J. D. (1985). Psychiatric
disorder in primary care. Archives of General Psychiatry, 42,
583-587.
Kessler, R. c., McGonagle, K. A., Zhao, S., Nelson, C. B.,
Hughes, M., Eshleman, S., et al. (1994). Lifetime and 12
month prevalence of DSM-IIl-R psychiatric disorders in the
United States. Results for the National Comorbidity Survey.
Archives of General Psychiatry, 51 (1), 8-19.
Kiecolt-Glazer, J. K., McGuire, L., Robles, T. F., & Glaser, R.
(2002). Emotions, morbidity, and mortality: New perspec tives
from psychoneuroimmunology. Annual Review of Psychology,
53, 83-107.
Kleinman, A. (1988). Rethinking psychiatry: From cultural category
to persanal experience. New York: Free Press.
Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chvron,
E. S. (984). Interpersonal psychotherapy of depression. New
York: Basic Booksx
Kronish, 1. M., Rieckmann, N., Halm, E. A., Shirnbo, D.,
Vorchheimer, D., Haas, D. c., et al. (2006). Persistent de-
pression affects adherence to secondary prevention behaviors
after acute coronary syndromes. Journal of Internal Medicine, 21
(1), 1178-1183.
Kupfer, D. J., First, M. B., & Regier, D. A. (Eds.). (2002). A
research agenda for DSM- V. Washington, DC: American
Psychiatric Publishing, Inc.
Laing, R. D. (960). The divided self: An existential study in sanity and
madness. Harmondsworth: Penguin.
Lamb, H. R., Weinberger, L. E., & Gross, B. H. (2004).
Mentally ill persons in the criminal justice system: Some
perspectives. Psychiatric Quarterly, 75(2), 107-126.
Lee, S. (2001). From diversity to unity: The classification of .
mental disorders in 21st century China. Psychiatric Clinics of
North America, 24(3),421-431.
Lipscomb, H. J., Dement, J. M~, Epling, C. A., Gaynes, B. N.,
McDonald, M. A., & Schoenfisch, A. L. (2007). Depressive
symptoms among working women in rural North Carolina: A
comparison of women in poultry processing and other low-
wage jobs. International Journal of Law and Psychiatry, July 30.
Lopez, S. R., & Guarnaccia, P. J. J. (2000). Cultural psycho-
pathology: Uncovering the social world of mental illness.
Annual Review of Psychology, 51,571-598.
Lurigio, A. J., & Fallon, J. (2007). Individuals with serious mental
illness in the criminal justice system: The case of Richard P.
Clinical Case Studies, 6(4),362-378.
Mangalore, R., Knapp, M., & Jenkins, R. (2007). Incomerelated
inequality in mental health in Britain: The concentration index
approach. Psychology and Medicine, 37(7), 1037-1045.
Marder, S. R., Essock, S. M., Miller, A. L., Buchanan, R. W.,
Casey, D. E., & Davis, J. M. (2004). Physical health mon-
itoring of patients with schizophrenia. American Journal of
Psychiatry, 161,1334-1349.
Marwaha, S., & Johnson, S. (2004), Schizophrenia and em-
ployment: A review. Social Psychiatry and Psychiatric Epi-
demiology, 39, 337-349.
Mechanic, D., Bilder, S., & McAlpine, D. D. (2002). Employing
persons with serious mental illness. Health Affairs, 21, 242-253.
Mental Health: A report of the Surgeon General. (999).
Rockville, MD: U.S. Dept of Health and Human Services.
Mental Health: Culture, race and ethnicity-A supplement to
Mental Health: A report of the Surgeon General. (2001).
Rockville, MD: U.S. Dept of Health and Human Services.
Miranda, J., Lawson, W., Escobar, J., & NIMH Affective
Disorders Workgroup. (2002). Ethnic minorities. Mental
Health Services Research, 4(4),231-237.
Moore, M. E., & Hiday, V. A. (2006). Mental health court
outcomes: A comparison of re-arrest and re-arrest severity
between mental health court and tradition.
Mowbray, C. T., & Holter, M. C. (2002). Mental health and
mental illness: Out of the closet? Social Service Review, 760),
135-179.
Mueser, K. T., & Tarrier, N. (1998). Handbook of social functioning
in schizophrenia. Boston, MA: Allyn and Bacon.
Murray, c., & Lopez, A. D. (1996). The global burden of disease:
A comprehensive assessment of mortality and disability from
diseases, injuries and risk factors in 1990 and projected to 2020.
Boston, MA: Harvard University Press.
Newman, S. c., &Bland, R. C. (991). Mortality in a cohort of
patients with schizophrenia: A record linkage study. Canadian
Journal of Psychiatry, 36, 239-245.
President's New Freedom Commission on Mental Health. (2003).
Achieving the promise: Transforming mental health in America.
Washington, DC: Department of Health and Human Services.
Prince, J. D., & Segal, S. P. (2005). An empowering medical
model of mental health care. Psychiatric Services, 56, 903.
Proctor, E. K., & Davis, L. E. (1994). The challenge of racial
difference: Skills for clinical practice. Social Work, 39(3),
314-323.
Proctor, E. K., Morrow-Howell, N. L., Dore, P., Wentz, J., Rubin,
E. H., Thomson, S., et al. (2003). Comorbid medical
conditions among depressed elderly patients discharged home
after acute psychiatric care. American Journal of Geriatric
Psychiatry, 11 (3),329-338.
Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S.J.,
Judd, L. L., et al. (1990). Comorbidity of mental disorders
with alcohol and other drug abuse. Results from the Epide-
miologic Catchment Area (ECA) Study. Journal of the
American Medical Association, 264(19), 2511-2518.
Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W.,
Locke, B. A., & Goodwin, F. K. (993). The de facto US mental
and addictive disorders service system, Epidemiologic
catchment area prospective I-year prevalence rates of
disorders and services. Archives of General Psychiatry, 50(2),
85-94.
Robiner, W. N. (2006). The mental health professions: Workforce
supply and demand, issues, and challenges. Clinical Psychology
Review, 26, 600-625.
Robinson, D. G., Woerner, M. G., McMeniman, M.,
Mendelowitz, A., & Bilder, R. M. (2004). Symptomatic and
functional recovery from a first episode of schizophrenia or
schizoaffective disorder. American Journal of Psychiatry,
161,473-479.
Romero, D., Chavkin, W., Wise, P. H., Smith, L. A., & Wood, P.
R. (2002). Welfare to work? Impact of the

maternal health on employment. American Journal of Public
Health, 92(9), 1462-:-1468.
Rosen, A. (2003). Evidenced-based social work practice: Chal-
lenges and promise. Social Work Research, 27(4),197-208.
Rosen, A., & Proctor, E. K. (2003). Developing practice guidelines
for social work intervention. New York: Columbia University
Press.
Rosen, A., Proctor, E. K., & 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.
Schiepers, O. J., Wichers, M. C., & Maes, M. (2005). Cytokines
and major depression. Progress in Neuropsychopharmacology
and Biological Psychiatry, 29(2), 201-217.
Scholte, W. F., Olff, M., Ventevogel, P., de Vries, G. J., Jansveld,
E., Cardozo, B. I., et al. (2004). Mental health symptoms
following war \ and repression in eastern Afghanistan. Journal
of the American Medical Association, 292(5), 626-628.
Schulberg, H. c., Saul, M., & McClelland, M. (1985). Assessing
depression in primary medical and psychiatric practice.
Archives of General Psychiatry, 12, 1164-1170:
Semidei, J., Feig-Radel, L., & Nolan, C. (2001). Substance abuse
and child welfare: Clear linkages and promising responses.
Child Welfare, 80, 109-128.
Shen, Y. c., Zhang, M. Y., Huang, Y. Q., He, Y. L., Liu, Z. R.,
Cheng, H., et al. (2006). Twelve-month prevalence, severity,
and unmet need for treatment of mental disorders in
metropolitan China. Psychological Medicine, 36(2), 257-267.
Snowden, L. R. (2003). Bias in mental health assessment and
intervention: Theory and evidence. American Journal of Public
Health, 93(2}, 239-243.
Stanhope, V., Solomon, P., Pernell-Arnold, A., Sands, R. G., &
Bourjolly, J. N. (2005). Evaluating cultural competence
among behavioral health professionals. Psychosocial Rehabili-
tation Journal, 28(3), 225-233.
Steadman, H. J., & Naples, M. (2005). Assessing the effectiveness
of jail diversion programs for persons with serious mental
illness and co-occurring substance use disorders. Behavioral
Sciences and the Law, 23, 163-170.
Stewart, W. F., Ricci, J. A., Chee, E., Hahn, S. R., & Morganstein,
D. (2003). Cost of lost productive work time among US
workers with depression. Journal of the American Medical
Assoc~tion,289,3135-3144.
Sturm, R., Ringel, r. S., & Andreyeva, T. (2003). Geographic
disparities in children's mental health care. Pediatrics, 112(4),
e308.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry (Norton
reissue, 1997). New York: William Alanson White Psychiatric
Foundation.
Sullivan, H. S. (1956); Clinical studies in psychiatry (Norton reissue,
1973). New York: William Alanson White Psychiatric
Foundation.
Szasz, T. S. (1960). The myth of mental illness. New York:
Harper & Row.
Szasz, T. S. (1997). The manufacture of madness: A comparative
history of psychiatry and the inquisition. Syracuse, NY:
Syracuse University Press.
MENTAL HEALTII: OVERVIEW 231
c, &
Ustun, T. B., Ayuso-Mateos, J. L., Chatterji, S., Mathers,
Murray, C. J. L. (2004). Global burden of depressive dis-
orders in the year 2000. British Journal of Psychiatry, 184,
386-392.
Vinck, P., Pham, P. N., Stover, E., & Weinstein, H. M. (2007).
Exposure to war crimes and implications for peace building in
northern Uganda. Journal of the American Medical Association,
298(5), 543-554.
Wang, P. S., Demler, 0., Olfson, M., Pincus, H. A., Wells, K. B.,
& Kessler, R. C. (2006). Changing profiles of service sectors
used for mental health care in the United States. American
Journal of Psychiatry, 163(7), 1187-1198.
Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., &
Kessler, R. C. (2005). Twelve-month use of mental health
services in the United States: Results from the National
Comorbidity Survey Replication. Archives of General Psychiatry,
2(6), 629-640.
Webb, S. A. (200l). Some considerations on the validity of
evidence-based practice in social work. British Journal of Social
Work, 31, 57-79.
WHO World Mental Health survey Consortium. (2004).
Prevalence, severity and unmet need for treatment of mental
disorders in the World Health Organization World Mental
Health Surveys. Journal of the American Medical Association,
291, 2581-2590.
Williams, D. R., & Williams-Morris, R. (2000). Racism and
mental health: The African American Experience. Ethnicity and
Health, 5(3-4),243-268.
Wiseman, F. (Producer/Writer/Director). (1967). Titicut follies
(motion picture, banned in United States, 1967-1992).
Cambridge, MA: Zipporah Films.
World Health Organization. (2001a). Mental health: New
understanding, new hope. The world health report. Geneva:
World Health Organization.
World Health Organization. (2001 b). Mental health resources in the
world. Initial results of Project Atlas (Fact Sheet No. 260, April,
2001). Geneva: World Health Organization.
World Health Organization. (2004). Prevalence, severity, and
unmet need for treatment of mental disorders in the World
Health Organization World Mental Health Surveys. Journal of
the American Medical Association, 291(21), 2581-2590.
World Health Organization and International Committee of the
Red Cross. (n.d.). Information Sheet: Mental Health and Prisons.
Retrieved November 7, 2007, from http://www.euro.
who.int/Document/MNH/WHO _ICRC_InfoShcMNH_
Prisons.pdf,
World Health Organization and World Bank. (1996). In C. J. L.
Murray & A. D. Lopez (Eds.), The global burden of disease.
Cambridge, MA: Harvard School of Public Health.
Zimmerman, M. (1994). Interview guide for evaluation DSM- IV
psychwtric disorders and the mental status examination. East
Greenwich, RI: Psych Products Press.
FURTHER READING
Boothroyd, R. A., Best, K. A., Giard, J. A., Stiles, P. G., Suleski,
J., Ort, R., et al. (2006). Poor and depressed, the tip of the
iceberg: The unmet needs of enrollees in an
232 MENTAL HEALTI-I: OVERVIEW
indigent health care plan. Administration and Policy in Mental
Health, 33(2), 172-181.
Brekke, J. S., Prindle, c., Bae, S. W., & Long, J. D. (2001).
Risks for individuals with schizophrenia who are living in the
community. Psychiatric Services, 52, 1358-1366.
Ciechanowski, P. S., Katon, W. J., Russo, J. E., & Hirsch, I. B.
(2003). The relationship of depressive symptoms to symptom
reporting, self-care and glucose control in diabetes. General
Hospital Psychiatry, 25(4), 246-252.
Frasure-Smith, N., Lesperance, F., & Talajic, M. (1993). De-
pression following myocardial infarction. Impact on 6-month
survival. Journal of American Medical Association, 270(15),
1819-1825.
Glassman, A. H. (1997). The central nervous system, depression
and cardiac death. Encephale, 23(3), 55-58.
Hodges, J. Q., & Anderson, K. M. (2005). What do social workers
need to know about mental health courts? Social Work in
Mental Health, 4(2), 17-30.
Horan, W. P., Subotnik, K. L., Snyder, K. S., & Neuchterlein, K.
H. (2006). Do recent-onset schizophrenia patients experience a
social network crisis? Psychiatry: Interpersonal and Biological
Processes, 69, 115-129.
Husain, N., Gater, R., Tomenson, B., & Creed, F. (2004).
Social factors associated with chronic depression among a
population-based sample of women in rural Pakistan. Social
Psychiatry and Psychiatric Epidemiology, 39(8), 618-624.
Keicolt-glaser, J. K., McGuire, L., Robles, T. F., & Glaser, R.
(2002). Psychoneuroimmunology and psychosomatic medi-
cine: Back to the future. Psychosomatic Medicine, 64, 15-28.
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,
62,617-627.
Kiecolt-Glaser, J. K., & Glaser, R. (2002). Depression and
immune function: Central pathways to morbidity and mor-
tality. Journal of Psychosomatic Research, 53( 4), 873-876.
Kiecolt-Glazer, J. K., McGuire, L., Robles, T. F., & Glaser, R.
(2002). Psychoneuroimmunology: Psychological influences
on immune function and health. Journal of Consulting and
Clinical Psychology, 70(3), 537-547.
Lustman, P. J., & Clouse, R. E. (2005). Depression in diabetic
patients: The relationship between mood and glycemic control.
Journal of Diabetes and Its Complications, 19(2), 113-122.
Musselman, D. L., Betan, E., Larsen, H., & Phillips, L. S. (2003).
Relationship of depression to diabetes types 1 and 2:
Epidemiology, biology, and treatment. Biological Psychiatry,
54(3), 317-329.
Orley, J., & Wing, J. K. (1979). Psychiatric disorders in two
African villages. Archives of General Psychiatry, 36(5), 513-520.
Rosen, A. (2003). Evidenced-based social work practice: Chal-
lenges and promise. Social Work Research, 27(4),197-208.
Rosen, A., Proctor, E. K., & 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.
Ruo, B., Rumsfeld, J. S., Hlatky, M. A., Liu, H., Browner, W. S.,
& Whooley, M. A. (2003). Depressive symptoms and
health-related quality of life: The heart and sole study. Journal
of the American Medical Association, 290 (2),215-221.
Sherbourne, C. D., Wells, K. B., Meredith, L. S., Jackson, C. A.,
& Camp, P. (1996). Comorbid anxiety disorder and the func-
tioning and well-being of chronically ill patients of general
medical providers. Archives of General Psychiatry, 53(10),
889-895.
World Health Organization. (2007). Mental Health and Prisons
Information Sheet. Retrieved April 30, 2007, from
www.euro.who.int/Document/MNHIWHO_ICRC_
InfoShcMNH]risons.pdf.
SUGGESTED LINKS
World Health Organization Mental Health page.
http://www . who. int/topics/mentaLhealth/en/ National
Institute of Mental Health. http://www.nimh.nih.gov/
National Institute of Drug Abuse.
http://www.nida.nih.gov/
President's New Freedom Commission. http://www
. mentaUtealthcommission.gov/ World Health
Organization 2001 Report. http://www . who
.int/whr/200 1 /en/whrO I_en. pdf President's New
Freedom Commission Report.
http://www . mentalhealthcommission.gov/reports/FinalReporti
toc.html
Mental health: A report of the Surgeon General.
http://www .surgeongeneral.gov/library/mentaUtealth/home .html
Mental health: Culture, race and ethnicity-Supplement to the
Surgeon General's Report.
http://mentalhealth.samhsa.gov/ ere/default. asp
-CATHERINE G. GREENO
PRACTICE INTERVENTIONS
ABSTRACT: This entry focuses on services for adults with
severe mental illness, specifically the five psychosocial
interventions considered evidence-based practices. The
emergence of psychiatric rehabilitation; the only professional
discipline designed to serve a specified population, is
described. The primary historical practice approaches, which
are the foundation for psychiatric rehabilitation, are
discussed. Each of the five evidencebased practices is then
described with the empirical supporting evidence. The
emphasis on this population and interventions were selected
as social workers are the major providers for this population
and frequent implementers and developers of these
interventions.
KEY WORDS: severe mental illness; psychiatric re-
habilitation; evidence-based practice; assertive com-
munity treatment; family psychoeducation; supported

employment; integrated treatment for co- occurring
substance abuse disorders; illness management and
recovery
Adults with a severe mental illness have a critical need' for
a combination of psychopharmacological treatment and
psychosocial service interventions if they are to both
reduce the symptoms of the disorders and improve the
functional disabilities that result from these severe ill-
nesses. This synergistic role of medication and psychoso-
cial interventions was greatly clarified by a study by a
prominent social worker, Gerard Hogarty, where he un-
dertook an experiment that assessed four conditions in the
aftercare of those with schizophrenia released from
hospitals: medication alone, sociotherapy alone, medica-
\
tion and sociotherapy, and a control condition. The key
finding was that those receiving both medication and
sociotherapy, a combination of support ive therapy, social
case work, and rehabilitation counseling, had the best
functional outcomes (Hogarty & Goldberg, 1973; Hogarty,
Goldberg, & Schooler, 1974). Since this land mark study,
further research by Hogarty as well as others has supported
this finding. A recent eulogy to Hogarty in a leading
psychiatry journal noted, "His seminal studies provided
proof that combining psychosocial treatments with
pharmacotherapy leads to better outcomes than
monotherapies" and his studies were conducted with
unique creativity, impeccable science, and infectious en-
thusiasm (Lehman & McGlashan, 2006, p. 1677).
This entry will focus on the psychosocial interven tion
portion of the equation, as social workers are fre quently the
primary providers as well as participants in the
development of these interventions. Initially, a description
of those with severe mental illness will be provided, along
with definitions. of key terms, followed by a discussion of
psychiatric rehabilitation. Then a description of the five
psychosocial evidenced- based practices for this
population, accompanied by support ing empirical
evidence, will be presented.
';.
Who Are Adults
with Severe Mental Illness?
Adults with severe mental illness are those with psy chotic
disorders, which primarily include those diag nosed with
schizophrenia, bipolar, and major affective disorders.
Individuals with borderline personality and anxiety
disorders may also be included if they have a disability
resulting from the disorder. Although not everyone with
these disorders has a psychiatric disabil ity, many do. A
psychiatric disability is defined as an inability to achieve
commonly accepted age-appropri ate milestones in major
life domains due to a mental disorder. As a result of these
social functional deficits,
..
MENTAL HEALTH: PRACTICE
INTERVENTIONS 233
adults with severe mental illness ch aracteristically tend to
be unemployed, unmarried, and to have difficulty with
interpersonal relationships. Given their lack of
employment, they tend to be economically disadvan taged
and are often financially supported by federal disability
benefit programs. In addition, this population is extremely
vulnerable to a variety of psychological, medical, and social
problems, including cognitive defi cits, poor health status,
and having relatively high rates of substance abuse,
physical and psychological trauma, homelessness, criminal
justice involvement, and loss of custody of their children.
Therefore, they require a variety of psychosocial
interventions from a diversity of human service systems.
Psychiatric Rehabilitation
Since the late 1980s (the psychosoci al rehabilitation
movement was earlier than this-the 1960s), the profes sional
practice field of psychiatric rehabilitation has emerged and
coalesced from a diversity of specialized program
approaches and models designed to address the
psychosocial problems and functional disabilities of this
population. Interestingly, this is one of the few profes sional
practice fields limited to serving a very specific population.
The most widely accepted definition of psy chiatric
rehabilitation is "to help persons with psychiatric
disabilities to increase their ability to function success fully
and to be satisfied in the environments of their choice with
the least amount of ongoing professional intervention"
(Anthony, Cohen, Farkas, & Gagne, 2002, p. 101). The
rehabilitation practice interventions encompass programs
and strategies that are aimed at employment, education,
housing, and other aspects of social functioning and
community living. Consequently, psychiatric rehabilitation
is systematic practice efforts that help adults with severe
psychiatric disabilities pro gress in their own process of
recovery (Corrigan, Mueser, Bond, Drake, & Solomon,
2008). These rehabilitation practices are in contrast to·
treatment which refers to psychiatric medications and
psychotherapy. Traditional insight- oriented psychotherapy
is not generally used with this population as research has
found these interventions to have negative consequences
for those with schizophrenia (Drake & Sederer, 1986).
Psychiatric rehabilitation has its roots in a diversity of
practice orientations. One of the major impetuses was the
psychosocial rehabilitation center movement that emanated
from Fountain House, a program started by discharged
psychiatric patients in the late 1940s. Psychosocial centers
give "members" the opportunity to work, recreate, and live
in the community in an atmosphere of support,
respectfulness, and acceptance (Rutman, 1993). Members
work in the program by
234 MENTAL HEALTH: PRACTICE
INTERVENTIONS
preparing the noon-day meal, being receptionists, and
engaging in other tasks necessary to operate the pro gram
functionally. Center programming includes edu cational,
vocational, and social groups, as many of the original
agencies were administered by social group workers. The
particular program model developed by these agencies is
the Clubhouse model (http://www. iccd.org/default.aspx),
which is a central meeting place for members. This
program model is now incorporated into man y
comprehensive mental health agencies.
There are more formalized highly structured ap-
proaches to learning social skills for community living
based on social learning theory. These programs began in
the hospitals. The UCLA group headed by Robert
Liberman developed highly structured, curriculum-
\
based behavioral modules to learn new skills for adults
with severe mental illness. These curriculums are cur rently
available for purchase (http://www.mentalhealth.
ucla.edu). More recently, psychiatric rehab ilitation skills
training has incorporated cognitive interventions to
compensate for cognitive deficits of this population and to
teach concrete skills in the environment in which they are
to be used (Glynn et al., 2002; Penn & Mueser, 1996;
Velligan, Ritch, Maples, Bow-Thomas, & Dassori, 2002).
Other approaches to rehabilitation focus on improving an
individual's own resources by modifying the environment,
offering supports, or selecting an environment that will
help clients to succeed at their own goals. This may mean
finding a job or housing arrangement that can
accommodate the needs, deficits, and strengths of the
client. The rehabilitation approach includes the provision
of supports, teaching problem solving techniques, as well as
coping skills in situ, and has resulted in the development of
a variety of support models, for example, supported
employment, supported housing, and supported education.
Consumers themselves have developed a number of
peer support approaches, including consumer- operated
services and mutual aid/peer support groups (Clay, 200S). lt
is not surprising that these consumer programs and
practices have close ties to psychiatric rehabilita tion, given
the value placed on empowerment and the history of the
psychosocial center movement be ing founded by
consumers themselves.
Probably the most influential person in the articula tion
of psychiatric rehabilitation practices and values is William
Anthony of the Boston University Center for Psychiatric
Rehabilitation (http://www.bu.edu/cprf). His training was
that of physical rehabilitation and he argued for the equal
status of psychiatric disabilities with physical disabilities.
His writings stress the importance of social skill training as
well as the need to provide environmental supports an d
modifications for
adults with psychiatric disabilities. He was very much a
leader in infusing federal policy initiatives with psy chiatric
rehabilitation practices and orientation. For example, the
federal Community Support Program that influenced
program models, practices, and philosophy of serving
adults with severe mental illness in the com munity from
1980 to early 2000 came from the writings and the work of
Anthony and his Center staff as well as the psychosocial
center directors (Corrigan et al., 2008). The philosophies
were client-centered, strengths- based approaches, respect
for the client, and client self- determination. The most
recent policy promotion of the federal government to
transform the mental health system to a recovery
orientation which emerged from the President's New
Freedom Commission on Mental Health (2003) was
initially articulated by Anthony in the early 1990s .
However, consumers had been writing personal stories of
recovery for years. Recovery in this context does not mean
cure or cessation of signs, symptoms, and functional
disabilities associated with psychiatric illnesses, but it
refers to identifying, selecting, and pursuing goals that are
personally meaningful and important to the individual,
despite the symptoms of the illness and the resulting
disability (Solomon & Stanhope, 2004). "[A] recovery
orientation consists of changing the nature of the rela-
tionship between providers and service recipients to enact
power-sharing, addressing the need for providers to
subscribe to hope in their dealings with recipients,
incorporating individualization in treatment (recovery)
planning through recipient goal-setting, and strength ening
recipients' autonomy rather than promoting increased
dependence" (Felton, Barr, & Clark, 2006, pp. 112-113).
Psychosocial Evidence-Based Practices for
Adults With Severe Mental Illness
For years, the Community Support Program put forth
monographs promoting certain program models for
working with adults with severe mental illness. Many of
these made good clinical and experiential sense, given the
needs of the population. However, all too frequently these
interventions lacked empirical evi dence to warrant saying
that they were truly effective in reaching desirable
outcomes for those with psychia tric disabilities. Since
early 2000, five psychosocial in terventions have achieved
the level of evidence-based practice (EBP) and all fall
within the domain of psychiatric rehabilitation (Drake,
Merrens, & Lynde, 2005). These EBPs are assertive
community treatment, family psychoeducation, supported
employment, illness management and recovery (IMR) , and
integrated dual disorders treatment, and each will be
described here.

The Substance Abuse and Mental Health Services Ad-
ministration has developed draft toolkits to assist in their
implementation and is currently in the process of finalizing
them (http://mentalhealth.samsa.gov/ cmhs/ communi
tysupport/too lkitsf).
ASSERTIVE COMMUNITY TREATMENT The most
well-known of the EBPs is assertive community treat ment,
which was developed by Stein and Test, a psy chiatrist and
a social work faculty member, respectively. Assertive
community treatment is a self-contained, com prehensive
intervention delivered by a multidisciplinary team
comprising a psychiatrist, nurse, social worker, case
managers, and other specialized professional providers
contingent on client needs, such as substance abuse,
employment, or benefit coanselors. The team provides
social services, rehabilitation, and psychiatric treatment in
the community 24 hours a day, seven days a week to meet
client needs on a time- unlimited basis. The team functions
with a low client-to-staff ratio, shared case loads, and
assertive outreach to clients. The service pro gram is
designed for those with the most severe and persistent
symptoms of mental illness, which is estimated to be about
10-20% of the population served in the public mental
health sector. The team members offer all services,
including medication management, individual supportive
counseling, crisis intervention, and skill and behavioral
training. Numerous systematic reviews (Corrigan et a1. ,
2008) have consistently concluded po sitive outcomes for
decreased hospitalizations, improve ment in stable housing,
consumer and family satisfaction, and cost reduction.
Other positive outcomes-decre ased psychiatric symptoms,
improved social functioning, vo cational functioning,
quality of life, and adherence to prescribed
medication-have been inconsistent (Corrigan et a1.).
F AMIL Y PSYCHOEDUCA TION Family psychoeducation
is an adjunctive intervention for families with a relative
having a severe psychiatric disorder who is involved in
treatment. There are a number of models, but all encompass
providers joining and collaborating with families to develop
an alliance, educating them about their relative's illness,
teaching problem-solving skills, creating social supports for
the family, and assisting in the development of skills to cope
with the relative's illness. One of the models was developed by
two social workers, Anderson and Hogarty (Anderson, Reiss,
& Hogarty, 1986), and another, McFarlane's Multifamily
Groups (McFarlane, 2002), has included involvement of
social workers. Research has found no advantage of one
model of family psychoeducation over another, due to the
similarity in service elements
MENTAL HEALTH: PRACTICE
INTERVENTIONS 235
(Corrigan et a1., 2008). The critical elements appear to be
education, family support, psychopharmacology, case
management for the relative with a psychiatric disorder,
and a minimum of 9-month participation in the
intervention. Strong positive outcomes are fewer relapses,
reduced rehospitalizations, and consequentl y,
cost-effective (Corrigan et al., 2008). There are briefer and
less intensive family educational interventions (where the
ill relative is not required to be in treat ment) that are widely
offered, including one by the National Alliance for Mental
Illness called Family-to Family (www.nami.org}.
However, these educational interventions have not as yet
achieved EBP status.
SUPPORTED EMPLOYMENT Supported employment is
an approach to assist clients to obtain and maintain
competitive jobs consistent with their individual goals,
preferences, strengths, and abilities. A supported em-
ployment team composed of at least two employment
specialists works collaboratively with the mental health
treatment team and assists the client with all stages of
employment-identifying, finding, and maintaining a job
(Drake et al., 2005). The key element is integration of
vocational and mental health services. Other essen tial
elements are rapid job search by beginning job finding
soon after program entry and support provided overtim e,
contingent on client needs and desires. Evi dence has found
higher rates of competitive employ ment when compared
with. those by traditional approaches to vocational
rehabilitation, as well as less time to first job, longer job
tenure, and higher earnings (Drake et a1., 2005).
INTEGRA TED TREATMENT FOR CO-OCCURRING
SUBSTANCE ABUSE DISORDERS This service ap-
proach is to treat both mental illness and substance use
disorders by the same team of providers in the same
location at the same time. The core comp onents of the
service are integration (as opposed to either sequential or
parallel service), comprehensiveness, assertive outreach,
reduction in negative consequences, time- unlimited
service, treatment provision consistent with client's stage of
recovery, use of multiple psychotherapeutic modalities,
and offering a sense of hope (Drake et al., 2005). Research
has found positive outcomes in such domains as substance
abuse, psychiatric symptoms, housing, hospitalizations,
arrests, functional status, and quality of life (Drake et a1. ,
2005).
ILLNESS MANAGEMENT AND RECOVERY IMR is a
series of weekly sessions lasting 3-6 months in which
providers assist clients to develop personal strategies for
coping with mental illness and moving forward with their
236 MENTAL HEALTH: PRAcncE INTERVENTIONS
lives. Frequently, IMR is provided to a group of clients, but
can be offered individually. Consistent with client desires,
family members and other supporters may read educational
handouts, attend sessions, assist clients in developing and
enacting a plan for coping with their symptoms, help to reduce
symptomatic exacerbations of the illness in order to prevent
relapses, and assist in pursuing their recovery goals.
Components of IMR are educating clients about mental
illness, employing strategies to increase medication
adherence, training in relapse prevention and in coping skills
to effectively manage the illness (Drake et al., 2005).
Currently, the limited research on the IMR program entity
indicates promise. However, research on the components of
IMR has found that education about mental illness improves
knowledge; cognitive behavioral interventions, specifically
behavioral tailoring (that is, a system of strategies to
incorporate medication taking into a client's daily routine),
increase medication adherence; relapse prevention programs
decrease relapses and rehospitalizations; and coping skills
training reduces symptomatic behaviors. Evidence is stronger
for the service components than for the program model per se
(Mueser et al., 2002).
Conclusion
Regardless as to which human service sector social workers
are employed, they are likely to encounter this client
population. Involvement in these diversified systems has
generated new practice interventions for the population. For
example, possible loss of a child's custodvhas produced
specialized parenting programs. Currently service
interventions, specifically EBPs, are available on a limited
basis and they address a.minimum of the population's needs.
With further research, emerging best practice interventions,
such as consumeroperated services and family education, will
likely achieve the status of EBPs. The challenge today is to
support the public behavioral health-care system in the
implementation ofEBPs (McHugo et al., 2007).
We have clearly progressed in the realm of service
provision for this highly vulnerable population, but we still
have a long way to go, particularly, since new issues are
continually arising that need to be addressed. Social workers
have played a significant role in the development of these
practice interventions and will no doubt continue to do so, as
they are the primary providers of service for this population.
The main challenge to social work practitioners is to be
knowledgeable about the diversity of psychiatric
rehabilitation interventions, specifically EBPs, and to be
willing and capable to implement them. Another major
challenge is to adapt or develop new innovative and effective
programs to address the needs of the most vulnerable of this
population, those who are involved in the criminal justice
system, and those who are homeless, and to protect mothers
from losing custody of their children.
REFERENCES
Anderson, c., Reiss, n, & Hogarty, G. (1986). Schizophrenia
and the family. New York: Guilford Press.
Anthony, W., Cohen, M., Farkas, M., & Gagne, C. (2002).
Psychiatric rehabilitation (2nd ed.). Boston: Center for
Psychiatric Rehabilitation.
Clay, S. (Ed.). (2005). On our own, together: Peer programs for
people with mental illness. Nashville, TN: Vanderbilt
University Press.
Corrigan, P., Mueser, K., Bond, G., Drake, R., & Solomon, P.
(2008). Principles and practice of psychiatric rehabilitation; An
empirical approach. New York: Guilford Press.
Drake, R., & Sederer, L. (1986). The adverse effects of inten-
sive treatment of chronic schizophrenia. Comprehensive
Psychiatry, 27, 313-326.
Drake, R., Merrens, M., & Lynde, n (Eds.). (2005). Evidence-
based mental health practice. New York: Norton.
Felton, B., Barr, A, & Clark, G. (2006). ACTteam members'
responses to training in recovery-oriented practices.
Psychiatric Rehabilitation Joumal, 30, 112-119.
Glynn, S., Marder, S., Liberman, R., Blair, K., Wirshing, W.,
Wirshing, D., et al (2002). Supplementing clinic-based
skills training with manual-based community support ses-
sions: Effects on social adjustment of patients with
schizophrenia. American Joumal of Psychiatry, 159,829-837.
Hogarty, G., & Goldberg, S. (1973). Drug and sociotherapy in
the aftercare of schizophrenia patients: One-year relapse
rates. Archives of General Psychiatry, 28, 54-64.
Hogarty, G., Goldberg, S., & Schooler, N. (1974). Drug and
sociotherapy in the aftercare of schizophrenia patients: III.
Adjustment of nonrelapsed patients. Archives of General
Psychiatry, 31, 797-805.
Lehman, A., & McGlashan, T. (2006). Remembering Gerard
Hogarty. Psychiatric Services, 57, 1677.
McFarlane, W. (2002). Multifamily groups in the treatment of
severe psychiatric disorders. New York: Guilford Press.
McHugo, G., Drake, R., Whitley, R., Bond, G., Campbell, K.,
Rapp, c., et al. (2007). Fidelity outcomes in the National
Implementing Evidence-Based Practices Project.
Psychiatric Services, 58, 1279-1284.
Mueser, K., Corrigan, P., Hilton, D., Tanzman, B., Schaub, A.,
Gingerich, S., et al. (2002). Illness management and
recovery for severe mental illness: A review of the
research. Psychiatric Services, 53,1272-1284.
Penn, n, & Mueser, K. (1996). Research update on the psy-
chosocial treatment of schizophrenia. American Journal of
Psychiatry, 153,607-617.
Rutman, 1. (1993). And now, the envelope please ... Psycho-
social Rehabilitation Journal, 16, 1-3.
Solomon, P., & Stanhope, V. (2004). Recovery: Expanding
the vision of evidence based practice. Brief Treatment and
Crisis Intervention, 4, 311-321. (Reprinted in Roberts, A., &
Yeager, K. (Eds.). (2006). Foundations of evidence-based
social work practice. New York: Oxford University Press.)

Velligan, P. T., Ritch, J., Maples, N., Bow-Thomas, C., &
Dassori, A. (2002). A randomized single-blind pilot study of
compensatory strategies in schizophrenia outpatients.
Schizophrenia BuUetin, 28, 283-292.
FURTHER READING
Clay, S. (Eds.). (2005). On our own, together. Nashville, TN:
Vanderbilt University Press.
Drake, R., Merrens, M., & Lynde, D. (Eds.). (2005). Evidence-
Based mental health practice. New York: Norton.
Linhost, D. (2006). Empowering people with severe mental iUness.
New York: Oxford University Press.
Pratt, c., Gill, K., Barrett, N., & Roberts, M. (2006). Psychiatric
rehabilitation (2nd ed.). San Diego: Academic Press.
Ralph, R., & Corrigan, P. (2005). Rec~very in mental iUness.
Washington, DC: American Psychological Association.
Sands, R., & Solomon, P. (20(91). Social work curriculum and
psychiatric rehabilitation. Psychiatric Rehabilitation Skills, 5,
405-413.
Solomon, P. (2000). Services for families of individuals with
schizophrenia: Maximizing outcomes for relatives. Disease
Management and Health Outcomes, 8, 211-221.
Solomon, P. (2004). Peer support/peer provider services:
Underlying process, benefits, and critical ingredients. Psy-
chiatric Rehabilitationloumal, 27,392-401.
Solomon, P. (1996). Moving from psychoeducation to family
education for families of adults with serious mental illness.
Psychiatric Services, 47, 1364-1370.
SUGGESTED LINKS
http://mentalhealth.samhsa .gov/cmhs/communitysupport/
toolkits/
http://www . bu .edu/epr/ http://www
. iccd.org/default .aspx http://www .
mentalhealth. ucla.edu
- PHYLLIS SOLOMON
MENTAL ILLNESS. [This entry contains three suben tries:
Adults; Children; Service Systern.]
ADULTS
ABSTRACT: This entry focuses on serious mental illness
among adults, including those having serious and
persistent mental illness. Social work's historic and current
roles in service delivery are reviewed, its present trends in
the field (including the recovery movement,
evidence-based practices, comorbidity, and the integra tion
of physical and mental health), as well as the service
delivery system and the current needs and challenges it
faces, are discussed.
KEY WORDS: serious mental illness; serious and per sistent
mental illness (SPMI); evidence-base d practice; recovery
movement; comorbidity; mental health
MENTAL ILLNESS: ADULTS
237
Mental illness touches most American families when one
considers that in any given year almost one-quarter of the
U.S. adult population has a diagnosable mental disorder.
Of these adults, 5-6% are considered seriously mentally ill
(SMI), with almost 3% having a serious and persistent
mental illness (SPMl) (Kessler, Berglund, Glantz et al.,
2004). The Surgeon General's Report on Mental Health
(U.S. Public Health Service, 1999) defines SMI as
applying to mental disorders that interfere with some area
of social functioning. SMI includes bipolar disorders,
severe forms of depression, obsessivecompulsive disorder,
panic disorder, and schizophrenia.
With millions of adults being diagnosed with one or
more mental disorders each year, it is critically important
for social workers to be able to diagnose and treat this
at-risk and vulnerable group. To stabilize these
individuals, while reducing symptoms and facilitat ing
recovery, it is imperative that social workers be trained in
crisis intervention, groupwork, problem-solving skills,
cognitive remediation, case-monitoring, case man-
agement, and vocational rehabilitation (Burgess &
Roberts, 2005).
Millions of adults encounter potentially crisisinducing
events that they are unable to cope with on their own. The
most vulnerable individuals are those with preexisting
chronic mental and psychiatric disorders (for example,
bipolar disorder, obsessive-compulsive disorder,
schizophrenia, and psychosis). Crisis intervention
frequently leads to early resolution of acute crisis episodes,
while providing early intervention and a turning point so
the individual can learn to use new resources and coping
skills in order to regain their equilibrium and social
functioning (Roberts, 2005). For detailed information on
crisis assessment and intervention, see the entry on Crisis
Intervention in this volume.
We have come a long way since the 1700s when
persons with mental illness were warehoused in over-
crowded jails and poorhouses, and punished and de graded
in dungeon-like institutions. There were only a few
advocates in the late 1700s and 1800s, such as Dr. Philippe
Pinel in France, William Tuke in England, Dr. Benjamin
Rush in the United States, and social reformer and social
worker Dorothea Dix, whose tireless legislative advocacy
led to the funding of 32 state mental hospitals, which
emphasized humane care of the mentally ill during the
1800s. The most dramatic changes in the care of the
mentally ill came with the de institutionalization
movement of the 1960s, the passage of the Community
Mental Health Center Act in 1963, and the rapid
proliferation of mental health advocacy coalitions since
mid-1970s (Burgess & Roberts, 2005; Roberts & Kurtz,
1987). In fact, as of 2007, there
238 MENTAL ILLNESS: ADULTS
were several thousand mental health advocates who have
been trained as volunteers and full- time staff at county and
statewide Mental Health Associations (MHAs) and
National Alliance of the Mentally III (NAMI) chapters
nationwide. Many of the executive directors ofNAMI and
MHA organizations are MSWs. The two largest groups of
mental health advocates are family members of the
mentally ill and social workers.
Historic and Current Role
and Contributions to Service Delivery
The discovery of psychotropic medications to address the
serious symptoms of mental illness contributed to the de
institutionalization of the mentally ill in the United States
in the 1950s and 1960s (Geller, 2000).
\
This movement resulted in many institutions being
closed as individuals with serious mental illness were
integrated back into their communities to live and r eceive
community-based treatment. In the 1970 s the United
States moved from a community mental health center
approach to a community support model, which is still the
dominant model of treatment today. The community
support .model combines the latest discov eries in
psychotropic medications and evidence- based
psychosocial interventions to address the social welfare
needs of individuals with mental illness in becoming
citizens in their community when given support and
access to mainstream resources such as h ousing and
vocational opportunities (Goldman, 1998). An exten sion
of this model is the volunteer support network of
individuals with mental illness or "consumers" , forming
their own networks for support and advocacy and
embracing a recovery model of treatment.
Moving from a strong hospital-based service system to
a community-based service system, which empha sizes
coordination of services to help maintain indivi duals in
the community, significantly reduced the number of
inpatient hospitalization. Certai nly this was the goal of
such a transformation of service delivery for not only
financial savings but also from a human rights
perspective. The movement has been successful with both
the frequency and duration of inpatient hospitali zations
having been dramatically reduced (Geller, 2000). But with
such success has also come some unin tended
consequences, often the result of an inadequate funding
stream that has remained flat or in fact de creased in recent
years due to national budgetary policy and the effe cts of
inflation. Thus, the result of this underfunded
transformation of service delivery is a fragmented mental
health delivery system with an increase in the number of
mentally ill homeless (Mechanic & Rochefort, 1990), a
shortage of inpatient beds (Salinsky & Loftis, 2007), high
rates of
unemployment and disability among persons with ser ious
mental illness (Crowther, Marshall, Bond, & Huxley,
2001), lack of effective care for older adults with mental
illness (President's New Freedom Commission on Men tal
Health, 2003), and a lack of parity in private health
insurance between physical health benefits and mental
health benefits (Hennessy & Goldman, 2001). Certainly
the role of social and legislative advocacy is critical for
social workers delivering ser vices to the serious mentally
ill.
Trends
The major trends that have influenced policy and ser vice
delivery across the United States include the following:
1. Recovery movement: A continuation of the growth and
strength of the recovery movement among consumers
seeking to assure that the services they receive are
consumer-driven and responsive to their goals, hopes,
and dreams (Anthony, 2000);
2. Managed care: As a response by states to cost control
there is an increasing trend across the country to include
behavioral health within state Medicaid managed care
plans (U.S. Public Health Service, 1999). Previously,
behavioral health tended to be carved out of managed
care plans and paid for on a fee-for-service basis. The
inclusion of behavioral health in these Medicaid
managed care plans will need to be followed in terms of
both outcomes and quality of services provided to
individuals withSPMI;
3. Integration of physical and mental health: Recent re-
search has confirmed that individuals with SPMI have
on average a 2S-year shorter lifespan than the
non-SPMI citizen (Parks, Svendsne, Singer et al., 2006).
Some of this dramatic decrease in longevity is
associated with obesity and related heart disease,
metabolic side effects related to newer psychotropies,
and the high rate of smoking among individuals with a
SPMI. Given these factors and the recognition that often
an individual's mental illness becomes the sole medical
focus of those practitioners treating them, a major trend
across the country is focusing on how to better integrate
treatment of both physical and mental health needs of
consumers who have SPMIj
4. Co-occurring disorders: Integrated dual diagnosis
treatment: Approximately 50% of individuals with
SPMI abuse substances (Torrey et aI., 200l). The
research has increasingly demonstrated that effective
treatment requires mental health and substance abuse
services to be provided by a single

multidisciplinary team providing services within the
same setting. Historically the treatment of mental
illness and substance use have been highly
compartmentalized and fragmented. Many states are
beginning to address the need for truly integrated
treatment by changes in both policy regula tion and
financing models;
5. Evidence-based practices: Since the mid-1990s, there
has been a rapid sweeping demand for services that
are based on the best science available. Governments
as well as private insurance com panies are expecting
providers to be retooling their practice to include the
best available evidence-based practices (EBPs).
There is strong consensus that this is clearly in the
best interest of consumers but there :ire obstacles at
the provider level that have to be addressed and
resolved (Wolfe, 1999). These include a lack of
financing by government and third party payers to
support the cost of delivering EBPs; clinician
resistance to retooling their skills in order to deliver
EBPs with reasonable fidelity to the researched
practice model; concern among providers that some
EBPs are based on research with populations who do
not have the cornorbidity issues that consumers deal
with on a daily basis within treatment programs; and
inadequate resources available to support the cost of
retraining the practitioner workforce in an EBP
(Wolfe, 1999). This is further complicated by many
schools of social work not recognizing the need to
retool their own academic content to match the
contemporary need for students who have both an
understanding and openness to embracing lifelong
learning required for EBP.
The Recovery Movement
The concept of recovery is having a major impact on the
delivery of mental health services across the coun try. The
movement began in the late 1980s through the writings of
individuals with mental illness who detailed their
improvement with the assistance of treatment. They
highlighted reduced symptoms, improving self-esteem,
and regaining both the quality of and control of their lives.
Their observations were supported by empirical research
that showed a generalized improved course of outcomes
for many individuals in treatment as interventions
advanced and improved (Deegan, 1988).
While there is no single agreed-upon definition of
recovery, the President's New Freedom Commission on
Mental Health (2003) defined it as the process by which
people are able to live, work, learn, and participate fully in
their communities. For some individuals, recovery is
MENTAL ILLNESS: ADULTS
239
the ability to live a fulfilling and productive life despite a
disability. For others, recovery implies the reduction or
complete remission of symptoms.
The accomplishments of the consumer advocacy
groups over time have been many as they have had a very
discerning impact on mental health services, leg islation,
and research (U.S. Public Health Service, 1999). For
example, consumer groups and their families have had a
great impact at the national and state policy level by
establishing the priority that mental health services be
adapted to meet individual needs. They have a strong role
in every state in every dimension of planning delivery and
evaluation of mental health services (U.S. Public Health
Service, 1999).
SAMSHA Identified EBPs
In 2002 the Department of Health and Human Services,
Substance Abuse and Mental Health Services Adminis-
tration (SAMHSA, 2002), Center for Mental Health
Services, began their release of implementation resource
kits to speed the adoption of six practices that were
identified by a consensus panel of researchers, clinicians,
administrators, consumers and family advocates as cur-
rently evidencing a strong evidence base for treatment of
SPMI. A strong commitment to recovery principles are
included in each of the following toolkit practices.
• Standardized pharmacological treatment Much research
has gone into establishing appropriate medication
guidelines, including the appropriate use of the
newer atypical antipsychotic medications. Following
appropriate medication guidelines can reduce
hospitalizations and symptoms for consumers with
severe and persistent mental illness.
• Illness management and recovery skills This program
places a strong emphasis on helping consumers set
and pursue personal goals and to implement plans of
action in daily living. Skills taught within this
program include recovery strategies, practical facts
about mental illness, the stress-vulnerability model
and strategies for treatment, building social support,
using medication effectively, reducing relapses and
coping with stress, coping with problems and
symptoms, and getting need met in the mental health
system.
• Supported employment Supported employment is an
approach to helping consumers with mental illness
find and retain competitive employment in the
community. The program model includes emp-
loyment specialists who work closely with both the
consumers and employers to support positive
outcomes in the workplace. Key principles of this
program model include eligibility based on consumer
choices and preferences, supported
240 MENTAL ILLNESS: ADULTS
employment asan integrated treatment, continuous
follow-along supports, and help with moving beyond
patient role and developing new employment related
roles as part of the recovery process.
• Family psycho-education The program emphasizes a
partnership between consumer, family members,
practitioners, and supporters. Strategies include re-
lationship building, problem solving, education, col-
laboration, family-to-family group support, and an
atmosphere of hope and cooperation. Activities in-
clude learning about mental illness; learning new
ways of mastering mental illness; reducing tension
and stress within the family; overcoming obstacles of
being a caregiver, teaching coping and social skills to
siblings and parents bf patients, providing social
support and encouragement to each other; focus on
the future; and finding ways for family and
supporters to help the consumer with their mental
illness.
• Assertive community treatment Assertive community
treatment focuses on strategies to help consumers
remain out of the hospital, increase their skills of
daily living, and to reduce the need for thei r mental
illness to be their primary daily struggle. Services
include a 24 x 7 multidisciplinary team of practi-
tioners who deliver customized services to the con-
sumer in natural settings in the community. The
program focuses on symptom management, housing,
finances, employment, medical care, substance
abuse, family life, and activities of daily life. Unfor-
tunately, because of the costs of having social work-
ers available 24 x 7, ACT teams only currently
operate in one dozen states, and about 100 counties
and cities nationwide. This program has been found
to be cost-effective and cost-saving in preventing
numerous long-term hospitalizations, and therefore
should be expanded nationwide.
• Integrated dual disorders treatment This program is for
consumers who have co-occurring disorders (mental
illness and substance abuse addition). Effective
treatment approaches include addressing these dual
disorders with one treatment team in one setting. The
approach includes individualized treatment, based on
the consumer's current stage of recovery; education
about the illness; case management; hous ing
assistance; money management; relationships and
social supports; and counseling designed especially
for consumers with co-occurring disorders.
Service Needs
The President's New Freedom Commission concluded in
2003 that indeed the mental health delivery system was
severely fragmented, unnecessarily complex, and
financially wasteful. Envisioning a public and private
mental health system that was recovery focused, the re port
recommended a transformation of the entire system to
eliminate the barriers and problems identified so as to
better meet the service needs of individuals with mental
illness. The report's recommendations identified the
following service needs:
• Early mental health screening, assessment, and
referral to services
• Understanding that mental health is essential to
overall health
• Mental health care that is consumer- and family-
driven
• Disparity in mental health needs eliminated
• Technology used to access mental health care and
information
• Excellent mental health care delivered and research
accelerated.
Service Challenges and Dilemmas
To transform the current system of care, there will need to
be national action on establishing mental health as a
priority and funding the system of care at a level that
allows the recovery of individuals with mental illness to be
effectively supported throughout the lifespan by EBPs.
Within this framework of priorities the need to address
effectively both the physical health and mental health of
individuals with SPMI will require aggressive action and
financing to prevent the catastrophic morbidity that
historical lack of attention has allowed. A corresponding
transformation that needs to occur in order to support an
effective system of care is identifying the ways in which to
attract both increased numbers of psychiatric social
workers and other medical professionals committed to this
area of service delivery.
Implications for Social Work
Practice and Research
The future of mental health care and treatment in the
United States is very promising. Pharmacological devel-
opments, new technology, and best practices based on
evidence-based studies provide strong documentation of
the effectiveness of emerging assessment, community
support, and treatment protocols. However, achieving our
hopes, goals, and challenges can only become a reality in
the future with increased federal and state funding of
community-based day treatment, 'service de livery, and
research to the millions of individuals suffering from
comorbid mental disorders each year.
Given the trends, service needs, challenges, and
dilemmas outlined in this entry there are several sig.
nificant implications for social work practice and re search.
These include the following:

1. Practitioners and schools of social work need to embrace
content in their practice and classrooms that acquire and
teach the skills necessary to deliver EBP services. This
will require motivation, time, effort, and money to
retrain these workforces;
2. Practitioners and schools of social work need to become
expert in understanding the new reality of the recovery
movement as public policy, legislation, regulations, and
practice realities will all need to be consistent with a
consumer-driven service delivery system;
3. Social work researchers, in light of the emphasis on
development of EBPs that .rely on randomized clinical
trials as the gold standard, will need to increasingly
utilize ~uch methodology in their own research designs;
4. On average, a 17 -year gap exists between research that
shows effective treatments and those treatments being
broadly available at the provider level (Institute of
Medicine, 2001). As a result, social work researchers
and their interdisciplinary colleagues need to design
strategies to significantly reduce lag time between
scientific findings and practitioner utilization. This
challenge can be partially addressed by social work
researchers forming strong collaborative partnerships
with provider agencies that facilitate and expedite
research to practice and practice to research; and
5. Given the amazing advances in neuroscience and
psychopharmacology, and its interrelationship . with
behavior and mental health, it is imperative that the field
of social work increases its understanding of the
neuroscience of the brain and new psychiatric
medications, and how the latest advances will
increasingly effect the delivery of EBPs and behavioral
health services in the future (Aron & Zimmer, 2005).
The implications of these rapid neuroscience advances
(for example, diagnostic imaging, electrical implants)
would suggest that the field of social work will have to
grapple with the increasing medicalization of the
delivery of behavioral health services. Absent an
effective response to the neuroscience advances, the
field of social work could quickly be left behind in one
of its key practice areas.
REFERENCES
Anthony, W. A. (2000). A recovery-oriented service system:
Setting some system level standards. Psychiatric Rehabilita-
tionJournal, 24(2),159-167.
MENTAL ILLNESS: AOUL TS 241
Aron, L., & Zimmer, C. (Eds.). (2005). The new frontier:
Neuroscience advancements and their impact on nonprofit be-
havioral health care providers. Milwaukee, WI: Alliance for
Children & Families.
Burgess, A. W., & Roberts, A. R. (2005). Crisis intervention for
persons diagnosed with clinical disorders based on the
stress-crisis continuum. In A. R. Roberts (Ed.), Crisis intervention
handbook: Assessment, treatment and research (3rd ed., pp.
120-141). New York: Oxford University Press.
Crowther, R. E., Marshall, M., Bond, G. R., & Huxley, P. (200l).
Helping people with severe mental illness to obtain work:
Systematic review. British Medical Journal, 322,204-208.
Deegan, P. E. (988). Recovery: The lived experience of rehabilitation.
Psychosocial Rehabilitation Journal, 11 (4), 11-19.
Geller,]. L. (2000). Psychiatric services as reflected in psychiatric
services. Psychiatric Services, 510), 41-67.
Goldman, H. H. (1998). Deinstitutionalization and community care:
Social welfare policy as mental health policy. Harvard Review of
Psychiatry, 6, 219-222.
Hennessy, K. D., & Goldman, H. H. (200l). Full parity: Steps toward
treatment equity for mental and additive disorders. Health Affairs,
20(4), 58-67.
Institute of Medicine. (2001). Crossing the quality chasm: A new
health system for the 21 st century. Washington, DC: National
Academies Press.
Kessler, R. C, Berglund, P. A., Glantz, M. D., et al. (2004).
Estimating the prevalence and correlates of serious mental illness
in community epidemiological surveys. In R. W. Manderscheid &
M. ]. Henderson (Eds.), Mental Health, United States, 2002
(DHHS Publication No~ SMA3938). Rockville MD: Substance
Abuse and Mental Health Services Administration, Center
forMental Health Services.
Mechanic, D., & Rochefort, D. A. (1990). Deinstitutionalization: An
appraisal of reform. Annual Review of Sociology, 16, 301-327.
Parks, ]., Svendsne, D; Singer, P., et al. (Eds.). (2006). Morbidity and
mortality in people with serious mental illness.
President's New Freedom Commission on Mental Health. (2003).
Achieving the promise: Transforming mental health care in
America. Final report (Report No. SMA-03-832). Rockville, MD:
U.S. Department of Health and Human Services.
Roberts, A. R. (2005). Bridging the past and present to the future of
crisis intervention and crisis management. In A. R. Roberts (Ed.),
Crisis intervention handbook: Assessment, treatment and research
(3rd ed., pp. 3-34). New York:
Oxford University Press.
Roberts, A. R., & Kurtz, L. (1987). Historical perspectives on the care
and treatment of the mentally ill. Journal of Sociology and Social
Welfare. 14(4), 75-94.
Salinsky, E., & Loftis, C. (2007). Shrinking inpatient psychiatric
capacity: Cause for celebration or concem? National Health Policy
Forum, 823, 1-21.
Substance Abuse and Mental Health Services Administration
(SAMHSA). (2002). About evidence-based practices:
Shaping mental health services toward recovery. Retrieved
September 2, 2007, from http://mentalhealth.samhsa.gov/
cmhs/communi tysupport/too Iki ts/about.asp.
242 MENTAL ILLNESS: ADULTS
Torrey, W. c., Drake, R. E., Dixon, L., Bums, B. j., Flynn, L.,
Rush, A. [., et al. (200l). Implementing evidence-based
practices for persons with severe mental illness. Psychiatric
Services, 52(1), 45-50.
u.s. Public Health Service. (1999). Mental health: A report of the
Surgeon General (DHHS Stock No. 017-024-01653-5).
Rockville, MD: Department of Health and Human Services,
U.S. Public Health Service.
Wolfe,]. (1999). Overcoming barriers to evidence-based practice:
Lessons from medical practitioners. American Psychological
Association, 6( 4 ). 335--448.
-CATHERINE N. DULMUS AND ALBERT R. ROBERTS
CHILDREN
ABSTRACT: The primary focus of the entry is service
\
utilization. As background, the risks for and prevalence
of childhood mental disorders are summarized. Then, the
current children's mental health services system is
described, including the role of non specialty sectors of
care and informal support system s. Service use barriers
and disparities, pathways to services, and strategies to
increase service use are discussed. The conclusion notes
other current issues in child mental health, including the
need to implement evidence-based treatments.
KEY WORDS: child mental health; children's services;
child mental health services; children's service barriers
The Surgeon General's Report on Mental Health de fines
child mental health as the achievement of ex pected
developmental cognitive, social, and emotional
milestones, and the presence of secure attachments,
satisfying social relationships, and effective coping skills
(USDHHS, 1999). Mental health disorders are significant
deviations from developmentally appropri ate emotions,
behaviors, or relationships. Social work ers in many
settings, including mental and general health clinics,
schools, child welfare, and juvenile jus tice, are called
upon to treat youth with mental health disorders or to refer
them to appropriate services (Webb, 2003).
Much recent research, as well as discussion at the
national level, focuses on children's access to and use of
mental health services (Garland, Lau, Yeh, McCabe,
Hough, & Landsverk, 2005; Ringeisen & Hoagwood,
2002; USPHS, 2000). Therefore, this entry takes these
issues as its primary focus. The entry begins with a brief
summary of the prevalence of and risks for child mental
disorders. A description of the children's mental health
service system is then provided. Next, issues of service
access and utilization are discussed. Th ese include the
extent of unmet need, service use disparities, pathways to
and barriers to mental health services, and recent
strategies designed to increase service access and use. The
entry concludes with a brief description of other current
issues in child mental health.
Prevalence and Risks
Approximately 20% of children and adolescents have a
psychiatric diagnosis. Anxiety and disruptive disorders
are some of the more frequent disorders. About 5-7% of
children have a serious emotional disturb ance (SED). In
addition to a diagnosis, these children experience
impairment that substantially interferes with and limits
their functioning in family, school, or community ac-
tivities (U.S. Government, 1993).
The influences on children's mental health an d the
development of disorders are multiple, interactive, and
complex. They include both biological and envi ronmental
factors and occur at different systemic levels, including
the child, family, and community (Menaghan, 1999 ;
USDHHS, 1999). Assessment and treatment planning
must take into account the social and cultural environment
and developmental stage of the child. Risk factors for
mental health disorders in clude living in poverty (and its
attendant stressors), parental mental illness or substance
abuse, insecure attachments with caregivers, marital and
family discord, child abuse, early trauma, and living in
dangerous and resource-poor neighborhoods. Likewise,
certain factors protect children who are at risk for
developing mental disorders, including a warm and caring
family environment, high self- esteem, the availability of
adult role models, and supportive schools and
communities. Much remains to be learned about the
specific processes by which children develop mental
health problems, whether and ho w these processes vary
across disorders, and whether and how they vary for
children from different backgrounds and cultures.
Service System
Mental health services for children have their origins in
juvenile justice.
In the late 19th century, the juvenile courts in Bos ton
and Chicago recognized the need to house juvenile
offenders separate from adults and to make efforts to
rehabilitate them (Pumariega, Winters, & Huffine, 2003).
These early court services were the forerunner to child
guidance clinics. Several sources (Lourie & Ira, 2003;
Pumariega, Winters, & Huffine, 2003) describe in detail
the development of the child mental health service system
from its initial efforts to reform juvenile delinquents to the
current system, which is guided by "system of care"
principles.
The landmark study by Jane Knitzer (1982, Unclaimed
Children), supported by the Children's

Defense Fund, documented the lack of community services
for children with SED, the over-reliance on institutional
care, and the lack of coordination among children's service
agencies. Earlier reports had also noted gaps and
inadequacies in children's mental health services. These
calls for reform resulted in sev eral federal initiatives to
help states and communities develop community-based
services for children and their families. These included the
Child and Adolescent Service System Program (CASSP)
in 1984 and the Comprehensive Community Mental
Health Service for Children and their Families program in
1992. The "system of care" philosophy guided these
initiatives. Systems of care are comprehensive and coordi-
nated services designed to meet the multiple needs of
children with SED and their families. Beth Stroul and
Robert Friedman outlined the guiding principles for the
development of community-based systems of care (Stroul
& Friedman, 1986). These include that services are
family-focused, individualized, culturally competent, least
restrictive, and coordinated, with parents and families as
full partners with professionals in treatment planning and
decision-making processes. Homebased services, intensive
case management, and wraparound services were
implemented in an attempt to keep children in their homes
and to reduce hospitalization and out-of-home placement.
The mental health service system for children con sists
of an array of services and extends beyond specialty
mental health treatment (Stroul & Friedman, 1986). Many
children with mental health disorders receive services from
agencies whose primary purpose is other than that of
treating mental health problems. Nonspe cialty mental
health services include those provided by the education,
child welfare, juvenile justice, and general health care
sectors.
A recent study in Cook County found that 63 and 71 %
of male and female juvenile detainees, respectively, had a
mental health disorder with impairment (Teplin, Abram,
McClelland, Dulcan, & Mericle, 2002). Numerous studies
have found that children in the public child welfare system,
including those in foster care, have mental health problems
and that many do not receive mental health treatment. The
Individuals with Disabilities Education Act requires
schools to provide special education and related services,
such as counseling, to children with emotional and
behavioral disturbances. Schools are referred to as the "de
facto" mental health system for children and adolescents
because of the number of children with mental health
disorders who receive services in the school (Hoagwood &
Erwin, 1997). In fact, schools are the only source of help
for some children with mental disorders.
MENTAL ILLNESS: CHILDREN
243
Natural support systems, as well as alternative and
non-traditional sources of care, are important components
of the system of care, and are especially relevant for
ethnic-minority children. A study by McMiller and Weisz
(1996) found that, compared with Caucasians, African
American and Latino families were less likely to seek help
for child problems from formal mental health agencies and
were more likely to seek help from informal sources,
including family, friends, neighbors, and clergy.
Culturally sensitive services take into ac count contextual
factors and complement, rather than supplant, the informal
and alternative resources that are available to and valued
by families (Pumariega, 2003).
Service Access and Utilization
Despite changes in the service system over the last 25
years, approximately 60-80% of children with mental
health disorders do not receive treatment. Moreover, ethnic
minorities are less likely to receive services for their
mental health problems, or to receive more restric tive
services, than are Euro-American children.
BARRIERS TO SERVICES Service use barriers exist at
every level, including the child, family, agency, and
community. Owens and colleagues (2002) described three
categories of barriers: (1) structural, including waiting
lists, transportation problems, lack of insurance, and
inconvenient agency hours, (2) perceptions about
problems, including parent inability to identify problems,
and (3) perceptions about mental health services, including
stigma, prior negative experiences with services, and
child's refusal to use services. The stresses of daily living,
especially for lower-income families, and parent mental
health problems are also barriers to children receiving
services. Policies related. to the financing of services
restrict the amount and type of treatment that children
receive. Medicaid, which provides for health care for
low-income children, places limits on treatment duration
and does not uniformly cover in-home services. Moreover,
not all mental health providers will accept Medicaid
reimbursement.
Some studies have found that ethnic-minority chil dren
have higher levels of unmet need for services than do
Caucasian children (Cuffe, Waller, Cuccaro, Purnariega, &
Garrison, 1995; Garland & Besinger, 1997; Garland,
Hough, Landsverk, McCabe, Yeh, Ganger, et al., 2000;
Kataoka, Zhang, & Wells, 2002; Zahner & Daskalakis,
1997). The Surgeon General's Report on Mental Health
points out that it is difficult to interpret these findings,
partly because of knowledge gaps about the prevalence of
psychiatric disorders and impairment in different ethnic
groups. Moreover, cultural beliefs affect problem
identification and
244 MENTAL ILLNESS: CHILDREN
help-seeking behaviors. Nonetheless, although specific
patterns may vary across studies, ethnic- minorities tend to
be overrepresented in more restrictive services and, as
noted, have higher levels of unmet need for mental health
services. A number of reasons can be posited for these
disparities. Histories of and experiences with oppression
and discrimination can lead to mistrust of mainstream
mental health providers; in addition, practitioners and
agencies may lack knowledge and skill inthe provision of
culturally competent services. Ethnic minority families
may also experience more social and economic hardships
that interfere with accessing and using services. Research
is needed to further understand why these disparities exist
and to develop interventions and policies to improve
service access for all children (Kataoka, Zhang, & Wells,
2002).
PATHWAYS TO SERVICES The concept of "pathways"
refers to the help-seeking process and sequence of con-
tacts to access mental health services. Social networks,
both informal (friends, family) and formal (social agen-
cies, courts), influence the direction of the pathway,
including whether and what services are accessed and
treatment continuance. Parents and other adults, in cluding
social workers in nonspecialty menta l health sectors, play
a primary role in facilitating children's access to mental
health services. The term "gateway provider" refers to
adults whose decisions about chil dren's need for mental
health services strongly influ ence children's pathways
through the service system (Stiffman, Pescosolido, &
Cabassa, 2004).
Identification of need by a parent (or other adult) is' the
first step for children to receive help. (Sometimes
children, especially adolescents, seek help on their own
initiative. Literature, not reviewed here, exists on ado-
lescent help-seeking). Adults vary in their knowledge
about what constitutes "normal" and "abnormal" child
behavior, as well as their ability and willingness to
tolerate and accept difficult behavior. Children with
externalizing behaviors are more likely to be identified as
needing help than are children with internalizing
disorders. Ethnicity and culture affect what child
behaviors parents perceive as problematic as well as
beliefs and attitudes about asking for help (Dixon, 2002 ;
Slade, 2004).
Once a problem is identified, parents must decide
whether and from whom to seek help. The stigma
associated with mental health disorders and services may
prevent parents from contacting mental health specialists.
Rather, parents might discuss their concerns with the
child's pediatrician or teacher, their family physician or
clergy, or their colleagues and neighbors. Children in state
custody are dependent on social
workers and other professionals to identify problems and
make referrals to mental health services. The abil ity of
these gateway providers to identify mental health
problems, guide parents, and facilitate referrals to ap-
propriate services determines whether and when chil dren
receive mental health treatment.
Barriers to services continue to exist even when initial
access is successful, as documented by high rates of
dropping out and not keeping appointments. For example,
a recent study found that 36% of families who requested
services from an urban mental health clinic ne ver came to
an appointment; in a similar sample of families who used
the services, 45% of the scheduled appointments were not
kept (McKay, Pennington, Lynn, & McCadam, 2001).
Families of lower socioeconomic status and ethnic
minority families are more lik ely to drop out of treatment.
Economically and socially disadvantaged families may
have different expectations about what treatment is and
their role in it than do the professionals who provide
treatment. Parent cognitions and attributions about
parenting and child behavior, child and parent rela-
tionships with mental health professionals, and child and
parent perceived treatment acceptability all affect whether
children stay in treatment or drop-out.
STRATEGIES TO INCREASE SERVICE ACCESS
AND USE Children who need but do not receive mental
health treatment will remain at risk for poor outcomes.
Investigators have, therefore, turned their attention to how
to decrease service use barriers and increase ser vice
utilization. Four of these strategies are described later.
Although each has limitations, each also has the po tential
to help children access and use mental health services
(Slade, 2002; Staudt, 2003).
Educating Gateway Providers. Children are more apt
to receive referrals for mental health services when gateway
providers have knowledge of children's problems and
community resources (see Stiffman et al., 2001, 2006).
Training and continuing education for professionals who work
with children, about pertinent issues such as assessment
methods and community resources, may increase children's
access to services. Public education and media campaigns
related to childhood disorders and community resources can
provide information to parents (and other adults) and could
possibly reduce the stigma associated with help-seeking.
School-based Mental Health Services. "Schoolbased
mental health services" refers to a variety of prevention and
intervention models based in schools. Most schools have
social workers and other helping professionals, but their roles
may be circumscribed and leave little or no time to provide
treatment to children

with serious mental health problems (Porter, Pearson,
Keenan, & Duval-Harvey, 2003). Therefore, some
schools contract with mental health specialists to pro-
vide on-site services. Research findings show that,
compared with the usual practice of referring children
and families to community clinics, school-based mental
health services significantly increase receipt of mental
health treatment. Despite their promise, many schools,
especially rural and small schools, do not have school-
based mental health services (Slade, 2003).
Culturally Competent Services. It is a truism to
state that social workers in all settings need to be
culturally competent. Unfortunately though, too often
child and family cultural beliefs about acceptable
treatments or the use of alternative healing methods
are not assessed. Social workers can use eco- maps and
culturagrams to learn about the family's informal
supports and cultural beliefs and values. The
establishment of ethnic-specific centers, designed to
serve a specific ethnic community, is also a strategy to
ensure the provision of culturally competent services.
Yeh, Takeuchi, and Sue (1994) studied ethnic-specific
centers for Asian American children. In terventions
were specific to the Asian culture, language, and
values (for example, sensitivity to shame, and family
involvement). Asian American children using services
from the ethnic-specific center dropped out less and
had better outcomes than their counterparts who used
services from a mainstream center.
Engagement Interventions. The goal of engage-
ment interventions is to help children and families
keep appointments and stay in treatment (Staudt,
2003). Common components include: (1) addressing
practical problems and daily stresses, (2) eliciting
child and parent view of the problem, the goals,
treatment expectations, and prior experiences with
services, (3) explaining what treatment consists of and
the roles of practitioners and clients, (4) addressing
class/ethnic differences that could interfere with the
helping relationship, (5) asking about the role of
family and significant others and enlisting them to
support children and parents, and (6) asking what will
interfere with keeping appointments and
problem-solving these obstacles. Compared with
services as usual, engagement interventions increase
retention and appointment keeping. However, even
among families who received engagement
interventions, the rate of premature termi nation
ranged from 17 to 29%, and 26-51 % of the
appointments were missed.
Other Issues and Trends
Research shows that well-developed systems of care
result in improved access to services and lower rates of
MENTAL IllNESS: CHILDREN 245
out-of-home placement and hospitalization (Bickman,
1996). However, they do not necessarily result in better
outcomes for children and families. Interest has there-
fore turned to increasing intervention research and to
implementing evidence-based treatments in commu nity
settings. Evidence is accumulating about effective
treatments and interventions for children with men tal
disorders (Burns, Hoagwood, & Mzrazek, 1999; Kazdin
& Weisz, 2003). However, the treatments that result in
positive outcomes for children in efficacy research do
not always show the same positive results when
implemented in community settings. Researchers are
continuing to investigate the factors that affect the
effective dissemination and implementation of evi-
dence-based treatments in "real-world" settings. As
research on evidence-based treatments advances, it must
proceed hand in hand with research on services
utilization (Ringeisen & Hoagwood, 2002). Issues of
service access and use matter little if effective treat ments
are not available. Likewise, the availability of effective
treatments makes little difference if children and
families can not access them.
Another related line of inquiry is how the culture and
climate of organizations impacts service quality and
subsequent child and family outcomes. In addition,
much more needs to be learned about the needs of
parents of children with mental disorders and how to
best help them help their children. Finally, policies that
provide equitable resources to all and reduce poverty
will go far in advancing the mental health and wellbeing
of children and their families.
REFERENCES
Bickman, L. (1996). A continuum of care: More is not always
better. American Psychologist, 51, 689-701.
Bums, B. J., Hoagwood, K., & Mrazek, P. J. (1999). Effective
treatment for mental disorders in children and adolescents.
Clinical Child and Family Psychology Review, 2, 199-254.
Cuffe, S. P., Waller, J. L., Cuccaro, M. L., Pumariega, A. J., &
Garrison, C. Z. (1995). Race and gender differences in the
treatment of psychiatric disorders in young adolescents.
Journal of the American Academy of Child and Adolescent
PsychiatTy, 34, 1536-1543.
Dixon, A. (2002). Culturally competent practices with children
and youth who have serious emotional disturbance. In
Handbook of serious emotional disturbance in children and
adolescents (pp. 77-92). New York: John Wiley & Sons.
Garland, A. F., & Besinger, B. A. (1997). Racial/ethnic differences
in court referred pathways to mental health services for
children in foster care. Children and Youth Services Review, 19,
651-666.
Garland, A. F., Hough, R. L., Landsverk, J. A., McCabe, K. M.,
Yeh, M., Ganger, W. C, et al. (2000). Racial and ethnic
246 MENTAL ILLNESS: QULDREN
variations in mental health care utilization among children in
foster care. Children's Services: Social Policy, Research, and
Practice, 3, 133-146.
Garland, A. F., Lau, A. S., Yeh, M., McCabe, K. M., Hough, R. L.,
& Landsverk, J. A. (2005). Racial and ethnic differences in
utilization of mental health services among high-risk youths.
American Journal of Psychiatry, 162, 1336-1343.
Hoagwood, K., & Erwin, H. D. (1997). Effectiveness of school-
based mental health services for children: A 1 O-year research
review. Journal of Child and Family Studies, 6, 435-451.
Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for
mental health care among u.s. children: Variation by ethnicity
and insurance status. American Journal of Psychiatry, 159,
1548-1555.
Kazdin, A. E., & Weisz, J. R. (2003).' Evidence-based psy-
chotherapies. New York: The Guilford Press.
Knitzer, J. (1982). Unclaimed children. Washington, OC:
Children's Defense Fund.
Lourie, 1. S. (2003). A History of Community Child Mental Health.
In A. J. Pumariega, et al. (Eds.), The handbook of child and
adolescent systems of care: The new community psychiatry (pp.
1-16). San Francisco: jessey-Bass.
McKay, M., Pennington, J., Lynn, C. J., & McCadam, K. (2001).
Understanding urban child mental health service use: Two
studies of child, family, and environmental correlates. Journal of
Behavioral Health Services and Research, 28, 475-483.
McMiller,W. P., & Weisz, J. R. (1996). Help-seeking preceding
mental health clinic intake among African-American, Latino,
and Caucasian youths. Journal of the American Academy of Child
and Adolescent Psychiatry, 35, 1086-1094.
Menaghan, E. G. (1999). Social Stressors in Childhood and
Adolescence. In A handbook for the study of mental health:
Social contexts, theories, and systems (pp. 315-327). New York:
Cambridge University Press.
Owens, P. L., Hoagwood, K., Horwitz, S. M., Leaf, P. J., Poduska,
J. M., Kellam, S. G., et al. (2002). Barriers to children's mental
health services. Journal of the American Academy of Child and
Adolescent Psychiatry, 41, 731-738.
Porter, G. K., Pearson, G. T., Keenan, S. & Duval-Harvey, J.
(2003). School-based mental health services: A necessity, . not
a luxury. In The handbook of child and adolescent systems of care
(pp. 250-275). San Francisco, CA: [ossey-Bass.
Pumariega, A. J. (2003). Cultural competence in systems of care for
children's mental health. In The handbook of child and adolescent
systems of care (pp. 82-104). San Francisco, CA: [ossey-Bass,
Pumariega, A. J., Winters, N. c., & Huffine, C. (2003). The
evolution of systems of care for children's mental health:
Forty years of community child and adolescent psychiatry.
Community Mental HealthJourna~ 39, 399-425.
Ringeisen, H., & Hoagwood, K. (200n Clinical and research
directions for the treatment and delivery of children's mental
health services. In Handbook of serious emotional disturbance in
children and adolescents (pp. 33-55). New York: John Wiley &
Sons.
Slade, E; P. (2004). Racial/ethnic disparities in parent perception
of child need for mental health care following school
disciplinary events. Mental Health Services Research, 6, 75-92.
Slade, E. P. (2003). The relationship between school charac-
teristics and the availability of mental health and related health
services in middle and high schools in the United States. The
Journal of Behavioral Health Services and Research, 30, 382-392.
Slade, E. P. (2002). Effects of school-based mental health
problems on mental health service use by adolescents at school
and in the community. Mental Health Services Research, 4,
151-166.
Staudt, M. M. (2003). Helping children access and use services: A
review. Journal of Child and Family Studies, 12, 49-60.
Stiffman, A R., Striley, c., Horvath, V. E., Hadley-Ives, E.,
Polgar, M., Elze, D., et al. (2001). Organizational context and
provider perception as determinants of mental health service
use. The Journal of Behavioral Health Services & Research, 28,
188-204.
Stiffman, A. R., Freedenthal, R. S., Dore, P., Ostmann, E.,
Osborne, V., & Silmere, H. (2006). The role of providers in
mental health services offered to American-Indian youths.
Psychiatric Services, 57,1185--:1191.
Stiffrnan, A R., Pescosolido, B., & Cabassa, L. J. (2004).
Building a model to understand youth service access: The
gateway provider model. Mental Health Services Research, 6,
189-198.
Srroul, B. A, & Friedman, R. M. (1986). A system of care for
children and youth with severe emotional disturbances.
Washington, OC: Georgetown University Child Development
Center, CASSP Technical Assistance Center.
T eplin, L. A., Abram, K. M., McClelland, G. M., Dulcan, M. K.,
& Mericle, A. A. (2002). Psychiatric disorders in youth in
juvenile detention. Archives of General Psychiatry, 59,
1133-1143.
U.S. Department of Health and Human Services. (1999).
Mental Health: A Report of the Surgeon General. Rockville, MD:
U.S. Department of Health and Human Services, Substance
Abuse and Mental Health Services Administration, Center for
Mental Health Services, National Institutes of Health,
National Institute of Mental Health, 1999.
U.S. Public Health Service. (2000). Report of the Surgeon General's
Conference on Children's Mental Health: A National Action
Agenda. Washington, DC: Department of Health and Human
Services.
U.S. Government. (1993). Federal Register, 58, 29425.
Webb, N. B. (2003). Social work practice with children. New York:
The Guilford Press.
Yeh, M., Takeuchi, D. T., & Sue, S. (1994). Asian-American
children treated in the mental health system: A comparison of
parallel and mainstream outpatient service centers. Journal of
CUnical Child Psychology, 23, 5-12.
Zahner, G. E. P., & Daskalakis, C. (1997). Factors associated with
mental health, general health, and school-based service use for
child psychopathology. American Journal of Public Health, 87,
1440-1448.

FURTHER READING
Atkins, M. S., Frazier, S. L., Birman, D., Adil, J. A., Jackson, M.,
Graczyk, P. A., et aL (2006). School-based mental health
services for children living in high-poverty urban commu-
nities. Administration and Policy in Mental Health and Mental
Health Services Research, 33, 14-159.
Farmer, E. M. Z., Bums, B. J., Phillips, S. D., Angold, A., &
Costello, E. J. (2003). Pathways into and through mental
health services for children and adolescents. Psychiatric
Services, 54, 60-66.
Garland, A. F., Hough, R. L., McCabe, K. M., Yeh, M., Wood, P.
A., & Aarons, G. A. (2001). Prevalence of psychiatric
disorders in youths across five sectors of care. Journal of the
American Academy of child and Adolescent Psychiarry,40,409-418.
Staudt, M. (2003). Helping children access and use services.
Journal of Child and Family Studies, 12,49-60.
U.S. Public Health Service. (2000). Report of the Surgeon General's
Conference on Children's Mental Health: A National Action
Agenda. Washington, D.C.: Department of Health and
Human Services.
SUGGESTED LINKS
American Academy of Child and Adolescent Psychiatry
www.aacap.org.
US Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration (SAMHSA) has a
page on child and adolescent mental health
www.mentalhealth.org.
-MARLYS STAUDT
SERVICE SYSTEM
ABSTRACT: This entry describes the extent of the mental
health problem in the United States, trends in treatment
rates; and evidence that public recog nition of mental illness
and related interventions. is increasing both in the United
States and internationally. Em phasis is given to the
structure of the mental health system's major sectors, to the
key roles that social workers play, and to the challen ges
they face, outlined at the conclusion of several sections, in
providing effective and quality care against the complex
backdrop of this system.
KEY WORDS: mental health services system; evidence-
based practice; service access; disparities; financi ng;
e
. mental health specialty sector; general medical sector;
managed care; voluntary support sector; social services
However irrational it may both appear and sometimes in
fact be, and however frustrating for social workers, other
mental health providers a nd mental health care consumers,
the mental health treatment system is, in
MENTAL ILLNES: SERVICE SYSTEM
247
fact, a system. Through custom, regulation, and provi sion
of incentives it encloses social workers and other mental
health professionals in a framework of personal and
organizational relationships, informal norms, and local,
state, and federal policies that influence greatly when, how,
and who receives mental health care.
Social workers have been key players in the mental
health services system from its inception and continue to
serve in many important roles. At a rate of about 35 per
100,000 population, social work is second only to the
counseling profession in the number of clinically active
practitioners (West et al., 2002). Social workers also
provide assistance as administrators, policy makers, and as
researchers. Because they are aware of their clients'
lived-environments and of the day-to-day reali ties of
providing assistance in mental health programs, social
workers are sensitive to operations of the mental heath
treatment system. Moreover, they have a parti cular stake in
seeing thai the system functions in an orderly and
productive fashion.
Landmark Mental Health Reports
Several authoritative reports mark a growing acceptance
that mental illness is something more than ordinary
problems in living and that it is treatable. The most recent
of these was the report by the President's New Freedom
Commission on Mental Health, Achieving the promise:
Transforming mental health care in America (Hogan et al.,
2003). In 1999, the Surgeon General of the United States
issued the first Surgeon General's report on mental health
(U .S. Department of Health and Human Services
[USDHHS], 1999). It discussed the mental health treatment
system clearly and indepth, including its history, current
status, and future prospects. Later, a supplement to the
Surgeon General's report, Mental health: Culture, race,
and ethnicity. A supplement to mental health: A report of
the Surgeon General, focused on racial, cultural, and ethnic
disparities in treatment access and quality of care
(USDHHS, 2001). In 2002, the Institute of Medicine (laM)
issued a report Unequal treatment: Confronting racial and
ethnic differences in health care. Although it emphasized
racial and ethnic differences in general health status and
health care and only touched on mental health, the 10 M
report did address systems-related issues extensively.
Mental Illness and the Mental Health
Treatment System in Global Perspective
International awareness about mental health also has
grown appreciably in recent decades. International per-
spectives serve to highlight the variety of mental health
treatment systems around the world and the differing
248 MENTAL ILLNES: SERVICE SYSTEM
cultural matrices in which they reside. Studying 14
countries, one group of investigators found great diversity
as organizational and. financial characteristics of systems
interacted with a country's cultural characteristics
(Demyttenaere et al., 2004). The International
Consortium on Mental Health Policy and Services was
convened to address international differences. It pre pared
mental health policy guidelines that consider
demographic, economic, and cultural factors in devel-
oping countries' current mental health service systems
(Gulbinat et al., 2004). As Western thinking about mental
health is exported along with mental health treatment
technology, a challenge for clinicians and researchers is to
respect non-Western cultural defini tions of mental health
and indigenous mental-health-
related interventions. \ (Kessler et al., 2005). These data point to a substantial
Mental lllness in the United States
With what size problem must the mental health treatment
system cope? Recent, best epidemiological evi dence
agrees with earlier estimates, underscoring just how
widespread mental health problems are. Consider ing the
12-month period before research interviews conducted
between 2001 and 2003, researchers deter mined that the
rate of mental illness or substance abuse disorder, as
assessed using DSM-IV criteria, was 30.5% among adults
(Kessler et al., 2005). This rate is high, and it has not
changed significantly from the 29.4% rate found during
interviews conducted between 1990 and 1992. Treatment
rates differ between these two time periods, however.
Between 1990 and 1992, only about 20% of adults
identified as suffering from.erno tional disorders received
any treatment, but between 2001 and 2003, almost 33%
received treatment.
Rigorous national estimates of mental disorders for
older adults are lacking, but national estimates are
available for children and youth aged ~ 17. Using a proxy
indicator that does not itself provide a true diag nosis but
is strongly associated with a diagnosis of men tal illness,
researchers (Kataoka, Zhang, & Wells, 2002) reported
that, over the preceding 6 months, between 15% and 21 %
of children suffered from a mental health problem.
However, only about 20% of children and youth
exhibiting treatment need were in fact treated.
Mental illness is associated with considerable role
impairment-inability to relate to friends and family,
school, the world of work, and otherwise to meet day-
to-day responsibilities. About 59% of persons diagnosed
with depression, one of the most widespread forms of
mental illness, report severe or very severe role impair-
ment (Kessler et al., 2003). Because of this high level of
role impairment, the World Health Organization lists
mental illness as one of the world's most socially
burdensome diseases (World Health Organization, 2002 ).
A challenge for the future is to further refine and evaluate
interventions that overcome role impair ment for persons
with treatment needs that, while significan t, are less
severe than those affecting persons with chronic and
persistent mental illness (discussed later).
The Specialty Mental Health Services Sector When
social workers and other trained personnel provide
treatment for mental health problems recognized as such,
they participate in the specialty mental health sector.
Among adults needing mental health treatment, about
9.7% visited a nonpsychiatrist mental health clinician
between 1990 and 1992, and 14.1 % visited a
nonpsychiatrist practitioner between 2001 and 2003
increase in treatment provided to persons in need since
mid-1990s but also indicate that high levels of unmet
treatment needs continue.
Whether public or private, most treatment is pro vided
under managed care. Managed care is heteroge neous,
comprising organization types such as Health
Maintenance Organizations (HMOs) and Managed Be-
havioral Health Care Organizations (discussed later),
clinician selection and management strategies (pre ferred
providers and practice networks), practice man agement
techniques (pretreatment authorization and utilization
review), and incentive management strategies (for
example, capitation, where programs o r providers are paid
per-person rather than as under fee-for-service, per- hour
or procedure, and other risk-
~ transfer strategies) (Rosenthal, Minden, Kimmel,
Henderson, & Manderscheid: 2004).
Managed care has achieved cost control largely by
reducing the number of persons treated in psychiatric
hospitals and reducing the length of inpatient stays
(Frank, McGuire, Norman, & Woodward, 1997). It is
bureaucratic, however, owing to its emphasis on rules and
procedures and its attempts to limit practitioner d iscretion.
It places a premium on being savvy in the ways of the
system. A challenge for social work is to build on its
tradition of advocacy to insure that vulner able clients
receive all benefits they are entitled.
The General Medical Sector
Persons with mental illness often visit general health care
providers and programs for mental health pro blems. They
do this because mental illness occurs in tandem with
physical illness, the stigma that is asso ciated with general
medical problems is less than that associated with mental
illness and mental heath treat ment; and because clients are
more familiar wi th health care than with the mental health
treatment system.

Depression has received special attention: Depres-
sion is 3 times more likely to occur among primary care
visitors than in the community at large, and it is one of
the most common problems seen in primary care
(Pincus, Pechura, Elinson, & Pettit, 2001). However, too
often, physicians, nurses, and others in general medical
practice do not perform accurate diagnosis or provide
effective treatment.
This lower quality of care in general medical care
has inspired mental health care quality improvement
programs and these sometimes have been implemented
with demonstrable success (Wells et al., 2000). Other
proposals for improving how well professionals recog-
nize and treat mental illness in general health care
settings go further, calling for a comprehensive restruc-
turing of primary health' care practice that would in-
clude changing reimbursement policies to favor
recognizing and treating mental health problems along
with general. health care problems and creating ongoing
linkages with mental health specialists (Pincus, Pechura,
Keyser, Bachman, & Houtsinger, 2006). Recognizing
that mental health intervention is a core function of
primary care, the United Kingdom's National Health
Service established a new professional role, the Primary
Care Mental Health Worker (Bower, 2002).
In the United States, social workers' professional
training positions them well to work with medical per-
sonnel in primary care settings in order to recognize
mental health problems and to intervene. A challenge is
to bring social worker expertise to bear as medical
settings come to incorporate mental health as a core
function.
The Social Services Sector
Mentally ill persons are more likely than others to be
poor because, as noted previously, some persons with
mental illness struggle to succeed in the everyday world.
This is especially true for the 2.4%-3.3% of persons
estimated to suffer from psychotic and other severe and
persistent mental health problems and who are officially
considered to have serious mental illness (SMI) (Kessle r
et al., 2004). Twelve percent of social workers trained in
mental health practice work in public social service
programs-far more than any other mental health
professions. They provide direct mental health
counseling for persons with mental illness and refer
them into specialty-sector treatment (Duffy et al., 2004 ).
Many persons suffering from SMI qualify for Social
Security's Supplemental Security Income (SSI) pro-
gram. Through SSI, they are eligible for insurance
coverage under the Medicaid program and for Medi-
caid-financed mental health treatment.
MENTAL ILLNES: SERVICE
SYSTEM 249
Participants in the Temporary Assistance for Needy
Families (T ANF) program, an employment-focused
successor to Aid to Families with Dependent Children,
suffer at high rates from mental illness (J avakody ,
Danziger, & Pollack, 2000). Mental illness interferes
significantly with their ability to meet the program's
work requirements. TANF is time-limited; participants
are denied support after a fixed interval. Timely treat-
ment of their mental health problems can help them
become employed before their eligibility for T ANF
support runs out. These individuals are particularly in
need of mental health treatment to successfully make the
transition to work.
Abused and neglected children and youth are served
in the child welfare system, and many participating
children and youth have significant mental health pro-
blems. Almost 42% of children placed in foster care
suffer from a DSM-IV disorder (Garland et al., 2001 ).
The child welfare system is a key mental health system
gatekeeper, as it screens vulnerable childre n and youth
and refers them into treatment (Farmer et al., 2001).
When suffering with uncontrolled symptoms and
unassisted social disability, persons with mental illness
can be arrested and subsequently incarcerated. In fact,
persons with mental illness are crowding jails and pris-
ons, with grave personal and societal consequences.
Large numbers of persons with SMI have moved from
confinement in mental hospitals to confinement in jails
and prisons (Harcourt, 2006).
More than any other profession, social workers re-
cognize mental health problems in social service parti-
cipants and, through direct intervention or referral,
provide them with assistance. A challenge for the future
is to support them in these functions by providing them
with proven methods and adequate financial support.
The Voluntary Support Sector
Social support, or provision of emotional and material
assistance by a nonprofessional to persons in need, is
ofren the first, and sometimes the sole, assistance sought
for mental health problems. Friends and family
members provide considerable emotional and material
support to persons with mental illness. Family members
are especially supportive to persons with SMI, who
often live with them. Mentally ill persons who live wit h
their families are less reliant on the mental health
treatment system (Snowden, in press).
Organized peer support in the form of self-help
groups has come to play a great role in assisting persons
with mental illness to cope successfully with their
problems. The self-help movement, in which persons
with a similar mental health condition share their
experiences and advocate for better treatment, is a
powerful force for
250 MENTAL ILLNES: SERVICE SYSTEM
social change. Notable mental health support and advo cacy
organizations include Recovery Inc., Schizophrenics
Anonymous, National Depressive and Manic-Depressive
Associations, and Emotions Anonymous (Solomon, 2004).
Consumer-directed mental health treatment agencies are
an outgrowth of this movement.
Financing
Most health insurance plans offer a mental health ben efit
that can be used to purchase mental health treat ment. The
largest public health insurance plans, Medicaid and
Medicare, include mental health coverage. Indeed,
because it pays for treatment of disabled persons
qualifying under Social Security's SSI plan as well as for T
ANF participants and children treated under auspices of
the child \welfare system, Medicaid pays for more mental
health treatment than any other insurer (Frank, Goldman,
& Hogan, 2003).
Mental health claims represent only a small percen tage
of all insurance claims filed (Finkelstein et a1., 2004 ).
Nevertheless, insurers continue to be skeptical about
whether mental health conditions are valid complaints and
concerned that mental health treatment will be open- ended
and without tangible benefit. For this reason, mental health
insurance benefits often are "carved out" of general health
benefits and assigned to be administered by a managed
behavioral health care firm.
The scope of coverage for mental health problems
continues to lag behind that for general medical problems.
Parity legislation has been enacted to insure equality of
health and mental health insurance coverage. Disparities
in coverage persist, however, because parity legislation
leaves loopholes by which payers can evade true coverage
equality (Hennessy & Barry, 2004);
Disparities in Access and Quality of Care Few people
who need mental health care receive it, but members of
ethnic minority communities are far less likely than others
to be treated (USDHHS, 2001). Asian Americans and
Latinos, particularly those with limited proficiency in
English, are underrepresented in all types of care. African
Americans are underrepresented in specialty sector
outpatient treatment, but they are overrepresented in
emergency and inpatient settings. When treated, members
of ethnic minority groups are especially likely to leave
treatment prematurely.
Cultural factors are believed to act as access barriers to
seeking treatment. Cultural barriers include that mental
health problems are understood and expressed in terms of
complaints that are not mental illness, that people other
than mental health treatment specialists are mor e accepted
as sources of assistance, that the
concept of mental illness holds a great stigma, and that the
mental health treatment system has often failed to
understand the special circumstances of minority persons
and to welcome them into treatment. Many min ority
persons lack proficiency in the English language, which is
also a major barrier to treatment.
Overcoming racial and ethnic disparities in access and
quality of mental health care remains a key chal lenge
facing the mental health treatment system.
Quali ty, Effectiveness,
and Evidence-Based Practice
Some clinicians, administrators, researchers, and policy
makers have lamented that intervention strategies that are
believed to be effective from the best research are not
provided in routine treatment. Their concern has inspired a
movement that goes by several related names, perhaps best
known as evidence-based practice. Evidence-based practice
seeks to replace usual care with treatment protocols
supported by findings from research (Leff, 2004). A
somewhat broader, related concern is to upgrade the
quality of care provided on an ongoing basis in mental
health practice (lOM, 2001.).
Evidence-supported treatments must be exported or
translated to fit the real-world settings where they are to be
used. To successfully implement these treatments in the
real world is to understand the mental health treat ment
system and to marry characteristics of the treatments with
characteristics of the system. Success ful implementation
requires effective policies and financial incentives, which
mental health program managers, staff support delivery of
evidence-supported treatments, and also that local
communities believe in and encourage their use.
Summary
Mental illnesses are consistently among the most bur-
densome of population health problems across societies
worldwide. Even while Western mental health con cepts
and intervention technologies have been adopted by
developing countries in recent years, and while, in the
United States especially, public recognition that mental
illness is treatable has grown, there remains a high level of
mental health need that is unmet by existing service
systems. Ethnic minorities are particularly underserved by
the mental health system, raising the problem of
differential access to services on the basis of social and
cultural factors. Additionally, limita tions surrounding
quality of care and service effective ness in the current
system landscape are prevalent. The disconnect that
oftentimes exists between the best empirical research and
routine treatment in the clinical practice setting is one
important example in this regard.
j
I

As one of the largest groups of mental health profes-
sionals, and one that is active in a variety of practice sectors,
social workers are particularly challenged to address the gap
that exists between consumer mental health need and use of
effective services. Much of their ability to do so depends on
the availability of.financial and other institutional resources in
the practice setting. Also critical are the structuring of policies
and procedures within the system and its related institutions in
such a way that facilitates their navigation by social workers
and clients and brings to bear social worker expertise in each
of the complex sectors in which they operate.
REFERENCES '
Bower, B. (2002). Primary car,e mental health workers: Models of
working and evidence of effectiveness. British Journal of
General Practice, 52(484), 926-933.
Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, 1.,
Kovess, V., Lepine, J. P., et aI., for WHO World Mental
Health Survey Consortium. (2004). Prevalence, severity and
unmet need for treatment of mental disorders in the World
Health Organization World Mental Health Surveys. JJVVU\,
291, 2581-2590.
Duffy, F. F., West, J. c, Wilk, J., Narroe, W. E., Hales, D.,
Thompson, J., et a1. (2004). Mental health practitioners and
trainees. In R. W. Manderscheid & M. J. Henderson (Eds.),
Mental health, United States, 2002 (chap. 21, DHHS Publi-
cation No. SMA 3938). Rockville, MD: Center for Mental
Health Services, Substance Abuse and Mental Health Services
Administration.
Farmer, E. M. Z., Bums, B. J., Chapman, M. V., Phillips, S. D.,
Angold, A., & Costello, E. J. (2001). Use of mental health
services by youth in contact with social services. Sodal
Services Review, 75(4), 605-624.
Finkelstein, E., Bray, J., Lason, M. J., Miller, K., Tompkins, c.,
Keme, A., et a1. (2004). Prevalence of, and payments for,
mental health and substance abuse disorders in public and
private sector health plans. In R. W. Manderscheid & M. J.
Henderson (Eds.), Mental health, United States, 2002 (chap. 13,
DHHS Publication No. SMA 3938). Rockville, MD: Center
for Mental Health Services, Substance Abuse and Mental
Health Services Administration.
Frank, R. G., Goldman, H. H., & Hogan, M. (2003). Medicaid and
mental health: Be careful what you ask for. Health Aff~~,22,
101-113.
Frank, R. G., McGuire, T. G., Notman, E. H., & Woodward, R. M.
(1997). Developments in Medicaid managed behavioral health
care. In R. W. Manderscheid & M. A. Sonnenschein (Eds.),
Mental health, United States, 1996 (chap. 20, DHHS
Publication No. SMA 96-3098). Washington, DC: U.S.
Government Printing Office.
Garland, A. F" Hough, R. L., McCabe, K. M., Yeh, M., Wood, P.
A., & Aarons, G. A. (2001). Prevalence of psychiatric
disorders in youths across five sectors of care. Journal of the
American Academy of Child and Adolescent Psychiatry, 40(4),
409-418.
MENTAL ILLNES: SERVICE SYSTEM 251
Gulbinat, W., Manderscheid, R., Baingana, F., Jenkins, R.,
Khandelwal, S., Levav, 1., et al. (2004). The international
consortium on mental health policy and services: Objectives,
design and project implementation. International Review of
Psychiatry, 16, 5-17.
Harcourt, B. E. (2006). From the asylum to the prison: Rethinking
the incarceration revolution. Texas Law Review,
84(7),1751-1786.
Hennessy, K., & Barry, C. L. (2004). Parity in the federal
employees' health benefits program: An overview. In R. W.
Manderscheid & M. J. Henderson (Eds.), Mental health, United
States, 2002 (chap. 13, DHHS Publication No. SMA 3938).
Rockville, MD: Center for Mental Health Services, Substance
Abuse and Mental Health Services Administration.
Hogan, M. F., Adams, J., Arredondo, R., Carlile, P., Curie, C. G.,
Fisher, D. B., et al. for President's New Freedom Commission
on Mental Health. (2003). Achieving the promise: Transforming
mental health care in America. Final report (DHHS Publication
No. SMA-03-3832). Rockville, MD: U.S. Department of
Health and Human Services.
Institute of Medicine [Committee on Quality of Health Care in
America]. (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC:
National Academy Press.
Jayakody, R., Danziger, S., & Pollack, H. (2000). Welfare reform,
substance use, and mental health. Journal of Health Politics,
Policy and Law, 25,627-644.
Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmetneed for
mental health care among U.S. children: Variation by ethnicity
and insurance status. American Journal of Psychiatry, 159,
'1548-1555.
Kessler, R. C., Berglund, P., Demler, 0., [in, R., Koretz, D.,
Merikangas, K. R., et a1. (2003). The epidemiology of major
depressive disorder: Results from the National Comorbidity
Survey Replication (NCS-R). JAMA, 289, 3095-3105.
Kessler, R. c., Berglund, P. A., Glantz, M. D., Koretz, D. S.,
Merikangas, K. R., Walters, E. E, et al. (2004). Estimating the
prevalence and correlates of serious mental illness in
community epidemiological surveys. In R. W. Manderscheid
& M. J. Henderson (Eds.), Mental health, United States, 2002
(chap. 12, DHHS Publication No. SMA 3938). Rockville,
MD: Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration.
Kessler, R. C., Demler, 0., Frank, R.· G., Olfson, M., Pincus, H.
A., Walters,E. E., et al. (2005). Prevalence and treatment of
mental disorders: 1990 to 2003. New England Journal of
Medicine, 352, 2515-2523.
Leff, H. S. (2004). A brief history of evidence-based practice and a
vision for the future. In R. W. Manderscheid & M. J.
Henderson (Eds.), Mental health, United States, 2002 (chap. 17,
DHHS Publication No. SMA 3938). Rockville, MD: Center
for Mental Health Services, Substance Abuse and Mental
Health Services Administration.
Pincus, H. A., Pechura, C. M., Elinson, L., & Pettit, A. R. (2001).
Depression in primary care: Linking clinical and
252 MENTAL ILLNES: SERVICE SYSTEM
systems strategies. General Hospital Psychiatry, 23(6),
311-318.
Pincus, H. A., Pechura, c., Keyser, D., Bachman, J., &
Houtsinger, J. K. (2006). Depression in primary care:
Learning lessons from a national quality improvement
program. Administration and Policy in Mental Health and
Mental Health Services Research, 33, 2-15.
Rosenthal, M. B., Minden, S. L., Kimmel, W. A., Henderson,
M. J., & Manderscheid, R. W. (2004). Toward a typology
of behavioral health care: Featuring purchasing,
partitioning, and risk transfer. In R. W. Manderscheid &
M. J. Henderson (Eds.), Mental health, United States, 2004
(chap. 4, DHHS Publication No. SMA 3938). Rockville,
MD: Center for Mental Health Services, Substance Abuse
and Mental Health Services Administration.
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.), for
Committee on Understanding and Eliminating Disparities
in Health Care, Board on Health Scienc~s Policy (HSP),
Institute of Medicine. (2002). Unequal treatment: Confront-
ing racial and ethnic differences in health care. Washington,
DC: National Academy Press.
Snowden, L. R. (2007). Explaining mental health treatment
disparities: Ethnic and cultural differences in family
involvement. Culture, Medicine, and Psychiatry, 31 (2
):389-402.
Solomon, P: (2004). Peer support/peer provided services:
Underlying processes, benefits, and critical ingredients.
Psychiatric Rehabilitation J oumal, 27 (4), 392-401.
U.S. Department of Health and Human Services. (1999).
Mental health: A report of the Surgeon General. Rockville, MD:
Public Health Service, Office of the Surgeon General.
U.S. Department of Health and Human Services. (200l).
Mental health: Culture, race, and ethnicity. A supplement to
mental health: A report of the Surgeon General. Rockville, MD:
Public Health Service, Office of the Surgeon General.
Wells, K. B., Sherboume,C., Schoenbaum, M., Duan, N.,
Meredith, L., Unutzer, J., et al. (2000). Impact of
disseminating quality improvement programs for
depression in managed primary care: A randomized
controlled trial. JAMA, 283, 212-220.
West, J., Kohout, J., Pion, G. M., Wicherski, M. M., Vandi-
vort-Warren, R. E., Palmiter, M. L., et al. (2002). Mental
health practitioners and trainees. In R. W. Manderscheid &
M. J. Henderson (Eds.), Mental health, United States, 2000
(chap. 20, DHHS Publication No. SMA 3938). Rockville,
MD: Center for Mental Health Services, Substance Abuse
and Mental Health Services Administration.
World Health Organization. (2002). The worM health report
2002: Reducing risks, promoting healthy life. Geneva,
Switzerland: Author.
-LONNIE R. SNOWDEN
MENTAL RETARDATION. See Disability:
Overview.
ABSTRACT: Meta-analysis is widely used in the social,
behavioral, and medical sciences to combine results of
multiple studies and produce relevant information for clinical
practice and social policy. It is most often used to synthesize
quantitative data on treatment effects, but has many potential
applications. Meta-analysis includes a set of techniques for
quantitative data synthesis that can (and should) be performed
in the context of a systematic efforts to minimize bias at each
step in the research review process. Without careful efforts to
eliminate bias, meta-analysis can lead to wrong conclusions.
KEY WORDS: evidence; empirical; research; literature
reviews; quantitative data
Meta-analysis is the quantitative synthesis of results of
multiple studies. It can estimate trends, assess variations
across studies, and correct for errors and bias in a body of
research. This is important, given the rapid accumulation of
evidence on many topics relevant for social work,
inconsistencies across studies, and well-known limitations of
traditional research review methods. A systematic review uses
replicable procedures to minimize bias in research synthesis;
meta-analysis is usually one of the last steps in this process.
Meta-analysis has distinct advantages over other approaches
to research synthesis, and it has limitations.
History
Karl Pearson conducted the first quantitative synthesis in
1904, when he computed an average correlation from 11
studies of a vaccine against typhoid. Methods for quantitative
synthesis appeared in statistical texts and articles in the 1930s,
but were rarely used until the late 1970s when several teams
produced large meta-analyses on psychotherapy (Smith &
Glass, 1977), class size (Glass & Smith, 1978), interpersonal
expectancy effects (Rosenthal & Rubin, 1979), and the
validity of employment tests by race (Hunter, Schmidt, &
Hunter, 1979).
Books on the conceptual, theoretical, and statistical
foundations of meta-analysis appeared in the 1980s and 1990 s
(Cooper & Hedges, 1994; Hedges & Olkin, 1985; Light &
Pillemer, 1984). There have been many recent advanc'es· in
the science of research synthesis, including developments in
information retrieval (Rothstein, Turner, & Lavenberg, 2004),
systematic review methods (Higgins & Green, 2006; Shadish
& Myers, 2004), and statistics for metaanalysis (Becker,
Hedges, & Pigott, 2004; Hedges & Pigott, 2001).
 META-ANALYSIS 253

Uses Systematic Review Methods

Meta-analysis can combine many forms of quantitative . Systematic reviews are conducted in phases tha t are
data, and address diverse research questions. For exam ple, parallel to the steps in primary research ( Cooper, 1998).
Ahnert, Pinquart, and Lamb (2006) synthesized results of Objectives and methods are laid out in advance.
40 studies to estimate proportion of children who had Reviewers specify the study designs, populations, inter-
secure attachments to nonparental caregivers. Syntheses ventions, comparisons, and outcome measures that will be
have assessed the strength of associations between included and excluded; this limits reviewers' freedom to
attitudes and behavior (Glasman & Albarracin, 2006), select studies on the basis of their results, or on some other
sensation-seeking and alcohol use (Hittner & Swickert, basis.
2006), and interpersonal stress and psychosocial health in Diverse sources and strategies are. used to locate
youth (Clarke, 2006). Several thousand meta-analyses potentially relevant studies. In addition to keyword
have been conducted on effects of social, behavioral, searches of several electronic databases, hand-searching of
educational, and medical interventions (see relevant journals may be needed to find eligible studies
www.cochrane.org and www.campbellcollaboration. org). that are not properly indexed (Hopewell, Clarke; Lefebvre,
In addition to assessing main effects, meta-analysis can & Scherer, 2006). Reviewers make special attempts to
explore variations. For instance, Wilson, Lipsey, and locate relevant "gray literature" (unpublished and
Soydan (2003) compared effects of mainstream programs hard-to-find studies), in order to minimize the "file drawer
for juvenile delinquency for minority versus. majority problem" (Hopewell, McDonald, Clarke, & Egger, 2006;
youth. Quantitative methods have been used to synthesize Rothstein et al., 2004).
information on diagnostic accuracy (for example, Key decisions are made by independent raters who
misdiagnosis of conversion symptoms; Stone et al., 2005) compare notes, resolve differences, and document rea sons
and the prognostic performance of tests. for their decisions (Higgins & Green, 2006). Raters extract
data from study reports onto paper or electronic coding
Potential Sources of Error and Bias forms to capture information about treatment
Errors and biases can arise in the original studies, in the characteristics, settings, participants, study design and
dissemination of study results, and in the review process implementation characteristics, data collec tion procedures,
itself. Primary studies may systematically overestimate or measures, raw data, statistical results, and the coding
underestimate effects, due to design and implemen- process itself. These data are then available for use i n the
rationIssues that leave them vulnerable to threats to analysis of results.
validity (Shadish, Cook, & Campbell, 2002). Confirmation Reviewers assess methodological characteristics of
bias (the tendency to support favored hypotheses and primary studies, because study design and imple mentation
ignore evidence to the contrary) can arise in the reporting, issues affect the credibility of results (Glazerman, Levy, &
publication, and dissemination of results of original Myers, 2002; KuDZ & Oxman, 1998; Schultz, Chalmers,
studies. Statistically significant results are more likely to Hayes, & Altman, 1995; Schulz & Grimes, 2002; Shadish,
be reported, published, and cited (Dickersin, 2005), & Ragsdale, 1996). There are many approaches to study
making these results more readily available than other, quality assessment (juni, Altman, & Egger, 2001; [uni,
equally valid findings. Witschi, Bloch, & Egger, 1999). Some focus on overall
The integration of results from multiple studies is a design features, while others emphasize thre ats to validity
complex task not easily performed with "cognitive (Wortman, 1994) or vulnerability to certain types of bias
algebra." The conclusions of narrative reviews can be (Higgins & Green, 2006). However, there is general con-
influenced by trivial properties of research reports sensus among methodologists and meta-analysts that study
(Bushman & Wells, 2001). Several quantitative ap- qualities should be assessed individually, rather than being
proaches to research synthesis have been developed and summed into total study-quality scores (Shadish & Myers,
tested. "Vote counting" (tallying the number of studies 2004). The impact of specific study qualities can then be
that provide evidence for and against a hypothesis) relies examined in the analysis.
on tests of significance, and can lead to the wrong
conclusions (Carlton & Strawderman, 1996).
Meta-analysis provides more reliable estimates of effects. Understanding Meta' Analysis Meta-analysis
A research synthesis is vulnerable to bias when the includes an array of statistical methods and techniques.
sample of studies is restricted to published reports, when Results of primary studies are converted to common
reviewers fail to consider variations in study qualities, and metrics, called effect sizes, before they are pooled across
when results are reported selectively. For these reasons, studies. The term effect size (ES) refers to a class of
meta-analyses are often lodged in systematic reviews. statistics that represent the direction and
254 META~ANALYSIS
strength of a relationship between two variables. ES
metrics include the odds ratio, risk ratio, correlation
coefficient, standardized mean difference (SMD), and
standardized mean gain score (Lipsey & Wilson, 2001).
The most common ES for continuous data, the SMD,
is the difference between the means of two groups,
divided by their pooled standard deviation. When group
means and standard deviations are not available, SMDs
can be calculated or estimated from a variety of other
statistics (Lipsey & Wilson, 2001). Since SMDs are
upwardly biased when based on small samples (Hedges,
1981), meta-analysts use a correction for small sample
bias, known as Hedges' g. Simiiar corrections are
available for odds ratios and correlation coefficients.
Other adjustments can be made to handle outliers,
compensate for restrictions in range, and adjust for
Unreliable measures (Hunter & Schmidt, 2004).
Depending on the review's central questions, it may
or may not make sense to pool results across studies with
different sample characteristics, types of treatments, or
outcome measures. Meta-analysis can produce an over-
all (average) ES estimate that accounts for different
sample sizes and variances (study-level ES are weighted
using inverse variance methods, so that larger studies
and those with more precise estimates contribute more to
the overall average than smaller studies and those with
less precision).
Several statistical models are available for pooling
data. Fixed effect models assume that all studies provide
estimates of the same population ES and any differences
between studies are due to chance (sampling error). Ran-
dom effects models assume that there are other sources
of variation that are not taken into account. Mixed
effects models assume that some of the variation i n the
ES distribution is systematic (and can be accounted for
by moderators), and some of the variation is random.
Forest plots provide graphic displays of the ES dis-
tribution on a given outcome in a set of studies, show ing
point estimates and confidence intervals. Pooled
estimates and results of homogeneity tests are often
reported on Forest plots. .'
Homogeneity analysis is used to determine whether a
mean ES is representative of the distribution of data
from a set of studies. It compares the observed variance
in effects across studies with the variance that would be
expected because of sampling error.
Subgroup analysis is performed by partitioning the
sample and calculating average ES for subgroups.
Metaanalysts caution against the use of many subgroup
analyses, because this can become akin to "fishing" for
significant results in primary studies.
There are two primary approaches to moderator
analysis. The first is an analog to the analysis of
variance, in which the moderator is a categorical vari-
able. Average ES are calculated for each category (or
subgroup) and tests of significance are used to assess
between-group differences. For example, one can use
this approach to see whether effects differ for rando-
mized experiments versus nonrandomized studies,
younger versus older children, or shorter- versus long-
er-term treatments. The second method uses weighted
multiple regression analysis to assess the potential
impact of one or more continuous moderators on the
ES; this is sometimes called meta-regression.
Funnel plots are used to identify possible biases in a
distribution of ES. In a bivariate scatterplot, study ES
are plotted on the horizontal axis with their standard
errors (or inverse variance) on the vertical axis. In the
absence of publication bias, the plot will resemble an
inverse funnel. The appearance of asymmetry in the
funnel plot indicates that results may be biased, perhaps
by the systematic exclusion of studies with negative or
null results (Egger, Smith, Schneider, & Minder, 1997).
Several methods are used to identify and correct for
publication bias (Rothstein, Sutton, & Bomstein, 2005).
Sensitivity analysis is used to determine whether
findings are robust (consistent) under different assump-
tions. It is often used to explore the potential impact of
outliers or missing data on overall results.
Most statistical software programs can perform basic
meta-analysis (Lipsey & Wilson, 200l). The Cochrane
Collaboration offers a no-cost, downloadable program
called Review Manager (RevMan) that includes rou-
tines for computing, weighting, and pooling the most
common ES rnetrics; it also produces Forest plots and
funnel plots (www.cc-ims.net/Revlvlan). Stand-alone
meta-analysis programs, such as Comprehensive Meta
Analysis, have additional capabilities for moderator and
sensitivity analyses.
Reporting Guidelines
Moher et al. (1999) developed the quality of reporting
of meta-analyses statement to improve reports on sys-
tematic reviews and meta-analyses, The statement in-
cludes a checklist of items and a flow diagram that
should be used to describe how studies were identified,
screened, and selected for the review.
Advantages
Meta-analysis imposes discipline on the process of re-
search synthesis and offers more transparency than tra-
ditional narrative methods. It provides an efficient way
to summarize results of a large number of studies, and
can lead to the discovery and exploration of important
variations across studies.

. Limitations
Meta-analysis requires considerable effort and expertise. In
the hands of analysts who are unaware of important
substantive issues, meta-analysis can become a mechanical
exercise. Conceptual issues are especially important in the
lumping and splitting decisions that go into meta-analysis:
absent a strong theoretical rationale, pooling results across
different types of treatments, samples, or outcomes produces
results that are not meaningful. Finally, a meta-analysis of
very weak studies will produce unreliable results.
Current Status
Meta-analysis is widely used in the social sciences, especially
in psychology and education (Petticrew & Roberts, 2006),
and it is, the standard for synthesizing results of clinical trials
in medicine. Several governmental and nonprofit
organizations sponsor or produce systematic reviews and
meta-analyses. Of particular relevance for social work are the
international, interdisciplinary Cochrane Collaboration and
the Campbell Collaboration, which synthesize studies on
health care and social care, respectively. Building on
advances in the science of research synthesis, these groups
produce guidelines for systematic reviews and meta-analysis.
Implications for
Social Work Practice and Policy Meta-analysis can
add rigor and transparency to ongoing efforts to synthesize the
growing bodies of empirical research that are relevant for
social work. Thus, it has an important role in the development
of knowledge for social work and human services.
REFERENCES
Ahnert, L, Pinquart, M., & Lamb, M. E. (2006). Security of
children's relationships with nonparental care providers: A
meta-analysis. ChiIJ Development, 77,664-679.
Becker, B. J., Hedges, L., & Pigott, T. D. (2004). CampbeU
collaboration statistical analysis policy brief. Retrieved June
12, 2006, from http://www
.campbellcollaboration.orgfMG/ StatsPolicy Brief. pdf.
Bushman, B. J., & Wells, G. L. (2001). Narrative impressions
of literature: The availability bias and the corrective prop-
erties of meta-analytic approaches. Personal and Social
Psychology Bulletin, 27, 1123-1130.
Carlton, P. L., & Strawderman, W. E. (1996). Evaluating
cumulated research I: The inadequacy of traditional
methods. Biological Psychiatry, 39, 65-72.
Clarke, A. T. (2006). Coping with interpersonal stress and
psychosocial health among children and adolescents: A
meta-analysis. Journal of Youth and Adolescence, 35, 11-24.
Cooper, H. (1998). Synthesizing research (3rd ed.). Thousand
Oaks, CA: Sage.
Cooper, H., & Hedges, L. (1994). Handbook of research synthe-
sis. New York: Russell Sage Foundation.
, . .1.
META-ANALYSIS 255
Dickersin, K. (2005). Publication bias: Recognizing the
problem, understanding its origins and scope, and pre-
venting harm. In H. R. Rothstein, A. J. Sutton, & M.
Borenstein (Eds.), Publication bias in meta-analysis:
Prevention, assessment, and adjustments. Chichester, UK:
John Wiley & Sons.
Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997).
Bias in meta-analysis detected by a simple, graphical test.
British MedicalJoumal, 315,629-634.
Glasman, L. R., & Albarracin, D. (2006). Forming attitudes
that predict future behavior: A meta-analysis of the
attitude-behavior relation. Psychological BuUetin, 132,
778--822.
Glass, G. V., & Smith, M. K. (1978). Meta-analysis of research
on the relationship of class size and achievement. Educa-
tional Evaluation and Policy Analysis, 1, 2-16.
Glazerman, S., Levy, D. M., & Myers, D. (2002). Nonexperi-
mental replications of sodal experiments: A systematic review.
Princeton, NJ: Mathematica Policy Research, Inc.
Hedges, L. V. (1981). Distribution theory for Glass's estimator
of effect size and related estimators. Journal of Educational
Statistics, 7, 119-128.
Hedges, L. V., & Olkin, I. (1985). Statistical methods for meta-
analysis. Orlando, FL: Academic Press.
Hedges, L. V., & Pigott, T. D. (2001). The power of statistical
tests in meta-analysis. Psychological Methods, 6(3),
2003-2217.
Higgins, J. P. T., & Green, S. (Eds.). (2006). Cochrane hand-
book for systematic reviews of interventions. Chichester, UK:
John Wiley & Sons, Ltd.
Hittner, J. B., & Swickert, R. (2006). Sensation seeking and
alcohol use: A meta-analytic review. Addictive Behaviors,
31, 1383-1401.
Hopewell, S., Clarke, M., Lefebvre, C., & Scherer, R. (2006).
Handsearching versus electronic searching to identify re-
ports of randomized trials. In The cochrane daiobase of sys-
tematic reviews, Issue 4. Chichester, UK: Wiley.
Hopewell, S., McDonald, S., Clarke, M., & Egger, M. (2006).
Grey literature in meta-analyses of randomized trials of
health care interventions. In The cochrane database of sys-
tematic reviews, Issue 2. Chichester, UK: Wiley.
Hunter, J. E., & Schmidt, F. L. (2004). Methods of metaanalysis:
Correcting error and bias in research findings (Znd ed.).
Thousand Oaks, CA: Sage Publications.
Hunter.]. E., Schmidt, F. L., & Hunter, R. (1979). Differential
validity of employment tests by race: A comprehensive review
and analysis. Psychological Bulletin, 86, 721-735. juni,
P.,Altman, D. G., & Egger, M. (2001). Assessing the quality
of controlled clinical trials. British Medical Journal,
323(7303),42-46.
juni, P., Witschi, A., Bloch, R., & Egger, M. (1999). The
hazards of scoring the quality of clinical trials for meta-
analysis. Journal of the American Medical Association, 282,
1054-1060.
Kunz, R., & Oxman, A. D. (1998). The unpredictability para-
dox: Review of empirical comparisons of randomised and
nonrandomised clinical trials. British Medical Journal, 317
(7167), 1185-1190.
Light, R. J., & Pillemer, D. B. (l984). Summing up: The science of
reviewing research. Cambridge, MA: Harvard University Press.
Lipsey, M. W., & Wilson, D. B. (2001). Practical meta-analysis.
Thousand Oaks, CA: Sage Publications.
Moher, D., Cook, D. J., Eastwood, S., Olkin, 1., Rennie, D.,
Stroup, D. F., et al. (l999). Improving the quality of reports of
meta-analyses of randomised controlled trials: The QUOROM
statement. The Lancet, 354,1896-1900.
Petticrew, M., & Roberts, H. (2006). Systematic reviews in the social
sciences: A practical guide. Oxford, UK: Blackwell Publishing,
Ltd.
Rosenthal, R., & Rubin, D. B. (l979). Interpersonal expectancy
effects: The first 345 studies. Behavioral and Brain Sciences, 3,
377-386.
Rothstein, H., Sutton, A. J., & Bornstein,' M. (Eds.). (2005).
publication bias in meta-analys~: Prevention, assessment, and
adjustments. Chichester, UK: Wiley.
Rothstein, H. R., Turner, H. M., & Lavenberg, J. G. (2004).
The Campbell Collaboration Information Retrieval Policy Brief.
Retrieved June 12, 2006, from http://www.campbellcolla-
boration.org/MG /IRMG Policy Briefkevised.pdf
Schultz, K. F., Chalmers, 1., Hayes, R. J., & Altman, D. G. (l995).
Empirical evidence of bias: Dimensions of methodological
quality associated with estimates of treatment effects in
controlled trials. JAMA, 273, 408-412.
Schulz, K. F., & Grimes, D. A. (2002). Allocation concealment in
randomised trials: Defending against deciphering .. The Lancet,
359, 614-618.
Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002).
Experimental and quasi-experimental designs for generalized causal
inference. Boston: Houghton Mifflin.
Shadish, W. R., & Myers, D. (2004). Campbell Collaboration
Research Design Policy Brief. Retrieved June 12, 2006, from
http://www .campbellcollabora tion.org/MG /Res Des Policy
Brief.pdf
Shadish, W. R., & Ragsdale, K. (l996). Random versus non-
random assignment in controlled experiments: Do you get the
same answer? Journal of Consulting and Clinical Psychology,
64(6), 1290--1306.
Smith, M. L., & Glass, G. V.' (1977). Meta-analysis of psy-
chotherapy outcome studies. American Psychologist, 32,
752-760.
Stone, J., Smyth, R., Carson, A., Lewis, S., Prescott, R., Warlow,
c., et al. (2005). Systematic review of misdiagnosis of
conversion symptoms and "hysteria." British Medical Journal,
332, 989-994.
Wilson, S. J., Lipsey, M. W., & Soydan, H. (2003). Are
mainstream programs for juvenile delinquency less effective
with minority than majority youth? A meta-analysis of
outcomes research. Research on Sociai Work Practice, 13, 3-26.
Wortman, P. M. (l994). Judging research quality. In H. Cooper &
L. V. Hedges (Eds.), The handbook of research synthesis (pp.
97-109). New York: Russell Sage Foundation.
-JULIA H. LITTELL
METHODS OF PRACTICE INTERVENTIONS
ABSTRACT: This article defines social work methods
and then presents a framework with criteria for
analyzing methods from a social work perspective.
These criteria are organized into the boundary, value,
prescriptive, de scriptive, therapeutic bond and tasks,
and evidence dimensions. The framework is designed
to encourage social workers in all functions to analyze
how well a particular method meets these interrelated
client-centered criteria, and to use them, modify them,
or not use them accord ingly. The lessons from this
analysis are summarized in terms of the profession's
continuing role in identifying essential criteria and
building knowledge about ef fective social work
methods.
KEY WORDS: social work methods; practice wisdom;
evidence-based practice; criteria for analyzing methods;
client-centered; social justice; interventions/interven tion
clusters; practice theories; social work values
Social work has prioritized the need for critical analyses of its
practice methods and fordocumentation of their effectiveness
(Doe & Lowery, 2004; Fraser, Nelson, & Rivard, 1997;
Videka-Sherman, 1988). Disagreements exist about whether
intervention informative research or other approaches should
be used for this priority, and whether all practice should be
evidence-based (Doe & Lowery, 2004; Gibbs & Gambrill,
2002; Lurn, 1999; Prince & Austin, 2001; Proctor, 2003).
There is agreement in one important area, however: "To best
serve clients, it behooves social workers to make sure that
they provide the best interventions" (Schreiner, Ng, &
Sherraden, 2006, p. 28). The word "client" is often used in this
article; however, the worker contracts to act on behalf of many
types of systems such as organizations and communities and
the word client should be understood here to mean any entity
with which the worker contracts to act on its behalf. This
article defines what a best social work method or intervention
is and presents a framework for critically analyzing methods.
Examples illustrate the framework's utility to practitioners,
administrators, researchers, funders, and policy developers
and analysts. The article concludes with lessons about
essential criteria and the process for analyzing methods.
Definition of Social Work Methods
Social workers have an ethical responsibility to understand the
professions' methods, including their definition and
recommended use with clients (Gorey, Thyer, & Pawluck,
1998). These methods are defined
"'~

as theoretical and systematic approaches to the social
work process, which includes engagement, assessment,
goal setting and planning, intervention or action stra-
tegies, and the monitoring of changes. Changes can
occur in individuals, families, and groups; communities
and organizations; and social institutions and social
policies (Gorey et aL, 1998; Lee, 2003; Schreiner et al. ,
2006). The definition includes terms often used
interchangeably although they operate at different epis-
temological levels. Practice theories such as general
systems theory are included, along with practice ap-
proaches and models such as solution-focused and
group mutual aid approaches, and the political and
social action community modeL Practice frameworks
and perspectives are also methods, for example,
gendersensitive policy analysis frameworks and the
strengths perspective. Given the range of methods in
this definition, a set of preferred criteria for all soc ial
work methods is presented next.
Criteria for Analyzing Social Work Methods THE
PURPOSE OF THESE CRITERIA AND DIMEN-
SIONS Table l 's criteria and dimensions are a frame-
work for critically analyzing social work methods. The
literature suggests all methods have challenges and gaps
as well as strengths in terms of these criteria (Doe &
Lowery, 2004; Fortune & Proctor, 2001; Fraser et al.,
1997; Prince & Austin, 2001; Reamer, 2006; Reich,
1998). Social workers can critically analyze methods to
judge how well they meet criteria for each dimension
and then decide whether they (a) meet most of the
criteria sufficiently, (b) have gaps and challenges that
can be addressed by adapting or combining them with
other methods, or (c) have such gaps and challenges that
they are insufficient as social work methods.
The framework is not a formal rating system, but it
facilitates analyses and discussions about methods
among colleagues. It can be used in all functional areas,
from direct practice to policy practice, and in other
helping professions. It consists of interrelated and over-
lapping boundary, value, descriptive, prescriptive, ther-
apeutic bond and task, and evidence dimensions. This
framework, like others, makes explicit its underlying
assumptions, judgments, and comparisons about the
phenomena (Schreiner et al., 2006).
THE BOUNDARY DIMENSION This dimension an-
swers the question, "How broad or narrow should a
social work method be?" The profession's service and
ethics priorities require methods to be broad enough for
assessment, intervention, and monitoring at micro,
. mezzo, and macro levels, consistent with person in
METHODS.OF PRACTICE
lNTERValTIONS 257
environment, social justice, and strengths criteria (Table
1).
The Person in Environment Criterion. Methods
should focus on the person, his or her environment, and
on transactions between the two. Transactions often
reflect identifiable patterns in their exchanges, resource
gaps and barriers, strengths, and power differences.
Social workers should assess and intervene in the
goodness of fit between individuals and the family unit,
small group, social or cultural network, organization,
community, large institution, or social policy as needed
(Germain & Gitterman, 1996; Johnson, 1999). For
example, family practitioners should use methods that
focus assessment and intervention on intergenerational
environmental factors as well as nuclear family factors,
especially with families of color (Dilworth-Anderson &
Burton, 1999; McGoldrick, 1998). Substance abuse,
health care, school, and policy practitioners should use
such methods as well (Johnson, 1999; Karls, Lowery,
Mattaini, & Wandrei, 1997).
The Social Justice Criterion. Person in environment
methods should also focus on unjust social, political, and
economic disparities that affect clients. This social
justice priority encourages collaborative workerclient
(or other systems with which the worker contracts for
service) social action (Stuart, 1999), which connects
"poor people to policies designed to improve their
well-being" (Schreiner et al., 2006, p. 30). This type of
anti-oppression practice requires practitioners and
administrators to help clients or other types of systems
gain access to decision-making' opportunities that
correct unjust disparities, thus transferring power from
traditional decision-makers to empowered consumers
(Chandler, 2006; Dessel, Rogge, & Garlington, 2006).
Hyde (2004) recommends that administrators use a
multicultural organizational development method rather
than a traditional one to enhance organizational
assessment, strategic planning, leadership development,
and collaboration with clients. Nontraditional methods
prioritize community and consumer partnerships in
practice settings, such as memberships on executive and
advisory boards and peer leadership roles (Delgado,
2000; Wertheimer, Beck, Brooks, & Wolk, 2004). Si-
milarly, community practitioners and researchers should
use planning methods that involve community members
in identifying oppressive social policies to be changed
and in selecting preferred strategies to achieve their
goals. Examples include social' planning and
neighborhood organizing methods (Freeman, 1996;
Johnson, 1999; Stuart, 1999; Tsui, Cheung, & Gellis,
2004; Weil, 1996) .
258 METIloDS OF PRAcnCE INTERVENTIONS
Critical Thinking and Analysis Framework for Social Work Methods
THE SIX DIMENSIONS AND
RECOMMENDATIONS
The Boundary Dimension
Recommendation: A social work
method should be sufficiently broad
to facilitate assessment,
intervention, and monitoring at
micro, mezzo, and macro system
levels.
The Value Dimension Recommendation:
A social workmethod should be
sufficiently explicit about its
values so that inconsistencies
between those values, social
work values, and clients' values
can be determined.
The Descriptive Dimension
Recommendation: A social work method
should respect and include multiple
culturally based realities in terms of
ethnicity and language, gender, social
class, age, location, disabling conditions,
religion, and sexual orientation for
describing and assessing clients'
situations.
The Prescriptive Dimension
Recommendation: A social work
method should provide explicit
guidelines for its use with particular
client populations, along with detailed
information about its interventions and
their use with clients based on those
guidelines.
The Therapeutic Bond and Task
Dimension
Recommendation: A social work method
should acknowledge power
differences between social workers
and clients, and recommend how
those differences can be handled by
establishing power sharing
relationships and roles.
The Evidence Dimension
Recommendation: A social work
method should provide
clear parameters about how its use
with clients should be monitored,
evaluated, and redesigned as needed
from a client-centered perspective.
TABLE 1
ANALYZE THE QUALITY OF SOCIAL WORK METHODS
BASED ON THE FOLLOWING CRITERIA
Person in Environment Criterion: Is there a focus on clients, their environments, and on
transactions between the two? The environment ranges from the family (the intimate
environment), to social institutions, and to policies that impinge on client systems.
Social Justice Criterion: Is there attention to disparities in health, education, employment,
housing, and other needs resulting from institutionalized discrimination and
oppression? Disparities require collaborative social action with clients to achieve
systems change.
Strengths Criterion: Is there a strengths priority that requires using clients' strengths as
intervention resources, providing capacity building services, and increasing their
opportunities for participation in decision making in areas that affect their lives?
Values Clarification Criterion: Is there consistency between a method's values and how those
values are operationalized, and between a method's values and social work values so the
potential effects on clients can anticipated and managed?
Client-Centeredness Criterion. Is there a focus on how a method supports clients' value
priorities as the basis for their goal setting, planning, and preferred individual and
environmental changes? The integration of clients' values
into social work services helps to insure that methods and their values are
client-centered.
Individual, Family, and Group Criteria: Are implicit or explicit assumptions of a method's
theories about human behavior culturally sensitive in their distinctions between normative
and nonnormative behavior, and in terms of culturally-based versus ethnocentric
explanations of individual, family, and group development?
Organization and Community Criterion: Do the assumptions of a method's descriptive theories
about organizational and community contexts constrain or support the development and
life opportunities of vulnerable populations, including the context of social work practice
settings, social institutions, and clients' communities? Clarity about how particular client
populations may be marginalized within those mezzo and macro contexts is important.
Practice Principles Criterion: Is there a focus on how a method's principles bridge or translate
its prescriptive theories into practice, and prescribe how preferred changes or outcomes
are to be accomplished? Practice principles should include details about the helping
process (appropriate client populations and problem situations) and required social worker
resources (knowledge, skills, and training).
Intervention Criterion: Is it clear how and under what circumstances a method's interventions
are to be used either singularly or in intervention clusters to accomplish changes at micro,
mezzo, and macro levels based on identified practice principles? Detailed intervention
instructions help to insure a method's appropriate use with clients, fidelity across social
worker-elient situations, and replications with other client populations in other practice
settings.
Relationship Criterion: Is the linkage clear between the expected quality of social
worker-elient relationships and priority outcomes at micro, mezzo, and macro levels (for
example, a full partnership, collaborative, or expert teacher-student relationship)? Full
partnerships imply power-sharing worker-elient relationships in all social work functions.
Role Criterion. Do a method's roles for clients and social workers reflect a division of tasks
and action steps that is consistent with the recommended relationship between them? The
expected roles should also be consistent with a client's preferred views of change,
consumer roles, and effective interventions or services.
Evaluation-Specific Criterion: Is it clear how a method systematically field tests or otherwise
examines the effects of its interventions and builds social work knowledge from practice
wisdom or by using collaborative and participatory client-centered evaluation models?
Such models actively involve stakeholders, including clients; direct service, community,
and policy practitioners; administrators; peer helpers; and cultural organizations and
indigenous leaders. Stakeholder input and feedback are required to redesign and
enhance the effectiveness of interventions.
J

The Strengths Criterion. A strengths priority re-
quires that methods assess and acknowledge
strengths first or at least concurrently with an
assessment of problems. Examples of strengths
related to the client or other types of systems, his or
her or its environment, and their transactions include
attitudes, values, talents, relationships and supports,
skills, opportunities, and other resources (Germain
& Gitterman, 1996).This process helps social
workers to reframe strengths as solutions that clients
or other systems are already using to cope with or
change their situations (Cowger & Snively, 2002;
Greene et al., 2006). It also provides a neutral
context in which problems, challenges, skill gaps,
and needs can be assessed and intervened in.
Some methods are strongly identified with a
strengths priority, such> as the strengths perspective,
empowerment practice, and resilience theory (Cochran
& Nichols-Casebolt, 2004; Greene, Lee, & Hoffpauir,
2005; Parsons, 2002; Saleebey, 2002). However, Staudt,
Howard, and Drake (200l) contend this priority should
be a requirement for all social work methods in contrast
to a pathology focus. Pathologyfocused methods blame
the victim, such as the medical model, individually
focused family approaches, expert community .
organizing models, top-down organizational
development approaches, and individual selfsufficiency
policy frameworks (Banerjee, 2003; Freeman, 2001a ;
Hasenfeld, 2000; McGoldrick, 1998; Nybell & Gray,
2004).
THE VALUE DIMENSION The value dimension an-.
swers this question: "How explicit should a social work
method be in terms of its values?" A method's values
should be sufficiently explicit that consistency among its
values and with social work values is clear (Table 1).
Clarity allows social workers to analyze a method's
appropriateness for and relevance to clients' and other
system's needs. The focus is on two criteria, values
clarification and client- or system-centeredness.
The Values Clarification Criterion. A method
should explicitly identify its values so that social
workers can understand and monitor potential
effects from using the method. Value clarity allows
workers to explore consistency between a method's
values and their application.For example, Banerjee
(2003) concludes that welfare to work approaches
emphasize values "primarily aimed at making work
the societal norm" (p.413). One such program
trained participants to ·develop a micro- enterprise,
based on an explicit assets development value
(Banerjee, 2003). Agreements with local employ-
ment and welfare offices stipulated participants
would work 20 hr per week to allow time for
training. Some participants withdrew from the
program or did not start a
J
METHODS OF PRACTICE
INTERVENTIONS 259
micro-enterprise after graduation. Program administra-
tors discovered employment and welfare case managers
were requiring participants to work 40 hr, based on their
interpretation that the "work first" value meant full-time
work. The case managers' application of that value
conflicted with the program's assets development value
(Banerjee, 2003).
A method's values should be consistent with social
work values. The Code of Ethics defines self-
determination as enhancing "clients' capacity and op-
portunity to change and to address their own needs"
(NASW, 1999, p. 4). The mental health recovery para-
digm supports consumer-defined choices or self-deter-
mination. Clinicians and administrators should apply
this value by providing clients or other systems, as
appropriate, with accurate and thorough information
about services, treatment options, and their choices
(Carpenter, 2002).
The Client-Centered Criterion. Methods should
encourage service providers, administrators, and
policy practitioners to explore clients' or other
relevant systems' value priorities. Their priorities
are the basis for goal setting, planning, and
implementing individual and systems changes.
Many mental health consumers value participation
in decisions thataffect them as individuals with
disabilities. Some client-centered macro strategies
have increased consumer involvement in mental
health policy. Examples include "creating recovery
work groups of consumers and policy makers, and
employing consumers to train policymakers and
professionals on recovery issues" (Carpenter, 2002 ,
p. 91).
THE DESCRIPTIVE DIMENSION The question an-
swered by this dimension is "To what extent should a
social work method be culturally sensitive or non-
ethnocentric in its descriptions and assessments of
clients' or other systems' situations?" Methods should
demonstrate respect for and inclusion of multiple reali-
ties related to cultural differences: ethnicity and lan-
guage, gender, social class, age, location, disabling
conditions, religion, and sexual orientation. A meth od's
descriptive theories should use culturally sensitive
explanations about human behavior, growth and devel-
opment, and how problems occur and are maintained by
individual and environmental factors. Descriptive
theories include developmental, cognitive, social learn-
ing, social influence, and cultural theories related to
micro and mezzo or macro criteria.
The Individual, Family, and Group Criterion.
Methods should describe their assumptions about hu-
man behavior and acknowledge in what ways they are
culturally sensitive. If gaps exist in this area, based on
the social worker's critical analysis, the method should
260 METHODS OF PRACTICE INTERVENTIONS
be adapted or combined with other methods to enhance its
cultural competence. Methods' descriptive theories
distinguish between normative and nonnormative be havior
according to their implicit or explicit assumptions. Because
many of these theories are European American in origin,
their assumptions are often ethnocentric, for example, an
emphasis on individualism. In contrast, one method
explains Latino family development based on cultural
theories that assume collecti vism and close family
relationships are strengths (Gutierrez, Alvarez, Nemon, &
Lewis, 1996).
Methods should be culturally sensitive in terms of
gender issues. Male-oriented theories on moral devel-
opment and leadership do not account for the effects of
oppression on women's development in general, and on
poor women of color in particular. Some authors have
proposed more gender-sensitive theories to enhance social
work practice and research, for example, struc tural
feminist theory and feminist standpoint theory,
respectively (Swigonski, 1994; Van Den Bergh, 1995 ).
Methods should be culturally sensitive in terms of group
development theories. Some theories explain how cultural
differences in group development can be useful in diab etic
education groups with poor and Latino clients. (Brown,
Kouzekanani, Garcia, & Craig, 2002).
The Organization and Community Criterion.
Methods should clarify their assumptions about "the
structure and function of complex social systems, orga-
nizations, and communities" (Freeman, 1990, p. 40), and
how they affect the development and well- being of clients.
Critical social theory assumes that those sys tems
sometimes constrain the strengths and problems of poor
people and people of color (Agger, 1998). Other cultural
theories explain how such constraints affect the
development of task groups in multicultural communities
and economic development efforts in African American
communities (Freeman, 2004; Gutierrez et al., 1996).
However, some methods' descriptive theories ignore
effects from organizational contexts (Finn & Jacobson,
2003). One religious-based counseling agency served
diverse clients, including lesbian, gay, bi-sexual, and
transgender clients. Those clients were integrated into
general services but were not provided culturally sensitive
services to address sexual orientation and related issues.
Staffs believed those services were not available because
the agency's religious philosophy (or descriptive theory)
assumed homosexuality is against God's teachings. They
pointed out some effects of the organization's oppressive
climate on clients. But administrators said specialized
services were not offered because economic cut- backs had
limited the availability of all services.
THE PRESCRIPTIVE DIMENSION This dimension
centers on the following question: "How prescriptive
should a social work method be regarding with whom
and how it should be used?" These methods should
provide explicit practice principles to guide their use
with particular populations, along with detailed infor-
mation-about their interventions and applications
(Table 1). Methods should be clear about the sources
of their principles and interventions: practice wisdom,
evidence-based research findings, or a combination of
both. Examples of prescriptive or practice theories are
task centered, group mutual aid, structural family
therapy, community social and economic
development, and total quality management (Edwards,
Cooke, & Reid, 1996; McGoldrick, 1998; Weil, 1996 ).
The Practice Principle Criterion. A method's
principles should prescribe the types of clients and
problem situations for which it is appropriate or inap-
propriate, the expected individual and environmental
outcomes, the phases of helping and the timing of those
phases, and recommended practice modalities for the
method's use (individual, family, or small groups in
direct practice; and task or focus groups in community
practice) (Delgado, 2000; Finn & Jacobson, 2003 ).
Principles should clarify the required knowledge, atti-
tudes, skills, and special training workers need to use a
method. Methods also have an ethical responsibility to
include risk management strategies in their principles.
Reamer (2006) cautions workers about using high- risk
methods in emerging practice areas wi thout training and
supervision supports to prevent harm to clients.
Finn and Jacobson (2003) indicate a method's
knowledge, and skill practice principles should clarify
how to accomplish changes in situations. For example, a
solution-focused practice principle suggests workers focus
on what is possible and changeable in a situation rather
than what is impossible and intractable. Such principles
are related to a method's prescriptive and descriptive
theories. The prescriptive theory for the solution-focused
method involves the use of questions that reveal multiple
realities and local knowledge about a situation. The
method's social construction (descriptive) theory assumes
that problems develop when realities and local knowledge
are ignored or suppressed (Gingerich & Eisengart, 2000;
Saleebey, 1994).
The Intervention Criterion. Methods should pro-
vide detailed instructions about their interventions and
how and under what circumstances they should be used.
For example, the narrative approach recommends using
naming questions to explore clients' narratives when
they have difficulties discussing related feelings,
experiences, or value priorities (Kelley, 2002). The
purpose is to help clients gain voice (power to name
important

experiences) or agency (taking action to change aspects
of the environment). Naming questions include: "What
were you feeling when _______ occurred in your nar-
rative?" "What is the most important or valued part of
your narrative to you?"
A method should also clarify how to use intervention
clusters, for example, to accomplish mezzo level
changes. Gutierrez et al. (1996) outline an organizing
method for multicultural communities involving an
intervention cluster for handling conflict. It includes
anticipating conflict between different social class a nd
cultural groups, decreasing boundaries, building alli-
ances, addressing conflict constructively, and building
consensus. These authors note that using this inter-
vention cluster may be difficult for practitioners who
have not previously experienced cross cultural activities
and who are unaware that the emergence of conflict is a
sign that "meaningful cross cultural work is taking
place" (p. 504).
THE THERAPEUTIC BOND AND TASK
DIMENSION This dimension raises the following
question: "To what extent should social work methods
address social worker or client or other system
relationships and roles based on their power
differences?" A method should acknowledge those
differences between clients or other systems and social
workers, and explain how it specifically helps to effect
power transfers from social workers and environmental
systems to clients (or other systems) (Table 1). Methods
should acknowledge challenges to power-sharing during
their use, and suggest how such challenges can be
handled" (Starin, 2006) in terms of worker-client- other
system relationships and roles.
The Relationship Criterion. Methods should identify
the type of therapeutic bond or relationship required
between social workers and clients or other systems to
accomplish preferred outcomes at micro, mezzo, and
macro levels (Rauch, 2005). Relationships are
considered incidental in some methods, but in other
methods they are an essential nonspecific aspect of
intervention (a vehicle for change). For example, the
behavioral approach identifies such relationships as
scientific and collaborative in order to help clients'
achieve behavioral changes, but not emotionally-
involved (Mattaini, 1999). The strengths perspective
recommends a nonhierarchical partnership between
social workers and clients in which power sharing and
an emotionally supportive atmosphere are explicit re-
quirements for individual and environmental changes
(Saleebey, 2002).
The Role Criterion. Table 1 indicates methods used
to identify roles, which consist of a division of tasks and
action steps between clients, social workers,
MErnODS OF PRACTICE
INTERVENTIONS 261
and others. For instance, the task-centered approach
requires collaborative worker-client roles. Clients are
expected to assume a self-monitoring role in completing
mutually planned homework tasks. Family members,
teachers, friends, and co-workers may be asked to
provide feedback to clients to enhance the latter's self-
monitoring role. These environmentally based roles
complement the social worker's role in reinforcing
changes accomplished by clients and other stake holders.
Methods also are expected to encourage attention to
clients' preferred views of consumer roles, change, and
services (Myers & Thyer, 1997). Moreover, methods
should explain how social workers can explore clients'
preferences in this regard, help them to understan d a
model's prescribed roles, and clarify how they can
exercise options and choices regarding each. Preparation
for roles requires good communication and conceptual
skills for all social workers (Starin, 2006).
THE EVIDENCE DIMENSION Evidence addresses the
following question: "How thoroughly should a social
work method specify the conditions of its
effectiveness?" Table 1 recommends that methods
provide clear parameters about how to monitor,'
evaluate, and redesign their use as needed. Targets to be
monitored include "policies, the implementation of
programs, and practice interventions" (NASW, 1999,
p.13). Methods that meet much of the criteria for the five
previous dimensions are likely to have clear evaluation
criteria.
The Evaluation.Specific Criterion. This criterion
clarifies what social work methods define as evidence
or acceptable documentation of their effects. As a
foundation for evidence, methods should be clear about
which of their interventions work best with whom (the
client population and characteristics), leading to what
preferred outcomes, under what circumstances, and for
how long (durability of changes). Methods should
identify their preferred sources of evidence and their
rationales for those preferences. Some methods that
emphasize practice wisdom as evidence suggest such
wisdom helps to identify intangible aspects of the
worker-elient relationship and complexities related to
clients' strengths and problems (Holmes, 2003). In
contrast, methods that require evidence-based research
findings suggest the results may be more effective in
clarifying program fidelity, whether an intervention' is
used consistently . across social worker-elient
situations, and the differential effects of intervention
clusters on clients and their environments (DeCoster &
Cummings, 2005).
Methods should explain which evaluation designs
they recommend for field testing their interventions,
including case studies, and single system, comparison,
and control group designs. The cognitive -behavioral
262 MErnODS OF PRACTICE INTERVENTIONS
method has field tested its interventions developmentally,
beginning with initial pilot tests of an intervention component
by using case studies or single system designs. Field testing
often progresses to pilot testing two or more other intervention
components, or to replications with different client
populations in different practice settings, using comparison or
delayed intervention group designs.
Methods should recommend field testing their inter-
ventions with collaborative, participatory, or clientcentered
evaluation models, rather than expert researcher approaches.
Examples include empowerment evaluation, participatory
action research, and ethnographic or narrative inquiry
(Chamberlayne, Bomat, & Wengraf, 2000; Fetterman, 2001;
Patton, 2002). Participatory models transfer evaluation
knowledge from researcher-experts to program stakeholders,
such as clients, practitioners at all levels, administrators, and
community members. The focus is on programs that serve
disenfranchised and oppressed populations or those that work
toward social justice and client selfdetermination. The process
helps stakeholders to develop ownership of the evaluation
process and its products (Fetterman, 2001; Secret, Jordan, &
Ford, 1999).
Lessons from this Analysis
of Social Work Methods
This analysis of criteria for social work methods has
confirmed the profession's unique client-centered values and
helping process. The criteria are essential whether they are
applied to methods developed by social workers or to methods
developed by other helping professionals that are used by
social workers. The profession should continue to examine the
relevance of these criteria in analyzing methods and identify
other criteria in the literature that can enhance this process.
The current analysis has confirmed also the centrality of social
workers' roles in analyzing methods. Workers should analyze
how clearly methods describe their use with clients or other
systems from a social work perspective, consider their own
experiences in using methods with clients and others, and
identify conclusions about a method's quality based on these
criteria. Workers may modify their use of some methods or
refrain from using others deemed insufficient. They are likely
to disagree in their assessments of methods' qualities based on
the criteria; however, their different perspectives can help the
profession sort out future issues and lessons.
Methods vary in h~w well they meet these criteria.
The strengths perspective focuses broadly on person in
environment, social justice, and strengths criteria. It does not
meet criteria for operationalizing its interventions as well
(Cowger & Snively, 2002). Task-centered
and other social-learning-based methods do not address the
environment sufficiently. Changing mezzo and macro factors
requires combining those approaches with multilevel methods
such as the structural-political approach (Freeman, 2001b).
This analysis has identified areas of continuing dis-
agreement within the profession. Examples include whether
antioppression practice should be required, clinicians should
address social justice issues, capacity building should be
taught in all community practice courses, and all methods
should be evidence-based. A conclusion of this analysis is that
evidence should be defined as a blending of knowledge from
practice wisdom and the results of intervention informative
research. Those sources provide complementary evidence for
enhancing practice, such as important dynamics related to
worker-client relationships (practice wisdom), and
documentation of intervention or program fidelity
(evidence-based findings) (Zayas, Gonzalez, & Hanson,
2003).
Future Trends
Future trends can be inferred from this analysis of practice
methods and related criteria. As social service organizatons,
research collaboratives, policy analysis groups, and funding
organizations are affected by decreased economic resources,
demands for accountability are likely to increase. This means
that evidence-based practice may become a future
requirement for social workers at micro, macro, and mezzo
system levels, rather than the emerging trend it is today.
Another future change may involve a shift from traditional
fields of practice to combinations of social work functions as
the needs of client systems and the environment change.
Examples could include social workers who are community
practitioners-policy analysts or clinical
practitioners-researchers. Such a trend will require social
workers to have greater knowledge about practice methods
across different size client systems, such as individuals,
families, communities, organizations, and social institutions.
Social workers will also need skills to identify, analyze, and
apply a range of criteria for judging how well multisystems'
practice methods meet clients or other systems' complex
needs.
REFERENCES
Agger, B. (1998). Critical social theory: An introduction. Boulder,
CO: Westview Press.
Banerjee, M. M. (2003). Realities of life before and after welfare
reform: Perspectives of women of color. Qualitative Social
Work, 2,411-433.
Brown, S. A., Kouzekanani, K., Garcia, A. A., & Craig, L. H.
(2002). Culturally competent diabetes self-manage education
for Mexican Americans. Diabetes Care, 25,259-268.

Carpenter,}. (2002). Mental health recovery paradigm: Impli-
cations for social work. Health & Social Work, 27, 86-94.
Chamberlayne, P., Bomar, }., & Wengraf, R. (2000). The tum to
biographical methods in Social Science. London: Routledge.
Chandler, M. (2006). The rights of the medically uninsured:
An analysis of social justice and disparate health outcomes.
Journal of Health and Social Policy, 21,17-36.
Cochran, }., & Nichols-Casebolt, A (2004). Risk and resilience
ecological framework for assessment and goal formation.
Child and Adolescent Social Work Journal, 21, 211-235.
Cowger, C., & Snively, C. (2002). Assessing client strengths.
In A R. Roberts & G.}. Greene (Eds.), Social workers' desk
reference (pp\221-225). New York: Oxford University Press.
DeCoster, V. A~ & Cummings, S. M. (2005). Helping adults with
diabetes: A review of evidence-based interventions. Health &
Social Work, 30, 259-263 ..
Delgado, M. (2000). Commu~ity social work practice in an urban
context: The potential of a capacity enhancement perspective. New
York: Oxford University Press.
Dessel, A, Rogge, M. E., & Garlington, S. B. (2006). Using
intergroup dialogue to promote social justice and change.
Social Work, 51, 303-315.
Dilworth-Anderson, P., & Burton, L. (1999). Critical issues in
understanding family support and older minorities. In T. P.
Miles (Ed.), Full color aging: Facts, goals, and recommendations
for America's diverse elders (pp. 93-105). Washington, DC:
Gerontological Society of America.
Doe, S. S., & Lowery, D. (2004). The role of evaluation in
developing community-based interventions: A COPe project.
Journal of Community Practice, 12, 71-88.
Edwards, R. L., Cooke, P. W., & Reid, P. N. (1996). Social work
management in an era of diminishing federal responsibility.
Social Work, 41, 468-480.
Fetterman, D. M. (2001). Foundations of empowerment evaluation.
Thousand Oaks, CA: Sage Publications.
Finn, J. L., & Jacobson, M. (2003). Just practice: Steps toward a
new social work paradigm. Journal of Social Work Education, 39,
57-78.
Fortune, A E., & Proctor, E. K. (2001). Research on social work
interventions. Social Work Research, 25, 67-69.
Fraser, M. W., Nelson, K. E., & Rivard, J. C. (1997). Effectiveness
offamily preservation services. Social Work Research, 21,
138-153.
Freeman, E. M. (1990). Theoretical perspectives for practice with
families. In S. M. L. Logan, E. M. Freeman, & R. G. McRoy
(Eds.), Social work practice with B.lack families: A culturally
specific perspective (pp, 38-52). New York: Longman.
Freeman, E. M. (1996). Welfare reforms and services for children
and families: Setting a new practice, research, and policy
agenda. Sodal Work, 41,521-532.
Freeman, E. M. (2001a). Assessment: Clients as experts on their
experiences, recovery motivation, and power resources.
Substance abuse intervention, prevention, rehabilitation, and
systems change strategies: Helping individuals, families, and
groups to empower themselves (pp. 181-201). New York:
Columbia University Press.
Freeman, E. M. (200lb). The substance abuse policy and funding
subsystem: Sociopolitical and power issues.
METI-IODS OF PRACTICE INTERVENTIONS 263
Substance abuse intervention, prevention, rehabilitation, and systems
change strategies: Helping individuals, families, and groups to
empower themselves (pp. 61-88). New York:
Columbia University Press.
Freeman, E. M. (2004). Economic and social development within
Black families and communities. In E. M. Freeman & S. L.
Logan (Eds.), Reconceptuadzing the strengths and common
heritage of Black families: Practice, research, and policy issues (pp.
281-305). Springfield, IL: Charles C. Thomas Publisher.
Germain, C. B., & Gitterman, A. (1996). The life model of social
work practice (2nd ed.). New York: Columbia.
Gibbs, L., & Gambrill, E. (2002). Evidence-based practice:
Counterarguments to objectives. Research on Social Work
Practice, 12,452-476.
Gingerich, W. J., & Eisengart, S. (2000). Solution-focused brief
therapy: A review of the outcome research. Family Process, 39,
477-498.
Gorey, K. M., Thyer, B. A, & Pawluck, D. E. (1998). Differential
effectiveness of prevalent social work practice models: A
meta-analysis. Social Work, 43, 269-278.
Greene, G. J., Kondrat, D. C, Lee, M.Y., Clement, J., Siebert, H.,
Mentzer, R. A., et al. (2006). A solution-focused approach to
case management and recovery with consumers who have a
severe mental disability. Families in Society, 87, 339-350.
Greene, G. J., Lee, M. Y., & Hoffpauir, S. (2005). The languages
of empowerment and strengths in clinical social work: A
constructivist perspective. Families in Society, 86, 267-277.
Gutierrez, L., Alvarez, A. R., Nemon, H., & Lewis, E. A. (1996).
Multicultural community organizing: A strategy for change.
Social Work, 41,501-508.
Hasenfeld, Y. (2000). Social services arid welfare-to-work:
Prospects for the social work profession. Administration in
Social Work, 23, 185-199.
Holmes.], (2003). Narrative in psychiatry and psychotherapy:
The evidence? Journal of Medical Ethics: Medical Humanities,
26,92-96.
Hyde, C A (2004). Multicultural development in human service
agencies: Challenges and solutions. Social Work, 49, 7-15.
Johnson, Y. M. (1999). Indirect work: Social work's uncelebrated
strength. Social Work, 44, 323-334.
Karls, J. M., Lowery, C. T., Mattaini, M. A, & Wandrei, K. E.
(1997). The use of the PIE (Person-in-Environment) System in
social work education. Journal of Social Work Education, 33,
49-58.
Kelley, P. (2002). A narrative therapy approach to brief treat-
ment.JoumalofBriefTherapy, 1,91-100.
Lee, M. Y. (2003). A solution-focused approach to crosscultural
social work practice. Families in Society, 84, 385-395.
Lum, D. (1999). Culturally competent practice: A framework for
growth and action. Pacific Grove, CA: Brooks/Cole.
Mattaini, M. A. (1999). Clinical interventions with families.
Washington, DC: NASW Press.
McGoldrick, M. (1998). Re-visioning family therapy through a
cultural lens. In M. McGoldrick (Ed.), Re-visioning family
therapy: Race, culture, and gender in clinical practice (pp. 3-19).
New York: Guilford Press.
264 METHODS OF PRAcnCE INTERVENTIONS
Myers, L. L., & Thyer, B. A. (1997). Should social work clients
have the right to effective treatment? Social Work, 42, 288-298.
National Association of Social Workers (1999). Code of ethics.
Washington, DC: NASW. Retrieved February 23, 2007, from
http://www.naswdc.org/pubs/code/code.asp.
Nybell, L. M., & Gray, S. S. (2004). Race, place, space:
Meanings of cultural competence in three child welfare
agencies. Social Work, 49, 17-26.
Parsons, R. J. (2002). Guidelines for empowerment-based social
work practice. In A. R.Roberts & G. J. Greene (Eds.), Social
workers' desk reference (pp, 396-401). New York:
Oxford University Press.
Patton, M. Q. (2002). Qualitative research and evaluation methods.
Thousand Oaks, CA: Sage Publications.
Prince, J., & Austin, M. J. (2001). Innovative programs and
practices emerging from the. implementation of welfare
reform: A cross-case analysis. Journal of Community Practice,
9,1-14.
Proctor, E. K. (2003). Research to inform the development of
social work interventions. Social Work Research, 27, 3-4.
Rauch, G. (2005). Relationship-based practice and reflective
practice: Holistic approaches to contemporary child care
social work. Child and Family Social Work, 10, 111-123.
Reamer, F. G. (2006). Nontraditional and unorthodox inter-
ventions in social work: Ethical and legal implications.
Families in Society, 87,191-197.
Reich, M. (1998). The sociopolitical context and social work
method 1890-1950. Social Service Review, 72, 161-181.
Saleebey, D. (1994). Culture, theory, and narrative: The
intersection of meanings in practice. Social Work, 39, 351-359.
Saleebey, D. (2002). The strengths approach to practice. In D.
Saleebey (Ed.), The strengths perspective in social work practice
(3rd ed., pp. 80-94). Boston: Allyn & Bacon.
Schreiner, M., Ng, G. T., & Sherraden, M. (2006). Cost-
effectiveness in individual development accounts. Research on
Social Work Practice, 16,28-37.
Secret, M., Jordan, A., & Ford, J. (1999). Empowerment
evaluation as a social work strategy. Health and Social Work, 24,
120-127.
Starin, A. C. (2006). Clients' role choices: Unexplored factors in
intervention decisions. Clinical Social Work Journal, 34,
101~119.
Staudt, M., Howard, M. 0., & Drake, B. (2001). The oper-
ationalization, implementation, and effectiveness of the
strengths perspective: A review of empirical studies. Journal of
Social Service Research, 27, 1-21.
Stuart, P. H. (1999). Linking clients and policy: Social work's
distinctive contribution. Social Work, 44, 335-347.
Swigonski, M. E. (1994). The logic of feminist standpoint theory
for social work research. Social Work, 39, 387-393.
Tsui, M., Cheung, F. C. H., & Gellis, M. (2004). In search of an
optimal model for board-executive relationships in voluntary
human service organizations. International Social
Work,47,169-186.
Van Den Bergh, N. (Ed.). (1995). Feminist practice in the 21st
century. Washington, DC: NASW Press.
Videka-Sherman, L. (1988). Meta-analysis of research on social
work practice in mental health. Social Work, 33, 325-338.
Weil, M. (1996). Community building: Building community
practice. Social Work, 41,501-508.
Wertheimer, M. R., Beck, E. L., Brooks, F., & Wolk, J. L. (2004).
Community partnerships: An innovative model of social work
education and education. Journal of Community Practice, 12,
123-140.
Zayas, L. H., Gonzalez, M. J., & Hanson, M. (2003). "What do I
do now?": On teaching evidence-based interventions in social
work practice. Journal of Teaching in Social Work, 23, 59-72.
FURTHER READING
Auslander, G. K. (2000). Outcomes of social work intervention in
health care settings. Social Work in Health Care, 31 , 31-46.
Breton, M. (1999). Sharing power. Journal of Progressive Human
Services, 10,33-51.
Dybicz, P. (2004). An inquiry into practice wisdom. Families in
Society, 85, 197-203.
Fong, R., & Furuto, S. (2001). CulturaUy competent practice:
Skills, interventions, and evaluations. Boston: Allyn & Bacon.
Gambrill, E. D. (2003). Evidence-based practice: Sea change or
the emperor's new clothes? Journal of Social Work Educa tion,
39, 3-23.
Min, J. W. (2005). Cultural competency: A key to effective future
social work with racially and ethnically diverse elders.
Families in Society, 86, 347-358.
Stewart, P. E. (2004). Afrocentric approaches to working with
African American families. Families in Society, 85, 221-228.
-EDITH M.
FREEMAN
MEXICAN AMERICANS. See Latinos and Latinas:
Mexican.
MICRO,MIXED. See Clinical Social Work.
MIGRANT WORKERS
ABSTRACT: This entry discusses migrant workers in the
United States and the unique circumstances and
conditions they face. Included in the discussion are
social problems faced by migrants with respect to
health, housing, working conditions, child labor, and
education. Policy issues are addressed, including rele-
vant national, international, and corporate laws. Mi-
grant patterns, demographics, and definitions are
presented. Finally, social work programs, responses,
and interventions are identified.
KEY WORDS: migrant workers; child labor; human
rights; immigrants

Definitions and Demographics
A migrant is defined as "any person who lives ternpor arily
or permanently in a country where he or she was not born,
and has acquired some significant soc ial ties to this
country." The UN Convention on the Rights of Migrants
defines a migrant worker as a "person who is to be engaged,
is engaged or has been engaged in a remu nerated activity
in a State of which he or she is not a national" (United
Nations Human Rights, 2007). Migrants are people who
make choices about when to leave and where to go, even
though these choices are sometimes extremely
constrained,
There are currently three to five million migrant
workers in the United States (Formichelli, 2006). It is
difficult to obtain a more accurate population estimate
:because of the transitory \ housing and labor practices of
migrants and their overwhelming fear of arrest, deten tion,
and deportation. Approximately 93% of migrant workers
are foreign-born and 65% are here illegally ( Housing
Assistance Council, 2004). U.S. Department of Labor
Employment & Training Administration (2000) reports
that 90% of migrant farm workers co me to the United
States from Mexico, 2.1% from Central
. America, 1 % from Puerto Rico, and 0.8% from the
Caribbean. Eighty percent of these migrant workers,
mainly farm workers, are Latino and two- thirds are
under35 years. Sixty-six percent of these work ers have
their children with them as they work. Other types of
migrant workers include day laborers, domestic workers,
restaurant personnel, and construction workers.
Migrant workers on average have a sixth grade edu-
cation. Their average annual income is less than $7,500 .
Eighty-eight percent of migrant workers are men who are
in this country on their own, many of whom send money
back to their families. Fifty- five percent of migrants are
married. Of those, 71 % are not living with their spouses .
Many start the migrant life in their early 20 s and return to
their home countries within a few years to live in the homes
that were built with money earned in the United States
(Housing Assistance Council, 2004 ). These migrants may
return .to the United States seve ral more times before they
are too old to work, returning to their countries of origin
such as Mexico, Central America, and South America (that
is, Guatemala, Honduras, Argentina, and Brazil), and the
Caribbean Basin (that is, Haiti, Bahamas, Jamaica, and
Dominican Republic).
Human Rights and Immigration Policies
HELSINKI DOCUMENT AND ADDITIONAL CONVENTIONS
The Helsinki Final Act of 1975 discusses human rights and
fundamental freedoms. Conditions for promoting equality
of opportunity with respect to working
MIGRANT WORKERS
265
conditions, education, social security, health services,
housing, access to trade unions, and cultural rights are
addressed (Ramos, 1995). In 1992, the United States
together with 51 other nations agreed to adopt the
Helsinki document regarding migrant workers.
Two other conventions, designed by the Interna tional
Labour Organization, provide additional support for the
treatment of migrant workers. The Migration for
Employment Convention, 1949 No. C97, and the Mtgrant
Workers Convention, Supplementary Provisions, 1975 ,
address a myriad of issues, including recruitment, contract
conditions, medical examinations, vocational training,
liberty of movement, termination appeals, and job security
(International Labour Organization, 1978). The chief aim
of these conventions is to ensure equality of opportunity or
nondiscrimination between national and migrant workers.
The UN Convention on Protection of the Rights of all
Migrant Workers was adopted by the UN General
Assembly in 1990 and ratified in 2002. This conve ntion
expands upon the scope of the International Labour
Organization conventions by requiring human rights
protections for migrant workers and their families, re-
gardless of their legal status in their country of immedi ate
residence (Business for Social Responsibility, 2006 ).
Article 7 of the UN convention states that nondiscri-
mination be applied, without any distinctions based on
sex, race, language, color, religion or convictions, poli tical
opinions, national, ethnic origin, age, property, marital
status, birth, or any other status (Business for Social
Responsibility, 2006). The Commission on Se curity and
Cooperation in Europe (CSCE) is the man dated
monitoring organization charged with overseeing
compliance to the Helsinki Final Act of 1975 regarding
migrant workers. In the United States, members of
Congress, both House and Senate, together with pre-
sidential appointees from State, Defense, and Com merce
Departments comprise the CSCE representative body.
This group examines migrant worker issues of co mpliance
with participating state, national, and in ternational
organizations. CSCE is concerned with pro vision of
services, health and safety, families and education, and
enforcement and reform of labor laws. The consistent
message that the CSCE finds and en courages is the
integration of migrant workers, econom icallyand socially,
with the rest of the country, without rejecting the migrant
workers cultures. The CSCE has determined that socially
related and work-related problems are closely linked and
that principles of respect, equality, and nondiscrimination
need to be applied, consistent with international
obligations (Commission on Security and Cooperation in
Europe [CSCE], 2007). By bringing to the forefront
discussions of migrant
266 MIGRANT WORKERS
workers experiencing impermissible discriminations, the
CSCE has focused on lack of access to the job market,
wages, contracts, promotion, and terms and conditions that
include safety and health regulations or access or
protections. Toward that end, the CSCE has established a
tolerance unit that publishes an an nual hate crimes report
and trains law enforcement on how to respond to hate
crimes (CSCE, 2007).'
FEDERAL LABOR LAWS Federal laws have been en-
acted regarding the enforcement of labor standards,
including child labor standards. The Fair Labor Standards
Act of 1938 regulates working conditions for all workers,
adult and children, working within the United States. The
U.S. Department of Labor oversees enforcement, acts as
the administering organization, and dispenses fines and
penalties for violations. However, enforcement is lax. For
example, according to Human Rights Watch, the
Department of Labor's Wage and Hour Division
investigated only 0.006% of employment cases related to
domestic workers, although 98% of domestic worker cases
reported to Human Rights Watch were complaints
regarding unpaid wages (Borak, 2005). Because of lack of
enforcement of federal labor laws, other organizational
entities have begun to address' fair labor issues on behalf
of migrant workers. Unions have lodged complaints about
the treatment of Mexican migrant workers in the United
States under the North American Free Trade Agreement.
SECURITY POLICIES Security concerns are figuring
prominently in the development of and debate on im-
migration legislation, much of which focuses on migrant
labor (Bruno, 2005). In May 2005, the Emergency Sup-
plemental Appropriations Act for Defense, the Global War
on Terror, and Tsunami Relief named the REAL ID Act,
which became law as Division B of P.L. 109-13. This
legislation contains immigration and identification
document-related provisions intended to improve
homeland security. Among these are provisions to change
the Immigration and Nationality Act (INA) with respect to
asylum and other types of relief from removal, and to
expand the terrorism-related grounds for alien
inadmissibility and deportation. Additionally, the Act sets
standards for state-issued driver's licenses . and personal
identification cards. These guidelines pose serious concern
for those migrant workers who are in the country illegally,
by limiting their access to services, particularly health care
via Medicaid. The newly proposed Medicaid requirements
will stipulate that two forms of citizen identification be
presented to obtain eligibility status.
Social Problems and Policies
HEAL TH A migratory lifestyle and harsh working con-
ditions create a myriad of health problems for migrant
workers. Migrant farm workers, in particular, have
extremely low incomes and they work 6 days a week,
10-12 hr a day (Health and Human Resources Admin-
istrations, 2007). When the weather is bad and crops are
not growing well, the result is malnutrition. People
working 10-12 hr a day in 95°F have tremendous nutri-
tional needs (The Pan American Health Organization,
2005). They have more complex health problems than do
members of the general population (National Cen ter for
Farmworker Health, 2007). They suffer more frequently
from infectious disease and have more clinic visits for
diabetes. Contact dermatitis is also common due to
pesticide exposure among migrant farm workers
(Occupational Safety and Health Administration, 2003 )
(OSHA Training Institute, 2003). Other common health
ailments affecting migrant workers include cancer,
hypertension, and asthma. Many of these health problems
stem from poor nutrition.
The health of migrant workers' children is another area
of concern. These children often suffer from Vitamin A
deficiencies, which can cause ear infections that can lead
to deafness if left unaddressed. Pesticide exposure is
another serious health issue. One recent study revealed that
48% of migrant children had worked in fields when the
plants were wet with pesticides and 36% had been sprayed
either directly or indirectly by pesticide drifts. Thirty- four
percent of children's homes had been sprayed in the
process of crop-dusting the fields. When crops are sprayed
the pesticide mixes with dew and when it dries, the residue
remains on clothes and skin. Such exposure is particularly
dangerous for children because their higher metabolic
rates and lower body weights make them more susceptible
to the toxic effects of pesticides than are adults
(Environmental Protection Agency, 2005).
There are laws to protect farm workers but there are
limitations to its coverage (Migrant Farmworker Justice
Project, 2000). An example is that Occupational Safety
and Health Administration (OSHA) safety standards apply
only to farms that hire at least 10 w orkers. That covers
471,500 workers nationwide but excludes one million
workers that labor on small farms (OSHA Training
Institute, 2003). In 1980s, the EPA enacted the Worker
Protection Act that required growers regardless of the
number of workers to provide training and information
abo~t pesticides used on crops, protec tive clothing,
waiting periods for re-entry into treated fields, and
hand-washing facilities to be constructed in the fields
(Environmental Protection Agency, 2005).

In 1996, however, the EPA amended the standards.
Now workers who have not received pesticide training can
work up to five days in the field without receiving any
information about the dangers. Additionally, the new
standards reduced days that growers must provide water for
hand washing, for pesticide exposure, from . one time per
week to one time per month. Currently, workers who had
never received pesticide training could work 5 days in the
fields without any information about the dangers. The new
standards also reduced days that growers must provide water
for hand-washing from one month to one week for certain
pesticides. Two years after the EPA relaxed the standards,
skin rashes reported by field workers began to increase. In
1998, the rate was about 11 cases per 10,00'0 workers. By
2001, the rate jumped to about' Z? cases per 10,000 workers
(U.S. Department of Labor and Labor Statistics, 2007).
Lack of health insurance is another reason why migrant
workers have disproportionate health risks. This is
exacerbated by the workers being transitory, rarely residing
in one place long enough to qualify for health insurance.
Routine medical examinations account for only 14% of all
visits to local health depart ments or clinics (FQHCs,
Federally Qualified Health Clinics) which have Migrant
Health Clinics. The Migrant Health Act signed in 1962, and
followed by the Economic Opportunity Act of 1964 was the
genesis of Community Health Centers in the United States.
In 1975, Congress permanently authorized neighborhood
health centers and community migrant health centers.
Today, under section 330 of the Public Health Service Act
(PHSA), the Community Health Center programs are now
known as the Community, Migrant, Public Housing, and
Homeless Health Centers. Currently, there are over 1,000
community, migrant, and homeless health centers
strategically located to serve over 3,600 urban and rural
communities in every state (National Association of
Community Health Centers, 2007).
Health Resources Services Administration (HRSA),
Division of Federally Qualified Health Clinics (FQHCs),
Department of Migrant Health, is attempting to address
migrant workerss' health issues through a national nur sing
voucher program that is instituted in regions where migrants
work for a few months, then move to another location.
Workers can bring vouchers to participating clinics to
purchase health-care services.
An enormous barrier to receipt of health services is
language and literacy. This barrier i s compounded by
cultural barriers. For example, the Guatemalans in South
Florida speak ",27 dialects of Indian Tribal languages and
not necessarily English. Health depart' ments in South
Florida were attempting to deliver AIDS
MIGRANT WORKERS
267
education messages in Spanish to Guatemalans who did not
speak Spanish. Further, men were attempting to speak to
women about sexual issues, which is not an acceptable topic
for conversation among same gen- . der, let alone
mixed-gender interactions (Potocky & Dodge, 2007).
HOUSING As a prime example of substandard housing,
"camps" in McGonagall Canyon, within the jurisdic tion of
the city of San Diego, have served as home to migrant
workers for decades (Sifuentes, 2006). Nor are makeshift
camps the exception to migrant worker hous ing needs.
Camps extend from Indiantown, Florida to Bridgeton, New
Jersey; from Oregon to Illinois; and spanning the states in
between. The states that receive the most migrant workers
are New York, Texas, Florida, New Jersey, Illinois , and
California. All of them face substandard and deteriorating
housing conditions.
There have been numerous reports of shared housing
among migrant workers; sometimes as many as 30 in ,
dividuals have been found to be living in a two' bedroom
dwelling (Evans, 2003). This overcrowding is done to
defray the costs of living expenses (Daugherty, 2006).
CHILD LABOR AND EDUCATION PROGRAMS The
prohibition of premature and excessive child labor is one
on which all civilized countries have agreed (Browne,
Frondorf, Harrison-Spoerl, & Krishnan, 2004). Frequent
moves across the country, questionable legal status, and
market or employment pressures make poor migrant
farmers particularly susceptible to child labor abuses.
Economics, specifically, the poverty of the pa rents
combined with the need for cheap labor, sug gests difficulty
in determining alternatives to child labor (Browne et al.,
2004).
Federal guidelines clearly state that employment hours
for children under 14 are to be outside of school hours, in
nonhazardous agricultural jobs, with their parentss'
consent. However, child labor laws are rarely enforced by
the government, not addressed by employ, ers and
consistently circumvented by the migrant work, ers and
their families (Sifuentes, 2006).
Education of migrant children is also a challenge.
The Migrant Education Program was established in 1965
as part of Title I of the Elementary and Secondary
Educations Act. Migrant Head Start was founded in 1969
for infants, preschoolers, toddlers, farm workers, and their
families. Migrant Head Start programs may run from 6
weeks to 9 or 10 months a year. Head Start program days
can last from 8-12 hr daily for 5-7 days a week based on
the needs of the migrant families and their hours worked in
the field. During the 1998-1999
268 MIGRANT WORKERS
academic year, 571,690 children participated in Mi grant
Head Start programs and 318,785 participated in Migrant
Head Start summer programs, out of 783,867 children who
were eligible to participate (Branz-Spall & Rosenthal,
2003).
Additional programs such as project SMART (Summer
Migrants Access Resources through Technology), and
New Generations System both originating in Texas, allow
for interstate educational opportunities and an academic or
health record information transfer system designed for
mobile migrant students. These programs enable teachers
to work with teaching counterparts in other states on a
national distance learning program via sat ellite. The
programs help teachers collaborate to address the need for
curriculum continuity, students health history, add
additional after school activities (Branz-Spall &
Rosenthal, 2003).
Social Work Roles
Effective social work practice with these migrant families
is more complicated than working with other illegal
immigrants or marginal and vulnerable populations. It
involves understanding of language and cultural specifics
unique to migrant workers, and how best to meet their
needs. Social work is addressing migrant worker needs at
the micro and macro levels. This includes accessing
services, advocacy, and organizing. Fine (2005) identified
at least 139 worker centers in over 80 U.S. cities, towns ,
and rural areas spanning 32 states that address migrant
worker issues. Organizations such as Coalition for
Humane Immigrant Rights of Los Angeles (CHIRLA),
National Day Laborer Organizing Network (NDLON),
Coalition of Immokalee Workers in Florida, Latino
Workers Center, and the Filipino Workers Center are
among those that provide information, legal and social
services, outreach, and worker organizing and civil rights
advocacy. Social workers should be aware of and
collaborate with them to work on humane and effective
policies for migrant workers and their families.
At the policy level, social work should support ef forts
that enable migrant workers to more successfully address
housing, education, health care, discrimination, wages,
working conditions, and ultimately comprehensive
immigration reform that allow migrant workers to become
integrated into American society.
Discussion
The most significant challenge for migrant workers as of
2007 in the United States is the issue of immigration. There
is lack of consensus on both sides of the aisle with opinions
ranging on one extreme from rounding up, arresting, and
deporting undocumented workers (who
comprise large proportions of our migrant workers) to the
polar opposite position of having porous borders and lax
immigration policies, by permitting easy entrance to the
United States through all entry points, and providing
universal access to health care, employment protections,
and citizenry rights. Some of the obvious ethical issues
relating to migrant workers are (a) who gets to determine
who receives services and under what conditions; (b) once
individuals are in the United States ca n we force them back
to nations where they are politically punished for their
beliefs or for being members of certain races or ethnicities;
(c) why do we have the right to withhold taxes from
migrant workers without providing them commensurate
access to services such as taxes support?; and (d) how can
we ethically provide services to children born in the United
States while denying such services to their parents or
caregivers.
With regard to migrant workers and confidentiality,
disclosure of illegal status on mandatory reporting
mechanisms such as health care provider forms can trigger
a cascade of red flags for the individual with questionable
citizenship. FQHCs and 330-1ook-alikes can handle the
issue by typing a series of zeroes into where social securit y
numbers would normally appear. The problematic areas
are employment forms, school-enrollment forms, and
arrest documents. Lack of resources is an area that
deserves a highlighted mention because migrant workers,
even with the meager programs and protections of the
Migrant Health Centers and Migrant Head Start, have a
dearth of programs or services that address their needs.
Given the emerging hostile political environment in the
United States, which opposes providing monies for
services to address the needs of undocumented workers,
funds for migrantrelated programs have become
increasingly scarce and competitive. An additional barrier
to resources is the financial downturn the United States is
facing with. the faltering dollar in global markets, the
unstable stock market, and foreclosure rates for
Americans. Our citizens cannot afford to be as generous as
they have been previously. Children of migrant workers
are often asked to help their parents during peak picking
times. While this practice is illegal i n the United States, the
growers tum a blind eye and schools tend to punish the
practice instead of finding alternatives. The conflict,
however, between accepted American school standards
and the monetary requirements of migrant workers and
their children manage to put both groups at odds. In terms
of family dynamics, the majority of migrant farm workers
are male and married. Their families often remain in their
countries of origin and money is sent back home to the
families. While the men are here, howeve r, farm worker
labor camps often provide sex workers to the

migrant workers. Often the sex workers carry infectious
diseases (for example, HIV or AIDS, Gonorrhea,
Chlamydia, Tuberculosis, etc.), which they transmit to
their customers who in tum infect their family members
upon their return to their homelands. The strain of family
separation, poverty and the migratory lifestyle of migrant
workers cannot lend itself to family cohesion. By its
nature, the standard of living of migrant workers is
stressful and not conducive to good health, long life
expectancy, and family unity. In combination, all of the
above-mentioned issues create an environment of hardship
and oppression.
REFERENCES '
Borak, J. (2005). Women migrant workers: Embracing empower-
ment over victimization. Presented at the Eighth International
Women's Policy Research Conference, Washington, OC.
Branz-Spall, A. M., & Rosenthal, R. W. (2003). Children of the
road: Migrant students, our nation's most mobile population.
Journal of Negro Education, 72(1), 55-62.
Browne, M. N., Frondorf, A., Harrison-Spoerl, R., Krishnan, S.
(2004). Universal moral principles and the law: The failure of
one- size- tits-all child labor laws. Houston Journal of Inter-
national Law. Retrieved January 20, 2007, from www.access
mylibrary.org.
Bruno, A. (2005). Immigration legislation and issues in the 109th
congress. Retrieved January 10, 2007, from www.
lwvelmhurst.org.
Bureau of Western Hemisphere Affairs. (2003). U.S.-Mexico
Binational Commission Labor Working Group Report. Retrieved
january 10, 2007, from www.state.gov.
Business for Social Responsibility. (2006). Migrant labor.
Leading Perspectives, Fall. Retrieved January 20, 2007, from
www.bsr.org,
Commission on Security and Cooperation in Europe, United
States Helsinki Commission. (2007). Combating hate crimes
and discrimination in the OSCE. Retrieved December 8, 2007,
from www.csce.gov.
Daugherty, J. (2003). That glass of OJ is squeezing back. The Palm
Beach Post. Retrieved December 5, 2006, from www.
newsbank.com.
Environmental Protection Agency (EPA). (2005). Ensuring
migrant farm workers use safety equipment when handling
pesticides. Retrieved January 10, 2007, from www.EPA.gov.
Evans, D. (2003). Sometimes there are no good choices.
The Palm Beach Post. Retrieved December 5, 2006, from
www.newsbank.com.
Fine, J. (2005). Worker centers organizing communities at the
edge of the dream. Economic Policy Institute Briefing Paper.
Retrieved January 20, 2007, from www.epi.org.
Formichelli, L. (2006). A harvest of hope. Retrieved January 10,
2007, from www.Minoriry Nurse.com.
Health and Human Resources Administrations (HRSA). (2007).
Migrant health in community health centers. National
Association of Community Health Centers. Retrieved january
10, 2007, from www.nahc.corn.
MIGRANT WORKERS 269
Housing Assistance Council. (2004). USDA section 514/516
farmworker housing: Existing stock and changing needs.
Retrieved January 10, 2007, from www.ruralhome.org.
International Labour Organization. (1978). C143 migrant workers
(supplementary provisions) convention, 1975. Retrieved
January 20, 2007, from www.ilo.org,
Migrant Farmworker Justice Project. Retrieved January 20, 2007,
from www.nfwm.org,
National Association of Community Health Centers. (2007).
About health centers. Retrieved December 8, 2007, from
www.nachc.com.
National Center for Farmworker Health. (2007). Migrant farm
worker health care. Retrieved January 10,2007, from www.
ncfh.org.
OSHA Training Institute. (2003). Occupational Safety and health
of migrant workers. Retrieved January 10, 2007, from
www.osha.gov.
Pan American Health Organization. (2005). Migrant farm workers
from Mexico, Central and South America. Retrieved January
10,2007, from www.pario.org.
Potocky, M., & Dodge, K. (2007). Bridging cultural chasms
between providers and HIV positive Haitians in Palm Beach
County, Florida. Journal of Health Care for the Poor and
Underserved, 18, 105-117.
Ramos, J. (1995). Migrant workers. In R. L. Edwards and J. G.
Hopps (Eds.), Encyclopedia of social work. Washington, DC:
NASW Press.
Sifuentes, E. (2006) Migrant workers face evictions. North County
Times the Californian. Retrieved January 20, 2007, from
www.NCfimes.com.
United Nations Human Rights. (2007). Fact sheet No. 24, the
rights of migrant workers. Retrieved January 10,2007, from
ohchr.org.
U.S. Department of Labor Employment & Training Adminis-
tration. (2000). National agricultural workers survey. Re-
trieved January 10, 2007, from www.doleta.gov.
U.S. Department of Labor and Labor Statistics. (2007). Migrant
labor. Retrieved January 10, 2007, from www.dokl.
gobwww.dol.gov.
FURTHER READING
Department of Homeland Security of Immigration Statistics.
(2002). Yearbook of immigration statistics. Retrieved January 10,
2007, from www.dhf.gov.
International Convention of the Protection of the Rights of all
Migrant Workers and Members of their Families, G.A. res
45/158, annex, 45 U.N. GAOR supp. (No. 49A) , U.N. Doc.
A/45/49 (1990), Entered into force July 1, 2003.
National Farmworker Ministry. (2000). Survey: Migrant
fannworkers.
United Nations. (2005). International Migration Report ST/
ESA/SER, A/220. Retrieved January 10,2007, from www.
un.org.
SUGGESTED LINKS Business for Social
Responsibility http://www.bsr.org;
www.bsr.org
270 MIGRANT WORKERS
Migrant Farmworker Health Care. N & L Center for
FarmworkerHealth.Ncfh·org
U.S. Department of Labor & Labor Statistics
www.dol.gov/oasam/programs/crc/crcwelcom.htm
-RICHARD WOLFF AND KAREN DODGE
MILITARY SOCIAL WORK
ABSTRACT: The history of military social work in the
United States is rooted in the civilian professional
social work community and is a microcosm of that
sector. Military social work has a rich history of
providing services to military men and women and
their families during periods of peace, conflict, and
national crises. They have been involved in
humanitarian operations and have participated in
multinational peace-keeping operations. Social work
in the Army, Navy, and Air Force is tailored to the
mission of their particular service. However, joint
operations between the services are becoming more
frequent. Military social workers adhere to the NASW
code of ethics while providing service to an institution
with its own unique culture, standards, and values.
KEY WORDS: armed forces; military social work
Characteristics
Social work practice in the Zl sr-centurv U.S. military
continues the rich tradition of commitment to at-risk
populations that began over 145 years ago during the Civil
War. The U.S. Armed Forces have employed active-duty,
uniformed, professional social workers for more than
two-thirds of a century. Since World War II, military social
work practice has evolved into a welldefined career option for
social workers who serve in every branch of the military as
commissioned officers and as civilian employees. Military
social work began as social casework in mental health settings
and now encompasses multiple fields of practice and
intervention methods at all levels in the U.S. Department of
Defense (DoD), including military family policy, child
welfare, health care, substance abuse, mental health, hostage
repatriation, combat stress, and humanitarian relief. The
number of social workers employed at any given time by DoD
varies according to the size of the military establishment. The
influence of military social workers on DoD policy relating to
the social welfare of the military community and on military
missions involving a social welfare or mental health
component has also expanded over time.
History of Military Social Work
Social Work services for uniformed personnel and their
families were provided by the American Red Cross from
World War I to the end of World War II. From 1942 to 1945
about 1,000 American Red Cross psychiatric social workers
were assigned to named general and regional hospitals in the
United States and overseas. (NASW, 1965). In 1942 six
professionally qualified psychiatric social workers were
assigned to the newly formed Mental Hygiene Consultation
Service at Ft. Monmouth, New Jersey, in an enlisted status. In
October 1943 the War Department published the Military
Occupational Specialty 263 for Psychiatric Social Work
Technicians (War, 1943). It was not until June 1945 that an
Army social work branch was incorporated into the office of
the surgeon general. The position of psychiatric social work
consultant was created to head that branch.
Over the last decade, Reserve and National Guard
personnel (Ready Reserve) have been more meaningfully
involved with the active military than ever before. Increased
participation of citizen soldiers in military missions has also
resulted in a growing need for social work services to these
military members and their families.
Military social work encompasses a full range of
generalist and specialist settings and requires skills that range
from individual therapy to policy practice. Military social
workers practice in settings that include military combat units,
mental health facilities, substance abuse treatment programs,
hospitals, prisons and confinement facilities, community
service agencies, research facilities, and commander's staffs
in major military headquarters. Military social workers'
functions include child and family welfare, medical social
work, mental health, substance abuse treatment, research,
program administration, policy formulation, and in hu-
manitarian and peacekeeping missions. Under special
conditions, other populations may become recipients of
military assistance, including civilians who have been victims
of war and victims of natural disasters.
Each of the services requires social workers to obtain a
Master's Degree in Social work from an institution accredited
by the Council of Social Work Education. Social workers who
qualify and become uniformed social workers will be
commissioned as a social work officer.
Several factors inherent in military life contribute to the
development of generalist skills by active-duty military social
workers. A typical military career includes multiple and
diverse professional assignments that are often dictated by
organizational need rather than by personal choice. Therefore,
military social workers must

exercise both personal and professional flexibility and
develop a broad range of generalist social work skills
applicable to their changing professional assignments.
Nearly all social work officers will serve in an isolated or
overseas tour of duty at some point in their military career.
The limited availability of resources in these assignments
requires the individual practitioner to develop and provide
a broad range of services.
All military services facilitate the development of
macro skills by their social work officers. As a routine part
of their career education, military social workers are
provided training in military leadership, management, and
administration. This education process begins with a basic
officer orientation course and continues through senior
service scho~l. For a select few an opportunity will be
given for them to obtain their doctorate degrees. They will
be utilized in research and high-level leadership positions,
upon completion of their education.
The Military Family Lifestyle
Regardless of their age, gender, or racial and ethnic mix,
military personnel and their families have a different
lifestyle from that of other groups of Americans. As
Whitworth (1984) so aptly noted over 22 years ago, eight
factors make military family life unique: (a) mobility, (b)
separation, (c) periodic absence of parents, (d) adjustment
of children, (e) overseas living, (f) highstress and high-risk
jobs, (g) conflicts between those of the military system,
and (h) authoritarian management requirements. These
eight unique factors remain accurate in today's military.
Military families are likely to experience all of these
factors-e--many of them repeatedly and some of them
simultaneously-during their affiliation with the armed
forces.
The attitude of today's military leaders toward fa milies
is significantly different than in previous years when the
military viewed marriage and family life as unrelated to
the military mission. Each of the services has family
support policies, programs, and services desig ned to meet
the unique needs of military families. In today's married
and family-focused U.S. Armed Forces, health care and
social service delivery systems are firmly in place to
address the needs of service members and their families.
Army Social Work
Historically, social workers have embraced the Army's
mission by providing support to soldiers and families
through the entire deployment cycle (peace and war).
Social workers have functioned as an integrated part of the
military with social workers most recently
MILITARY SOCIAL WORK 271
deploying with U.S. forces to assist "Operation Iraq
Freedom" (2003 to present) with the goal of implementing
programs that reduce stress (including combat stressjand
substance abuse.
Social workers provide a variety of services, includ ing
individual counseling, group counseling, and command
consultation. They emphasize preventive health in primary
care clinics, including screening for depression and other
psychological or psychosocial issues.
Army social workers are deployed with the soldiers
they serve and thus are in a position to provide "front line"
intervention. They are supported by an equal complement
of Reserve component social workers in the Combat
Support Hospitals and Combat Stress Control units. There
are close to 400 civil servant social workers plus contract
staff who practice along with uniformed social workers
(although not in areas of direct combat).
Social workers have also deployed with units involved
in peacekeeping and as part of multinational forces
observers. Specifically, they have been deployed to the
Sinai Peninsula, Bosnia, and Kosovo. They were the sole
mental health asset in Croatia and Somalia (personal
conversation with chief of army social workers, Co l.
Yvonne Tucker-Harris, August 2007). Major changes in
Army doctrine over the past few years have had an impact
in social work practice. As a result of past experiences,
there is a: greater emphasis on educating military leaders on
combat stress; how to prevent it, how to detect it, and the
resources that are available, including Combat Operational
Stress Control Teams. The Army's Training and Doctrine
Command along with the Army's Medical Department
Center and School share the responsibility for training in
combat stress for our fighting force. There has also been a
trend toward deployment with brigade combat teams,
which seems to work extremely well in support of the
soldiers in the theater of operation (Field Manual 8-51,
1994).
Although there has been a trend toward integration into
behavioral health teams, social work maintains a separate
department or service in most hospitals.
Social Work in the Navy
The Navy's social work program was provided by civilian
social workers assigned to the Red Cross and large Navy
relief offices, as well as by other volunteer agencies in the
Navy. The first professional social worker was employed
by the Navy Relief Society in 1945, the end of World War
II (Raiha, 1999). Social work programs in the Navy
include behavioral science support to Navy and Marine
Corps commanders and personnel, medical and psychiatric
social work at naval hospitals, research on the military
family, family advocacy, and drug and alcohol prevention
and rehabilitation.
272 MILITARY SOCIAL WORK
In 1973, with the repatriation of American prisoners of
war from Southeast Asia, the Navy developed a
prevention-oriented social work program designed to
provide outreach services to families of servicemen
missing in action and to returning prisoners of war and
their families. This program has since ended, but social
workers have remained in naval hospitals to provide a
variety of services. There are currently about 200 civilian
social workers employed in naval hospitals.
In 1979 the Navy Family Support Program was
established. In 2006, around 75 Fleet and Family Sup port
Centers (FFSCs) operated throughout the world. These
centers provide the on-site means by which the Family
Support Program is implemented: they are multifunctional
centers managed by Navy personnel (as opposed to
medical personnel) that offer a variety of services,
including deployment readiness services (for service
members and families), Ombudsman programs designed
to support military families, personal financi al services,
support programs for new parents, transition assistance
services for military members and families preparing to
return to civilian life, family employment services,
relocation assistance to help families during the frequent
military moves, family advocacy services designed to
prevent and intervene in child abuse and neglect and
spouse abuse cases, sexual assault prevention and support
services, life skills programs, and a variety of volunteer
services. Approximately 400 civilian social worker s are
employed full time in these centers.
Active Duty Navy social workers were first deployed
in a wartime mission to Kuwait in 2007 to support the
Navy's Warrior Transition Program designed to screen
returning Sailors and Marines for potential combat stress
and mental health issues and to help prepare them mentally
and emotionally for return to the continental United States.
Social workers in today's Navy serve as staff officers at
Navy headquarters, program managers for the Family
Advocacy Program in the Bureau of Medicine and Surgery
and the Rape/Sexual Assault Program at the Bureau of
Naval Personnel, regional Family Advocacy Program
managers in Navy and Marine Corps installations,
directors and practitioners of hospital social work, and
Family Advocacy Program managers, repre sentatives, and
practitioners in Family Service Centers.
Social Work in the Air Force
The position of social work consultant to the Air Force
surgeon general and the commissioning of Air Force so.
cial work officers dates back to 1952. Since then, the role of
active duty social workers has continued to expand in both
peace-time and war-time missions.
The history of Air Force social work reflects a pro-
fession that has continuously risen to meet the needs of
airmen and their families. The Children Have a Poten tial
(CHAP) program is an early example of this kind of
support. Established in 1961, the program was designed to
promote military readiness by supporting families with
disabilities. Air Force social workers provided counseling
and referral, client advocacy and case management while
ensuring access to medical care and appropriate
educational resources for children with special needs. The
program was later expanded to include adult family
members of airmen, and became known as the Exceptional
Family Member Program.
In 1996, the Air Force established the Integrated
Delivery System (lDS), a working group representing the
helping agencies of an Air Force base. Utilizing their
community organization and networking skills, social
workers immediately became key IDS participants in
efforts to promote coordinated responses to the challenges
of the Air Force community.
In 2006, the Air Force claimed the largest number of
active duty social workers in the Department of De fense.
With 190 officers serving across the world, social workers '
presence within the Air Force Medical Services has risen
to new heights. As part of the Air Force Biomedical
Sciences Corps that consists of 16 diverse allied health
social work officers have successfully competed for
leadership roles ranging from Headquarters Air Force to
commanding entire medical treatment facil ities or their
associated squadrons. Career-broadening opportunities
have seen social work skills utilized in psychological
operations, medical readiness, recruiting, family support,
and health and wellness In the aftermath of the terrorist
attack on the W orld Trade Center and the Pentagon on
September 11,2001, the role of the Air Force social worker
dramatically changed. Social workers were increasingly
called upon to support airmen and their families, at home
with family support programs that addressed the impact of
family separation, and abroad, in the midst of the front
lines of the global war on terrorism.
Traumatic stress response teams incorporated the most
current concepts in crisis management and were activated
in the aftermath of terrorist bombings as well as natural
disasters such as Hurricane Katrina. Social workers used
specialized training in grief counseling and posttraumatic
stress disorder to help airmen deal with the effects of these
events. They also played prominent roles in
postdeployment health risk appraisals, hoping to avert
another Gulf War Syndrome, as well as assisting families
in coming back together through reunion and reintegration
programs. The Air Force continues to successfully deploy
social workers in support of Operation Enduring Freedom
(Afghanistan), Operation Iraqi

Freedom, and in a variety of other locations in the Middle
East. Air Force social workers now operate throughout the
area of responsibility, traveling to forward operating bases
where they support soldiers, sailors, and mariners, in the
same way they have always supported airmen.
Challenges and Trends
Recent events related to war and terrorism have had a
significant impact on our way of living our politics and on
our sense of survival. The psychological and psychosocial
implications of future conflicts are as yet unclear. What is
clear however is that military social workers will have a
major role in any future encounter with enemy forces,
whether in support of our soldiers in direct combat, or in
support of peacekeeping activities. Social workers of the
different services will increasingly be in support of one
another as they intervene in the problems of the military
and the military family. It is also clear that the "citizen
soldier," members of the reserve components will continue
to be a vital part of our national defense and of the military
social work community.
Acknowledgments
The authors thank the following individuals who made
significant contributions to this entry. Yvonne Tucker
Harris, Social Work Consultant to the Army Surgeon
General, Col. MSC, U.S. Army, Barry Adams LCDR,
MSC, U.S Navy, Bureau of Medicine and Surgery and
Robert J. Campbell Lt Col Social Work Consultant to the
Air Force Surgeon General.
REFERENCES
Field Manual 8-51. (1994, September), Combat stress control in a
theateT of operations tactics, techniques, and procedures. Dir-
ectorate of Combat Doctrine, Development, AMEDD Center
and School.
National Association of Social Workers. (1965). Mental health and
psychiatric services. New York: National Association of Social
Workers.
Raiha, N. K. (1999). Medical social work in the U.S. Armed .
Forces. In Social work practice in the military (pp. xxviii, 358 p.).
New York: Haworth Press.
War Department Letter. (1943, October 18). Psychiatric social
workers, SSN 263. Washington, DC.
Whitworth, S. (1984). Testimony on military families. Hearings of
the select Committee on Children, Youth and Families, U.S.
House of Representatives, 98th Congress 2nd Session,
Washington, DC: U.S. Government Printing Office.
FURTHER READING
Applewhite, L., Brintzenhofe-Szoc, K., Hamlin, E., & Timber-
lake, E. (1995, January). Clinical social work practice in the
U.S. Army: An update. Military MediCine, 160,288.
Bureau of Labor Statistics. (2004, September). Current population
file.
MOTIVATIONAL INTERVIEWING 273
Daley, J. (Ed.). (1999). Social work practice in the military.
Binghamton, NY: The Hayworth Press.
Department of the Army Deputy Chief of Staff, Office of Army
Demographics. (2004, September 15). Data from the Defense
Manpower Data Center.
Garber, D. L., & NcNelis, P. J. (1987). Military social work,
Encyclopedia of social work (pp. 1726-1736). Washington, DC:
NASW Press.
Hamlin, E. R., Pehrson, K. L., & Gimmill, R. (1996). Social work
service in Army medical treatment facilities: Are they
reorganizing? Military Medicine, 161 (1),33-36.
Harris, J. J. (1993). Military social work as occupational practice.
In P. A. Kurzman & S. H. Akabas (Eels.), Work and well-being:
The occupational social work advantage (pp. 276-290).
Washington, DC: NASW Press.
Harris, J. J. (1999). History of Army social work. In Daley (Ed.),
Social work practice i~ the military (pp, 3-22). Binghamton,
NY: The Hayworth Press.
Office of the Assistant Secretary of Defense. (1993). Military
family demographics: Profile of the military community. Arlington,
VA: Military Family Clearing House.
Pehrson, K. L. (2002). Retention and the social work officer.
Journal of the Army Medical Department, July-September, 43-51.
Torgerson, F. G. (1956). A historical study of the beginnings of
individualized social services in the United States Army. Unpub-
lished doctoral dissertation, University of Minnesota.
-JESSE J. HARRIS AND KYLE L. PEHRSON
MOTIVATIONAL INTERVIEWING
ABSTRACT: Motivational interviewing (Ml) is a clin-
ical assessment and feedback approach intended to
increase the likelihood that people will make
changes in their behavior. The acronym FRAMES
describes the clinical components of MI: giving
personal Feedback regarding a client's individual
status, placing Responsi bility for change with the
individual, giving Advice on the need to change in a
supportive (that is, not authori tarian) manner,
providing a Menu of different change options, using
an Empathic counseling style, and, re inforcing the
client's Self- efficacy regarding their ability to
succeed in making changes. The clinical
effectiveness of MI with substance abusing
populations is well documented.
KEY WORDS: motivational interviewing; substance
abuse; assessment; FRAMES
Introduction
Motivational interviewing (Ml) and other brief
motivational interventions are quickly gaining popularity
as alternative or adjunctive approaches to more
274 MOTIVATIONAL INTERVIEWING
traditional psychotherapeutic approaches design ed to
produce behavior change among clients (Ryder, 1999 ;
Walitzer, Dennen, & Connors, 1999; Yahne & Miller,
1999). While initially used with addictive behavior
problems, such interventions have been implemented with
success for a variety of behaviors rang ing from diabetes
self-management (Doherty, Hall, James, Roberts, &
Simpson, 2000) to water disinfection prac tices (Thevos,
Quick, & Yanduli, 2000) to treatment adherence among
psychiatric patients (Swanson, Pantalon, & Cohen, 1999)
to fruit and vegetable intake among African Americans
(Resnicow et al., 2001).
Empirical Support
A rapidly growing theoretical and empirical litera ture has
demonstrated the ~ffectiveness of brief moti vational
interventions with substance abusing populations (Burke,
Arkowitz, & Mechola, 2003; DiClemente, Bellino, &
Neavins, 1999; Miller, Andrews, Wilbourne, & Bennett,
1998). In a recently published meta- analysis of controlled
clinical trials of the briefest form of motivational
interventions, motivational interviewing, Burk e et al.
(2003) concluded that MI was "equivalent to other active
treatments and superior to no treatment or placebo
controls for problems involving alcohol or drugs" (p. 856 ).
Moreover, these investigators documented an average
within treatment group effect size of .82, with participants
reducing their drinking by an average of 56% across
studies. Thus, there is strong support for considering MI
interventions "empirically supported therapies" (ESTs),
which are defined by Hall (2001) as "treatments that ha ve
been demonstrated to be superior in efficacy to a placebo
or another treatment" (p. 503).
Principles
Miller and Rollnick (2002) describe the five principles
ofMI as (a) expressing empathy, (b) developing discre-
pancy, (c) avoiding argumentation, (d) rolling with
resistance, and (e) supporting self- efficacy. These five
guidelines distinguish MI from more traditional
confrontation-of-denial counseling approaches for sub-
stance use problems. In contrast to traditional ap proaches,
motivational interventions are intended, through support
and persuasion, to increase the like lihood that people will
make changes in their behavior by helping them to
recognize that problems exist in their lives and to
overcome ambivalence about change. This directive,
client-centered counseling style has as an overarching
goal to create and magnify discrepancies between client
goals and current behavior. In this re gard, motivational
interventions appear to be particularly effective for c lients
at earlier stages of change
or who demonstrate high levels of anger (Heather,
Rollnick, Bell, & Richmond, 1996; Waldron, Miller, &
Tonigan, 2001), and hold promise for use in " window of
opportunity" situations (for example, emergency room
visits, substance-related arrests) during which motiva tion
to change may be especially malleable (Heather et al.,
1996; Monti et al., 1999).
Interventions and Techniques According to
Rollnick and Miller (1995), brief motivational
interventions are defined by "a directive, clientcentered
counseling style for eliciting behavior change by helping
clients to explore and resolve ambivalence about reducing
substance involvement."
These authors list the following key points concern ing
the "spirit" of motivational interventions:
1. Motivation to change is elicited from the client, and
not imposed from without.
2. It is the client's task, not the counselor's, to articulate
and resolve his or her ambivalence.
3. Direct persuasion is not an effective method for
resolving ambivalence.
4. The counseling style is generally quiet and eliciting.
5. The counselor is directive in helping the client to
examine and resolve ambivalence.
6. Readiness to change is not a client trait, but a
fluctuating product of interpersonal interaction.
7. The therapeutic relationship is more like a
partnership or companionship than expert/recipi ent
roles.
The specific techniques of MI are derived from a nd
informed by this spirit of motivational interventions.
Miller and Rollnick (2002) identify six components
typically present in the most effective brief motiv ational
interventions, and these components inform the specific
techniques used across brief in terventions. FRAMES is
an acronym for the six components, and refers to (a)
giving personal Feedback regarding a cli ent's individual
status; (b) placing Responsibility for change with the
individual; (c) giving Advice on the need to change in a
supportive (that is, not authoritar ian) manner; providing a
Menu of different change options; using an Empathic
counseling style; and, re inforcing the client's
Self-efficacy regarding their abil ity to succeed in making
changes.
Effectiveness with Adolescents
Very recently, a small empirical literature has emerged
concerning the effectiveness of MI with adolescent
drinkers; three college-based studies and one emer gency
room-based study have been published (that is,

Borsari & Carey, 2000; Larimer et al., 2001; Marlatt et al.,
1998; Monti et al., 1999; Roberts, Neal, Kivlahan, Baer, &
Marlatt, 2000). All four clinical trials found the approach
effective, when compared with assessment-only, for reducing
alcohol problems in this age group. Small to medium effect
sizes (.12 to .42) were documented in the original studies;
using unit-free, biascorrected effect size calculations, Burke,
Arkowitz, and Dunn (2002) documented somewhat larger
effect sizes (that is, .23 to .57). Across all four studies,
treatment effects appeared both statistically and clinically
significant, with treatment effects sustained as much as 208
weeks posttreatment.
Thus, motivational interviewing, when used with late
adolescent drinkers, meets Hall's (2001) criterion for an
empirically supported therapy (that is, superior in efficacy to a
placebo or another treatment). Across these clinical trials,
treatment effects were independent of putative moderator
variables including gender, parental history of alcoholism,
history of conduct disorder, and stage of change. However, it
should be noted that each study involved predominantly
non-Hispanic white youth (80%+), and included only older
adolescents (college students in Borsari and Carey (2000),
Larimer et al. (2001), and Marlatt et al. (1998); mean age of
18.4 years in Monti et al. (1999». To address these limitations,
NIAAA is currently supporting major clinical trials examining
the efficacy of MI with younger and more diverse adolescent
drinkers and drug users (for example, NIAAA grant R01
AA013825 [PI:
E.P. Wagner] is examining impact of MI on drinking and
related behaviors among Hispanic 10th graders).
Interest in MI has burgeoned over the past 15 years, and at
present many social workers and most addiction treatment
clinicians are at least somewhat familiar with the approach.
Certification in MI, both as a practitioner and a trainer, is now
available, and theoretical and empirical publications on the
approach have been widely disseminated. MI may be
particularly appealing to social workers as it is consistent with
harm reduction approaches to addictive behaviors. Harm
reduction has been conceptualized as a peace movement and is
aligned with the humanistic values around which social work
is organized (Brocato & Wagner, 2003). MI specifically, and
harm reduction approaches generally, may reduce the ethical
conflicts confronted by social workers conducting more
traditional and coercive interventions for substance use
problems.
REFERENCES
Borsari, J. B., & Carey, K. B. (2000). Effects of a brief motiv-
ational intervention with college student drinkers. Journal of
Consulting and Clinical Psychology, 68, 728-733.
MOTIVATIONAL INTERVIEWING
275
Brocato, J., & Wagner, E. F. (2003). Harm reduction: A social
work practice and social justice agenda. Health and Sodal
VVork,28,117-125.
Burke, B. L., Arkowitz, H., & Dunn, C. (2002). The efficacy of
motivational interviewing. In W. R. Miller & S. Rollnick,
Motivational interviewing: Preparing people for change (Znd ed., pp.
217-250). New York: Guilford Press.
Burke, B. L., Arkowitz, H., & Mechola, M. (2003). The efficacy
of Motivational Interviewing: A meta-analysis of controlled
clinical trials. Journal of Consulting & Clinical Psychology, 71,
843-861.
DiClemente, C. c., Bellino, L. E., & Neavins, T. M. (1999).
Motivation for change and alcoholism treatment. Alcohol
Research & Health, 23, 86---92.
Doherty, Y., Hall, D., James, P. T., Roberts, S. H., & Simpson, J.
(2000). Change counselling in diabetes: The development of a
training programme for the diabetes team. Patient Education &
Counseling, 40, 263-278.
Hall, G. C. N. (200l). Psychotherapy research with ethnic
minorities: Empirical, ethical, and conceptual issues. Journal
o{Consulting and Clinical Psychology, 69, 502-510.
Heather, N., Rollnick, S., Bell, A., & Richmond, R. (1996).
Effects of brief counseling among male heavy drinkers iden-
tified in general hospital wards. Drug and Alcohol Review, 15,
29-38.
Larimer, M. E., Turner, A. P., Anderson, B. K., Fader, J. S.,
Kilmer, J. R., Palmer, R. S., & Cronce, J. M. (2001). Evalu-
ating a Brief Alcohol Intervention With Fraternities.journal of
Studies on Alcohol, 62, 370-380.
Marlatt, G. A., Baer, J. S., Kivlahan, D. R., Dimeff, L. A.,
Larimer, M. E., & Quigley, L. A., et al. (1998). Screening and
brief intervention for high-risk college student drinkers:
Results from a 2-year follow-up assessment. Journal of Con-
sulting & Clinical Psychology, 66, 604c-615.
Miller, W. R., Andrews, N. R., Wilbourne, P., & Bennett, M. E.
(1998). A wealth of alternatives: Effective treatments for
alcohol problems. In W. R. Miller & N. Heather (Eds.),
Treating addictive behaviors (2nd ed.,pp. 203-216). New York:
Plenum Press.
Miller, W. R., & Rollnick, S. (Eds.). (2002). Motivational
interviewing: Preparing people for change (2nd ed.). New
York: Guilford Press. -
Monti, P. M., Colby, S. M., Barnett, N. P., Spirito, A., Rohsenow,
D. J., & Myers, M., et al. (1999). Brief intervention for harm
reduction with alcohol-positive older adolescents in a hospital
emergency department. Journal of Consulting & Clinical
Psychology, 67, 989-994.
Resnicow, K., Jackson, A., Wang, T., De, A. K., McCarty, F., &
Dudley, W. N., et al. (200l). A motivational interviewing
intervention to increase fruit and vegetable intake through
Black churches: Results of the eat for life trial. American
Journal of Public Health, 91, 1686---1693.
Roberts, L. J., Neal, D. J., Kivlahan, D. R., Baer, J. S. & Marlatt,
G. A. (2000). Individual drinking changes following a brief
intervention among college students: Clinical significance in
an indicated preventive context. Journal of Consulting and
Clinical Pyschology, 68, 500-505.
276 MOTIVATIONAL INTERVIEWING
Rollnick, S., & Miller, W. R. (1995). What is motivational
interviewing? Behavioural and Cognitive Psychotherapy, 23,
325-334.
Ryder, D. (999). Deciding to change: Enhancing client motiv-
ation to change behaviour. Behaviour Change, 16, 165-174.
Swanson, A. j., Pantalon, M. V., & Cohen, K. R. (999).
Motivational interviewing and treatment adherence among
psychiatric and dually diagnosed patients. Journal of Nervous &
Mental Disease, 187,630-635.
Thevos, A. K., Quick, R. E., & Yanduli, V. (2000). Motivational
interviewing enhances the adoption of water disin fection
practices in Zambia. Health Promotion International,
15,207-214.
Waldron, H. B., Miller, W. R., & Tonigan,]. S. (2001). Client
anger as a predictor of differential response to treatment.
Project MATCH hypotheses: Results and causal chain analyses
(pp. 134-148, NIH Publication No. 01~238). Bethesda, MD:
National Institute on Alcohol Abuse and Alcoholism.
Walitzer, K. S., Derman, K. H., & Connors, G. ]. (1999).
Strategies for preparing clients for treatment: A review.
Behavior Modification, 23, 129-151.
Yahne, C. E., & Miller, W. R. (1999). Enhancing motivation for
treatment and change. In B. S. McCrady & E. E. Epstein
(Eds.), Addictions: A comprehensive guidebook (pp. 235-249).
Oxford University Press: New York.
SUGGESTED
LINKS http://www .
motivationalinterview. org/
http;//casaa.unm.edu/mi.html
http;//www.mid-attc.org/accessed/mi.htm
-ERIC F. WAGNER
. MULTICULTURALISM
ABSTRACT: This entry defines the concept of multi-
culturalism and explains, from a historical and contemporary
perspective, its evolution and significance in social work. The
relationship between multiculturalism, socioeconomic justice,
oppression, populations at risk, and discrimination is
explained. The importance of preparatory training for social
workers to meet the challenges of multiculturalism is
presented. In addition, examples of cross-cultural training
models are provided. Implications of multiculturalism for
clinical practice and policy development are discussed.
KEY WORDS: multicultural social work; cultural diversity;
cultural competency; crosscultural practice
Definitions, Assumptions, and
Shifting Demographics
A number of terms, including multiculturalism, diversity,
cultural diversity, cultural competency, and
cross-cultural practice, are often used in the literature to
describe patterns of interaction, awareness, and sensitivity to
"special populations." These populations are typically
nonwhite and often considered oppressed, disenfranchised,
and marginalized. Multiculturalism has been defined as an
ideology that suggests that society should consist of, or at least
recognize and include with equal status, diverse cultural
groups (Sue, 20()6). Multiculturalism is often considered as
the opposite of monoculturalism, which implies a normative
cultural unity and preexisting homogeneity. As
monoculturalism assumes rejection of differences and a belief
in the superiority of dominant culture, multiculturalism
represents acceptance, appreciation, utilization, and
celebration of similarity and differences (Fong, 2005;
Gutierrez, Zuniga, & Lum, 2004).
Multiculturalism as an ideal has been regarded both as the
entitlement of cultural groups and as a form of civil rights
grounded in human dignity and the equality of cultures. It is
seen as a move toward interculturalism, the beneficial
exchange where cultures learn about each other (Anderson &
Collins, 2007). Cultural diversity is an essential component of
multiculturalism, leading to a broader representation of
perspectives, worldviews, lifestyles, language, and
communication skills. Acknowledging diversity suggests that
subordinate groups are not necessarily. required to give up
their identity or assimilate to dominate norms (Lum, 2004;
Weaver, 2005). For dominant groups, this may mean that new
ways of relating to those of different cultures need to be
acquired .
Multiculturalism is even more essential as the US.
population becomes increasingly diversified. According to
the 1980 census, 1 in every 5 Americans was nonwhite, and
in that year there were about 14 million foreign-born
residents. A decade later, 1 in 5 Americans identified as
nonwhite, and there were about 20 million foreign-born
residents (Gould, 1996). On the basis of 2000 Census data,
White non-Latinos accounted for 69% of the population,
while Latinos (who can be of any race) made up 13%, African
Americans 13%, and Asian Americans 4% (US. Census,
2001). In 2002, 11.8% or 33 million of the U.S. population
were foreign-born (U.S. Census, 2006). In 2005, 33% of the
U.S. population was identified as nonwhite minorities, and
Hispanics were the largest and fastest growing minority
group.
Currently, there are four states, Texas, Hawaii, New
Mexico, and California, and the District of Columbia in which
the combined population of minorities exceeds the majority
population (US. Gov Info, 2005). These trends are expected
to continue, and it is likely that

by 2010, 1 of every 3 persons in the United States will
belong to a racial minority group. By 2050, non-
Hispanic Whites are predicted to make up just 50% of
the population, with Latinos accounting for 24%,
African Americans 15%, and Asian Americans 8%
(Liao et al., 2004).
Simultaneously, the United States is in the midst of a
dramatic shift in the age distribution. By 2030 more
than 20% of Americans will be 65 years or older
(Council on Social Work Education [CSWE] 2001b).
With this population shift, social workers are facing
growing demands for formulating policy and providing
services to enhance the physical, mental, and social
well-being of people who have been historicallv
marginalized. Practitioners must be prepared for
multicultural social work practice and therefore use
modalities consistent with the life experiences and
cultural values of the clients and client systems (Lum,
2004; Sue, 2006).
Background and Significance:
Historical and Contemporary Perspectives
Although much of the literature suggests the need for
European Americans to accept other cultures, the reality
is that many of these other cultural groups were actually
on U.S. soil long before Europeans arrived. A close
look at history reveals a country in which the original
settlers, Native Americans, were exploited:
Many were killed and displaced by European
Americans (Weaver, 2005). Africans were forcibly
brought to this country, enslaved, and treated as
property by European Americans (Davis & Proctor,
1989). In fact, much of the labor force used to build this
country consisted of Africans, Chinese, Japanese, and
Latinos (Schmitz, Stakeman, & Sisneros, 2001).
To examine the evolution of multiculturalism in
social work practice, it is necessary to examine the
origins of the social work profession. In its earliest
conceptualization, the profession evolved from the need
to address growing social problems related to
industrialization, urbanization, and immigration at the
end of the 19th century (Popple, 1995). The early
Settlement House workers tried to be "neighbors" to the
poor and employed a "pluralist" approach based on the
belief in the equal value of some (especially White)
immigrant cultures. By the early 1900s, staff members
of the Charity Organization Societies were becoming
professionally trained to provide direct services to
mostly White immigrant children and families. At the
time, it was believed that in America immigrants should
be better off if they left their culture behind, assimilated,
adapted, and became a part of the "melting pot"
(Martinez-Brawley & Brawley, 1999).
MULTICUL1URALISM
277
By the 1930s and 1940s, a number of factors-
including the Depression, the passage of the Social
Security Act of 1935, the advent of the Second World
War, and the Cold War-led to a sense of national pride
in the United States and reinforced the belief that people
of color should "abandon" their distinct identities and
attempt to assimilate to the White norm (Logan, 2003;
Van Soest, 1995). In the post-World War II era, social
work saw a renewed focus on psychotherapeutic
approaches, as a growing number of middle- and
upper-income clients were seeking therapy from social
workers. Practice methods and theories were considered
culturally neutral and universally appropriate to all
client groups regardless of demographic characteristics
(Schiele, 2007).
However, the Civil Rights Movement of the 1960s
brought attention to growing racial and economic
inequalities. This necessitated growing recognition of
pluralistic perspectives and encouraged both the nation
and the profession of social work to recognize and value
diverse populations and cultural differences. For exam-
ple, Norton (1978) used the term "the dual perspective "
to emphasize that the world view of persons of color
and Whites is different. During this period, the Council
on Social Work Education (CSWE) developed accred-
itation standards of nondiscrimination in schools of
social work in the United States and developed five
ethnic minority task forces to address issues specifically
pertinent to American Indians, Asian Americans,
Chicanos, Puerto Ricans, and African Americans
(Newsome, 2004).
By the mid-1970s, social work programs were re-
quired by the CSWE to address issues of difference,
privilege, oppression, and discrimination at both the
baccalaureate and graduate levels. In their attempts to
focus on race, racism, and people of color, some schools
began offering courses on Institutional Racism
(Dumpson, 1970). Beginning in 1978, accredited
schools of social work were required by CSWE to con-
sider cultural diversity in admissions, faculty hiring,
and curricula (McMahon & Allen-Meares, 1992).
From the mid-1970s to the mid-1980s, schools of
social work also began to add gender and feminist
practice theories to the curriculum, and CSWE estab-
lished commissions on people of color and women
(Spencer, Lewis, & Gutierrez, 2000). From the mid-
1980s to the mid-1990s, the concept of diversi ty was
broadened again to include sexual orientation, and the
CSWE Commission on Gay, Lesbian, Bisexual and
Transgender (GLBT) Issues was established. Despite
these proactive initiatives, a 1988 study of the impact of
content on special populations on social work
278 MULTICULTURALISM
practice revealed a lack of clear understanding of the
special needs of minority populations (Moore & Isher-
wood, 1988). Similarly, McMahon and Allen-Meares
(1992) charged that the social work professional literature
portrayed social work practice as focusing on individual
interventions and "virtually ignores the societal context of
the client" (p. 536).
In fact, CSWE (2001 a) expanded the definition and
scope of diversity as curriculum content, listing 14
sources of oppression in the Educational Policy and the
Accreditation Standards. These standards stipulated that
social work education should prepare "social workers to
practice without discrimination, with respect. And with
knowledge and skills related to clients' age, class, color,
culture, disability, ethniciry, family structure, ge nder,
marital status, natidnal origin, race, religion, sex, and
sexual orientation" (p. 5). The recent trend to broaden the
scope of multiculturalism in social work beyond
ethnically sensitive practice is illustrated by the infusion
of content on GLBT (Hartman & Laird, 1998; Sanders &
Kroll, 2000), aging (Volland, & Berkman, 2004),
disabilities (Gilson & DePoy, 2002), and social class
(Shapiro, 2004) in the MSW curriculum. Some have
called for the inclusion of religion and spirituality in
education and practice as a diversity component and as
part of a holistic spirituality assessment (Canda,
Nakashima, & Furman, 2004). Moreover, the recent trend
of many schools on international social work practice has
broadened the concept of multiculturalism to embrace
aspects of globalization, immigration, and refugee issues
(Healy, 2004).
Schiele (2007) expressed concern that expanding these
definitions of diversity may serve to dilute the lesson of
racism's persistence. According to Schiele, the "equality
of oppressions" paradigm suggests that all groups are
equally oppressed and may serve to even further minimize
the content in social work education on people of color.
Instead of increasing the number of oppressions, Schiele
proposed a model of "differential vulnerabil ity" which
acknowledges that some groups are at greater risk than
others.
There has not been sufficient content on racism and
people of color in the social work curriculum. Despite
social work accreditation policies calling for the infu sion
of content related to minorities into the curricu lum, Van
Soest (1995) reported that the White European norm for
social work practice is still domi nant. Similarly, Lum
(2004) conducted an extensive review of social work
journals and found that only 9% of the articles addressed
multicultural issues, and that people of color were largely
absent in publications over a more than 30- year history.
Clearly, incorporating multicultural perspectives and
applying these concepts
in various practice settings and with diverse populations
continues to be a challenge.
Multicultural Training
for Social Work Professionals
Building cultural competence is the primary goal for
multicultural social work practice. Cultural competence is
the integration and transformation of knowledge about
individuals and groups of people into specific standards,
policies, practices, and attitudes used in appropriate
cultural settings to increase the quality of services (Lum,
2004; Weaver, 2005). This means learning new patterns
of behavior and effectively applying them in appropriate
settings and populations. The Board of Directors for the
National Association of Social Workers (2001) has
approved 10 NASW Standards for Cultural Competence
in Social Work Practice. Not only understanding and
having knowledge of different cultures, these standards
also called for social workers to be aware of the impact of
social policies and programs on diverse populations, and
to advocate for clients when needed.
Almost all multicultural training to promote cultural
competence begins by encouraging a social worker to
become aware of one's own assumptions, values, and
biases about human behaviors, which may facilitate and
hinder one's ability to be an effective practitioner (Lum,
Zuniga, & Gutierrez, 2004). Pinderhughes (1989)
recommends that social workers be knowledgeable about
culture, race, class, ethnicity, and their interrela tionship
with power or powerlessness. Through a process of
developing cultural self-understand ings, as well as an
understanding of the client's cultural identity and per-
ceptions of power, the practitioner is able to use this
knowledge to enhance cross-cultural practice outcomes.
The next step is to understand the worldview of
culturally different clients. Such understanding is
followed by developing and applying appropriate inter-
vention strategies with diverse client groups (Weaver,
2005). Martinez-Brawley and Brawley (1999) have
extended the multiculturalism teaching debate even
further and called for a contemporary "transcultural
perspective" in which a social worker can have
"multi-consciousness" and cultural competence. In this
state a social worker can be engaged with many cultural
influences and enriched by the experience of interact ing
with other groups. These authors envision social workers
going beyond cultural sensitivity and growing
transculturally through interactions that provide an
opportunity to gain in-depth knowledge about different
cultures, disciplines, and cultural perspectives.
Another training approach, referred as "critical
multiculturalism," involves a profound exploration of
oppression, differences, and prejudice (Schmitz et al.,
J

2001). Such an examination of White privilege and
understanding of internalized oppression often pro vokes
resistance, fear, and denial. However, the educa tional
process of critical self- awareness can lead to the
destruction of stereotypes and improved understanding
and appreciation of diversity.
Multicultural specialists have also adopted innovative
strategies and training models via curriculum develop-
ment and field education. Case examples that contain
lived experiences and narratives of GLBT individua ls
demonstrate the need to incorporate the coming out
process within the study of the minority identity
development (Schlope, 2004). Other teachers have used
experiential learning such as simulation, exercises
regarding aging and disability (Kane, 2003). Applying
yet another training method, geriatric' education
rotational field placement models are used to teach
students about diversity in the aging field (Netting, Hash,
& Miller, 2002).
Ultimately, understanding organizational and insti-
tutional forces that enhance and negate cultural com-
petence is critical in multicultural social work. It is based
on the premise that an organization that values diversity is
in a better position to provide culturally relevant services
to their multicultural population. Introducing the Diversity
and Social Work Training Program created by the Ackerman
Institute for the Family, Kaplan and Small (2005) identify
elements critical to the program's success over 12 years .
These include multicultural recruitment strategies,
rnentorships, partnerships with outside organizations, and
the provision of a long-term institutional commitment,
biracial collaborations, and institutional change.
Recognizing _ the need to improve cultural compe-
tence in field education, Armour, Bain, and Rubio (2004 )
have called for field supervisors to stop "avoid ing" racial
issues. Their pilot study of diversity training for 11 field
instructors illustrated successful adapta tion of a
transferable model of multicultural training which seeks
to increase comfort with diversity, atten tion to issues of
power and control in field instructor student relationships,
and knowledge about oppressed groups. Their
pretraining, posttraining, and 6-month follow- up
evaluation revealed significant decreases in field
supervisor's avoidant behaviors with students over time.
Multiculturalism: Implications
for Clinical Practice and Social Policy
Our review of literature reveals two main streams of
multicultural social work practice trends: (a) culture-
specific interventions and (b) cross-cultural- universal
approaches. In clinical social work, the standard used to
diagnose normality and abnormality is derived from
MULTICULTURALISM
279
Euro-American perspectives. As such cross-cultural-
universal approaches are culturally bound and may be
inadequate in application to ethnically diverse groups.
Multicultural specialists have called for culture- specific
interventions that take into account issues of race, culture,
gender, behavioral norms, and sexual orienta tion (Ewalt,
Freeman, Fortune, Poole, & Witkin, 1999; Weaver,
2005).
A cross-cultural study by Wells, Klap, Koike, and
Sherbourne (2001) demonstrates greater unmet needs for
alcoholism and drug abuse treatment and mental health
care among African American and Hispanics relative to
Whites. Similarly, such findings on racial disparities in
mental health (Alegria et al., 2002) call for interventions
targeted at specific cultural groups such as American
Indians (Williams & Ellison, 1996), African Americans
(McRoy, 2007), Latinos (Garcia & Zuniga, 2007), and
Asian Americans (Fong, 2007).
Disparities in outcomes for persons of color as com-
pared to Whites have led to more focused attention on the
need for understanding how policies and practices
differentially impact populations of color. For example,
although there have been improvements in the overall
health of Americans in the past several decades, com-
pelling evidence demonstrates that members of racial and
ethnic minority groups suffer increasing disparities in
terms of incidence, prevalence, mortality, burden of
diseases, and adverse health outcomes, when compared
with White Americans (Williams & Rucker, 2000).
Some populations, especially African Americans, are
differentially impacted by poverty and racism, jus tifying
greater attention to reducing their disparate outcomes
(Schiele, 2007). Children of color are dispro portionately
represented among the population of chil dren in the
nation's foster care system, and African Americans are
disproportionately represented in the juvenile and the
criminal justice system (McRoy, 2004). Despite current
affirmative action policies, racial minor ities and students
from lower socioeconomic status are underrepresented in
higher educational systems (Studley, 2003). The fact that
such disparities continue to exist despite the many
successes of the Great Society Program indicates that
much work is still to be done in the area of social justice
in American society. Unfortunately, the social work
profession has yet to fulfill its social justice mission
through more involvement in social activism on behalf of
oppressed people (Davis & Bent-Goodley, 2004; Van
Soest & Garcia, 2003).
Acknowledging the significance of multicultural
practice, some practitioners continue to support a uni-
versal, cross-cultural intervention. Particular! y, macro
practitioners argue that social programs need to be
280 MULTICULTURALISM
universally based and not targeted to specific popula tions
and groups (Specht & Courtney, 1994). Dewe~s (2001)
presents a postmodern approach to clinical prac tice that
links the perspectives of cultural competence, diversity,
social constructionism, and a generalist strengths-based
orientation for work with families. Freeman and
Couchonnal (2006) provided guidelines for using narrative
approaches with culturally diverse clients in a range of
practice settings in combination with task-centered,
solution-focused, family systems, and crisis intervention
models.
Multicultural practice has been applied to group work
with GLBT clients (DeLois & Cohen, 2000) and cultural
sensitivity training for transracial adoptive parents (Vonk,
2001). The intersections between cultural diver sity and
social problems stch as family violence and substance
abuse are being highlighted (Fong, McRoy, &
Ortiz-Hendriz, 2006). Davis and Proctor (1989) have
identified the significance of race, gender, and class in
individual, family, and group treatment. Their use of
empirical data and practice theories to examine the
interrelationships between socioeconomic status and
family problems, choice of treatment approach, group
dynamics, and treatment outcomes provides social work-
ers with much needed concrete guidelines to consider
when grappling with differences in the helping process.
With multiculturalism's focus on the interrelationships
between race, class, gender, ethnicity, and age, the soc ial
work profession can produce the next generation of
practitioners who are not only competent in working
within communities of color but also cognizant of the
differential impact of social policies on diverse client
populations. This role of advocate and translator of diverse
client groups requires a sophisticated understanding of
diversity not only across groups but also within cultural
groups. By the same token, social workers need to expand
their knowledge and skill base to embrace and
comprehend the impact of sexual orientation, religious
background, immigration, and aging on human behavior
and social problems.
Multicultural social work practice will enhance the
effectiveness of social work intervention in all fields of
practice on the individual and family intervention le vel. It
also enhances social workers' ability to identify macro
intervention strategies and to collaborate with policy
makers on alleviating inequality, while reducing prejudice,
poverty, oppression, and other forms of social injustice
(Van Soest & Garcia, 2003). An understanding of
multiculturalism leads social workers to examine how race
and class may interact to perpetuate dispro portional and
disparate outcomes in all levels of practice. It will heighten
their sensitivity to diversity both among and within
different ethnic and racial groups
and, therefore, result in more effective intervention
outcomes. Training in "undoing racism" is beginning to be
used by some agencies seeking to examine how
unconscious or conscious racism can potentially differ-
entially impact service delivery (People's Institute for
Survival and Beyond, 2007). This awareness is just one
aspect of the importance in multicultural practice.
Conclusion
Our examination of the evolution of social work's focus on
multiculturalism reveals a pattern of shifting from
assimilation perspectives in the early formative years of
the profession to a focus on cultural pluralism and racism.
Recently, the profession endorsed an expansion of the
multicultural concepts beyond racial groups to include
gender issues, sexual orientation, social class, and abilities.
Multiculturalism is closely related to im portant social
work values such as self-determination, empowerment,
advocacy, strengths perspectives, and a client-centered
approach. Social workers need to balance the importance
of a client's cultural values in the process of assessment,
intervention, and evaluation, advocating the use of
universal and culture-specific strategies in the helping
process. Continued racial disparities in health outcomes
and access to care necessi tate that social workers are
sensitive to and aware of how group differences impact
social problems at the individual and group level.
Enhanced multicultural awareness moves members of the
profession forward in intervention strategies at the
individual, familial, group, and societal levels that take
into account how culture, values, norms, and behaviors all
interact in resolving social problems. Hence, multicultural
social work continues to be exciting and challenging field
of practice in this ever-changing global age.
REFERENCES
Alegria, M., Canino, G., Rios, R., Vera, M., Calderon, J., & Rusch,
D., et al. (2002). Mental health care for Latinos:
Inequalities in use of specialty mental health services among
Latinos, African Americans, and non- Latino whites.
Psychiatric Services, 53(12), 1547-1555.
Anderson, M. L., & Collins, P. H. (2007). Race, class and gender:
An anthology (5th ed.). Belmont, CA: Wadsworth/ Thomson
Learning.
Armour, M. P., Bain, B., & Rubio, R. (2004). An evaluation study
of diversity training for field instructors: A collabora tive
approach for enhancing cultural competence. Journal of Social
Work Education, 40(1),27-38.
Canda, E. R., Nakashima, M., & Furman, L. D. (2004). Ethical
considerations about spirituality in social work: Insights from a
national qualitative survey. Families in Society, 85(1),27-35.

Council on Social Work Education. (2001a). Educational policy and
accreditation standards. Alexandria, VA: Author.
Council on Social Work Education. (2001b). Strengthening the impact
of social work to improve the quality of life for older adults and their
families: A blueprint for the new millennium. New York: Author.
Davis, K., & Bent-Goodley, T. (Eds.). (2004). The color of social
policy. Alexandria, VA: Council on Social Work Education.
Davis, L., & Proctor, E. (1989). Race, gender and class. Englewood
Cliffs, NJ: Prentice-Hall.
DeLois, K., & Cohen, M. B. (2000). A queer idea: Using group work
principles to strengthen learning in a sexual minorities seminar.
Social Work with Groups, 23(3), 53-67.
Dewees, M. (2001). Building cultural competence for work with
diverse families: Strategies from' the privileged side. Journal of
Ethnic and Cultural,Diversity in Social Work, 9(3), 33-51.
Dumpson, J. R. (1970). Special committee on minority groups.
Social Work Education Reporter, 18,30.
Ewalt, P. L., Freeman, E. M., Fortune, A. E., Poole, E. L., & Witkin,
S. L. (1999). Multicultural issues in social work:
Practice and research. Washington, DC: NASW Press.
Fong, R. (2005). The future of multicultural social work.
J. Daley (Ed.). Advances in Social Work, 6(1), 43-50.
Fong, R. (2007). Cultural competence with Asian Americans.
In D. Lum (Ed.), Culturally competent practice: A framework for
understanding diverse groups and justice issues (3rd ed., pp.
328-350). Belmont, CA: Thomson & Brooks/Cole.
Fong, R., McRoy, R., & Ortiz-Hendrie, C. (2006). Intersecting child
welfare, family violence and substance abuse: Culturally competent
approaches. Alexandria, VA: CSWE.
Freeman, E. M., & Couchonnal, G. (2006). Narrative and culturally
based approaches in practice with families. Families in Society,
87(2), 198-208.
Garcia, B., & Zuniga, M. E. (2007). Cultural competence with Latino
Americans. In D. Lum (Ed.), Culturally competent practice: A
framework for understanding diverse groups and justice issues (3rd
ed., pp. 299-327). Belmont, CA:
Thomson & Brooks/Cole.
Gilson, S. F., & DePoy, E. (2002). Theoretical approaches to
disability content in social work education. Journal of Social Work
Education, 38(1),153-165.
Gould, K (1996). The misconstruing of multiculturalism: The
Stanford Debate and social work. In P. Ewalt, E. Freeman, S. Kirk,
& D. Poole (Eds.), Multicultural issues in social work (pp. 29-42).
Washington, DC: NASW Press.
Gutierrez, L., Zuniga, M., & Lum, D. (2004). Education for
multicultural social work practice: Critical viewpoints and future
directions. Alexandria, VA: CSWE.
Harrman, A., & Laird, J. (1998). Moral and ethical issues in working
with lesbians and gay men. Families in Society, 79, 263-276.
Healy, L. M. (2004). The international dimensions of multicultural
social work. In L. Gutierrez, M. Zuniga, & D. Lum (Eds.),
Education for multicultural social work practice: Critical viewpoints
and future directions (pp, 307-318). Alexandria, VA:CSWE.
MULTICULTURALISM 281
Kane, M. N. (2003). Teaching direct practice techniques for work
with elders with Alzheimer's disease: A simulated group
experience. Educational Gerontology, 29(9), 777-779.
Kaplan, L., & Small, S. (2005). Multiracial recruitment in the field of
family therapy: An innovative training program for people of
color. Family process, 44(3), 249-265.
Liao, Y., Tucker, P., Okoro, c., Giles, W., Mokdad, A., & Harris, V.
(2004). REACH 2010 surveillance for health status in minority
communities-United States, 2001, 2002. Retrieved February 6,
2007, from www.cdc.gov/MMWR/ preview/mmwrhtml/ss5306a
l.htrn.
Logan, S. (2003). Issues of multiculturalism: Multicultural practice,
cultural diversity and competency. In R. English (Ed.),
Encyclopedia of social work, 19th ed., 2003 Supplement (pp.
95-105). Washington, DC: NASW Press.
Lum, D. (2004). Social work practice and people of color (5th ed.).
Belmont, CA: Brooks Cole. .
Lum, D., Zuniga, M., & Gutierrez, L. (2004). Multicultural social
work education: Themes and recommendations. In L. Gutierrez,
M. Zuniga, & D. Lum (Eds.), Education for multicultural social
work practice: Critical viewpoints and future directions (pp.
319-325). Alexandria, VA: CSWE.
Martinez-Brawley, E., & Brawley, E. (1999). Diversity in a changing
world: Cultural enrichment or social fragmentation? Journal of
Multicultural Social Work, 7(lJ2), 19-35.
McMahon, A., & Allen-Meares, P. (1992). Is social work racist? A
content analysis of recent literature. Social Work, 37(6),533-539.
McRoy, R. (2004). The color of child welfare. In K. Davis & T.
Bent-Goodley (Eds.), The color of social policy (pp, 36-63).
Alexandria, VA: CSWE.
McRoy, R. (2007). Cultural competence with African Americans. In
D. Lum (Ed.), Culturally competent practice:
A framework for understanding diverse groups and justice issues
(3rd ed., pp. 276-298). Belmont, CA: Thomson & Brooks/Cole.
Moore, V. L., & Isherwood, J. T. (1988, March). Utilizing professional
knowledge and values: Practice dilemmas for workers with
oppressed populations. Paper presented at the Council on Social
Work Education's Annual Program Meeting in Atlanta, Georgia.
National Association of Social Workers. (2001). NASW standards for
cultural competence in social work practice. Retrieved February
16, 2007, from http://www.socialworkers.
org/sections/c:redentials/culturaL comp.asp.
Netting,F. E., Hash, K., & Miller, J. (2002). Challenges in developing
geriatric field education in social work. Journal of Gerontological
Social Work, 37(1), 89-110.
Newsome, M., Jr. (2004). Analysis of past and present movements in
cultural competence theory and practice knowledge in social work
education. In L. Gutierrez, M. Zuniga, & D. Lum (Eds.),
Education for multicultural social work practice: Critical views and
future directions (pp. 3-18). Alexandria, VA: CSWE.
Norton, D. (1978). The dual perspective. New York: CSWE. People's
Institute for Survival and Beyond. (2007). Undoing racism. Retrieved
February 18, 2007, from http://www.pisab. org/anti-racist-princlples.
282 MULTICULTURALISM
Pinderhughes, E. (1989). Understanding race, ethnicity and
power; The key to efficacy in clinical practice. New York: Free
Press.
Popple, P. (1995). Social work profession: History. In R.
Edwards (ed.), Encyclopedia of social work (19th ed., pp.
2282-2291). Washington, OC: NASW Press.
Sanders, G., & Kroll, 1. (2000). Generating stories of resili-
ence: Helping gay and lesbian youth and their families.
Journal of Marital and Family Therapy, 26(4), 433-442.
Schiele, J. H. (2007). Minority fellowship program: Implica-
tions of the equality-of-oppressions paradigm for
curriculum content on people of color. Journal of Social
Work Education, 43(2),83-1000.
Schlope, R. D. (2004). Practitioners need to ask: Culturally
competent practice requires knowing where the gay male
client is in the coming out process. sTnith College Studies in
Social Work, Special Issue: 'Pedagogy and Diversity, 74(2),
257-270.
Schmitz, C. L., Stakernan, C, & Sisneros,]. (2001). Educating
professionals for practice in a multicultural society:
Understanding oppression and valuing diversity. Families
in Society, 82(6), 612-622.
Shapiro, T. M. (2004). The hidden cost of being African Ameri-
cans: How wealth perpetrates inequality. New York: Oxford
University Press.
Specht, H., & Courtney, M. E. (1994). Unfaithful angels: How
social work has abandoned its mission. New York: The Free
Press.
Spencer, M., Lewis, E., & Gutierrez, L. (2000). Multicultural
perspectives on direct practice in social work. In P. Allen-
Meares & C Garvin (Eds.), The handbook of social work
direct practice (pp, 131-149). Thousand Oaks, CA: Sage.
Studley, R. E. (2003). Inequality, student achievement, and
college admission: A remedy for underrepresentation.
Retrieved March 28, 2007, from http://cshe.berkeley.edu/
publications/docs/ROP .Studley .1.03.pdf.
Sue, D. W. (2006). Multicultural social work practice. Hoboken,
NJ: Wiley.
U.S. Bureau of the Census. (2001). Statistical abstracts of the
United States: 2000. Washington, DC: U.S: Government
Printing Office.
U.S. Bureau of the Census. (2006). Population finder. Retrieved
February 8, 2907, from http://factfinder.census.gov/
servlet/SAFFFactsChariteration?_submenuId = factsheet ,
2&_sse = on.
U.S. Gov Info/Resources. (2005). Number of "majority-minority"
states grows. Retrieved March 8, 2007, from http://usgo-
vinfo.about.com/od/censusandstatistics/a/minmajpop.htm.
Van Soest, D. (1995). Multiculturalism and social work edu-
cation: The non-debate about competing perspectives.
Journal of Social Work Education, 31(1), 55-65.
Van Soest, D., & Garcia, B. (2003). Diversity education for
social justice; Mastering teaching skills. Alexandria, V A:
Council on Social Work Education.
Volland, P. J., & Berkman, B. (2004). Educating social
workers to meet the challenge of an aging urban popula-
tion: A promising model. Academic Medicine, 79(12),
1192-1197.
Vonk, M. E. (2001). Cultural competence for transracial adop-
tive parents. Social Work, 46(3),246-255.
Weaver, H. N. (2005). Explorations in cultural competence:
Journeys to four directions. Belmont, CA; Brooks/Cole.
Wells, K., Klap, R., Koike, A., & Sherbourne, C. (2001).
Ethnic disparities in unmet need for alcoholism, drug
abuse, and mental health care. American Journal of Psych-
iatry, 158(12), 2027-·.;.2032.
Williams, D. R., & Rucker, T. D. (2000). Understanding and
addressing racial disparities in health care. Health Care
Financing Review, 21,75-90.
Williams, E. E., & Ellison, F. (1996). Culturally informed
social work practice with American Indian clients:
Guideline for non-Indian social workers. Social Work,
41,147-151.
FURlHER READING
Council on Social Work Education. (1973). Guidelines for
implementation of accreditation standard 1234 A. New York,
NY: Author.
-EUN-KYOUNG OTHELIA LEE AND RUTH Mckor
MURDER. See Community Violence: Violence.
MUSLIM SOCIAL SERVICES
ABSTRACT: Zakat or obligatory charity is a foundation
of Muslim social services. Social services with
Muslims date back more than 1,400 years to the time
of the Prophet Muhammad. His biography reflects his
involvement in the care of the poor, widows, and
orphans and engagement in social justice for women
and minorities. Muslim communities throughout the
United States are providing social services for
Muslims; however, an institutionalized network of
professional social services sensitive to the needs of
Muslims is in the developmental stage.
KEY WORDS: Muslim; social services; Islamic social
services; spiritual competence
Background
As the Muslim community in the United States has grown, so
has its social service needs. Worldwide there are about 1.5
billion Muslims, 7 million of whom live in the United States
(Haddad & Esposito, 2000).
Religious Foundations
The provision of social services by Muslims for those in need,
regardless of their faith background, is prescribed in Islamic
teachings. Zakat or obligatory charity, one of

the five pillars of Islam, is a religious foundation upon
which the provision of social services is based. The other
pillars include Shahadah or declaration of faith, Salat or
five obligatory prayers, Sawm or fasting during Ramadan
and the Hajj or Pilgrima ge to Mecca, Saudi Arabia, Islam's
birthplace, once in a Muslim's life time. Zakat is incumbent
upon each Muslim who has wealth left at the end of the
year after paying all expenses and debts. The fulfillment of
this obligation requires each person with re maining wealth
to give 2.5% of it to those in need. Zakat can be given
directly to an individual, family, mosque, or social service
organization. It provides the basis of the Islamic social
welfare system. Throughout the Qur'an, the scriptural text
of Islam, Muslims are reminded of their duty to care for the
needy, widows, and orphans, and to strive for social justice.
In chap. 2, verse 177, the Muslims are taught that
religiosity is not just the rituals of the faith, includ ing
prayer and fasting, but that it also involves care of the
needy,widows, and orphans and utilizing means, financial
and otherwise, to seek social justice and end oppression. In
the Qur'an, chap. 107, known as Sura Al Maun, Muslims
are reminded about the importance of caring for the
miskeen (poor and needy) and that being seen engaging in
the rituals means little without ful filling neighborly needs
or small kindnesses, that is, without engaging in tasks that
in social work are known as meeting common human needs
(Ali, 1999).
Historical Development
The history of social services and Muslims dates back to
the early days of the Prophet Muhammad. He was in many
ways an early day social worker addressing the needs of the
poor, widowed, orphaned, women, and enslaved. Much of
the Prophet Muhammad's life exemplified his concern for
the poor and disadvantaged in his society.
Voluntary disaster relief has been and continues to be a
major social service effort among Muslims inter nationally.
The relief effort is manifested through organization s such
as the national Red Crescent Societies throughout the
world and Islamic Relief worldwide. Islamic Relief USA,
incorporated in California in 1993, has engaged in relief
efforts during Hurricane Katrina as well as regular efforts
in collaboration with the ILM Foundation to feed the
homeless on U.S. streets. Islamic Relief USA also
collaborates with various organizations in the annual
Humanitarian Day, which provides essentials such as food,
hygiene kits, and medical care. Other domestic projects
supported by Islamic Relief include the continuing support
of the UMMA Community Clinic's medical services, toy
drives for disadvantaged children, community support
MUSLIM SOCIAL SERVICES
283
programs, and much more. One of Islamic Reliefs domestic
projects that has grown in recent years is the financial
assistance program for families in need. Working with
mosques and community organizations, Islamic Relief
provides emergency financial assistance to families in need
(http://www.irw.org/wherewework/ unitedstates).
In the United States and Canada the development of
mosques and Muslim communities led to various efforts to
address the social service needs of the growing population
of Muslim converts as well as the developing immigrant
community. From the early 1900s, as Muslim communities
developed and prayer halls and mosques were built, they
became the center for mutual assistance and immigrant
resettlement, helping new residents find work and get
established. Bagby, Perl, and Froehle's (2001) study of
contemporary American mosques found that around 24%
of regular mosque participants have incomes of less than
$20,000 and live below the poverty line. Over 90% of
mosques in America provide cash assistance to members in
need. Most mosques provide counseling, priso n outreach,
food assistance, and clothing/thrift assistance. One third or
less of mosques provide or participate in tutor ing, voter
registration, antidrug or anticrime activities, day care, and
substance abuse programs. Most notable is the
disproportionate involvement of predominantly African
American mosque communities in prison ser vices and
antidrug or anticrime activities. The study also indicates
that about 25% of today's mosques pro vide new Muslim
classes, fitness programs, or parenting/ marriage
counseling classes (Bagby et al., 2001).
McCloud (1995) in her research on African Amer ican
Muslim communities discusses the social service efforts of
communities. In the mid-1940s, the First Muslim Mosque
of Pittsburgh's constitution indicated that among its
purposes were "to furnish aid in case of sickness, death, or
permanent disability" (p. 26). Muslim women in this
community were at the forefront of developing a Red
Crescent Club patterned after the American Red Cross as
well as a Young Muslim Women's Association chartered in
1946 whose activities included "aid to dependent children,
widows, and the elderly. Muslim men likewise developed a
Young Men's Muslim Association which engaged in social
services in the local community, the most significant of
which was the Islamic Boys Club" (p. 27).
The Ahmadiyya community, influential among African
Americans from the 1920s to the 1980s, is noted for its
emphasis on providing social services na tionwide,
including food and clothing programs for Muslims in crisis
in the United States and abroad. Provision is viewed as part
of the community's pledge
 284 MUSLIM SOCIAL SERVICES
to serve humanity (McCloud, 1995). The Nation of Islam,
established in the 1930s, grew significantly under the
leadership of Malcolm X and was one of the earliest
organizations to address the economic and social service needs
of Muslims. It developed in lowincome inner-city
communities with largely African American populations. The
Nation is well known for
. its role in promoting economic self-sufficiency by providing
employment opportunities to its members and in addressing
the transition and reintergration needs of the formerly
incarcerated African Americans who become members of the
Nation (Haley, 1964; McCloud, 1995). In the 1960s, the
Islamic Party of North America members held neighborhood
cleanup drives, and classes in crafts, sewing, and hygiene.
Other programs provided by the Islamic Party include prison
services, martial arts, Boy Scout troops, and food drives
(McCloud, 1995).
In the 1960s, the Muslim Student Association (MSA)
developed to provide social support to foreign Muslim
students. Today, the MSA continues to address the need for
social support and religious accommodation for foreign
students, second and third generation children of immigrants,
converts, and the children and grandchildren of converts on
college campuses throughout the United States. Out of the
MSA emerged a new national organization known as the
Islamic Society of North America, which was originally
developed to address the needs of Muslim immigrants to the
United States and Canada, many of whom settled here despite
early plans to return to their country of origin.
The Islamic Circle of North America (lCNA) developed as
a national organization headquartered in New York City with
local chapters throughout the United States. ICNA Relief is
the social welfare department ofICNA, which is engaged in
the implementation of relief and community development
projects. Its purpose is to address the basic human and social
service needs of underserved communities in the United
States. Several organizations have been established as part of
ICNA Relief to fulfill its mission. Among them are
UMMAH-United Muslim Movement Against Homelessness
and Muslim Family Services (MFS), which was established in
Detroit in 1998. The primary focus ofMFS is to promote
healthy marriages, adolescence development, and
parent-adolescent relations. It also serves as a liaison with the
Detroit family courts and provides ernergency food and
income assistance (http://www.icna.org/
icna/icna-relief/muslim-family-s.html) .
In 1971, the Arab Community Center for Economic and
Social Services (ACCESS) opened in a storefront in south
Dearborn, Michigan, to address the cultural,
linguistic, and social needs facing Arab immigrants. Dearborn
is home to one of the largest Arab communities in the United
States, many of whom are Muslims. In 1988 the ACCESS
Community Health and Research Center opened as a fully
integrated community health center composed of medical,
public health and research, mental health, family counseling
services and environment programs (http://www
.accesscommunity. org/site/PageServer?pagename =
ACCESS_History2).
In the 1990s, domestic violence prevention and
intervention efforts began to take shape in local communities
as a result of the advocacy and educational efforts of Shareefa
Al Kateeb. In 1993, Al Kateeb conducted the first national
study regarding the prevalence of physical violence among
Muslims in the United States .. Study results indicated that
comparable to trends in other faith groups, 10% of Muslims
were experiencing physical abuse (http://www.peacefulfami-
lies.org/about.html), By 2000, the Peaceful Families Project
was established to promote education and awareness about
domestic violence within Muslim families.
In 1995, the Muslim Community Center for Human
Services was established as a nonprofit agency, and the first
Muslim organization in Texas and in 1997 in Georgia, the
Baitul Salaam Network, was established to address the social
service and shelter needs of Muslim women and children
experiencing domestic violence
(http://www.baitulsalaam.net/hiStory .html).
By 1999, the need for a nationwide effort in the United
States and Canada became apparent. Out of this need
developed the Islami~ Social Services Association (lSSA) of
the United States and Canada. Today this organization has
formed two organizations, the Islamic Social Services
Association Canada (lSSA-Canada) and the Islamic Social
Services Association-United States OSSA-USA). ISSA-USA
and ISS A-Canada are the only national level organizations
established with the primary mission to promote awareness of
the social service needs of Muslims living in the United States
and Canada (http://www.issausa. org-index
files/aboutus.htm, ISSA provides diversity training for
mainstream providers as well as training and consultation for
local Muslims wanting to establish a social service effort in
their local community.
Implications for Social Workers
There are several issues to consider in the effective provision
of social services to Muslims. First is the need for social
workers to receive preparation to effectively address the
needs of Muslims living in the United States from a culturally
and spiritually competent perspective. Social workers are
largely ill-prepared to

address the needs of religious and spiritual people (Canda
& Furman, 1999; Russel, 2006). Social service providers
and social work students indicate that they are largely
unfamiliar with Muslims, their traditions, beliefs, and
diverse social service needs (Nadir, 2005; Nadir &
Dziegielewski, 2001).
Second is the need to increase the very small cadre of
Muslims in the fields of social work, counseling, and
psychology. Muslims, especially those whose families
have immigrated to the United States over the past 40
years, tend to choose careers in medicine, computer
sciences, and engineering. African American Muslims
have been more inclined to the human services but still are
few as a result of the general underrepresentation of
African American and other people of color in higher
education and in the field. \
Third, Muslims as a whole lack knowledge and ex-
perience with professional social workers and social
services. From an Islamic perspective, the provision o f
social services is a form of worship and a volunteer effort.
It is not viewed as a professional endeavor for which
qualified individuals are paid. Those who provide social
services are volunteers in most predominantly Muslim
countries.
Fourth, Muslims naturally seek help from family,
community members, their local Imam, and other mos que
leaders. These natural helpers tend not to have the
professional knowledge and skills to assist with the
individual, marital and family problems experienced by
congregants. Also most social services in the U.S. Muslim
community are provided on a volunteer basis. Few
organizations have the funding to hire from the limited
pool of professionally educated Muslim social workers.
Most Muslim social service organizations are new to the
government grant process. Garnering financial support for
comprehensive professional services within the Muslim
community has been difficult and is not sufficient to
sustain the needed services.
In addition, many Muslims are connected to family in
lands where poverty is high. Seventy-five percent of the
U.S. Muslim population is in the middle to upper income
level. When they compare poverty in the United States to
poverty in their homelands, they see that individuals "back
home" always have the greater need, the real need.
Therefore, their money almost always goes overseas to
help those in need in countries outside of the United States.
Also, Muslim donations to social service and relief
organizations slowed down significantly in the aftermath
of September 11, 2001, as many of the major Muslim relief
organizations were accused of supporting terrorism.
Fifth, Islamic and Muslim Social Service agencies
providing direct services are still a very small number of
MUSLIM SOCIAL SERVICES 285
nonprofits nationwide. They still are in the nascent stage of
institutional development.
Conclusion
While Muslim social services are young to the U.S.
landscape, they are growing and developing. More and
more Muslims are becoming interested in the field of
social work however this is still a small cadre in the field.
And, finally, today's social workers lack knowledge and
are ill prepared to provide culturally and spiritually
sensitive services to Muslim Americans. The future
suggests a need for macro social work practice and
organizational development to bolster the development of
Muslim social service agencies as well as recruitment of
Muslims to the field of social work. Infusion of content
regarding Islam and Muslim American practices and life in
the social work curriculum, as well as continuing
education for current practitioners are essential for the
development of effective culturally and spiritually
competent social services for Muslim Americans.
REFERENCES
Ali, Y. (1999). The Qur'an translation. New York: Tahrike Tarsile
Qur'an.
Bagby, 1., Perl, P., & Froehle, B. (2001). The mosque in America: A
national portrait. Washington, DC: Council on American
Islamic Relations.
Canda, E. R., & Furman, L. (1999). Spiritual diversity in social work
proctice: The heart of helping. New York: Fee Press.
Haddad, Y., & Esposito, J. (2000). Muslims on the Americaniza-
tion path? New Yark: Oxford University Press.
Haley, A. (1964). The autobiography of Malcolm X. New York:
Ballantine Books.
McCloud, A. B. (1995). African American Islam. New York:
Routledge.
Nadir, A. (2005). Reflections on teaching about the Muslim
reality. Ref1ections, 11(3),29-37.
Nadir, A., & Dziegielewski,S. (200l). Islam. In M. Van Hook, B.
Hugen, & M. Aguilar (Eds.), Spirituality within religious
traditions in socioi work proctice (pp, 146-166). California:
Brooks/Cole.
Russel, R. (2006). Spirituality and social work: Current trends and
future directions. Arete, 30(1), 42-52.
SUGGESTED LINKS
ACCESS Community Health and Research Center http://www
.occesscommunity .org/site/P ageServer?pagename
ACCESS_History2
Baitul Salaam Network/Baitul Salaam Residence for Abused and
Neglected Women and Children
http://www.baitulsalaam.net/history .heml
Islamic Relief USA
http://www . irw . org/whereweworklunitedstates
Islamic Social Services Association USA
http://www. issausa.org
286 MUSLIM SOCIAL SERVICES
Islamic Social Services Association Canada
http://www.issaservices.com!
Muslim Community Center for Human Services
http://www.mcc-hs.org/
Muslim Family Services
http://www . icna .org/icna/icna-relief/muslim-family-s. html
Peaceful Families Project
http://www . peacefulfamilies .org/ about. html
-P AMELA ANEESAH NADIR
MUTUAL-AID GROUPS. See Self-Help Groups.
MUTUAL AID SOCIETIES
ABSTRACT: Mutual aid associations were established
as early as colonial times in this country but gained
prominence among the early immigrant populations
during the 17th and 18th centuries. They typically
arose among newly immigrated groups, particularly
among ethnic groups and cultures with extended
kinship networks. The purpose of this discussion is
to present characteristics and social welfare
functions of mutual aid societies as they developed
in the United States.
KEY WORDS: mutual aid; mutual aid societies; fraternal
orders; benefit society; self help
Mutual Aid Societies
Fraternal organizations, friendly societies, or benefit
societies flourished in the 18th century in Europe (Chodes,
1990). It was not, however, until the latter part of the 19 th
century that fraternal organizations in the United States
rose in popularity (Beito, 1994). At that time, the rapid
urbanization of American society, with its consequent
dissolution of traditional family relationships and social
life, produced a widespread interest in new types of
association for recreational and economic purposes.
Because of the common themes of mutual aid and
cooperation, as well as, being organized around some
commonality, these associations have come to be known
as "mutual aid societies" or mutual aid associations
(MAASs).
MAASs were established as early as colonial times in
this country but gained prominence among the early
immigrant populations during the 17th and 18th cen turies.
They typically arose among newly immigrated groups,
particularly among ethnic groups immigrating from rural
communities and cultures with extended kinship networks
(Beito, 1994; Hoyt, 2002). The purpose of this discussion
is to present characteristics and
social welfare functions of mutual aid societies as they
developed in the United States.
Characteristics of Mutual Aid Societies Studies of
mutual aid groups in Western society show that these
groups evolve among populations that are facing difficult
or even disastrous situations (Borman, 1984; Lieberman &
Borman, 1979). They arise often when the primary bonds
of kinship, neighborhood, family, and religion are weak,
and they appear to have reached a crest of development in
the modem urban-industrial period (Borman, 1984;
Lieberman & Borman, 1979).
Essentially, mutual aid organizations are voluntary
associations or common interest groups, and those in-
volved in the group generally share this commonality.
They are self-supporting and operate outside the aegis of
formal institutions or agencies (Beito, 1996, 2000a,
2000b; Borman, 1984).
Mutual aid societies typically provide four functions
for their members: economic assistance, cultural preser-
vation, social interchange, and mutual protection.
Economic assistance has historically taken the form of
low-cost mutual or burial insurance, free or low interest
loans, or charity. Among ethnic immigrant groups, cultural
preservation also has been an important func tion of mutual
aid societies as the immigrant group strives to preserve its
native customs and traditions as it adjusts to the American
culture. For these groups, such activities as the
sponsorship of cultural heritage programs reinforce
community ties and group identity. Similarly, mutual aid
societies provide members an opportunity for a level of
social interaction with others with whom these members
share a commonality that they may not find possible in
broader society. Finally, mutual aid societies provide
mutual protection as members band together against
encroachment by forces outside their control (Lieberman
& Borman, 1979).
Mutual Aid Societies
Among American Ethnic Groups
As the massive waves of immigration to America brought
many adjustment problems for immigrants and their
families, these societies arose as a form of social
organization to help replace the support of ex tended
kinship and community ties from the native culture and. to
provide economic assistance. Lacking outside supports,
members of immigrant groups turned to their own group
and organized large networks for self-help and mutual aid
(Katz & Bender, 1976).
A thorough presentation of the history and significance
of all the major ethnic mutual aid societies that have
developed in this country is beyond the scope of

this discussion. Following is an illustrative list of ethnic
mutual aid and benevolent societies common within U.S.
history.
Italian American mutual aid societies included the
Benedetto Society, the Flavia Gioia Society, the Isola de
Stromboli Society, the San Rocco Society, and the Order
of the Sons of Italy (Iorizzo & Mondello, 1980). Among
Irish American mutual aid societies the follow ing were
prominent: the Charitable Irish Society, the Friendly Sons
of St. Patrick, the Ancient Order of Hibernians, and the
Irish Home Society. The Knights of Columbus, while
contemporarily a Catholic fraternal society, initially was
organized by the Irish American community (Fallows,
1979). The African American community also developed a
network of benevolent societies, fraternal orders, ~ nd other
mutual aid societies mostly affiliated with the black
church. Historically, the black church has been a
significant vehicle for attempting to meet the economic
and welfare needs of the African American community on
a mutual aid basis. African American mutual aid societies
included: the National Association of Colored Women
(NACW) (Martin & Martin, 1985; Norman, 1977;
Peebles-Wilkins, 1989; Williams & Williams, 1984).
Mexican American mutual aid societies also known as
mutualistas, included La Alianza Hispano America, La
Sociedad Progresista Mexicana, Comite de Beneficien cia
Mexicana, La Sociedad Cervantes, La Sociedad Mutualista
Mexicana, Sociedad Union Cultural Mex icana, and more
contemporarily the League of United Latin American
Citizens (Barrera, 1988; Briegel, 1974; Gann & Duignan,
1986; Gibson, 1987; Hernandez, 1979; Rivera, 1987;
Rodriguez, 1978). In the Jewish Community, the
Workmen's Circle (Arbiter Ring) is an example of an
organization that exists to this day.
The Social Welfare Function of
Mutual Aid Societies
Gilbert, Specht, and Terrell (1993) describe five funda-
mental social institutions: kinship, religion, economics,
mutual assistance, and politics. Kinship, through the
family, provides for procreation, socialization, protection
and emotional support. Religion, through churches, pro-
vides for spiritual development. Economics, through
business, provides for production, distribution, and con-
sumption. Mutual assistance, through support groups and
voluntary agencies and associations, provides for mutual
aid and philanthropy. Politics, through government,
provides for the mobilization and distribution of resources
for collective goals. Mutual assistance or sup port functions
come into play when individuals are not able to meet their
needs through the major institutions that operate to carry
out the other functions described
MUTUAL AID SOCIETIES
287
earlier. The institution of social welfare is that pattern of
relationships, which develops in society to carry out
mutual support functions (Gilbertxs, Specht, 1974; Gilbett
& Terrell, 2004).
From this perspective, mutual support is the core
function of social welfare. Mutual suppott comes into play
when human needs are not being met via family, political,
religious, or economic activities. Prior to government
funding for this type of assistance, funding came from
indigenous sources or from locally-based institutions such
as settlement houses and churches. MAASs became the
community organizations for many of these communities
(Hoyt, 2002).
Lieberman and Borman (979) offer three explanatory
models for the development of mutual aid societies that
have relevance to Gilbert and Specht's notion of mutual
suppott and assistance as a core function of social welfare.
The first, functionalist, refers to the emergence of new
service groups in response to unmet needs and gaps in
service by professionals and their institutions. The second,
alternative pathways, describes new self help groups
organized to provide services already available but whose
members desire a form of delivery more consistent with
group values. The third, affiliative bond, sees self- help
organizations as responding to social alienation by
fulfilling underlying needs for identity and community
among their members.
Mutual Aid Societies Today
Mutual aid societies were one of the cornerstones of social
welfare in the United States until the early 20th century
(Beito, 1994). Although mutual aid societies have
generally declined, there appears to be reemer gence of
ethnic associations concerned with mutual aid. This is
particularly so for the newer immigrant groups with
distinct cultural patterns (Beito, 1996; Hoyt, 2002; Jenkins ,
1988). The Bui 1981 study (Jenkins, 1988), for example,
identified more than 500 MAASs created by the
Indochinese refugee community in the United States from
1975 to 1980. A similar development has emerged with
more contemporary migrations of Southeast Asians and
other Third World populations (Hoyt, 2002). These
associations reported various functions, including social or
fraternal, educational or cultural, and political.
Within the mainstream populations, mutual assis tance
societies have also evolved into more institutional forms
such as trade unions, credit unions, cooperatives, and clubs
and fraternal organizations such as the Oddfellows, the
Moose, or the Woodmen. Within professional service
populations, contemporary mutual aid efforts have been
characterized by what has become known as the self- help
movement (Hatzidimitriadou,
288 MUTUAL AID SOCIETIES
2002). Such self-help or mutual aid groups share common
attributes such as being peer led and address a common
problem or condition with little or no connection with
professionals (Hatzidimitriadou). Such self help efforts make
use of the mutual aid functions of social groups and have been
found effective in addressing concerns of vulnerable
populations at both the individual and social level (Gitterman
& Shulman, 2005).
As immigration continues into the United States,
particularly from Third World countries that are linguistically
as well as culturally distinct, these associations will continue
to play an important role in buffering the effects of rapid
acculturation. They represent an adaptive strategy that appears
to have been successful for refugees, immigrant groups, and
other populations (Borman, 1984;'Hoyt, 2002). Similarly, as
government continues its devolution and privatization of
social programs, mutual aid and self help efforts will continue
to emerge. They may well continue to serve the functions that
mutual aid societies historically provided earlier generations
of ethnic communities.
REFERENCES
Barrera, M. (1988). Beyond Aztlan: Ethnic autonomy in comparative
perspective. New York: Praeger.
Beito, D. T. (1994). Thy brother's keeper: The mutual aid tradition
of American fraternal orders. Policy Review. Hoover Institution
Press, Fall, No. 70, pp. 55-60.
Beito,D. T. (1996). Poor before welfare: Fraternal societies and
mutual-aid societies kept the poor afloat long before the
welfare state. National Review, 48(8), 42-44.
Beito, D. T. (2000a). From mutual aid to the welfare state:
Fraternal societies and social services, 1890-1967. Chapel Hill,
NC: University of North Carolina Press.
Beito, D. T. (2000b). From mutual aid to welfare state: How fraternal
societies fought poverty and taught character. Backgrounder No.
677. Washington, DC: Heritage foundation.
Borman, L. D. (1984, Summer). Self-help/mutual aid in changing
communities. Social Thought, 49-62.
Briegel, K. (1974). Alianza Hispano-Americana, 1894-1965:
A Mexican American fraternal insurance society. Doctoral
dissertation, University of Southern California, Los Angeles.
Chodes, J. (1990). Friendly societies: Voluntary social security
and more. The Freeman: Ideas on Uberty. 40(3).
Fallows, M. R. (1979). Irish Americans: Identity and assimilation.
Englewood Cliffs, NJ: Prentice Hall.
Gann, L. H., & Duignan, P. J. (1986). The Hispanics in the United
States: A history. Boulder, CO: Westview Press.
Gibson, G. (1987). Mexican Americans. In A. Minahan
(Ed.ein-chief}, Encyclopedia of social work (18th ed., pp.
135-148). Silver Spring, MD: National Association of Social
Workers.
Gilbert, N., & Specht, H. (1974). Dimensions of social welfare
policy. Englewood Cliffs, NJ: Prentice-Hall.
Gilbert, N., Specht, H., & Terrell, P. (1993). Dimensions of social
welfare policy (3rd ed.). Englewood Cliffs, NJ:
Prentice-Hall.
Gilbert, N., & Terrell, P. (2004). Dimensions of social welfare
policy (6th ed.). Englewood Cliffs, NJ: Prentice-Hall.
Gitterman, A., & Shulman, L. (Eds.). (2005). Mutual aid groups,
vulnerable and resilient populations, and the life cycle (3rd ed.).
New York: Columbia University Press.
Hatzidimitriadou, E. (2002). Political ideology, helping mech-
anisms and empowerment of mental health self-help/mutual
aid groups. Journal of Community & Applied Social Psychology,
12,271-285.
Hernandez, J. (1979). The political development of mutual aid
societies in the Mexican American community: Ideals and prin-
ciples. Doctoral dissertation, University of California, River-
side, CA.
Hoyt, J. (2002, Winter). Reflections on immigrant organizing, and
the "universals." Social Policy, 37-41.
Iorizzo, L. J., & Mondello, S. (1980). The Italian Americans.
Boston: Twayne Publishers.
Jenkins, S. (Ed.). (1988). Ethnic associations and the welfare state:
Services to immigrants in five countries. New York:
Columbia University Press.
Katz, A. H., & Bender, E.l. (1976). Self-help groups in western
society: History and prospects. The Journal of Applied Behav-
ioral Science, 12, 265-282.
Lieberman, M. A., & Borman, L. D. (1979). Self-help
groups for coping with crisis. San Francisco: jessey-Bass.
Martin, J. E., & Martin, E. P. (1985). The helping tradition in the
black family and community. Silver Spring, MD: National
Association of Social Workers.
Norman, A. J. (1977, December). Mutual aid: A key to survival
for black Americans. The Black Scholar, 9(4), 44-49.
Peebles-Wilkins, W. (1989, Spring). Black women and American
social welfare: The life of Fredericka Douglass Sprague Perry.
AFFILIA, 4(1), 33-44.
Rivera, J. A. (1987). Self-help as mutual protection: The
development of Hispanic fraternal benefit societies. The
Journal of Applied Behavioral Science, 23(2}, 387-396.
Rodriguez, R. C. (1978). Mexican-American civic organizations:
Political participation and political attitudes. San Francisco:
R & E Research Associates.
Williams, c., j-, & Williams, H. B. (1984).
Contemporary voluntary associations in the
urban black church: The development and
growth of mutual aid societies. Journal of Voluntary
Action Research, 13(4), 19-30.
FURTHER READING
Axinn, J., & Stem, M. J. (2007). Social welfare: A history of the
American response to need. Boston: Allyn & Bacon.
Babcock, E. (2006). The transformative potential of Belizean
migrant voluntary associations in Chicago. International
Migration, 44(1), 31-53.
Bender, E. l. (1986). The self-help movement seen in the context
of social development. Journal of Voluntary Action Research,
15(2), 77-84.

Gonzales, S. A (1985). Hispanic American voluntary organiza~
tions. Westport, CT: Greenwood Press.
Hernandez, J. (1983). Mutual aid for survival: The case of the
Mexican American. Malabar, FL: Robert E. Krieger.
Humphreys, K. (1997, Spring). Individual and social benefits of
mutual aid self-help groups. Social Policy, 27(3), 12-19.
Humphreys, K., & Hamilton, E. (1995, Winter). Alternating
themes: Advocacy and self reliance. Social Policy, 26(2), 24-32.
Kahn, A, & Bender, E. I. (1985). Self-help groups as a crucible
for people empowerment in the context of social development.
Social Development Issues, 9(2), 4-13.
Koehler, R. (2000). The organizational structure and function of
La Nuestra Familia within Colorado state correctional
facilities. Deviant Behavior, 21 (2), 155-179.
Lee, c., & Avon, C. (2005). The power of groups
for older adults:
A comparative study of European American and Latino senior
mutual aid groups. Social Work with Groups, 28(2), 23-39.
Ochs, M., & Paves, M. (2003, Summer). Immigrant organizing:
Patterns, challenges & opportunities. Social Policy, 33(4),
19-24.
Schmidt, A J. (1980). Fraternal organizations. Westport, CT:
Greenwood Press.
MUTUAL AID SOCIETIES 289
Skocpol, T., & Oser, J. (2004, Fall). Organization despite
adversity. South Atlantic Quarterly, 103(4),367-437.
Weaver, H. (1992). African-Americans and social work:
An overview of the ante-bellum through progressive eras.
Journal of Multicultural Social Work, 2(4),91-102.
Weisser, M. R. (1985). A brotherhood of memory: Jewish land-
smanshaftn in the New World. New York: Basic Books.
Wituk, S., Shepherd, M., Slavich, S., Warren, M., & Meissen.G,
(2000). A topography of self-help groups: An empirical
analysis. Social Work, 45(2), 157-165.
Woodson, R. L. (1988). Black A~erica's legacy of entrepre-
neurship. National}oumal of Sociology, 9(2),4-13.
SUGGESTED LINKS
Ethnic Fraternal Societies and Mutual Aid: Resources.
http://www.hsp.org/default.aspx?id= 431
Fraternal and Benevolent Societies.
https://familychronicle.com/FraternalSocieties.html
Southeast Asian Resource Action Center.
http://www2.hsp.org/col1ections/manuscripts/s/searac3021.htm
-SANTOS'H. HERNANDEZ
NARCOTICS. See Alcohol and Drug Problems:
Overview.
NARRATIVES
ABSTRACT: Narrative therapy was developed by
Michael White and David Epston, social workers
from Australia and New Zealand respectively, in the
late 1980s, spreading to North .America in the
1990s. It falls under the rubric of postmodernism,
which challenges the idea of absolute and universal
truths. Its focus on empowerment, collaboration, and
viewing problems in social context fit with social
work values. Clients and social workers join
together to deconstruct and reconstruct problem
saturated stories through externalizing problems and
searching for unique outcomes. Although empirical
outcome data are limited, many social workers find
the
KEYconcepts
WORDS: useful.
empowerment; externalization; unique
outcomes; problem saturated stories; social
construction; postmodern
Narrative therapy (NT) was developed by Michael White
and David Epston, of Australia and New Zealand
respectively, in the late 1980s and popularized in North
America in the 1990s by Stephen Madigan of British
Columbia ( www.therapeuticconversations.com) , Jeffrey
Zimmerman and Victoria Dickerson of California
(http://www.victoriadickerson.com). and Jill Freedman and
Gene Combs of Chicago, all with narrative therapy training
centers and all of whom have published a great deal on the
subject. Freedman and Combs's text on narrative therapy
(1996) has become a classic in the field, and Dickerson,
Epston, and Madigan all have articles outlining the
development of their ideas and practices in a special issue
on narrative therapy in the Journal of Brief Therapy (2004).
Both social workers, White and Epston's ideas were first
disseminated internationally in their book, Narrative Means
to Therapeutic Ends (1990). They developed NT in reaction
to modernism, which held that there are universal laws and
truths that can be uncovered through scientific discovery
and that all phenomena can be explained, and to the
modernist therapies prevalent in the 1980s. Postmodernism
challenges the idea of absolute truth and grand theories that
explain human behavior.
291
As noted by family therapists Nichols and Schwartz in
their recent text (2007), narrative therapy has been
embraced by many social workers as it fosters community
support for and empowerment of clients. NT's focus on
social justice, viewing problems in cultural context,
individualization of clients, and collaboration with and
respect for them through hearing and honoring their views
fits with traditional social work values. Early on,NT's
emphasis on meaning versus problems or solutions
attracted some social workers (for example, see Hoffman,
1993). NT is useful for social workers as it bridges micro-
and macropractice through work with communities and
groups as well as with individuals and families. In fact
White, through his training center in Adelaide, Australia,
has sponsored international conferences called Narrative
Therapy and Community Work with a journal by the same
name (www.dulwichcentre. com.au). NT has been applied
to work with multicultural populations (Kelley, 1995),
persons with gender issues (Laird, 1996), persons with
medical disabilities (Kelley & Clifford, 1997), and trauma
and abuse survivors (Laube, 2004; O'Leary, 2004).
Although NT has been found useful by many social
workers, it has been criticized by some social workers and
family therapists for lack of empirical outcome data, for not
taking family dynamics into account, and for the
difficulties it presents for managed care practice (Kelley,
1998). There has been some research, especially
qualitative, demonstrating effectiveness of NT, but there is
still tension between adherents of evidencebased practice
and some narrative therapists, as post modernism denies
objectivity.
NT is more a way of thinking about people and the
problems they face than specific therapy techniques, but
there are some general principles and practices within it. It
draws from social constructionist ideas of some
psychologists and philosophers who believe reality is
socially constructed, as well as from the field of literary
deconstruction (White & Epston, 1990). The goal of NT is
first to help clients understand the stories around which
they have organized their lives (deconstruction), and then
to broaden and challenge them, creating new realities
(reconstruction). While clients' problems are not denied or
minimized, other aspects of them and their lives, which
may also be true, are brought forth, helping clients see more
alternatives and ways out of an impasse (White & Epston,
1990).
292 NARRATIVES
Using a collaborative approach, where clients are experts
on their lives, clients and therapists join together to understand
and fight the effects of the problem. Key concepts are
externalizarion, where persons are separated from their
problems so that they can assess and challenge them, and
unique outcomes, those aspects of them and their lives that
challenge the problem saturated stories. In the process, clients
are encouraged to question familial and cultural stories that
have restricted them. Reflecting teams and witness groups,
where others observe, reflect, and comment on their
observations, and letters to clients and by them, further help
clients examine their life stories (White & Epston, 1990).
NT shares some similarities to solution-focused brief
therapy developed by De Shazer and Berg (1993) and
strength-based social ~ork of Saleeby (2002) and others,
which were developed at about the same time as NT was. They
are all empowerment-based approaches aimed at mobilizing
strengths.' The "exceptions" of solution-focused brief therapy,
where clients are asked to look for times when the problem
does not occur, are similar to NT's concept of unique
outcomes. There are differences, too, however. NT does not
ask for exceptions to problems directly, but instead searches
for unique outcomes through careful listening and questioning
from a "not knowing" stance. NT differs from strength-based
approaches in that problems as well as strengths are discussed
and explored, and the past, as well as the present and the
anticipated future, is examined. Not only do clients assess
what the future . would look like if the problems were solved
or amelio-
rated, they also assess what the future would look like if things
stayed the same (White & Epston, 1998).
For practice in the United States, integration with other
approaches is usually needed to meet the demands of managed
care (for further information on this topic, see Kelley, 1998).
Solution-focused brief therapy and cognitive therapy are
especially favored by many managed care companies because
they are short-term therapies and have more empirical data
supporting them, especially cognitive therapy (Kelley, 1998).
NT can be integrated with both solution-focused brief therapy,
for the abovementioned reasons, and cognitive therapy, as it
helps clients "see" things differently. NT can be conducted in
few sessions, too, which may be spread over time. The use of
letters, witness groups, and community support decreases the
number of sessions needed. NT is more collegial and less
prescriptive than cognitive therapy and it has more emphasis
on meaning, but the approaches complement one another
(Kelley, 1998). Care must be taken, however, so that the key
principles of collaboration and "not knowing" are not
compromised when integrating NT with other approaches.
REFERENCES
De Shazer, S., & Berg, I. K. (1993). Constructing Solutions.
Family Therapy Networker, 12,42-43.
Freedman, J., & Combs, G. (1996). Narrative therapy: The social
construction of preferred realities. New York: Norton.
Hoffman, L. (1993). Exchanging voices: A collaborative approach to
family therapy. London: Karnac Books.
Journal of Brief Therapy. (2004). Special issue on narrative therapy.
3(2), 81-169.
Kelley, P. (1995). Integrating narrative approaches into clinical
curriculum: Addressing diversity through understanding.
Journal of Social Work Education, 31 (3),347-357.
Kelley, P. (1998). Narrative therapy in a managed care world.
Crisis Intervention, 4(2/3),113-123.
Kelley, P., & Clifford, P. (1997). Coping with chronic pain:
Assessing narrative approaches. Social Work, 42,266-277.
Laird, J. (1993). Revisioning social work education. New York:
Haworth Press.
Laube, J. (2004). Narrative group treatment for loss and
trauma. Journal of Brief Therapy, 3(2),125-136.
Nichols, M., & Schwartz, R. (2007). Narrative therapy. In The
essentials of family therapy {3rd ed., pp. 261-277). Boston:
Pearson Educational Foundation.
O'Leary, P. (2004). Therapeutic relationships with men sexually
abused in childhood: A narrative approach. Journal of Brief
Therapy, 3(2), 153-169.
Saleeby, D. (2002). The strengths perspective in social work practice
{3rd ed.).Boston: Allyn-Bacon.
White, M., & Epston, D. (1990). Narrative means to therapeutic
ends. New York: Norton.
SUGGESTED LINKS
www.dulwichcentre.com.au
www.therapeuticconversations.com
www.victoriadickerson.com
-PATRICIA KELLEY
NATIONAL ASSOCIATION OF SOCIAL
WORKERS
ABSTRACT: The National Association of Social
Workers (NASW) is the largest membership
association of professional social workers in the world
with nearly 150,000 members. Formed in 1955 by
uniting seven predecessor organizations, NASW has a
dual mission of protecting and advancing the
profession of social work and of advocating for social
justice issues. The NASW national office is based in
Washington, DC, with chapters in each state, Puerto
Rico, Guam, and the Virgin Islands. There are also
separate chapters in New York City and Metro
Washington, DC, as well as an international chapter for
U.S. social workers living abroad.
KEY WORDS: NASW; association; advocacy;
insurance

The National Association of Social Workers is the
largest membership organization of professional social
workers in the world, with nearly 150,000 members.
Over 80% of the members are women, and 12% identify
as a member of color. NASW is one legal entity with 56
chapters that serve as administrative units. Chapters
exist in every state, as well as New York City, Puerto
Rico, the Virgin Islands, Guam, and Washington, DC;
there is also an international chapter. There is a
23-person national governing board.
The national office, fi~st located in New York City
and then in suburban Washington, DC, has been in its
current location near Capitol Hill since 1992. The
national office includes the executive director and a
level of staff deemed necessary to carry out national
programming. In 2007, there were 140 staff in the
national office. The operating budget for fiscal year
2007 is $20 million.
When members join NASW, they automatically
receive membership in their state chapter at no
additional fee. The size and diversity of NASW's mem-
bership are significant assets in the organization's
advocacy efforts on behalf of social workers and the
clients they serve.
History
NASW was founded in 1955 by a merger of seven major
social work organizations, they were the American
Association of Social Workers, the American Associa-
tion of Medical Social Workers, lnc., the National
Association of School Social Workers, the American
Association of Psychiatric Social Workers, the
American Association of Group Workers, the Asso-
ciation for the Study of Community Organization, and
the Social Work Research Group. All the members of
the predecessor organizations were "blanketed-in" as
members (NASW, 1955), and NASW began with
22,027 members. Many of the structural elements in-
itiated by the new organization remain in place more
than 50 years later, despite debate and efforts for change.
For example, the newly formed NASW established a
triennial Delegate Assembly as the means through
which its membership would determine policy for the
association and as a means for revising its bylaws. At the
first Delegate Assembly in 1956, delegates amended and
adopted 18 policy statements of the predecessor
organizationson topics such as civil rights and liberties,
economic and labor conditions, immigration, peace, and
public welfare (NASW, 1957). Social policy has
continued to be a major focus of all subsequent Delegate
Assemblies, and NASW publishes all adopted policies
online and in a publication called Social Work Speaks
(NASW, 2006).
NATIONAL ASSOCIATION OF SOCIAL
WORKERS 293
In 1960, the Delegate Assembly adopted a Code of
Ethics for the profession. The Code, which has been
amended five times (1967,1979, 1990, 1996, and 1999) ,
sets the standards of ethical behavior for professional
social workers. NASW members affirm that they will
abide by the standards set forth in the Code, and NASW
monitors member compliance.
NASW has continued to develop its credentialing
and certification program, and, in 2006, added three
credentials" in gerontology social work, bringing the
total number of credentials offered to 10. The credentials
indicate advanced practice experience.
In addition, NASW develops standards for social
work practice in a variety of settings (such as long- term
care settings and health care settings) as well as
standards for issues such as cultural competence, the use
of technology in practice, and genetics and social work
practice.
To more fully address specific practice areas, NASW
has nine specialty practice sections to which members
may choose to belong. These include Aging, Alcohol,
Tobacco and Other Drugs, Child Welfare, Children,
Adolescents and Young Adults, Health, Mental Health,
Private Practice, School Social Work, and Social and
Economic Justice & Peace. The sections offer a variety
of continuing education opportunities, including tele-
conferences, area-specific newsletters, and internet chat
rooms.
NASW's Role in Accreditation and Licensure The
1960 Delegate Assembly also approved the estab-
lishment of a credentialing program. The first creden tial,
which remains in effect today, was the Academy of
Certified Social Workers (ACSW). Qualified members
of the predecessor groups who had two years of
membership and two years of practice experience were
automatically accepted, and when the credential went
into effect in 1962, 18,500 members were certified.
Today, over 40,000 members hold the ACSW
credential.
Social work efforts toward licensure began in the
1940s. Since then, NASW and its state chapters have
worked to ensure that all 50 states have some level of
licensure for social workers to seek legal recognition,
protection and reimbursement for services, as in other
professions. However, the definition of social work and
what is protected by licensure laws vary from state to
state. This lack of a uniformly accepted definition of
social work practice remains a challenge for legal reg-
ulation. It also contributes to confusion in the public's
understanding about the social work profession.
Legislative and Political Activity
The social policy goals established by the NASW
Delegate Assembly serve as the base for social action
294 NATIONAL ASSOCIATION OF SocIAL
WORKERS
programs at the federal, state, and local levels. The
legislative agenda changes from year ro year in response to
emerging issues, but some topics are relatively con-
. stant and recurring.
The national office includes five full-time lobbyists, a
staff person dedicated to grassroots organizing, and one
person who staffs the Political Action for Candidate
Election (PACE) function. Many state chapters also have
lobbyists on staff or they contract for these services.
NASW has the capacity to mobilize its membership across
the country and has developed a track record of success on
issues of importance to social workers.
NASW is active in electoral politics at both the state
and federal levels. Since 1975, NASW's political action
arm, PACE, has raised funds to support social
service-oriented candidates at all levels of government.
Additionally, encouraging social workers to run for elected
office is an important focus for NASW.
Related Entities
In addition to PACE, NASW has several other related .
entities that assist in carrying out its mission. These include
the NASW Press, the NASW Center for Workforce Studies,
the separately incorporated NASW Foundation (previously
known as the Research and Education Fund), the Legal
Defense Fund, and NASW Assurance Services, Inc., a
for-profit subcorporation that offers insurance products for
members.
In 1990, NASW initiated the NASW Press, a fullscale
publisher that now annually produces five journals,
including the flagship journal Social Work, several reference
works and numerous professional books. Journals are
available online; Social Wark Abstracts is online and in
CD-Rom format. The Encyclopedia of Social Wark (jointly
published with Oxford University Press) is in print and
online versions.
In the late 1980s, NASW established a national and
chapter management information system to allow for better
data collection about its membership. While this
information was a valuable resource, data about the entire
social work workforce was needed, especially for
legislative initiatives. In 2004, grant funding was secured
to develop the NASW Center for Workforce Studies. In
2006, the Center released findings from a benchmark study
of 10,000 licensed social workers, which defined the status
and needs of the profession (Whitaker, Weismiller, &
Clark, 2006).
The NASW Foundation was separately incorporated as
a nonprofit charitable organization in 2001. Numerous
activities are housed in the Foundation. There are several
endowment funds that support a
variety of scholarships or awards, and the NASW Pioneer
Program is part of the Foundation's activities.
Additionally, the National Social Work Public
Education Campaign is housed in the Foundation. The
multiyear, multimedia campaign began in 2005, and has
been developed in partnership with over 60 schools of
social work. The goal of the campaign is to promote the
social work profession among the general public. The
centerpiece of the campaign is www.helpstartshere.org, a
consumer Web site written by social workers.
The NASW Legal Defense Fund (LDF) exists to
provide financial support for legal matters of importance to
the profession as a whole and for social woikers who
require legal representation in the course of upholding the
NASW Code of Ethics. The LDF facilitates NASW's
participation on Amicus Curiae (a "friend of the court") in
significant cases and produces publications on legal issues
for social workers.
The NASW Assurance Services Inc. was established as
the NASW Insurance Trust to provide high quality
professional liability (malpractice) and group life insur-
ance for NASW members. About 70,000 NASW members
are enrolled in the insurance programs (NASW Assurance
Services, Inc., 2007) .
Future Direction
In 2007, NASW developed an international web portal for
social work. The search engine for the portal has the
capacity to find related social work organizations and
schools and programs of social work.
Also, in 2007, NASW launched the Social Work
Reinvestment Initiative. The goal of the initiative is to
encourage government and employers' investment in the
profession of social work. Each state chapter has
developed a reinvestment plan, and a piece of federal
legislation will be introduced in 2008.
A long-range goal for the future is working with other
national social work organizations to unify the profession
of social work.
REFERENCES
NASW Assurance Services, Inc. Website (2007). Retrieved
November 5,2007, from http://www.socialworkers.org/assur
ance/.
National Association of Social Workers. (1955). Bylaws of the
National Association of Social Workers. New York: Author.
National Association of Social Workers. (1957). Goals of social
policy. New York: Author.
Whitaker, T., Weismiller, T., & Clark, E. (2006). Assuring the
sufficiency of a frontline workforce: A national study of licensed
·social workers. Executive summary. Washington, OC: National
Association of Social Workers.
National Association of Social Workers. (2006). Social work
speaks. Washington, DC: Author.

FURTHER READING
National Association of Social Workers. (1987). Mark Battle.
In Encyclopedia of social wark (18th ed., pp. 333-340). Silver
Spring, MD: Author.
National Association of Social Workers. (1995). Sheldon
Goldstein. In Encyclopedia of social wark (19th 00., pp.
1747-1764). Washington, OC: Author.
SUGGESTED LINKS
NASW Web site
www.socialwarkers.arg NASW
Consumer Web site
www.helpstartshere.arg NASW
Foundation Web site
www.naswfoundation.arg
University of Minnesota Social Welfare Archives
http://special.lib . umn.edu/swha/
Code of Ethics of the National Association of Social Workers
http://www .socialwarkers .arg/pubs/code/default .asp
Social Work Portal
http://www .socialwarkers .arg/swpartal/
-ELIZABETH J. CLARK
NATIVE AMERICANS. [This entry contains two subentries:
Overview; Practice Interventions.]
OVERVIEW
ABSTRACT: First Nations Peoples, the original inhabitants
of what is now the United States, are diverse and growing
populations. There are approximately 4.3 million First
Nations Peoples within the boundaries of the United States,
accounting for 1.5% of the general population. First Nations
people tend to be younger, poorer, and less educated than
others in the United States. The contemporary issues faced by
these peoples are intimately intertwined with the history of
colonization and current federal policies that perpetuate
depend, ency and undermine self-determination. Social
workers must. overcome the negative history of the profession
with First Nations Peoples, in particular social work in-
volvement in extensive child removals and coercive ster-
ilization of indigenous women. Social workers have the power
and ability to make important differences in en, hancing the
social and health status of First Nations Peoples; but this must
begin with an awareness of their own attitudes and beliefs, as
well as an awareness of how social workers have contributed
to, rather than worked to alleviate, the problems of First
Nations Peoples.
KEY WORDS: American Indians; First Nations Peoples;
Indian Child Welfare Act; indigenous; Native Americans;
sovereignty .
.
1
NATIVE AMERICANS: OVERVIEW
295
First Nations Peoples, also known as Native Americans,
American Indians, and indigenous peoples, are the original
inhabitants of what is now the United States. Indeed,
indigenous people are found throughout the world and some
of their territories straddle international borders. For example,
the Akwesasne Mohawk reservation .is partly within the
United States and partly within Canada. This article focuses
on First Nations Peoples within the United States, but it is
important to keep in mind that indigenous peoples transcend
national divisions.
Terminology
There is no consensus as to which of the many terms that refer
to indigenous peoples is best, but individuals often have clear
preferences (Weaver, 2005). Addition, ally, there are regional
differences as to commonly used terms. For example, the term
American Indian is in common use in the Southwest and is the
label generally used by the federal government, while the term
Native American is more commonly used in the Northeast.
The term First Nations, commonly used in Canada and
increasingly prominent in the United States, is often
associated with a strong sense of sovereignty. and indigenous
nationhood. Given that all these terms group hundreds of
diverse peoples together, it is generally preferable to use more
specific terms for particular tribes or nations such as
Comanche, Seminole, or Odawa, whenever possible.
An individual's right to choose the term that is most
comfortable is closely tied with cultural identity. This being
the case, it is imperative that social workers accept and use
terms that clients prefer. Throughout the history of contact
with Europeans, First Nations Peoples have had terms
imposed upon them. For example, the Ni Mii Puu were named
Nez Perce by interpreters from the Lewis and Clark expedition
of 1805 (Nez Perce Nation, 2007). This imposed term is the
one most often used by those outside that nation today, thus
continuing to undermine the inherent right to self, name and
have identity respected. While many Native Nations have
asserted their right to be called by their own names, this is
typically not respected by federal entities such as the u.S.
Census Bureau, which still uses terms that some indigenous
people find offensive like the "Sioux" and "Eskimo." In the
discussions of Census data that follow, the terms used by the
Census Bureau 'are presented initially to preserve accuracy,
but are followed with more respectful terms.
An Overview of First Nations People
At the time of the 2000 Census, 4.3 million people (1.5% of
the U.S. population) reported they were American Indian or
Alaska Native (Ogunwole, 2006).
296 NATIVE AMERICANS: OVERVIEW
The largest indigenous groups identified in the Census
were Cherokee (875,276), Navajo (309, 575; also known as
Dine), Choctaw (173, 314), Sioux (167, 869; also known as
the three interrelated groups Lakota, Dakota, and Nakota),
Chippewa (159,744; also known as Anishinabe) and
Apache (104,556). The largest Alaska Native group is the
Eskimo (56,824; also known as Inuit; Ogunwole, 2006).
First Nations Peoples tend to have lower educational
attainment than other people in the United States.
According to the 2000 Census, 71 % of First Nations
Peoples age 25 and older had at least a high school degree,
compared with 80% of the total population. Only 11 % had
a Bachelor's degree, compared with 24% of the general
population (Ogunwole, 2006). Median earnings for First
Nations Peoples were substantially lower than their
nonindigenous counterparts for full time, year round work.
Native men had median annual earnings of $28,900 and
Native women had median annual earnings of $22,800,
compared with $37,100 for nonindigenous men, and
$27,200 for nonindigenous women.
The majority of First Nations Peoples no longer live on
land that is under the control of their nations and this has
been the, case for decades (Beck, 2002). In 2000, 33.5% of
First Nations Peoples lived on reservations or trust lands
(Ogunwole, 2006). The indigenous population that lives on
reservations tends to be younger, poorer, and less educated
than their urban counterparts.
History
While the history of each indigenous group varies, there are
several key aspects of history common across most First
Nations groups. Six key areas that roughly correspond to
sequential historical eras are discussed here: the
establishment of treaties, genocide, the reservation era,
boarding schools, termination, and urban relocation.
When Europeans came to this continent they recognized
the different First Nations groups as distinct sovereign
nations (Cote, 2001). Treaties were established on a
government to government basis, recognizing that nations
such as the Cherokee and Onondaga were of equal stature
with nations such as England and France. After the
American Revolution, treaties were established between
the United States and various native nations. The federal
government reserved the power to make treaties
exclusively for itself, thus affirming that individual states
did not have standing to make legally binding agreements
with First Nations Peoples. This government to government
relationship continues today and, in most instances, unless
specific legislation like PL 280 has been passed in a
particular state, native nations are not subject to state
jurisdiction. Public Law 280 is a controversial statute
passed in 1953 that
transferred criminal and civil jurisdiction over tribal lands
from the federal government to six states and created an
opportunity for other states to assume such jurisdiction
(Tribal Court Clearninghouse, 2007).
As the fledgling United States gained power, it in-
creasingly waged wars against First Nations Peoples. These
were often campaigns of genocide designed to decimate
native peoples in order to take their lands, subjugate them,
and subsume them under the power of the United States.
Ultimately, the wars perpetrated upon indigenous peoples
and the spread of disease (both deliberate and
unintentional) led to the annihilation of up to 99% of the
indigenous people in the United States (Stiffarm & Lane,
1992). The remnants of First Nations Peoples were
relegated to reservations by the late 1800s.
Reservations were usually established on land consid-
ered undesirable by the people of the United States that
mayor may not be a part of the traditional territories of the
people placed there. Even these supposedly protected areas
were encroached upon by white settlers and prospectors.
The federal government took legal action to significantly
reduce the size of some reservations followed by an
allotment policy that allocated specific parcels of
reservation land to nuclear families. The remaining
"surplus" land was then opened to white settlement.
Once First Nations Peoples were relegated to ever
shrinking territories, the federal government increased its
push for assimilation. This was tantamount to cultural
genocide. The primary vehicle of this policy was a system
of boarding schools with the slogan "Kill the Indian, Save
the Man." This slogan reflected the belief that if indigenous
children were taken from their homes and communities
they might be socialized into an American value system,
thus no longer remaining culturally distinct. This
educational system, which emphasized vocational skills
and Christianity, was implemented after the U.S. Civil War
and continued until the 1970s. The legacy of these
institutions are native communities where generations of
people have no noninstitutional role models for parenting,
thus leading to widespread child abuse and neglect.
By the 1950s, the federal government began to take
different approaches to assimilate First Nations peoples.
Congress enacted legislation to terminate or legally end the
existence of various Native Nations, thus extinguishing the
reservation status of tribal. lands and ending treaty rights
for members of those nations. At the same time the
government began a major relocation program to move
Native people from reservations to cities where, in theory,
they were more likely to find employment (Beck, 2002).
The relocation program resulted in the majority of native
people residing in urban areas, but training and job
placement services
 NATIVE AMERICANS: OVERVIEW
297

were inadequate and did not take into account the loss of Nations groups who experience the greatest amounts of
social support systems that native people would experience poverty are the Lakota/Dakota/Nakota at 38.9%, the Dine
when leaving their traditional homelands. at 37%, and the Apache at 33.9%. Among Alaska Natives,
Athabaskans are the poorest population with 22.9% living
Key Issues in poverty, followed by the Inuit with 21.3% in poverty
There are several key issues that social workers must (Ogunwole, 2006).
consider when working with First Nations Peoples. Three While the social and health statistics for First Nations
that will be discussed here are diversity, sovereignty, and Peoples are often very poor, it is important that social
social or health status. workers do not approach work with these populations from
Extensive diversity exists among First Nations Peoples. a deficit perspective. In fact, First Nations Peoples have
There are well over 500 different Native Nations that displayed incredible strength and resilience, surviving
continue to exist within the United States. There are many colonization for more than 500 years. The fact that First
others that are recognized urider state law such as the Nations Peoples continue to exist as distinct peoples is
Unkechug in New York and Houma in Louisiana. Different testament to their strength. In fact, culture itself can be a
Native Nati~ns have different forms of government, socia-l source of empowerment for many native people.
structures, languages, customs, and spiritual beliefs.
Additionally, there is significant variance among people
within a particular Native Nation. Some people are strongly Social Policy Issues
grounded in their cultures and follow traditional ways, There are three major social policy issues discussed here
some strongly identify as being indigenous but do not that are critical for social workers to understand, all of
espouse traditional ways, still others express little which have their roots in the sovereignty of First Nations
connection to their cultures. A social worker must seek to Peoples: the Indian Child Welfare Act (1978), the
understand not only tribal-specific content, but also how a relationship of First Nations to the U.S. federal
particular client experiences his or her cultural identity. government, and economic development. Indeed, a law
It is crucial for social workers to understand the concept like ICW A is only possible because First Nations
of sovereignty. Because First Nations Peoples have always . are legally distinct entities rather than ethnic groups.
been recognized as members of distinct nations, they have The Indian Child Welfare Act (lCWA) is a federal law
legal standing that is quite different from other ethnic or that is binding on social workers, regardless of where they
cultural groups in the United States. Native Nations practice. ICW A was passed in response to the large
typically have their own governments, systems of law numbers of indigenous children separated from their
enforcement, and social service systems. This may open up families and communities through foster care and adoption.
a wealth of resources and services not available to By the 1970s, 25-35% of First Nations children were in
nonindigenous clients. A fun, damental understanding of substitute care with 85% of these placements being with
sovereignty is necessary in order for a social worker to non-Native families (Mannes, 1995). This led to massive
understand the policies and laws that apply specifically to disruption in the ability to transmit culture from generation
First Nations Peoples. to generation, thus threatening cultural continuity for many
The social status and health status of First Nations First Nations Peoples. In response to this crisis, ICW A
Peoples are significantly worse than other populations on affirmed that Native Nations have a right to jurisdiction in
most social indicators. Native people experience high rates any child welfare case where an "Indian child" (defined by
of violence, trauma, and imprisonment (Bachman, . 1992), law as a minor enrolled or eligible for enrollment in a
much of which is associated with alcohol use (Sugarman & federally recognized Native Nation) is being removed from
Grossman, 1996). First Nations Peoples suffer home. A child welfare worker who recognizes there is a
disproportionately from health problems such as diabetes, possibility of removing an "Indian child" from home must
tuberculosis, and alcohol related problems, as well as identify the child's nation and call that nation immediately.
suicide (Kavanaugh, Absalom, Beil, & Schliessmann, Many nations have Web sites that include contact
1999)~ Indigenous people are also overrepresented in the information for their social service departments. Native
homeless population (U.S. Department of Health and Nations may choose to cede jurisdiction to a state or county
Human Services, 2001). department of social services, but a department of social
Poverty is a major concern for First Nations Peoples. services can never assert jurisdiction without the express
In 2000, 25.7% were living in poverty, compared with permission of the child's nation. Additionally, ICWA
12.4% of the total population. There are, however, established a set of placement priorities for instances in
significant tribal differences in poverty status. The First which a child must be removed from
298 NATIVE AMERICANS: OVERVIEW
home. Ideally, a child will be placed with the extended
family. If this is not possible, the child can be placed with
someone from his or her First Nation, any Native Nation,
or any qualified foster or adoptive family, in that order.
This set of placement preferences affirms that cultural
continuity is in the best interest of the child and must be
honored whenever possible.
The government to government relationship be tween
First Nations and the United States has shifted as the latter
gained stature and power. What initially began as legal
agreements between equals became re lationships of one
group dominating others. Indeed, the United States has
taken the stance that First Nations are not only junior
partners but are wards of the federal government or
incompetents in need of protection. Under this legal stance
the United States has created and perpetuated extensive
dependency. For example, the U.S. government must grant
permission to First Nations to establish casinos that have
the potential to bring revenue to impoverished
communities. Additionally, the federal government
handles leasing of native land and mineral resources and
holds the profits in government bank accounts rather than
allowing First Nations Peoples to manage many of their
own resources. This creation and perpetuation of depen-
dency is contrary to social work values of empowerment
and self-determination. Only through active involvement
in monitoring U.S. social policy can social workers begin
to understand the forces that undermine self- sufficiency
among First Nations Peoples.
Economic development is a crucial issue for First
Nations Peoples and is at the heart of addressing many
social and health problems. Sovereignty is a powerful
foundation for economic development that opens up
avenues not open to others in the United States. As noted
above, however, sovereignty itself continues to be
undermined, thus perpetuating poverty and dependency.
First Nations need the ability to act like nations. Social
workers must recognize the crippling effect of
- colonization, not just as a historical artifact but as a
contemporary and extraordinarily powerful force that
stands in the way of enhancing the lives of First Nations
Peoples. Informed social workers can be powerful allies
working with First Nations Peoples to challenge the
perpetuation of federal dependency and furthering op-
portunities to alleviate poverty and foster economic
development.
Issues for Social Work Practice
Social workers must overcome the negative history of the
profession with First Nations Peoples, in particular, social
work involvement in extensive child removals and
coercive sterilization of indigenous women. Social
workers often operate under the authority of entities
sanctioned by the United States and state governments and
thus are associated with colonizing and disempowering
forces. Indeed, social workers must challenge social
injustice, including that perpetuated by their employers.
The core components of social work, social justice,
empowerment, and a focus on the strengths and resilience
of clients, must be a reality in working with First Nations
clients rather than just vague principles lost in everyday
practice.
While social workers have many important skills and
talents, perhaps the most important value they can bring to
their work with First Nations clients is a strong sense of
social justice. Advocacy skills are crucial in insuring that
appropriate policies that respect sovere ignty and promote
the well-being of First Nations Peoples are enacted. Social
justice and advocacy are important on the micro as well as
the macro level. For instance, a social worker may need to
advocate on behalf of an individual who is not receiving
payments that the federal government has collected for
leasing grazing rights on reservation lands. It is also
important to advocate that the federal government
relinquish its self-appointed role as guardian for
indigenous peoples which perpetuates dependency and
disempowerment.
Stereotypical and paternalistic attitudes toward First
Nations Peoples continue to be the foundation for federal
oppression and perpetuation of problems such as poverty.
Social workers can begin to work on changing
discrimination and oppression by reflecting on how their
own attitudes and beliefs may contribute to these issues. As
awareness of their own role in perpetuating problems
increases, social workers will be better positioned to help
work for societal change.
Future Directions
The social and health status - of Nativ e Americans is
typically poor compared to other populations in the United
States and may in fact be declining in some areas such as
increased incidence of chronic diseases like cancer
(Intercultural Cancer Council, 2002). These serious
concerns must be viewed within the context of Native
American struggles for self-deterrninatlon and
self-sufficiency. Indicators of social and health status are
likely to remain troubling as long as attempts at empow-
erment are hindered by a social environment that does not
recognize sovereignty.
The contemporary issues faced by First Nations
Peoples are intimately intertwined with the history of
colonization and current federal policies that perpetuate
dependency and undermine self-dererrnination. Social
workers have the power and ability to make important
differences in enhancing the social and health status of

First Nations Peoples but this must begin with an awareness of
their own attitudes and beliefs and awareness of how social
workers have contributed to, rather than worked to alleviate,
the problems of First Nations Peoples.
REFERENCES
Bachman, R. (1992). Death and violence on the reservation.
New York: Auburn House.
Beck, D. R. (2002). Developing a voice: The evolution of self-
determination in an urban Indian community. Wicazo Sa
Review, 17(2), 117-141.
Cote, C. (2001). Historical foundations of Indian sovereignty
in Canada and the United States: An overview. American
Review of Canadian Studies, 31(1/2),15-23.
Intercultural Cancer Council. (2002). A~an Indians/Alaska
Natives and Cancer. Retrieved March 2002, from http://
iccnetwork.org/cancerfacts/cfs2htm.
Kavanaugh, K., Absalom, K., Beil, W., & Schliessmann, L.
(1999). Connecting and becoming culturally competent: A
Lakota example. Advances in Nursing Science, 21(3), 9-31.
Mannes, M. (1995). Factors and events leading to the passage
of the Indian Child Welfare Act. Child Welfare, 74(1),
264-282.
Nez Perce Nation. (2007). http://www.nezperce.org/content/
history/nimiipu.htm, accessed November 13, 2007.
Ogunwole, S. (2006). We the people: American Indians and
Alaska natives in the United States (Census 2000 Special Rep.).
Washington, DC: US Census Bureau.
Stiffarm, L. A., & Lane, P., Jr. (1992). The demography of
Native North America: A question of American Indian
survival. In M. A. Jaimes (Ed.), The state of native America:
Genocide, colonization, and resistance (pp. 23-53). Boston:
South End Press.
Sugarman, J. R., & Grossman, D. C. (1996). Trauma among
American Indians in an urban county. Public Health Reports,
111(4),321-327.
Tribal Court Clearinghouse. (2007). http://www.tribal-insti
tute.org/lists/pI280.htm, accessed November 13, 2007.
United States Department of Health and Human Services.
(2001). Mental health: Culture, races, and ethnicity-A sup-
plement to mental health. A report of the Surgeon General.
Rockville, MD: Author.
Weaver, H. N. (2005). Explorations in Cultural Competence:
Journeys to the Four Directions. Belmont, CA: Thomson
Brooks/Cole.
SUGGESTED LINKS Bureau of Indian
Affairs www.doi.gov/bureau-indian-affairs
.html Indian Health Service
www.ihs .gov
National Congress of American Indians
www.ncai.org
National Indian Child Welfare Association (NICWA)
www.nicwa.org
-HILARY N. WEAVER
NATIVE AMERICANS: PRACTICE INTERVENTIONS
299
PRAcnCE INTERVENTIONS
ABSTRACT: This entry provides an overview of historical
and current demographics, diversity, and cultural
expressions of American Indian and Alaskan native
communities in the United States. It discusses chal lenges
related to historical traumas, colonial impacts, and
current health risks and suggests some ways in which
current theories and practices developed by theorists and
communities can be utilized to address those challenges
and promote healing. It also summarizes cultural and
ethical concerns that practitioners working in and with
native communities need to be aware of in order to work
effectively and responsibly.
KEY WORDS: Native American; indigenous; historical
trauma; decolonizing practice frameworks
Demographics and Diversity
There are more than 562 federally recognized tribes in the
United States. Additionally, hundreds of tribes are either
state-recognized or remain legally unrecognized by either state
or federal governments, either because of lack of initial
recognition by the federal government or the termination of
such recognition because of federal policies. Tribes are
sovereign nations that existed prior to the institution of the
federal government of the United States. Most nations still
exist today, regardless of whether they are recognized by state
or federal governments.
American Indians and Alaskan natives (AIl AN or Native
Americans) constitute a geographically, ethnically,
linguistically, and culturally diverse group. Many native
languages are in active use today, and native languages are the
first language spoken for some AI/AN in rural, traditional
areas. Native languages are being taught with increasing
frequency as a first or second language for children in urban or
less traditional areas.
There are few things that can be said about tribes that are
generalizable across the continent; there is huge diversity in
land, economy, culture, traditions, and populations. Some
tribes have no reservation or land base, some have more land
than some states. Some tribes have no local economy or job
opportunities, some tribes have active businesses, including
casinos, fisheries, or other industries. Some tribes have tens of
thousands of members, others have a few hundred, or under a
hundred. Some border on urban areas, others are extremely
remote. There are a few generalizations that can be made
about the AI/AN population as a whole, however. The AI/AN
population is young: about 33% of the AI/AN population in
the 2000 census was under age 18, compared with 26% of the
total population. The AI/AN
300 NATIVE AMERICANS: PRACTICE
INTERVENTIONS
population is also poorer than the general population; the
median income is substantially lower than that of the
general population, with a difference of "-'10,000 dollars
per year for men and women. All AN families are also more
than 2 times likelier than the general population to live in
poverty. At present, AI/AN of sole or multiple races
represent 1.5% of the U.S. population (Ogunwole,2002).
Membership in a tribe confers citizenship in that tribe or
Nation. The Bureau of Indian Affairs (BIA, a federal
agency) took over the right of determining who could nor
could not be a member of a given tribe in the 1800s, a right
that was not fully restored to tribes until the 1970s. Some
tribes retain the BIA criteria for membership, which is
based on percentage of Indian blood or "blood quantum,"
but oth'er tribes have revised their membership criteria and
use a range of criteria including
"lineal descendancy, residency in the community, and
descendancy from a treaty signer, among other require-
ments. Although the BIA keeps centralized records, tribes
determine who mayor may not be a member.
Although many Native Americans are enrolled in a
tribe, there are an increasing numbers of individuals with
native heritage who are not enrolled. This is due to a
number of factors; intermarriage, changing enrollment
criteria, dislocation of families from reservations or tribal
areas, the forced relocation of families due to federal
relocation programs in the 1950s and 1960s (which
relocated families from reservation to urban areas
presumably for jobs), and the termination policies of the
federal government in the 1950s, which terminated federal
recognition of some tribes: Many Native Americans today
are multiracial, as evidenced by the increase in the number
of Native Americans recognized by the federal census in
2000 after it became possible to check more than one racial
or ethnic category.
The concentration of AI/AN in rural versus urban areas
is changing as well. There are now more Native Americans
in urban areas than in. reservation or rural areas
(Ogunwole, 2002). Urban Indian communities exist in
most urban centers. Many communities support AllAN
health centers and cultural centers or social service
agencies.
Historical and Present-Day Challenges Contact and
colonization in North America began in the late 1400s, but
contact by traders began earlier than that, especially in
coastal or inland river areas. Traders for fur or other goods
often established interdependent relationships with
different tribes, without necessarily challenging tribal
sovereignty. They did, however, sometimes heighten
intertribal conflict in order to establish areas in which to
trade. Early colonists often
followed those patterns. As colonization increased, de-
mand for property and gold increased, and there was a
quick shift from treaties and trade to outright massacres
and land grabs. The missionaries came alongside the
colonists to convert the Indians and "civilize" their ways of
life. In the process of "civilization," the missionaries and
the colonists denigrated traditional spiritual, cultural, and
familial practices and actively tried to destroy native
lifeways. Although most tribes survived early colonization,
their numbers and strength were greatly reduced (Richter,
2001).
Alongside massacres were other genocidal approaches
designed to kill Indians and destroy their cultures; such as
the biological warfare of "smallpox blankets," where
blankets were deliberately infected with smallpox and
given to natives, after which entire communities became ill
and died since Indians had no history of smallpox and
therefore no immunity. While tribes did fight back, their
resistance was often fragmented and severely impacted by
the tactics and weapons of the colonists. Even when tribes
integrated non-native ideas and developed a society that fit
within the confines of non-native culture (such as the
Cherokee in Tahlequah), they were pushed out as
non-natives sought further land and resources. The
experience of the "Trail ofT ears" of the Cherokee, where
they were force-marched a thousand miles to demarcated
land in Oklahoma, was shared by many other nations over
the next few hundred years who were forcibly relocated
from their homelands and spiritual sites to unknown,
distant, and often barren lands.
As the wave of colonization and missionary work
moved westward and later from the west coast inland,
further massacres occurred, such as the well-known
massacre of Wounded Knee in 1890. Tribes were pushed
onto smaller and smaller reservations (Brown, 1970).
Native spiritual practices were outlawed by the federal
government in 1890 (in an act that was not repealed until
the American Indian Religious Freedom Act of 1978),
driving all ceremonies for healing and wellness that were
not associated with the Christian church underground.
Meanwhile the sustenance of families and communities
was undermined on the Plains as the buffalo were
slaughtered into near extinction and families were forced
into allotted acres to farm, often on land that could not
sustain farming. In 1959, Alaska, after over a century of
Russian control followed by U.S. colonization, became a
U.S. state. This occurred without sufficient recognition of
the tribes in Alaska as sovereign nations, and with a great
deal of pressure to pull natural resources out of the area by
corporations. On the west coast, the gold rush in California
occurred alongside a deliberate effort to murder California
Indians, including a bounty for every Indian killed.

Further north, the natives of the Pacific Northwest were
pushed onto reservations and had their fishing rights
curtailed while rivers were dammed and traditional
areas flooded. In the south, the new border with Mexico
literally divided native communities and separated fa-
milies. Other traumas inflicted on native communities
included the forced sterilization of native women (which
continued until at least the 1970s), the rnutilation of
corpses, and experimental medical procedures (Walters
& Evans-Campbell, 2004).
These historical events, and others, are important for
practitioners to know not only because their impacts are
felt through the generations but also because anni-
versaries of massacres or dates that mark communi ty
periods of mourning can affect individuals and families.
Sometimes personal experiences of traumas in everyday
life can be heightened if they fall on or near an anni-
versary of a community or familial tragedy. Every
cornmunity has its own history of trauma, and
practitioners from outside of the community benefit
from knowing more about those experiences to facilitate
their ability to assist clients in understanding
connections between individual, family, and community
traumas.
Additionally the oppression faced by tribes has not
been eliminated. Tribes today face many challenges to
their well-being and sovereignty, including challenges
to hunting or fishing rights, challenges to treaty rights in
general, including a severe lack of promised
educational, social and health services, pressures to sell
their land or tum over natural resources to corporate
interests, "radioactive colonization" (the effort to store
radioactive waste on tribal lands), and the incarceration
of Indian political activists (Deloria, 1985; Jaimes ,
1992).
It is also important for practitioners to know the
history of missionary and non-missionary social
workers and their work with native communities over
the past few hundred years. There is a significant history
of social experiments on Native Americans, often done
with the intent to "kill the Indian but save the man" (a
saying attributed to Richard Henry Pratt, a federal
boarding school leader). Although boarding schools for
native children began in South America in the 1500s,
they began being systematized across North.America in
the 1800s. In many communities all or nearly all AI/ AN
children attended boarding school from the late 1800s
through the 1950s. AllAN children were forced to attend
boarding schools often many miles from their families.
Their parents were often fined or imprisoned if they did
not agree to have their children attend. Children had
their traditional clothing taken from them, had their hair
forcibly cut, and were often prohibited from speaking
their own language. Physical and sexual abuse was
rampant in most boarding schools.
NATIVE AMERICANS: PRACTICE
INTERVENTIONS 301
Children came to the boarding schools and stayed sev-
eral years. Returning to their communities they had
become strangers who did not know their own families,
customs, or practices. They had often been subjected to
intense trauma, and had been raised in very impersonal,
brutal, and institutional ways (Bensen, 2001). In the
1960s the Indian Adoption Project, funded by the federal
government and operated through charities and
nonprofits, intentionally removed native children from
their families and placed them in non-native homes for
adoption. This project in the United States was mirrored
in Canada, where people remember the "sixties scoop"
generation in which social workers drove into native
communities and "scooped up" native children, never to
be seen again by their families (Bensen, 2001).
In response to these practices and the efforts of native
activists the Indian Child Welfare Act (lCW A) was
enacted in 1978 by the federal government. This law
restricted the ability of states and other entities to
remove AI/AN children from native families and
cultures and placed legal requirements on states to
provide services to families to prevent childre n from
being removed or assist in them returning home. This
law reduced some of the more significant child welfare
problems but it faces continuing challenges as it was
passed without funding and without federal over sight to
ensure continued compliance. However, it did
strengthen the ability of tribes to develop their own
social service and child welfare programs in order to
provide services for families who fall under tribal
jurisdiction or Iive-in reservation areas.
Contemporary native social workers and psycholo-
gists conceptualize the ongoing effects of historical and
intergenerational traumas as a "soul wound" or "spirit
wound" that affects both individuals and communities
(Brave Heart & DeBruyn, 1998; Duran & Duran, 1995).
Unhealed grief from traumatic events does not go away,
it gets passed down from generation to generation,
which affects and interacts with the different traumas of
each generation. This is often referred to as
intergenerational trauma or historical trauma.
Current and historical traumas have lead to a spec-
trum of health problems evident in most AI/AN
communities across the continent. Rates of diagnosed
mental health disorders are high and the suicide rate of
Native Americans represents 190% of the rate of t he
general population. Suicide is the leading cause of death
for Native Americans aged 15-24 (U.S. Commission on
Civil Rights, 2004). According to one study, 32.2% of
AI/AN females reported suicide attempts in the previous
12 months as did 22.2% of native males (with 10.5% of
Caucasian and 9.7%
302 NATIVE AMERICANS: PRACTICE INTERVENTIONS
of African American female and 4% of Caucasian and
5.2% of African American male populations) (Frank &
Lester, 2002).
Alcohol and drug abuse is also evident at high rates;
however, it is important to note that AI/AN have a bimodal
drinking pattern, with high rates of both heavy drinkers and
those who completely abstain from alco hol, demonstrating
both the historical and conternporary impact of al cohol
upon native communities and the strong cultural value
promoting complete abstention from alcohol for both
health and spiritual reasons (May & Smith, 1988). Alcohol
is involved in 5 times more deaths of natives than
non-natives (National Center for He alth Statistics [NCHS),
1999). Illicit substance use is more common for AI/AN, use
begins at an earlier age, and the mortality rate is higher than
for non, natives (Indian Health Service [IHS], 1997 ;
Substance Abuse and Mental Health Services
Administration [SAMHSA], 2000). Drug abuse,
particularly the use and abuse of methamphetamine is on
the rise in AI/ AN communities, fueled by the complex mix
of jurisdictionallegal responsibilities in reservation
communities and a dearth of legal resources, which has led
to an explosion of methamphetamine dealers and
manufacturers taking up residence in some reservation
areas.
HIVand AIDS are also on the rise in All AN com'
munities. The HIV infection rate for Native American
communities is increasing at a rapid rat e in relation to the
percentage of natives in the population, as is mor tality due
to AIDS (Centers for Disease Control and Prevention
[CDC], 2001).
Other health concerns are also evident at high rates in
AI/AN communities. Type II diabetes is at "epidem ic"
proportions, and AI/AN have the highest rate of this disease
in the world. Tuberculosis, cardiovascu lar disease, and
death due to unintentional injuries also disproportionality
affects native communities (U.S. Commission on Civil
Rights, 2004).
AIs/ANs also experience high rates of interpersonal
violence. AIs/ANs have 2-2.5 times higher rates of vio lent
victimization than any other racial group, even when
controlled for income (Greenfield & Smith, 1999). There
are a few studies that have found that c hildhood
victimization and rates of abuse and neglect among AI/ AN
children are higher than those for Caucasian chil dren
(National Indian Justice Center [NI]C], 1990), and one
study found thatl4% of males were sexually abused prior to
age 16 (Robin, Chester, Rasmussen, Jaranson, & Goldman,
1997). Studies that show higher rates of child hood abuse
and neglect within AI/AN communities need to be
examined cautiously however, since other studies
challenge those findings and native families often face
discrimination in the child welfare system and/or higher
rates of reporting of abuse or investigation of allegations,
which contribute to a disproportionality of native chil dren
in the U.S. child welfare system in relation to the
population (Fox, 2004).
Native women are at high risk for sexual violence.
Sexual violence, including rape and the murder and
desecration of women's bodies, has been a part of the
colonial experience from the very beginning. Pregnant
women had their babies tom from their bodies, and had
their vaginas cut from them in some colonial massacres. In
the current era, 60% or more of those who rape Indian
women are non-Indian, mostly Caucasian. Federal law
prohibits tribes from prosecuting non- Indians on tribal
reservations for crimes that occur on reservations. The only
body that can prosecute anyone for sexually violent crimes
in Indian country is the federal government, since it falls
under the Major Crimes Act (passed in 1885). However ,
the federal government has a very low rate of prosecutio n
of rape and sexual abuse (Smith, 2005).
Native concepts of gender and sexuality are not
commonly equivalent to Western concepts. Histori cally,
native communities included gender roles that accounted
for "third" or additional genders beyond male or fema le,
and many included specific cultural or spiri tual roles for
people who did not fit within the bound aries of male or
female (Jacobs, Thomas, & Lang, 1997). Such individuals
often wore the dress of the opposite sex and many had
partners of the same biol ogical sex (but different gender),
although some also remained single. There are many terms
utilized in native languages for such individuals, such as
winkte (in Oglala Lakota) or n'dleeh (in Navajo).
Additionally a term used by con, temporary. native
communities is "two-spirit," a term created by two- spirit
activists and community members in 1990 (Anguksuar ,
1997). In the colonial period, twospirit people were often
targeted by missionaries and colonists and deliberately
killed or forced to hide their identity. Today, two- spirit
people face a range of responses in their communities, from
traditional acceptance to hostile or violent reactions.
Because of ongoing 'traumas and discrimination as both
native and two-spirit people and the intersection of the
two-spirit community with the GLBTI (gay, lesbian,
bisexual, transgender, intersex) communities, two- spirit
individuals face a high risk of health challenges such as
drug and alcohol use, suicide risk, and HIV exposure
(Fieland, Walters, & Simoni, 2007).
Native Cultural Concepts, Values, and Ethics
It is difficult to talk about native culture without gen-
eralizing, because of the vast diversity that exists. With the
understanding that this summary is a generalization, a nd
that many AI/AN communities and families

may have differing values, concepts, and ethics, the
following summary can be made of some crucial areas of
cultural difference between native and non-native cultures.
These cultural concepts and values represent some
common cultural strengths that have enabled communities
to continue to survive despite efforts from others to
abandon those strengths. Many natives today have a
"blended" cultural style that integrates some native
concepts from their tribe, some pan-Indian native concepts,
and some mainstream non-native values and practices.
Others may "code-switch" by expressing different
values-based behaviors at different times depending on
context in order to express and show respect in different
settings.
Native Americans often have' different concepts of who
and what constitutes family. Family members can include
not only aunts, uncles, and grandparents, but in some
cultures your cousins are literally' your brothers and
sisters, while uncles or aunts can play parental roles. Often
all elders in the community are counted as grandparents,
while all women of parental age are "aunties" and men are
"uncles" to the children in the community. Households
often are composed of multiple generations living under
one roof, and it is normal in many cultures for adult
children to remain in their parent's home and raise their
children there (Swinomish Tribal Mental Health Project,
1991).
Another common cultural difference lies in concepts of
time and causation. Many native people and indigenous
people in other areas do not have a strictly linear sense of
time. Time is often seen more as cyclical or spiraling, or
occurring, and things occur as they are meant to occur by
Creator and spiritual forces; Likewise, the mainstream
worldview's assumption that determining a cause leads to
an effect, and changing the cause can lead to a different
effect, is alien to most native cultures. Things occur in
relation to one another, and what one sees, for' example, as
mental health symptoms, could be tied to a number of
physical, spiritual, and environmental concerns, and
interventions can be determined only after time has been
taken to understand how the different concerns interrelate
and how balance can be restored.
Communication patterns for native peoples can differ
from non-native communication patterns. For example,
non-native practitioners can misinterpret a young native
person who consistently looks at the floor or anywhere but
their counselor's eyes, but this is often a sign of respect of
the counselor, rather than low selfesteem. Likewise, many
cultures have rich traditions of storytelling, in which
humor and engaging stories are used to teach lessons about
the world and how to act in it, and often humor and other
verbal exchanges are used
NATIVE AMERICANS: PRACTICE
INTERVENTIONS 303
to give subtle hints or say something indirectly. Teasing
and similar forms of humor can be used to send messages
of acceptance and also provide indirect feedback to the
recipient. Handshakes are often gentle, and are more of an
exchange of spirit by lightly touching the hands o(the other.
Indigenous Wellness and Healing Practices Native
American tribes, communities, and individuals engage in a
range of healing interventions and ceremonies that pull
from traditional sources or blend traditional sources and
other religious beliefs such as Christianity. AI/AN in both
urban and rural areas report using traditional healing
practices in addition to mainstream, non-native health
providers (Gurley et al., 2001; Waldram, 1990). Healing
through ceremony is generally intended to remove any
negative influence that could be harming the individual (or
the community) and help restore the individual to a healthy
balance physically, mentally, emotionally, and spiritually.
Often . illnesses are regarded as being due to spiritual harm,
either from a spiritual entity or from ill-intentioned
medicine directed at the individual from another person.
Therefore, the person needs to be cleansed and healed from
that harm, and strengthened so that they are not vulnerable
to further harm. Some of the many types of traditional
ceremonies include sweat lodges ("sweats"), naming cer-
emonies, pipe ceremonies, Sun Dance ceremonies, stomp
dances, and potlatches or giveaways. There are many
variations in these and other ceremonies by region, tribe,
clan, or family. Spiritual and religious activities to promote
healing also take place in arenas that blend traditional and
Christian beliefs, such as the Native American Church and
the Shaker Church. Spiritual involvement and religiosity
can be predictive of improved mental and physical health
(Hill & Pargament, 2003).
It is also important to note that many other traditional
activities such as weaving, basket-making, gathering
berries or roots, hunting, story-telling, and other traditions
contain spiritual values and beliefs that often interrelate
with healing practices and also help families and
individuals find balance and health. Many of these
acti~ities have roots in various Creation stories and are tied
to lessons given to humanity by Creator in order for
Creation to be in harmony and life to continue in a good
way.
Retraditionalization is a way to name the current trend
in native communities to strengthen traditional spiritual
practices, reclaim and return practices that have been
discontinued or driven underground, and bring native
families who have not been exposed to traditional spiritual
practices into ceremonies and learn cultural and spiritual
traditions. Retraditionalization is
304 NATIVE AMERICANS: PRACTICE
INTERVENTIONS
a strong force in today's native communities, both rural and
urban (Straus & Valentino, 2001). Especially in urban
areas, sometimes cultural activities reflect influ ences from
many different tribes, or a blending of tradi tions from
different areas, commonly seen in pan- Indian powwows or
other gatherings. There is practice and some research
evidence that having a positive racial or ethnic i dentity can
build resilience (Noh, Beiser, Kaspar, House, & Rummens,
1999) and participation in cultural acti vities can mitigate
the impact of bias, and buffer against mental health
symptoms for Als/ANs (Whitbeck, McMorris, Hoyt,
Stubben, & LaFromboise, 2002).
A good example of the movement to integrate tra-
ditional healing into social service systems is the Sys tems
of Care and Circles of Care Projects funded by the
SAMHSA. Tribal sites who 'are working in this federal
grant program to develop wraparound mental health
systems for youth and families in their tribes and com-
munities have developed innovate ways to blend main-
stream mental health services and traditional health and
healing services, including developing culturally specific
diagnostic terms for mental health disturbances and the
process of healing or rebalancing (Cross, Earle,
Echo-Hawk Solie, & Manness, 2000). Within indigenous
spiritual beliefs, the spirit and physical worlds
"intermingle," and the sacred is not separate from the
secular (Grim, 2000; Hazel & Mohan, 2001). In this vein,
tribal programs use traditional activities such as canoe
carving and journeying from tribe to tribe (as in the Pacific
Northwest) to teach youth skills to help self regulate their
behaviors and actions and provide men torship from elders
and teachers (Cross et al., 2000). These tribal grantee sites
are also working to develop "practice based evidence";
finding ways to demonstrate the . efficacy of traditional
practices using tribally controlled research studies in order
to respond to the trend within funding sources of restricting
the types of services offered to t hose that have been
empirically studied (evidence-based practices).
It is important to recognize that for many native people,
spiritual or religious practices (or both) are considered
deeply private and ofren participation in such practices is
limited to members of the community, certain families or
clans, or those who have had specific ,instructions from
elders or others. Often, certain songs or other practices go
along with ceremonies, but often
those songs or traditions are passed down through families
or given from elders to younger people for specific reasons
and are meant to only be used by those individuals.
For mental health practitioners, it is also important to
note that it is normative in many native cultures for
individuals to receive messages through dreams, speak
with deceased relative's spirits, or receive messages or
signs from the spirit world, often in answer to prayer. These
are not signs or symptoms of mental health dis turbances
unto themselves, and practitioners should imbue discussi on
of such events with respect.
Ethical Considerations for Practitioners
In addition to concerns noted in the other portions of this
entry, there are some issues that practitioners need to keep
in mind and recognize appropriately in order to effectively
and ethically work in and with tribal com munities. The
following is not exhaustive, but meant to cover some areas
of common concern.
It is important for practitioners to recognize and inter act
with tribes as sovereign nations. Tribes often operate their
own social service programs and their decision making
structure is determined by their own laws and traditions, as
well as through interactions with other governments. This
is important not only for practitioners who may interact
with tribal governments through avenues such as the ICW
A, but also for researchers who seek to involve tribes in the
creation of a research study.
It is also important when working with families to focus
on tribal, individual, and familial strengths and focus on
how cultural and familial strengths can be enhanced in
order to utilize traditional forms of protec tion and healing.
Service delivery strategies need to be designed with the
input of tribes or families, and advice and suggestions need
to be respectfully sought from clien ts themselves in order
to ensure that services are appropriate and meet the client's
needs. There are many innovative service delivery
strategies that have been developed by tribes and Indian
organizations, and self-determination of needs and services
is an important strategy that can help break down justifiable
historical mistrust.
Practitioners need to understand that often both the
client and the source of solutions is the community itself.
Even if a practitioner is simply working with an individual
client, often the community itself needs to be involved at
some level in addressing healing past traumas. Although
external facilitators can help if re quested,
community-based leaders and elders need to be the ones
determining how to approach and heal commu nity traumas.
Additionally it is important to note the different
expectations for "helpers" in many tribal communities.
Often native families and individuals call on people known
to them and the community as helpers or healers first prior
to agencies, or alongside seeking help from agencies.
Those traditional helpers are not nine-to- five workers, they
live and exist within the community they help and they are
often called upon at all hours of the day and night. Often,
these helpers accept gifts from families

but they do not receive a paycheck for their assistance.
Tribal social service staff, although usually paid, often has
the same sets of expectations from community members.
Gift giving in general is a sign of respect and the will-
ingness to establish an ongoing reciprocal relationship with
someone. Likewise, being given food is a sign of similar
sentiments and should not be refused (Swinomish Tribal
Mental Health Project, 1991).
Theories and Practice Strategies
Any theory or practice model used to work with and in
native communities needs to incorporate an understanding
of historical and intergenerational trauma, discrimination,
and the impact of these on the mental, physical, emotional,
and spiritual states of AI/AN com, munities and
individuals, as well as the effects of racism and poverty. It
must also integrate an understanding of cultural values and
strengths, and recognize how communities have survived
intense traumas. Failure to do so can result in a
pathologizing of individual and cornmunity patterns of
coping (Browne & Fiske, 2001).
One way of conceptualizing native worldviews and
utilizing native worldview structures in the assessment of
needs and strengths, development of interventions, and
assessment of progress for individuals, families, or
communities is the relational worldview model (Cross,
1995; Cross et al., 2000). This visual and interactive
methodology can easily and effectively draw out multiple
challenges and strengths and determine how challenges
and strengths relate to one another. A "medicine wheel" is
constructed, dividing a circle into four quadrants, with
each quadrant representing a different area of concern;
emotional, physical, spiritual, and environmental. The
name of the quadrants and their area of concern can vary
according to the topic under consideration. Then a
facilitator or leader can help draw out the issues in each
area, and discuss how each area interrelates, and therefore
influences each other. Any interventions can then take into
account the interdependent nature of concerns and be
designed in order to establish overall balance rather than to
simply eliminate a problem or symptom in one or more of
the areas.
Another theoretical approach to help understand the
effects of traumas and help determine possible points of
intervention is the "indigenist" stress-coping model of
Walters and Simoni (2002).
This model contextualizes historical, structural, and
interpersonal determinants (such as historical trauma and
bias-related victimization), and examines how cultural
factors such as identity, spirituality, and traditionalhealth
practices can moderate the health and wellness of the
person or community. It also examines unmoderated
effects of traumas on health outcomes and
NATIVE AMERICANS: PRACTICE
INTERVENTIONS 305
the effect of health outcomes on factors such as identity
and acculturation.
It is based on a fourth world framework (O'Neil, 1986)
that recognizes the colonized position of indigenous
communities and the importance of integrating the
sociocultural landscape and impacts of a colonized
positionality within any analysis of health, trauma, and
wellness.
Practitioners and researchers who work in and with
native communities need to be aware and conscious of the
historical and present-day harmful interactions between
researchers, non-native practitioners, and native
communities and adopt a decolonizing perspective that
centralizes and honors native experiences
(Evans-Campbell & Walters, 2004; Walters, Simoni, &
Evans-Campbell, 2002). This includes recognizing the lack
of AI/AN participation in social service and health research
and the design of such services and studies and altering
these trends by increasing representation and working
directly with community leaders and elders through all
phases of research or program design and implementation.
This occurs with a recognition and understanding of
justifiable native mistrust. AIs/ANs often have high levels
of distrust of health care systems and research (Fieland et
al., 2007) and it is important to interpret such mistrust as a
healthy and understandable response to previous
interactions and as a way to express the need to protect the
community from further harm.
Native psychologist Duran (2006) has developed a
counseling approach that blends Western and traditional
native healing traditions. It is based on a spiritual
framework and uses native healing ways 'such as naming
addictions or mental health concerns as spirits that are
visiting a person and developing a relationship between the
person and their visiting spirit or spirits in order to do what
is proper and necessary to have the spirit leave the
individual and help the person heal from its effects. This
naming of addictions and problems as spirits is a different
way of approaching problems than the Western practice of
diagnosis, and is a "shifting of root metaphors" (p. 7). This
shifting helps allowing for a separation between the client
and their problem and draws out the relationship between a
person and their challenges. The counselor is then a
facilitator of the clients' own spiritual path to healing in a
way that does not pathologize the client. Great emphasis is
also placed on determining the source of client's "soul
wounds" and tracing out intergenerational traumas in order
to help frame the client's healing within the context of
healing of their ancestor's pain and protection of their
children and future generations from similar pain and
trauma.
A methodological and theoretical tool that is used with
communities and with families in order to help
306 NATIVE AMERICANS: PRAcrICE
INTERVENTIONS
illustrate and draw out intergenerational trauma to see its
effects on the generations is an intergenerational trauma
genogram. This tool has been developed by many
practitioners, including the native psychologist Stone (Stone,
2006). It is designed as most genograms are, but the levels of
generations can either signify generations of the community or
generations of a family. The traumas experienced by each
generation can then be drawn out and discussed, which allows
inter, ventions to be raised, which can help provide healing not
only to the client or the generation presenting with addictions
or related concerns, but healing for the traumas unhealed in
each generation that have been passed down and continue to
affect each generation.
There are more approaches and tools that are in use and
being developed but\ most pull on or root them, selves in
native approaches to healing, and to some degree or another
blend in Western approaches as appropriate. There are rich
resources to draw on and honor in AI/AN communities across
the continent, including many promising and effective
approaches being used by tribes and tribal communities.
There are many institutional challenges that impact and
limit the ability for AIl AN to obtain adequate health care.
Even though tribes were promised health care (as well as
education and other services) in exchange for land, federal
follow-through to support their end of that bargain has been
insufficient to meet the need. The U.S. Commission on Civil
Rights in 2004 recognized this problem when they stated
"Persistent discrimination and neglect continue to deprive
Native Americans of a health system sufficient to provide
health care equivalent to that provided to the vast majority of
Americans" (p. 6). IHS, a federal agency, was developed to
provide health services on or near reservations, but the system
is severely underfunded, with more money per person being
spent within the prison system for health care services
(Forquera, 2001). IHS also has a severe lack offundingfor
mental health, and an inadequate number of providers per
population (Smith, 2005). Although more than half of all
AI/AN live in urban areas, just 1% of the IHS budget is
reserved for urban Indian health centers; 24.5% of AI/AN
haveno medical insurance (rate for Caucasians, 10.8%)
(Brown et al., 2000). When AI/AN do access urban or rural
non, native health providers, they can face discrimination
based on ethnicity (Monette, Albert, & Waalen, 2001).
Addressing health problems is also complicated by the
complex web of jurisdictions across tribal and reservation
communities. There is commonly a blend of providers with a
heavy emphasis on IHS services and a few private agencies,
combined with tribal social services in some areas and county
and state systems with the BIA being "payor oflast resort" for
some health treatments. This limits and frustrates access to
services. Additionally, legal concerns from child welfare to
prosecution for abuse and other crimes is broken and
fragmented. Some crimes fall under federal [urisdiction and to
the BIA, but that varies by whether the victim or the
victimizer being Native American, and determining those
concerns can limit or eliminate legal follow, through. Some
crimes fall under tribal law, and tribes often have fragmented
or underfunded systems. Some crimes may fall under state
law, especially in some states that utilize public law 280 (P.L.
280), and then prosecution and follow-through lie with the
state. Services for both survivors and offenders are limited
and often located at great distance. Some tribes and
communities are find, ing innovative ways of using restorative
justice, including mediation and reconciliation, to address
crimes and traumas in ways that utilize traditional ethics and
promote healing (Mccaslin, 2005).
Even with significant institutional and jurisdictional
challenges, there has been a rapid growth over the last ten
years in native-designed or community-designed social
service delivery systems and theoretical models, and research
done in and with tribal communities in respectful and positive
ways. Tribes and AI/AN comrnunities are struggling against
great odds but finding ways to draw from the strengths of their
cultures and ancestors to develop ways to heal past and
current traumas and increase health and balance in their
communities.
REFERENCES
Anguksuar (LaFortune, R.). (1997). A postcolonial perspective on
western misconceptions of the cosmos and the restoration of
indigenous taxonomies. In S. E. Jacobs, W. Thomas, & S.
Lang (Eds.), Two-spirit people: Native American gender
identity, sexuality and spirituality (pp. 217-222). Urbana:
University of Illinois Press.
Bensen, R. (Ed.). (2001). Children of the dragonfly: Native
American voices on child custody and education. T uscon, AZ:
University of Arizona Press.
Brave Heart, M. Y. H., & DeBruyn, L. M. (1998). The American
Indian holocaust: Healing historical unresolved grief.
American Indian and Alaska Native Mental Health Research;
8(2), 56-78.
Brown, D. (1970). Bury my heart at wounded knee, New York:
Henry Holt and Company.
Brown, E. R., Ojeda, V. D., Wyn, R., & Levan, R. (2000).
Racial and ethnic disparities in access to health insurance and
health care. UCLA Center for Health Policy Research and
Kaiser Family Foundation, Los Angeles.
Browne, A. J., & Fiske, J. (2001). First nations women's en-
counters with mainstream health care services. Western ]
oumal of Nursing Research, 23, 126-147.
Centers for Disease Control and Prevention (CDC). (2001).
Death rates and number of deaths by state, race, sex, age and
cause, 1994-1998. Atlanta, GA: Author.

Cross, T. L. (1995). Understanding family resiliency from a
relational worldview. In H. L. McCubbin, E. A. Thompson, A.
I. Thompson, & J. E. Fromer (Eds.), Resiliency in ethnic minority
families: Vol. 1: Native and immigrant American families.
Madison, WI: University of Wisconsin.
Cross, T., Earle, K., Echo-Hawk Solie, H., & Manness, K. (2000).
Cultural strengths and challenges in implementing a system of
care model in American Indian communities. In Systems of
care: Promising practices in chiIJ.ren's mental health, 2000 series
(Vol. 1). Washington, DC: Center for Effective Collaboration
and Practice, American Institutes for Research.
Deloria, V. (Ed.). (1985). American Indian policy in the twentieth
century. Norman, OK: University of Oklahoma Press.
Duran, E. (2006). Healing the soul wound: Counseling with American
Indians and other native peoples. New York:
Teacher's College Press. \
Duran, E., & Duran, B. (1995). Native American postcolonialist
psychology. Albany, NY: University of New York Press.
Evans-Campbell, T., & Walters, K. L. (2004). Catching our
breath: A decolonization framework for healing indigenous
families. In R. Fong, R. McRoy, & C. O. Hendricks (Eds.),
Intersecting chiIJ. welfare, substance abuse, and family violence:
Culturally competent approaches, Alexandria, VA:
CSWE.
Fieland, K. c., Walters, K. L., & Simoni, J. M. (2007). Deter-
minants of health among rwo-spirit American Indians and
Alaskan natives. In I. Meyer & M. Northridge (Eds.), The
health of sexual minorities: Public health perspectives on lesbian,
gay, bisexual and transgender populations. New York:
Springer.
Forquera, R: (2001). Urban Indian health. Menlo Park, CA: The
Henry J. Kaiser Family Foundation.
Fox, K. E. (2004). Are they really neglected? A look at worker
perceptions of neglect through the eyes of a national data
system. First Peoples ChiIJ. and Family Review, 1 (1), 73-82.
Frank, M. L., & Lester, D. (2002). Self-destructive behaviors in
American Indian and Alaska Native high school youth.
American Indian and Alaska Native Mental Health Research,
10(3),24-32.
Greenfield, L. A., & Smith, S. K. (1999). Americrm Indians and
Crime (No. NC]173386 BJS Publication) Washington, DC:
U.S. Department of Justice.
Grim, J. A (2000). Cultural identity, authenticity, and community
survival: The politics of recognition in the study of native
American religions. In L. Irwin (Ed.), Native American
spirituality: A critical reader (pp, 37--60). Lincoln:
University of Nebraska Press.
Gurley, D., Novins, D. K., Jones, M. c., Beals, J., Shore, J. H., &
Manson, S. M. (2001). Comparative use of biomedical
services and traditional healing options by American Indian
veterans. Psychiatric Services, 52(1),68-74.
Hazel, K. L., & Mohatt, G. V. (2001). Cultural and spiritual
coping in sobriety: Informing substance abuse prevention for
Alaska Native communities. Journal of Community Psychology,
29(5), 541-562.
Hill, P. H., & Pargament, K. I. (2003). Advances in the
conceptualization and measurement of religion and
NATIVE AMERICANS: PRACTICE INTERVENTIONS 307
spirituality: Implications for physical and mental health
research. American Psychologist, 58( 1 ), 64-74.
Indian Health Service OHS). (1997). Trends in Indian health, 1996.
Rockville, MD: U.S. Department of Health and Human
Services, Public Health Service, Indian Health Service, Office
of Planning, Evaluation and Legislation, Division of Program
Statistics.
Jacobs, S. E., Thomas, W., & Lang, S. (Eds.). (1997). Twospirit
people: Native American gender identity, sexuality and spirituality.
Urbana: University of Illinois Press.
Jaimes, M. A (Ed.). (1992). The state of native America: Genocide,
colonization and resistance. Boston, MA: South End Press.
May, P. A, & Smith, M. B. (1988). Some Navajo Indian
opinions about alcohol abuse and prohibition; A survey and
recommendations for policy. Journal of Studies in Alcohol,
49, 324-334.
McCaslin, W. (Ed.). (2005). Justice as healing: Indigenous ways.
St. Paul, MN: Living Justice Press.
Monette, L., Albert, D., & Waalen, J. (2001). Voices of twospirited
men: A survey of aboriginal two-spirited men across Canada.
Toronto: 2-Spirited People of the 1st Nations.
National Center for Health Statistics (NCHS). (1999).
Alcohol consumption by state, race/ethnicity, sex, and age,
1997-1999. Washington, DC: National Vital Statistics
Reports, National Vital Statistics System, United States.
National Indian Justice Center (NI]C). (1990). Child abuse and
neglect in American Indian and Alaska native communities and the
role of the Indian Health Service. Unpublished final report, U.S.
Department of Health and Human Services.
Noh, S., Beiser, M., Kaspar, V., House, E, & Rummens, J.
(1999). Perceived racial discrimination, depression and
coping: a study of Southeast Asian refugees in Canada.
Journal of Health and Social Behavior, 40, 193-207.
Ogunwole, S. (2002). We the people, American Indians and Alaska
natives in the United States. Census 2000 special reports.
Washington, DC: U.S. Department of Commerce, Economics
and Statistics Administration, U.S. Census Bureau.
O'Neil, J. D. (1986). The politics of health in the fourth world: - A
northern Canadian example. Human Organization, 45(2), 119-128.
Richter, D. K. (2001). Facing East from Indian country. Boston, MA:
Harvard University Press.
Robin, R. W., Chester, B., Rasmussen,J. K.,Jaranson,J. M., &
Goldman, D. (1997). Factors influencing utilization of mental
health and substance abuse services by American Indian men
and women. Psychiatric Services, 48, 826-834.
Smith, A (2005). Conquest: Sexual violence and American Indian
genocide. Cambridge, MA: South End Press.
Straus, T., & Valentino, D. (2001). Retribalization in urban Indian
communities. In S. Lobo & K. Peters (Eds.), American Indians
and the urban experience (pp. 85-94). Walnut Creek, CA:
AltaMira Press.
Stone, J. (2006, June). Post-colonial stress, historical trauma, and
mental health/substance abuse disorders. Paper presented at
the IHSjSAMHSA National Behavioral Health Conference,
San Diego, CA.
308 NATIVE AMERICANS: PRACTICE
INTERVENTIONS
Substance Abuse and Mental Health Services Administration
(SAMHSA). (2000). Summary findings from the national
household survey on drug abuse. Rockville, MD: Department
of Health and Human Services, Office of Applied Studies,
SAMHSA Administration.
Swinomish Tribal Mental Health Project. (1991). A gathering
of wisdoms: Tribal mental health; A cultural perspective. La
Conner, WA: Swinomish Tribal Community.
U.S. Commission on Civil Rights. (2004). Native American
health care disparities. Washington, DC: Office of the Gen-
eral Counsel, U.S. Commission on Civil Rights.
Waldram, J. B. (1990). The persistence of traditional medicine
in urban areas: The case of Canada's Indians. American
Indian and Alnska Native Mental Health Research, 4, 9-29.
Walters, K. L., & Evans-Campbell, T. (2004, February).
Measuring historical trauma among urban American Indians.
Paper presented at the University; of News, Mexico,
School of Medicine, Albuquerque, NM.
Walters, K. L., & Simoni, J. M. (2002). Reconceptualizing
native women's health: An "indigenist" stress-coping
modeL American Joumal of Public Health, 92, 520-524.
Walters, K. L., Simoni, J. M., & Evans-Campbell, T. (2002).
Substance use among American Indians and Alaska
natives:
Incorporating culture in an "indigenist" stress coping para-
digm. Public Health Report, I 17(SuppL 1), SlO4-5117.
Whitbeck, L. B., McMorris, B. J., Hoyt, D.R., Stubben, J. D.,
& LaFromboise, T. (2002). Perceived discrimination, trad-
itional practices, and depressive symptoms among Ameri-
can Indians in the upper midwest. Journal of Health and
Social Behavior, 43(4), 400-418.
FURTIIER READING
Lobo, S., & Peters, K. (Eds.). (2001). American Indians and the
urban experience. Walnut Creek, CA: AltaMira Press.
SUGGESTED LINKS
National Indian Child Welfare Association (NICWA)
http://www.nicwa.org
One Sky Center
http://www .oneskycenter .org
Indian Country Child Trauma Center: University of
Oklahoma
http://www.icctc.org
The Honor Project: University of Washington, Seattle
http://www.honorproj.com
Indigenous Wellness and Research Institute: University of
Washington. Seattle
http://www.iwri.org
Tribal Law and Policy Institute
http://www.tribal-institute .org
Native American Rights Fund
http://www.narf·org
White Bison
http://www . whitebison.org Native
Wellness Institute
http://www.nativewellness.com
-MIRIAM L BEARSE
NATIVE HAWAIIANS AND PACIFIC
ISLANDERS
ABSTRACT: Native Hawaiians and other Pacific Islanders
(NHOPI) comprise 0.3% of the total u.s. population, with
the largest groups being Native Hawaiians (401,000),
Samoans (133,000), and Chamorros or Guamanians
(93,000). Core cultural values and traditions have sustained
NHOPI as they confront cultural changes and challenges to
their health and well-being. Directions for social work require
accurate assessments of the problems challenging NHOPI
based on information that both disaggregates NHOPI from
other populations, and includes NHOPI in the design and
delivery of culturally based solutions to resolve problems.
KEY WORDS: Native Hawaiians; Pacific Islanders;
cultural strengths; cultural values; culture
Native Hawaiians and other Pacific Islanders (NHOPI) are
part of the panoramic landscape of racial diversity in the
United States. In 2000, NHOPI were recognized for the first
time asa distinct racial group (U.S. Census, 2001). Prior to
2000, information on NHOPI was aggregated with other
minority populations such as Asian Americans, and the
diversity inherent in Pacific Island cultures was often
obscured by the other groups. NHOPI are the original
inhabitants of thousands of islands in the Pacific Ocean
including Hawaii, Samoa, Guam, Northern Mariana Islands,
Marshall Islands, Palau, Federated States of Micronesia, New
Zealand, Tahiti, and Tonga. Pacific Islands that are U.S.
associated jurisdictions include: (a) the territory of American
Samoa, (b) the territory of Guam, (c) the Commonwealth of
the Northern Mariana Islands, (d) the Republic of the Marshall
Islands, (e) the Republic of Palau, and (f) the Federated States
of Micronesia (Chuuk, Kosrae, Pohnpei and Yap). NHOPI
comprise 0.3% (874,000) of the total U.S. population (281
million) with the largest groups being Native Hawaiians
(401,000), Samoans (133,000) and Chamorros or
Guamanians (93,000) (U.S. Census, 2001). Of all the racial
groups in the United States, HOPI have the largest number of
persons, with 55% of the total population, with multiracial
backgrounds, the common combinations NHOPI and Asian
(29%) and NHOPI and white (24%). The overwhelming
majority (73%) of NHOPI reside in the western region of the
United. States, particularly in Hawaii, California, and
Washington, with others residing in Texas, New York,
Florida, and Utah.

History
Contact with Western civilization wrought significant
changes for NHOPI. In Hawaii, trends of decline and
recovery characterize Native Hawaiian history. Decline is
evident in the depopulation of Native Hawaiians, from the
estimated 300,000 to 800,000 at the point of Western
contact in 1778, to 40,000 in 1893 (Stannard, 1989 ).
Primarily attributed to infectious diseases intro duced by
Westerners, the depopulation of Native Hawaiians is
associated with multiple cultural losses, including the loss
of native religion, language, and political power. The
overthrow of the Hawaiian monarchy by the U.S.
government in 1893 paved the way for annexation in 1898
and statehoodin 1959. During this period, recovery became
evident as the census of Native Hawaiians increased due to
high rates of interracial marriages to immigrants from Asia
and other continents. Since the 1960s, r ecovery was also
evident in a cultural renaissance, which reaffirmed native
spirituality, language, and traditions such as hula (dance)
and bo'oponopono (family practice). It is explicit in a
political agenda that highlights the recent apology from the
United States for its role in the overthrow of the monarchy
(ApologyBill, 1993), as well as the develop ment of
legislation on self-determination (AkakaBill, 2005).
For other islands of the Pacific, contact with countries
such as Spain, England, Netherland s, the United States, and
Germany from the 1500s onward affected cultural change.
For example, Samoa, Guam and the Marshall Islands, like
Hawaii, experienced the loss of political power and cultural
ways. Associated with the United States as territories since
1900 and 1960, respectively, residents of American Samoa
and Guam are considered U.S. nationals, maintain
American political structures, and have adopted many
Western practices .. Considered a republic of the United
States, the Marshall Islands experienced the detonation of
nuclear weapons in the 1940s and 1950s, which resulted in
the contamination of food and water, increases in cancer
and other diseases, and the irrevocable altering of cultural
life (Kroon et al., 2004).
CULTURAL STRENGTHS AND CHALLENGES
Cultural strengths, evidenced in NHOPI values and
traditions, have contributed to the perpetuation ofNHOPI
cultures even though their adoption of American ways has
increased. NHOPI values and traditions emphasize a
worldview of collective affiliation rather than indi-
vidualism, and underscore the interdependence of the
individual, family, community, environment, and trans-
cendent realm. Values such as aloha (love, compassion),
ho'omana (spirituality), 'ohana (family), kuleana
NATIVE HAWAIIANS AND PACIFIC
ISLANDERS 309
(responsibility) in Native Hawaiian culture; and inafa'-
maolek (interdependence), familia (family), and chenchule'
(reciprocity in the contributions of material goods) in
Chamorro culture are illustrative of th e importance of
relationships. In Samoan culture, the phrase E leai se isi e tu
[aa-mauga (No one stands like a mountain), emphasizes the
idea that people are interconnected and should always
consider how one's actions will affect others (Mokuau &
Tauili'ili, 2004).
Even with such cultural strengths, NHOPI experi ence
multiple challenges to their health and well- being. When
compared to the general U.S. population, NHOPI are at
increased risk for poorer health outcomes in areas such as
heart disease, cancer , and substance abuse, and these
disparities are often complicated by socioeconomic
realities such as poverty, low levels of education, and
limited access to health care (President's Advisory
Commission on Asian Americans and Pacific Islanders,
2003; U.S. Centers for Disease Control, 2005). For
example, Native Hawaiian women, when compared with
other ethnic and racial groups in the United States, have the
second highest mortality rates for all cancers combined, and
are diagnosed at significantly younger age s and later stages
for breast cancer (Braun, Fong, Gotay, Pagano, & Chong,
2005). Furthermore, high rates of substance abuse and child
abuse plague Samoan com munities, sometimes resulting in
incarceration of adults and removal of children from the
'aiga (family).
DIRECTIONS FOR SOCIAL WORK The profession of
social work is committed to working with racially and
ethnically diverse populations. In 2000, the census des-
ignation of NHOPI as a distinct racial category for the first
time reinforced the commitmen t of social work because all
federal activities are guided by racial and ethnic standards
established by the U.S. Census. In particular, federal
agencies' efforts to distribute funds and to affect the social,
economic, and physical health of populations in the United
States must be in concordance with census- designated
racial and ethnic groups in the nation.
In alignment with federal requirements, new direc tions
for social work are predicated on several assump tions: (l)
conventional Western health and h uman services have
failed (Pryor, Finau & Fairbairn-Dunlop, 2001; Tsark,
1998) to reduce the scope and severity of challenges
compromising NHOPI health, (2) accurate assessments of
problems challenging NHOPI are requisite and should be
based on information that disaggregates NHOPI from other
larger populations, (3) culturally based solutions that
incorporate cultural strengths (values and practices) can
complement, and on occasion substitute for, Western
services, and (4) participation of
310 NATIVE HAWAIIANS AND PACIFIC
ISLANDERS

NHOPI can enhance the design and delivery of social services.
Acting upon these assumptions requires only that we look to
the NASW Code of Ethics for standards that emphasize that
social workers should "recognize the strengths that exist in all
cultures," and "demonstrate competence in the provision of
services" to the culturally diverse.
Tsark, J. (Ed.). (1998). Pacific Health Dialog: Journal of Community
Health and Clinical Medicine of the Pacific. Special issue: The
health of native Hawaiians. Vol. 5, No.2.
U.S. Census. (200l). The native Hawaiian and other Pacific islander
population: 2000. Retrieved November 15, 2005, from
http://www.census.gov/prod/200lpubs/c2kbrOl-14.pdf.
U.S. Centers for Disease Control. (2005). Native Hawaiians & other
Pacific islander populations. Retrieved October 26, 2005, from
http://www.cdc.gov/omh/populations/NHOPI/ NHOPl.htm.

REFERENCES
Akaka Bill. (2005). The native Hawaiian government reorganization
SUGGESTED LINKS
act of 2005. Retrieved January 20, 2007, from
Asian & Pacific Islander American Health Forum
http://akaka.senate.gov /akakabill-b.html.
Apology BilL (1993). U.S. Public Law No. 103-150. http://www . apiahf.org
Office of Hawaiian Affairs
Braun, K., Fong, M., Gotay, c., Pagano, I., & Chong, C. (2005).
Ethniciry and breast cancer in Hawaii: Increased \ http://www.oha.org
survival but continued disparity. Ethnicity & Disease, 15,
453--460.
-NOREEN MOKUAU
Kroon, E., Reddy, R., Gunawardane, K., Briand, K., Riklon, S., Soe,
T., & Balaoing, G. (2004). Cancer in the Republic of the Marshall
Islands. Pacific Health Dialog: Journal of Community Health and
Clinical Medicine oithe Pacific, 11, 2, 70-77. NATURAL HELPING NETWORKS. See SelfHelp
Mokuau, N., & Tauili'ili, P. (2004). Families with native Hawaiian Groups.
and Samoan roots. In E. Lynch & M. Hanson (Eds.), Developing
Cross-Cultural Competence (3rd ed., pp. 345-371). Baltimore:
Brookes Publishing Company.
President's Advisory Commission on Asian Americans and Pacific
NEIGHBORHOOD CENTERS. See Settlements and
Islanders. (2003). Asian Americans and Pacific islanders Neighborhood Centers.
addressing health disparities: Opportunities for building a healthier
America. Washington, DC: Author.
Pryor, J., Finau, S., & Pairbairn-Dunlop, P. (Eds.). (200l) Pacific
Health Dialog: Journal of Community Health and Clinical Medicine
NONPROFIT SYSTEMS. See Charitable Foundations;
of the Pacific, Special issue: The health of Samoans and other Contexts/Settings: Agency and Organization in Nonprofit
Pacificans, Vol. 8, No.1. Settings.
Stannard, D. (1989). Before the horror: The population of Hawaii on
the eve of western contact. Honolulu: University of Hawaii Social
Science Research Institute.
NUTRITION. See Hunger, Nutrition, and Food Programs.
OBESITY. See Eating Disorders; Hunger, Nutrition, and
Food Programs.
OCCUPATIONAL SOCIAL WORK
ABSTRACT: Occupational {industrial} social work, one
of the newest fields of policy and practice, has evolved
since the- mid-1960s to become a dynamic arena for
social service and practice innovation. Focusing on
work, workers, and work organizations, occupational
social work provides unique opportunities for the pro-
fession to affect the decisions and provisions of man-
agement and labor. Despite the risks inherent in
working in powerful and often proprietary s ettings,
being positioned to help workers, their families, and
job hunters enables professional social workers to have
the leverage both to provide expert service and to
become agents of progressive social change.
KEY WORDS: employee assistance programs; labor
union; health-care expenditures; social welfare
system; troubled employees; social services;
confidentiality
In the United States, occupational {industrial} social work
is generally defined as programs and services under the
auspices of labor or management that utilize profes sional
social workers to serve members or employees and the
legitimate social welfare needs of the labor or industrial
organization. It also includes the use by a voluntary or
proprietary social agency of trained social workers to
provide social welfare services or consultation to a trade
union or employing organization under a specific
contractual agreement. The employing organizations are
not only labor unions and corporations, but often
government agencies and not-for-profit organizations (for
additional definitions of occupational social work, see
Akabas, Kurzman, & Kolben, 1979, p. 5; Barker, 2003, p.
302; de Silva, 1988, p. 283; Googins & Godfrey, 1987, p.
5; Kurzman & Akabas, 1981, p. 52; Straussner, 1990, p. 2 ).
In ecological terms, occupational social work is a field
of practice "where the focus is on the individual in the
status of worker, the environment as defined by employing
organizations and trade unions, work as
311
the goal of functional performance among client
populations, and social policy as a recognition of the
interconnection between social welfare and the world of
work" (Akabas & Kurzman, 1982, p. 197).
Conceptual Framework
On an international level, the Department of Eco nomic and
Social Affairs of the United Nations (1971, p. 3) defines
occupational social welfare as "the range of programs,
operations and activities carried out at any level or by any
group which promotes or preserves the welfare of the
worker and protects him and his family from the social
costs of the work process and work setting." The three
major differences between the international definition
provided by the United Nations and the definition
commonly accepted in the United States are instructive.
First, the United Nations offers a somewhat broader
conception of what actually constitutes occupational social
welfare activities; sec ond, that organization does not
emphasize professional social workers as the principal
providers of services; and third, the international definition
places little emphasis on the auspices of programs and
services, which have been a central focus of the American
definition (Masi, 2006). (Although a discussion on
international occupational social welfare programs is
beyond the scope of this entry, it should be noted that
occupational social work practice has existed on a large
scale abroad for many years as a permanent and frequently
governmentsupported field of practice. Such countries as
Belgium, Brazil, France, Germany, Holland, India,
Ireland, Israel, Peru, Poland, and Zambia have
well-established occupational social welfare programs and
services.)
Professional practice in world-of-work settings in the
United States includes addressing, for example, the need
for youth employment training, outplacement services,
personnel and guidance programs, worker retraining and
upgrading, and programs of vocational rehabilitation. The
broader world-of-work rubric is helpful in identifying a
conceptually important larger perspective, which includes
a general emphasis on the social welfare needs of workers
and work organizations.
The conceptualization of an occupational social
welfare system and the social work profession's entry into
this arena as a site for program development and service
delivery are important, given current fiscal
312 OCCUPATIONAL SOCIAL WORK
trends. Public welfare expenditures have been declining
for some time. However, the private, occupational welfare
system-which spent $852 billion in the form of employee
benefits and services in 1992 (Kerns, 1995)-has been
expanding rapidly. By 1992, for example, private
(occupational) health-care expenditures exceeded public
(governmental) health expenditures by more than $100
billion (Hoeffer & Colby, 1997). The social work
profession's willingness to playa role in the development
and administration of such benefits and services becomes
increasingly important as the occupational system takes on
an ever greater role in financing services to the more than
146 million Americans in the work force, and their
families.
Furthermore, occupational social work provides easy
access to a population in its n'aturallife space and offers the
profession an opportunity to develop a universal service
delivery system unencumbered by the usual eligibility and
categorical requirements of the public sector. Service here
is an earned entitlement, universally available to all
participants in the work force without cost and in a familiar
environment-the world of work. In Kahn's sense (1973),
these are not stigmatized "case services." Rather, these
programs and services represent social utilities of the
workplace-on tap, as needed, for all work force
participants and their families. Like the social worker in
the school system or the settlement house worker in the
neighborhood, an occupational social worker generally
serves clients from within the functional community of
work.
Social Work Functions
Among employing organizations, employee assistance or
employee counseling programs are perhaps the best known
and most rapidly developing social work services. Usually
located in a medical or human resource office, these
programs employ the largest number of individual social
workers today and represent the most prevalent social
work service under the auspices of the major institutional
arrangements in the world of work: employers and trade
unions. Social workers, however, also serve in company
training units, affirmative action offices, corporate social
responsibility departments, and human resources
divisions. Typical titles may include employee counselor,
affirmative action officer, community relations consultant,
substance abuse services coordinator, employee resources
manager, corporate relocation officer, human resources
policy adviser, career planning and development
counselor, training consultant, charitable allocations
analyst, urban affairs adviser, or coordinator of corporate
health and wellness programs (Kurzman, 1992).
The majority of social workers employed by organized
labor provide services through union counseling and
advocacy programs, frequently called personal or
membership service units. Such union programs are a
source of employment for a modest number of social
workers, primarily in the Northeast (Kurzman & Maiden,
2008; Molloy & Kurzman, 1993). Professional social
workers also have assumed responsibility for overseeing a
variety of individual programs sponsored by union locals
and district councils and at the headquarters of
international unions and the American Federa tion of Labor
and Congress of Industrial Organizations (AFL-CIO),
which coordinates the work of a major portion of the labor
union movement, Typical titles for social workers
employed in these organizations include personal services
worker, education program director, occupational safety
and health officer, health and security plan man ager,
membership services coordinator, career training and
upgrading adviser, preretirement services worker, day care
consultant, legislative analyst, benefit plan administrator,
community services liaison, substance abuse program
supervisor, and director of retiree services (Akabas &
Kurzman, 2005). A job description for the prototypical
occupational social welfare specialist may list some of the
following duties:
• Counseling and other activities with troubled
employees or members (in jeopardy oflosing their
job) to assist them with their personal problems and
to help them achieve and maintain a high level of
performance.
• Advising on the use of community services to meet
the needs of clients and establishing linkages with
such programs.
• Training front-line personnel (union representatives,
foremen, line supervisors) to enable them to
determine when changes in an employee's job
performance warrant referral to a social service unit
and carrying out an appropriate approach to the
employee/member that will result in a referral.
• Helping to initiate new welfare, community health,
recreational, and educational programs for active and
retired employees or members.
• Assisting in the administration of the benefit and
health-care structure and helping plan for new
initiatives;
• Consulting on the development and administration of
an appropriate affirmative action plan for women,
immigrants, minorities, and the disabled.
• Advising on labor coalition building and on
organizational positions in relation to pending social
welfare legislation (Kurzman & Akabas, 1993, chap.
3; Molloy & Burmeister, 1990).

Historical Background
The historical roots of occupational social work in the
United States can be found in what has been termed
"welfare capitalism"-those benefits and services
provided voluntarily by employers in the late 19th and
early 20th centuries in an effort to socialize, retain, and
control a raw, unskilled, and badly needed labor force at
a time of rapid industrialization (Brandes, 1976).
Paternalistic in nature, inconsistent and inadequate in
provision, directed at fostering dependence and loyalty
in employees, the early programs were more an
instrument of management than a service to workers.
Companies hired staff, usually called welfare secre-
taries, to administer the programs, and serv ices, which
may include improving sanitation, providing housing,
supervising safety, and dffering classes. The welfare
secretaries, as the hand-maidens of management, were
increasingly perceived as policing an immigrant work
force to prevent malingering and to discourage workers'
identification with a growing trade union movement.
Their covert responsibility to investigate employees and
to see that labor unions did not gain a foothold in
industry ensured the enmity of American Federa tion of
Labor President Samuel Gompers and distrust (by
workers) of employers' motives for providing such
programs.
Although initially these welfare secretaries had no
formal training, this situation gradually began to change
after World War 1. The idea of welfare secre taries
received considerable attention from two national
organizations whose goals prominently included
occupational social welfare services-the National Civic
Federation and the American Institute for Social
Service. Popple (1981) noted that this stimulus was
important and that by 1920 more graduates of the New
York School for Social Work were taking jobs in
industry than in any other setting. Social workers often
served in the role of social welfare secretaries, although
not always with that title. During the 1920s, welfare
secretaries began dying out, and by 1935 they had
largely disappeared, with some of their func tions being
assumed by personnel officers arid some by industrial
nurses.
Industrially based social work reemerged during
World War II when new groups of employees entered
, the labor force to respond to the wartime shortage in the
work force. These new workers, many of them women
and minorities, needed help in becoming acculturated to
the experience of full-time employment in industry and
often in balancing the complex roles now of employee
and single parent. The major employers of occupational
social workers were the airplane and
OCCUPATIONAL SOCIAL WORK 313
munitions industries and the unions representing the
shipping industry and merchant seamen. Bertha Rey-
nolds, a prominent social work theoretician and practi-
tioner, was hired to direct the joint labor-management
program of the United Seamen's Service, which served
members of the National Maritime Union. Reynolds's
(1975) superb work at the National Maritime Union
during World War II further strengthened these bonds of
trust between organized labor and the social work
profession.
Often overlooked as a model for promoting the
growth of occupational social work was the
participation of social workers in the armed forces
during World War II. With its numbers swelled by a war
effort on two fronts, the military became the major
national employer. This work force, moreover, had to
adapt to new job specifications in an alien environment
under hostile and anxietyproducing working conditions.
Social workers took on major direct service roles in
helping to meet the needs of soldiers and their families
and thereby established an ongoing role for the
profession in the military for the postwar period. In
1946, the office of the Surgeon General established a
permanent army commissioned officer corps of social
workers, which grew and expanded to the other
branches of military service in succeeding years (Garber
& McNelis, 1995). The professional social workers in
the Medical Service Corps of the three branches of the
armed forces may be conceptualized as occupational
social workers insofar as they work for an employing
organization to serve the health and welfare needs of its
work force.
Modem Development
Modem occupational social welfare practice can be
dated from the mid-1960s, when two important events
occurred. Management at Polaroid in Boston decided
that their innovative employee counseling program was
meeting a definite need of this growing corporation and
should become a permanent part of the organization
("Counseling and Consultation," 1978). Directed by an
experienced social worker, die counseling department
had proved its value to the workers and to the manage-
ment both through the direct service function and
through its role as human resource consultant to the
decision makers of the corporation. At the same time,
Weiner, Akabas, and Sommer (1973) in New York were
establishing a labor-based mental health and re-
habilitation program at the Sidney Hillman Health
Center of the Amalgamated Clothing Workers of
America. These two innovations of the late 1960s con-
tinued into the early 1970s and set the stage for the
growth and development of the field.
314 OCCUPATIONAL SOCIAL WORK
If one were to apply Rostow's (1960) paradigm for
analyzing the growth of an economy to the growth of a
social welfare sector, one might say that the "tradi tional"
period for occupational social welfare was up through the
end of World War 11. The postwar period, until the
mid-1970s, saw a "development of preconditions" and was
followed by a period of "take off' from 1975 to the present.
There are signs now that the field may be close to entering
the early stages of its "drive to maturity," although it is
unlikely that Rostow's final phase of "high mass
consumption" is realistic in the
foreseeable future. . National Institute of Mental Health, the Rehabilitation
Evolution of Practice
Growth in occupational social work practice sinc e the
mid-1970s reflects a concert'ed effort and a concentra tion
of human and fiscal resources. By the mid-1970s,
employers were coming to the realization that they had to
deal with a changing work force as well as to new social
legislation. Women, minorities, and persons with
disabilities were entering the work force in great num bers
and with new needs. In the movement-oriented spirit of
the day, they were voicing their needs for day care,
nondiscriminatory assignments, flextime, barrierfree work
sites, career-training and upgrading programs, and
concessions on some "quality of life" issues. The federal
Hughes Act (Pub. L. No. 91-616), Rehabilita tion Act
(Pub. L. No. 101-336), Occupational Safety and Health
Act (Pub. L. No. 91-596), Employee Retirement Income
Security Act (Puh L. No. 93-406), Age Discrimination in
Employment Act (Pub. L. No. 90-202), and Title V11 of
the Civil Rights Act (Pub. L. No. 88-352) were among the
new work-related laws to which industry had to become
responsive.
The permanent attachment of women to the world of
work reminded industry of what social workers already
knew-that work and family were not separate worlds and
that what occurs in one inevitably affects what happens in
the other. Therefore, employers needed to understan d that
linkages to the family, the neighborhood, and the
community at large were outcomes not merely of the new
mandates of sociallegislation but of the changing
complexion both of the American work force and of the
communities in which they manufactured their goods and
marketed their services. Employers needed help from a
profession that would offer generalists capable of bringing
both clinical and organizational sophistication to bear on
industry's new human service agendas.
Unions began to develop a system of direct services to
their members; these services were in addition to the
occupational social welfare benefits that were essentially
fiscal. Organized labor, having won
significant financial gains at the bargaining tabl e, now
needed to bring in new services to maintain the loyalty of
members to the union and its leaders (Akabas, 1977).
Federal agencies, responding to these conditions and to
the various mandates of the new social legislation, began
to support social work education and training programs in
this arena. Foremost in this effort was the National
Institute on Alcohol Abuse and Alcoholism, which began
to realize that alcoholism in industry was an issue of
growing concern that required federal support for training
and for introducing programs at the work site. The
Services Administration, and the Manpower
Administration of the u.S. Department of Labor also
showed their interest and support for social work
initiatives at the workplace. Several philan thropic
foundations, especially the Lois and Samuel Silberman
Fund and the Johnson Foundation, demonstrated their
interest in fostering the systematic devel opment of
curriculum and practice models for this growing field of
practice. The National Association of Social Workers
(NASW) underwrote a 2-year joint project with the
Council on Social Work Education (CSWE) to promote
the preparation of professional social workers for
occupational social work practice (Akabas & Kurzman,
2005).
Several graduate schools of social work provided
leadership in conceptualizing occupational practice and in
refining models for this field. The first among the
landmark events in this area was the establishment of an
Industrial Social Welfare Center at the Columbia
University School of Social Work in 1970. This event was
followed by the initiation of occupational social work
programs in 1974 at the schools of social work at Boston
College, Hunter College, and the University of Utah. Th en,
in 1978, Columbia University and Hunter College (along
with CSWE) sponsored the First National Conference on
Social Work Practice in Labor and Industrial Settings.
Challenges
Focus ON ALCOHOLISM AND "TROUBLED EM-
PLOYEES" An early issue concerned whether direct
service programs should focus primarily on substance
abuse, particularly alcoholism, or whether the service
should be more broadly conceptualized, offering services
to workers (or members) with any personal or emotional
problems. Because the early funding for the labor and
industrial service programs came largely from the Na tional
Institute on Alcohol Abuse and Alcoholism, and the early
affiliation of occupational social workers was primarily
with the Association of Labor-Management

Administrators and Consultants on Alcoholism, the focus
on substance abuse prevailed. (Founded in 1971, the
Association of Labor-Management Administrators and
Consultants on Alcoholism was subsequently reconstituted
in 1989 as the Employee Assistance Professionals
Association [EAPA].) Today this situation has changed,
partly in response to leadership from social work, and
partly also in reaction to the needs of the field. A broad
model of service, customarily offered in industry under the
auspices of an employee assistance or employee
counseling program, or in unions, under a personal
services or member assistance program, has become
the·prevailing model. Although there are still those, for
example, who feel that EAP practitioners should adhere to
a narrow and EAP A-promoted core technology model
(Mannion, 2006; Maynard, 2003), which focuses on the
EAP as a management tool to ensure worker productivity;
today most social workers embrace a comprehensive
service model, which conceptualizes the EAP as a benef it
(entitlement) designed to help workers to function more
effectively in the key arenas of life-work, family, and
community (Kurzman, 1993, chap. 2). Specifically:
Comprehensive EAPs are free and confidential
workplace entitlements are voluntarily sponsored
by employers or trade unions (or jointly by both).
In-house (internal) and contract (external) EAPs
respond to the human service needs of workers and
their families and to the corresponding agendas of
the work organization. Under the overall direction
of professional health or mental health staff, such
EAPs address comprehensive current and prospect-
ive biopsychosocial programs of education,
prevention, assessment, treatment, case
management, and referral. (Kurzman, 1993, p. 35)
Proponents of the core technology model (Roman &
Blum, 1988; White & Sharar, 2003) envision the
comprehensive service model as promoting "boundary
erosion." They want to return to an exclu sive focus on
"troubled employees" whose personal problems adversely
affect their job performance. This focus, however, does
not appear to be the preference of either management or
labor, both of which appear to strongly prefer social work's
comprehensive service model.
ENSURING CONFIDENTIALITY Another issue has been
whether confidentiality is truly possible in these
settings, especially in management-sponsored pro grams.
The placement of such programs generally under the
personnel or medical department, b oth of which have
manifest or latent monitoring functions, makes the issue
more serious. Since a breach of confidentiality
OcCUPATIONAL SOCIAL WORK 315
could mean the loss of a worker's job or a stigma that could
affect the worker's advancement, the issue of
confidentiality takes on special importance in this set ting.
Because the corporate world is not oriented to human
services, the social worker must always be pre pared to
question managers' understanding of the nature and
boundaries of confidentiality and their willingness to
respect workers' rights. Although this issue remains central
to all occupational social work practice, instances of actual
abuse are rare (Cunningham, 1994).
MOTIV A TIONS OF CORPORATIONS AND THE
PROFESSION Some have questione d the motives of the
social work profession in embracing the occupa tional
arena, especially at a time when corporations dominate
the allocation of national resources. They ask whether
the profession is motivated to move into the area
primarily to demonstrate its capacity for en-
trepreneurship and to maximize practitioners' income
and prestige. Do the trends in occupational social work
mean that social work is or will become less committed
to serving the poor, who often are not members of the
work force? Given the national trend toward "pri-
vatization" of the economy in general and of the human
services in particular, is occupational social work an-
other step in this direction by a profession historically
committed to the public and voluntary sectors? In vie w
of the recent growth of private entrepreneurship in such
service sectors as child care, nursing homes, edu cation,
and home health care, and the parallel growth of private
clinical practice, will occupational social work become
still a further move towar d modeling the profession on
the profit-making sector?
Although the profession has begun to address some of
these ethical issues (Kurzman, 1988, 1998; NASW Code of
Ethics, 1999), the answers to these questions are not yet
clear and must await the further evolution and maturation
of this field of practice. However, there are several
promising signs. First, leaders in the profession are willing
to discuss these issues openly, partly to increase awareness
of potential problems and to ensure that the fundament al
issues will be addressed both by individual social workers
and by gatekeepers in professional agencies and
organizations. Second, the recent growth of occupational
social work in government and not-for-profit settings has
created a balance in this emer ging field that gives promise
of a measured and varied perspective in the field. Third,
leaders in the development of occupational social work
have suggested a broad world-of-work framework as the
arena for specialization, and this perspective has been
supported by NASW and CSWE. This view of the field
casts the net for service more broadly than merely over
316 OcCUPATIONAL SOCIAL WORK
those with an active and relatively permanent attachment to
the labor force and includes the newly employed, the
unemployed looking for work, and the disadvantaged and
disabled.
SOCIAL SERVICE VERSUS SOCIAL CHANGE The final
issue is related to the question of "privatization" and is
perhaps the most fundamental of all. Briefly stated, it is
whether social workers' participation in the world of work
will be exclusively, or even largely, as providers of service or
whether they will also act as agents of social change. This
issue is an old and honored one and embraces Richmond's
(1917) focus on the tension between "retail" and "wholesale,"
Schwartz's (1969) discussion of "private troubles" and
"public issues," Wilensky and Lebeaux's (1965) concern
witA the "residual" and "institutional," and the Milford
Conference's (1929) attention to "cause" as well as
"function."
To be fully responsive to the profession's dual mis sion,
Iversen (1998, p. 561) accurately notes that occupational
social workers will increasingly need to enlarge their practice
domain to focus on what she terms "the full spectrum of
individuals' work situations." In this context, Mor Barak
(2000, pp. 205, 208) suggests that occupational social work
practice today should refer broadly to
the need for social work intervention not only with
workers in the workplace but also with individuals and
groups at the point of entry to, or exit from, the world
of work, and with those who are temporarily or
chronically unemployed ... , The main element in the
field's recent evolution has been the move away from
defining it by its practice location ... to defining it by
its practice mission.
Inseparably related to this question is the issue of social
control and whether occupational social workers' professional
use of self will be primarily in service to the individual or to
the employing organization. As Bakalinsky (1980, p. 472)
has argued:
Concern for the well-being of people, individually and
collectively, historically has been social work's
trademark. Industry, on the other hand, places its
primary value on production and profits. Its people are
viewed as a commodity having only instrumental
value for the industry's central purpose.
Walden (1978) questioned whether occupational social
workers will serve only the individual needs of workers or will
move organizationally to address collective issues, such as
hazardous working conditions, the dehumanization of
workers, and violations of affirmative action.
Ultimately, this question cannot be answered easily or
absolutely. Social workers have had to deal with these same
dilemmas in such settings as public welfare, corrections,
school social work, addiction services, and child welfare. The
fundamental question that social workers must ask is, whose
agent are we? Clarity about role and function means that
people are the central focus of attention and yet that social
workers will develop the organizational sophistication
necessary to mediate between individuals and their
environment. In occupational social work, no less than in
other fields of practice that appear to constrain options,
practitioners must hold fast to their dual commitment to being
providers of expert social services and agents of progressive
social change. This is a historical mandate of the s,pcial work
profession.
Trends and Future Direction
Five current trends are likely to shape the future of the field.
First, the change in focus of employee assistance programs
(EAPs). The external (contractual) paradigm is replacing the
internal (in-house) model, and the preponderance of new EAP
programs and services is, and will continue to be, provided by
proprietary firms. Responding to employers' concerns for
health care cost-containment, EAPs are assuming many
managed, behavioral health-care functions. They are making
mental health referrals primarily to established (preferred)
providers-frequently clinical social workers-working in both
agency and private practice settings. The dominant social
work conceptualization of the EAP as a comprehensive service
employee benefit will continue to prevail, focusing not merely
on the provision of individual services but increasingly on
wellness, education, case management, and prevention.
Working in concert with human resources department
directors in management settings, and with health and benefit
plan administrators in labor venues, EAP managers will be
taking on a much larger role in the areas of benefits
management, work/family programming, community
advocacy, disability management, and compliance with
workplace-focused laws and regulations.
Second, the arenas of affirmative action, training, and
compliance offer new roles for occupational social workers.
Affirmative action, on behalf of both workers and applicants,
is a serious and expanding responsibility of virtually all work
organizations today, given the numerous federal statutes that
mandate compliance (Akabas & Kurzman, 2005, pp. 83-84),
and American employees' individual and collective
predisposition toward litigation. The range of current federal
laws,

for example, covers race (Equal Employment Opportun-
ity Act of 1972, Civil Rights Acts of 1964 and 1991) ;
gender (Equal Pay Act of 1963, Pregnancy Discrimin-
ation Act of 1978, Family and Medical Leave Act of
1993); age (Age Discrimination in Employment Act of
1967, Retirement Equity Act of 1984, Older Workers
Benefit Protection Act of 1990); safety (Occupational
Safety and Health Act of 1970, Drug Free Workplace
Act of 1988); and disability (Employment Opportunities
for Disabled Americans Act of 1987, Americans with
Disabilities Act of 1990). Both management and labor
look to professional social workers' understanding of
these variables, their training expertise, and their skills
in performing key mediating functions. Occupational
practitioners today are conducting diversity manage'
ment training (Mor Barak, 2000); stress management
workshops and critical incident stress debriefing-in a
post 9/11 world (Greene et al., 2006); sexual harass ment
colloquia to ensure employers' conformance with Title
VII of the Civil Rights Act (Akabas, 1995, p. 1784); and
retirement (and preretirement) seminars, both for
employers and for trade unions (Stuen & Worden, 1993).
Third, the changing composition of the American work
force. This will engender a new and potentially expan-
sive role for occupational social workers. Once largely
White, American-born, and male, the labor force today
is very rapidly becoming more heterogeneous than it
was even 20 years ago (Akabas & Gates, 2000; Akabas
& Kurzman, 2005, pp. 34-39; Gray & Barrow, 1993;
Mor Barak, 2000; Poverny, 2000). Immigrants and re-
fugees; African Americans, Asian Americans, and
Latinos; gay and lesbian domestic partners; men and
women older than 65 years; dual-career and single'
parenting women; and persons with physical, emotional,
and developmental disabilities all are permanent
participants in the world of work today. Immigrants, for
example, bring their own languages, perspectives, and
cultural values to the workplace. The numbers, more,
over, are large: The foreign-born population in the
United States has increased more than 55% in the last 15
years. Occupational social workers therefore are being
called upon to help supervisors understand the
importance of demonstrating respect for their newest
employees, and to assist in the formation of work groups
to help all workers become comfortable with respecting
the beliefs and customs of their newest coworkers. The
new American labor force also includes large cohorts of
single-parents and dual-career couples, who need
family-friendly (yet cost-effective) programs and
benefits to help them with both their elder care and their
child care obligations. Similarly, many today are
working well past the age of 65,
OCCUPATIONAL SOCIAL WORK 317
sometimes because they want to, but ofte n because they
need to, given the gradual move of full social security
benefits forward to age 67, increased life expectancy,
and the trend toward discontinuance of emplover-funded
defined pension plans. Finally, persons with disabilities,
formally relegated to sheltered work, shops, now are
moving into the mainstream of American life, including
the competitive workplace. Occupational social workers'
cultural competence, appreciation for the strengths
inherent in heterogeneity; and social systems sensit ivity
all provide a goodness-offit for helping workers and
work organizations with these issues, thereby creating
an ever expanding occupational portfolio.
Fourth, the expanded role of federal and state govern,
ments. In part, as a result of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996,
Workforce Investment Act of 1998, Work Incentives
Improvement Act of 1999, and Job Creation and Worker
Assistance Act of 2002, new roles for occupa tional
social workers have evolved. A national "work first"
policy has emerged, stressing employment as a
prerequisite for government benefits and as a mandate
for most entitlements. As a result,governrnent at all
levels is finding a need for occupational social workers'
expertise. The Employment and Training Adrninistra-
tion of the U'.S. Department of Labor, the Commissioned
Corps of the U.S. Public Health Service, State
Employment Services Divisions, Municipal and County
Vocational Education Departments and Job Centers, and
government-funded welfare-to-work programs are
rapidly becoming new occasions for occupational social
work employment.
Finally, the needs of labor unions, which now represent
only 12 % of all workers in America. Clinical social
workers staffing member assistance programs, gr oup
workers running retraining and upgrading programs for
dislocated members, researchers documenting evidence'
based outcomes of union-managed health and benefit
programs, and community organizers helping to develop
strategies for enrolling new members from emerging
sectors of the economy are likely to provide a value'
added to trade unions. The potential for employment of
more occupational social workers in labor
settings-especially those representing govern ment
workers-today is present because of the emer ging needs
of organized labor, and a clear maturation of the
relationship between the labor movement and the social
work profession.
Occupational social work continues to be an impor-
tant arena for the profession of social work because
work itself is so central to the lives of our clients and
their families. Indeed, leaders suggest that a principal
318 OCCUPATIONAL SOCIAL WORK
measure of progress toward equality in America will emerge
from the world of work. It is therefore imperative that social
workers be present.
REFERENCES
Akabas, S. H. (1977). Labor: Social policy and human services.
In J. B. Turner, R. Morris, M. N. Ozania, B. Phillips, P.
Schreiber, and B. K. Simon (Eds.), Encyclopedia of social work
(17th ed., Vol. 1, pp. 738-744). Washington: NASW Press.
Akabas, S. H. (1995). Occupational social work. In R. L.
Edwards, J. G. Hopps, L. D. Bernard, D. M. Di Nitto, P. L.
Ewalt, M. Frumkin, et al. (Eds.), Encyclopedia of social work
(19th ed., Vol. 2, pp. 1779-1786). Washington: NASW
Press. ' Springer.
Akabas, S. H., & Gates, L. (20(\)0). A social work role: Promoting
employment equity for people with serious and persistent
mental illness. Administration in social work, 23 (3/4), 163-184.
Akabas, S. H., & Kurzman, P. A. (Eds.). (1982). Work, workers and
work organizations: A view from social work. Englewood Cliffs,
NJ: Prentice-Hall.
Akabas, S. H., & Kurzman, P. A. (2005). Work and the work~ place:
A resource for innovative policy and practice. New York:
Columbia University Press.
Akabas, S. H., Kurzman, P. A, & Kolben, N. S. (1979). Labor and
industrial settings: Sites for social work practice. New York:
Columbia University, Hunter College and CSWE.
Bakalinsky, R. (1980). People vs. profits: Social work in industry.
Social Work, 25(6), 471-475.
Barker, R. L. (2003). The social work dictionary (5th ed.).
Washington, DC: NASW Press.
Brandes, S. D. (1976). American welfare capitalism: 1880-1940.
Chicago: University of Chicago Press.
Counseling and consultation at Polaroid. (1978). Practice Digest,
5(2), 6--7.
Cunningham, G. (1994). Effective EAPs. Thousand Oaks, CA:
Sage.
Department of Economic and Social Affairs. (1971). Industrial
social welfare. New York: United Nations.
de Silva, E. G. (1988). Services to customers: Customer assistance
programs. In G. M. Gould & M. L. Smith (Eds.), Social work in
the workplace: Practice and principles (pp. 283-298). New York:
Springer.
Garber, D. L., & McNelis, P. J. (1995). Military social work. In R.
L. Edwards, J. G. Hopps, L. D. Bernard, D. M. Di Nitto, P. L.
Ewalt, M. Frumkin, et al. (Eds.), Encyclopedia of social work
(19th ed., Vol. 2, pp. 1726-1735). Washington:
NASWPress.
Googins, B., & Godfrey, J. (1987). Occupational social work.
Englewood Cliffs, NJ: Prentice-Hall. - i-
Gray, M., & Barrow, F. (1993). Ethnic, cultural and racial
diversity in the workplace. In P. A Kurzman & S. H. Akabas
(Eds.), Work and well~being: The occupational social work
advantage (pp. 138-152). Washington: NASW Press.
Greene, P., Kane, D., Christ, G., Lynch, S., and Corrigan, M.
(2006). FDNY crisis counseling. New York: Wiley.
Hoeffer, R., & Colby, I. C. (1997). Social welfare expenditures:
Private. In R. L. Edwards, J. G. Hopps, L. D. Bernard, D. M.
Di Nitto, P. L. Ewalt, M. Frumkin, et al. (Eds.), Encyclopedia of
social work (19th ed. Supplement, pp. 274-281). Washington:
NASW Press.
Iversen, R. R. (1998). Occupational social work for the 21st
century. Social Work, 43(6), 551-566.
Kahn, A. J. (1973). Social policy and social services. New York:
Random House.
Kerns, W. L. (1995). Role of the private sector in financing social
welfare programs. Social Security Bulletin, 58( 1 ), 66-73.
Kurzman, P. A (1988). The ethical base for social work in the
workplace. In G. M. Gould & M. L. Smith (Eds.), Social work
in the workplace: Practice and principles (pp, 16--27). New York:
Kurzman, P. A (1992). EAP staffing: Past, present, and future.
Employee Assistance Quarterly, 8(2), 79--88.
Kurzman, P. A (1993). EAP programs: Toward a cornprehensive
service model. In P. A Kurzman & S. H. Akabas (Eds.), Work
and well~being: The occupational social work advantage (pp.
26-45). Washington: NASW Press.
Kurzman, P. A (1998). Workplace ethics: Issues for human
service professionals. In R. Chadwick (Ed.), Encyclopedia of
applied ethics (Vol. 4, pp. 555-560). San Diego: Academic
Press.
Kurzman, P. A, & Akabas, S. H. (1981). Industrial social work as
an arena for practice. Social Work, 26(1), 52-60.
Kurzman, P. A, & Akabas, S. H. (Eds.). (1993). Workandwell~
being: The occupational social work advantage. Washington:
NASWPress.
Kurzman, P. A, & Maiden, R. P. (Eds.). (2008). Labor's
contributions to workplace human services. Binghamton, NY:
Haworth Press.
Mannion, L. (2006). Employee assistance and the concept of
authority. Journal of Workplace Behavioral Health, 22(1),
103-112.
Masi, D. (Ed.). (2006). The international employee assistance
compendium. Bloomington, IL: Chestnut Health Systems.
Maynard, J. (2003). Understanding the essence of employee
assistance. Journal of Employee Assistance, 1 (1), 18-20.
Milford Conference. (1929). Generic and specific: A report.
Classic series. Washington: NASW Press. (Reprinted 1974)
Molloy, D., & Burmeister, L. (1990). Social workers in union-
based programs. In S. L. A Straussner (Ed.), Occupational social
work today (pp. 37-51). Binghamton, NY: Haworth Press.
Molloy, D. J., & Kurzman, P. A. (1993). Practice with unions:
Collaborating toward an empowerment model. In P. A.
Kurzman & S. H. Akabas (Eds.), Work and well-being: The
occupational social work advantage (pp. 46-60). Washington:
NASW Press.
Mor Barak, M. E. (2000). Repositioning occupational social work
in the new millennium. Administration in Social Work,
23(3/4),201-210.
National Association of Social Workers [NASW]. (1999).
Code of Ethics. Washington: NASW Press.
Popple, P. R. (1981). Social work practice in business and
industry: 1875-1930. Social Service Review, 55, 257-269.

Poverny, L. M. (2000). Employee assistance practice with
sexual minorities. Administration in Social Work, 23(3/4),
69-91.
Reynolds, B. C. (1975). Social work and social living: Explor-
ations in philosophy and practice. Classic series. Washington,
NASW Press. (Reprinted 1951)
Richmond, M. L. (917). Social diagnosis. New York: Russell
Sage.
Roman, P., & Blum, T. (1988). The core technology ofEAPs :
A reaffirmation. Almacan, 18(8), 17-22.
Rostow, W. W. (1960). The stages of economic growth. Cam-
bridge, England: Cambridge University Press.
Schwartz, W. (1969). Private troubles and public issues: One
social work job or two? Social Welfare Forum, 1969. (pp. 22-
43). New York: Columbia University Press.
Straussner, S. L. A. (Ed.). (1990). Occupational social work
today. Binghamton, NY: Haworth Press.
Stuen, c., & Worden, B. D. (1993). The older worker and
service delivery at the workplace. in P. A. Kurzman & S.
H. Akabas (Eds.), Work and well-being: The occupational social
work advantage (pp. 256-275). Washington: NASW Press.
Walden, T. (1978). Industrial social work: A conflict in def-
initions. NASW News, 23(5), 3.
Weiner, H. ]., Akabas, S. H., & Sommer,].]. (1973). Mental "
health care in the world of work. New York: Association Press.
White, W., & Sharar, D. (2003). Origins, evolution and solu-
tions. EAP Digest, 23(4),16-24.
Wilensky, H. L., & Lebeaux, C. N. (1965), Industrial society
and social welfare. New York: Free Press.
FURTHER READING
Briar, K. H. (1988). Social work and the unemployed. Silver
Spring, MD: NASW.
Feinstein, B. B., & Brown, E. G. (1982). The new parmership:
Human services, business and industry. Cambridge:
Schenkman.
Gould, G. M., & Smith, M. L. (Eds.). (1988). Social work in the
workplace: Practice and principles. New York: Springer.
Hasenfeld, Y. (2000). Social services and welfare-to-work
programs: Prospects for the social work profession.
Administration in Social Work, 23(3/4),185-199.
Kurzman, P. A. (1987). Industrial/occupational social work.
In A. Minahan, R. M. Becerra, S. Briar, C.]. Coulton, L. H.
Gingsberg, ]. G. Hopps, et al. (Eds.), Encyclopedia of social
work (18th ed., Vol. 1, pp. 899-910). Silver Spring, MD:
NASW Press.
Kurzman, P. A. (2000). Bakalinsky's conundrum: Should
social workers practice in the world of work?
Administration in Social Work, 23(3/4), 157-161.
Masi, D. A. (1982). Social work in industry. Lexington, MA:
Lexington Books.
McGowan, B. G. (1984). Trends in employee counseling pro-
grams. New York: Pergamon Press.
Mor Barak, M. E. (2005). Managing diversity: Toward a globally
inclusive workplace. Thousand Oaks, CA: Sage.
Mor Barak, M. E., & Bargal, D. (Eds.). (2000). Social services
in the workplace: Repositioning occupational social work
in the new millennium. Binghamton, NY: Haworth Press.
l
ONCOLOGY SOCIAL WORK 319
Skeels, ]. W. (1965). Social welfare programs of labor and
industry. In H. L. Lurie (Ed.), Encyclopedia of social work
(15th ed., Vol. 1, pp. 735-740). New York: NASW Press.
Smith, M. L., & Gould, G. M. (1993). A profession at the
crossroads: Occupational social work - Present and future.
In P. A. Kurzman & S. H. Akabas (Eds.), Work and well-
being (pp. 7-25). Washington: NASW Press.
Thomlison, R. ]. (Ed.). (1983). Perspectives on industrial social
work practice. Ottawa: Family Service Canada.
Weiner, H. ]., Akabas, S. H., Kremen, E., & Sommer, ]. ].
(1971). The world of work and social welfare policy. New York:
Columbia University School of Social Work, Industrial
Social Welfare Center.
-PAUL KURZMAN
OLDER ADULTS. See Aging: Overview; Life Span:
Oldest Senior/Aged-Late ("Old Old").
ONCOLOGY SOCIAL WORK
ABSTRACT: Oncology social work is a specialization of
social work in health care. Its practitioners provide
supportive services and programs, education, research,
administration, policy development, and advocacy to
address the social, psychological, and spiritual concerns
of cancer patients, their families, and caregivers from
pre-diagnosis through treatment, survivorship, and end of
life care or bereavement. The coming decades will
present many challenges and opportunities for oncology
social workers in helping patients, families, and care-
givers overcome barriers to quality of life and care.
KEY WORDS: oncology social workers; cancer; psycho-
social care; health care
Oncology social work is a specialization of social work in
health care. It is the major professional discipline providing
psychosocial services to patients, families, and caregivers
facing the impact of the diagnosis and treatment of cancer
(Association of Oncology Social Work [AOSW], 2001a). Its
practitioners focus on supportive services and programs,
education, research, administration, policy development, and
advocacy to address social, psychological, and spiritual
concerns from prediagnosis through treatment, survivorship,
and end of life care or bereavement. The need for these
services and programs is significant (Institute of Medicine,
2007). According to the American Cancer Society (2007),
"cancer is the second leading cause of death in the United
States. Half of all men and one third of
320 ONCOLOGY SOCIAL WORK
all women will develop cancer during their lifetimes." The
most prevalent types of cancer are prostate, lung, breast,
blood, and colon cancer. For many patients, cancer is now
a chronic disease. There are an estimated 10,000,000
cancer survivors in the United States, and advances in early
detection and treatment, along with an aging population,
portend a likely increase in that number in coming years
(Hewitt, Greenfield, & Stovall, 2006).
History
Oncology social work as a distinct practice area emerged
in the United States in the mid-1970s, about the same time
that other health-care professionals began specializing in
oncology. The National Cancer Act of 1971 mobilized
resources to fight cancer, create cancer treatment centers,
and establish training programs. Survival rates of patients
increased with new research findings, use of clinical trials,
and development of new chemotherapeutic agents,
surgical techniques, and radiation technologies. It soon
became evident that patients, families, and caregivers
needed better information, education, and attention to
social, psychological, and other issues they experienced in
dealing with active treatment and its side effects, the acute
and chronic aspects of cancer, the years of survivorship or
end of life care, and bereavement.
At treatment centers or departments, clinical social
workers and other professionals became part of multi-
disciplinary oncology teams to help address the complex
issues affecting both quality of life and medical outcomes.
This teamwork approach still characterizes much of the
delivery of psychosocial services to patients in cancer
centers today, particularly in pediatric oncol ogy programs.
An expanding body of research by oncology professionals
informs oncology social work practice. Much of this
research is multidisciplinary. The Association of Pediatric
Oncology Social Workers (APOSW) was formed in 1977,
and the National Association of Oncology Social Workers
(NAOSW) in 1984. NAOSW became AOSW in 1993,
changing its status from a professional organization to an
educational nonprofit organization. It works to advance
excellence in psychosocial care of cancer patients,
families, and caregivers through education, research,
resource development, networking, and advocacy. Both
APOSW and AOSW have Standards of Practice (AOSW,
200la) to guide clinicians, and members of each utilize the
guidelines in NASW's Code of ethics (NASW, 1999). In
addition, AOSW outlines practice parameters in its scope
of practice (AOSW, 2001b). Each organization is involved
in clinical research,
public education, and continuing professional educa tion
and training through national and regional conferences.
Each supports special interest groups and fosters member
networking through listservs. and newsletters.
ONCOLOGY PRACTICE SETTINGS, ROLES, AND
SERVICES Oncology social workers practice wherever
cancer patients are treated and followed, primarily in
major medical centers, cancer centers, community hos-
pitals, outpatient oncology clinics, and oncology or social
work private practices. With the move to in creased
outpatient care in the 1980s, oncology social workers
began to provide services in other settings, such as
hospices, home health agencies, and wellness and other
support communities. Oncology social workers are also
found in academic, research, and policy making settings.
Oncology social workers have many different roles,
and they often perform multiple functions within those
roles. Roles may include clinical social worker, counse lor,
psychotherapist, support group leader, educator, in-
formation specialist, researcher, case manager, discharge
planner, patient navigator, advocate, program developer,
policy analyst, consultant, and others. Further, many
oncology social workers volunteer knowledge and ex-
pertise to national and local oncology organizations and
groups as board and committee members, support group
leaders, consultants, or special project directors.
Most pediatric oncology social workers practice in
major cancer centers or in community hospitals with
pediatric oncology programs. Children and adolescents
with cancer generally have their care directed and
monitored from those settings, even when part of treat-
ment occurs in their local communities. There is a
comprehensive and coordinated approach to care and
special emphasis on family-centered care (Lauria, Clark,
Hermann, & Steams, 2001).
Oncology social workers offer an array of services,
including crisis intervention, supportive counseling,
psychotherapy, pain and other symptom management,
palliative and end of life care support, bereavement
counseling, assistance with decision making, case man-
agement, care coordination, discharge planning, patient
navigation, individual advocacy on financial, employment
and other resource needs, disease-specific education,
information on complementary and alternative medicine,
training in relaxation and other stressreducing techniques,
and provision of support groups, advocacy, and .special
programs such as summer camps (AOSW,2001b).
In addition to patient-focused services, at the macro
level, oncology social workers provide their expertise to

institutions and agencies to help them understand the
psychosocial impact of cancer and its treatment and to
assist in their development of programs; to communities
to educate and to help develop or strengthen resources for
patients; and to professionals to provide education and
training in oncology through teaching, research, and
publishing.
EDUCATION AND TRAINING Most oncology social
workers have a Master of Social Work (MSW) degree.
Education provides a theoretical knowledge base, and
clinical practice results in essential oncology experience
and expertise. Oncology social workers generally hold
licenses in the states in which they practice and must
complete annual continuing education courses and ethics
training. Additionally, AOSW offers certification in
oncology social work (OSW-C).
Challenges
There are numerous challenges for oncology social
workers in practice today. First, is the enormous cost of
treating cancer, which influences how care is deliv ered and
poses problems for oncology professionals, insurance
providers, and patients. Cost containment measures have
led to new service delivery models and to staff reductions
in many cancer settings. Remaining staff often struggle to
provide adequate psychosocial. services and secure
funding for them. This comes at a time when empowered
patients seek more information, education, help in
navigating the system, and better quality of care. It also
comes when there is renewed interest in cancer prevention
and timely diagnosis, and with the prospect of greater
numbers of cancer patients with the aging of the society.
Patients and caregivers tum for guidance to oncology
professionals and organizations, such as the American
Cancer Society, the Leukemia & Lymphoma Society, the
National Coalition for Cancer Survivorship, the Patient
Advocate Foundation, Candle lighters Childhood Cancer
Foundation, and others.
The number of Americans without, or with inade quate,
medical insurance (Freeman, 2001) presents a second
concern. Even those with third party coverage require
more help than ever to access and navigate a complex and
fragmented health-care system (C-Change, 2005) and the
resources and support they need. This is particularly true
for patients facing special barriers, suc h as language,
cultural differences, mental illness, cognitive limitations,
illiteracy, or poverty (Smedley, Stith, & Nelson, 2003).
Cultural competency is an imperative for today's oncology
social workers, as is client advocacy.
ONCOLOGY SOCIAL WORK 321
Finally, the burgeoning numbers of cancer survivors is
creating new attention and requests for services and
programs to address issues often faced by these
10,000,000 Americans (Hewitt, Greenfield, & Stovall,
2006; NCI, 2003-2004).0£ particular interest is
facilitating the transition from patient to survivor, the need
for new guidelines for this stage of the cancer experience,
and planning and coordination to assure that often
complex needs are met (Hewitt, Weiner, & Simone,
2003).
The call for more evidence-based practice in all
disciplines, advances in gene and other therapies, new
attention to palliative and end-of- life care, emphasis on
the period of survivorship, continuing concern about costs
and service delivery, adapting to the needs of an
increasingly multicultural society, and the imperative of
improving access and helping patients navigate the cancer
care system (C-Change, 2007) will both challenge and
create opportunities in the next decade and beyond.
Oncology social workers will need to increase their
knowledge, provide evidence for interventions, inte grate
research and practice, master new technologies, assume
new roles, and explore innovative approaches to helping
patients manage all phases of cancer treatment and
survivorship.
REFERENCES
American Cancer Society. (2007). Detailed guide: What is cancer?
Retrieved December 2, 2007, from http://www. cancer.org
Association of Oncology Social Work. (200la). Standards of practice.
Retrieved December 2, 2007, fromhttp://aosw.org/
html/prof-standards.php
Association of Oncology Social Work. (200lb). Scope of practice.
Retrieved December 2, 2007, from http://aosw.
org/htrnl/prof-scope.php
C-Change. (2005). Cancer patient navigation: Published information.
Retrieved December 2,2007, from http://
www.c-changetogether.org/aboucndc/newsroom/reports/
Cl'Npaper.pdf
C-Change. (2007). Retrieved December 2, 2007, from http://
www.cancerpatientnavigation.org
Freeman, H. P. (200l). Voices of a broken system: Real people, real
problems. President's Cancer Panel-Report of the Chairman
2000-2001. National Cancer Institute, National Institutes of
Health.
Hewitt, M., Greenfield, S., & Stovall, E. (Eds.). (2006).
From cancer patient to survivor: Lost in transition. Washington,
OC: The National Academies Press, Institute of Medicine and
National Research Council of the National Academies.
Hewitt, M., Weiner, S. L., & Simone, ]. V. (Eds.). (2003).
Childhood cancer survivorship; Improving care and quality of
322 ONCOLOGY SOCIAL WORK
life. Washington, DC: Institute of Medicine, The National
Academies.
Lauria, M. M., Clark, E. J., Hermann, J. F., & Stearns, N. M.
(2001). Social work in oncology: Supporting survivors, families and
caregivers. Atlanta, GA: The American Cancer Society.
NCI. (2003-2004). Living beyond cancer: Finding a new balance.
President's Cancer Panel, Annual Report (2003-2004).
National Cancer Institute, National Institutes of Health.
NASW. (1999). Code of ethics. Retrieved March 8, 2007, from
http://www .socialworkers.org/pubs/code/default.asp
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003).
Unequal treatment: Confronting racial and ethnic disparities in
health care. Washington, DC: Institute of Medicine, The
National Academies.
FURTHER READING'
American Cancer Society. (20P6). Facts and figures 2006.
Retrieved December 2007, from http://www.cancer.org
Institute of Medicine Report. (2007). Cancer care for the whole
patient: Meeting psychosocial health needs. Washington, DC:
The National Academies Press, Institute of Medicine and
National Research Council of the National Academies.
SUGGESTED LINKS
American Cancer Society (ACS).
http:// www.cancer.org
American Society of Clinical Oncology (ASCO).
http://www.asco.org
Association of Oncology Social Work (AOSW).
http://www.aosw.org
Association of Pediatric Oncology Social Workers (APOSW).
http://www .aposw .otg
Association of Psychosocial Oncology (APOS).
http://www .apos-society .org
Cancer Care.
http://www .cancercare .otg
Candlelighters Childhood Cancer Foundation (CCCF).
http://www .candlelighters .otg
C-Change.
http://www . c-changetogether .org,
Health and Social Work.
www.naswpress.org/publications/journals/health/hswintro.html
Intercultural Cancer Council (ICC).
www.iccnetwork.org
Journal of Psychosocial Oncology.
www.haworthpress.com/web/JPO Leukemia
& Lymphoma Society (LLS). http://www
.lis .otg
National Association of Social Workers (NASW).
http://www .socialworkers .otg
National Coalition for Cancer Survivorship (NCCS).
http://www .canceradvocacy .org/
Patient Advocate Foundation, (PAF).
http://www . patientadvocate .org/
Social Work in Health Care.
http://www.haworthpress.com/store/product.asp? sid
-MARIE M. LAURIA
OPPRESSION
ABSTRACT: If social workers are to avoid unintended
collusion with pervasive oppressive systems and if they are to
be successful in promoting social and economic justice, a firm
grasp of the nature of oppression with its dynamics of power
and its systemic character is required. The concept of
oppression is presented here, followed by discussion of its
dynamics and common elements and the need for social
workers to engage in anti-oppressive practice in order to
expose and oppose oppressive relationships and systemic
power arrangements.
KEY WORDS: discrimination; power; diversity;
racism; privilege; anti-oppressive social work
practice
The social work profession has a historic mandate to
oppose oppression-a commitment usually stated in terms
of challenging social injustice and promoting social and
economic justice-that is expressed in the National
Association of Social Workers' Code of Ethics (NASW,
1996), the IntematioTUll Declaration of Ethical Principles of
Social Work of the International Federation of Social
Workers (IFSW, 1994), and the Educational Policy and
Accreditation Standards of the Council on Social Work
Education (CSWE, 200l).
Oppression Defined
Oppression is a multidimensional social phenomenon, a
dynamic and relational group-based concept that is not
accidental-though usually unintentional-and which, once
integrated into societal institutions and individual
consciousness, comes to permeate almost all relations
and, depending on the circumstances, involves all
individuals in the role of both oppressor and oppressed at
one time or another (Gil, 1998; Mullaly, 2002). Thus,
there are multiple definitions of oppression, all of which
have an underlying theme related to the use and misuse
of power in human relationships. Oppression is
commonly understood as the domination of a powerful
group-politically, economically, socially, culturally- over
subordinate groups. Another common definition is that
oppression is an institutionalized, unequal power
relationship-prejudice plus power (Rothenberg, 1988).
Bulhan(1985) defined oppression more specifically
as a situation in which one segment of the population
acts to prevent another segment from attaining access to
resources or acts to inhibit or devalue them to dominate
them. Lipman-Blumen (1984, 1994) focused on the
institutional nature of oppression as the act of molding,
immobilizing, or reducing opportunities,
,.,.
L

which thereby restrains, restricts, or prevents social,
psychological, or economic movement of an individual or
group. Pinderhughes (1973) defined oppression as a
relatively constant pattern of prejudice and discriminat ion
between a privileged, favored individual and one who is
exploited and deprived of privilege due to mem bership in
a devalued group.
Young (2000) suggested that oppression is not based
on anyone group membership and, as a means of distin-
guishing among various experiences, identified "five
faces" of oppression-exploitation, marginalization,
powerlessness, cultural imperialism, and violence-
emphasizing that the presence of any of these five
experiences or faces constitutes oppression, and that most
people experience some combination of these.
Frye's (1995) definitibn focused on the livedexperi-
ence of oppression as "living ... one's life ... confined and
shaped by forces and barriers which are not acci dental or
occasional and hence avoidable, but are sy stematically
related to each other in such a way as to catch one between
and among them and restrict or penalize motion in any
direction" (p. 39).
Dynamics and Common
Elements of Oppression
Elements that are common to all oppressions regardless of
the target population (Pharr, 1988) serve to both
rationalize and maintain oppressive systems. First, op-
pression always bestows power and advantage on cer tain
people who are regarded as the norm and denies power
and advantage to others based on their status as "other" or
different. The defined norm (for example, white, male,
heterosexual) is the standard of rightness against which all
"others" are judged; the "other" (that is, not White, not
male, not heterosexual) is not only different from the
norm, but is also believed and perceived to be inferior and
deviant, which then justifies conferring advantage on
those who fit the norm and disadvantaging the "other."
A second common element is that all types of oppres-
sion are held in place by ideology and violence or the
threat of violence. The ideology on which racial oppres-
sion is based is that of superiority based on race (that is,
white supremacy). Likewise, the ideology on which sex-
ual oppression is based is that of superiority based on
gender (that is, male), and the basis for homosexual
oppression is an ideology of superiority based on sexual
orientation (that is, heterosexuality). Violence, which is
used to enforce' and maintain all oppressions, comes in
many forms and may be physical and direct (for exampl e,
lynching, rape, battering, gay bashing) or personal and
psychological (for example, name-calling based on domi-
nant ideology and negative stereotypes). Violence may
OPPRESSION 323
be indirect or institutionalized. For example, it may be
associated with high poverty rates, the predominance of
men of color in the criminal justice system and on death
row, and the reality of police brutality.
A third common element of all oppression is that it is
institutionalized. This means that racism, sexism, and
heterosexism are built into the norms, traditions, laws, and
policies of a society, so that even those who have
nonracist, nonsexist, and nonheter osexist beliefs are
compelled to act in accordance with institutional inter ests,
that is, "business as usual." Institutionalized racism,
specifically, ensures white entitlement and benefits re-
gardless of the intentions of individuals in those
institutions.
A fourth common element of oppression is the in-
visibility endured by groups who are oppressed. By
keeping the oppression structurally invisible, indivi duals
and groups are socially defined in a way that inhibits
recognition of the group's heterogenei ty by the dominant
group. In addition, the internalization of external
sociopolitical judgments that devalue as pects of one's
identity inevitably leads to individuals undervaluing and
ignoring substantive parts of their own origins and
history.
The issue of multiple identities further complicates the
dynamics of oppression. Individual conditions of
oppression often involve a convergence between as pects
of one's experience where one is a target of op pression
(for example, as a low-income, disabled female , a Latina,
an African American, a gay woman) with other aspects of
one's experience as privileged (for example, a middle- or
high-income gay person, a disabled Euro American male)
(Rose, 2002). Understanding the presence of power,
privilege, advantage, or constraints introduced through
oppression in one's life draws attention to experiences and
realities that may have been denied or minimized and lays
the foundation for connecting with others different from
oneself.
Implications for Social Work
and Future Trends
In well-established oppressive relationships, their struc-
tures are invisible to both the subordinate party and the
more powerful party. The sources of oppression are
embedded within the psychological makeup of all par ties,
thereby obscuring the realities of the relationships. Thus,
the greatest challenge for social work profes sionals is to
uncover, make visible, expose, and oppose oppressive
relationships and systemic power arrange ments that give
privilege and advantage to one group over anot her.
Adopting oppression as the major expla nation for social
problems and an anti-oppressive social work practice as a
way of dealing with problems helps to
324 OPPRESSION
avoid blaming the victims of social problems, links the
personal with the political, and addresses the systemic nature
of oppression and thus avoids technical or minor social reform
solutions (Mullaly, 200l).
REFERENCES
Council on Social Work Education. (2001). Educational policy and
accreditation standards. Alexandria, VA: Author.
Frye, M. (1995). Oppression. In M. L. Andersen & P. H.
Collins (Eds.), Race, class, and gender: An anthology (2nd ed.,
pp. 37-41). Belmont, CA: Wadsworth.
Gil, D. (1998). Confronting injustice and oppression: Concepts and
strategies for social workers. New York: Columbia University
Press.
International Federation of Social Workers. (1994). International
declaration of ethical P,rinciples of social work. Oslo, Norway:
Author.
Lipman-Blurnen.}. (1984). Gender roles and power. Englewood
Cliffs, N]: Prentice Hall.
Lipman- Blumen, ]. (1994). The existential bases of power rela-
tionships: The gender role case. In H. L. Radtke & H.]. Starn
(Eds.), Power/gender: Social relations in theory and practice (pp.
10~135). Thousand Oaks, CA: Sage.
Mullaly, R. (2001). Confronting the politics of despair:
Towards the reconstruction of progressive social work in a
global economy and postmodern age. Social Work Education,
20(3),303-320.
Mullaly, R. (2002). Challenging oppression: A critical social work
approach. Don Mills, Ontario: Oxford University Press.
National Association of Social Workers. (1996). Code of ethics.
Washington, DC: Author.
Pharr, S. (1988). Homophobia: A weapon of sexism. Inverness, CA:
Chardon Press.
Pinderhughes, C. A. (1973). Racism and psychotherapy. In C.
Willie, B. Kramer, & B. Brown (Eds.), Racism and mental health
(pp. 61-121). Pittsburgh: University of Pittsburgh Press.
Rose, S. (2002, March). Social work at a crossroads: A reflection
paper. Presented at the Social Work at the Crossroads
Conference, California State University, Fresno, Department
of Social Work Education.
Rothenberg, P. (1988). Racism and sexism: An integrated stwly.
New York: St. Martin's Press.
Young, I. M. (2000). Five faces of oppression. In M. Adams, W. j.
Blumenfeld, R. Castenada, H. W. Hackman, M. L. Peters, &
X. Zuniga (Eds.), Readings for diversity and social justice (pp.
35-49). New York: Routledge.
FURTHER READING
Adams, M., Blumenfeld; W. ]., Castenada, R., Hackman, H. W.,
Peters, M. L., & Zuniga, X. (Eds.), Readings for diversity and
social justice. New York: Routledge.
Bulhan, H. A. (1985). Frantz Fanon and the psychology of oppression.
New York: Plenum Press.
Garcia, B., & Van Soest, D. (2006). Social work practice for social
justice: Cultural competence in action, a guide for students.
Alexandria, VA: Council on Social Work Education.
Van Soest, D., & Garcia, B. (2008). Diversity education for social
justice: Mastering teaching skills, 2nd edition. Alexandria, VA:
Council on Social Work Education.
-DOROTHY VAN SOEST
ORGANIZATIONAL DEVELOPMENT
AND CHANGE
ABSTRACT: Organization development is a planned change
technology using a consultant who facilitates, with high
employee involvement, members of an organization through a
process of identifying new organizational visions or problems
to be solved and developing and implementing plans for
organizational improvement. Action research is used to gather
relevant data, which are reviewed by managers and staff to
guide change activities. Organizational change can also be
initiated by lower-level staff or occur through the leadership
of an organization's executive, who creates a sense of urgency
for change, articulates a vision, and involves employees in
activities to improve the functioning of the organization.
KEY WORDS: organization development; process con-
sultation; action research; planned change; employee
attitude surveys; change leadership
Introduction
In this age of decreasing resources for human services,
increasing accountability requirements, managed care, and
expectations for improved client outcomes, staff of any human
services agency must be engaged in organizational change
(Austin, 2004). Often, such change is spontaneous, based on
immediate reactions to environmental pressures or internal
problems, using only whatever existing staff knowledge or
practice experience is available. However, planned
organizational change technologies are available which, if
used thoughtfully and deliberately, can enhance prospects for
an organization's ability to adapt and thrive. The most
common planned organizational change technology is
organization development (OD). OD and other forms of
organizational change can be applied by agency leaders,
mangers, or staff, and may involve the use of outside
consultants.
Organization Development Organization
development (OD) as a field of practice had its origins in the
1940s and is now well established, with professional
associations, training programs, and

academic degrees (French & Bell, 1999), and OD con-
sultants are operating in all types of organizations, in-
cluding the human services. One comprehensive
definition of OD describes it as "a long- term effort, led
and supported by top management, to improve an
organization's visioning, empowerment, learning, and
problem-solving processes, through an ongoing, colla-
borative management of organizational culture- with
special emphasis on the culture of existing work teams
and other configurations-using the consultantfacilitator
role and the theory and technology of applied behavioral
science, including action research" (French & Bell, 1999,
pp. 25, 26). An OD initiative often includes the formation
of a steering committee with broad representation of
differen:t components of the workforce to guide the' goal
setting, data collection, intervention planning,
implementation, and evalua tion of the process. Employee
involvement in planning and decision makin g is an
important principle of OD. Ultimately, OD is intended to
improve organizational functioning and to help achieve
the strategic goals of the organization.
Certain technologies, when used as part of an OD
initiative, are part of a larger strategy and plan to achieve
organization-wide goals. Many of these can be used
individually to address specific problems in a work unit,
division, or even the whole organization.
Organization Development Technologies Action
research is a core technology of OD (French & Bell, 1999,
Ch. 7). An OD process typically begins when an agency
executive identifies a need for change, such as inadequate
program performance, significant employee morale
issues, or the need for a new organizational culture. The
OD consultant facilitates the organization through the
action research process: data collection to identify
problems, issues, or visions; data feedback to staff;
analysis of data and action planning; implementation of
action plans; additional data collection to assess results;
and continuation of the cycle. Common data collection
methods are employee attitude surveys, reviews of
administrative data such as program performance data,
and interviews or focus groups with staff and outside
stakeholders.
Problem solving groups are often formed after survey
results are fed back to employees to address problems
identified by the survey. Team building workshops begin
with data collection, usually interviews by the consult ant,
followed by off-site sessions to address issued iden tified
during data collection. In addition to group problem
solving on identified issues,' team building can include
structured experiences in which a group has an experience
such as being told to solve a problem
ORGANIZATIONAL DEVELOPMENT AND CHANGE 325
using either competitive or collaborative method.
Instrumented learning, in which participants fill out an
instrument describing, for example, a personality profile
or management style can be used to structure di scussions
about team functioning. Workshops can also be used for
role clarification, when team members have role confusion
or disagreement. Process consultation (Schein, 1999) in
which the consultant meets individually with a manager
to discuss issues and alternatives, much as a counselor
does, is a common OD method.
On a larger scale, the consultant can facilitate a
process of integrated strategic change or organization re-
design, which in an OD context should be done with
significant employee involvemen t. Agency executives as
well as representatives from other levels of the or-
ganization can all provide input to help ensure that the
proposed changes are appropriate and likely to be suc-
cessfully implemented. Other change technologies such
as total quality management or reengineering, which are not
always done as part of an OD process, can also be used as
part of an OD effort. Large group interventions, variously
referred to as search conferences, open space meetings,
world cafes, or future searches (Cummings & Worley,
2005), can also be done in the context of OD. These
interventions typically involve all or many members of
the organization (ranging to over 2,000 participants )
meeting at one time with facilitators to collaboratively
assess the organization's situation and develop action
plans.
Other Planned Change Models
Other forms of organizational change include using an
agency executive as a change leader (Kotter, 1996) ,
change initiated by lower-level staff, and consultation
involving other professionals. Proehl (2001) has devel-
oped an organizational change process specifically for
human services organizations. The process begins with a
change agent, typically an agency executive, creating a
sense of urgency, pointing to forces requiring change
(Kotter, 1996). A coalition for change is formed, including
people with credibility, power, and interest in the
problem. Next, clarifying the change imperative identifies
problems, visions, and expected outcomes. Assessing the
present identifies strengths and obstacles and as sesses
organizational readiness. A plan for change includes
strategies, processes, and activities. Short-term successes
and acting quickly and revising frequently build energy for
the process. Finally, evaluating and celebrating the change
includes assessing results and celebrating. Throughout
the process, attention must be paid to the human factor,
keeping staff involved and dealing with resistance.
326 ORGANIZATIONAL DEVELOPMENT AND CHANGE
Another change model for human service organiza-
tions (Lewis, Packard, & Lewis, 2007) includes tactics for
use by lower-level employees who want to initiate change,
including assessing the organization forimportant
preconditions such as a participative management
philosophy and basic management competence, and also
addresses presenting the change proposal to agency
decision makers. Steps that are unique to this perspec tive
include lower-level staff developing their abilities to
influence upward in the organization, aligning the
proposed changes with the interests of key decision
makers, and determining the most effective persons and
methods to introduce the change proposal to
agency decision makers. , Austin, M. (Ed.). (2004). Changing welfare services: Case studies of
In addition to being change leaders (Kotter, 1996),
administrators may also hire \ consultants. Most consul-
tants can be classified as expert consultants who bring
content expertise in areas such as industrial engineering or
information technology, or process consultants who are
process experts, in the mode of a social work prac titioner,
facilitating the client organization in assessing situations,
and making decisions. In selecting a consult ant, expertise,
style, and fit with the organization's needs sho uld be
considered (Yankey & Willen, 2006).
Implications for Social Work
Some research has shown the effectiveness of OD
interventions (French & Bell, 1999, pp. 312-319).
Substantive research in this field is rare (Worley &
Feyerherm, 2003) but receiving increasing attention
(Pettigrew, Woodman, & Cameron, 200l). Reports of
organizational change processes should include both
well-developed theories of change and substantive eva-
luation components (but not necessarily experimental
designs) in order to advance knowledge in this field.
There are notable compatibilities between OD and
social work (Resnick & Menefee, 1993), including ethics,
values, and theoretical orientations. There have been a
number of applications of OD and organizational change
in human service organizations (Packard, 2002;
Perlmutter, 2000). DuBrow, Wocher, and Austin (200l),
in a report of OD in a county human service agency, noted
challenges in applying OD in human service
organizations. Austin (2004) and colleagues reported 21
organizational change projects in county government
initiated in response to the 1996 welfare reform
legislation. In 1992, Administration in Social Wark devoted
a special issue to organizational change (Bargal & Schmid,
1992).
Environmental demands and pressures for change will
continue to challenge human service organiza tions, and
social workers are particularly well suited to use
technologies of planned organizational change
to respond. Social work values of empowerment of clients
and communities (Hardina, Middleton, J., Montana, S., &
Simpson, 2007) and an education including a systems
perspective, group dynamics, and the importance of
process give social workers a solid foundation of skills
relevant to change leadership. With additional training in
planned organizational change, social workers can lead
and facilitate organizational change in their agencies and
serve as consultants helping others to improve operations
and outcomes in human service organizations.
REFERENCES
local welfare reform programs. New York: The Haworth Press.
Bargal, D., & Schmid, H. (1992). Special issue: Organizational
change and development in human service organizations,
Administration in social work. 16(3/4).
Cummings, T., & Worley, C. (2005). Organization development
and change (8th ed.). Mason, OH: South-Western.
DuBrow, A., Wocher, D., & Austin, M. (2001). Introducing
organizational development (OD) practices into a county
human service agency. Administration in Social Work, 25(4),
63-83.
French, W., & Bell, C. (1999). Organization development (6th ed.).
Upper Saddle River, NJ: Prentice-Hall.
Hardina, D., Middleton, J., -Montana, S., & Simpson, R. (2007).
An empowering approach to managing social service
organizations. New York: Springer Publishing Co.
Kotter, J. (1996). Leading change. Boston, MA: Harvard Business
School Press.
Lewis, J., Packard, T., & Lewis, M. (2007). Management of human
service programs (4th ed., Ch. 11). Belmont, CA:
Thompson/Brooks Cole.
Packard, T. (2002, February). Organizational change in human
service organizations: A model and research agenda. Nashville:
Council on Social Work Education Annual Program Meeting,
Perlmutter, F. (2000). Initiating and implementing change. In R.
Patti (Ed.), The handbook of social welfare management (pp.
445-457). Thousand Oaks, CA: Sage.
Pettigrew, A., Woodman, R., & Cameron, K. (2001). Studying
organizational change and development: Challenges for future
research. Academy of Management Journal, 44(4), 697-713.
Proehl, R. (2001). Organizational change in the human services.
Thousand Oaks, CA: Sage. .
Resnick, H., & Menefee, D. (1993). A comparative analysis of
organization development, with suggestions for what organ-
ization development can do for social work, Journal of Applied
Behavioral Science, 29(4), 432-445.
Schein, E. (1999). Process consultation revisited. Reading, MA:
Addison-Wesley. University Associates. Retrieved from
http://www.universityassociates.com
Worley, C, & Feyerherm, A. (2003). Reflections on the future of
organization development. Journal of Applied Behavioral
Science, 39(1), 97-115.

Yankey, J., & Willen, C. (2006). Consulting with nonprofit
organizations: Roles, processes, and effectiveness, In R.
Edwards &J. Yankey (Eds.), Effectively managingnontyrofit
organizations (pp. 407-428). Washington, DC: NASW Press.
SUGGESTED LINKS Organization
Development Institute.
http://members.aol.com/odinst/index. htm
Organization Development Network.
http://www.odnetwork.org/
-THOMAS PACKARD
ORGANIZATIONAVLEARNING
ABSTRACT: The professional commitment of practitioners
in a changing society requires them to continuously
acquire new professional knowledge. Since robust and
relevant knowledge is often in short supply, practitioners
must learn to acquire the knowledge they need. Similarly,
social agencies must become institu tions that support the
development of practice innovations by engaging in
organizational learning. This implies that they both adopt
an organizational culture and create structural
arrangements conducive to learning. Given this
imperative, the following entry reviews the philosophical,
conceptual, and methodological underpinnings of
organizational learning as a strategy for guiding
practitioners and organizations in a systematic endeavor to
invent and manage knowledge. A methodology for the
application of organizational learning in social services is
presented.
KEY WORDS: organizational learning; evidence- based
practice; reflective practice; knowledge management;
practice wisdom; best practices
The professional commitment of practitioners in human
services is to the needs of their clients in the context of
their society. As those needs evolve, practi tioners must
acquire new strategies and a range of practice
interventions for assisting their clients with the challenges
they face. Yet, scholars disagree on the issue of the
appropriate sources of knowledge prac titioners should
acquire and use in building suitable interventions. The
positivist, and mainly quantitative, epistemology views
rigorous research findings as the most efficacious way to
support practice and to achieve desired outcomes. This
model implies that practitioners should adopt an
evidence-based practice mode of operation (Gibbs, 2003 ).
Yet, evidence-based
ORGANIZATIONAL LEARNING 327
practice assumes that valid evidence exists and is avail-
able and that the scientific findings are unambiguous and
unequivocal. This is often not the case. Rosen, Proctor,
and Staudt (1999) found that fewer than 14% of the
research articles in social work journals addressed the
development of effective interventions. Practi tioners
cannot therefore rely solely on robust evidence. They must
also learn to acquire knowledge and compe tency in the
helping process from their own and their peers'
accumulated experiences backed by relevant the ories.
This is sometimes called practice wisdom (Dybicz, 2004 ).
Similarly, social agencies must become institu tions that
support the development of practice innova tions by
engaging in organizational learning.
Organizational Learning
Since the mid-1970s and especially during the last decade ,
organizational learning has emerged as a "fun damental
concept in organizational theory" (Arthur &
Airnan-Smith, 2002, p. 738). Yet, despite the abun dance
of literature on the subject, organizational learn ing
remains a subtle concept and without an accepted
definition (Bontis, Crossan, & Hulland, 2002). There is,
however, widespread agreement in the literature that there
are two main key components of organizational learning:
in order for organizations. to promote a learn ing
environment they must have both an organizational culture
and structural support conducive to learning (Lipshitz,
Popper, & Friedman, 2002).
The cultural aspect of organizational learning refers to
norms and values that support learning and to their
linguistic, ritual, narrative, and symbolic reflections. It can
be assessed along four dimensions: (a) innovation- beliefs
that support getting, sharing, and using new ideas to
promote organizational work; (b) safety- beliefs that
promote freedom of discussion and the ability to test ideas
that may not always work out; (c) goal-centered- beliefs
that encourage developing goals and setting long- range
objectives to achieve them; and (d) leadership- an
administrative philosophy that supports and rewards new
ideas.
The structural aspect of organizational learning re fers
to learning mechanisms that allow. practitioners to
exchange information and to learn collabora tively. It can
be assessed along four dimensions: (a) collaboration- staff
regularly meet together to learn from each other and
review program progress measures; (b) planfullness- staff
set measurable outcomes to be achieved and make sure
plans and activities link to outcomes; (c) diffusion- staff
actively share their program successes with each other and
with other related organizations; and (d) infrastructure-
organizational resources and time are set aside to
328 ORGANIZATIONAL LEARNING
promote learning (Orthner, Cook, Sabah, & Rosenfeld,
2006). In social work, supervision is probably the most
common learning mechanism.
Challenges
Several facets of social service organizations create un-
ique challenges for promoting organ izational learning.
Social services are usually bureaucratic monopolies and
part of the public sector. Although states and munici-
palities have privatized services, governments contract
primarily with nonprofit organizations (Van Slyke, 2003 ).
Therefore, competition, which is a major incentive to learn
in the private sector, is often absent. Furthermore, social
services usually have an inputs orientation whenever
learning requires constant reflection on outputs and
butcomes. Moreover, caseworkers' activity consists
mostly of client-practitioner dyads whenever regular team
work facilitates collaborative exchange of information and
organizational learning.
Promoting Organizational
Learning in Social Services
Sabah and Rosenfeld (2001) developed an initial sys-
tematic methodology for the application of organiza tional
learning to social services. It has been since refined and
applied in other countries, including the United States.
The basic premise of the methodology is that in order to
invent the knowledge they need, prac titioners have to
draw on a spectrum of existing knowledge sources and,
predominantly, on their own practice expertise. However,
this source of knowledge is mostly tacit and
unsubstantiated. Therefore, the methodology, based on
Schon's writing on reflection in and on practice (1983) ,
aims to structure an enduring reflective dialogue among
practitioners wherein they collabora tively externalize and
share their tacit knowledge.
Moreover, the methodology intends to support the
systematic verification of that practice wisdom, as well as
that of other sources of knowledge, in terms of their
capacity to generate new and effective actionable
knowledge. It also intends to facilitate "double- loop
learning" (Argyris & Schon, 1974), that is to allow
practitioners to question the values, assumptions, and
policies that underlie their present practice in addition to
adjusting practice according to the disparity between
expected and attained results. Finall y, the methodology
aspires to do more than smooth the process of inventing
new knowledge. It seeks to transform social services into
"learning organizations," that is, organizations in which
practitioners "continually expand their capacity to create
the results that they truly desire, where new and expansive
patterns of thinking are nurtured, where
collective aspiration is set free, and where people are
continually learning how to learn together" (Senge, 1990 ,
p. 3).
The methodology includes seven steps: (a) formu-
lating a learning question, that is an unsolved major
professional issue that the agency must solve in order to
fulfill its mission; (b) assembling a learning team, that is a
group of practitioners in the agency that directly address
that professional issue in their daily practice; (c) gathering
relevant existing knowledge from a spec trum of sources
and specifically learning from prior successful attempts to
solve similar issues; (d) formulat ing a tentative model that
is an initial answer to the learning question; (e)
implementing the model in prac tice and methodically
improving it thru constant group reflection; (f)
formulating and sharing the (never) final model; and (g)
formulating the next learning question (Sabah & Orthner,
2007).
Future Directions
There is still considerable work to be done to refine
conceptual models underpinning organizational learn ing.
Moreover, rigorous empirical testing of the impact of this
methodology on discretionary decision- making,
organizational effectiveness and interventions results is
imperative in order to convince governments to invest in
Organizational learning. Organizational learning has,
however, already established itself as a promising model
for guiding organizations and social workers to develop
practice innovations, at both the micro- and macrolevels,
using a continually evolving professional knowledge
base. In the near future, the gradual intro duction of
information and communication technolo gies in social
agencies will give practitioners from di fferent agencies
the opportunity to learn collabora tively. The development
and use of virtual communities of practice combined with
organizational Learning will enable social workers to
share knowledge and to promote inter- organizational
asynchronous learning. The application of technology and
virtual knowledge sharing to promote learning across
agencies is likely to strengthen and create new strategies
for application of the organizational learning model.
REFERENCES
Argyris, c., & Schon, D. (1974). Organizationalleaming: A theory
of action perspective. Reading, MA: Addison-Wesley.
Arthur, ]. B., & Aiman-Smith, L. (2002). Gainsharing and
organizational learning: An analysis of employee suggestions
over time. Academy of Management Journal, 44(4), 737-754.
Bontis, N., Crossan, M., & Hulland, ]. (2002). Managing an
organizationalleaming system by aligning stocks and flows.
Journal of Management Studies, 39, 437--469.
J

Dybicz, P. (2004). An inquiry into practice wisdom. Families in
Society, 85(2}, 197-203.
Gibbs, L. B. (20m). Evidence-based practice for the helping pro-
fessions: A practical guide with integrated multimedia. Pacific
Grove, CA: Thompson Brooks/Cole.
Lipshitz, R., Popper, M., & Friedman, V.]. (2002). A multifacet
model of organizational learning. The Journal of Applied
Behavioral Science, 38(1}, 78-98.
Orthner, D. K., Cook; P. G., Sabah, Y. M., & Rosenfeld,]. M. (2006).
Impact of organizational learning on after school programs: An
international study. Evaluation and Program Planning, 29, 70-78.
Rosen, A., Proctor, E. K., & Staudt, M. M. (1999). Social work
research and the quest for effective practice. Social Work Research,
23, 4--14.
Sabah, Y., & Orthner, D. K. (2007): Implementing organiza-
tionallearning in schools: Assessment and strategy. Children and
Schools, 29(4}, 243-246.
Sabah, Y., & Rosenfeld, ]. (2001). How to transform social agencies
into learning organizations. Mifgash, IS, 143-162 (in Hebrew).
Schon, D. A. (1983). The reflective practitioner: How professionals
think in action. New York: Basic Books
Senge, P. M. (1990). The fifth discipline. New York: Doubleday. Van
Slyke D. M. (20m). The mythology of privatization in contracting
for social services, Public Administration Review, 63(3},296-315.
-YEKUTIEL SABAH AND PATRICIA COOK-CRAIG
ORGANIZATIONS AND ASSOCIATIONS
ABSTRACT: In U.S. society, individuals are designated
"professional" when they meet the requirements for a
profession. However, professions are developed and
maintained through various professional organizations
and associations. As social work has evolved, the pro-
fessional membership and professional education
organizations have periodically unified, split, and later
reunified when maintaining an identity as a single
profession competed with the need to address the
interests .of different practice specialties, ed ucational
levels, and special interest groups within social work.
KEY WORDS: profession; professional organizations;
National Association of Social Workers (NASW);
Council on Social Work Education (CSWE)
The body of theory developed under the rubric of the
sociology of professions has consistently identified as
occupations those professions that have been implicitly
granted a monopoly to provide services in a sensitive area
of human functioning. In tum, each profession is
ORGANIZATIONS AND ASSOCIATIONS 329
given the authority to determine the requisite preparation
and credentials to enter its ranks (Freidson, 1994; Pavalko,
1988). As social work emerged as a recognized profession
in the United States, the National Asso ciation of Social
Workers (NASW) emerged as the organization with the
primary responsibility to stake out the claim for social
work's monopoly among the human services professions
and the Council on Social Work Education (CSWE)
developed as the primary authority determining the
necessary educational preparation for entering the
profession.
NASW was created in 1955 from a merger of the
American Association of Social Workers and other
practice specialty organizations in a n effort to create a
unified voice for social work. NASW's promulgation of a
Code of Ethics, development of a working definition of
social work practice, creation of a national certifica tion
program for social workers, and aggressive political
advocacy helped to draw together competing interests.
Eventually, however, organizations concerned with social
work practice specializations, ethnicity, and fields of
practice reemerged and today NASW is only one of
several voices for the profession. While generally ac cepted
as representing the whole of social work, NASW reports a
membership of only 150,000 social workers (NASW,
2006). In comparison, workforce estimates by the Bureau
of Labor Statistics suggest there are more than 560,000
social workers in the United States (BLS, 2006).
In 1952 CSWE was formed as a merger of competing
groups concerned with the development of social work
education, including the American Association of Schools
of Social Work, which focused exclusively on
master's-level education, and the National Association of
Schools of Social Administration, which focused on both
undergraduate and one-year graduate professional
certificate programs. Granted the authority to accredit
social work education programs at both the baccalaure ate
and master's levels, CSWE has been the major force in
determining the content and quality of professional social
work education. The importance of CSWE's accreditation
standards are reflected in a number of important
prerequisites. For example, membership in NASW and
qualification for their specialty certification requires
graduation from an accredited social work program, as
does enrollment in the Academy of Certified Social
Workers. Most state social work licensing bodies also
require an accredited social work degree to qualify as a
licensed (or certified) social worker (ASWB, 2006).
In addition to accreditation, CSWE provides a variety
of services that support both social work educators and
programs, such as publishing the Journal of Social
330 ORGANIZATIONS AND ASSOCIATIONS
Work Education and books related to instruction and
curriculum development, sponsoring annual conferences,
providing a forum where diverse interest groups can
contribute to social work education, and promoting global
social work through programming and representation (for
example, representing the United States in the
International Federation of Schools of Social Work).
Other associations have been developed to represent the
interests of social work educators at each educational
stratum (bachelor's, master's, and doctoral). Although
many educators are engaged with students at more than one
level, these organizations provide forums for strengthening
curricula and instruction, increasing the effectiveness of
program administration, serving as a voice for specific
education levels with NASW and CSWE, and advocating
for federal legislation and funding related to social work
education.
At the Baccalaureate of Social Work (BSW) level, the
Baccalaureate Program Director's Association (BPD)
includes in its services an annual conference, publishing
the Journal of Baccalaureate Social Work, an active website
and listserv, an extensive set of tools for assessing
outcomes of baccalaureate programs, and representation in
related social work organizations. Both individuals
(including persons other than program directors) and
colleges and universities involved at this level may be
members of BPD.
The MSW is the terminal practice degree in social work
and, therefore, the highest degree subjected to accreditation
standards and periodic review. At the master's degree level
(MSW), the National Association of Deans and Directors
of Schools of Social Work (NADD) has become the
primary body of representation, although many of the
schools affiliated to NADD also offer BSW and doctoral
programs. However, membership in NADD is open only to
accredited master'slevel institutions and thus participation
is restricted to the deans/directors/chairpersons of MSW
programs. NADD maintains a Web site; has established
goals to strengthen the involvement of deans and directors
in legislative advocacy; contributes to the intellectual
development of social work research, practice, policy, and
education; seeks to enhance 'collaboration among
professionals in higher education (including interfa cing
with CSWE); and helps schools of social work keep abreast
of changing national trends (NADD, 2002).
The interests of doctoral-level social work education are
promoted by the Group for the Advancement of Doctoral
Education (GADE). Recognizing that there are no standard
guidelines for building and accrediting high quality
doctoral programs with sufficient
academic rigor, GADE has developed strategies to assist
interested schools. GADE also holds annual meetings,
maintains a listserv, publicizes funding sources for doc-
toral students and doctoral programs, and advertises social
work education positions for persons with doctoral
degrees (GADE, 2006).
A pervasive agenda for social work education is the
promotion of more and better research regarding social
work practice and social work education. To further this
agenda the above groups have contributed to the
development of the Institute for the Advancement of
Social Work Research (IASWR) and the Action Net work
for Social Work Education and Research (ANSWER). In
addition, the Society for Social Work Research (SSWR)
has been formed to foster the development of research and
research programs in social work. The programs and
activities of these research and education organizations are
detailed at their Web sites.
The pattern of unifying, splitting, and reunifying as a
profession continues into the 21st century. A major push
for unification occurred in the 1950s, but gradually the
pressure for greater support for specialties within both
membership organizations and those associations
concerned with social work education eroded the em-
phasis on social work as a single profession. In 2007,
however, a new movement toward reunification among
ten professional social work organizations addressed this
issue at the "Wingspread Conference." The conference
was based on the recognition that social work "requires a
strong unified voice to enhance its ability to serve, to
educate, to develop research, and to influence social
services, social policy, and social changes." The
representatives of these organizations responded by
signing a resolution to "create a unified profession with
one social work organization by 2012" and setting up a
transition team to implement this resolution.'
REFERENCES
Freidson, E. (1994). Professionalism reborn: Theory, prophecy, and
policy. Chicago: University of Chicago Press.
Pavalko, R. M. (1988). Sociology of occupations and professions,
(2nd ed.). Itasca, IL: F. E. Peacock.
SUGGESTED LINKS
Action Network for Social Work Education and Research
(ANSWER).
https://www.socialworkers . org/advocacy/answer Association
of Baccalaureate Program Directors (BPD). http://www .
bpdonline. org
Association of Social Work Boards (ASWB).
http://www.aswb.org
Bureau of Labor Statistics (BLS).
http://www.bIs.gov/oco/ocos060.htm#emply
J

Group for the Advancement of Doctoral Education (GADE).
http://web . uconn. edu/gade/ gadeguidelines. pdf
Institute for the Advancement of Social Work Research
(ISWER).
http://www . iaswresearch.org
International Association of Schools of Social Work (IASSW).
http://www . iassw-aiets .org
National Association of Deans and Directors of Schools of Social
Work (NADD).
http://www .cswe .org/naddssw
National Association of Social Workers (NASW).
https://www.socialworkers.org/nasw/default.asp Society
for Social Work Research (SSWR). http://www .sswr
.org/aboutus. php
-BRADFORD W. SHEAFOR
ORGANIZATIONS AND GOVERNANCE
ABSTRACT: Most social service organizations are iden-
tified by the U.S. Internal Revenue Service as non-
profits, designated as SOld organizations. They are
overseen by governing boards, which ensure that all the
activities of the organization contribute to advan cing its
mission. These boards also identifystrategic goals, hire
and guide the executive, oversee the organ ization's
finances, help raise funds for it, and ensure
accountability to stakeholders.
KEY WORDS: accountability; board; constituencies;
governance; organizational effectiveness; strategic
goals
Importance and Function of Governance Most social
services are offered through nonprofit organizations
designated as SOld organizations. The U.S. Internal Revenue
Service grants nonprofit status to those organizations that
meet its stringent requirements. Approved organizations are
also exempt from paying taxes on their income, and donors
are allowed to deduct contributions from their individual
income taxes. A governing board is a required component for
every nonprofit organization.
Responsibilities and Functions
Boards are composed of community leaders who carry a
number of important responsibilities. These 'are recom-
mended (Ingram, 2003): Define the organization's mission
and ensure that all activities contribute to carrying it out. It
should select and oversee the chief executive.
ORGANIZATIONS AND GOVERNANCE
331
The board should provide financial oversight of the
organization and ensure its long-term financial health. It
should participate in obtaining the financial resources needed
to operate the organization through fundraising activities. It
should serve as the link between the organization and the
community, serving as ambassadors to the public and seeking
to enhance the organization's public esteem. It is responsible
for maintaining the legal and ethical integrity of the organiza-
tion. It should set strategic goals and then oversee the
executive in focusing activities and resources on achieving
them. The board should recruit and orient its new members
and seek to improve its own performance.
Among the most important values boards should promote
is accountability to the organization's stakeholders, including
staff, consumers, donors, legislators, and other community
leaders. People in each of these groups entrust the board to
ensure that the resources entrusted to the organization are used
appropriately and effectively. In effect, the board makes
implicit promises to each of them that their trust is deserved
and should continue. Good stewardship of resources involves
understanding stakeholders' interests and showing how it
serves them productively. The board should model the values
it intends for others in the organization to follow (Holland,
2002).
Patterns of Board Composition and Structure Most boards
are composed of 12-24 people who meet monthly or quarterly
to discuss the activities of the organization. Some boards
select their own members, while others are composed of
members elected by constituencies. In the past, boards were
often composed of a few wealthy individuals in the
community who financed their organizations. In the 1960s,
many federal grants to nonprofits required the addition of
consumers to boards. Many boards were seen as elitist, sexist,
and removed from the concerns of clients. Continued com-
munity credibility made it important to begin recruiting more
diverse members. Most contemporary boards meet monthly or
quarterly, make use of roles of officers, and divide their work
among several committees. For some boards, the length of
time served is indefinite, while term limits are increasingly
being used to ensure new perspectives and energy for board
work. Some organizations, such as feminist ones, try to
sustain more egalitarian (nonhierarchical) structures and
relationships among board and staff.
Often, the main time boards are highly active is when there
is a turnover in the executive. Once this crisis is settled, many
boards revert to periodic reviews and discussions of the
executive's activities. Despite the
332 ORGANIZATIONS AND GOVERNANCE
clear functions recommended for boards, the quality of
their work varies widely, and tightening IRS scrutiny is
one of the few means for enforcing higher standards
(Panel on the Nonprofit Sector, 2005). IRS is raising
demands for evidence of good board per formance by
expanding reporting requirements in the annual Form 990
reports required of all nonprofits. As a result, many boards
add little distinctive value to their organizations.
Models of board effectiveness are offered by some
highly effective ones. Using organizations' financial
performance and external reputation as initial criteria,
Holland and Jackson (1998) found that effective boards
are distinguished by several practices; They make active
use of the organization's mission, values, and norms in
carrying out all their work. They often refer to these
underlying values and principles in addressing items on
the meeting agenda. They are actively engaged in
identifying strategic goals and priorities for the organi-
zation and ensuring a strategic approa ch to its future. They
recognize complexities and subtleties in the issues they
face and draw upon multiple perspectives to dissect
complex problems and to synthesize innova tive
responses. Effective boards are actively engaged in
developing and maintaining healthy, two-way commu-
nications and positive relationships with all the organi-
zation's stakeholders. They nurture the development of
their board members as a group, attend to the group's
collective well-being, and foster a sense of cohesiveness
and teamwork. They ensure that all their members are well
informed about the organization and others like it,
understand the interests of the staff working there, and are
clear about the board's own role and responsibilities. They
evaluate the board's own perform ance and make use of the
feedback to improve group performance (see also
Holland, 1996).
Roles and Relationships
Among Boards, Executives, and Staff
The roles of boards, executives, staffs, and volunteers
have evolved over the stages of an organization. In the
early formative period of an organization, a few highly
motivated volunteers, often mobilized by a charismatic
leader, come together to address an unmet need in the
community. Duties are not clearly defined or differen-
tiated. Over time, this group begins formulating job
assignments and deadlines. This has been found to be a
difficult transition to bringing some order and orga-
nization into the activities, which the founders may resist
(Block & Rosenberg, 2002).
Boards move slowly (and sometimes er ratically) from
engagement in all operations into the more specialized
role of overseeing the organization and
its executive, formulating policies and goals for the
future, and making sure activities contribute d irectly to
the organization's mission. Board members serve as
volunteers, although their leadership role must be or is
distinguished from those volunteers who carry out aspects
of the organization's program operations and activities.
Organizations must develop clear distinctions of roles
and responsibilities to work effidently, especially between
those of the board and those of the executive. The board
sets goals and policies regarding such crucial matters as
finance and programs and then delegates to mana gers the
responsibilities for keeping accurate re cords of income,
expenses, and services. Staff of the organization may be
asked by the board to provide input to its deliberations on
issues related to staff members' responsibili ties.
Boards' legal obligations. include ensuring that all
resources are used to carry out the organizational mis sion
and that all decisions are focused on the long- term well
being of the organization, its services and consu mers.
By-laws serve to guide the board's work and ensu re that
these functions are carried out faithfully in advancing the
mission. IRS Form 990 is required as one component of
demonstrating the board's compliance with these legal
obligations.
Representation of Constituencies
Many contemporary boards include representatives of
their constituency groups on the board. Organizations
serving elderly people often include some consumers on
their boards. Parents of children in private schools or
training centers for the developmentally disabled like wise
often serve on boards of those organizations. Their
perspectives are valuable complements to the ap proaches
of professionals and lay leaders who do not have such
personal experiences. One challenge to such boards is the
difficulty some people have with distinguishi ng between
the organization's long-term interests in survival and
effectiveness in comparison with their own short- term
benefits and interests (Ritvo, Ohlsen & Holland, 2004).
Impacts on Organizational Effectiveness
In their positions as overseers of whole organizations,
boards have extensive impacts on organizational effec-
tiveness. Organizations that have highly productive
boards are seen to have better financial performance,
increased income, stronger focus on mission, greater
visibility in their commu nities, deeper engagement in
strategic planning, stronger evaluation activities, and
higher ratings by executives (Brown, 2005).

Productive boards provide orientation for their newco-
mers and on-going education for all. They nurture
leadership skills among members. They model
self-evaluation and change, modelin g to staff how
improvements are made rather than just demanding
improvements in the staffs work (Chait, Holland,&
Taylor, 1996).
There are a number of important challenges facing
contemporary bo'ards. Competition for members, growing
demands, on them, tighter reporting require ments, and
multiplicity of volunteer opportunities make it difficult to
recruit and retain talented board members. Increasing
competition for financial support requires that boards
become more engaged in fundraising, a new skill for
many. Developing partnerships and cooperative services
with other organizations require skills in negotiation
and'problern-solving, while com pliance with multiple
requirements demands more time. Sustaining public trust
in and credibility of the organizat ion add further to time
demands. Advocacy efforts are scrutinized for possibly
crossing the line into partisan political activity. Rising
expectations of accountability and transparency must be
addressed with ongoing board development, including
developing new skills and preparing members for lea-
dership roles on the board. Boards skilled in all these
dimensions are essential for organizational survival and
effectiveness.
ORGANIZATIONS AND GOVERNANCE 333
REFERENCES
Block, S. R., & Rosenberg, S. (2002). Toward an understanding
of Founder's Syndrome: An assessment of power and privilege
among founders of nonprofit organizations. Nonprofit
Management and Leadership, 12(4),353-368.
Brown, W. A. (2005). Exploring the association between board
and organizational performance. Nonprofit Management and
Leadership, 15 (3), 317-339.
Chait, R. P., Holland, T. P., & Taylor, B. E. (1996). Improving the
performance of governing boards. New York: Greenwood Holland,
T. P. (1996). How to build a more effective board.
Washington, DC: BoardSource.
Holland, T. P. (2002). Board accountability: Some lessons from
the field. Nonprofit Management and Leadership, 12(4),409-428.
Holland, T. P., & Jackson, D. K. (1998). Strengthening board
performance: Findings and lessons from field demonstration
projec~.NonprofitMana~tand~srop,9(1), 121-134.
Ingram, R. T. (2003). Ten basic responsibilities of nonprofit boards.
Washington, DC: BoardSourceP on the Nonprofit Sector.
(2005). Strengthening transparency, governance, accountability
of nonprofit organizations. Washington, DC:
Independent Sector.
Ritvo, R. A., Ohlsen, J. D., & Holland, T. P. (2004). Ethical
governance. Chicago: American Hospital Association.
SUGGESTED LINK
www.boardsource.org
-TOM HOLLAND
PAIN
ABSTRACT: Pain is a multidimensional experience that
embodies the complex relationship of body, mind,
emotions, and spirit. Pain is a subjective experience.
As such, assessment begins with the patient's report
and is enhanced with diagnostic studies, tools, and
observed behavioral, physical, and emotional
responses. Pain may be acute or chronic andean b~
related to a chronic condition or progressive
life-threatening illness-both of which create important
psychological, spiritual, functional, and socioeconomic
consequences. The undertreatment of pain is well
documented, especially in vulnerable populations,
including the elderly and the poor. Among the many
barriers to adequate pain management is the fact that
treatment of pain may involve the use of medications
classified as controlled bubstances creating an
environment of legislative, regula tory, and law
enforcement scrutiny absent from most medical
conditions. Pain is a clinical, ethical, policy, and
advocacy issue impacting vulnerable populations and
inviting social work attention and advocacy.
KEY WORDS: pain; acute; chronic; suffering; delegiti-
rnation; undertreatrnent
Definitions
I
The International Association for the Study of Pain
defines pain as an unpleasant sensory and emotional
experience associated with tissue damage ot described in
terms of such damage (Mersky & Boggduk, 1994). Pain
may be acute or chronic and can be related to a chronic
condition or progressive life threatening illness- both of
which create important psychological, spiritual,
functional, and socioeconomic consequences.
Acute pain may be related to injury, a surgical
procedure, inflammation, or an unknown cause and
generally disappears within an expected period of time as
healing occurs. Usually with sudden onset, there are often,
but not always, objective physical signs such as
hypertension and tachycardia.
Chronic pain extends beyond the expected healing
time and may last indefinitely, be constant, or inter mittent.
Examples include pain related to disorders such as
arthritis, diabetes, HIV, or cancer, in which
335
the pain may be associated with the disease or conse quent
to treatments. Chronic pain may be preceded by an initial
injury such as a sprain or be related to an ongoing
condition such as arthritis. In some cases there is no
discernable cause or evidence of injury . Rarely associated
with signs of nervous system arousal, persons living in
chronic pain may not appear to be in pain, leading
inexperienced clinicians and significant others to
challenge the credibility of patient reports.
The experience of pain is unive rsal. Under normal
conditions pain is a biological warning signal alerting us
that something is wrong within the body or that we should
cease a hurtful, potentially harmful activity. If one is born
without the ability to feel pain, that individual is at h igh
risk of injury and death as they have no signal to alert
them to potential damage to their bodies. Clinicians seek
to diagnose the underlying physical conditions that cause
pain and intervene medically, surgically, or
pharmacologically. In many instances or ganic causes
cannot be found with current diagnostic tools and this
serves as a frustration to clinicians and patients. This is
not evidence however that the reported pai~~
psychological in origin.
The Najlonal Center for Health Statistics report o f
2006 indicates that between 1999 and 2002 more than
one-quarter of Americans (26%) age 20 and over re ported
that they had a problem with pain that persisted more than
24 hr at some time during the month pre ceding the survey
interview. Almost 60% of adults 65 years and older who
reported pain indicated that it had lasted for 1 year or
more.
There is evidence that pain impacts productivity, work
and economic status, function, family, psycholo gical
well-being, and other aspects of quality of life requiri ng
comprehensive assessment both in the setting of a chronic
pain condition or a life-threatening illness. The annual
cost of chronic pain in the United States, including
health-care expenses, lost income, and lost productivity, is
estimated to be $100 billion (National Institutes of Health,
1998). The presence of pain invites assessment of
suffering, which is a construct that involves threat,
beyond the body, to the dignity and integrity of the whole
person (Cassell, 1991).
The absence of technology or laboratory tests to
objectively measure pain fosters the potential for
delegitimation of pain complaints (Ware, 1992). Since
336 PAIN
virtually all persons experience pain at some point in
their lives, the notion of a pain that does not heal or has
no observable cause or cure is a concept often difficult to
integrate-emotionally and cognitively.
Pain has become a focus of specialty medical care
and research and technology; neurochemical and neu-
rologic mechanisms have been identified that point to
the synergistic influence of-physiology, emotion, cogni-
tion, and behavior (Baliki & Apkarian, 2007; Foley,
1999). A biopsychosocial spiritual approach has evolved
to reflect the complex relationship and interplay among
the sensory, affective, behavioral, social, economic,
spiritual, and cognitive factors often embodied in
chronic pain and ·in situations where pain is related to
serious illness, disability, or end of life (Turk,
\
Monarch, & Williams, 2002).
Culture infuses pain experience and factors such as .
gender, genetics, age, socioeconomic class, and race
have been identified as variables that can influence the
expression of pain, access to care, and response to
medications. (Anderson et al., 2000; Bernabei et al.,
1998; Bonham, 2001; Cleeland et al. 1994; Hoffman &
Tarzian, 2001; International Association for the Study of
Pain, 2002).
Social Work Roles and Interventions
Historically, treatment of pain has been the responsi-
bility of physicians and nurses. However, as we
examine the multidimensional nature of pain, it is clear
social work's commitment and competence to relieve
suffering and to enhance the quality of life places pain
clearly within the province of the profession's role and
responsibility .
The subjective nature of pain requires that the clin-
ician begin with the person's report of pain, comple-
mented by diagnostic studies, observed or described
behaviors, coping styles, and function that are limited
and influenced by the biases of the observers. There are
a variety of pain intensity scales and assessment tools
that can be adjusted to age, language, and cognitive
ability and are useful for documenting outcome of treat-
ments (http://www.cityofhope.org/prc/pain~assessment.
asp). There are functional and psychological tests that
can enhance understanding of the multiple dimensions
of pain and its effect on self- image, function, mood, and
family relationships. Associations between pain, anx-
iety, depression, psychiatric vulnerability, stress, and
trauma mandate comprehensive assessment to identify
the multidimensional variables that influence the pain
experience for both the patient and the family, responses
of clinicians, and ultimately inform appropriate
interventions.
Challenges
The undertreatment of pain is well documented (http://
www.painfoundation.org/page.asp?file=Newsroom/pai
n Facrs.htm). Studies indicate that women, elders, those
who speak a language different from their clinician, the
poor, and other vulnerable populations, including those
with psychiatric illness or addiction, are at increased risk
of undertreated pain (Anderson et al., 2000; Bernabei et
al., 1998; Bonham, 2001; Cleeland et al., 1994; Herr &
Garand, 2001; Hoffman & Tarzian, 2001; International
Association for the Study of Pain, 2002). This poses
both an ethical and a public policy challenge. Among
the many barriers to adequate pain management is the
fact that treatment may involve the use of medications
classified as controlled substances, thereby creating an
environment oflegislative and regulatory scrutiny absent
from most medical conditions. The complexity of this
issue is reflected in malpractice cases and criminal
litigation that have involved undertreatment and
overtreatment of pain as well as cases in which
prescribers were charged with criminal offenses such as
manslaughter and drug trafficking. Additionally
concerns related to substance abuse and addiction
suffuses the treatment environment of clinicians and
patients mandating education to dispel myths and mis-
conceptions as well as skilled assessment, treatment,
and evaluation of outcomes.
Whether pain is chronic or related to life-threatening
illnesses, a multidimensional treatment plan should be
recommended. This may include medications, surgical
approaches, biofeedback, complementary and integra-
tive interventions, family education and counseling, and
psychosocial and cognitive-behavioral interventions.
This combined approach is designed to impact the
relationship of body, mind, and spirit and reflects
recognition that pain and suffering often require an
acknowledgement and integration of loss and a de-
liberate focus on restoring or creating new sources of
meaning.
A small number of social workers have expertise in
this specialty area. The subjective nature and multi-
dimensional aspects implicit in the pain experience
reflects the basic social values of "starting where the
client is" and a "person in environment approach." This
synergism invites social work participation in this rich
and challenging field. Clinicians, researchers, educa-
tors, and policy advocates have expertise, both as gen-
eralist and specialist practitioners, to improve the care
of persons with pain whether through direct treatment or
enhancing the political, socioeconomic, cultural, and
ethical environment in which treatment is provided.

REFERENCES
Anderson, K. 0., Mendoza, T. R., Valero, V., Richman, S. P.,
Russell, c., Hurley, J., DeLeon, c., Washington, P., Palos G.,
Payne, R., & Cleeland C. S. (2000). Minority cancer patients
and their providers: Pain management attitudes and practices.
Cancer, 88, 1929-1938.
Baliki, M. N., & Apkarian, A. V. (2007). Neurological effects of
chronic pain. Journal of Pain and Palliative Care Pharma-
cotherapy, 21, 59-61.
Bernabei, R., Gambassi, G., Lapane, K., Landi, F., Gatsonis, c.,
Dunlop, R., Lipsitz, L., Steel, K., & Mor, V. (1998). Manage-
ment of pain in elderly patients with cancer. Journal of the
American Medical Association, 279, 1877-1882.
Bonham, V. L. (200l). Race, ethnicity and pain treatment:
Striving to understand the causes and solutions to the dis-
parities in pain treatment. Journal ofLdw, Medicine & Ethics,
29,52-68. '\
Cassell, E. J. (1991, May-June). Recognizing suffering. Hastings
Center Report, 24--31.
Cleeland, C. S., Gonin, R., Harfield, A. K., Edmonson, J; H.,
Blum, R., Stewart, J. A., et al. (1994). Pain and its treatment in
outpatients with metastatic cancer. New England Journal of
Medicine, 330, 592-596.
Foley, K. (1999). Advances in cancer pain. Archives of Neurolog;y,
56, 413-417.
Herr, K. A., & Garand, L. (200l). Assessment and measurement of
pain in older adults. Clinics in Geriatric Medicine, 17, 457-478.
Hoffman,D. E., & Tarzian, A. J. (200l). The girl who cried pain: A
bias against women in the treatment of pairi. Journal of Law,
Medicine & Ethics, 29,13-27.
International Association for the Study of Pain. (2002). Pain
clinical updates: Culture and pain, 10(5).
Mersky, H., & Boggduk, N. (Eds.). (1994). Classification of chronic
pain (2nd ed.). Seattle, W A: IASP Press.
National Center for Health Statistics. (2007). Health, United States,
2006. With chartbook on trends in the health of Americans (pp.
68-71). Hyattsville, MD: Author.
National Institutes of Health. (1998). NIH guide: New directions in
pain research I. Retrieved September 4, 1998, from
http://grants.nih.gov/grants/guide/pa-files/pA-98-lOL html
Turk, D. c., Monarch, E~ S., & Williams, A. D. (2002).
Cancer patients in pain: Considerations for assessing the
whole person. HerJUltolog;y/Oncolog;y Clinics of North America,
16,511-525.
Ware, J. (1992). Suffering & the social construction of illness: The
delegitimation of illness experience in chronic fatigue
syndrome. Medical Anthropolog;y Quarterly, 4, 347-361.
FURTHER READING
Johnson, S. H. (200l).,Relieving unnecessary, treatable pain for
the sake of human dignity. Journal of Law, Medicine & Ethics, 29,
11-12.
Unruh, A. M. (1996). Gender variations in clinical experience.
Pain, 65, 123-167.
PALLIATIVE CARE 337
SUGGESTED LINKS American Pain
Foundation. http://www.painfoundation.org/
American Pain Society.
http://www .ampainsoc .org/
Center for Health Law Studies, St. Louis University American
Society of Law, Medicine and Ethics. http://www.painandthelaw
.org/
City of Hope, Pain and Palliative Care Resource Center.
http://www .cityofhope .org/prc/
Department of Pain Medicine and Palliative Care, Beth Israel
Medical Center.
http://stoppain.org
International Association for the Study of Pain.
http://www . iasp-pain.org/AM/T emplate .cfm? Section=Publica
tions&Template=/CM/HTMLDisplay·cfm&ContentID=2307
- TERRY ALTILIO
PALLIATIVE CARE
ABSTRACT: Palliative care seeks to prevent and relieve
suffering associated with serious illness for persons of all
ages. The philosophical underpinnings of palliative care and
the core elements of palliative care programs are described.
The history of the hospice and palliative care movement,
distinctions between hospice and palliative care programs and
the roles and functions of social work in palliative care are
reviewed. Contemporary issues that present challenges to the
field that concerns the scope, focus, and intent of palliative
care, the educational gaps in training of health-care profes-
sionals, the absence of a single social work leadership
organization with a focus on palliative care, and the need to
improve the qualiry and quantity of social work research are
discussed.
KEY WORDS: hospice; end of life; palliative
medicine; oncology; health care; terminal illness
Definitions
Palliative care· seeks to prevent and relieve suffering
associated with serious illness for persons at any age. To
palliate means to lessen the severity of an illness without
curing and involves making one comfortable. It is both a
philosophy of care regarding the delivery of care to the
seriously ill, and is emerging as a subspecialty of medical,
nursing, and social work practice. The World Health
Organization (WHO) defines palliative care as " ... an
approach that improves the quality of life of patients and their
families facing the problem
338 PALLIATIVE CARE
associated with life-threatening illness, through the pre-
vention and relief of suffering by means of early identi-
fication and impeccable assessment and treatment of pain
and other problems, physical, psychosocial and spiritual"
(World Health Organization [WHO], 2007).
Palliative care uses a team approach to meet the needs
of patients and their families. Core team mem bers
commonly include a physician, nurse, social worker, and
chaplain, but may also include occupa tional therapists,
complementary therapists, nutrition ists, and other
professionals depending upon the distinctive needs of the
individual and family. For the person with a
life-threatening illness, the palliative care team provides
relief from pain and, other distressing symptoms,
integrates psychological and spiritual aspects of care,
offers support to a~sist individuals to live as actively as
possible, and endeavors to enhance their quality of life as
they move toward death. For the family, the team offers a
support system to help them cope during the patient's
illness and into their own bereavement, and to meet other
needs that may arise before and after the death. Embedded
within the WHO definition is also an affirmation of life
while regarding dying as a normal process, and an intent to
neither hasten nor postpone death (WHO, 2007).
Since the 1990s there has been a strong national
movement in the United States to improve care of the
dying and to establish palliative care as a medical sub-
specialty. The Soros Foundation's Project on Death in
America provided financial support to develop a cadre of
palliative care leaders in medicine, nursing, and social
work to advance the field (Aulino & Foley, 2001). The
American Board of Hospice and Palliative Medicine
developed to initiate a certification process in hospice and
palliative medicine. As a result, there has been significant
growth and development of palliative care programs apart
from hospice programs.
Comparison Between Hospice and
Palliative Care Programs
Both hospice and palliative care programs stem from the
same philosophy of care, yet there are important
differences in eligibility for services, r eimbursement, and
care settings. The primary source of funding for hospice
care comes from Medicare (for those who are older than
65 years or who are disabled), which has a significant
impact on the delivery of hospice care in the United
States. To receive the Medicare Hospice Bene fit, two
physicians must certify that the individual's prognosis is
for a life expectancy of 6 months or less if the terminal
illness runs its normal course; in addi tion, patients have to
agree to therapy with a palliative inten t (Center for
Medicare Advocacy, 2006). Thus
nonhospice palliative care programs may offer services
across the continuum of illness, with no restrictions on
the nature of disease or expected prognosis, and may be
given alongside curative treatment. By con trast, the
hospice model of palliative care is provided for persons
no longer seeking curative therapies, who have a life
expectancy of about 6 months or less (National Con-
sensus Project for Quality Palliative Care, 2004). In
addition, federal regulations require hospice programs to
provide interdisciplinary care and bereavement sup port.
The composition of the palliative care team, and the
extent and nature of bereavement support may vary
across palliative care programs.
The number of palliative care programs is growing
rapidly in the United States. The Center to Advance
Palliative Care is a national organization dedicated to
increasing the availability of quality palliative care
services and provides health-care professio nals with
training and technical assistance to develop palliative
care programs in hospitals and other health-care set tings.
Most programs have developed in acute care hospitals
where palliative care team works alongside the primary
physician. A smaller n umber of programs have emerged
to provide palliative care in the patient's home or in
long-term care facilities. Alternatively, 90% of hospice
care is provided in the patients' homes, with additional
programs providing care in nursing homes,
assisted-living residences, or residential hospices (Mayo
Clinic, 2007).
Hospice-hospital partnerships are becoming more
common as are other innovative models of care. The
Promoting Excellence in End-of-Life care national pro-
gram of the Robert Wood Johnson Foundation funded 22
demonstration projects representing a range of
health-care settings and patient populations to develop
innovative models for palliative care delivery. The pro-
jects provided services across a range of settings, includ-
ing rural areas, integrated health systems, outpatient
clinics, cancer centers, nursing homes, renal dialysis
clinics, inner city public health and safety net systems,
and prisons. Populations served included prison in mates,
military veterans, renal dialysis patients, Native
Americans, Native Alaskans, African American pa tients,
innercity medicallyunderserved patients, pedia tric
patients, and persons with serious mental illness. These
projects demonstrated ways to expand access to palliative
services and improve quality of care and will likely
stimulate additional innovations in care (Byock, Twohig,
Merriman, & Collins, 2006).
Social Work Roles
Professional values, skills, and knowledge of social
workers with emphasis on individual and family

strengths, the importance of "person in environment,"
promotion of social justice, cultural competence, and
self-det~rmination are a natural fit in the palliative care
context. Roles of social work in hospice and palliative care
are diverse. Social workers often address psychoso cial,
cultural, and spiritual issues and advocate for the
individual and family within the team and health- care
system. They develop comprehensive psychosocial
assessments and treatment plans, provide psychoso cial
interventions, implement nonpharmacologic ap proaches
to pain and other forms of suffering (for example,
psychological and spiritual distress), help to examine and
resolve ethical dilemmas, address finan cial concerns, help
with advance care planning, and provide interventions to
address grief and bereavement across the life span.
In 2004, the National Association of Social Work ers
(NASW) released the NASW Standards for Palliative and
End of Life Care. The standards reflect core elem ents of
social work functions related to ethics and values,
knowledge, assessment, intervention or treat ment
planning, self-awareness, empowerment and ad vocacy,
documentation, interdisciplinary teamwork, cultural
competence, continuing education, and super vision,
leadership, and training.
Palliative care social workers in hospice and pallia tive
care programs have distinctive and clearly delineated roles
and functions as members of the inter disciplinary team;
however, many social workers who are not on these teams
or in medical settings will never theless interface with
families facing life-threatening illnesses or those who are
grieving the death of a family member and thus may
provide palliative care services in other work settings.
Social work is the most broadly ba sed profession in
relation to the multiple settings where practitioners
provide services to persons with life- threatening
conditions or to those who have ex perienced deaths in
their social networks, or traumatic losses in their lives. In
most health-care social work settings, practitioners will
interact with clients and their family members who are
experiencing loss, grief, and trauma. Social work
competencies for palliative and end-of- life care have been
put forth that address knowledge, skill, and values needed
across a variety of practice settings (Gwyther et al., 2005 ).
Finally, there is tremendous need for social workers to
take leadership roles in macro level interventions to effect
change in policy, law, and practice, and to devel op more
responsive and comprehensive community based service
systems. Advocacy and interventions are needed to
address ongoing concerns with impedi ments to effective
policy, ethical issues in end of life decision- making and
advance directives, inadequate
PALLIATIVE CARE 339
pain management, inequities in access to and quality of
care, and limited availability of professional care givers
(Stjernsward, Foley, & Ferris, 2007; Werth & Blevins,
2002).
Challenges
There are a number of contemporary issues that present
challenges to the field. First concerns the scope, focus, and
intent of palliative care. It is not uncommon to see the
terms "hospice" and "palliative care" used inter-
changeably, perpetuating the myth that palliative care is
limited in scope to "end-of-life" care. More than half of
deaths that occur in the United States are character ized by
advanced chronic diseases and the "ambiguous dying
syndrome," and these individuals and their family
members may benefit from palliative care services
(Bern-Klug, 2004). The extent to which specialty pal-
liative care services (growing in number) will experi ence
fewer access barriers than do hospice programs and be
able to more comprehensively meet the needs of thos e
with advanced chronic diseases is unknown. A public
health strategy would provide even greater levels of
integration of palliative care into all levels of the
health-care system (Stjernsward et al., 2007).
The second challenge addresses how to meet the
educational gaps in training of health- care professionals
in order to improve palliative care in graduate social
education and post-master's programs. Beginning in 1999 ,
state-of-the-art textbooks have been published in social
work, medicine, and nursing to serve as refer ences for
faculty, practitioners, and students (for exam ple, see
Berzoff & Silverman, 2004). While there are several
educational training programs underway, con certed effort
will be required across disciplines.
Third, the absence of a single social work leadership
organization with a primary focus on palliative care has
limited the creation of social work initiatives, and been a
barrier to effecting change. The establishment of a
professional leadership organizational structure is essen-
tial to the advancement of the field (Kramer, Christ,
Bern-Klug, & Francoeur, 2005). Major advances were
made in June 2007, when the Social Work Hospice and
Palliative Care Network was officially established as a
national organization to unite social work professionals,
stakeholder organizations, and consumers to advance the
field and advocate for quality palliative care
(SWHPN,2007).
Finally, there is a need to increase the quality and
quantity of social work research in palliative care. Social
work practitioners make meaningful contribu tions to
improving palliative care through their work in divergent
practice settings across the life span, their role in
addressing mental health needs, grief, and
340 P AUIA TIYE CARE
psychosocial aspects of well-being, and their commitment to
promoting culturally competent, effective, and humane care,
particularly for the most vulnerable and oppressed members of
society. However, the federal government and several national
and professional institutes have called for steps to increase the
participation of social workers in research as well as to
improve the quality, quantity, and dissemination of social
work research (NIH, 2003). A national research agenda has
been proposed to stimulate and guide social work research in
palliative care (Kramer et al., 2005).
REFERENCES
Aulino, F., & Foley, K. (200l). The project on death in America.
Journal of the Royal Society of Medicine, 94,
492-495. \ http://aosw.org/
Bern-Klug, M. (2004). All Aboard Advancing the Social Work
Research Agenda in End-of-Ufe and Palliative Care. Binghamton,
NY: Hawthorne Press.
Berzoff, J., & Silverman, P. R. (Eds.). (2004). Uvingwith dying:
A handbook for end-of-life healthcare practitioners. New York:
Columbia University Press.
Byock, 1., Twohig, J. S., Merriman, M., & Collins, K. (2006).
Promoting excellence in end-of-life care: A report on in-
novative models of palliative care. Journal of Palliative Medi-
cine, 9(1), 137-151.
Center for Medicare Advocacy. (2006, January 5). New hospice
regulatiOns: One step forward, two steps back? CMA Weekly Alert.
Retrieved March 3, 2007, from http://www.
medicareadvocacy.org/ AlertPDFs/2006/0 1.05 .06.Hospice
Regs.pdf.
Center to Advance Palliative Care. About CAPe. Retrieved March
7, 2007, from http://www.capc.org/about-capc.
Gwyther, L., Altilio, T., Blacker, S., Christ, G., Csikai, E. L., &
Hooyman,N., et al. (2005). Social work competencies in
palliative and end-of-life care. Journal of Social Work in
End-of-life and Palliative Care, 1,87-120.
Kramer, B. J., Christ, G. H., Bern-Klug, M., & Francoeur, R. B.
(2005). A national agenda for social work research in palliative
and end-of-life care. Journal of Palliative Medicine, 8, 418-431.
Mayo Clinic. (2007). Hospice care: An option for people with terminal
illness. Retrieved November 15, 2007, from http://
www.mayoclinic.com/health/hospice-care/HQ00860.
NASW Standards for Palliative and End of life Care. Retrieved
November 16, 2007, from https://www.socialworkers.org/
practice/bereavement/standards/ standards0504 New. pdf.
Accessed November 16, 2007.
National Consensus Project for Quality Palliative Care. (2004).
Clinical practice guidelines for quality palliative care. Brooklyn,
NY: Author.
NIH Plan for Social Work Research. (2003). Retrieved November
15, 2007, from http://obssr.od.nih.gov/Documents/
Publications/SWR_Report.pdf.
Stjernsward, J., Foley, D.M., & Ferris, F. D. (2007). The public
health strategy for palliative care. Journal of Pain and Symptom
Management, 33, 486-493.
SWHPN: The Social Work in Hospice and Palliative Care
Network. (2007). News release: New organization to advocate for
quality end of life care. Retrieved November 16, 2007, from
http://swhpn.org/news/.
Werth, J., & Blevins, D. (2002). Public policy and end-of-life
care. American Behavioral Scientist, 46, 401-417.
World Health Organization. (2007). WHO definition of palliative
care. Retrieved March 3, 2007, from http://www.
who.int/cancer/palliative/definition/en/
SUGGESTED LINKS
American Academy of Hospice and Palliative Medicine.
http://www.aahpm.org/
Americans for Better Care of the Dying.
http://abcd-caring.org/
Association of Oncology Social Work:
Association of Pediatric Oncology Social Workers.
http://www.aposw.org/
Center to Advance Palliative Care.
http://www . cape .org/
City of Hope Pain and Palliative Care Resource Center.
http://www .cityof/wpe .org/pre/
College of Palliative Care at AAHPM.
http://www . aahpm. org/ about/college .html
International Association for Hospice and Palliative Care.
http://www.hospicecare.com/
National Hospice and Palliative Care Organization.
www.nhpco.org
National Palliative Care Research Center.
http://www.npcrc.org/
Social Work in Hospice and Palliative Care Network.
www.swhpn.org
- BETTY J. KRAMER
PAROLE. See Criminal Justice: Overview; Probation and
Parole.
PARTNERS. See Couples; Marriage and Domestic
Partners.
PEACE
ABSTRACT: This entry discusses the relationship of war and
peace to social work practice. The historic and current
mandate for social workers to work for peace is presented.
The inevitable tie of war to everyday social work practice is
described, and the relationship between social justice and
peace is illustrated.
KEY WORDS: war; peace; social justice; war costs;
globalization

The world generated more wealth in 20th century than
in any other, and it also generated more bloodshed, with
160,000,000 war deaths (Scaruffi, 2007) and greater
inequities (Ford Foundation, 2007). Coinciding with
tremendous technical improvement in weapons follow-
ing World War I, civilian deaths increasingly ac counted
for a greater proportion of war deaths (Scaruffi, 2007).
Conflict remains a critical obstacle for policies for
social and economic development and social justice
throughout the world, with negative impacts on
economic growth and the equitable distribution of
government finances. Wars and conflicts are major
causes of poverty and human misery. They disrupt
economies and communities and make poor people
\
even poorer.
Historic Mandate to Work for Peace
The social work mandate to work for peace is grounded
in the professions' core values and the fact that war has a
significant impact on every individual, group, organi-
zation, community, and nation-state. Social work's his-
toric mission has been congruent with those who
promote peace and nonviolence. The lofty goals for
positive outcomes found in social work professional
organization's stated missions, values, and ethics are
unequivocally aligned with peacemaking.
Social work has consistently advocated for a just and
peaceful world and has maintained a consistent anti-
violence stand (Mizrahi, 2003). The relevance of peace
and peace issues for social work is grounded in the
NASW statement of ethics, and explicated in the 1999
policy statement "International Policy on Human
Rights" (NASW, 1999), a policy statement approved by
the NASW Delegate Assembly, August 2002 (NASW,
2002), and the NASW Board of Directors vote to take a
position against the war in Iraq (Mizrahi, 2003). The
International Association of Schools of Social Work
supports the ISW4Peace Project, a Web site and
network set up for international social work faculty to
take action and share teaching materials to further the
goal of international peace (www.isw4-
peace.org/index.php ?id= 3).
In 1915 Jane Addams, one of the founders, became
president of the Women's International Peace Congress
(later renamed the Woman's International League for
Peace and Freedom). After its first meeting held at The
Hague, she traveled throughout Europe and lobbied
heads of states to end World War I. She remained
president for 14 years. At the end of the war she lobbied
for liberal peace terms for Germany and worked in
Germany to feed starving children (The New York
Times, 1935).
PEACE 341
Social work's commitment to peace and or action to
prevent war is not universal among social workers,
social work scholars, and social work organizations. A
review of the leading social work journals during the
Viet Nam War found that social work's major journals
carried virtually no articles, letters, editorials, or short
subjects related to the war and concluded that the
dominant discourse constructed in the journals
excluded meaningful engagement with the war. In
1968, at the height of the war and the building of a
national and international protest against it, only one
article tangentially related to the war was published in
the leading social work journals, and no editorials, book
reviews, or letters to the editor were published
(Chandler, 2004). However, the National Association of
Social Workers, The International Federation of Social
Workers, and the International Association of Schools
of Social Work have opposed the war in Iraq.
The Inevitable Tie of War to
Daily Social Work Practice
War priorities drain national budgets and divert ener-
gies, goods, and services to meet military obligations,
energies, goods, and services that could be used to meet
the needs for the most vulnerable populations. The U.S.
president's 2008 budget includes $460.7 billion for war
and war preparation. The next two largest items are
education and health, getting $56.8 billion and $53.1
billion, respectively (Shah, 2007). If this amount is
spent, the U.S. military expenditures will account for
more than 43% of the world's total military
expenditures, and more than the combined spending of
the next 14 nations (Shah, 2007). The president's 2008
budget and budget message was openly predicated on
the need to cut domestic spending in order to pay for the
war in Iraq and Afghanistan and increase the military
budget. His proposed domestic discretionary budget
cuts that would decrease spending for each of the next
five years were overwhelmingly focused on the poor
and vulnerable populations; They included Medicare,
Medicaid, nutrition programs for women, infants, and
children, rural development, adult basic literacy
education, K-12 education for the disadvantaged, Pell
grants, special education, energy conservation, state and
tribal assistance grants, child care, children and family
services, Indian health facilities, Indian health Service,
low-income home energy assistance, homeless
assistance, housing for persons with disabilities,
housing for the elderly, community oriented policing
services, employment and training services, and
veterans medical care and hospital services. Issues of
war and peace are directly related to the services social
work clients receive. In addition,
342 PEACE
war drains the personal income of every worker and client.
Wars are currently responsible for the world's
12,000,000 refugees and asylum seekers. War refugees
and asylum seekers in the United States from Viet Nam,
Africa, Cambodia, all the Balkan states, the Middle East,
the Caribbean, and South and Latin America have serious
service needs that tax the already over burdened social
service sectors of our local communities.
Twenty thousand service personnel are returning from
Iraq and Afghanistan with significant physical
disabilities, and it is estimated that as many as 400,000 are
returning with mental health service needs. The 400,000
figure is based on 19~ of the returning service members
reporting mental health problems (Hodge, 2006). This
does tiot account for those who may have such problems
but do not report them. These veterans are returning at a
time when federal funding available to local community
services, including Veteran's Administration health care,
is being cut.
Peace, Justice, and Social Work Practice Peace and
justice represent complex and intric ately related concepts
when placed in the context of professional social work
practice. Advocacy for justice is an especially important
peace work in social work practice with individuals,
groups, organizations, communities, or governments. Jane
Addams helped us to understand the connection between
bread and peace, and peace and social justice. Contrary to
the citation often attributed to Pope Paul VI, "If you want
peace, work for justice," this phrase can be found in
Addams's book Newer ideals of peace (1906, p. 36). Bertha
Reynolds, Mahatma Gandhi, Martin Luther King, [r.,
Jimmy Carter, and many others have written how peace is
not possible without justice. Incidents of violence are
often carried out as a form of retribution with perpetrators
believing that they are carrying out justice. However,
there can also be no justice without peace. Nonviolence
and justice are of equal importance because of their
interdependence. Central to this position is Socrates'
argument that violence is antithetical to justice and that
the ideal state operates whereby justice never does wrong
nor harm; and, therefore to be just, one must not harm
anyone (Beck, 1986). Violence and justice are
incompatible because once one takes up arms the issue of
equalitarianism is moot. Some must die that others may
live, and the killing of innocent people is a given.
Pragmatically and ethically social work has not been
and is not neutral on issues of war and peace. With the
globalization of information and economies, social work
has the opportunity to be a part of an emerging
global social ethic that fosters a just, peaceful, and
humane global society.
REFERENCES
Addams, J. (1906). Newer ideals of peace. New York: McMillan.
Beck, S. (1986). The way to peace. Farmingdale, New York:
Coleman.
Chandler, S. K. (2004, December). Curiously uninvolved: Social
work and protest against the war in Vietnam. Journal of Sod-
ology and Social Welfare, 6. Retrieved October 9,2007, from
http://www.encyclopedia.com/doc/l G 1-126791644 .html
Ford Foundation. (2007). Peace and social justice (pp. 1-21).
New York: Author.
Hodge, C. W. (2006). Mental health problems, use of mental
health services, and attrition from military service after
returning from deployment to Iraq and Afghanistan. Journal of
American Medical Assodation, 9, 1023-1032.
Mizrahi, T. (2003). The legacy of peace. NASW News, 4, 2.
National Association of Social Workers Delegate Assembly.
(1999). International policy on human rights. New York:
Author.
National Association of Social Workers Delegate Assembly.
(2002). Peace and sodaljustice. New York: Author.
The New York Times. (1935, May 22). Obituary: Jane Addams; A
foe of war and need. Retrieved October 9, 2007, from
http://www.nytimes.com/learning/general/onthisday /bday/
0906.html
Scaruffi, P. (2007). Wars and genoddes of the 20th century.
Retrieved October 9, 2007, from http://www.scamffLcom/
politics/massacre.html
Shah, A. (2007). World military spending. Retrieved October 9,
·2007, from http://globalissues.org/Geopolitics/AnnsTrade/
Spending. asp
FURTHER READING
International Association of Social Work. (2006). International
statement on peace and social justice. New York: Author.
http://www.ifsw.org/en/p38000220.html
-CHARLES D. COWGER
PEDIATRIC AIDS. See HIV/AIDS: Children.
PENSION AND RETIREMENT PROGRAMS
ABSTRACT: In the American retirement income pic ture,
private pensions occupy a critical but underused place.
Roughly one-half of Americans do not have private
pension coverage, and those who do not tend to be
concentrated in the lower levels of the overall income
distribution. Pension coverage and adequacy

are reviewed here as is the place of private pensions in
assuring income adequacy in old age. Pressures on
Social Security and "traditional" pensions will make the
place of defined contribution (401k-type plans)
increasingly important to older individuals, including
social workers.
KEY WORDS: pension; 401K; defined benefit;
defined contribution
Increasing numbers of individuals variously identified
as older adults, the young-old, or, more recently, as
aging baby boomers who will tum 65 years beginning
in 2010, have made the question of work and retire ment
central to contemporary social policy. The key policy
issues raised by this tterid are, first of all, whether older
adults should be encouraged to work or to retire and,
second, if they are to transition from work to
retirement, how can their economic well-being be
assured.
Public and private pensions have historically helped
shape the work and retirement landscape and will con-
tinue to do so in the future. Developed in the late-19th
and early 20th centuries, private pensions aided
employers in easing older workers out of the labor
force, provided many older adults with a modicum of
economic security in old age, and, more broadly,
contributed to the development of retirement in old-age
as a normative stage in modem American life (Morgan
& Kunkel, 2000).
More recently, however, the work and retirement
landscape has begun to change in rather dramatic
fashion. The aging of the baby boomers and the rela-
tively small cohorts following behind have raised the
specter of both future labor shortages and funding
shortfalls in Social Security and private pensions.
Together, these developments are placing a new pre-
mium on the role of older workers in the contemporary
economy. Rather than trying to retire them as has
historically been the case, a growing chorus of
economists and policymakers are devising ways to
encourage or even coerce older workers to stay em-
ployed longer (Schieber & Nyce, 2004; Wattenberg,
2004). The design of private pensions directly affects
the work and retirement decision that older workers
make.
Private Pension Types and Trends
The two principal types of employer-sponsored private
pensions are defined benefit (or "traditional") plans
(DBPs) and defined contribution plans (DCPs). Two
other well-known and government-subsidized private
retirement vehicles are individual retirement accounts,
PENSION AND RETIREMENT PROGRAMS 343
or IRAs, (generally available to workers with no em-
ployer-sponsored plan) and Keogh plans (available to
the self-employed and small business owners).
In a DBP, employers contractually promise
employees a given level of benefit upon retirement in
accordance with a formula specified in the plan. There
are three principal types of DBPs: (a) flat benefit
formula wherein a given dollar amount is paid in for
each year of service recognized under the plan, (b)
career-average formula wherein employees earn a
percentage of the pay they received while participants
and receive a percentage of their career-average pay
multiplied by the number of years of service, and (c)
final-pay formulas wherein the plan pays benefits on
earnings during a specified numbe-r of years, usually at
the end of an employee's career with the employee when
the employees earnings are highest.
In DCPs, employers make provision for contribu-
tions to an account established for each participating
employee. The final retirement benefit equals the total
of employer contributions, employee contributions, and
investment gains and losses. Employer contributions
are often based on a specific formula, such as a
percentage of employee salary or company profits.
There are several types of DCPs, the most common
being moneypurchase plans (mandatory employer
contributions as a percentage of worker salary),
profit-sharing plans (amount derived from company
profits), a thrift savings plan (essentially an employee
savings -account, often with matching contributions
from the employer), and 401(k) plans (a qualified
deferral arrangement under this section of the tax code
thai: allows an employee to have a portion of
compensation-otherwise payable in cash-contributed to
a plan, such as those listed above) (EBRI, 1997a,
1997b).
Because of these features, a major difference be-
tween DBPs and DCPs is that DCP benefits cannot be
calculated in advance (EBRI, 1997b). Indeed, there is a
fundamental conceptual distinction between the two
types of plans. Strictly speaking, only DBPs are "pen-
sions" by virtue of their paying a monthly benefit that is
based on a formula tied to length of service and earn-
ings. In contrast, DCPs should be understood as tax-
deferred savings plans, providing benefits that are based
on the underlying assets, interest, dividends, and capital
appreciation that they generate (Friedland, 1996). Im-
portantly, workers themselves are responsible for
managing their DCPs, whereas employers manage and
are legally required to honor contractual obligations
under DBPs. Concern about the growth of DCPs was
sharpened by the revelation in 2000 that the average
OCP account had lost value for the first time in the
program's 20-year history (Hakim, 2001).
344 PENSION AND RETIREMENT PROORAMS

TABLE 1
Retirement Plan Trends: Participation by Plan Types

2003 1999 1995 1991 1987 1983 1979 2005

PARTICIPATION BY PLAN
12 14 19 29 37 44 62 DBP only (%) 10
61 54 50 40 32 23 16 DCPonly (%) 63
27 28 30 30 30 31 22 DBP and DCP (%) 27
From "Fast Facts from EBRI #56," by EBRI, June

TABLE 2 corporate employers" (EBRI, 1997c). Quite restrictive

U.S. Retirement Plan Assets, 1995-2004 ($ trillions)
PLAN TYPE 1996 1998 2000 2002 2004
DBP 1.54 1.95 1.95 1.44 1.87
DCP 1.52 2.11 2.3' 1.82 2.55
IRA 1.47 2.15 \ 2.63 2.53 3.48
From "Fast Facts from EBRI #16," by EBRI, February 3,2006.
As shown in Table 1 since mid-1970s, there has been a
pronounced shift in plan participation away from DBPs
and toward DCPs.
The shift toward DCPs and away from DBPs is also
seen in the emerging dominance in pension assets held by
DCP plans over DBP ones. Table 2 shows the decided
trend between 1995 and 2004, with DCP assets surpassing
DBP ones by 1997. Also included in the table are the data
pertaining to assets held in IRAs. While not
employer-sponsored, the IRA data are im portant in this
context because a high proportion of IRA assets is the
result of "rollovers" made from DCPs into IRAs around
the timeof worker retirement (EBRI, 2006).
Individual Retirement Accounts (lRAs) were estab-
lished by the Employee Retirement Income Security Act
(ERISA) of 1974 to give workers who did not have
employer-based pensions an opportunity to save for
retirement on a tax-deferred basis. Legislation in 1981
markedly liberalized IRA eligibility to include workers
who also had employer-based coverage. However, in 1986
restrictions for the latter group were again imposed,
limiting the tax-deferral provision to those families with
relatively low incomes. Because of this change, by the
1990s, the number of active IRA participants dropped,
with only 9.2% of workers with employer-based coverage
and 6.3% of those without it currently contributing to IRA
plans (EBRI, 1997a).
Finally, the federal tax code now encourages the
self-employed to establish retirement savings vehicles.
Keogh (or H.R. 10) plans were authorized in 1962 and
allow "unincorporated small business owners, farm ers, and
those in professional practice to establish and participate in
tax qualified plans similar to those of
until ERISA's passage in 1974, Keogh plans have been
liberalized over the years, now allowing contributions that
are. the lesser of 25% of employee's compensation or
$30,000 per year.
More than other retirement savings vehicles, Keogh
plans remain the province of higher income individuals.
Table 3 shows the percentage of people with IRA/Keogh
coverage by income, and the median value of those
IRA/Keogh holdings, also by income.
Private Pension Coverage
The degree and distribution of private pension coverage is
of particular importance in the United States because of
the relatively higher reliance the United States places on
private retirement income protection than do other
industrial nations (Schulz & Myles, 1990). Nor is this
reliance offsetby any requirement that private firms offer
pension (or many other employee) benefits.
Private pension coverage in the United States is
heavily affected by salient employer and employee
characteristics. Table 4 shows that worker participa tion in
employer-sponsored retirement plans varies markedly by
firm size (large, medium, small) and workers' employment
status (full-part-time). Full-time workers, employees in
large and medium-size firms, and especially government
employees are more likely to have retirement program
coverage.
Differences by Gender and Race
Pension coverage and adequacy of benefits also varies
across different subsets of workers. Most pronounced is
variability associated with income: higher income in-
dividuals enjoy broader coverage and greater benefits.
And, as Table 5 indicates, income is a far greater predictor
of pension coverage than is gender. Of particular interest is
that, while at all income levels, pension coverage is in fact
higher among women than it is among men, men enjoy
somewhat higher pension coverage overall-49,4% vs.
47.2%. This results from the important reality that women
are more highly concentrated in the bottom wage tiers
wherein coverage for all workers is lower than for higher
income workers. This
 PENSION AND RETIREMENT
PROGRAMS 345

TABLE 3
IRA/Keogh Ownership and Value, by Family Income
PERCENTAGE WITH lRA/KEOGH MEDIAN VALUE OF IRA/KEOGH
1992 . 2004 1992 2004
Total 26.10% 29.10% $19,769 $30,000
Family Income
<$10,000 5,000 11,862
$10,000-24,999 16,000 7,908
$25,000-49,999 17,000 15,815
$50,000-99,999 24,000 15,815
>$100,000 83,000 39,539
From "Fast Facts from EBRI #33," by EBRI, September 26, 2006.

TABLE 4
Pe,rcentage of Employees Participating in Employer Benefit Programs
BENEFIT PROGRAM
MEDIUM AND LARGE SMALL PRIVATE FIRM STATE AND LocAL
PRIVATE FIRM GOVERNMENTS
1989 2003 1990 2003 1987
199
35 42 89 9
8 20 8 8
31 31 9 9
3 0
9 10 49 16
2 4 8 42
6 7 4 5
"lndlvlduals may participate in both DB and DC plans 5 9
From "EBRI Data Book on Employee Benefits (chap. 4)," by EBRI, 2005. 3 3

TABLE 5 than those for Non-whites. As with gender, the role of

Percentage of Wage and Salary Workers Aged 21-64 income is shown to be more important than race in
Participating in Employment-Based Retirement Plan, accounting for participation (Table 8). However, as in the
by Annual Earnings and Gender, 2004 case of women, the median individual benefit received by
non-Whites is far less than for Whites. When the mean
ANNUAL EARNINGS MEN (%) WOMEN (%)
balances in the individual account plans (DCPs, IRAs,
<$5,000 9.50 9.70
$5,000-9,999 12.10 14.50 Keoghs) are examined, race and ethnicity are shown to be
$10,000-14,999 15.50 23.50 very significant differentiators, with non-Hispanic Whites
$15,000-19,999 22.90 35.00 having accumulated balances of $142,419 and non-whites
$20,000-29,999 36.00 51.00 holding only $63,278 (Copeland, 2006). Again, this
$30,000-39,999 52.90 65.00
seeming anomaly results from non-Whites being
$40,000-49,999 65.20 72.80
>$50,000 72.40 74.90 concentrated in lower paying occupations. Interestingly, it
From "Fast Facts from EBRI #17," by EBRI, November 17,2005. does not arise from non-Whites being disproportionately
found in jobs where pension benefits are not offered at all.
lower distribution of women's income and, in tum, Using data from the Survey of Income Program
pension and annuity returns is seen in Table 6 , where a Participants, Sun and Ghilarducci (2004) report that 61 %
"two-to-one" pattern-men receiving roughly twice what of Blacks, 59% of Whites, and 42% of Latinos work where
women do-has continued to hold over a 30-year period. employers offer pension plans.
Income also trumps race as a factor accounting for
workers eligible for private pension coverage choosing to
participate. Thus, as seen in Table 7 , participation rates of Future Trends
White non-Hispanics are only somewhat higher There is great interest in encouraging older adults to work
longer. The decline in prominence of DBPs in
346 PENSION AND RETIREMENT PROGRAMS
. TABLE 6
Median Income from Pensions and Annuities by Gender (2000 Dollars)
YEAR 1975 1980 1985
Male 10,01 10,38 10,72
Femal 9 1 9 1
e 6,897 5,432 5,445
From "Retirement annuity & employment-based pension income among individuals age 50 and over," by EBRl, 2005.
TABLE 7
Participation Rates of Family Heads, by Race/Ethnicity, in an
Employment-Based DCP, 1995, 1998,2001, 2004
RACE 1995 1998 2001 2004
White, Non- 75.50 79.00 74.90 78.30
Hispanic (%)
Non-White (%) 67.50 69.60 74.40 67.50
recent decades is partly predicated on this concern since
the workings of DBPs encourage rather than discourage
worker retirement whereas DCPs do not (Quinn &
Burtless, 1997). The increase in the normal retirement age
under Social Security and the elimination of the Social
Security earnings test for workers aged 65-69 are also
designed to encourage longer work lives.
However, the principal factor encouraging extended
work life may be the simple reality that many older adults
will not have enough money to retire reasonably
comfortably. As Munnell (2006) notes, Social Security,
which provides 72.7% of the retirement income of
. middle-tier retirees, will become less valuable in the future
because of the raised normal retirement age, rising
Medicare Part B premiums, and expanded taxation of
benefits. In the private sector, increased reliance on OCPs
introduces new pitfalls: just under one- half of workers are
eligible to participate in OCPs, and of those who are
eligible to participate 20% do not. The accum ulated
holdings are also inadequate in terms of income
replacement in retirement: the average account balance in
OCP and IRA plans for workers aged 55-65 is only
$60,000, which would translate into an annuity of only
roughly $400 per month (Munnell & Sunden, 2006). And,
the role of pensions in the overall retire ment picture is a
very uneven one given how both participation and
benefits are greatly affected by workers' income. Th~ s,
while private pensions account for 10% of income for
persons aged 65+, they constitute 21 % for the 'top income
quintile, 29% for the second quintile, 26% for the third
quintile, 18% for the fourth, and only 8% for the fifth
(Munnell & Perun, 2006).
Recent policy enactments and proposals have been
directed at increasing private pension participation and
1990 1995 2000 2005
11,88 12,30 13,61 14,4
2 0 00
5,881 6,151 6,818 7,584
modifying pension provisions in ways that would en-
courage older adults to continue working longer. Most
notable is the Pension Protection Act (PPA) of 2006.
Many of the provisions pertaining to DBPs center on
strengthening the future solvency of DBPs (although there
is concern that these efforts might have the unintended
effect of leading more employers to abandon their DBPs
altogether). But, the PPA also takes a major step toward
encouraging workers covered under DBPs to be able to
continue working at older ages by allowing them to work
on a part-time or flexible basis while being able to draw on
their pension benefit. By doing so, the law no longer forces
workers with DBP coverage to make a dichotomous
choice between work and retirement (Hudson & Gonyea,
2007; Sheaks, 2007).
Important provisions of the PP A also pertain to OCPs.
Under the new law, employers may now automatically
enroll their employees in 401(k) plans; until now,
employees had to take the initiative to enroll and, as noted,
many did not. The law also allows employers to provide
investment advice to employees, and it allows employees
to diversify their investments beyond the employer's own
stock where that is the case. These steps acknowledged,
the PP A does not, however, do anything to assist the 53%
of workers in the American labor force who have no
private pension protection whatever.
Private pensions occupy a major place in the retire ment
income picture, yet they often fall short in helping provide
adequate retirement income. This is in part due to
employers not being required to offer pension benefits (and
many small employers do not) and to eligible workers
choosing not to participate or not to contribute all that they
might. But weaknesses in the other two "legs" of the
so-called "three-legged retirement stool"-Social Security
and individual savings-put added pressure on private
pensions. In any event, there are a number of macro-level
pressures building that will encourage or potentially force
em- . ployees to stay at work longer. Shortcomings in
private pension coverage arid benefits may contribute to
those pressures, whether intended to or not.
For social workers, the issues around private pensions
raised in this review are both professional and personal.
Whether working in clinical or community
 PERMANENCY PLANNING 347

TABLE 8
Percentage of Wage and Salary Workers Aged 21--64 Who Participated in
an Employment~Based Plan, by Earnings and Race/Ethnicity, 2002
EARNINGS <$5K $10-15K $20-25K $30-35K H0-45K
Race/Ethnicity >$50K
White (0/0) 9 2 50 6 70
Black (0/0) 6 40 3 6 74
Hispanic (0/0) 6 1 31 4 3 70
Other (0/0) 8 40 8 59 64
5 1 45 6 70
"EBRI Issue Brief" by EBRI, October 2003, estimates from Current Population Survey.
1 4 3
5 1 8
8

settings, it is important that practicing social workers be informed
about the critical role private pensions must play in their clients'
curtent and future wellbeing. Because of the profession's concern
with vulnerable populations and social justice, social workers will
be dealing largely with individuals and groups whose pen, sion
coverage is inadequate or non-existent. Heightening private
pension participation should be added to the list of concerns
social workers address with their clients. As for the retirement
needs of social workers themselves, it is imperative that they, too,
review their Social Security, pension, and savings profile. Social
Security will continue to provide an income floor for most social
workers, but a reasonably comfortable retirement will require
additional income flows. Thanks to the Pension Protection Act of
2006, both social workers and their clients will have easier access
to pension coverage. They should both avail themselves of it.
REFERENCES
Copeland, C. (2006). Individual account retirement plans: An
analysis of the 2004 survey of consumer finance. EBRI Issue
Brief#293. Washington, DC: EBRI.
EBRI. (1997a). Defined benefit and defined contribution plans:
Understanding the differences. In FuruIamenraIs of employee
benefit programs (chap. 6, 5th ed.). Washington, DC: EBRI.
EBRI. (1997b). Pension plans. In FuruIamentals of employee . benefit
programs (chap. 5, 5th ed.). Washington, DC: EBRI.
EBRI. (1997c). Self-employment plans. In FuruIamenraIs of
employee benefit programs (chap. 17, 5th ed.) . Washington, DC:
EBRI.
EBRI. (2006, February 3). Traditional pension assets lost dom-
inance a decade ago, IRAs and 401 (k)s have long been
dominant. Fast facts from EBRI #16. Washington, DC:
EBRI.
Friedland, R. (1996). Privatizing social insurance. Public Pol, icy &
Aging Report, 7(4), 11-15.
Hakim, D. (2001, July 9). 401 (k) accounts are losing money for
the first time. New York Times, pp. AI, Al2.
Hudson, R. B., & Gonyea, J. G. (2007). The evolving role of
public policy in promoting ~ork and retirement. Gener-
arions,31(1),68-75.
Morgan, L, & Kunkel, S. (2000). Aging: The social context.
Thousand Oaks, CA: Pine Forge Press.
Munnell, A. (2006). Policies to promote labor force participation of
older workers. Chestnut Hill, MA: Center for Retirement
Research, Boston College.
Munnell, A., & Perun, P. (2006). An update on private pensions.
Chestnut Hill, MA: Center for Retirement Research Issue
Brief, Boston College.
Munnell, A., & Sunden, A. (2006). 40l(k) plans are stiUcoming up
short. Chestnut Hill, MA: Center for Retirement Research Issue
Brief, Boston College.
Quinn, J., & Burtless, G. (1997). Retirement trends and patterns in
the 1990s: The end of an era? Public PoliCy & Aging Report,
8(3), 10-14.
Schieber, S., & Nyce, S. (2004). Demographics matter: The
economic reality of an aging society. Public Policy & Aging
Report, 14(3), 11-15. .
Schulz, J. H., & Myles, J. (1990). Old age pensions: A com-
parative perspective In R. H. Binstock & L K. George (Eds.),
Handbook of aging and the social sciences (3rd ed.). San Diego:
Academic Press.
Sheaks, C. (2007). Phased retirement: Facts, figures, and policies.
Generations. 31 (1), 57-62.
Sun, W., & Ghilarducci, T. (2004). Latinos' low pension cover, age
and disenfranchisement from the U.S. financial system. South Bend,
IN: Institute for Latino Studies, University of Notre Dame.
Wattenberg, B. (2004). Fewer: How the new demography of
depopulation wiU shape our future. Chicago: Ivan R. Dee.
-ROBERT B. HUDSON
PENSION PROGRAMS. See Retirement: Pension and
Retirement Programs.
PERMANENCY PLANNING. See Adoption; Child
Foster Care; Child Welfare: Overview.
348 PERsoN-IN-ENVIRONMENT
PERSON,IN,ENVIRONMENT
ABSTRACT: The person-in-environment perspective in
social work is a practice-guiding principle that high lights
the importance of understanding an individual and
individual behavior in light of the environmental contexts
in which that person lives and acts. The per spective has
historical roots in the profession, starting with early
debates over the proper attention to be given to individual
or environmental change. Theoretical approaches that
have attempted to capture the mean ing of
person-in-environment are presented, as well as
promising, conceptual developments.
KEY WORDS: person-in-~nvironment perspective;
person-in-situation (person-in-context); ecosystem
framework; ecological theory; general systems theory
The person-in-environment perspective in social work is a
practice-guiding principle that highlights the im portance
of understanding an individual and his or her behavior in
light of the various environmental contexts in which that
person lives and acts (CSWE, 2004). These contexts
include (but are not limited to) social, economic, political,
communal,' historical, reli gious, physical, cultural, and
familial environments. This definition incorporates the
notion that there is a reciprocity to the
person-environment relationship, such that the individual
can impact the various elements of the environment, just
as the environment can exert a conducive or inhibiting
influence on the individual. The definition also includes
the notion that an understanding o f the person in his or her
total context creates opportunities for assessment and
interventions that are directed at individual functioning, at
environmental conditions, or both. It is important to note
that this definition is not coextensive with the va rious
theoretical or operational formulations that have
attempted to give more substance to the person-
in-environment perspective. For example, this perspec-
tive is not the same as the various ecosystem models with
which it is commonly identified, and whic h it predates in
the literature and in practice.
The person-in-environment perspective has been
linked to definitions of social work practice since the
concept's earliest articulation in the first working defi-
nition of practice (Bartlett, 2003, reprinted from Bartlett,
1958). The preambles to both the current Educational
Policy and Accreditation Standards of the Council on
Social Work Education and the most recent National
Association of Social Work Code of Ethics identify
attention to the individual in e nvironmental context as a
crucial element in defining social work
practice, as does the definition of practice promulgated by
the International Federation of Social Workers (CSWE,
2004; IFSW, 2006; NASW, 1996).
Historical Background
The notion that both person and his/her environ ment are
central considerations in social work prac tice . has strong
historical roots. Although emphasis assigned to either
personal change or environmental change has varied over
time, neither the "person" nor the "environment" half of
this equation was ever completely eclipsed within the
practice and academic communities.
This early history is best exemplified by the public
debate between Jane Addams and the founders of the
settlement movement, on the one hand, and Mary
Richmond and other leaders in the Charity Organiza tion
Society, on the other (Germain & Hartman, 1980;
Peterson, 1979). Addams underscored the importance of
the social, cultural, and policy environment in the lives of
individuals and families, and embraced social-
environmental change as a way of improving lives of
people in poverty and social distress (Austin, 2001 ;
Germain & Hartman, 1980). By contrast, Richmond ,
adopted a medical model defined by a process of diag-
nosis and treatment that was focused on identifying and
correcting individual deficits (Germain & Hartman, 1980;
Peterson, 1979). A careful reading of the histor-
icalliterature, however, suggests that while the debate
between proponents of these two positions was often
lively, in practice both Richmond and Addams inter vened
with individuals, families, and larger systems (Germain &
Hartman, 1980).
The medical model favored by Richmond provided
fertile ground for implanting the emerging theory and
practice of psychotherapy into soc ial casework during the
post-World War I period. Many in mainstream social
work at this time eschewed emphasis on promot ing
environmental or system change, adopting instead a
concern for psychodynamic factors thought to deter mine
human functioning. However, even with this trend toward
more psychological approaches to case work, there were
countervailing voices continuing to insist on the
importance of the social, economic, political, and cultural
environments in explaining so cial problems and in
defining strategies to improve the lives of individuals and
families. Ada Sheffield, for example, expanded on the
concept of a client's "total situation," in which individuals
and their immediate environments were interrelated
(Sheffield, 1931). Bertha Reynolds an d Harry Laurie also
advocated for the importance of social and economic
aspects of the environment as cause and potential solution
for social

problems (Germain & Hartman, 1980; Schriver, 1987a,
1987b).
While the professional practice community was
experiencing the tension between proponents of psy-
chological approaches and those advocating the impor-
tance of environmental strategies, leaders in the
profession were also preoccupied with a quest to define
social work's scope and purpose. An early attempt was
the Milford Conference and the 1929 final conference
report. The report specifically mentioned adjustments in
the environment and use of community resources as a
proper concern of social work (Brieland, 1977;
Holosko, 2003). Following the formation of the Na-
tional Association of Social Wor\<ers (NASW) in 1955,
a study group, headed by Harriet Bartlett, was
commissioned to develop a ~orking definition of social
work practice. The group report identified three generic
methods as proper to social work practice: (a) changing
the individual in relation to the social environment, (b)
changing the social environment in relation to the
individual, or (c) both in relation to their interaction
(Bartlett, 2003). Although the original working defini-
tion had its share of critics, including Gordon's (1962 )
reexamination of the definition and Wakefield's (2003)
reconsideration of both Gordon's critique and the
working definition itself, the notion that the person-
in-environment was the proper domain of social work
practice remained intact.
Theoretical Conceptualizations
As early as the 1950s, a few social work sch olars had
begun to look for ways to better conceptualize the so-
called person-environment perspective. By the 1970s
this quest had become a major preoccupation in disci-
plinary discourse. Over the next several decades, two
major, interrelated frameworks were advanced specifi-
cally for the purpose of giving theoretical substance to
the person-environment perspective: (a) general sys-
tems theory and (b) ecological theory and life model.
General Systems Theory
Hearn (1958,1969) is usually credited with introducing
general systems theory into the social work literature
(Drover & Shragge, 1977). Other early contributors to
the application of general systems theory to social work
include Pincus and Minihan (1973), Meyer (1976),
Goldstein (1973), Gordon (1969), and Lathrope (1969).
General system theory, based largely on the work of
theoretical biologist Bertalanffy (1950, 1969), became
ascendant in the social work literature in the 1960s and
1970s, and remained the prevailing paradigm until the
introduction of ecological systems theory (or
ecosystems theory) in the late 1970s and 1980s.
PERsoN-IN-ENVIRONMENT 349
Bertalanffy was concerned with what he saw as the
increasingly mechanistic and atomized view projected
by contemporary science, in which parts and processes
of a given phenomenon were identified and studied as
isolated entities. He argued that an element is best
understood in relation to its constituent parts (sub-
systems) and in relation to larger or more complex ele-
ments of which it is a constituent part. He defined
"system" as "sets of elements standing in interrelation"
(1969, p. 38). Bertalanffy identified two kinds of
systems: "closed systems," that is, "systems that are
considered to be isolated from their environment"
(1969, p. 39) and "open systems," characteristic of
living organisms, which are in constant interaction with
their environments. Other concepts he emphasized
included "subsystems," the constituent elements of a
larger system in a hierarchical order, and "feedback," or
the flow of.information in an open system that allows
regulation (change) and stability (homeostasis) in
relation to other systems.
The concept of a hierarchy of systems, in which a
system was comprised of a set of subsystems and in tum
constituted a subsystem of a larger entity/system, was
crucial to the application of systems theory in social
work. Persons and other systems were understood to be
influenced by contiguous systems and by larger systems
of which they were a part. System theory reinforced the
notion that the focus of social work practice should be
on neither person nor environment, but rather on trans-
actions between person (a system) and systems in the
environment (Gordon, 1969; Lathrope, 1969; Pincus &
Minihan, 1973).
Because of system theory emphasis on linkages be-
tween systems of differing sizes and complexity, early
theorists were convinced that systems theory would aid
in unifying social work practice, including the dual
focus on person and environment (Gordon, 1969; Hearn,
1969; Pincus & Minihan, 1973). However, not everyone
was enthusiastic about System Theory's potential.
Drover and Shragge (1977), for example, argued that
systems theory did not account for values and ideology.
Leighninger (1977,1978) shared the concern for values,
particularly-with regard to what he viewed as an implicit
acceptance of status quo (emphasis on achieving
homeostasis) and consequent inadequacy of the theory
to deal with larger social change or conflict. Others
suggested that the level of abstraction of the model was
somewhat distant from human phenomena the model
was said to describe (Drover & Shragge, 1977; Germain,
1978a). Still others argued that the systems theory focus
on transactions took attention away from the "person,"
and, therefore, was inconsistent with so cial work's
commitment to the centrality of the indi vidual (Mishne,
1982).
350 PERSON-IN-ENVIRONMENT
The general system paradigm was the major influence
in social work theorizing for approximately two decades.
At the time it provided a useful challenge to
psychodynamic theory as the reigning conceptual model
for practice, and brought renewed attention to larger
elements in the social environment (Leighninger, 1977 ).
Although largely replaced by ecological (ecosystem)
theory, general system theory concepts are still operative in
a number of family therapy models, particularly in
"structural family therapy" developed by Minuchin (1974).
Ecosystems Theory and the Life Model Ecosystems
theory in social work, draws on general systems theory and
the science of ecology, the study of
\
living organisms within their environments. The ecolo-
gical or ecosystem perspective is usually associated with
the work of Germain and Gitterman (Germain, 1973, 1977,
1978a, 1978b, 1981; Germain & Gitterrnan, 1996;
Gitterman & Germain, 1981) and Meyer (1983).
Although general systems theory provided useful tools for
organizing assessments and planning interventions with
various systems (macro and micro) relevant to a particular
case, many came to view systems theory as too
mechanistic and too abstract to deal effectively with the
phenomena of people's daily lives (Germain, 1978a;
Peterson, 1979). The discipline of ecolo gy, based as it is on
living organisms in relationship to other systems with
which they interact in an environment, appeared to offer a
more concrete and lifelike metaphor for conceptualizing
the traditional person-inenvironment perspective.
The core principle of the ecosystem perspective is that
each individual (family, group) is in an interdependent and
constant relationship with the larger environment and with
other elements that make up his or her environment
(Germain & Gitterman, 1996). This means that an
individual cannot be understood adequately without
reference to the environmental context the individual
inhabits (Brower, 1988). The perspective emphasizes that
the environment can exert a facilitative or an inhibiting
effect on well-being of individuals, just as individuals can
impact the environment in ways that promote or damage
the ability of the environment to facilitate life (Germain,
1981). To a greater extent than general systems theory,
ecosystems theory stressed the mutuality of
person-environment relationships (Germain, 1973, 1981).
Similarly, while general systems theory helped
practitioners think systematically about influences external
to the individual, the ecosystem framework and the life
model of practice based on this framework went further by
insisting on
the absolute necessity of considering the whole human
context in any practice situation.
The most comprehensive critique of the ecosystem
framework was leveled by Wakefield (1996a, 1996b ).
Two of his arguments are pertinent to this discussion.
First, he challenged the notion that social work needs one
all-encompassing conceptualization like the eco system
framework to give coherence to disparate forms of
practice, including interventions with differing em phasis
on person and environment. He further argued that the
ecosystem perspective "looses the specialness of the
person" with its identification of person as one system
among many others and a focus on transactions rather than
persons (1996b, pp. 198-199). Gitterman (1996 )
responded to Wakefield by arguing that an overarching
conceptualization like the ecosystem framework helps us
to understand that no one domain-specific theory or model
accounts for all of social reality. He further argued that the
ecosystem model, rather than dismissing the importance of
the person, captures the uniqueness of each person in his
or her singular context. Other critiques of the ecosystem
perspective have generally accepted the framework, but
have suggested that typical conceptualiz ations of the
ecosystem framework lacked attention to identified as-
pects of person or cultural-social-physical environment
(Besthorn & Canda, 2002; Devore, 1983; Epple, 2004 ;
Saleeby, 1992, 2004). Despite its critics, the ecosystem
framework continues to have a great deal of currency as a
conceptualization of person-in-environment, so much .so
that the ecosystem framework is sometimes treated
(erroneously) as synonymous with the person-in-envir-
onment perspective. The perspective continues to be
identified in theoretical and research literature as a guiding
framework (Rogge & Cox, 2001).
Recent Conceptual Developments
A series of new theoretical approaches have emerged in
the literature since the early 1990s, providing alternate
formulations for the person-environment relationship.
These perspectives offer a fresh look at the relationship
between individuals and their contexts, with the possi-
bility of new avenues for intervention and research.
Nonlinear, Dynamical Systems Theory Several
theorists have begun to extend systems theory by applying
nonlinear, dynamical systems theories to com plex clinical
problems. Proponents argue that human behavior is
frequently more complex and apparently unpredictable
than can be explained by simple, linear cause and effect
relationships (Warren, Franklin, & Streeter, 1998; Warren
& Knox, 2000). Dynamical

systems theories attempt to account for change in sys-
tems over time, including feedback loops that may
recursively alter the process of change in unexpected
ways (Warren et al., 1998). Warren and Knox (2000)
have successfully applied mathematical formulae based
on dynamical systems theory to the behavior of adoles-
cent sex offenders. These authors suggest that the model
may be useful for other types of compulsive behavior.
Risk and Resilience Theory as an
Ecosystem Approach
Linking ecological theory with concepts drawn from
epidemiology and public health, theorists posit that
there are risk factors and protective factors inherent in
the environment and in the person (Fraser, Richman, &
Galinsky, 1999, 2004). Risk factors increase the
likelihood of harm or the continuation of a harmful
situation; protective factors support positive outcomes
even in situations of risk (Fraser, Richman, & Galinsky,
1999, 2004). What makes this framework useful for
social workers and researchers is the conceptual and
operational support it provides for multilevel
assessment, intervention, and evaluation. There is a
growing body of social work literature, including
empirical studies, supporting this perspective,
particularly (though not exclusively) in child welfare
(Corcoran & Nichols-Casebolt, 2004; Early & Vonk,
2001; Fraser, 1996,2004; Fraser, Richman, & Galinsky,
1999; Greene & Cohen, 2005; Little, Axford, &
Morpeth, 2004; Unger, 2001). A very new, intriguing
development in risk-resilience theory is the suggestion
that the fields of genetics and social epidemiology may
have something to offer social workers through
promising work on gene-environment interactions
(McCutcheon, 2006).
Person and Environment in
Social Constructivist Theory
Since the 1990s, the social work literature has seen
increasing interest in the implications of social con-
structionist theories. Those who adopt some form of
constructivist perspective agree that the impact of the
environment on individuals is not direct, but rather is
mediated by various meaning-making processes
through which people make sense of their
environmental realities (Allen, 1993; Carpenter, 1996;
Gergen, 1999; Kondrat, 2002; La.ird, 1993). Social
constructionism serves as the basis for newer forms of
therapy with individuals and families, including
solution-focused and narrative therapies (Berg & De
[ong, 1996; Franklin, 1996; Gergen, 1999). Consistent
with a belief that knowledge and reality are humanly
constructed,
PERSON-TN-ENVIRONMEN
T 351
constructivist researchers adopt qualitative, interpreti-
vist approaches to inquiry (Schwandt, 1994). More than
earlier person-in-environment conceptualizations, con-
structivism advances the notion of the human beings as
active agents in constituting their own social envir-
onments. However, social constructionist theorizing has
tended to focus on the construction of micro (inter-
personal) realities, and has not consistently accounted
for the macro environment, except to suggest that larger
social structures do impact individual realities
(Kondrat, 1999,2002; Laird, 1993). In an effort to
include larger systems more securely in constructivist
thinking, Kondrat (1999, 2002) proposed a
macro-constructivist conceptualization of
person-in-environment, based on Giddens'
Structuration Theory (1979, 1984, 1987). This
formulation suggests that, larger social structures and
institutions, even society itself, are all social con-
structions, constituted and maintained by the social
actions and interactions of people over time. She sug-
gests that the individual is in the environment not so
much the way a smaller box is within a larger box (the
historical metaphor) as Germain (1978a) proposed, but
rather the way players are in the football game or
dancers in the ballet. The game and the dance do not
exist without the players/dancers. This conceptua-
lization is said to offer a more dynamic link between
individuals and their environments, both micro and
macro (Kondrat, 2002).
Operationalizing Person-in- Environment
A number of attempts have been made to operationalize
the terms "environment" and "person" to provide
practitioners with a consistent tool to guide assessment
and intervention across practice situations. By and
large, these efforts have been atheoretical; that is to say,
have formulated operational termsdirectly from the
person-environment practice principle, without
reference to given theories. The "genogram" and "eco-
map" are familiar examples (Hartman, 1978; Walton &
Smith, 1999). The most comprehensive attempt to op-
erationalize person-in-environment was the PIE classi-
fication system developed by Karls ~d Wandrei (1992,
1994) (Karls, Lowery, Mattaini, & Wandrei, 1997;
Williams, Karls, & Wandrei, 1989). The PIE classifica-
tion system is described as an instrument for coding
common problems of adult clients. It is a four-factor
system (a) person's problems in social functioning, (b)
problems in the environment affecting a person's func-
tioning, (c) mental health problems (using the DSM),
and (d) health problems (Karls & Wandrei, 1994). A
number of studies and case applications were described
in the book that presented the system. This system held
352 PERsON-IN-ENVIRONMENT
the initial promise of doing for social work what the DSM
does for psychiatry-that is, provide a common
nomenclature to guide assessment and intervention.
Critics, however, suggested that the system was too
focused on aggregating discrete problems, that it may
have limited cultural applicability particularly in more
collectivist cultures, and that it was too reliant on the
medical model (Karls et al., 1997). The strong problem
focus may also be incompatible with more recent em-
phases on client strengths, not captured in the PIE
formula. For whatever reason, the PIE sys tem has not
been further developed in the literature in any systema tic
way.
Conclusion
. \
Wakefield's (1996a, 1996b) provocative question as to
whether the profession's historical quest for one all-
encompassing theory to capture the disparate forms of
social work practice may have been answered by recent
history. Currently, there are a number of alternate and
coexisting conceptualizations for the relationship
between person and environment that are bridging
interdisciplinary boundaries in unexpected and promising
ways. For better or worse, the search for one
discipline-unifying conceptualization may not have been
realized. Nevertheless, to date, the principle that social
work practice is characterized by a
person-in-environment perspective seems to have stood
the Jest of time.
REFERENCES
Allen,]. A. (1993). The constructivist paradigm: Values and
ethics. Journal of Teaching in Social Wark, 8,31-54.
Austin, D. (2001). Guest editor's foreword. Research on Socktl Wark
Practice, 11(2), 147-151.
Bartlett, H. M. (2003). Working definition of social work practice.
Research on Social Work Practice, 13(3),267-270. (Reprinted
from Bartlett, H. (1958). Working definition of social work
practice. Social Wark, 3(2), 5-8.)
Berg, 1. K., & De long, P. (1996). Solution-building conversa-
tions: Co-constructing a sense of competence with clients.
Families in Society, 77(6), 376-391.
Bertalanffy, L. V. (1950). The theory of open systems in . physics
and biology. Science, 111, 23-29.
Bertalanffy, L. V. (1969). Grneral system theory. New York:
George Braziller.
Besthorn, F. H., & Canda, E. R. (2002). Revisioning environment:
Deep ecology for education and teaching in social work.
Journal of Teaching in Social Wark, 22(1), 79-101.
Brieland, D. (1977). Historical overview. Social Wark, 22(5),
341-346.
Brower, A. M. (1988). Can the ecological model guide social
work practice? Social Service Review, 62(3), 411-429.
Carpenter, D. (1996). Constructivism and social work treatment.
In F. J. Turner (Ed.), Social wark treatment: Interlocking
thearetical approaches (4th ed., pp. 146-167). New York:
Free Press.
Corcoran, ]., & Nichols-Casebolt, A. (2004). Risk and resilience
ecological framework for assessment and goal formation.
Child and Adolescent Social Wark Journal, 21(3), 211-235.
Council on Social Work Education. (2004). Educational Policy and
Accreditation Standards, Retrieved on December 9, 2006, from
http://www.cswe.org
Devore, W. (1983). Ethnic reality: The life model and work with
black families. Social Casework, 64(9), 525-531.
Drover, G., & Shragge, E. (1977). General systems theory and
social work education: A critique. Canadian Journal of Social
Wark Education, 3(2), 28-39.
Early, T. ]., & Vonk, M. E. (2001). Effectiveness of school social
work from a risk and resilience perspective. Children and
Schools, 23(1),9-31.
Epple, D. M. (2004). Encounter with soul. Clinical Social Wark
Journal, 31(2),173-188.
Franklin, c., & Nurius, P. S. (1996). Constructivist therapy:
New directions in social work practice. Families in Society,
77(6),323-325.
Fraser, M. W; (1996). Aggressive behavior in childhood and early
adolescence: An ecological-developmental perspective. Social
Wark, 41(4), 347-361.
Fraser," M. W. (2004). The ecology of childhood: A multisystems
perspective. In M. W. Fraser (Ed.), Risk and resilience in
childhood (2nd ed., pp. 1-12). Washington, DC:
National Association of Social Workers.
Fraser, M. W., Richman,]. M., & Galinsky, M.]. (1999). Risk,
protection and resilience: Toward a conceptual framework for
social work practice. Social Wark Research, 23(3), 131-143.
Gergen, K.]. (1999). An invitation to social construction. Thousand
Oaks, CA: Sage.
Germain, C. B. (1973). An ecological perspective in casework
practice, Social Casewark, 54, 323-330.
Germain, C. B. (1977). An ecological perspective on social work
practice in health care. Social Wark in Health Care, 3(1),67-76.
Germain, C. B. (1978a). General-systems theory and ego
psychology: An ecological perspective. Social Service Review,
52( 4), 535-550.
Germain, C. B. (1981). The ecological approach to people-
environment transactions. Social Casewark, 62(6), 323-331.
Germain, C. B. (1987). Human development in contemporary
environments. Social Service Review, 61 (4), 565-580 .
Germain, C. B., & Gitterman, A. (1996). The life model of social wark
practice (Znd ed.). New York: Columbia University.
Germain, C. B., & Hartman, A. (1980). People and ideas in the
history of social work. Social Casewark, 61 (1),323-331.
Giddens, A. (1979). Central problems in social theory: Action,
structure and contradiction in social analysis. Berkeley and Los
Angeles, CA: University of California Press.
Giddens, A. (1984). The constitution of society. Oxford: Polity Press.
Giddens, A. (1987). Social theory and modem sociology.
Stanford: Stanford University Press.

Gitterman, A. (1996). Ecological perspective: Response to Pro-
fessor Jerry Wakefield. Social Service Review, 70(3), 472-476.
Goldstein, H. (1973). Social work practice: A unitary approach.
Columbia, SC: University of South Carolina.
Gordon, W. (1962). A critique of the working definition.
Social Work, 7(4), 3-13.
Gordon, W. (1969). Basic constructs for an integrative and
generative conception of social work. In G. Hearn (Ed.),
General Systems Approach: Contributions toward a holistic
conception of social work (pp. 5-11). New York: Council on
Social Work Education.
Greene, R. R., & Cohen, H. L. (2005). Social work with older
adults and their families: Changing practice paradigms.
Families in Society, 86(3), 367-374.
Hartman, A. (1978). Diagrammatic assessment of family rela-
tionships. Social Casework, 59(8), 465~76.
Hearn, G. (1958). Theory building in social casework. Toronto,
Ontorio: University of Toronto.
Hearn, G. (Ed.). (1969). General systems approach: Contributions
toward a holistic conception of social work. New York:
Council on Social Work Education.
Holosko, M. ]. (2003). Guest editor's foreword. Research on Social
Work Practice, 13(3),265-266.
International Federation of Social Workers. (2006). Definition of
social work. Retrieved December 3, 2006, from http://
www.ifsw.org/en/p38000208.html
Karls,]. M., Lowery, C. T., Mattaini, M. A., & Wandrei, K. E.
(1997). The use of PIE (person-in-environment) system in
social work education. Journal of Social Work Education,
33(1),49-58. '
Karls,]. M., & Wandrei, K. E. (1992). PIE: A new language for
social work. Social Work, 37(1),80-85.
Karls, ]. M., & Wandrei, K. E. (Eds.). (1994). Person-in-
environment system. Washington, DC: NASW.
Kondrat, M. E. (1999). Who is the self in self-aware: Professional
self-awareness from a critical theory perspective. Social Service
Review, 73(4),451-477-
Kondrat, M.E. (2002). Toward an actor-centered social work:
Re-visioning person-in-environment through a critical theory
lens. Social Work, 47(4), 435-448.
Laird, ]. (1993). Family-centered practice: Cultural and con-
structionist reflections. Journal of Teaching in Social Work,
8,77-109.
Lathrope, D. (1969). The general systems approach in social work
practice. In G. Hearn (Ed.), General systems approach:
Contributions toward a holistic conception of social work (pp.
45-62). New York: Council on Social Work Education.
Leighninger, R. (1977). Systems theory and social work. Journal
of£ducation for Social Work, 13(3),44-49.
Leighninger, R. (1978). Systems theory. Journal of Sociology and
SocwlWelfare,5(4),446-480.
Little, M., Axford, N., & Morpeth, L. (2004). Research review:
Risk and protection in the context of children in need. Child and
Family Socwl Work, 9(1), 105-117.
McCutcheon, V. V. (2006). Toward an integration of social and
biological research. Social Service Review, 80(1),159-178.
Meyer, C. (1976). Socioi work practice (Znd ed.). (1970). New
York: Free Press.
PERSON-IN-ENVIRONMENT 353
Meyer, C. (1983). Clinical social work in the eco system perspective.
New York: Columbia University Press.
Minuchin, S. (1974). Families and family therapy. Cambridge:
Harvard University.
Mishne, J. M. (1982). The missing system in social work's appli-
cation of systems theory. Social Casework, 63(9), 547-553.
National Association of Social Workers. (1996). Code of ethics.
Retrieved December 3,2006, from http://www.social
workers.org/pubs/code/code.asp
Peterson, K.]. (1979). Assessment in the life model: A historical
perspective. Social Casework, 60(10), 586-596.
Pincus, A., & Minihan, A. (1973). Social work practice: Model and
method. Itasca: Peacock.
Rogge, M. E., & Cox, M. E. (2001). The person-inenvironment
perspective in social work journals: A computer-assisted
content analysis. Journal of Social Services Research, 28(2),
47-68.
Saleeby, D. (1992). Biology's challenge to social work: Em-
bodying the person-in-environment perspective. Social
Work,37(2), 112-118.
Saleeby, D. (2004). 'The power of place': Another look at the
environment. Families in Society, 85(1), 7-16.
Schriver, ]. M. (1987a). Harry Lurie's critique: Person and
environment in early casework practice. Social Service Review,
61(6). 514-532. ,
Schriver,]. M. (1987b). Harry Lurie's assessment and prescription:
An early view of social workers' roles and responsibilities
regarding political action. Journal of Sociology and Social
Welfare, 14(2), 111-127.
Schwandt, T. A. (1994). Constructivist, interpre tivist approaches
to human inquiry. In N. K. Denzin & Y. S. Lincoln (Eds.),
Handbook of qualitative inquiry (pp. 118-137). Thousand Oaks,
CA: Sage.
Sheffield, A. (1931). The situation as the unit of case study.
Social Forces, 9, 465-474.
Unger, M. (2001). The social construction of resilience among
problem youth in out-of-home placement: A study of
health-enhancing deviance. Child and Youth Care Farum,
30(3),137-154.
Wakefield, ]. C. (l996a). Does social work need the ecosystems
perspective? Part 1. Is the perspective clinically useful? Social
Service Review, 70(1),1-32.
Wakefield, ]. C. (1996b). Does social work need the ecosystems
perspective? Part 2. Is the perspective clinically useful? Social
Service Review, 70(2), 183-213.
Wakefield,]. C. (2003). Gordon versus the working definition:
Lessons from a classic critique. Research on Social Work
Practice, 13(3),284-298.
Walton, E., & Smith, C. (1999). The genogram: A tool for
assessment and intervention in child welfare. J oumal of Family
Social Work, 3(3), 3-20.
Warren, K., Franklin, c., & Streeter, C. L. (1998). New directions
in systems theory: Chaos and complexity. Social
Work,43(4),357-373.
Warren, K., & Knox, K. (2000). Offense cycles, thresholds and
bifurcations: Applying dynamical systems theory to the
behaviors of adolescent sex offenders. Journal of Social Service
Research, 27(1), 1-27.
354 PERSON-IN-ENVIRONMENT
Williams, J. B. W., Karls, J., and Wandrei, K. (1989). The
person-in-environment (PIE) system for describing problems
of social functioning. Hospital and Community Psychiatry,40,
1125-1126.
FURTHER READING
Berger, P., & Luckmann, T. (1966). The social construction of
reality. Garden City, NY: Doubleday.
Buffum, W. E. (1988). Measuring person-environment fit in
nursing homes. Journal of Social Service Research, 11(2/3),
35-54. . charitable giving could lead to personal salvation. This
Coulton, C. J., Holland, T. P., & Fitch, V. (1984). Person-
environment congruence and psychiatric patient outcome in
community care homes. Administration in Mental Health,
12(2), 71-88. , faith, repentance, and regeneration ("born again"
Dean, R. G. (1993). Teaching a constructivist approach to clinical
practice. Journal ofl'eaching in Social Work, 8, 55-75.
Kemp, S. P. (2001). Environment through a gendered lens:
From person-in-environment to woman-in-environment.
AFF1LlA, 16(1), 7-30.
Lutz, W. A. (1956). Concepts and principles underlying social
casework practice. New York: National Association of Social
Workers.
Minahan, A. (1977). Introduction to special issue. Social Work,
22(5),339.
Minahan, A. (1981). Purpose and objectives of social work
revisited. Social Work, 26(1), 5-6.
Monkman, M. M. (1991). Outcome objectives in social work
practice: Person and environment. Social Work, 36(3 ),
253-258.
-MARY E. KONDRAT
PERSONNEL. See Management: Human Resources.
PHARMACOLOGY. See Psychotropic Medications.
PHILANTHROPY
ABSTRACT: Philanthropy is defined as the voluntary effort
to increase the well-being of humankind. While
philanthropic activities in the early days of the United
States were largely influenced by religious beliefs and
values, since the late 1800s there has also been an
emphasis on social responsibility in an age of shifting
cultural traditions and rapid economic development. Still,
religious organizations remain the largest recipi ents of
donations, with human services receiving a
fraction of charitable giving. (
"Philanthropy" can be defined as the voluntary effort to
increase the well-being of humankind. As such,
philanthropy includes the giving by private individuals of
their money or time to charitable organizations. The former
act is commonly referred to as "charitable giving" or
"charitable donations" and the latter act, "volunteerism."
Philanthropy is critically important to societal well-being in
the United States of America, given this nation's reliance on
individual initiative and private means to social welfare.
Philanthropy in colonial America was fueled by religious
beliefs. By the mid-1700s, there was a growing belief that
sentiment was spread by religious revivals that swept the
country in the late 1720s and then again in the 1780s, lasting
into the 1830s. These religious movements, which promoted
experiences), emphasized good deeds. This included
charitable giving to the poor. In the process, all souls could be
saved. Thus, charitable giving becam~ an investment in one's
salvation (Trattner, 1999).
This increased charitable giving, in tum, helped fund the
growth of charitable agencies to assist the poor. Societies for
the Prevention of Pauperism emerged in the early 1800s in
eastern cities such as New York, Boston, and Baltimore. In
the mid~1800s, provident associations and "associations to
improve the condition of the poor" were established through
charity. Many of these agencies would eventually recruit
health and human service volunteers and employees, pioneers
in the profession of social work. City missions and other
religious affiliated organizations followed in the mid-to-late
1800s, charity-driven organizations such as the YMCA,
Salvation Army, and Red Cross. The YMCA, especially, was
well supported by local businessmen who had used its
services in making their earlier transition from rural areas to
cities during the Industrial Boom (Leiby, 1978; Trattner,
1999). I
While early American philanthropy was inspired by I
I
religious beliefs related to personal salvation, in the latter half !
of the 1800s, business and professional leaders began to see
philanthropy as a matter of social responsibility and
enlightened self-interest. This changing m0!A.y~t~on for
charitable g~ving an~ volunteerism resulted m part from
I
thegrowmg gap m wealth and income between elite
Americans and poor immigrant laborers.
"Charity organization societies," run by social work
pioneers such as Mary Richmond and based upon the new
secular concept of "scientific philanthropy," were established
by community leaders to better coordinate and deliver
services to the needy. To deter indiscriminate giving, Charity
Organization Societies began training their volunteers to
interview poor

families and assess individual need. "Deserving" indi-
viduals defined as ... were referred to the most appro-
priate community services, which were regularly
monitored to avoid duplication and redundancy. Busi-
ness leaders including William Waldorf Astor, Andrew
Carnegie, J. P. Morgan, and Mrs. Cornelius Vanderbilt
were prominent supporters of these charity organization
societies, often volunteering as trustees on their boards
(Katz, 1996; Leiby, 1978; Trattner, 1999).
The Charity Organization Society emphasis on
research, documentation, and technical skills led to the
establishment of professional social work education
programs at universities such as Indiana University,
Ohio State, the University of Minnesota, Columbia
University, and Bryn Mawr College.
The Charity Organization Societies also contributed
to the establishment of Community Chests, the prede-
cessor of the modem United Way system. In fact, United
Way of America traces its origin to the Charity
Organization Society of Denver in 1887. This Denver
organization centrally organized fund-raising for
several community charities, making it the first
federated fundraising organization in American history.
Because they reflected the concept of scientific
philanthropy, the community chests were popular with
business and professionalleaders. That is, the "chests"
provided a means by which to assess community needs
and services systematically. Local businesses acting on
their own lacked these community assessment and
evaluation skills. Community chests allowed requests
for financial support by local health and human service
to be evaluated for credibility in much the same way that
charity organization societies investigated individual
need. Thus, community chests and later, United Way,
became valued mechanisms for the community-wide
coordination of charitable efforts (Marx, 2004).
Another organized philanthropic effort beginning in
the late 1800s was the settlement house. Using T oynbee
Hall in London, England as a model, American
settlement houses were private nonprofit organizations,
established in poor, inner-city neighborhoods to promote
the social welfare of residents. The first was founded in
New York City in 1886, The most famous, Hull House,
was established by Jane Addams in Chicago three years
later (Addams, 1961). By 1910, there were 400
settlement houses serving the poor in the United States
(Katz, 1996; Leiby, 1978; Trattner, 1999).
Like charity organization societies and community
chests, settlement houses were founded on the principle
of scientific philanthropy. Observation, information
gathering (or in today's terms, "data collection"), and
documentation were believed to be prerequisites to
social advocacy and other philanthropic acts. Where
PHILANTHROPY 355
Socialist and Communist radicals promoted the strug gle
among classes, social worker Jane Addams and other
settlement leaders encouraged cooperation among
classes in promoting social welfare. This included chari-
table giving and volunteerism. Settlements provided
many services to poor immigrants including kinder-
garten classes, public kitchens called "coffee houses,"
gymnasiums, lectures, dances, nurseries, post office
branches, employment referral, visiting nurses, arts and
crafts courses, libraries, penny savings banks, art
galleries, and music halls (Marx, 2004).
Business and professional groups at the turn o f the
20th century also made charitable donations to an ex-
panding array of local "service clubs," many of which
still operate today. In 1910, Rotary International was
started, followed by the Kiwanis in 1916 and the Lions
in 1917. These groups typically concentrated their do-
nations on a specific group in need, including street
boys, crippled children, and blind people. Along with
mutual aid societies and fraternal organizations such as
the Masons, Odd Fellows, Eagles, and Loyal Order of
Moose, these service clubs, through charitable giving
and volunteers, provided the growing profession of
social work with grassroots resources by which to help
those in need (Marx, 2004).
As the American business sector became national in
scope, so too did its philanthropy. During the Pro-
gressive era, roughly 1900-1920, wealthy business
families increasingly established their own foundations
to make donations in a business-like manner. By 1920 ,
there were about 120 such foundations in the United
States, including the Russell Sage Foundation, created
in 1907, the Rockefeller Foundation, established in
1913, and the Commonwealth Fund, started in 1918.
The most successful business leaders, men such as
Andrew Carnegie, John D. Rockefeller, and J. P.
Morgan, took charitable giving during this period to an
unprecedented scale. Carnegie, who encouraged
wealthy Americans to give back to their communities
during their lifetime, systematically contributed to the
establishment of about 3,000 public libraries world wide.
Rockefeller focused much of his philanthropy on
education and health-related projects. For example, his
major financial gifts led to the founding of the
University of Chicago and Spelman College, the presti -
gious black women's college in Atlanta. In his lifetime,
Carnegie gave $350 million to charity, while
Rockefeller made $530 million in donations (Marx,
2004).
Following the New Deal of Franklin Roosevelt and
the Great Society programs of Lyndon Johnson, the
administrations of Presidents Ronald Reagan, George
H. W. Bush, William Clinton, and George W. Bush have
actively encouraged increases in volunteer ism and
356 PHILANTIlROPY
charitable giving to address unmet social welfare needs. In
1965, total U.S. charitable giving in inflationadjusted
dollars was $91.20 billion.
Since that time, giving has grown to $260.28 billion in
2005, an increase of 185%. Most of this philanthropy
consists of individual giving. For example, in 2005, close
to 77% of total U.S. charitable giving was from
individuals.
The largest recipient of American charitable giving has
consistently been religious organizations. From
2001-2005, religion received 38.9% of total U.S. giving. In
contrast, from 2001-2005, giving to human services
represented 9.3% of total U.S. giving, boosted in part by
giving for disaster relief. previously, human service giving
had fallen from a high of 14.8% Of total U.S. charitable
giving in die years 1966-1970 to a low of 8.7% in the
period 1996-2000. Similarly, since 1965, charitable giving
to health services has dropped from 12.8% of total U.S.
charitable giving to 9.4% in the years 2001-2005. Clearly,
competition for American charitable donations has
increased.
Trends and Challenges
Attracting greater donations to health and human services
is a future challenge for the profession of social work
(USA Giving Foundation, 2006).
REFERENCES
Addams, J. (1961). Twenty years at Hull-House. New York:
Penguin.
Katz, M. B. (1996). In the shadow of the poorhouse: A social
history of welfare in America. New York: BasicBooks.
Leiby, J. (1978). A history of social welfare and social work in the
United States. New York: Columbia University.
Marx, J. (2004). Social welfare: The American partnership.
Boston: Pearson.
Trattner, W. 1. (1999). From poor law to welfare state: A history
of social welfare in America, (6th ed.). New York:
The Free Press.
FURTIIER READING
Barber, D. M. (2002). Finding funding: The comprehensive guide W
gTant writing. Long Beach, CA: Bond Street Publishers.
Berkowitz; E. D. (1991). America's welfare state from Roosevelt to
Reagan. Baltimore: John Hopkins University Press.
Brinckerhoff, P. C. (2000). Social entrepreneurship: The art of
mission-based venture development. New York: Wiley.
Brinckerhoff, P. C. (2003). Mission based marketing: How your
non-profit can succeed in a more competitive world. Hoboken, NJ:
Wiley.
Browning, B. (2005). Grant writing for dummies. Hoboken, NJ:
Wiley.
Burlingame, D. E, & Poston, M. J. (Ed.). (1999). The impact of
technology on fundraising. San Francisco: [ossey-Bass
Publishers.
Day, P. J. (2000). A new history of social welfare. Englewood
Cliffs, NJ: Prentice-Hall.
Edles, L. P. (1993). Fundraising: Hands-on tactics for nonprofit
groups. New York: McGraw-Hill.
Gilpatrick, E. (1989). Grants for nonprofit organizations: A guide to
funding and gTant writing. New York: Praeger.
Gitlin, L. N., & Lyons, K. J. (2004). Successful gTant writing:
Strategies for health and human service professionals. New York:
Springer.
Harrington, M. (1962). The other America: Poverty in the US.
New York: MacMillan.
Howe, F. (1991). The board member's guide to furu1raising:
What every trustee needs to know about raising money. San
Francisco: jessey-Bass Publishing.
Jansson, B. ·(2001). The reluctant welfare state: American social
welfare policies-past, present,and future. Pacific Grove, CA:
Brooks Cole.
Josephson, M.(1962). The robber barons. New York: Harcourt
Brace.
Klein, K. (2000). Fundraising for the long haul. San Francisco:
[ossey-Bass.
Loewen, J. W. (1995). Lies my teacher wld me. New York:
Touchstone.
Lohmann, R. (1992). The Commons: Perspectives on nonprofit
organizations and voluntary action. San Francisco:
[ossev-Bass.
Marmor, T. R., Mashaw, J. L., & Harvey, P. L. (1990). America's
misunderstood welfare state. New York: Basic Books.
Mink, G., Solinger, R., & Piven, F. F. (2003). Welfare: A
documentary history of u.s. policy and politics. New York
University Press.
Mishra, R. (2001). Globalization and the welfare state. Northampton,
MA: Edward Elgar.
Patterson, J. T. (1994). America's struggle against poverty
1900-1994. Cambridge, MA: Harvard University Press.
Rifkin, J. (1995). The end of work: The decline of the global labor
force and the dawn of the post-market era. New York:
Putnam.
Skocpol, T. (1996). Protecting soldiers and mothers: The political
origins of social policy in the United States. Cambridge, MA:
Harvard University.
Smith, A. (1982). The wealth of nations. New York: Penguin
Books.
Smith, H. S., McLean, D., & Coles, R. C. (2001). Grantsmanship
& fundraising fundamentals: Guidelines for human and leisure
services professionals. Reston, VA: American Association for
Leisure and Recreation.
Thurow, L. C. (1981). The zero-sum society: Distribution and the
possibilities for economic change. New York: Penguin Books.
Wilson, W. J. (1996). When work disappears. The world of the new
urban poor. New York: Knopf.
Young, J., Wyman, K., & Swaigen, J. (2002). Fundraising for
non-profit gToups. Bellingham, W A; North Vancouver, B.C.:
Self-Counsel Press.
Zinn, H. (1995). A people's history of the United States: 1492present.
New York: HarperCollins.
-JERRY MARX

PIE. See Person-in-Environment.
POLICE SOCIAL WORK
ABSTRACT: Police social workers are professionally
trained social workers or individuals with related aca-
demic degrees employed within police departments or
social service agencies who receive referrals primarily
from police officers. Their primary functions are to
provide direct services such as crisis counseling and
mediation to individuals and families experiencing so-
cial problems such as mental illness, alcohol and sub-
stance use and abuse, domestic violence, and child
abuse, among others. Ad8 itional functions of police
social workers include training police officers in stress
management, mental illness, substance abuse, domestic
violence, and child abuse; providin g consultation to
police officers; arid counseling police officers and their
families.
KEY WORDS: police social work; criminal justice; crisis
intervention; law enforcement
Approximately 80% of the patrol work that police officers
perform consists of responding to calls that involve social
problems (Mastrofski, 1983; Scott, 1981; Trojanowicz &
Dixon, 1974). Percentages vary based on the officer' s
assignment and community char acteristics, and some
officers estimate that their work involves more than 80%
responding to calls for service that require social problem
solving related tasks. Responding to these calls requires
that police officers have skills in crisis counseling,
mediation, referral, and the provision of information
instead of traditional crime fighting skills. Mandatory
domestic violence arrest and mandated child abuse
reporting laws require that police officers provide a
specific and similar interven tion in response to these
situations that is based on following general orders. These
general orders require that officersintervene according to
directives and limit the amount of discretion that they may
use. However, the interventions that are provided by
police officers in response to social problems that do not
involve violations of the law, such as neighbor disputes
and family disputes among others, provide officers with a
wide range of individual discretion. These types of police
calls do not require a consistent intervention that is
mandated by general orders. Consequently police offi cers
can provide mediation, referrals to a wide range of
community agencies, and various types of information
regarding the problem.
POLICE SOCIAL WORK 357
Additional services that police officers may provide
include transportation, assisting individuals with ob-
taining emergency resources, and contacting a support
system or community service provider. To provide ef-
fective community policing services to citiz ens with
whom they have contact, police 'officers need to have
some knowledge of the culture and values of the corn-
munity and community resources. Trojanowicz and
Bucqueroux (1990) described community policing as
initiatives that involve the police and co mmunity working
together in partnership to seek innovative solutions to
community problems such as crime and disorder. In such
partnerships community residents act as unpaid volunteers
within these initiatives.
Providing effective community services to indivi duals
experiencing social problems can be very time consuming
for police officers. Taken together, these issues provide
the foundation for the practice of police social work. Less
often performed functions of police social workers are the
provision of direct services to departmental staff, police
officers, and their families. In general, police social
workers assist law enforcement organizations and police
officers with managing social problems and the primar y
functions of police social workers involve the provision of
direct services to individuals and families who are the
recipients of police calls for service.
History
August Vollmer is known as "the father of modem
professional policing in the United States" (Mac Namara,
1989, p.178) and is the most influential police reformer of
the early 20th century, perhaps of all time (Vila & Morris,
1999). At the meeting of the Interna tional Association of
Chiefs of Police in 1919, Vollmer delivered an address
titled The policeman as social. worker (Vollmer, 1971), in
which he acknowledged the rela tionship between police
work and social work. Vollmer stated that social
problems, such as poverty, unemploy ment, alcohol, and
gambling, among others, are contributing f actors to
criminal behavior. He suggested that police officers were
beginning to recognize the contributions that social work
principles could offer them when responding to these
social problems.
Although Vollmer focused on the police officer "as
social worker," thirty-three years after his speech, the first
published description of employing a social worker within
a police department appeared. The Rochester Public
Safety Commission and the City's Council of Social
Agencies concluded that social work servi ces were
ineffective because individuals were unaware of services.
Since police officers have frequent contact with social
problems such as juvenile delinquency,
358 POLICE SocIAL WORK
mental illness, and family problems, the Commi ssion and
Council agreed to place a social work liaison at police
headquarters. The social workers' task was to refer
families and individuals to social service agencies. Over
an 8-month period more than 200 families were referred .
It was anticipated that social work practice would reduce
the crime rate, thereby benefiting the Rochester Police
Department, and benefiting social service agencies
through referrals of cases that had police contact
(American City, 1952).
Penner (1959) later described the use of social work ers
and caseworkers in The Englewood Project, an ex-
periment conducted from August 1954 to August 1957 in
the Englewood Police District of, Chicago, Illinois. The
goals of the project were to assess the feasibility of police
and social service agehcy cooperation to prevent juvenile
delinquency, and to utilize casework skills to manage
referrals that were received from police officers.
Subsequent to The Englewood Project in the 1950s, the
Police-Social Service Project, a demonstration project
sponsored by the Jane Addams College of Social Work,
University of Illinois with funding provided by the
Illinois Law Enforcement Commission and local gov-
ernment sources, was initiated in 1970 in Wheaton ,
Illinois, and 1971 in Niles, Illinois. The project u tilized
social workers and second. year MSW students who were
placed in police departments (Michaels & Treger, 1973;
Treger, 1975).
Following these early descriptions of police social
work, other descriptions emerged in the literature. Some
police social work program models, such as the Detroit
model, were formed between a law enforcement and a
social service agency. Social workers were em ployed
within social service agencies, not within the police
department, and received referrals from police officers
(Holmes, 1982). The Philadelphia model com prised a
team of social workers, mental health workers, and patrol
officers who identified and transported homeless
individuals to a rehabilitation center for services (Finn,
1988).
Several recent descriptions of police social workers
working within police departments have been published.
These police departments include the Albuquerque and
Boston Police Departments (Vallianatos, 2000), the Los
Angeles Police Department (Goodstein, 2000), and
several police departments located in North Carolina- the
Lumberton Police Department, the Chapel Hill Police
Department, and the Orange County Sheriff's Of fice
(Dean et al., 2000).
Police Social Work Practice
Police social workers perform functions such as (a)
training in domestic violence, child abuse, mental
illness, alcohol and substance use and abuse, and stress
management; (b) case consultation and t he provision of
information concerning how to manage a case situation or
where to refer an individual or family for services; and (c)
counseling police officers and their families within a law
enforcement employee assistance program, outpatient
mental health agency, or private practice. These functions
are performed less frequently than are direct practice with
individuals and families who come
to the attention of the police. -
Patterson (2004a) investigated the types of inter-
ventions provided by a police social work team and found
that 85% of the.cases in the sample were referred by
police officers. The services provided by the team
included crisis intervention (31 %), short-term counsel ing
(19%), follow up (8%), information concerning other
services provided by the police department (8%) ,
mediation (5%), case status information (4%), and
referrals (25%). Among a sample of23 police social work
teams, Zimmerman (1988) found that interven tions were
provided in the following manner: 21 pro grams provided
counseling or therapy; 13 provided crisis intervention; 8
provided referrals; 7 provided as sessment and
consultation; 4 provided public speaking; 2 provided
client advocacy, followup, and outreach; 3 provided
general services; and 1 program provided trans portation to
clients. Referrals were received by the 23 programs in the
following manner: all of the programs received referrals
from the police department, 16 programs received
referrals from self or family and friends, 12 from schools ,
11 from the court system, 10 from social service agencies ,
3 from churches, 2 from hospitals, 2 from the probation
department, and 1 program received a referral from the
fire department.
The practice of police social work has also been
described in numerous social work texts. Treger (1995 )
described police social work as the provision of social
work services to victims, offenders, and indivi duals and
families who are referred to the social worker by police
officers. The police social worker may be employed both
within and outside of police depart ments, mental health
agencies, and private practice. Ba~ton (2000) discussed
the tension filled relationships between some police
officers and social workers that arise from different
working practices, stereotypical ideas that ea ch group
holds about the other, and lack of trust. Barton asserted
that closer working relation ships can eliminate these
barriers.
Knox and Roberts (2002) emphasized that police
social workers provide case findings, referrals, mental
health and suicide assessments, crisis intervention, family
violence intervention, victim assistance and advocacy
services, and services to child sexual assault

services victims, the mentally ill, homeless individuals, and
youth. Finally, Barker (2003) defined police social work as
professional social work practice in police pre, cincts,
courthouses, and jails focused on the provision of
interventions and social services to crime victims, individuals
who are accused of crimes, and their fa, milies. Some police
social workers provide counseling to police officers and their
families related to work stress. Whereas some police social
workers are civilians, others are sworn police officers who are
also professional social workers.
Within soine police departments individuals who perform
these functions may have a related degree and are not MSW or
BSW level social workers. Some in, dividuals who perform
police sociai work functions may be counselors or other
mental health professionals. Some civil service regulations
require that police social workers hold an academic degree in
social work or a related area, in addition to social work or
related work experience. Job titles and descriptions may also
vary across jurisdictions that hire police social workers. Some
jurisdictions may not use "social worker" as a job title.
Police Social Work Program Models
Many types of police social work program models have been
implemented. Some models utilize individuals who hold
social work degrees and are employed by a law enforcement
organization, whereas other models utilize social workers who
are employed by a social service organization. In either case,
police social workers are employed within small teams or
units. Zimmerman's (1988) analysis of 23 police social work
partnerships primarily located in suburban Illinois described
the small staffing patterns that are typical of police social
work programs. A total of 46 staff were employed among
these programs; 11 programs employed 1 social worker, 7
employed 2, 3 employed 3, and 2 programs employed 6 social
workers.
The Birmingham Police Department employs civilian
social workers with training in social work and related fields.
Police social workers wear civilian clothes instead of
uniforms, drive unmarked police vehicles, monitor and carry
police radios, and respond to calls such as domestic violence,
housing needs, and transportation. Funding for the program is
provided by the city of Birmingham. In 1997, ......,2,189 calls
for service were received with mental health needs compris-
ing the largest category (Steadman, Deane, Borum, &
Morrissey, 2000).
The Rochester Police Department utilizes a similar model,
the Family and Crisis Intervention Team (FACIT). Civilian
social workers and counselors with
POLICE SOCIAL WORK 359
related degrees are employees of the police department, drive
unmarked police departmental vehicles, and respond to calls to
assist police officers. The FACIT unit responds to a wider
variety of calls that includes landlord-tenant-neighbor
disputes, homicide and sui, cide victims and survivors,
domestic violence, child abuse and elder abuse, runaways,
homelessness, mental illness, and alcohol and substance
abuse, among others. The unit also provides a critical incident
response to notify next of kin in the aftermath of homicides,
fatal fires, accidents, and other traumatic incidents, and· re-
sponds to the needs of employees and customers follow, ing
bank robberies (RPD Bureau of Organizational Development
and Administration, n.d.). The Police Department
Organizational Development (The City of Rochester
2003-2004 Budget, n.d.) report indicated that FACITwould
anticipate 5,380 requests for services in 2003-2004. This was
an increase from the actual number of 4,944 requests received
in 2001-2002.
Although police social workers who are employees within
police departments are employed in small units, nationwide
the majority of police social workers are perhaps involved in
ad hoc collaborations and partner' ships that have been
developed and maintained. These ad hoc collaborations occur
when police officers con' sult with social service agencies to
obtain information or make referrals for individuals and
families to receive services. The social workers may not
consider them' selves police social workers because their
primary tasks do not involve working with the police. Given
that there are ......,13,000 local law enforcement agencies
nationwide that employ """'436,000 law enforcement officers
(Bureau of Justice Statistics, 2003), and that ......,80% of
police work involves social problems, ad hoc collaborations
with social service agencies are the most common.
Current Research
Few outcome studies are available that describe the
effectiveness of police social work program models. Borum,
Williams, Deane, Steadman, and Morrissey (1998) evaluated
the effectiveness of the Birmingham Police Department police
social work team compared with two other models, a mobile
mental health crisis team that assists officers and a team of
specialty trained police officers who respond to calls involving
mentally ill individuals, on four dimensions: meeting the
needs of mentally ill individuals, helping them avoid
incarceration, reducing the amount of time that officers spend
on these calls, and maintaining community safety. They found
that officers who were employed in a department where they
had access to the specialty trained police officers rated the
team as highly effective on all four
360 POLICE SOCIAL WORK
dimensions. The model that utilized police social work-
ers was rated moderately effective on three of these
dimensions. Regarding reducing the amount of time that
officers spend on calls involving mentally ill in-
dividuals, police officers rated the social work team as
less effective than the team of specialty trained officers.
In particular police officers were concerned that the
social work team did not reduce the amount of time that
they were at the scene of the call because they had to be
present for the safety of the social workers. Dean et al.
(2000) provide a plan for the development and operation
of police social work partnerships using illustrations
based on five model programs. Dean et al. also suggest
that program evaluations be conducted to assess
program effectiveness .. Components of a police social
work program evaluation sh6uld include measures that
assess the response time to arrive at the scene of a call,
appropriateness of referrals, quality of assessments,
counseling effectiveness, service gaps, and consumer
satisfaction. They suggest that measuring these areas can
provide evidence of effectiveness, which is important
given that effective police social work programs are
more likely to receive support from key stakeholders.
Conducting research within law enforcement set-
tings can be challenging because of concerns about how
the data will be used and obtaining institutional
approval. Despite these challenges, police social
workers have evaluated the effects of law enforcement
training (Patterson, 2004b) and stress and coping stra-
tegies among police officers (Patterson, 2000,2002b,
20mb). Additional areas of research conducted by
police social workers include topics that are important
to law enforcement organizations. For example, law
enforcement organizations are based on a paramilitary
organizational model that is reported by police officers
to be a primary source of stress. An important research
question is whether police officers with military
experience adapt to this organizational model
differently from those without military experience
(Patterson, 2002a). The law enforcement response to
runaway youth has also been investigated. Families
contact police officers to report and search for runaway
youth. The data contained in missing person police
reports can be utilized to identify the service needs of
missing children and their families, inform social work
practitioners and researchers of the factors that
precipitated runaway behavior, and identify the
interventions provided by police officers (Patterson, in
press).
Challenges
Challenges in police social work practice include con-
fidentiality, safety concerns, and the ability to function
within an authoritarian paramilitary law enforcement
setting and to establish and maintain positive working
relationships with police officers. Police social workers
need to have excellent assessment and crisis interven-
tion skills, and the ability to engage voluntary clients
who have police contact. Bar-on (1995) suggested that
cultural, occupational, and gender differences; societal
expectations for different services from social workers
and police officers; different philosophies regarding
human nature; and the higher level of education required
for social work practice than for law enforcement work
sometimes make collaboration difficult. On the con-
trary, when knowledgeable and skilled social workers
understand and work through these challenges success-
ful collaborations and partnerships with police officers
can be established and maintained.
Future Directions
The demand for social workers who possess the skills
necessary to collaborate with police officers is likely to
increase. The increased need for police social workers,
and social workers who can form collaborations with
police officers, is related to: (a) the effects of work and
life stress on police officers' well-being, the law enforce-
ment organization and the community with whom they
work; (b) the use of police officers in schools where
opportunities for collaboration with school social work-
ers exist to meet the needs of youth and their families;
and (c) the need for law enforcement training in do-
mestic violence, elder and child abuse, and mental
health. Increased demand will also result from commu-
nity-policing initiatives, calls from community resi dents
to 911 and 311 operators for 24-hr assistance with social
problems that are dispatched to police offi cers, and
improving the well-being of police officers. Another
focus for collaboration is the provision of early
intervention and other services to victims and survivors
of traumatic incidents, disasters, and terrorism. This
includes helping first responders, such as police officers,
to cope in the aftermath of such events. Under the
leadership of the New York City Police Department's
(NYPD) Community Affairs Mental Health Team lea-
der (Telesco, 2002), police social workers played a role
in providing a disaster response (Patterson, 2003a). The
collaboration was possible because of prior established
working relationships with police officers, social work
knowledge of community resources, and previous ex-
perience in crisis intervention. It is also important for
social workers to understand the functions of law
enforcement at the scene of a disaster (Patterson &
Telesco, 2004).
Organizations such as the Association of Police
Social Workers (APSW) are essential for advancing the
practice of police social work. In 2007 APSW had

45 police social worker members. Forty two members were
located in Illinois and employed in 36 police departments
throughout the state. Three members were located and
employed in Wisconsin. The goals of APSW are to promote
awareness and serve as a resource for police social work. The
APSW also provides networking and support for professional
development.
Police social work will continue as an important area of
social work practice whether or not social workers who
collaborate with police officers identify as police social
workers. Given that the majority of police work involves
responding to social problems, police officers will continue to
rely on social service agencies for assistance. Additionally,
law enforcement organizations have begun to pay attention to
law enforcement stress and its effects \ on the organization,
police officers, their families, and the communities where
officers work. Furthermore, law enforcement organizational
efforts to decrease the stigmatization associated with police
officers' seeking professional help from mental health
professionals, including social workers, is beginning to
change police officers' attitudes. Clearly, the future demand
for police social workers and social workers who understand
law enforcement culture and how to collaborate with police
officers is likely to increase.
Acknowledgments
The author wishes to express institutional acknowledgments
to the Rochester Police Department (RPD), the Westchester
County Department of Public Safety, and the New York City
Police Department (NYPD). Acknowledgments are also
expressed to Des Raftery of the APSW and Tanya Manvelidze
for assistance with locating sources for this entry.
REFERENCES
Barker, R. L. (2003). Police social work. In The social work
dictionary (5th ed.). Washington, DC: NASW Press.
Bar-on, A (1995). They have their job, we have ours: Reassessing
the feasibility of police-social work cooperation. Policing and
Society, 5, 37-51.
Barton, R. (2000). Police officers and the interface with social
work. In M. Davies (Ed.), The BlackweU encyclopedia of social
work (p. 257). Malden, MA: Blackwell.
Borum, R., Wil1iams, M., Deane, M. A., Steadman, H. J., &
Morrissey, J. (1998). Police perspectives on responding to
mentally ill people in crisis: Perceptions of program effect-
iveness. Behavioral Sciences & the Law, 16,393--405.
Bureau of Justice Statistics. (2003). Local police departments 2000.
Washington, DC: U.S. Department of justice, Office of Justice
Programs.
Coordinating police and social work. (1952). The American City,
67, 163.
POLICE SOCIAL WORK 361
Dean, C. W., Lumb, R., Proctor, K., Klopovic, J., Hyatt, A., &
Hamby, R. (2000). Social work and law enforcement partnerships:
A summons to the viUage strategies and effective practices.
Charlotte, NC: The Governor's Crime Commission, North
Carolina Department of Crime Control and Public Safety.
Finn, P. (1988). Dealing with street people: The social service
system can help. The Police Chief, 55,47-51.
Goodstein, L. (2000, September 6). Trying to prevent the next
killer rampage by changing police tactics. The New York Times,
pp. AI, A20.
Holmes, S. A (1982). A Detroit model for police-social work
co-operation. Social Casework, 63, 220-226.
Knox, K., & Roberts, A R. (2002). Police social work. In A. R.
Roberts & G. J. Greene (Eds.),.Social worker's desk reference (pp.
668-672). New York: Oxford University Press.
MacNamara, D. E. J. (1989). August Vollmer. In W. G. Bailey
(Ed.), The encyclopedia of police science (pp~ 657-659). New
York: Garland Publishing.
Mastrofski, S. (1983). The police and noncrime services.
In G. P. Whitaker & C. D. Phillips (Eds.), Evaluating per-
formance of criminal justice agencies (pp. 33-61). Beverly Hills,
CA: Sage.
Michaels, R. A, & Treger, H. (1973). Social work in police
departments. Social Work, 69, 67-75.
Patterson, G. T. (2000). Demographic factors as predictors of
coping strategies among police officers. Psychological Reports,
87, 275-283.
Patterson, G. T. (2002a). Predicting the effects of military service
experience on stressful occupational events in police officers.
Policing: An International Journal of Police Strategies and
Management, 25, 602-618.
Patterson, G~ T. (2002b). Development of a law enforcement
stress and coping questionnaire. Psychological Reports, 90,
789'-799.
Patterson, G. T. (2003a). Police-social work col1aboration in
response to the World Trade Center attacks. International
Journal of Mass Emergencies and Disasters, 21, 87-102.
Patterson, G. T. (2003b). Examining the effects of coping and
social support on work and life stress among police officers.
Journal of Cri~inal Justice, 31, 215-226.
Patterson, G. T. (2004a). Police social work crisis teams:
Practice and research implications. Stress, Trauma and Crisis, 7,
93-104.
Patterson, G. T. (2004b). Evaluating the effects of child abuse
training on the attitudes, knowledge and skil1s of police
recruits. Research on Social Work Practice, 14, 273-280.
Patterson, G. T. (in press). Examining missing person police
reports to identify the service needs of runaway youth and their
families. Human Behavior and the Social Environment.
Patterson, G. T., & Telesco, G. A. (2004). The law enforcement
response to mass violence. In L. Straussner & N. Phil1ips
(Eds.), Social work and mass violence (pp. 117-125). Boston,
MA: Allyn & Bacon.
Penner, G. L. (1959). An experiment in police and social agency
co-operation. Annals of the American Academy of Political and
Social Science, 322, 79-88.
362 POLICE SOCIAL WORK
RPD Bureau of Organizational Development and Administration.
(n.d.). Retrieved December 3,2007, from http://www.
cityofrochester.gov/publicsafety/police/index.cfrn?id= 344 .
Scott, E. J. (1981). Calls for service: Citizen demand and initial police
response. Washington, OC: National Institute of Justice.
Steadman, H. J., Deane, M. W., Borum, R., & Morrissey, J. P.
(2000). Comparing outcomes of major models of police
responses to mental health emergencies. Psychiatric Services,
51, 645-649.
Telesco, G. A. (2002). Rescue and recovery: Providing crisis
intervention to the families of the victims of the World Trade
Center. Reflections, 8, 12-18.
The City of Rochester 2003-2004 Budget. (n.d.). Retrieved
December 3, 2007, from http://www.cityofrochester.gov/
main/docs/budget/app0304 .pdf ' state, privatization, the U.N. Millennium Development
Treger, H. (1975). The police-social work team: A new model
interprofessional cooperation: A university demonstration project in
manpower training and development. Springfield, IL:
Charles C. Thomas.
Treger, H. (1995). Police social work. In R. L. Edwards (Ed.), The
encyclopedia of social work (19th ed., pp. 1843-1848).
Washington, OC: NASW Press.
Trojanowicz, R., & Bucqueroux, B. (1990). Community policing:
A contemporary perspective. Cincinnati, OH:
Anderson.
Trojanowicz, R. c., & Dixon, S. L. (1974). Criminal justice and
the community. Englewood Cliffs, NJ: Prentice-Hall.
Vallianatos, C. (2000). Social workers intervene at police
stations. NASW News, 45, 14.
Vila, B., & Morris, C. (1999). The role of police in American society.
Westport, CT: Greenwood Press.
Vollmer, A. (1971). The policeman as social worker. In Pro-
ceedings of the annual conventions of the international associ ation of
chiefs of police: 1913-1920 (Vol. 3, pp. 32-38). New York:
Arno Press/New York Times.
Zimmerman, S. 1. (1988). Police social work in twenty-three
programs: Program description and analysis of interdisciplinary
relations. Unpublished doctoral dissertation. Chicago, IL:
The Graduate College of the University of Illinois at Chicago.
SUGGESTED LINKS The Association of
Police Social Workers.
http://www.policesocialworkers.org/
Hanover Park Police Department 2005 Annual Report.
http://www.hanoverparkiUinois.org/Services/Police/AnnualReport
Current.pdf
RPD Bureau of Organizational Development and Administration.
http://www .cityofroch'ester .gov/publicsafety/police/index .cfm?
id=344
The City of Rochester 2003-2004 Budget.
http://www.cityofrochester.gov/main/docs/budget/app0304.pdf
Wilmette Police: Social Worker.
http://www.wilmette.com/police/social.htm
A Brief Overview: Police/Social Work Partnership Programs.
www.brockport.edu/crj/BriefOverview.doc
Social Work and Law Enforcement Partnerships: A Summons to
the Village.
www.ncgccd.org/pubs/SWAPP.pdf
-GEORGE T. PATTERSON
POLICY PRACTICE
ABSTRACT: Major socioeconomic developments during
the last decades of the twentieth century and the beginning
of the new millennium, including globalization,
urbanization, the diminishing nationally funded welfare
Goals, and the consequent rapid expansion of private
nonprofit health and welfare organizations, contributed
greatly to the integration of social policy in macro social
work practice. In this context, policy practice based on
specific macro social work knowledge, values, and skills
includes problem-solving intervention methods for human
wellbeing. This trans- ' formation challenges and enhances
social work's goals for both individual and societal
development.
KEY WORDS: macro practice; community work; socio-
economic justice; social planning administration
Before World War II social policy practice (SPP) was not
adequately integrated in social work practice meth ods.
Social work curricula had not sufficiently incorporated
SPP as a planned problem-solving intervention method.
Instead, social work education emphasized mainly
historical aspects for social work students to understand
social welfare policy and programs for the poor (Essex &
Massat, 2005; Figueira-Mcfronough, 2007). World- wide,
national, and local socioeconomic developments,
however, during the second part of last century and the
beginning of the new millennium, have stimulated more
integration of SPP in social work methods, especially in
conjunction with the evolution of intertwined macro social
work interventions: community organization (or
community practice), policy analysis, social planning, and
administration (Ellis et al., 2006; Long, Tice, & Morrison,
2006). In this context, SPP is also closely associated with
the interdependence of micro (clinical) and macro
(planning) social work approaches (the "individual-in
society" orientation) for planned societal change and
reform to ensure human wellbeing of individuals, families,
organizations, communities, and institutions (Long et al.,
2006; Pearlmutter, 2002).
Thus, in the new millennium social workers are more
centrally concerned and engaged in SPP, which
j

includes both policy formulation and implementation,
especially in the context of social and economic devel-
opment. As conceptualization of social w ork practice has
changed over the years and continues to evolve, the older
professional debate about whether or not social work
practice methods include SPP, is no longer at the epicenter.
Rather, today many writers content that macro social work
and, therefore, SPP, concerns all social work practitioners
(Gould, 2006; Reichert, 2003; Weiss, 2003), including
those engaged in micro practice. As a responsibility of all
social workers, practitioners should understand and
analyze the effects of social policy d ecisions on clients.
Consequently, they should participate in the formulation
and modification of social policy, being active at multiple
social policy levels, including the personal, the
organizational, the community, and the legislative
(Hoefer, 2005; Iatridis, 2005; Pierce, 2000).
spp Nature and Foundations
Typically, policies are statements that prescribe courses of
action for public and private organizations, commu nities,
and institutions. Policies that affect the welfare of citizens
are known as social policies. Planning in social planning
denotes a deliberate intervention for action to improve
human wellbeing based on a rational problem solving
strategy aimed at combating community prob lems (Long
et al., 2006). SPP in social work refers, therefore , to
planning the formulation, implementation and evaluation
of social policies and programs of public and private
organizations and communities that affect society as a
whole and people's well-being (Chapin, 2007; DiNitto,
2007).
SPP also connotes an academic field of inquiry
concerned with the description, explanation, pre-
:- scription, implementation, and evaluation of those
planned interventions to reform societal conditions for the
well-being of individuals, families, groups, organization s,
communities, institutions, and societies (Midgley, 2000;
Sherraden, 2002). In this country SPP is pursued in
several academic settings, including schools of social
work, public health, and public policy, or departments of
sociology and political science , rather than'in academic
departments of social policy or SPP as such. This
reaffirms the multidisciplinary nature of macro social
work and SPP.
Typically, SPP engages both micro and macro
approaches. Ending hunger requires more than under-
standing individual behavior, or providing "direct" social
services, donations, and humanitarian aid. Instead,
reducing hunger also necessitates the incor poration of
SPP antihunger, reformist, planned inter ventions to
change societal conditions in different
POLICY PRACTICE
363
societal systems (sanitation, roads, schools, health care,
labor practices, agricultural production, distribution, and
public subsidies).
While overarching SPP focuses on the interests and
development of society as a whole and on measures to
help individuals, including poor people and other
powerless individuals (Dinito, 2007), it also involves
interventions to change policies and reform societal
conditions through policy analysis, planning, adminis-
tration, community work, and activism (Chapin, 2007;
Gould, 2006). Hence, SPP in social work has shifted from
traditional orientations, which exclude practice, to
prescriptive, problem-solving, action- oriented, and
practice-oriented methods (Gould, 2006; latridis, 199,4,
2005; Jansson, 1999; Midgley, 2000; Sherraden, 2002).
ITs KNOWLEDGE BASE Typically, macro social work
and SPP is based not only on basic social work
knowledge but also reflects interdisciplinary
dimensions related to professional purpose s across a
wide range of societal systems. Of central
importance are, thus, multi discipline theories,
models, and knowledge concerned with societal
change reforms through organizing and development
efforts, mobilizing citizens, organizations, and
communities for people's well- being. This requires
knowledge of the broader economic, cultural, and
political systems; understanding policy formulation
processes and the people and organizations who use
them to make policy; and analytical frameworks for
SPP, including system approaches of input, process,
output, and feedback (Pierce, 2000).
ITs VALUES SPP interventions depend on and are
driven by values (beliefs about what is right or
desirable) that provide the foundation of all social
work practice to enhance human well- being. Macro
and SPP interventions emphasize distributive social
and economic justice or equality, self- determination,
empowerment of the disadvantaged, and social
services as a human right for all (Ife, 200l). For
example, health care polici es, driven by such values
may result in universal coverage and access for all; in
contrast, other values concerned only with reduction
of health care costs and efficiency may result only in
cost reduction and increased efficiency (Reichert,
2003). Democratic self-government and citizen
participation in social re form efforts promote the
dignity and respect of consumers and communities.
Social and Economic Distributive Justice is crucial
both as a goal and a process in all methods of macro
practice, including SPP. It concerns fairness in rela-
tionships among people in the context of full and equal
participation in societies, which are equitable
 364 POLICY PRACTICE
and all members feel physically, psychologically, and
socially secure.
Distributive justice demands that SPP sees that re-
sources are allocated in democratic, fair, and participa tory
ways, and that distributions of goods and services not be
left to random selection serving the needs of the power
structure or support economic mechanisms that
undermine moral commitments and social work values, or
exclude active participation in decision- making of those
affected (Adams, 2000; figueira-McDonough, 2007;
Reichert, 2003).
Justice models differ considerably and may produce
differential SPP outcomes. The Utilitarian model, based
on early classical liberalism, is sensitive to pro moting
interests of majorities at the expense of mino rities and
social inclusion. The Market model, reflecting Adam
Smith's variation of utilitarianism and individu alism,
reinforces economic market outcomes and is sensitive to
unfettered powerful interests (Nozick, 1974). The
Fairness model, based on social contract theory (Rawls,
1971), is sensitive to interests of the most disadvantaged.
The Socialist-Marxist model, based on Marxism, results
in favoring working classes (Heilbroner & Thurow, 1998;
Iatridis, 1994).
Clearly, it matters which justice perspective pre vails.
Macro practitioners and all social workers are committed
to support the disadvantaged: All people have equal rights
to basic liberties, while inequalities are tolerated only if
they favor the least well off.
I TS SKILLS AND ROLES In planning social change
, reforms through organizations, coalitions, and commu nities,
practitioners engage in a wide variety of skills and roles
that are driven by the different nature of macro
interventions and stages or steps of SPP pro cesses. For
example, issues of community needs assessment and
outcome-evaluation call for research skills and roles;
issues of identifying and promoting social action and
reform legislation calls for political, judicial, legislative,
and regulatory skills and roles; achieving client and
citizen participation in reforms call for advocacy,
negotiating, networking, and lobby ing skills and roles,
particularly when advanced capit alism is dominated by
right conservative political institutions serving the
interest of rich White males; redistribution and
reallocation of organizational and community resources
calls for administrative, organiz ing, and empowering
skills and roles; community devel opment efforts require
skills in social and economic growth, social ca pital
formation, and coalition building; formulation and
approval of policies and programs call for educational and
analytic skills and roles; implemen tation of intervention
policies calls for management,
mobilization, and development of resources, fund rais ing
skills and roles; identification of different courses of
action and selecting solutions to organizational and
community problems calls for rational planning skills and
roles; bringing people togethe r around common interests
or needs calls for mobilizing and activist skills and roles;
helping clients to meet their needs calls for educational
and enabling skills and roles; developing organizational,
community, and societal assets calls for leadership s kills
and roles; issues of inequality and social exclusion call for
power redistribution skills and roles (Iatridis, 1994,
2005; Long et al., 2006; Mizrahi & Morrison, 1993).
Macro skills and roles may also require different
practice orientations: laissez- faire (no intervention, or
doing little); rational, characterized by positivism and
scientific reasoning: it benefits from objective proce dures,
quantification, and technical methods or tools; normative,
reflecting values (rather than empiricism) dominan t in
communities; and critical, based on postpositivism and
postmodernism (Ellis et a1., 2006; Iatridis, 2000, in
Midgley, 2000).
LEVELS AND TYPES Macro and SPP practice consists of
interventions at different administrative and geographic
levels: local, county, state, regional, national,
international, or global. Multilevel interventions are also
required. For example, eliminating segregation at local
levels, may require additional social action and judicial
decisions at higher levels (U.S. Supreme Court) and
federal executive regulations. Macro and SPP
interventions may be designed to achieve differential
social change outputs: calling for the passing of reform
laws; administrative regulation policies; or judi cial
decisions (Chapin, 2007). Thus, macro social workers
practice in diverse settings: neighborhood and
community-based development organizations; local,
state, and national governments; international agencies
or NGOs for socioeconomic development; and nonprofit
organizations for health, welfare, housing, and urban
planning.
Central SPP Issues
Although macro and SPP address a wide variety of
problems, three related issues are crucial, implicitly or
explicitly: the desired system or society, the organiza tion
of resources, and the distribution of goods and services
(Iatridis, 1994).
The desired society. What kind of society (community or
organization) is sought? Is health care a right or privilege?
In democracies, policies are democratic (for example,
he~lth care is a human right), whereas in eli tism, policies
are elitist (for example, health care is

a privilege). Public policies are framed in the context of
the society sought, and policies of nonprofit agencies are
framed by the organization's mission values.
Organization of resources. How should societal insti-
tutions be structured? What resources should be used and
how? In industrial societies, educational institu tions, not
the family, are assigned responsibilities of formal
education. Should free economic markets be responsible
for health care?
Distribution of goods and services. What share of goods
and services should be allocated to whom and why? How
should power and social services be distributed? Based on
which distributive justice criteria? What are (and should
be) the rates of life expectancy, infant mo rtality, hunger,
or poverty for different population groups, and how
'should they be distributed? (Bernasek, 2006).
SPP Process
SPP is a sequential, cyclical, system process, which
integrates the above three issues. Analyses of the de sired
system's values (inputs to the system) leads to the
organization of goods and services (throughputs), and, in
tum, to well-being distributions (outputs). Finally,
feedback flows lead to the review and repetition of the
SPP process. Typically, the SPP process consists of two
interlinked stages. The Analysis-Formulation stage (policy
problems and needs are analyzed; policies are cre ated,
recommended, and approved) requires cognitive skills;
and the Implementation stage (plans are made, resources
secured and organized, implemented, progress monitored
and assessed, and intervention outcomes are evaluated)
involves organizational, administrative, and community
advocacy or activist managerial procedures (Netting,
Kettner, & McMurtry, 1993). Feedback flows link the two
stages and the three issues. For example, if health care
output indicators do not conform to input goals, if health
distribution indices are unacceptable or costs
unaffordable, then feedback mechanisms lead to reviews
and adjustments of values, input goals, and institutional
arrangements. The intervention cycle is repeated until the
desired outputs are achieved.
STEPS OF THE ANALYSIS STAGE The process in this
stage starts with formulations of client's problems, and
analyses of socioeconomic conditions surroundi ng
them. Key players (individuals, groups, organizations,
communities, and institutions) who shape policies
(elected, appointed officials, organized groups, consu-
mers, and community leaders) are identified. In brief,
practitioners identify the nature of t he problem and its
socioeconomic environment, factors contributing to the
problem, key policy issues and their implications,
POLICY PRAcncE 365
effectiveness of current policies, past efforts to resolve the
problem, decision-making bodies, policy alter natives and
their implications (comparisons, costs, and benefits), and
recommendations. In brief, it includes the following steps:
statement of the problem, alternative solutions, selection
of a course of action, and recommendations for approval
(DiNitto, 2007; Jansson, 1994).
STEPS OF THE IMPLEMENTATION STAGE In this stage
practitioners organize resources (budgets, alloca tions,
training staff, secure space and equipment, com munity
support through activism or advocacy, educate
consumers, consider administrative, and judicial issues),
monitor and assess progress of implementing programs,
and evaluate outcomes. In brief, this stage includes the
following steps: design of an implementa tion plan,
monitor and assess its implementation pro gress, evaluate
outcomes, and consider feedback issues.
The S.C.LE.N.C.E. process model (each letter standing
for specific tasks) summarizes these SPP pro cess stages
and steps:
S: sociopolitical environments: the statement of the
problem, its societal context, its ideological
frameworks, and its social justice implications
C: causes of the problem: literature reviews of etiology and
implications, how the problem develops, and ma jor
policy questions, and present policies
I: interventive approaches: alternative solutions and their
impact
E: establishment, ranking, comparing, and selection of
solutions based on selected criteria: their pros and
cons, expected outcomes, groups like ly to support or
reject solutions
N: narrative of implementation plan: explanation of plan to
those affected, secure human and physical resources
needed, and selection of methods to evaluate
progress and outcomes
C: characteristics of implementation: mon itoring of
performance, leadership and coordination, cost or
budget, space, equipment, problems anticipated,
training required, participatory democratic
involvement
E: evaluation of outcome: assessing whether goals and
objectives have been achieved and wh ether the
intervention should be continued (DiNitto, 2007 ;
Dye, 1987; Iatridis, 1994; Jansson, 1994; Pierce ,
2000).
Challenges
Clearly, the future directions of social work macro
practice and SPP depend upon many national, interna-
tional, political, economic, social, and technological
366 POLICY PRACTICE
factors, most of which can be hardly predicted at this point.
Nevertheless, it is crucial how the profession as a whole
and social work practice in particular will respond to at
least two major current challenges that have immediate
future implications: The world-wide trend for planned
socioeconomic development, and in this context, the
related expansion and upgrading of nonprofit health and
welfare organizations.
PLANNED SOCIOECONOMIC DEVELOPMENT Traditional
macro and SPP approaches are directly challenged by
emerging global development, including how the world
is, how it should be developing, and how communities
everywhere should, be organized for advanced
capitalism's world competition. For example, if the
2000 U.N. Millennium Developmenr Declaration
signed by 189 countries is to achieve by 2015 its unique
eight development goals, more extensive and effective
macro practice and SPP at all levels is needed to cut in
half extreme poverty and hunger; achieve universal
primary education; promote gender equality and em-
power women; reduce child mortality; improve mental
health; combat HIV IAIDS, malaria, and other
diseases; ensure environmental sustainabilirv: and
develop a global partnership for development.
This unprecedented, comprehensive, planned socio-
economic development challenges already most macro
practice methods at most levels: crucial national policies
shift up to international institutions (European Union,
WTO, World Bank, IMF, and NAFT A). Others shift down
to local institutions, generating "Cosmopolitan Localism"
(that is, thinking globally, bur. acting locally; local
governments with a global orientation trying to protect
local development from global economic competition).
This SPP bifurcation· transforms national socioeconomic
policies for development (Levinson, 2001). necessitating
much more effective global, national, and local grass roots
macro and SPP approaches. At this point, most global
economic development, based almost exclusively on
economic market imperatives, operates almost
independently and unaccountable to . national political or
policy systems.
PRIVATIZATION AND EXPANSION OF NOT-FoRPROFIT
ORGANIZATIONS At the same time, the dismantling of
central components of nationally funded welfare states,
recent privatization growth, and the concomitant
expansion of private social work organizations also
challenge macro practice. Intensified competition in
business and not-for-profitagencies at all levels
compels social organizations to upgrade their efficiency
and policy practice. The more organizations
expand, and engage in socioeconomic development, the
greater the need to upgrade and improve their macro
practice.
Development requires not only strong, competitive
business establishments, but also strong, competi tive
social work agencies that rely on updated, efficient policy
practice, rather than on elitist organizational structures,
and ineffective community development strategies.
Effectiveness of SPP has emerged as a pre condition for
successful operations and fundraising, do nors becoming
more interested in the effectiveness of their charities
(three out of every four indicate that effectiveness makes
them give more) (Moynihan, 2006). This makes the
challenges to macro practice more compelling.
IMPLICATIONS FOR SOCIAL WORK The social work
profession has traditionally and continuously evolved
and adjusted successfully to similar societal changes
by transforming, expanding, and improving its
practice knowledge, education, and research.
Practitioners, researchers, and social work educators
can now play central roles in responding successfully
to these complex challenges in ways that will guide
future professional directions.
Social work practitioners and researchers engaged in
social change reform efforts have the experience, visions,
and strategies to face these challenges by im proving
macro practice and addressing several key issues: How
can macro practice integrate further its basic methods of
community practice, policy analysis, social planning, and
administration? Bringing together a comprehensive macro
intervention method seems timely and appropriate. Can
there be a sharper focus of a macro practice as a discipline
relating more directly to socioeconomic develop ment
(theory and practice)? Can we articulate a more
operational socioeconomic justice value system for social
work and macro practice? Can we synthesize more
effectively theory and prac tice? Can we develop a more
unifying concept of social
work practice to guide practitioners? .
Social work educators can also address these and other
issues in the context of curriculum building to train more
and more effective macro graduates. How can we
strengthen macro practice aspects of the curri culum with
emphasis on socioeconomic development? How can we
incorporate political and socioeconomic development
content? How can we prepare graduates for technical
revolutions? How can we face the chal lenges in global
work and in rapidly urbanizing cities and neighborhoods ?
Can we train committed and com petent macro leaders at
the doctoral or Ph.D. social work level?

REFERENCES
Adams, M. (2000). Introduction. In M. Adams, W. J. Blumen feld,
R. Castaneda, H. W. Hackman, M. L. Peters, & X. Zuniga
(Eds.), Readings for diversity and social justice. New York:
Routledge.
Bemasek, A. (2006, December 3 I). Health care problem?
Check the American psyche. New York Times, p. 3, Section 3.
Chapin, R. K. (2007). Social policy for effective practice: A strengths
approach. Boston, MA: McGraw-Hill.
DiNitto, D. M. (2007). Social welfare (6th ed.). Boston:
Pearson.
Dye, T. R. (1987). Understanding public policy. Englewood Cliffs,
NJ: Prentice Hall.
Ellis R. A., Mallory, K. C., Gould, M. Y., & Shatila, S. L. (2006).
The macro practitioner's workbook. Thomson and Brooks/Cole.
Essex, E. L., & Massat, C. R. (2005). Preparing school social
workers for their wider role: Policy and practice. School Social
Work Journal, 29(2), 25-39.
Figueira-Mcfionough, J. (2007). The welfare state and social work:
Pursuing social justice (p, 456). London: Sage.
Friedman, T. (2005). The world is flat: A briefhistory of the 21 st
century. New York: Farra, Straus, and Giroux.
Gambrill, E. (2006). Evidence-based practice and policy:
Choices ahead. Research on Social Work Practice, 16(3),
338--357.
Gould, N. (2006). An inclusive approach to knowledge for mental
health social work practice and policy. BritishJournal of Social
Work, 36, 109-125.
Heilbroner, R., & Thurow, L. (1998). Economics Explained.
New York: Touchstone Books.
Hoefer; R. (2005). Altering state policy: Interest group effect-
iveness among state-level advocacy groups. Social Work,
50(3),219-227.
Jansson, B. S. (1994). Social policy: From theory to policy practice
(2nd ed.). Pacific Grove, CA: Brooks/Cole.
Jansson, B. (1999). From policy practice to social justice. Pacific
Grove, CA: Brooks/Cole.
Iatridis, D. (1994). Social policy: Institutional context of social
development and human services. Monterey, CA: Brooks/ Cole.
Iatridis, D. (2005). Organizations for social care: Policy practice for
development. Athens, Greece: Hellenic Grarnmata [In Greek].
He, J .. (2001). Human rights" and social work. Cambridge, UK:
Cambridge University Press.
Levinson, M. (2001, Fall). Mismanaging globalization. Dissent,
48(4), pp 5-7.
Long, D. D., Tice, C J., & Morrison, J. D. (2006). Macro social
work practice: A strength perspective. Thomson, Brooks/Cole.
Midgley, J., et al. (Eds.). (2000). The handbook of social policy.
Thousand Oaks, CA: Sage
Mizrahi, T., & Morrison, J. (Eds.). (1993). Community organization
and social administration: Advances, trends, and emer ging
principles. New York: The Haworth Press.
Moynihan, B. (2006, December 25). Wealth and philanthropy:
Who gives (and why). The Globe, p. A19.
POLICY PRAcnCE 367
Netting, F. L., Kettner, P. M., & McMurtry, S. L. (1993). Social
work macro practice. New York: Longman.
Nozick, R. (1974). Anarchy, state and utopia. New York: Basic
Books.
Pearlmutter, S. (2002). Achieving political practice: Integrating
individual need and social action. Journal of Progressive Human
Services, 13(1),31-51.
Pierce, D. (2000). Policy practice. In J. Midgley, B. M. Tracy, &
M. Livermore (Eds.), The handbook of social policy (pp, 53-63).
Thousand Oaks, CA: Sage.
Rawls, J. (1971). A theory of justice. Cambridge, MA: Harvard
University Press.
Reichert, E. (2003). Social work and human rights: A foundation for
policy and practice. New York: Columbia University Press.
Saulnier, C. F. (2000). Policy practice: Training direct service
social workers to get involved. Journal of Teaching in Social
Work, 20(1-2),121-144.
Sherraden, M., Closar, B., & Sherraden, M. (2002). Innovation in
social policy. Social Work, 47(3), 209-223.
Weiss, I. (2003). Social work students and social change: On the
link between views on poverty, social work goals and policy
practice.lnternational}ournal of Social Welfare, 12(2), 132-141.
Zlotnik, J. L., & Solt, B. E. (2006). The institute for the
advancement of social work research: Working to increase our
practice and policy evidence base. Research on Social Work
Practice, 16(5),534--539.
FURTHER READING
Appleby, G. A. (2001). Practice and theoretical knowledgebased
theory for clinical and policy practice. Journal of Gay & Lesbian
Social Services, 12(3-4), 1-4.
Beresford, P., & Croft, S. (200l). Service users' knowledge and the
social construction of social work. Jourrial of Social Work, 1(3),
295-316.
Blau, J., & Abramovitz, M. (2004). The dynamics of social welfare
policy. Oxford University Press.
Congress, E. (1999). Social work values and ethics. Chicago:
Nelson Hall.
Dolgoff, R. (2001). An exploration in social policy and ethics:
Ethical judgment before or after the fact? Social Work Forum,
35, 67-86.
Franklin, C, & Johnson, C (1996). Family social work practice:
Onward to therapy and policy. Journal of Family Social Work,
1(3), 33-47.
Hagen, J. L., & Davis, L. V. (1992). Working with women:
Building a policy and practice agenda. Social Work, 37,
495-502.
Iatridis, D. (1983). Neoconservatism reviewed. Social. Work,
28,101-107.
Iatridis, D. (1988). New social deficit: Neoconservatism's policy
of social underdevelopment. Social Work, 33, 11-15.
Karger, H. J., & Stoesz, D. (2002). American social welfare policy.
Boston: Allyn & Bacon:
Keller, T. E., Whittaker, J. K., & Burke, T. K. (2001). Student
debates in policy courses: Promoting policy practice skills and
knowledge through active learning. Journal of Social Work
Education, 37(2),343-355.
368 POLICY PRACTICE
Linhorst, D. M. (2002). Federalism and social justice: Implications
for social work. Social Work, 47(3),201-208.
Mahaffey, M., & Hanks, J. (Eds.). (1982). Practical politics:
Social work and political responsibility (pp. 45-54). Silver
Spring, MD: National Association of Social Workers.
Matthies, A. L. (2005). Between science, practice and politics:
Practice research as a defining approach of social work research.
European Journal of Social Work, 8(3),273-278.
Mendes, P. (2003). Teaching social policy to social work students: A
critical reflection. Australian Social Work, 56(3),220-233.
National Association of Social Workers. (1994). NASW code of
ethics. Washington, DC: Author.
National Association of Social Workers. (1996). Code of ethics.
Washington, DC: Author.
Pierpont, J. H., Pozzuto, R., & Powell, j: Y. (200l). Service learning
and systems of care: Teaching students to learn from clients.
Journal of Family Social Work,S (3), 79-93.
Reisch, M., & Gorin, S. H. (2001). Nature of work and future of the
social work profession. Social Work, 46(1), 9-19.
Rocha, C. J. (2000). Evaluating experiential teaching methods in a
policy practice course: The case for service learning to increase
political participation. Journal of Social Work Education, 36(1),
53-63.
Sunder, P. A., & Kelly, M. J. (2002). Legislative policy briefs:
Practical methodology in teaching policy practice. Journal of
Teaching in Social Work, 22(1-2),49-60.
Weaver, R. D., & Nackerud, L. .0. (2005). Evaluating the effects of
an applied learning exercise on students' interest in social policy.
Journal of Teaching in Social Work, 25(3/4), 105-120.
Weekes, M. S. (1999). Social welfare policy practice: Influences,
perspectives, approaches. Maatskaplike Werk/Social Work,
35(4), 313-321.
Wilding, P. (1997, December). Globalization, regionalism and social
policy. Social Policy and Administration, 31(4), 410-428.
Wyers, N. L. (1991). Policy-practice in social work: Models and
issues. Journal of Social Work Education, 27, 241-250.
Zubrzycki, J., & McArthur, M. (2004). Preparing social work
students for policy practice: An Australian example. Social
Work Education, 23(4), 451--464.
-DEMETRIUS S. IATRIDIS
POLITICAL IDEOLOGY AND SOCIAL
WELFARE
ABSTRACT: Political ideologies shape public policy
debates as well as the social policy strategies devel-
oped to address "social problems." The clashes
among long-standing political
traditions-conservatism, liberalis m, radicalism, and
feminism-reflect funda mental and often
irreconcilable differences regarding social,
economic, and political life. The four political
ideologies are compared for their varied perspectives on
several core issues that underpin social welf are provision,
including human nature, need, the general welfare, social
problems, racial inequality, and the role of government.
The resulting distinctions provide social workers with a
framework to more effectively assess social welfare
policy.
KEY WORDS: ideology; social welfare; conservatism
liberalism; radicalism; feminism
An ideology is a relatively coherent and comprehensive
system of ideas (beliefs, traditions, principles, and myths)
about human nature, institutional arrange ments, and
social' processes held by individuals and groups in society
(Blau & Abramovitz, 2007). Forsome people, the word
ideology suggests rigid ideas, biased thinking, or simplistic
notions. While this is sometimes the case, in practice most
ideological thinking is fluid, contested, and complex.
The Role and Function of Political Ideologies The three
standard political ideologies-conservatism, liberalism,
and radicalism-draw upon longstanding political
philosophies that contain core assumptions about social
life. Each ideology offers (a) an explanation of social
problems and conditions; (b) criteria that help people
decide what is right and wrong, good and bad, fair and
unfair; (c) a road map or a frame of reference for
individuals that helps to organize tremendous
complexities; and (d) a general plan for political action.
Feminism, also discussed below, presents a gendered
critique of these mainstream perspectives (Blau &
Abramovitz, 2007). Although different ideologies co exist
in a single society, in most cases, one ideology prevails
and provides a framework for seeing the world, shaping
public policy, and guiding both scientific inquiry and
professional practice. In today's large, internally divided,
and unequal societies, the governing ideology typically
reflects the economic and political interests of the
established powers. Its messages may appear so natural
and logical that one can easily miss how powerfully these
ideas shape individual thinking and uphold the status quo.
Taken for granted or regarded as truth, the dominant set of
ideas often screens out important alternative views by
labeling them as unrealistic, deviant, or extreme. Groups
backing an oppositional ideology such as feminism rarely
have equal access to the center of power where decisions
are made (Bachrach & Baratz, 1963).
The clash among the three main ideologies has
dominated both u.s and world politics for centuries. The
stakes in the outcome of the conflict are high

because the winning system of beliefs plays a key role in
who benefits and who loses from the distribution of
income, wealth, and power and because the prevailing
ideology does not go unchallenged. Instead, other ideo-
logical perspectives provide the basis for negotiating,
resisting, and changing the overarching view of social life
(Love, 2006). History is filled with stories of indi viduals
and social movements that resisted mainstream ideas and
in the process transformed both their own thinking and the
world. Depending on the strength of the challenge,
officialdom may try to ignore, co- opt, or repress the new
ideas. Such as those presented by the civil rights, gay
rights, and women's movements (Bachrach & Baratz,
1963; Piiven & Cloward, 1979).
Political Ideology and' the U.S. Welfare State
Awareness of political ideology is critical for social work,
given the critical role it played in the nation's response to
the two major economic crises of the 20th century that
fueled both the rise of the welfare statethe institution
intended to provide a minimum level of income and
services to individuals and families-in the 1930s and then
its contraction since the mid- 1970s. Those in charge
blamed the first crisis-the collapse of the economy in the
1930s-on the failure of the market. By the 1920s, the rise
of monopolies and other structural changes in the
economy had weakened the institutional arrangements put
in place to support profitable production and political
stability in the 1890s. The severity of the 1930s Great
Depression led the nation's leaders to call upon the
government to address their economic woes. However
reluctantly, they replaced the accepted conservative
laissez-faire economic policies with liberalism that
supported a redistribution of income downward and an
expanded role of the state. The resulting New Deal
programs, especially the welfare state, increased the
standard of living and reduced the hardship millions of
individuals and families faced (Jansson, 2005).
The second major crisis of profitability surfaced in the
mid-to-late 1970s as the changes in the domestic and
global economies weakened the institutional ar-
rangements put into place to promote economic growth
and political stability in the 1930s an d later, after World
War II. This time the nation's leaders sought to restore
profits by undoing the New Deal, that is, by redistributing
income upward and downsizing the state, including the
welfare state. They effectively abandoned postwar
liberalism for a return to conservative laissez- faire
economics now variously called Neoli beralism,
Reaganomics, or Supply-Side Economics.
[Nee-liberalism represents an updated and more ex treme
version of the "classical liberal" theory developed
j
POLITICAL IDEOLOGY AND SOCIAL
WELFARE 369
in the 18th and 19th centuries by Adam Smith and David
Ricardo. They argued that market forces selfregulate the
capitalist economy, thereby limiting the need for
government. Viewed as conservative today, the theory was
considered economically liberal when developed (Kotz,
2003).] To build public support for this Uvturn in public
policy, its proponents blamed the stagnating economy on
"big government," the expanded welfare state, and the
gains of social movements. The resulting tax cuts,
privatization (social welfare responsibility shifted from the
public to the private sector), devolution (social welfare
responsibility shifted from the federal government to the
states), and the attack on social movements caused
retrenchment in social programs. At the same time the Far
Right gained considerable influence over the legislative
agenda through electoral victories as well as legislation
such as the Contract with America in 1994. They sought to
restore "personal responsibility," "family-values," and a
"color-blind" social order-key components of conservative
political thought.
Competing Ideological Perspectives
The problem of racial inequality is used as an illustration,
given both the widely held but incorrect belief that the
majority of social welfare clients are persons of color and
given the racialization of contemporary social policy
debates. (Neubeck & Cazenave 2001; Gilens, 1999).
CONSERVATISM The rise of the U.S. welfare state
represented a departure from traditional market-driven.
laissez-faire conservatism that opposed government in-
tervention in the economy. Since the mid-1970s two types
of conservatism have taken hold of social welfare policy:
social conserva~m and laissez-iaite conservatism. The former
has exerted as much if not more influence during the last 30
years than the latter.
Social conservatism, also referred to as the Far Right,
is rooted in religious beliefs. It regards human nature as
determined by the original sin, 'as more evil than good, and
sees human beings as inherently flawed. If left unchecked,
their uncontrollable impulses, untamed self-interest, and
narrow selfish needs can create social chaos everywhere.
This negative view of human nature as unbridled leads
social conservatism to conclude that people are too unruly
to be trusted to care for or govern themselves. Thus the
general welfare or the common good depends on
maintaining order by ensuring compliance with the moral
authority of God, the patriarchal authority of the family,
and the mandates of the state.
370 POLITICAL IDEOLOGY AND SOCIAL WELFARE
Social conservatism calls on the government to intervene
in some areas of social life while strongly opposing its
activities in others. It endorses using the robust power of
the state to aid business. But contrary to popular wisdom it
also supports the use of public policy to regulate personal
life by penalizing "irresponsible" or immoral behavior
such as drugs, crime, abortion, di vorce, single
motherhood, homosexuality, undocu mented immigration,
and the youth culture. Further, it encourages the
government to restrict abortion rights, conduct pray er in
school, ban same-sex marriages, reverse judicialleniency,
privatize Social Security, and reduce, if not eliminate, the
welfare rolls. At the same time, social conservatism,
deplores government intervention in other spheres of life, .
especially those related to the welfare ~tate. It holds "big
government," social programs, and social movements
responsible for driving religion out of the schools, abetting
the civil rights movement, liberating women, promoting
homosexuality, weakening our national defenses, and
launching the War on Poverty (Klatch, 1987). To dis-
mantle the welfare state, social conservatism calls for tax
cuts, privatization, devolution, and program cut backs. It
also disparages social welfare professionals as the "new
class," "a liberal elite," "the intelligentsia," and "SOcial
engineers," who support the welfare state simply to further
their own interests, not to help others.
Finally social conservatives typically explain social
problems in ways that blame the victim. In the case of racial
inequality, they have moved 'from the now discre dited
belief in biological inferiority to notions of cul tural
inferiority, which hold that existing inequities reflect
moral or cultural rather than raci al differences (D'Souza,
1995; Mead, 1992). These explanations argue that when
persons of color do not succeed, the failure stems not from
racism but from personal and commu nity values, that is, a
culture of poverty that violates the traditional American
values of hard work, thrift, deferral of gratification, and
respect for marriage. Social conservatism adds that all
Blacks are too dependent on the government: poor Blacks
on welfare, middleclass Blacks on government jobs, and
Black owners of small businesses on government
set-asides. Based on these arguments and the view that
racism no longer exists, social conservatism calls for a
return to raceneutral or color-blind social policy.
Lalssez-faire conservatism is grounded in classical
economics that puts its faith in a self- regulated market and
disdains government intervention in the economy.
Neo-liberalism, the name given to the mid-1970s revi val
of this economic theory, should not, however, be confused
with political liberalism that refers to politica l rather than
economic beliefs or with neo-conservatism
that refers to socially conservative beliefs held by a group
of 1960s liberals who turned to conservatism in the
mid-1970s.
Unlike social conservatism, .laissez-faire conserva-
tism exalts human reason and intelligence. It regards
human nature as rational, self-regulated, and competi tive
and individuals as autonomous, detached, and dedicated
to the pursuit of self-interest. The general welfare depends
on leaving individuals alone to compete in the m arket
economy, with a minimum of con trol or interference from
the state. Instead an "invisible hand" maintains order by
coordinating market activities. It automatically channels
the selfish motives of many individuals into
complementary activities that e nhance the well being of
all.
Laissez-faire conservatism calls upon the govern ment
to maximize individual freedom by doing as little as
possible. That is, the government should stay out of the
market-except to perform a few important oversight
functions such as protecting national secur ity, private
property, and basic liberties. Driven by economic rather
than moral concerns; lalssez-faire con servatives argue that
"big" government interferes with the unrestricted pursuit
of self-interest, limits the abil ity of individuals to be
self-determining, and stifles both initiative and
innovation. Further, it believes that the redistributive
nature of social welfare. programs wrongly promotes
equality over freedom (Mullaly, 1997; Klatch, 1987).
However reluctantly laissez-faire conservatism ac-
cepts a temporary welfare state limited to emergencies
(the residual welfare state) as a necessary evil. It toler ates
a meager safety net for the "truly needy" (Will, 1988; Ball
& Dagger, 1998, p.116), favors local or state rather than
federal social welfare programs (devolu tion), and
promotes private over public sector provision
(privatization). It tolerates abortion and other such
services as long as they remain in private hands and do not
interfere with personal liberty. Paradoxically, except for
extreme libertarians who oppose all taxation, in practice
lalssez-faire conservatives support "corporate
welfare"-various tax deductions and business
subsidies-although this violates the rules of free competition
on which conservatism stands (Abramovitz, 2001; Zepezauer,
2004).
Both social and laissez-faire conservatives define
personal and societal needs in relation to market behavior.
Drawing on neoclassical economic theory, both schools
presume that people know what they nee d and have all the
information required to make an informed choice.
Because human decisions are shaped by nothing other
than market forces, the individual's market be havior
expresses actual need. Individuals reveal their

needs or market "preferences" by virtue of how they spend
their money. People buy what they need and need what
they buy-and these choices accurately reflect their true
physical and emotional requirements. The needs of
society as a whole represent no more or less than the sum
total of millions of individual preferences. In brief,
consumer demand for goods and services backed up by
the dollar translates into need. Because people buy what
they need, the gap between needs and resources-the liberal
justification for the welfare state -does not exist. This
individualized understanding of social needs also supports
conservatism's 'opposition to nearly all forms of
government intervention in the economy.
Lalssez-faire conservatives explain social problems as the
result of individual choice. Its three economic explanations of
racial inequality either blame the vic. tim or dispute the
existence of racism. The human capital theory holds that
Blacks and Whites have equal opportunity to pursue their
self-interest in the market. Therefore, racial disparities
grow not from racism but from differences in personal
traits (motivation, behavior, ability, talent, and so forth)
and differential choices to invest in human capital (that is
health, education). The irrational firm theory holds that racial
discrimination cannot exist for long in a profit-driven
market economy. Any preference for hiring White people
becomes economically irrational because it deprives the
business of the profit-enhancing value of cheaper Black
labor. Given this reality faced with competition from
nondiscriminating firms the inefficient discriminating
firms go bankrupt. The rational odds theory (or racial
profiling) suggests that discrimination makes sense be-
cause the individuals in question belong to a group whose
statistical pattern makes discriminatory judgments
reasonable. The cab driver who is reluctant to pick up
young Black males, the police officer who collars a Black
teenager, the store clerk who keeps an extra eye on Black
customers-all are working on a rational assumption of
criminal behavior based on the statistical odds.
Laissez-faire conservatives call for changes in individual
behavior but otherwise look to market forces to end racial
inequality.
_ LIBERALISM Liberalism also contains two sectors:
pragmatic and humanitarian liberalism. In the United
States, pragmatic liberalism, also called reform liberal-
ism, broke with laissez-faire conservatism in the early
20th century as people lost faith in the capacity of the
totally unregulated market to meet basic needs, max imize
success, keep the economy afloat, and sustain the civic
peace. Humanitarian liberalis m, also known as social
democracy, is more common in western Europe
j
POLITICAL IDEOLOGY AND SoCIAL
WELFARE 371
and stands somewhere between liberalism and left wing or
socialistic radicalism on the ideological continuum
(Mullaly, 1997).
Pragmatic liberalism shares laissez- faire's positive
view of human nature as rational, self- interest, and
competitive but adds that everyone merits an equal
opportunity to succeed. As more and more people failed to
achieve the good life in the rapidly industrializing soc iety,
pragmatic liberalism concluded that the disad vantaged
lacked an equal chance to compete for success in the
market. Like laissez-faire conservatism, prag matic
liberalism defines need in relation to individual's
interaction with the market. However, pragmatic liber-
alism adds that some people lack the financial where-
withal to buy what they need. Therefore, their market
behavior does not accurately mirror what they require to
survive. Equating consumer preferences with real needs
allows the community to wrongly conclude that poor
people actually prefer less food, second- hand clothes,
inferior education, and substandard housing. For
pragmatic liberalism, the general welfare or the common
good requires that everyone has an equal opportunity to
maximize the pursuit of self- interest and to achieve at least
a minimum standard of living. To this end, this brand of
liberalism moved away from the laissez- faire economic
doctrine to the support of goverriment intervention in the
economy; It asks the state to crea te the conditions that
would enable the disadvantaged to compete for success in
the market on an equal footing with others and to meet at
least the subsistence needs of those the market cannot
serve. Pragmatic liberalism explains social problems in
both social and individual terms. It argues that racial. in-
equality stems from prejudice (beliefs and attitudes) and
racial discrimination (actions and behaviors), both of
which deny persons of color equal opportunities to pursue
their self-interest and to succeed in the mar ket economy
and other spheres of life. It calls on the government to
ensure legal equality, meaning equal treatment under the
law; to reduce or eliminate the racially biased barriers; and
to provide needed supports.
Humanitarian liberalism regards human nature as
rational and autonomous but also altruistic, dependent,
cooperative, and interdependent. Its definition of need goes
beyond mere survival to the ability to particulate fully in
society. Humanitarian liberalism holds that the market
responds to economic demand (that is, purchas ing power)
rather than need and thus fosters inequality. The general
welfare cannot be achieved unless every one has access to
a community-defined measure of well being based on the
general standard of living in wider society. Without such
resources, individuals are "in need" because they cannot
think, compete for
3 n POLITICAL IDEOLOGY AND SOCIAL WELFARE

success, vote intelligently, develop relationships, enjoy Human nature reflects the existing mode of production
leisure time, or otherwise participate fully in society. The (for example, feudalism, capitalism, socialism, or com-
general welfare also rests on people putting the common munism) and the individual's location in society's class
good ahead of one's private desires, cooperat ing rather structure. Marx adds, "The mode of production of rna-
than competing, and sharing responsibility for others, and teriallife conditions the general process of social, poli-
otherwise promoting social cohesion and solidarity. tical, and intellectual life. It is not the consciousness of
Humanitarian liberalism concludes that the govern- men [sic] that determines their existence, but their social
ment rather than the market is best positioned to create existence that determines their consciousness." (Tong,
the conditions needed to meet basic needs, and max imize 1998, pp. 94-95). Thus, it is through social production
civic participation, that is to ensure the basic right of and human labor that individuals collec tively create the
citizenship defined as communit y membership not society that in tum shapes them.
national origins. These rights include (a) civil rights (the Instead of defining need in terms of market behavior,
right to individual liberty and equality be fore the law); (b) radicalism argues that the class structure and the profit
political rights (the right to vote and to run for political motive socially construct need. For example, the wealth y
office); ~d (c) social rights (the right to a tend to expect a relatively high standard of living,
community-defined adequate standard of liv ing via the whereas marginalized and deprived people, hav ing access
market plus a universal, comprehensive, and adequate to fewer possibilities, often settle for less.
system of government-provided benefits). Ac cess to . These low expectations harm the poor but benefit the
social rights can reduce social, economic, and political affluent as rising expectations can lead deprived groups to
inequality; defuse collective resentment bred b y social demand a larger share of the economic and political pie.
stratification; and otherwise promote social solidarity and Further, the profit-driven culture of consumerism actually
cohesion. Humanitarian liberalism ap proximates the creates need. It induces people to realize their personal
human rights model. identity through what they consume and encourages
Humanitarian liberalism explains social problems as a people to "need" what companies produce whether or not
product of unequal institutional arrangements and racial the product is necessary or good for . them. At the same
inequality as a product ofinstitutionalized racism or those time, the market economy allows important needs for
established laws, customs, and practices that appear to be income, food, housing, and health care to go unmet. It
intrinsically free of racial bias (that is, race neutral or also fails to register the need for parks, school s, satisfying
color-blind) but whose impact falls heavily and unfairly work, environmental protections, and other
on persons of color. It denotes patterns, procedures, improvements in the quality of life that do not yield a
practices, and policies that consistently benefit White profit. For radicalism, the main aim of production and
persons while penalizing, disadvantaging, and exploiti ng distribution is the full satisfaction of human needs.
persons-of-color by ignoring the consequences of past The general welfare rests on a: social or collective
prejudice, discrimination, and racial subordination .. To definition of need. Only after everyone reaches this civic
erase racial inequality requires more than the standard should other needs be met. Given the market
conventional legal responses to racial discrimination as economy's cash nexus, reliance on competition, need for
the latter do necessarily alter embe dded racial coercion; and widespread social stratification, its
hierarchies. Instead the achievement of racial equality dynamics tend to alienate people from each other, their
must move beyond the individual's right to legal equality work, and their environment, and fail to produce the
before the law to the collective or human right to necessary social solidarity. The notion of the gen eral
nondiscrimination and beyond equality of opportunity to welfare is more possible in an egalitarian society where
equality of result, which involves undoing the racial people contribute according to their ability and receive
hierarchies of domination and subordination. resources according to their need. Such socie ties promote
participatory over elite democracy, and minimize special
privilege based on an unequal distribution of resources.
Radicalism sustains skepticism about the role the
government in capitalist societies and their capacity to
RADICALISM Radicalism regards human nature as
achieve the above ends. Given the government's ties to the
socially constructed through the historic interplay of
dominant class's members and interests, its leaders can
human biology, the physical environment, and human
only go so far. By definition the elite must support the
society. Human nature is the product of human activ ity
interests of the powerful, mediate their internal c lass
and is not fixed. According to Karl Marx, a father of
rivalries, and contain working-class
radicalism, "All history is nothing but a continuous
transformation of human nature" (Jaggar, 1983, p. 130).

demands. Welfare states exist primarily to cushion the
blows of the market inequality, to create the conditions
for profitable production, to enforce the class structure.
Radicalism also insists that "the people" can influence the
government through social movements and other
elements of class struggle. In the final analysis, radical-
ism argues that human liberation requi res a welfare
society-one that subordinates the interests of the market
to the people. Among other things, such a transformed
society would replace private ownership of production
and the profit motive with communal control over all
areas of life.
Radicalism argues that social problems are socially
constructed as well and reflect unequal power arrange-
ments (Mullaly, 1997). In this view, racial inequality
derives from institutionalized racism, but also from the
social construction of the meaning of race. Since mod ern
genetic analysis (DNA) reports greater variation within
racial groups than between them, the "races" are riot
biologically distinct groups (Omi & Winant, 1994). Even
so, being born or labeled Latino, African American, or
Native American in the United States has immediate and
often negative and unequal outcomes. The fluidity of
racial attribution (for example, in the mid-1800 s
California changed the designations of Mexican and
Chinese Americans) also points to a social rather than a
biological basis of race. Radicalism argues that the
powers-that-be often assign social, poli tical, and
economic meanings to physiological racial categories to
achieve other ends. The resulting elabo rate system of
pseudo-intellectual categories, stereotypic assumptions,
and negative contentions are then used to justify a system
that installs White power and privilege to the
disadvantage of persons ofcolor.
FEMINISM Feminism criticizes each of the prior political
ideologies for focusing solely on male experiences,
regarding women as inferior, or remaining silent on
women. Feminism in general seeks to account for the
experience of women resulting from women's subordi-
nation to men, but there are three basic versions of
feminism-. -liberal, cultural, and socialist. All three have
responded to earlier criticisms of their analysis by
regularly taking account of race and class dynamics as
well as gender.
Liberal, cultural, and socialist feminism each add a
gendered dimension to the discussion of human nature.
Liberal feminism argues that men and women share a
common human nature beneath the surface of male or
female differences. It rejects standard liberalism's view
that women are irrational by nature and therefore in ferior
as contradictory to liberalism's claim that because all
humans possess the capacity for reason they should
POLITICAL IDEOLOGY AND SocIAL WELFARE 373
be treated equally. Cultural feminism, sometimes referred
to as radical feminism, holds that the powers-that- be
presume that biology is destiny and define women as
inferior and subordinated to men. They argue instead that
while male and female may differ biologically, the social
categories of woman and man are neither natural nor
eternal. Socialist feminism argues that human nature is
socially constructed through the interaction of two deeply
intertwined master systems- capitalism and
patriarchy-along with racism.
When it comes to the definition of need, feminism
broadens the definition to include personal and societal
needs for care regarded as a universal aspect of human
life. The need for care arises because all individuals need
care to thrive and to develop fully but also because at
some time anyone may not be able to care of them selves
or others. By not noticing the centrality of the need for
care in human life, the nation's leaders can degrade the
activities of care, exploit the caregivers (most of whom
are women), and fail to provide for the needs of both
individuals and society as a whole.
All three feminisms insist that the general welfare
cannot be achieved without ending women's oppres sion.
Liberal feminism emphasizes sexism (for example
differential treatment of people based on sex), calling it
an arbitrary constraint on the freedom of both women and
men. For them the general welfare rests on equal
opportunity to participate fully in all societal institu tion.
For cultural feminism the general welfare depends on
eliminating male contr ol of women's bodies, labor, and
resources as well as male control of marriage,
employment, and government because the resulting
domination deprives women of power and self-
determination in all spheres of life. Socialist feminism
highlights the gender division of labor. It argues that since
this gendered structure serves both capitalism and
patriarchy, the general welfare requires altering or elim-
inating it from the workplace and the home along with the
ideologies that justify the subordination of women an d as
well as domination based on class and race.
Feminists of all political stripes also question the role
of the government as outlined by the three main
ideologies. They fault conservatism for ruling out state
support, liberalism for allowing the state to downplay
women's rights, and radicalism for critiquing the state's
relationship to class structures but not patriarchy or
racism. It critiques all three perspectives for ignoring the
particular sources of women's oppression, the con ditions
needed for effective care, and the definition of care giving
as work. They argue that to be relevant for women the
analysis of the state must be broadened to include the
family, social reproduction, the gender division of labor,
and women's political struggles.
374 POLITICAL IDEOLOGY AND SOCIAL WELFARE
Liberal feminism sees government as an ally. It calls upon
the state to end all of the sexist practices that bar women
from full participation in society as well as all male or
female double standards. Cultural feminism neither offers
a specific analysis of the state nor auto, matically sees the
government as an ally. But it argues that women cannot
be free until society gives up the glorification of
motherhood for all women, the sexual objectification of
women, homophobia, and other oppressive structures.
Socialist feminism argues that the state often reproduces
and reinforces unequal power relations based on gender,
race, and class. Socialist feminists also point to the
emancipatory potential of the welfare state. By providing
women with income outside of employment and
marriage; its programs can increase the individual and
'collective leverage of wo men with both employers and
male partners, which in. tum weakens the power of both
capitalism and patriarchy.
Ideology is more that abstract ideas. It has raised hopes,
inspired fear, and drawn blood for millions of human
beings. For better or worse, the impact of political
ideologies is also woven tightly into the fabric of social
work and social welfare policy. One look at the shift in
public policy since the mid,1970s-from lib, eralism to
conservatism-reveals its power as does the changes won
by mobilized social movements. In order to serve their
clients well, understand service delivery, influence public
policy, and promote social change, social workers must
understand the pros and cons of ideological prescriptions.
This will make it easier to stand against ideologies that
violate the profession's values, goals, and commitments
and to join with allies to promote social justice as called
for in the NASW Code of Ethics.
FURTHER READING
Abramovitz, M. (1996). Regulating the lives of women: Social welfare
policy from colonial times to the present. Boston: South End Press.
Abramovitz, M. (2004). Saving capitalism from itself: Whither the
welfare state? New England Journal of Public Policy, Falll
Winter, 21-32-
Abramovitz, M. (2006). Welfare reform in the United States:
Race, class, and gender matters. Critical Social Policy 26(2),
336-364.
Ball T., & Dagger, R. (1998). Ideals and ideologies: A reader (3rd
ed.). New York: Longman.
Ehrenreich, B. (1987). The new right attack on social welfare.
In F. Block, R. Cloward, B. Ehrenreich, & F. F. Piven (Eds.),
The mean season: The attack on the welfare state (pp. 161-195).
New York: Pantheon.
Frederickson, G. M. (2002). Racism: A short history. Princeton:
Princeton University Press.
George, V., & Wilding, P. (1874). Ideology and social welfare (p.
67). London, England: Routltedge and Kegan Paul.
Harvey, D. (2005). Neoliberalism: A brief history. New York:
Oxford University Press.
Kaufman, C. (2003). Ideas for action: Relevant theory for radical
change. Cambridge: South End Press.
Klatch, R. (1987). Women of the new right. Philadelphia, PA:
Temple University Press.
Mullaly, R. (1997). Structural social work: Ideology, theory and
practice. New York: Oxford University Press.
Michael, 0., & Winant, H. (1994). Racial formation in the United
States from the 1960s to the 1990s. New York: Routledge.
Tronto, J. C. (1993). Moral boundaries: A political argument for an
ethic of care (pp. 162-165). New York: Routledge.
-MIMI
ABRAMOVITZ
POLITICAL INTERVENTIONS
ABSTRACT: Since the Progressive Era, social workers
have played important roles in political struggles for
social justice. They have criticized, designed, and
implemented an array of social policies and have in'
creasinglv campaigned for and held political office. Even
so, there has been considerable ambivalence within the
profession about the extent to which social workers
should engage in political action. A major challenge
facing the profession during this century will be to ensure
that social work students and practi- . tioners understand
the impact of political processes on their own and their
clients' lives and develop the skills to identify which
forms of political intervention are effective for different
goals and contexts.
KEY WORDS: political intervention; social move, ments;
globalization; electoral politics; identity politics; radical
social work
Introduction
Political intervention is individual or collective action
intended to influence public discourse, the structure and
policies of government, and ultimately the distri bution of
rights and resources in a society. Methods of political
intervention can vary significantly in their'
contentiousness and the degree to which they challenge
the status quo. Among the least contentious are what
scholars have described as conventional, insider, or
institutional strategies. These include "the use of the
electoral system, the judicial system, and the peace' ful
petitioning of public officials (lobbying, testifying at
public hearings, presentations, letters, petitions)"

(Gamson, 1998, p. 66). Extra-institutional methods include
more confrontational strategies like protests, sit-ins, civil
disobedience and disturbance, and even sometimes
violence (Tarrow, 1998).
Social Work Political Intervention
Social workers have long been involved in political
intervention, and Table 1 describes a variety of roles in
which social workers can be politically active (Domanski,
1998; Gamble & Weil, 1995).
While the profession's commitment to political ac tion
and social justice has tracked broader societal struggles for
political and economic power (Fisher, 1995), there has
been considerable ambivalence within th e profession about
what role social workers should play in these political
struggles. Thompson (1994) states " since its beginnings
the social work profession has been at war with itself about
the extent to which it should engage in matters of social
justice and reform" (p. 457). On the one hand, social
workers have rhetorically committed themselves to mainly
institutional forms of political intervention. Since the
1970s, for instance, there has been increasing support for
expanded political intervention i n social work education
and practice. CSWE Educational Policy and Accred itation
Standards have emphasized the need to prepare social work
students for political intervention and de lineatedthe roles
this political activity could take, including legislativ e
advocacy, expert testimony, and holding political office
(Fisher, 1995; Mickelson, 1997). The most recent
standards state that one of the major purposes of the
profession is "to pursue policies, services and resources
through advocacy and social or polit ical actions that
promote social and economic justice" (CSWE, 2001, p. 4 ).
The National Association of Social Workers (NASW)
has also been part of this growing tide of support for
political intervention. Since the 1970s, NASW has aimed
to expand the profession's role in politics with the creation
in 1971 of the Education and Legislative Action Network
(ELAN) and in 1976 of the Political Action for Candidate
Election (PACE) com-mittee. PACE has aimed both to
increase the number of social workers elected to public
office and exert greater
TABLE 1
Sodal Work Roles in Political Intervention
Voter Campaigner Community organizer
Coalition builder Policy analyst .
Advocate Activist Lobbyist
Advocate researcher
Witness
POLITICAL INTERVENTIONS
375
influence over the agenda setting and policy-making
process. Its, 1996 Code of ethics states: "Social workers
should be aware of the impact of the political arena on
practice and should advocate for changes in policy and
legislation to improve social conditions in order to meet
basic human needs and promote social JUStice" ([604] [a )).
Some studies suggest that the participation of social workers
in electoral politics has increased over the past few decades
and that social workers are more politically active than the
general public (Hamilton & . Fauri, 2001; Parker &
Sherraden, 1991; Reeser & Epstein, 1990). Nevertheless,
some have argued that the profession has failed to follow
through on its professed commitment to institutional action
(Haynes & Mickelson, 2003; Rees, 1991; Wagner, 1997).
Social workers, like most professional groups, have
typically eschewed extra-institutional action, and while
NASW has increased its political activity, the social work
educators have not kept place. In 1996, fewer than 20% of
bachelor programs and fewer than 50% of master programs
nationally provided practica on government relations,
electoral politics, and policy advocacy (Wolk, Pray,
Weismiller, & Dempsey, 1996), and only about 10% of
MSW programs describe having a "politicized"
concentration (Haynes & Mickelson, 2003). Social workers
who are politically active seem far more likely to engage in
institutional activities, such as voting and legislative
advocacy than extrainstitutional ones (Domanski, 1998;
Gray, van Rooyen, Rennie, & Gaha, 2002). Domanski
(1998) surveyed a random sample of 513 social work health
care leaders and found that while over 90% reported that
they (a) voted, (b) talked about social and policy issues with
their colleagues, families, and friends, and (c) provided
advocacy services to clients, less than 10% reportedly
engaged in any organized political demonstrations and just
13% testified at public or congressional hearings.
Scholars attempting to understand why the profes sion
has been more active or failed to fully endorse and engage
in political activities identify a number of ob stacles,
including: (a) the perception that political ac tion conflicts
with the core social work value of impartiality (Fisher,
1995; Haynes & Mickelson, 2003; Mickelson, 1997); (b )
the field's drive to obtain the status of a profession, and a
greater stress on clinical social work than community
practice and political intervention (Abramovitz, 1998 ;
Wenocur & Reisch, 1989); and (c) federal laws, such as the
Hatch Act and the IRS Code regulating tax exempc~ status
for nonprofit organizations, that place re al limits on the
extent to which public sector employees and
government-funded social service agencies can en gage in
political activity but are also commonly
376 POLITICAL INTERVENTIONS
misunderstood by practitioners as being more restrictive
than they actually are (Berry & Arons, 2003; Chaves,
Stephens, & Galaskiewicz, 2004, p. 297; Fabricant &
Fisher, 2002; Thompson, 1994).
History
Social work political action in the United States has
waxed'and waned in concert with broader societal shifts in
economic, political, and social conditions. The in tensity of
political intervention by the social work profession is best
understood as a result of the interplay between these
broader forces, the obstacles listed ear lier, and the efforts
of individual "moral entrepreneurs" (Zald & Garner, 1987)
to frame social work as political in nature, emphasize the
profession's 'stated mission to work for social change and
justice, and take the personal and professional risks
inherent in challenging the status quo.
THE PROGRESSIVE ERA Social and economic condi-
tions at the turn of the 19th century provided fertile
ground for activism by social workers. Rapid indus-
trialization, urbanization, and immigration flooded
American cities with capital, jobs, and people. Some
prospered, but poverty was widespread. Social work's
'ambivalence toward political intervention has its
roots in the differing approaches to ameliorating the
social ills of the Progressive Era adopted by its
"founding mothers," Jane Addams and Mary
Richmond, and their institutions, the Settlement
House Movement (SHM), and Charity Organization
Societies (COS), respectively.
The COS casework approach to poverty focused on
treating and changing the individual to adapt to socie tal
conditions. While Mary Richmond acknowledged the
influence of structural conditions on individual problems
in her book Social diagnosis (1917), her chief aim was to
make charitable giving and casework more scientific and
efficient. Her book served as a response to Abraham
Flexner's claim in 1915 that social work was not a true
profession because it lacked a theoretical foundation
(Haynes & Mickelson, 2003). The COS approach
dominated the field in the late 19th century, and by
1892,92 COS agencies operated in cities across America
(Abramovitz, 1998, p. 514).
The COS approach was challenged at the turn of the
century, however, by the growth of the women's club
movement and SHM. By 1910 the General Federation of
Women's Clubs (GFWC) claimed over a million members
across the country and through its many reform-oriented
committees, on issues such as civil service reform and
child labor, it informed local chapters about national
policy (Skocpol, 1992, p. 331).
The SHM brought educated middle and upper class men
and women to live in and serve poor communities. In
contrast to the COS model, many individuals in both
movements held that unjust societal structures were the
primary cause of poverty. Settlement workers, therefore,
aimed not just to provide services but help the poor
participate fully in the democratic process and push for
social policy reforms. By 1910 there were over 400
settlement houses across the country, 60% of whose
members were women (Skocpol, 1992, p. 345).
Settlement house workers Jane Addams and Florence
Kelley drew upon and worked in conjunction with the
network of reform-minded women's clubs to secure
government intervention in areas such as mothers'
pensions, workers' compensation, and child labor laws
(Abramovitz, 1998). Although these movements were
segregated, African American social work ers in both
movements used self-help and political activism to address
community problems. In Chicago, for instance, Irene
McCoy, who played a prominent role in the
African-American women's club federations, led a
city-wide coalition that pushed for improvements in
education, employment, and housing and worked to
increase women's participation in electoral politics
(O'Donnell, 2001). Despite their movements' segrega tion,
White settlement leaders Addams, Kelley, and Lillian
Wald were vocal proponents for civil rights and racial
justice and worked with W. E. B. DuBois to establish the
National Association for the Advance ment of Colored
People (NAACP) in 1909 (Reisch & Andrews, 2002, p.
21).
These and other radical social workers, such as Ellen
Gates Starr, cofounder of Hull House, and social work
researchers Robert Hunter and Grace and Edith Abbott,
were the moral entrepreneurs of the progressive period,
documenting the structural causes of poverty, sharply
criticizing government policies and class divi sions, and
employing various methods of political intervention,
including coalition-building and legislative advocacy, to
achieve significant legislative victories. Al so noteworthy
during this period was the election in 1917 of the first
social worker to Congress, Jeanette Rankin (Haynes &
Mickelson, 2003).
These political activities did not come without costs,
however. Reisch and Andrews'(2002) note that Addams, a
pacifist, was "vilified" and "labeled a sub versive and a
traitor by legislative committees" when she opposed WWI,
not to be "rehabilitated in the public's eye until late in her
life when she received the Nobel Peace Prize for her work"
(p. 14). Jeanette Rankin also suffered when she lost her bid
for re-election in 1919 after voting against America's entry
into WWI (Haynes & Mickelson, 2003). The war and the
conser-
JI

vative and repressive environment that followed tem-
porarily subdued political reform efforts, and the
profession directed its attention toward
professionalization and further development of the
casework approach during the 1920s (Blau &
Abramovitz, 2004; Specht & Courtney, 1994).
THE NEW DEAL The Great Depression, with unem-
ployment at 25% in 1933 (Blau & Abramovitz, 2004),
heralded a period of radical and militant social activism
in the United States and intensified the debate within
social work over individual treatment and social
change. Private relief agencies that focused on
casework were ill equipped to meet the increased
demand for services and many in the profession began
to challenge psychological and moral explanations for
individual problems and question the efficacy of
casework.
Social work reformers active in the Progressive Era
became key players in national politics and social re-
form, convincing political leaders of the need for sig-
nificant government intervention and playing key roles
in drafting the Federal Emergency Relief Act of 1933
and the Social Security Act of 1935 (Abramovitz,
1998). Social worker Harry Hopkins advised President
Roosevelt about New Deal programs and became the
head of the Federal Emergency Relief Administration
and then the Works Progress Administration (Haynes &
Mickelson, 2003, p. 15). Another social worker,
Frances Perkins, became Secretary of Labor. By the end
of the decade, thousands of social workers had taken
public sector jobs in New Deal programs. As
Abramovitz (1998) states: "For better or worse, social
work had become a part of the machinery of the state"
(p. 515). The radical flank of the profession found voice
in the Rank and File Movement, a social worker union-
ization movement, which included 15,000 members at
its peak in 1935. This movement adopted a Marxist
class analysis of society and social problems and allied
itself with the Communist Party (Reisch & Andrews,
2002). Social work leaders associated with the
movement-Mary van Kleek, Bertha Reynolds, Jacob
Fisher, Harry Lurrie, and Frank Bancroft-called for a
radical restructuring of society and the creation of a
strong welfare state that included national unem-
ployment insurance (Spano, 1982).
World War II, postwar prosperity, and the anti-
Communist "red scare" that followed in the 1950s saw
social work radicals targeted as subversives by govern-
ment committees and marginalized within the social
work field. The field's drive for professionalization re-
turned with vigor as it embraced ego-psychology and
clinical practice methods (Haynes & Mickelson, 2003).
At the same time, however, growing militancy in the
POLITICAL
INTERVENTIONS 377
Southern African American community and the
emerging Civil Rights Movement sparked a period of
radical social change in the country of which social
workers were a part. Civil rights activist and social
worker Whitney Young, for instance, would become
executive director of the Urban League in 1961 and
served as president of NASW from 1969 until his death
in 1971
(http://www.socialworkers.orgJdiversity/black_ history
/young.asp ).
THE GREAT SOCIETY In 1964, soon after the
assassination of President Kennedy, President Johnson
shared his vision of a "Great Society," in which the civil
rights agenda would be realized, communities would
exert greater control over their own governance, and,
ultimately, poverty would be eliminated. The
cornerstone of Johnson's "War on Poverty" was the
Economic Opportunity Act (EOA), which created
several community-oriented programs, including Job
Corps, VISTA, Head Start, the Office of Economic
Opportunity, and Community Action Programs
(CAPs). The CAP, in particular, aimed to have
"maximum feasible participation" by low-income
individuals in the development and coordinatiori of
local social programs. With CAP funding, Community
Action Agencies sprouted up across the nation and by
1965, over 1,000· were in operation (Fisher, 1994, p.
123).
These political reforms from above fueled idealism
and radical social activism from below and the Civil
Rights and Women's and Anti-War Movements bur-
geoned. While social workers participated in these
movements, they rarely became national leaders
(Reisch & Andrews, 2002, p. 158). Rather, social work
activism focused mostly on War on Poverty programs
and the National Welfare Rights Organization
(NWRO), which arose in the mid-1960s to organize
welfare recipients to fight for a guaranteed adequate
income. The NWRO adopted the strategy advocated by
social worker and sociologist Richard Cloward and
political scientist Frances Fox Piven: To overload the
welfare system in the belief that this would bring about
the collapse of the welfare system and its replacement
with a guaranteed annual income. While the welfare
system was not driven to collapse, by the time the
NWRO ended in 1973, the number of welfare recipients
had increased by 6 million (Reisch & Andrews, 2002, p.
151).
Social workers' experiences during this period
helped to legitimize community organizing and politi-
cal intervention methods within the field. As mentioned
earlier, both NASW and CSWE took significant steps
during the 1970s, 1980s, and 1990s to increase the
attention paid to political action in social
378 POLITICAL INTERVENTIONS
work education and practice. Some social work educa tors,
such as Daniel Thursz, even encouraged social workers to
strategically employ extra- institutional methods of action
(Thurz, 1975). However, on the whole, the profession' s
original ambivalence about po litical intervention remains.
\ the social work profession's preference for conventional
Advocates for greater political activity within the
profession faced increased difficulties during the con-
servative Reagan and Bush administrations. In the 1980 s
Reagan sought to demobilize many movements for
change through budget cuts and challenges to the legal
status of change-oriented nonprofits (Walker, 1991 ).
Social work activism during this period centered on the
fairly conventional and reactive goals of gaining licensing
in every state, encouraging social workers to run for
elected office, and opposing welfare reform. More
progressive goals, such as opposing the "repeal" of
welfare and promoting universal health care, went largely
unachieved.
Future Trends
In the 21st century, political intervention faces new
challenges as a result of economic globalization, the in-
stitutionalization of protest and identity politics, among
other factors. Economic globalization- broadly, the
expanding global flow of money, goods, and services- has
led, to some extent, to a diminution of the state's ability to
control economic conditions , as corporations can more
easily move production to coun tries with the cheapest
labor and often escape state regulation (Prigoff, 2000 ).
And yet, the primary targets of political intervention in the
United States during the 20th century, and particularly
since the 1930s, have been federal and state governments ,
because expanded social welfare policies and government
intervention in the free market are regarded as means to
ameliorate the negative consequences of a market
economy (Fisher, 1995; Reisch, 2005).
This traditional activist focus on the state may need to
be supplemented by interventions that target cor porations
and international financial institutions, such as the WTO
and World Bank. Efforts to influence these targets,
however, have typically entailed the use of
extra-institutional methods, such as protests and boy cotts
(Prokosh & Raymond, 2002)-the tactics social workers
have traditionally been reluctant to employ.
Complicating these new dynamics further is the
institutionalization of protest , which has reduced the
efficacy of once powerful activist tactics (Meyer &
Tarrow, 1998). As Reisch (2005) notes "At one time ,
strikes, boycotts, and sit-ins were regarded as radical
tactics. Now they are accepted tools in political struggle
by groups at all points on the ideological spectrum. As a
result, they have frequently lost the critical element of
surprise that originally made them effective" (p. 295 ).
Institutionalization has led some groups to radicalize their
tactics (such as the property viole nce employed by a small
number of anti- WTO activists in Seattle in 2001). Given
forms of political action, it is unclear.
What this institutionalization of protest will mean for
the profession's ability to challenge dominant dis course,
set new political agendas based on social work principles
and policies, and influence corporate beha vior to ensure
that it becomes more socially responsible.
Finally, the emergence since the 1960 s of a wide
variety of political movements based on various forms of
identity-sexual, racial, ethnic, gender-has com plicated
political activism. In response to these devel opments,
social work activists and scholars have called for the
creation of broad-based, multicultural, cross national
coalitions to influence governmental policies and check
the power of multinationals (Chesler, 2001; Fisher, 1995 ;
Reisch, 2005; Wilson, 1999). Wilson states " Adequate
political solutions to the global eco nomic problems
confronting the majority of Americans will not be found
until White, Black, Latino, Asian, and Native Americans
begin thinking more about what they have in common and
less about their differences" (p. 117). Scholars recognize
the difficulties inherent in creating and maintai ning such
alliances. There are descriptions, however, of successful
multicultural and cross-national coalitions
(Leondar-Wright, 2005; Prokosh & Raymond, 2002).
The challenge to social work educators and the
profession as a whole is to ensure that student s learn the
skills and receive the- experiences they need to identify
which forms of political intervention are effec tive for
different goals and contexts. Indeed, social workers seem
more likely to engage in political activity if they have such
experiences during their education (Hamilton & Fauri,
2001; Rocha, 2000). At the same time, it has expanded
and strengthened the power of professional social work
organizations to put their ethi cal principles of social
justice into practice at the agency, communit y, and policy
levels.
REFERENCES
Abramovitz, M. (1998). Social work and social reform: An arena
of struggle. Social Work, 43(6),512-526.
Berry, J., & Arons, D. (2003). A voice for nonprofits,
Washington, DC: Brookings Institution Press.
Blau, J., & Abramovitz, M. (2004). The dynamics of sodal welfare
policy. Oxford: Oxford University Press.
Chaves, M., Stephens, L., & Galaskiewicz, J. (2004). Does
government funding suppress nonprofits' political activity?
American Sodological Review, 69(2), 292-316.

Chesler, M. (200l).The charge to the white male brigade.
Journal of Applied Behavioral Sciences, 31 (3), 192-304.
Council on Social Work Education. (200l). Educational policy
and accreditation standards. Alexandria, VA: Author.
Domanski, M. (1998). Prototypes of social work political par-
ticipation: An empirical model. Social Work, 43(2), 156-167.
Fabricant, M., & Fisher, R. (2002). Settlements under siege: The
struggle to maintain community organizations in New York city.
New York: Columbia University Press.
Fisher, R. (1994). Let the people decide: Neighborhood organizing in
America. New York: Twayne Publishers.
Fisher; R. (1995). Political social work. Journal of Social Work
Education, 31(2), 194-203.
Gamble, D., & Weil, M. (1995). In R. Edwards (Ed-In-Chief),
Enclyclopedia of social work (19th ed.;Vol. 1, pp. 483-494).
Silver Spring, Maryland: National Association of Social
Workers.
Gamson, W. (1998). Social movements and cultural change.
In M. Giugni, D. McAdam, & C. Tilly (Eds.), From contention
to action (pp. 57-77). New York: Rowman & Littlefield
Publishers, Inc.
Gray, M., van Rooyen, C, Rennie, G., & Gaha, ]. (2002).
The political participation of social workers: A comparative
study. International Journal of Sodal Welfare, 11, 99-110.
Hamilton, D., & Fauri, D. (2001). Social workers' political
participation: Strengthening the political confidence of social
work students. Journal of Social Work Education, 37(2), 321-332.
Haynes, K., & Mickelson, ]. (2003). Affecting change: Sodal workers
in the political arena. Boston: Allyn and Bacon.
Leondar-Wright, B. (2005). Class matters: Cross-class alliance
building for middle-class activists. Gabriola Island: New
Society Publishers.
Meyer, D., & Tarrow, S. (1998). The movement society: Contentious
politics for a new century. New York: Rowman & Littlefield.
Mickelson,]. (1997). Advocacy. In R. Edwards (Ed.ein-Chlef},
Enclyclopedia of social work (19th ed., Vol. 1, pp. 95-100).
Silver Spring, Maryland: National Association of Social
Workers.
National Association of Social Workers. (1996). Code of ethics.
Washington, DC: NASW Press.
O'Donnell, S. (2001). "The right to work is the right to live":
The social work and political and civic activism of Irene
McCoy Gains. Sodal Service Review, 75(3),456-478.
Parker, M., & Sherraden, M. (1991). Electoral participation of
social workers. New England Journal of Human Services, 11 (3),
23-28.
Prigoff, A. (2000). Economics for social workers: Social outcomes of
economic globalization with strategies for community action.
London: Brooks/Cole.
Prokosh, M., & Raymond, L (Eds.). (2002). The global activist's
manual: Local ways to change the world. New York: Thunder's
Mouth Press/Nation Books.
Rees, S. (1991). Achieving power: Practice and policy in social
welfare. North Sydney, Australia: Allen and Unwin.
POLITICAL INTERVENTIONS 379
Reeser, L c., & Epstein, L (1990). Professiona/ization and
activism in social work: The sixties, the eighties and the future. New
York: Columbia University Press.
Reisch, M. (2005). Radical community organizing. In M. Weil
(Ed.), The handbook of community practice (pp. 287-304).
Thousand Oaks: Sage Publications.
Reisch, M., & Andrews,]. (2002). The road not taken: A history of
radical social work in the United States. New York: Brunner-
Routledge -.
Richmond, M. '(1917). Social diagnosis. New York: Russell Sage
Foundation.
Rocha, C. (2000). Evaluating experiential teaching methods in a
policy practice course: The case for service learning to
increase political participation. Journal of Social Work Edu-
cation, 36(1), 53-63.
Skocpol, T. (1992). Protecting soldiers and mothers: The political
origins of social policy in the Unites $tates. Cambridge: Harvard
University Press.
Spano, R. (1982). The rank and file movement. Washington, DC:
University Press of America.
Specht, H., & Courtney, M. (1994). Unfaithful angels. New York:
The Free Press.
Tarrow, S. (1998); Power in movement. Cambridge: Cambridge
University Press.
Thompson,]. (1994). Social workers and politics: Beyond the
Hatch Act. Sodal Work, 39(4), 457-465.
Thurz, D. (1975). Social action as a professional responsibility
and political participation. In T. R. Pennock & ].W. Chapman
(Eds.), Participation in politics (pp, 13-232). New York:
Leibor-Atherton.
Wagner, A. (1997). Social work and the global economy. In M. C.
Hokenstad & L Midgley (Eds.), Issues in international social
work (pp. 45-56). Washington, DC: NASW Press.
Wenocur, D., & Reisch, M. (1989). From charity to enterprise:
The development of American social work in the market economy.
Urbana: University of Illinois Press.
Wilson, [. (1973). Introduction to sodal movements. New York:
Basic Books, Inc.
Wilson, W. (1999). The bridge over the racial divide. Los Angeles:
University of California Press.
Wolk, ]., Pray, ]., Weismiller, T., & Dempsey, D. (1996).
Political practia: Educating social work students for policy-
making. Journal of Sodal Work Education, 32(1), 91-100.
Zald, M., & Gamer, R. A. (1987). Social movement organizations:
Growth, decay, and change. In M. Zald & [. McCarthy (Eds.),
Social. movements in an organizational society (pp. 121-141).
New Brunswick: Transaction Books.
FURTHER READING
Anner, ]. (1996). Beyond identity politics. Boston: South End Press.
Burghardt, S., & Fabriacant, M. (2005). Which side are you on?
Social work, community organizing, and the labor movement.
In M. Weil (Ed.), The handbook of community practice (pp.
204-214). Thousand Oaks, CA: Sage Publications.
Fisher, R. (1999). Social action community organization: Pro-
liferation, persistence, roots, and prospects. In M. Minkler
380 POLITICAL INTERVENTIONS
(Ed.), Community Organizing & Community Building for Health
(pp. 53-67). New Brunswick, NJ: Rutgers University Press.
Mizrahi, T. (2001, March). The status of community organizing
in social work at the end of the 20th century: Community
practice context, complexities, contradictions and
contributions. Research on Social Work Practice, 11 (2),
176-189.
Reisch, M. (2000). Social workers and politics in the new
century. Social Work, 45(4), 293-297.
Walker, J. (1991). Mobilizing interest groups in America: Patrons,
professions and social movements. Ann Arbor: Michigan Uni-
versity Press.
-MEGAN MEYER
POLITICAL PROCESS
ABSTRACT: Although most policy is created as a series
of processes, these processes differ considerably
depending on which political actors are engaged.
Knowledge of both formal political system processes
(rules, rulemaking, promulgation of rules) and the
informal political system processes (relationships,
influence, negotiations) are necessary if one is to
understand both how political systems work and how to
begin to make the necessary changes if a relevant social
justice goal is not being met.
KEY WORDS: Congressional committees; promulga tion
of rules; informal political process; rule- making
process; policy analysis; policy evaluation
Every aspect of our lives and the lives of our clients are
affected by public policy. Such policy is developed in the
political arena on both the local, state, and national levels. The
political process is not value-free or neutral. However,
understanding the political process is the key to influencing
the system on behalf of social worker clients and
constituencies.
Knowledge of both the formal political processes (such as
committee structures, who can introduce a bill, rule-making,
and promulgating a bill) and the informal political system
processes (relationships, influence, public pressure, and
negotiations) are necessary to understand how the political
system works and, more importantly, to make changes needed
to secure or retain socially just policies and programs. Once
one has the knowledge of the political system, then the "art" of
influencing the system can be mastered (see entry on
Advocacy).
The political process was designed to' address and even
encourage conflicting points of view with a process of checks
and balances. Although most policy is created as a series of
processes, these processes differ considerably depending on
the political actors engaged, for example, elected officials,
interest groups, media, lawyers, and bloggers (Dye, 2005).
The Formal Process
The United States Constitution is the underpinning for the
formal process. It ensures input from multiple sources and
includes provisions for conflict resolution between groups
and a balance of power among the three branches of
government. There are three branches of government: one to
make the laws (Congress-legislative), another to execute them
(White House-administrative), and the third to interpret them
(Supreme Court-judicial). All three branches of government
have their own formal rules and procedures and methods by
which they could be influenced. This discussion focuses
primarily on the legislative branch, but briefly comments on
the other two branches.
The essence of the legislative process is to make choices
between multiple and conflicting objectives. All legislation
must pass through formal political steps. The compromised
required to mount legislation is timeconsuming and often
difficult. On a rare occasion a bill passes through Congress or
a state legislature at lightning speed, but usually these are bills
that either respond to a critical situation (that is, natural
disasters, war, and others) or have overwhelming public
support.
The first step in the process is for some individual, group,
or organization to conceive the idea or identify an issue and
redress a problem for which a law would help. If not an
elected official, the person must convince at least one
legislator for the need to adopt the issue and begin the process
of creating a new or revised public policy. From here the idea
is written in the form of what is called a "bill." The idea stage
thus is the very first point of potential political influence.
The elected. membership of legislative bodies include as
Congress (Senate and House of Representatives, and, each of
the 50 states upper and lower bodies). These bodies are
divided into committees. Each committee focuses on an area
of policy, such as environment, health, education, foreign
affairs, and agriculture. A proposal is drafted into a Bill form,
and assigned to a Committee. It is within the committee that a
bill is given its most thorough and formal review. A
significant way that committee members obtain their
information on a bill is through public testimony (oral as well
as written}-thus the committee becomes

a key public access point. Individuals with relevant, in-
depth, professional, or personal experience, such as social
workers, clients, and other constituencies can have a
tremendous effect on the outcome of the policy, especially
if well organized and coordinated.
When a bill is assigned, there should be an ana lysis of
whether or not there is a likelihood of the bill's passage.
The wrong committee assignment, or assignment to
multiple committees, makes passage less likely. Biparti san
sponsorship is a good predictor of passage, as is
sponsorship by powerful senior legislators. Finally, the
analysis should include the support and opposition by
community groups and parties, both formally listed and
informally known. It is important to assess both how
extensive and and intensive the opposition is. (For ex-
ample, while most Americans support a women's right to
choose, the minority opposing abortion are vocal and well
organized.) Advocates for a proposed bill need to prepare
responses to the opposition's point of view as well as to
understand tactics of opponents (Staples, 2004).
The key person in the committee is the chairperson.
The chair has sole discretion over the committee and may
choose to present a bill in such a way as to influ ence the
action taken by the committee members. The chair may
choose not to place the bill on the commit tee's agenda. In
general, the legislative committee may (a) report the bill
favorably to the whole committee as is, (b) report
favorably with amendments, (c) report favorably on a
substitute bill, (d) report on the bill unfavorably, (e) send
the bill to another committee for review, or (f) table the bill
altogether in an effort not to take action.
Depending on the committee recommendation, the next
step is for the bill to go before the full body of its origin
(either the Senate or the House of Representa tives for
federal legislation) for review. From that review, if it
passes with a majority vote from that house, the bill
proceeds to the second house for the identical process. If a
bill is passed by both legislative bodies, but with their own
versions of the bill, the differences are worked out in a
Conference Committee made up of members from both
bodies. The bill must then be approved again by each
legislative body before it goes to the president or governor
for signature or veto. A signed law is called an Act or a are different and at times conflicting voices among their
Statute.
Regulations
Once a bill has been signed into law, there are addi tional
steps before a law is fully implemented; that process is
called "promulgating the rules." It is an important part of
the political process that can be influenced. Here the
agency or department, that will
J
POLITICAL PROCESS 381
administer the Act determines how the law will be
implemented, enforced, and assessed through a series of
written regulations.
The "regs" as they are sometimes referred to, are
additional policies that transform the legislative ideal into
the practical design and delivery. Regulations shar pen and
clarify staffing requirements, service provider
responsibilities, client eligibility, treatment modalities, and
accountability and reponing mechanisms. The rules or
regulations are not developed by elected officials but by
governmental employees who mayor may not understand
the intent of the bill, and can therefore consider ably alter
the intent of the legislation. They are usually influenced by
the elected president or governor's views of the
law-whether they were an initiator, enthusiastic supporter,
or passively accept the will of the legislature would make a
difference in how the law is put into effect.
Public input is always sought during the rule-writing
stage, and this offers social workers and others an op-
portunity to assure the original intent or improve a poorly
conceived bill. Here again one must know the formal. rules
(see the Administrative Procedure Act,
www.oalj.dol.gov/libapa.htm] as well as identify the staff
assigned to the duty of promulgating the rules.
Obviously the key component within the political
process is the politician. It is helpful to have elected
officials who agree with social work values. Even better is
to have social workers elected to office. As of 2007 there
were 10 social workers elected to Congress (two senators
and eight representatives) and hundreds of state and local
legislators (PACE Web site, www.social
workers.org/pace). There is some evidence that social
workers are more effective in the political arena than
attorneys, who commonly are legislators (Haynes &
Mickelson, 2006).
As legislators, politicians represent large constituent
groups with a variety of positions, values, and ideas. For
the most part, elected officials want to do what is best for
their community and country. Conflict arises because
politicians vary considerably in age, experience, training,
political ideology, and party affiliation (and levels of
commitment within party affiliation). Addi tionally, there
constituents on an issue. The political process requires one
to not only know the rules and regulations but also to be
familiar with those who make and play within those rules
and regulations. Legislators are human, and one must
understand where the legislators stand on issues and who
can influence their opinions; what their passions, peeves,
styles of operation, and communication are? It is here that
we start the transition from the formal process to the
informal process.
382 POLITICAL PROCESS
The Informal Process
Social workers must be aware of formal political pro-
cesses, but they also need to understand that there is a
parallel track of informal processes by which political
changes and legislative policy are made or created. It is
frequently this informal, anecdotal process or relation-
ship-building that triggers the formal political process, but
neither process is separate, and both are necessary to get
legislation that reflects real needs and real solutions.
Human nature is the underpinning of the informal
process. Simply put, "people influence people." Usually
referred to as "politics," the informal processes are ac-
tually the individual-to-individual, or group-to- group
influences, motives, or : relationships that affect the
process and outcome of legislation, Social workers must
understand and get involved in this part of the political
process since they are often best suited to interpret theirs
and their clients' needs and interests.
Politicians are responsible for a whole district or state,
those who voted for them and those who did not. They
have a responsibility to their constituents within their
district, as well as to the individuals in other districts.
They must listen to opposing opinio ns within these
diverse constituent groups. The diversity can make
decision making difficult and complex. They also have
their own ideology, preferences, and priorities about what
government should and should not be involved with.
Furthermore, they also give an ear to friends and
colleagues who helped them financially and with other
support to become successful.
Each politician sees the world differently, and each
needs information and exposure to an issue so as to
understand and respond to the policies t hat effect social
work clientele. One's background, friends, egos, and goals
play into actions that are taken in the legislative arena. Just
as one needs to understand the formal rules, one must
know the players and their roles in the poli tical process.
This also includes getting to know the key staff people and
being helpful to them (for example, providing
information, giving them publicity).
In examining the committee process as an example,
there is an informal aspect that is as important as the
formal part; the latter is that the chair of a committee is
appointed by the leader of the legislative body; the former
is the chair may be appointed because of an ability to work
with their political party leader or as a pay- back for
support of previous legislation: The chair also may be
appointed on the basis of their opposition to certain
polices. Chairs thus are not simply appointed because they
are the "best" people for the job.
Within committees, group dynamics can create and
destroy good public policy. Pressure from constituents,
the public, or their political party could stop legislators
from supporting a bill even if they agree with it. Legis-
lators may also see potential impacts of legislation on
their re-election possibilities. With every vote cas t, a
legislator must balance a multitude of factors. What is
most significant is understanding which factor can be used
to influence the vote. This is "politics": The art of
influence (Haynes & Mickelson, 2006).
Good legislators try to compromise with win- win
situations, an arduous task at best. For example in work-
ing to generate public jobs to address a high unemploy-
ment rate one might have to work with defense- related
groups and increase the military budget to create jobs for
the community.
When attempting to influence the political process,
one must undertake an analysis of the political situa tion. It
is as important to focus on both the formal and informal
political processes, which will provide input into the
legislation and creation of its regula tions if passed.
Traditional policy analysis focuses on an analysis of the
issues and its fiscal impact, of the legislation. Substantive
analysis should include look ing at current statutes and
regulations, and how this new piece of legislation fits
within the body of existing law. Even the most thoroughly
conceived policy will have some negative effect, although
the goal is to keep that to a minimum. The review should
include its impact and consequences of overall
furtherance of social justice.
The fiscal analysis should include examination of
start-up and first-year costs, as well as ongoing costs: cost
of new staff, staff training, public information, and
retraining and education of existing staff if appropriate.
For social work policy, the analysis sho uld also consider
the human cost: what the cost would be to current or
prospective clients in either lost human resources or
increased cost to other programs if this legislation were i
not enacted. i
Implications for the Social Work Profession The
National Association of Social Workers' Code of Ethics
I
states: "Social workers should be aware of the impact of
the political arena on practice and should advocate for
changes in policy and legislation to improve social
conditions in order to meet basic human needs and
promote social justice" (see entry on Code of Ethics). It is
imperative that social workers understand that the
political process is not value-free or neutral, and that
social workers cannot operate independently of the
political process. Therefore, all social workers-c- snot only
social workers in policy or political settings-must know
policy development, implementation, and revision to
make them informed,
i
I
j

knowledgeable, and able to take action when a policy
impedes or harms their clients.
Policy always affects social work practice service to
clients in whatever setting and whatever client popula-
tion at all governmental levels. Consequently, social
workers have the obligation to affect change. Not acting
within the political process is not staying "bias, free"
(Haynes and Mickelson, 2006). Nonaction is, in fact, its
own political act within the political process, and it is
one that is at odds within the social worker's Code of
Ethics. There are numerous entrances within the poli -
tical process where social work expertise can influence
and inform legislative policy, rule-making, and imple-
mentation. This can be at the agency, community, or
professional level. They can take the lead in a campaign
or join with allies as part of coalitions. Social work skills
such as brokering, mediating, negotiating, and influen -
cing are skills as used in the political process, and can be
called upon to make sure that the political process serves
the broadest response to the cause for social justice (see
also entry on Social Justice).
REFERENCES
Dye, T. (2005). Understanding public policy (Llrh ed.). Upper
Saddle River, NJ: Pearson Prentice Hall.'
Haynes, K. S., & Mickelson, J. S. (2006). Affecting change:
Social workers in the political arena (6th ed.). Boston:
Allyn & Bacon.
Staples, L. (2004). Roots to power: A manual for grassroots
organizing (2nd ed.). Westport, Cf: Praeger.
SUGGESTED LINKS Administrative
Procedure Act (APA).
www.oalj.dol.gov/libapa.htm
Federal Register.
www.gpoaccess.gov/fr/index.html National
Association of Social Workers.
www.socialworkers.org
Political Action for Candidate Election (PACE).
www.socialworkers.orgJpaee
The U.S. House of Representative Web site.
www.house.gov
www.senate:gov
www.supremecouTtus.gov
www.whitehouse.gov
Democratic Caucus for the House of Representatives.
www.dems.gov
Republican Caucus.
www.gop.gov
National Women's Political Caucus.
www.nwpe.org
Congressional Black Caucus.
www;cbcfinc.org
-JAMES S. MICKELSON AND KAREN S. HAYNES
j
POLITICAL SOCIAL WORK 383
POLITICAL SOCIAL WORK
ABSTRACT: Since at least the 1970s, formal
definitions of social work practice have included
intervention in the policy and legislative processes
(Gibelman, 2005). While knowledge of political
intervention and policy development has been an
integral part of social w ork practice since the
inception of the profession, there is increasing
acknowledgement of the need for and value of
full-time social work practice in a political setting.
This entry defines political social work and explains
its nature.
KEY WORDS: campaign; elected office; government;
politics; political
Definition
Dr. Nancy Humphreys, director and founder of the
Institute for Political Social Work at the University of
Connecticut, encouraged the profession to define
political social work as a distinct practice specializa tion.
"She distinguished political social work from 'the
responsibility every social worker has to be politi cal.'
Political social work, she said, 'is working in the
political arena full, time using social work skills.'''
(Stoesen & Pace, 2007).
Politics encompasses various aspects of government,
including the conduct of government, running for and
holding elected office, working on political campaigns,
working for elected officials, and the formation and
implementation of public policy. Macro social work
practice focuses on changes and improvements in the
larger society (Gibelman, 2005). Therefore, political
social work can be defined as that part of macro practice
that relates to government, especially the conduct of
government, the making of governmental policy and
running for and holding elected office. However, others
(Robert Fisher, YR) define it a specialization that con -
tains both micro and macro elements.
HISTORY AND CURRENT STATUS In 1976, NASW
established its political action committee, Political
Action for Candidate Election (PACE). This allowed
the organization to pool money from members to
support and elect politicians who were aligned with
social work issues and values. In 1994, NASW made
a commitment to elect more social workers into
public office and to increase electoral advocacy. A
dues checkoff, a pro cess by which ten dollars is
automatically added to the amount of an NASW
member's annual renewal and which the member has
to deduct in order for it not to be included, was
created to fund both national and
384 POLITICAL SOCIAL WORK
chapter political action committees (Weismiller & Rome,
1995). Since then, national and state chapters have focused
efforts on educating social workers about the political
process, how to run for office and how to be involved in
political campaigns. Currently 48 chapters have established
PACE (political action committees):
In the 2006 federal elections, NASW provided nearly
$450,000 and endorsed 224 candidates for Congress.
Social workers seeking and winning elected office are
documented early in the profession, when social workers
ran for office, were elected and served as members of city
councils, mayors, and members of Boards of Education.
Jeanette Rankin, the first woman elected to Congress in
1916, prior to women's suffrage, was also the first social
worker elected to high public office. Rankin, a settlement
~nd child welfare worker, was convinced she could
improve the social conditions she encountered by running
for public office and enacting social reform legislation
(Weismiller & Rome, 1995).
Ronald Dellums, a psychiatric caseworker from
Oakland, was elected to Congress in 1970 and re-elected
every term until he resigned in February, 1998. While in
Congress, Dellums led efforts to end apartheid in South
Africa and to slow the arms race, and he introduced a
universal national health service bill every year until he
retired. In 2005, a petition drive urged him to run for
Mayor of Oakland, an election he won in 2006. He has put
forth a program to make Oakland a model city (E llis,
2007). He was followed by Barbara Lee, another social
worker who was the only Member of Congress who on
September 14, 2001, 'voted against giving President Bush
war powers after the September 11 th attacks.
Social worker Barbara Mikulski was the first female
Democrat elected to the U.S. Senate in her own right. She
was elected to the Senate in 1987 and has been reelected
for a third term. She began as a community activist and
then successfully ran for and served on the Baltimore City
Council, then in the U.S. House of Representatives and
finally in the U.S. Senate (Biography, 2007).
As of 2007, there are ten social workers in Congress,
two in the U.S. Senate, and eight in the U.S. House of
Representatives. As of 2005, NASW was able to identify
177 social workers holding elective office (NASW, 2007).
Additionally, as of 2007, NASW had identified 37 social
workers practicing in legislative offices in the
.u .S. Congress.
In 1995, the Nancy A. Humphreys Institute on Political
Social Work was founded at the University of Connecticut.
One of the purposes of the institute is to "work to increase
the number of social workers who pursue careers in
electoral politics" (Home Page, 2005).
Since its inception, the Institute has offered a campaign
school for social workers. The University of Houston
Graduate School of Social Work offers a concentration in
political social work. (See http://www.sw.uh.edu/aca
demics/courselistings.php for course listings and also
http://www.sw .uh.edu/academics/collegeoverview .php
for an overview.)
SKILLS A survey of social workers serving in elected
office demonstrates that most of the 12 skill areas iden-
tified in NASW's standards for the classification of social
work practice (Gibelman, 2005) applied to political social
work. The respondents mentioned:
1. The 'people' skills of listening, responding,
persuading, and caring are of primary importance
2. Political skills, such as linking, brokering, and
advocacy
3. Ability to consider alternative solutions to problems
and to attempt to achieve consensus
4. Negotiation and mediation (Haynes & Mickelson,
2006).
As important, the politicians noted that all of these skills
had been taught in their social work education and these
skills link to those delineated in the NASW classification
study. The politicians suggested that social workers may
need to learn how to transfer the skills of working with
individuals and small groups to working with
constituencies and larger groups (Haynes & Mickelson,
2006).
Social workers' training provides the skills to work
effectively in the area of politics. Politicians must be able
to keep abreast of current issues and must be able to
respond to the demands and needs of their constituencies.
The survey of social workers in political office showed
they had little trouble with these challenges and they
credited their social work training as providing the
foundation to overcome these challenges (Haynes &
Mickelson, 2006).
The knowledge of direct social work service that
students receive as part of their education enhances their
skills as political social workers in their ability to create
and advocate for policies that will be effective for clients,
social workers, and agencies. This knowledge provides an
important contribution to the political environment. A
Maine legislator who responded to the survey wrote:
Too many decisions are made affecting the clients
we serve to leave it only to non-social workers. So
few come with our background, and there are many
who just don't grasp the approach of problem solv-
ing or understand human behavior (p. 189).
..J
!

Effective societal change, legislative policy making, and
electoral politics require the use of essential social work
skills. For example, U.S. Senator Barbara Mikulski took
her local knowledge of Alzheimer's disease, along with
personal experience, and changed nursing home
regulations. U.S. Senator Debbie Stabenow used her social
work direct practice background and social work lens to
enact legislation supporting children and families when
parents get divorced. This legislation, originally enacted
when she was a member of the Michigan House of
Representatives, was used as a model by other states
(Haynes & Mickelson, 2006).
Politicians in many arenas are called upon to assist
their constituencies to navigate government agencies and
services and most of them utilize their staff to facilitate
this important role. Social workers are well qualified and
trained for these positions, which usually require short
term and task-centered activities and linking people to
resources. These social workers may assist people with
accessing benefits and services, resolve disputes between
people and government agencies, and create a group to
identify and address common needs or issues.
Settings
The career path for political social workers takes many
forms. In some cases, it starts with students who have
BSW or MSW field internships in political settings such as
policy advocacy organizations, with lobbyists or in
legislative offices. In some cases , social workers volunteer
at the community level. They may participate in political
elections, serving as campaign workers and then if their
candidate wins, they may be hired on as staff members.
Political social workers can also serve in a volunteer
public service capacity, which is in addition to a full time
social work position. Service in this capacity in cludes
election or appointment to school boards and being
appointed to and serving on various local government
committees and commissions. In some cases, social
workers decide to continue working in their practice
setting and run for a part-time office. This decision may be
motivated by experiences of working with clients and
coming to understand that the situation for clients will
change only when the policy is changed.
Besides political social work internships for students,
other ways to enter this arena include attending political
meetings, especially meetings of the group in which you
hope to serve; building relationships with the constituency
and with the key people involved in the particular area;
working on a campaign; becoming
POliTICAL SOCIAL WORK
385
appointed to a local committee or comrrussion; and
working with a political party on the local level.
V ALUES AND ETHICS Political social workers are held
to the same values and ethics of the profession as any other
social worker. According to the NASW Code of Ethics
(NASW, 1999), social justice is a social work value based
upon the ethical principle, social workers chaUenge social
injustice. This is further explained as:
Social workers pursue social change, particularly
with and on behalf of vulnerable and oppressed
individuals and groups of people. Social workers'
social change efforts are focused primarily on
issues of poverty, unemployment, discrimination,
and other forms of social injustice. These activities
seek to promote sensitivity to and knowledge about
oppression and cultural and ethnic diversity. Social
workers strive to ensure access to needed informa-
tion, services, and resources; equality of
opportunity; and meaningful participation in
decision making for all people (p. 9).
Section six of the NASW Code of Ethics, "Social Workers'
Ethical Responsibilities to the Broader Society," forms a
strong foundation for political social work, Section 6.04(a )
especially addresses this area of practice:
(a) Social workers should engage in social andpol-
itical action that seeks to ensure that all people have
equal access to the resources, employment,
services, and opportunities they require to meet
their basic human needs and to develop fully. Social
workers should be aware of the impact of the polit-
ical arena on practice and should advocate for
changes in policy and legislation to improve social
conditions in order to meet basic human needs and
promote social justice [p. 27).
EDUCATION The current Council on Social Work
Education (CSWE) accreditation standards include the
following in their purposes of social work:
The profession of social work is based on the values
of service, social and economic justice, dignity and
worth of the person, importance of human relation-
ships, and integrity and competence in practice.
With these values as defining principles, the pur-
poses of social work are:
• To enhance human well-being and alleviate poverty,
oppression, and other forms of social injustice.
386 POLITICAL SOCIAL WORK
• To formulate and implement social policies, services,
and programs that meet basic human needs and
support the development of human capacities.
• To pursue policies, services, and resources through
advocacy and social or political actions that promote
social and economic justice (CSWE, 2004, p. 4).
These three purposes very directly acknowledge the
importance of advocacy and social and political ac tions.
Accredited programs of social work design edu cation
programs to prepare social workers to fulfill t he purpose of
the profession. The challenge is to provide every social
work student with an opportunity to ex perience the
political process. Lobby days sponsored by many NASW
chapters are proven and excellent ways to interest and
engage students in the re levance to social work practice
including clinical functions. T rain ing in basic
political.knowledge and advocacy are key to every social
worker's education.
In addition to classroom instruction about the poli tical
arena and advocacy, field placements a t both the bachelor's
and master's levels include political settings, such as
advocacy organizations, legislative offices, and campaign
organizing. These field placements enhance the student's
understanding by providing an inside view of social work
in a political setting.
Challenges
Moving into political social work, especially elected
office, presents some unique challenges. Often employ ers
do not understand social work training, so are confused by
a social worker applying for such a position. There a re
some additional challenges to running for political office,
including difficulty in raising the necessary funds for a
campaign, especially if the social worker works in a
nonprofit organization that needs support for the diverse
community. The organizat ion may be concerned their
funding could be threatened by the activities of the political
social worker. In addition, ethical practice means that
social workers cannot garner support from their clients the
way other professions may. Social workers often have
limited personal financial resources and may be unable to
take the necessary time away from their employment or
leave their employment in order to run for office (Haynes
& Mickelson, 2006). While these challenges should be
considered, they should not dissuade the social worker
from seeking the available resources to address them and
continuing in the pursuit of political social work.
FUTURE OF POLITICAL SOCIAL WORK In her 2007
address, Dr. Humphreys offered suggestions to promote
the specialization, "including agreeing on a definition of
'political social work,' supporting social workers who
run for office, de mystifying the political process and
promoting politics as a career track for young social
workers'.' (Stoesen & Pace, 2007). NASW's efforts to
actively encourage and participate in the electoral ad-
vocacy process through federal and state political ac tion
committees, to document social workers in elective
office, to highlight social workers in this specialty prac-
tice area, will support and enc ourage social workers to
consider this career track.
Respondents to the Haynes & Mickelson survey offered
the following concerning social work education:
1. Social work education should include content on
political and legislative processes from an action-
oriented perspective, and not only a historical,
descriptive approach. Content on class advocacy, a
highly valued social work ideal, should be
reintroduced into all courses.
2. The policy course should include experiential and
skill-based assignments and should be designed for
both graduate and undergraduate students.
3. Field practicum experiences for all students should
include political activities, and specialized
placements should be available, so students can
experience working on an elected official's staff,
lobbying during state legislative sessions, and policy
development for public and nonprofit organiza tions,
4. Social work organizations should become more
politically active and aware. They should promote
political advocacy as a legitimate professional role.
Client data, which may be useful in supporting or
opposing legislation, should be obtained.
5. Social work organizations must investigate most
closely the legal and regulatory constraints on
political activity and organizational members in order
to dispel myths about these obstacles (p. 188).
Reaching and educating employers and the public
regarding the excellent education and skills social workers
bring to the political arena will need to occur to enhance the
ability of social workers to be employed in this area.
REFERENCES
Biography. (n.d.). U.S. Senator Barbara Mikulski. Retrieved
August 20, 2007, from http://mikulski.senate.gov/Senator M
ikulski/biography .html

Council on Social Work Education. (2004). Purposes of the social
work profession. In Educational policy and accreditation
standards (p. 4) Brochure. Alexandria, VA: Author. Retrieved
August 20, 2007, from http://www.cswe.org/NR/
rdonlyres/111833AO-C4F5-475C-8FEB-EA 740FF4D9F1/0/
EPAS.pdf
Ellis,J. W., IV. (2007, January/February). Meet Mayor Dellums:
Envisioning the future. Oakland Magazine. Retrieved August
20, 2007, from http://www.oaklandmagazine.com/media/Oak
land- Magazine/January- February- 2007 /Meet-Mayor -
Dellums/
Gibelman, M. (2005). What social workers do (2nd ed.).
Washington, DC: NASW Press.
Haynes, K. S., & Mickelson, J. S. (2006). Affecting change: social
workers in the political arena (6th ed.). Boston, MA:
Pearson.
Home Page. (2005). Nancy A. Humphreys Institute for political social
work. Retrieved August 27, 2007, from http://web.
uconn.edu/poli tical institute/
National Association of Social Workers. (1999). Ethical prin-
ciples. In Code of ethics of the national association of social workers
Brochure. Washington DC: Author. Retrieved August 20,
2007, from http://www.socialworkers.org/pubs/ code/code.asp
National Association of Social Workers. (2007). Political action .
for candidate election. Retrieved August 27, 2007, from http://www
.socialworkere.org/pace/default.asp
Stoesen, L., & Pace, P. R. (2007, June). Leaders focus on
reinvestment plans: The meeting included remarks from
several members of Congress. Retrieved August 20, 2007,
from https://www.socialworkers.org/pubs/news/2007/06/lead
ers.asp?back = yes
Weismiller, T., & Rome, S. H. (1995). Social workers in politics.
In R. L. Edwards &J. G. Hopps (Eds.), Encyclopedia of social
work (19th ed., pp. 2305-2313). Washington DC:
NASW Press.
-REBECCA MYERS AND CHRISTI GRANSTAFF
POLITICS. See Political Interventions; Political Pro cess;
Political Social Work.
POVERTY
ABSTRACT: Poverty has been a subject of concern since
the beginnings of social work. This entry reviews three
key research areas. First, the extent and dynamics of
poverty are examined, including the measurement of
poverty, patterns of cross-sectional and comparative
poverty rates, the longitudinal dynamics of poverty,
and poverty as a life-course risk. Second, reasons for
poverty are discussed. These are divided int o
individual versus structural level explanations. The
concept of
POVERTY 387
structural vulnerability is offered as a way of bridging key
individual and structural determinants in order to better
understand the existence of poverty. Third, strategies and
solutions to poverty are briefly reviewed.
KEY WORDS: causes of poverty; human capital; labor
market; life course; poverty dynamics; poverty meas-
ures; poverty rates; residential segregation; social wel-
fare state; solutions to poverty; structural vu lnerability
Context
The subject of poverty has been of central importance to
the profession of social work. In fact it could be argued that
addressing poverty lies at the heart of what the profession
stands for. As Simon notes, the original twin missions of
social work were "those of relieving the misery of the most
desperate among us and of building a more just and
humane social order" (1994, p. 23). This mission rings true
today as well. The National Associa tion of Social Work's
Code of ethics begins by stating, "the primar y mission of the
social work profession is to enhance human well- being and
help meet the basic human needs of all people, with
particular emphasis to the needs and empowerment of
people who are vulnerable, oppressed, and living in
poverty" (1996, p. 1). Likewise, the Council on Social
Work Education's curriculum policy statement declares
that the purpose of the social work profession is to
"enhance human well- being and alleviate poverty,
oppression, and other forms of social injustice" (2003, p .
4).
Social work has placed a heavy emphasis on alleviat ing
poverty for at least two reasons. First, poverty has been
viewed as undermining the concept of,a just society. In an
affluent nation such as the United States, it appears patently
unfair that not only are many left out of such prosperity, but
that they also live in debilitating economic conditions.
Second, social workers have long understood that poverty
underlies many of the problems and issues that they
confront on a daily basis. Whether the discussion re volves
around racial or gender inequalities, family stress, health
disparities, childwelfare, eco nomic development, or a host
of other topics that social workers routinely confront,
research indicates that pov erty is intricately connected to
each of these subjects. The alleviation of poverty is
therefore perceived to be essential in striving toward the
enhancement of human well- being and helping to "meet the
basic human needs of all people" (NASW, 1996, p. 1). As a
result, the profession has historically engaged in research,
practice, organizing, and advocacy on the local, state, and
federal levels with respect to poverty alleviation.
388 POVERTY
This entry addresses the scope and nature of poverty,
with a particular emphasis upon poverty in the United
States. Three fundamental questions are addressed.
First, what are the parameters and dynamics of poverty?
Second, how can the existence of poverty be best un-
derstood? And third, what can be done to alleviate the
conditions of poverty?
The Extent, Prevalence, and
Dynamics of Poverty
Poverty has been conceptualized and measured in a
number of different ways. Over 200 years ago, Smith in
his landmark treatise, Wealth of nations (1776), defined
poverty as a lack of those necessities that "the custom of
the country renders it indecent for creditable people,
even of the lowest o'rder, to be without." This type of
definition is what is known as an absolute approach. A
minimum threshold for living conditions is determined,
and individuals falling below that threshold are
considered poor. An example of this approach is the
manner in which the official poverty line is drawn in the
United States. The US. poverty line is calculated by
estimating the income needed for differ, ent sizes of
households to obtain what is considered a minimally
adequate basket of goods and services for the year. For
example, in 2006 a family of four was considered in
poverty if its total income fell below $20,614 (U.S.
Census Bureau, 2007). The often used standard of
defining poverty as living on less than a dollar a day in
developing countries is another example of an absolute
measure of poverty.
Alternatively, poverty can be constructed in a rela-
tive rather than absolute sense. A frequently used re-
lative measure is one that defines the poor as being in
households whose incomes fall below 50% of the
population's median household income. This measure is
often found within a European context, as well as in
comparative analyses across industrialized countries.
A third type of measure attempts to incorporate more
than just low income by factoring in additional aspects
of deprivation such as illiteracy, high mortality rates,
and chronic unemployment. The focus here is on the
concept of social exclusion or "the inability to
participate in the activities of normal living"
(Glennerster, 2002, 89). This type of measure has been
used by the United Nations in its construction of a
human poverty index for both the developing and
developed nations (United Nations Development
Programme, 2006), and has been discussed most
notably in the work of Sen (1992).
Beyond the various approaches to measuring pov-
erty, the dimension of time is fundamental in under-
standing the extent and dynamics of poverty. Poverty
can be understood from a cross' sectional, longitudinal,
or life-course perspective.
CROSS,SECTlONAL RATES In 1959 the US. poverty
rate stood at 22.4% (US. Census Bureau, 2007). During
the 1960s the rate fell sharply, such that by 1973 it had
reached a low of 11.1 %. Since 1973, the overall rate of
poverty has fluctuated between 11 % and 15% (Hoynes ,
Page, & Stevens, 2006). It has tended to rise during
periods of economic recession (early 1980s, early 1990s,
early 2000s), and has fallen during periods of economic
expansion (middle to later 1980s, middle to later 1990s).
The poverty rate in 2006 stood at 12.3%, which
represented 36.5 million individuals, or about one out of
every eight Americans (US. Census Bureau, 2007). The
percentage of the population falling into poverty or near
poverty (125% of the poverty line) was 16.8% (or 49.7
million Americans), whereas 5.2% of the popula tion (or
15.4 million Americans) experienced extreme poverty
(falling below 50% of the poverty line). Of those who
fell into poverty in 2006, 42% were living below 50% of
the poverty line (U.S. Census Bureau, 2007).
Consequently, a significant proportion of the poor in
America are also experiencing extreme poverty.
In addition, Census Bureau data indicate that certain
characteristics put individuals at a greater risk of
experiencing cross-sectional poverty. These include
having less education, being young or old, non, Whites,
living in single-parent families, residing in economic,
ally depressed inner cities or rural areas, or having a
disability (US. Census Bureau, 2007). In combination ,
these characteristics can substantially raise the risk of
poverty. For example, Black children under the age of 5
residing in a female headed household had an overall
poverty rate of 58.9% (U.S. Census Bureau, 2007).
Cross-sectional poverty rates have also been ana-
lyzed from a comparative perspective. The Luxembourg
Income Study (LIS) has gathered income and demo-
graphic information on households in ",,30 industria '
lized nations from 1967 to the present. Variables have
been standardized across the various national data sets,
allowing researchers to conduct cross- national analyses
regarding poverty and income inequality. This body of
research shows that U.S. poverty rates (and income
inequality) tend to be the highest in the developed world.
Whether one looks at relative or absolute poverty among
working-age adults, children, or the elderly, the story is
much the same (Srneeding; 2005a). For example, in a
study of international poverty rates among children, the
United States ranked second highest among 26
industrialized countries with a poverty rate of 21.9%
(poverty was measured as falling

below one half of the country's median income). The
only country with a higher rate of poverty among chil-
dren was Mexico at 27.7%. In contrast, the poverty rate
for children in Denmark stood at 2.4% (UNICEF, 2005).
For American children in married couple families,
single-parent families, or cohabiting families, the story
is much the same-a far greater percentage of American
children are at risk of poverty compared with their
counterparts in nearly all other developed countries
(Weinshenker & Heuveline, 2006).
LONGITUDINAL DYNAMICS Since the 1970s, re-
searchers have increasingly sought to uncover the
longitudinal dynamics of poverty. The focus has
been on understanding the extent of t urnover in the
poverty population from year to' year and
determining the length of poverty spells. These
studies have relied on several nationally
representative panel data sets, in~ eluding the Panel
Study of Income Dynamics (PSID), the National
Longitudinal Survey of Youth (NLSY), and the
Survey of Income and Program Participation
(SIPP). Results from these longitudinal analyses
have shed considerable light on understanding the
patterns of U.S. poverty. Several broad conclusions
can be drawn from this body of work.
First, most spells of poverty in the United States are
fairly short. The typical pattern is that households are
impoverished for one or two years and then manage to
get out of poverty (Bane & Ellwood, 1986; Blank, 1997;
Duncan, 1984; Walker, 1994). They may stay there for a
period of time, only to experience an additional fall into
poverty at some-point (Stevens, 1999). Since their
economic distance above the poverty line is often not
that far, a detrimental economic event such as the loss of
a job, the breakup of a family, or a medical problem can
easily throw a family back below the poverty line
(Duncan et al., 1995; Iceland, 2006; McKernan &
Ratcliffe, 2005).
Analysts that have looked at monthly levels of pov-
erty have found even greater fluctuation in poverty spell
dynamics. For example, Iceland (2003) examined the
monthly fluctuations in and out of poverty from 1996 to
1999 and found that 34% of Americans experienced
poverty for at least 2 months during this time period ,
while half of all poverty spells were over within 4
months, and four-fifths were completed at the end of 1
year.
On the other hand, this body of work has also shown
that there is a small number of households that do
indeed experience chronic poverty for years at a time.
Typically they have characteristics that put them at a
severe disadvantage vis-a-vis the labor market (for
POVERTY
389
example, individuals with serious work disabilities,
female headed families with large numbers of children,
racial minorities living in economically depressed inner
city areas). Their prospects for escaping poverty for any
significant period of time are greatly diminished
(Devine & Wright, 1993; Wilson, 1996).
Finally, research into the dynamics of poverty shows
that many households who encounter poverty will re-
experience poverty at some point in their future. Using
annual estimates of poverty from the PSID data, Stevens
(1994) calculated that of all persons who had managed
to get themselves above the poverty line, over half
would return to poverty within 5 years.
The picture of poverty drawn from this body of
research is thus characterized by fluidity. Individuals
and households tend to weave their way in and out of
poverty, depending upon the occurrence or nonoccur-
rence of particular detrimental events (for example, job
loss, family disruption, ill health). Similar findings have
been found with respect to the longitudinal patterns of
welfare use (Bane & Ellwood, 1994; Blank, 1997;
Duncan, 1984; Rank, 1985, 1994a).
LIFE,COURSE RISK A third approach for assessing the
scope of poverty has been to analyze poverty as a
life-course event. Rowntree's (1901) description of
11,560 working-class families in the English city of
York was pioneering in developing this approach.
Likewise, Hunter (1904) in his book Poverty sought to
locate impoverishment within the context of the life
course. Recently, the work of Rank and Hirschl has
attempted to gauge the extent of poverty across the
America life course.
Their results indicate that between the ages of 20 and
75, nearly 60% of Americans will experience at least
one year of impoverishment, while 68% of Amer icans
will encounter poverty or near poverty (125% below the
official poverty line). The odds of encounter ing poverty
across adulthood are significantly increased for African
Americans and those with lower levels of education-91
% of Blacks will encounter poverty between the ages of
20 and 75 versus53% for Whites, while 75% of those
with less than 12 years of education will experience at
least a year of poverty compared with 48% for those
with 12 or more years of education (Rank, 2004; Rank &
Hirschl, 1999a).
Consistent with the earlier studies of poverty dy-
namics, individuals experiencing poverty often do so for
only one or two consecutive years. However, once an
individual experiences poverty, they are quite likely to
encounter poverty again (Rank & Hirschl, 2001 a,
2001b).
390 POVERTY
Rank and Hirschl's analyses (l999b, 1999c) also
indicate that poverty is prevalent during childhood and
old age. Between the time of birth and age 17, 34% of
American children will have spent at least one year
below the poverty line, while 40% will have
experienced poverty or near poverty (125% of the pov-
erty line). Similarly, 40% of the elderly will encounter
at least one year of poverty between the ages 60 and 90,
while 48% will encounter poverty at the 125% leveL
The likelihood of using a social safety net program is
also exceedingly high. Consequently, 65% of all
Americans between the ages 20 and 65 will at some
point reside in a household that receives a means-tested
welfare program (including food s,tamps, Medicaid,
Supplemental Security Income, Aid to Families with
Dependent Children (AFDC), or other cash assis tance).
Furthermore, 40% of the American population will use
a welfare program in five or more years (although
spaced out at different points across the life course). As
wi th the life-course patterns of poverty, the typical
pattern of welfare use is that of short spells.
Consequently, only 15.9% of Americans will reside in a
household that receives a welfare program in five or
more consecutive years (Rank, 2004; Rank & Hirschl,
2002).
One program that has a particularly wide reach is the
Food Stamp Program. Slightly over half (50.8%) of all
Americans between the ages 20 and 65 will at some
point reside in a household that receives food stamps,
and it is further estimated that 42% ·of all American
households will suffer from food insecurity (Rank &
Hirschl, 2005).
For the majority of Americans, it would appear that
the question is not if they will encounter poverty; but
rather, when, which entails a fundamental shift in the
perception and meaning of poverty (Rank, 2004).
The Causes of Poverty
A second major area of research has examined the
factors and causes underlying poverty. Much of the
debate in the literature has centered upon the extent to
which poverty can be understood as a result of
individual versus structural failings. As O'Connor
(2001) notes in her history of 20th century poverty
research, the thrust of this research has shifted from an
examination of industrial capitalism as a fundamen tal
cause of poverty at the tum of the century, to a highly
technical analysis of the demographic and behavioral
characteristics of the poor and welfare recipients being
modeled as the causes for poverty by the end of the 20th
century.
One reason for this shift has been the growing im-
portance of survey research within the social sciences.
Such an approach lends itself more readily to an ern-
pirical analysis of individual characteristics, rather than
the structural conditions underlying poverty. For exam-
ple, race and gender are often treated as individual
demographic attributes to be controlled for within mul-
tivariate models, rather than as structural dimensions of
social and economic stratification in their own right
(O'Connor, 2001). As is argued below, focusing upon
particular individual factors helps to explain who loses
out in the competition to find economic opportunities,
while the more structural dynamics in society help to
explain why there are not enough viable economic
opportunities in the first place.
INDIVIDUAL FACTORS The notion of poverty result ing
from individual deficits goes bac k hundreds of years.
Survey research confirms that a majority of
Americans continue to believe that this is a very
important reason for the existence of poverty
(Feagin, 1975; Gans, 1995; Gilens, 1999; Kluegel &
Smith, 1986; Smith & Stone, 1989). In partic ular, the
argument has been that the poor lack the correct
attitudes, motivation, or morals to get ahead
(Schwartz, 2000). A variation on this argu ment has
been that generous welfare programs have created
work and marriage disincentives, leading to
counterproductive behaviors such as out-of- wedlock
teenage childbearing and avoidance of work, which
in tum creates government dependency that further
traps individuals and families into a cycle of poverty
(Mead, 1986; Murray, 1984; Olasky, 1992).
Researchers examining the attitudes of the poor have
found little evidence for the position that the poor have a
different set of attitudes which have contributed to their
poverty (Duncan, 1984; Edwards, Plotnick, & Klawitter,
2001; Rank, 1994a, 1994b; Seccombe, 1999). Contrary
to popular opinion, the poor tend to amplify and reiterate
mainstream American values such as the importance of
hard work, personal responsibility, and a dislike of the
welfare system. Although poverty is accompanied by
increasing . levels of stress and frustration, the vast
majority of the poor express a similar set of core
attitudes and motivations as middle-class Americans
(Lichter & Crowley, 2002). Furthermore, the impact of
social welfare programs on altering individual behavior
and thereby fostering dependency has been shown to be
minimal (Blank, 1997; Hays, 2003; Moffitt, 1992 ;
Rank, 1989). In short, there is little empirical support for
the argument that the counterproductive attitudes of the
poor or the generosity of the U.S. welfare s ystem creates
or exacerbates poverty.
On the other hand, evidence overwhelmingly con-
firms the importance of human capital in affecting
earnings (and consequently the risk of poverty). Human

capital refers to the skills, education, and credentials
that individuals bring with them into the labor market
(Becker, 1964). The importance of human capital has
been studied extensively within the labor economics
and social stratification literatures. Individuals acquir-
ing greater human capital tend to be in greater demand
in the market place. As a result, they are able to pursue
more lucrative careers resulting in higher paying and
more stable jobs. Those lacking in human capital are
unable to compete as effectively in the labor market,
and therefore must often settle for unstable, low wage
work.
The effect of human capital upon the risk of pov erty
has been shown to be substantial (Karoly, 2001;
Schiller, 2008). In particular, greater levels of educa-
tion, skills, and training ~re strongly associated with
higher levels of earnings (U.S. Census Bureau, 2007).
Conversely, those lacking in marketable job skills and
education are at a much greater risk of experiencing
poverty.
Additional research has demonstrated that levels of
human capital are highly dependent upon levels of
parental human capital and economic resources. Chil-
dren of parents with greater income, wealth, education,
and so on, are more likely to acquire greater human
capital than children coming from lower-income back-
grounds. These differences, in tum, affect children's
future life chances and outcomes, including the risk of
poverty. Recent research has demonstrated a strong
association between parents and their children with
respect to levels of education, occupational status, in-
come, and wealth (Bowles, Gintis, & Groves, 2005;
d'Addio, 2007; Levine & Mazumder, 2007).
Beyond human capital, several other individual and
family characteristics have been shown to be important
in increasing or decreasing the risk of poverty. These
include family structure, number of children, work dis-
ability, and age (Blank, 1997; Iceland, 2006). Each of
these factors can be conceptualized as impacting indi-
viduals' ability to take advantage of labor market op-
portunities. Specifically, poverty rates tend to be higher
for single-parent families, households with large num-
. bers of children, those with work disabilities, and
younger adults (US. Census Bureau, 2007).
STRUCTURAL FACTORS Various structural factors
have been shown to be critical in understanding the
existence of poverty in the United States and else where.
Perhaps most important of these has been an emphasis
on the failure of the economy to provide enough viable
economic opportunities and jobs for alL Several
pioneering studies of poverty conducted at the end of
the 19th and beginning of the 20th
POVERTY
391
century focused heavily on the importance of labor
market failings to explain poverty. The work of Booth
(1892-1897), Rowntree (1901), Hull House (1895),
Hunter (1904), and DuBois (1899) all emphasized the
importance of inadequate wages, lack of jobs, and un-
stable working conditions as a primary cause of
poverty.
Recent research has also demonstrated a mismatch
between the number of decent paying jobs that can
adequately support a family versus the number of in-
dividuals in search of such jobs (Harvey, 2000; Quigley,
2003). For example, Bartik (2001) used several differ-
ent approaches and assumptions to estimate the number
of jobs that would be needed to significantly address the
issue of poverty in the United States. He concluded that
even in the booming U.S. economy of the late 1990s,
between five and nine million more jobs were needed in
order to meet the needs of the poor and disadvantaged.
In addition to the' imbalance between numbers of
jobs versus those in need of jobs, during the past 25
years, the American economy has been producing an
increasing percentage of low-paying jobs, jobs that are
part-time, and jobs that are lacking in benefits (Fligstein
& Shin, 2004; Hacker, 2006). Studies ana lyzing the
percentage of the US. workforce falling into the
low-wage sector have shown that far more American
workers fall into this category than do their counterparts
in other developed countries. For example, Smeeding et
al. (2001) found that 25% of all US. full-time workers
could be classified as employed in low-wage work
(defined as earning less than 65% of the national
median earnings for full-time jobs). This was by far the
highest of the countries analyzed (the overall average
was 12.9%). The result is that more Americans are
working at jobs that simply do not support a family at an
adequate income level.
A second structural factor affecting a society's over-
all rate of poverty is the effectiveness of the social
welfare state in pulling individuals and families out of
economic destitution. Countries with a more compre-
hensive welfare state (such as the Scandinavian and
Benelux countries) are able to cut poverty much more
than countries with a weak safety net (such as the
United States or Australia). Research has repeatedly
demonstrated the significant impact that a social
welfare state exerts on poverty reduction (Alesina &
Glaeser, 2004; Ritakallio, 2002; Smeeding, 2005a).
A third set of structural factors examined has been
the impact of racial and gender discrimination. Sub-
stantial research has shown that economic, social, and
political discrimination remains prevalent in American
society (Feagin, 2000; Massey, 2007) and impacts the
life chances of racial minorities and women in various
392 POVERTY
ways, resulting in higher rates of poverty am ong these
groups. For example, Oliver and Shapiro (1995), Shapiro
(2004), and Johnson (2006) have demonstrated the legacy
of discrimination through historical racial differences in
wealth and asset inequalities:
Finally, considerable work has examined th e role of
residential segregation in combination with other pat terns
of discrimination, as a further structural cause of poverty,
particularly for African American and Latino populations.
This body of work has demonstrated that residential
segregation on the basis of race is wide spread, leading to
deteriorating economic and social conditions within
neighborhoods (Massey & Denton, 1993). Residential
segregation restricts the opportu nities available to urban
Black and Latino families through social isolati on
andincreasing levels of depri vation. These, in tum, ensure
high levels of poverty and widespread social
disorganization (Charles, 2003, 2006; Jargowsky, 1997 ;
Yinger, 1995). Wilson (1987, 1996) and Anderson (1990,
1999) have also emphasized the importa nce of collapsed
economic opportunities com bined with patterns of social
isolation and residential segregation resulting in high rates
of urban poverty among minorities.
THE ROLE OF STRUCTURAL VULNERABILITY The
recent concept of structural vulnerability (Rank, 1994 ,
2004; Rank, Y oon, & Hirschl, 2003) bridges the earlier
discussed importance of human capital with the broader
significance of structural forces. This framework recog-
nizes that human capital and other labor market attri butes
are associated with who loses the economic game (and
hence will be more likely to experience poverty), but that
the structural elements in society ensure that there will be
losers in the first place.
Consequently, it is argued that a certain percentage of
the American population will experience economic
vulnerability as a result of the structural failings men tioned
earlier. Individuals experiencing such economic
deprivation are likely to have characteristics putting them
at a disadvantage in terms of competing in the eco nomy
(less education, fewer skills, single-parent fa milies, illness
or incapacitation, minorities residing in inner cities, and so
on). These characteristics help to explain who in particular
is at a greater risk of poverty. However, given the overall
structural failings, a signifi cant percentage of the American
population will experience economic vulnerability
regardless of what their individual characteristics are.
The critical mistake that social scientists have often
made is equating the question of who loses out at the game,
with the question of why the game produces losers in the
first place. They are, in fact, distinct and
separate questions. While deficiencies in human capital
and other marketable characteristics help to explain who in
the population is at a heightened risk of en countering
poverty, the fact that poverty exists in the first place results
not from these characteristics, but rather from the lack of
decent opportunities and sup ports in society (for example,
jobs that pay a living wage, access to health care, affordable
child care, low cost housing). By focusing solely on
personal characteristics, such as education, individuals can
be shuffled up or down in terms of their being more likely
to land a.job with good earnings, but someone still loses out
if there are not enough decent paying jobs to go around. In
short, the structural' vulnerability perspective argues that
we are playing a large-scale version of a musical chair
game with many more players than available eight chairs.
Poverty Alleviation
The social policies of the United States have largely
emphasized altering the incentives and disincentives for
those playing the game through welfare reform, or in a very
limited way, upgrading their skills and ability to compete in
the game through job training programs, while at the same
time leaving the structure of the game untouched.
When the overall poverty rates in the United States do in
fact go up or down, they do so primarily as a result of
structural impacts that increase or decrease the number of
viable opportunities. In particular, the per formance of the
economy has been historically impor tant. Why? Because
when the economy expands, more opportunities are
available for the competing pool of labor and their families.
The reverse occurs when the economy slows down and
contracts. Consequently, during the 1930s and early 1980 s
when the economy was doing badly, poverty rates went up,
while during periods of economic prosperity such as the
1960s or the middle to late 1990s, the overall rates of
poverty declined (Hoynes et a1. 2006).
Similarly, changes in various social supports and the
social safety net available to families make a difference i n
terms of how well such households are able to avoid
poverty or near poverty. When such supports were in-
creased through the War on Poverty initiatives in the 1960s ,
poverty rates declined. Likewise, when Social Security
benefits were expanded during the 1960s and 1970s, the
elderly's poverty rates declined precipitously (Katz & Stem,
2006). Conversely, when social supports have been
weakened and eroded, as in the case of children's programs
since mid-1970s, their rates of pov erty have gone up
(Seccombe, 2000) .
. Consequently, social policies with the potential to
effectively reduce the extent of poverty are largely

those that increase and enhance the overall pool of
opportunities as well as improving the living conditions and
capacities of those seeking such opportunities. As Rank
(2004) discusses, these policies can take several different
forms. Of foremost importance is ensuring the existence of
decent paying jobs that can support a family above the poverty
line (Kenworthy, 2004; Quigley, 2003). This includes job
creation strategies, as well as raising and indexing the
minimum wage up to a living wage and continuing support for
the Earned Income Tax Credit (EITC).
A second fundamental poverty alleviation strategy is to
increase the affordability and access to several key social and
public goods, including ;J. quality education, health care,
available housing, and child care. These social goods are vital
iIi building and maintaining healthy and productive citizens,
yet are often in short supply for low income U.S. households
in .the United States (Esping-Andersen, 2007). In addition,
ensuring that a strong and effective safety net is in place when
economic setbacks occur is essential (Zuberi, 2006).
A third strategy targets the lingering patterns of
discrimination found in both the housing market and
occupational structure for racial minorities and women.
Vigilant enforcement of fair housing laws and anti-
discrimination policies in the work place are essential for
breaking down decades of discriminatory practices (Blau,
Brinton, & Grusky, 2006; Yinger, 1995). In addition, stronger
enforcement of child support laws would help millions of
women at risk of poverty who are heading families with
children (Cancian & Meyer, 2006).
A final poverty reduction strategy is the development and
implementation of asset building policies for lowerincome
households and communities (Schreiner & Sherraden, 2007;
Shapiro & Wolff, 2001). These include individually based
policies such as the Children's Trust Fund in the United
Kingdom, or Individual Development Accounts in the United
States, as well as community revitalization and reinvestment
policies that have been implemented across the United States
(for greater detail with respect to specific poverty reduction
strategies, see the following entries: Asset Building;
Community Development; Community Economic
Development; Community Organization; Earned Income Tax
Credit; Economics and Social Welfare; Education Policy;
Employment and Unemployment; Income Security:
Overview; Social Capital; Social Development; Social Policy:
Overview; Social Services: Overview).
Taken as a whole, these policies have the potential to
dramatically reduce the extent of poverty and economic
vulnerability that currently exists in the United
POVERTY 393
States. Social work practice and advocacy should strive toward
the development and implementation of such poverty
alleviation strategies. By doing so, the profession of social
work will be proactively engaging in its primary mission to
enhance "human well-being and help meet the basic human
needs of all people, with particular emphasis to the needs and
empowerment of people who are 'vulnerable, oppressed, and
living in poverty" (NASW, 1996, 1).
REFERENCES
Alesina, A., & Glaeser, E. L. (2004). Fightingpoverty in the US and
Europe: A world of difference. New York: Oxford University
Press.
Anderson, E. (1990). Streetwise: Race, class and change in an urban
community. Chicago: University of Chicago Press.
Anderson, E. (1999). Code of the street: Decency, violence, and the
moral life of the inner city. New York: W. W. Norton.
Bane, M. 1., & Ellwood, D. T. (1986). Slipping into and out of
poverty: The dynamics of spells. Journal of Human
Resources, 21,1-23.
Bane, M. 1., & Ellwood, D. T. (1994). Welfare realities: From
rhetoric to reform. Cambridge,MA: Harvard University
Press.
Bartik, T. 1. (2001). Jobs for the poor: Can labor demand policies
help? New York: Russell Sage Foundation.
Becker, G. S. (1964). Human capital. New York: Columbia
University Press.
Blank, R. M. (1997). It takes a nation: A new agenda for fighting
poverty. Princeton, N]: Princeton University Press.
Blau, F. D., Brinton, M. c, & Grusky, D. B. (2006). The
declining significance of gender? New York: Russell Sage
Foundation.
Booth, C. (1892-1897). Life and labour of the people of London, first
series: Poverty. London: Macmillan.
Bowles, S., Gintis, H., & Groves, M. O. (2005). Unequal chances:
Family background and economic success. New York:
Russell Sage Foundation.
Cancian, M., & Meyer, D. R. (2006). Child support and the
economy. In R. M. Blank, S. H. Danziger, & R. F. Schoeni
(Eds.), Working and poor: How economic and policy changes are
affecting low-wage workers (pp. 338-365). New York:
Russell Sage Foundation.
Charles, C. Z. (2003). The dynamics of racial residential
segregation. Annual Review of Sociology, 29, 167-207.
Charles, C. Z. (2006). Won't you be my neighbor? Race, class, and
residence in Los Angeles. New York: Russell Sage Foundation.
Council on Social Work Education. (2003). Handbook of
accreditation standards and procedures. Alexandria, V A:
Commission on Accreditation.
d'Addio, A. C. (2007). Intergenerational transmission of disad-
vantage: Mobility or immobility across generations? A review of
the evidence for OECD countries. GECD Social, Employment and
Migration Working Papers, No. 52. Paris: OECD publications
service.
394 POVERTY
Devine, J. A., & Wright, J. D. (1993). The greatest of evils:
Urban poverty and the American usvierclass. New York:
Aldine de Gruyter.
DuBois, W. E. B. (1899). The Philadelphia Negro. Philadelphia:
University of Pennsylvania Press.
Duncan, G. J. (1984). Years of poverty, years of plenty: The changing
economic fortunes of American workers and families. Ann Arbor,
MI: Institute for Social Research.
Duncan, G. J., Gustafsson, B., Hauser, R., Schmaus, G., Jenkins, S.,
Messinger, H., et al. (1995). Poverty and social-assistance
dynamics in the United States, Canada, and Europe. In K.
McFate, R. Lawson, & W. J. Wilson (Eds.), Poverty, inequality
and the future of social policy: Western states in the new world
order (pp, 67~108). New York:
Russell Sage Foundation.
Edwards, M. E., Plotnick, R., & Klawitter, M. (200l). Do attitudes and
personality characteristics affect socioeconomic outcomes? The
case of welfare use by young women. Social Science Quarterly,
82, 827~843.
Esping-Andersen, G. (2007). Equal opportunities and the welfare
state. Contexts, 6, 23~27.
Feagin, J. R. (1975). Subordinating the poor: Welfare and Ameri can
beliefs. Englewood Cliffs, NJ: Prentice-Hall.
Feagin, J. R. (2000). Racist America: Roots, current realities, and
future reparations. New York: Routledge.
Fligstein, N., & Shin, T. J. (2004). The shareholder value society: A
review of the changes in working conditions and inequality in the
United States, 1976 to 2000. In K. M. Neckerman (Ed.), Social
inequality (pp. 401~32). New York: Russell Sage Foundation.
Gans, H. J. (1995). The war against the poor: The underclass and
antipoverty policy. New York: Basic Books.
Gilens, M. (1999). Why Americans hate welfare: Race, media, and the
politics of antipoverty policy. Chicago: University of
Chicago Press. . A review. Journal of Economic Literature, 30, 1-61.
Glennerster, H. (2002). United States poverty studies and poverty
measurement: The past twenty-five years. Social Service Review,
76, 83-107.
Hacker, J. S. (2006). The great risk shift. New York: Oxford
University Press.
Harvey, P. (2000). Combating joblessness: An analysis of the
principal strategies that have influenced the development of
American employment and social welfare law during the 20th
century. Berkeley Journal of Employment and Labor Law,
21,677-758.
Hays, S. (2003). Flat broke with children: Women in the age of welfare
reform. New York: Oxford University Press.
Hoynes, H. W., Page, M. E., & Stevens, A. H. (2006). Poverty in
America: Trends and explanations. Journal of Economic
Perspectives, 20, 47-68.
Hull House. (1895). Hull House maps and papers. New York:
Thomas Y. Crowell.
Hunter, R. (1904). Poverty: Social conscience in the progressive era.
New York: Macmillan.
Iceland, J. (2003). Dynamics of economic well-being: Poverty
1996-1999. Current Population Reports, Series P70-91.
Washington, DC: U.S. Government Printing Office.
Iceland, J. (2006). Poverty in America: A handbook. Berkeley, CA:
University of California Press.
[argowsky, P.A. (1997). Poverty and place: Ghettos, barrios, and the
American city. New York: Russell Sage Foundation.
Johnson, H. B. (2006). The American Dream and the power of wealth:
Choosing schools and inheriting inequality in the land of
opportunity. New York: Routledge.
Karoly, L. A. (2001). Investing in the future: Reducing poverty
through human capital investments. In S. H. Danziger & R. H.
Haveman (Eds.), Understanding poverty (pp. 314-356).
Cambridge, MA: Harvard University Press.
Katz, M. B., & Stern, M. J. (2006). One nation divisible: What America
was and what it is becoming. New York: Russell Sage Foundation.
Kenworthy, L (2004). Egalitarian capitalism: Jobs, incomes, and
growth in affluent countries. New York: Russell Sage Foundation.
Kluegel, J. R., & Smith, E. R. (1986). Beliefs about inequality:
Americans' views of what is and what ought to be. New York:
Aldine de Gruyter.
Levine, D. 1., & Mazumder, B. (2007). The growing importance of
family: Evidence from brothers' earnings. Industrial Relations, 46,
7-21.
Lichter, D. T., & Crowley, M. L. (2002). Poverty in America:
Beyond welfare reform. Population Bulletin, 57,1-36.
McKernan, S. M., & Ratcliffe, C. (2005). Events that trigger poverty
entries and exits. Social Science Quarterly, 86, 1146-1169.
Massey, D. S. (2007). Categorically unequal: The American
stratification system. New York: Russell Sage Foundation.
Massey, D. S., & Denton, N. A. (1993). American apartheid:
Segregation and the making of the underclass. Cambridge, MA:
Harvard University Press.
Mead, L. (1986). Beyond entitlement: The social obligations of
citizenship. New York: Free Press.
Moffitt, R. (1992). Incentive effects of the U.S. welfare system:
Murray, C. (1984). Losing ground: American social policy,
1950-1980. New York: Basic Books.
National Association of Social Workers. (1996). Code of ethics.
Washington, DC: NASW Press.
O'Connor, A. (200l). Poverty Knowledge: Social science, social policy,
and the poor in twentieth-century U.S. history. Princeton, NJ:
Princeton University Press.
Olasky, M. (1992). The tragedy of American compassion.
Washington, DC: Regnery Publishing.
Oliver,M.L., & Shapiro, T.M. (1995). Blackwealth/White wealth:
A new perspective on racial inequality. New York: Routledge.
Quigley, W. P. (2003). Ending poverty as we know it: Guaranteeing a
right to a job at a living wage. Philadelphia: Temple University
Press.
Rank, M. R. (1985). Exiting from welfare: A life-table analysis.
Social Service Review, 59, 358-376.
Rank, M. R. (1989). Fertility among women on welfare: Incidence and
determinants. American Sociological Review, 54, 296-304.
Rank, M. R. (1994a). Living on the edge: The realities of welfare in
America. New York: Columbia University Press.

Rank, M. R. (1994b). A view from the inside out: Recipients'
perceptions of welfare. Journal of Sociology and Social Welfare,
21, 27~7.
Rank, M. R. (2004). One nation, under1mvileged: Why American
poverty affects us all. New York: Oxford University Press.
Rank, M. R., & Hirschl, T. A. (1999a). The likelihood of poverty
across the American adult lifespan. Social Work, 44, 201-216.
Rank, M. R., & Hirschl, T. A. (1999b). The economic risk of
childhood in America: Estimating the probability of poverty
across the formative years. Journal of Marriage and the Family,
61,1058-1067.
Rank, M. R., & Hirschl, T. A. (1999c). Estimating the proportion
of Americans ever experiencing poverty during their elderly
years. Journal of Gerontology: Social Sciences, 54B, S184-S193.
Rank, M. R., & Hirschl, T. A. (2001a). Rags or riches? Estimating
the probabilities of poverty and affluence across the adult
American life span. Social Science Quarterly, 82, 680-686.
Rank, M. R., & Hirschl, T. A. (2001b). The occurrence of poverty
across the life cycle: Evidence from the PSID. Journal of Policy
Analysis and Management, 20, 737-755.
Rank, M. R., & Hirschl, T. A. (2002). Welfare use as a life course
event: Toward a new understanding of the U.S. safety net.
Social Work, 47,237-248.
Rank, M. R., & Hirschl, T. A. (2005). Likelihood of using food
stamp during the adulthood years. Journal of Nutrition Education
and Behavior, 37,137-146.
Rank, M. R., Yoon, H. S., & Hirschl, T. A. (2003). American
poverty as a structural failing: Evidence and arguments. Journal
of Sociology and Social Welfare, 30, 3-29.
Ritakallio, V. M. (2002). Trends of poverty and income inequality
in cross-national comparison. European Journal of Social
Security, 4, 151-177.
Rowntree, B. S. (1901). Poverty: A study of town life. London:
Thomas Nelson and Sons.
Schiller, B. R. (2008). The economics of poveny and discrimination.
Englewood Cliffs, N]: Prentice Hall.
Schreiner, M., & Sherraden, M. (2007). Can the poor save?:
Saving and asset building in individual development accounts. New
Brunswick, N]: Transaction.
Schwartz, ]. (2000). Fighting poveny with vinue: Moral reform and
America's urban poor, 1825-2000. Bloomington, IN:
Indiana University Press.
Seccombe, K. (1999). So you think 1 drive a CadiUac?Welfare
recipients' perspectives on the system and its reform. Needham-
Heights, MA: Allyn & Bacon.
Seccombe, K. (2000). Families in poverty in the 1990s:
Trends, causes, consequences, and lessons learned. Journal of
Marriage and the Family, 62,1094-1113.
Sen, A. (1992). Inequality reexamined. New York: Russell Sage
Foundation.
Shapiro, T. M. (2004). The hidden cost of being African American:
How wealth perpetuates inequality. New York: Oxford
University Press.
POVERTY 395
Shapiro, T. M., & Wolff, E. N. (2001). Assets for the poor: The
benefits of spreading asset ownership New York: Russell Sage
Foundation.
Simon, B. L. (1994). The empowerment tradition in American social
work: A history. New York: Columbia University Press.
Smeeding, T. A. (2005a). Public policy, economic inequality, and
poverty: The United States in comparative perspective. Social
Science Quanerly, 86, 955-983.
Smeeding, T. A. (2005b). Poor people in rich nations: The United
States in comparative perspective. Luxembourg Income Study
Working Paper, No. 419. Syracuse, NY: Maxwell School of
Citizenship and Public Affairs.
Smeeding, T. A., Rainwater, L., & Burtless, G. (2001). U.S.
poverty in a cross-national context. In S. H. Danziger & R. H.
Havemen (Eds.), Understanding poverty (pp. 162-189).
Cambridge, MA: Harvard University Press.
Smith, A. (1776). An inquiry into the nature and causes of wealth of
nations. London: W. Strahan and T. Cadell.
Smith, K. B., & Stone, L. H. (1989). Rags, riches, and bootstraps:
Beliefs about the causes of wealth and poverty. Sociological
Quarterly, 30, 93-107.
Stevens, A. H. (1994). The dynamics of poverty spells:
Updating Bane and Ellwood. American Economic Review,
84,34-37.
Stevens, A. H: (1999). Climbing out of poverty, falling back in:
Measuring the persistence of poverty over multiple spells. The
Journal of Human Resources, 34, 557-588.
UNICEF. (2005). Child poverty in rich countries. Innocenti
Report Card, No.6.
United Nations Development Programme. (2006). Human
development report 2006. New York: Oxford University Press.
U.S. Census Bureau. (2007). Income, poveny, and health insurance
coverage in the United States: 2006. Current Population Reports,
Series P60-233. Washington, DC: U.S. Government Printing
Office.
Walker, R. (1994). Poverty dynamics: Issues and examples.
Aldershot, UK: Avebury.
Weinshenker, M., & Heuveline, P. (2006). The international child
poverty gap: Does demography matter? Luxembourg Income Study
Working Paper, No. 441. Syracuse, NY: Maxwell School of
Citizenship and Public Affairs.
Wilson, W.]. (1987). The truly disadvantaged: The inner city, the
underclass, and public policy. Chicago: University of Chicago
Press.
Wilson, W. ]. (1996). When work disappears: The world of the new
urban poor. New York: Knopf.
Yinger, ]. (1995). Closed doors, opportunities lost: The continuing
costs of housing discrimination. New York: Russell Sage
Foundation.
Zuberi, D. (2006). Differences that matter: Social policy and the
working poor in the United States and Canada. Ithaca, NY:
Cornell University Press.
-MARK R. RANK
396 PRACTICE GUIDELINES
PRACTICE GUIDELINES. See Ethics and Values;
Evidence-based Practice Guidelines.
PRACTICE INTERVENTIONS AND
RESEARCH
ABSTRACT: Social work is distinguishable from other
disciplines by its emphasis on producing change that
affects clients and their environment. This emphasis
has influenced the nature of social work practice
research, which calls for attention to the develop ment,
design, and implementation of change strategies
through the use of the science of intervention research.
\
This paper provides a definition of intervention re-
search, highlights its culturally congruent elements, and
addresses its implications for social work evidence based
practice and practice guidelines.
KEY WORDS: social work; practice; intervention
Introduction
The social work profession has long been preoccupied
with the extent to which its research is able to inform and
guide practice and policy (Briar & Miller, 1971; Fortune
& Reid, 2003; Rosen, Proctor, & Staudt, 1999).
Although, there has been an increase in the production of
intervention research, and improve ment in its theoretical
and methodological scientific sophistication, intervention
research remains scarce (Fraser, 2004).
What Is Inter-vention Research?
Intervention research is conducted to understand, de sign,
and test the feasibility, efficacy, and effectiveness of
intervention strategies, with the goal of improving
practice and policy (Rubin, 2000; Shilling, 1997; Thyer ,
2000). Thomas and Rothman's (1994) science of
intervention research paradigm, which has exten sively
guided social work intervention studies, defines
intervention research as an intrusion into the environ ment
of an individual, couple, family, or other target unit that is
intended to bring about beneficial changes for the
individual or others involved. By providing a systematic
model of intervention planning, design, and
implementation, this paradigm promotes the involve ment
of the client, community, and agency contexts in all
stages of the research.
The paradigm encompasses three phases: (a) knowl-
edge development, (b) knowledge utilization, and (c)
design and implementation (Thomas & Rothman,
1994). The knowledge development stage focuses on the
use of social and behavioral sciences to generate practical
information related to the problemls) that the intervention
attempts to address. This step is conducted through (a) a
literature review, (b) q ualitative and quantitative data
collection where the researcher de fines the problem of
concern, (c) identifying risk and protective risk factors,
(d) specifying conceptual frame works and theories that
inform the design and delivery of the intervention
components, and (e) identifying existing empirical
research. In the knowledge develop ment stage, it is
critical to use practice experience to inform the
intervention content and study implemen tation. The
knowledge utilization stage, which employs data
generated in the knowledge development stage, aims to
inform and pilot the intervention content and delivery
strategies. This stage allows the researcher to make
decisions about the feasibility and acceptability of the
study, effect size, and the type of cont rol group to be used
in the efficacy trial. The purpose of the design and
implementation stage encompasses the methodologies
used to test the design and effectiveness of the inter-
vention. Controlled field testing employs a systema tic
evaluation of the intervention and randomized controlled
designs. Finally, if the trial proves effec tive,
dissemination can take place. Thus, this research
paradigm. encourages innovation and facilitates the
systematic development of efficacious intervention
models.
Fraser (2004) has identified recent social work inter-
vention research advances: First, more culturally and
contextually relevant theoretical models are available.
Second, new methods for dealing with randomiza tion,
attrition, and selection biases now exist, alo ng with
culturally congruent measures. Although rando mized
controlled clinical trials are viewed by many researchers
as the "Gold Standard," alternatives (for example,
interrupted time-series designs, regression dis continuity
designs) have been encouraged and used in intervention
science. Third, analytical approaches, such as mixture
modeling, propensity score matching, and approaches for
dealing with missing data, have grown in sophistication.
To strengthen the integrity and ~ffectiveness of the
research, use of manualized treatment protocols and
quality assurance and quality control measures to assure
fidelity of the study's implementation have increased.
Culturally Congruent Intervention
Over the past decade, a strong emphasis has been placed
on the importance of the design of culturally congruent
social work interventions to meet the needs of the
profession's diverse client population. Thomas

and Rothman's (1994) development intervention model
allows researchers to incorporate values, practice wisdom,
and agency context as well as worldviews of the clients,
agency, and community into the early stages of the design,
and later, into implementation of the studies (Galinsky,
Turnbull, Meglin, & Wilner, 1993; Zayas, 2003). Culturally
congruent intervention research must (a) include consumers,
stakeholders, and the community in the early stages of the
research so as to assure that the intervention fits well with
real-world settings and encompasses the client's and the
community's worldviews and their belief systems (Coulton,
2005); (b) employ culturally congruent recruitment and
retention strategies (Witte et .al., 2004); (c) be guided by
conceptual theoretical frameworks and measurements that are
culturally relevant to the population (El-Bassel et al., 2001);
(d) employ culturally competent researchers (El-Bassel et al.,
2001; Witte et al., 2004); and (e) involve a community
advisory board in every stage of the research (Sormanti,
Pereira, El-Bassel, Witte, & Gilbert, 2001; Witte et al., 2004).
How Intervention Research in Social Work
Affects Evidence ... Based Practice
Social work intervention research plays a fundamental role in
the development and progress of evidence-based practice
(EBP) and practice guidelines that make up e~ential core
elements of social work practice (Gambrill, 1994; Proctor,
2004; Reid, 2002; Rosen, 2003). Social workers are expected
to understand and use research evidence in defining client
problems and in selecting interventions that lead to best
outcomes (Proctor, 2003). Rooted in intervention studies,
practice guidelines advise social workers how to apply EBP in
their practice (Proctor, 2003). Unfortunately, the social work
profession has limited access to evidence-based interventions
to guide the use of EBP (Howard & Jenson, 2003; Mullen &
Bacon, 2003; Proctor & Rosen, 2003) and inform practice
guidelines (Fortune & Reid, 2003; Fraser, 2004; Gambrill,
1994; Proctor & Rosen, 2003). Each year, less than a dozen
published studies focus on intervention research that
practitioners may be able to replicate (Fraser, 2004) . To
advance the social work profession and to continue to promote
EBP and practice guidelines, intervention research should re-
main in the forefront of the profession's mission.
Conclusion
Intervention research remains extremely valued in the social
work profession because it provides empirically based
solutions, advances the profession's ability to help clients by
providing the best social work practices, improves and
enhances clients' social conditions, leads to
PRACTICE INTERVENTIONS AND REsEARCH 397
efficacious service delivery systems and social policies that
change clients' lives (Shilling, 1997; Thomas & Rothman,
1994), and informs EBP and practice guidelines (Proctor &
Rosen, 2003).
REFERENCES
Briar, S., & Miller, H. (1971). Problems and issues in social casework.
New York: Columbia University Press.
Coulton, C. 9005). The place of community in social work practice:
Conceptual and "methodological developments. Social Work
Research, 29(2), 73-87.
El-Bassel, N., Witte, S., Gilbert, L., Sormanti, M., Moreno, c.,
Pereira, L., et al. (2001). HIV prevention for intimate couples: A
relationship-based model. Families, Systems and Health,
19(4),379-395.
Fortune, A E., & Reid, W. (2003). Empirical foundations for practice"
guidelines in current social work. In A. Rosen & E. K. Proctor
(Eds.), Developing practice guidelines for social work intervention
(pp. 59-79). New York: Columbia University Press.
Fraser, M. W. (2004). Intervention research in social work:
Recent advances and continuing challenges. Research on Social
Work Practice, 14(3),210-222.
Galinsky, M. J., Turnbull, J. E., Meglin, D. E., & Wilner, M. E.
(1993). Confronting the reality of collaborative practice research:
Issues of practice design, measurement, and team development.
Social Work, 38, 440-449.
Gambrill, E. (994). Social work research: Priorities and obstacles.
Research on Social Work Practice, 4(3), 359-388.
Howard, M. 0., & Jenson, J. M. (2003). Clinical guidelines and
evidence-based practice in medicine, psychology, and allied
professions. In A Rosen & E. K. Proctor (Eds.), Developing
practice guidelines for social work intervention (pp. 83-107). New
York: Columbia University Press.
Mullen, E. J., & Bacon, W. F. (2003). Practitioner adoption and
implementation of practice guidelines and issues of quality
control. In A Rosen & E. K. Proctor (Eds.), Developing practice
guidelines for social work intervention (pp. 223-235). New York:
Columbia University Press.
Proctor, E. K. (2003). Research to inform the development of social
work interventions. Social Work Research, 27(1), 3-6.
Proctor, E. K. (2004). The search for social work treatments of choice:
What interventions work better than others? Social Work Research,
28(2), 67-69.
Proctor, E. K., & Rosen, A. (2003). The structure and function of
social work practice guidelines. In A Rosen & E. K. Proctor
(Eds.), Developing practice guidelines for social work intervention
(pp, 108-127). New York: Columbia University Press.
Reid, W. (2002). Knowledge for direct social work practice:
An analysis of trends. The Social Service Review, 76( 1),6-35.
Rosen, A (2003). Evidence-based social work practice: Challenges
and promise. Social Work Research, 27(4), 197.
Rosen, A, Proctor, E. K., & Staudt, M. M. (1999). Social work
research and the quest for effective practice. Social Work Research,
23(1),4-14.
398 PRAcncE INTERVENTIONS AND REsEARCH
Rubin, A. (2000). Social work research at the tum of the
millenium: Progress and challenges. Research on Social Work
Practice, 10,9-14.
Shilling, R. F. (1997). Developing intervention research programs
in social work. Social Work Research, 21(3), 173-180.
Sormanti, M., Pereira, L., El-Bassel, N., -Witte, S., & Gilbert, L.
(2001). The role of community consultants in designing an
HIV prevention intervention. AIDS Education and Prevention,
13(4),311-328.
Thomas, E. ]., & Rothman.]. (1994). An integrative perspective
on intervention research. In ]. R. E. Thomas (Ed.), Intervention
research: Design and development for human service (pp. 3-20).
Binghamptom, NY: Haworth Press.
Thyer, B. A. (2000). A decade of research on social work practice.
Research on Social Work Practice, 10, 5-8.
Witte, S., El-Bassel, N., Gilbert, L., Wu, E., Chang, M., &
Steingless, P. (2004). Recruitment of minority women and
their main sexual partners in an HIV/STI prevention trial.
Journal of Women's Health, 13(10), 1137-1147.
Zayas, L. H. (2003). Service-delivery factors in the develop ment
of practice guidelines. In A. Rosen & E. K. Proctor (Eds.),
Developing practice guidelines for social work intervention (pp.
193-220). New York: Columbia University Press.
-NABILA EL-BASSEL
PREVENTION
ABSTRACT: Primary prevention involves coordinated
efforts to prevent predictable problems, to protect exist ing
states of health and healthy functioning, and to promote
desired goals for individuals and groups, within
supportive physical and sociocultural environments. This
entry discusses the history of this basic approach to
professional helping from medical, public health, and
social science perspectives and theories, along with an
analysis of its substantial evidence- based practice. The
entry concludes with a review of practice methods for
increasing individual strengths and social supports, while
decreasing individual limitations and social stresses,
which, together, characterize most contempor ary
preventive services.
KEY WORDS: primary prevention; prevention; protec-
tion; promotion; ecological or systems perspective;
epidemiology; incidence; prevalence; wellness
orientation; strengths perspective; public health theory;
universal preventive interventions; selective preventive
interventions; indicated preventive interventions; New
York Society for the Prevention of Pauperism; New
York House of Refuge
A Sense of the Term
Primary prevention is an idea whose time has come (Klein &
Goldston, 1977). Primary prevention involves actions taken
by individuals to prevent predictable problems, protect existing
states of health and healthy functioning, and promote desired
states of functioning within supportive or benign physical and
sociocultural environments (Gullotta & Bloom, 2003). This
threepart definition extends beyond the lay meaning of pre-
vention alone, since something positive must often be
promoted to take the place of something negative that has
been prevented. Contemporary thought emphasizes the
dynamic ecological perspective integrating preventive,
protective, and promotive actions among individuals and
groups, and the settings in which they live (Durlak, 2003;
Gullotta & Bloom, 2003). Many significant elements in the
human and natural environments may be used in achieving
desired goals in primary prevention, rather than dealing only
with personal factors surrounding an individual's presenting
problem. Helping professionals have a role to play in creating
and initiating primary prevention programs, but we need to
respect the strength of self-help groups and individual
initiatives in directing their own lives toward positive goals.
History and Definitions
Primary prevention is a term rooted in ancient folk wisdom
(such as "a stitch in time saves nine") and continues to date in
sophisticated research and demonstration projects, as well as
the self-help movement, in which laypeople have reasserted
responsibility for their physical and emotional health (see, for
example, The new wellness encyclopedia (1995); and
numerous lifestyle magazines). This entry takes self-help and
organized health initiatives as the dual contexts within which
to view professional services to facilitate primary prevention
as a beneficial cost-effective contribution to the health of the
nation (Yodanis & Godenzi, 2003).
Medicine's long history included not only setting broken
bones and discoyering specific chemicals (herbs and drugs)
and technologies that served specific uses; it also included
preventive medicine for addressing predictable illn~sses
before they occurred, in part because sustaining any injury or
illness often had deadly outcomes throughout most of history.
However, preventive medicine was traditionally set within the
perspective of germ theory, that is, illness was caused by some
microscopic entity in the individual, which only a doctor
could diagnose and treat (Leavell & Clark, 1953). The
language of medicine-patients' compliance because the doctor
and not the patient knew best- indicates the posture that
consumers were

to take. The emphasis on microscopic entities tended to
blind professionals to the social issues of poverty,
crowding, and sanitation that were affecting health.
The public health field developed the perspective that
there were identifiable agents of disease, hosts or victims
of the problem, and environments in which the host and
the agent met with problematic outcomes. Any or all of
these could be points of entry to address problems, which
were seen as a population rather than as individuaL
concerns (MacMahon, Pugh, & Ipsen, 1960). From this
population perspective great strides were made in the 19 th
and 20th centuries in some parts of the world to increase
longevity by improving water quality, mass vaccinations,
and sanitation systems.
This public health effort was extended to mental health
and conceptualized 'as primary prevention (ac tions taken
to reduce the incidence-new cases- of a problem),
secondary prevention (actions taken to re duce the
prevalence or number of existing cases), and tertiary
prevention (actions taken to reduce the unto ward effects
of diseases that had been resolved to the extent possible)
(Caplan, 1964). While these distinctions throw light on
the connection of incidence and prevalence, they
inadvertently introduced misunder standings of language,
such as trying to prevent some thing that has already
occurred. The terms prevention, treatment, and
rehabilitation provide a more direct statemen t of the
helping situation. This language still appears in
contemporary writing, but not always with the clarity that
its originators gave it.
Epidemiology, the science of the distribution in time
and space of elements of disease and health, provides
strong tools in the analysis of human conditions, from the
days of Dr. John Snow and the cholera epidemic in
London, 1848 (based on epidemiological evidence alone ,
Dr. Snow removed the handle of a contaminated public
water pump) to current times, as in the ana lysis and
resolution of the puzzling Legionnaire's Disease (Fraser &
McDade, 1979), where a previously unknown pathogenic
bacterium was identified through the use of
epidemiological methods. Epidemiological types of in-
vestigations are used-with issues suc h as schizophrenia
(Boyle, 2004), substance use (Mason, Cheung, & Walker,
2004), and HIV risk (Mitchell, Kaufman, Beals, & The
Pathways of Choice and Healthy Ways Project Team,
2004).
Social psychology (and its modem descendents in
environmental psychology, positive psychology, and
community psychology) and social work have led in the
emphasis on the health and strengths of people, which can
be employed to address concerns and achieve desired
goals, even in the face of serious problems. Clients and
consumers have replaced patients in
PREvENTION 399
the vocabulary of social workers, reflecting participants'
important contributions in resolving their own con cerns
and achieving their goals. A persontsj-in environmentts)
perspective is the mantra for soci al workers regardless of
specialty. There is a wellness orientation, explicit in the
work of psychologists Cowen (2000) and Durlak (1997) ,
as well as Saleebey (1992) and others in social work, that
builds on the strengths of people. Albee (1983, 2003 )
connects all expressions of professional helping- or more
accurately, differential helping-with a just (or unjust) so-
ciety, in which various minorities suffer at the hands of
dominant self-interest groups, themes that resonate with
social work from its beginnings with Jane Addams and the
settlement house movement. Pollan (2007) discusses how
eating healthy foods has been subverted by' an
overcompetitive food industry, an underprotec tive
government, a reductionist nutritional science, and a
co-opted mass media, leading to mass public confu sion.
His solution is to eat real foods (not processed or artificial
ones), not too much (since we do not need as much as we
have been eating), and mostly plants (cut down on red
meat and dairy products).
Theories Regarding
Primary Prevention for Social Work
Five general theories on primary prevention guide cur rent
social work thinking, with other models seeking to
amplify specific situations. The public health theory, de-
scribed earlier, directs social workers to think be yond a
specific problem for a specific person to see the contri-
butions of the agent of disease as well as the facilitating or
resisting efforts of the environment itself. Moreover, the
public health model encourages interdisciplinary
cooperation because epidemic-sized problems or poten-
tials know no professional boundaries.
Another general perspective might be termed the
intervention target model (Gordon, 1983; Mrazek &
Haggerty, 1994), which distinguishes three categories of
intervention from a medical model perspective:
1. A universal preventive intervention targets the gen-
eral public or a whole population that has not been
identified as having individual risks, so that the
intervention benefits everyone in the group. An
example would be prenatal care for every child.
2. Selective preventive measures are procedures tar-
geted to individuals or subgroups in a population
whose risk of developing specific problems are
higher than average. For example, social workers
and visiting nurses might be involved in home
visitation and infant care and training in social
development for low-birth-weight children of ado-
lescent mothers.
400 PREVENTION
3. Indicated preventive intervention would be employed
with high-risk individuals having minimal but
detectable symptoms foreshadowing mental
disorders; or individuals showing biological
makers indicating predisposition for mental dis-
orders, but who do not meet DSM,III~R diagnostic
levels at the current time (Mrazek & Haggerty,
1994, p. 25). For example, encouraging a person
with a family history of schizophrenia to receive
counseling in the early adolescent and adolescent
years to monitor their behavior and, if necessary,
receive an atypical antipsychotic medication to
"prevent" the onset of this disorder.
This last example is both exciting and frightening. It
is exciting that a serious m~ntal health issue might be
avoided; frightening in that our knowledge to make
such determinations is embryonic. The specter of
Nazi-like eugenics hangs in the background of this last
example with its gruesome history of compulsory
sterilization and massive extermination of
"undesirable" people. Nonetheless, social workers will
have to be aware of these three categories of universal,
selective, and indicated preventive measures, as they
have become part of the federal funding landscape.
A third general theory follows from the work of
George Albee who offered what social workers would
see as a bio~psycho,sodo,cultural perspective on the nature
of mental illness. Albee (l983, 2003) put the incidence
of mental disorders into a formula, each point of which
offers varying degrees 'of potential for preventive
intervention:
Incidence of mental disorder
organic factors + stress + exploitation coping
skills + self -esteem + support group
What this formula suggests are the major causal sources
of, and protections against, mental disorder. Social
workers will be familiar with these biological, psycho'
logical, and sociocultural factors, such as genetic coun-
seling, talking therapies employee assistance work, and
social action against exploitations and discriminations
based on ethnicitv, gender, age, physical facility, or
sexual orientations. The tools used to reduce these
problematic factors include education, promoting social
competency, natural caregiving, and community organ-
ization or systems (Gullotta, 1987).
A fourth theory involves a cognitive and social systems
perspective (Bandura, 1986), which differs from the in,
stinctive causation model of Freud, and the external
causation model of Skinner, by including both internal
cognitions and feelings (especially self-efficacy, the
feeling that "I can do a specific action on my own
behalf') along with perceived rewards or punishments
from the environment. This model, involving partial free
will along with strong influences from both internal and
external sources, has been used in many research
projects that -have guided social work thinking
(Bandura). It involves four kinds of helping actions:
most effective are those that demonstrate to clients that
they can master some part of the required task, which
encourages them to go on and master other aspects.
Vicarious awareness of the rewards and punishments
meted to others in situations like one's own is another
strong influence. Weaker influences are verbal persua-
sions, while physiological reactions are underused, help,
ing clients to be aware of internal reactions that may
interfere with visible actions, such as some performance
anxiety that can be reduced in part by deep breathing and
relaxing before the performance (Bandura).
A fifth theory is the weUness model (Cicchetti,
Rappaport, Sandler, & Weissberg, 2000; Cowen, 2000),
or the strengths 11Wdel (Durlak, 1997; Durlak & Wells,
1997; Saleebey, 1992); both argue that starting with
psychosocial assets is just as effective as beginning with
disease prevention, and both are preferable to the costly
experience of treating victims of disease one by one.
Note that DSM,III~R does not even discuss health
except as the absence of illness. There are vested inter'
ests preoccupied with individual and collective patholo-
gies. However, Cowen (2000, p. 482) points to research
(Tolan & Guerra, 1994; Yoshikawa, 1994, 1995)
suggest' ing that "effective early, comprehensive,
family-oriented competence enhancement programs for
preschoolers" were more effective in delinquency
prevention than any specifically targeted adolescent
program. In short, a promotive "jump-start" has the
potential for forestalling diverse, maladaptive outcomes
more than later prevention programs aimed at high-risk
groups.
Social workers are making increasing contributions
to the conceptual and empirical sides of primary pre-
vention. For example, Keller (2005) offers a systemic
model of the youth mentoring intervention, clarifying
the point that mentoring resides within a mutually
reinforcing (or inhibiting) network of other
relationships, which has implications for child welfare
agency policies and practices that would go beyond the
personal elements in the youth's situation (Brimer,
2005). Bacallao and Smokowski (2005) discuss an
acculturation model forsecond-culture acquisition for
Latino immigrants, with empirical evidence suggesting
assimilation as a risk factor, and biculturalism as a
protective factor, leading to a model for effective
bicultural skills training. LeCroy (2004) evaluates a
prevention program that focuses on positive
developments

for early adolescent girls from diverse backgrounds, using
an experimental pre-post test design. leCroy emphasized
positive self-image, inde pendence, and making and
keeping friends as part of a healthy psycho social
development in the contemporary world.
Evidence~Based Practice of
Primary Prevention
For the past half century of its development, the science of
primary prevention has lacked a rigorous research base, but
in the past several decades, researchers from many fields
have come together to construct a solid foundation, so
much so that prevention's most vocal critics in the area of
counseling interventions and psy chopharmacology find
themselves in the embarrassing situation of knowing less
about what works and might work (at least in regards to
children and adolescents) than the preventionists they once
so roundly criticized (Gullotta & Adams, 2005; Gullotta &
Blau, in press). Even so, evidence- based practice isin its
infancy as we begin to see the outlines this research will
take in the future. With this cautionary background, we
present an overview of the knowledge base for primary
prevention from our vantage point as editors of the
Encyclopedia of primary prevention and health promotion
(Gullotta & Bloom, 2003).
Recently, some 250 prevention specialists from around
the world published an extensive life span re~ view of
preventive and health promotive interventions. The
Encyclopedia of primary prevention and health promotion
(2003) covered 152 topics identifying, when pos sible,
strategies that worked (often with three or more successful
trials), strategies that might work (with some promising early
results or some fruitful theory), and strategies that do not
work. Not every topic area revealed programs that worked,
although many did; however, all of the areas did suggest
some promising leads that need independent confirmation.
It may be useful to list some of these topic areas, so that
readers will comprehend the range of subject matter at their
disposal. First, we present several examples of topics
related to prevention: child abuse and neglect; motor vehicle
accidents; aggressive behavio r; asthma, attention deficit
hyperactivity disorder; birth defects, cancer, chronic
diseases, criminal behavior, delinquency, (psychological)
depression; disordered eating behavior; divorce
(preventing problems affecting children and adolescents);
elder abuse; gambling; HIV/AIDS, unintentional injuries,
intimate partner violence, loneliness- isolation in older
adulthood; and obesity. Topics related to promotion include
academic success; successful adoption; work with African
American adolescents; anger re gulation; death with
dignity; effective child care, environmental health;
PREVENTION 401
correcting racial and ethnic disparities; strengthening
families; effective foster care; handling grief in older
adulthood; prosocial behavior; and physical fitnes s and
health. This is a partial list of topics, and because of page
constraints, we will only illustrate what readers can find in
two areas: the prevention of HIV /AIDS and the promotion
of self-esteem.
Current applications of primary prevention knowledg e:
The prevention ofHIV/AIDS. This topic has five separate
entries for each of the age groupings. With early childhood
HIV/AIDS prevention, the authors (Cornman & Johnson,
2003) list as evidence-based research on the use of
antiretroviral medications with an infected mother during
delivery and following birth; delivery by caesarean section
to prevent contamination; and avoiding breastfeeding after
delivery. The research studies supporting each of these
strategies that work is described in detail. For school-aged
children, Bryan and Johnson (2003) report no large-scale
research projects; Centers for Disease Control and
Prevention's (CDC's) list of HIV/STD prevention
"programs that work" largely deal with older children and
adolescents. Marsh, Johnson, and Carney (2003) address
the evidence-based programs that work for adolescents in
terms of the specifics of condom use, abstinence from sex,
frequency of sex, and number of sexual partners. In all
cases of effective interventions, HIV risk is personalized
through information and interpersonal skills training
exercises to enhance perceptions of personal risk and
methods to resolve them. Programs having more
long-lasting effects are more likely to emphasize condom
use, rather than abstinence alone. Programs that work with
adults include individualized strategies to reduce risk of
HIV and other STDs; small-group strategies,
community-level strategies, and mass-media strategies to
reduce risk of HIV (Johnson, Marsh, & Carey, 2003). With
older adults, Amico and Johnson (2003) report little
large-scale research in this area, less than 1% of the total
HIV/AIDS literature, even though there are some 80,000
people aged more than 50 with AIDS. What this kind of
broad review of the HIV/AIDS area tells us is that our
society is focusing on certain segments of the population
only, using primarily psychosocial methods that actively
involve participants in their personalized
knowledge-building to prevent this disease, in the face of
the fact that there is no cure for the condition.
With regard to current efforts to promote self- esteem in
young people, DuBois (2003a, 2003b, 20mc) reviews the
literatures on self-esteem, from early childhood through
adolescence. In early childhood, DuBois found many kinds
of programs, some seeking to increase self esteem directly,
others indirectly; apparently, these are
402 PREVENTION
similarly. effective. In school-aged populations, DuBois
found that programs specifically focusing on changing
self-esteem (as opposed to those that did not have this
specific focus) yielded higher effect sizes to enhance
selfesteem. Likewise, programs with well-defined
theories were more effective than those without. In
adolescence age group, DuBois reviews Haney and
Durlak's (1998) study showing an average effect size of
0.27 across 120 evaluation programs, giving readers
some sense of the scope and depth of reporting methods
to promote selfesteem. Haney and Durlak emphasize
that these findings are most appropriate for youth
entering the programs already exhibiting low
self-esteem or pre-existing problems. Just as important
are the studies indicating programs that do not work, so
as the prevent communities and schools from wasting
th~ir resources on these often appealing but inefficient
services.
RESOURCES ON PREVENTION There are a number
of journals dedicated in whole or in large part to primary
prevention, including American Journal of Community
Psychology, American Journal of Epidemiology, American
Journal of Orthopsychiatry, American Journal of Public Health,
Community Mental Health Journal, Health and Social Wark,
Health Policy Quarterly, Hospital and Community Psychiatry, J
ourryal of Community Psychology, Journal of Health and Social
Behavior, Journal of Preventive Psychiatry, Journal of Primary
Prevention, Journal of School Health, Prevention in Human
Services, Prevention Science, Preventive Medicine, Public
Health Reports, and Social Policy, Studies in Crime and
Crime Prevention. In other mainline journals, such as
Social Work, Social Service Review, American Psychologist,
Psychological Bulletin, American Journal of Sociology,
and Social Welfare, there are occasional articles
relevant to primary prevention. As this listing makes
clear, social work users have to be prepared to read
interdisciplinary materials and to interpret their
findings within the social work ideology and context.
The current and future generations of social work
students will know how to use search engines to
locate studies on specific topics, and will download
these papers directly. This will completely change the
nature of, and expectations for, empirically supported
information in primary pre vention as well as other
areas in social work.
Each of the federal and state agencies has offices
concerned with prevention issues. For example, the full
name of the CDC is the Centers for Disease Control and
Prevention. Many of these agencies take their
assignment seriously, but there is variability in the
quality of these offices dependent on budgetary issues
and the commitment of those responsible for policy in
the larger organization. Many national
;;'-
nongovernmental agencies also have rrussions related to '
primary prevention, such as ASH (Action on Smoking
and Health) and the Southern Poverty Law Center
[
(teaching tolerance, fighting hate, and seeking justice). '
The Practicers) of Primary Prevention
There are two issues regarding practice methods in
primary prevention. The first concerns what specific
methods are available that students and practitioners can
develop skills in delivering in appropriate situations. We
can distinguish among methods that increase individual
strengths and social supports from other methods that
decrease individual limitations and social stresses. It is
beyond the scope of this entry to present a comprehensive
report on methods, but we will indicate . some
representative practices.
To increase individual strengths, the following
methods have been used in many research projects and
are well developed in manuals (Albee & Gullotta, 1997;
Bloom, 1996): preventive problem solving, anticipatory
instruction, promotion of optimism, social skills
training, nutrition and lifelong exercise, immunization,
affective education, and assertiveness training. To
decrease individual limitations, practitioners have used
cognitive reframing, thought stopping, stress in-
oculation, accident prevention training, relapse pre-
vention, genetic counseling, relaxation training, stress
management, and parent effectiveness training. To in-
crease social supports, the following methods have been
employed: peer tutoring, bonding, encouraging friend-
ships, social support networks, self-help groups, social
empowerment, and institutionalized efforts to attain
desired ends. To decrease social stresses, social action,
ombudsman programs, social justice efforts, among
others, have been used (Bloom, 1996).
The second issue regarding practice methods in pri-
mary prevention involves translating theory and re-
search from nonsocial work domains into usable social
work practice. Efforts must be made to translate unfa-
miliar language into terms that are comprehensible and
useable by social workers by operationalizing the major
concepts and propositions into specific actions a task
educator has to facilitate. The development of practice
manuals in various demonstration projects will greatly
aid in this effort.
The Past, Present, and Future
of Primary Prevention in Social Work ANCIENT
HISTORY: THE NEW YORK SoCIETY FOR TIIE
PREVENTION OF PAUPERiSM (1817-1823) AND
TIIE NEW YORK HOUSE OF REFUGE (l824-1934)
Social work historians generally mark the beginning of

social work in the late 19th century, with Jane Ad dams
and Mary Richmond, whereas we find the beginnings of
primary prevention a half century earlier, in the forma tion
of the New York Society for the Prevention of Pauperism
(SPP) in .1817 (Bloom & Klein, 19951996). This
organization was based on an elem entary but identifiable
scientific theory, empirical research, a practice
technology, a strong value stance, and a self critical
adaptive facility. The SPP found many causes of poverty,
rather a single cause. For each suggested cause, a study
group was set up to understand that condi tion and propose
methods for preventive, not ameliora tive, action. The SPP
pioneered a system of district visitors in America
(borrowed likely from German models- the three founding
members of SPP were in close contact with Eur opean
thinking and programs); the evolution of this idea
continued in the Association for Improving the Conditions
of the Poor (1843) to the Charity Organization Society
(1888) and into our own times. However, the SPP was
organized to " ... strike at the roots of those evils"
(Pumphrey & Pumphrey, 1961, p. 61) responsible for
causing new generations of paupers, and started several
organizations to do this, including a savings bank for
working people, initiated efforts to coordinate charitable
contributions, established a library for working people,
attempted to set up a winter fuel program for summer
subscribers, and sought ways to provide employment for
those who could not find it; "either by the establish ment of
houses of industry, or by supplying materials for domestic
labor" (Pumphrey & Pumphrey, 1961, p. 62). However,
the SPP took on more than it could manage, and through
critical self-appraisal, it re- formed and focused all its
efforts on a new enterprise, the New York House of
Refuge (1824), a rehabilitation center for juveniles in
danger of committing serious adult crimes. This
organization lasted more than a century.
CURRENT REALITIES: SOCIAL WORK AND PRIMARY
PREVENTION TODAY Primary prevention is inherently
interdisciplinary, given the complexity of the issues
involved. In the social welfare area, social work is often
the lead helping profession, but is surrounded by vital
secondary services, fiscal, genetic counseling, legal, and
others. On the other hand, social work has a long
tradition of being a secondary profession within some
other dominant helping setting, such as a hospi tal.
Occasionally, social workers suggest modifica tions that
make the dominant approach more humane and
client-friendly (Tadmor, 2003). In primary pre vention, it
is likely that social work will provide secondary
assistance for the near future, until it formulates
PREVENTION' 403
programs that have demonstrated effectiveness for the
community at large.
FUTURE ASPIRATIONS FOR PRIMARY PREVENTION:
OPTIMISTIC FORECAST For example, with an increasing
proportion of the American GNP being directed at health
care (although only 4% of the national health care budget
is allocated to prevention services) with dec reasing
successful results and over 30 million people without
adequate medical insurance, it is surely time to take
primary prevention and health consumers ser iously.
These future programs will have to engage the hearts and
minds, as well as the bodies, o f the general public, for
which new ideas and strategies will be needed. Each of
prevention's delivery mechanisms provides numerous
opportunities for social workers to de, velop expertise to
forward the movement of a healthier society.
CAPTURING THE ENTHUSIASM OF NEW GENERATIONS
OF STUDENTS FOR PRIMARY PREVENTION Many
students enter social work with the anticipation of
working with individual clients in treatment con texts.
Yet, when asked, many students profess interest in
working to prevent predictable problems, protect
existing states of help, and promote desired client goals.
Probably the best strategy at this time is to con nect
primary prevention. with the main body of social work
practice, as another tool in the armamen tarium of the
versatile helping professional in social work, while
increasing knowledge of the theories, re search, and
practice in primary prevention as such. As financing of
public programs becomes increasingly tight, policy
makers will be forced to address the obvious, that dolla rs
spent preventing problems will be better spent than
dollars used to treat victims of preventable problems and
to repair the social fallout of their problems.
DISTINCTIVENESS AND SIMILARITIES OF PRIMARY
PREVENTION WITH THE OTHER HELPING ApPROACHES
The major differences among the help ing approaches
rests on when services are delivered, and the social and
personal resources that can be used with the service.
With primary prevention, we can often facilitate the
participation of clients in their own behalf to prevent
problems and promote goals. It is easier for clients to
look forward to continued health and desired objectives,
than to accept psychosocial efforts after the problems
have occurred. All social work helping ap proaches share
a generalized problem-solving approach of assessing the
persontsj-in-environmentts}, so as
404 PREvENTION

to get the greatest hold on the challenge facing the (pp. 528-534). New York: Kluwer Academic/plenum
helping professional. There are many specific differ- Publishers.
ences in theories and practice methods, but these are not Cowen, E. L. (2000). Psychological wellness: Some hopes for the
nearly as important as the similarities in objectives and future. In D. Cicchetti, J. Rappaport, 1. Sandler, & R. P.
the underlying problem-solving process. The basic Weissberg (Eds.), The promotion of well ness in children and
question is how to get prevention, treatment, and re- adolescents (pp. 477-503). Washington, DC: CWLA Press.
DuBois, D. L. (2003a). Self-esteem, early childhood. In T. P.
habilitation to work together for the good of their
Gullotta & M. Bloom (Eds.), Encyclopedia of primary prevention
clients (Alexander, Robbins, & Sexton, 2000).
and health promotion (pp. 937-945). New York:
Kluwer Academic/plenum Publishers.
REFERENCES DuBois, D. L. (2003b). Self-esteem, childhood. In T. P. Gullotta
Albee, G. W. (1983). Psychopathology, prevention, and the just & M. Bloom (Eds.), Encyclopedia of primary prevention and health
society. Journal of Primary Prevention, 4( 1), 5-40. promotion (pp. 945-953). New York:
Albee, G. W. (2003). The contribution of society, culture, and Kluwer Academic/Plenum.Publishers.
social class to emotional disorders. In T. P. Gullotta & M.
DuBois, D. L. (2003c). Self-esteem, adolescence. In T. P. Gullotta
Bloom (Eds.), Encyclopedia of primary prevention and health & M. Bloom (Eds.), Encyclopedia of primary prevention and
promotion (pp. 97-lOM. New York: Kluwer Academic/plenum health promotion (pp. 953-961). New York:
Publishers.
Kluwer Academic/plenum Publishers.
Albee, G. W., & Gullotta, T. P. (1997). Primary prevention works.
Durlak, J. A. (1997). Successful prevention programs for children and
Thousand Oaks, CA: Sage.
adolescents. New York: Plenum.
Alexander, J. F., Robbins, M. S., & Sexton, T. L. (2000).
Durlak, J. A. (2003). Effective prevention and health promotion
Family-based interventions with older, at risk youth: From
programming. In T. P. Gullotta & M. Bloom (Eds.),
promise to proof to practice. The Journal of Primary Prevention,
Encyclopedia of primary prevention and health promotion (pp.
21(2), 185-205.
61--69). New York: Kluwer Academic/Plenum Publishers.
Amico, K R., & Johnson, B. T. (2003). HIV/AIDS, Older
Durlak, J. A., & Wells, A. M. (1997). Primary prevention mental
adulthood. In T. P. Gullotta & M. Bloom (Eds.), Encyclopedia
health programs for children and adolescents. American Journal
of primary prevention and health promotion (pp, 554-561). New
of Community Psychology, 26, 775-802.
York: Kluwer Academic/plenum Publishers.
Fraser, D. W., & McDade, J. E. (1979). Legionellois. Scientific
Bacallao, M. L., & Smokowski, P. R. (2005). "Entre doe mundos"
American, 241(4), 82-101.
(Between two worlds): Bicultural skills training with latino
Gordon, R. (1983). An operational classification of disease prevention.
immigrant families. Journal of Primary Prevention,
In J. A. Steinberg & M. M. Silverman (Eds.), Preventing mental
26(6),485-509.
disorders (pp. 20-26). Rockville, MD:
Bandura, A. (1986). Social foundations of thought and action: A social
Department of Health and Human Services.
cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
Gullotta, T. P. (1987, Fall/Winter). Prevention's technology.
Bloom, M. (1996). Primary prevention practices. Thousand Oaks,
Journal of Primary Prevention, 8(1 & 2), 1-22.
CA: Sage.
Gullotta, T. P., & Adams, G. R. (Eds.). (2005). Handbook of
Bloom, M., & Klein, W. C. (1995-1996). John Griscom and
adolescent behavioral problems: Evidence-based approaches to
primary prevention at the beginning of the 19th century. The
prevention and treatment. New York: Springer.
Journal of Applied Social Sciences, 20(1), 15-24.
Gullotta, T. P. & Blau, G. M. (Eds.). (in press). Handbook of
Boyle, M.(Z004). Preventing a non-existent illness? Some issues
childhood behavioral issues: Evidence-based approaches to prevention
in the prevention of "schizophrenia." Journal of Primary
and treatment. New York: Routledge.
Prevention, 24(4), 445-469.
Gullotta, T. P., & Bloom, M. (Eds.). (2003). Encyclopedia of primary
Brimer, P. (2005). Editors' strategic implications for Keller, r.E.
prevention and health promotion. New York: Kluwer
(2005). A systemic model of the youth mentoring
Academic/Plenum Publishers.
intervention. Journal of Primary Prevention, 26(2), 169-188.
Haney, P., & Durlak, J. A. (1998). Changing self-esteem in
Bryan, A., & Johnson, B. T. (2003). HIY/AIDS, Childhood.
children and adolescents: A meta-analytic review. J oumal of
In T. P. Gullotta & M. Bloom (Eds.), Encyclopedia of primary
Clinical Child Psychology, 27,423-433.
prevention and health promotion (pp. 535-541). New York:
Johnson, B. T., Marsh, K. L., & Carey, M. P. (2003). HIV/ AIDS,
Kluwer Academic/Plenum Publishers.
adulthood. In T. P. Gullotta & M. Bloom (Eds.), Encyclopedia
Caplan, G. (1964). Principles of preventive psychiatry. New York:
of primary prevention and health promotion (pp. 548-554). New
Basic Books.
York: Kluwer Academic/plenum Publishers.
Cicchetti, D., Rappaport, J., Sandler, 1., & Weissberg, R. P.
Keller, T. E. (2005). A systemic model of the youth mentoring
(Eds.). (2000). The promotion of wellness in children and
intervention. Journal of Primary Prevention, 26(2), 169-188.
adolescents (pp. 477-503). Washington, DC: CWLA Press.
Cornman, D. H., & Johnson, B. T. (2003). HIV/AIDS, Early
childhood. In T. P. Gullotta &M. Bloom (Eds.), Encyclopedia of
primary prevention and health promotion

Klein, D. c, & Goldston, S. E. (1977). Primary prevention: An
idea whose time has come (DHEW Publication No. ADM
77-447). Washington, DC.
Leavell, H. R. & Clark, E. G.(Eds.). (1953). Textbook of preventive
medicine. New York: McGraw-Hill.
leCroy, C. W. (2004). Experimental evaluation of "Go Grrrls"
preventive intervention for early adolescent girls. Journal of
Primary Prevention, 25(4),457-473.
MacMahon, B., Pugh, T. F., & Ipsen, J. (1960). Epidemiological
methods. Boston: Little, Brown.
Marsh, K. L., Johnson, B. T., & Carney, M. P. (2003). HIV/ AIDS,
adolescence. In T. P. Gullotta & M. Bloom (Eds.), Encyclopedia
of primary prevention and health promotion (pp. 541-548). New
York: Kluwer Academic/plenum Publishers.
Mason, M. J., Cheung, I., & Walker, t. (2004). The social
ecology of urban adolescent substance use: A case study
utilizing geographic information systems. Journal of Primary
Prevention, 25(2), 271-282.
Mitchell, C. M., Kaufman, C. E., Beals, J., & The Pathways of
Choice and Healthy Ways Project Team. (2004). Equifinality
and multiflnality as guides for preventive intervenons:
HIV risk/protection among American Indian young adults.
Journal of Primary Prevention, 25(4), 491-510.
Mrazek, P. J., & Haggerty, R. J. (1994). Reducing risks for mental
disorders: Frontiers for preventive interventions. Washington, DC:
National Academy Press.
Pollan, M. (2007, January 28). Unhappy meals: Thirty years of ,
nuttitional science has made America sicker, fatter, and less well
nourished. A plea for a return to plain old food. The New York
Times Magazine, pp. 38-47, 65, 67, n.
Pumphrey, R. E., & Pumphrey, M. W. (Eds.). (1961). The heritage
of American social work. New York: Columbia University
Press.
Saleebey, D. (Ed.). (1992). The strengths perspective in social work
practice. New York: Longman.
Tadmor, C. S. (2003). Perceived personal control. In T. P. Gullotta
& M. Bloom (Eds.), Encyclopedia of primary prevention and
health promotion (pp. 812-821). New York:
Kluwer Academic/Plenum Publishers.
The new weUness encyclopedia. (1995). From the editors of the
University of California at Berkeley Wellness Newsletter.
Tolan, P. H., & Guerra, N. G. (1994). Prevention of delin. quency:
Current status and issues. Applied and Preventive Psychology, 3,
251-273.
Yodanis, c., & Godenzi, A. (2003). Cost benefit
analysis. In T. P. Gullotta & M. Bloom (Eds.),
Encyclopedia of primary prevention and health promotion (pp.
330-335). New York:
Kluwer Academic/plenum Publishers.
Yoshikawa, H. (1994). Prevention as cumulative protection:
Effects of early family supporr and education on chronic
delinquency and its risks. Psychological Bulletin, 115,28-54.
Yoshikawa, H. (1995). Long-term effects of early childhood
programs on social outcomes and delinquency. The Future of
Children,S, 51-75.
-MARTIN BLOOM AND THOMAS P. GULLOTTA
I
1
PluMARy HEALTH CARE 405
PRIMARY HEALTH CARE
ABSTRACT: The definition of primary health care in-
corporates a number of characteristics and strategies.
It ideally offers patient services that are
comprehensive and continuous using a
multidisciplinary team ap proach with focus on the
whole person in the commu nity context. There is
consensus that primary health care is a fragmented
system that has not lived up to its promises and is
being threatened by new form s of health delivery and
access. The future of social work in pri mary health
care is precarious. Social workers must be proactive
during this time of change and become more content
rich to insure their place within the primary
health-care team.
KEY WORDS: primary health care; primary care; Insti-
tute of Medicine; primary health- care team; Federally
Qualified Health Centers (FQHCs); behavioral health;
boutique medical practices; Retail- Based Clinics
(RBCs); Convenient Care Clinics (CCCS); National
Health Service Corps
Definition of Primary Health Care
The definition of primary health care incorporates a number of
characteristics and dimensions. The Institute of Medicine
(lOM) report on Manpower Policy for Primary Health Care
(Institute of Medicine, 1978) was pivotal in the formulation of
a definition for primary health care, defining it by three basic
characteristics: scope, character, and integration of services.
The definition further described five attributes essential to
practice: accessibility, comprehensiveness, coordination,
continuity, and accountability.
In 1996, given the changes in the health-care field, the
10M Committee on the Future of Primary Care adopted a new
definition using the 1978 attributes as a cornerstone and
reaffirmed the importance of primary care as
multidimensional. This definition is as follows: "Primary care
is the provision of integrated, accessible health care services
by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained
partnership with patients, and practicing in the context of
family and community" (Donaldson, Yordy, Lohr, &
Vanselow, 1996). This definition identifies three additional
perspectives to the 1978 definition: (a) patient and family, (b)
community, and (c) integrated delivery system. The definition
acknowledges the context of family and community in
understanding the patient's living conditions and cultural
background and the necessity to function within the broader
health-care delivery system.
 406 PRIMARY HEALTH CARE
In both the 1978 and 1996 report, the committee
affirmed a team approach with a variety of medical and
allied medical professionals, including social workers
as part of the team. Disease prevention and health
promotion are the major themes in the delivery of
primary health care given its focus on life stages,
health-care access, and the inclusion of family and
community.
SETTINGS Primary health care in the United States is
provided by hospitals in their outpatient and clinic
settings, in physician solo and group practices, by health
maintenance organization, and in federal, state, or
locally funded neighborhood health centers. Consid-
ering its multidimensional definition! the full spectrum
of primary health care usually occurs in clinics or health
maintenance organizations. The Federally Qualified
Health Centers (FQHC) program includes all the di-
verse public and nonprofit organizations and programs
that receive federal funding. The program that began 40
years ago as part of the antipoverty program under
President Johnson. These have grown to over 1,000
community centers at more than 4,000 sites serving over
16 million patients in urban and rural settings. Medical
services are targeted to uninsured and underserved
populations. The centers must include supportive
services that promote access to health care such as
translation, transportation, home visiting, parenting
education, case management, child care during visits,
environmental health risk reduction, and eligibility
'.' workers to assist in obtaining social services (U .S. De-
partment of Health and Human Services, 2007).
SERVICES In general, clinical services are provided by
physicians, nurse practitioners, or physician assistants
who have the authority to direct the delivery of personal
health services to patients. Usually these physicians are
in family medicine, internal medicine, or general
pediatrics (Phillips, 2005). Primary health care ideally
offers patient services that are comprehensive and con-
tinuous using a multidisciplinary team approach. Its
focus is on the whole person in the context of the
patient's medical history and life circumstances rather
than treating only acute problems (Safran, 2003) and
includes appropriate referrals and coordination of care.
A crucial role for many primary health-care clinics
is to insure universal access to health care, particu larly
for the underserved, and to ensure culturally com petent
gender-specific interventions for current health
problems (U.S. Department of Health and Human Ser-
vices, 2007; Van Hook, 2003). In addition to giving the
patient a "health care home" for episodic care and
chronic continuous care, services'include healthcare
assessment and screening, health promotion,
health education, and disease prevention on both a
community and patient level (Canadian Association of
Social Workers, 2003; Showstack, Anderson,
Rothman, & Hassmiller, 2003).
There are a variety of models of providing care. In
Kaiser Permanente (a health maintenance organization)
primary care providers work together with specialists to
deliver a coordinated and quality health-care
experience. Patient care teams consist of primary care
physicians, nurses, nurse practitioners, and physician
assistants (Halvorson, 2003). Denver Health is a large
integrated public safety net system. Ten family health
centers and 13 school-based clinics located throughout
Denver's underserved neighborhoods are an integral
component of this system (Gabow, 2003). In a study of
27 Neighborhood Health Centers in New York City, the
authors found that psychosocial services were. a needed
and important service, generally provided by social
workers (Rizzo, Mizrahi, & Kirkland, 2005).
Integration of Behavioral Health and
Primary Health Care
The integration of behavioral health and primary health
care offers an excellent model for participation of social
workers on primary health-care teams. This integration
may be structural (use of shared facilities),
administrative' (shared administrative re sources), or
functional (complete integration of clinical services
with staff jointly responsible for patient welfare)
(LaGrenade, 1998). Although the integration of
behavioral health and primary health care would appear
to be most .desirable, there appears to be no economic
incentives for this type of integration and
reimbursement of social workers and other nonphysi-
cians remain an important factor. Not everyone who has
health insurance is covered for mental health or
substance abuse. In addition, Medicaid reimbursement
may be limited for nonphysician providers. Many pri-
mary care physicians treat behavioral health problems
with medications so that patients may not be seen in
specialty care (National Association of Community
Health Centers, 2006a).
In an examination of mental health and substance
abuse services in the community health centers, the
number of patients diagnosed with mental health or
substance abuse disorders increased from 210,000 in
1998 to 800,000 in 2003. More than two-thirds of the
community health centers offered on-site mental health
services and more than half provided substance abuse
treatment. The trends in the community health centers
parallel a rise in the rate of these treatments in primary
health care in general. Proportionally, however, the
increasing number of patients did not reflect

a rise in the number of mental health or substance
abuse clinicians in the commuriity health centers
because of the rise in use of psychotropic medications
prescribed by primary care physicians (Druss et al.,
2006). Kaiser-Permanente designed a new primary
care system in Northern California that provided
behavioral medicine specialists who were identified as
psychologists or clinical social workers on the primary
care team. Their role was to evaluate patients, create
treatment plans, provide brief interventions, and
coordinate care (Dea, 2000).
Several studies have been funded by the federal
government to encourage the integration of primary
health care and behavioral health. One study designed
to promote outreach and engagement of the homeless
in health care and in community mental health agen-
cies found that co-location and joint staffing were the
most effective in improving-access to services com-
pared with cross referral and clinical case management
(National Association of Community Health Centers,
2006b).
Social workers and mental health providers (not
defined) were used in a collaborative demonstration
program at six different sites to integrate behavioral
health services into pediatric primary care settings
focusing on families. Directors found that they had to
be innovative in billing, but also admitted that much of
their interaction with families was not billable. Given
bundled rates and shorter appointment times for
physical care, they could not bill for additional time
spent addressing the behavioral health needs of
parents. The co-location of a variety of services and
supports to families is an important strategy for
increased utilization of mental health services
(Rosman, Perry, & Hepburn, 2005).
Roles of Social Workers
The role of social workers in primary health care is
varied. Specifically the roles identified in the literature
include health promotion and disease prevention with
a focus on the individual and community, risk assess-
ment, service provision, counseling, consultation,
education and training, case advocacy, coordination,
case management, community development and
capacity building, community action, policy analysis
and development, research, emergency preparedness,
health informatics, social marketing, and building
partnerships (Lesser, 2000; Mizrahi, Rizzo, &
Kirkland, in press; Siefert & Henk, 2001).
The literature describes few research studies of
evidence-based practice for social workers in primary
health care. The data from the Uniform Data System
(UDS) collected from the FQHC (community health
PRIMARY HEALTH CARE 407
center) program has a category only for licensed mental
health providers, making it impossible to know how
many of these providers were social workers (U.S.
Department of Health and Human Services, 2005). The
general literature on primary health care mainly
referred to licensed mental health providers, behavioral
health providers (Halvorson, 2003), or primary care
team members so that it is not possible to know if social
workers were part of the team, any outcomes specific to
social workers or any role differentiation from other
team members who were mental health providers.
Literature specific to social work and primary health
care often focuses on social workers as case managers.
The community case management program in Sedgwick
County, Kansas, has a case management team based at
each of four hospitals consisting of a social worker and a
nurse to help the uninsured find a primary health-care
home. Using the nurse social worker team helps clients
to access the care and sup- port the need (Wetta-hall,
Berry, Ablah, Gillispie, & Stepp-Cornelius, 2004).
Geron and Keefe (2006) noted that using social workers
trained in geriatrics was as effective or more effective
than using more expensive workers such as nurses or
physicians for care coordination and case management.
CHALLENGES In 2000, the 10M issued a report noting
the need to redesign the nation's health-care delivery
system (Institute of Medicine, 2000). In 2003 the
Annals of Internal Medicine published articles on the
Future of Primary Care, which were followed by a
number of editorial comments in subsequent issues.
There appears to be an agreement that primary health
care in the United States has fallen short of its
promises of accessibility, comprehensive,
coordinated, accountable, and continuous
patient-centered care. There are no mechanisms to
coordinate a full range of services needed by those
with multiple serious illnesses. The system is complex
and fragmented by clinicians, facilities, and services
created on the basis of insurance reimbursement
requirements (Phillips, 2005).
There is speculation that the expectations of primary
health care may be too high. Primary care providers
must be up to date on all of the latest discoveries and
treatments and be expert diagnosticians. They must also
deal with chronic illness and recognize behavioral and
social problems. Given these expectations, general
internists may need longer residencies in the 21st
century (Morud, 2004). There has been a call for
improved training, visibility, and improved pay for
primary care physicians who often have longer hours,
receive less pay than other types of physicians, and
408 PRIMARY HEALTH CARE
who render many services that may not be covered by
insurance (Murden, 2004).
In other cases, primary care is being threatened by
new forms of health delivery and access. Among these
are the boutique practices that have the characteristics
of primary health care guaranteeing access, a continu-
ous relationship with a primary care physician and
personalized referral to a specialist in return for a retai-
ner fee (ranging from $1,500 to $20,000) in addition to
fees for care. However boutique medicine puts primary
health care in an elite class category that separates
medicine into a class system based on income and
ability to pay (Showstack, Anderson, Rothman, &
Hassmiller, 2003).
Another form of health \care that is growing in
popularity offers universal access, convenience, and
low price. Retail-Based Clinics (RBCs) or Convenient
Care Clinics (CCCs) located in stores such as Wal,
Mart, Target, and CVS promise quick attention for
routine visits such as sore throats, minor aches and
pains, and flu shots with no appointment needed (Mis-
hori, 2007). The American Medical 'Association and
the American Academy of Pediatrics have expressed
many concerns regarding this trend, including
fragrnenration of care, lack of continuity of care, and
lack of a primary care home.
In response to the growing concerns regarding the
future of primary health care and its new forms of
delivery and access, the American Academy of Family
Physicians in 2005 launched a national project called
TransforMed (www.transforrned.com), The purpose of
the project was to transform the way primary care is
delivered in the United States by focusing on studying
national demonstration projects and implementing
transformed models of high performance practices.
These transformed practices embrace four overarching
goals: personal medical home, patient-centered care,
continuous care relationship, and whole person orien-
tation. Eight areas are targeted for improvement, which
follow the basic tenets of primary health care, including
a team approach, open access scheduling with multi-
lingual approach to care, and comprehensive practice
service offering disease prevention and wellness
promotion and acute or chronic disease management
(http:// transformed.com/transformed.cfrn) .
Future Trends and Directions
The place of social work in primary health care remains
precarious. The transformation of primary health care is
dominated by physicians, medical schools, and health
insurance companies. Although social workers are
named as members of the health-care team in the 10M
definition, the literature does not acknowledge
social workers specifically as team members. Social
workers are in a competitive position with other
professionals who can also perform similar roles on the
team such as psychiatric nurses, marriage and family
therapists, psychologists, health educators, and related
professions (Canadian Association of Social Workers,
2003; Salvatore, 1988). For example, counseling on
health risk behaviors such as smoking cessation and
risky drinking may often be conducted by a health
educator or nurse practitioner. Author's observation is
usually in the purview of a person who holds a public
health degree or the nurse practitioner rather than the
social worker.
Yet social workers are perceived as highly valued
members of the health-care team in health center
studies (Mizrahi, Rizzo, & Kirkland, in press). Never-
theless, the issue of reimbursement remains. Reimbur-
sement may be easier in clinics and health centers that
receive federal or state funding for serving the unin-
sured or underserved populations where behavioral
health services are mandatory, but social work can only
be reimbursed under Medicaid for clinical social work
services where patients have a mental health diagnosis.
This eliminates specific reimbursement for broader
psychosocial services (Rizzo, Mizrahi, & Kirkland,
2005).
The 10M report (2000) suggested 10 new rules to
redesign and improve care, which recall some of the
basic tenets of primary health care, including contin-
uous healing relationships, patient control, customiza-
tion based on patient needs and values, and cooperation
among clinicians. As new models evolve, it behooves
social workers to be proactive during this time of
transformation to insure its place within the primary
healthcare team. Although social workers have the
basic skills to work in a primary health-care setting at
the micro and macro, they may need to become more
content rich. Social workers should be knowledgeable
in the areas of public health and primary health care,
including health promotion and disease prevention,
health-care policy, and the effects of disease on
biopsychosocial functioning.
Participation in special programs that include ma-
ternal and child health issues are also important and will
enhance the social work family focus. Field work
placements in primary health-care settings will build
bridges for the future hiring of social workers (Rock &
Cooper, 2000). As hospital social work becomes less
attractive to social workers because of downsizing, de-
professionalization, and increasing stress, social work
educators need to provide classroom and field opportu-
nities for education in prevention and primary health
care. The National Health Service Corps has a loan
repayment program (that includes social workers) in

exchange for a commitment to work in a federally
designated health professional shortage area. Schools
can offer continuing education courses in primary
health-care issues. Hospital social work can provide
basic experience that can be transferred to primary
health care. Social workers also need to educate other
professionals, patients, the public, and policy-makers
their unique person in environment skills and their
ability to work on both a micro and macro level. Addi-
tional roles include becoming consultants to healthcare
staff on the psychosocial aspects of health care,
continuing education and research with a partnership
between a school of social work and a major medical
center. Social workers should be leaders in advocating
for the integration of behavior health and primary
health care. Social work 'needs to keep informed on the
issues .being debated and new models initiated in
primary health care and work to insure their participa-
tion as a member of the primary health-care team.
REFERENCES
Canadian Association of Social Workers (CASW). (2003,
November). Preparing for change: Social work in primary
health care. Retrieved October 26, 2007, from http://www.
casw-acts.ca/advocacy/primary _health_e. pdf
Dea, R. A. (2000). The integration of primary care and behavioral
healthcare in Northern California KaiserPermanente.
Psychiatric Quarterly, 71 (1), 17-29.
Donaldson, M. S., Yordy, K. D., Lohr, K. N., & Vanselow, N. A.
(Eds.). (996). Primary care America's health in a new era (pp.
27-51). Washington, DC: National Academy Press.
Dross, B. G., Bornemann, T., Fry-Johnson, Y. W., McCombs, H.
G., Politzer, R. M., & Rust, G. (2006). Trends in mental health
and substance abuse services at the nation's community health
centers: 1998-2003. Arnerican Journal of Public Health, 96(0),
1779-1784.
Gabow, P. (2003). Editorial: The future of primary health care.
Annals of Internal Medicine, 138(3), 231-232.
Geron, S. M., & Keefe, G. (2006). Moving evidence-based
interventions to populations: A case study using social
workers in primary care. Home Health Care Services Quar~
terly, 250-2), 95-113.
Halvorson, G. (2003). Kaiser permanente. Annals of Internal
Medicine, 138(3),232.
Institute of Medicine. (978). Primary care in medicine: A
Definition. In A manpower policy for primary health care:
Report of a study (Chapter 2). Washington, DC: National
Academy Press.
Institute of Medicine, Committee on Quality of Health Care in
America. (2000). Crossing the quality chasm, A new health
system for the 21st century. Washington, DC: National Acad-
emy Press.
LaGrenade, J. (998). Integrated primary mental health care.
Challenges for the new millennium session 3. West Indian
Medical}ournal, 47(Suppl. 4),31-33.
PRIMARY HEALTH CARE 409
Lesser, J. (2000). Clinical social work and family medicine: A
partnership in community service. Health and Social Work,
25(2), 119-126. .
Mishori, R. (2007, January 16). Is 'Quick' enough? The Washington
Post, Health Section, pp. Fl, F4.
Mizrahi,T., Rizzo, V. M., & Kirkland, K. (in press). Perspectives
on the roles and value of social work in neighborhood health
centers. Journal of Health and Social Policy.
Morud, C. (2004). The future of primary care. Letter to the editor.
Annals of Internal Medicine, 1400),69.
Murden, R. A. (2004). Payment and the future of primary care.
Letter to the editor. Annals of Internal Medicine, 140(3), 70.
National Association of Community Health Centers. Healthcare
for the Homeless Clinicians Network. (2006a, May).
Integrating primary & behavioral health care for homeless
people. Healing Hands, 10(2), 1-2.
National Association of Community Health Centers. Healthcare
for the Homeless Clinicians Network (2006b, May). Linking
HCH with mental health services. Healing Hands, 10(2),3-6.
Phillips, R. L. (2005). Primary care in the United States:
Problems and possibilities. British Medical Journal, 331,
1400-1402. Retrieved from http://bmj.com
Rizzo, V., Mizrahi, T., & Kirkland, K. (2005). Psycho-Social
dimension of patient care in neighborhood health centers.
Journal of Community Health, 30(2),125-136.
Rock, B. D., & Cooper, M. (2000). Social work in primary care: A
demonstration student unit utilizing practice research. Social
Work in Health Care, 31 (1), 1-17.
Rosman, E. A., Perry, D. F., & Hepburn, K. S. (2005, August).
The best beginning: Partnerships between primary health care
and mental health and substance abuse services for young
children and their families. Georgetown University National
Technical Assistance Center for Children's Mental Health.
Retrieved October 26, 2007, from http://gucchd.
georgetown.edu/files/products_publications/T A Center/best
beginfinal.pdf
Safran, D. G. (2003). Defining the future of primary care:
What can we learn from patients? Annals of Internal Medicine,
138(3), 248-255.
Salvatore, E. P. (988). Issues in collaboration and teamwork:
A sociological perspective on the role definition of social work
in primary health care. In D. C. Wertz (Ed.), Research in the
sociology of health care. A research annual (Vol. 7, pp.
119-139). Greenwich, Cf: JAI Press.
Showstack, J., Anderson, A., Rothman, A. A., & Hassmiller, S.
(2003). Primary care at a crossroads. Annals of Internal
Medicine, Supplement The Future of Primary Care, 138(3),
242-243.
Siefert, K., & Henk, M. (2001). Social work in primary health
care. Monograph series, Society for Social Work Leadership
in Health Care.
U.S. Department of Health and Human Services, Health Re-
sources and Services Administration (HRSA), Bureau of
Primary Health Care (BPHC). (2005). Bureau of Primary
Health Care Section 330 Grantees Uniform Data System
(UDS) Calendar Year 2005 Data, National Rollup Report.
Prepared by John Snow, Inc.
410 PRIMARY HEALTIl CARE
U.S. Department of Health and Human Services, Health Re-
sources and Services Administration (HRSA), Bureau of
Primary Health Care (BPHC). (2007). Retrieved January
8,2007, from http://bphc.hrsa.gov
Van Hook, M. P. (2003). Psychosocial issues within primary
health care settings: Challenges and opportunities for social
work practice. Social Work in Health Care, 38(1), 63-80.
W etta- Hall, R., Berry, M., Ablah, E., Gillispie, J. M., & Stepp-
Cornelius, L. M. (2004). Community case management: A
strategy to improve access to medical care in uninsured
populations. Care Management Joumal, 5(2), 87-93.
FURlHER READING
Aliotta, S. (2004). Integrating medical and mental health care. The
Case Manager, 15(1),56-60.
Browne, C. V., Smith, M., Ewalt, P. L., & Walker, D. D. (1996).
Advancing social work practice in health care settings: A
collaborative partnership for continuing education, Health &
Social Work, 21(4), 267-276.
Cleaveland, C. R. (2004). The future of primary care, letter to the
editor. Annals of Internal Medicine, 140(1),69.
Gross, A M., Gross, J., & Eisenstein-Naveh, A R. (1983).
Defining the role of the social worker in primary health care.
Health and Social Work, 8(3),174-181.
Henk, M. L. (1989). Public health role. In Matthew L. Henk (Ed.),
Social work in primary care (pp, 113-126). Newbury Park, CA:
Sage.
Matus, J. C. (2003). Boutique medicine: Good medicine with a
bad taste or just bad medicine? Department of Health Services
Administration, Xavier University, Cincinnati, OH. Retrieved
January 30, 2007, from http://www.aameda.org/Mem
berServices/Exec/ Articles/winter03/boutiquemedMatus.pdf
McGuire, J., Bikson, K., & Blue-Howells, J. (2005). How many
social workers are needed in primary care? A patient-based
needs assessment example. Health & Social Work, 30(4),
305-313.
Moore, G., & Showstack, J. (2003). Primary care medicine in
crisis: Toward reconstruction and renewal. Annals of Internal
Medicine, 138(3),244-247.
Proser, M., & Cox, L. (2004). Health centers' role in addressing
the behavioral health needs of the medically underserved.
National Association of Community Health Centers. Special
Topics Issue Brief No. 8, Washington, DC.
Rothman, A A, & Wagner, E. H. (2003). Chronic illness
management: What is the role of primary care? Annals of
Internal Medicine, 138(3),256-261.
Sandy, L. G., & Schroeder, S. A (2003). Primary care in a new
era: Disillusion and dissolution? Annals of Internal Medicine,
138(3),262':"267.
Showstack, J., Lurie, N., Larson, E. B., Rothman, A. A., &
Hassmiller, S. (2003). Primary care: The next renaissance.
Annals of Internal Medicine, Supplement, The Future of Primary
Care, 138(3),268-272.
Showstack, J., Rothman, A A, & Hassmiller, S. (2003).
Primary care at a crossroads. Annals of Internal Medicine,
Supplement, The Future of Primary Care, 138(3),242-243.
Siefert, K. (1989). The generalist's role. In M. L. Henk (Ed.),
Social work in primary care (pp. 55-66). Newbury Park, CA:
Sage.
Sox, H. C. (2003). Editoral: The future of primary care. Annals of
Internal Medicine, 138(3),230-231.
Thompson, L. E., & Hess, H. J. (1989). The integration of
primary health care and social work in the educational setting.
In M. L. Henk (Ed.), Social work in primary care (pp. 31-54).
Newbury Park, CA: Sage.
U.S. Department of Health and Human Services, Health Re-
sources and Services Administration (HRSA), Maternal and
Child Health Bureau (MCHB). Retrieved October 10, 2007,
from http://mchb.hrsa.gov/training/docurnents/fs/ SW.doc
World Health Organization, Primary health care. (1978). Report
of the International Conference on Primary Health Care,
Alma-Ara, USSR, September 6-12, (Health for All Series, No.
1) Geneva.
SUGGESTED LINKS American Academy
of Family Physicians. www.transformed.com
National Health Service Corps.
http://nhsc . bhpr .hrsa.gov/resources/sdm/chapter I .asp
-REBECCA S. ASHERY
PRISONS. See Criminal Justice: Corrections.
PRIV A TE PRACTICE. See Context/Settings:
Private/Independent Practice Settings.
PRIVATIZATION
ABSTRACT: Privatizing social services has taken a new turn as
America enters the 21st century. Although it was once possible to
separate private and public social services, the growing trend
toward public-private partnerships has made such earlier
distinctions meaningless since more and more private social
services are supported with public money. There are advantages
and disadvantages inherent in the mixing of public and private
social services, but perhaps the greatest problem may be the
support of a growing trend for all levels of government to
dissociate themselves from their longstanding public social
service responsibilities.
KEY WORDS: social policy; social welfare history;
public-private partnerships; voluntary organizations
The auspices under which social services should be funded
and delivered have been debated (throughout

the history of American social work). For example,
before the Social Security Act was created in 1935 very
simple social services were provided by private charity
organizations and churches as a way to help needy
persons. These early social services consisted of practi-
cal helpful efforts to people in need, such as help with
household chores and forms of practical advice to help
persons improve their living conditions. Mary
Richmond, who is given credit for the development of
contemporary social work, first organized and gave de'
finition to what we now call social services. Her highly
elaborate scheme for providing social services depended
on private funds raised by the Charity Organization
Societies (Watson, 1922, pp. 137-,141). These social
services were usually in the form of advice provided by
volunteers who sought to help the poor. Mary Richmond
went on to become a founding member of the Family
Service Association of America, one of to, day's premier
nonprofit organizations providing private social
services.
But even this early form of private social services
lacked a clear dividing line between private and public
social services because very often public money was
used to provide services offered by the private agency.
Mary Richmond herself urged that the public money
collected for "relief" in Philadelphia be turned over to
the Philadelphia Charity Organization Society to ad,
minister as social services, which would "rehabilitate"
those in economic need (Richmond, 1930, p. 142). In
these early days little public money was available to
provide public social services, and private social ser-
vices grew steadily, particularly social services offered
by sectarian organizations. Although most early secular
organizations such as Catholic Charities, Jewish social
services (later called Jewish Family Services), and the
extensive work of the Church of the Latter Day Saints
'complimented the services provided by the Charity
Organization Societies, the services of these organiza-
tions were usually provided first to their own members.
However, the client base for services offered by private
organizations gradually expanded so that by the mid,
1990s social services had grown in scope and well be'
yond those offered only by traditional social service
organizations and by social workers (Ax inn & Stem,
2005, Chapter 3).
Somewhat in contrast with the very early form of
social services, private social services today often are
thought of as forms of counseling and therapy that take
place with a private therapist, while public social ser-
vices are thought of as discussions with welfare clients.
However, in reality the growth of private social services
. goes far beyond the individual therapist's office and
public social services go beyond the needs of welfare
PRIVATIZATION 411
clients. The growth and development of social services
has been financed by public funds, creating an eclectic
mix of public and private social service activities: Pub,
lie and private mixing began in earnest in 1962 when the
Social Security Act was amended to provide public
money for public social services, causing local welfare
offices to change their names from Departments of
Public Welfare to Departments of Social Services (Mott,
1976). But the lack of sufficient numbers of qualified
social service workers in the public sector caused
Departments of Social Services to contract with private
agencies to meet the demands for more social services.
Title XX was added to the Social Security Act in 1974,
which set aside specific sums of public money for social
services, greatly expanding the availability of social
services in both traditional and nontraditional social
work settings. Since Title XX constituted a Con,
gressiona1 repudiation to the efforts of the Department
of Health, Education, and Welfare to define social
services, states were free to fund any activity they de'
fined as a social service, thus greatly complicating ef-
forts to clarify the exact nature of social service
activities (Dobe1stein, 1980). In 1980 Congress col,
lapsed a number of public social programs into a single
Social Service Block Grant, causing a further accelera-
tion in the use of public money to purchase services
from private nonprofit agencies. Thus, by the 1980 s
earlier distinctions between private and public social
services had all but disappeared as private social service
agencies made use of public money in order to make
social services available to a wide variety of persons in a
wide array of organizational settings.
Kramer's research into contracting for social services
in the San Francisco area in 1984 was an early study that
brought to light the amount of fiscal mixing that had
taken place in providing what were usually thought of as
private social services (Kramer, 1984). Kramer also
found that social services lacked any general definition,
but were specific activities unique to the organizations
that provided them.
The Mental Health Services Act of 1962 (funded in
1964) also provided public money for social services
that often had to be purchased from private contracting
organizations. The private practice of individual social
workers also underwent considerable change as well
during these same years. Today most private social
work practitioners receive insurance reimbursements
either from private insurance carriers, or, p erhaps,
indirectly from a public source. Under President
Clinton's administration and expanded under the Bush
administration, "Charitable Choice" was a new policy
that allowed public funds to support social services
provided through religious organizations and
412 PRIVATIZATION
faith-based institutions, including churches. Charitable
Choice was formally legislated as part of the 1996 wel fare
reform (Temporary Assistance to Needy Families also
called the Personal Responsbility and Work Opportunity
Reconciliation Act).
There are very few examples. of "stand alone," strictly
private social services today that do not receive any
government funds from local, state, or federal sources.
Most social services are provided under con tract, and
frequently in a variety of nontraditional so' cial service
agencies. Proprietary nursing homes are required to
provide social services; public schools provi de social
services. Various kinds of social services are provided in
prisons; social services are provided in hospitals, public
housing projects, and even in pub lic and private recreation
\centers. Both public and private funds support these and a
variety of other social services.
A traditional view of social services held that public
social services served the social needs of the general
population, while private social services filled the gaps in
public social services. Today, however, the earlier notio n
of separation between public and private social services,
whether received from a public organization, a private
organization, or from an individual practi tioner, no longer
serves a useful purpose. Instead, it might be more
productive to think about "privatiza tion" of social services
as a growing public use of the capacity of private
organizations to meet larger public social goals, since
public funding is driving the direc tion of these private
organizations. In many cases private organizations today
cannot sustain financial in, dependence without the
assistance of public funding. Privatization of social
services today has become an important link in the vast
network of American private-public partnerships.
Mixing public and private funds and thus sup porting
private organizations that provide social services has
created a number of issues. While on the one hand public
funds bolster private organizations' capacity to provide
necessary services, the private organizations that receive
this funding must provide those services in a
nondiscriminatory and publicly accountable way. In other
words, private organizations that use public funds must
comply with any public restrictions that may be placed on
the use of those funds. Thus, in accepting public funds,
private social organizations lose considerable autonomy,
which may have been an important consideration in
developing the private organization in the first place.
A second issue resulting from mixing public and
private funds concerns the public entities or agencies that
provide the funds. Rather than expanding its own
pool of public social services, public organizations find
themselves in the position of service managers and
overseers, rather than service providers. In other words,
by using public funds to contract with private organiza-
tions to provide necessary or in some cases legislatively
required social services, public organizations no longer
provide core services that may be needed by those served
by the public agency. Becoming service managers, rat her
than service providers, can change the entire character of
the public social service agency, often by replacing social
workers with business-oriented case managers who
seldom have direct contact with or education about the
clients who receive services.
Atomization and fragmentation also develop from
mixing public and private social servi2es. This is a third
challenge. Private organizations are likely to compete
with one another to obtain public funding; as a result
social service funding may not be dir ected at the most
significant problems in a community. There is much
criticism in recent years about how nonprofit organiza-
tions are behaving like the corporate sector in terms of
placing the bottom-line ahead of client needs (Dolgoff,
Feldstein, & Skolnik, 1993). Instead, public social ser vice
money may be spread around to several private
organizations, thereby meeting local political demands for
public support by organizations with high public profiles.
For example, it is not unusual to see public money
allocated for child day care spread to several private
organizations that may provide day-care ser vices. In such
cases areas of greatest need may be over looked in favor of
funding services to favored organizations (which might
have greater political acceptability in a community).
Privatization today has also become associated with
efforts to reduce the profile of government in social
welfare activities. Beyond "cost saving" arguments that
have not been substantiated, providing social services by
funding private organizations allows governments at all
levels to dissociate themselves from criticism often raised
about whether government. should undertake social
welfare commitments. Some years ago Wilensky and
Lebeaux argued that public social services were a
necessary and "legitimate function of modem industrial
society helping individuals achieve self fulfillment"
(Wilensky & Lebeaux, 1965, p. 140). In today's socially
and economically conservative times, privatization of
social services risks abandoning publicsector responsi-
bility for social services. In conclusion, social service
providers, whether in private or public settings, not for
profit or proprietary organizations, as individual con-
tractors or agency employees, are challenged to provide
the most ethical, evidence- based, competent services
required by their clients. As social services become

more atomized the burden of the appropriate use of social
service resources rests on each social service provider.
REFERENCES
Axinn, J., & Stem, M. J. (2005). Sodal welfare: A history of the
American response to need (6th ed.). Boston: Allen and Bacon.
Dobelstein, A. (1980). Politica, economics and public welfare (pp.
95-96). Englewood Cliffs, NJ: Prentice HalL
Dolgoff, R., Feldstein, D., & Skolnik, L. (1993). Understanding
social welfare (3 ed., pp. 306-310). New York: Longman.
Kramer, R. (1984). Sodal service contracting in the bay area.
Berkeley: University of California Berkeley.
Mott, P. E. (1976). Meeting human needs. The social and political
history of Title XX (p. 3). Columbus; OH: National Conference
on Social Welfare. \
Richmond, M. (1930). The long view. New York: Russell Sage.
Watson, F. (1922). The charity organization movement in the Unites
States. New York: Macmillan.
Wilensky, H., & Lebeaux, C. (1965). Industrial society and sodal
welfare. New York: Free Press.
FURTHER READING
Dobelstein, A. (1999). Moral authority, ideology, and the future of
American socioi welfare. Boulder, CO: Westview Press.
Dobelstein, A. (2002). Sodal welfare policy and analysis (3 ed.).
Pacific Grove, CA: Brooks/Cole.
Johnson, E. (2004). Privatizing identity in the global city. In
Hoebling and Rieser (Eds.), What is American: New identities in
U.S. culture (pp. 211-228). Vienna: Lit Verlag.
Longman, R., & Karger, H. (1997). Social work and community in a
private world: Getting out in public.
Richmond, M. (1899). Friendly visiting among the poor. New York:
.Macmillan.
-ANDREW DOBELSTEIN
PRIVILEGE
ABSTRACT: Privilege is the invisible advantage and resultant
unearned benefits afforded to dominant groups of people
because of a variety of sociodernographic traits. Privilege
provides economic and social boosts to dominant groups
while supporting the structural barriers to other groups
imposed by prejudice. Social work education and practice
seldom challenges us to evaluate the effects of privilege on our
professional relationships and the concomitant systems of
oppression that marginalize many of the groups we work with.
Privilege nurtures dependence, distances us from others, and
creates a barrier to reflective social work practice.
Acknowledging the effects of privilege increases our capacity
to affirm our humanity and that of the communities we serve.
PRIVILEGE 413
KEY WORDS: privilege; advantage; power; invisibility;
dominance; structural inequities; oppression; meritocracy
Privilege in the social work context is defined as, " ... that
powerful but often unspoken and taken for granted sense
that one fits, that one is an active and powerful participant
and partner in defining and making decisions about one's
world. Privilege is the sum total of the benefits one
accrues as a result?" (Schriver, 1995, p. 28). Privilege
becomes invisible because of our assumptions that we
live in a meritocracy, which we think of as a basic U.S.
democratic ideal or truth (Vodde, 2000).
The invisibility of privilege makes it hard to discuss
and uncover. In her early work, McIntosh (1989) states
that meritocracy was a myth and that the privilege
enjoyed by men and Whites was unearned. She later
exposes other categories of unearned privilege, the
system that advantages some people because of preju dice
related to one's sexual orientation, class, age, abil ity,
nationality, or religion. Other authors suggest that
recognizing privilege, such as that afforded of hetero-
sexuals, helps to reduce prejudice (Simoni, Meyers, &
Walters, 2001).
In 1988, McIntosh stated, "There is still a more taboo
subject than race privilege: the daily ways in which
heterosexual privilege make some persons com fortable or
powerful; providing supports, assets, ap provals, and
rewards to those who live or expect t o live in heterosexual
pairs" (p. 85). She also described gender privilege as
invisible to men who benefit while affecting the daily
lives of both men and women in very significant and
discreet ways.
As cited earlier, this body of literature on privilege
started in the late 1980 s but did not reach the mainstream
social work discourse by 1995 as evidenced by the
absence of a section on privilege in the previous
Encyclopedia of Social Work (Edwards, 1995). Since then, a
growing body of work has developed.
In 1996, Swigonski furthered the social work dis-
course by stating that privilege refers to the unearned
advantage enjoyed by a particular group simply because
of membership in that group. She posits that Afr~centric
theory and practice is one useful fra mework that allows
us to view and "challenge the invisible hege mony of
privilege" (p. 160). Other such frameworks include
feminist theory (McNamara & Rickard, 1989), black and
white racial identity theories (Helms, 1990), and writings
about First Nations Peoples (Weaver, 2003) and Asian-
(Fong, 2003) and Latino/a N-Americans (Zuniga, 2003 ).
Studies of gay and lesbian persons of color (Walters,
Longres, Han, &
414 PRrvILEGE
Icard, 2003) demonstrate the complexities of working
with people across oppressed statuses.
Using the language of White invisibility and advantage
rather than privilege, Sue (2006) helps us to in corporate
these frameworks and at the same time promotes a
cross-disciplinary perspective.
Pinderhughes (1989) challenged social workers to
evaluate their experiences with power, status differences,
participation in oppressive strategies, and their own
privilege in order to process relevant information on
diversity and oppression. Academic preparation, in cluding
the modeling behavior of teachers, often ne.glects this type
of self-reflective practice.
Van Soest & Garcia (2003) defined culturally com-
petent social work as a commitment to social and eco-
nomic justice, and human rights, rather than simply
developing knowledge and skills. This approach emerges
from an analysis ci the impact of privilege and oppressive
systems on individuals, families, and communities.
Gil (1998) challenged social workers to create just
alternatives for the unjust systems we encounter. In stead,
our professional curriculum and in-service trainings often
focus on multiculturalism or pluralism rather than on
issues of power, privilege, and structural change. Although
this focus on diversity and multiculturalism increases our
understanding of bias and prejudice, it does not equip
social workers to dissect power and privilege dimensions
and develop strategies for addressing them.
Cramer & McElveen (2003) discussed the relationship
of power to privilege and economic advantage using
Chisom and Washington (1996) formula that prejudice
plus power equals racism. They further posit that "if a
person is economically powerful, other people's lives may
be negatively affected in services, status, life- style, and so
forth (p. 41)." White privilege is relatively underexposed
and refers to White people having privileges that others do
not have. Social workers, espe cially White social workers,
may be less effective in practice if they unknowingly
reinforce the inequities related to White privilege and
when they fail to understand that their privilege may be
interpreted by African-American consumers as
untrustworthy or racist.
Much of the Social Work literature examines the cost
of privilege to persons from oppressed groups. But, there
is also a body of literature that captures the cost of
privilege
. to the beneficiaries. These costs are psychological, social,
moral, spiritual, intellectual, material, and physical
(Goodman, 2001). For example, those privileged may
experience the following losses: positive mental health,
authentic sense of self and human connection, moral and
spiritual integrity, developing a full range of knowledge as
in a continued distorted view of our and others' histories,
access to the wisdom from other cultures, and opportu-
nities for real democracy and justice (Bowser & Hunt,
1987). Privilege nurtures dependence and creates a barrier
to reflective social work practice. It distances us from
others, causes us to view ourselves as caretakers rather
than collaborators, and limits our ability to be vulnerable,
thereby decreasing our capacity for intimacy and authen-
ticity (Pinderhughes, 1989).
McIntosh (1988) challenges us to act daily in ways that
dismantle privilege and unearned advantage. Social
workers should recognize the systems of dominance' that
exist and their intentional invisibility. The power of the
structure depends on this invisibility and the unwitting
participation of those groups that benefit from the
privilege-Whites, males, heterosexuals, and so forth. Social
workers are particularly challenged to understand that these
inequities do not stem from individual acts of meanness or
prejudice but rather from racialized and other policies and
practices that exist in the Social Work context: the places
and spaces where consumers, communities, and
practitioners meet.
Social workers are charged to actively challenge
privilege by using it to help divest the very structures that
maintain it (Vodde, 2000). The open question is whether we
will continue our participation in maintaining these
invisible and unfair disparities or use our power to support
social and economic justice and construct more equitable
systems. Ultimately, how would the later correct the
disproportionaliry between the people and communities we
serve and those who staff our practice and academic
institutions. And, how would this shift privilege?
REFERENCES
Bowser, B. P., & Hunt, R. G. (1987). Impacts of racism on white
Americans. Newbury Park, CA: Sage.
Chisom, R., & Washington, L. (1996). Undoing racism. New
Orleans, LA: People's Institute.
Cramer, D. N., & McElveen,]. S. (2003). Undoing racism in social
work practice. Race, Gender, and Class, 10(2), 41.
Edwards, R. L. (1995). Encyclopedia of social work (19th ed.).
Washington, DC: NASW Press.
Fong, R. (2003). Culturalcompetence with Asian Americans.
In D. Lum (Ed.), Culturally competent practice: A [ramework for
understanding diverse groups and justice issues (pp. 260-281).
Belmont, CA: Brooks/Cole- Thomson Learning.
Gil, D. (1998). Con[rontingjustice and oppression: Concepts and
strategies for social workers. New York: Columbia
University Press.
Goodman, D. ]. (2001). Promoting diversity and social justice:
Educating people [rom privileged groups. Thousand Oaks, CA:
Sage.
Helms, J. E. (1990). Black and white racial identity: Theory, research
and practice. New York: Greenwood Press.

McIntosh, P. (1988). White privilege and male privilege: A per-
sanal account of coming to see correspondences through work in
women's studies (Working paper 189). Wellesley College
Center for Research on Women: Wellesley, MA.
McIntosh, P. (1989, July/August). White privilege:
Unpacking the invisible knapsack. Peace and Freedom,
10-12.
McNamara, K., & Rickard, K. M. (1989). Feminist identity
development: Implication for feminist therapy with
women. Journal of Counseling and Development, 68, 184-193.
Pinderhughes, E. (1989). Understandingrace, ethnicity, andpower:
The ke:y to efficacy in clinical practice. N ew York: Free Press.
Schriver, J. M. (1995). Human behavior and the social environ-
ment: Shifting paradigms in essential knowledge for social work
practice. Boston: Allyn & Bacon.
Simoni, J. M., Meyers, T., & Walters, K. L. (200l). Hetero-
sexual identity and heterosexism: Recognizing privilege to
reduce prejudice. Journal qf Homosexuality, 41(1), 157-172.
Sue, D. W. (2006). Multicultural social work practice. New
Jersey: Wiley. .
Swigonski, M. E. (1996). Challenging privilege through
Afrocentric social work practice. Social Work, 41,153-161.
Van Soest, D., & Garcia, B. (2003). Diversity education for
social justice: Mastering teaching skills. Alexandria, VA: CSWE.
Vodde, R. (2000). De-centering privilege in social work edu-
cation: Whose job is it anyway? Race, Gender and Class,
7(4), 139.
Walters, K. L., Longres, J. F., Han, c., & Icard, L. D. (2003).
Cultural competence with gay and lesbian persons of color.
In Lum, D. (Ed.), Culturally competent practice: A framework
for understanding diverse groups and justice issues (pp.
310-342). Belmont, CA: Brooks/Cole-Thomson Learning.
Weaver, H. N. (2003). Cultural competence with First Nations
Peoples. In D. Lum (Ed.), Culturally competent practice: A
framework for understanding diverse groups and justice issues (pp.
197-216). Belmont, CA: Brooks/ Cole- Thomson Learning.
Zuniga, M. E. (2003). Cultural competence with Latino
'Americans. In D. Lum (Ed.), Culturally competent practice:
A framework for understanding diverse groups and justice issues
(pp. 238--260). Belmont, CA: Brooks/Cole-Thomson
Learning.
SUGGESTED LINKS
Anti Racist Alliance
http://www.antiracistalliance.com/
European Dissent
http://nameorg.org/pipermail!name-mce_nameorg
.org/2005September/000211.html
McGill Equity Subcommittee on Queer People
http://www.mcgill.ca/queerequity/heterosexism/
Tim Wise
http://www.timwise.org/
The People's Institute for Survival and Beyond
http://www.pisab.org/
White Privilege.com
http://whiteprivilege.com/
-CHERYL FRANKS AND MARION RIEDEL
PROBA nON AND PAROLE 415
PRIVILEGED COMMUNICATION. See Code of
Ethics; Confidentiality and Privileged Communication.
PROBATION AND PAROLE
ABSTRACT: Community-based supervision allows the
legal system to hold criminal offenders accountable
for their behavior without the significant costs and
potential harms associated with incarceration. When
offenders are placed. on probation (in lieu of
incarceration) or parole (as a follow- up to
incarceration), they are also usually involved in other
programs as well, in cluding victim or offender
mediation, substance abuse treatment, workforce
development, restitution, commu nity service, and
electronic monitoring.
KEY WORDS: justice; crime; incarceration; commu-
nity; supervision; reentry
Probation and parole are essential components of the juvenile
and criminal (adult) justice systems. Probation sentences (or
"dispositions" in juvenile court terminology) limit the
freedom of offenders while avoiding the cost of incarceration.
Following a legal finding of guilt (or "responsibility" in
juvenile court), an offender may be given a period of
probation lasting from several months to several years. Parole
refers to a period of community supervision that follows an
offender's release from incarceration (or "placement" in
juvenile court). Offenders on probation or parole may risk
additional sanctions and even reimprisonment if they violate
the rules and conditions of parole. Programs provided by adult
parole agencies are often referred to as "reentry," while
juvenile parole programs may be known as "aftercare."
Origins
Probation first appeared in the United States. in the 1840s. A
Boston, Massachusetts, shoemaker and abstinence advocate
named John Augustus worried that alcoholics and homeless
people were being imprisoned inappropriately. He asked court
officials to release these offenders to his custody instead, and
he promised to help them find employment and to reform their
destructive habits. Augustus performed this service for
hundreds of people in the Boston area. His efforts attracted the
attention of other communities and other courts. In 1878
Massachusetts became the first state to enact the concept of
probation into law and to provide money for paid probation
officers (Cromwell & Killinger, 1994, pp. 11-21). By 1925,
probation was authorized by law in every state in the country.
The
416 PROBATION AND PAROLE
concept of parole, or discretionary release from impri-
sonment, is as old as prisons themselves. The first
American prisons were opened in the 1600s as "peni-
tentiaries," or places where offenders ("penitents")
could quietly reflect on their sinful behavior and even-
tually be reformed (Travis, 2005). The length of im-
prisonment was determined individually, and decisions
to release prisoners from incarceration were often made
by prison authorities and later "parole boards."
POPULA nONS In 2005, 4.9 million adults were under
the supervision of federal, state, or local probation or
parole authorities, an increase of 55% over the number
of probationers and parolees in ,1990 (Glaze &
Bonczar, 2006, p. 11). Women represented 23% of all
probationers and 12% of all parolees. More than half
(55%) of adults on probation in 2005 were Caucasian or
white, while nearly a third (30%) were African-
American and 13 % were Hispanic or Latino. Among
adults on probation in 2005,50% had been convicted of
felonies, 48% were convicted of misdemeanors, and 2
% were charged with other infractions. In more than
half of all cases; the most serious offense committed by
probationers in 2005 was either a drug law violation, a
charge of driving while intoxicated, or larceny or theft
(Table 1).
The number of adults on probation in the United
States grew 56% between 1990 and 2005, climbing
from 2.7 million to 4.2 million. During the same
period, the number of adult parolees increased 48%,
from 531,407 to 784,408 (Graph 1).
There is no nationwide system for measuring the
number of juvenile probationers, but the U.S. De-
partment of Justice maintains a research program that
TABLE 1
Most Serious Offense of Adults on Probation at
Year End 2005
Drug law violations Driving
while intoxicated
Larceny/theft
. Other assault
Domestic violence
Fraud
Burglary
Minor traffic offenses
Sexual assault
Other offenses
From Table 3 of Probation and parole in the United States, 2005 (p.
by L E. Glaze and T. P. Bonczar, 2006, Washington, DC:
Bureau of Justice Statistics, U.S. Department of Justice
[NCJ215091].
monitors the number of juvenile court cases ending with
a term of probation as the most restrictive disposition
(see the Statistical Briefing Book at http://ojjdp.ncjrs.
org). In 2004, an estimated 601,900 delinquency cases
resulted in a term of probation, which was 42% more
than the number of cases placed on probation in 1985 .
Probation was the final disposition in more than half
(53%) of the 1.1 million delinquency cases handled by
juvenile courts nationwide in 2004. Three of every four
probation cases in 2004 involved male juveniles. Two
of every three probation cases involved Caucasian
youth and 30% involved African-American juveniles.
Programs
Probation and parole are legal mechanisms that allow
justice agencies to maintain jurisdiction and supervision
over offenders, without the costs of incarceration.·
While offenders are under a term of probation or parole,
they are ordered to comply with certain conditions and
to cooperate with a variety of other treatment and
rehabilitation programs, such as substance abuse, men-
tal health, sex offender, and domestic violence treat-
ment. Programs typically used for probationers and
parolees include restitution (offenders repay or repair
the damages resulting from their crime), house arrest
(offenders live in their own homes and may not leave
except for work or other apptoved activities), electronic
monitoring, (offenders wear telephonic devices that
alert authorities if they leave home without permission),
and community service (offenders perform unpaid work
as repayment to the community). The most common
program elements, however, are usually direct
supervision and office-based visits with a probation or
parole officer.
Probation and parole programs are administered un-
der a variety of organizational and governmental struc-
tures. In some jurisdictions, either the state or local
government may have complete responsibility for all
aspects of community supervision. In other jurisdic-
tions, the state and local government may share the
28 responsibility .
% With the exception of federal crimes, all criminal
15
12 offenders in the United States are tried and sentenced by
10 state or county-level courts. The responsibility for
6 carrying out community-based sentences remains with
the court that imposed the sentence or the parole board
6
or other authority that granted release. The philoso phies
5 and values that shape the use of probation and parole
can vary substantially from one jurisdiction to the next.
5 6), One jurisdiction may use only rudimentary probation
and fines. Another jurisdiction may have an elaborate
3
array of supervision and treatment programs
10
i
j
 PROBATION AND PAROLE 417

5,000,000

4,500,000

4,000,000

3,500,000

3,000,000

2,500,000
2,000,000

1,500,000

1,000,000

500,000

o
1990 1995 2000 2005

1990 1995 2000 2005

2,670,234 3,077,861 3,826,209 4,162,536
Probation
531,407 679,421 723,898 784,408
Parole 3,201,641 3,757,282 4,946,944
4,550,107
Total

Retrieved from U.S. Department of Justice. http://www.ojp.usdoj.gov/bjs/pub/pdflppus05.pdf

GRAPH 1 Between 1990 and 2005, the number of adults on probation and parole in the United States increased 56% and 48%, respectively.
From Table 3 of Probation and parole in the United States, 2005 (p. 6), by L. E. Glaze and T. P. Bonczar, 2006, Washington, DC: Bureau of
justice Statistics, u.s. Department of justice [NCj21509l]. Copyright 2006 by the U.S. Department of justice. Reprinted with permission.

offering various levels of punitiveness combined with
rehabilitation. (The strength and effectiveness of
community-based supervision is often directly and
inversely related to the scale of impr isonment favored by a
state or county.) In other words, secure confine ment may
be used less extensively in jurisdictions with a rich array
of non incarceration alternatives.
When courts or parole authorities make decisions
about the length of community supervision, their judg-
ment is largely based on the degree to which an offender
. is thought to present future risk to the public safety. or the
likelihood that an offender will commit a new crime. They
must also consider whether programs are available to
address the rehabilitation needs of the offender (for
example, substance abuse treatment). The decision must
also account for the seriousness of the criminal act and the
public's attitude toward the offender. In highly visible or
notorious cases, justice
officials may be reluctant to use community supervision
even if the probability of re- arrest appears to be low and
viable treatment alternatives exist.
Assessment
The use of community-based supervision offers an ef-
fective balance between protecting the public and con-
trolling or rehabilitating individual offenders. Without
access to a full range of community- based supervision
options, the justice system would be able to use only
incarceration for convicted offenders and adjudicated
delinquents. Probation and parole are potentially cost-
effective methods for achieving the important goals of
public safety, punishment, and rehabilitation of offen ders.
Providing supervision in the community allows offenders
to work and to receive needed treatment in the sam e social
context in which they must live upon their release from
the justice system, which enhances
418 PROBATION AND PAROLE.
their adjustment to society and reduces the likelihood of
future recidivism.
REFERENCES
Cromwell, P. F., & Killinger, G. G. (1994). Community-based
corrections: Probation, parole, and intermediate sanctions (Jrd
ed.). Minneapolis: West Publishing Co.
Glaze, L. E., & Bonczar, T. P. (2006). Probation and parole in the
United States, 2005. Washington, DC: U.S. Department of Justice,
Bureau of Justice Statistics [NCJ215091].
Travis, J. (2005). But they all come back-facing the challenges of
prisoner reentry. Washington, DC: Urban Institute Press.
FURTIIER READING
Griffin, P., & Torbet, P. (Eds.). (2002). De,sktop guide to juvenile
probation practice. Pittsburgh, PA: National Center for
Juvenile Justice. \ guidelines for professional conduct (Abbott, 1988, 2003).
Peters ilia, J. (2002). Community corrections. InJ. Q. Wilson & J.
Petersilia (Eds.), Crime-Public policies for crime control (pp.
483-508). Oakland, CA: Institute for Contemporary Studies.
Solomon, A. L. (2006, Spring). Does parole supervision
work?-Research findings and policy opportunities. Perspectives.
Publication of the American Probation and Parole Association.
Available at http://www.urban.org/publica tions/1000908.html
SUGGESTED LINKS
Probation and Parole Statistics, U.S. Department of Justice, Bureau
of justice Statistics. http://www.ojp.usdoj.gov/bjs/pandp.htm
Probation as a Juvenile Court Disposition, U.S. Department of
Justice, Office of juvenlle Justice and Delinquency Prevention.
http://ojjdp.ncjrs.org
American Probation and Parole Association.
http://www . appa-net. orgl
International Community Corrections Association.
http://www . iccaweb .oig]
National Probation Service for England and Wales.
http://www . probation. homeoffice .gov. uk
-JEFFREY A. BUTTS
PROFESSIONAL CONDUCT
ABSTRACT: The professional review process delineates
procedures for hearing complaints of alleged profes-
sional misconduct by NASW members. It provides
mechanisms for conducting hearings and alternate dis-
pute resolution (ADR) via mediation, monitoring pro-
fessional behavior, and sanctioning and developing
corrective actions for NASW members who are in
violation of the NASW Code of Ethics. The process,
originally identified in 1967, has been modified
overtime to reflect the best identified means for con-
ducting fair hearings and carrying out the most appropriate
interventions.
KEY WORDS: adjudication; professional conduct; peer
review; ethical misconduct; mediation
Professional conduct is behavior as defined by the ethical
principles or behavioral guidelines growing out of the
underlying value base of a profession. The professional
value base delineates the overall goals, objectives, and
mission; the ethical principles provide a prescription for
professional conduct based on those underlying values.
Values tend to provide an overview of the profession's
focus, and ethics translate those values into specific
As clear or deliberate as those guidelines may seem,
practitioners are frequently confronted with ethical
dilemmas or instances that require a personal interpretation
or application of the underlying value scheme. For the most
part, social workers manage ethical challenges responsibly,
behaving on the basis of solid professional integrity. In
some instances,' they may stretch the limits of ethical
integrity. In rarer instances, social workers have conducted
themselves in a fashion that appears to run truly counter to
the value base and ethical framework. Their behavior is
such that clients, peers, or co-workers bring an action to
question whether it conforms to the expectations of
appropriate professional conduct.
Most professional associations have the responsibil ity
and mechanisms for monitoring professional behavior and
sanctioning members who are in violation of ethical
principles or standards. Frequently these mechanisms are
founded on a system of peer review. The major
professional social work association in the United
States-the National Association of Social Workers
(NASW)-has such a system. It is founded on a clearly
defined value base that delineates the profession's mission
and goals. This value base, articu lated in the NASW Code
of Ethics (NASW, 1999), is designed to outline the
parameters of members' behavior. The Code describes to
the profession, the public, and the consumer the focus,
responsibilities, and boundaries of the social work
profession. In addition, the profession has a system for
reporting alleged ethical violations, and a peer review
process for evaluating these allegations, mediating
disputes, determining corrective interventions such as
ethics education, or bringing sanctions against those
members whose behavior is determined to be in violation
of acceptable ethical standards. This peer review activity,
referred to as professional review, is undertaken within
NASW by Ethics

Committees, formerly known as Committees on Inquiry
(COO, which operate in all 56 chapters ofNASW and at
the national level (Stoesen, 2004).
The professional association sets standards for
membership and monitors its members in light of those
ethical standards. The peer review process does not
preclude legal action, including malpractice by others in
the courts or action by state licensing and regulatory
bodies. Conversely, professional social workers may
make unethical decisions that are not necessarily illegal.
However, it does identify professional misconduct and
facilitate member rehabilitation. In addition to hearing
complaints of alleged ethical violations by members,
peers also serve important roles in educating members
about the components of ethical professional practice
and risk rnanagelnent.
Purpose of Professional Review
The professional review process is designed to advance
the mission of NASW. The process affords a fair me-
chanism for examining complaints of practices that run
counter to or are detrimental to the overall ethical
mission of the social work profession. In addition to
contributing to the maintenance of high ethical stan-
dards of practice, "the process is designed to correct or
improve social work practice" (NASW, 2005, ix).
Whenever possible, the professional review process is
"intended to be constructive and educative rather than
punitive" (NASW, 2005, x). Recommendations for
growth and vehicles for. improvement are frequently
suggested. In some more serious instances of profes-
sional misconduct, penalties or sanctions, such as sus-
pension from membership in NASW or notification of
state regulatory boards, may be necessary in carrying
out the professional responsibility to protect the
consumer from unethical practices (NASW, 2005).
Professional Review versus Judicial Hearings Formal
peer review procedures provide for a fair hearing,
without legal representation. Although each party
involved in the peer review may retain their own
counsel, such legal representative may not attend or
participate in the professional review hearing (NASW,
2005). Notwithstanding, no court has found NASW's
procedures insufficient to protect the due process rights
of the parties involved. Among the safeguards included
in the professional review procedures are provisions for
specific written notification to the respondent of
complainants' allegations, opportunity to answer and be
heard, to present witnesses and other evidence, to
confront one's accusers, and to appeal an adverse
decision to' a higher body. Although certain compo-
nents of court proceedings (for example representation
i
j
PROFESSIONAL CoNDUCT 419
by counsel,testimony under oath, subpoena power,
transcript of the record), are not part of the peer review
process, clearly defined procedures, such as those out-
lined above, help to ensure that respondents' rights are
protected and that all parties are treated equitably. A
complainant or respondent can consult an attorney at
any time; however, the attorney cannot be directly
involved in the hearing process or at the mediation
table.
Rationale for Peer Review
All professions claim that only peers have the compe-
tency to evaluate professional behavior (Greenwood,
1957). According to that perspective no one knows the
parameters of acceptable, ethical professional behavior
better than the collection of professionals educated and
socialized in the behavioral expectations of that
profession. These "standards for professional
performance are reached by consensus within the
profession" (Greenwood, 1957, pp. 49-50) and are
transferred to and adopted by others. as a requirement
for professional membership. In joining NASW, each
member, by signing the application form, agrees to
abide by the NASW Code of Ethics and to submit to
proceedings for any alleged violation of the Code in
accordance with NASW bylaws.
The professional review process, based on peer-
review,' serves as a major factor in compliance with
ethical standards. Peers set the ethical standards for
membership, and peers enforce adherence to' those
standards.
History of Professional Review
From shortly after its inception in 1955, NASW has had
a Code of Ethics followed by a mechanism for the
hearing of complaints of ethical misconduct or viola-
tion. Adjudication in this circumstance occurs within
the framework of professional peer review and is not
conducted within a court of law.
For over 30 years well-defined adjudication proce-
dures provided for three categories of complaint: (a)
against NASW members for alleged unethical conduct,
(b) against agencies for alleged violations of their
personnel standards, and (c) against agencies for limit-
ing or penalizing social workers for ethical professional
actions taken on behalf of clients (NASW, 1989, 1994).
In 1998 an Adjudication Review Task Force was
formed to reevaluate the Association's then current
professional review system.
In 2001 the NASW Board of Directors approved a
recommendation by the Task Force to streamline and
bring consistency to the professional review process.
The changes were designed "to minimize variability in
420 PROFESSIONAL CONDUCT
chapters' resources, experience and expertise," thus lim-
iting liability. These changes also served to "centralize
administration of the review process and mandate med-
iation of certain complaints" (O'Neill, 2001). The pro-
fessional review procedures detailed in the 2001 edition
of the NASW Procedures for Professional Review
(NASW, 2001) reaffirmed the commitment ofNASW to
advance the ethical practice of its members as out lined in
the NASW Code of Ethics (most recently r~vised in 1999).
The procedures also reaffirmed the association's
commitment to support the use of mediation for particular
categories of complaint.
Prior to the 2001 changes, complaints against mem-
bers were reviewed by chapter committees, and if com-
plaints met the designated requirements, a hearing was
held at the chapter leveL T vio levels of appeal existed:
first, the National Committee on Inquiry (NCO!), and
second, the National Board's Executive Committee.
Under the 2001 changes, an Intake Subcommittee of the
NCOI, which included two members of the chapter in
which the allegation occurred , two NCOI alternates, and
one NCOI member who served as chair, reviewed
complaints to determine if they met criteria for accep-
tance, and determined whether the complaint should be
referred back to the chapter's review committee for
adjudication or mediation. In the case of mediation,
which was introduced in 2001 as an alternative to a
formal hearing, "the outcome is (to be) determined by the
participants themselves,' and no determination is made by
NASW as to whether a violation has oc curred" (O'Neill,
2001).
It was determined that a decision rendered by the
National Intake Subcommittee to refer to mediation or
adjudication could not be appealed. Certain com plaints,
such as those dealing with "sexual relationships, physical
contact or sexual harassment" had to be re ferred to
adjudication hearing. Complaints that could be referred
by the National Intake Subcommittee to either
adjudication or mediation include "commitment to
clients; self-determination; conflicts of interest; privacy
and confidentiality; impairment of collea gues; unethical
conduct of colleagues; dual or multi ple relationships with
supervisees; client records; billing; private conduct;
dishonesty; fraud and deception; impairment;
misrepresentation; and solicitations" (O'Neill, 2001).
Complaints referred for mediation are frequently handled
by means of Alternative Dispute Resolution (ADR)
(Polowy & Zula, 1998).
In 2004 the Adjudication Review Task Force re-
commended to change the name-Committee on
Inquiry-to Ethics Committee; in 2005 the Delegate
Assembly approved this recommendation with the
change occurring in 2005. The NCOI became the
National Ethics Committee and Chapter Committees on
Inquiry became known as Chapter Ethics Commit tees.
For the most part, responsibilities remained the same as
those designated in the 2001. revisions of the Procedures
with several significant exceptions.
In 2004 the NASW Board of Directors approved to
terminate the use of professional review for hearing
complaints pertaining to personnel actions by a gencies,
organizations, and universities (Stoesen, 2004). "While
realizing the importance of advocacy with agencies and
organizations to change their policies and procedures to
assure services are being provided in keeping with ethi cal
standards, the reality is that NASW [and its Na tional
Ethics Committee] have limited options in terms of
ensuring changes and that these complaints increase
NASW's liability" (Chase as quoted by Stoesen, 2004).
The Peer Review Process
As it stands, professional review is carried out by mem-
bers ofNASW through the various Ethics Committees.
Complaints are reviewed initially by an Intake Sub-
committee of the National Ethics Committee and, if they
are deemed to meet the complaint criteria, are referred to
the Chapter Ethics Committee for either adjudication or
mediation. The size and composition of these chapter
committees vary based on need. The committees must
reflect the diversity of membership within the chapter and
have enough members to guarantee that hearings are
conducted in a fair and timely fashion. For cases
involving mediation, the committees must have sufficient
members skilled in techniques of mediation and
amelioration.
Each Chapter Ethics Committee has the responsi bility
to act in a fair and timely fashion on all com plaints
referred by the National Ethics Committee. The 2005
edition of the NASW Procedures for Professional Review
(NASW, 2005) spells out the format and time lines to
which both adjudication and mediation must adhere. In
addition, the Procedures provide guidance on the filing of
a complaint, and the delineation of the criteria and
mechanism for accepting a complaint. Re sponsibilities of
all involved, including complainants (persons filing a
complaint), respondents (persons being accused), chapter
officials, and Ethics Committee members, are explained
with accompanying deadlines indicated.
In some instances, members who are respondents may
refuse to participate in an adjudication hearing or
mediation or may resign from membership. NASW takes
the approach that such action does not stop the
proceedings; rather the respondent's resignation or-fail-
ure to cooperate is noted and the process commences
according to plan. In cases in which a complainant

wishes to withdraw his or her complaint, the respondent
must grant his or her permission before the process can be
terminated. Procedures governing such factors as the use
of consultants, the inclusion of legal counsel, and
composition of ethics committees are described in detail in
the procedures manual (NASW, 2005). In instances
involving mediation or ADR in which parties refuse to
participate, the procedures require the review to be
converted to a standard adjudication hearing (Polowy &
Zula, 1998).
The 2005 revisions of the NASW Procedures for
Professional Review, effective July 1, 2005, emphasize
collaboration between the newly named National Ethics
Committee and the Chapter Ethics Committees (NASW,
2005). The revised procedures describe the purpose of
professional review, the process for filing, and
specifications of who may file a request for professional
review. Specifics of confidentiality are spelled out for all
parties involved in the process together with consequences
for breaches.
Findings and Sanctions
The Chapter Ethics Committee is responsible for sub-
mitting a report of its findings, conclusions, and recom-
mendations to the Chapter Executive Committee. This
report shall state whether the alleged ethical violations are
founded on fact and shall include recommendations for
corrective action, penalties, or sanctions. In cases
involving mediation, the corrective plan of action shall be
submitted and periodic follow-up reports submitted plus a
final report after the goals identified in mediation have
been achieved.
The Chapter Executive Committee either approves the
report as presented or sends it back to the Chapter Ethics
Committee for reconsideration with an accompanying
reason for disagreement. In most cases the reason for
reconsideration is a procedural one. The de tails for such
action are contained within the professional review
procedures (NASW, 2005).
Once accepted by the Chapter Executive Commit . tee,
copies of the report together with information about the
appeals process are sent to both the complaina nts and
respondents. The only avenue of appeal is the National
Ethics Committee.
In addition, the procedures (NASW, 2005) provide
guidance for the monitoring of corrective actions as well as
the implementation of sanctions. Mechanisms for the
removal of sanctions or for reinstatement in the association
and the closing of cases also are included.
Trends and Patterns
Over the years several major studies have examined
alleged violations of the Code of Ethics and the findings
,
i
j
PROFESSIONAL CONDUcr 421
of professional review proceedings (Berliner, 1989;
McCann & Cutler, 1979; National Center for Social Policy
and Practice, 1993; Reamer, 1995; StromGottfried, 2000,
2003). In examining complaints against members of
alleged unethical conduct, McCann and Cutler (1979)
found the total number of complaints occurring between
1955 and 1977 accelerated during the latter years with
40% of the total professional review during the last two
years of the time frame (1976-1977). These findings
should be interpreted in light of the fact that violations
could not be processed until 1967 , the first year the
adjudication process was in effect. They noted that only
15% of the complaints filed, or 154 cases, involved
complaints of unethical conduct. Later, findings of the
National Center for Social Policy and Practice indicate that
between the years 1982 and 1992 76% of the cases
involved complaints of ethical misconduct. The noted
increase was confirmed by other researchers (Berliner,
1989; Reamer, 1995; Strom-Gottfried, 2000,2003). The
increase in the total number of cases parallels the growth
of the association.
Strom-Gottfried (2000, 2003), in examining alleged
ethics violation complaints (N = 894) submitted between
1986 and 1997, found a good deal of variability in the number
of cases reported per year. There was a steady increase in
reported cases between 1987 and 1993, with a decrease in
subsequent years. Almost one-fourth (24%) of the complaints
filed were not accepted for adjudication. Many of them were
rejected because of technical reasons such as not meeting time
limits, lack of supporting evidence, or poorly drafted reports.
Twelve percent were accepted for review, but closed before
adjudication occurred; 8.6% of the cases were withdrawn by
the complainant after acceptance for review but prior to
adjudication; 2% were resolved through formal or informal
mediation; 1 % was terminated due to complainant violation
of the process. Of the 428 cases that went through the hearing
process, ethics violations were found in 62.3% (267) of the
cases heard.
Between 1955 and 1977, one or more allegations in
25% of the 154 cases heard were upheld (McCann &
Cutler, 1979). Between 1979 and 1985, 41% of 233 cases
heard resulted in founded allegations (Berliner, 1989).
Between 1982 and 1992, 42% of the alleged violations
were founded (National Center for Social Policy and
Practice, 1993). Between 1986 and 1997, 30% of alleged
violations were founded (StromGottfried, 2000, 2003).
The reasons for the decrease are not known. It may be
directly related to increased emphasis on ethics education
coupled with risk management workshops provided by the
NASW Insurance
422 PROFESSIONAL CONDUcr
Trust (presently known as the NASW Assurance Ser-
vices, Inc.). It also may reflect the increased activity on
the part of state regulatory boards and insurance mal-
practice hearings, or it may directly reflect greater ad-
herence on the part of professionals to the standards
outlined in the Code of Ethics. Bringing a case in one
venue does not preclude bringing charges in another.
An alleged violation can be heard by a state licensing
board, by an Ethics Review Committee, as an insurance
malpractice suit in a court of law, and, if appropriate, in
criminal court.
Violations Involving Clients
Reported alleged violations include a broad range of
activities. Strom-Gottfried (2000), i~ examining 428
NASW cases in which alleged ethical violations were
substantiated, noted the following 10 major categories:
boundary violations (N = 254), which included both
sexual relationships and dual (nonsexual) relationships;
poor practice (N = 160) such as premature termination,
poor case referral or transfer, prolonged care, use of
unapproved techniques, failure to act in situations in-
volving self-destructive clients or in cases involving child
abuse, providing no back-up coverage, disputed diagnosis
or intentional misdiagnosis among others; competence (N =
88) such as failure to seek consultation, insufficient
education or training, practitioner impairment; faulty
record keeping (N = 70); honesty issues (N = 51);
breach of confidentiality (N = 41); issues related to
informed consent (N = 37); billing issues (N =23); and
conflict of interest (N = 22). Of the 428 cases examined,
781 violations were found.
The above categories are consistent with malprac-
tice claims data presented by Reamer (1995) for the
years 1969-1990. Although not all malpractice cases
include ethical violations, the vast majority do contain
some aspect of ethical misconduct (Reamer, 2003). In
cases where it is deemed that ethical misconduct has
occurred, sanctions that are proportional to the infrac-
tion will be presented. In situations involving serious
ethical violations, possible sanctions may include pub-
lication of the peer review process findings in the
NASW News; suspension or expulsion from NASW
membership; revocation of NASW credentials such as
the ACSW or the QCSW, and removal from related
directories; notification to state licensure boards; a
letter of censure; notification to the individual's mal-
practice insurance carrier; and notification to the Dis-
ciplinary Action Reporting System administered by the
Association of Social Work Boards (NASW, 2005,33).
In some cases, the hearing panel may determine that
corrective action, rather than immediate sanction is in
order based on the findings of the hearing. In these
latter cases, corrective measures are clearly delineated,
including specific activities, accompanying timelines,
and expectations for supervision; and sanctions speci-
fied, if the corrective action is not fully implemented
(NASW, 2005). In cases involving mediation or ADR,
a signed document is developed specifying the outcome
of the mediation agreement between the parties ln-
volved. The contents of this signed document typically
contain details of corrective action, re stitution, possible
censure, other details deemed relevant to the case by the
parties involved and sanction plans if the contents of the
signed agreement are not carried out.
The Function of a Professional
Association Versus Regulatory Action
All states, territories, and the District of Columbia have
some form of legal regulation of the social work profes-
sion; however, the degree of control and monitoring
varies considerably among jurisdictions. Although the
goal of regulation is to protect the consumer from un-
ethical practice, the degree to which this is achieved
cannot be guaranteed given the lack of uniform stan-
dards. Sixteen states, or more than 25%, incorporate the
NASW Code of Ethics (1999) in its entirety as a basis
for review in their licensing law. In those states the
Code is included in the state disciplinary process,
establishing a significant connection between the Code
and disciplinary action
In some states a strong working relationship exists
between NASW and the state social work regulatory
boards; in other jurisdictions this is not the case.
Because of this lack of uniformity, NASW is
continuing to take an active leadership role in not only
providing a process by which to examine complaints of
alleged unethical practice but also in continuing to
educate its members on the high ethical standards
espoused in the NASW Code of Ethics (1999). Reamer
(2003), in discussing ethics and professional
misconduct, noted the profession's "increasingly
mature grasp of ethical issues." It is a process
continuously being examined and refined. The NASW
National Ethics Committee and Chapter Ethics
Committees playa major role in meeting the ongoing
challenge of maintaining ethical practice through the
NASW system of professional peer review
emphasizing protection, prevention, and education.
Professional review has become more effective with
each attempt to further streamline the process. In addi-
tion, NASWand various licensing boards had made
major commitments to ethics education of professional
social workers. However, limitations and challenges
still exist. The review process is only as effective as the
members who generously volunteer to serve as peer

reviewers and those individuals who are willing to bring
alleged ethical violations to the forefront for review.
Unfortunately the process does not apply to social workers
who are not members of NASW. Depending on the nature
of their violations, those non- NASW members .can be
reviewed through malpractice suits, other legal channels
and professional licensing board action. Fortunately a
large number of non-NASW bodies such as licensing
boards and courts of law are utilizing the NASW Code of
Ethics as the standard for social work practice and
professional conduct.
REFERENCES
Abbott, A. A. (1988). Professional choices: Values at work.
Silver Spring, MD: NASW Press.
Abbott, A. A. (2003). Understanding transference and
counter-transference: Risk management strategies for pre-
venting sexual misconduct and other boundary violations in
social work practice. Psychoanalytic Social Work, 10(2), 21-41.
Berliner, A. K. (1989). Misconduct in social work practice, Social
Work, 34(1), 69-72.
Greenwood, E. (1957). Attributes of a profession, Social Work,
2(3), 45-?5.
McCann, C. W., & Cutler, J. P. (1979). Ethics and the alleged
unethical, Social Work, 24(1), 5-8.
National Association of Social Workers. (1989). NASW chapter
guide for the adjudication of grievances (revised ed.). Silver
Spring, MD: Author.
National Association of Social Workers. (1994). NASW procedures
for the adjudication of grievances Ord ed.). Washington, DC:
Author.
National Association of Social Workers. (1999). Code of ethics of
the National'Association of Social Workers. Washington, DC:
Author. Retrieved from www.naswdc.org/pubs/code/ default.
asp
National Association of Social Workers. (2001). NASW procedures
for professioiUll review (4th ed.). Washington, DC:
Author.
National Association of Social Workers. (2005). NASW procedures
for professional review (4th ed., revised). Washington, DC:
Author. Retrieved from www.socialworkers.org/
nasw/ethics/procedures.pdf
National Center for Social Policy and Practice. (1993). A study of
the trends in adjwiication of complaints concerning violations
ofNASW's code of ethics. Unpublished report commissioned
byNASW.
O'Neill, J. V. (2001). NASWrevised professional review process.
NASW News, 46(3).
Polowy, C. I., & Zula, M. (1998). Social workers alternative dispute
resolution. Washington, DC: NASW.
Reamer, F. G. (1995). Malpractice claims against social workers:
First facts, Social Work, 40(5), 595-601.
Reamer, F. G. (2003). Boundary issues in social work: Managing
dual relationships, Social Work, 48(3), 121-133.
Stoesen, L. (2004). Professional review procedures changes,
NASW News, 49(8).
PROFESSIONAL IMPAIRMENT 423
Strom-Gottfried, K. (2000). Ensuring ethical practice: An
examination of NASW code violations, 1986-97, Social
Work, 45(3),251-261. .
Strom-Gottfried, K. (2003). Understanding adjudication: Origins,
targets, and outcomes of ethics complaints, Social Work,
48(1),85-94.
'--ANN A. ABBOTT
PROFESSIONAL IMPAIRMENT
ABSTRACT: Practitioners who were presumed to be competent
may develop difficulties that interfere with job performance.
Such professionals are considered impaired and may suffer
from compassion fatigue, substance abuse, mental disorders,
and other forms of distress associated with daily living.
Practicing while impaired is unethical and can potentially be
harmful to clients. Colleague Assistance Programs from
professional associations or diversion systems and legal sanc-
tions imposed by state regulatory boards are . forms of .
intervention strategies that are employed. Self-care strategies
and consciousness-raising among professionals are the best
forms of prevention.
KEY WORDS: Code of Ethics; colleague assistance
program; disciplinary action reporting system;
diversion program; exploratory study; impaired
professional; protection from harm; self-care
Impaired professionals should be distinguished from in-
competent professionals since prior to the onset of their
difficulty, such professionals were presumed to be per-
forming their duties adequately and ethically. By defi-
nition, the impaired professional is no longer able to render
adequate client services because of difficulties such as
substance misuse or abuse, depression or some form of
mental disorder, or psychological distress associated with
work and other problems of daily living. Frequently,
impairment is identified with a substance abuse disorder,
but stress-induced conditions caused by compassion
fatigue or burnout, financial hardships, physical illness , or
other concerns also cause impairment. Indications of
impairment include poor judgment and unacceptable job
performance characterized by tardiness, absenteeism,
dramatic mood changes, changes in hygiene and physical
appearance, boundary concerns or personal involvement
with clients, inability to recall what transpired in an
interview, and other difficulties may be indicators of
impairment. Practicing while im paired is unethical and is a
consumer protection issue that requires some form of
action taken on the part of
424 PROFESSIONAL IMPAIRMENT
the affected practitioner. Otherwise, a colleague, pro-
fessional association, or state licensing board should
intervene. The prevailing response to impairment is
revocation or license suspension by a regulatory body.
Legal Sanction
The response to impaired professionals by state boards and
professional associations has been uneven, and some state
boards do not provide assistance programs. More recently,
state boards such as the one in Massachusetts report that
impaired professionals are referred to the state NASW
(National Association of Social Workers) chapter for peer
assistance. By contrast, the Michigan state board has a very
structured program and diversion system that includes drug
screening, personal interviews, and other intervention
options that are closely monitored by licensing board
members (Association of State Social Work Boards, 2006,
p. 9). The focus of' other boards may be problem-specific.
The state of Wisconsin, Department of Regulation and
Licensing, for example, has a specific impaired profes-
sionals procedure {or chemical dependency (http://drl.
wi.gov./dept/ipp.htm). NASW state chapters also lack
uniformity in providing structured support for impaired
professionals, and some state chapters have discontinued
established colleague assistance programs. The
Massachusetts state NASW chapter has had a well-
developed Social Work Assistance Network since the
eighties, and as early as the seventies, while the New York
State Chapter developed a model colleague inter- . vention
program for colleagues with substance abuse problems.
However, Both NASW and regulatory boards tend to place
emphasis on consumer protection and sanctions. The
Association of State Social Work Boards maintains a
confidential Disciplinary Action Reporting System, which
reports final actions taken against professionals who have
been fined, warned, put on probation, or had a license
suspended or revoked. This flagging system is only
available to member boards. Impaired professionals who
have been sanctioned may be reported in this system by
state boards without an impaired professional diversion
system.
Peebles-Wilktns (1997) conducted an exploratory
survey of the constituent state members of the Association
of Social Work Boards (ASWB) in conjunction with a
project sponsored by NIAAA. Among the 41 states
responding, alcohol and drug abuse was of concern in more
than 50% of the states. Reports about social workers
practicing while impaired came from colleagues, clients,
the NASW Committee on Inquiry, and self-referrals. Some
boards had not encountered any concerns about social
workers practicing while impaired. Interest was expressed
in providing a
structured diversion program rather than simply license
revocation or suspension, but as a rule of thumb, there
were few assistance programs in place. Some states relied
on NASW to provide assistance, but the caveat is that all
licensed social workers are not necessarily members of
NASW.
The current NASW's Code of Ethics (l999a) (in section
4.05 on Impairment) is very clear about ethical
responsibilities of professionals':
1. Social workers should not allow their own personal
problems, psychosocial distress, legal problems,
substance abuse or mental health difficulties to
interfere with their professional judgment. and
performance or to jeopardize the best interests of
people for whom they have a professional
responsibility.
2. Social workers .. , should immediately seek
consultation and take appropriate remedial action by
seeking professional help, making adjustments in
workload, terminating practice, or taking any other
steps necessary to protect clients and others.
Since all practicing social workers are not subject to
NASW sanctions, it is essential that state regulatory
bodies be involved in the prevention and intervention
programs for impaired social workers.
The number of professional social workers practi cing
while impaired is unknown since formal research on
prevalence is virtually non-existent, However, it is
estimated that about 20% of practicing social workers are
impaired (NASW, 199%, p. 296). The nature of the
worker-elient relationship is such that it is difficult to
determine what transpires. Professionals experiencing
difficulties that interfere with work performance are
ethically expected to seek help, and this expecta tion could
account for the perceived limited emphasis on impairment
from professional associations and regulatory bodies.
Siebert (2005) found that social workers at high risk for
substance abuse tended to use informal assistance
networks, but others were deterred from seeking help
because of beliefs that counseling would not be effective
or concerns about negative professional consequences or
exposure. Concerns about privacy invasion and
defamation of character may also deter colleagues from
reporting or intervening with impaired professionals
because of fear of legal liability.
Practice Interventions
Intervention on behalf of impaired professionals is
required to protect consumers from harm. Methods of
intervention include peer assistance, therapy, referral,
supervision and consultation, sanctioning and monitoring
performance, and suspension or revocation

of license. Access to drugs, compassion fatigue, and other
concerns are prevalent among health-care professionals, and
the nursing and psychological associations have developed
elaborate intervention programs. In North Carolina, for
example, the Nursing Assistance Program is focused solely on
chemical dependency and is provided as an alternative to
disciplinary action (North Carolina Board of Nursing, 1995).
The American Psychological Association (2006) has devel-
oped a monograph with a model program to assist licensing
boards and regional psychological associations in providing
colleague assistance programs. The suggested model program
takes into account the many aspects of impairment and
encourages prevention and early intervention through
self-referral and self-care.
Trends
In addition to more uniform responses from regulatory bodies
and the professional association, self-care is one of the best
alternatives for preventing and alleviating impairment and
should be the continued future emphasis in social work. There
is a need for consciousnessraising among professionals to help
them be aware of the connection between their personal
histories and individual vulnerabilities (Siebert, 2004).
Practitioners must be encouraged to "take care while giving
care." Murphy and Dillon (2008) describe several useful
techniques for professional self-care. Their suggestions
include strategies such as renewal and relaxation, connecting
with sustaining forces, developing selfempathy, maintaining
good health practices, and sharing positive experiences with
colleagues when feeling depleted. In some instances,
changing jobs may be the most effective strategy for
protecting oneself and clients from harm. Beyond these
suggestions, there is a future need to develop formal research
on the prevalence of social workers practicing while impaired.
Social workers should advocate for universal self-referral and
prevention programs focusing on self-care.
REFERENCES
American Psychological Association. (2006). Advancing col-
league assistance in professional psychology. Washington, DC:
Author.
Association of Social Work Boards. (2006). Impairment to
practice. Association News, 16(3), 1, 8-9.
Murphy, B. C., & Dillon, C. (2008). Interviewing in action in a
multicultural world (chap. 15, 3rd ed.). Belmont, CA:
Thomson Brooks/Cole.
National Association of Social Workers. (1999a). Code of ethics of
the National Association of Social Workers. Washington, DC:
Author.
PROFESSIONAL LIABILITY AND
MALPRACTICE 425
National Association of Social Workers. (1999b). Professional
impairment. In Social work speaks: NASW polU:y statements (pp.
296-300). Washington, DC: Author.
North Carolina Board of Nursing. (1995). Alternative programs for
chemical dependency. Raleigh, NC: Author.
Peebles-Wilkins, W. (1997). Exploratory survey: Impaired social
workers. In AASSWB Association News (7(1), 6-7), Research:
Boards are looking at impairment and acting. Research supported
by grant no. 1 T26 SP07770 to Maryann Amodeo, Faculty
Development on Alcohol and Other Drug Problems, Center
for Substance Abuse Prevention and the National Institute on
Alcohol Abuse and Alcoholism.
Siebert, D. (2004). Depression in North Carolina social workers:
Implications for practice and research. Social Work Research,
28(1), 38.
Siebert, D. (2005). Help seeking for AOD misuse among social
workers: Patterns, barriers and implications. Social Work,
50(1), 70-74.
FURTHER READING
Negreen, S. K (1995). A chapter guide on colleague assistance for
impaired social workers. Washington, DC: National Association
of Social Workers.
New York City Chapter and National Association of Soci~l
Workers. (n.d.). Helping social workers who have alcohol and
other drug problems: Intervening with colleagues. Washington,
DC: National Association of Social Workers.
SUGGESTED
LINKS http://www .apa. org/practice/ accua
http://www .aswb. org
http://drl.wi.gov./dept/ipp .htm
http://www.naswdc.org
http://www.ncbon.com
-WILMA PEEBLES-WILKINS
PROFESSIONAL LIABILITY AND
MALPRACTICE
ABSTRACT: Malpractice claims against social workers are a
reality. Although social workers are trained as students in the
importance of adhering to the NASW Code of Ethics, the
results of ethics and other practice violations are increasing
liability and risk. Social workers have a strong commitment to
clients, to communities, and to social justice, but attention to
ways of reducing risk, including malpractice insurance and
ethics audits, is critical to reducing the numbers of malpractice
and ethics complaints against social workers and ultimately,
to enhancing the profession.
KEY WORDS: ethics; risk management; malpractice;
ethical violations
426 PROFESSIONAL LIABIUTY AND MALPRACTICE
Introduction
Malpractice and risk management are terms that have
crept into social work practice as the profession matures
and joins the litigious environment in which other
professions have found themselves. Social workers have a
strong commitment to the NASW Code of Ethics, to
assisting clients to achieve their goals, to developing
healthier communities, and to social justice on a global
leveL However, the profession needs to be vigilant about
our own protections as we are about those of our clients.
The NASW has a whole elaborate proce dure to address
professional conduct and assure that its members adhere
to the Code of Ethics addressed in the entry entitled
"Professional Conduct."
DEFINITIONS Malpractice isvdefined as any profes-
sional misconduct, unreasonable lack of skill or
fidelity in professional or fiduciary duties. The word
"malpractice" signifies involvement in a legal tort
action (Reamer, 1997).
There are four major elements required for a situation
to become a malpractice case that has the probability of
being substantiated.
• There must be a legal duty. The social worker must
have a legal duty to provide a service that was not
provided.
• Professionals have an obligation to adhere to a standard
of care. The NASW Code of Ethics is accepted as the
standard for the profession of social work.
Therefore, social workers, whether members of
NASW or not, have an obligation to be know-
ledgeable about the standards and to anticipate being
judged against those standards.
• There must be a breach of that duty and the client must
have suffered measurable harm or injury. A case in
point, DeShaney v. Winnebago involved a child who
was severely beaten by his father, and the state child
protection agency was sued for not determinin g, in
the course of their investiga tion, that sufficient risk
existed to remove the child from the home and the
father's custody (Schroeder, 1999). In the DeShaney
case, the client suffered measurable harm, but the
question remained whether or not the age ncy and the
social worker breached their duty.
• Finally, there mUst be proximate cause. That is, there
must be a causal connection between the breach of
the duty and the harm or injury (NASW Trust,
2003).
Malpractice and risk management are polar opposites. If
one can effectively manage risk, the reality of a mal-
practice suit that is sustainable is less likely. Reamer
(1997) points out that social workers are confronted with
situations that do not fit nic ely into one set of rules or
regulations. The NASW Code of Ethics may par tially
address the issue; the state licensing regulations may
address the issue; and the agency in which social workers
find themselves may also address the situation.
Malpractice risks are discussed in the continuing edu-
cation that social workers are required to have' for
licensure, but ways of reducing risk are seldom outlined.
COURT DECISIONS In 1989, a court decision limited
liability protection for social workers. In DeShaney v.
Winnebago County Department of Social Services, the U.S.
Supreme Court, in a six to three decision, decided not to
extend liability against social workers and the county
social services department in Wisconsin (Bullis, 1990). lt
was a complex case; DeShaney was a threeyear- old child
abuse victim, and the allegations were that the social
services department did not pursue their investigation
when the father denied the allegations of physical abuse.
Subsequently, the child was admitted to the hospital on
several occasions with bruises and head trauma, which
eventually led to irreversible brain dam age. DeShaney
was expected to be confined to an in stitution for the
severely retarded for the rest of his life.
For social workers in public child welfare agenc ies,
this case was a wake- up call to the future liability that
agencies and the individual social workers could find
themselves facing in such situations. Since 1990, public
agencies have developed and tested several types of risk
assessment tools to assist social workers in making an
initial determination about the level of risk in any child
abuse investigation. Will these instruments hold up under
the scrutiny of a lawsuit? Only time will tell. However,
even the justices in the DeShaney case noted that st ate
legislatures can enact laws to make claims against social
service agencies and individual social workers easier.
(Bullis, 1990).
Perhaps the most cited case involves "duty to warn"
and omission of the a professional social worker's duty to
protect clients as well as potential victims of violent
clients. In 1976, Tarasoff vs. Board of Regents of the
University of California, the Court held that profes sionals
have a duty to disclose confidential information to protect
third parties when four factors are present: (1) a threat of
violence, (2) an imminent threat, (3) evidence that the
threat is likely to be carried out in the near. future, and (4 )
identified victim or victims. A therapist in the health clinic
at the University of California saw a client wh o indicated
that he planned on killing his former girlfriend. The
therapist reported his concerns to the university and to law
enforcement, both of which declined to notify the intended
victim.

Weeks later, the individual made good on his threat and
did, in fact, kill the young woman (Houston-Vega,
1997). All licensed professionals have a duty to
disclose confidential information to protect third parties
if the four factors mentioned earlier are present.
However, "foreseeable threat" is interpreted differently
in various jurisdictions
AREAS FOR RISK/MALPRACTlCE Although there are
several areas of concern for social workers, four
major issues will are described here.
• Incorrect diagnosis/treatment. Incorrect diagnosis,
and particularly incorrect treatment, are becoming
larger issues for social workers. Kutchins and Kirk
(1987) identified some of the ethical problems that
have been neglected as more social workers make
use of the Diagnostic and Statistical Manual of
Mental Disorders (now the DSM IV-TR). Part of
their concerns centered around the authority of
j
social workers to make diagnoses based on the
DSM-III, as well as the issue of social workers
being at risk for making an incorrect diagnosis in
order for an individual or family to qualify for
treatment (Kutchins & Kirck, 1987). Although this
problem is not limited to social workers, the social
worker may see the longer term benefits to a client
of not having a severe diagnosis, while still being
able to receive services. However, this choice is
both an ethical issue as well as an action that
increases risk of malpractice.
• Confidentiality. Confidentiality is one of the basic
tenets of the social worker/client relationship. Social
work practitioners and students are constantly
reminded that the interests of the client must be·
protected. In 1980, a family court judge in the State of
New York included confidentiality as one of the
essential attributes in the relationship between social
work and client.
(Hector M. v. Commissioner of Social Services of the
City of New York et al., 1980) Gerald Schwartz
identified two cases that upheld the confidentiality of
the social worker/client relationship, the New York
case just cited and another earlier New Y orkcase
(Community Service Society v. Welfare Inspector
General, 1978). In this case, the court determined that
social workers had the same privileged
communication with their clients as that which exists
between attorney and client or physician and patient
(Schwartz, 1989).
While the T arasoff case is the one most often
cited with respect to waiver of confidentiality,
there are other circumstances that also apply and of
which social workers should be aware. The most
PROFESSIONAL LIABILITY AND MALPRACTICE 427
obvious waiver is one that the client gives, and the
client has the right to waive their privilege of
confidentiality and to limit the time period of the
waiver and the party or parties to whom the waiver
applies. Other circumstances include some
criminal investigations and the occasion when a
client brings a complaint against a licensed social
worker regarding confidentiality to a state licens-
ing board (Schwartz, 1989).
• Documentation. Case documentation is a form of
clinical, ethical, and legal accountability (Ames,
1999); Inexperienced social workers often do not
fully comprehend the importance of accurate and
timely case documentation. Social work students are
often reminded that "If it isn't written down, it didn't
happen," but how many actually understand the
critical nature of documentation is yet another
question. Case records not only are neces-· sary to
reflect what actually occurred with the treatment of
the client, but it provides a way of determining
whether or not a worker in an agency has met
minimum standards of care. Accurate documentation
is a critical element of risk management. Good
documentation can protect a social worker; poor or
missing documentation can put a social worker into a
liable situation as well as negatively affect the
standard of care (Ames, 1999).
• Boundary violations. Boundary violations cover a
number of topics, but sexual misconduct is the area
most focused on within boundary violations. Berliner
(1989) reviewed all individual ethics complaints filed
with NASW from 1978 to 1985. One in every 12
complaints involved a social
. worker's inappropriate sexual behavior toward a
client. At the time of Berliner's data collection,
14% of the sexual misconduct cases involved pri-
vate practitioners. Kimberley Strom-Gottfried
examined the same NASW data for the period of
1986-1997. Her data revealed the most commonly
occurring violations were still sexual activity, fol-
lowed by dual relationships and other boundary
violations (Strom-Gottfried, 2003). When com-
pared with Berliner's data, Strom-Gottfried docu-
mented an increase in boundary violations in the
same period. This increase occurred when
mandatory continuing education credits were
becoming standard requirements for licensure and
relicensure in almost every state.
Risk Management Strategies
NASW Assurance Services, a wholly owned subsidiary
of the National Association of Social Workers (NASW)
428 PROFESSIONAL LIABILITY AND MALPRACTICE
offers professional malpractice insurance for individuals
who are members of NASW. As part of training on
offered risk management, six strategies have been identi-
fied for reducing risk (NASW Insurance'Trust, 2003).
• Assume a proactive stance. Social workers and other
professionals should/must consider the preventive
aspects of risk management: Carrying malpractice
insurance, having an accountant set up to handle
their private practice accounts, consulting with an
attorney when setting up a prac tice, and providing
adequate documentation in client files.
• Risk often is avoidable. Being familiar with the pol,
icies and procedures of an agency can assist social
workers who are employees, to minimize risk that
develops from lack of knowledg;.
• Reduce risk where you carl. Social workers should be
encouraged to take a comprehensive look at their
environment and eliminate or reduce risk factors as
much as possible.
• Education in the area of ethics, good practices, trans-
ference, and counter-transference is essential. Con,
tinuing education in the area of ethics is a
requirement in every state for licensure. However,
many ethics classes and workshops focus on ethical
violations rather than risk avoidance.
• Supervision and consultation should be in place. Social
workers in private practice should be especially
mindful of the need to have ongoing consultation in
their practice. Solo practices run the risk of not
putting regular consultation in place. But all social
workers including those community and adrninis-
trative practitioners who work with boards, polit ical
bodies, and community organizations also need to
be mindful of the impact of their inter' ventions on
others-even indirectly.
• Transfer by sharing the burden of risk. The risk is shared
when social workers are aware of their agency's
policies and procedures, and when they take other
precautions, such as carrying malprac tice insurance,
and arranging to have ongoing
consultation/supervision.
Education and Training Challenges
FOR SOCIAL WORK STUDENTS In a review of ethics
curricula used in schools of social work (Boland, Prom
& Anderson, 2005 ) two findings are key: (l) social work
students, while trained to recognize ethical dilemmas,
were not fully invited to participate in the proces s as
equals, and (2) social work students were not trained ,
with regards to their awareness of the ethical resolu tion
process, to engage themselves in the resolution process.
In other words, when social work graduates
find themselves in - the laboratory rather than behind the
observation mirror, they do not have the ability to
participate fully in the process. Swindell and her
colleagues define the challenge as that of developing a
pedagogy that supports students in becoming ethical delegates
within both their personal and personal lives (Swindell, &
Watson, 2007).
IMPLICATIONS FOR SOCIAL WORK PRACTITIONERS AND
AGENCIES For practitioners and the agencies that
employ them and for those in private practice, the
challenge is even greater. Reamer recommends an ethics
audit be periodically conducted in agencies to assess the
extent to which the agency and social work ers have
procedures in place to identify ethics- related risks, and
to reduce the possibility of ethics- related com, plaints or
litigation (Reamer, 2000). In an ethics audit, an agency
has the opportunity to review the policies and procedures
regarding various areas, including eli ents' rights,
informed consent, confidentiality, docu mentation,
supervision, training, fraud, and conflict of interest.
Agency ethics commi ttees or corporate com pliance
committees are often formed to conduct the audit, report
the findings to the Board of Directors, and implement
the changes in agency policies approved by the Board.
Reamer (2000) states that "Such systemic attempts
(ethics audits) to highlight, address, and monitor the
ethical dimensions of social work practice will, in th e
final analysis, strengthen the profession's integrity"
(Reamer, 2000).
Social workers now find themselves in a litigious
environment. Over the last two decades, licensing boards
have placed annual requirements for continuing
-education credits in the ar ea of ethics, as a way of keeping
the issue of ethics in the forefront of practice
considerations as professionals renew their licenses. The
trends appear to be in the direction of increased regulation
and greater expectations are being placed on social
workers who are new to the profession.
Concerns about malpractice appear to have become
integral parts of the professional lives of social workers.
Education and training have been found to reduce risk, but
timing, commitment, and engagement are critical to
success. Every case against a social worker and every
ethics violation affects the individual, the client, the
agency, and the profession.
REFERENCES
Ames, N. (1999). Social work recording: A new look at an old
issue. Journal of Social Work Education, 35(2), 227-238.
Berliner, A. (1989). Misconduct in social work practice. Social
Work, 69-72.

Boland-Prom, K., & Anderson, S. (2005). Teaching ethical
decision making using dual relationship principles as a case
example. Journal of Social Work Education, 41(3), 495-510.
Bullis, R. (990). Cold comfort from the supreme court: Limited
liability protection for social workers. Social Work,
35(4),364-366.
Kutchins, H., & Kirk, S. (987). DSM-III and Social Work
Malpractice. Sodal Work, 205-211.
NASW Insurance Trust. (2003). Washington, DC: National
Association of Social Workers.
Reamer, F. G. (1000). The social work ethics audit: A risk-
management strategy. Social Work, 45(4), 355-366.
Schroeder, L. (999). The legal environment of social work.
Washington, DC: NASW press.
Schwartz, G. (989). Confidentiality revisited. Social Work,
223-226.
\
Strom-Gottfried, K. (2003). Understanding adjudication: Ori-
gins, targets and outcomes of ethics complaints. Social Work,
480),85-94.
Swindell, M., & Watson, J. (2007). Ethical delegates in the social
work classroom: A creative pedagogical approach. Journal of
Sodal Work Values and Ethics, 40).
FURTHER READINGS
Fulcher, L. (2002). Cultural safety and the duty of care. Child
Welfare, 54(5), 689-708.
Gorman, H. (2003). Which skills do care managers need? A
research project on skills, competency and continuing pro-
fessional development. Social Work Education, 22(3), , 245-259.
Gostin, L. (2002). Surveillance and public health research:
Privacy and the right to know. Public health law and ethics:
A reader. Berkely, CA: University of California Press.
Kirkpatrick, W., Reamer, F., & Sykulski. (2006). Social work
audits in health care settings: A case study. Health & Sodal
Work, 31(3),225-228.
Leschied, A., et al. (2003). The empirical basis of risk assessment
in child welfare: The accuracy of risk assessment and clinical
judgment. Child Welfare, 55(5), 540.
McAuliffe; D. (2005). Putting ethics on the organizational
agenda: The social work ethics audit on trial. Australian Social
Work, 58(4), 357-369.
McCarty, D; & Clancy, C. (2002). Telehealth: Implications for
social work practice. Social Work, 47(2), 153-161.
Melville, R. (2005). Human research committees and ethical
review: The changing research culture for social workers.
Australian Social Work, 58(4), 370--383.
Munro, E. (999). Protecting children in an anxious society.
Health, Risk & Sodety, 10), 117-127.
Reamer, F. G. (987). Informed consent in social work. Social
Work, 32(5), 425-429.
Reamer, F. G. (987). Ethics committees in social work. Sodal
Work, 32(3), 188-192.
Reamer, F. G. (995). Malpractice claims against social workers:
First facts. Social Work, 40(5), 595-600.
Reamer, F. G. (2003). Boundary issues in social work: Managing
dual relationships. Social Work, 480), 121-133.
I
PROGRAM EVALUATION 429
Reamer, F. G. (2005). Documentation in social work: Evolving
ethical and risk-management standards. Social Work, 50(4),
325-334.
Reamer, F. G. (2005). Update on confidentiality issues in practice
with children: Ethics risk management. Children &
Schoo~,27(2), 117-120.
Sloan, L., Edmond, T., Rubin, A., & Doughty, M. (1998).
Social workers' knowledge of and experience with sexual
exploitation by psychotherapists. Social Work, 430),43-53.
Watkins, S. A., & Watkins, J. C. (983). Malpractice in clinical
social work: A perspective on civil liability in the 1980s.
Behavioral Sdences & the Law, 10),55-69.
- YVONNE CHASE
PROGRAM EVALUATION
ABSTRACT: This entry discusses how four types of
program evaluations can be ~sed in social service pro-
grams: (a) needs assessments, (b) process evaluations,
(c) outcome evaluations, and (d) cost-efficiency evalu-
ations. The future of program evaluation within the
social work profession is also discussed along with
various trends.
KEY WORDS: accountability; program evaluation; logic
model; needs assessments; process evaluations;
outcome evaluations; cost-efficiency evaluations;
cost-benefit evaluations; cost-effect iveness evaluations
Many definitions of program evaluation exist (Ginsberg,
2001; Pawlak & Vinter, 2004; Weinbach, 2005). Overall,
program evaluation is defined by a set of philosophies and
methods that aim to determine "what works" in human service
delivery systems (Unrau, Gabor, Grinnell, 2007, 2008).
Program evaluations are always designed for a specific social
service program (Rossi, Lipsey, & Freeman, 2003; Shaw,
Greene, & Mark, 2006). The results of evaluation are
particular to one specific client group, experiencing specific
conditions of one specific program over a specific time frame in a
specific location. In a nutshell, program evaluations util-
. he sound social science research principles and techniques to
make judgments about programs for the purposes of
improving efficiency, effectiveness, and the overall
experience of services.
Accountability to various stakeholder groups is a central
theme of program evaluation (American Physiological
Society, 2002; Posavac & Carey, 2007; Preskill & Russ-Eft,
2004). For example, stakeholders such as clients want
assurances that available services will deliver promised
benefits, the profession is invested in knowing what works for
different client groups, and
430 PROGRAM EVALUATION
. funding bodies that provide funds for programs want to
know that their dollars are committed to effective services
(Bamberger, Rugh, & Mabry, 2007; Davidson, 2005;
Fitzpatrick, Sanders, & Worthen, 2004). Other typical
stakeholder groups include program administrators, social
workers, and citizens living in a program's service area.
Types of Program Evaluations
There are many different types of program evaluations
(Donaldson, 2001; Fraser, Taylor, Jackson, & O'Jack,
1991; Nugent, Sieppert, & Hudson, 200l). Four types that
commonly appear in social service programs are as
follows: (a) needs assessments, (b) process evaluations,
(c) outcome evaluations, and (d) cost-efficiency eva-
luations (Kettner, Moroney, & Martin, 2008). All four
types rely on the evaluator having the knowledge and
skills to systematically collect and analyze data that will
answer specific questions in an evaluative context- that is,
for the purposes of making judgments about existing
services and informing decisions about future program
planning.
NEEDS ASSESSMENTS These evaluations aim to determine the
nature, scope, and locale of a social problem (if one exists)
and propose feasible, useful, and relevant solutionis} to the
problemts) (Hatry, Cowan, Weiner, & Lampkin, 2003;
Harry, Wholey, & Newcomer, 2004). Needs assessments
are born out of observed problems with or gaps in (or
absence of) existing social services. Community leaders in
response to public unrest, landmark cases, fluctuations in
political and economic conditions, and changes in basic
demographic trends often request needs assessments. For
example, a director of a family social service agency may
notice low attendance at parent support groups and may
request a needs assessment to determine if the agency's
group intervention is outdated or, perhaps, targeting the
wrong needs (Connell, Kubisch, Schorr, & Weiss, 1995).
Or, a child is abducted from a public school ground during
the lunch hour and an inquiry is undertaken to explore the
general safety of children and supervision practices at all
public schools.
The first step in needs assessments is to conduct an
analysis of a social problem (for example, child prosti-
tution, drug abuse, discrimination) in a specified locale,
such as an organization, neighborhood, community, and
so on. However, in needs assessment it is not en ough to
establish the magnitude of problems, it is also necessary to
identify viable strategies to address identified needs
(O'Sullivan, 2004; Patton, 1997). .
Needs Questions. Specific questions addressed by needs
assessments are classified here under four general
categories: (a) Demographics: What is the demographic
profile of a community, or the people experiencing the
need? (b) History: Have needs changed over time? Have
services evolved over time? What conditions have changed
in the community in the past five years? What types of
solutions have worked in the past? (c) Demand: Are
existing program services meeting the needs of the people
being served? What are the gaps in existing services? Are
there specific groups asking for services but not receiving
any? and (d) Strengths: What are the positives in the
community? What are the signs of resiliency in the
community?
PROCESS EVALUATIONS These evaluations describe the nature
(for example, type, frequency, duration) of actual program
operations and client service activities. The focus is on the
program's approach to client service delivery, as well as on
how the program manages its dayto-day operations. In
other words, the means of service delivery is of primary
concern, while the end result is of secondary concern.
Attention is given to how a program's services are
delivered to clients and what administrative mechanisms
exist to support these services (Chen, 2006).
In general, there are two major categories of
processes-the client service delivery system within the
program and the program's administrative support systems
that sustain client service delivery. Client service delivery
is composed of what workers do (for example,
interventions, activities) and what clients bring to the
program (for example, client characteris tics). On the other
hand, administrative support systems comprise the
organizational activities that exist to support the program's
client service delivery system (for example, supervision,
support staff, emergency petty cash funds, evaluation
activities).
Process evaluations involve monitoring and measuring
variables such as communication flow, decision making
protocols, staff workload, client record-keeping, program
supports, staff training, and worker-elient activities.
Indeed, the entire sequence of activities that a program
undertakes to achieve benefits for program clients or
consumers is open to the scrutiny of process evaluations.
Process Evaluation Questions. There are many published
examples in the literature of how process evaluations can
help us in our professional practice. The questions they can
answer can be classified under six general categories: (a)
Program Structures: What is the program's organizational
structure? What is the flow of communication? How are
decisions made? What are the minimum qualifications for
staff hiring? (b) Program Supports: What program supports
exist to help workers
 PROGRAM EVALUATION 431

do their jobs? Are principles of cultural competence of clients who experience more success than others? (d)
integrated into staff training and supervision? (c) Client Causality: Is there any evidence that the program can
Service Delivery: What is the quality of worker activity? claim responsibility for positive changes in clients? (e)
What do workers do? How often? (d) Decision Making: Satisfaction: Are stakeholders satisfied with program
How are practice decisions made? How are worker services?
activities and decision making documented? (e) Ptogmm
Integrity: Is the program being implemented in the way
COST-EFFICIENCY EVALUATIONS These evaluations
that it was designed? Ifnot, how does the program
demonstrate fiscal accountability and raise
deviate from the' original program "blueprint"? and (f)
awareness of costs associated with providing
Compliance: Is the program meeting standards set by
services to specific populations (Levin & McEwan,
funders, accrediting bodies, or governmental agencies?
2000; Neumann, 2005). A program is considered
costefficient when it is able to achieve its desired
OUTCOME EVALUATIONS These evaluations deter-
client outcomes at lower cost, compared with
mine the amount and direction of change
another program d A
experienced by clients during or after a program's
" bati "£
services (Compassion Capital Fund National
Resource Center, 2006; Lampkin & Hatty, 2003).
striving for the same en s. pro anon program, or
More specifically, they aim to demonstrate the
example, costs less than a "jail program" simply because
degree and nature of change, if any, for clients after
the probation program does not have expenses for 24- hr
they have received program services-that is, at
supervision, an institutional facility, and so on. If the
program exit or some later follow up point. The
probation program is successful in preventing future
essence of an outcome evaluation is captured by the
criminal behavior, the savings are even greater. Costs
familiar phrase "begin with the end in mind."
associated with prevention, however, are difficult to
Outcome evaluations focus on the conceptual
estimate because we cannot know for certain whether
destination on a program map because they tell us
the absence of the problem was a result of the program.
where program staff and clients are headed as th ey
Cost-efficiency evaluations alone provide us with
work together. This focus helps to keep program
data and information associated with program expenses.
administrators and workers in sync with the
When combined with process and outcome evaluation,
program's mandate (which is reflected in the
data from cost-efficiency evaluations can give us
program's mission or goal).
valuable insight as to how program resources are best
Outcome evaluations tell us whether programs are
allocated. Because cost-efficiency evaluations produce
working, but unless experimental methodology is
dollar figures for program processes and outcomes, they
incorporated and program processes are carefully
have utility only when we know precisely what the
monitored, they are silent about why programs are
program is doing (process evaluation) and precisely
working-or failing to work (Urban Institute, 2003).
how much client change is produced (outcome
Because experimental methodology is rarely used and
evaluation).
program processes are often ignored, outcome evalu-
Cost-Efficieri.cy Questions. The questions that can be
ations have earned the name of "black box" evaluation
answered via cost-efficiency evaluations can be classi-
(Brun, 2005). This label communicates the idea that
fied under three general categories: (a) Unit Costs:
clients entering the black box of the program emerge
What is the average cost per client? What is the average
somehow changed (hopefully for the better), but it is not
cost per unit of service (for example, intake, assessment,
obvious what aspects of the program are associated with
intervention, follow up)? (b) Cost Distribution: What
any observed client outcomes.
percentage of costs go to direct client services, admin-
Outcome Questions. The questions that can be
istrative activities, and program development? What
answered by outcome evaluations can be classified
services were not provided due to lack of funds? and (c)
under five general categories: (a) Program Integrity: Is the
Cost Reduction/Recovery: Is there any way in which cost
program achieving the desired client change? To what
could be reduced without loss of effectiveness, perhaps
degree is the program accomplishing its program Futureinstead
Trendsof individual therapy?
by offering group therapy
objectives? Is the program achieving predetermined The history of the social work profession tells a story
Are strategies for cost recovery possible?
minimum standards of achievement (benchmarks)? (b) that social work has long struggled with the integration
Program Effects: Are people who have been through the research and practice methods (Adam, Zosky, & Unrau,
program better for it? Are they better off than others 2004; Tripodi & Potocky-Tripodi, 2006). Much of the
who went through similar programs? How long do client struggle has been focused at the practitioner
improvements last? (c) Differential Effects: Given the
demographics of clients served, are there subgroups
432 PROGRAM EVALUATION
level. In particular, scholars have explored the question of
how social work practitioners could best embrace and
incorporate research methods into their practice frame-
works (Epstein, 1996; Fraser, Taylor, Jackson, & O'Jack,
1991; Meyer, 1996; Penka & Kirk, 1991; Rosen, 1996;
Rubin, Franklin, & Selber, 1992; Wakefield & Kirk, 1996;
Witkin, 1996). When program-level evaluatio ns are used
in conjunction with case-level evaluations (Bloom,
Fischer, & Orme, 2006), they have added benefit to
understanding and applying the profession's knowledge
base. Writings on programlevel evaluation in social
service programs date back to the 1960s (Suchman, 1967),
but the impetus for human service administrators
embracing program evaluation methods can be linked to
tlte passing of the Government Performance and Results
Act in 1993.
Program evaluation now serves a key function in the
social work profession and is here to stay (Westerfelt &
Dietz, 2005; Wholey, Harry, & Newcomer, 2004). The
National Association of Social Work and the Council on
Social Work Education both recognize research and
evaluation as core tools of the profession. Program
evaluation has a central role in the interdisciplinary
movement toward evidence- based practice (Mullen,
Bellamy, & Bledsoe, in press).
As social workers demonstrate leadership in evalu-
ating social services and programs, the profession
becomes a collaborative player with other disciplines and
professions such as psychology, sociology, anthro pology,
and nursing in building knowledge to better understand
complex human behaviors and social pro blems. Steeped
in values of diversity and justice, social work ad ds a
unique perspective to theory testing and other applied
knowledge development efforts. In deed, a major area yet
to be developed in program evaluation of social service
programs is multicultural competence- a topic that is
budding in education evaluatio n but deserves more
attention in the human service sector (McKinney, 2008 ).
TRENDS IN EVALUATlON Harry, Wholey, and New-
comer (2004) have delineated five trends that they see
will influence the evaluative enterprise over the next
few years.
One trend is increased emphasis on evaluation for
government audits and program reviews.· Faced with
mounting skepticism about the effectiveness of their
expenditures, public funders' demands for accountabil ity
have increased significantly in recent years . Efforts to
develop evaluation templates and standard report ing
forms have increased. A challenge for program
administrators and staff is that externally derived eva-
luation requirements and standardized forms are often
burdensome and seldom produce inf ormation useful to
local programs. Many local organizations are becoming
more proactive in program evaluation as a means of
meeting accountability requirements in a manner that is
compatible with operations and organizational cul ture and
also, at the same time, produces information that is useful
locally.
A second trend is continued expansion of the use of
client surveys as a data collection procedure. Tradition-
ally, clients have been looked at skeptically as sources of
data, as it has been assumed that, somehow, their
perspectives would be subjective, reflecting their biases.
However, more and more clients are being viewed as a
key stakeholder group that possesses valuable insight
about their program experiences. Client surveys can
address a range of issues, including satisfaction with
services, experiences with program staff and procedures,
and benefits obtained.
A third trend is that new technology will speed up and
enrich evaluation procedures. One set of challenges facing
organizations in conducting evaluations is data collection,
management, and data analysis. These are not only labor
intensive activities but also require a level of technical
expertise that many social service organizations lack.
Computers are increasingly used in conducting program
evaluations and their use is likely to increase. One
example of a comprehensive computer- assisted
evaluation facility is the eva luation site operated by the
Canadian Association of Family Resource Programs
(http://wwW.frp.Ca/fL evaIFAQs_index.asp); this facility
will carry out a variety of evaluation tasks. The system
allows clients to directly complete their surveys on- line
and also accepts surveys completed on paper, which can
be scanned. The system also performs a variety of pre pro-
grammed analyses in real time and provides reports of the
results.
A fourth trend is increased use of evaluation infor-
mation to improving social service programs. In addition
to being a means of meeting accountability requirements,
program evaluation is essential for mon itoring and
program improvement purposes. By collect ing and
analyzing data for need, process, outcome, or cost,
valuable feedback is generated. When such data are
collected routinely, the resulting information pro vides
administrators and staff with feed back about how well
program processes work and to what extent out come
objectives are being met. Such feedback is essen tial in a
process of quality improvement.
A fifth trend is that university education will in-
creasingly include evaluation material in their curricu la.
In recent years, there has been a renewed recognition
within schools of social work of the need

to ensure that evaluation content is adequately represented in the
curricula. This trend is driven by an increased level of evaluation
activities within organiza-
- dons, which are responding to increasing demands for
accountability and also recognizing that evaluations provide
valuable information for program planning and delivery. Thus, in
the years to come, there is likely to be an increasing demand for
social work graduates who can contribute to their organization's
program evaluation activities.
REFERENCES
Adam, N., Zosky, D., & Unrau, Y. (2004). Improving the research
climate in social work curricula; Clarifying learning
expectations across BSW and MSW research courses. Journal
of Teaching in Social Work, 24(3), 1-18.
American Physiological Society. (2002). Planning and effective
program evalUation: A short course for project directors.
Bethesda, MD~ Author.
Bamberger, M. J., Rugh, J., & Mabry, L. (2007). Real world
evaluation: Working under budget, time, data, and political
constraints. Thousand Oaks, CA: Sage.
Bloom, M. J., Fischer, J., & Orme, J. G. (2006). Evaluating
practice: Guidelines for the accountable professional (5th ed.).
Boston: Allyn & Bacon.
Brun, C. F. (2005). A practical guide to social service evaluation.
Chicago: Lyceum.
Chen, R T. (2006). Practical program evaluation: Assessing and
improving planning, implementation, and effectiveness. Thousand
Oaks, CA:- Sage.
Compassion Capital Fund National Resource Center. (2006).
Measuring outcomes. Washington, DC~ Author.
Connell, P. J., Kubisch, A c., Schorr, L. B., & Weiss, C. H.
(1995). New approaches to evaluating communities initiatives:
Concepts, methods, and contexts. Washington, DC: The Aspen
Institute.
Davidson, E. J. (2005). Evaluation methodology basics: The nuts and
bolts of sound evaluation. Thousand Oaks, CA: Sage.
Donaldson, S. I. (2001). Overcoming our negative reputation:
Evaluation becomes known as a helping profession. American
Journal of Evaluation, 22, 355-361.
Epstein, I. (1996). In quest of a research-based model for clinical
practice: Or, why can't a social worker be more like a
researcher? Social Work Research, 20(2), 97-100.
Fitzpatrick, J. L., Sanders, J. R., & Worthen, B. R. (2004).
Program evaluation: Alternative approaches and practical guide-
lines (3rd ed.). White Plains, NY: Longman.
Fraser, M., Taylor, M. J., Jackson, R., & O'Jack, J. (1991).
Social work and science: Many ways of knowing? Social Work
Research and Abstracts, 27(4), 5-15.
Ginsberg, L. H. (2001). Social work evaluation: Principles and
methods. Boston: Allyn & Bacon.
Harry, H. P., Cowan.]., Weiner, K., & Lampkin, L. M. (2003).
Developing community-wide outcome indicators for specific ser-
vices. Washington, DC: Urban Institute.
Hatry, H. P., Wholey, J, S., & Newcomer, K. E. (2004).
Other issues and trends in evaluation. In J. S. Wholey,
_J
PROGRAM EVALUATION 433
H. P. Harry, & K. E. Newcomer (Eds.), Handbook of practical
program evaluation (Znded., pp. 670--684). San Francisco:
Wiley.
Kettner, P. K., Moroney, R. K., & Martin, L. L. (2008).
Designing and managing programs: An effectiveness-based
approach (3rd ed.). Thousand Oaks, CA: Sage.
Lampkin, L. M., & Harry, H. P. (2003). Key steps in outcome
management. Washington, DC: Urban Institute.
Levin, H. M., & McEwan, P. J. (2000). Cost-effectiveness analysis:
Methods and applications (2nd ed.). Thousand Oaks, CA:Sage.
McKinney, R. (2008). Becoming a culturally sensitive researcher.
In R. M. Grinnell Jr., & Y. A Unrau (Eds.), Social work research
and evaluation: Foundations of evidencebased practice (8th ed.,
pp. 345-366). New York: Oxford University Press.
Meyer, C. H. (1996). My son the scientist. Social Work Research,
20(2), 101-104.
Mullen, E., Bellamy, J., & Bledsoe, S. (in press). Evidencebased
social work practice. In R. M. Grinnell Ir., & Y. A Unrau
(Eds.), Social work research and evaluation:
Foundations of evidence-based practice (Brh ed.). New York:
Oxford University Press.
Neumann, P. (2005). Using cost-effectiveness analysis to improve
health care. New York: Oxford University Press.
Nugent, W. R., Sieppert, J. D., & Hudson, W. W. (2001).
Practice evaluation for the 21 st century. Belmont, CA: Brooks/
Cole.
O'Sullivan, R. G. (2004). Practicing evaluation: A collaborative
approach. Thousand Oaks, CA: Sage.
Patton, M. Q. (1997). Utilization-focused evaluation. Thousand
Oaks, CA: Sage.
Pawlak, E. J., & Vinter, R. D. (2004). Designing and planning
programs for nonprofit and government organizations. San
Francisco: Wiley.
Penka, C. E., & Kirk, S. A (1991). Practitioner involvement in
clinical evaluation. Social Work, 36, 513-518.
Posavac, E. J., & Carey, R. G. (2007). Program evaluation:
Methods and case studies (7th ed.). Englewood Cliffs, NJ:
Prentice-Hall.
Preskill, R, & Russ-Eft, D.(2004). Building evaluation capacity.
Thousand Oaks, CA: Sage.
Rosen, A (1996). The scientific practitioner revisited: Some
obstacles and prerequisites for fuller implementation in
practice. Social Work Research, 20(2), 105-11l.
Rossi, P. H., Lipsey, M., & Freeman, R E. (2003). Evaluation:
A systematic approach (7th ed.). Thousand Oaks, CA: Sage.
Rubin, A, Franklin, c., & SeIber, K. (1992).
Integrating research and practice into an
interviewing skills project: An evaluation.
Journal of Social Work Education, 28(2), 141-152.
Shaw, I. F., Greene, J. c., & Mark, M. M. (Eds.).
(2006). The SAGE handbook of evaluation. Thousand Oaks,
CA:Sage.
Suchman, E. (1967). Evaluative research: Principles and practice in
public service and social action programs. New York: Russell
Sage Foundation.
Tripodi, T., & Potocky-Tripodi, M. (2006). International social work
research: Issues and prospects. New York: Oxford University
Press.
434 PROGRAM EVALUATION
Unrau, Y. A., Gabor, P. A., & Grinnell, R. M., Jr. (2007).
Evaluation in social work: The art and science of practice (4th. ed.).
New York: Oxford University Press.
Unrau, Y. A., Gabor, P. A., & Grinnell, R. M., Jr. (2008).
Program evaluation. In R. M. Grinnell Jr. & Y. A. Unrau (Eds.),
Social work research and evaluation: Foundations of
evidence-based practice (8th ed., pp. 527-539). New York:
Oxford University Press.
Urban Institute. (2003). Surveying clients about outcomes.
Washington, DC: Author.
Wakefield, J. c., & Kirk, S. A. (1996). Unscientific thinking
about scientific practice: Evaluating the scientist-
practitioner model. Social Work Research, 20(2), 83-95.
Weinbach, R. W. (2005). Evaluating social work services and
programs. Boston: Allyn & Bacon. . progressive social work derive from several practice traditions
Westerfelt, A., & Dietz, T. J. (2005). Planning and conducting .
agency-based research: A workBook for social work students in field
placements (Znd ed.). Boston: Allyn & Bacon.
WholeY,J. S~, Hatty, H. P., & Newcomer, K. E. (Eds.). (2004).
Handbook of practical program evaluation (Znd ed.). San
Francisco: Wiley.
Witkin, S. L. (1996). If empirical practice is the answer, then what
is the question? Social Work Research, 20(2), 69-75.
FURTHER READING Tzavaras-Catsambas, T., & Preskill,
H. S. (2006). Reframing evaluation through appreciative inquiry.
Thousand Oaks, CA:
Sage.
W. K. Kellogg Foundation. (1998). Evaluation handbook. Battle
Creek, MI: Author.
W. K. Kellogg Foundation. (2004). LOgic model development guide.
Battle Creek, MI: Author.
-RICHARD M. GRINNELL JR.,
YVONNE A. UNRAU, AND PETER GABOR
PROGRESSIVE SOCIAL WORK
ABSTRACT: Since the beginning of the profession,
progressive social work has been characterized by a lived
commitment to activism for social and economic justice. Since
the mid-1980s, the rise of global capitalism has vitiated
support for robust social welfare programs and has had a
conservatizing effect on the profession, rendering the
progressive agenda both more urgent and more difficult.
Meanwhile, the modernist ideals that gave rise to
progressivism were challenged by postmodernisr thinkers.
Progressive social work has responded to both challenges with
innovation and energy, but theoretical and practical
conundrums remain.
KEY WORDS: progressive social work; welfare state;
postmodernism; globalization
Introduction: Defining and Describing
Progressive Social Work
Progressive social work has existed within social work since
the beginning of the profession (Fabricant & Fisher, 2002;
Reisch, 2004; Selmi & Hunter, 2001; Reisch & Andrews,
2002; Reisch, 2004). In the United States, this community has
sustained for nearly two decades a scholarly journal, the
Journal of Progressive Human Services UPHS), has its own
organization, the Social Welfare Action Alliance (SW AA), holds
annual conferences and an internet discussion board sponsored by
that organization, and has a visible presence at the conferences
and meetings of the standing organizations of the profession.
Core concepts associated with the contested label of
and analytical perspectives, including those called radical,
critical, structural, and some iterations of feminist and
empowerment social work. While acknowledging the debates
and distinctions among these groupings-and the reluctance
with which people in this diverse community accept the label
progressive (Wagner, 1999)-we will use the term in this essay as
encompassing all of these conventions.
Progressive social work is distinguished by its emphasis of
ongoing analysis of the ways in which individual and
institutional (or personal and political) forces interact; critical
examination of the power dynamics infused into all social
welfare and social work endeavors; attention to the centrality
of basic human needs and human rights grounded in these
needs; aversion to the pathologizing and labeling of behaviors
that can be explained as functional and adaptive to the
experience of oppression and unmet human needs; and the
level and type and direction of action that flows from these
analyses.
The last point is most fundamental. For progressives, it is
not enough to see; one must do (Bak, 2004; Ferguson &
Lavalette, 2004; Fook, 2003; Healy, 2001; Healy & Leonard,
2000; Van Wormer, 2004; Witkin, 1999).
Given an analysis of the roots of private troubles in public
environments and relations (Mills, 1959), progressive
activism is aimed at fundamental transformation of human
relations and structures. Not all work purported to be for
"empowerment" or "justice" is necessarily seen as
"progressive"; indeed, the depoliticized and deradicalized use
of these. concepts is criticized by progressives as concealing
the need for fundamental change (De Maria, 1997; Dominelli,
2005; Wachholz & Mullaly, 2000). Progressive social workers
often do support and pursue "reformist" agendas. However,
these are generally seen as palliative tactical efforts

to alleviate private troubles while the strategic agenda of
transformation is pursued simultaneously.
In the field, progressive social workers can be found in
every type of agency and organization, including private
practice, .and in every field of practice, includ ing clinical
practice; they use the full range of social work methods and
modalities and draw upon a wide range of practice theories.
There is among progressives, however, an emphasis on
action grounded in an analysis of all social, political, and
economic structures that impede the fulfillment of basic
human needs. For most progressive social workers, these
include the way we live on the planet and the prevailing
mode of production and distribution of essenti al goods and
services (Boyle, 2007; Voss, 2004). The scope of analysis
spans social work relationships and methods as well as the
social welfare institution (Baines, 2000; Gil, 1998, 2004 ;
Healy, 2000; Hick, Fook, & Pozzuto, 2005; Thompson,
2005).
Continuity and Change
The entry on Progressive Social Work in the 19 th edition of
the encyclopedia (Bombvk, 1995) sets forth the theoretical
base of progressive social work,its agen da, its values and
its practice principles. Unchanged is the agenda described
by Bombyk. the creation of political, social, and economic
systems that have as their raison d' etre the meeting of
common human needs and the unfolding of human
potential. Values that endure include anti- authoritarianism,
collaboration, equality, democracy , and a concern for
ethics and spirituality. Theories and theoretical constructs
that continue to be integral to progressive work include
those derived from political economic analysis, power
analyses, the dynamics of oppression and exploitation,
human needs theory, and theories of social movements and
social transformation. Practice theories that continue to in-
fluenceprogressives include structural social work the ory
and some forms of empowerment and feminist practice.
Bombyk also listed several practice principles derived from
the theoretical orientations mentioned above; these include
striving for collaboration and egalitarianism in
relationships, the use of power ana lyses and personal or
political assessments, developing comprehensive, holistic
intervention strategies, the use of consciousness- raising
techniques, and engaging the realities and expertise of
people in client status at all phases of the social work
process.
While this core remains, recent changes in the con text
of social work have stimulated new challenges,
innovations, and, quite possibly, opportunities for pro-
gressive social work (DeFilippis, Fisher, & Shragge, 2006;
Denzin, 2002; Dominelli, 2004; Ferguson, 2006;
j
PROGRESSIVE SOCIAL WORK
435
Leonard, 1997). These changes, which int eract, lie in the
realm of both the practical and the intellectual work we do:
the development of global capitalism with its attendant
practices of neoliberalism, and the intro duction of
postmodemism and its attendant debates (Ferguson,
Lavalette, & Whitmore, 2004; Mullaly, 2001,2002; Parton
& O'Byme, 2000).
During this decade of rapid change, and in keeping with
the times, the progressive social work community in the
United States has been particularly informed, strengthened,
and energized by the lively debate, theo retical advances,
and practice innovations in other English speaking
countries-particularly Canada, Australia, New Zealand,
Great Britain, and Scotland. Incr easingly, progressives are
examining the effects on social welfare systems and
practices resulting from the advance of global capitalism
(Gilbert, 2002; Vij, 2007) and the resistance to
neoliberalism emerging in Cen tral and South America and
elsewhere (Glatzer & Rueschemeyer, 2005; Mishra, 1999 ).
The remainder of this entry focuses on the structural and
intellectual challenges to social work and to progressives'
responses to these challenges.
Globalization
Four interrelated elements of economic globaliza tion have
received particular attention in the progressive literature:
(a) the effects of neoliberalism on social welfare and social
work practice, (b) the reduction of rights and entitlements,
(c) the impact of technology on the workforce and the
nature of work, and (d) militarization, both as fuel for and
consequence of globalization.
Progressives believe that neoliberal policies and
practices are designed to support privatization of the
economy. Effects of these policies have included the
corporatization and commodification of services once
thought to be the domain and mandate of public social
welfare programs (Razin & Sadka, 2005; Stoesz, 1997 ;
Teeple, 2000). Consequences identified by progressive
social workers include "rationed" care (Harris, 2003, 2004) ,
commodification of services needed to meet basic human
needs (Noonan, 2006), routinization and "deskilling" of
practice (Butler & Drakeford, 2000; Reisch, 2006), and a
shrinking (perhaps abandonment) of the welfare state as we
know it (Ferguson, Lavalette, & Mooney, 2002; Gough,
2000a, 2004; McDonald, Harris, & Wintersteen, 2003).
Privatization's orientation to profit and performance has
required expansion of managed care and emphasis on
evidence-based practice in every sphere of social service
(Scheyett, 2006). The use of contracted services to control
costs has created a "day labor" force within social work;
while providing
 •
PROGRESSIVE SocIAL WORK
entrepreneurial opportunities and employment flexibil-
ity for many social workers, this pattern has also resulted
in routinization of the social work enterprise and, most
importantly, may be reducing the significance of the
worker-client relationship, long thought to be the nexus
of practice (Jones, 2004).
Rights and entitlements believed to be integral to the
social welfare institutions of liberal democratic states
have long been an arena for action of progressives, but
progressives point out that their advance is inconsistent
with the interests of economic globalization (De Feyter,
2002). Indeed, the 1996 "welfare reform" legislation not
only ended rights and entitlements for poor people-easy
targets who had been vilified public ally and blamed for
the country's economic woes for decades-bdt
undermined the edifice of rights and entitlements for all
in the United States (Abramovitz, 2004). Some say it
ended the right to rights (Baptist & Bricker-jenkins,
200l).
Progressives note that the elimination of economic rights
has been accompanied by control and contain. ment of
civil and political liberties and furthered by an
intensification of pernicious institutionalized biases and
prejudices such as racism, sexism, xenophobia, and the
like. Increasingly, social workers are asked to perform
surveillance along with service functions (Schram,
2006). The shift in emphasis from caring to control is
particularly evidenced in efforts to prepare for employ-
ment those who are required under current public wel-
fare policies to accept employment at any wage
(Fording, Soss, & Schram, 2007; Moffatt, 1999).
Technology, particularly electronics, has fueled glo-
balization and transformed the world of work, creating
economic insecurity and new demands for services just
as public support and resources for them decline. Pro-
gressives emphasize the consequences of the shift from
an industrial to an electronic age. Jobs. once performed
by a skilled labor force are now performed by robots and
electronic devices. The use of labor-replacing technol-
ogy has resulted in massive layoffs in industry, banking,
and other service sectors. Since many of those jobs have
not only gone abroad but are' gone forever, we are seeing
the emergence of a "new class," largely carved out of the
middle-income population, whose role may be
expendable in the new economy. Some displaced work-
ers are being able to meet their needs by taking on
multiple jobs and "cutting back," while others are pushed
into poverty. Social work programs and methods based
in the structures and relationships of the industrial age
may be outmoded (Bricker-jenkins & Baptist, 2006).
Militarization has created new demands for services
and challenges for progressive practice. Veterans and
soldiers' families need more and more services even as
military budgets drain public coffers. In poor commu-
nities, military service promises the education, training,
and employment that were once provided through a
public education system that, like social welfare, is
being defunded and by an economy with fewer and
fewer jobs (Davis, Cummings, MacMaster, &
Thompkin, 2007). These conditions have challenged
progressives, typically anti-war, to engage with the
military in new ways that are consistent with their
values and commitments.
Postmodemism
Emerging philosophical trends of postmodemisrn and
poststructuralism rendered action more difficult just as
conditions demanded action (Noble, 2004; Wood,
1997). Social work and social welfare arose in the era of
"modernity," characterized by "metanarratives" and
belief in the potential universality of concepts of justice,
needs, and rights (Leonard, 1995; Pease & Fook, 1999).
Although there are many iterations and debates among
them, postmodernist and poststructuralist thinkers
challenged modernity's "universalized" discourse,
advancing the notion that there are many competing
"truths" shaped by such multiple interacting factors as
culture and language, experience of oppression and
power, social relationships, consciousness, and more
(Howe, 1994, 1996; Ife, 1999; Smith & White, 1997).
Some postmodernists, affirming the relativity of
"truth," reject the "privileging" of any particular truth.
The challenge to social work is clear: If justice, needs,
rights, and truths are diverse and relative, and if the
imposition of one group's notions over others' must be
eschewed, what is the basis for action in the world, and
who can claim the right to act in ways that affect others
(Solas, 2002; Taylor-Gooby, 1994)? The challenge to
progressive social workers, whose very essence is
action for justice, is particularly crucial and sharp:
"How do we uphold a metanarrative of 'social justice'
while at the same time deconstructing it?" (Fook, 2003 ,
p. 127).
Standpoint theorists have helped address activists'
dilemma. They agree that all truth is relative and in-
complete, but reaffirm a concrete basis for judgment and
action. They assert that one's social group member ship
shapes both one's truth and one's power to impose it on
others. Particularly (but relatively) powerful groups
include capitalists, men, straight people, academics, and
professionals (Campbell & Ungar, 2003; Witkin, 1999).
The material and historical exercise of their power can
be analyzed and challenged. This theoretical stance
underpins much progressive antioppression work.
J

The philosophical challenges to modernity also
benefited progressive work. Its epistemological interro-
gation of positivism breathed new life into alternative
epistemologies and to collaborative, participatory, nar-
rative, and other qualitative approaches to research
(Alavarez & Gutierrez, 2001; Denzin, Lincoln, & Giardina,
2006; Fook, 1996; Fraser, 2004; Golightley, 2004); its
emphasis on the forces that shape conscious ness and "false
consciousness" reenergized the politi cized approaches to
feminist practice (Dominelli, 2002a; Gorey, Daly, Richter ,
Gleason, & McCallum, 2003; Israeli & Santor, 2000;
Mizrahi, 2007; Orme, 2003) and empowerment practice
(Cox & Joseph, 1998; Hur, 2006; Lee, 2001); it stimulated
a more complex understanding of dynamics of oppression
and the potential for anti-oppressive practice (Dominelli,
2002b; Mullaly, 2002; Van Wormer, 2004); it unmasked
but generated correctives to the power agenda and
functions of the welfare state (Ferguson, 2004; Pease &
Fook, 1999; Scheyett, 2006; Stepney, 2006) and social
work education (Corvo, Selmi, & Morey, 2003; Dudziak,
2004; Husebo & Andrews, 2004; Preston-Shoot, 2004;
Rossiter, 1996, 2001); it facilitated narrative and the
validation of multiple truths in discourse with clients and
colleagues (Bullock, 2004; Cohen, 1998; Darling, Hager,
Stockdale, & Heckert, 2002; .Peile, 1998; Spratt & Callan,
2004); and it provided a firm philosophical foundation for
strengthening diversity and for a potential transformation
of the worker-client relationship from one of "ser vice" to
one of "solidarity" (Beresford & Croft, 2004;
Bricker-jenkins, Young, & Honkala, 2008). The new
relationships are based more in power and class analyses
than in naive notions of "partnership" in practice (Heron,
2005; Lavalette & Mooney, 2001; Morley, 2004, Olson,
2007; Solas, 2000).
In sum, progressive social workers have been unwilling
to abandon an emancipatory agenda but take seriously the
challenges that postmodernism has made to its traditional
philosophical underpinnings. Progressives have made
efforts to bridge, merge, or fuse the competing
philosophical traditions (Dominelli, 2005; Ife, 1997, 1999 ;
Leonard, 1997; Mullaly, 2001, 2002; Pease & Fook, 1999).
While differences remain among them, there appears to
be consensus on these principles to inform practice: that
there are multiple "truths" and ways that power and
oppression are created, experienced, and maintained; there
is a need for structural changes to eliminate the "empirical
realities" of domination and oppression; analysis cannot
substitute for action, which must take place even in
uncertainty, for failure to act is to act; and while
acknowledging our power and
1
PROORESSlVE SOCIAL WORK 437
privilege, we must "synthesize a politics of difference with
a politics of solidarity in practice" (Mullaly 200l).
Innovations in Progressive Social Work Building on
the core described by Bombyk (1995), progressives have
responded to the structural and intellectual changes of the
past decades with innovations as well as critique.
Specifically, there have been developments and
refinements in practice frameworks and concepts as well
as demonstrations of progressive practice in multiple
settings.
Several authors propose "anti-oppression" as a
framework that can bridge structural and postmodern
approaches (Dominelli; Mullaly, 2002; Van Wormer ,
2004). They preserve the sociopolitical analysis of
personal troubles, affirming the universality of the hu man
need for health and autonomy, and use new social
movement theory to ground action' in particular and unique
communities. Ferguson and Lavalette (2006) have refined
the notion of "resistance" in practice, illustrating ways it
can be used in agencies and the po litical arena.
Meta-analyses of theory and research in feminist practice
(Israeli & Santor, 2000) and empowerment practice (Hur,
2006) have reaffirmed political consciousness and
activism as essential elements of effective practice.
Reconceptualizing "community" in the context of
globalization and postmodernism has stimulated action
based in a more nuanced, less roman tic notion of both
"place" and "non-place" communities (Defilippis, Fisher,
& Shragge, 2007; Fisher, Fabricant, & Simmons, 2005).
A human rights approach to social work, developed
early on by progressives (Baptist, Bricker-jenkins, &
Dillon, 1999; lfe, 2001; Jones, Bricker-jenkins, & KWRU,
2002; Witkin, 1999; Wronka, 1992) has now gained
currency in mainstream social work (Reichert, 2003;
Wronka, in press). A framework that focuses specifically
on economic human rights has emerged from a collabora-
tion between progressive social workers and people living
in poverty (jones, Bricker-jenkins & KWRU, 2002). Social
workers can be found in most of the approximately one
hundred member organizations of the Poor People's
Economic Human Rights Campaign (PPEHRC) where
they are applying and refining this economic human rights
framework with poor and homeless people. Recently they
have united with parents of children in care to challenge
public child welfare agencies' denial of both civil and
economic human rights (Bricker-jenkins, Young, &
Honkala, in press). With others, they are also taking up the
theoretical project of refining social movement theory and,
in particular, interrogating the concept of "the poor" as an
identity group (Thompson, 2002). The national
organization of progressive social and
438 PROGRESSIVE SOCIAL WORK
human service workers, SW AA, has made a formal alli-
ance with PPEHRC, holding joint conferences and actions
since mid-1990s.
In addition to these emerging concepts and frame-
works, a tremendous diversity of approaches to progres-
sive practice is evidenced in the literature. For example,
progressives have used a critical "lens" to develop re search
and practice in such varied fields as child welfare (Parton,
1999; Spratt, 2001, 2004; Spratt & Houston, 1999), youth
work (Rogowski, 2004; Skott-Myhre, 2005), caregiving
(Berg-Weger, Rubio, & Tebb, 2000; Dow & McDonald,
2003), addictions (Morell, 1996), and mental health
(Ferguson, 2003; Furlong, 2003; Morley, 2003). The
literature also demonstrates a wide range of progressives'
interests, examples include "macro" research (Clarke,
Islam, & Paech, 2006; Gardner, 2003), social work
education (Prichard, 2006), international policy studies
(Gough, 2000b), the exploration of ethical issues (Deitz &
Thompson, 2004; De Maria, 1997), practice with groups
(Cohen & Mullender, 1999), community development
(George & Marlowe, 2005), and community organizing
(Fisher, Brooks, & Russell, 2007).
The activist character of progressive social work and
the very nature of praxis are such that much of progressives'
most innovative work and important debates often are not
reflected in mainstream publications. However, at least
two discussion boards are essential resources:
http://groups.yahoo.com/bertha-swaa is based in the U.S.,
and http://www.radicaLorg.uk/barefoot is based in Great
Britain. Both use technology effectively to advance
practice rapidly and document current work and
discussions among progressive practitioners and scholars.
Taken together, current discussions and literature may
evidence a growing class analysis among progressives
fueled by several factors (Fabricant & Burghardt, 1992;
Lavalette & Mooney, 200l) including increasingly
restrictive policies and programs lead to heightened
awareness of the ways that social workers may unwittingly
collude in the oppression of their clients; a commodified,
de-skilled, privatized social welfare system has led to
increasing economic hardships experienced by social
workers and mounting impediments to meeting clients'
needs; advances in anti-oppression theory and practice
have facilitated an analysis of the ways that systems of
oppression are both interconnected and selectively used to
undermine solidarity among groups; and collaborations
between social workers and groups led by immigrants, the
homeless, and others living in poverty have been built on
and deepened an understanding of common class interests
and the potential of class-based action.
Challenges and Future Trends
In the coming decade, progressives face theoretical and
practical challenges and opportunities in a postmodem,
globalized world. Most fundamental is the debate about
the future of the welfare state itself. In the face of historic
structural transformation, institutionalized means to meet
human need will continue to be a necessary and significant
element in the evolving social contract. Some analysts
urge advocacy to save what can be saved of the existing
social welfare state; others believe that the institution of
social welfare is an artifact of the past industrial age and
seek unity with those displaced in our labor-replacing
electronic age through class-based activism (Glatzer &
Rueschemeyer, 2005). There appears to be consensus that
the robust programs of the past are incompatible with the
interests of global capital, but analytical and strategic
questions remain.
Related to positions on the future of the welfare state
are debates about arenas for action. For example, some
progressive social workers view electoral politics and the
standing organizations of the profession as primary sites of
struggle; others regard them as instruments of a corporate
class whose interests are incompa tible with most people
(http://groups.yahoo.com/ bertha-swaa). Some,
distinguishing between strategies and tactics, attempt to
work in both. The PPEHRC allied with a chapter of the
National Association of Social Workers in using
legislative tactics in their strategic effort to build a national
movement to end poverty (Bricker-jenkins, 2004). As
resources and services are increasingly rationed and
controlled, analyses of the welfare state under
neoliberalism also influence the degree to which
progressives are willing to seek and support concessions;
some are more willing than others to accept, for example,
health insurance instead of universal health care, or the
elimination of "extreme poverty" rather than the abolition
of poverty.
The workplace is a continuing arena for struggle
among progressives. Agencies are becoming more. re-
strictive and, while there appears to be an overall increase
in social work jobs, they appear to be less well paid and
less satisfying (Ferguson & Lavalette, 2006). The tum to
evidence-based practice, while stressing accountability in
an era of shrinking material resources, inevitably limits
innovation and deflects attention from the struggle for
concrete services (Reisch, 2006). Actions outside the " arc
of legitimacy" are increasingly discouraged. For example,
a clinical social worker was reprimanded by the state
licensing authority and threatened with loss of her
professional license when she was arrested for civil
disobedience in a non-violent protest (Jones, 2002 ).
Despite an increasingly repressive environment, however,
immigrant workers and others have

continued to use oppositional tactics in a strategic effort
to build community-based alternatives to neoliberal
policies (DeFilippis, Fisher, & Shragge, 2007).
Even the project of theorizing and educating for
practice may be impeded as some universities and
foundations direct rewards and funding to scholarship
considered "rigorous;" when this term refers primarily to
the production of quantified data and studies about
limited phenomena (Davis, Cummings, MacMaster, &
Thompkin, 2007). Similarly, the very meaning of core
concepts in progressive social work analysis has been
contested. Historically, such concepts as human need,
empowerment, feminism, and class have been stripped
of radical content ~ they entered the mainstream (Agger,
1989; Joseph, 1986; Wachholz &
Mullaly, 2004). \
Nevertheless, historical conditions present new
opportunities for progressive social workers. While
practice auspices may limit some opportunities for ac-
tion, they force needed attention to the micro processes
of progressive practice. Further, the need and possibili-
ties for action and organizing outside the agency be-
comes clearer. In England, social workers have gone on
strike, not for better pay, but for the right to fulfill their
professional mandates (Ferguson & Lavalette, 2004).
Although social workers in the U.S. have had an am-
bivalent relationship with unions (Rosenberg & Rosen-
berg, 2006), progressives typically are supportive of
labor organizing and may well provide seasoned leader-
ship in similar efforts. Organizing and action can also be
informed by refined theory; some progressives are
reexamining social movement theory and, in particular,
. interrogating the concept of "the poor" as an identity
group (Thompson, 2002). This theoretical work is vital
to the need to engage with the "new class of poor," the
economically displaced families who are coping with
poverty despite successful education and employment
histories (Bricker-jenkins & Baptist, 2006).
At least two additional challenges and opportunities
will likely become pressing for progressive social work-
ers in the near future: forging stronger links to the anti-
war/peace movement and with the global movements for
resistance to neoliberalism (Bircham & Charlton, 2001;
Reza, 2003). In the US, the former has been deeply
divided over the rights of people in the Middle . East,
rendering alliances difficult. Meanwhile, particularly in
the southern hemisphere, resistance to globalization's
neoliberalism has matured into new forms of the social
contract between the state and the people, producing
changes in the definition and role of social workers. In
the US, as part of the World Social Forum process, the
first United States Social Forum was held in 2007.
Organized under the banner "Another world is
j
PROORESSlVE SOCIAL WORK 439
possible, another US is necessary," the event brought
together 20,000 activists, mostly from grass-roots orga-
nizations, for four days of dialog and networking. While
social work had no organized presence at the forum,
some individual social workers in attendance noted with
optimism that progressives' evolving analyses and
actions strongly suggest a move toward alignment with
forces of resistance globally and in U.S. communities.
Acknowledgements
The authors acknowledge the substantial contributions
to this entry from the participants of the internet dis-
cussion board of the Social Welfare Action Alliance,
most especially David Boyle, Jean Brookbank, Shawn
Cassiman, Marcia Cohen, Christie Coho, Michael
Dover, Joan Dworkin, Betty Mandell, Marilynn Moch,
Fred Newdom, Sandford Schram, and Ann Withorn.
The discussion: can be accessed at http://groups.yahoo.
corn/group/bertha-swaa under the thread, "Progressive
social work: poetry, pipe dream, or practice?"
REFERENCES
Abramovitz, M. (2004, March). The real purpose of welfare
reform. BCR Reports: Newsletter of the Social Welfare Action
Alliance, p. 1.
Agger, B. (1989). Socio(onto)logy: A disciplinary reading. Chi-
cago: University of Illinois Press.
Agger, B. (1992). Marxism, feminism, deconstruction: Reading
sociology. In C. Gailey & V. Muller (Eds.), The politics of
culture and creativity. Tallahassee, FL: Florida State University
Press.
Alavarez, A. R., & Gutierrez, L. (2001). Choosing to do
participatory research: An example and issues of fit to
consider. Journal of Community Practice, 9(1),1-20.
Baines, D. (2000). Everyday practices of race, class, and gender:
Struggles, skills, and radical social work. Journal of Progressive
Human Services, 11 (2),5-27.
Bak, M. (2004). Can developmental social work change an unfair
world? International social work, 47(1), 81-94.
Baptist, W., & Bricker-jenkins, M. (2001). A view from the
bottom: Poor people and their allies respond to welfare reform.
The Annals of the American Academy of Political Science, 577,
144-156.
Baptist, W., Bricker-jenkins, M., & Dillon, M. (1999). Taking the
struggle on the road: The new freedom bus-Freedom from
unemployment, hunger, and homelessness. Journal of
Progressive Human Services, 10(2), 7-29.
Beresford, P., & Croft, S. (2004). Service users and practitioners
reunited: The key component for social work reform. British
Journal of Social Work, 34, 53-68.
Berg-Weger, M., Rubio, D. M., & Tebb, S. S. (2000). The
caregiver well-being scale revisited. Health & social work,
25(4),255-263.
Bircham, E., & Charlton, J. (2001). Anti-capitalism: A guide for
the movement. London: Bookmarks.
440 PROGRESSIVE SOCIAL WORK
Bombyk, M. (1995). Progressive social work. In R. Edwards
(Ed.), Encyclopedia of social wark (19th ed., pp. 1933-1942).
Washington, DC: NASW.
Boyle, D. P. (2007, January 5). Progressive social wark. Personal
communication.
Bricker-jenkins, M. (2004). Legislative tactics in a movement
strategy: The economic human rights-Pennsylvania campaign.
Meridians, 4(1), 108-113.
Bncker-jenkins, M., & Baptist, W. (2006). The movement to end
poverty in the United States. In R. E. HowardHassman & C. E.
Welch Jr. (Eds.), Economic rights in Canada and the United
States (pp. 103-117). Philadelphia:
University of Pennsylvania Press.
Bricker-jenkins, M., Young, c., & Honkala, C. (2007). Using
economic human rights in the movement to end poverty:
The Kensington welfare rights union and the poor people's
economic human rights campaign. In E. Reichert (Ed.),
Challenges in human rights: A social wark perspective. (pp.
122-137). New York: Columbia University Press.
Bullock, H. (2004). From the front lines of welfare reform: An
analysis of social worker and welfare recipient attitudes.
Journal of Social Psychology, 744(6), 571-588.
Butler, 1.,& Drakeford, M. (2000). Editorial. British Journal of
Social Work, 30(1),1-2.
Campbell, c., & Ungar, M. (2003). Deconstructing
knowledge claims: Epistemological
challenges in social work education. Journal of
Progressive Human Services, 14(1), 41-59.
Clarke, M., Islam, S. M. N., & Paech, S. (2006). Measuring
Australia's well-being using hierarchical needs. The Journal of
Socio-Economics, 35(6), 933-945.
Cohen, M. B. (1998). Perceptions of power in client/worker
relationships. Families in society, 79(4), 433-442.
Cohen, M. B., & Mullender, A (1999). The personal in the
political: Exploring the group work continuum from indi-
vidual to social change goals. Social Work With Groups, 22(1),
13-31.
Corvo, K., Selmi, P., & Morey, S. (2003). Icons of conformity:
The marketing of social work education. Journal of Community
Practice, 11 (1), 85-99.
Cox, E. 0., & Joseph, B. H. R. (1998). Social service delivery and
empowerment: The administrator's role. In L. M. Gutierrez,
R.J. Parsons, & E. O. Cox (Eds.), Empowerment in social work
practice: A sourcebook (pp. 167-186). Pacific Grove, CA:
Brooks/Cole.
Darling, R. B., Hager, M. A, Stockdale, J. M., & Heckert, D. A
(2002). Divergent views of: clients and professionals: A
comparison of responses to a needs assessment instrument.
Journal of Social Service Research, 28(3), 41-63.
Davis, C., Cummings, S., MacMaster, S., & Thompkin, A. (2007).
Responding to the war with Iraq among social work faculty in
the USA, UK, and Australia. International Social Work, 50(2),
185-195.
De Feyter, K. (2002). Human rights: Social justice in the age of the
market. London: Zed Books.
De Maria, W. (1992a). Alive on the streets, dead in the classroom:
The return of radical social work and the
manufacture of radicalism. Journal of Sociology and Social
Welfare, 19(3),137-158.
De Maria, W. (1992b). On the trail of a radical pedagogy for
social work. British Journal of Social Wark, 22(3), 231-252.
De Maria, W. (1997). Flapping on clipped wings: Social work
ethics in the age of activism. Australian Social Wark, 50(4), 3-19.
Defilippis, J., Fisher, R., & Shragge, E. (2006). Neither romance
nor regulation: Re-evaluating community, International Journal
of Urban and Regional Research, 30(3), 673-689.
DeFilippis, J., Fisher, R., & Shragge, E. (2007). What's left in the
community? Oppositional politics in contemporary practice.
Community Development Journal. Retrieved September 11,
2007, from http://cdj.oxfordjournals.org/cgi/con
tent/full/bsmO 1 Ov 1
Deitz, c., & Thompson, J. (2004). Rethinking boundaries:
Ethical dilemmas in the social worker-client relationship.
Journal of Progressive Human Services, 15(2), 1-24.
Denzin, N. K. (2002). Social work in the seventh moment.
Qualitative Social Wark, 1 (1), 25-38.
Denzin, N. K., Lincoln, Y. S., & Giardina, M. D. (2006).
Disciplining qualitative research. International Journal of
Qualitative Studies in Education, 19(6),769-782.
Dominelli, L. (2002a). Feminist social wark: Theary and practice.
New York: Palgrave Macmillan.
Dominelli, L. (2002b). Anti-oppressive social wark: Theory and
practice. New York: Palgrave Macmillan
Dominelli, L. (2004). Social work: Theary and practice for a
changing profession. Oxford: Polity Press.
Dominelli, L. (2005). Social wark futures: Crossing boundaries,
transfarming practice. New York: Palgrave Macmillan.
Dow, B., & McDonald, J. (2003). Social support or structural
change? Social work theory and research on care-giving.
Australian Social Wark, 56(3), 197-208.
Dudziak, S. (2004). Educating for justice: Challenges and
openings on the context of globalization. In 1. Ferguson, M.
Lavalette, & B. Whitmore (Eds.), Globalisation, global justice
and social wark.London: Taylor & Francis.
Fabricant, M. B., & Burghardt, S. (1992). The welfare state crisis
and the transformation of social service work. Armonk, NY:
M.E. Sharpe.
Fabricant, M., & Fisher, R. (2002). Settlement houses under siege:
The struggle to sustain community organizations in New Yark City.
New York: Columbia University Press.
Ferguson, 1. (2003). Mental health and social work. In D. Baillie,
K. Cameron, L A Cull, J. Roche, & J. West (Eds.), Social wark
and the law in Scotland. Basingstoke:
Palgrave Macmillan/Open University.
Ferguson, 1. (2004). Neoliberalism, the third way and social
work: The UK Experience. Social Work and Society, 2(1), 1-9.
Retrieved September 11, 2007, from http://www.soc
work.net/2004/ 1/articles/4 25jFerguson2004.pdf
Ferguson, 1. (2006). Another world is possible: Radical social
work in the 21st century. Socialno Delo, 45(3-5).
Ferguson, 1., & Lavalette, M. (2004). Beyond power discourse:
Alienation and social work. British Journal of Social Work,
34,297-312.

Ferguson, 1, & Lavalette, M. (2006). Globalisation and global
justice: Towards a social work of resistance. International
SodaIVVork,49(3),309-318.
Ferguson, I., Lavalette, M., & Mooney, G. (2002). Rethinking
welfare: A critical perspective. London: Sage.
Ferguson, I., Lavalette, M.,& Whitmore, B. (Eels.). (2004).
Globalisation, global justice and social work. London: Taylor &
Francis.
Fisher, R., Brooks, F., & Russell, D. (2007). "Don't be a
blockhead" ACORN, protest tactics, and refund anticipation
loans. Urban Affairs Review, 42(4), 553-582.
Fisher, R., Fabricant, M., & Simmons, L. (2005). Understanding
contemporary university-community connections:
Context, practice, and challenges. Journal of Community
Practice, 12(3), 13-34.
Fook,]. (1996). The reflective researcher: Social workers' theories of
practice research. Sydney: Allen & Unwin.
Fook,]. (2003). Critical social work: The current issues. Quali-
tative Social VVork, 2(2), 123-130.
Fording, R., Soss, ]., & Schram, S. (2007, July). Distributing
discipline: Race, politics, and punishment at the front lines of
welfare reform. University of Kentucky Center for Poverty
Research Discussion Paper Series, DP2007-04. Retrieved
September 11, 2007, from http://www.ukcpr.org/Publica
tionsjDP2007 -04/pdf
Fraser, H. (2004). Doing narrative research: Analysing personal
stories line by line. Qualitative Social Work, 3(2), 179-201.
Furlong, M. (2003). Self determination and a critical perspective
in casework: Promoting a balance between interdependence
and autonomy. Qualitative Sodal VVork, 2(2), 177-196.
Gardner, F. (2003). Critical reflection in community-based
evaluation. Qualitative Social VVork, 2(2), 197-212.
George, P., & Marlowe, S. (2005). Structural social work in
action: Experiences from rural India. Journal of Progressive
Human Services, 16(1),5-24.
Gil, D. G. (1998). Confronting injustice and oppression: Concepts and
strategies for social workers. New York: Columbia University
Press.
Gil, D. G. (2004). Perspectives on social justice. Reflections:
Narratives of Professional Helping, 10,32-39.
Gilbert, N. (2002) . Transformation of the welfare state: The silent
surrender of public responsibility. New York: Oxford University
Press.
Glatzer, M., & Rueschemeyer, D. (Eds.). (2005). Globalization and
the future of the welfare state. Pittsburgh: University of
Pittsburgh Press.
Golightley, M. (2004). Social research methodology: A critieal
introduction. British Journal-of Social Work, 34(4), 602-603.
Gorey, K. M., Daly, C, Richter, N. L., Gleason, D. R., &
McCallum, M.]. A. (2003). The effectiveness of feminist
social work methods: An integrative review. Journal of Sodal
Service Research, 29(1), 37-55.
Gough, I. (2000a). The needs of capital and the needs of / people:
Can the welfare state reconcile the two? In I. Gough (Ed.), Global
capital, human needs, and sodal policies:
Selected essays, 1994-99 (pp, 3-29). New York: Palgrave.
.J
i
j
PROGRESSIVE SOCIAL WORK 441
Gough, I. (2000b). Why do levels ofhurnan welfare vary across
nations? In I. Gough (Ed.), Global capital, human needs, and
social polides: Selected essays, 1994-99 (pp. 105-130). New
York: Palgrave.
Gough, I. (2004). Human well-being and social structures:
Relating the universal and the local. Global Sodal Policy,
4(3),289-311.
Harris,]. (2003). The social work business. London: Routledge.
Harris, ]. (2004). Globalisation, neo-liberal managerialism and
UK social work. In I. Ferguson, M. Lavallette, & B. Whitmore
(Eds.), Globalisation, global justice and social work. London: Taylor
& Francis.
Healy, K. (2000). Social work practices: Contemporary perspectives
on change. London: Sage.
Healy, K. (200l). Reinventing critical social work: Challenges
from practice, context and postmodernism. Critical Sodal Work,
2(1). Retrieved September 11, 2007, from http://
www.criticalsocialwork.com/units/soc ialwork/ cri t ical.nsf/
printerFriendl y View /7 62E38 9 7 93 B864 5 D85 25 6
EA8006 36F2B
Healy, K., & Leonard, P. (2000). Responding to uncertainty:
Critical social work education in the postmodem habitat.
Journal of Progressive Human Services, 11 ( 1), 23-48.
Heron, B. (2005). Self-reflection in critical social work practice:
Subjectivity and the possibilities of resistance. Reflective
Practice, 6(3), 341-351.
Hick, S. F., Fook, ]., & Pozzuto, R. (2005). Social work: A critical
tum. Toronto: Thompson Eelucational Publishing.
Howe, D. (1994). Modernity, postmodemity and social work.
British Journal of Sodal Work, 24, 513-532.
Howe, D. (1996). Surface and depth in social work practice. In N.
Patron (Ed.), Social theory, social change and social work.
London: Routledge.
Hur, M. H. (2006). Empowerment in terms of theoretical
perspectives: Exploring a typology of the process and com-
ponentsacross disciplines. Journal of Community Psychology,
34(5), 523-540.
Husebo, S., & Andrews,]. (2004). Collaborative education in a
radical.social work course. Journal of Progressive Human
Services, 15(1), 25-40.
Ife,]. (1999). Postmodernism, critical theory and social work.
In B. Pease & ]. Fook (Eds.), Transforming social work practice:
Postmodern critical perspectives. Sydney: Allen & Unwin.
Ife,]. (200l). Human rights and social work: Towards rights-based
practice. New York: Cambridge University Press.
Israeli, A. E., & Santor, D. A. (2000). Reviewing effective
components of feminist therapy. Counselling Psychology
Quarterly, 13(3),233-247.
Jones, c. (2004). The nee-liberal assault: Voices from the
frontline of British state social work. In I. Ferguson, M.
Lavallette, & B. Whitmore (Eds.), Globalisation, global justice
and social work. London: Taylor & Francis.
Jones, J., Bricker-jenkins, M., with members of the Kensington
Welfare Rights Union. (2002). Creating strengths-based
alliances to end poverty. In D. Saleebey (Ed.), The strengths
perspective in sodal work (3rd ed., pp. 186-212). Boston:
Allyn & Bacon .
442 PROGRESSIVE SocIAL WORK
Lavalette, M., & Mooney, G. (Eds.). (2001). Class struggle and
social welfare. London: Routledge.
Lee, J. A B. (2001). The empowerment approach to social work
practice: Building the beloved community (2nd ed.). New York:
Columbia University Press.
Leonard, P. (1995). Postrnodernism, socialism and social welfare.
Journal of Progressive Human Services, 6(2), 3-19.
Leonard, P. (1997). Postmodern welfare: ReconstruCting an
emancipatory project. Thousand Oaks, CA: Sage.
McDonald, c., Harris, J., & Wintersteen, R. (2003). Contingent
on context? Social work and the State in Australia, Britain,
and the USA British Journal of Social Work, 33, 191-208.
Mills, C. W. (1959). The sociological imagination. New York:
Oxford University Press.
Mishra, R. (1999). Globalization and 'the welfare state.
Cheltenham, UK: Edward Elgar.
Mizrahi, T. (2007). Women's ways of organizing: Strengths and
struggles of women activists over time. AFFILIA, 22(1),39-55.
Moffatt, K. (1999). Surveillance and government of the welfare
recipient. In A S. Chambon, A Irving, & L. Epstein (Eds.),
Reading foucault for sodal work. New York: Columbia
University Press.
Morell, C. (1996). Radicalizing recovery: Addiction, spirituality,
and politics. Sociol Work, 41 (3), 306--312.
Morley, C. (2003). Towards critical social work practice in mental
health: A review. Journal of Progressive Human Services,
14(1),61-84.
Morley, C. (2004). Critical reflection in social work: A response
to globalisation? International Journal of Social
Welfare, 13(4), 297-303. . Rossiter, A (1996). A perspective on critical social work.
Mullaly, B. (2001). Confronting the politics of despair: Toward
the reconstruction of progressive social work in a global
economy and postmodern age. Social Work Education;
20(3),303-320.
Mullaly, B. (2002): Challenging oppression: A critical sodal work
approach. Don Mills, OT: Oxford University Press.
Noble, C. (2004). Postmodern thinking: Where is it taking social
work? Journal of Social Work, 4(3),245-267.
Noonan, J. (2006). Democratic society and human needs. Montreal:
McGill-Queen's University.
Olson, J. J. (2007). Social work's professional and social justice
projects: Discourses in conflict. Journal of Progressive Human
Services, 18(1),45-69.
Orme, J. (2003). It's feminist because I say so!: Feminism, social
work and critical practice in the UK. Qualitative Social Work,
2(2),131-154.
Parton, N. (1999). Reconciling child welfare practices: Risk,
advanced liberalism, and the government of freedom. In A S.
Chambon, A. Irving, & L. Epstein (Eds.), Reading foucault for
sociai work. New York: Columbia University Press.
Parton, N., & O'Byrne, P. (2000). Constructive sodal work:
Towards a new practice. Basingstoke: MacMillan.
Pease, B., & Fook, J. (Eds.). (1999). Transforming social work
practice: Postmodern critical perspectives. Sydney: Allen &
Unwin.
Peile, C. C. (1998). Emotional and embodied knowledge:
Implications for critical practice. Journal of Sociology and Social
Welfare, 25(4), 39-59.
Preston-Shoot, M. (2004), Responding by degrees: Surveying the
education and practice landscape. Social Work Educa-
tion,23(6),667-692.
Prichard, D. (2006). Deconstructing psychopathology: Con-
textualizing mental disorders in teaching psychosocial as-
sessment. Journal of Progressive Human Services,J 7( 2), 5-26.
Razin, A, & Sadka, E. (2005). The decline of the welfare state:
Democracy and globalization. Cambridge, MA: MIT Press; Reeser,
L. c., & Epstein, I. (1990). Professionalization and activism in
social work: The sixties, the eighties, and the future. New York:
Columbia University Press.
Reichert, E. (2003). Sodal work and human rights: A foundation for
policy and practice. New York: Columbia University Press.
Reisch, M. (2004). American exceptionalism and critical social
work: A retrospective and prospective analysis. In I. Ferguson,
M. Lavalette, & B. Whitmore (Eds.), Globalisation, global
justice and social work. London: Taylor & Francis.
Reisch, M. (2006). Editorial: Workforce study falls short. Sodal
Work, 51(4), 291-293.
Reisch, M., & Andrews, J. (2002). The road not taken: A history of
radical social work in the United SWtes. New York: Brunner-
Routledge.
Reza, F. (Ed.). (2003), Anti-imperialism: A guide for the movement.
London: Bookmarks.
Rogowski, S. (2004). Young offenders: Towards a radical/critical
social work practice. Youth amI Policy, 82,60-74.
Journal of Progressive Human Services, 7(2), 23-41.
Rossiter, A (2001). Innocence lost and suspicion found: Do we
educate for or against social work? Critical Social Work, 2(1).
Retrieved July 24,2007, from www.criticalsocialwork. com
Schram, S. (2006). Welfare discipline: Discourse, governance, and
globalization. Philadelphia: Temple University Press.
Scheyett, A. (2006). Silence and surveillance: Mental illness,
evidence-based practice and a foucaultian lens. Journal of
Progressive Human Services, 17(1), 71-92.
Selrni, P., & Hunter, R. (2001). Beyond the rank and file
movement: Mary van Kleeck and social work radicalism in the
great depression, 1931-1942. Journal of Sociology and Social
Welfare, 28(2), 75-100.
Skott-Myhre, H. A (2005). Captured by capital: Youth work and
the loss of revolutionary potentiaL Child and Youth Care
Forum,34(2),141-157.
Smith, c., & White; S. (1997). Parton, Howe and postrnod-
ernity: A critical comment on mistaken identity. British
Journal of Social Work, 27, 275-295.
Solas, J. (2000a). Can a radical social worker believe in human
rights? Australian Sodal Work, 53(1),57-70.
Solas, J. (2000b). The tyranny of therapeutic dialogue. Social
Semiotics, 10(3),347,--353.
Solas, J. (2002). Once were Marxists: Reclaiming the radical
imperative in human service practice. Journal of Social Work,
2(2),233-246.
J

Spratt, T. (200l). The influence of child protection practice
orientation on child welfare practice. British Journal of Social
Work, 31, 933-954.
Spratt, T. (2004). Radical drama with children using critical
social work methods. In S. Hick, J. Fook, & R. Pozzuto
(Eds.), Social work: A critical tum. Toronto: Thompson Edu-
cational Publishing. .
Spratt, T., & Callan,]. (2004). 'Parents' views on social work
interventions in child welfare cases. British Journal of Social
Work, 34,199-244.
Spratt, T., & Houston, S. (1999). Developing critical social
work in theory and in practice: Child protection and com-
municative reason. Child and Family Social Work, 4(4),
315-324.
Stepney, P. (2006). Mission impossible? Critical practice in
social work. British Journal of Social Work, 36(8),1289-1307.
Stoesz, D. (1997). The end of social work. In M. Reisch & E.
Gambrill (Eds.), Social Work in the 21st Century (pp.
368-375). Thousand Oaks, CA: Sage.
Taylor-Gooby, P. (1994). Postmodernism and social policy: A
great leap backwards? Journal of Social Policy, 23(3),
385-404.
Teeple, G. (2000). Globalization and the decline of social reform:
Into the twenty-first century. Toronto: Garamond.
Teeple, G. (2004). The riddle of human rights. Amherst, NY:
Humanity Books.
Thompson, N. (2002). Social movements, social justice and
social work. BritishJournal of Social Work, 32, 711-722.
Thompson, P. (2005). Who's afraid of Saul Alinsky? Radical
traditions in community organizing. FORUM: for
promoting 3-19 comprehensive education, 47(2), 199-206.
Van Wormer, K. (2004). Confronting oppression, restoring
justice: From policy· analysis to social action. Alexandria, VA:
CSWE.
Vij, R. (Ed.). (2007). Globalization and welfare: A critical reader.
New York: Palgrave Macmillan.
Voss, R. (2004). Reclaiming our mojo: Challenging the notion
of nontraditional versus conventional methods in social
work practice. Journal of Baccalaureate Social Work, 10(1),
12-27-
Wachholz, S., & Mullaly, B. (2000). The politics of the text-
book: A content analysis of the coverage and treatment of
feminist, radical and anti-racist social work scholarship in
American introductory social work textbooks published
between 1988 and 1997. Journal of Progressive Human Ser-
vices, 11(2),51-76. .
Wagner, D. (1999). Progressive, not. Journal of Progressive
Human Services, 10(2),3-6.
Witkin, S. (1999). Constructing our future. Social Work, 44,
5-8.
Wood, C. (1997). To know or not to know: A critique of
postmodernism in social work practice. Australian Social
Work, 50(3), 21-27.
Wronka, J. (1992). Human rights and social policy in the 21st
century. New York: University Press of America.
Wronka, J. (2008). Human rights and social justice: Action and
service for the helping and health professions. Lanham, MD:
Sage.
PROSTITIITION 443
SUGGESTED
LINKS
http://www.economichumanrights.org
http://www .globalpolicy. org
http://www.radical.org.uk/barefoot
http://www.socialwelfareactionalliance.org
http://www . universityofthepoor .org
-MARY BRICKER-JENKINS AND BARBARA
HUNTER-RANDALL JOSEPH
PROSTITUTION
ABSTRACT: Social workers often come in contact with
women, men, and adolescents who use prostitution as a means
of survival. Individuals may earn their entire income in this
manner. They may use it to supplement low earnings or
welfare benefits, or they may exchange sex for drugs, shelter,
or the protection of pimps. Violence, drug use, arrest, and
transmission of sexually transmitted disease (STD) or HIV are
constant risks of prostitution. Those who engage in
prostitution, whether as prostitutes or as clients, represent the
entire spectrum of American society. This entry discusses a
number of psychosocial issues relevant to understanding the
lives of women who engage in prostitution and implications
for providing social work supports and services.
KEY WORDS: prostitution; sex work; HIVjAIDS; violence
against women; substance abuse
Defining and Estimating
Prostitution and Sex Work
Estimating the number of people engaging in prostitution is
difficult because of the iUegal nature of the activity and
disagreement on the definition. It is generally accepted that
reports of arrests for prostitution significantly undercount the
actual numbers. In 2005, only 84,891 arrests were made for
prostitution and commercialized vice in the United States
(USDOj, 2006). Most prostitutes make efforts to hide their
activities.
In addition, definitions of prostitution vary widely.
In its broadest definition, prostitution includes the exchange
of sex for money, drugs, shelter, or some other commodity.
Goldstein, Ouellet, and Fendrich (1992) reported women
exchanged sex for dental work, furniture, automobile repairs
and tires, television sets, clothes, and professional services of
both physicians and lawyers. The definition of "sex" for
prostitution has often been limited to acts involving physical
contact and not other activities that may all result in
444 PROSTITUTION
orgasm, such as lap dancing, erotic dancing, massage, or
sadomasochistic activities. The more recent term "sex
worker" has socio-economic and political implications for
women who engage in prostitution. it implies that they
have control over their lives, their activity is "work" and
should be regulated in some manner, and they should be
compensated appropriately. Occupa tional safety
regulations, and benefits accrued from work such as social
security and medical benefits should also apply.
Sociocultural Factors and Vulnerability Prostitution
has existed throughout recorded history and has been
more or less accepted at various times and in different
cultures. As with any other social
\
institution, its endurance is a reflection of the social
. need· it meets. Shedlin (1990) found prostitutes "per-
ceived their most important sexual function as provid ing
what other women, 'straight women,' do not like or refuse
to provide" (p. 140).
Poor drug-using women often exchange sex for drugs,
whereas poor drug-using men have other options such as
theft or drug dealing. Factors that tend to influence
women's decisions to barter sex for drugs include the
availability of men who are willing and able to enter into
such a transaction, whether the woman ha s any alternative
criminal skills (for example, sho plifting or forgery), and
how afraid the woman is of engaging in prostitution or
other illegal activities (Goldstein et al., 1992).
Although all sex workers are vulnerable to arrest,
sexually transmitted diseases (STDs), and violence, the
settings in which they engage in their trade may pro vide
more or less protection. Those who work in off street
settings may have somewhat more protection but may be
controlled by an "employer," "madam," or "pimp."
Prostitutes who are on call and must go to a location of the
client's choosing may place themselves at greater risk than
those who work on their own in a Known environment.
Those who engage in street work are usually the most
vulnerable and have fewer resource s with which to protect
themselves (Weiner, 1996) and many are homeless ( Sex
Workers Project, 2003). The clients of prostitutes ,
"johns," may physically abuse the women, refuse to
compensate them after services are rendered, or steal from
them. Often they are not arrested even though they
participate in the activity of prostitution.
Sex, Drugs, and HIV
Drug use is relatively high among prostitutes (Weiner,
1996) and is greater among female prostitutes than among
other female arrestees (Kuhns, Heide, &
Silverman, 1992). The frequency and choice of drugs used
vary among different populations of prostitutes
(Alexander, 1987; Goldstein et al., 1992). Prosti tutes who
inject drugs face risk of HIV infection. Cocaine use is a
risk factor in the transmission of STDs (Gunn et al., 1995 )
and HIV (Weiner, Wallace, Steinberg, & Hoffman, 1992).
For many women, the drug dealer has replaced the pimp
as the protector. Under such circumstances, drug use
increases the number of high-risk sexual encounters.
Much of the research on prostitutes and HIV trans-
mission has focused on the working lives of prostitutes.
Prostitutes' private sexual relations, however, may be
important in understanding the transmission of HIV, .
especially when boyfriends or husbands are their risk of
infection (Day, 1988). Weiner (1996) found streetwalkers
more consistently used condoms for sex with clients, but
were less consistent in using them with their boyfriends or
husbands. This occurred even when their partner had a
history of intravenous drug use.
Civil Liberties and Criminalization Because of
social stigma and financial factors, It IS extremely
difficult for prostitutes to find and hold legitimate jobs.
The criminalization of prostitution, particularly the use
and exchange of illegal drugs for sex, forces practitioners
"underground" and into associations with criminals. Once
in such settings arrest histories accumulate. This may
preclude prostitutes from participating in some
rehabilitation and education programs or, after training,
from qualifying for licenses that would allow them to earn
legitimate incomes.
Challenges and Trends
In 1949 the United Nations adopted a resolution in favor
of the decriminalization of prostitution; this reso lution has
been ratified by 50 countries exc luding the United States.
Various countries handle decriminaliza tion or legalization
in different ways including licensing legal sex workers
with a minimum age and health re quirements, mandatory
health examinations, requiring activities to take place in
private settings, zoning laws, and regulations of brothels.
New Ll.S. legislation (HR 972, 2005) mandates
"intensifying policing of sex workers and low income
people presumed to be sex workers" (BPPP, 2006 ).
Decriminalization and legalization of prostitut ion would
allow specific and limited work. Cooper (1989) has
suggested additional benefits for decriminalization by
offering "women-especially those from economically
deprived backgrounds-the opportunity to earn a living,
support themselves and exercise so me control over their
own sexuality" (p. 112). Many poor women and children
are caught
I
.~

up in sex trafficking and are forced to engage in prosti-
tution. It is unclear whether decriminalization of pros-
titution will reduce trafficking, which remains a problem
in many European countries that already have legalized
forms of prostitution (Otchet, 1998).
Implications for Social Workers
To provide appropriate services, social workers must
understand the life circumstances of this vulnerable and
disenfranchised population. The social dynamics of
prostitution highlight discrimination on the basis of sex,
race, sexual orientation, age, citizenship status, and
socioeconomic status. Evidence indicates that they e ven
face discrimination when approaching social ser vice
agencies for help (Se:J$: Workers Project, 2003). Given
the life circumstances of many of these indivi duals,
prostitution is an alternative that may provide prostitutes
and their families with essential resources.
Workers must appreciate and understand both the
strengths and vulnerabilities of such families and offer
services in a way that supports strengths while consider-
ing a harm-reduction approach that may reduce risks
(Rekart, 2006). Those who work with these women also
need to be concerned about the potential of vio lence from
pimps, johns, drug dealers, boyfriends, and spouses. The
act of asking for or accepting help or even talking to a
social worker may have serious conse quences. Agencies
need to include training to help staff develop sensitivity to
the needs of sex workers and provide needed services such
as mental and physical health, drug detoxification,
housing job training, domestic violence, legal aid, and
advocacy (Sex Workers Project, 2093).
Social workers are encouraged to look for creative
ways to provide outreach and develop relation ships with
this vulnerable population interested in re maining
concealed. Help should be offered to support the strengths
of these clients without compromising them. Working
with such individuals "stretches" work ers to
operationalize their professional values about self-
determination, dignity, and acceptance (Weiner, 1996).
REFERENCES
Alexander, P. (1987). Prostitution: A difficult issue for feminists.
In F. Delacoste & P. Alexander (Eds.), Sex work:
Writings by women in the sex industry. San Francisco, CA:
Cleis Press.
Best Practices Policy Project (BPPP). (2006). New federal
legislation against prostitution. Retrieved October 20, 2006, from
http://www . bestpracticespolicy .org/subpage9 .html Cooper, B.
(1989). Prostitution: A feminist analysis. Women's Rights Law
Reporter, 11(2),99-119.
1
;
J
1
PROSTITIJTION 445
Day, S. (1988). Prostitute women and AIDS: Anthropology.
AIDS, 2,421-428.
Goldstein, P. I., Ouellet L. J., & Fendrich, M. (1992). From bag
brides to skeezers: A historical perspective on sex-for drugs
behavior. Journal of Psychoactive Drugs, 24, 349-361.
Gunn, R. A., Montes, I. M., Toomey, K. E., Rolfs, R. T.,
Greenspan, J. R., Spitters, C. E., et al. (1995). Syphilis in San
Diego County 1983-1992: Crack cocaine, prostitution, and the
limitations of partner notification. Sexually Transmitted
Diseases, 22(1), 60--66.
HR 972. (2005). Trafficking Victims Protection Reauthorization Act
of 2005. Retrieved October 28, 2006, from http://www.
state.gov/g/tip/rls/61106.htm.
Kuhns, J. B. D., Heide, K. M., & Silverman, I. (1992). Substance
use/misuse among female prostitutes and female arrestees.
International Journal of the Addictions, 27, 1283-1292.
Otchet, A (1998). Should prostitution be legal? December 1998 The
United Nations Educational, Scientific and Cultural Or-
ganization. (UNESCO) Courier, December, 37-39.
Rekart, M. L. (2006). Sex-work harm reduction, The Lancet,
366,2123-2134.
Sex Workers Project, Urban Justice Center. (2003). Revolving
Door: An analysis of street-based prostitution in New York
City. NY: Urban Justice League. Retrieved October 20, 2007,
from http://www.sexworkersproject.org/publications/
RevolvingDoor.html
Shedlin, M. G. (1990). An ethnographic approach to under-
standing HIV high-risk behaviors: Prostitution and drug
abuse. NIDA Research Monograph, 93, 134-149.
U.S. Department of Justice, Federal Bureau of Investigation
(USOO}). (2006). Crime in the United States. Retrieved
October 20, 2006, from http://www.fbi.gov/ucr/05cius/
data/table_29.html
Weiner, A (1996). Understanding the social needs of street-
walking prostitutes. Social Work, 41, 97-105.
Weiner, A, Wallace, J. I., Steinberg, A, & Hoffman B. (1992,
July). Intravenous drug use, inconsistent condom use and
fellatio practiced by crack using streetwalking prostitutes are
risky behaviors for acquiring AIDS. In Abstracts of VII
International Conference on AIDS. Amsterdam.
SUGGESTED LINKS Best Practices Policy
Project (BPPP). http://www .bestpracticespolicy
.org/index.html
HIV InSite: Sex Workers, School of Medicine, University of
California, San Francisco.
http://hivinsite.ucsf.edu/InSite?page = li-06-13
Prostitutes' Education Network (PENet).
http://wWw .bayswan. org/penet. html
Prostitution Research & Education Website.
http://www.prostitutionresearch.com/
The Sex Workers Project, Urban Justice Center.
http://www . sexworkersproject.org/
-ADELE WEINER
446 PROTECTIVE SERVICES
PROTECTIVE SERVICES. See Adult Protective
Services; Child Welfare: Overview.
PSYCHOANALYSIS
ABSTRACT: Psychoanalysis is both a theory and a
therapy, largely based on the work of Sigmund Freud
but widely expanded over the last hundred years. The
four core models (ego psychology, drive theory, object
relations, and self-psychology) entail the systematic
exploration of irrational, and generally unc onscious,
behavior. Feminism, postmodernism, and cultural
competence add ideological dimensions for exploring
individual and family life, sexuality, w6 rk and
organizations, and wide-ranging social struggles. New
research in neuroscience is confirming the biological
basis for unconscious emotional processing within the
human brain.
KEY WORDS: psychoanalysis; ego psychology; object
relations; drive theory; self-psychology; organizational
theory; free clinics; Sigmund Freud; neuroscience
Definitions and Descriptions
Nearly 90 years ago, progressive mental health acti vists
descended on Budapest, Hungary, to attend the Fifth
International Psychoanalytic Congress. There, Sigmund
Freud called for "the conscience of society [to] awake,"
and for psychoanalysts to create "clinics where treatment
will be free" (Freud, 1918). From 1918 onward, the
psychoanalysts formally refuted Europe's monarchist
traditions, not only with their belief in the dynamics of the
individual unconscious, but also by pooling their vision
toward the greater good: They joined municipal
governments, mounted lecture programs in the public
schools, and advocated for reforms in mental health and
the regulation of human sexuality. As the great feminist
Emma Goldman wrote "the brilliance of Freud's mind gave
one the feeling of being led out of a dark cellar into broad
daylight. For the first time I grasped the full significance of
sex repression and its effect on human thought and action"
(Goldman, 1977).
Psychoanalysis is both a theory and a therapy, largely
based on the work of Sigmund Freud but expanded over
the last 100 years into a constellation of mental health
treatment methods. The predominant theme in
psychoanalysis is the systematic exploration of irrational
behavior, the domain of the unconscious in all spheres. As
a theory, psychoanalysis is a way of
understanding the multiple dimensions of the human mind
of the individual, the group, and society at large. The
therapy is predicated on the belief that unexa mined
unconscious processes impede" optimum human
functioning and freedom, and that insight into these
processes allows individuals, families, communities, and
organizations to develop mature and equitable selves
(Brandell, 2004). Freud, who began his career as a,
neurologist, named segments of brain activity, and these
psychoanalytic concepts are now imbedded in Western
language and culture. Social work is no excep tion. Key
social work terminology from "trauma" to "ego," from the
"identity" to "transitional object," and the recognition of
human sexuality (where biology is not destiny) stem from
the psychoanalytic literature.
Today psychoanalysis extends over four core models:
ego psychology, drive theory, object relations, andself-
psychology. Feminism, postmodernism, and cultural
competence add ideological dimensions to these models
for exploring individual and family life, sexuality, work,
and wide-ranging social struggles. More recently, neu-
ropsychoanalysis has supplemented this with dramatic
insights into brain physiology (Solms & Turnbull, 2003).
The models do overlap, but each one has its own
psychodynamic theory and its own therapeutic
interventions. As a result, a clinician's treatment ap proach
is usually a mix of a number of models that provide
particular techniques determined by the cli ent's need,
temperament, social arrangement (from individual to an
entire organization), and preference. For example, in
describing his multimodal approach to therapy as
"Systematic Eclecticism," Lazarus (1981) emphasize d that
the social worker must be flexible, versatile, and open
minded in implementing different clinical techniques from
a range of theoretical approaches in order to promote
therapeutic change.
The broadest theoretical model is "ego psychology," a
system of integrated mental activity that creates a
workable balance between a person's unwitting urges and
social reality (Goldstein, 1995). Anna Freud' s idea that the
"executive ego" is an unconscious mediating hub for a
functional system of necessary and protective "defenses"
was taken up by American social workers in the 1940s and
is still widely practiced today alongside Dennis Saleebey's
strength's perspective (Saleebey, 2005). Clinical
interventions from this perspective are direct and
supportive, and are designed to enhance human
motivation, coping, self-esteem, and resilience. In
contrast, "drive theory" analysts explore dreams, interpret
transference and counter-transference processes in the
relationship between the therapist and the client, and
promote insight and responsibility
 )
through self-reflection (Pine, 1990). This is the most
classical model, and it centers on the psychological
impasses caused by deeply repressed sexual or aggressive
conflicts, or on symptoms that may emerge in adult hood
but result from childhood trauma and environ mental
cruelty (Brenner, 1990). Following after drive theory, the
"object relations" model tracks how we hide internal
dramas in memory, and how we later replicate earlier roles
whether or not we want to (Greenberg & Mitchell, 1983).
Object relations treatment helps cli ents assess whether
their current perceptions of reality and behavior are
actually an effort to make sense of a painful past. The
fourth model is "self-psychology" and is widel y applied in
social work (Eson, 1998). The "self' is construed as the
very motor of personality whose ongoing development
requires affirming and empathic relationships with others.
Where drive theorists may view aggression, for example,
as instinctual (or innate) and in need of sublimation,
self-psychologists try to repair the damage caused by
inadequate early nurturing, be it the larger environment or
immediate caretakers (Goldstein, 2002). While these
theories have shaped "virtually all forms of psychothe rapy
practiced today," said Stephen Mitchell, "both object
relations theories and psychoanalytic self- psychology
have been among the most important influences on
casework within social work" (Mitchell & Black, 1995).
To understand how intrapsychic process es influence adult
interpersonal behavior in violent families, for example,
social workers have added object relations theory to
feminist and family systems theories (Walker, 1984).
Psychoanalysis supports the idea of unique human
potential but it is not simply individualistic. As a theory
and a therapy, it aims to help people develop insight into
troubling questions such as "Why do we find our selves in
work environments that seem just like family of origin?"
or "What fears of the 'other' do we project in the form of
racism?" (Galatzer-Levy & Cohler, 1993). Psychoanalysis
can be used to probe complicated moti vations and
conflicts that may underlie a range of human behaviors. It
can give people the opportunity to examine their
assumptions, understand their origins in their lives,
modify them if necessary, and make better choices for
themselves and their communities (Menninger, 1967).
Whether consulting to an organization or treating a n
individual, the psychoanalyst works within and among the
four core models, and also explores certain features
common to all systems of approach. Social work pro -
fessionals tend to stress culturally relevant practice, search
out reasons for normative and non- normative human
behavior, and respect client self-determination.
PSYCHOANALYSIS
447
We attempt to link together our clients' actions, inten tions,
emotions, perceptions, and events 'as a system. These are
the fundamental tenets of psychoanalysis (Fisher, 1991).
Main Developers and Contributors
"I discovered some new and important facts about the
unconscious in psychic life," said Sigmund Freud at the
end of his life. "Out of these findings grew a new science,
Psycho-Analysis" (from a 40-second ei\ ;erpt of. freud
speaking in English and recorded in London in December
1938, less than a year before his death .
http://web.utk.edu/'"'-'wmorgan/psy470/freudvoi. htm).
Psychoanalysis did not come into existence by accident of
course, and thinkers since Plat o have explored the nature
of unconscious mental processes. But Freud's
psychoanalytic theory offered what no other theory had
offered before-a systematic human psychology that is also
a genuine explanatory merger of person and environment,
of individual development and cultural hegemony (Gay,
1998).
Freud's legacy is daunting, but psychoanalysis today is
not the work of one man. His daughter Anna Freud
(1895-1982) pioneered child analysis and stand ardized the
mind's structure of unconscious ego defenses. Alfred
Adler (1870-1937), originator of school-based child
guidance clinics, sought to preempt adult psycho logical
problems by promoting the child's awareness of social
groups. Wilhelm Reich (1897-1957), a pioneer of
body-oriented therapies, saw himself- like many of the
analysts of the 1920s and early 1930s- as a broker of social
change for whom psychoanalysis was a chal lenge to
conventional political codes, a social mission more than a
medical discipline. Heinz Hartmann (1894-1970 )
investigated human adaptive capacity within and outside
an "average expectable environ ment." While developing
her vivid view of infantile fantasy life, Melanie Klein
(1882-1960) found new ways of thinking about "object
relations," the associations of affect, envy, and guilt, and
the reparative quality of human relationships. Donald
Winnicott (1896-1971), also an object relations theorist
and originally a pediatrician, deepened our understanding
of human subjectivity and contributed key concepts of the
"holding environment," the "true self/false self" dia lectic,
and "transitional objects." Harry Stack Sullivan
(1892-1949), arguably the most influential American
psychoanalyst, spearheaded the "interpersonal school"
where both analyst and client are "participant obser vers"
in the therapy. Sullivan's work has had an enor mous
influence on contemporary social science and social
constructivism. For Jacques Lacan (1901-1981),
448 PSYCHOANALYSIS
perhaps the most significant (and prov ocative) French
thinker since Descartes, psychoanalysis grapples with
deeper meanings, including the rich nature of human
desire, by breaking up conventional patterns of lan guage
and thought. Erich Fromm (1900-1980) placed Freud's
psychodynamic system into a broader Marxist historical
perspective and viewed the unconscious as an
existentialist social creation. Karen Homey (18851952),
prefiguring feminist literature, introduced cul tural and
gender relativism into Fre udian theory, and saw that sex
roles were not innate but derived from social meanings
attached to biological differences. For Sandor Ferenczi
(1873-1933), a modernist Hungarian intellectual whose
work anticipated active short- term treatment, authenticity
is essential to overcome the
\
trauma of early abuse (Stanton, 1991). For Bruno
Bettelheim, steeped in the romantic activism of central
Europe's left-wing youth movements, psychoanalysis
represented human liberation, social empowerment, and
freedom from bourgeois convention. Heinz Kohut
(1923-1981) gave us self-psychology. Erik H. Erikson
(1902-1994), who garnered the Pulitzer Prize for his
sequencing of psychosocial life stages, particularized the
social environment's influence on identity and human
development. And Jessica Benjamin and Nancy
Chodorow have confronted society's deeply gendered
constructions of women's identity and intersubjec tiviry,
making them today's psychoanalytic pioneers (Benjamin,
1997; Chodorow, 2001).
Statistics and Demographics
Freud's wide-ranging theory was one of the early
twentieth-century revolutionary innovations that inau-
gurated the modem era, and all psychodynamic mental
health treatment derives from psychoanalysis (Moore &
Fine, 1995). In its first decades, men and women were
treated in roughly equal numbers, as were people of all
ages and social classes. Usage of psychoanalytic treat-
ment has varied widely, both in length of treatment and in
target populations, in the last 100 years. Mistakenly
viewed as an elitist branch of office-based psychiatry
reserved for affluent people and intellectuals, in fact
modem psychoanalysis is embraced today by medical and
nonmedical therapists in urban and rural clinics, in
medical and psychiatric hospitals, in child care, educa-
tion, and in substance abuse treatment (Hale,' 1978).
Psychodynamic therapies are recommended for the
treatment of clinical depression and anxiety, personality
disorders, harmful family dynamics, and organizational
resistance to change (Aiello, 1999). At times, clinicians
have argued against these therapies for people with severe
psychiatric disorders, suicidal depression, and severe
untreated substance abuse
(Valenstein, 1968). Nevertheless, psychodynamic
treatment of "biologically based" psychiatric disorder s is
still relevant, says Gabbard (1992), who studied the
intimate and reciprocal connection between psychoso cial
and neurophysiological factors (Gabbard, 1992). An
equally deep awareness of the need for social acti vism
drives this work. Drawing on object relations, American
interpersonal perspectives, intersubjective approaches,
and postrnodernism, analysts have demon strated its value
for disenfranchised groups and populations at risk
(Altman, 1995). Contemporary clinicians do and must
take into account the lived realities of race, and gender
and economic inequalities (and their reci procal interface
with individual psychology); in fact, psychoanalysts have
done so since 1918 when Freud mandated free and
low-cost out-patient clinics for all psychoanalyt ic
institutes (Danto, 2005).
Current Applications
Optimal treatment depends on client needs. Though
weekly single-client sessions remain standa~ d in the
treatment of individuals, psychoanalysis is applied at
every level of practice and in every treatment arena. From
family and group therapists to organizational con sultants,
psychoanalysts help clients explore how and when their
judgments are unconsciously influenced by history,
illness, affect, and culture (Wishnie, 2005). Object
relations theory, for example, and the concept of psychic
structure (id, ego, and super-ego) help us appreciate the
multiple levels on which irrational be havior plays out
(Goldstein, 2002). Individual clients range from trauma
witnesses to Alzheimer caretakers, from people with
psychiatric disorders to homeless people, from
adolescents questioning their sexuality to older people
coping with end-of-life anxiety (Luepnitz, 2002). Family
therapists listen for a family's uncon scious dynamics and
the communication patterns that can c ontribute to
symptomatic behavior. In group therapy, psychoanalysts
focus on the members' unconscious aggressive,
psychotic, or paranoid transferences before working
through interpersonal conflicts (Tuttman, 1991). On this
micro level, psychoanalysts beli eve that clients can
change for the better. If given a safe environment in
which to foster insight into, or reframe, a current problem
that may stem from an ear lier (and often traumatic)
conflict now repressed or disassociated from memory, we
can recast the narrative.
Psychoanalysis has never been limited to indivi duals.
"The replacement of the power of the individual by the
power of a community," Freud wrote, "constitu tes the
decisive step of civilization" (Freud, 1930). On this
macro level, psychoanalysts believe that self reflective
social systems (from work organizations to
 PSYCHOANALYSIS 449

local and national communities) become more tolerant preformulated measurements for behavioral and
and democratic. Psychoanalysis points out the cognitive therapies), and some still argue that
conflicts, the broad range of milieus, and the equally psychoanalysis offers an alternative epistemology to
broad range of perspectives-historical, political, that of scientific research (Roth & Fonagy, 1996). But
economic, scientific, and international-faced by today's since the 1970s, psychoanalysts have studied the actual
social workers. For example, white-on-black racism internal processes of treatment modalities
can be viewed psychoanalytically as a defense (fear of (psychotherapy process research) as well as their
the unknown) or a projection (their fault, not our guilt) outcomes (Tuckett, 2001). Evidence for the
(Altman, 2000)~ Coupling these insights with effectiveness of adult psychoanalytic psychotherapy
appropriate social policy can reduce interracial tension. has been established, along with the relevance of these
Work organizations too benefit from object relations findings to child psychotherapy (Fonagy, 2003b).
theory to explain, for example, employees' reluctance Despite this empirical validation, many still believe the
to form attachments to a corporation that fails to myth that psychoanalytic therapy has not yet met the
provide a holding environment; drive theory explores "gold standard" of the randomized controlled trial, and
patterns of aggression and gratification. Consultants, therefore that it is less valuable than competing
who are highly attuned to the psychodynamics of the treatments in today's medical market. Psychoanalysis
consultation process itself, can develop strategic was born out of a fertile exchange between the sciences
interventions for agencies questioning their mission as in early-twentieth-century Vienna, and this complex
well as "the impact of unconscious motives on group intellectual dialogue is ongoing, attempting to resolve
and organizational membership" (Eisold, 1995). two fundamental questions: (a) how is psychoanalytic
Regardless of the level of intervention, the client's "knowledge" established? and (b) what methodology
unconscious does not have a social class; class is a and epistemology underlie psychoanalytic theory?
social arrangement that may resonate with a client's (Haynal, 1993).
subjectivity, but is no more innate than the clothes we The latest technology in neuroscience, together with
wear. This subjectivity, or class consciousness, has today's more stringent research methods in psy-
always been a theme in psychoanalysis. As Barbara chotherapy, is allowing us to understand more clearly
Levy Simon (1994, pp. 89-90) noted in her study of the how the brain and mind intersect (Gabbard, 2000). The
empowerment. tradition in American social work, neuro-psychoanalytic investigations of Mark Solms
"Freud's message emphasized not only the pathos of and Oliver Sachs have gone a long way in
individual pathology but also the possibility of healing, demonstrating the biological basis for unconscious
recovery and restoration .... [The first emphasis] has emotional processing within the human brain. Inter-
received thorough attention from historians of Freud's estingly, this laboratory-based neuroscientific work
impact on social work. By contrast, the effects on the confirms many of Freud's original observations, not
profession of his second emphasisthat of human least the pervasive influence of nonconscious processes
reconstruction and plasticity-still await an evenhanded and the organizing function of emotions for thinking
chronicle." (Westen & Gabbard, 2002a, 2002b). Likewise,
Research Support, New Approaches, and evolutionary psychiatry underscores how behavior is
Evidenced-Based Practice shaped by evolutionary forces and is no less
Freud called off his Project for a Scientific Psychology because "biological" than neurochemistry-underpins both
he was hampered by the limited technology available in organic and psychotherapeutic psychiatry (Price &
1895, not because he thought that biology was irrelevant. David, 1998).
Given today's vast improvements in medicine and Integrations
specifically neuroscience, biological theories of mental Almost a century since Freud broke with history, when
health have entered public awareness in the way Winnicott's true self and Lacan's language and Reich's
psychoanalysis did 100 years ago. The Nobel Prize politics seem far way, social work's strengths-based
winner Eric Kandel has described a new science of the modern rationalism still has the power of the original
mind. "Cognitive neuroscience," he writes, '''could psychoanalytic movement. Today, the psychoanalytic
provide a new foundation for the future growth . of metanarrative lives on in social work for precisely the
psychoanalysis" (Kandel, 1999). Current empirical qualities that make us agents of change: the recognition
research on the efficacy of insight-oriented psycho- of the impact of culture, self-determination, respect for
therapy has become increasingly significant (Fonagy, individual and group identity (racial, ethnic, spiritual),
2003a). Traditionally, psychoanalysts have trusted in the freedom of sexuality, social justice, and most of all,
clinical case report for evaluation (unlike critical and self-reflective thinking.
450 PSYCHOANALYSIS
REFERENCES
Aiello, T. (1999). Child and adolescent treatment for social work
practice: A relational perspective for beginning clinicians. New
York: Free Press.
Altman, N. (1995). The analyst in the inner city. Hillsdale, NJ:
The Analytic Press.
Altman, N. (2000). Black and white thinking: a psychoanalyst
reconsiders race. Psychoanalytic Dialogues, 10, 589-605.
Benjamin, J. (1997). Shadow of the other: Intersubjectivity and gender
in psychoanalysis. New York: Routledge.
Brandell, J. (2004). Psychodynamic social work.:NC!\V York:
Columbia University Press.
Brenner, C. (1990). An elementary textbook of psychoanalysis.
New York: Doubleday.
Chodorow, N. (2001). The power of feeli~gs: Personal meanings , "in
psychoanalysis, gender and'culture. New Haven,J::;'f:Yale
University Press.
Danto, E. A. (2005). Freud's free clinics-Psychoanalysis & social
justice, 1918-1938. New York: Columbia University Press.
Eisold, K. (1995, July 7). Psychoanalysis today: Implications for
organizational applications. Paper presented at ISPSO
International Symposium, London.
Elson, M. (1998). Self psychology in clinical social work. New York:
W. W. Norton.
Fisher, D. J. (1991). Cultural theory and psychoanalytic tradition.
New Brunswick, NJ: Transaction.
Fonagy, P~ (2Q03a). The research agenda: The vital need for
empirical research in child psychotherapy. Journal of Child
Psychotherapy, 29(2}, 129-136.
Fonagy, P. (2003b, June). Psychoanalysis today. World Psychiatry,
2(2}, 73-80.
Freud, S. (1918). Lines of advance in psychoanalytic psychotherapy
(Vol. 17, p. 167, Standard Edition). London: Hogarth Press.
Freud, S. (1930). Civilization and its discontents (Vol. 21, p. 144,
Standard Edition). London: Hogarth Press.
Gabbard, G. O. (1992). Psychodynamic psychiatry in the "decade of
the brain." American Journal of Psychiatry, 149, 991-998.
Gabbard, G. O. (2000). A neurobiologically informed perspective on
psychotherapy. British Journal of Psychiatry, 177, 117-122.
Galatzer-Levy, R. M., & Cohler, B. J. (1993)~ The essential other-a
developmental psychology of the self. New York:
Basic Books.
Gay, P. (1998). Freud: A life for our time. New York: W. W.
Norton.
Goldman, E. (1977). Living my life. New York: New American
Library.
Goldstein, E. (1995). Ego psychology and social work practice (2nd
ed.). New York: Free Press.
Goldstein, E.(2002}. Object relations theory and self psychology in
social work practice. New York: Free Press.
Greenberg, J., & Mitchell, S. (1983). Object relations in
psychoanalytic theory. Cambridge, MA: Harvard Universiry
Press.
Hale, N. G., Jr. (1978). From Berggasse XIX to Central Park West:
The Americanization of psychoanalysis, 1919-1940. Journal of
the History of the Behavioral Sciences, 14; 299-315.
Haynal, A. (1993). Psychoanalysis and the sciences. Berkeley, CA:
University of California Press.
Kandel, E. (1999}.,Biology and the future of psycho-analysis: A new
intellectual framework for psychiatry revisited. American Journal
of Psychiatry, 156,505-524.
Lazarus, A. (1981). The practice of multimethod therapy. New York:
McGraw-Hill.
Luepnitz, D. (2002). Schopenhauer's porcupines. New York:
Basic Books.
Menninger, K. (1967). The vital balance. New York: Viking
Compass.
Mitchell, S., & Black, M. (1995). Freud and beyond-A history of
modem psychoanalytic thought. New York: Basic Books.
Moore, B. E., & Fine, B. D. (Eds.). (1995). Psychoanalysis: The major
concepts. New Haven, CT: Yale University Press.
Pine, F. (1990). Drive, ego, object, & self-A synthesis for clinical
work. New York: Basic Books.
Price, J., & David, A. (1998). Evolutionary psychiatry. London:
Routledge.
Roth, A., & Fonagy, P. (Eds.). (1996). What works for whom?
New York: Guilford.
Saleebey, D. (2005). The strengths perspective in social work practice
(4th ed.). Boston: Allyn & Bacon.
Simon, B. L. (1994). The empowerment tradition in American social
work-a history. New York: Columbia University Press.
Solms, M., & Turnbull, O. (2003). The brain and the inner world: An
introduction to the neuroscience of subjective experience. New
York: Other Press.
Stanton, M. (1991). Siindor Ferenczi: Reconsidering active inter-
vention. Northvale, NJ: Jason Aronson.
Tuckett, D. (2001). Evidence based psychoanalysis: An imperative
and an opportunity. International Forum on Psychoanalysis,
10,211-215.
T uttman, S. (Ed.). (1991). Psychoanalytic group iheory and therapy:
Essays in honor of Saul Scheidlinger. American Group
Psychotherapy Association Monograph 7. Madison, CT:
International Universities Press.
Walker, L. E. (1984). The battered woman syndrome. New York:
Springer Publishing.
Westen, D., & Gabbard, G. O. (2002a). Developments in cognitive
neuroscience. 1. Conflict, compromise, and connectionism.
Journal of the American Psychoanalytic Association, 50, 53-98.
Westen, D., & Gabbard, G. O. (200lb). Developments in cognitive
neuroscience. n. Implications for theories of transference.
Journal of the American Psychoanalytic Association,50,99-134.
Valenstein, A. F. (1968). Indications and contraindications for
psychoanalytic treatment. International Journal of Psycho-
Analysis, 49,265-265.
Wishnie, H. A. (2005). Working in the countertransference.
Northvale, NJ: Jason Aronson.
-ELIZABETH ANN DAN TO

PSYCHODRAMA
ABSTRACT: Psychodrama is an action oriented method
that shares many of social work core values, for
example nonjudgmental acceptance of others, viewing
individuals in their context, a deep belief in humans'
creative c potential, and empowering people who are
disenfranchised, stigmatized, or oppressed. The
creator of this method was also a pioneer in family
therapy, group therapy, and community organization.
Psychodrama may be applied to other theoretical
approaches in dealing with psychological or social
problems, and has been applied to many population
groups and in dealing with many issues (for example,
trauma, addiction, crisis intervention) .
KEY WORDS: action methods; experiential group work;
sociometry; role play; spontaneity and creativity; com-
munity work; person in context
, i
'
Psychodrama is an experiential and action-oriented
method, which, like social work practice, aims toward
exploring and resolving psychological and social pro-
blems. Postulating that humans learn by action and
interaction in a given context, pscyhodrama works by
having participants enact problems issues or concerns
rather than merely talk about them (Blamer, 1996;
Moreno, 1946). It is part of the Triadic System, along with
sociometry and group psychotherapy, created by Jacob
Levi Moreno, MD, (1889-1974) in the early decades of the
20th century and developed further by many of his
students (Blamer, 2000).
Moreno began exploring his innovative ideas as a
medical student in Vienna in 1911-1917 (Hare & Hare,
1996; Marineau, 1989). During his training as a
psychiatrist, the prevailing school of thought was
psychoanalysis. Moreno considered this approach as too
narrow. In a meeting with Freud, he stressed the
importance of working with people in their homes and their
"natural" surroundings, not to analyze their dreams, but to
"encourage them to dream again." Work ing with people in
their context was a radical departure from the predominant
psychoanalytic method, which involved one patient in the
analyst's office. During these years Moreno observed
children at play in a city - park and was fascinated by their
creativity, freedom of
expression, and ability to resolve conflicts. Watching
closely, he also noted the positive emotional effects on
those engaged in enacting their fantasies, emotions, and
concerns. He then would tell them stories and have them
play various roles. This led to future experimentation in
improvisation techniques, involving the children and, at
times, their parents. At age 32, he
PSYCHODRAMA 451
created The Theatre of Spontaneity, which was open to
the community. Creating and enacting dramas relevant to
people's lives that were neither scripted nor rehearsed was
viewed both as artistic and therapeutic.
Another concurrent venue where Moreno contin ued to
develop his ideas, reflective of his originality as an
independent thinker, creator and activist, was his work
with prostitutes. Appalled by their living condi tions,
humiliation, and harassment by the police, he initiated
what may be defined today as community organization
and group therapy. Along with a physician specializing in
venereal disease and a newspaper repor ter, Moreno
visited their homes "not to refo rm the girls or analyze
them, but rather to return them to some dignity" (Moreno,
1946). He felt driven to help them, he wrote, " because the
prostitutes had been stigmatized for so long as despicable
sinners and unworthy people? they had come to accept
this as an unalterable fact" (Moreno, 1989, p. 48). As the
initial meetings with their group focused on concrete
problems such as lack of medical care, Moreno
discovered the healing power of group sharing, noticing
that they were feeling less isolated, more i dentified with
each other, and empowered to seek medical ,treatment
when needed. This experience led to more elaborate
formulations of what later became known as group
psychotherapy.
As a young doctor Moreno held posts of medical
officer in the Mittendorf refugee camp for Austrians
fleeing the invasion of the Italian army. Prior to that he
informally created the House of Encounter in Vienna,
where volunteers aided homeless and needy people
anonymously (Marineau, 1989).
In 1925, Moreno immigrated to the U nited States and
continued the theoretical work, which he named
Sociometry (Moreno, 1934/1993) while working at the
Sing Sing prison and the Hudson School for Girls. Serving
as the scientific backbone for psychodrama, sociometry
set out to measure experiential networks of connectedness
through attraction, repulsion, or neu trality, which are all
present in social interactions. During the 1930 s he
researched his ideas and explored their applications in
many clinical settings and profes sional conferences.
Challenging contemporary axioms of psychotherapy,
which followed the medical models of pathology and
cure, Moreno's ideas were to be co opted decades later by
Family Therapy theorists and practitioners as basic tenets
of System Theories. "The change of locus of therapy ...
means literally a revolution in what was always
considered appropriate medical practice. Husband and
wife, mother and child, are trea ted as a combine, often
facing one another and not separate, because separate
from one another they may not have any tangible mental
ailment."
452 PSYCHODRAMA
In 1932, Moreno introduced Group Psychotherapy to the
American Psychiatric Association as a viable therapeutic
method. As he always viewed patients in their context,
Moreno is also considered one of the earliest pioneers of
Family Therapy. His theories and methods represented a
departure from traditional psychoanalytic thought and
postulated that we learn through action and interaction and
thus we heal. Moreno stated that interpersonal and
intrapsychic issues leave an imprint on the body long before
the body-mind paradigm became widely accepted. In de-
monstrating how the drama of the body can reveal and heal
both physically and emotionally he famously said:
"The body remembers what the mind forgets." He described
the goals of psychodrama as threefold: achieving
\
a perceptual shift, emotional expression, and behavioral
change. Moreno developed many techniques, aimed at
facilitating spontaneity and creativity, which, in his
formulation, were the cornerstone of mental health.
In spite of its status of a method that remained out of the
mainstream, psychodrama has had direct influence on various
important schools of thought in sociology, psychotherapy, and
social work. Its indirect impact is reflected by adoption of
many of its ideas and techniques by various schools of
psychotherapy and in training and consultation (Gershoni,
2003; Hare & Hare, 1996). Research on the method's impact
and effectiveness is an ongoing endeavour (Kipper & Hundal,
2003; Kipper & Ritchie, 2003) testing the hypothesis that
concretization of internal and external realities in the form of
role playing or behavioral simulation has therapeutic
advantages (Kipper, 1986).
As a group model, psychodrama involves enactment of
internal or external issues and past, present, or future conflicts.
The process consists of three distinct phases:
Warm up-Group exercises aimed at facilitating safety,
openness, and spontaneity. Enactment-Staging of the
scenefs).:
Sharing-Closure, and deepening of group support.
In conducting the session, the therapist (director) utilizes
group therapy and sociometric and psychodramatic
techniques (for example, doubling and role reversal).
Revisiting problematic scenes with the help of a skilled
director and group members has a. powerful healing effect on
three levels that are essential for therapeutic change:
cognitive, emotional, and behavioral. The protagonist whose
drama is enacted not only benefits from emotional expression
and new insights, but also has an opportunity to acquire new
behaviors relative to problems from the past or in preparation
for anticipated difficulties. Group members, who play parts in
the
drama (auxiliaries), as well as other members (audience) also
benefit from it directly or indirectly (Dayton, 1994). By
sharing their reaction to the enactment and how it touches
their own lives, the audience supports the protagonist and
paves the way for future work.
Psychodrama has attracted many social workers to seek
training in this method, whether to apply it to other modalities
or for clinical and supervision practice. The training and
examinations for certification are rigorous, and about one
third of certified psychodarmatists (128 of 403) are social
workers (American Board of Examiners, 2006-2007).
REFERENCES
American Board of Examiners in Psyhodrama, Sociometry and
Group Psychotherapy. (2006-2007). Directory and Cer-
tification Standards, P. O. Box 15572, Washington, OC
20003-0572.
Blatner, A. (1996). Acting. In Practical applications of psycho-
dramatic methods (3rd ed.). New York: Springer.
Blamer, A (2000). Foundation of psychodrama; history, theory and
practice (4th ed.). New York: Springer.
Dayton, T. (1994). The drama within, Psychodramatic and
experiential therapy, Health Communication, Inc. Deerfield
Beach, FL.
Gershoni, J. (Ed.). (2003). Psychodrama in the 21st century:
Clinical and educational applications. New York: Springer.
Hare, P. A, & Hare, J. R. (1996). J. L. Moreno, Key figures in
couseling and psychotherapy. London: Sage.
Kipper, D. A. (1986). Psychotherapy through role playing. New
York: Bruner/Mazel.
Kipper, D. A., & Hundal, J. (2003). A survey of clinical reports on
the application of psychodrama, Journal of Group Psychotherapy,
Psychodrama and Sociometry, 55, 141-157.
Kipper, D. A, & Ritchie T. D. (2003). The effectiv:eness of
psychodrama: A meta-analysis. Group Dynamyics: Theory,
Research, and Practice, 7, 13-25.
Marineau, R. (1989). Jacob Levi Moreno (1889-1974). London:
Routledge.
Moreno, J. L. (1946). Psychodrama, Vol. 1. New York: Beacon
House.
Moreno, J. L. (1989). The Autobiography of}. L. Moreno, MD, J
oumal of Group Psychotherapy, Psychodrama and Sociometry,
42(1),3-125.
Moreno, J. L. (1993). Who shaU survive? Foundations of sociometry,
group psychotherapy and sociodrama. McLean, VA:
American Society of Group Psychotherapy and Psychodrama
(Original work published 1934).
SUGGESTED LINKS
www.asgpp~org
www.GrouPsychodrama.com
http://www.blamer.com/adamf/evel2/pdbkprc .hem
-JACOB GERSHONI

PSYCHOEDUCATION
ABSTRACT: Psychoeducation, which describes a range
of direct interventions that are focused on participants'
education, support, and coping skills development, has
become extremely popular in social work practice since
the 1970s. Such programs are delivered in many service
settings and with many types of client populations. This
article includes a definition of the term, a review of its
origins in social work practice, its range of applications,
the practice theories, and professional values from which it
draws, and a review of the research evidence for its utility.
KEY WORDS: psychoeducation; social work practice;
group intervention
Definitions and Descriptions Psychoeducation is a term that
describes a range of individual, family, and group
interventions that are focused on educating participants
about a significant challenge in living, helping participants
develop adequate social and resource supports in managing
the . challenge, and developing coping· skills to deal with the
challenge. While these three elements characterize all
psychoeducational programs, additional goals may in clude
reducing participants' sense of stigma, changing
participants' cognitions with regard to the issue, identifying
and exploring feelings about the issue, developing
problem-solving skills, and developing crisis manage ment
skills related to the issue (Griffiths, 2006). The targets of
change may include the participants themselves, their
significant others (usually a family member), or the larger
community ( through advocacy efforts) (Roffman, 2004).
There is a great variety in how psychoeducation is
organized and delivered. Programs may be provided in one
hour (Clemens, 2004) or in one day (Pollio, North, & Reid,
2006), up to 15 sessions or more (Brennan, 1995), and
with open- or closed-ended structures (Botsford & Rule,
2004). Some programs for youth are integrated into school
curricula (Dore, NelsonZlupko, & Kaufmann, 1999). Most
psychoeducation services are led by human service
professionals, but some are led by consumers or family
members of consumers, and some are co-led by
professionals and consumers (Ruffolo, Kuhn, & Evans,
2006). Psychoeducation can be a "stand alone "
intervention, but it is often used as one method among
several for helping clients and families with a particular
life challenge .
.. ,L ...
PSYCHOEDUCATION
453
Main Developers and Contributors
The concept of psychoeducation has evolved since the
1960s as an interdisciplinary enterprose among educators
and psychotherapists (Authier, 1977). It was initi ally used
to describe a. process of educating practitioners about the
nature of mental, emotional, and behavioral problems
(Mykelbust, 1973), and also as a means of preparing
clients to undergo analytic psychotherapy (teaching clients
about the modality, about communication, and how to
handle aggressive impulses) (Authier, 1977).
Contemporary uses of psychoeducation can be traced back
to the 1970s, when knowledge about mental disorders
began to focus on biological rather than family processes.
Many social workers abandoned their "expert" and
"psychotherapist" images and became more collaborative
with clients and families, eager to share information with,
rather than isolate, them. The psychoeducational model
was first implemented in the late 1970s for individuals
with schizophrenia and their families by such pioneers as
Hatfield (1979) and Kanter (1980). The actual practice was
underway before the current term was applied, with
Anderson, Hogarty, and Reiss (1980), representing the
fields of psychiatry and social work often being credited
with its adoption.
Statistics, Demographics, and
Current Applications
It is difficult to estimate the numbers and types of
psychoeducational interventions being provided in the
United States and around the world. The philosophy of
psychoeducation has become exceedingly popular and is
applied to a variety of health, mental health, and human
development challenges. A sample of such programs
derived from a Psychlnfo literature review revealed the
following applications: General parenting skills
development, families experiencing mental illness (usually
schizophrenia or bipolar disorder) or substance abuse in a
member, families of children with emotional and
behavioral. problems, families of persons facing various
chronic and life threatening physical conditions,
permanency planning for the adult offspring of aging
parents, seronegative partners, family members, and
children with HIV/AIDS, trauma recovery for youth in
residential treatment, incarcerated male and female
inmates, university women who have experi enced sexual
assault, social workers who experience vicarious
traumatization, juvenile offenders incarcerated as adults,
women in substance abuse treatment, adoles cent girls who
experience negative social pressures, per sons experiencing
bulimia, children of divorce, youth experiencing bullying
behavior, separation resilience
454 PSYCHOEDUCATION
groups for couples who spend much time apart, and
families participating in family preservation services.
Psychoeducational groups have also been used suc-
cessfully with racial and ethnic minority populations,
including low income Latino women with HIV/AlDS
(Subramanian, Hernandez, & Martinez, 1995), Korean/
American families of persons with mental illness (Shin,
2004), black women adjusting to college, racial identity
development in school children (Candelario & Huber,
2002), psychosocial competence for black women (Jones
& Hodges, 2001), American Indian identity development
(Weaver & Brave Heart, 1999), and minority families of
mentally ill clients (Jordan, Lewellen, & Vandiver, 1995).
Current Change Philosophy and Techniques While
psychoeducation programs may differ in philosophy and
technique, most are derived from several practice theories
that facilitate movement toward the three overall goals of
education, support, and improved coping. The first major
function of these programs is to help participants
reorganize their experience of a problem in living from a
subjective ("I feel so alone with this problem") to an
objective ("Other people deal with this as well-what a
relief!") frame of reference, which facilitates a sense of
cognitive mastery (Hayes & Gantt, 1992). The social work
value of empowerment is always incorporated as
participants are helped to use new skills and information to
better manage their challenges. In psychoeducation
programs participants may be empowered at the personal
(changing patterns of thinking, feeling, and behaving),
interpersonal (managing their relationships more
effectively), or political levels (changing their manner of
interacting with larger systems) (Lee, 2001).
Psychoeducation relies on learning theory (how people
acquire, make sense of, and use new information) (Constas
& Sternberg, 2006), cognitive psychology (challenging
maladaptive thinking processes, suggesting alternative
ways of thinking, removing cognitive deficits) (Berlin,
2002), dynamic psychology (emotional aspects of purpose,
fears, goals, hopes, and perceptions of the self) (Goldstein,
1995), and developmental psychology (maturational
processes, stages of illness and adjustment for both clients
and family members) (Morse, 2004). When provided in
groups, psychoeducation facilitates the integration of
information into each participant's experience.
There are some cautions that must be considered by
social workers who provide psychoeducational inter-
ventions. First, social workers need to be sure that the type
and manner of their educational methods are con- .
. sistent with the learning styles of participants. There
are many types of intelligence and many ways that people
can learn (Gardner, 1999). Second, the nature of
psychoeducation (the social worker/participant rela-
tionship and the selection of topics and activities) must be
consistent with traditions in the participants' cultures
(Jordan et al., 1995). Third, the "stage" of the participant' s
level of knowledge and needs must be considered with
regard to their readiness and ability to accept certain types
of information about problems in themselves or a family
member. Fourth, the social worker must consider whether
other important needs of the participant are being
neglected, especially in group set tings where material may
be generically presented. Fi nally, psychoeducation
programs should not try to do too much (education,
psychotherapy) for participants,
sacrificing breadth for depth. .
Evidence-Based Practice Psychoeducation
is said to be among the most effective of the
evidence-based practices that have emerged in clinical
trials and practice settings (Lukens & McFarlane, 2006). In
addition to increasing participants' levels of knowledge,
outcome criteria for psychoeducation may include various
measures of participant's well-being, competence,
confidence, self-identity, racial identity, ego strength,
social skills, coping behavior, and respite. For the
significant others of participants, program outcomes may
include reduced relapse, greater medication adherence, and
reduced impulsive behavior (Barton, 1999). Many
single-subject and quasi-experimental designs have been
utilized to test the effectiveness of these interventions on
client populations, and some experimental studies have
also been conducted. Most studies show that
psychoeducation is equal to or superior than alternative
interventions (Griffiths, 2006). Still, it is difficult to make
generalizations about the effectiveness of psychoeducation
because there is such variety in the nature of programs and
participant goals. Psychoeducation is commonly
associated with families of persons with schizophrenia,
and in one meta-analysis of randomized controlled trials (n
= 10), it was found that medication compliance was
improved in one study, and that all studies significantly
decreased relapse or readmission rates at 9-18 months
follow-up, compared with standard care (Pekkala &
Merinder, 2007). There was also evidence that
psychoeducation has a positive effect on participants' sense
of well-being.
Distinctiveness and Integration
The distinctiveness of psychoeducation can be seen in its
didactic/educational approach, partnership, or nonhierarchical
relationship between the social worker and participants, and
an open acknowledgment of participants'

special expertise in the topic area (given their experience
with the problem). It is also integrative of other forms of
social work practice. As noted earlier, it draws freely from
several direct practice theories and is often utilized as one
part of an overall intervention plan that integrates therapy,
medication, and case management. It is also frequently
provided in group formats and as such adapts aspects of
the educational, support, and therapy formats in the
Toseland and Rivas (2005) typology.
REFERENCES
Anderson, C. M., Hogarty, G. E., & Reiss, D. J. (1980). Family
treatment of adult schizophrenic patients: A research-based
psychoeducational approach. Schizophrenia Bulletin, 4,
512-520. ' Oxford University Press.
Authier, J. (1977). The psychoeducational model: Definition,
contemporary roots, and content. Canadian Counselor, 12(1),
15-22.
Barton, R. (1999). Psychosocial rehabilitation services in com-
munity support systems: A review of outcomes and policy
recommendations. Psychiatric Services, 50(4),525-534.
Berlin, S. B. (2002). Clinical social work practice: A cognitive-
integrative perspective. New York: Oxford University Press.
Botsford, A L., & Rule, D. (2004). Evaluation of a group
intervention to assist aging patients with permanency planning
for an adult offspring with special needs. Social Work,
49(3),423-431.
Brennan, J. W. (1995). A short-term psychoeducational
multiple-family group for bipolar patients and their families.
Social Work, 40(6), 737-743.
Candelario, N., & Huber, H. (2002). A school-based group
experience on racial identity and race relations. Smith College
Studies in Social Work, 73(1), 51-72.
Clemens, S. E. (2004). Recognizing vicarious traumatization:
A single session group model for trauma workers. Social Work
with Groups, 27(2-3), 55-74.
Constas, M. A, & Sternberg, R. J. (2006). Translating theory and
research into educational practice: Developments in content
domains, large-scale reform, and intellectual capacity.
Mahwah, NJ: Lawrence Erlbaum.
Dore, M. N., Nelson-Zlupko, L., & Kaufmann, E. (1999).
Friends in need: Designing and implementing a psychoedu-
cational group for school children from drug-involved fam-
ilies. Social Work, 44(2), 179-190.
Gardner, H. (1999). Intelligence reframed: Multiple intelligences for
the 21st century. New York: Basic Books.
Goldstein, E. G. (1995). Ego psychology and social work practice
(2nd. ed.). New York: Free Press.
Griffiths, C. A (2006). The theories, mechanisms, benefits, and
practical delivery of psychosocial educational interventions
for people with mental health disorders. International Journal of
Psychosocial Rehabilitation, 11 (1), 21-28.
Hatfield, A (1979). Help-seeking behaviors in families of
schizophrenics. American Journal of Psychiatry, 7, 563-569.
Hayes, R., & Gantt, A. (1992). Patient psychoeducation: The
therapeutic use of knowledge for the mentally ill. Social Work
in Health Care, 17(1),53-67.
PSYCHOEDUCATION 455
Jones, L. V., & Hodges, V. G. (2001). Enhancing psychosocial
competence among black women: A psychoeducational group
model approach. Social Work with Groups, 24(3-4), 33-52.
Jordan, c., Lewellen, A., & Vandiver, V. (1995). Psychoedu-
cation for minority families: A social work perspective.
International Journal of Mental Health, 23(4), 27-43.
Kanter, J. (1980). Coping strategies for families of the mentally ill.
Washington, DC: National Alliance for the Mentally Ill.
Lee, J. A. B. (2001). The empowerment approach to social work
practice: Building the beloved community (2nd ed.). New York:
Columbia University Press.
Lukens, E. P., & Mcfarlane, w. R. (2006). Psychoeducation as
evidence-based practice: Considerations for practice, research,
and policy. In A R. Roberts & K. R. Yeager (Eds.), Foundations
of evidence-based social work practice (pp. 291-313). New York:
Morse, W. C. (2004). Psychoeducational Perspective Overview.
University of Michigan; Transcript of a spoken commentary.
Retrieved March 10,2006, from: http://www.
coe.missouri.edu/J\vrcbd/pdf/PSYPERSP .PDF
Mykelbust, H. R. (1973). Identification and diagnosis of children
with learning disabilities: An interdisciplinary study of
criteria. Seminars in Psychiatry, 5(1), 55-77.
Pekkala, E., & Merinder, L. (2007).Psychoeducation for schizo-
phrenia. The cochrane database of systematic reviews (Issue No. 1).
New York: Wiley.
Pollio, D. E., North, C. S.,& Reid, D. L. (2006). Living with
severe mental illness-What families and friends must know:
Evaluation of a one-day psychoeducational workshop. Social
Work, 51 (1),31-38.
Roffman, R. (2004). Psychoeducationalgroups.ln C. D. Garvin, L.
M. Gutierrez, & M. J. Galinsky (Eds.), Handbook of social work
with groups (pp. 160-175). New York: Guilford.
Ruffolo, M. C., Kuhn, M. T., & Evans, M. E. (2006). Developing a
parent-professional team leadership model in group work:
Work with families with children experiencing behavioral and
emotional problems. Social WOrk, 51 (1), 39-47.
Shin, S. (2004). Effects of culturally relevant psychoeducation for
Korean American families of persons with chronic mental
illness. Research on Social Work Practice, 14(4), 231-239.
Subramanian, K., Hernandez, S., & Martinez, A (1995). Psy-
choeducational group work for low-income Latina others with
HIV infection. Social Work With Groups, 18(2-3), 65-78.
Toseland, R. W., & Rivas, R. F. (2005). An introduction to group
work practice (5th ed.). Boston: Allyn & Bacon.
Weaver, H. N., & Brave Heart, M. Y. (1999). Examining two
facets of American Indian identity: Exposure to other cultures
and the influence of historical trauma. Journal of Human
Behavior in the Social Environment, 2(1-2),19-33.
FURTHER READING
Anderson, C. M., Reiss, D. J., & Hogarty, G. E. (1986).
Schizophrenia and the family: A practitioner's guide to psychbe-
ducation and management. New York: Guilford.
456 PSYCHOEDUCA1l0N
Center for Mental Health Services. (2006). Evidence-based
practices: Shaping mental health services toward recovery:
Family psychoeducation. National Mental Health Information
Center, Center for Mental Health Services. Retrieved from
mentalhealth.samhsa.gov/cmhs/communitysupport/
toolkits/family/default. asp
Corcoran, J. (2003). Clinical applications of evidence-based family
interventions. New York: Oxford University Press.
DeLucia-Waack, J. L. (2006). Leading psychoeducational groups for
children and adolescents. Thousand Oaks, CA: Sage.
Griffiths, C. A. (2006). The theories, mechanisms, benefits, and
practical delivery of psychosocial educational interventions
for people with mental health disorders. International Journal of
Psychosocial Rehabilitation, 11 (1),21-28.
Jackson, R. L. (Ed.). (2004). African American communication & .
identities: Essential readings. Thousand Oaks, CA: Sage.
Jones, L. V. (2004). Enhancing psychosocial competence among
black women in college. Social Work, 49(1), 75-84.
McFarlane, W. R. (2002). Multifamily groups in the treatment of
severe psychiatric disorders. New York: Guilford.
Miklowitz, D. J., & Goldstein, M. J. (1997). Bipolar disorder: A
family-focused treatment approach. New York: Guilford.
Walsh, J. (2000). Clinical case management with persons having mental
illness: A relationship-based perspective. Pacific Grove:
Wadsworth-Brooks/Cole.
SUGGESTED LINK Psychoeducational Counseling
Services. Psychoeducation. www.psychoeducation.com"
-JOSEPH WALSH
PSYCHOMETRICS
ABSTRACT: Measurement is a fundamentally import ant
component of social work research. This entry briefly
covers two important notions in psychometrics:
reliability and validity. Reliability concerns errors of
measurement, and validity concerns the accuracy of the
inferences that are made from scores from a meas-
urement procedure. Both norm-referenced and criter-
ion-referenced measurement procedures are discussed.
KEY WORDS: measurement; psychometric theory; reli-
ability; validity; generalizability theory
Psychometrics can be defined as the science, theory, and
technology of measurement. Measurement, in tum, can be
defined as any systematic procedure used to assign
numbers to objects in order to represent characteristics of
the objects, or to assign the objects to categories that
reflect characteristics of the objects (Nunnally &
Bernstein, 1994). There are two principal topics in
psychometric theory, those of validity and
measurement error. The following overview will be
organized around these two issues. Psychometric theory,
as currently formulated, consists of a theory of validity
(Messick, 1989), and theories of measurement error,
including classical theory (Lord & Novick) and gener-
alizability theory, or G-theory (Brennan, 2001).
Validity
Validity concerns the appropriateness of inferences made
from scores from a measurement procedure (Messick,
1989). According to validity theory, the researcher does
not validate a scale, but rather provides evidence to
support inferences to be made from scores from the
measurement procedure. This conceptualiza tion differs
from more traditional conceptualizations in which validity
attaches to a particular measurement procedure (see, for
example, Messick, 1989). Validity theory defines a variety
of forms of evidence used to support a particular inference
to be made from scores. The process of "validation" thus
becomes that of accumulating these types of evidence, and
is an ongoing process continuously informed by
refinements in, and reconceptualizations of, notions of the
constructs in which researchers are interested.
The "forms of evidence used to support a particular
inference are what used to be called "types of validity";
face, content, criterion, convergent, and divergent; among
others. All of these forms of evidence are neces sary to
provide a strong case supporting a particular inference.
Messick (1989) discusses these issues in de tail, and
validity in general, and the reader is referred to this
important work on validity.
A critically important validity topic is differential
validity. Differential validity, known as bias in measure-
ment in the educational measurement literature, concerns
the possibility that scores need to be interpreted differently
for different groups. An example of differential validity
would be the need to interpret scores from a depression
measure differently for males and females. This would be
evidenced, for example, by different values for validity
coefficients for scores from a depression measure for
males and females.
Measurement Error
Measurement error is the focus of what has typically been
referred to as "reliability theory."
N ORM~ REFERENCED MEASUREMENT In
normreferenced measurement, inferences are
made by comparing persons' scores to those
from other persons. One example of this
would be using a distribution of scores from a
depression scale for a group of persons to
make inferences concerning who is more, or
less,

depressed relative to others in the group. Inferences are made
from both the rank order of the scores and from the
differences between the scores (Brennan, 2001). The variance
of errors of measurement associated with such inferences is
referred to, in generalizability theory, as the "relative error
variance," and it can be shown that the classical measurement
theory error variance is a special case of this error variance
(Brennan, 2001; Cronbach, GIeser, Nanda, & Rajaratnam,
1972).
Another important notion is that of a person's "true score,"
or in. generallzabilitv theory their "universe score." In both
cases, the "true" of "universe" score is an error free score, and
reflects an .idea] measurement. For a given group or sample
of population of persons there will be a variance \ of : these
true, or universe, scores, and this variance ift~ferred to as the
"true score" or the "universe score" variance. The classical
notion of true score variance is a special case of the concept of
universe score variance from generalizability theory
(Brennan, 2001; Cronbach, GIeser, Nanda, & Rajaratnam,
1972).
Reliability theories generally include indices that
characterize the amount of measurement error in a set of
scores. The classical theory index is the "reliability
coefficient," defined as the ratio of true score to observed
score variance, with the observed score variance the sum of
the true and error variance. The reliability coefficient for a set
of scores from measurement procedure i can be expressed as,
U2 rel,
= 2 T2
UT + uE
where uf == the true score variance, and u1 == the error
variance. The reliability coefficient, which is equivalently
defined as the squared correlation between observed and true
scores, indicates on a 0-1 scale how good a job the
distribution of observed scores does in representing the
distribution of true scores. The closer the reliability
coefficient is to 1.0, the better the observed score distribution
represents the true score distribution, and vice versa as this
coefficient approaches O.
The reliability coefficient is a special case of the so-called
generalizability coefficient from generalizability theory, which
is given by,
u 2
P Iowa: American College Testing.
u# + u2(8)
g
where U == the universe score variance, and u2 (8) == the
relative error variance. It is important to note that both the
classical reliability coefficient and the generalizability
coefficient from g-theory make use of the relative error
variance. These indices characterize
1
PSYCHOMETRICS 457
the measurement error associated with making relative
inferences from a set of scores.
CRlTERION,REFERENCED MEASUREMENT In criterion-
referenced measurement a person's score is compared with a
"criterion" or "cut," score for purposes of placing the person
into some category. For example, the score obtained by a
person taking a licensing examination might be compared
against a specific score used to determine whether he or she
"passed" the exam. In criterion-referenced measurement it is
the "absolute error variance" that is appropriate for
characterizing measurement error. The absolute error variance
describes the error associated with using a person's observed
score as an estimate of her or his universe score. The absolute
error variance will usually be greater than, and will never be
less than, the relative error variance. The distinction between
relative and absolute error cannot be made in classical
measurement theory (Brennan, 2001; Cronbach, GIeser,
Nanda, & Rajaratnam, 1972).
"Dependability indices," as opposed to reliability
coefficients, must be used to characterize the measurement
error associated with criterion-referenced inferences. One of
them, that comes from generalizabilitv theory, has a very
similar form to the generalizability coefficient and the
classical reliability coefficient, and is defined as,
u2
ep= P
u't + u2(~)
where u2(~) = the absolute error variance.
Generalizability theory is best suited for
characterizing the dependability of
classification decisions made in
criterion-referenced measurement.
The estimation of the reliability coefficient, or gen-
eralizabillty coefficient, for norm-referenced measurement
applications, and of dependability indices for
criterion-referenced applications, are critical endeavors in
research and in the development and application of
measurement procedures. Methods for their estimation can be
found, for classical theory, in most measurement and research
texts; and for generalizability theory in such sources as
Brennan (2001) and Cronbach, GIeser, Nanda, and
Rajaratnam (1972).
REFERENCES
Brennan, R. (1983). Elements of generalizability theory. Iowa City,
Brennan, R. (2001). Generalizability Theory. New York:
Springer-Verlag.
Cronbach, L., Gieser, G., Nanda, H., & Rajaratnam, N. (1972).
The dependability of behavioral measurements. New York: Wiley.
Lord, F., & Novick, M. (1968). Statistical theories of mental test
scores. Reading, MA: Addison-Wesley.
458 PSYCHOMETRICS
Messick, S. (1989). Validity. In R. Linn (Ed.), Educational
Measurement (3rd ed., pp. 13-104), New York: Macmillan.
Nunnally, J., & Bernstein, 1. (1994). Psychometric Theory
(3rd ed.). New York: McGraw-Hill.
FURTHER READING
American Educational Research Association, American Psy-
chological Association, & National Council on Measurement
in Education (1999). Standards for educationa l and psychological
testing (2nd ed.). Washington, OC: Author.
Brennan, R. (1984). Applications of generalizability theory.
In R. A. Berk (Ed.), Criterion referenced measurement: State of the
art (pp, 186-232). Baltimore, MD: Johns Hopkins Press.
Cronbach, L., GIeser, G., & Rajaratnam, N. (1963). Theory of
generalizability: A liberalization ~f reliability theory. British
Journal of Mathematical and Statistical Psychology, 16, 137-173.
Drasgow, F., & Parsons, C. (1983). Application of unidimen-
sional item response theory models to multidimensional data.
Applied Psychological Measurement, 7(2), 189-199.
Hambleton, R. (1984) . Test score validity and standard setting
methods. In R. A. Berk (Ed.), Criterion referenced measurement:
State of the art (pp. 80-124). Baltimore, MD: Johns Hopkins
Press.
Hambleton, R. (1989). Principles and selected applications of
item response theory. In R. L. Linn (Ed.), Educational
Measurement Ord ed., pp. 147-200). New York: Macmillan.
Hambleton, R., & Swarnanathan, H. (1985). Item response theory:
Principles and appUcations. Boston, MA: Kluwer/ Nijhoff.
Harrison, D. (1986). Robustness of IRT parameter estimates to
violations of the unidimensionality assumption. Journal of
Educational Statistics, 11 (2),91-115.
Hudson, W. W. (1982). The cUnical measurement package.
Homewood, IL: Dorsey.
Hudson, W. W., & McMurtry, S. (1997). Comprehensive
assessment in s~cial work practice: The multi-problem
screening inventory. Research on Social Work Practice, 7(1),
79-98.
Hulin, c., Drasgow, H., & Parsons, C. (1983). Item response
theory: AppUcations to psychological measurement. Homewood,
IL: Dorsey.
Nugent, W. R. (1992). Psychometric characteristics of self-
anchored scales in clinical practice. Journal of Social Service
Research, 15, 137-152.
Nugent, W. R. (1993). Differential validity in social work
measurement. Social Service Review, 67, 631-650.
Nugent, W. R. (1993). A validity study of a self-anchored scale
for self-esteem. Research on Social Work Practice, 3, 276-287.
Nugent, W. R. (1994). A differential validity study of the
self-esteem rating scale. Journal of Social Service Research,
19,71-86.
Nugent, W. R. (1994). An investigation of the dependability of
clinical cutting scores using generalizability theory. Journal of
Social Service Research, 18, 89-107.
Nugent, W. R., & Hankins, J. A. (1989). The use of item response
theory in social work measurement and research. Social Service
Review, 63, 447-473.
Nugent, W. R., & Hankins, J. A. (1992). A comparison of
classical, item response, and generalizability theories of
measurement. Journal of Social Service Research, 16, 11-40.
Nugent, W. R., & Thomas, J. (1992). Validation of a clinical
measure of self-esteem. Research on Social Work Practice, 3,
191-207.
- BILL NUGENT
PSYCHOSOCIAL AND PSYCHIATRIC
REHABILITATION
ABSTRACT: Psychosocial (or psychiatric) rehabilita tion is a
mixture of skills and support for persons severely impaired
by mental illness. The population in need is vast.
Practitioners marshal support at the level needed while
helping a person develop skills that will gradually reduce
the need for support. Financial support is gained. by
offsetting treatment and other supports such as institutional
care. Social workers are especially well qualified for this
work on multidisciplinary treatment teams. Recovery is
key to most agency mission statements.
KEY WORDS: psychosocial; psychiatric;
rehabilitation; support; skills
Psychosocial rehabilitation is variously defined. The simplest
is "a mixture of skills and support needed to maintain a person
in a community, a dynamic process increasing skills so less
support is necessary" (Anthony, Cohen & Farkas, 1990). At
this writing the United States Association for Psychiatric
Rehabilitation (USPRA) is polling its members on preferences
for five definitions. These show a progression from specific,
reimbursable, disability reduction services "recommended by
a physician or other health professional" to more expansive
definitions in that "skills" and support are more generally
defined. While keeping an understandable emphasis on
providing defined reimbursable services, the field has been
increasingly concerned with hope, recovery, and resilience as
research has pointed to the importance of these factors.
Although rehabilitation counselor program graduates are
accepted members of treatment teams and USPRA offers
certification, it is clear that important rehabilitation skills can
be learned by both professionals and nonprofessionals.
Successful multidisciplinary treatment teams, including social
workers, contribute unique skills and offer the recovery help
that patients need. Recovery is seen not as cure, but as getting
over and moving on

from the tragedy of mental illness. Recovery involves
drawing on one's capacity for resiliency, having hope or
reasonable expectations, and finding meaning in life apart
from mental illness, a concept to be refined through further
research (Liberman & Koplewicz, 2005).
Recently, the USPRA shifted the "P" in its name from
"psychosocial" to "psychiatric" to focus more on illness
and the need for medication for most (but not all) persons
with mental illness. This change in name is viewed by
some as being controversial; however, because it implies
an overemphasis of medical/psychiatric interventions
while possibly downplaying the impor-
. tant role of psychological and social services, although
supporters do not view the change in this way. Rehabi-
litation services for the persistently mentally ill include
both "psychosocial" and "psychiatric" interventions.
Main developers and contributors: Developers have
emerged from all mental health disciplines. Some are listed
here.
Gerald Hogarty, MSW, and Carol Anderson, MSW,
Ph.D. (social workers): development of supportive family
interventions
Robert Liberman, M.D. (psychiatrist): research and
development of skills training modules provided strong
empirical data showing cost-effectiveness of rehabilitation
interventions (see UCLA Center for Research on
Treatment and Rehabilitation of Psychosis)
William Anthony, Ph.D. (psychologist), and Marianne
Farkas, Sc.D. (psychologist/sociologist): development of
the Center for Psychiatric Rehabilitation and the
Psychiatric Rehabilitation Journal
Gary Bond, Ph.D. (psychologist): research on
employment
Martin Gittelman, Ph.D. (psychologist): development
of AAPR/W APR and the International Journal of Mental
Health
Phyllis Solomon, Ph.D. (social work researcher):
definition of special population needs-"throw away"
people such as prisoners, homeless, substance abusers.
Many contributions have come from abroad, using the
results of different cultures, mental health systems, and
approaches to mental illness. Working with the field of
physical medicine and rehabilitation, psychiatry has helped
by (a) focusing on restoring function without much
attention to etiology, (b) calling attention to the need to
provide services to and accommodation for disability, and
(c) successful advocacy for rights of disabled persons.
Statistics and Demographics Rehabilitation
services are directed at those whose need is defined by
inability to recover baseline functioning after an episode of
mental illness. Almost any person with
I
PSYCHOSOCIAL AND PSYCHIATRIC REHABILITATION 459
almost any diagnosis can suffer from severely reduced
functionality. The chronic mental illnesses associated with
significant impairment are schizophrenia, bipolar illness,
substance abuse, and dementia, with their comorbidities.
Some victims of posttraumatic stress disorder, depression,
and eating disorders are so impaired as to benefit from
rehabilitation services. The population needing treatment is
vast, both in the United States (New Freedom Commission
on Mental Health, 2003) and worldwide (World Health
Report, 2000, with needs far beyond the present and likely
future supply of service providers of any and all
professional disciplines .
Substance abuse services include a significant private
rehabilitation sector of residential treatment and partial
care, while most psychosocial rehabilitation services are
provided in public settings or publicly supported programs
by multidisciplinary treatment teams with psychiatrists,
psychologists, and social workers as well as rehabilitation
counselors, and occupational and recreation therapists. The
No data exist on the numbers, but many thousands of social
workers are providing or obtaining support services as well
as assisting their clients in developing skills needed to
function better in their social environments. Using a broad
understanding of mental health care, much of the routine
work done by all mental health disciplines on behalf of
those with persistent mental disorders can be seen as
rehabilitation.
Membership Organizations Supporting
Psychosocial and Psychiatric Rehabilitation One of the
largest membership organizations is the USPRA. It has
about 1,400 agency and individual members and is part of
the International Association for Psychosocial
Rehabilitation Services (IAPRS), which also has a
Canadian chapter (see www.uspra.org). The World
Association for Psychosocial Rehabilitation (W APR,
www.wapr.info) is active in 95 countries, has 36 national
association branches (of which the American Association
has about 200 members) with thousands of members,
especially in developing countries. In contrast to IAPRS,
W APR has more psychiatrist members, does not provide
certification, and tends to favor assisted outpatient
treatment and conjoint use of medications in most, but not
all, patients. W APR functions also as the World
Psychiatric Association's Section on Rehabilitation
(www.wpanet.org). The American Psychological
Association has a section on Rehabilitation Psychology and
publishes the Journal of Rehabilitation Psychology. All
organizations involved in rehabilitation espouse advocacy
for programs, research, human rights (including the right to
treatment), freedoms, and fight against stigma. These are
found in consensus statements on their Web sites.
460 PSYCHOSOCIAL AND PSYCHIATRIC REHABILITATION
Current Applications
Psychosocial/psychiatric rehabilitation, often referred to
as "Rehab," has become a popular and encompassing
term, showing how the concept has moved from its initial
applications to people with persistent mental illness.
"Rehabilitation" and "recovery" are to be found in the
mission statements of most public and many private
mental health agencies. Despite the vast use of the term
rehabilitation services, these services often fall prey to
budget cuts ahead of services deemed more "medically
necessary." The successful employment of rehab
interventions is built around cost-effectiveness and
feasibility studies, because rehab programs are most often
funded when shown to be cost-effective, Success ful rehab
interventions, for example, are aimed at redu-
\
cing and preventing hospitalization by providing less
restrictive alternatives with continuity of care, such as
community residences, while developing a person's skills
for dealing with illness and housing. Increased
employment also reduces spending for public assistance,
and so sheltered and supportive emplo yment programs are
used while job skills are developed. Support for social
programs and skills is variable. A special issue of
Psychiatric Rehabilitation (2007) describes efforts at service
system transformation for mental health recovery.
Current Change in Philosophy and Techniques Current
optimism that almost every person and condition can
benefit from "rehab" has its roots in the optimism and
hope of the 1930s mental hygiene movement.
Psychosocial rehabilitation has roots also in human
resource development, vocational rehabilitation, physical
rehabilitation, client-centered therapy, and special
education and learning approaches. All the above ap-
proaches are consistent with social work values and
methods for helping people. Within the Rehab field
change is based on careful assessment of needs and a
person's goals, especially what will be meaningful for
recovery.
Support interventions include (a) getting the per son to
the least restrictive environment and ensuring continuity
of care, (b) dealing with social and govern mental agencies
that can provide housing, food, money, health insurance,
and so forth, which often have eligibility criteria, and
other constraints that work against a least restrictive
environment and continuity of care ("a system in
shambles," Cook et al., 2005; New Free dom Commission
Report, 2003), (c) working with those in the person' s
immediate surroundings, such as family members, peers,
and care providers. Protection from victimization is a high
priority. A wide variety of community- oriented settings
include halfway houses
and psychosocial clubs, supportive and sheltered em-
ployment, and so forth. Although rehabilitation is gen-
erally described as "community- based" it need not be
located in the general community. It can be a thera peutic
community, separate from the main stream, yet using
community support mechanisms in the specially created
community. Social work skills in community organization
can be very helpful in such special settings. Outstanding
psychiatric rehabilitation communities include Spring
Lake Ranch in Vermont and Gould Farm in
Massachusetts.
Skill interventions are directed at the individual and
start with separating the person from the illness, and so
psychoeducation (really just education) about the nature,
signs and symptoms, and treatment (espe cially
medication) of a person's illness come first. Housing skills
are second in importance, followed by employment,
interpersonal relationships, quality of life, and so forth, all
subject to change according to individual goals.
Shifting from assuring that support is provided to
skills development can be very challenging, as such items
as disability payments can be powerful forces against
further progress. Passion, morality, philosophy of life, and
other personal factors often are decisive in bringing about
change beyond milestones that may be comfortable and
secure, but which nonetheless do not lead a person to
realize a fuller potential.
Outcome measures are related to the study subject and
objectives. Institutional measures include rehos-
pitalization, reincarceration, cooperation with medi cation,
duration of and participation in treatment, cost- benefit
analyses, and so forth. Individual assess ments are usually
related to skills and competencies in the domains list ed
above.
Standard texts include those by Anthony, Cohen, and
Farkas (1990), Liberman (1992), and Pratt, Gill, Barrett ,
& Roberts (2002), and their collaborators.
Evidence-Based Practice
Specialty journals regularly report random assigned
controlled studies of various techniques and modalities.
Journals include Psychiatric Rehabilitation Journal (pub-
lished quarterly by the Center for Psychiatric Rehabili-
tation and the USPRA), the International Journal of
Psychosocial Rehabilitation (www.psychosocial.com), the
International Journal Of Mental Health (USA), Rehabilitation
Psychology (American Psychological Associ ation),
American Journal of Psychiatric Rehabilitation (USA), and
rehabilitation-oriented articles in all major mental health
discipline journals. One confound ing factor in all
rehabilitation research is that an effect ive
multidisciplinary treatment team works better than the
sum of its parts. This is evident from site visits to

identically staffed and funded programs, which none-
theless vary in quality and outcome. In a good program,
such as Fountain House (where there are "members"
rather than patients), there is a sense of meaning an d
belonging that biases toward positive results of what ever
technique or modality is being tested. An ineffect ive
team, despite the excellent work of some of its members,
can bias toward negative results. Another confounding
factor is the wide variety of communities and populations
from which research results are reported, leading to an
emphasis on cultural competence develop ment
(Stanhope, Solomon, Pernell-Arnold, Sands, &
Bourjoll,2005).
Research has established the efficacy of assertive
community treatment and social skills training, the
importance of involving family and relatives in treat ment,
refined evaluation and psychometrics that allow reliable
and valid assessments of modalities, the impor tance of
involving community structures and agencies, the
harmful effects of stigma, and the great importance of
involving patient/clients/consumers/users both as
individuals and organizations. Research has also shown
that traditional treatments may not affect rehabilita tion
outcome, especially if narrowly directed at symp tom
reduction. Time-limited community treatment has not
been shown to be superior to time-limited hospital
treatment. Fragmentation of services and discontinuity of
treatment can ruin rehabilitation outcomes (New
Freedom Commission, 2003).
Distinctiveness from Other Approaches
Rehabilitation zealots seeking separatism formerly
argued that rehabilitation was separate and distinct from
treatment, which they saw as authoritarian, paternalistic,
and wedded to a medical model. The "medical mod el" is
useful for separating illness from person and consistent
with models of physical illness and rehabilitation, but
some authors attempt to distinguish between treatment
and rehabilitation (for example, Anthony, Cohen, &
Farkas, 1990, p. 9), while others see rehabilitation as
partof treatment. Treatment is overly concerned with the
past, causation and diagnosis, and dedicated to symptom
reduction or the development of insights, while
rehabilitation is concerned with improved functioning
and satisfaction in specific environments. But treatment
can be directed at improved functioning, including
achieving the same through symptom reduction and/or
insights. Another distinction, that rehabilitation followed
treatment, has withered as rehabilitation has been
successfully begun during treatment. Current thinking
places rehabilitation as a treatment modality, and so
rehabilitation is seen as a set of treatment modalities.
Rehabilitation has
PSYCHOSOCIAL AND PSYCHIATRIC REHABILIT AnON 461
become so positive and encompassing a concept that it
combines both community organization (support) and
working with individuals (skills and coping develop-
ment). Among the many concepts it shares with physi cal
medicine and rehabilitation is less concern with causation
and more concern about how to reduce disability.
Rehabilitation uses technology, but usually low- cost and
transferable. Finally, WHO defines men tal health as a
positive state, not just absence of symp toms: "A state of
well being in which the individual realizes his or her own
abilities, can cope with the normal stresses of life, can
work productively and fruitfully, and is able to make a
contribution to his or her community" (World Health
Organization, 2001).
Roles for Social Work
Rehabilitation is well integrated into social work prac tice.
It can be distinguished by its concerns with skills and
support to increase functioning, emphasis on recovery,
and de-emphasis on the past, diagnosis, and etiology.
Social workers are especiall y well suited for rehabilitation
work. One arm of their training, community organization
and obtaining social supports, fits in well with the support
arm of Anthony's definition earlier. Another arm of social
work education, counseling, promotes skills d evelopment.
Social workers are used to working with a person's
strengths, which is consistent with the rehabilitation
philosophy of using a person's strengths to maximize
quality of life while minimizing the illness. Social work
counseling is often informal and less concerned with the
etiological and theoretical issues. Rehabilitation shares
similar values. The emphasis is on informality and
comfort. Psychiatric rehabilita-' tion, like physical
rehabilitation, is more concerned with recovering the
function than with whatever caused its loss.
Psychodynamics are rarely discussed.
Trends and Directions
Rehabilitation constituents include (a) patients/
clients/recipients, (b) families (often speaking for
members too impaired to speak for themselves), and (c)
professionals, who have their own interdisciplinary
tensions. Directions result from consensus among these
groups, such as focusing on recovery, but there are
disagreements over many issues, such as forced treat-
ment, recovery goals (modest or fu1l?), and allocation of
resources (how much for consumer organizations?
self-help"), It is easy to lose perspective amid a welter of
personal and political agendas and feel caught be tween
extremes. But these extremes, such as the extent of
recovery possible, participation in the mainstream versus
separateness, and so forth, engender a creative tension,
and Tepper (2007) argues for "acceptance of
462 PSYCHOSOCIAL AND PSYCHIATRIC REHABILITATION
where one is while simultaneously acknowledging t he
need to change and grow." All sides agree on some points
as evidence is brought to bear, such as the following:
a. Community-based rehabilitation has been eased as
crime has dropped in major cities, but
b. increased criminalization of mental illness has
resulted in more imprisonment of people with
mental illness whose law breaking is incidental to
their illness. One result of this trend is more
rehabilitation programs in jails and prisons. These
can become special communities that in corporate
rehabilitation ideals and modalities into what
becomes, at least in part, a therapeutic commu nity.
The Community-Oriented Rehabilitation Program
at Sing Sing h~s reduced Lyear reincar ceration rates
by 80%.
c. Rehabilitation is benefiting from increased evidence
for the efficacy of no pharmacological treatments,
information systems that ease longitudinal studies.
d. With the development of functional magnetic
resonance imaging and other measures of the brain
at work, it is possible to get som e evidence of how
an intervention is working. Measures of
neurogenesis and synapse formation will assist in
documenting recovery.
Challenges will continue to revolve around a tendency
toward biomedical reductionism fueled in part by
pharmaceutical adverti sing and a public desire for both a
quick fix and complete cure. This can be seen in the
double standard applied to treatment modalities:
The patient improves on medication- "It works!" but
worsens when the medication stops-"That shows it was
working." But when a patient improves with re-
habilitation the usual response is to look for other factors
to account for a positive outcome. When a patient's
condition deteriorates after stopping rehabili tation, the
response is to dismiss rehabilitation as ineffecti ve. This
standard applies to other nonbiological treatments and is
waning as evidence accumulates. Also, rehabilitation
risks losing support whenever it tries to go beyond
medical necessity.
REFERENCES
Anthony, W. A, Cohen, M., & Farkas, M. (1990). Psychiatric
rehabilitation. Boston University, Center for Psychiatric
Rehabilitation.
Cook, J. A., Lehman, A. F., Drake, R., McFarlane, W. R., Gold, P.
B., Leff, H. S., et al. (2005). Integration of psychiatric and
vocational services: A multisite random ized, controlled, trial
of supported employment. American Journal of Psychiatry,
162(10), 1948-1956.
Liberman, R. P. (1992). Handbook of psychiatric rehabilitation.
Boston, Allyn and Bacon.
Liberman, R. P., & Kopelewicz, A (2005). Recovery from
schizophrenia: A concept in search of research. Psychiatric
Services, 56, 735-742.
New Freedom Commission on Mental Health. (2003). Achieving
the promise: Transforming mental health care.in America. Final
report (DHHS Publication No. SMA 03-3832) Rockville,
MD.
Pratt, C. W., Gill, K. J., Barrett, N. M., & Roberts, M. M. (2002).
Psychiatric rehabilitation. (Znd ed.). New York, Elsevier.
Psychiatric Rehabilitation Journal. W. A Anthony & K. ]. Gill
(Eds.). (2007). Mental health recovery and system trans-
formation [Special issue]. 31(1),1-86.
Stanhope, V., Solomon, P., Pernell-Arnold, A., Sands, R. G., &
Bourjoll, ]. N. (2005). Evaluating cultural competence among
behavioral health professionals. Psychiatric Rehabilitation
Journal, 28(3), 225-233.
Tepper, M. C. (2007). Psychosocial rehabilitation: A new comer's
eye. Psychiatric Services, 58(8), 1116-1118.
World Health Organization. (2001, November [revised]).
Mental health: Strengthening mental health promotion. (Fact Sheet
No. 220). Geneva, Switzerland: Jose Bertolote (editor).
World Health Report. (200l). Mental health: New understanding,
new hope. Geneva, Switzerland: Rangaswamy Srinvasa
Murthy (editor-in-chief).
-ZEBULON C. T AINTOR
PSYCHOSOCIAL FRAMEWORK
ABSTRACT: The psychosocial framework is a distinctive
practice model that originated early in the profession's history.
Its goals are to restore, maintain, and enhance the personal and
social functioning of individuals. Drawing on psychological
and social theories, it has evolved considerably from its
Freudian and ego psychological underpinnings. It has
incorporated new knowledge on gender and diversity.
Assessment, the client-worker relationship, respect for
diversity, and an appreciation of client strengths are
fundamental to the psychosocial approach. It uses both
individual and environmental interventions and can be applied
to a broad range of client populations. There is empirical
evidence for the utility of psychosocial intervention but more
research on the psychosocial framework is needed.
KEY WORDS: psychosocial framework; practice ap-
proach; person- situation perspective; diagnostic
model; clinical social work

Although a psychosocial or person-situation perspec tive is
at the core of all social work practice, the psy chosocial
framework has been a distinctive practice model that had
its origins in the early history of the profession. It has
evolved considerably over time in response to new
theoretical and practice developments and grea ter
understanding of the needs of diverse and vulnerable
populations. It continues to be used widely by social work
practitioners, particularly. those who consider themselves
to be clinical social workers.
The goals of the psychosocial framework are to restore,
maintain, and enhance the personal and social functioning
of individuals through mobilizing strengths, supporting
coping capacities, building self-esteem, mod ifying
dysfunctional patterns of thinking, feeling, and relating to
others, linking people to necessary resources, and
alleviating environmental stress. It draws on diverse
theories of human behavior and the social environment.
Although it has been mainly used with individuals, it can
also be utilized in work with families and groups (Northen,
1969; Woods & Hollis, 1990).
History
The psychosocial framework had its earliest origins in the
beginning of social casework and the writings of
Richmond (1917). Viewing environmental conditions as
crucial in affecting individuals, Richmond neverthe less
saw each person as unique in the way he or she dealt with
these social factors. The "diagnostic school" or
"differential" approach emerged in the 1920s, taking its
name from the fact that it emphasized diagnosis as the
foundation of all intervention. It developed further during
the period of the "psychiatric deluge" after World War I
when Freud's views began to gain acceptance in certain
segments of the social work profession. At the end of the
1930s and throughout the postWorld War II period, ego
psychological concepts also were incorporated into the
diagnostic model (Goldstein, 1984, 1995). They helped to
bridge the psychological and social spheres and were used
to help correct some of the excesses of the Freudian
emphasis.
In 1940, Hamilton published the widely used text,
Theory and practice of social casework, which puts forth the
principles of the evolving diagnostic approach. Hamilton
began to use the term "psychosocial." Diagnostic social
workers such as Austin (1948), Garrett (1958), Hollis
(1949), among others, tried to define the goals and
techniques of social casework as differentiated from
psychotherapy during the 1940s and 1950s.
In the early 1960s, Florence Hollis wrote Casework:
A psychosocial therapy (1964), which became a text that was
widely used by several generations of social workers in
the United States and other countries. Hollis'
PSYCHOSOCIAL FRAMEWORK
463
thinking evolved over the years as seen in later editions of
the book (Hollis, 1972; Hollis & Woods, 1981; Woods &
Hollis, 1990), the most recent of which was published after
her death in 1987.
More recently, the psychosocial framework is no longer
associated mainly with Hollis' writings. Others have made
important contributions to updating the model with newer
theoretical and practice developments and have tried to
carry forth the psychosocial tradition in their writings
(Applegate & Bonovitz, 1995; Berzoff, Flanagan, & Hertz,
1996; Brandell & Perlman, 1997; Elson, 1986; Goldstein,
1984, 1995, 2001; Mishne, 1993; Strean, 1979).
Nevertheless, Hollis' writings constitute the most
systematic statement of the psychosocial framework.
Theoretical Underpinnings
and Related Theory
The person-situation perspective is central to the psy-
chosocial approach, which draws on many developmen tal
and environmental theories that help to understand the
person, the situation, and the interactions between them. It
focuses on the psychological and social factors that limit
successful or optimal coping and cause various forms of
suffering and maladaptation.
To understand the personality in depth and the coping
capacities that people bring to their life transac tions, the
psychosocial framework employs contemporary
psychodynamic theories, including Freudian
psychoanalysis, ego psychology, attachment and object
relations theory, self psychology, relational theory, and
intersubjectivity (Berzoff, Flanagan, & Hertz; 1996;
Brandell & Perlman, 1997; Goldstein, 2001). It places
importance on integrating knowledge with respect to
emotional disorders and serious forms of psychopathology.
It embodies new perspectives on female development, the
adult life cycle, the impact of trauma, gay and lesbian
development, and cultural, ethnic, and racial diversity. It
incorporates the findings of observational studies of infants
and small children that enlarge and to some extent modify
our understanding of developmental processes. Cognitive
theory and new knowledge about the influence of
biological factors on personality and psychopathology add
an important dimension to our understanding of human
functioning. Communications, family, and small group
theories shed light on the nature of interpersonal
interactions. Role theory provides an important link
between social and environmental influences and
personality development. Crisis theory adds an important
dimension to showing how stressful circumstances disrupt
an individual's usual means of coping. Knowledge
regarding the impact of organizational structure and
processes, the service
464 PSYCHOSOCIAL FRAMEWORK
delivery. system, the community, and the society are also
essential to understanding person- environmental
transactions (Woods & Hollis, 1990).
Major Components
Diagnosis or assessment of the client's current and past
functioning and life circumstances is fundamental to the
psychosocial framework. Because each individual
presents with a unique constellation of· biological
predispositions, needs, coping capacities, interpersonal
relationships, stressors, cultural background, and envir-
onmental resources, correct assessment of the client's total
person-situation functioning must be individua lized and
rehited to developing and implementing an appropriate
interventive plan. Although time constraints may require
that the assessment process be abbreviated and focused,
accurate understanding is just as important in crisis and
short, term intervention as in ongoing work.
Understanding and empathizing with the client's per-
ception of his or her needs and difficulties is essential to
the assessment process. The use of clinical or medical
diagnoses may provide important information about
symptom constellations and discrete disorders that have a
certain etiology and course but should be augmented by a
fuller psychosocial assessment. Thus concluding that a
client has a learning disability, medical problem, erno-
tional disorder, and the like has important implications but
is not sufficient for the purposes of assessment and the
planning of intervention. The focus and nature of inter,
vention follows from the assessment and the client should
be involved in establishing the treatment plan.
The client-worker relationship is a crucial element in
the psychosocial framework. The worker shows human
concern for clients and conveys certain key attitudes and
values. These include acceptance of the client's worth,
empathy, genuineness, a nonjudgmental attitude toward
the client, appreciation of the client's individuality or
uniqueness, respect for the client's right to
self-determination, and adherence to confidentiality
(Woods & Hollis, 1990). The worker may use the
relationship with the client to help bring about change in
keeping with the assessment of the client's needs and
interventive goals. Sometimes the worker functions as a
role model or provides corrective experiences for the
client. The worker, however, must guard against impos ing
his or her own values on the client, using the client to meet
the worker's needs, or encouraging too m uch dependence
on the worker.
An important interventive principle, particularly in the
engagement phase, is being where the client is. It is
advisable for the worker to show respect for the client's
diversity and recognize the factors that are influencing
the client's participation in the helping relationship. These
involve the client's motivation and expectations, previous
experiences in getting help, values, gender, religion,
sexual orientation, class, ethniciry, race, ego functioning,
current life situation, and the characteris tics of the service
delivery setting itself.
Both participants influence the client-worker rela-
tionship. Sometimes, however, the client's or worker's
past relationships influence and distort the real relation'
ship between client and worker. These latter responses are
termed transference and counter, transference reac tions
and may become disruptive (Woods & Hollis, 1990). In
these instances, they need to be managed effectively.
When ending the relationship because the work is
complete or prematurely disrupted, the worker must
consider the meaning the relationship has to the client and
help the client deal with the feelings involved.
The psychosocial approach tries to mobilize client
strengths. In codifying and refining the psyc hosocial
framework, Hollis (1964, 1972) and Hollis and Woods
(1981) described and studied individual techniques that
can be used flexibly in the interventive process. These
included sustainment, direct influence, explora-
tion-description-ventilation, person, in-situation reflec-
tion, pattem-dynamic reflection, and developmental
reflection. Hollis classified environmental intervention
according to the type of resource employed, the type of
communication used, and the type of role assumed. The
latter consisted of provider, locator, creator of a resource,
interpreter, mediator, and aggressive interve ner. Although
the psychosocial framework did not gen erate the use of
cognitive-behavioral and other types of evidence- based
practice techniques, many of these int erventions can be
incorporated into the psychosocial approach.
Because of shared theoretical assumptions about
human behavior and basic practice principles, the psy-
chosocial approach and the crisis intervention model are
consistent with one another (Golan, 1978) and other forms
of dynamically oriented short, term treatment (Reid &
Epstein, 1972). The crisis and brief treatment models
require somewhat different skills than do more extended
forms of treatment because the constraints of time dictate
faster assessments and more active and focused
interventions. An important issue today is the degree to
which briefer forms of intervention are used because they
are indicated or as a blanket approach irrespective of
client need in order to save money.
Diverse and Special Populations
With its early roots in Freudian theory and ego psychol-
ogy, the psychosocial approach came under attack in the
1960s for viewing difference as pathology or

deviance, and for not being attuned to the needs, problems,
and strengths of diverse, oppressed, and vulnerable
populations (Wasserman, 1974). Since that time, the
psychosocial framework has expanded to encompass new
perspectives on women's development and roles and the
unique experiences, characteristics, strengths, and coping
strategies of African Americans, Latinos, Asians, and other
people of color, and of other oppressed groups such as gays
and lesbians (Goldstein, 1995). It has attempted to
incorporate many of the principles that have been
suggested by more sensitive, affirmative, and empowering
interventive models (Collins, 1986; Drescher, 1998; Falco,
1991; Goldstein, 2003; Gutierrez, 1990; Hirayama &
Cetingok, ~988; Jordan, 1990; Phillips & been on the therapeutic alliance and therapist
Gonzalez-Ramos, 1989; Robinson, 1989; Ryan, 1985).
Likewise, changes in society and in the clients needing
help have focused greater attention on the application of
the psychosocial approach to special populations.
Psychosocial intervention has been utilized with every
conceivable type of client populations and client problem,
including victims and perpetrators of rape and other forms
of violent assault, child abuse, domestic violence,
substance abuse the homeless and chronically mentally ill,
adult survivors of sexual abuse, and persons with AIDS
(Turner, 1983, 1995).
Issues in Research
Historically, the psychosocial approach derived consider-
able strength from the extensive experiences of practi-
tioners, that is, from "practice wisdom." In the late 1960s
and throughout the 1970s, critics of the psychosocial
framework drew attention to its lack of an empirical base
and to the disappointing results of research on casework
effectiveness (Mullen, Dumpson, & Associates, 1972). It
later came to light that the studies in question were
seriously flawed as the interventive goals, processes, and
treatment outcomes were not well selected, defined,
operationalized, and measured (Perlman, 1972). More
rigorous research methodology was advocated (Bloom,
1983, pp. 560-582; Blythe & Briar, 1985, pp. 483-488;
Fischer & Hudson, 1983, pp. 673-693; Levy, 1983, pp.
583-602; Reid, 1983, pp. 650-672).
In the years since these early studies, the evidence on
treatment outcomes for psychosocial intervention reflects
more positive results (Rubin, 1985, pp. 469-476;
Thomlison, 1984, pp. 51-56). Greater sophistication in
research methodology and design and more willingness on
the part of theorists to subject their ideas to investigation
have led to more systematic study of the theories that
inform the psychosocial model. For example, there is
significant research on child
. and adult development and the ways in which people cope
with stress, crisis, and various types of life demands
I
PSYCHOSOCIAL FRAMEWORK
465
and events. Tools for assessing adaptive and maladaptive
personality functioning also have evolved. In contrast to
these developments, intervention research has lagged
considerably but there have been significant research
studies that address psychotherapy process and outcome
based on psychosocial principles (Fonagy, 2006; Lambert
& Hill, 1994; Weston, Novotny, & Thompson-Brenner,
2006).
An important thrust of process-oriented studies has
addressed the common factors that are associated with
positive outcomes across different therapeutic models.
Lambert and Bergin (1994, p. 163) list33 such features.
Perhaps the two most important foci in these studies have
characteristics such as accurate empathy, positive regard,
nonpossessive warmth, and congruence or genuineness
(Howard & Orlinskv, 1986).
There is a good deal of evidence for the effectiveness of
psychosocial interventions and psychotherapy based on
psychodynamic principles that are not often integrated into
courses on evidence-based practice (Fonagy, 2006; Rubin,
1985; Thomlison, 1984). Nevertheless, isolating the
specific factors that are associated with effectiveness has
been more difficult. The task of operationally defining
psychosocial variables, interventions, and outcomes
remains a challenging task and there is a dearth of evidence
for psychosocial interventions in comparison to
cognitive-behavioral approaches. Thus, research on
psychosocial intervention still is at an early stage.
Outcome evaluation, while important, is not the only
type of research methodology that can be used to study
practice. Although systematic studies of the effectiveness
of intervention with specific target problems and popula-
tions are needed, qualitative and other diverse research
strategies are equally necessary (Reamer, 1992). Further,
those involved in clinical practice should play a greater role
in the formulation, design, and implementation of such
studies either by acquiring practice research expertise
themselves or through collaboration with researchers
interested in and challenged by the problems inherent in
conducting clinical studies.
Challenges and Dilemmas
Although the strength of the psychosocial framework
approach has been its openness to new knowledge over the
years and its willingness to discard ideas that are not useful,
it is now more difficult to delimit its knowledge base
precisely and to present a fully integrated view of its
theoretical underpinnings. Ironically, it may be more
accurate today to describe the psychosocial framework as a
perspective that guides practice rather than as discrete
practice model. Nevertheless, it does rely on a core of
theoretical concepts and practice principles.
466 PSYCHOSOCIAL FRAMEWORK
The continuing popularity of the psychosocial framework
among social work practitioners shows that it has stood the
test of time (Mackey, Urek, & Charkoudian, 1987). There has
been lingering cri ticism, however, that the psychosocial
framework is too pathology oriented, psychotherapeutic in
nature, and appropriate to the treatment of the "worried well"
rather than work with clients presenting with difficult
problems in living (Specht & Courtney, 1994). No doubt,
some of this criticism stems from the fact that many private
practitioners utilize the psychosocial framework. This criti-
cism ignores its broadened application and considerable
evolution. Although the psychosocial model includes
psychotherapy, it has a broader scope and interventive
repertoire (Strean, 1978; T umer, 1978).lt may be shortterm or
long-term in nature ~nd involve discharge planning, case
management, and linkage to community and social resources,
the support of functioning, or modification of longstanding
personality or interpersonal difficulties. Moreover, the view
that the goals of psychotherapy itself are only
self-understanding or selfactualization rather than helping
clients cope more effectively with their life circumstances
represents a gross misunderstanding of the treatment process
(Goldstein, 1996). Likewise, even those in private practice
work with clients who present with complex problems and
sometimes tragic life situations. The psychosocial model
originated in and has been used extensively in agency-based
practice since its inception. Social work practitioners have
applied its principles and techniques in work with a broad
range of clients
. and client problems. Nevertheless, it is important for there to
be a continuing effort to apply the psychosocial framework to
the problems of diverse, oppressed, economically
disadvantaged, and special populations in today's agency
practice arena and to study its effectiveness in work with these
and other populations.
REFERENCES
Applegate, J. S., & Bonovitz, J. M. (1995). The facilitating
partnership. Northvale, NJ: Jason Aronson.
Austin, L. (1948). Trends in differential treatment in social
casework. Social Casework, 29,203-211.
Berzoff, J. L., Flanagan, M., & Hertz, P. (Eds.). (1996). Inside out
and outside in. Northvale, NJ: Jason. Aronson.
Bloom, M. (1983). Empirically based clinical research. In A.
Rosenblatt & D. Waldfogel (Eds.), Handbook of clinical social
work (pp. 560-582). San Francisco: jessey-Bass.
Blythe, B. J., & Briar, S. (1985). Developing empirically based
models of practice. Social Work, 30,483--488.
Brandell, J. R., & Perlman, F. T. (Eds.). (1997). Theory and practice
in clinical social work. N ew York: Free Press.
Collins, B. G. (1986). Defining feminist social work. Social Work,
31, 214-220.
Drescher, J. (1998). Psychoanalytic therapy and the gay man.
Hillsdale, NJ: The Analytic Press.
Elson, M. (1986). Self psychology in clinical social work. New York:
W. W. Norton.
Falco, K. L. (1991). Psychotherapy with lesbian clients: Theory into
practice. New York: Brunner/Mazel.
Fischer, J., & Hudson, W. (1983). Measurement of client
problems for improved practice. In A. Rosenblatt & D.
Waldfogel (Eds.), Handbook of clinical social work (pp.
673-693). San Francisco: [ossey-Bass,
Fonagy, P. (2006). Evidence-based psychotherapies. In Psyc-
hodynamic diagnostic manual (pp. 765-818). Silver Spring, MD:
Alliance of Psychoanalytic Organizations.
Garrett, A. (1958). Modem casework: The contributions of ego
psychology. In H. J. Parad (Ed.), Ego psychology and dynamic
casework (pp. 38-52). New York: Family Service Association
of America.
Golan, N. (1978). Treatment in crisis situations. New York: Free
Press.
Goldstein, E. G. (1984). Ego psychology and social work practice.
New York: Free Press.
Goldstein, E. G. (1995). Ego psychology and social work practice
(Znd ed.). New York: Free Press.
Goldstein, E. G. (1996). What is clinical social work? Looking
back to move ahead. Clinical Social Work Journal, 24, 89-104.
Goldstein, E. G. (2001). Object relations theory and self psychology in
social work practice. New York: Free Press.
Goldstein, E. G., & Horowitz, L. (2003). Lesbian identity and
contemporary psychotherapy: A framework for clinical practice.
Hillsdale, NJ: The Analytic Press.
Gutierrez, L. M. (1990). Working with women of color:
An empowerment perspective. Social Work, 35,149-154.
Hamilton, G. (1940). Theory and practice of social casework .
New York: Columbia University Press.
Hirayama, H., & Cetingok, M. (1988). Empowerment:
A social work approach for Asian immigrants. Social Casework:
The Journal of Conremporary Social Work, 69,41--47.
Hollis, F. (1949). The techniques of casework. Journal of Social
Casework, 30, 235-244.
Hollis, F. (1964). Casework: A psychosocial therapy. New York:
Random House.
Hollis, F. (1972). Casework: A psychosocial therapy (2nd ed.).
New York: Random House.
Hollis, F., & Woods, M. E. (1981). Casework: A psychosocial
therapy (3rd ed.). New York: Random House.
Howard, K. I., & Orlinsky, D. E. (1986). Process and outcome.
In S. L. Garfield s, A. E. Bergin (Eds.), Handbook of psycho-
therapy and behavior change (3rd ed., pp. 311-381). New York:
Wiley.
Jordan, J. V. (1990). Relational development through empathy:
Therapeutic applications. In Empathy revisited, Work in progress
(No. 40, pp. 11-14). Wellesley, MA: Wellesley College, Stone
Center.
Lambert, M. J., & Bergin, A. (1994). Psychodynamic approaches.
In A. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy
and behavioral change (4th ed., pp. 467-508). New York:
Wiley.

Lambert, M. J., & Hill, C. E. (1994). Assessing psychotherapy
outcomes and process. In A. Bergin & S. L. Garfield (Eds.),
Handbook of psychotherapy and behavioral change (4th ed., pp.
72-113). New York: Wiley.
Levy, R. L. (1983). Overview of single-case experiments. In A.
Rosenblatt & D. Waldfogel (Eds.), Handbook of clinical sodal
work (pp. 583-602). San Francisco: jessey-Bass.
Mackey, R. A., Urek, M. B., & Charkoudian, S. (1987). The
relationship of theory to clinical practice. Clinical Social Work
Journal, 15,368-383.
Mishne, J. M. (1993). The evolution and application of clinical theory.
New York: Free Press.
Mullen, E. J., & Dumpson, J. R., & Associates (Eds.). (1972).
Evaluation of social intervention. San Francisco: jessey-Bass.
Northen, H. (1969). Social work with groups. New York:
Columbia University Press.
Perlman, H. H. (1972). Once more with feeling. In E. J.
Mullen, J. R. Dumpson, & Associates (Eds.), Evaluation of social
intervention (pp. 191-209). San francisco: J ossey - Bass.
Phillips, L. J., & Gonsalez-Ramos, G. (1989). Clinical social work
practice with minority families. In S. M. Ehrenkranz, E. G.
Goldstein, L. Goodman, & J. Seinfeld (Eds.), Clinical social work
with maltreated children and their families: An introduction to
practice (pp. 128-148). New York: New York University Press.
Reamer, F. J. (1992). The place of empiricism in social work.
Journal of Social Work Education, 28, 260-269.
Reid, W. J. (1983). Developing intervention methods through
experimental designs. In A. Rosenblatt and D. Waldfogel (Eds.),
Handbook of clinical social work (pp, 650--672). San Francisco:
[ossey-Bass.
Reid, W. J.,& Epstein, L. (1972). Task-centered casework.
New York: Columbia University Press.
Richmond, M. L. (1917). Social diagnosis. New York: Russell Sage
Foundation.
Robinson, J. B. (1989). Clinical treatment of black families:
Issues and strategies. Sodal Work, 34,323-329.
Rubin, A. (1985). Practice effectiveness: More grounds for optimism.
Social Work, 30,469-476.
Ryan, A. S. (1985). Cultural factors in casework with Chinese
Americans. Social Casework: The Journal of Contemporary Social
Work, 66,333-340.
Specht, H., & Courtney, M. (1994). Unfaithful Angels.
New York: Free Press.
Strean, H. S. (1978). Clinical social work. New York: Free Press.
Strean, H. S. (1979). Psychosocial theory and social work practice.
New York: Free Press.
Thomlison, R. J. (1984). Something works: Evidence from practice
effectiveness studies. Social Work, 29, 51-56.
Turner, F. J. (1978). Psychosocial therapy: A sodal work perspective.
New York: Free Press.
Turner, F. J. (Ed.). (1983). Differential diagnosis and treatment in
social work practice (3rd ed.). New York: Free Press.
Turner, F. J. (Ed.). (1995). Differential diagnosis and treatment in
social work practice (4th ed.). New York: Free Press.
Wasserman, S. L. (1974). Ego psychology. In F.J. Turner(Ed.), Social
work treatment (pp, 42-83). New York: Free Press.
PSYCHOTROPIC MEDICATIONS
467
Weston, D., Novotny, C. M., & Thompson-Brenner, H. (2006). The
empirical status of empirically supported psychotherapies:
Assumptions, findings, and reporting in controlled clinical trials.
In Psychodynamic Diagnostic Ma'nual (pp. 631-663). Silver Spring,
MD: Alliance of Psychoanalytic Organizations.
Woods, M. E., & Hollis, F. (1990). Casework: A psychosocial therapy.
New York: McGraw Hill.
-EDA G. GOLDSTEIN
PSYCHOTHERAPY. See Pyschosocial and Pyschiatric
Rehabilitation.
PSYCHOTROPIC MEDICATIONS
ABSTRACT: To advance the discussion of the interface
between psychopharmacology and contemporary social work
practice, we present a brief primer on the different types of
medications used in psychiatry and our current understandin g
of how they work. We also discuss how decisions are made
about psychiatric medications in the real world to treat some
of the more common mental illnesses. Along the way, we will
also presen t some of the recent research in
psychopharmacology of particular interest to social workers
and the clients they serve, as well as some of the future
directions we can expect in the years to come. From that
foundation, we review major activities of social workers in
psychiatric medication, address some of the key controversies
centering on issues of access, the role of drug companies, and
especially medication for children. We conclude with brief
reflections on what is "best practice" and notions of the future
of interdisciplinary practice in health, mental health, and
beyond.
KEY WORDS: psychiatric medication; social work roles in
psychopharmacology; decision-making in psychiatry;
meaning of medication; interdisciplinary practice; in-
formation and referral around psychiatric medication;
medication monitoring and adherence; controversy and social
justice issues with medications
Psychopharmacology 101
BASIC NEUROTRANSMISSION AND A THEORETICAL
UNDERPINNING OF DRUG ACTION Our current un-
derstanding of the mechanism of the action of the drugs used
in the treatment of mental illnesses is grounded in the theory
of neurotransmission. Our knowledge in this
468 PSYCHOTROPIC MEDICA nONS
area has been developed in an incremental way from a
variety of sources, including neuro-anatomy, neuro-
imaging, biochemistry, and pharmacology. What has
developed is a basic understanding of how a number of
chemicals affect the function of the brain. Our under-
standing is, however, quite limited and our understand ing
of the mechanism of the action of the d rugs used in
psychiatry is only at the early stages. At the microscopic
level, the cells of the brain or neurons that are involved with
behavior, memory, and emotions, communicate with one
another via a chemical messenger system. There are
surprisingly only a handful of these chemical messen gers,
called neurotransmitters, currently identified as being
important in our understanding of how cells com municate,
as well as how drugs can be used to manipulate intercellular
communication iri the treatment of men tal illnesses. The
connection point between two neurons is called a synapse, a
tiny area where neurotransmitters are released by one cell
and picked up by the next cell, increasing or decreasing the
likelihood that the next neuron will propagate the signal .
An entire field of neuroscience is dedicated to the study of
these processes and some of what is known or presupposed
is presented below in discussing specific medications.
OVERVIEW OF CLASSES AND CUTTING EDGE
RESEARCH
Antidepressant Medications. The drugs in the
category of antidepressants primarily work with the
neurotransmitters serotonin, norepinephrine, and dopa-
mine, increasing the functional amount of these chemicals
that affect neurotransmission in the brain. The most
frequently prescribed drugs in this category are known as
selective serotonin reuptake inhibitors (SSRIs), and seem
to work by raising the levels of serotonin in the synapse
(Schatzberg, Cloe & DeBattista, 2007). Among this class
are such familiar drugs as Prozac (fluoxetine), Zoloft
(sertraline), and Lexapro (escitalopram). These
medications are typically well tolerated by those who take
them, though they are known to cause such sideeffects as
nausea, diarrhea, and headaches. An older class of
antidepressants, called tricyclics because of their chemical
structure, also increases the amount of serotonin in the
synapse, but additionally increase the amount of
norepinephrine. These medications, such as Elavil
(amitriptyline) and Tofranil (imipramine) carry significant
risk of cardiac death when taken as an overdose, so have
been largely abandoned, though they are still used when
other drugs are ineffective or not tolerated. Effexor
(venlafaxine) and Cymba Ita (duloxetine) are two newer
drugs that work on both serotonin and norepinephrine
without the significant cardiac risk of the tricyclics.
Wellbutrin (bupropion) raises the
norepinephrine and dopamine levels in the synapse and has
shown efficacy in treating depression as well as aiding
smoking cessation (Sadock & Sadock, 2005).
Research in the area of antidepressants has been pro-
gressing, with many important studies that go beyond those
sponsored by drug companies to achieve approval for new
medications (Stahl, 2007). There have recently been some
large head-to-head trials of antidepressants to determine
differences in both effectiveness and tolerabil ity (Rush et
al., 2006), two crucial dimensions not only for prescribers
and clients but for social workers charged with deciphering
current research. There are also some large studies
comparing the effectiveness of medications to the
effectiveness of psychotherapies or their com bination
(Pampallona, Bellini, Tibaldi, Kupelnick, & Munizza,
2004). Future directions in the pharmacologic treatment of
depression will likely include medications that target all
three of the currently targeted neurotrans mitters: serotonin,
norepinephrine, and dopamine. One such medication
recently approved is transdermal selegi line, a patch that is
applied to the skin. It is a new formulation of an older
medication called an "MAOI," but with fewer side effects
and dietary restrictions (Feiger, Rickels, Rynn, Zimbroff, &
Robinson, 2006). There are also novel targets for
antidepressants under development, including the
neurotransmitters neurokinin, vasopressin, and CRF (Stahl,
2007).
Antipsychotic Medications. Antipsychotic medi-
cations have existed since the 1950s and proved revolu-
tionary in changing the way people thought about the
treatment of serious mental illnesses. Many historians
credit the discovery of these medications, at least in part, to
fundamental changes in the mental health system, moving
the care of people with serious mental illnesses out of large
institutions and into community settings. All the current
medication for treating psychosis seems to work by
modulating the amount of dopamine available for
neurotransmission, generally by blocking the receptors for
dopamine. The older antipsychotics, the so-called "typical"
or "conventional" antipsychotics, including such drugs as
Thorazine (chlorpromazine), Trilafon (perplienazine), and
Haldol (haloperidol), have worked almost exclusively by
blocking dopamine receptors in the synapse. Though
highly effective in controlling some of the symptoms of
psychosis such as hallucinations and paranoid delusions,
(often referred to as "positive" due to the presence of
certain symptoms or issues), they are not considered as
effective for the so-called "negative" symptoms of
psychosis such as flattening of affect or loss of normal
emotional expressiveness and social withdrawal (the
absence of desired behaviors). These medications also
have a high burden of side effects that vary from drug to
drug. These include

movement disorders (stiffness, gait disturbances, tardive
dyskinesia), difficulties in the regulation of blood pres'
sure, dry mouth, constipation, and sedation. Many of the
side effects can be treated either with another medication o r
by adjusting dosages. However, there are occasional
life-threatening side effects that affect the heart and
nervous system, and some of the side effects, especially
tardive dyskinesia, can be permanent, even after the drug is
stopped. Some of the newer antipsychotics, the "atypical"
antipsychotics, are thought to offer comparable . efficacy
with fewer of the side effects that plagued the "typicals,"
although research is now further exploring that assertion
(see below). The atypical antipsychotics include Risperdal
(risperidone), Zyprexa (olanzapine), Abilify (aripiprazole),
and Clozaril (clozapine). These newer drugs are not
without their own set of risks. Many have been associated
with significantly increased risk of weight gain, diabetes,
and high cholestero1. Clozapine is associated with a
potentially fatal blood disorder, agranulocytosis, for which
regular blood tests are indicated (Sadock & Sadock, 2005).
A recent large NIMH,led study, known as CATIE,
compared a subset of typical and atypical antips ychotics to
determine if there was a difference in efficacy and
tolerability between several of the newer antipsychotic
drugs and one of the older medications (Lieberman, Stroup
& McEnvoy, 2005). It suggested that one of the older anti
psychotics, perphenazine, was just as ef fective and well
tolerated as the newer medications, but at a significantly
lower cost (Rosenheck et al., 2006). Future medications
under development for psychosis include several new
atypical anti psychotics that also target dopamine, as well
as medications that target novel neurotransmitter systems,
including glutamate and serotonin (Stahl, 2007).
Anti-Manic and Mood Stabilizing Agents. This group
of medications is used to treat people with bipolar disorder or
similar disorders that involve mood instability. The
mechanism of action of these medications is less clearly
understood than many others, but they tend to decrease the
electrical excitability of the neuron to decrease firing in the
synapse. Lithium, the prototypical mood stabilizer, is a natural
element thought to be very effective in treating mania as well
as preventing episodes of mania and mood cycling. Its side
effects include nausea and diarrhea, possible kidney damage,
and tremors. It is potentially fatal in overdose and must be
monitored with frequent blood tests to ensure that the level of
lithium in the blood is high enough to be effective, but not so
high as to cause toxicity. The rest of the mood stabilizers were
initially developed as medications to treat seizures. They
include Depakote (valproic acid), Tegratol (carbamazepine},
and Lamictal
PSYCHOTROPIC MEDICATIONS 469
(lamortigine). Several of these medications also require
periodic blood tests to monitor levels. Potentially serious
side-effects are also well known, including liver damage,
skin rashes, and problems with immune-system cells
(Sadock & Sadock, 2005).
Anti-Anxiety Medications. Medications specifically
used to treat anxiety include several classes of medications
that vary in their potential for abuse and dependency, a
significant concern among prescribers, consumers, and social
workers alike (Rosenbaum, 2005). Most work by interacting
with the receptor for the neurotransmitter GABA, decreasing
neuron firing. Ben, zodiazepines, the most commonly used
class, include such drugs as clonazepam (Klonopin),
lorazepam (Ativan), and alprazolam (Xanax). The advantage
of these medica, tions is the rapid onset of action, usually
demonstrating efficacy in reducing anxiety after the first dose.
That advantage also contributes to their tendency to become
drugs of abuse because of the immediately rewarding
sensation of decreased anxiety. That said, they are very
effective medications for many anxiety disorders, are
considered to have relatively few side effects beyond sedation,
and are not particularly dangerous in overdose. The same
cannot be said of the older medications used for anxiety, the
barbiturates, that could lead to respiratory arrest in overdose.
Another new medication approved for generalized anxiety
disorder is buspirone (Buspar). This medication can be very
effective for some people, without the risk for abuse or
dependence; however it is generally not effective if a person
has already been on one of the benzodiazepines (Sadock &
Sadock, 2005).
Future directions for anxiety disorders include new
medications targeting serotonin activity that is specific to
anxiety, and medications that affect another neuro-
transmitter that is important in anxiety, cholecystokinin.
Other medications are expected to target the same receptor
as that targeted by benzodiazepines, but with a lesser risk
of dependence (Stahl, 2007).
Stimulant Medications. Among the other types of
psychiatric medication are the stimulants, including
methylphenidate (Ritalin) and amphetamines (Dexedrine,
Adderall), which are widely used to treat children and adults
with poor concentration and hyperactivity (Schatzberg et a1.,
2007). They work by increasing the release of the
neurotransmitter dopamine in the brain. These medications
work quickly and have a significant potential for abuse, so are
listed as controlled substances with more stringent prescribing
requirements. Despite this risk, they remain the treatment of
choice for most people diagnosed with ADHD because of
their effectiveness. There are longer-acting preparations of
stimulants under development, as well as stimulants with less
potential for abuse (Stahl, 2007).
470 PSYCHOTROPIC MEDICATIONS
Antihypertensive and Anticholinergic Medications.
Medications typically used for medical treatment of high
blood pressure, such as the beta-blocker proprano lol
(Inderal) and clonidine, are now used in psychiatry for
performance anxiety, for hyperactivity in children, and to
treat symptoms of withdrawal from drugs of abuse, such
as alcohol and heroin. These medications block receptors
for norepinephrine and epinephrine. Anticholinergic
medications block acetylcholine re ceptors in the brain and
are commonly used to treat some of the side effects of
antipsychotic medications, including muscle stiffness,
tremor, and akathesia (a sense of internal restlessness and
agitation) (Sadock & Sadock, 2005).
TYPICAL DECISION TREES "AND PHILOSOPHY Decisions
about medications for the treatment of mental illness are
multifaceted and involve collaboration be tween the
prescriber and the client or consumer of medication,
Many people come to a prescriber with clear preferences
and expectations, while others present with limited
understanding or even a limited capacity to understand
due to the symptoms of their illness. Most prescribers
would agree that the first important step i s ensuring an
accurate diagnosis. Then available treat ment options, both
pharmacologic and psychosocial, can be determined. Of
course, there are potential draw backs to all treatments,
whether they are side effects or investments in time and
money for psychosocial interventions. Every effort should
be made to ensure that the client undedtands the options,
along with the risks and benefits, so that informed
decisions can be made in collaboration with the providers.
The more clearly the person understands t he rationale for
different options and can make meaningful contributions
to the decision making process, the more likely all parties
will be satisfied with the process.
Depression. When a patient first presents with a diagnosis
of major depression, several treatment modalities are
appropriate for consideration, depending on the severity of
symptoms and the patient's preferences (American Psychiatric
Association, 2000). Medications alone, psychosocial
intervention alone, medications combined with psychosocial
intervention and, in more severe cases, electroconvulsive
therapy (ECT), may be options. Specific effective
psychotherapies alone may be considered for people with mild
to moderate symptoms, who have a preference for non-
pharmacologic approaches, or for whom a specific psy-
chosocial stressor is identified. Medications are an option for
people with even mild major depression, given the consensus
about their ~ffectiveness and relative safety. All the
antidepressant medications have
been shown to be relatively comparable in their efficacy
in aggregate, though there is no sure-fire way to predict
which medication may be more effective for a particular
person; so the choice of an initial antidepressant is based
largely on the side-effect profiles of the medica tions
(American Psychiatric Association, 2000). As SSRIs are
generally well tolerated and effective, they are the usual
first-line treatment. It is important to note, however, that
all the currently available antide pressant medications take
at least several weeks before they reach maximum
efficacy, though the side effects may be apparent even
after the first dose. Guidelines on the effective use of
antidepressants suggest that a trial of 6-8 weeks be
conducted unless side-effects are dangerous or intolerable
(APA, 2000). If the initial medica tion is not effective in
relieving symptoms, or is only partially effective, choice
of medication can be reeval uated and the plan altered in
collaboration with the person taking the medication.
Options include adding psychosocial interventions such
as psychotherapy, if none has been provided, changing to
another medication in the same class, changing to a
different class of medications, or adding a second agent to
augment the effect of the first. Once an effe ctive
treatment regimen has been found, it is generally
recommended that it be continued for a period of about
six months before a decision is made whether to continue
the treatment to prevent relapse or discontinue treatment
(APA, 2000).
Bipolar Disorder. When a client presents with symptoms
of classic mania (elevated mood, decreased need for sleep,
increased risk-taking behaviors), the definitive diagnosis of
bipolar disorder is simple to make. Most cases of bipolar
disorder, however, are not so apparent. The majority of people
with bipolar disorder will actually present with symptoms of
depression, as this phase is far more common in the natural
course of the illness. It is therefore imperative that practi-
tioners obtain a thorough longitudinal history, accounting for
episodes of mood disturbance over time. If a bipolar diagnosis
is suspected, the first line of treatment is a mood stabilizer,
irrespective of whether the person is presenting in a depressed
or manic episode. It has become apparent in clinical practice
that getting better control over the cycling of moods and
preventing relapses of major mood episodes are paramount for
successful treatment. The most-studied mood stabilizing
medication is lithium, though because of its potential toxicity
and side effects, it is not often the first medication utilized
(Blanco, Laje, Olfson, Marcus, & Pincus, 2002). Other
acceptable mood stabilizers, such as the atypical
antipsychotics or valproic acid (Depakote) are usually tried
first. If depression is so severe that medication to target its
symptoms seems necessary, then an
I
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antidepressant can be added as a secondary agent, but may
be discontinued after the depressive episode re solves,
though the mood-stabilizer is generally contin ued to
reduce mood cycling and prevent the return of serious
mood symptoms (APA, 2002). A newer anti epileptic drug,
lamotrigine (Lamictal), has been found to be very
effective for treating depressive episodes in bipolar
disorder as well as preventing recurrence, though it is no t
very effective for treating acute episodes of mania. If, for
example, a client with a known history of a previous manic
episode presents complaining of de pressed mood, low
energy, thoughts about death, and crying episodes,
lamotrigine may be a good choi ce for the long term
(Goodnick, 2007).
Schizophrenia. Medication treatment for psychotic
disorders presents specific. challenges to practitioners because
of the very nature of psychosis: clients often have a difficult
time determining what experiences are real and what
experiences are creations of their minds. A person presenting
to the emergency room with paranoid delusions may have
difficulty trusting the clinicians who are trying to help and in
giving adequate informed consent to agree to a trial of
medications. Given these complicating factors, there is
extensive clinical experience in using antipsychotic drugs to
treat symptoms of schizophrenia and recent large studies
assessing the relative effectiveness of the drugs. In general, the
currently available antipsychotic drugs have been found to be
roughly equivalent in treating the symptoms of psychosis, so
choosing a medicine is largely based on: important peripheral
factors: history of response to particular medications, side
effects, method of administration, cost, and availability of the
medication in different treatment settings. Even with careful
planning, the need to try multiple medications before finding a
good fit is the rule. Some people will have to discontinue a
medicine because it does not adequately control symptoms,
others because of intolerable side effects. Currently,
practitioners generally start with the newer atypical
antipsychotics as first-line agents because of their
comparatively favorable side-effect profiles. If the first agent
is not tolerable or effective, change to another atypical or one
of the older typical antipsychotics is warranted. In case several
medications have failed, a trial of clozapine may be initiated. It
is reserved for these treatment-resistant cases because of the
risk of agranulocytosis (Lehman et aL, 2004).
Once-a client's symptoms are controlled in the acute phase
to an acceptable degree, prescribers and other involved
providers such as social workers can plan for the long-term
treatment needs in cooperation with the client and family.
Sometimes dosages of medication can be lowered during the
stable phases of illness to reduce
PSYCHOTROPIC MEDICATIONS 471
side effects, though it is generally accepted that medi-
cation should not be stopped entirely, as it may lead to
increased risk of relapse. Adherence to a medication
regimen can be very difficult for some clients during this
phase for a variety of reasons, including the belief that
because symptoms are well con trolled, medication is no
longer needed. The availability of long- acting
formulations of antipsychotics has added a very useful
tool for long-term management, reducing the need to take
pills every day. Currently risperidone (Risperdal),
haloperidol (Haldol}, and fluphenazine (Prolixin) are
available in injectable forms that permit dosing only once
every several weeks, and drug companies are work ing
toward the goal of developing long-acting prepara tions of
other antipsychotics (Stahl, 2007).
Anxiety Disorders. The first-line pharmacological
treatment for generalized anxiety disorder (GAD),
post-traumatic stress disorder (PTSD), and panic disorder are
SSRI antidepressants. Given their safety, tolerability, and
demonstrated effectiveness, most psychiatric practitioners will
begin with a trial of one of these medicines. It can take several
weeks before one can determine whether they are effective in
reducing symptoms, though the side-effects are usually
apparent much earlier. Because of this delay in effect,
practitioners often prescribe a benzodiazepine medication
along with the SSRI for a short period of time for clients who
want more immediate relief of symptoms. Physicians are
rightly cautious when prescribing benzodiazepines, given
their potential for abuse and dependence, particularly with the
short-acting medicines such as alprazolem (Xanax) and
diazepam (Valium), though they certainly have an appropriate
use. For people who experience circumscribed episodes of
anxiety, such as people with a fear of flying or intense
performance anxiety, shortacting benzodiazepines are very
effective and are often prescribed on an as-needed basis. A
long-acting benzodiazepine, such as clonazepam (Klonipin] is
often a very helpful second medication when an SSRI fails to
adequately control symptoms (Schatzberg, 2007).
Key Activities in the Interface of
Social Work practice and Psychopharmacology
Clearly, a meta-function of social workers in general, no
matter what the level of practice, or field of service, is to
be first and foremost an effective resource to clients,
families, and the prescribers and providers who are
involved in the decision-making processes. The social
worker should ask: What type of support, information,
skill, connection, or opportunity can I provide to help this
client, family, or provider feel more knowledgeable,
confident, and positive with respect to care? Thus, the
foundation to fulfilling that role is to build satisfactory
472 PSYCHOTROPIC MEDICATIONS
collaborations and partnerships with clients, their families,
and others, most especially when it comes to practice
related to psychiatric medicati on. While a number of
important roles have been described in the literature, this
summary for the encyclopedia focuses on three specific
social work activities in real world practice with respect to
psychiatric medication.
MAKING AND MANAGING REFERRALS AND
INFORMA TION EXCHANGES In a large national
survey of clinical social workers conducted by the senior
author, just under three quarters of respondents (72%) said
they referred clients to a prescriber "often or frequently" in
a typical month, making it one of the two most frequently
performed tasks around medication.' Given the long
association of social workers with "information and
referral," it is not surprising that almost all the respon dents
described this as an appropriate role, which they felt
competent in fulfilling (Bentley, Walsh, & Farmer, 2005a).
Successful collaboration and information exchange
with other providers demand that interdisciplinary
relationships be "characterized by equality, flexibility,
decreased professional control, mutual un derstanding and
shared goals" (Bentley & Walsh, 2002, p. 643).
Admittedly, this is an ideal that is unlikely to be achieved
in all circumstances, due to ideological differ ences or
logistical challenges that arise when managing
collaborative care for clients. For example, all providers do
not embrace a client-centered "partnership" perspective
nor do all privilege the client's goals, experiences, and
choices. Conversely, social workers do not always
acknowledge the expertise and validity of other provider
roles and are at times subject to the dismissal or
diminishment of their own professional legitimacy. Thus,
intentional efforts are required on a momentto-moment
basis to build non-threatening alliances with other
providers and demystify the helping processes and the
service-treatment delivery system for clients. Suggestions
for maximizing the quality of referrals are for social
workers to prioritize the preparation of clients for seeing a
prescriber by coaching them in anticipation of the nature of
a medication assessment and its various potential
outcomes, including receiving or not receiving a
prescription (Bentley, Walsh, & Farmer, 2005b). Social
workers are also encouraged to develop "referral highways"
(O'Malley, 1996) and constantly build and nurture one's
referral base through as much interaction as possible, not to
mention competent comprehensive information sharing, as
permissions grant. Timely follow up with clients and
prescribers and using strategies to "cement" the referral are
also recommended (Bentley et al., 2005b).
Especially in a society growing more cautious about
psychiatric medication but seemingly more dependent on
it, it is important for social workers to maintain a balanced
perspective on psychiatric medication, to share both w hat
is known and not known about the effectiveness and
mechanism of action of psychiatric medication. When
providing information and referral services, there can be
no overinvestment in either accepting or rejecting
medication as an option. Social workers are likely to be
more effective, and appreciated, if they are cognizant of
the very real "costs" and "benefits" of psychiatric
medication to individuals and to the society at large. They
should be prepared to face challenging ethical dilemmas
such as managing pressure from families or prescribers to
support the use of medication even with ambivalent
clients. They may find it difficult to find the line between
encouraging clients to take advantage of a reasonable
option for care, and subtly coercing the decisions (Bentley
et al., 2005b). Having said that, there appears to be
evidence that for most mental, emotional, and behavioral
issues, the successful integration of psychosocial
interventions, therapeutic services and
psychopharmacology may be the most powerful for many
people. But as always, we cannot generalize from groups
to anyone individual.
ADDRESSING CLIENT MEANING/REACTION Social
workers are well suited to help clients talk about the
personal impact of, for example, receiving a recommen-
dation for a medication evaluation, receiving or filling a
prescription, and of course, taking the medication itself.
Indeed the national survey of social workers affirms that
the most frequent activity around psychiatric medica tion is
talking to clients about their feelings about it (Bentley et
al., 2005a). There is a small but growing literature in
sociology, anthropology and philosophy that pays specific
attention to the subjective experience of both adults and
children with psychiatric medication. Bradley (2003 )
reviews the complexity and variety of client responses to
social workers from "positive transference" (when the
client feels good about the worker's concerns) to anger,
guilt, or embarrassment. Jerry Floersh and Jeffrey
Longhofer have done impressive research on the impact of
taking medications on children and adolescents. They have
raised important questions about the impact of medication
on selfreliance, body image, and "illness identity"
(Floersch, 2003; Longhofer, Floersch, & Jenkins, 2003).
Following initial data analysis of an NIH study on the
subjective response of children to their psychiatric
medication, Floersch and colleagues note that
"Psychotropic treatment creates a context for meaningful
promises. Yet the gap between promised effects and the
actual, creates a

phenomenological space for the production of meaning"
(Floersch et al., 2007). Likewise, as a huge part of the
social context of medication, parents of children who are
prescribed medication not only influence the meaning of
medication for children, but will also have their own
reactions and questions, and may feel responsible for the
child's need for medication or blame others (Rappaport &
Chubinsky, 2000; Townsend, Floersch, Winbush, Munson,
& Findling, 2007). Social workers can encourage clients
and families to share their own positive, negative, benign,
upsetting, and life-altering experiences and emotions about
medication use.
MONITORING AND ADHERENCE The social worker's
role across settings and fields of practice is to keep an eye
on clients' progress vand movement toward their goals. As
non-medical providers, social workers are not responsible
for measuring and monitoring tempera'ture, blood
pressure, medication blood levels, or urine outputs.
Instead, with respect to psychiatric medica tion, social
workers monitor the client's experience with therapeutic
and adverse side effects, whether physical, psychological,
or social (Bentley & Walsh, 2006). While social workers
cannot provide medical interven tion in cases of worrisome
side effects, they can assist the client in obtaining
adjustments to medication or help the client negotiate
changes to the intervention plan with the prescriber. Of
course, social workers can also help the client track
therapeutic effects, including any desired decrease in
symptoms, especially the impact of medication on the
client's overall functioning and perceived quality of
everyday life. They should be available to provide
whatever psychosocial support or resources are needed to
advance the client's treatment or service delivery in light of
the monitoring process. This could include providing
additional up-to-date information on medication basics,
such as that presented earlier. In addition, social workers
can provide sirnple "how to" ideas on coping with minor
side effects, gather more assessment information, connect
clients or families to relevant community resources or
environmental supports, provide emotional or decisional
support and problem-solving, or share their own profes-
sional experiences of medication use with clients, to name
a few.
Non-adherence to medication, psychiatric, or other-
wise, is incredibly common in its fullest of definitions. It
can refer to anything from partially taking medica tion or
not taking it as prescribed (perhaps 50% of prescriptions in
general) to not having the prescription filled at all (about
20% of all prescriptions) (Franson & Smith,1998). The
argument made here is that the irn mense literature on
medication adherence reflects
I
j
PSYCHOTROPIC MEDICATIONS
473
the consensus that adherence is a multi-dimensional and
deeply complex issue. Like many others before them,
Bentley and Walsh (2006) have suggested a model for
non-adherence, which calls for social workers to examine
characteristics of clients such as health beliefs, important
aspects of the treatment itself (such as the attitudes of
providers, the complexity of the regimen, and especially
negative side effects), aspects of the social environment
(such as family opinions about medication or church
positions), and aspects of the illness (such as denial or
grandiosity). It is noted that providers tend to stress
symptoms or "lack of patient insight" when discussing
adherence; clients on the other hand, stress side effects.
Indeed, the senior author's current research on the impact
of taking psychiatric medication has affirmed that the
presence or absence of especially severe or bothersome
side effects could be an important defining feature of the
subjective medication experience of people with serious
mental illness (Bentley, in press).
Controversies, Social Justice, and
a Critical Perspective for Social Workers
CONCERNS ABOUT ACCESS AND
REIMBURSEMENT Bentley and Walsh (2006) list ten
situations in which social workers who work with clients
around psychiatric medication may need to go beyond
typical modes of practice, many of which are concerned
with access restrictions to clients of appropriate
medication evaluation and treatment. There may be a
clinician who has a personal "policy" against referring for
medication, or ignores the client's right to decide about use,
agencies that restrict clinic hours, prescribers who
overmedicate or hold fast to conservative medication
philosophies. Indeed in the survey of NASW social
workers (Walsh, Farmer, Taylor, & Bentley, 2003),
worries about competent prescribing (avoiding
overmedication and undermedication), long waiting lists
for medication screening, and worries about managed care
and reimbursement were three of the most bothersome
ethical dilemmas faced by clinical social workers in this
area, and (interestingly) significantly more bothersome to
women social workers. And there is cause for alarm.
Researchers recently concluded that low Medicaid
reimbursement rates negatively impact the quality of
psychiatric services provided to children, which in tum
creates distrust of those services (McMillen, Fedoravicius,
Rowe, Zima, & Ware, 2006). Specifically, over-
burdensome rules of prior authorization, "fail first"
requirements, and the use of generics or other lists of
preferred drugs, all serve to restrict access to psychiatric
medication (Koyanagi, Forquer, & Alfano, 2005). like-
wise, cost of medications and the lack of adequate
Medicare reimbursements have been associated with
474 PSYCHOTROPIC MEDICATIONS
poor medication adherence and poor health among the
elderly (Mojtabai & Olfson, 2003). Thus social workers
may have to advocate for parity of coverage between
medical and psychiatric treatment, fair reimbursement
rates, and access to medication. This, in Gerhart's clas sic
definition, often means making persistent demands to
people with power, either with the clients or on their behalf
(Gerhart & Brooks, 1983).
PSYCHIATRIC MEDICATION FOR CHILDREN It
would be difficult to find a mental health care topic
garnering more media attention of late than the use of
psychiatric medication for children. There have been
concerns expressed about the dramatic increase in the use
of all classes of medication for children, including
antipsychotics, the pervasiveness of "off-label use," the
impact of medication on physical an d psychological
development, ironically, both the use of children in clinical
trials and the lack of clinical trails with chil dren, the
contraband use of prescription medications among
children, and the pressure put on parents by schools to get
children medicated (Bentley & Collins, 2006). Moses and
Kirk (2006), for example, argue that too often
psychosocial effects of medication on identity and
autonomy are underexplored. In addition, there has been
an outcry about the quality of psychopharmacological care
for children in the child welfare system in particular,
especially the overuse of medication, trun cated medication
assessments, and insufficient communication between
child welfare workers and prescribers (McMillen et al.,
2006). At least one project is now underway (Cohen,
2006) to provide training to child welfare workers about
medication use, drug development, communication with
medical providers, and alternatives to psychiatric
medication. A key aspect of the training will be to raise the
awareness of those employed in child welfare settings of
the socio-political, economic, ethical, and scientific issues
surrounding the prescription of psychotropic drugs for
children and to reflect more critically on their own
practices. It should be noted that i n addition to concerns
about children, high prescription rates for women,
increasing use of antipsychotic medication for the elderly
and racial disparities in psychopharmacological
management of schizophrenia are among the additional
areas where social justice issues interface with the topic of
concern here, albeit beyond the scope of this chapter.
SUSPICION ABOUT DRUG COMPANIES Most would
argue there continues to be some level of public wariness
about drug companies, likely due in part to widespread
dissemination about large profits, but increasingly
common are media stories about their role in silencing
information about negative effects of medications as is the
case currently with Zyprexa and Eli Lilly. A psychia tric
survivor group called Mindl-reedom.corn and maker Eli
Lilly are fighting in the courts about the availability of
early data on the side effects of the medication that
according to the advocacy group contains damning
information. This controversy follows others that have
occurred over the years with respect to Neurotin, Ritalin,
and Seroquel, to name just a few.
A related area that has also garnered much deserved
attention is the use of direct-to-consumer advertising by
makers of psychiatric (and other) medication. Research
shows that advertisements do not really adhere to the "fair
balance" requirement, or make the required provi sions for
getting more detailed information (Kaphingst, Dejong,
Rudd, & Daltroy, 2004). More recently, social worker Jeff
Lacasse's research has powerfully demon strated that
frequently advertisements actually present information
about anti-depressants, which is inconsistent with
scientific evidence (2005), specifically, exaggerat ing the
level of causal knowledge we have about the mechanism
of action in psychopharmacology. Making matters worse
is Lacasse's contention that this bias in advertising serves
to undermine the use of psychosocial approaches. Because
of the public's distrust of pharmaceutical companies, much
more attention is being paid to the associations and
relationships between those companies and the academic
and governmental researchers doing clinical trials. Indeed,
many medical journals are now demanding full published
disclosure of these associations in peer-reviewed
publications.
Conclusion
This is the context of social work practice and psycho-
pharmalogical practice: Social workers work with pre-
scribers, clients, and families right in the midst of
exploding knowledge about neurotransmission, increasing
research into the specificity of drug action and new modes
of administration, differing views of scientific certainty
about effectiveness, controversy about medication use
with children and others, social injustices relat ed to access,
and, perhaps most importantly, vastly different
experiences of people with psychiatric medi cation. Social
workers can play an important role in helping people
clarify personal beliefs, values, and am biguities, and make
sense of both media messages and the scientific deluge of
knowledge. They can take action toward reducing
disparity in mental health practice. Equipped with
up-to-date knowledge about what medications are used for
which mental or behavioral disorders and emotional
distress, they can help provide

clients with the current scientific rationale for medica tion
use in general and how decision-making happens with
specific people. Drawing on the long tradition of practice,
they can offer a wide variety of concrete and
not-so-concrete "resources" available to help manage the
medication dilemmas of clients. These might in clude
providing education about medication, emotional support
for medication decision-making, referral to prescribers,
brokering financial resources, teaching negotiation skills,
or using problem-solving skills, to name a few (see
Bentley & Walsh, 2006).
There are many facilitating and restraining forces
shaping the future of interdisciplinary practice in men tal
health, including the collaboration between social workers
and prescribers specifically. Certainly the ex pectation that
all providers will set aside irrelevant disciplinary
boundaries and move toward a more holistic, integrated
and comprehensive approach to care is most welcome. It is
encouraging that more and more this means integrating
"best practice" knowledge from clinical research and
academic scholarship with data on the lived experiences of
clients who take psychiatric medication. Maintaining a
critical perspective on medication use in society can be
juxtaposed with an appreciation of "the power of
integrated treatment to improve the quality of lives of
people with mental illness and emotional distress and those
that love them." (Bentley & Walsh, 2002, p. 645).
REFERENCES
American Psychiatric Association. (2000). Practice guideline for
the treatment of patients with major depressive disorder
(revision). American Journal of PsychiatTy, 157(4 Suppl.),
1-45.
American Psychiatric Association. (2002). Practice guideline for
the treatment of patients with bipolar disorder (revision).
American Journal of Psychiatry, 159(4 Suppl.), 1-50.
Bentley, K. J., & Collins, K. S. (2006). Psychopharmacological
treatment for child and adolescent mental disorders. In C.
Franklin, M. B. Harris, & P. A. Meares (Eds.), The school
services sourcebook; A guide for school-based professionals (pp.
15-30). New York: Oxford University Press.
Bentley, K. J., & Walsh, J. (2002). Social workers' roles in
psychopharmacotherapy. In A. R. Roberts & G. J. Greene
(Eds.), Social workers' desk reference (pp. 643-645). New York:
Oxford University Press.
Bentley, K. J., & Walsh, J. (2006). The social worker & psy-
chotropic medication: Toward effective collaboration with
mental health clients, families and providers (3rd ed.).
Belmont, CA: Wadsworth.
Bentley, K. J., Walsh, ]., & Farmer, R. (2005a). Roles and
activities of clinical social workers in psvchopharmacother-
apy: Results of a national survey. Social Work, 50(4), 295-303.
J
PSYCHOTROPIC MEDICATIONS 475
Bentley, K. J., Walsh, J., & Farmer, R. (2005b). Referring clients
for psychiatric medication: Best practices for social workers.
Best Practices in Mental Health, 1 (1),59-71.
Blanco, c., Laje, G., Olfson, M., Marcus, S. c, & Pincus, H. A.
(2002). Trends in the treatment of bipolar disorder by
outpatient psychiatrists. American Journal of PsychiatTy, 159:
1005-1010.
Bradley, S. (2003). The psychology of the psychopharmacology
triangle: The client, the clinicians and the medication. Social
Work in Mental Health, 1 (4),29-50.
Cohen, D. (2006). Development, implementation, and evaluation
of a critical skills curriculum on psychotropic medication for
social workers in child welfare and mental health. (Project
funded by consumer and prescriber grant program, Attorney
general, State of Florida, New York, Ohio, Oregon, Texas and
Vermont.
Feiger, A. D., Rickels, K., Rvnn, M. A., Zimbroff, 0. L., &
Robinson, D. S. (2006). Selegiline transdermal system for the
treatment of major depressive disorder: An 8-week,
double-blind, placebo-controlled, flexible-dose titration tria!'
Journal of Clinical Psychiatry, 67(9), 1354-1361.
Floersch, J. (2003). The subjective experience of youth psycho-
tropic experience. Social Work in Mental Health, 1 (4), 51-69.
Floersch, J., Townsend, L., Munson, M., Winbush, V., Kranke,
D., Faber, R., et a!' (2007, January 13). Adolescent experience
of psychotropic tTeatment. Paper presentation at the Society for
Social Work and Research, San Francisco, CA
Franson, K. L., & Smith, S. L. (1998). Compliance: Problems and
opportunities. Clinics in Geriatric Medicine, 14(1),7-16.
Gerhart, U. c., & Brooks, A. 0. (1983). The social work
practitioner and antipsychotic medications. Social Work, 28,
454-460.
Goodnick, P. J. (2007). Bipolar depression: A review of ran-
domised clinical trials. Expert Opinions in Pharmacotherapy,
8(1), 13-21.
Kaphingst, K. A, Dejong, W., Rudd, R. E., & Daltroy, L. H.
(2004). A content analysis of direct-to-consumer television
prescription drug advertisements. Journal of Health Commu-
nications, 9(6), 561-562.
Koyanagi, c., Forquer, S., & Alfano, E. (2005). Medicaid policies
to contain psychiatric drug costs. Health Affairs, 24(2),
536-544.
Lacasse, J. R. (2005). Consumer advertising of psychiatric
medications biases the public against non-pharmacological
treatment. Ethical Human Psychology and PsychiatTy, 7(3),
175-179.
Lehman, A F., Lieberman, J. A, Dixon, L. B., McGlashan, T. H.,
Miller, A L., Perkins, D.O., et a!' American Psychiatric
Association; Steering Committee on Practice Guidelines
(2004). Practice guideline for the treatment of patients with
schizophrenia (Znd ed.). American Joumal of PsychiatTy, 161(2
Supp!.), 1-56.
Lieberman, J. A., Stroup, T. S., McEnvoy, J. P., et al, Clinical
Trials ofIntervention Effectiveness (CATIE) Investigators.
(2005). Effectiveness of antipsychotic drugs in patients ~ith
chronic schizophrenia. New England Journal of Medicine,
353(12), 1209-1223.
476 PSYCHOTROPIC MEDICATIONS
Longhofer, J, Floersch, ]., & Jenkins, J. (2003). Medication
effect interpretation and the social grid of management. Social
Wark in Mental Health, 1( 4 ), 71-89.
McMillen, J. c, Fedoravicius, N., Rowe, ]., Zima, B. T., & Ware,
N. (2006). A crisis of credibility: Professionals' concerns
about psychiatric care provided to clients of the child welfare
system. Administration and Policy in Mental Health, 34(3),
203-212.
Mojtabai, R., & Olfson, M. (2003). Medication costs, adherence,
and health outcomes among medicare beneficiaries. Health
Affairs, 22(4), 220-229.
Moses, T., & Kirk, S. A. (2006). Psychosocial side effects of drug
treatment of youth. In S. A. Kirk (Ed.), Mental disorders in the
social environment (pp. 385-407). New York: Columbia
University Press.
O'Malley, J. F. (1996). Managed care referral. Chicago: Irwin
Professional Publications.,
Pampallona, S., Bollini, P., Tibaldi, G., Kupelnick, B., &
Munizza, C. (2004). Combined pharmacotherapy and psy-
chological treatment for depression: A systematic review.
Archives of General Psychiatry, 61(7), 714-719.
Rappaport, N., & Chubinsky, P. (2000). The meaning of
psychotropic medications for children. Journal of the American
Academy of Child & Adolescent Psychiatry, 39(9), 1198-1200.
Rosenbaum, J. F. (2005). Attitudes toward benzodiazepines over
the years. Journal of Clinical Psychiatry, 66(2 suppl.), 4-8.
Rosenheck, R. A., Leslie, 0. L., Sindelar, J., Miller, E. A., Lin, H.,
Stroup, T. S., et al. (2006). Cost-effectiveness of
second-generation antipsychotics and perphenazine in a
randomized trial of treatment for chronic schizophrenia.
American Journal of Psychiatry, 163(12), 2080-2089.
Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A.,
Stewart, J. W., Warden, D., et a1. (2006). Acute and longer-
term outcomes in depressed outpatients who required one or
several treatment steps: A STAR *D report. American Jour-
nalofPsychiatry, 163(11), 1905-1917.
Sadock, B. J., & Sadock, V. A. (2005). Kaplan & Sadock's
comprehensive textbook of psychiatry (8th ed.). Philadelphia:
Lippincott Williams & Wilkins.
Schatzberg, A. F., Cole, J. 0., & DeBattista, C. (2007).
Manual of clinical psychopharmacology (6th ed.). Arlington, VA:
American Psychiatric Publishing, Inc.
Stahl, S. M. (2007). Overview of trends in modem psycho-
pharmacology. CNS Spectrums, 12(2), 103-105.
Townsend, L., Floersch, J., Winbush, V., Munson, M., &
Findling, R. (2007, January 13). Parenting adolescents who take
psychiatric medication. Paper presentation at the Society for
Social Work and Research, San Francisco, CA.
Walsh, J., Farmer, It., Taylor, M. F., & Bentley, K. J. (2003).
Ethical dilemmas of practicing social work~rs around psy-
chiatric medication: Results of a national study. Social Work in
Mental Health, 1(4),91-105.
SUGGESTED LINKS
http://www .dr-bob .org/tips/
http://www.mentalhealth.com/p30-note . html
www.mentalhelp.net
www.nami.arg
www.nimh.nih.gov
http://www . nmha. org/index. cfm
www.mentalhealth.org
-KIA J. BENTLEY AND CHRISTOPHER P. KOGUT
PUBLIC SOCIAL SERVICES. See Social Services.
PUBLIC HEALTH
ABSTRACT: Public health social work is based on an
epidemiologic approach to preventing, addressing,
and solving social health problems. It originated in
the early 20th century, drawing upon both social
work and public health theories, frameworks,
research, and practice. Public health social work is
characterized by an emphasis on prevention and I,
health promotion. The field has evolved to become
multi-method and interdisciplinary, making it
particularly relevant to 21st century practice .
Widespread changes on both domestic and
international fronts-such as globalization, increased
migration, natural and man-made disasters, persistent
chronic diseases, and resulting health disparities- are
examples of current challenges that benefit from a
public health social work approach.
KEY WORDS: public health social work; prevention;
public health; health
Background
Social work and public health appear similar, given their
shared historic core missions to promote social justice and
enhance community well-being. While the two professions
have a long history of working together on complex social
health problems, they also differ significantly in orientation,
approach, and current practice (Krieger, 2003; Moroney,
1995; Sisco & Frounfelker, 2002; Stover & Bassett, 2003;
Turnock, 2004).
Social work: Social work defines itself as a profession
dedicated to (a) the restoration and enhancement of human
social functioning and (b) the promotion of change in social
conditions to reduce human suffering (International
Federation of Social Workers [IFSW], 2000; National
Association of Social Workers [NASW], 1996). Based on the
values of respect for equality, worth, and dignity of human
beings, social work uses a human
 PUBLIC HEALTH
477

rights and social justice orientation to address the com plex developed, the primary focus of public health is preven tion
needs of people in their environments (Marsh, 2003). and health promotion for the entire population (Bracht,
Public Health: Public health is defined by the Institute of 2000).
Medicine as a field of practice concerned with "assuring
the conditions in which people can be healthy" (Committee HISTORY OF PUBLIC HEALTH SOCIAL WORK The
for the Study of the Future of Public Health, 1988). Public social work profession's involvement in public health dates
health is an interdisciplinary field, based on biological and back to the early 20th century, when social work ers first
social sciences; its mission is to promote and protect the worked in infectious disease control, maternal and child
health of whole populations, and to prevent illness, injury, health, and settlement houses (Popple & Leighninger,
and other disabling conditions (Moroney, 1995). Th is 2004). From the beginning, public health social workers
broad mission necessitates multidimensional practices in made an effort to distinguish their prac tice from other types
order to meet society's changing health needs. Thus, the of social work. Located in public health settings, they
core functions of public health are numerous and include applied a preventive focus to case work and used informal
assessment and monitoring of community health, health risk analysis to promote early intervention. While their
promotion and disease prevention, advocacy, policy an- focus was on individuals, public health social workers
alysis, and evaluation (Turnock, 2007). The " public health incorporated an early understanding of social determinants
model" is distinguished by its systematic, theory driven, of health and viewed entire communities as target
epidemiological approach to preventing social and health populations. To maximize their impact, public health s ocial
problems and promoting population health, widely workers partnered across disciplines in what were
applicable to many issues (Center for Injury Re search and considered nontraditional services at the time. (Bracht,
Policy, 2007; Turnock, 2004). Epidemiology, public 1978; Cowin, Rice, & Schmidt, 1965; Rice, 1959). The
health's foundation method, utilizes the study of factors Federal Children's Bureau was an early example of
affecting health and disease in human populations and the government investment in public health social work efforts.
application of that knowledge to imp rove health and Established in 1912 and run primarily by social workers ,
decrease disease (T urnock, 2007). Recent workforce this federal agency was dedicated to the promotion of
studies estimate the total number of public health work ers maternal and child health (Kotch, 2005; Watkins, 1985).
in the United States to be 500,000, including doctors , The early successes of the Children's Bureau set the
nurses, oral health practitioners, and other allied health stage for the later National Maternity Act, also known as
professionals. This figure is generally considered to be less "Sheppard- Towner," which provided federal grants to
than what is needed to assure the public's health; hence, states for a period of nine years, and whose achieve ments
workforce development and infrastructure are subjects of laid the groundwork and rationale for later federal- state
considerable current attention (Gebbie & Turnock, 2006). collaboration in maternal and child health (Jaros & Evans,
In addition, the persistent underfun ding of public health is 1995). The Social Security Act of 1935 established a
an ongoing concern; estimates indicate that 4% or less of number of public health social work pro grams in maternal
U.S. health care expenditures goes to public health and child health, including Maternal and Child Health
(Turnock, 2007). Together, the workforce issues, lack of Services, Child Welfare Services, and Crippled Children's
funding, and numerous emerging public health problems Services (Kotch, 2005). During the 1940s and 1950s, broad
have led some to assert that U.S. public health is in a state legislative actions at the
of crisis (Gorin, 2001). . federal level resulted in the establishment of the National
Public health has many similarities to social work; it is Institutes of Health and the Center for Disease Contro l,
based on a social justice philosophy and encom passes a which strengthened research, treatment, and service
range of professional specializations focused on method, provision related to health and mental health (Moroney,
population, or specific issues (Krieger & Birn, 1998; 1995). Over the next 50 years, this federal funding of
Marsh, 2003). Because of the focus on society as a whole , public health gradually fostered in creased opportunities
public health emphasizes social and environmental factors for public health social workers in schools, health centers,
in its methods, theories, and practices. However, while and social agencies (Bloom, 1995). During this time, much
public health draws liberally from th e behavioral sciences, of public health social work was concentrated in secondary
it differs from social work in its grounding in the biological and tertiary interventions to lessen the impact of health
sciences and its use of epidemiology (Turnock, 2004 ). problems after they had already arisen. Professiona l
While much of social work is focused on intervention with interest in primary prevention-the prevention of illness and
individual, families, and communities after problems have dysfunction
478 PuBLIC HEAL1H
before they develop-was spurred by Rapoport's 1961
seminal attempt to conceptualize it for the social work
profession (Rapoport, 1961). By the 1970s, primary
prevention was the focus of a federal call to action and
viewed as a timely concept across health and human
services (Klein & Goldston, 1977). Social work interest
in prevention was fueled by a growing awareness of
social and environmental factors, particularly as they
influenced chronic disease processes and mental health
issues.
Over the next 20 years, the social work literature
highlighted the power of the public health model
(Bracht, 1978; Hooeyman, Schwanke, & Yesnes, 1980;
Raskin, 1980). Diligent efforts were made to introduce
epidemiology to social workers and to promote
prevention throughout social work education and in the
workplace (Siefert, Jayaratne, & Martin, 1992; Tendler
& Metzger, 1978; Wilkinson, Rounds, & Carr-Copeland,
2002). Many public health social work programs were
created during the second half of the 20th century, as
roles expanded beyond direct services to include
program administration, research, planning and
evaluation, and advocacy. The civil rights movement
and related successes resulted in in creased public health
social work programs, and social workers were involved
in the development of major health initiatives (Gorin &
Moniz, 2004). With the enactment of Medicaid and
Medicare in the 1960s, there was an unprecedented rush
of health programming that expanded social services
and public health.
By the 1980s, new issues such as AIDS, substance
abuse, violence, and aging emerged as public health
social work challenges (Moroney, 1995). Social work
involvement in community prevention partnerships
spotlighted the value of time-tested social work methods
such as community organizing and planning (Bracht,
1999). A small but substantive body of research con-
tributed to a social work perspective on risk, protection,
resilience, and prevention, and has continued to grow
(Hawkins, 2006). Dual degree master's programs in
public health and social work proliferated, building
upon the natural overlap between the two professions
(Ruth, Wyatt, Chiasson, Geron, & Bachman, 2006).
These programs, along with other educational
initiatives, appealed to new generations of students
interested in public health social work leadership.
The two fields increasingly recognized one another's
strengths and possibilities. Social work came gradually
to the concept of health outcomes and began using
epidemiology to frame interventions in diverse practice
arenas such as AIDS, homelessness, chronic disease,
substance abuse, violence or abuse, and maternal and
child health (Bolen, 2003; Jaffee & Perloff, 2003;
MacMaster, 2004; Smith & Bride, 2004, Wolf &
Mitchell, 2002). Public health sharpened its under-
standing of the multiple determinants of health and
began to more openly consider the role of oppression in
health disparities (Boehmer, 2002; House, 2002;
Krieger, 2003). Partnerships between public health and
social work continue to expand. Examples of newer
areas of collaboration include urban health, oral health,
tobacco control, and toxic waste activism (Krieger &
Higgins, 2002; Northridge, 2004; Rogge &
Cornbs-Orme, 2003; Rosenthal & Cairns, 1994).
Public mental health assumed a more prominent
focus by the 21st century, embracing ecological
approaches and identified community-based efforts as
core to its mission (Awofeso, 2004; Committee on
Assuring the Health of the Public in the 21st Century,
2002; Foster, Qaseem, & Connor, 2004). One of the
many impacts of September 11th, 2001, was to call
attention to the mental health consequences of "new"
public health threats such as bioterrorism, disasters, and
community trauma (Gorin, 2002).
CURRENT PUBLIC HEALTH SOCIAL WORK
PRAC. TICE Because of their broad missions and multi-
method approaches, social work and public health have
both been challenged in their definition and concep-
tualization of professional practice (Gibelman, 1999;
Turnock, 2004). The broad spectrum offunctions and
specializations in social work and public health con-
tribute to definition-defying syntheses. Consequently,
public health social work can be focused on any of the
numerous essential functions of public health, making
the diverse blending of roles a particular challenge. A
public health social worker can be a researcher, policy
analyst, program developer, provider of direct services,
or administrator (Association of Schools of Public
Health [ASPH], 2006; Association of State and T erri-
torial Public Health Social Workers [ASTPHSWj,
2005). Many social work~rs in health settings have been
engaged in public health social work without full
cognizance of how they are defining, combining, or
applying both skill sets (Sisco, Markham, Wyatt,
Bachman, & Ruth, 2004). Some social workers find
themselves formally or informally working in preven-
tion due to the needs of the populations they serve, but
may not recognize their work as part of public health. In
order to improve awareness of PHSW, a number of
organizations are working to create and publicize a
coherent set of public health social work definitions,
standards, and competencies; incorporation of these into
schools of social work and public health is clearly an
important next step (American Public Health
Association [APHA], 2006; ASTPHSW, 2005; NASW,
2006).

Challenges
The integration of the public health model and meth ods
into social work education and practice has been, at best,
gradual. Almost 50 years have passed since Rapoport
(1961) initially conceptualized prevention for social work ;
today, the public health skills of prevention, health
promotion, and social epidemiology are increasingly
viewed by experts as critical to social work's survival as a
core health profession in health care's "brave new world"
(Vourlekis, Ell, & Padgett, 2001). The most recent practice
standards for social workers in health care settings now
identify prevention, health promotion, and health
education as core competencies for practitioners (NASW,
2006). The 2005 National Institutes of Health (NIH) call
for 'Research on Social Work Practice and Concepts in
Health explicitly urged the use of a public health
framework in its proposals, noting the potential
contribution of social work to health outcomes in the
United States (Jenson, 2006).
However, this integration at the policy level appears to
have had limited impact on the social work profes sion.
Beyond MSW -MPH programs, graduate schools of social
work do not appear to teach prevention, health promotion,
or social epidemiology (Ruth et al., 2006). A recent
content analysis of social work literature in peer- reviewed
journals showed that only 5% of articles reflected content
on prevention, health promotion, or health education
(Bethke, Ruth, Wyatt, Markham-Piper, Cohen, & Sisco,
2006). Workforce studies indicate a small minority of
current social workers describing themselves as "public
health social workers" (Whitaker, Weismiller, & Clark,
2006). Descriptive studies of public health social workers
suggest they encounter workplace obstacles, including
lack of familiarity with and consensus regarding the
definition, content, capacities, and roles of public health
social workers (Ruth et al., 2006).
Additionally, during a time of increase d attention to the
crisis in the public health workforce, it is alarming to note
that the field of public health rarely recognizes social work
as part of its workforce (Gebbie & Turnock, 2006; Bethke
et al., 2006). The most recent report issued by the Institute
of Medicine on public health infrastructure identified
numerous professions likely to partner with public health,
but social work was not listed among them (Gebbie,
Rosenstock, & Hernandez, 2002).
Several factors appear to have impeded the develop-
ment of a more vibrant integration of public health social
work; Foremost are the radical changes in the health care
system since 1980s. The shift to cost containment and
managed care challenged social work in health care
settings to adapt in order to survive. While these changes
resulted in a shift to more interdisciplinary and
PuBLIC HEALTH
479
community-based practice and a growing emphasis on
evidence-based interventions and outcomes evaluation, it
is unclear if public health social work acti~ ities have
increased (Dziegielewski & Holliman, 2001; Vourlekis,
Ell, & Padgett, 2001). In the market-driven competition of
the current health care environment, fiscal accountability
has been central, with prevention generally representing a
small percentage of health care expenditures (Rosenberg &
Holden, 1999). In such a climate, there may be little room
for public health social work innovations; expansions of
social work roles in hospitals, for instance, have proven
frustrating and uneven despite the efforts of social work
leaders (Mizrahi & Berger, 2005).
Second, the majority of the profession is focused on
clinical interventions despite the work of prevention-
oriented social workers (Jacobson, 2001). The overall
practice of social work remains generally psychothera-
peutically oriented and focused on individuals although
there are opportunities and need for other kinds of macro
and community intervention in areas such as gerontology,
child welfare, and AIDS (Berkman, Gardner, Zodikoff, &
Harootyan, 2005; Kaplan, Tomaszewski, & Gorin, 2004).
The amount of general health content in MSW
programs is uncertain; the most recent study indicated that
only half of programs included a basic course on health
(Kadushin & Egan, 1997). The impact of dual degree
MSW -MPH programs on overall MSW curricula has also
gone generally unstudied. Their presence may promote the
perception that public health content is widely available in
social work education; however, most MSW students are
not enrolled in MSW-MPH programs and therefore may
never encounter public health social work concepts or
practices. Moreover, the existence, value, and potential of
MSW-MPH programs has been largely unacknowledged
by the profession's educational and professional
organizations (Bracht, 2000). There is a need for social
work educators to recognize their leadership potential and
incorporate more mentoring, resources, evaluation, and
career development into them (Ruth et al., 2006; Sisco &
Frounfelker,2oo2).
T rends and Future Directions Unquestionably,
public health methods are increasingly valued in a society
characterized by vast demographic shifts, globalization,
complex migratory patterns, and persistent health
disparities. Even before September 11 and its attendant
increase in funding for public health, interest and concern
for the adequacy of the public health workforce had
burgeoned (Gebbie, Rosenstock, & Hernandez, 2002;
Gorin, 2001).
480 PuBLIC HEAL TIl
Clearly, the use of the public health model has expanded
within social work, particularly in areas such as substance
abuse and child abuse (Bolen, 2003; Spence, DiNitto, &
Straussner, 2001).
Despite the obstacles, there are historical strengths upon
which public health social work can build to underscore its
importance to both professions. The future of public health
social work may hinge upon interdisciplinary recognition that
profound societal shifts call for both social work and public
health skills. Both professions' employers must come to
realize they need the dual competencies of public health social
workers to ensure more effective outcomes. Public health
social work, anchored in evidence-based practice, can, serve
as a bridge to the use of benchmark indicators, epidemiology,
program effectiveness studies, arid integration of research into
practice (Fortune & Proctor, 2001; Gambrill, 2006; Gorin,
2001).
Research outcomes in public health and social work have
burgeoned, and processes are needed to make useful
knowledge available to practitioners (Brekke, Ell, & Palinkas,
2007; Zlotnik & Galambos, 2004). Recognition of the long lag
time between clinical research and utilization of knowledge in
practice settings has led to the development of translational
science, the goal of which is to facilitate dissemination and
adaptation of research findings into practice as quickly as
possible (Brekke, Ell, & Palinkas, 2007). As a
research-oriented practice, public health social work can
contribute to this important challenge by assisting in
implementation of innovations to practice and program
evaluation. At the national level, the NIH Office of Behavioral
and Social Sciences Research (OBSSR) has called for more
"innovative, theory driven empirical research on social work
practice, concepts, and theory as these relate to ... the public
health goal of improving health outcomes ... " (NIH, 2007;
us Senate, 2002, p. 155). This social work-specific research
plan reflects a high degree of federal investment in social
work, and increases the likelihood that public health social
work interventions can be developed, tested, documented, and
disseminated into practice (Jenson, 2006).
If social work is to include itself in the public health
infrastructure, educational considerations must be explored.
There is a pressing need to develop alternative methods for
educating social workers who cannot afford degrees in public
health, but who wish to engage in public health social work.
Two potential strategies for increasing the availability of
public health training are infusion of public health content into
traditional MSW programs and development of continuing
education in public health social work. Given the trends in
public health in the United States and internationally,
graduate schools should recognize the potential of
MSW-MPH programs and provide the necessary supports
such as rnentoring, integration, and social marketing of public
health social work to employers in both sectors (Sisco et al.,
2004).
The powerful collaboration between public health and
social work can support both professions in moving "beyond
the confines of their specific disciplines, allowing them to see
and understand the individual within the context of the health
of the community ... [yielding] a new set of lenses through
which to view reality ... " (Gebbie, Rosenstock, & Hernandez,
2002, p. 116). In a society of rapid changes and pressing new
realities, public health social work is the profession's best
transdisciplinary response to improving the health and well
being of society.
REFERENCES
American Public Health Association. (2006). Social work section
newsletter. Retrieved April 24, 2007, from http://
www.apha.orflimembergroups/newsletters/sectionnewsletters
/ social/spring06
Association of Schools of Public Health. (2006). Other public
health fields. Retrieved] anuary 11, 2007, from http://www.
asph.org/document.cfm ?page= 7 07
Association of State and Territorial Public Health Social Workers.
(2005). Public health social work standard and competencies.
Ohio Department of Health.
Awofeso, N. (2004). What's new about the "New Public Health"?
American Journal of Public Health, 94, 705-709.
Berkman, B. ]., Gardner, D. S., Zodikoff, B. D .. , & Harootyan,
L. K. (2005). Social work in health care with older adults:
Future challenges. Families in Society, 86, 329-337.
Bethke, c, Ruth, B. ]., Wyatt, j., Markham-Piper, T., Cohen, M.,
& Sisco, S. (2006, November). Social work interest in prevention
and health promotion: A content analysis of social work literature.
Paper presented at American Public Health Association
Annual Meeting, Boston, MA.
Bloom, M. (1995). Primary prevention overview. In R. L.
Edwards (Ed-In-Chief), Encyclopedia of Social Work (19th ed.,
pp. 1967-1973). Washington, DC: NASW Press.
Boehmer, U. (2002). Twenty years of public health research:
Inclusion of lesbian, gay, bisexual, and transgender popula-
tions. American Journal of Public Health, 92, 1125-1130.
Bolen, R. M. (2003). Child sexual abuse: Prevention or pro-
motion? Social Work, 48,174-185.
Bracht, N. F. (1978). Social work in health care: A guide to
professional practice. New York: Haworth Press.
Bracht, N. F. (1999). Health promotion at the community level:
New advances. Thousand Oaks, CA: Sage.
Bracht, N. F. (2000). Prevention: Additional thoughts. Social Work
in Health Care, 30(4), 1-6.
Brekke, ]. S., Ell, K., & Palinkas, L. A. (2007). Translational
science at the National Institute of Mental Health: Can social
work take its rightful place? Research on Social Work Practice,
17, 123-133.

Center for Injury Research and Policy. (n. d). The public health
model approach. Retrieved December 1, 2007, from http://
www.jhsph.edu/injurycenter/Injury]roblem/model.html
Committee for the Study of the Future of Public Health, Division
of Health Care Services, Institute of Medicine. (1988). The
future of public health. Washington, DC:
National Academy Press.
Committee on Assuring the Health of the Public in the 21st
Century, Division of Health Care Services, Institute of
Medicine. (2002). The future of the public's health in the 21st
century. Washington, DC: National Academy Press.
Cowin, R. A., Rice, E. P., & Schmidt, M. D. (1965). Social work
in a child health clinic: A report of a demonstration. American
Journal of Public Health, 55, 821-83l.
Dziegielewski, S. F., & Holliman, D. C. (2001). Managed care and
social work: Practice implications in an era of change. Journal
of Sociology and Social Welfare, 28, 125-139.
Fortune, A. K., & Proctor, E. K. (2001). Research on social work
interventions. Social Work Research, 25, 67-69.
Foster, E. M., Qaseern, A., & Connor, T. (2004). Can better
mental health services reduce the risk of juvenile justice
system involvement? American Journal of Public Health, 94,
859-865.
Gambrill, E. (2006). Evidence-based practice and policy:
Choices ahead. Research on Social Work Practice, 16,338-357.
Gebbie, K., Rosenstock, L., & Hernandez, L. R. (2002). Who will
keep the public healthy? Educating public health professionals for
the 21st century. Washington, DC: The National Academies
Press.
Gebbie, K. M., & Turnock, B. J. (2006). The public health
workforce, 2006: New challenges; A two-decade trend of
increasing numbers of public health workers could end if
bioterrorism grants decrease. Health Affairs, 25, 923-933.
Gibelrnan M. (1999). The search for identity: defining social
work-past, present, future. Social Work, 44, 298-310.
Gorin, S. H. (2001). The crisis of public health: Implication for
social workers. Health and Social Work, 26, 49-53.
Gorin, S. H. (2002). The crisis of public health revisited:
Implications for Social Work. Health and Social Work, 27, 56-60.
Gorin, S. H., & Moniz, C. (2004). Will the United States ever have
universal health care? Health and Social Work, 29, 340-344.
Hawkins, J. D. (2006). Science, social work, prevention: Finding
the intersections. Sodal Work Research, 30, 137-152.
Hooyman, G., Schwanke, R. W., & Yesner, H. (1980). Public
health social work: A training model. Sodal Work in Health
Care, 6(2), 87-99.
House, J. S. (2002). Understanding social factors and inequalities
in health: 20th century progress and 21st century prospects.
Journal of Health and Social Behavior, 43, 125-253.
International Federation of Social Workers. (2000). Definition of
sodal work. Retrieved January 11, 2007, from http://www . ifsw
.org/en/p3 8000208.html
Jacobson, W. (2001). Beyond therapy: Bringing social work back
to human services reform. Social Work, 46, 51-6l.
Jaffee, K. D., & PerIoff, J. D. (2003). An ecological analysis of
racial difference in low birthright: Implications for
PuBLIC HEALTH 481
maternal and child health in social work. Health and Social
Work, 28, 9-22.
Jaros, K. J., & Evans, J. C. (1995). Public health services.
In R. L. Edwards (Ed-In-Chlef), Encyclopedia of Social Work
(19th ed., pp. 1683-1689). Washington, DC:
NASW Press.
Jenson, J. M. (2006). A call for social work research from the
National Institutes of Health. Social Work Research, 30,3-5.
Kadushin, G., & Egan, M. (1997). Educating students for a
changing health care environment: An examination of health
care practice course content. Health and Social Work, 22,
211-222.
Kaplan, L. E., Tomaszewski, E., & Gorin, S. (2004). Current
trends and the future ofHIV/AlDS services: A social work
perspective. Health and Sodal Work, 29, 153-160.
Klein, D., & Goldston, S. (1977). Primary prevention: An idea whose
time has come. Rockville, MD: National Institute of Mental
Health.
Kotch, J. (2005). Maternal and child health: Programs, problems, and
policy in public health. Boston: Jones and Bartlett Publishing.
Krieger, N. (2003). Latin American social medicine: The quest for
social justice and public health. American Journal of Public
Health, 93, 1989-199l.
Krieger, N., & Birn, A. (1998). A vision of social justice as the
foundation of public health: Commemorating 150 years of the
spirit of 1848. American Journal of Public Health, 88,
1603-1606.
Krieger J., & Higgins D. L. (2002). Housing and health: Time
again for public health action.' Am J of Public Health. 92,
758-768.
MacMaster, S. A. (2004). Harm reduction: A new perspective on
substance abuse services. Social Work, 49, 356-363.
Marsh, J. C. (2003). The social work response to violence.
Social Work, 48, 437-438.
Mizrahi, T., & Berger, C. S. (2005). A longitudinal look at social
work leadership in hospitals: The impact of a changing health
care system. Health and Sodal Work, 30, 155-165.
Moroney, R. M. (1995). Public health services. In R. L. Edwards
(Ed.vin-Chief), Encyclopedia of Social Work (19th ed., pp.
1967-1973). Washington, DC: NASW Press.
National Association of Social Workers. (1996). Code of ethics.
Retrieved January 11,2007, from http://www.socialworkers ..
org/pubs/code/code.asp
National Association of Social Workers. (2006). Public health
social work. Retrieved January 11, 2007, from http://www. soc
ial workers.org/research/naswResearch/Pu b I icH eal th/
default.asp
National Institutes of Health. (2007). Research on social work
practice and concepts in health (ROl). Retrieved January 11,
2007, from http:.//grants.nih.gov/grants/guide/pa-files/
PA-07-292.html
Northridge,M. E. (2004). Building coalitions for tobacco control
and prevention in the 21st century. AmericanJournal of Public
Health, 94, 178-180.
Popple, P. R., & Leighninger, L. (2004). Social work, social welfare
and American society. Boston: Allyn & Bacon.
482 PuBLIC HEALTH
Rapoport, L. (1961). The concept of prevention in social work.
Social Work, 6, 3-12.
Rice, E. (1959). Social work in public health. Social Work, 4, 82-88.
Rogge, M. E., & Combs-Orrne, T. (2003). Protecting children
from chemical exposure: Social work and U.S. social welfare .
policy. Social Work, 48, 439-450.
Rosenberg, G., & Holden, G. (1999). Prevention: A few thoughts.
Social Work in Health Care, 28(4), I-II.
Rosenthal, S. J., & Cairns, J. M. (1994). Child abuse prevention:
The community as co-worker. Journal of Community Practice, 1,
44--c61.
Roskin, M. (1980). Integration of primary prevention into social
work practice. Social Work, 25, 192-196.
Ruth, B. J., Sisco, S., Markham, P. K., Bachman, S.,& Wyatt, J.
(2005, December). Evidence-bcised practice in public health social
work: A powerful tool for integration and revitalization. Presented
at American Public Health Association Annual Meeting,
Philadelphia, P A
Ruth B. J., Wyatt J. W., Chiasson E., Geron S., Bachman S.
(2006). Social work and public health: Comparing graduates
from a dual-degree program. Journal of Social Work Education,
42, 429-439.
Siefert, K., [ayaratne, S., & Martin, L. D. (1992). Implementing
the public health social work forward plan: A researchbased
prevention curriculum for schools of social work. Health and
Social Work, 17, 17-27.
Sisco S., & Frounfelker, R. (2002, November). Public health social
work: What a great idea! Paper presented at American Public
Health Association Annual Meeting, Philadelphia, P A
Sisco, S., Markham, P. K., Wyatt, J., Bachman, S., & Ruth, B. J.
(2004, November). Public health social work in the workplace.
Presented at American Public Health Association Annual
Meeting, Washington, DC.
Smith, B. D., & Bride, B. E. (2004). Positive impact: Acom-
rnunity-based mental health center for people affected by HIY.
Health and Social Work, 29, 145-148.
Spence, R. T., DiNitto, D. M., & Straussner, S. L. A (Eds.). (2001).
Neurobiology of addictions: Implications for clinical practice (pp.
81-102). Binghamton, NY: Haworth Press.
Stover, G. N.,& Bassett, M. T. (2003). Practice is the purpose of
public health. American Journal of Public Helath, 93, 1799-1801.
Tendler, D., & Metzger, K. (1978). Training in prevention: An
educational model for social work students. Social Work in
Health Care, 4,221-231.
Tumock, B. J. (2004). Public health: What it is and how it works.
Boston: Jones & Bartlett Publishing.
Tumock, B. J. (2007). Essentials of public health Boston: Jones &
Bartlett Publishing
U.S. Senate. (2002). Report 107-216: Departments of Labor, Health
and Human Services, and Education, and Related Agencies
Appropriation Bill, 2003. Retrieved January 11, 2007, from
http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi ? dbname=
1 07 _con~reports&docid=f:sr216.pdf
Vourlekis, B. S., Ell, K., & Padgett, D. (2001). Educating social
workers for health care's brave new world. Journal of Social
Work Education, 37,177-191.
Watkins, E. L. (1985). The conceptual base for public health
social work. In A. Gitterman, R. B. Black & F. Stein (Eds.),
Public health social work in maternal and chiUI health: A forward
plan (pp. 17-34). New York: Columbia University Press.
Whitaker, T., Weismiller, T., & Clark, E. (2006). Assuring the
sufficiency of a frontline workforce: A national study of frontline
social workers (Executive Summary). Washington, DC:
National Association of Social Workers.
Wilkinson, D., Rounds, K. A., & Carr-Copeland, V. (2002).
Infusing public health content into the social work curriculum.
Journal of Teaching in Social Work, 22(3/4), 139-154.
Wolf, M. S., & Mitchell, C. G. (2002). Preparing social workers to
address HIV/AIDS prevention and detection: Implications for
professional training and education. Journal of Community
Health, 27, 165-180.
Zlotnik, J. L., & Galambos, C. (2004). Evidenced-based practices
in health care: Social work possibilities. Health and Social Work,
29, 259-261.
FURlHER READING
Bayer, R., & Stuber, ]. (2006). Tobacco control, stigma and public
health: Rethinking the relations. American Journal of Public
Health, 96, 47-50.
Carlton, T. (1988). The public's health. Health and Social Work,
Fall, 242-244.
Coulton, C. (2005). The place of community in social work
practice research: Conceptual and methodological develop-
ment. Social Work Research, 29, 73-86.
Delgado, M. (2000). Community social work practice in an urban
context: The potential of a capacity-enhancement perspective. New
York: Oxford University Press.
Ernst, J. S., & Sowbel, L. (2007). Bringing the community in:
Partnerships for aging enrichment. Journal of Gerontological
Social Work, 48, 387-403.
Fullilove, M. T. (2002). Social and economic causes of depres-
sion. Journal of Gender Specific Medicine, 5, 38-41.
Galea, S., & Ahem, J. (2006). Considerations about specificity of
association, causal pathways, and heterogeneity of association
in multilevel thinking. American Journal of Epidemiology, 163,
1079-1082.
Galea, S., & Vlahov, D. (2001). Social determinants and the
health of drug users: Socioeconomic status, homelessness, and
incarceration. Public Health Reports, 117(Supp. 1), s135-s145.
Gilbert, N. (1982). Policy issues in primary prevention. Social
Work,27,293-297.
Link, B. G., & Phelan, J. C. (2006). Stigma and its public health
implications. Lancet, 367, 528-529.
Lurie, A, & Monahan, K. (2001). Prevention principles for
practitioners: A solution or an illusion? Social Work in Health
Care, 33, 69-86.
Minkler, M., & Wallerstein, N. (Eds.). (2002). Community based
participatory research for health. San Francisco: [osseyBass
Publishers.
Ohmer, M. L., & Korr, W. S. (2006). The effectiveness of
community practice interventions: A review of the literature.
Research on Social Work Practice, 16, 132-145.
 PuRCHASING SOCIAL SERVICES 483

Payne, M. (2005). Modem social work theory (3rd ed.). Chicago: Suicide Prevention Resource Center (SPRC), Substance Abuse
Lyceum Books. and Mental Health Services Administration (SAMHSA), US.
Stoesz, D. (2002). From social work to human services. Journal of Department of Health and Human Services (HHS).
Sociology and Social Welfare, 29(4), 19-37. www.sprc.orgj www.samhsa.gov
W orld Health Organization.
SUGGESTED LINKS The American www.who.int/tobacco/en
Psychological Association. www.apa.org www.who.int/topics/suicide/en/
The American Psychiatric Association. www.who.int/violence_injuryJrrevention/en/
www.psych.org www.who.int/violence_injuryJrrevention/violence/world_reporti
The Centers for Disease Control and Prevention (CDC). . factsheets/en/index .html
www.cdc.gov
Environmental Protection Agency (EPA). -BETTY J. RUTH AND SARAH SISCO
www.epa.gov
Institute of Medicine (10M) of the National Academies.
www.iom.edu '
Group for Public Health Social Work Initiatives (GPSI).
http://www . bu.edu/ssw/mswmph/about/ gpsi. html PUBLIC HEALTH SERVICES. See Health Care:
Healthy People 2010. Overview.
www.healthypeople.gov
,The National Association of Social Workers (NASW).
www.socialworkers.org
www.socialworkers.org/research/naswResearch/PublicHealth/de
fault.asp PUBLIC RELATIONS. See Media Campaigns.
The National Institutes of Health (NIH).
www.nimh.nih.gov
Office on Women's Health, U.S. Department of Health and
Human Services, National Women's Health Information Center.
www.4woman.gov/violence/index·cfm PUBLIC WELFARE. See Appendix Distinctive Dates
Office of Vioience Against Women, US. Department of Justice. in Social Welfare History; Political Ideology and Social
http://www . usdoj .gov/ovw/ Welfare; Public Health; Social Welfare Expenditures.
The Office of the Surgeon General, Office of Public Health and
Science in the Office of the Secretary, U.s. Department of Health
and Human Services.
www.surgeongeneral.gov/tobacco
Substance Abuse and Mental Health Services Administration
(SAMHSA), US. Department of Health and Human Services PUERTO RICANS. See Latinos and Latinas: Puerto
(HHS). Ricans.
www.drugabusestatistics.samhsa.gov
www.samhsa.gov

PURCHASING SOCIAL SERVICES. See Con-

tracting Out of Social Services. .
 QUALITATIVE RESEARCH
ABSTRACT: The term qualitative methods is relatively
new. There is no single definition, although they share
features in common, that is, flexibility, holism, natur-
alism, and insider perspectives. Epistemological
debates continue among qualitative researchers, and the
diverse methodological approaches often reflect the
influence of constructivist critiques. The basic
approachesethnography, grounded theory, case studies,
narrative, phenomenological, and action research-are
de' scribed along with the fundamentals of data
collection and analysis, the role of theory, standards for
rigor, ethical issues, and social work values. Rapid
growth in the popularity of these methods ensures that
they will play a key role in the professions' knowledge
develop, mentin the future.
KEY WORDS: qualitative methods; epistemology;
constructivism; postpositivism; ethnography;
grounded theory; rigor
The term qualitative methods is relatively new to the
research lexicon compared with the venerable age of
some of its constituent approaches such as
ethnography. Historically rooted in 19th century
anthropological studies of non-Western cultures, these
methods have become increasingly complex and
diverse as they have been embraced by researchers in
sociology, psychology, nursing, medicine, and social
work (Creswell, 2007; Marshall & Rossman, 2006;
Miles & Huberman, 1994; Morse, 1994; Padgett, 2008).
Distinguishing Features of Qualitative Methods
There is no single definition for "qualitative
methods." The distinction between them and
quantitative research, that is, "a mile wide and an
inch deep" versus "a mile deep and an inch wide;" is
often invoked to increase understanding of their
special features (Padgett, 2008).
Other contrasts include the following:
• Insider rather than outsider
• Person-centered rather than variable-centered
• Holistic rather than particularistic
{ • Depth rather than breadth
r:
Qualitative methods are inductive rather than hypo-
i subject matter to optimize "what works." In practice,
thetico,deductive. They favor naturalistic observation
485
J
and interviewing. As such, they imply a degree of
closeness and an absence of controlled conditions that stand
in contrast to the distance and control of experimental
studies.
Qualitative studies seek to convey the complex
worlds of respondents in a holistic, on-the-ground
manner. Furthermore, they assume a dynamic reality, a
state of flux that can only be captured via intensive
engagement with respondents. Unlike the pre-coded
standard, ized questionnaire, the qualitative researcher
must be a sensitive instrument of observation, capable
of flexibility, and on-the-spot decision-making about
following promising leads.
Paradigmatic and Epistemological Underpinnings A
primary source of epistemological difference among
qualitative researchers is between postpositivism and
prag, matism on the one hand and constructivism and
interpre, tivism on the other (Denzin & Lincoln, 2005;
Padgett, 2008; Patton, 2002). Coming into full flower
by the 1990s, epistemological debates centered on
fundamental questions about the nature of reality (a
single "objective" reality versus subjectively-derived
multiple realities) and the relationship between the
researcher and study participants (detachment versus
immersion). Although the salience of these
differences tends to be felt more deeply on the
constructivist side and within the halls of academia,
most qualitative researchers accept the premise of
multiple interpretations and reject the notion of
"pure" objectivity and neutrality.
Much of the vocal opposition to positivism has come
from scholars in the field of education such as Yvonna
Lincoln, Egon Guba, Harry Wolcott,. and John
Creswell. Along with sociologist Norman Denzin.these
individuals pioneered the development of interpretivist
and social constructivist approaches as stand-alone
alternatives. Similar disagreements over epistemologi-
cal stance can be found in anthropology, sociology,
psychology, nursing, and social work.
The rapid growth in the popularity of qualitative
methods in recent years has done little to increase
consensus about these issues. Philosophical pragmatism
is often cited as a foundation for avoiding such debates
entirely and focusing instead on matching method to
much of the qualitative research taking place in social
486 QUALlT A TIVE RESEARCH
work and elsewhere implicitly adopts a pragmatic
stance in that epistemological allegiances are not given
priority.
Primary Approaches to Qualitative Research The
following sections provide brief descriptions of six of
the primary types of qualitative methods, described in
rough chronological order (beginning with the earliest).
ETHNOGRAPHY Ethnography has its roots in the
study of non-Western people and cultures (Bernard,
2000). Though rarely explicated as a set of skills
imparted in a classroom, ethnography is defined by its
commitment to prolonged engagement using a holistic
perspective. Data collection is done bvobservation
(with varying amounts of participation) and through
interviews conducted with selected informants.
Pioneered by anthropologists and adapted by the
"Chicago School" of sociology to studies of urban life,
ethnography has endured as the primary means of
understanding a social group or culture and its requisite
beliefs and values (Emerson, 2001). Despite its
pedigree as the first qualitative method, ethnography
does not preclude use of quantitative techniques, for
example, measuring caloric intake or quantifying social
networks.
Ethnography and its parent discipline of anthropol-
ogy underwent a profound identity crisis by the late
1970s in which previous canons of objectivity and the
invisibility of the researcher were questioned. The
methodological self-consciousness that resulted has
produced new approaches such as "auto-ethnography"
in which the authors' role in the inquiry becomes the
focus of interest. Adopted by researchers in other dis-
ciplines (including social work), ethnography has re-
tained its value as a method for naturalistic research
using its hallmark technique of participant observation.
GROUNDED THEORY The most commonly used of
all qualitative methods, grounded theory (GT) has its
roots in the Chicago School of sociology and its paren-
tage in the collaboration of Barney Glaser and Anselm
Strauss dating back to the 1960s (Charmaz, 2006;
Glaser & Strauss, 1967; Strauss & Corbin, 1990). GT
has emerged as the most systematized and documented
of qualitative methods. Glaser and Strauss developed
GT as a means of generating theory relying upon an
iterative process of data collection and analysis, using
inductive thinking and constant comparative analysis. Data
analysis in GT involves coding, comparison, and
thematic interpretation of data to reveal conceptual
frameworks and "mid-range" theories of human social
behavior and interaction. GT's attractions include its
flexibility and transparency of method. Distinct from
content analysis (which involves identifying and usually
counting occurrences of specified phenomena within
texts), GT is designed to yield conceptually rich
understanding.
NARRATIVE TECHNIQUES Narrative techniques
share a focus on the form and content of speech,
whether monologic or dialogic. Rooted in philosophy,
literary criticism, linguistics, and psychotherapy,
narrative analyses assume that much can be learned
from the ways that individuals tell stories and converse
with one another. Pioneers of these methods include
William Labov, Elliott Mishler, Gordon Gee, and
Catherine Reissman. Two basic variants of narrative
techniques include analysis of interviews about life
experiences (with an emphasis upon natural
story-telling) and analyses of conversation and
discourse. The former approach shares some features in
common with narrative therapy in which story-making
is part of the therapeutic encounter. The latter reflect a
sociolinguistic focus upon the ways that social status
(gender, social class, race, age, ethnicity, and so on) is
revealed during speech events (Reissman, 1993).
PHENOMENOLOGICAL ANALYSIS
Phenomenological analysis (PA) owes much to the
philosophers Edmund Husserl and Alfred Schutz and to
the developmental work of Duquesne University
psychologist Amedeo Giorgi. As a qualitative method,
PA seeks to grasp holistically the "lived experience"
and the life worlds of study participants who share a
particular experience in common. Its technique of
repeated interviews and reflective immersion in the data
requires the researcher to "bracket" his or her own
personal experiences and feelings in order to fully
capture the experience of others, for example, being a
cancer survivor, a crime victim, a first-time parent
(Giorgi, 1985).
CASE STUDY ANALYSIS The intensive study of a
bounded entity, that is, a single case or group of cases,
has long been recognized as an important form of
inquiry in the social and natural sciences. Case study
analyses in research are different from their use in
clinical training (where cases, or vignettes, are pre-
sented for pedagogic reasons). A "case" may be an
individual, an agency, a village, an innovation, or an
important event-its selection as the focus of study is an
indication of its capacity to inform and expand
understanding on a deeper level. To achieve maximum
depth, case studies involve multiple forms of data
(which may also be quantitative). Multiple case studies,
which usually entail within-case and across-case analyses,
.J

are appropriate when the phenomenon encompasses
more than one entity and comparisons are needed
(Stake, 1995).
ACTION AND COMMUNlTy,BASED ApPROACHES
These approaches, rooted in 1960' s liberation
movements, are united by their commitment to.
research as a vehicle for social change and
community empowerment. Although not
necessarily qualitative, these ap proaches tend to
emphasize community immersion and
involvement, which, in tum, favor in-depth
interviewing and rapport-building. Action
researchers often engage in partnerships with
community members to ensure that local needs are
being seryed and that the research findings are
beneficial to the community (Israel, Eng, Schulz, &
Parker,Qualitative
2005). Designs: Methods of Data
Collection and Analysis
Qualitative studies may be longitudinal or cross-
sectional, single-site or multi-site, and single-group or
group-comparative. Some general principles character-
izing the vast majority of qualitative designs include the
following: flexibility, multiple sources of data (when
applicable), multiple interviews with each participant
(when possible), iterative phases of data collection and
analysis, and careful documentation of all activities
during the study (Padgett, 2008).
The three primary means of data collection in qua-
litative research are interviews, observation.rand analy-
sis of documents. A qualitative. interview is minimally
structured and intended to yield lengthy and rich accounts
from study participants, which are audiorecorded and
transcribed verbatim. Observational data produce field
notes, which are also analyzed as texts. Some
researchers use photography and video recording,
although these bring greater ethical concerns regarding
confidentiality. Existing documents might include case
records, personal diaries, minutes from meetings, and so
on. Although the specifics of data analysis depend upon
the type of method, all share in common immersion in
the data, inductive thinking, and a search for deeper
meaning (Padgett, 2008).
Sampling in qualitative research is typically purposive
and designed to maximize the retrieval of rich,
meaningful data. Sample sizes can range from a single
case to fewer than 10 (as in PA) to 25 or more (as in GT ).
The ultimate size of a study's sample depends upon the
quality of the data and when saturation (redundancy) is
achieved. A design emphasis on multiple interviews with
each participant is an important factor in addressing
concerns about small samples and shallow, insufficient
data. For these. reasons, qualitative studies
QUALITATIVE REsEARCH 487
are not expected to be generalizable in the traditional
scientific sense, but their findings should have credibil-
ity and wider applicability (Padgett, 2008).
Use of qualitative data analysis (QDA) computer
software has become increasingly common, with pro-
grams such as NVIVO and A TLAS/ti providing tools
for data management and retrieval with the following
caveat: QDA software does not perform the most
important functions of qualitative analysis, that is,
conceptualization, 'categorization, and comparison.
The Role of Theory in Qualitative Research While a
strength of qualitative studies lies in their avoidance of
strict allegiance to any given theory (or theories), this
does not preclude drawing upon theories to inform the
study. Often easier to incorporate when broken down
into conceptual building blocks, theories contribute
sensitizing concepts that may (or may not) be found
relevant during analysis (Charmaz, 2006) Though not
designed to test theories deductively, quali tative studies
offer fertile ground for their application (Padgett, 2008).
Standards for Quality and Rigor Qualitative
research adheres to different standards than quantitative
research: though there is little consensus on what those
standards should be. Under the general heading of
"trustworthiness," qualitative studies are judged by their
ability to convey deeper understanding of a phe-
nomenon through use of systematic application of the
methods of choice. A successful qualitative study is in-
formative and thought-provoking; it also "rings true" in
the sense of reflecting the insider perspective obtained
from immersion and analyses based upon the
participants' own words (Charmaz, 2006; Padgett,
2008).
A number of strategies for rigor have been put forth,
including data triangulation (use of more than one source
of data), peer debriefing to minimize investigator bias,
keeping an audit trail, or documentation of data and
analytic decisions, negative case analysis to avoid prema-
ture and untested conclusions, member checking to seek
participant input, and prolonged engagement. The de-
ployment of one or more of these strategies enhances
study rigor and credibility.
Ethical Issues
In addition to seeking voluntary informed consent and
protecting confidentiality, qualitative researchers must
address concerns specific to their methods, that is, the
sensitivity of personal revelations and fears of identity
disclosure. The sharing of personal and sometimes
painful information is not uncommon in qualitative
studies, but such emotions almost always resolve
without harm.
488 QUALITATIVE RESEARCH
Nevertheless, qualitative researchers anticipate this and build
into the study referral mechanisms for outside counseling if
warranted. Unintended disclosure of a study participant's
identity is another risk, given the detailed description found in
a qualitative report, but changing unimportant details helps
mitigate against this. The inherent flexibility of qualitative
inquiry en, sures that ethical issues require attention at all
times. In addition, social work researchers must make
allowances for mandated reporting of child abuse and
imminent threats of harm.
Social Work Values in Qualitative Research Qualitative
methods attract researchers with a predisposition toward
being socially responsible (and socially active), in part
because the're is no expectation that they be "value-neutral" as
there is in quantitative methods. In addition to action' and
community-based research, feminist studies, critical race
theory, and queer theories (among others) are explicitly
devoted to addressing inequality and injustice.
The researcher's choice of topic consonant with social
advocacy is one manifestation of this ethos, for example,
studying the health problems of poor children as opposed to
those of middle class children, but the conduct of qualitative
research is also considered a means to this end. Two primary
ways that this occurs are (a) the em, phasis on egalitarian
partnership of researcher and re, searched; and, (b) an
emphasis on participants' voicing their responses freely and in
their own words.
Trends
Growing recogrution that qualitative methods "go where
quantitative methods cannot go" has led to a boom in their
popularity in recent years. The National Institutes of Health, a
major source of funding and prestige in the United States, has
issued helpful guide, lines for qualitative researchers and has
funded an in' creasing number of studies on drug abuse, AIDS,
mental illness, and immigrant health. This trend toward
widespread acceptance has also spawned increased interest in
mixed methods studies using both quantitative and qualitative
methods (Padgett, 2004). Although mixed methods studies
carry a risk of short, changing the qualitative portion of the
study, their attraction is likely to continue into the future. It is
also noteworthy that the heterogeneity of qualitative methods
has contributed to "internal mixing" (for example, case studies
combined with GT analyses in the same study) and to new
com, binations (for example, the constructivist grouru1ed theory
of Kathy Charmaa).
Qualitative methods have also gained greater prominence
as research, practice and policy have "gone
global," for example, AIDs, violence against women, the
aftermath of wars and natural disasters, drug trafficking.
Qualitative methods have a number of advantages in this
regard, including their multidisciplinary foundation, attention
to cultural sensitivity, flexible designs, and ability to adapt to
local conditions of other cultures. Increased interest in
community-based approaches, rapid assessment, and
culturally-appropriate partnerships is evidence of the growing
awareness of the globalization of many social problems and
their potential solutions.
Within social work, qualitative research had tremendous
relevance, given the complexity of human pro' blems and its
ethos of egalitarianism. This is especially visible among the
membership of the Society for Social Work arid Research
(SSWR), an organization that has grown rapidly since the
mid-1990s, in part because of its inclusion of qualitative
methods content within its annual conference program.
REFERENCES
Bernard, H. R. (Ed.). (2000). Handbook of methods in cultural
anthropology. Walnut Creek, CA: Altamira Press.
Charmaz, K. (2006). Constructing grounded theory. Thousand Oaks,
CA: Sage.
Creswell, J. W. (2007). Qualitative inquiry and research design.
Thousand Oaks, CA: Sage.
Denzin, N. K., & Lincoln, Y. S. (Eds.). (2005). Handbook of
qualitative research. Thousand Oaks, CA: Sage.
Emerson, R. M. (2001). Contemporary field research. Prospect
Heights, IL: Waveland Press.
Giorgi, A (1985). Phenomenology and psychological research.
Pittsburgh, PA: Duquesne University Press.
Glaser, B. G. & Strauss, A L. (1967). The discovery of grounded
theory. Chicago: Aldine.
Israel, B. A, Eng, E., Schulz, A. J., & Parker, E. A. (Eds.).
(2005). Methods in community,based partidpatory research for
health. San Francisco: [ossey-Bass. ~
Marshall, c., & Rossman, G. B. (2006). Designing
qualitative research. Thousand Oaks: Sage.
Miles, M., & Huberman, A (1994). Qualitative data analysis. '
Thousand Oaks, CA: Sage. .'
Morse, J. M. (Ed.). (1994). Critical issues in qualitative research
methods. Thousand Oaks, CA: Sage.
Padgett, D. K. (in press, 2008). Qualitative methods in social work
research. Thousand Oaks, CA: Sage.
Padgett, D. K. (Ed.). (2004). The qualitative research experience.
Pacific Grove, CA: Brooks/Cole Publishers.
Patton, M. (2002). Qualitative research and evaluation methods.
Thousand Oaks, CA: Sage.
Reissman, C. (1993). Narrative analysis. Newbury Park, CA:
Sage.
Stake, R. (1995). The art of case study research. Thousand Oaks,
CA: Sage.
Strauss A, & Corbin, J. (1990). The basics of qualitative research.
Newbury Park, CA: Sage.

SUGGESTED LINKS
www.nsf.gov/pubs/2004/nsf04219/start.htm (Proceedings from
workshop on qualitative methods at the National Science
Foundation)
http://obssr .ad. nih.gov/Documents/CanferencesAnd_ Warkshops/
Qualitative.PDF (Document produced by the National Insti tutes of
Health in 1999) http://www.uofaweb.ualberta.ca/iiqm/Canferences
.cfm (Comprehensive site from the University of Alberta's
International Institute for Qualitative Methodology)
http://www.ualberta ;ca/-ijqm/ (International Journal of Quali-
tative Methods)
http://www.rwva.edu/sss/QR/web.htmi (includes the journal The
Qualitative Report and other resources) http://www,c4qi.arg/
(International Center for Qualitative Inquiry and annual conference
headed by Professor Norman
Denzin) .
http://www .qualitativeresearch. uga.edu/QualPage/ (Resources
) provided through Professors Judith Norris and Judith Preissle)
http://www.quarc.de (German-English site with links to other
resources)
http://www.lsoft.com/scripts/wl.exe?SLl = QUALRS-L&H =
LISTSERV.UGA.ED (multi-disciplinary resources and listserv from
the University of Georgia) http://qualitative-research.net
(German-English site with online journal)
http://sophia.smith.edu/ -jdrisko/qualres .htm (Professor James
Drisko's compendium of resources)
httfJ://www.nova.edu/ssss/QR/QRl-4/wark.html (Listing of qualitative
journals)
http:///www.scolari.com (information and downloadable software
demos for Atlas.ti, NVIVO, The Ethnograph, etc.)
. www.researchtalk.com (Training and workshops on Long Island, NY)
http;/lcaqdas .soc . surrey .ac. uk! (support for computer-assisted
qualitative data analysis)
http://onlineqda.hud.ac.uk/Introductian/index.php (assistance in .
qualitative data analysis using computer software)
- DEBORAH PADGETT
QUALITY ASSURANCE AND TQM. See Management:
Quality Assurance.
QUALITY OF CARE
ABSTRACT: Assessing and improving the quality of
social services is one of the most pressing concerns for
social work practice and research. Practice in nearly every
setting is affected by stakeholder expectations that
agencies monitor and improve quality. This entry
addresses the meaning of the phrase "quality of care"
QUALITY OF CARE 489
with respect to social work services, considers this topic in
relation to quality improvement, quality assurance, and
evaluation of services, and points to the research that is
needed in order to assess and improve quality.
KEY WORDS: quality concerns; assessment; research
Assessing and improving the quality of social services is
one of the most pressing concerns for social work practice
and research. Practice in nearly every setting is affected by
stakeholder expectations that agencies monitor and
improve quality. One expert has characterized the shift
toward increased accountability as perhaps "the largest
scale social experimentation since the New Deal"
(Clyman, 1999, p. 167). This entry (a) addresses the
meaning of the phrase "quality of care" with respect to
social work services, (b) considers this topic in relation to
quality improvement, quality assurance, and evaluation of
services, and (c) points to the research that is needed in
order to assess and. improve quality.
. History of Quality Concerns in Social Work
Social work has long been concerned with quality, as
reflected in its historical emphasis on supervision and
lifelong learning, the designation of competence as a core
value in NASW's Code of Ethics, development and
publication of standards and best practices (for example,
Child Welfare League of America, 2000; NASW, 2002),
and performance assessment requirements (Hatry, 1997 ).
Recently, spurred by accountability demands and
accreditation, an important literature on quality has
started to develop in administrative social work (see
Kettner, 2002), often focused on total quality
management (for example, Boettcher, 1998). The
profession has also approached quality improvement
through outcome evaluation processes. However,
questions of quality have received very little systematic
conceptual or research attention.
Definitions of Quality
Quality has proven to be a challenging construct to define,
much less to measure and improve. At least three issues
complicate the definition of quality. First, multiple
stakeholders have an interest in quality, and have a stake in
determining whether services are deemed to be of high
quality. These stakeholders include purchasers and payers
of social services, the administrators, supervisors, and
providers of social service agencies, the clients who
receive services, and society at large, given its sanction for
social work as a recognized profession. Quality often
seems to be in the eye of the beholder (Martin & Kettner,
1996), but different voices must be respected. Otherwise
"measured" quality
490 QuALITY OF CARE
may be disputed, and efforts to improve quality will be
thwarted over differences in definition.
Second, what components or elements of service
should be assessed' when defining quality? Martin (1993),
a social work scholar, proposed 15 dimensions to quality
in social service organizations, including such varied
aspects as access to services, conformity, courtesy, and
reliability. According to the dominant conceptual model of
quality in health services, quality is defined (and
determined) by the structures in service
. delivery, the processes of service delivery, and the actual
outcomes of care as received or delivered (Donabedian,
1982). The structure of care reflects such issues as
resources and actual access to care. Quality involves both
the interpersonal and technical processes of care through
such factors \ as cultural competence, congruence with
best evidence, and sensitivity to client preferences. And
ultimately, quality is dependent on attaining positive
effects.
Third, what is the basis, or criteria, for judging quality?
The social work profession and most social work agencies
have assessed quality on the basis of professional
judgment. Criteria have been drawn from explicit or
implicit notions of how agencies should work, such as the
length of await list for service. Social work does not yet
have a strong quality of care research tradition, but the
importance of using evidence or data in assessing and
monitoring quality is increasingly recognized and
advocated (Proctor, 2002; McMillen et al., 2005).
Social service quality of care has been defined as the
extent to which interventions lead to desired client
outcomes, while delivered consistent with ethical stan-
dards of practice and the best available practice knowl edge
(Megivem et al., in press). This definition reflects
structure, process, and outcomes as key components, and.
incorporates the perspective of multiple stake holders in
assessing the convergence of resources, interpersonal
skills, cultural competence,' and technical knowledge. This
definition also encompasses several of Martin's (1993)
domains (competence, conformity, performance,
reliability). In its shortest form, this definition of quality
care can be viewed as technically proficient care,
sensitively delivered.
What Factors Influence Quality?
From this definition of quality derives an understanding of
the many factors that influence the quality of social work
services. Structurally, quality is enhanced when
service-providing organizations have cultures that are
receptive to change and new practices-particularly those
with established evidence of effectiveness-are willingly
adopted, and have processes and infrastruc tures for
evaluating and improving services. Other key
structural elements are an adequate funding base, an
adequate number of trained staff, carefully defined mission
statement and goals, a workable strategic plan, and
information technology systems that support and aid
service planning and case decision making. Of course,
policy decisions in the larger macrosystem and the work of
advocates often carry significant influence on services and
their quality.
The knowledge, skill, and attitudes of frontline service
providers are. also important. In particular, their
receptivity to evaluating-and if necessary, changing-their
practice methods has a major effect on quality of care.
Because co-occurring problems are the norm rather than
the exception for most clients, social work typically
requires a complicated mix of service types and sources,
further complicating the task of delivering high-quality
care. The quality of component services likely varies, and
the coordination of care itself increases the challenge for
quality.
The extent to which clients and, as appropriate, their
family members are actively engaged in care also impacts
service quality. A growing body of research suggests that
vulnerable populations experience disparities in both
access and quality of care. Yet often the clients served by
social work have little voice in determining where they
receive care or what kind of care they receive. This is
particularly true for children, disenfranchised minorities,
and persons with cognitive impairment.
Research on Quality of Care
Three kinds of research activities are needed to help
advance an understanding of what constitutes quality care
for social work. First, it is important for studies to capture
what key stakeholders define as quality care. In all
likelihood, definitions will vary and the findings of such
research can be used to modify current working definitions
of quality. Second, social work has a pressing need to
develop new knowledge of effective treatments through
conducting efficacy arid effectiveness research, along with
systematic observational studies that link processes and
outcomes of care. Knowledge of "what works" can be
further advanced by meta-analyses and systematic reviews
of published intervention studies. Third, social workers
need to develop consensus around guidelines for practice,
based on the best available-and growing-supply of
research evidence.
Beyond these questions of what quality means, a host of
additional questions need systematic study. Questions
about variation are at the heart of quality of care research,
with key questions focusing on demographic, geographic,
and provider variations in outcomes, processes, and
consumer experience. Such research can

help identify potential disparities in quality as well as
the extent to which outcomes differ across providers.
Wide variations in outcomes compel administrators and
providersto investigate possible causes and identify how
to achieve greater consistency in service quality.
Research can also help . identify structural serv ice
factors associated with the level of quality processes and
client outcomes. For example, how do payment levels
and structure, professional regulation, and ac creditation
affect quality? How can these elements best be
structured to support quality?
Research is also needed on process factors, addres-
sing for targeted groups of clients such questions as,
"Who gets what service?" "Who gets, more or less ser-
vice]" and "Who gets guideline-conforming care?"
Finally, researchers need to 'examine variations in the
interactions between consumers and providers, such as
those capturing client experiences with cultural sensi-
tivity and provider competence.
Ultimately, some of the most important research will
address whether the services defined as high quality
actually lead to better outcomes. Is guideline-conform-
ing care better than alternatives? And for what client
groups? Such studies will explore various quality
indices as independent variables, with client outcomes
as the variable. Such studies will require use of risk,
adjusted outcome measures that enable valid
comparisons across providers while accounting for the
differences in clients served and the severity of their
problems.
Professional Roles for Quality Assessment
and Improvement
Social workers at all levels can engage in efforts to
assure quality in their individual and "agency practices.
Social workers who deliver services directly to consu-
mers can (a) participate in efforts to define quality of
care in their fields of practice, (b) assess their o wn
practice processes in relation to available quality
standards of care, (c) vigorously assess consumer pro,
gress, (d) regularly solicit feedback from consumers, (e)
develop personalized plans to improve their social work
practice, and (f) if employed in agency work, participate
in agency-based quality assurance efforts.
Managers and administrators need to lead agency
efforts to define quality of care practices, prioritize
which quality indicators willbe measured regularly,
build a data Structure that can provide administrators the
information on quality that they need to assess progress
and identify problems for quality improvement,
organize targeted quality improvement efforts, and
review progress of these efforts. Agencies with
administrators engaged in these types of efforts could
typify what some scholars now term learning
organizations-organizations that strategically
QUALITY OF CARE
491
and continuously use learning processes to transform
themselves (Watkins & Marsick, 1996),
A new social work professional role has been rapidly
developing in the last few years, the agency-based
quality assurance professional (QAP) who may work at
a variety of levels in agency hierarchy, depending on
individual skill sets and agency complexity. The QAP
may direct an agency's entire quality enterprise and hold
a title such as Vice President for Quality. Or, the QAP
may work in an entry-level capacity, mainly col, lecting
agency quality data, such as reviewing client records. In
smaller agencies, a clinician or administrator may be
given QAP duties as part of their portfolio of duties.
Since no professional training programs exist for QAPs
at this time, social workers are prime to move into QAP
positions.
The QAP's potential responsibilities can be grouped
into four main categories: leading, coUecting, analyzing, and
improving. In leading agency quality activities, the QAP
brings stakeholders together to define quality care
standards, prioritizes which care processes and out,
comes will be measured by the agency, determines the
best available data collection strategies, and engages
additional stakeholders to participate in quality assur-
ance activities. After agency data is analyzed the QAP
leader also helps determine new targets for quality
improvement.
QAPs also participate in coUecting agency data that
supports the quality enterprise. Sources of data include
agency records, administrative data, agency consumers,
agency employees, and consumer-employee inter-
actions. This data is then analyzed, with an accent on (a)
variation, to assess potential disparities among cli ent
groups, agency units, and providers, (b) change over
time, especially in monitoring the effects of quality
improvement initiatives, and (c) the degree to which the
agency is meeting specific quality standards.
In improving agency practice, the QAP facilitates
meetings of quality teams that may focus their attention
on identifying root causes of quality problems, identify-
ing potential actions to address these causes, and imple-
menting change strategies. These strategies may involve
changes in structure (financing, incentives, or personnel
additions, subtractions or substitutions) or care
processes and will likely involve the engagement of
multiple stakeholder groups.
REFERENCES
Boettcher, R. E. (1998). A study of quality- managed human
service organizations. Administration in Social Work, 22, 41-56.
Child Welfare League of America. (2000). CWLA standards of
exceUence for adoption services. Washington, DC: Author.
492 QUALITY OF CARE
Clyman, R. B. (1999). A systems perspective on research and
treatment with abused and neglected children. Child Abuse and
Neglect, 24, 159-170.
Donabedian, A. (1982). Exploraticms in quality assessment and
monitoring, Volume II: The criteria and standards of quality. Ann
Arbor, MI: Health Administration Press.
Hatty, H. P. (1997). Outcomes measurement and social services:
Public and private sector perspectives. In E. Mullen & J.
Magnabosco (Eds.), Outcomes measurement in the human
services. Washington, DC: NASW Press.
Kettner, P. M. (2002). Achieving exceUence in the management of
human service organizations. Boston, MA: Allyn & Bacon.
Martin, L. L. (1993). Total quality management in human service
organizations. Newbury Park, CA: Sage Publications.
Martin, L. L., & Kettner, P. M. (1996). Measuring the performance
of human service organizations. Thousand Oaks, CA:
Sage. \ (that is, delineating the interrelation of factors influencing
McMillen, J. C., Proctor, E. K., Megivem, D., Striley, C. W.,
Cabassa, L. J., Munson, M. R., et al. (2005). Quality of care in
the social services: Research agenda and methods. Social Work
Research, 29, 181-191.
Megivem, D., McMillen, J. C., Proctor, E. K~, Striley, C. W.,
Cabassa, L. J., & Munson, M. R. (in press).
Quality of care:
Expanding the social work dialogue. Sdcial Work.
National Association of Social Workers (NASW). (2002).
NASW Standards for cultural competence in social work practice.
Washington, DC: NASW.
Proctor, E. K. (2002). Quality of care and social work research
(Editorial). Social Work Research, 26(4), 195-197.
Watkins, K. E., & Marsick, V. J. (1996). In action: Creating the
learning organization. Alexandria, V A: American Society for
Training and Development.
-ENOLA PROCTOR AND J. CURTIS McMILLEN
QUANTITATIVE RESEARCH
ABSTRACT: This entry describes the definition, his tory,
theories, and applications of quantitative methods in
social work research. Unlike qualitative research,
quantitative research emphasizes precise, objective, and
generalizable findings. Quantitative methods are based on
numerous probability and statistical theories, with
rigorous proofs and support from both simulated and
empirical data. Regression analysis plays a para rnountly
important role in· contemporary statistical methods, which
include event history analysis, gener alized linear
modeling, hierarchical linear modeling, propensity score
matching, and structural equation modeling. Quantitative
methods can be employed in all stages of a scientific
inquiry ranging from sample selection to final data
analysis.
KEY WORDS: event history analysis; generalized linear
modeling; hierarchical linear modeling; propensity score
matching; regression; structural equation modeling
Quantitative research is the systematic examination of
social phenomena, using statistical models and mathe-
matical theories to develop, accumulate, and refine the
scientific knowledge base. Unlike qualitative research,
quantitative research emphasizes pre cise, objective, and
generalizable findings (Rubin & Babbie, 2001), and is
characterized by hypothesis testing, using large samples,
standardized measures, a deductive approach, and rig-
orously structured data collection instruments (Marlow,
1993). Examining the relationship of one, two, or multiple
variables, quantitative analysis can be either descriptive
the study phenomena) or explanatory (that is, defining the
mechanisms generating the phe nomena). Whereas the
results of qualitative research usually cannot be
generalized beyond the study sample, the results of
quantitative research on tested practices can be applied to
a whole population and provide evidence to support policy
development promoting social justice.
Quantitative research emerged from the positivist
tradition developed in the 1820s by the French philo-
sopher Auguste Comte, who applied principles of the
Scientific Revolution to practical social purposes. In
contemporary social sciences, logical positivism is often
narrowly defined by equating it with the hypo-
thetic-deductive approach (Grinnell, 1997). The re cent
philosophical shift among the helping professions
emphasizing evidence-based practices has propelled the
use of quantitative methods in social work research
(Gambrill, 2003).
Theories and Applications Quantitative
methods are based on numerous probabil ity and statistical
theories. These theories are derived analytically with
rigorous 'proofs, and supported by both simulated and
empirical data. For instance, the central limit theorem
forms the foundation of probability-sampling techniques.
Three proven relationships form the theorem's core: (a)
between the mean of a sampling distribution and the mean
of a population; (b) between the standard deviation. of a
sampling distribution (that is, standard error) and the
standard deviation of a population; and (c) between the
normal sampling distribution and the possible non- normal
population distribution (Guo & Hussey, 2004).
Quantitative methods can be employed in all stages of
a scientific inquiry, ranging from sample selection to final
data analysis. Various methods can be applied

• to the different stages of research and project develop-
rnent.. To develop valid and reliable measurement
instruments, researchers use Cronbach's alpha, the gen-
eralizability theory, exploratory factor analysis, confir-
matory factor analysis, item response theory, and other
psychometric approaches (Cronbach, GIeser, Nanda &
Rajaratnam, 1972; Lord, 1980; Thompson, 2004).
Probability sampling methods, such as simple random
sampling, systematic sampling, stratified sampling, clus-
tered sampling, and multistage clustered sampling (Co-
chran, 1977), are used to select a sample representative of
the study population. However, researchers also use
nonprobability methods of sample selection (that is,
sample selection is not based on a predetermined prob-
ability, rather on a variety of non-statistical reasons
\
such as research purpose, convenience, or subjective
judgment) with a caveat about statistical inferences (Guo
& Hussey, 2004)~ A meta-analysis may be used by
researchers in reviewing prior studies of a . topic; this
approach allows the mean effect size (that is, the- average
strength of association between variables) to be calculated
across the previous studies (Hunter & Schmidt, 2004).
Researchers looking to increase the internal validity of a
study evaluating the effectiveness of a treatment program,
may choose a randomized clin ical trial, or
quasi-experimental design, to control for extraneous
factors (Shadish, Cook, & Campbell, 2002).
Quasi-experimental designs are typically used in con-
junction with analytical strategies such as statistical
control, ex post matching, and propensity score match ing
that enhance internal validity (Guo, Barth, & Gibbons,
2006). After data is collected, numerous ana lytical
methods are applied to describe data and test or confirm
research hypotheses, including (a) univaria te methods
(that is, measures depicting central tendency and
dispersion); (b) bivariate methods (for example,
cross-tabulation with chi- square or nonparametric tests,
mean comparisons with independent t test or analysis of
variance, and product-moment corr elation analysis (Kiess,
2002»; and (c) multivariate methods (for example,
analysis of covariance, multivariate analysis of variance,
multivariate analysis of covariance, mul .tiple regression
analysis (Neter, Kutner, Nachtsheim, & Wasserman,
1996), generalized linear modeling (Long, 1997), event
history analysis (Allison, 1995), hierarchical linear
modeling (Raudenbush & Bryk 2002), structural equation
modeling (Bollen, 1989), and single-subject time serie~
analysis (Nugent, Sieppert, & Hudson, 2001».
Furthermore, in multivariate analysis of data with missing
values, researchers use expectation- maximization or
multiple-imputation approach to impute missing data.
Such procedures often assume that missing data are
missing at random or are
I
QUANTITATIVE REsEARCH 493
missing at completely random (Little & Rubin, 2002). In
evaluating a study's statistical power, researchers conduct
power analysis that essentially focuses on the balance of
four elements: statistical power or the ability of rejecting a
false hypothesis, statistical significance or fixing the
probability of making a type I error at a low level, sample
size, and effect size (Cohen, 1988).
Among all statistical approaches, the ordinary-least~
square (OLS) regression model is perhaps the most im portant
because it serves as the foundation for advanced models and
is the key to understanding multivariate analysis (Neter et
a1., 1996). It isa technique used to characterize the
relationship between a dependent variable (t hat is, outcome
or response variable) and a set of independent variables
(that is, explanatory variables). When applying the OLS
regression model, a user makes five basic assumptions
about the way in which observations are generated: (a) the
dependent variable is a linear function of a specific set of
independent variables, plus a disturbance; (b) the mean
value of the disturbance term is zero; (c) the disturbance
terms all have the same variance and are not correlated with
one another; (d) the observations on the independent
variable are considered fixed in repeated samples; and (e)
the number of observations is greater than the number of
independent variables, and there are no perfect linear
relationships between the independent . variables
(Kennedy, 2003). These assumptions are crucial to a
consistent and unbiased estimation of the regression mode1 .
In practice, researchers often conduct statistical tests to
detect violations of these assumptions, and take remedial
measures if harmful violations exist. A regression
coefficient estimated by such a model reveals the net
relationship between an independent variable and the
dependent variable: the value of a regression coefficient
indicates the amount of change in the dependent variable
that is produced by a one-unit increase in the independent
variable, while holding all other independent variables
constant. An Rvsquare statistic is a measure of explanatory
power of the regression model, indicating the propor tion of
variation in the dependent variable that is accounted for or
explained by the independent variables included in the
mode1.
Advanced Statistical Methods
In the course of the past 25 years, quantitative methods in
social work research have undergone a significant change,
driven primarily by the development of userfriendly
software that enabled practical application of new
statistical methods. The quantitative methods have been
further refined by the proliferation of studies that apply
these methods to solving challenging problems in
494 QUAN:nT A TlVE RESEARCH
social behavioral research. This section provides an
overview of advanced statistical models that have been
increasingly adopted by social work researchers.
Event history analysis (EHA, that is, survival analysis) is a
class of statistical methods for studying the occur rence
and timing of events. A key feature of event history data is
censoring, which refers to nonoccurrence of the event
under study by the end of a study period (that is, right
censoring), or occurrence of an event that differs from the
study event before the end of a study period (that is,
random censoring under the noninformative assumption),
or the time origin of event is unknown (that is, left
censoring). The life-table and Kaplan-Mei er methods are
descriptive, approaches to event- history data. The Cox
proportional hazards
\
model (that is, Cox regression) is the most popular
model in EHA that tests influences of multiple covari ates
on timing of event occurrence. The Cox regression
analyzes an unobserved variable, commonly called a
hazard rate, as the dependent variable. This rate is posited
as the instantaneous probability of an event occurring,
which translates the length of ti me it takes an event to
occur into a rate expressing the speed at which it occurs
within a prespecified period. The hazard rate can be linked
to a set of independent variables in the Cox regression.
When all other variables are held constant, this allows a n
assessment of the association between each variable and
the hazard rate and of whether this association is
statistically significant. The model allows the inclusion of
time-varying covariates, that is, covariates that may
change in value over the cours e of the study period. Other
EHA models include parametric regression models that
assume a certain type of probability distribution about
survival times, the discrete- time model that applies a
binary logistic regression to "person- time" data, and the
discrete-time model that applies a multinomial logit model
to "person-time" and multiple-event data (Allison, 1995 ).
Recent advances in EBA center on statistical methods
handling multivariate failure time data (Lin, 1994) . Two
types of such models (that is, f railty models and marginal
models) are developed to correct for bias in significance
testing induced by clustering of event times. Therefore,
these models may be viewed as EHA of multilevel data
(Guo & Wells, 2003). EHA has been widely employed in
social work research, particularly in the fields of child
welfare, welfare policy, evaluation of welfare-to- work
programs, marriage and family, and mental health.
Hierarchical linear modeling (HLM, that is, random
effects model or mixed effects model) is a method for
analyzing nested or clustered data. OLS regression is
inappropriate for such, analysis because of the
correlation of outcome variables among individuals
withinthe same group. However, HLM uses random effect
(that is, random intercept or random slop e), a lump sum of
unobserved variables measuring extra het erogeneity for
each high-level unit, to correct for bias in significant
testing induced by data clustering (Raudenbush & Bryk,
2002). Thus, HLM models are extremely useful in testing
hypotheses about multilevel influences of study variables
on the outcome variable, or testing hypotheses regarding
the multilevel influences of indi vidual and group
characteristics on change trajectories of an outcome. For
instance, to model the change of students' ou tcome over
time, an analyst may employ a 3- level hierarchical modeL
At Level 1, each student' s change is represented by an
individual growth trajectory based on a unique set of
predictors (that is, mean at baseline, linear or curvilinear
terms measuring rate of change, and time- varying
covariates). These individual growth parameters then
become a set of outcome variables in a Level 2 model that
are regressed on time-fixed individual characteristics. The
Level 2 parameters (that is, impacts of individual
characteristics) become a set of outcome variables in the
Level 3 model, which exam ines the interaction of
classroom characteristics and individual characteristics.
HLM has several advantages in the analysis of
longitudinal data. First, responses on any ou tcome
variable from the same individual over time will be
correlated, which violates the assumption of independent
observations embedded in most statis tical models dealing
with cross-sectional data, How ever, HLM accounts for
this correlation. Second, when applying conventional
linear models to longitu dinal data, analysts generally
underestimate the standard errors of the impacts, and may
erroneously assume statistical significance. HLM not only
effectively handles this problem but also others inherent i n
longitudinal data, such as time- varying predictors,
unequal groups at data points over time, and the need to
control for the effects of potentially confounding
independent variables (Diggle, Liang, & Zeger, 1994;
Lindsey, 1993; Raudenbush & Bryk, 2002). Social work
research often involves grouped data (for example, sibling
groups, mother-child dyads, neighborhoods) and
longitudinal data; therefore, it is important to use HLM to
perform rigorous tests of research hypotheses (Guo,
2005).
Multiple regression models for categorical and limited
dependent variables are designed to analyze dependent
variables that are binary, multicategorical, ordinal,
counted, censored, or from truncated populations (Long,
1997). A fundamental difference of these m odels from
OLS regression is that they are nonlinear. Typically, in
such models, researchers use a link func tion to transform
the original dependent variable.

Although the dependent variable is not a linear function of
independent variables, the transformed variable through the
link function is. For this reason, such models are also known as
generalized linear models. Depending on the distribution of the
original dependent variable, the analyst may choose different
link functions. Hence, there are six models defined by the type
of dependent variable and the nature of link function: (a) binary
logit and probit models; (b) multinomial logit and probit
models; (c) ordered logit and probit models; (d) negative
binomial and Poisson models; (e) tobit model; and, (f)
truncated modeL Categorical and limited dependent variables
are common in social work research because outcome variables
are typically binary (for example, presence or absence), ordinal
(for' example, disagree, neutral, or agree), mulncategorical (for
example, multiple reasons for exiting from foster care:
reunification, adoption, guardianship), and counted (for
example, number of times using services). A review of social
work applications of these models from 1990 through 1999
shows the importance of (a) recognizing the nonlinear nature of
models to interpret a nonlinear regression coefficient with
caution; (b) understanding the difference between the
maximum likelihood approach and OLS approach to use
appropriate sample size; (c) understanding statistics analogous
to F tests (for example, Wald, likelihood ratio, and Lagrange
multiplier tests) to perform significance testing promptly; and
(d) understanding pseudo R-square measures anddebates
concerning their merit (Orme & Buehler, 2001).
Propensity score matching (PSM) is an approach to
controlling for selection bias. When experimental designs are
infeasible, researchers must rely on observa-
c
tional data to discern differential impacts of social ser-
vices on treated and untreated clients. More generally, when
assignment to conditions is nonrandom, analyses of services
data require special procedures to correct biased selection into
conditions, and to obtain an accurate estimation of
counterfactuals (that is, outcomes that would have been
observed for participants had they not participated). The PSM
approach is essentially a two-stage analysis that includes (a)
the creation of a matched sample using logistic regression and
matching procedures (such as nearest-neighbor matching
within caliper, Mahalanobis metric matching, or other ap-
proaches), and (b) a follow-up multivariate analysis based, on
the matched sample (Rosenbaum & Rubin, 1983). Recently,
economists have developed propensity score analysis using
nonparametric regression (that is, kernel or local linear
matching) that analyzes pre- and post-intervention data
(Heckman, Ichimura, & Todd, 1997), and matching estimators
that impute the miss-ingcounterfactual by using average
outcome for
QUANTITATIVE REsEARCH 495
individuals with "similar" values on observed covariates
(Abadie, Drukker, Herr, & Imbens, 2004). Increasingly, the
PSM approach has been applied in social work evaluations,
particularly in studies using observational data to assess
service effectiveness (Guo, Barth, & Gibbons, 2006).
Structural equation modeling (SEM, that is, covariance
structure analysis, or analysis of moment structures) is a class of
methodologies that seeks to represent hypotheses about the
means, variances, and covariances of observed data in terms of
a' smaller number of "struc- " tural" parameters defined by a
hypothesized underlying model (Kaplan, 2000). The classical
SEMs assume continuous latent-variables, multivariate
normality of observed data, and independence of study
observations. -In conducting SEM analysis, researchers use the
observed variance-covariance data to estimate parameters
implied by a theoretical model. The level of equality between a
population variance-covariance matrix and the model-implied
variance-covariance matrix serves as a fundamental hypothesis
of SEM, which is key to understanding issues of identification,
estimation, and goodness-of-fit of the estimated model (Bollen,
1989). Path analysis with observed variables, confirmatory fac-
tor analysis, and the general SEM with latent variables, are types
of SEMs. Recent advances extended the conventional SEM to
models that allow categorical latentvariables, such as latent class
analysis (that is, mixture modeling) and factor mixture analysis
(Muthen & Muthen, 2006).
REFERENCES
Abadie, A., Drukker, D., Herr,]. L., & Imbens, G.W. (2004).
Implementing matching estimator for average treatment
effects in Stata. The Stasa loumal, 4(3),290-311.
Allison, P. D. (1995). Survival analysis using the SAS system.
Cary, NC: SAS Institute.
Bollen, K. A. (1989). Structural equations with latent variables.
New York: Wiley.
Cochran, W. G. (1977). Sampling techniques (3rd ed.). New York:
Wiley.
Cohen, j. (1988). Statistical power analysis for the behavioural
sciences. New York: Academic Press.
Cronbach, L. j., Gieser, G. C, Nanda, H., & Rajaratnam, N. (1972).
The dependability of behavioral measurements: Theory of
generalizability of scores and profiles. New York: Wiley.
Diggle, P. L., Liang, K-Y., & Zeger, S. (1994). Analysis of
longitudinal data. New York: Oxford University Press.
Gambrill, E. D. (2003). Evidence-based practice: Implications for
knowledge development and use in social work. In A. Rosen
& E. K. Proctor (Eds.), Developing practice guidelines for social
work intervention: Issues, methods, and research agenda (pp.
37-58). New York: Columbia University Press.
Grinnell, R. M. jr. (1997). Social work research and evaluation (5th
ed.). Itasca, IL: F.E. Peacock.
496 QuANTITATIVE REsEARCH
Guo, S. (2005). Analyzing grouped data with hierarchical
linear modeling. Children and Youth Services Review, 27,
637-652.
Guo, S., Barth, R., & Gibbons, C. (2006).' Propensity score
matching strategies for evaluating substance abuse services
for child welfare clients. Children and Youth Services Review,
28,357-383.
Guo, S., & Hussey, D. L. (2004). Nonprobability sampling in
social work research: Dilemmas, consequences, and strat-
egies.Journal of Social Service Research, 30(3), 1-18.
Guo, S., & Wells, K. (2003). Research on timing of foster care
outcomes: One methodological problem and approaches to
its solution. Social Service Review, 77(1), 1-24.
Heckman, J. J., lchimura, H., & Todd, P. E. (1997). Matching as an
econometric evaluation estimator: Evidence from evaluating a
job training programme. Review of Economic
Studies, 64, 605-654. ' Social Work Research, 25, 49-61.
Hunter, J. E., & Schmidt, F. L. (2004). Methods of meta-analysis:
Correcting error and bias in research findings. Newbury Park,
CA: Sage.
.Kaplan, D. (2000). Structural equation modeling: Foundations .
andextensions. Thousand Oaks, CA: Sage.
Kennedy, P. (2003). A guide to econometrics (5th ed.). Cambridge,
MA: The MIT Press.
Kiess; H. O. (2002). Statistical concepts for the behavioral sciences
(3rd ed.). Boston, MA: Allyn and Bacon.
Lin, D. (1994). Cox regression analysis of multivariate failure
time data: The marginal approach. Statistics in Medicine, 13,
2233-2247.
Lindsey, J. K. (1993). Models for repeated measures. New York:
Oxford University Press.
Little, R. J. A., & Rubin, D. B. (2002). Statistical analysis with
missing data (2nd ed.). New York: Wiley.
Long, J. S. (1997). Regr~sion models for categorical and limited
dependent variables. Thousand Oaks, CA: Sage.
Lord, F. M. (1980). Applications of item response theory to practical
testing problems. Hillsdale, NJ: Lawrence Erlbaum.
Marlow, C. (1993). Research methods. Pacific Grove, CA:
Brooks/Cole.
Muthen, L. K., & Muthen, B. O. (2006). Mplus user's guide (4th
ed.). Los Angeles, CA: Muthen & Muthen.
Neter, J., Kutner, M. H., Nachtsheim, C. J., & Wasserman, W.
(1996). Applied linear regression models (3rd ed.). Chicago, IL:
Irwin.
Nugent, W. R., Sieppert, J. D., & Hudson, W. W. (2001).
Practice evaluation for the 21st century. Belmont, CA: Brooks/
Cole.
Orme, J., & Buehler, C. (200l). Introduction to multiple
regression for categorical and limited dependent variables.
Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchica1linear
models: Applications and data analysis methods (2nd ed.).
Thousand Oaks, CA: Sage.
Rosenbaum, P. R., & Rubin, 0. B. (1983). The central role of the
propensity score in observational studies for causal effects. Bio-
metrika, 70, 41-55.
Rubin, A, & Babbie, E. R. (2001). Research methods for social work.
Belmont, CA: Wadsworth{fhomson.
Shad ish, W. R., Cook, T. D., & Campbell, D. T. (2002).
Experimental and quasi-experimental designs for generalized causal
inference. New York: Houghton Mifflin.
Thompson, B. (2004). Exploratory and confirmatory factor analysis.
Washington, DC: American Psychological Association.
-SHENyANG
Guo
 RADICAL SOCIAL WORK. See Progressive Social
Work.,
RAPE. See Child Abuse and Neglect; Sexual
Assault.
RECORDING
ABSTRACT: Social workers keep records to
demonstrate accountability to their agencies, clients,
communities, and profession. They also record to
enhance practice and support a variety of
administrative functions. This entry describes the
history of recordkeeping in social work, and
identifies important contributions to its devel-
opment. The author discusses current issues related
to computerization, wide access to sensitive
personal information in records, and privacy
legislation. The entry also outlines the
characteristics of good records, those that meet the
complex
KEY WORDS: demands of contemporary
accountability; privacy;practice.
computerization; HIP AA; social work practice;
agency management
Why record? Social workers keep records to demon,
strate accountability to their agencies, communities,
clients, and profession. Accountability involves de'
scribing and assessing the client, situation and the need
for services, and explaining and evaluating all service
decisions, actions, processes, and outcomes. Being
accountable means demonstrating compliance (or pro'
viding a rationale for failing to comply) with agency
policies, legal standards, practice guidelines, and
professional ethics and values.
Accountability is the most important, but not the
only, reason social workers keep records. Social
workers record to enhance practice and support
administrative functions. Recording encourages
practitioners to be systematic in their thinking and
writing. It involves monitoring and reflecting upon the
client-situation and the service transaction at regular
intervals, from intake through termination and
follow-up. Records promote continuity of service and
communication among practitioners. Information from
records is used in managing the agency and claiming
reimbursement
497
J
for services. They serve as a resource in professional
development, supervision, and consultation, and in
accreditation and other reviews. Records can be used in
oversight and to improve servicesat the case, case, load,
and program levels. Finally, records may be introduced
as evidence in court, in cases where client confidentiality
and testimonial privilege are waived. Recordkeeping is
an important practice, skill that in, volves complex
professional judgments. In every record, social workers
must balance the need to be accountable with their
responsibility for protecting client privacy. They must
weigh the value of enhancing practice and meeting
administrative requirements against the need to be
efficient ~nd use limited resources economically. For
many practitioners and agencies, records are an ongoing
problem. The demand for accountability continues to
grow, but the time, resources, and personnel required to
prepare and manage records have not kept pace (Kagle &
Kopels, 2008).
The history of recording in social work parallels the
history of social work practice. As practice developed
and changed, so too did social work records. Records not
only reflected but also contributed to the develop, ment
of important practice theories and policy initiatives. For
example, Richmond based her seminal studies of social
work practice, including Social diagnosis (1917), on her
analysis of agency records. Fanshel's studies of child
welfare records (1977) led to substantial changes in foster
care practice and policy. Before 1900, records were in fact
ledgers where charity workers inscribed the name of the
recipient, the "facts" of the case, and what "relief' was
given. By 1920, with the advent of social casework and
training for practice, records included not just the "facts,"
but also the worker's judgment about the "client's prospects
for successful citizenship" (Sheffield, 1920). Books on
recording by Bristol (1936) and Hamilton (1936) helped to
shift the record's focus to individualizing the client,
understanding the service process, and developing
diagnostic judgment. More recently, the focus has shifted
to accountability.
Weed (1968) originally developed the Problem-
Oriented Medical Record to train medical students to
identify and respond to health problems. The P,OMR has
been widely adopted as an integrative approach to re-
cordkeeping in multidisciplinary health and mental
health agencies. Kiresuk and Sherman (1968) developed
Goal Attainment Scaling to gauge program
effectiveness.
· 498 RECORDING
This approach continues to influence recordkeeping, as
practitioners and agencies develop tools for documenting,
monitoring, and evaluating service progress and outcomes.
Wilson (1978) offered guidance in using process recording in
social work education. Kagle (1996) developed the
Service-Centered Record to assist practitioners in balancing
accountability, client privacy, and efficiency. This approach
focuses the content of the record on describing, monitoring,
and providing the rationale for service decisions and actions.
Current Issues and Trends for the Future Today, three
interrelated factors are changing how records are compiled,
managed, and .used. First, practitioners and agencies
increasingly rely on computers to prepare, store, manage,· and
retrieve information. Although few agencies and practitioners
have entirely replaced paper records, most use computers to
create documents, fill out forms, and file reports. In the near
future, many agencies will completely automate their records,
and practitioners will use computers and other technologies
for virtually all recordkeeping tasks.
Second, information from records has become widely
accessible inside and outside the agency. Because records play
a crucial role in securing authorization for services,
demonstrating compliance with practice guidelines and
seeking reimbursement for services rendered under managed
care and other financing arrangements, sensitive personal
information is routinely available to agency personnel and
oversight agencies. Despite myriad efforts to protect client
privacy, legitimate concerns about the security of paper and
computerized records and about unauthorized or inadvertent
releases of information remain.
Third, social workers and their agencies are working to
comply with a variety of complex, overlapping, and
sometimes contradictory state and federal laws that set
standards for managing personal information and client
records. The most important of these is the federal Privacy
Rule under the Health Insurance Portability and
Accountability Act (HIPAA, 2003). HIPAA applies to any
practitioner or agency that transfers information electronically
and serves clients with health or m~ntal health problems.
HIPAA limits the disclosure of certain information, such ~s
health status and psychotherapy notes, and requires numerous
administrative, physical, and technical safeguards. However,
HIPAA permits disclosures to some businesses and other
entities that do not offer similar protections, thus raising
important legal and ethical concerns. HIP AA has also been
criticized for its complex legalities, added costs for
management and training, and restrictions that affect
communication and research.
In the past, social workers disagreed about the content and
focus of records. Should they focus on understanding the
client-situation, describing the service process and
worker-client relationship, monitoring service goals and
outcomes, or meeting administrative guidelines ? Today, there
is general agreement that records should:
• focus on service delivery, documenting the overall
purpose of service; service goals, plans, decisions, and
actions; and indicators of progress, impact, and
outcome.
• include thorough, fair, and unbiased assessments of the
client-situation and the service process.
• be limited to information about the clientsituation
necessary to understand the 'need, purpose, goals,
impact, and outcomes of service.
• document the client's role in service process, including
decision-making and action-taking.
• identify cultural issues that may influence problems,
needs; resources, .services, or outcomes.
• be written as if the client and a wide range of other
interested parties may have access to their contents.
• be well-written, well-organized, and up-to-date (Kagle
& Kopels, 2008).
REFERENCES
Bristol, M. C. (1936). Handbook on social case recording.
Chicago: University of Chicago Press.
Fanshel, D. (1977). Parental visiting of foster children:
A computerized study. Social Work Research and Abstracts,
13(3),2-10.
Hamilton, G. (1936). Social case recording. New York: Columbia
University Press.
Health Insurance Portability and Accountability Act of 1996
(HIPAA). (2003, April). 104-191; Privacy Rule. Retrieved
October 18, 2006, from www.hhs.gov/ocr/hipaa
Kagle, J. D. (1996). Social work records (2nd ed.). Prospect
Heights, IL: W aveland P~ess.
Kagle, J. D., & Kopels, S. (2008). Social work records (3rd ed).
Prospect Heights, IL: Waveland Press.
Kiresuk, T. J., & Sherman, R. E. (1968).
Goal-attainment scaling: A general method
for evaluating comprehensive mental health
programs. Community Mental Health Journal, 4,443-453.
Richmond, M. E. (1917). Social diagnosis. New York: Russell
Sage.
Sheffield, A. E. (1920). The social case history: Its construction and
content. New York: Russell Sage.
Weed, L. L. (1968). Medical records, medical evaluation and p~tient
care. Cleveland: Case Western Reserve University Press.
Wilson, S. J. (1978). Recording-Guidelines for social'workers.
New York: Free Press.
-JILL DONER KAGLE
I
j
j

REFORM. See Health Care Reform.
REFUGEES. See Displaced People; Immigrants and
Refugees; Immigration Policy.
REGULATION. See Licensing.
REHABILITATION
ABSTRACT: Rehabilitation is a complex, multi-
dimensional approach within health care that uses an
interdisciplinary model of specialized services. The
comprehensive treatment team generally includes
medical specialists and therapists who specialize in
physical therapy, occupational therapy, speech
therapy, cognitive t herapy, psychology, and
recreational therapy. Social workers playa key role
in the treatment team, particularly in care
coordination, discharge planning, and community
reintegration. Trends in comprehensive medical
rehabilitation will continue to be signi ficantly
influenced by forces within the larger health- care
arena. Technological advancements and the social
trend toward health and fitness offer great promise
for the improvement and expansion of rehabilitation
services.
l,(EY WORDS: Disablement theory; treatment;
comprehensive rehabilitation; levels of
rehabilitation; best practices; postrehabilitation
planning
A confluence of factors within the last century, such as
improved medicine, higher standards of living, and better
hygienic practices, has given rise to reduced infant mor-
tality rates and longer life spans. The more recent trend of
lower birth rates in the United States and other modem
industrialized countries, coupled with more people living
longer, has shifted the demographics of the population
toward a much higher proportion of older adults.
As our society increasingly ages and medicine
advances to help more individuals survive injury and
disease, health care must continue to shift and expand to
meet their needs. Currently, more than 75% oftotal
health-care spending is devoted to chronic diseases such as
cardiovascular disease (for example, heart disease and
stroke), cancer, and diabetes (Roland & Scheiber, 1996).
Diabetes and arthritis affect millions each year, who
experience a long course of pain, disability, and decreased
quality of life. Indeed, one of every 10
REHABILITATION 499
Americans report significant limitations in activity or
disabilities resulting from chronic diseases (Center for
Disease Control [CDC], 1994). Better survival rates from
catastrophic injuries such as traumatic brain injury or
spinal cord injuries are also associated with significant
increases in individuals living with a disability. Overall
prevalence estimates of disability vary between 5.2% and
18.2% of adults in the United States (Dejong et al., 2002).
With such large numbers of people coping with the . loss of
function following disease and injury, the demand for
rehabilitation services has grown.
The term rehabilitation has a multitude of meanings and
is used in a wide variety of contexts. For the purposes of
this discussion, rehabilitation is defined as the process of
restoring function and skills lost to injury or disease.
Originating from the Latin word rehabilitare, which means
to make fit again, the purpose of rehabilitation in a
health-care setting is ultimately to help an individual regain
as close to normal function as possible. The general model
of rehabilitation includes a comprehensive array of
specialized services delivered by a team of professionals,
including physiatrists (physical medicine doctors
specialized in rehabilitation), physical therapists,
occupational therapists, speech therapists, and other
specialists trained to help remediate cognitive and physical
deficits. Social workers and psychologists are also central
to a comprehensive rehabilitation team.
History
The genesis of rehabilitation began before World War I
with a group of physicians who used a series of techniques
involving electrical stimulation, massage, physical
exercise, hydrotherapy, and heat to treat injuries (Gritzer &
Arluke, 1985). Their innovative approach gained
prominence through their treatment of returning soldiers
during the war.
Following the war, rehabilitation and physiatry re-
ceived very little attention until the demand for their unique
treatments reemerged with the advent of World War II. In
1946, Dr. Howard Rusk pioneered the formal development
of physiatry as a specialty within physical medicine and
instituted a formal training program for physicians in
rehabilitation methodologies. In the context of treating
injured veterans in an air force hospital, he and his
colleagues promoted a major shift in treatment from the
traditional emphasis on rest during convalescence to active
reconditioning. Dr. Rusk further laid the foundation for the
principal objectives of modem rehabilitation practice: to
restore health and normal functioning when possible, to
alleviate disability to the greatest degree possible, and to
retrain and provide adaptive strategies for maximum
self-sufficiency.

500 REHABILITATION
Not unlike the developmental inspiration behind
physiatry, the origins of physical therapy emerged in treating
combat injuries. In addition, the poliomyelitis epidemic
from the 1920s to 1950s generated treatment techniques by
orthopedic assistants who later came to call themselves
physiotherapy aides (Moffat, 2003). In 1936, the American
Medical Association began accrediting physiotherapy
schools and heralded the transition of the physical therapist
from a medical technician to a professional practitioner. By
the 1980s, the field of physical therapy gained greater
autonomy and prominence' by severing ties with the
American Medical Association, accrediting their own
schools and practicing independently. More recently, the
expansion, of rehabilitation programs and the public's
greater emphasis on physical conditioning have generated ~
greater demand for physical therapists above any other
health professionals.
The roots of occupational therapy (OT) stem from the
field of mental health where its techniques were aimed at
minimizing the use of physical restraints among psychiatric
patients (Friedland, 2003). The settlement house
movement's emphasis on life skills to promote health and
well-being also significantly influenced the development
ofOT as a specialty. Although the profession was
challenged by the public perception that it merely provided
helpful distractions for patients, two factors helped the field
establish itself as a truly therapeuticintervention: (a)
physiatrists began to actively engage OTs in transitioning
patients from physical therapy to vocational rehabilitation,
and (b) the field developed greater expertise in cognitive
and sensory retraining. The Federal Medicare Regulation in
1987, which mandated physical and occupational therapy
for 3 hours daily and allowed OTs to bill separately for their
services, also helped solidify the discipline.
Theoretical Models
Theoretical underpinnings of medical rehabilitation de rive
from two primary sources: disablement theory and
treatment theory (Keith & Arnow, 2005). A basic under-
standing of these theories helps elucidate the rationale
driving the practice of rehabilitation and offers a platform to
guide future research and development in the field.
DISABLEMENT THEORY Disablement theory focuses on
the effects of injury and disease, using the following
concepts:
• Impairment involves loss of function at the organ
level (for example, spinal cord injury and the loss of
leg function).
• Disability refers to the inability to perform mean-
ingful tasks due to injury (for example, inability to
walk).
I
• Handicap refers to deficits associated with social role
functioning (for example, difficulty finding or
maintaining employment due' to social stigma
surrounding disability).
The original theory was advanced by the World Health
Organization (WHO) and integrated into its taxonomy of
impairment, disability, and handicaps. To date, the
theoretical paradigm of disablement has been highly
influential in shaping clinical practice, public policy, and
research.
In response to feedback from practitioners, research ers,
and advocates since the mid-1990s, WHO revised their
classification system to include a broader focus on health
for the entire population, abandoning its prior exclusive
focus on persons with disabilities. The revised
classification system, known as the International Clas-
sification of Functioning, Disability, and Health, also
adopted the following changes:
• The concept of impairment expanded to include
problems in body structure or function.
•The term handicap was eliminated and replaced by
participation, which encompasses involvement in life
situations. Health status, body function and , structure,
activities, and social and environmental factors are all
examined in association with an individual's
participation level.
• Contextual factors, referring to both environmental
and personal factors, were also added.
TREATMENT THEORY The basic assumption of this
theory contends that exposure to treatment is directly
related to clinical outcomes, such that more treatment
results in greater improvements (Granger & Hamilton,
1992). Although rehabilitation has generally pr acticed
under this assumption, the theory has largely remained
untested. In fact, its validity has been called into question
by managed care data that fail to demonstrate poorer
patient outcomes despite significantly reduced lengths of
stays (Keith, 1997). For example, between 1990 and 1999
lengths of stay dropped precipitously from an aver age of
28 days to 16 days, yet average functional improve ment
scores revealed very little change (Deutsch,Fiedler,
Granger, & Russell, 2002). Many credit improvements i n
the quality of treatment and therapeutic innovation with
maintaining positive outcomes, but this assumption also
lacks empirical evidence.
Comprehensive Rehabilitation Rehabilitation
is a complex, multidimensional approach within health
care that varies widely in the delivery of its services and in
the patients it serves. There is 'a unifying approach taken
by the field, however, which accepts

that an interdisciplinary model of specialized services is
essential to restore the health and optimal functioning of
individuals coping with disease or injury.
POPULA TIONS SERVED Detailed information on the
demographics of patients who receive rehabilit ation
services has only recently been systematically
collected. The Uniform Data System for Medical
Rehabilitation, the largest common dataset for the
rehabilitation industry, reported demographic data on
300,000 patients served by almost 700 rehabilitati on
facilities (Deutsch et al., 2002). Among the broad
range of conditions treated, such as strokes, traumatic
brain injuries, spinal cord injuries, orthopedic
disorders, .and neuromuscular diseases, the highest
percentage of admissions (just under a third of all
patients) :Was for orthopedic disorders. Strokes
represent the second highest rate of admissions, 23%
overall.
More comprehensive and detailed utilization and
outcome data are currently being collected using an
inpatient rehabilitation and outcomes system called
eRehabData. The American Medical Rehabilitation
Providers Association developed the system using the
Medicare Inpatient Rehabilitation Facilities - Patient
Assessment Instrument. As of 2002, complete data on
more than 117,000 patients have been collected (Keith &
Arnow, 2005).
LEVELS OF REHABILITATION CARE
Inpatient Acute Licensed Rehabilitation Pro-
grams. Inpatient rehabilitation is provided within (a)
specialized units of acute care hospitals; (b) inde-
pendent, specialized rehabilitation hospitals; and (c)
hospitals affiliated with larger health-care systems.
In the past decade of consolidation in health care,
larger health-care systems own and operate an
increasing proportion of rehabilitation hospitals and
units (Keith & Arnow, 2005).
Acute care hospitals are the primary referral source
for rehabilitation hospitals. Patients admitted to these
facilities typically require intensive medical
management and are often severely impaired. Staffing
to meet the needs of these patients, therefore, requires a
full cadre of medical and rehabilitation professionals.
Acute inpatient rehabilitation programs typically
employ more comprehensive and rigorous treatment
protocols than do other rehabilitation settings. They also
place comparatively greater emotional and physical
demands on patients.
Inpatient Skilled Licensed Rehabilitation Pro-
grams. Skilled nursing facilities 'also operate from a
variety of institutional settings: (a) units within acute
medical and surgical hospitals; (b) independent,
specialized rehabilitation hospitals; (c) long-term
care
REHABILITATION 501
facilities; and (d) independent, skilled rehabilitation
hospitals. Compared to acute rehabilitation programs,
there is a less intense need for medical supervision and
staffing. Most skilled nursing facilities serve patients
who need a longer period of recuperation, are generally
older, and may be unable to tolerate the rigors of acute
rehabilitation treatment. It is important to note that a
subgroup of skilled nursing facilities specializes in coma
stimulation/recovery and ventilator-dependent care.
Comprehensive Day Treatment Programs. Com-
prehensive day rehabilitation programs are designed to
prevent long-term institutionalization among indivi-
duals who are not impaired enough to require overnight
care, . but who cannot function independently enough tb
meet their daily needs. Most day treatment programs
are designed for behavioral health treatment (that is,
mental health and substance abuse treatment), but a
substantial subset targets individuals with cognitive and
physical disabilities. Programs are crafted around two
distinct missions: (a) to provide therapeutic services
with the goal of increased independence in the com-
munity and (b) to maintain functional abilities using a
more long-term model of care. Day treatment programs
for persons recovering from traumatic brain injury are a
classic example of a program geared toward increased
independence.
Outpatient Rehabilitation. Programs. Similar to
its inpatient counterparts, outpatient rehabilitation
care operates from a wide array of settings. The
Centers for Medicare and Medicaid Services (2002)
reported that more than 500 licensed comprehensive
outpatient rehabilitation facilities were fully
operational in 2000. Outpatient therapy is also
offered through such diverse sources as doctors'
offices, hospital outpatient departments, outpatient
therapy clinics, and industrial and occupational
health clinics. Children are more frequently served
by outpatient rehabilitation because financial pay-
ment sources prefer more ecologically appropriate
settings for youth.
Outpatient rehabilitation programs vary in the
intensity of their services, ranging from 5 days a week to
occasional visits and between 1 and 6 hours per treat-
mentday. These programs offer many advantages,
including access to rehabilitation equipment,
soclahzation, peer support, and interdisciplinary
treatment while living in a home-based setting.
Beyond the traditional outpatient rehabilitation
settings reimbursed through Medicare, Medicaid, and
private insurance, the industry has expanded to target
out-of-pocket payers. Services are now available
through community centers, sports and fitness facilities,
and even therapeutic spas and resorts. Demographic
trends in concert with a growing awareness of the need
502 REHABILITATION
for an active, healthy lifestyle suggest that nontradi tional,
self-payer models for outpatient services are likely to
increase.
Residential Rehabilitation Programs. For those with
life-long or chronic conditions, residential rehabilitation offers
therapeutic services over a longer period of time. The
residential model of services spans from transitioning patients
from acute inpatient rehabilitation to a more independent
community setting, offering long-term semi-independent
living situations, to providing restorative care for
persons.-coping 'with the 'evolving challenges of aging with a
disability.
Home and Community Programs. The home and
community setting marks the final level of care in the
rehabilitation spectrum of services. By design, most
programs are structured for \ medically stable patients who
are likely to benefit from occasional physical therapy,
occupational therapy, or skilled nursing services. Similar
to health-care programs overall, however, the gradual
aging of the population has stimulated the growth and
expansion of locally delivered rehabilitation. Some home
health agencies have begun to deliver 24-hr care coverage
with physician monitoring and a full scope of nursing,
physical therapy, occupational therapy, speech the rapy,
medical social services, mental health, and personal care
services (National Institute of Health [NIH], 2007). This
complete program package is most commonly geared
toward elderly patients recovering from an acute
hospitalization for joint replaceme nt surgery, stroke, or
other medical conditions.
The advantages of home care programs are intuitively
obvious, but their purported benefits and costeffectiveness
still lack empirical support. Providers and policymakers
nonetheless acknowledge the utilit y of providing
rehabilitation in the same environment where newly
restored functional skills and adaptive techniques will be
used. For special populations such as children or those who
experienced traumatic brain injuries, the familiarity of
home environment may be especially conducive to
rehabilitation.
Alternatively, the possible disadvantages of home based
rehabilitation should not be overlooked. Specia lists note
concerns over the limited, or sometimes lack of, medical
supervision in home-based care and less access to physical
equipment more readily available in inpatient or outpatient
facilities. Other problems include the increased burden on
caregivers and less peer and social support from other
patients. The balance of these concerns, along with the
distinct benefits of home-based programs, has led many in
the industry to recommend a combination of outpatient and
homebased rehabilitation for some patients.
BEST PRACTICES IN REHABILITATION SERVICES
Given both the breadth of disorders addressed by reha-
bilitation professionals and the variety of settings from
which services are delivered, programmatic
operations sometimes vary among programs. The
distinct role of rehabilitation within health care,
however, has led to common processes in the
provision of treatment.
Referral and Screening. Best practice dictates that
screening for possible rehabilitation should be conducted as
soon as a patient's neurological or medical conditien ~its
(NIH, 2006). The initial assessment of a patient's
appropriateness for rehabilitation care is conducted prior to
admission, often by referral sources. Referral sources include
acute hospitals, long-term care facilities, other acute care
services, Veterans Administration hospitals, and patients'
families. These sources are uneven in their ability to (a)
accurately identify patients who need rehabilitation (for
example, screening out patients who have completely
recovered or who have disabilities so severe that they could
not benefit from certain rehabilitation interventions); (b)
correctly determine when a patient's health condition is
optimal for referral (for example, waiting until a patient's
health status improves to a point that enables them to benefit
from rehabilitation, but early enough to maximize func-
tionaloutcornes): and (c) appropriately match patients to the
most optimal rehabilitation settings (considering patient
function, program intensity, level of care; proximityto family,
friends, and community resources; and personal, cultural, and
economic factors (O'Donnell & Hamilton, 1997). Given the
importance of accurate screening to quality of care and fiscal
management, the rehabilitation industry has invested heavily
in ongoing education and outreach to their referral sources.
Effective screening is a critical and complex process
that is ideally conducted by medically trained profes-
sionals with advanced knowledge of rehabilitation. The
screening process, like all facets of rehabilitation, should
be sensitive to the unique needs of patients and their
families. Use of standardized screening tools tailored to
various conditions (for example, TBI, stroke) can enhance
the accuracy of referrals. Also, while it is im portant for the
rehabilitation industry to be financially prudent in its
allocation of resources, ethics dictate that screening err on
the side of identifying all those who could potentially
benefit from rehabilitation. Follow-up assessments within
the rehabilitation setting serve to monitor the
appropriateness of an individual for comprehensive
medical rehabilitation.
Diagnosis and Assessment. In rehabilitation, diagnosis is
primarily focused on functional capacity and potential targets
for treatment. Key foci of assessment include the following:

• Neurological deficits
• Physical, emotional, cognitive, and language
expression and processing difficulties
• Medical problems
• Potential impediments to functional indepen-
denceand living in the community
Quality of care and accountability requirements of
managed care demand thorough documentation of
assessments throughout the process of rehabilitation. The
tools necessary for comprehensive assessment include
repeated clinical examinations and standardized
instruments. As with any assessment protocol in health
care, measures should be valid, reliable, and sensitive to
the appropriate phase of an individual's rehabilitation. In
assessing the prospect' of community integration,
evaluation includes living environment, family func-
tioning, and social support.
The physiatrist is generally the rehabilitation team lead
in determining diagnosis and treatment priorities. All
members of the multidisciplinary treatment team,
however, contribute to ongoing assessments of deficits and
formulation of plans of care.
Interdisciplinary Team Treatment. Rehabilitation was
unique in its multidisciplinary approach to health care for
several decades. Meta-analytic studies support the superiority
of a coordinated interdisciplinary model of treatment over
general medical care, but there is a scarcity of long-term.
outcome data (Teasel, Foley, Bhogal, & Speechley, 2003). In
spite of the limitations to its evidence-base, most health-care
disciplines have embraced the interdisciplinary model as a
guiding principle for treatment.
The comprehensive treatment team is generally com-
posed of medical specialists, including phvsiatry, physical
medicine, neurology, orthopedics, internal medicine, ger-
iatrics, psychiatry, and family practice. Depending on the
conditions, other specialists may be consulted or incorpo-
rated into the care team. Therapists on the team specia lize
in physical therapy, occupational therapy, speech therapy,
cognitive therapy, psychology, neuropsychology, and
recreational therapy. Social workers playa key role in the
treatment team, particularly in care coordination, discharge
planning, and community reintegration.
Although still the prevailing model in acute inpati ent
rehabilitation, more recently, the interdisciplinary team has
been somewhat modified to contain costs. In skilled
rehabilitation care and in-horne services, for example, the
formal team may represent only a few key specialists who l
consult with other disciplines on an as-needed basis.
Outpatient rehabilitation also increasingly uses a modified
approach, sometimes utiliz ing only one or two types of
specialists.
REHABILITATION 503
Documentation, Progress Monitoring, and Com-
munication. The multidisciplinary treatment team's
effectiveness is contingent on complete and timely
communication. Aside from informal verbal updates among
the treatment team, the primary, formal vehicle of
communication is the team conference. The frequency of team
meetings varies by the phase and associated intensity of the
rehabilitation process. For example, weekly meetings are
typical in the acute setting and follow a general process in
which each member reports on treatment and progress in
relation to the goals of the care plan. All information is
factored into the evaluation of a patient's potential for progress
and treatment plan modifications. The patient and family
members are often included in the meetings to engage them
fully in treatment decisions and postrehabilitation planning.
Beyond team meetings, written documentation is
central to quality patient care and to the fiscal survival of
rehabilitation providers. Detailed documentation of the
treatments provided and patient progress in relationship to
functional goals is a critically important clinical
management tool among rehabilitation providers. Such
paperwork alerts team members to necessary changes to
service regimens and guides after-care planning. Third
party payers and accreditation bodies have placed
additional demands on providers to record data justifying
treatment interventions and to document progress in
duplicate formats, often reducing the time allocated for
direct clinical care.
Discharge Planning. Although it is frequently difficult to
anticipate a patient's functional outcomes at the outset of a
rehabilitation program, some level of discharge planning
should ideally begin on the first day of services. More detailed
and focused planning should be initiated in response to the
achievement of treatment goals or when patients stagnate in
their clinical progress. The patients and their families are an
integral part of after-care planning, and as such, should be
engaged throughout the process.
Discharge options include ongoing rehabilitation in a
different setting, long-term care facilities, family care, or
alternative placement in the community. Given the trend
toward shorter lengths of stay in rehabilitation, there is a
growing need to address ongoing medical care, the
continuance of rehabilitation services in alter native
settings, and the provision of comprehensive support
services.
Social Work Roles
In keeping with the long tradition of medical social work,
social workers playa vital role in the multidisciplinary care
model of rehabilitation. More specifically, social
504 REHABILITATION

work professionals in the rehabilitation arena conduct the of care planning, insurance contracts, and benefits and
following: reimbursement have all come under the social worker's
• Psychosocial assessments purview (Chachkes, 2005).
• Psychosocial counseling Psychosocial health education serves as a means of
• Discharge planning offering patients and families some control and realistic
• Case management understanding of the challenges and options. involved in
• Psychosocial health education the rehabilitation process. The social work practi tioner
aims to help patients actively i ntegrate their diagnosis, plan
Their function has also expanded to managed care activ ities of care, anticipated outcomes, and needs into
such as reducing unnecessarily long lengths of stay and problem-solving and long-term planning. Often the
monitoring appropriate use of health-care resources. emotional turmoil associated with injury and disease leads
Social workers in rehabilitation center their energies on to a patient's sense of dependency and disernpo werment. A
supporting patients and their families in understand ing and social worker's educational interventions can help restore
coping with the significant stress and sense of loss or enhance an individual's sense of control and facilitate
associated with disease and disability. Their first task is active engagement in the rehabilitation (Boehm & Staples,
typically to gather information'on the patient's social and 2002).
emotional landscape. The assessment includes the physi cal
layout of the home environment, relevant psychoso cial
Research and Evaluation
history, support systems, and other issues related to the
There is an overall paucity of empirical support for the
patient's life. The social worker then shares this
effectiveness of rehabilitation. While many evaluations
"person-in-environment" perspective with the care t eam to
have been used to improve the quality of program
inform treatment planning.
operations, few studies have contributed to the larger body
Social work counseling, which is inherently strength-
of science (Whyte, 2003). A key challenge to
based, is consistent with the disability movement's em-
rehabilitation's research agenda is the lack o f consensus on
phasis on patient empowerment in adapting, changing, and
how to define and measure the goals of rehabilita tion
growing in response- to impairment or disability. The
(Granger, 1998). Core outcome indicators in the current
techniques are generally brief, solution- focused, and
literature include discharge to a home setting, improved
inclusive of the family as the major support structure for
functional status, lower treatment costs, re duced assistance
community transition.
or supervision needs, and increased activity (Keith, 1995 ).
Among the myriad contributions social workers make
More patient-centered indicators such as well- being,
to the rehabilitation process, perhaps none is more un ique
satisfaction, and other quality of life factors have only
than linking patients to community resources and
recently been addressed in research designs.
facilitating effective transitions to home or other settings.
Two areas of clinical focus in rehabilitation ha ve
Social workers often take the lead in discharge planning,
launched major initiatives in evidence- based practices:
which necessarily incorporates counseling and case plan-
rehabilitation following stroke and traumatic brain injury.
ning. With the advances inassistive device s, adaptive
For example, the U.S Agency for Health Care Policy and
equipment, and greater access to transportation, an in-
Research sponsored several centers to estab lish guidelines
creasing number of patients with more complicated needs
for poststroke rehabilitation (Gresham et al., 1995 ).
are returning to their home environment. This trend makes
Improvements to research and evaluation in rehabilitation
the social worker's task all the more critical and
will require stronger designs, more precise measures,
challenging. In many instances, social workers must act as
cost-effectiveness components, and dedicated involvement
patient advocates in procuring needed resources, facili tate
from providers and policy makers (Jette & Keysor, 2002).
family and caregiving networks to ensure a safe transition,
Effective research must also track patient outcomes beyond
and help support patients in coping with their emotional
the rehabilitation setting and into the home and community.
and physical challenges.
Case management in rehabilitation has evolved
somewhat distinctly from psychosocial counseling and
discharge planning, with an increased emphasis on uti-
lization management and cost containment. In addition to Future Trends
the mainstays of case management (for example, Trends in comprehensive medical rehabilitation will
psychosocial assessment, care planning, documenta tion, continue to be significantly influenced by the larger
and linkage to community resources), continuity health-care arena. The exponential growth in

.
j.

~:

health-care costs, the growing number of uninsured
individuals, and the diminishing number of physicians
participating in Medicare or Medicaid programs, for example,
will deleteriously affect the delivery of health-care services if
major change is not enacted. Most notably, the effectiveness of
the multidisciplinary model of rehabilitation will gradually
erode if pressure to serve more patients, by a less skilled
workforce, using lower levels of service and shorter lengths of
stay, continue to exert themselves.
Conversely, technological advancements offer great
promise for rehabilitation services. Adaptive equipment, such
as wheelchairs, can be customized to enhance the function of
more individuals and art7 likely to see greater improvements
over time. Scientific breakthroughs in robotics are also just
begirining to offer therapeutic advantages to rehabilitation and
may profoundly improve treatments for physical disabilities,
in particular.
Finally, the social trend toward health and fitness, the
obesity epidemic notwithstanding, has already influenced the
expansion of treatment provision and broadened patient
populations. More traditional hospital settings are now
offering health and fitness classes, while the fitness industry
has adopted rehabilitation programs as part of their service
package. The aging "baby boom" generation is already
accessing rehabilitation programs for a wider array of both
temporary and permanently disabling conditions, thus
increasing the demand for . more services.
REFERENCES
Boehm, A, & Staples, L. (2002). The functions of the social
worker in empowering: The voices of consumers and pro-
fessional. Social Work, 47(4), 449--460.
Center for Disease Control. (1994). Prevalence of disability and
associated health condition. Morbidity and Mortality Weekly
Report, 43, 730-739.
Centers for Medicare and Medicaid Services. (2002). Rehabili-
tation agencies and comprehensive outpatient rehabilitation facil-
ities, by hcfa region. http://www.cms.hhs.gov/medleam/
therapy
Chachkes, E. (2005). Social work and rehabilitation. In H. H.
Zaretsky, E. F. Richter, & M. G. Eisenberg (Eds.), Medical
aspects of disability (3rd ed., pp. 751-768). New York:
Haworth Press.
Dejong, G., Palsbo, S. E., Beatty, P. W., Jones, G. c., Kroll, T., &
Neri, M. T. (2002). The organization and financing of health
services for persons with disabilities. The Millbank Quarterly,
80, 261-301.
Deutsch, A, Fiedler, R. c., Granger, C. V., & Russell, C. F.
(2002). The uniform data system for medical rehabilitation
report of patients discharged from comprehensive medical
rehabilitation programs in 1999. AmericanJoumal of Physical
Medicine and Rehabilitation, 81,133-141,
RELIGION 505
Friedland, J. (2003). Why crafts? Influences on the development
of occupational therapy in Canada. Journal of Occupational
Therapy, 70, 204-213.
Granger, C. V. (1998). The emerging science of functional
assessment: Our tool for outcome analysis. Archives of Physical
Medicine and Rehabilitation, 79, 235-240.
Granger, C.V., & Hamilton, B. B. (1992). UDS report. The
uniform data system for medical rehabilitation report of first
admissions for 1990. American Journal of Physical Medicine and
Rehabilitation, 71, 108-113.
Gresham, G. E., Duncan, P. W., Stason, W. B., Adams, H. P.,
Adelman, A. M., & Alexander, D. N., et al. (1995). Post stroke
rehabilitation. Clinical practice guideline. Rockville, MD:
U.S. Department of Health and Human Services.
Gritzer, G., & Arluke, A (1985). The making of rehabilitation.
Berkeley: University of California Press.
Jette, A. M., & Keysor, J. J. (2002). Uses of evidence in disability
outcomes and effectiveness research. The Millbank Quarterly,
80,325-345.
Keith, R. A. (1995). Conceptual basis of outcome measures.
American Journal of Physical Medicine and Rehabilitation, 74,
73-80.
Keith, R. A (1997). Treatment strength in rehabilitation. Archives
of Physical Medicine and Rehabilitation, 78, 1298-1304.
Keith, R. A, & Arnow, H. U. (2005). Comprehensive re-
habilitation: Themes, models, and issues. In H. H. Zaretsky, E.
F. Richter, & M. G. Eisenberg (Eds.), Medical 'aspects of
disability (3rd ed., pp. 3-29). New York.
Moffat, M. (2003, Winter). History of physical therapy practice in
the United States. Journal of Physical Therapy Education.
National Institute of Health. (2007). Screening for rehabilitation
and choice of setting. Agency for Healthcare Research and
Quality, 5. http://www.ncbi.nlm.nih.gov.
O'Donnell, J. c., & Hamilton, B. B. (1997). Stroke
rehabilitation management in the VA: Impact of patient referral
source on outcomes. Durham, NC: U.S. Department of Veterans
Affairs.
Roland, D., & Scheiber, S. J. (1996). From baby boom to elder
boom: Providing health care for an aging population. Washington,
DC: Watson Wyatt.
Teasel, R. W., Foley, N. c, Bhogal, S. K., & Speechley, M. R.
(2003). An evidence-based review of stroke rehabilitation.
Topics in Stroke Rehabilitation, 10,29-58.
Whyte, J. (2003). Clinical trials in rehabilitation: What are the
obstacles? American Journal of Physical Medicine and
Rehabilitation, 82(Suppl.), SI6-S21. .
SUGGESTED LINKS
http://www.erehabdata.com
http://www.ahepr.gov
-DAVID W. SPRINGER AND KATHLEEN A. CASEY
RELIGION. See Christian Social Services; Faithbased
Agencies and Social Work; Jewish Communal Services;
Muslim Social Services.
506 REPRODUCTIVE HEALTH

REPRODUCTIVE HEALTH Almost half of pregnancies in the United States are

unintended, with 42% of them ending in abortion (Finer
ABSTRACT: Reproductive health includes family & Henshaw, 2006). Women with unintended
planning, prenatal care, and the broader scope of pregnancies are disproportionately young, low-income
primary care. Because a woman's health status at group, single, and non-white, primarily African Ameri-
conception is as important as prenatal care, genetic can (Finer & Henshaw, 2006). Unintended pregnancy
screening and 20th century medical technology, has biological, psychological, economic, and social
reproductive health includes "the preconceptual and consequences (Brown & Eisenberg, 1995). Compared
interconceptual periods and the menopause, and with women with planned pregnancies, those with
finally, not only reproductive tract problems but the unintended pregnancies initiate prenatal care later (Kost,
wide range of risk factors that influence a woman's Landry, & Darroch, 1998), have higher rates of
health in general." Quantitative indicators of behavioral risk factors during pregnancy (Berkowitz &
reproductive outcomes are useful for sum marizing Papiernik, 1993; Brown & Eisenberg, 1995; Poole &
progress in reproductive health. Important indicators Hawkins, 1999), and report higher rates of partner
are discussed and reveal significant racial disparities. physical abuse (Gazmararian et al., 1995).
\
. KEY WORDS: Pregnancy; preconceptive care; prenatal In 1970 the us. Congress enacted the Title X program
care; sexually transmitted infections; substance abuse, as part of the 1970 Public Health Service
tobacco, and alcohol; violence; nutrition and exercise; . Act. It is the sole federal program providing family
poverty; racism planning and reproductive health care, funding around
4,600 clinics, preventing an estimated 1.3 million un-
Introduction intended pregnancies each year. Since 1995, an average
Reproductive health includes family planning, prenatal of five million women each year obtained contraceptive
care, and the broader scope of primary care. Because a services from these clinics. Nearly two-thirds of the
woman's health status at conception is as important as clients have incomes below 100% of poverty level; 89%
prenatal care, genetic screening and 20th century med- have incomes below 200% of poverty level. Congress
ical technology, reproductive health includes "the pre- has not increased Title X funding since 1981 (Office of
conceptual and interconceptual periods and the Population Affairs [OPAl, 2001).
menopause, and finally, not only reproductive tract
problems but the wide range of risk factors that influ-
PRECONCEPTION CARE Preconception care (Moos,
ence a woman's health in general" (Kowal, 2004, p. 1).
2002; Moos & Cefalo, 1987) is a set of interventions to
Quantitative indicators of reproductive outcomes are
identify and modify biomedical, behavioral, and social
useful for summarizing progress in reproductive health.
risks to a women's health or pregnancy outcome.
Important indicators are shown in Table 1 and reveal
Preconception care counsels about unhealthy behaviors
significant racial disparities.
screens for and treats communicable diseases and endo-
Pregnancy crine conditions (that is, diabetes andhypothyroidism)
Each year more than six million American women and dispenses nutrients such as folic acid. Its goal is to
become pregnant. u.s. teen pregnancy rates and rates of increase awareness and address potential risks to
new cases of sexually transmitted infections (STls) women's health and pregnancy outcomes before a
rank among the highest among industrialized countries pregnancy is known (Johnson et al., 2006).
(Singh & Darroch, 2000; Weinstock, Berman, & Cates,
2004), as do infant mortality rate (IMR) , low birth PREGNANCY AND WOMEN'S HEALTH Maternal
weight (LBW), and preterm birth (PTB) (U'S, Depart- mortality rate (MMR) had decreased markedly during
ment of Health and Human Services [USDHHS], the 19th century, but without much progress being made
Health Resources and Services Administration, since mid-1980s. A Massachusetts study identified
Maternal and Child Health Bureau, 2004a, 2004b). The inadequate prenatal care as a prominent risk factor for
teenage birth rate fell to 40.4 births per 1,000 women in MMR and declared that one-third to one-half of all
2005 from its 1991 high of 61.8, representing the maternal deaths were preventable (Sachs et al., 1992).
lowest teen birth rate in its 65-year recording history Profound racial disparities exist for all four indica-
(Hamilton, Martin, & Ventura, 2007). tors in Table 1. This remains true even when control ling
for mothers' income and educational levels (Mustillo et
UNINTENDED PREGNANCY AND ITs al., 2004; Schoendorf, Hogue, Kleinman, & Rowley,
PREVENTION The USDHHS counts unintended 1992). Other social risk factors for IMR include
pregnancy among major public health problems education and marital status. IMR decreases
(Healthy People, 2010).
 REPRODUCTIVE HEALTH
507

TABLE 1
YEAR BLACK WmTE TOTAL DEFINITION INDICATORS
(NON' (NON,
HISPANIC) HISPANIC)
2003 30.7 8.7 12.1 Maternal deaths per 100,000 live births Maternal Mortality Rate
2003 13.6 5.7 8.2 Infant deaths per 1,000 live births Infant Mortality Rate
2005 14 7.3 6.8 Percent of newborns weighing less than 2,500 g Low Birth Rate
2005 18.4 11.7 12.7 Percent of births born less than 37 weeks gestation Pre term Birth
From "Maternal mortality and related concepts," by D. L. Hoyert, 2007, Vital Health and Statistics, 3(33). Hyattsville, MD: National
Center for Health Statistics. Retrieved July 29, 2007, from http://O-www.cdc.gov.milll.sjlibrary.org/nchs/data/series/sr_0J/sr03_OJ3.
pdf; Infant mortality statistics from the 2003 period linked birth/infant death data file. National Vital Statistics Reports (Vol. 54, No. 16), by T.].
Mathews and M. F. MacDorman, 2006, Hyattsville, MD: National Center for Health Statistics. Retrieved July 27,2007, from
http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_16.pdf; and Births: Preliminary data for 2005. National Vital Statistics Reports (Vol.
55), by B. E. Hamilton,]. A. Martin, and S.]. Ventura, 2007, Hyattsville, MD: National Center for Health Statistics. Retrieved July 15,
2007, from http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths05/prelimbirths05.htm

with increasing maternal education and unmarried
mothers are at higher risk for poor pregnancy outcomes
(Mathews & MacDorman, 2006). Marital status is a
marker for social, emotional, and financial support that
independently impact these outcomes. Young maternal
age, low education, and other negative social indicators
are risk factors for LBW and IMR (Hamilton et al.,
2007; Hillerneier, Weisman, Chase, & Dyer, 2007;
Mathews & MacDorman).
Prenatal Care. Early, comprehensive, and contin-
uous prenatal care provides diagnosis and treatment for
risk factors and advises pregnant women about beha-
viors to improve pregnancy outcomes (Brown, 1988;
Mathews & MacDorman, 2006). Psychosocial assess,
merit screens for risks, including tobacco, alcohol, and
other substance use, depression, and domestic violence.
Social worker screening and case management, avail,
able through "enhanced prenatal care" halves PTB or
LBW risks (Wilkinson, Korenbrot, & Greene, 1998).
The Institute of Medicine's seminal report on
prenatal care (Brown, 1988) identified four barriers to
prenatal care: (a) financial; (b) inadequate system
capacity; (c) organization, practices, and atmosphere of
prenatal services; and (d) cultural and personal. Despite
the acknowledged importance of prenatal services,
these barriers persist. In the 1980s Congress passed
numerous laws, including the Omnibus Budget Recon-
ciliation Act (OBRA) of 1987, expanding Medicaid
eligibility to 133% of the federal poverty level for
pregnant women and for 60 days postpartum (Margolis,
Cole, & Kotch, 2005). Its most important feature was
making Medicaid receipt independent from receipt of
Aid to Families with Dependent Children (AFDC) (now
with Temporary Aid to Needy Families (T ANF). In
recent years Medicaid waivers also have provided
women with well-woman care (Gold, 2003).
System issues relevant to inadequate prenatal care
include problems securing Medicaid and other access
barriers (that is, transportation problems), inconvenient
hours or long waits in clinics, and communication
problems with providers, Cultural and personal barriers
compound system barriers. Fear of providers or medical
procedures discourages some women, undocumented
immigrants may fear of discovery, and. women who
abuse alcohol or illicit drugs may fear of prosecution.
Lack of social support, stress, and depression also pre,
sent barriers to prenatal care (Brown, 1988; Sable &
Wilkinson, 1999).
Factors Affecting Women's
Reproductive Health
STIs, substance use, violence, and physical activity
impact on women's overall health status.
SEXUALL Y TRANSMITTED INFECTIONS STIs in'
crease women's morbidity, threaten fertility, and
directly cause poor birth outcomes. Chlamydia has the
highest infection rate of reportable STIs in the United
States (Centers for disease control and prevention
[CDC], 2006), is asymptomatic for many, and if un-
treated, can result in pelvic inflammatory disease and
infertility (Gray-Swain & Peipert, 2006). Gonorrhea
symptoms and health effects are similar (CDC, n.d.va:
Zar, 2005). Gonorrhea, chlamydia, herpes simplex
virus (HSV) infection, and bacterial vaginosis can
impact birth outcomes (CDC, n.d.eb).
Infection i.with human immunodeficiency virus
(HIV) can be transmitted to the baby during preg'
nancy, labor, delivery, or breastfeeding (perinatal
transmission). In the United States, HIV testing and
drug therapy has reduced the perinatal transmission rate
to 2% or less (CDC, 2004). Only 142 cases of
 508 REPRODUCTIVE HEALTH
HIV or AIDS were diagnosed among babies exposed
perina tally in the United States in 2005 (CDC, 2007). It is
important to note that this low perinatal HIV transmission
rate does not reflect women's reality in the developing
world where HIV prevalence rates among pregnant women
are between 25 and 45% (Reithinger, Megazzini, Durako,
Harris, & Vermtind, 2007).
Almost 90% of pregnant women with active hepatitis B
infection transmit it to their babies. Untreated infection
results in chronic infection rates and resultant liver disease
(March of Dimes, 2007). All U.S. babies are immunized at
birth for hepatitis B infection; two additional doses are
required during infancy to assure protection.
~ FASD prevalence is underreported (Fox & Druschel,
SUBSTANCE USE, TOBACCO, AND ALCOHOL Con-
current abuse of substances is frequent, complicating
research on any substance's impact on birth outcome.
Furthermore, many pregnant abusers are economically
disadvantaged, a risk factor for unfavorable perinatal
outcomes (Bolnick & Rayburn, 2003).
Social workers can use the professional five inter-
vention roles-teacher, broker, clinician, mediator, and
advocate-in working with substance using women (Sun,
2004). Women-centered substance abuse programs address
specific needs such as HIV or STI risk reduction, child
care, reproductive health services, and parenting classes
(Marsh, D'Aunno, & Smith, 2000). Treatment strategies
include empowering "recovering" women with
reproductive health knowledge and decision-making skills
(Jessup & Brindis, 2005). Absence of woman-centered or
pregnancy-specific services deters pregnant and parenting
women from seeking treatment. Few treatment programs
have special services for pregnant women (Brady et al.,
2001).
More than 200 women have been prosecuted for fetal
abuse for having abused substances during pregnancy
(Marcellus, 2004). Treating substance use by pregnant
women as criminal also deters women from seeking pre-
natal care and substance abuse treatment; social workers
are obliged to serve as extensions of the legal system
(Finkelstein, 1994; Paltrow, Cohen, & Carey, 2000).
Tobacco. Approximately 20% of American women
smoke, with higher rates found for those with less than a
high school education; health consequences include
infertility and conception delay (CDC, 2004). The IMR
in 2003 was 71 % higher for infants whose mothers
smoked compared with those nonsmoking (11.3 per
1,000 vs. 6.6) (Mathews & MacDorman, 2006).
Smoking during pregnancy is associated with LBW and
intrauterine growth retardation (CDC, 2004). In 2002
and 2003, 18% of pregnant women reported
i'
Ll
i
smoking cigarettes. While many women are able to quit
smoking during pregnancy, a significant proportion
resume with the stress of parenting (Fang et al., 2004).
Social workers are an important source of support for
smoking cessation for all women. Research-based smoking
cessation techniques are available (CDC, n.d.-c).
Alcohol. Excess alcohol consumption during preg-
nancy, especially during the first trimester, can result in
a spectrum of congenital malformations and develop-
mental disabilities known as fetal alcohol syndrome
(FAS) (Baumann, Schild, Hume, & Sokol, 2006; Foster
& Marriott, 2006). Fetal alcohol spectrum disorder
(FASD) is a less-severe manifestation of FA-S. FAS and
2003). Data from births during 1995-1997 indicate rates
in some states ranging from 0.3 to 1.5 per 1,000
live-born infants; rates were highest for African
American and American Indian or Alaska Native
populations (CDC, 2002). The quantity of alcohol re-
quired to produce partial FAS or FAE has not been
established. Current recommendations are to drink no
more than one to two units of alcohol once or twice a
week and avoid heavy drinking for pregnant women or for
those planning pregnancy (Foster & Marriott, 2006).
VIOLENCE AGAINST WOMEN Research since mid-
1980s reports that intimate partner violence (IPV) is
associated with increased mortality, injury and disability,
poor general health, chronic pain, substance abuse,
reproductive disorders, and poorer pregnancy. outcomes
(Plichta, 2004). Pregnant women are more vulnerable to
violence; homicide leads the causes of death for pregnant
and recently pregnant women (Shadigian & Bauer, 2005).
Since the mid-1980s, then U.S. Surgeon General C.
Everett Koop and' others recommended routine screening
forIPV during pregnancy (ACOG, 2006, 2007; USDHHS,
1986). However, screening rates and practices are far from
optimal and enhanced violence prevention training for all
practitioners working with women (Shadigian & Bauer,
2005). Screening protocols must include an adequate
referral network, and social workers are in a leadership
position to advocate for services in the form of counseling,
shelters, and legal assistance.
NUTRITION AND EXERCISE Insufficient physical ac-
tivity significantly contributes to women's morbidity and
mortality. Ensuring sufficient physical activity in daily life
is strongly related to social support and selfefficacy
(Smith, Cheung, Bauman, Zehle, & Mclean,

2005). Less than half of pregnant women are physically
active, increasing their risk for mood problems and pre-
eclampsia (Poudevigne & O'Connor, 2006; Saftlas,
Logsden-Sackett, Wang, Woolson, & Bracken, 2004).
Obesity during pregnancy increases risk of maternal,
fetal, and neonatal complications, diabetes,
pre-eclampsia, caesarian section, and birth defects
(Siega-Riz & Laraira, 2006). Women entering preg-
nancy at higher weights are more likely to retain their
increased gestational weight with subsequent pregnan-
cies; women who retain their pregnancy weight increase
risks of complications in future pregnancies, including
gestational diabetes (Bainbridge, 2006). Clinicians dis-
courage obese women from attemp~ing wright loss
during pregnancy (Yu, Teoh, & Robinson, 2006).
POVERTY AND RACISM Women head more than half
of poor families, and women and children constitute
the fastest growing segments of poverty dwelling
people (DeNavas-Walt, Proctor, & Lee, 2006).
Poverty is associated with inadequate health care and
nutrition, excess stress and limited altern atives
(Krieger, 200l). Problems persist for low- income
women's accessing re productive health services
beyond the postpartum per iod. Some states are
experimenting with Medicaid waivers for
well-women's health that would provide primary
health care servic es, including contraception and
cancer screening (Gold, 2003).
Social determinants of health such as poverty and
racism impact reproductive health outcomes (Krieger,
2001; Krieger, Rowley, Herman, Avery, & Phillips,
1993; Institute of Medicine, 2003). Lu and Halfon
(2003) posit that optimal reproductive outcomes result
from. health influences throughout life. Mustillo et a1 .
(2004) found that women's self-reported experiences
with racial discrimination were associated with PTB and
LBW and concluded that this discrimination may
contribute to the racial disparities in birth outcomes.
Challenges
Politics threaten Title X program efforts and other
measures to prevent unintended pregnancy. The Food
and Drug Administration faced political pressure when
reviewing over-the-counter approval for emergency
contraception (Wood, Drazen &" Greene, 2005).
Abstinence-only sex education is federally funded, de-
spite insufficient evidence of its effectiveness (Bruckner
& Bearman, 2005; Jemmott, Jemmott, & Fong, 1998).
Politics threaten Title X program efforts and other
measures to prevent unintended pregnancy. The Food
and Drug Administration faced political pressure when
REPRODUCfIYE HEALTH 509
reviewing over-the-counter approval for emergency
contraception (Wood et a1., 2005). In 1993, President
Clinton suspended President Reagan's 1984 Global Gag
Rule that had curtailed federal contributions for
international family planning organizations providing
abortion, counseling or reference for abortion, or advo-
cating legal abortion (Population Action International,
2006); President George W. Bush reinstated the policy
in 2001. A current international assistance program, The
President's Emergency Plan for AlDS Relief, reserves
one-third of all its funding for abstinence-only pro-
grams (Cohen, 2005).
ROLES AND IMPLICATIONS FOR SOCIAL WORK Social
workers work in the reproductive health arena at the
micro level by providing social support, counsel ing,
education, and financial assistance to women and
their families. Social workers must also help
communities and society through social work
practice at the macro level to support policies that
emphasize preven tion, increase access to the broad
spectrum of reproduc tive health services, and lessen
social determinants of health, such as poverty and
racism. Social workers can advocate for policies and
programs that reduce reproductive health risk factors,
such as programs for smoking cessation, substance
abuse prevention and treatment, violence prevention,
nutrition and fitness, and poverty alleviation. We can
advocate for access to reproductive health care for
poor women beyond pre natal care and delivery by
supporting Medicaid waivers for family planning and
other reproductive health care in the preconceptional,
postpartum, and interpartum periods. Finally, we
must staunchly support efforts to reduce unintended
pregnancy by supporting a woman's right to control
her fertility, expanding access to these services for
low-income women. As suggested by Miller,
Piccinino, and Tsui (2005, p. 109), "nothing in" the
history of this country suggests that the fam ily
planning needs of the population are likely to be met
without the strongest possible advocacy."
REFERENCES
American College of Obstetricians and Gynecologists Committee on
Health Care for Undeserved Women (ACOG). (2006). ACOG
Committee Opinion No. 343: Psychosocial risk factors: Perinatal
screening and intervention. Obstetrics & Gynecology,
108(2),469-477.
American College of Obstetricians & Gynecologists (ACOG). (2007).
Screening tools-domestic violence. Retrieved August 6, 2007,
from http://www.acog.org/departments/ deptriotice.cfrn ?recno=
17 &bulletin = 585
Bainbridge", J. (2006). Lingering pregnancy fat puts women in
danger. British Journal of Midwifery, 14, 644.
510 REPRODUCflVE HEALTH
Baumann, P., Schild, c, Hume, R. F., & Sokol, R. J. (2006).
Alcohol abuse-A persistent preventable risk for congenital
anomalies. International Journal of Gynaecology and Obstetrics,
95(1), 66-72.
Berkowitz, G. S., & Papiernik, E. (1993). Epidemiology of
preterm birth. Epidemiologic Reviews, 15,414-:-443.
Bolnick, J. M., & Rayburn, W. F. (2003). Substance use disorders
in women: Special considerations during pregnancy. Obstetrics
and Gynecology Clinics of North America, 30(3), 545-558.
Brady, T. M., Male, A. A, Parker, A., Sikali,E., Nooter, D., &
Huang, G. G. (2001). National estimates of the availability of
services for women in substance abuse treatment. Abstracts of
the Academy of Health Services Research Health Policy Meeings,
18, 6.
Brown, S. S. (1988). Prenatal care: Reaching mothers, reaching
infants. Washington, DC: Institute of Medicine, National
Academy Press.
Brown, S. S., & Eisenberg, L. (Eds.). (1995). The best intentions.
Washington, DC: Institute of Medicine, National Academy
Press.
Bruckner, H., & Bearman, P. S. (2005). After the promise:
The STD consequences of adolescent virginity pledges.
Journal of Adolescent Health, 36, 271-278.
Centers for Disease Control and Prevention (CDC). (n.d.>a).
Gonorrhea: CDC fact sheet. Retrieved August 1, 2007, from
http://www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.
htm#pregnant
Ceriters for Disease Control and Prevention (CDC). (n.d.vb).
STDs and pregnancy: CDC fact sheet. Retrieved August 1, 2007,
from http://www.cdc.gov/std/STDFact-STDs&
Pregnancy.htm
Centers for Disease Control and Prevention (CDC). (n.d.-c).
Smoking and tobacco use: Cessation program materials. Retrieved
August 7, 2007, from http://www.cdc.gov/tobacco/
quit_smoking/cessation/index.htm
Centers for Disease Control and Prevention (CDC). (2002).
Fetal alcohol syndrome-Alaska, Arizona, Colorado, and New York,
1995-1997. Morbidity and Mortality Weekly Report, 5 I, 433--435.
Centers for Disease Control and Prevention (CDC). (2004).
The health consequences of smoking: A report of the Surgeon
General. Washington, DC: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health. Retrieved August
7, 2007, from http://www .cdc.gov/to-
bacco/data_statistics/sgr/sgr_2004/index.htm
Centers for Disease Control and Prevention (CDC). (2006).
Sexually transmitted disease surveillance: 2005 Supplement,
Chlamydia prevalence moniioring project annual report, 2005.
Atlanta, GA: Department of Health and Human Services.
Retrieved August 1, 2007, from http://www .cdc.gov/std/
Chlamydia2005/CTSurvSupp2005Short.pdf
Centers for Disease Control and Prevention (CDC). (2007).
HIV surveillance report table I, 2001-2005. Atlanta, GA:
U.S. Department of Health and Human Services. Retrieved
July 15, 2007, from http://www.cdc.gov/hiv/topics/surveil-
Iance/basic.hrmwhivaidsexposure
Cohen, S. A. (2005, August). U.S. global AIDS policy and sexually
active youth: A high-risk strategy. The Guttmacher Report on
Public Policy, 8(3). Retrieved August 6,2007, from
http://www .guttmacher.org/pubs/tgr/08/3/gr080304 .html
DeN avas-Walt , c., Proctor, B. D., & Lee, C. H. (2006).
Income, poverty and health insurance coverage in the United
States, 2005. U.S. Population Bureau, Current census reports,
P60-231. Washington, DC: U.S. Government Printing Office.
Retrieved July 30, 2007, from http://www.census.
gov/prod/2006pubs/p60-231.pdf
Fang, W., Goldstein, A., Butzen, A, Hartsock, A., Hartmann, K.,
& Helton, M., et al. (2004). Smoking cessation in pregnancy:
A review of postpartum relapse prevention strategies. Journal
of the American Board of Family Practice, 17, 264-275.
Finer, L. B., & Henshaw, S. K. (2006). Disparities in rates of
unintended pregnancy in the United States, 1994 and 2001.
Perspectives in Sexual and Reproductive Health, 38, 90-96.
Finkelstein, N. (1994). Treatment issues for alcohol- and
drug-dependent pregnant and parenting women. Health and
Social Work, 19(1), 7-15.
Foster, R. K., & Marriott, H. E. (2006). Alcohol consumption in
the new millennium-weighing up the risks and benefits for our
health. Nutrition Bulletin, 31(4),286-331.
Fox, D. J., & Druschel, C. M. (2003). Estimating prevalence of
fetal alcohol syndrome (FAS): Effectiveness of a passive birth
defects registry system. Birth Defects Research, 67, 604-608.
Gazrnararian, J. A., Adams, M. M., Saltzman, L. E., Johnson, C.
H., Bruce, F. C., & Marks, J. S., et al. (1995). The relationship
between pregnancy intendedness and physical violence in
mothers of newborns. The/PRAMS Working Group. Obstetrics
& Gynecology, 85,10:31-1038.
Gold, R. B. (2003, October). Medicaid family planning
expansions hit stride. The Guttmaeher Report on Public Policy,
6(4).
Gray-Swain, M., & Peipert, J. (2006). Pelvic inflammatory
disease in adolescents. Current Opinion in Obstetrics &
Gynecology,J8,503-51O.
Hamilton, B. E., Martin, J. A, & Ventura, S. J. (2007). Births:
Preliminary data for 2005. National Vital Statistics Reports
(Vol. 55). Hyattsville, MD: National Center for Health
Statistics. Retrieved July is, 2007, from http://www.cdc.
gov/nchs/products/pubs/pubd/hestats/prelimbirths05/prelim
births05.htm Healthy People. (2010). Leading health indi-
cators: Family planning (200l). Retrieved June 8, 2006, from
http://www.healthypeople.gov/document/HTML/Volumel/
09Family.htm
Hillemeier, M. M., Weisman, C. S., Chase, G. A, & Dyer, A. M.
(2007). Individual and community predictors of preterm birth
and low birthweight along the rural-urban continuum in
central Pennsylvania. The Journal of Rural Health, 23(1),
42--48.
Institute of Medicine. (2003).lnB. D. Smedley, A Y. Stith, & A R.
Nelson (Eds.), Unequal treatment: Confronting racial

and ethnic disparities in health care. Washington, OC:
National Academy Press.
Jemmott, J. B., III, Jemmott, L. S., & Fong, G. T. (1998).
Abstinence and safer sex HIV risk-reduction interventions for
African American adolescents. Journal of the American Medical
Association, 279(19), 1529-1536.
Jessup, M. A, & Brindis, C. D. (2005). Issues in reproductive
health and empowerment in perinatal women with substance
use disorders. Journal of Addictions Nursing, 16(3), 97-105.
Johnson, K., Posner, S. F., Biermann, J., Cordero, J. F., Atrash, H.
K., & Parker, C. S., et al. (2006, April 21). Recommendations
to improve preconception health and health care-United States.
Morbidity and Mortality Weekly Report, 55(RR-6).
Kost, K., Landry, D. J., & Darroch, J, E. (1998). Predicting
maternal behaviors duringpregnancy: Does intention status
matter? Family Planning Perspectives, 30, 79-88.
Krieger, N., Rowley, D. L., Herman, A. A., Avery, B., & Phillips,
M. T. (1993). Racism, sexism, and social class: implications
for studies of health, disease, and well-being. American
Journal of Preventive Medicine, 9, 82-122.
Krieger, N. (2001). Theories for social epidemiology in the 21st
century: An ecosocial perspective. International Journal of
Epidemiology, 30, 668-677.
Lu, M. c., & Halfon, N. (2003). Racial and ethnic
disparities in birth outcomes: A life-course
perspective. Maternal and Child Health Journal, 7, 13-30.
>
Marcellus, L. (2004). Feminist ethics must inform practice
interventions with perinatal substance' users. Health Care for
Women International, 25(8), 730-742.
March of Dimes. (2007). Perinatology.com. Retrieved on August
6,2007, from http://www.perinatology.com/
Margolis; L., Cole, G., & Kotch, J. (2005). Historical foundations
of maternal and child health. In J. Kotch (Ed.), Maternal and
child health: Programs, problems, and policy in public health (2nd
ed., pp. 23-55). Sudbury, MA: Jones & Bartlett.
Marsh, J. c., D'Aunno, T. A, & Smith, B. D. (2000). Increasing
access and providing social services to improve drug abuse
treatment for women with children. Addiction,
95(8),1237-1247.
Mathews, T. J., & MacDorman, M. F. (2006). Infant mortality
statistics from the 2003 period linked birth/infant death data file.
National Vital Statistics Reports (Vol. 5~, No. 16). Hyattsville,
MD: National Center for Health Statistics. Retrieved July 27,
2007, from http://www.cdc.gov/nchs/
data/nvsr/nvsr54/nvsr5.4_16.pdf
Miller, C. A, Piccinino, L., & Tsui, A (2005). Family planning. In
J. B. Kotch (Ed.), Maternal and child health:
Programs, problems, and policy in public health (2nd ed., pp.
91-111). Sudbury, MA: Jones & Bartlett.
Moos, M. K. (2002). Preconceptional health promotion: Oppor-
tunities abound. Maternal and Child Health Journal, 6, 71-74.
Moos, M. K., & Cefalo, R. C. (1987). Preconceptional health
promotion: A focus for obstetric care. American Journal of
Perinatology, 4, 63-67.
REPRODUCflVE HEALTH 511
Mustillo, S., Krieger, N., Gunderson, E. P., Sidney, S., McCreath,
H., & Kiefe, C. I. (2004). Self-reported experiences of racial
discrimination and Black-White differences in preterm and
low-birthweight deliveries: The CARDIA study. American
Journal of Public Health, 94(12),2125-2131.
Office of Population Affairs (OPA) , U.S. Department of Health
and Human Services. (2001). Healthy people 201O-Reproductive
health. Washington, OC: Author. Retrieved june 4, 2007, from
http://opa.osophs.dhhs.gov/pubs/ hp2010jhp201O_rh.pdf
Paltrow, L. M., Cohen, D. S., & Carey, C. A (2000). Government
responses to pregnant women who use alcohol or other drugs.
Philadelphia, PA: Women's Law Project.
Plichta, S. B. (2004). Intimate partner violence and physical health
consequences. Journal of Interpersonal Violence,
19(11),1296-1323.
Pooie, V., & Hawkins, M. (1999). Pregnancy planning and
unintended pregnancy. In H. Grason, J. Hutchins, & G. Silver
(Eds.), Charting a course for the future of women's and perinatal
health, Vo!' 2-Reviews of key issues (pp. 81101). Baltimore, MD:
Women's and Children's Health Policy Center, Johns Hopkins
School of Public Health.
Population Action International. (2006). What you need to know
about the Mexico City Policy restrictions on U.S. family planning
assistance. Washington, DC: Author. Retrieved July 29, 2007,
from http://66.39.l33.l28/resources/publications/
globalgagrule/Mexico _City_Policy .pdf
Poudevigne, M. S., & O'Connor,P. J. (2006). A review of physical
activity patterns in pregnant women and their relationship to
psychological health. Sports Medicine, 36(1),19-38.
Reithinger, R., Megazzini, K., Durako, S., Harris, D., & Vermund,
S. (2007). Monitoring and evaluation of programmes to
prevent mother to child transmission of HIV in Africa. British
Journal of Medicine, 334,1143-1146.
Sable, M. R., & Wilkinson, D. S. (1999). The role of perceived
stress on prenatal care utilization: Implications for social work
practice. Health and Social Work, 24(2), 138-146.
Sachs, B. P., Brown, D. A., Driscoll, S. G., Schulman, E., Acker,
D., & Ransil, B. J., et al. (1992). Maternal mortality in
Massachusetts: Trends and prevention. The New England
Journal of Medicine, 316, 672-677.
Saftlas, A. F. Logsden-Sackett, N., Wang, W., Woolson, R., &
Bracken, M. B. (2004). Work, leisure-time physical activity,
and risk of preeclampsia and gestational hypertension.
American Journal of Epidemiology, 160(8),758-765.
Schoendorf, K., Hogue, c, Kleinman, J, & Rowley D. (1992)
Mortality among infants of Blacks as compared with White
college-educated parents. The New England Journal of Medi-
cine, 326, 1522-1526.
Shadigian, E. M., & Bauer, S. T. (2005). Pregnancy-associated
death: A qualitative systematic review of homicide and
suicide. Obstetrical & Gynecological Survey, 60(3), 183-190.
Siega-Riz, AM., & Laraira, B. (2006). The implications of
maternal overweight and obesity on the course of pregnancy
and birth outcomes. Maternal and Child Health Journal, 10(1),
153-156.
512 REPRODUCTIVE HEALTII
Singh, S., & Darroch, J. E. (2000). Adolescent pregnancy and
childbearing: Levels and trends in developed countries.
Family Planning Perspectives, 2000,32(1), 14-23.
Smith, B. J., Cheung, N. W., Bauman, A. E., Zehle, K., &
McLean, M. (2005). Postpartum physical activity and
related psychosocial factors among women with recent
gestational diabetes mellitus. Diabetes Care, 28(11), 2650-
2654.
Sun, A. P. (2004). Principles for practice with substance-
abusing pregnant women: A framework based on the five
social work intervention roles. Social Work, 49(3),383-394.
U.S. Department of Health and Human Services. (1986).
Surgeon General's workshop on violence and public health report
(DHHS Publication No. HRS-D~MC 86-1). Washington ,
DC: Health Resources and Services Administration. Re-
trieved August 6, 2007, from http://profiles.nlm.nih.gov/
NN/B/C/F/XUnnbcfx.pdf ~.
U.S. Department of Health and Human Services, Health Re-
sources and Services Administration, Maternal and Child
Health Bureau. (2004a). Child Health USA 2006. Rockville,
MD: U.S. Department of Health and Human Services.
Retrieved July 30, 2007, from http://www.mchb.hrsa.gov/
chusa_ 06/pages/pdf/c06.pdf
U.S. Department of Health and Human Services, Health
Resources and Services Administration, Maternal and
Child Health Bureau. (2004b). Women's Health USA 2004.
Rockville, MD: U.S. Department of Health and Human
Services. Retrieved July 30, 2007, from http ://
mchb.hrsa.gov/whusa04/
Weinstock, H., Berman, S., & Cates, W. (2004). Sexually
transmitted diseases among American youth: Incidence
and prevalence rates, 2000 Perspectives on Sexual and RePro-
ductive Health, 36(1), 6-10.
Wilkinson, D. S., Korenbrot, C. c., & Greene, J. (1998). A
performance indicator of psychosocial services in
enhanced prenatal care of Medicaid. eligible women.
Maternal and Child Health Journal, 2, 131-143.
Wood, A. J. J., Drazen, J. M., & Greene, M. F. (2005). A sad
day for science at the FDA. New EnglandJournal of Medicine,
353(12),1197-1199.
Yu, C. K. H., Teoh, T. G., & Robinson, S. (2006). Obesity in
pregnancy. British Journal of Obstetrics & Gynecology, 113,
1117-1125.
Zar, H. (2005). Neonatal chlamydial infections: Prevention
and treatment. Paediatric Drngs, 7, 103-110.
FURTIIER READING
Wilcox, L S. (2002). Pregnancy and women's lives in the
twenty-first century: The United States safe motherhood
movement. Maternal and Child Health Journal, 6, 215-220.
SUGGESTED LINKS
American College of Obstetricians and Gynecologists.
http://www.acog.org}
Guttmacher Institute.
http://www .guttmaeher .org/
March of Dimes. Peristats.
http://www.marchofdimes.com/peristats/default .aspx
Maternal and Child Health Bureau, U.S. Department of
Health and Human Services.
http://mchb .hrsa.gov/
National Center for Health Statistics.
http://www.cdc.gov/ochs/Default.htm
National Center for Health Statistics. Reproductive Health
Links. http://www.cdc.gov/nchs/about/major/natality/reproduc.htm
Office of Women's Health, U.S. Department of Health and
Human Services.
http://www .4woman.gov/owhl
Prescription for Change.
http://wikihealthcare.jointeommission.org}twiki/bin!view/P erform/
RxForChangeASmokingCessationCurriculum T oolForProfessionals
Cessation Program Materials.
http://www.cdc.gov/tobacco/quicsmoking/cessation/index.htm
-MARJORIE R. SABLE AND PATRICIA J. KELLY
RESEARCH. [This entry contains two subentries:
Overview; History of Research.]
OVERVIEW
ABSTRACT: This entry reviews the state of social work
research from the appearance of the social work re search
overview in the previous encyclopedia to the present day.
Social work research is defined, and its purposes,
contents, training, location, and auspices are briefly
discussed. Continuing issues and developments as well as
the emerging developments of evidence-based practice,
practice-based research, cultural competence, and
international social work research are featured.
KEY WORDS: Social Work Research; Practice-Based
Research; International Social Work Research; Evi-
dence-Based Practice; Generalizability
What is Social Work?
"Social work research is the use of social research methods
for developing, producing, and disseminating knowledge that
is pertinent to policies and practices that affect and/or are
implemented by social work organizations, practitioners, and
educators. It aims to describe and explain phenomena relevant
to social work" (Tripodi & Potocky-Tripodi, 2007, p. 12).
Ruben and Babbie (2005) further indicate that "[social work
research] is social science methodology applied to social
work ... [Unlike traditional academic researchers], social
work researchers ... aim not to produce knowledge for
knowledge's sake, but to provide the practical knowledge that
social workers need to solve everyday practice problems.
Ultimately, they aim to give the

field the information it needs to alleviate human suffering
and promote social welfare" (pp. 4-5).
What Are the Purposes of Social Work Research? The
three main functions of social work research are: using a
scientific orientation to provide a framework for practice,
building knowledge for practice, and "providing
situation-specific data to inform action, such as decisions
about practice, the operations of programs, or efforts to
achieve social change" (Reid, 1995, p. 2040). Notions
from social work research methodology can also be
employed to provide frameworks for making decisions
about practice. Thus, Di Noia and Tripodi (2007) use
single-case designs for providing information related to
the assessment, implementation, and evaluation of
practice' interventions.
What Do Social Workers Study?
The contents of social work research literature could be
divided into these categories: "studies of (1) the beha viors,
personality, problems, and other characteristics of
individuals, families, and small groups; (2) characteristics,
utilization, and outcome of services; (3) attitudes, orienta-
tions, and training of social workers, the profession, or
interdisciplinary concerns; and (4) organizations, commu-
nities, and social policy" (Reid, 1995, p. 2044).
A review of social work research journals of the past
decade can provide a good indication of what social work
researchers study. The contents of major social work
journals indicate that a variety of social problems and
social issues are reflected in research studies; knowledge
and instruments developed to produce knowledge are
focused on mental health, public health practices, sub-
stance abuse, minority and oppressed groups, poverty,
welfare policies, aging, and so forth. Essentially, the full
range of social work problems and practices are studied.
What Methods Do Social Work Researchers Use? Rosen,
Proctor, and Staudt (1999) have classified the research
articles they reviewed on the basis of the purpose of the
research as descriptive, explanatory, and control.
Descriptive studies assess the distribution characteristics
of single variables in one or more populations or samples.
In addition,studies that conceptualize relevant variables as
in qualitative research are included. Explanatory studies
investigate relationships among two or more variables, and
control studies investigate the effects of services or the
efficacy or effectiveness of interventions.
Tripodi and Potocky-Tripodi (2007) also indicate that
a variety of methods are used to provide evideilce for
achieving the knowledge objectives of social work
research: (a) case studies, participant observation, and
REsEARCH: OVERVIEW 513
techniques of instrument construction can be employed to
provide evidence for the development and operatio-
nalization of concepts; (b) qualitative methods, non-
participant observation, and participatory research can be
used to formulate theories and hypotheses; (c) census,
survey and epidemiological methods can be used to form
quantitative descriptions and to test correlational
hypotheses; and (d) quasi-experimental and experimental
designs can be used to test causal hypotheses.
Where Are Social Work Researchers Trained?
Social work researchers continue to receive their basic
research training from doctoral programs in social work or
related fields (Reid, 1995). In addition, a few receive
advanced training from post-doctoral progriJ.rns. More-
over, many researchers receive advanced training in
research and statistical methods at summer workshops in
major research universities, for example, courses in
survival analysis, epidemiological methods, multivari ate
analyses, and computerized programs that can be
employed in analyzing qualitative data.
Training can also be provided by governmental
agencies. The National Institute of Mental Health (NIMH),
for example, is supportive of training for social work
researchers. NIMH provided a research training workshop
at the University of Wisconsin in 1992-1993; research
dissemination workshops at the University of Michigan,
1994-1998, on child and adolescent mental health
services, mental health epidemiology, interven tion
research, and poverty and mental health; a two-day
research dissemination workshop in California for social
work faculty and social work practitioners; and a number
of pre-doctoral research training grants, two post-doctoral
training grants, and individual grants for. pre-doctoral and
post-doctoral students in social work education programs
during 1997 (Austin, 1999).
Where Is Social Work Research Conducted?
The research takes place in universities and research
centers, or in collaboration with investigators from other
institutions and administrators and practitioners at social
agencies. Research centers funded by federal agencies
such as NIMH or state-funded research centers that
evaluate the performance of social agencies are other
locations of social work research. Much research,
particularly as it relates to social work practice, is
agency-based research. Agencies often contain archives of
existing data that can be mined (Epstein, 200l). In
addition, social agencies may serve as sites for federally
funded research, or they may employ university re-
searchers to conduct or participate in needs assessments,
organizational studies, and program evaluations (Unrau,
Gabor, & Grinnell, 2006).
514 RESEARCH: OVERVIEW
What Are the Financial and Organizational
Supports for Social Work Research?
Financial support for social work research continues to
be "provided by a variety of sources, including
universities, agencies, federal and state research
funding, and foundations. Support from universities.
.. is primarily embedded in faculty salaries, office
space, equipment, and student research assistance"
(Reid, 1995, p. 2043). Social agencies may provide
management information sources, archival data, case
records, equipment, and time that practitioners might
spend in gathering and interpreting data. Many s tate
and federal agencies also provide grants for research
and evaluation studies. Per haps the most influential
agency that has provided large sources of funds for
social work research is NIMH
\
(Austin, 1999).
According to Austin (1999), NIMH has responded to
recommendations of the 1991 Task Force Report in a
very positive way, funding seven Social Work Research
Development Centers. Moreover, NIMH initially sup-
ported the creation of the Institute for the Advanc ement
of Social Work Research (IASWR). As a result of
collaboration between NIMH and IASWR, an increased
number of social work principal investigators were
funded.
NIMH has consistently been the largest funding
source for social work research (Austin, 1999). For
example, "in FY 1993, there were 38 research awards by
NIMH, for $9.5 million, made to social work educa tion
programs or Principal Investigators with social work
degrees. In FY 1995, there were 54 awards for $15.4
million, and in FY 1997, there were 60 ... for $15
million ... In FY 1993, there were 5 new research awards
to faculty and students in social work education
programs. In FY 1995, there were 14 and in FY 1997,
there were 23" (Austin, 1999, p. 5). Thus, there have
been, in general, increased levels of funding for social
work researchers in the 1990s.
Organizational mechanisms for facilitating the ex-
change of information among social work researchers
include research centers, federal and state agencies,
and universities and colleges. Two p redominant
organizations that have influenced the development
of social work research are the IASWR and the
Society for Social Work and Research (SSWR).
The creation of IASWR was recommended by the
NIMH Task Force on Social Work Research (Building
Social Work Knowledge, 1991) and it was founded with
the support of NIMH in 1993. It was financially sup-
ported by the Ford Foundation from 1997 to 1999 and
has received consistent financial contributions from
leading groups in the social work profession such as
National Association of Deans and Directors, Group
for the Advancement of Doctoral Education, the Council
on Social Work Education, the Association of
Baccalaureate Social Work Program Directors, and the
Society for Social Work and Research.
IASWR serves the research needs of the entire social
work profession. It also promotes social work research
that is conducted by other academic and professional
organizations (IASWR, 2006).
SSWR was founded in 1994 as a free-standing or-
ganization dedicated to the advancement of social work
research (SSWR, 2006). According to its by-laws, the
organization works collaboratively with IASWR on its
projects. Members of SSWR represent more than 200
universities and institutions, and include faculty in schools
of social work and other professional schools, research
staff in public and private agencies, and social work
graduate students. The membership of SSWR has
increased rapidly from approximately 200 to more than
1300 members from 45 states in the United States as well
as 15 other countries (SSWR, 2006).
SSWR holds an annual conference at which research
papers covering a range of social work topics and
research methods are presented. It also fosters
networking among social work researchers, advocates
for increased research funding, promotes advances in
knowledge, and provides recognition of significant
research contributions.
Continuing Issues and Developments
These are issues that were evident in the past decade and
that remain somewhat controversial: empirical practice
movement, choosing research methods, meta analysis,
research utilization, intervention research, and
generalizability .
EMPIRICAL PRACTICE MOVEMENT Empirical
practice is the use of social research methods to guide
practice decisions, particularly with respect to the
assessment of client problems and the evaluation of
social work interventions (Blythe, Tripodi, & Briar,
1994; Reid, 1995). Although single-subject, singlecase,
or single-system design has been a major compo nent of
empirical practice, other research methods have been
employed when evaluating practice (Blythe et al., 1994;
Tripodi, 1994). For example, qualitative procedures of
observation and unstructured interviewing as well as
archival data from social agencies have been used to
provide evidence about the control of internal validity
threats such as history and maturation. Nevertheless, the
main thrust of single-system designs (SSD) is the use of
time series data before and after interventions and the
manipulation of interventions such as a re-introduction
of an intervention after there has been

a natural withdrawal (that is, based on a clinical decision),
which resulted in relapse.
In a special issue of Social Work Research (1996, Vol.
20, No.2), three books were selected as representing
aspects of empirical practice and social work scholars
provided reviews of the ideas presented in these books:
Evaluating practice: Guidelines for the accountable profes-
sional (Bloom, Fischer, & Orme, 1999); Measures for
clinical practice: A sourcebook (Fischer & Corcoran, 1994);
and Direct practice research in human service agencies
(Blythe et al., 1994). Among the issu es raised were the
extent to which practitioners could be scientist-practi-
tioners, the conflict between practice and research, and the
advantages and disadvantages of single-system designs.
Proponents of the empirical practice movement asserted
that practitioners should evaluate their prac tice to be
accountable to clients and agency sponsors, especially in
managed care environments where agency outcomes were
tied to funds. Opponents of empirical practice believed
that the practitioner could not follow the rigid
requirements of empirical practice, particu larly those
procedures that appeared to require unethical
manipulations of interventions.
There is now a more balanced view of single-system
designs. It is clearly recognized that SSD is only one way
to secure evaluative knowledge and that the clin ical
interview as well as other research techniques are useful
(Di Noia & Tripodi, 2007; Vonk, Tripodi, & Epstein ,
2006). In fact, there is a trend to utilize more
methodological knowledge, that is, different research
procedures, to obtain knowledge pertinent to practice; and
this is clearly seen in practice research (Epstein, 2001). In
the coming years it is expected that practi tioners will
continue to use a variety of research meth ods, perhaps with
consultation from research experts, to garner information
relevant to practice.
CHOOSING RESEARCH METHODS In the past decade,
qualitative research courses have appeared in social work
doctoral programs; well-known research textbooks such as
that by Rubin and Babbie (2005) have included chapters
on qualitative methods; a few more qualitative research
articles have appeared in research journals; and textbooks
on qualitative research, for example, Qualitative methods in
social work research (Padgett, 1998) have been evident.
Distinctions between qualitative and quantitative
research methods were made to guide social work re-
searchers in their choice of methods. Padgett (1998), for
example, distinguished qualitative from quantitative
research as follows: "qualitative research is inductive,
seeking to discover; it is naturalistic and holistic; it deals
with open systems and dynamic reality; the
REsEARCH: OVERVIEW
515
qualitative researcher is an instrument of data collec tion;
and categories result from data analysis. in con trast,
quantitative research is deductive, based on the scientific
method, employs controlled conditions, is particularistic,
studies a stable reality, and uses standardized data
collection instruments; and in quantitative research,
categories precede data analysis" (cited in Tripodi
&Potocky-Tripodi; 2007, p. 40).
Research studies may have multiple objectives, some
of which might require both quantitative and qualita tive
methods within the same study. In fact, there is an
increasing emphasis on research studies that involve
several methods, that is, mixed methods research. Kazi
(2003) uses quantitative and qualitative research meth ods
in evaluating practice and Epstein (2001) illustrates how
collaboration of practitioners and researchers in mining
data from social agencies may result in using a
combination of research methods.
In the coming years it is expected that there will be
more mixed-methods research. Moreover, it appears there
will be fewer debates about quantitative or qualitative
methods; instead, it is likely there will be more attempts at
including multiple methods within the same studies. New
debates might deal with best prac tices for combining
research methods, and to what extent diverse methods
stemming from different epistemologicalpoints of view
can be combined.
MET A- ANAL YSIS Meta-analysis is a quantitative
method for synthesizing data from a large number of re-
search studies (Reid, 1995). Relationships between
variables, that is effect sizes, are combined in statistical
analyses. The studies that are included in meta- analysis are
quantitative and include statistics such as means, standard
deviations, and correlation coefficients.
Meta-analysis "offers discipline and precision; is a
descriptive tool; and brings statistical tools to the literature
review" (Videka-Sherman, 1995, p. 1716). It should be
noted, however, that meta-analysis is a procedure for
combining quantitative studies but not qualitative studies.
Hence, it does not supersede narra tive reviews of
qualitative research studies. Moreover, as Shadish, Cook
and Campbell (2002) indicate, metaanalysis can only be as
good as the studies that are included; jf the studies are
flawed, the meta-analysis will also be flawed.
Narrative reviews, on the other hand, can provide
detailed descriptions of qualitative categories used in the
development of theory (Shadish et al., 2002). Narrative
reviews of research studies are advantageous for
developing concepts and hypotheses that are conceptually
generalizable, that is, that can be employed in a variety of
situations.
516 REsEARCH: OVERVIEW
Meta-analysis can be useful for summarizing rela-
tionships of variables and average sizes in quantitative
studies. Two examples of meta-analytic studies in the late
1990s and early 2000s include that of Franklin, Grant,
Corcoran, Miller, and Bultman (1997), which analyzes 32
outcome studies on the primary prevention of adolescent
pregnancy and examines several moderator variables with
respect to the findings; and Dumaine (2003), which
analyzes 15 quantitative research studies to determine
effective interventions for clients diag nosed as severely
mentally ill and as substance abusers,
RESEARCH UTILIZATION The utilization of social
work research by practitioners continues to be an area of
concern. In general, practitioners do not read re search
studies, and they do n~t systematically search the literature
for evidence on which to base their practice. However,
there are some indications that practi tioners use methods
of research for evaluating practices and programs, use
standardized instruments when available for particular
substantive problems in assessment, and use
questionnaires and forms for gathering information about
clients and their families (Yonk et al., 2006).
From a cursory review of social work research journals
over a decade, it appears that there are very few articles
concerned with research about the process of utilizing and
integrating research in practice. Supporting this view,
Feldman (2005) asserted that there has been little research
dealing with how to utilize research findings in practice,
and that research utilization has been n eglected in the past
decade. He further noted that the last book on the topic was
written approximately 15 years ago by Grasso and Epstein
(1992).
Epstein (2001) has pioneered a movement of
practice-based research whereby research is inductively
generated in practice situations by practitioners colla-
borating with researchers. In addition, proponents of
participatory research have focused more directly on an
integration of practice and research. Allen-Meares,
Hudgins, Engberg, and Lessnau (2005), for example,
examined how 10 collaborative projects focused on
children and youth, and they applied the principles of
participatory research by analyzing multiple forms of
qualitative studies.
It is hoped that in the next decade the distance between
research and practice will diminish. More research is
needed on the different modes for implementing research
knowledge in practice. Perhaps this can be sparked by
more studies that are practice-based, as well as increased
use of participatory research modalities.
INTERVENTION RESEARCH Schilling (1997) refers to
an intervention by a social worker as an action with
clientele to enhance or maintain their functioning and
well-being. He cites the pioneering work of Thomas and
Rothman (1994) who asserted that intervention research
includes: (a) behavioral research related to interventions,
(b) knowledge utilization and applications of the research
in practice, and (c) the design, development, and
evaluation of interventions. Expanding on these notions of
intervention, Schilling (1997) specifies five types of
studies encompassed by intervention research:
(1) studies that attempt to understand problem phe-
nomena, undertaken with the objective of develop-
ing interventions; (2) research on the process of
helping; (3) longitudinal studies that observe what
happens to clients during and after their agency
contact; (4) studies that systematically design and
develop interventions; and (5) full-scale experi-
ments, testing clinical or social change strategies in
agency, field, and community settings (p. 174).
Two promising recent developments are team efforts and
intervention research, A social intervention group was
founded in 1990 at the Columbia University School of
Social Work with the purpose of developing, adapting, and
testing socio-behavioral interventions that aim to reduce
social problems among low-income urban populations
(Schilling, 1997). Over the years, under the leadership of
Schilling and Schinke, a number of intervention research
studies have been conducted. Two examples are:
Evaluation of a brief computermediated· intervention to
reduce HIV risk among early adolescent females (Di Noia,
Schinke, Pena, & Schwinn, 2004) and Reducing the risks of
alcohol use among urban youth: Three-year effects of a
computer-based intervention with and without parent
involvement (Schinke, Schwinn, Di Noia, & Cole, 2004).
Fraser, Galinsky, Richman, and Day at the Univer sity
of North Carolina have developed a sequential
experimentation approach to intervention research, created
a conceptual framework of practice based on risk and
resilience, and worked on projects to promote intervention
research (Fraser, Nash, Galinsky, & Darwin, 2000; Fraser,
Richman, & Galinsky, 1999; Richman & Fraser, 2001).
The promise of intervention research is in the
development of effective interventions that can be
implemented in social work practice (Fraser, 2004 ).
Among the difficulties in such research are developing
non-mechanistic protocols for implementing interven-
tions, accounting for variations among practitioners,
developing reliable and valid measures of effectiveness,
reducing attrition in field experiments, developing
meaningful control groups, controlling internal and

external validity threats, and developing replications
across sites, practitioners, and clients for interventions that
appear to be effective.
GENERALIZABILITY One of the most vexing problems
in social work research as well as in other forms of social
science research is that of generalizability. Yet there has
been very little work that explores the parameters and
extent of the problem. Nurius and Tripodi (1985) re~
viewed several years of literature in the 1980s and noted
that many different modalities were used to argue for
generalizabiliry in research studies. Statistical inference
was employed usually with non-representative samples;
replications were mentioned infrequently; qualitative and
quantitative comparisons of samples to populations were
made; and appeals to the literature with respect to
consistent findings were included (Nurius & Tripodi,
1985). By and large, it was clear that there were no
standards that were universally employed.
The issue of generalizability is continually evident in a
collection of 20 studies by social work researchers
(Alexander & Solomon, 2006). The authors were asked to
comment on the strengths and limitations of those studies
as well as specify the underlying principles for making key
decisions influencing the research process (Tripodi, 2006 ).
That special feature gave a perspective on how different
aspects of the research process are" often compromised in
agency and community research as a function of social,
political, ethical, and economic constraints" (Tripodi,
2006, p. 61). These constraints also affected the degree to
which results could be generalized:
A content analysis of the authors' commentaries
indicated that 15 studies emphasized limitations in
generalizabiliry; 10 studies, issues in internal
validity; and 5 made conclusions that their data
were suggestive of certain findings. Limitations
discussed included the type of sampling employed;
loss of subjects in data collection as well as in data
analysis; lack of clarity on the population to which
the researchers desired to generalize their results;
lack of replications, and so forth (Tripodi, 2006, pp.
61-62).
The methodological study of guidelines and 'criteria for
making generalizations has been lacking in social work.
Yet, the extent to which one can generalize knowledge is at
the root of using evidence on which social workers can
make decisions about their practice. It is hoped that
systematic guidelines for generalizations will be devel-
oped in the coming years.
Emerging Developments
These issues are topical in today's current research en-
vironment, and it is expected they will be important in
RESEARCH: OVERVIEW
517
the years to come: evidence-based practice, practice based
research, culturally competent research, and international
social work research.
EVIDENCE~BASED PRACTICE According to Sackett,
Straus, Richardson, Rosenberg, and Haynes (2000),
evidence-based practice (EBP) is "the conscientious,
explicit and judicious use of current best evidence in
making decisions about the care of the individual pa tient.
It means integrating individual clinical expertise with the
best available external clinical evidence from systematic
research" (p. 1). EBP, described elsewhere in detail
(Gambrill, 1999; Gambrill, 2003; Sackett, Rosenberg,
Gray, Haynes, & Richardson, 1996), is a movement that
involves the utilization of practice evi dence by
practitioners, which encourages them to select effective
intervention approaches for their clients.
To explicate the implementation stage of EBP,
Gambrill (1999) has identified and summarized the
following steps:
1. converting information needs into answerable
questions;
2. tracking down with maximum efficiency the best
evidence to answer key questions;
3. critically appraising that evidence for its validity and
usefulness;
4. applying the results of this appraisal to a particular
client;
5. evaluating the outcome (p. 3).
Despite the fact that these steps seem practicable, many
practitioners are still uncertain about the implementation
process and overwhelmed by the challenges. Often, social
workers lack the necessary skills, time, or resources to.
implement the EBP approach. A significant obstacle
involves access to the existing literature; many
practitioners work in settings where there is no direct
access to books and journals. Those who do have access to
literature find it difficult to stay completely informed on a
regular basis, given the vast amount of literature that is
available; it is also well beyond the capacity of their
education. Even those who have the expertise to evaluate
evidence find the task timeconsuming and challenging
(Lohr, 2000).
With the development of practice guidelines, avail-
ability of meta-analyses and systematic reviews of lit-
erature, and use of technology such as Web sites and other
electronic databases, the challenges associated with
compiling, evaluating, and utilizing the evidence co uld be
reduced (Gibbs, 2003; McNeill, 2006; Videka, 2003 ).
Despite the challenges, the interest in EBP movement is
rising, thus providing social workers, educators,
researchers, and policy developers a great
518 REsEARCH: OvERVIEW'
opportunity to improve relationships between science and
practice and expand partnerships (Jenson, 2005).
PRACTICE,BASED RESEARCH Practice- based
research (PBR) focuses on practitioners and draws them
into the research process, thus increasing the utiliza tion of
research knowledge. Yegidis and Weinbach (2002 )
reported that "a practice-oriented and practice informed
researcher is likely to produce research find ings that will
have value and be of benefit to those who deliver services
to clients" (p. 8). According to Epstein (2001) ,
"practice-based research may be defined as the use of
research-inspired principles, designs and informa tion
gathering techniques within existing forms of prac tice to
answer questions that emerge from practice in ways that
inform practice" (p. 17).PBR relies on the following
fundamental characteristics:
• it is inductive, that is, key concepts are derived from
practice wisdom;
• it utilizes non-experimental or quasi-experimental
designs;
• it se~ks descriptive or correlational knowledge;
• it may be retrospective or prospective;
• it may be quantitative or qualitative, but it relies on
instrumentation that is tailored to practice needs
rather than on externally standardized research
measures;
• it is collaborative, but it in its implementation,
practice requirements outweigh research consid-
erations (Epstein, 2001, p. 18).
The overall goal of PBR is to integrate practice and
research. In this case, research is conceptualized by
practitioners, using techniques compatible with prac tice.
Since this research takes place in agency settings, it tends
to be more naturalistic, heuristic, and reflective (Epstein,
2001). PBR inquiries can be carried out by agency
researchers, academics, practitioners, students, and
service recipients (Hess & Mullen, 1995).
PBR has received increased attention in the past years
and is evident particularly in clinical data- mining (COM)
studies (Auslander, Dobrof, & Epstein, 2001; Epstein &
Blumenfield, 2001; Gellis, 2001; Mason et al., 2001 ;
Peake, Epstein, & Medeiros, 2005; Zilberfein, Hutson,
Snyder, & Epstein, 2001) and participatory research (PR)
(Allen-Meares et al., 2005; Gellis, 2001; Wong & Chow,
2006) as ways of informing practice.
As in evidence-based practice, the challenges asso-
ciated with practice-based research include the issue of
generalizability. The findings from the PBR may only be
applied to the particular settings where the studies were
conducted. However, with replications at different sites by
one large agency or across different agencies,
the findings might be more generalizable. Developing and
employing research methods that assure both fide lity and
utilization applicability are a challenge for researchers
and practitioners. From a practice- research integration
perspective, however, "clinical data mining" may be a
credible alternative to randomized controlled experiments
(Sainz & Epstein, 2001).
As recent research trends and developments demon-
strate, the number of social work practitioners, research-
ers, and clients involved in collaborative activities in
developing and testing interventions is increasing. It is
hoped that more partnerships will be developed in the
coming years to increase research utilization among
practitioners to decrease the distance between research ers
and practitioners.
CUL TURALL Y COMPETENT RESEARCH In recent
years researchers have come to realize th at cultural
differences in clientele can affect studies in all phases of
the research process-from problem formulation to the
collection and analysis of data (Rubin & Babbie, 2005).
There is little research in relation to understand ing
differences that might occur as a result of cultural
variations and researchers' sensitivities. However, there is
a growing number of precautions that are included in
textbooks on research.
Rubin and Babbie (2005) state that cultural compe-
tence in social work research "mea ns being aware of and
appropriately responding to the ways in which cultural
factors and cultural differences should influ ence what we
investigate, how we investigate, and how we interpret our
findings" (p. 497). Prior to studying minority and
oppressed groups, Rubin and Babbie (2005) advise that
researchers should review literature concerning the
historical, economic, familial, tradi tional, and cultural
factors that affect those groups. Moreover, researchers
should avoid the biases of ethnocentrism and recognize
that there are variations within cultures as well as between
cultures.
Ortega and Richey (1998) make a number of sugges-
tions for increasing cultural competence: promoting
"methodological diversity, cross- cultural measurement
validity, consideration of environmental risk and resi-
liency factors, attention to the process of data collec tion,
and researcher self assessment" (p. 48). However, their
suggestions need to be tested empirically.
Social work researchers need a firm base of knowl-
edge, attitudes, and skills for conducting research in
different cultures. It is hoped that there will be future
research regarding the development of culturally com-
petent researchers. Moreover, instruments should be
developed to assess the extent to which social work
researchers are culturally competent.

Future Trends
With the pressure of globalization and the thrust of
international relations centered on such problems as human
trafficking, mental health and child welfare, international
social work has become increasingly important (Healy, 2001;
Hokenstad & Midgley, 2004). Concomitantly, international
social work research has also been of interest to the social
work profession. lung and Tripodi (2007) conducted a content
analysis of social work journals from 1995-1999 and from
2000-2004 to determine the extent to which there was an
increase in international social work research. As a minimum,
international social work research uses literature from two or
more countries to develop the research problem and
objectives, 'and it discusses the social work implications for
those countries (Tripodi & Potocky-Tripodi, 2007). For
national social work journals (United States, United Kingdom,
and India) the percentage of articles that were based on inter-
national social work research studies increased from 4.1 % in
1995-1999 to 9.5% in 2000-2004; for the same time periods
international social work research in social work research
journals (Social Service Review and Research on Social Work
Practice) increased from 2.8% to 4.0%. Hence, there was a
slight increase in international social work research.
In the future, it is expected that there will be more
attention paid to substantive and methodological issues in
international social work research. Moreover, since lung and
Tripodi (2007) found a slight decline in transnational
research, that is, comparative studies between countries,
international journals and research journals, it is hoped that
this type of research will increase in the next decade
REFERENCES
Alexander, L. B., & Solomon, P. (2006). The research process in
the human services: Behind the scenes. Belmont, CA:
Thomson, Brooks/Cole.
Allen-Meares, P., Hudgins, C. A., Engberg, M. E., & Lessnau,
B. (2005). Using a collaboratory model to translate social
work research into practice and policy. Research on Social
Work Practice, 15(1),29-40.
Auslander, G., Dobrof, j., & Epstein, I. (200l). Comparing
social work's role in renal dialysis in Israel and the United
States: The practice-based research potential of available
clinical information. Social Work in Health Care, 33(3/4),
129-151.
Austin, D. M. (1999). A report on progress in the development
of research resources in social work. Research on Social
Work Practice, 9(6), 673-707.
Bloom, M., Fischer, ]., & Orme, ]. G. (1999). Evaluating
practice: Guidelines for the accountable professional. Needham
Heights, MA: Allyn & Bacon.
REsEARCH: OVERVIEW 519
Blythe, B., Tripodi, T., & Briar, S. (1994). Direct practice
research in human service agencies. New York: Columbia
University Press.
DiNoia, ]., Schinke, S. P., Pena,]. B., & Schwinn, T. M.
(2004). Evaluation of a brief computer-mediated interven-
tion to reduce HIV risk among early adolescent females.
The Journal of Adolescent Health: Official Publication of the
Society for Adolescent Medicine, 35(1),62-64.
Di Noia, j., & Tripodi, T. (2007). A primer on single-case
design for clinical social workers (2nd ed.). Washington,
DC: NASW Press.
Dumaine; M. L. (2003). Meta-analysis of interventions with
co-occurring disorders of severe mental illness and sub-
stance abuse: Implications for social work practice.
Research on Social Work Practice, 13(2), 142-165.
Epstein, I. (2001). Using available clinical information in
practice-based research: Mining for silver while dreaming
of gold. Social Work in Health Care, 33(3/4),15-32.
Epstein, I., & Blumenfield, S. (Eds.). (2001). Clinical data-
mining in practice-based research: Social work in hospital .
settings. Binghamton, NY: Haworth Press.
Feldman, R. A. (2005). Critical infrastructure for social work
practice research: Pondering the past, framing the future. Paper
presented at the "Advancing practice research in social
work for 21st century" conference. SUNY Albany, NY.
Fischer, ]., & Corcoran, K. (1994). Measures for clinical
practice:
A sourcebook. New York: Free Press.
Franklin, c., Grant, D., Corcoran, ]., Miller, P.O., & Bultman,
L. (1997). Effectiveness of. Prevention programs for
adolescent pregnancy: A meta-analysis. Journal of Marriage
and the Family, 59,551-567.
Fraser, M. W. (2004). Intervention research in social work:
Recent advances and continuing challenges. Research on
Social Work Practice, 14(3), 210-222.
Fraser, M. W., Nash, j, K., Galinsky, M. j., & Darwin, K. E.
(2000). Making choices: Social problem-solving skills for
children. Washington, DC: NASW Press.
Fraser, M. W., Richman.]. M., & Galinsky, M.]. (1999). Risk,
protection, and resilience: Towards a conceptual
framework for social work practice. Social Work Research,
23(3), 131-143.
Gambrill, E. (1999). Evidence-based practice: An alternative
to authority-based practice. Families in Society,
80(4),341-350.
Gambrill, E. (2003). Evidence-based practice: Implications for
knowledge development and use in social work. In A.
Rosen & E. K. Proctor (Eds.), Developing practice guidelines
for social work intervention: Issues, methods, and research
agenda (pp. 37-58). New York: Columbia University Press.
Gellis, Z. D. (2001). Using a participatory research approach
to mobilize immigrant minority family caregivers. Journal
of Social Work Research and Evaluation, 2(2), 267-282.
Gibbs, L. E. (2003). Evidence-based practice for the helping pro-
fessions: A practical guide with integrated multimedia. Pacific
Grove, CA: Brooks/Cole-Thompson Learning.
Grasso, A. ]., & Epstein, I. (Eds.). (1992). Research utilization in
the social services: Innovations in practice and
administration. New York: Haworth Press.
Healy, L. (2001 ).Intemational social work: Professional action in
an interdependent world. New York: Oxford University
Press.
520 RESEARCH: OVERVIEW
Hess, P. M., & Mullen, E. J. (1995). Practuioner-reseoscher
partnerships: Building knowledge from, in, and for practice.
Washington, DC: NASW Press.
Hokenstad, M. C, & Midgley, J. (Eds.). (2004). Lessons from
abroad: Adapting international social welfare innovations.
Washington, DC: NASW Press.
IASWR. (2006). Institute for the advancement of social work
research. Retrieved October 2, 2006, from http://
www.iaswresearch.org/.
Jenson, J. M. (2005). Connecting science to intervention:
Advances, challenges, and the promise of evidence-based
practice. Social Work Research, 29(3), 131-135.
[ung, S. Y., & Tripodi, T. (2007). Trends in international social
work research. International Social Work, 50(5),691-698.
Kazi, M. (2003). Realist evaluation for practice. British Journal of
Social Work, 33(6), 803-818.
Lohr, K. N. (2000). Assessing ,"best evidence": Grading the
quality of articles and rating the strength of evidence.
Retrieved October 13, 2006, from http://www.rtLorg/epc/
grading urticle.htrnl/ .
Mason, J., Edlow, M., Lear, M., Scoppeta, S., Walther, V.,
Epstein, I., & Guaccero, S. (200l). Screening for psycho social
risk in an urban prenatal clinic population: A retrospective
practice-based research study. Social Work in Health Care,
33(3/4), 33-52.
McNeill, T. (2006). Evidence-based practice in an age of
relativism: Toward a model for practice. Social Work, 51(2),
147-156.
National Institute of Mental Health. (1991). Building social work
knowledge for effective services and policies: A plan for research
development. A report of the task force on social work research.
Washington, DC: Author.
Nurius, P. S., & Tripodi, T. (1985). Methods of generalization
used in empirical social work literature. Social Service Review,
59(2), 239-257.
Ortega, D. M., & Richey, C A. (1998). Methodological issues in
social work research with depressed women of color. Journal of
Social Service Research, 23(3/4),47-70.
Padgett, D. K. (1998). Qualitative methods in social work research:
Challenges and rewards. Thousand Oaks, CA: Sage
Publications.
Peake, K., Epstein, I., & Medeiros, D. (Eds.). (2005). Clinical and
research uses of an adolescent intake questionnaire: What kids need
to talk about. Binghamton, NY: Haworth Press.
Reid, W. J. (1995). Research overview. In R. L. Edwards & J. G.
Hopps (Eds.), Encyclopedia of social work (19 ed.). Vol. III, pp.
2040-2058). Washington, DC: NASW Press.
Richman, J. M., & Fraser, M. W. (Eds.). (200l). The context of youth
violence: Resilience, risk, and protection. Westport, CT:
Praeger Publishers.
Rosen, A., Proctor, E. K., & Staudt, M. M. (1999). Social work
research and the quest for effective practice. Social Work
Research, 23(1), 4-14.
Rubin, A., & Babbie, E. R. (2005). Research methods for social work
(5th ed.). Belmont, CA: Wadsworth/Thompson Learning.
Sackett, D. L., Rosenberg, W., Gray, J. A. M., Haynes, R. B., &
Richardson, W. S. (1996). Evidence-based medicine: What it
is and what it isn't. British Medical}ournal, 312(13), 71-72.
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg,W., &
Haynes, R. B. (2000). Evidence-based medicine: How to
practice and teach EBM (2nd ed.). New York: Churchill
Livingstone.
Sainz, A., & Epstein, I. (2001). Creating experimental analogs
with available clinical information: Credible alternatives to
"Gold-standard" Experiments? Social Work in Health Care,
33(3/4 ),.163-183.
Schilling, R. F. (1997). Developing intervention research pro-
grams in social work. Social Work Research, 21(3.), 173-180.
Schinke, S. P., Schwinn, T. M., Di Noia, J., & Cole, K. C (2004).
Reducing the risks of alcohol use among urban youth:
Three-year effects of a computer-based intervention with
and without parent involvement. Journal of Studies on Alcohol,
65(4), 443-449.
Shad ish, W. R., Cook, T. D., & Campbell, D. T. (2002).
Experimental and quasi-experimental designs for generalized causal
inference. Boston: Houghton-Mifflin.
SSWR. (2006). Society for social work and research. Retrieved
October 3,2006, from http://www.sswr.org/.
Thomas, E., & Rothman, J. (1994). An integrative perspective on
intervention research. In J. Rothman & E. Thomas (Eds.),
Intervention research: Design and development for human service
I
(pp, 3-23). New York: Haworth Press.
Tripodi, T. (1994). A primer on single.subject design for clinical 1
social workers. Washington, DC: NASW Press.
Tripodi, T. (2006). Book review: The research process in the
i
human services: Behind the scenes. Evaluation & Program ~
Planning, 29(1), 61-62. -1
Tripodi; T., & Potocky-Tripodi, M. (2007). International social work
research: Issues and prospects. New York: Oxford· University
Press.
Unrau, Y. A., Gabor, P. A., & Grinnell, R. M. J. (2006).
Evaluation for social workers. New York: Oxford University
Press.
Videka, L. (2003). Accounting for variability in client, population
and setting characteristics: Moderators of intervention
characteristic. I~ E. Proctor & A. Rosen (Eds.), Evidence based
practice and practice guidelines for social work (pp. 169-192).
New York: Columbia University Press.
Videka-Sherman, L. (1995). Meta-analysis. In R. L. Edwards & J.
G. Hopps (Eds.), Encyclopedia of social work (19 ed., Vol. III, pp.
1711-1719). Washington, DC: NASW Press.
Vonk, E. M., Tripodi, T., & Epstein, I. (2006). Research techniques
in clinical social work (2nd ed.). New York: Columbia
University Press.
Wong, D. K. P., & Chow, S. F. (2006). Beyond clinical trials and
narratives: A participatory action research with cancer patient
self-help groups. Patient Education & Counseling, 60(2),
201-205.
Yegidis, B., & Weinbach, R. (2002). Research methods for social
workers. Boston, MA: Allyn & Bacon. .
Zilberfein, F., Hutson, C, Snyder, S., & Epstein, I. (200l).
Social work practice with pre- and post-liver transplant
patients: A retrospective self study. Social Work in Health Care,
33(3/4), 91-104.
-TONY TRIPODI AND MARINA LALAYANTS
 RESEARCH: HISTORY OF RESEARCH
521

HISTORY OF RESEARCH administrative issues. Covering the lifespan, social work

ABSTRACT: An important attribute of a profession is the
systematic study of its practices, to c ontinually advance its
service modalities. Throughout its history the social work
profession has engaged in research and sought to
strengthen connections between research and practice.
National social work organizations and federal agencies,
especially the National Institute of Mental Health, have all
played key roles in stimulating and assessing the research
enterprise. International and interdisciplinary research,
advanced research methods and
research/practitioner/community partnerships provide
perspective for future efforts.
KEY WORDS: interdisciplinary; international; social
work organizations; research: federal agencies; history
An important attribute of a profession is the systematic
study of its practices, to continually advance its service
modalities. Since the inception of the social work profes-
sion more than a century ago, research on interventions,
social problems, and social policy have been important to
its purpose and functions. However, tension exists
between research and practice. Concerns about practi-
tioner's lack of demands for and use of empirical research
are coupled with concerns that researchers' studies are not
relevant to practitioners. To best understand social work
research and its history, specific efforts to stimulate social
work research within national and international contexts
can be examined.
Scope of Social Work Research
Austin (2003) provides an early history of research in
social work, including links between social work and
social sciences and turn-of-the-century studies of poverty's
causes. Early research included case studies from the
Charity Organization Society and the 1909 Russell Sage
Foundation-supported survey research, "The Standards of
Living among Workingmen's Families in New York City."
1'1'
Studies of workers, including children, led to workers'
'~;l
research benefits consumers, practitioners, policymakers,
educators, and the general public by examining prevention
and intervention strategies for health and mental health,
child welfare, aging, substance abuse, community
development, managed care, housing, economic
self-sufficiency, and family well-being; studying the
strengths, needs, and interrelationships of individuals,
families, groups, neighborhoods, and social institutions;
and providing evidence for improved service delivery and
public policies (lASWR, 2003).
Social work research employs multiple methods,
including quantitative and qualitative modalities, ranging
from case studies, to surveys, to quasi-experimental designs to
experimental designed randomized controlled trials. Focus
on community-based participatory research and action research
more fully engages consumers and communities in design
and implementation. Social workers engage in program
evaluation, frequently evaluating agency-based program
innovations. Data analysis becomes more sophisticated as
software and statistical programs advance, leading to
better understanding of outcomes, for example,
relationships between length of stay in care and time of
entry for foster children or differential. health outcomes
related to health disparities. Social work research includes
secondary data analyses of large data sets. The 1980 s saw
a major focus on single-subject design and a push toward the
practitionerresearcher. While this role was neve r fully
implemented, thee importance of practitioners'
systematically gathering information about their practice,
client attributes and service outcomes is important in
treatment planning and creating researcher-practitioner
partnerships.
The interest in evidence-based practice and thus the need
to identify the "best available evidence" draws attention to
the need for meta-analysis and systematic reviews of
research and more high quality research. The Campbell
Collaboration, with international social wor k leadership,
creates and disseminates systematic reviews of social
intervention research in social welfare, criminal justice,
and education, for use by decisionmakers and the public.

I compensation and child labor laws. Just as the profession

emerged into the two tracks of social action and casework,

.~ social work research also addressed these divergent

intervention methods.
Social work research initially occurred in agencies and
was supported by foundation dollars. As social work
National Organizations and Research SOCIAL
WORK RESEARCH GROUP Cyclically, organizations
focusing on social work research have developed. In 1948
the Social Work Research Group (SWRG) brought
training moved into universities so did researchers, with together researchers from universities, community
studies supported by public dollars. The Institute for the agencies, community planning councils, and federal
'l~ Advancement of Social Work Research (IASWR) defines agencies. SWRG merged into the National Association of
Ii
~:i
social work resear~h as addressing psychosocial problems,
treatment of acute and chronic conditions, and community,
Social Workers (NASW) when it was created in 1955 and
continued as a specialty section and then as a Coun cil until
'
organizational, policy, and it was dissolved when NASW restructured in
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522 RESEARCH: HISTORY OF RESEARCH
1974. Although initial SWRG members were not neces-
sarily degreed social workers, after the merger, new mem-
bers met the NASW degree requirements.
NATIONAL ASSOCIATION OF SOCIAL WORKERS
After restructuring, there was interest for NASW to
stimulate and develop research and to establish a clear-
inghouse on practice research, including identifying areas
where research was needed (Alexander, 1986; Fanshel,
1980). In 1986 NASW launched the National Center for
Social Policy and Practice, which briefly attempted to fill
these functions.
NASW was a force in the establishment of the Task
Force on Social Work Research (TFSWR) in 1988,
supported by NIMH (see below), and is the largest
financial supporter of the IASWR. NASW publishes five
major social work journals. In 1994 Social Work Research
and Social Work Abstracts separated into two journals to put
greater emphasis on scholarship and dissemination of
research findings. The NASW Foundation provides two
doctoral research fellowships and NASW offers a national
social work research award. NASW's Code of Ethics
addresses ethical issues related to social work research and
the importance of undertaking research to advance the
profession's knowledge base (NASW, 1999). Developed
by IASWR, NASW's website includes a research Web
page highlighting social work research contributions
(http://www .social workers.orgjresearchjdefault.asp) .
COUNCIL ON SOCIAL WORK EDUCATION The
Council on Social Work Education's (CSWE) mission
includes promotion of research. Beyond supporting
IASWR, in 2004, it established the Office of Social Work
Education and Research, housing the CSWE Minority
Fellows program to help ethnic minority students complete
doctorates, and working to implement the 2005 CSWE
Research agenda (http://www.cswe.org/NR/
rdonlyres/C497 86DD- EC1 C-4A 1 0- A389-694 2312D54
E7/0/CSWEResearchAgenda.pdf). Historically, CSWE
research address teaching research, use of research within
the curriculum, and data about social work education.The
educational policy statements and accreditation standards,
revised and amended over the decades specify evolving
requirements for the use of research, the teaching of
research, and the scholarly activities of faculty (CSWE,
2001).
INSTITUTE FOR THE ADVANCEMENT OF SOCIAL
WORK RESEARCH Responding to the TFSWR recom-
mendations, in 1993, five professional organizations
(NASW, BPD, CSWE, NADD, and GADE) created
IASWR,whose mission is to advance the profession's
knowledge base by building research capacity, by increas-
ing support and opportunities for research, by promoting
linkages among social work practice, research, and edu-
cation communities, and through representing the pro-
fession within the national scientific community. With a
small staff, IASWR performs multiple functions as a
broker, catalyst, convener, communicator, and advocate. It
promotes development, dissemination, and utilization of
research; provides technical assistance and researcher
training; convenes symposia on the state of research;
develops practice-relevant research agendas; participates
in interdisciplinary coalitions to promote and integrate
social work research into the broader sciences; serves as a
key link to federal research funding agencies (for example,
the NIH, National Science Foundation, Centers for Disease
Control and Prevention, National Institute of Justice); and
disseminates information about research funding
opportunities, conferences, new research findings,and
strategies for developing research capacities through its
weekly e-alert service, IASWR Listserv Announcements,
through its Web site, and through newsletters and
conference presentations (Zlornik & Solt, 2006).
SOCIETY FOR SOCIAL WORK AND RESEARCH
Founded in 1994, the Society for Social Work and
Research (SSWR) is a venue for social work researchers to
coalesce and promote knowledge building for the
profession. It became the sixth supporting organization of
IASWR in 2000 and its conference attracts 1,2001,400
participants. The conference provides a forum for doctoral
student presentations and offers workshops and symposia
on both methodology and research findings by senior
researchers. Researcher training and technical assistance is
presented by federal funders through IASWR
preconference institutes. SSWR membership has grown
exponentially in a decade, indicating high interest
specifically focused on research. SSWR offers
subscriptions to two research journals and established
several annual research awards, including outstanding
doctoral dissertation, early career achievement,
distinguished achievement, excellence in research,
doctoral fellows, and the Aaron Rosen lecture.
CHILD WELFARE RESEARCH Child welfare research is
prominently led by social workers, contributing to child
abuse and neglect prevention and treatment, out of home
placement, permanency planning, in-home family support,
family preservation, family reunification services,
adoption and postadoption services knowledge. Family-
centered care, child welfare teams, workforce issues, and

connection to mental health, substance abuse and juve-
nile justice systems, as well as data-driven outcomes and
accountability are all areas of social work research
output. The Child Welfare League of America's National
Council on Research in Child Welfare provided a forum
to bring together child welfare researchers to promote
research and to organize national conferences and
special journal issues; however the group disbanded in
early 2000. Subsequently a child welfare research
interest group meets regularly at the SSWR Conference.
AGING RESEARCH For gerontological researchers,
the Gerontological Society of America (GSA) provides
scholarly exchange and has a large social work
membership. GSA is also the grantee fo~ the John A.
Hartford Foundation's Scholars Program (supporting
gerontologicalleadership and scholarship for junior
social work faculty), Hartford Doctoral Fellows (to
support agingfocused doctoral dissertations), and
Doctoral Fellows Pre-Dissertation Awards, are all part
of the Foundation's Geriatric Social Work Initiative.
INTERDISCIPLINARY RESEARCH
ORGANIZATIONS Several interdisciplinary research
organizations have a social work presence, including the
Society for Prevention Research, the Research Society
on Alcoholism, the American Evaluation Association,
and the International Association for Psychosocial
Rehabilitation Services.
NA TIONAL INSTITUTES OF HEALTH SUPPORT
As the major funder of public health research in the
world, between 1993 and 2004, NIH funded almost 500
social work research grants with more than 50% from
NIMH and about 30% from the National Institute on
Drug Abuse (IASWR, 2005). It is important to examine
the history of social work and NIH.
NATIONAL INSTITUTE OF MENTAL HEALTH
From its establishment in 1949, the NIMH supported the
training of social workers. NIMH's Milton Wittman
played a significant role in supporting mental health
specific initiatives along with social work practice and
research beyond specific mental health settings. This
federal support is manifested in research training
programs at CSWE and several universities and was a
catalyst for doctoral education and research agenda
setting. In the early 1950s, NIMH supported a commit-
tee on advanced education that resulted in the expansion
of doctoral education beyond Bryn Mawr and the
University of Chicago, with research competence
expected of all doctoral students (Kendall, 2002).
REsEARCH: HISTORY OF
REsEARCH 523
In 1966, NIMH supported NASW's publication of
Five Fields of Social Services: Reviews of Research (Maas,
1966), systematic reports of research in family services,
public welfare, child welfare, neighborhood centers, and
social planning, all core domains that functioned under
social work auspices. Originally planned to also include
fields where social work is in a host setting as well as
regular research updates, the next steps never occurred.
In the late 1970s, NIMH supported an NASWhosted
conference, resulting in the Future of Social Work Research
(Fanshel, 1980), highlighting the importance of
researcher-practitioner linkages and noting shifts in the
social work research arena from agency auspices to
academic or think tank settings. The requirements for
professional schools to meet academic standards
reinforced social work faculties' pursuit of research and
promoted interdisciplinary scholarship.
Resulting from a CSWE-convened conference, the
report Research Utilization in Social Work Education (Briar,
Weissman & Rubin, 1981) described the teaching of
research as well as incorporating research into practice
classes. The project found support for the de velopment
of empirically-based models of social work practice and
an increasing research interest among social work
educators.
NIMH's prompting the profession to address
research continued after Dr. Wittman's retirement. In
1988, it funded the TFSWR. The TFSWR's three-year
examination of the status of research and research
training culminated in the landmark Building Social Work
Knowledge for Effective Services and Policies: A Plan for
Research Development (TFSWR, 1991) with
recommendations targeted toward NIMH, other
federal agencies, pro fessional associations, and social
work education programs. NIMH's advisory council
accepted the recommendations and directed NIMH to
support implementation, which included the early
operations of both IASWR and SSWR. The TFSWR
declared "a crisis in the current development of
research resources in social work," and that "the
contributions of practice- relevant research to the
knowledge base of soci al work practice lags far
behind the dynamic growth of the profession and
professional education" (TFSWR, 1991, p. viii). This
crisis pushed the profession to embark on strategic
actions to strengthen both the development of know-
ledge and the use of resea rch knowledge for practice.
The increased attention to research occurred in
concert with enhanced political foci on outcomes,
accountability, and evidence-based practice.
NIMH created the Social Work Research Develop-
ment Center's (PAR-92-78; PAR-99-130) program
524 RESEARCH: HISTORY OF RESEARCH
announcement that invited schools to apply for research
infrastructure funding. Until withdrawn in 2000, the
program supported eight centers (Washington University,
University of Washington, Portland State University,
University of Pittsburgh, University of Pennsylvania,
University of Tennessee, University of Michigan, and
Fordham University). The University of Michigan and
Washington University received a second five-year
funding. Building on success, Washington University
received an advanced Center for Research on Mental
Health in Social Services grant in 2004.
Training and technical assistance, encouraging BSW
and MSW programs to build research capacity and infuse
mental health research findings ,into curricula was also
supported by NIMH. In 2002, NIMH hosted Moving
Forward: Social Work Contributions to Mental Health Research.
The presentations, found at http://
www.socialworkers.org/research/naswResearch/0204m
Health/default.asp, document the advancements in many
areas' social work mental health research covers, including
child welfare, aging, criminal justice, veterans,
homelessness, poverty, healthcare, and substance abuse.
An increasing number of social work faculty in schools
withoutNIMH centers also successfully pursued funding
opportunities from NIMH. As the recommended actions
moved forward social work research interests expanded
beyond the NIMH borders.
NATIONAL INSTITUTE ON DRUG ABUSE Adapting
from NIMH, with Alan Leshner's move from NIMH to
direct NIDA, it launched efforts to build research infra-
structure. The Social Work Research Development
Program (PAR-00-008) was created to "build a stable
infrastructure for drug abuse research in schools of social
work and to increase interdisciplinary participation in drug
abuse research in order to improve the quality of
interventions aimed at reducing drug abuse and addiction
in this country" (http://www.drugabuse.gov/
DirReports/DirRep200/DirectorReport8.html). Seven
programs were funded: University at Albany, University of
Texas-Austin, Arizona State University, Columbia
University, Case Western Reserve University, University
of Illinois-Chicago, and Washington University. Training
for doctoral students and faculty and research training
curriculum were also supported by NIDA. Since 2005
IASWR and NIDA have supported early career researchers
to receive mentoring at the NIDA Blending conferences.
OTHER NIH INSTITUTES The National Institute on
Alcohol Abuse and Alcoholism (NIAAA), the National
Cancer Institute (NCI),and the National
Institute on Aging (NIA) all have interest in encouraging
social work research grantees. NCI provided small grants to
NASW and IASWR to examine practitioners' access and
use of research findings and the current state of social work
research across the cancer control continuum. NIAAA
developed and is testing a curriculum for social work
educators on research on alcohol use disorders and NIA
funds a summer workshop for faculty to receive training in
applying for NIA funding at St. Scholastica College.
OFFICE OF BEHAVIORAL AND SOCIAL SCIENCES
RESEARCH In 1995 -the Office of Behavioral and Social
Sciences Research (OBSSR) was created at NIH. Social
work is involved with OBSSR activities, including the
1996 symposium "Psychosocial Intervention Research:
Social Work's Contributions." IASWR joins other
behavioral and social sciences societies in the Coalition for
the Advancement of Health through Behavioral and Social
Sciences Research (CAHT-BSSR), ensuring social work's
presence in promoting research at NIH. Since 2003,
OBSSR has led a trans-NIH Social Work Researt'h
Working Group that developed and is implementing the
Congressionally requested NIH Plan for Social Work
Research (http:// obssr
.od.nih.gov/Documents/publications/SWR_Report. pdf).
Recommendations encourage social work research grant
applications, support researcher training and technical
assistance sessions, outreach to the social work community,
and summer workshops. A landmark was achieved
December 2005 when NIH released the Program
Announcements Research on Social Work Practice and
Concepts in Health (http://grants.nih.gov/grants/
guide/pa-files/PA-07 - 292.html (R 01); http://grants.
nih.gov/grants/guide/pa-files/PA-06-082.html (R03);
http:// grants.nih.gov /grants/guide/pa-files/P A-06- 234.
html (R21)). These announcements solidify NIH commit-
ment to the development of empirical research on social
work practice, concepts and theory, and the relevance of
social work interventions to NIH's mission.
Advocacy for Research
As the focus on research and its use increases so does the
profession's advocacy for the resources to carry it out. In
1997 NASW, CSWE, BPD, GADE, NADD,· and IASWR
came together to form the Action Network for Social Work
Education and Research (ANSWER). Managed through
NASW, this coalition, which also includes SSWR,
promotes legislation supportive of funding for social work
research, advocates for reports on federal social work
research activities and has supported the National Center for
Social Work Research Act (S.106 in the llOth Congress)
introduced

by Senator Inouye (D-Hl) since the 105th Congress in
1999. The legislation sparked greater attention to social
work within NIH and within CDC. Appropriations report
language has encouraged NIH, CDC, Agency for
Healthcare Research and Quality, Department of Defense,
and other federal entities to provide resources to support
social work research, to implement the 1991 TFSWR
recommendations, and the recommendations of the 2003
NIH Plan.
International Research
As globalization increases in prominence, international
research efforts and exchanges also expand. International
research can be looked at through several lenses, including
research occurring within one country but drawing on
knowledge from other countries; research on a country's
nonnative populations drawing from knowledge developed
from the native country and other countries; and
comparative research between two or more populations
(Tripodi & Potockv-Tripodi, 2007). Attention to the social,
economic, and health needs of immigrants and refugees,
resettlement and acculturation, the global war on terrorism,
impact of famine and genocide, health care issues such as
HIV, the burden of mental illness, cancer, and health
literacy are 'areas of international research. Social capitol,
microenterprise, community development, social policy,
prevention of abuse, neglect and disease, child welfare,
political rights, and economic well-being all benefit from
and stimulate cross-national research. Federal agencies
such as NIH, CDC, and the Agency for International
Development support international research as do foun-
dations such as Ford, Soros, and Bill & Melinda Gates.
International research exchanges occur through the
Campbell Collaboration (www.campbellcollaboration.
org), the International Consortium for Social Development
(http://www.icsd.info/). and SSWR. Interdisciplinary
organizations such as the International Society to Prevent
Child Abuse and Neglect (lSPCAN)
(http://www.ispcan.org/) disseminate research to enhance
practice and improve policy. The triennial International
Conference on Social Work.in Health and Mental Health is
a forum for scholarly exchange from diverse cultures and
societies.
Interdisciplinary Research Interdisciplinary
research is a challenge and opportunity for social work
since the roots of the profession draw from multiple
disciplines. Psychologists, anthropologists, sociologists,
physicians, and nurses are involved in social work relevant
research and are also faculty in social work education
programs, contributing to the profession's knowledge base.
Social work
REsEARCH: HISTORY OF REsEARCH
525
researchers are part of health care, social welfare, and
public policy research entities and think tanks, contributing
knowledge to address social problems. This raises the
question-what is unique about social work research? With
the growing importance of interdisciplinary research,
social workers connectedness to communities and their
knowledge of the complex needs of individuals and
families provide important input into the research
enterprise. NIDA's research infrastructure programs spe-
cifically encouraged interdisciplinary collaborators. For
example, the Arizona State'sSouthwest Interdisciplinary
Research Center (SIRC) draws on several disciplines'
expertise to undertake community-based prevention re-
search among populations experiencing health disparities
to address drug abuse, HIV, and mental health issues. The
John A. Hartford Foundation supports the Rand/Hartford
Interdisciplinary Geriatric Research Centers to build
geriatric research expertise. The second round was recently
funded, including social work as an interdisciplinary
partner (http://www.rand.org/health/proiects/ geriatric/).
NIH is also embarking on new interdisciplinary research
endeavors, providing new opportunities for social work,
suggesting that taking different strengths from contributing
disciplines and integrating them in new ways will lead to
new scientific discoveries (http://nihroadmap.nih.gov
/interdisciplinary /).
Current Status and Future Directions
The history of social work research reflects the importance
of external support for research,. the role of national
organizations in promotion, agenda setting and
dissemination of research, and the broad array of social
work research interests and expertise in methodology,
fields of practice and levels of focus-from clinical
interventions to policy impact. As the research enterprise
expands the profession needs to expand its efforts to
engage a broader array of research funders, including
federal and state agencies and foundations. Although much
of the last 15 years has focused on building capacities with
NIH, other parts of the Department of Health and Human
Services, as well as the Departments of Justice, Labor,
Education, Defense, Homeland Security, Veteran's Affairs,
and State can also support social work research. The
models of researcher development in gerontology
supported by the Hartford Foundation can serve as models
for foundations interested in substance abuse, child
welfare, mental health, poverty, civic engagement, and
community building, to support the next generation of
social work researchers.
Although much of the attention to social work research
is within the academy, social work researchers do continue
to work in some private and public
526 REsEARCH: HISTORY OF RESEARCH
agencies and within think tanks. Developing strategies . to
highlight nonacademic social work research outputs will help
expand recognition of social work research contributions and
strengthen the explication of social work interventions.
REFERENCES
Alexander, C. (1986). Foreword in Vldeka-Sherman, L., Studies
of research on social work practice: A bibliography (p. iv).
Silver Spring, MD: NASW.
Austin, D. (2003). History of research in social work. In R.
English, (Ed.), Encyclopedia of social work (19th ed.), 2003
Supplement. Washington, DC: NASW.
Briar, S., Weissman, H., & Rubin, A. (1981). Research utiliza~ tion
in social work education. New Y ork: Council On Social Work
Education.
Council on Social Work Education. (2001; revised 2004).
Educational Policy and Accreditation Stapdards. Alexandria,
VA: Author. '
Fanshel, D. (Ed.). (1980); Future of social work research.
Washington, DC: NASW.
Kendall, K. (2002). Council on social work education: Its antece~
dents and first twenty years. Alexandria, V A: Council on Social
Work Education.
IASWR. (2003). 1993-2003, A decade of linking policy, practice and
education through advancement of research. Washington, DC:
Author.
IASWR. (2005). Directory of social work research grants awarded by
the national institutes of health, 1993-2005. Retrieved March
30,2007, from www.iaswresearch.org
Maas, H. (1966). Five fields of social service: Reviews of research.
New York: NASW.
NASW. (1999). NASW Code of Ethics, adopted 1996, revised 1999.
Retrieved March 30, 2007 from http://www.social
workers.org/pubs/ code/code. asp.
Task Force on Social Work Research. (1991). Building social work
knowledge for effective services and policies: A plan for research
development. Monograph available from the Institute for the
Advancement of Social Work Research.
Tripodi, T., & Potocky-Tripodi, M. (2007). International social
work research: . Issues and prospects. New York: Oxford
University Press.
Zlotnik, J. L., & Solt, B. E. (2006, September). The Institute for
the Advancement of Social Work Research working to
increase our practice and policy evidence base. Research on
Social Work Practice.
SUGGESTED LINKS
Institute for the Advancement of Social Work Research.
http://www . iaswresearch.org
Society for Social Work and Research.
http://www.ssWr.org
NIH Plan for Social Work Research. (2003).
http://obsST,ad,
nih,govfDocu1'TlR:l1tS/Publications/SWR_Repon,pdf Campbell
Collaboration:
http://www ,campbellcollaboration .org
-JOAN LEVY ZLOTNIK
RESILIENCE
ABSTRACT: Building on an ecological perspective, the risk
and resilience approach to practice stems from empirically
based knowledge of human behavior and cont ributes to
the profession's strengths based philoso phy. The approach
is suitable for diverse individuals across the life course
and applicable to systems of all sizes. As an emerging
theory, it is increasingly used to inform intervention
models.
KEY WORDS: human behavior theory; research practice
base; diversity
Risk and resilience is a multi theoretical framework for
understanding how people maintain well-being despite
adversity (Fraser, 1997; Greene, 2002, 2007). Resilience is "a
pattern over time, characterized by good eventual adaptation
despite developmental risks, acute stressors, or chronic
adversity" (Masten, 1994, p. 5). A risk and resilience
perspective builds on ecological developmental theory and
draws on epidemiological research methods to distinguish
factors at multiple systems levels, including individual,
family, and community that are associated with
developmental outcomes (N ash & Bowen, 1999).
The concept of resilience represents a change in
perspective on individual, family, and community de-
velopment as well as a different approach to the helping
process, moving theorists and practitioners to a more
optimistic view of people's ability to cope and heal (Barnard,
1994). It offers new directions for assessment and intervention
that tap clients' natural propensity to overcome adversity
(Garmezy, 1993), and inspires ideas for new program
development (Richardson, 2002). The results of this
conceptual shift can be seen in several areas of social work,
including research, educational content, and practice.
The risk and resilience approach stems from converging
social science movements such as prevention science, a
research discipline that focuses on risk reduction; positive
psychology, a scientific approach that emphasizes the power
of the human spirit; and the health and wellness movement
that considers the benefits of positive thinking and continued
selfrealization. The idea that people can individually and
collectively overcome different types of pressures and hazards
is also relevant to the strengths-based perspective in social
work, providing a way of thinking about individual and
collective assets (Saleebey, 1997). E~stering those client
assets is intrinsic to social work practice.

Research Origins
Advocates of an empirical approach to human behavior
have also espoused risk and resilience theory (Fraser &
Galinsky, 1997). During the last 30 years, social scien-
tists have increasingly examined the idea that people
have the capacity to withstand and overcome adverse
events (Garmezy, 1993; Lifton, 1999; Masten, 1994),
raising crucial questions and generating ideas that appear
to rise to the level of a theory (Anthony & Cohler, 1987;
Greene, 2002, 2007). The growing salience of the. risk
and resilience perspective reflects social works' interest
in evidence-based practice (Witkin & Nurius, 1997),
focusing attention on issues such as preventive
interventions among adolescents (Pollard, Hawkins, &
Arthur, 1999); resilience in urban African American
youth (Miller & MacIntosh, 1999); and resilience among
older adults who have suffered hip fractures
(Zimmerman et al., 1999). Risk and resilience research
encompasses a wide array of quantitative longitudinal
studies such as those of children living in poverty by
Werner and Smith (1982, 1992) or qualitative studies of
Holocaust survivors by Bar-Tur and Levy-Shiff (1993),
Greene (2002), and Moskovitz (1983).
RESEARCH ApPROACHES Research on risk and
resilience has taken several forms. In the variable-focused
approach, researchers identify individual traits and
environmental characteristics that contribute to resili-
enceamong adults who have faced childhood adversity.
In the person-focused approach, researchers study resilient
behaviors in the context in which they occur, including
such factors as gender, ethnicity, age, sexual orientation,
and ability. In the asset-focused approach, researchers
explore how quality of life can be improved by
increasing the number or quality of resources includ ing
social capital. Research findings from these approaches
can be applied to fashion different types of intervention
strategies. For example, findings from a self-protective behaviors and strengths" (Greene, 2002 ,
variable-focused research study might lead to the
development of risk-reduction programs for low-birth-
weight babies; findings from a process-focused ap proach
might result in the creation of a course to teach coping
skills to children facing surgery; and out comes from
asset-focused research might be used to demonstrate the
need to implement a tutoring program (Masten, 2002).
THREE WAVES OF RESEARCH Richardson (2002)
has identified three waves of resilience research deli-
neating how these studies have been applied in various
resilience-enhancing educational and therapeutic in-
terventions. In the first wave of inquiry, researchers
explored the traits and environmental characteristics
REsIUENCE 527
that enabled people to overcome adversity. This know-
ledge was then used to design interventions that pro-
mote these positive attributes, such as the development
of school programs to build self-esteem. In the second
wave of inquiry, researchers investigat ed the processes
related to stress and coping. Interventions derived from
this type of research, such as family treatment models,
have been applied to families in crises (Walsh, 1998).
In the third wave of inquiry, currently underway,
researchers are examining less verifiable resiliency
factors such as how people grow and are transformed
following adverse events known as posttraumatic
growth (Tedeschi & Calhoun, 1996). Interventions
based on a growth orientation are intended to help
clients to self-actualize and often tap client creativity
and spirituality as sources of strength. In short, there is a
growing body of literature on interventions social
workers can use to reduce risk and promote resilience,
including prevention strategies, therapeutic effort s to
deal with immediate trauma, and community morning
strategies.
Terms
RESILIENCE It has been suggested that resilience may
not be a single concept, instead encompassing notions of
coping, self-efficacy, and competence (Gordon & Song,
1994). Definitions tend to be associated with particular
theorists: Rutter (1987) related resilience to markedly
successful adaptation following an adverse event;
Borden (1992) viewed resilience as the continuity of
personal narrative or life story; whereas Masten (1994 )
suggested that resilience is a developmental process
linked-_to· demonstrated competence, the learned
capacity to interact positively with the environment and
to complete tasks successfully. Resilience, then, refers
to a wide array of adaptive behaviors (Greene, 2007).
From a psychological point of view, resilience may
be seen as the "development of clusters of
p. 44). However, Strumpfer (2002) has proposed that the
process of "resiling" starts when someone perceives a
challenge or threat, motivating the person to set goals
and carry them out. In this sense, people do not have
(ongoing) resilience but manifest it in six demanding
situations:
1. Exceptionally challenging experiences, for exam-
ple, in a new or challenging job
2. Developmental transitions, including the transi tion
to parenthood
3. Individual adversity, for example, discrimination
or persecution
4. Collective adversity, for example, the aftermath of
natural disasters or war
528 REsILIENCE
5. Organizational change, including the use of
technology
6. Large-scale sociopolitical change, such as a Glasnost
event when a nuclear explosion in the former Soviet
Union caused alarm around the world (p. 308)
RISK AND PROTECTIVE FACTORS
Risk. Risk is a factor that influences or increases the
(statistical) probability of the onset of stress or negative
outcome following adverse events. Risk related .life
events may include childhood abuse, chronic family
conflict, academic failure, peer rejec-
. .
tion, neighborhood disorganization, or racism. Risks
such as natural disasters may occur at any time in a
person's life course and have affects at various systems
levels (Fraser, Richman, &,. Galinsky, 1999).
Cumulative risks are the number of negative events or
experiences in a life time and their additive effects. It is a
concept to identify clients as high risk or low risk
(Gilgun,2002). Fraser et al. (1999) argue that resilience
must be understood by taking. into account risk factors.
Conversely, Benard (1993) contends that resilience
should be used as a concept that stands alone as a means
of positively addressing client assets, focusing on a
client's natural self-righting tendencies (Garmezy, 1993 ).
Protective Factors. Protective factors are situations and
conditions that help individuals to reduce risk and enhance
adaptation. They may be internal personal characteristics such
as good problem-solving skills or external environmental
factors such as viable support networks that modify risks
(Rutter, 1987). Buffering factors are those that provide
resistance to or mediate risk.
A model in which risk factors increase the probabil ity
of a negative outcome is called an additive model. Rutter
(1987) has contended that risk and protective factors
interact to produce an outcome when stress is low, and at
such times protective factors are of less influence. This
approach in which risk and protective factors work only in
conjunction with each other is termed an interactive model.
Human Behavior
PERSON-ENVIRONMENT Some theorists consider the
conceptualization of risk and resilience to be at the level of
an emerging theory (Fraser, 1997; Greene, 2002, 2007).
The growing popularity of and interest in resilience is best
understood in conjunction with the social work
profession's person-environment perspective.
Person-environment relationships mirror the timing of life
events and are influenced 'by changes in
political, economic, and historical processes, as well as
social structures (Haraeven, 1996); whereas environ ments
are modified as people attempt to meet life stress, to
maintain their grounding, and to create greater
opportunities (Lifton, 1999). Social workers' increased
attention to resilient behaviors reflect a need to meet the
challenges of the prevailing intellectual and cultur al
climate of the day as well as those presented by the present
state of personal, social, and historical flux.
SHIFT IN· CONTENT The changing view of person-in-
environment has had ramifications for content in human
behavior and the social environment, with the orists calling
for an expansion content to include the more positive
resiliency concept (Begun, 1993; Gilgun, 1996a, 1996b ;
Greene, 2002, 2007). It has been argued that social work
practice requires the use of human behavior frameworks
that better address the complexity of li fe concerns (Begun,
1993) and how people positively respond to adverse
situations. This knowledge must then be used to foster
client strengths, adaptation, healing, and self- efficacy ..
Theories that examine healthpromoting behaviors across
the life course and focus on environments that promote
personal, family, and community well- being appear to be
increasingly in demand (Saleebey, 1997).
Social workers have long been committed to a
strengths-based practice that mobilizes "people's push
toward growth, self-healing, health, and other natural life
forces" (Germain, 1994, p. 138). However, atten tion to
risk and resilience theory is a theoretical ad vance that can
deepen social workers' understanding of adaptive
behavior, and provide ideas for highly usefu l intervention
strategies (Fraser et al., 1999).
Collective Resilience
ECOLOGICAL METAPHOR Neighborhoods, commu-
nities, and societies can be resilient in their own right. To
understand the resilience of larger-scale social phe nomena
requires the use of an ecological multisystemic metaphor
and an exploration of the behavior of the collective.
Through this understanding, practitioners may recognize
the social context in which individual resilience is
embedded-the larger social sy stems that act "as nested
contexts for social competence" (Walsh, 1998,p. 12).
.RELATIONAL PERSPECTIVE An ecological concep-
tion of resilience shifts attention to a systemic, rela tional
perspective. For example, resili ent behavior has been
shown to correlate with children having a positive
relationship with a parent or parental role model
(Garmezv, 1993; Rutter, 1987) because contemporary

societal conditions require attention to children, school,
family, and community partnerships to promote child,
hood competence. The enhancement, maintenance, and
construction of social conriections is central to a
resilience, enhancing social work practice (Herrenkohl,
Herrenkohl, & Egolf, 1994). This emphasis is also seen
as pertinent across the life course (Lewis & Harrell,
2002).
Diversity
'HOSTILE ENVIRONMENTS Because hostile environ,
ments may be detrimental to the development of a
positive sense of self (Chestang, 1984), theorists
have expressed concern fo r how to best socialize and
foster resilience among children who have increased
risk of racism and oppression (Billigsley,' 1968 ,
1992; Ogbu, 1985). There is growing support in the
literature that resilience is enhanced by an ethnic
family's cultural value s and provision of mutual
psychological support (Genero, 1998; McCubbin ,
Thompson, Thompson, & Futrell, 1998). Families
and other socializing agents in the community can
help children cope with a "negative public image" of
the self by teaching survival skills and affirming
ethnic pride. When this support is joined with
socializing children to have a positive racial or
ethnic, as well as personal identity, children can
develop stra tegies to resist discrimination (Greene,
Taylor, Evans, & Smith, 2002; Miller & MacIntosh,
1999). That is, resiliency characteristics can be
attributed to a family's "cultu rally unique protective
factors" (p. 159) that allow children to transcend the
risk of oppressive environments.
SOCIALIZATION The relational worldview can act as a
powerful socializing agent, particularly in ethnic
communities (Boykin & Toms, 1985; Daly, Jennings ,
Beckett, & Leashore, 1995). A relational perspective
to human development understands psychological
'growth as "a process of differentiation and separation in
relationships rather than disengagement and separation
from relationships" (Genero, 1998, p. 33). Thus,
socialization is viewed as a collective, cultural process
(Cross, 1998).
Social Work Practice
PHILOSOPHY A resilience, enhancing perspective is a
means of thinking about clients as survivors, people
who can, overcome risks or difficult life situations
(Borden, 1992; Wolin & Wolin, 1993). It is an ap-
proach to social work practice that believes in and
promotes clients' natural healing propensities
(Garmezy, 1993). It is " a practice based on the idea of
rebound, possibility, and transformation" (Saleebey,
1997, p. 297).
~
:'
,c.l
REsIUENCE 529
MODEL BUILDING Theorists have proposed resili-
ence-based models for social work practice (Fraser &
Galinsky, 1997; Gilgun, 2002; Gilgun, Chalmers, &
Keskinen, 2002; HeavyRunner & Marshall, 2003;
Palmer, 1997). For example, Fraser and Galinsky
have focused on a model of child well-being, while
Palmer (1997) has described practice with families
that experience issues of alcoholism.
Gilgun (2002) has developed a set of clinical rating
scales to assess youth 12-19 years of age. The 4,0
Strengths- Based Assessment Tools for Youth in Care
serves as a transcultural expression of natural healing
and is visually represented by the Indian medicine wheel
(Gilgun et al., 2002). It is used in child welfare settings
such as the Growing Home, a national thera- .. peutic
foster care agency headquartered in Minnesota.
Interventions are based on the idea that resilient children
need to accomplish four tasks: belonging, mastery,
independence, and generosity.
Models of resilience-enhancing practice often build
on other schools of thought familiar to social work.
HeavyRunner and Marshall (2003) have combined a
resilience approach with an appreciation of the dual
perspective, teaching students how to overcome
alcoholism at tribal colleges. Greene's Resilience-
Enhancing Model (REM) is a conceptual framework
based on the ecological developmental perspective that
examines how people maintain competence in their
environment over time. The model takes into account
social work values, ethics, diversity, current research
findings, best practices, and existing prevention and
educational programs. REM is guided by stress reduc-
tion, a health and wellness point of view, as well as
methods that focus on client capacity. This approach
allows practitioners to assess the balance between eli-
ents' stress and their ability to cope, to intervene, and to
foster client resiliency.
Walsh's family-centered model (1998) promotes fa-
mily well-being through interventions that identify and
fortify key interactional processes. This enables them to
withstand and rebound from disruptive life challenges.
The family unit is seen as having the potential to meet
crises through self-repair and growth. Practitioners ex,
amine and reframe family belief systems, the values and
attitudes that form a family's ideas about how to act, and
organizational and communication patterns. Family
organizational patterns, which are based on behavioral
expectations, reflect how the family is structured to
carry out tasks, such as their having the ability to rally
together to cope with stress. Communication patterns point
to the relationships in a family and how those
relationships influence the exchanges information
within that family.
530 REsILIENCE
Models of resilience-enhancing practice are just in
their infancy, with many interventions springing up
following September 11th. However, it can be antici-
pated that resilience-enhancing practice will be an
important part of the armamentarium of social work
interventions.
REFERENCES
Anthony, E. J., & Cohler, B. J. (987). The invulnerable child.
New York: Guilford Press.
Barnard, C. P. (994). Resiliency: A shift in our perception?
American Journal of Family Therapy, 22, 135-144.
Bar-Tur, L., & Levy-Shiff, R. (993). Holocaust review and
bearing witness as a coping mechanism of an elderly
Holocaust survivor. Clinical Gerontologist, H(3), 5-16.
Begun, A. L. (993). Human behavior and the social environment:
The vulnerability, risk, and resilience model. Journal of Social
Work Education, 29, 26-36.
Benard, B. (1993). Fostering resiliency in kids. Educational
Leadership, 51(3), 44-48.
Billingsley, A. (968). Black families in white America. Englewood
Cliffs, NJ:" Prentice Hall.
Billingsley, A. (992). Climbing Jacob's ladder: The enduring legacy
of African-American families. New York: Simon & Schuster.
Borden, W. (992). Narrative perspectives in psychosocial
intervention following adverse life events. Social Work, 37,
125-141.
Boykin, A. W., & Toms, F. D. (985). Black child socialization: A
conceptual framework. In H. P. McAdoo & J. L. McAdoo
(Eds.), Black children (pp. 33-52). Beverly Hills, CA: Sage
Publications.
Chestang, L. W. (984). Racial and personal identity in the black
experience. In B. W. White (Ed.), Color in a white society (pp.
83-94). Silver Spring, MD: NASW Press.
Cross, T. (l998). Understanding family resiliency from a rela-
tional world view. In I. Hamilton, E. A. McCubbin, A. I.
Thompson, & J. E. Fromer (Eds.), Resiliency in Native Ameri-
can and immigrant families (pp, 143-158). Thousand Oaks,
CA: Sage Publications.
Daly, A., Jennings, J., Beckett, J., & Leashore, B. R. (l995).
Effective coping strategies of African Americans. Social Work,
40, 240-248.
Fraser, M. W. (l997). Risk and resilience in childhood. Washing-
ton, DC: NASW Press.
Fraser, M. W., & Galinsky, M. J. (l997). Toward a resiliencebased
model of practice. In Mark. W. Fraser (Ed.), Risk and resilience
in childhood (pp. 265-276). Washington, DC:
NASW Press.
Fraser, M. W., Richman, J. M., & Galinsky, M. J. (999). Risk,
protection, and resilience: Toward a conceptual framework for
social work practice. Social Work Research, 23(3), 129-208.
Garrnezy, N. (l993). Children in poverty: Resilience despite risk.
Psychiatry, 56, 127-136.
Genero, N. P. (1998). Culture, resiliency, and mutual psychological
development. In I. Hamilton, E. A. McCubbin,
A. L Thompson, & J. A. Futrell (Eds.), Resiliency in
African-American families (Pt:>. 31-48). Thousand Oaks, CA:
Sage Publications.
Germain, C. B. (l994). Human behavior and the social envir-
onment. In F. G. Reamer (Ed.), The foundation of social work
knowledge (pp. 88-138). New York: Columbia University
Press.
Gilgun, J. F. (l996a). Human development and adversity in
ecological perspective, Part 1: A conceptual framework.
Families in Society, 77, 395-402.
Gilgun, J. F. (l996b). Human development and adversity in
ecological perspective, Part 2: Three patterns. Families in
Society, 77,459-476.
Gilgun, J. F. (2002). Completing the circle: American Indian
medicine wheel and the promotion of resilience in children and
youth care. Journal of Human Behavior in the Social Environment,
6(2), 65-84.
Gilgun, J. F., Chalmers, M., & Keskinen, S. (2002). The 4-D:
Assessing four dimensions of youth development: Belonging,
mastery, autonomy, & generosity. St. Paul, MN: Growing Home
National Office.
Gordon, E. W., & Song, L. D. (1994). Variations in the experience
of resilience. In M. C. Wang and E. W. Gordon (Eds.),
Educational resilience in inner-city America:
Challenges and prospects (pp. 27-44). Hillsdale, NJ: Lawrence
Erlbaum.
Greene, R. R. (2002). Resiliency: An integrated approach to practice,
policy, and research. Washington, DC: NASW Press.
Greene, R. R. (2007). Social work practice: A.risk and resilience
perspective. Monterey, CA: Brooks/Cole.
Greene, R. R., Taylor, N., Evans, M., & Smith, L. A. (2002).
Raising children in an oppressive environment. In R. R.
Greene (Ed.), Social work practice: A risk and resilience per-
spective (pp. 241-276). Monterey, CA: Brooks/Cole.
Haraeven, T. K. (1996). Aging and generational relations over the life
course: A historical and cross-cultural perspective. Hawthorne,
NY: Aldine de Gruvter,
HeavyRunner, I., & Marshall, K. (2003). Miracle survivors:
Promoting resilience in Indian students. Tribal College Journal,
14(4),10-14.
Herrenkohl, E. c., Herrenkohl, R, C., & Egolf, B. (1994).
Resilient early school-age children from maltreating homes:
Outcomes in late adolescence. American Journal of
Orthopsychiatry, 64, 301-309.
Lewis, J., & Harrell, E. B. (2002). Older adults. In R. R. Greene
(Ed.), Resiliency: An integrated approach to practice, policy, and
research (pp. 277-292). Washington, DC:
NASW Press.
Lifton, R. J. (1999). The protean self: Human resilience in an age of
fragmentation. Chicago: University of Chicago Press.
Masten, A. (l994). Resilience in individual development:
Successful adaptation despite risk and adversity. In M. C.
Wang & E. W. Gordon (Eds.), Educational resilience in innercity
America: Challenges and prospects (pp. 3-25). Hillsdale, NJ:
Lawrence Erlbaum.
McCubbin, H. L., Thompson, E. A., Thompson, A. L., & Futrell, J.
A. (l998). Resiliency in African American families. Thousand
Oaks, CA: Sage Publications.
,
_.
:~J
 REsTORATlVE]USTICE
531

Miller, D., & MacIntosh, R. (1999). Promoting resilience in urban Gitterman, A. (1998, April). Vulnerability, resilience, and social work
African American adolescents: Racial socialization and practice. The fourth annual Dr. Ephriam L. Unsansky Lecture,
identity as protective factors. Social Work Research, University of Maryland, Baltimore, MD.
23(3),159-170. Nash, J., & Fraser, M. W. (1998). After-school care for children: A
Moskovitz, S. (1983). Love despite hate. New York: W.W. resilience~based approach. Families in Society, 79, 370-382.
Norton.
Nash, J. K., & Bowen, G. L. (1999). Perceived crime and
informal social control in the neighborhood as a context for -ROBERTA R. GREENE
adolescent behavior: A risk and resilience perspective.
Social Work Research, 23, 171-186. .
Ogbu, J. U. (1985). A cultural ecology of competence among
inner-city blacks. In M. B. Spenser, G. K. Brookins, & W. R;
Allen (Eds.), The beginnings: The social and affective development RESTORATIVE JUSTICE
of black children (pp. 45-66). Hillsdale, NJ:
Lawrence Erlbaum. ABSTRACT: This entry defines restorative justice and
Palmer, N. (1997). Resilience in adult children of alcoholics: describes the models most relevant to social work. These are:
A nonpathological approach to social work practice. Health and victim-offender conferencing (sometimes incorrectly referred
Social Work, 22, 201-209. to as mediation); family group conferencing; healing circles;
Pollard, J. A., Hawkins, J. D., & Arthur, M. W. (1999). Risk and and community reparations.
protection: Are both necessary to understand diverse
Restorative justice is an umbrella term for a method of
behavioral outcomes in adolescence? Social Work Research, 23,
handling disputes with its roots in the rituals of indigenous
145-158.
Richardson, G, E. (2002). Metatheory of resilience and resiliency. populations and traditional religious practices (Zehr, 2002). A
Journal of Clinical Psychology, 58(3), 307-321. three-pronged system of justice, restorative justice is a
Rutter, M. (1987). Psychological resilience and protective non-adversarial approach usually monitored by a trained
mechanisms. American Journal of Orthopsychiatry, 57, 316-331. professional who seeks to offer justice to the individual
Saleebey, D. (1997). The strengths perspective in social work practice. victim, the offender, and the community, all of whom have
New York: Longman. been harmed by a crime or other form of wrongdoing.
Strumpfer, D. J. W. (2002, September). A different way of viewing Accountability is stressed
adult resilience. Paper presented at the 34th International ,.as the offender typically offers to make amends for the harm
Congress on Military Medicine, Sun City, North West
that was done.
Province, South Africa.
Restorative justice not only refers to a number of strategies
Tedeschi, R. G., & Calhoun, L. G. (1996). The posttraumatic
growth inventory: Measuring the positive legacy of trauma. for resolving conflicts peacefullybut also to a political
Journal of Traumatic Stress, 9, 455-471. campaign of sorts to advocate for the rights of victims and for
Walsh, F. (1998). Strengthening family resilience. New York: compassionate treatment of offenders (See for example,
Guilford Press. Bazemore & Schiff 2001; Umbreit et al., 2003). Instead of
Werner, E., & Smith, R. S. (1982). Vulnerable, but invincible: incarceration, for example, the option of community service
A longitudinal study of resilient children and youth. New York: coupled with substance abuse treatment might be favored.
McGraw Hill.
Werner, E., & Smith, R. S. (1992). Overcoming the odds: High risk
children from birth to adulthood. Ithaca, NY: Cornell University
Press. KEY WORDS: restorative justice; criminal justice; family
Witkin, S., & Nurius, P. (1997). Should human behavior theories group counseling; healing circles
with limited empirical support be included in HBSE classes?
In M. Bloom & W. C. Klein (Eds.), Controversial issues in
History
human behavior in the social environment (pp. 49-64). Boston:
Modem restorative principles have their roots in ancient
Allyn & Bacon.
cultures. Ancient societies favored reparative and often
Wolin, S. J., & Wolin, S. (1993). The ~esilient self. New York:
Willard. ritualistic responses to crime with a focus on restoring
Zimmerman, S., Smith, H.D., & Gruber-Baldwin, A. (1999). community peace to prevent blood feuds (Bazemore & Schiff,
Shortterm persistent depression following hip fracture. Social 2001). Unlike the adversarial form of justice that came later,
Work Research, 23(3) 187-196. from the late Middle Ages, when crime was viewed as an
offense against the state, the victim who was wronged was to
be compensated in some way.
FURTHER READING Victim-offenderconferencing is the first contemporary
Cross, W. E. (1991). Shades of black: Diversity in African-American restorative process and has its origins in 1974 in a
identity. Philadelphia, PA: Temple University Press.
532 REsrORATIVE JUSTICE
probation office in Canada where Canadian Mennonites
began to experiment with meetings between victims and
offenders to work out restitution arrangements. Victim
rights activists played a role in raising the consciousness of
their generation for the need for victims to be heard in the
criminal justice process and this process subsequently
gained in popularity across North America.
Family Group Conferencing was developed in New
Zealand as an adaptation of the traditional processes of
indigenous peoples. Such conferencing involves not
only the victim and offender in cases of crime and
delinquency, and not only the parents in child welfare
situations, but members of the extended family and
other key players in the decision making (such as how to
protect a child from abuse) in the community.
~
Healing circles stem from First Nations practices in
Canada. This form of dispensing justice is rooted in the
rituals of indigenous populations (tribal members) settling
disputes in sentencing circles. A feather or "talking stick"
may be passed around ceremoniously from speaker to
speaker to signify whose tum it is to speak.
Community reparations take place on a global scale,
often following war crimes or other crimes committed
by the state; truth and reconciliation commissions have
been set up such as those that took place in the 1990s in
South Africa and Peru. In intensely emotional sessions,
former officials of the previous regimes were brought
face to face with their victims, many of whom they had
tortured. Healing was centered on the communication
process itself rather than on retribution for the pain that
was inflicted.
Latest Research
Significantly, the Center of Restorative Justice and
Peacemaking, the leading center for research on restorative
strategies, is housed in a school of social work at the
University of Minnesota, St. Paul. Surveys conducted at
this institute and data collected from surveys worldwide
consistently provide evidence of participant satisfaction
with the restorative process and outcomes (Umbreit et al.,
2003). Rates of completed restitution agreements have
climbed while reoffending rates have decreased.
Best Practices
In 1991, Vermont decided to overhaul its system, setting up
reparative boards statewide to focus on repairing the
damage that had been done to the victim and the
community. Composed of volunteers, community boards
under the auspices of the Department of Corrections, are
charged with ensuring that low-risk, nonviolent offenders
are made aware of the impact of
their behavior on members of the community (Pranis,
2003). Pennsylvania and Minnesota have implemented
restorative programming statewide. AMICUS in Min-
nesota uniquely includes a gender-specific 'victimoffender
conferencing program for girls in trouble with the law.
;
,;
Cultural, Racial, and Ethnic Populations Through
embracing members of the extended family, restorative
justice has been found to be highly effective in minority
communities. These minority communities, including
Native, African-American, and Latino traditions, are
collectively rather than individually focused. The circle
healing approach as used hi the Yukon of Canada utilizes
traditional justice processes of tribal communities to view
crime holistically. Tapping into the strengths of community
resources, the process de- . velops sanctions based on
consensus of community members. Offenders and victims
alike are encouraged to share how aspects of social
oppression have influenced their behavior and worldviews.
There is often a. strong spiritual component in such
sentencing and healing circles.
Interdisciplinary Aspects
The facilitators may be lawyers, triballeaders, or clergy.
Often, as in Iowa, they are connected to victim assistance
programming. In Australia, the police play an active role.
In New Zealand, Canada, and, increasingly, in the United
States, social workers are trained for such facilitation.
Through the School of Social Work at the University of
Minnesota, St. Paul, professionals ate trained in conflict
resolution in communities, schools and work places (to
prevent bullying), as well as within the justice system.
Future Roles for Social Workers
The profession of social work, having backed away from
its early involvement in criminal justice as this system grew
progressively punitive, now has a unique opportunity to
become a part of an approach that is compatible with the
profession's ethics and values (Judah & Bryant, 2004; van
Wormer, 2004). The theme of restorative justice-violence
wounds, justice heals--holds an important message for
policymakers of a just society. This theme is highly
relevant to the most basic of the social work core
values-social justice (NASW, 1999). Restorative justice
very closely relates to social justice or fairness in that the
victims and offenders each have their interests represented
in the proceedings.
The social work profession, with its long history of
advocating for community-based treatment, its belief
.1

that most human beings are redeemable, and stress on
interdisciplinary team woik,can expect to be playing an
increasingly active role in facilitating non-adversarial
forms of justice such as those described in this entry.
REFERENCES
Bazemore, G., & Schiff, M. (2001). Restoring community justice.
Cincinnati, OH: Anderson.
Judah, E., & Bryant, M. (2004). Rethinking criminal justice:
Retribution vs.restoration. In E. Judah & M. Bryant (Eds.),
Criminal justice: Retribution vs. restoration (pp. 1-6).
Binghamton, NY: Haworth.
National Association of Social Workers (NASW).(l999).
Code of ethics. Washington, DC: NASW.
Pranis, K.(2oo3). The practice and efficacy of restorative justice.
In E. Judah & M. Bryant' (Eds.), Criminal justice:
Retribution vs. restoration (pp. 133-157); Binghamton, NY:
Haworth.
Umbreit, M., Vos, B., Coates, R., & Brown, K. A. (2003).
Facing violence: The path of restorative justice and dialogue.
Monsey, NY: Criminal Justice Press.
van Wormer, K. (2004). Confronting oppression, restoring justice.
Alexander, VA: Council on Social Work Education.
Zehr, H. (2002). The little book of restorative justice.· Intercourse,
PA: Good Books.
FURTHER READING
Beck, E. (2007). In the shadow of death: Restorative justice and· death
row families. New York: Oxford University Press.
Hudson, J., & Burford, J. (2000). Family group conferencing:
New directions in community-centered child and family practice.
Piscataway, NJ: Aldine Transaction.
Pranis, K. (2005). The little book of circle processes: A new/old
I
approach to peacemaking; Intercourse, P A: Good Books.
van Wormer, K. (Ed.). (2008). Restorative justice across the East and
the West. Hong Kong: Casa Verde.
SUGGESTED LINKS Center for Restorative
Justice and Peacemaking http://ssw .che. umn.edu.
I
Minnesota Department of Corrections
www.corr.state.mn.us/rj.
Restorative Justice Online
www. restorative justice .org
~ -KATHERINE VAN WORMER
RETIREMENT
ABSTRACT: The definition of retirement has become
increasingly complex. Freedom from work,
autonomy, and the pursuit of new Interests are
mediated by a sense of loss of value when
employment ends, by the resource picture in
retirement, and by the likeli hood that current and
boomer retirees are likely to
RETIREMENT
533
spend more years in retirement. The viability of Social
Security, Medicare, Medicaid, and pensions is also of
influence, and stereotypes of carefree years are thwarted
by caregiving responsibilities and avoided by those
continuing to seek fulfilling roles. Finally the
experience of retirement continues to be different for
important groups in society.
KEY WORDS: baby boomers; civic engagement;
income; old age
Definition
Role theory argues that employment is fundamental to
identity (Kim & Moen, 2001), and continuity theorists
have been concerned that an end to employment such as
in retirement may be psychologically stressful, given
the loss of a central role (Richardson & Kilty, 1991). A
financial or work definition of retirement is not
sufficient, as it
• explains only what someone is not doing, that is,
not continuing to work full-time for a wage or
salary.
• may no longer be true; in retirement, some people
are working at different jobs, not no longer
working.
• is silent on the lives and life styles that categorize
retirement.
The origins of "retirement" are also in efforts to create a
new and valued life stage. without full-time work that
buffers assaults to identity (Reitzes & Mutran, 2002).
Concepts such as "Freedom From Work" (Metlife,
2006a), autonomy (Atchley, 1974), and pursuit of new
interests therefore more comprehensively define
retirement.
The definition of retirement also subsumes ideas of
successful aging:
1. Relatively low risk of disease and disease-related
disability
2. Relatively high mental and physical functioning
3. Active engagement with life, including close
relationships with others and participation in
productive activities
4. Acceptance of age-determined decrements and
doing the best one can with what one has
5. Application of external resources to enlarge an
individual's opportunities and facilitate behaviors
that make for success in older age (Kahn, 2002)
The public's consideration of retirement is also marked
by growing concerns. A survey (Metlife, 2001) on the
attitudes of potential retirees (persons aged 38-55)
found that 50% looked forward to retirement. However,
534 RETIREMENT
95% saw planning for retirement as also planning for old
age; their greatest concerns about retirement were
becoming sick or dependent on others.
• 50% expected to continue working beyond
traditional retirement ages, and two thirds
expected to have part-time jobs.
• 85% did not believe they could rely on govern,
ment to pay for their long, term care needs in their
retirement years. Only 25% saw Medicare as such
a vehicle, and two thirds did not feel that they had
sufficient personal resources to cover such
expenses.
These somewhat mixed feelings about retirement are
consistent with concerns raised by role and continuity
theorists (Kim & Moen, 20b1; Richardson & Kilty,
1991) and support findings by Pinquart and Schindler
(2007) that retirees have three different responses to this
life stage and transition: (a) an initial decline in life
satisfaction, followed by a steady increase thereafter; (b)
a large increase in satisfaction at retirement, fol lowed
bya major decline; and (c) a temporary and very small
increase in life satisfaction at retirement. How, ever,
findings that resource-rich retirees are least likely to
experience declines in life satisfaction demonstrate the
critical nature of the financial and resource security of
retirement.
The meaning of retirement then is mediated by the
changing demography of retirement (including re-
sources), differences for key population groups, and
new challenges in the retirement years.
Demography
The aging population of the United States grew rapidly
in the 20th century (Wan, Sengupta, Velkopf, &
DeBarros, 2005), with increases in personal longevity,
greater number of aging persons, and a growing percen-
tage of the overall population being older than 65 years.
At the same time, birth rates and the available labor force
have been declining and are projected to continue to
decline. The implications of population change have
included calls for and actual efforts to modify Social
Security eligibility and benefits, Medicare, Medicaid,
and other pension and health benefits, key pillars of
support for individual retirement.
Extended Retirement Years. Even the choice of trad-
itional retirement age, such as 65 years, will mean
that many individuals will spend 30 plus years in
retirement, and for those who retire earlier there is a
likelihood that they will spend more years in
retirement than in prior employment. This poses
challenges in terms of how retirement support will be
provided and sustained, and what one's quality of life
will be during those years.
On the one hand, there is evidence that levels of
disability and chronic illness have been declining but on
the other there are reports that 80% of people older than
65 years have one chronic condition, 50% have two, and
"'40% have some type of disability (Wan et al., 2005).
Such findings suggest that the maintenance of health is
critical to quality of life in retirement, and availability of
sufficient resources to sustain a chosen life style and
meaningful opportunities and activities are also
important.
. ~
~
.,
Much has been achieved in
II
INCOME AND RESOURCES
ensuring sufficient resources for retirement. Social
Security, Medicare, pension plans, and health insur-
ance from employers have been identified as critical
components of such retirement "wealth," but both the
value and the security of those resources appear less
certain than in the past. This influences the views of J
retirement by both current and prospective retirees I
(Wan et al., 2005). Expressed fears for the viability of I
Social Security, Medicare, and Medicaid contribute to
uncertainty about retirement (Korczyk, 2004). I
BABY BOOMER ISSUES Summarizing the findings of a
survey of 55-70'year'01ds from across the United
States, a MetLife study (2006a) concluded that the
definition of retirement for baby boomers (in this sur'
vey those aged 50-59) was still essentially freedom
from work demands, but unlike older cohorts, boomers
saw this as not occurring on some fixed date but as a
process likely to stretch into one's 70s and 80s before
"freedom" is actually achieved. Boomers overall do
appear to have more resources than do older
generations, but there are concerns that their affluence
has been expressed more in spending than in saving
and that their retirement income, based upon greater
risk (401 (k) plans and lRAs rather than on defined
benefit pensions), may not be sufficient for longer
years of retirement. They are more likely to be
weighed down by growing health-care costs (Gist,
2006).
EARL y RETIREMENT OR LATER RETIREMENT Growing
affluence, employer incentives, and the avail, ability of
limited social security benefits at age 62 have all
contributed to the growth of a group of individuals
who choose to retire early. The data available are not
conclusive, but changes in dates for eligibility for full
social security benefits, a decline in the availability ,of
company-sponsored pensions and health insurance
benefits, and reductions in Social Security benefits for
earlier ages are believed to be discouraging continued
growth in early retirement (Korczvk, 2004).

Diversity of Population Groups
In a series of reports drawn from census data and surveys,
AARP and Medlife have captured many differences for a
range of important groups.
WOMEN Although they will live on average at least 3
years longer after age 65 than men, retired women will
more likely live in poverty, be alone, and be more
dependent upon social security without any additional
pension. They are also less likely to continue to be
employed after age 65 and therefore have opportunities to
accrue additional income (AARP, 2005).
AFRICAN AMERICANS African, Americans also are
more likely to live in poverty and to depend on Social
Security. African American men are more likely than any
other group to also have income from a pension, but the
proportion of African American women with a pension is
much lower (AARP, 2004a). The growing decline in the
availability of defined benefit pensions may therefore
particularly adversely effect the retirements of older
African American men.
LATINOS Poverty rates for older Latino men and women
are twice those for all persons aged 65 and older and there
is also a lower availability of income from pensions
(AARP, 2004b).
GAYS AND LESBIANS Gay and lesbian older persons,
particularly baby boomers appear to be more concerned
about their retirement years than are other retirees,
although many of their concerns are the same: outliving
one's income, getting sick or disabled, or becoming de-
pendent on others. Nevertheless, in Metlife's (2006b)
survey . of 1,000 self-identified LGBT people aged 40-61,
40% believed that being gay, lesbian, bisexual, or
transgender better prepared them for aging.
Challenges
There is a view of retirement encouraged by advertising
that it is a time free of responsibilities and marked instead
by more self-indulgent consumption. Yet this is not the
experience of many retirees.
SPOUSAL OR PARTNER CAREGIVING The concerns
expressed by retirees and potential retirees about becoming
sick or disabled often prove to be real concerns not only for
themselves but also for the people they live with,
principally spouses. Although women are predominately
the caregivers of others, in spousal relationships men are
nearly as likely to assume this role when care is needed
(Greenberg, Seltzer, & Brewer, 2006). Rather than a time
of freedom and self-indulgence,
RETIREMENT 535
retirement years for many are marked by increasing
demands of care-demands that will take a toll both on their
own health and on the retirement resources they had set
aside.
GRANDP ARENT CAREGIVING An increasing if new
aspect to caregiving in retirement years is care for
grandchildren. The number of children in grandparent
headed households has increased dramatically and in 2000
was estimated at 4.5 million children (U.S. Census Bureau,
2001). There may be both positive and negative
consequences for the retiree's own health. Among the
challenges are reductions in free time, limitations on
housing options, increased demands on resources, and even
situations where the retiree needs to return to work to
support this new family situation (Kropf & Yoon, 2006).
A NEED TO FEEL VALUED Although there have been
many volunteer and other service opportunities for retirees,
they have often been of the clerical receptionist and support
staff type; there are many retirees who wish to contribute to
their communities in more meaningful ways. There is
increasing concern that baby boomers with their higher
levels of education will be particularly hard to engage
unless more meaningful roles are created (Gerteis, 2004).
FINANCIAL EXPLOITATION AND ELDER ABUSE As
the resources available to retirees increase and their con-
cerns are not allayed about how to pay for long-term care
and ensure they have resources for their last years, their
seeking to improve their retirement resource picture in-
creases the potential for fraud and exploitation. Equally, as
the number of years of retirement that needs to be
supported also increase, the consequences of fraud and
exploitation are more catastrophic, for example, leaving
destitute a retiree previously well provided for financially
(Ferretti, Velasquez, & McCallion, 2007).
Roles for Social Workers
The following are three areas of development and support
where social workers will be important contributors.
REINVENTING RETIREMENT AND CIVIC
ENGAGEMENT The new retirement is likely to have paid
part-time or full time and significant unpaid work/volunteer
roles. Social workers will find new opportunities in
developing and supporting training programs for these new
roles and in working with not-for-profit, public, and private
sector agencies and employers to redesign the workday and
workspace to better accommodate this
536 RETIREMENT
reinvented retirement. An important task will be to create
opportunities that meet important social needs in new ways.
FINANCIAL EXPLOITATION Social workers have edu-
cational, preventive roles to play but also must become adept
in understanding the types of fraud occurring and the
protections available. A key challenge will be to work
effectively with retirees themselves, police agencies, attorney
generals' offices, and the banking sector to prevent and
respond to such fraud and exploitation.
CAREGIVER SUPPORT Support groups for caregivers,
creation and management of consumer-directed care
initiatives, and caregiver health promotion will be irnportant
roles for social workers to help retirees cope with new
caregiving responsibilities.
REFERENCES
AARP. (2004a). African,Americans 65 and older: Sources of retirement
income. Washington, DC: AARP Public Policy Institute.
AARP. (2004b). Hispanics 65 and older: Sources of retirement income.
Washington, DC: AARP Public Policy Institute.
AARP. (2005). Women 65 and older: Sources of retirement income.
Washington, DC: AARP Public Policy Institute.
Atchley, B. (1974). The meaning of retirement. Joumalof
Communications, 24, 97-101.
Ferretti, L., Velasquez, L., & McCallion, P. (2007). Facing the
challenges of financial exploitation and fraud [CD-ROM]. Albany,
NY: Center for Excellence in Aging Services.
Gerteis, M. (2004). Re,inventing aging: Baby boomer and civic
engagement. Cambridge, MA: Harvard School of Public Health.
Gist, J. (2006). Boomer wealth-Beware of the median.
Washington, DC: AARP Public Policy Institute.
Greenberg, J., Seltzer, M. M., & Brewer, E. (2006). Caregivers to
older adults. In B. Berkman (Ed.), Handbook of social work in
health and aging (pp. 339-354). New York: Oxford University
Press.
Kahn. (2002). On successful aging and well-being. The Gerontologist,
42(6), 725-726.
Kim, J. E., & Moen, P. (200l). Is retirement good or bad " for
subjective well-being? Current Directions in Psychological Science,
10, 83-86.
Korczvk, S. M. (2004). Is early retirement ending? Washington, DC:
AARP Public Policy Institute.
Kropf, N., & Yoon. (2006). Grandparent caregivers: Who are they? In
B. Berkman (Ed.), Handbook of social work in health and aging
(pp. 355-362). New York: Oxford University Press.
MetLife. (2001). The MetLife survey of American attitudes towards
retirement. New York: Metropolitan Life Insurance Company.
MetLife. (2006a). Living longer, working longer: The changing
landscape of the aging workforce-A MetLife study. New York:
Metropolitan Life Insurance Company.
MetLife. (2006b). Out and aging: The MetLife study of lesbian and gay
baby boomers. New York, NY: Metropolitan Life Insurance
Company.
Pinquart, M., & Schindler, I. (2007). Changes in life satisfaction in
the transition to retirement: A latent-class approach. Psychology
and Aging, 22(3), 442-455.
Reitzes, D. c., & Mutran, E. J. (2002). Self-concept as the
organization of roles. Sociological Quarterly, 43, 647-667.
Richardson, V., & Kilty, K. M. (1991). Adjustment to retirement.
Continuity or discontinuity. International Journal of Aging and
Human Development, 33, 151-169.
Wan, H., Sengupta, M., Velkopf, V. A., & DeBarros, K. A. (2005).
65+ in the United States (pp, 23-209). Current Population Reports.
Washington, DC: U.S. Government Publishing Office.
SUGGESTED LINKS American
Association on Retired Persons.
http://www.aarp.org
Social Security Administration.
www.socialsecurity.gov
Civic Ventures.
www.civicventures.org
Civic Engagement.
http://www . civicengagement.org/agingsociety/
Senior Corps and the Retired and Senior Volunteer Program.
http://www .seniorcorps .org/
OASIS (an education and volunteer program for mature adults).
http://www.oasisnet.org/index.htm
-PHILIP MCCALLION AND LISA FERRETTI
RUNAWAY AND HOMELESS YOUTH. See
Youth at Risk.
RURAL PRACTICE
ABSTRACT: Rural social work, whose history stretches back
a century, has been revitalized since the mid, 1970s.
Definitions, typologies, and characteristics of rurality are
provided, which serve as a framework-for rural practice,
policy, and research concerns: A primary focus is on those
concerns differentiating rural from urban social work. Social
workers interested in additional infermarion are given basic
references, as well as material on the National Rural Social
Work Caucus, the annual National 'Institute on Social Work
and Human Services in Rural Areas, the proposed electronic
journal, and the online listserv.
KEY WORDS: rural communities; rural practice; rural policy

Defining Rural Social Work
Rural social work, or social work in rural communities,
has experienced a checkered history since the early years
of the 20th century . But it has emerged as an important
force since mid-1970s. The National Institute on Social
Work and Human Services in Rural Areas has sponsored
over 30 consecutive annual meetings, new academic
programs are based on rural missions, and increasing
numbers of social workers are preparing for, or
practicing in, . rural environments (Daley & Avant,
1999).
Defining "rural" typically begins with the U.S. Cen-
sus of the Population, which earlier classified incorpo-
rated and unincorporated areas of 2,500 or larger as
urban and everything else as rural in 1991. Hence, New
York and Atlanta 'were urban and Tie Siding, Wy(;ming,
and Hot Coffee, Mississippi, were rural. Classification
with this rural-urban dichotomy was simple but of
limited value. For example, a town of 3,000 could be
classified as urban, even though most observers would
perceive it as rural. Conversely, rural migrants in large
numbers have carried their rural cultures and practices to
metropolitan locales but are considered "urban."
Examples include Appalachian Whites to Detroit, Native
Americans to Seattle, and Southern African-Americans
to Chicago. The authors contend that providing services
to these transplanted groups is a form of rural social
work even though it is practiced in a city (Davenport &
Davenport, 1995).
A more useful definition developed by the U.S.
Bureau of Census (1991) was based on a rural-urban
continuum. A metropolitan statistical area (MSA) in-
cluded a central city of 50,000 or more and the county in
which it was located. Nonrnetropolitan or rural locales
were everything outside of MSAs. According to
Galbraith (1992), this rural population included around
23% of the u.S. population. However, there still remain
considerable differences between an affluent bedroom
community 25 miles from a major city and a struggling
colonia in South Texas.
Thus, definitions of rural often describe key charac-
teristics of rurality. Deavers's (1992) three major char-
acteristics included the following: (a) small towns and
open country are associated with small-scale, lowdensity
settlement; (b) rural areas are distant from urban centers,
including physical distance as well as social and cultural
isolation; and (c) rural communities tend to feature
specialization of rural economies with little
diversification as typical of most urban locales.
Social scientists in the U.S. Department of Agricul-
ture (USDA) have classified nonmetropolitan counties
according to their main economic bases, the presence of
federally owned lands, and population characteristics
RURAL PRACTICE
537
(Bender et al., 1985). They developed a typology that
continues to have value for policy and practice consid-
erations. This typology, as summarized by Hassinger &
Hobbs (1992), includes farming-dependent counties,
manufacturing-dependent counties, mining-dependent
counties, specialized government counties, persistent
poverty counties, federal lands counties, and destina tion
retirement counties.
Such definitions, typologies, and classification sys-
tems underscore the diversity of economic function and
refute the prevalent myth of one rural America. Human
needs, including the needs for social services of a
retirement community would differ significantly from
those of a mining community, especially a boom town
with many young families. Similarly, the problems of a
university town with many educated, affluent persons
would vary from those of a poverty community in the
Mississippi Delta. Understanding such differences is
vital for good social policy and social work practice
(Davenport & Davenport, 1995).
Theories and Concepts
Theoretical bases of rurality may find an overview by
Davenport and Davenport (1984b) helpful. It examines
classical theory, determinist theory, compositional the-
ory, and subcultural theory. Practice and policy impli-
cations of each are given. Additionally, much useful
information may be gleaned from current research in the
disciplines of anthropology, sociology, and rural
sociology (Ginsberg, 2005; Lohman & Lohman, 2005 ).
The colorful history of rural social work may be
found in two useful volumes by Martinez-Brawley
(1980,1981). Davenport, Davenport, and Locke (2005)
have added an analysis of the contributions made by
such pioneers as Josephine c. Brown, Eduard C.
Lindeman, and Josephine Strode (Brown, 1933 ;
Lindeman 1921; Strode, 1938). Additionally, Ri ch
(2005) has examined the impact of the New Deal on
rural communities, especially those of the Civilian
Conservation Corps. Knowledge of these forbearers
allows us to build upon rather than replicate their
contributions.
Social Work Practice
Social workers practicing in rural areas must be pre-
pared to work with diverse populations and commu-
nities. As Brown (1933) noted more than 70 years ago ,
there can be great variation in rural people and
communities. The following examples of diverse rural
populations would contain a plethora of ethnic, cultural,
religious, social, gender, class, and socioeconomic
variables: Alaska Aleuts, Louisiana Cajuns, Ohio
Amish, New Mexico Pueblo, Wyoming Basque, North
538 RURAL PRACTICE
Carolina Hmong, Utah Mormons, Tennessee auto
workers, Georgia poultry factory workers, Atlantic
Coast Gullahs, Mississippi African Americans, South-
western T ex Mex, and New York migrant workers.
These and others underscore the importance' of the rural
social worker's ability to encounter and work sensitively
with clients from diverse backgrounds. Re fugees from
around the globe are increasingly being placed in rural
communities, which provide even more opportunities
and challenges for social work intervention. Moreover,
the past few years have witnessed a dramatic increase in
legal and undocumented migrants from Mexico, Central
America, and South America. Some towns such as
Noel, Missouri, are now over 50% Latino, with many
new residents being poor, undereducated, and with
liniited proficiency in the prevailing language. The
emergence of violent Latino gangs, including the Latin
Kings and Mara Salvatrucha (MS~ 13 ), are requiring
increased attention from rural social workers (Cordova,
Dannerbeck, Davenport, & Rademacker, 2005).
Many of social work's traditional social problems,
such as poverty, are found in greater numbers in rural
America (Carlton-Lal-lev, Edwards, & Reid, 1999). In
fact, "the presence of poverty has been greater in non-
metro areas in every year since the 1960 s when poverty
rates were first officially recorded" (Jolliffe, 2006 ).
Accordingly, federal assistance programs based on
poverty measures have distributed significant resources
to rural communities. Rural social workers play key
roles in developing, shaping, and delivering these
resources. However, an experimental index that uses
Fair Market Rent (FMR) could allocate a greater
percentage of funds to metropolitan areas at the expense
of rural ones (Jolliffe, 2006). Rural advocates should be
involved in any decisions to change its index or
formula.
Rural social workers are frequently employed in the
public sector and generally work in relatively isolated,
small local and county offices where they confront a
variety of complex problems. Because the specialized
services found in urban areas are seldom available, the
generalist practice model has evolved as best suited for
rural practice (Ginsberg, 1976). The value of this model
was actually advocated in the 1920s and 1930s by
Josephine c. Brown (Davenport & Davenport, 1984a),
who stressed "undifferentiated practice," which urged
the "social caseworker" to utilize both group and
community approaches. Many other authors have since
supported this model (Vice-Irey, 1986; Martinez-
Brawley, 1983). For example, a mental health worker
might treat several survivors of sexual assault and do-
mestic violence on a clinical basis, organize a support
group, establish a task force, plan for a shelter, and
lobby politicians for funding. This worker is likely to
treat many other individual problems, consult with
counselors and teachers on behavioral problems, serve
on a community committee on aging, and coordinate an
emergency food pantry.
Challenges and Dilemmas
Rural social workers must learn to practice with a lack
of anonymity because it is often the case that everyone
appears to know what everyone else is doing. Refer-
ences are made about "life in a goldfish bowl." This
"bowl" results in the worker's personal life being quite
visible, which definitely affects one's professional life
much more than it would in metropolitan areas. Failure
to attend religious services would be noticed and in
certain rural communities may be criticized. Personal
behavior at odds with local norms and values might
further alienate key leaders. Frequent trips to a city for
recreation and shopping may suggest to locals that their
town is deficient, and it removes money from hard-
pressed merchants already struggling with regional
Wal~Marts and box stores. The worker's personal life,
including privacy, is important but it must be balanced
with the best interests of the clients. Important local
leaders may be offended by the worker's personal life
style, and they may sit on boards and committees that
determine community programs and services. Workers
who become adept at the balancing act tend to do better
for their constituents. Some social workers find such
trade offs too onereas and may seek the anonymity of a
city.
Rural practitioners must anticipate value conflicts
between rural citizens, who tend to be conservative and
traditional, and human service workers, who lean to-
ward more liberal and nontraditional values (Davenport
& Davenport, '1995). Social workers with urban
backgrounds tend to experience more of these pro-
blems. Professionals espousing popular urban issues
(for example anti-gun legislation and anti-hunting pre-
scriptions) usually suffer loss of community acceptance
in locales where hunting is an ancient and timehonored
cultural tradition. Small and big game animals are often
an important part of everyday subsistence, especially to
Native Americans. Conspicuous vegan lifestyles and
warnings that beef is too expensive and unhealthy do
not win many friends in cattle country where "eat more
beef" signs are aimed at improving the local economy.
Savvy social workers often join groups such as Ducks
Unlimited, National Wild Turkey Federation, and
fishing clubs in order to gain acceptance, establish
relationships with leaders, and gain an enhanced
position from which to encourage improved service
delivery. Social workers may find that their community
opposes policies taken by the NAsw. For

example, t:h;e National Rifle Association (NRA), whose
extreme stands on any form of gun regulation, can be a
valuable resource in a resource-poor community. The NRA
promotes such programs as Hunters for the Hungry,
recreational activities for persons who are disabled, gun
safety classes for youth, and self-protection classes for rural
women who often travel alone in isolated areas
. (NRA, 2006). Participating in such activities result in an
ethical or professional dilemma to some rural social
workers. They must thoughtfully consider the rrade-offs
and decide if reaching their goal of securing better services
for their clients means working with not openly opposing
the NRA or other groups with policies and values inimical
to the social work profession. Academic social work
programs serving rural areas may want to recruit
students-from like communities who may be more
comfortable in these situations. Urban transplants may
struggle if they are used to more formal and defined
boundaries between personal and professional life.
Ethical issues and dilemmas, especially those related to
dual relationships, may accompany these value conflicts
(Miller, 1998). For example, the National Association of
Social Workers proposed a change in its Code of Ethics, in
1993, which would have prohibited a social worker from
employing or engaging in a business venture with a client.
This rule aimed at preventing client abuse would be
relatively' easy to obey in an urban setting. However, rural
workers argued that a ban against all forms of dual
relationships would be almost impossible to enforce: and
that clients were already protected by the mandate that
social workers place their client's interest before their own.
Strict adherence to such a standard could prevent a family
services worker from employing the only beautician,
carpenter, or plumber in 25 miles. Low-population density
and lack of skilled employees would make this rule
cumbersome for everyone. The social worker's
inconvenience would be compounded by some potential
clients who would not enter treatment or seek other
services if it meant losing employment where jobs were
scarce. Additionally, townspeople would notice and find it
strange that the social worker did not secure the services of
the only beautician, carpenter, or plumber in residence.
This could result in even more unwanted attention to that
person and possibly violate his or her right to
confidentiality.
NASW's change to the acceptance of some dual
relationships, as long as they are not exploitive, provides
needed leeway to rural social workers. Bodor (2005), in an
exhaustive overview of nonsexual dual and multiple
relationships, posits that such relationships may even be
seen as a strength, if not a necessity,
RURAL PRACTICE 539
of a good social worker. Regardless, there is still added
pressure on rural social workers to tread carefully. Con-
sultation with a colleague or supervisor will help ensure
that the client's interests are paramount.
Confidentiality may present special problems, espe-
cially if an overly narrow interpretation is used. The
transparency of small town life makes it easy to note who is
going to the family services or mental health agency, or
whose home a social worker visits. Next door neighbors
and concerned friends, who are important components of
the natural helping system, may inquire about the worker's
presence. Retreating behind "professionalism precludes a
breach of confidentiality" would offer scant protection to
the clients whose problems have probably already been
noticed by their friends, neighbors, or relatives. Dismissing
their desire to help lessens the worker's acceptance by the
community, and it quite likely reduces the chances the
clients will receive valuable neighborly assistance. The
experienced rural social worker would use practice wisdom
to encourage the support of natural helpers, while taking
precautions not to violate confidentiality (Patterson et al.,
1992). For example, the worker could reply:
"I'm pleased you're concerned about your neighbor, Ms.
Schroeder, but the agency's rules don't allow me to talk
about the people we help. However, I don't think just
dropping by to see how she's getting along would hurt
anything."
Trends "and Directions
The information age and the exploding use of technology
are beginning to have a major impact on rural social work
practice and the academic institutions preparing rural
practitioners. Creative distance education programs are
increasingly reaching site-bound students with access to
courses through online and telecommunication access
(Blakely, 1994). NASW's WEBEDcontinuing education
courses are available through its Web site and should be
quite valuable to members in the hinterlands (NASW,
2006).Combined with travelinginstructors and use of
available local resources, these approaches are increasing
the numbers of rural social workers who are better
equipped to serve clients. Additionally, these graduates
enhance their chances for supervisory and administrative
roles. Rural graduates can also use technology for
continuing education, supervision, and specialized
assistance from telemedicine centers. The rise in use of
computers and cell phones will increasingly allow social
workers to maintain contact with and develop services for
people living in remote locations. Dezendorf and Green
(1999) laud the emergence of electronic social work as a
special boon for rural communities and promote the
concept
540 RURAL Paxcncs
of electronic Hull Houses with community support net-
works and electronic support groups.
Professionally, many social workers interested in, rural
practice, research, and policy participate in the annual
National Institute on Social Work and Human Services.
This institute, which is hosted by the National Rural Social
Work Caucus and academic institutions, rotates around the
United States and is "a great place to make contacts and
increase knowledge. The published proceedings are
invaluable sources of information and are published by the
individual universities sponsoring the conferences and can
be found at www.Ruraloocialwork.org. The journal, Human
Services in the Rural Environment, is no Ionger published, but
back issues may be located at some universities or available
from rural colleagues. Com temporary Rural Social Work is
an electronic journal published by the National Rural
Social Work Caucus. Participants attending the annual
conferences are automatically considered members of the
National Rural Social Work Caucus. Also, there is a Web
site, www.RuraISociaIWork. org, that provides National
Rural Social Work Caucus members and the general public
with additional resources pertinent to rural social work.
REFERENCES
Bender, L. D., Green, B. L., Hady, T. E., Kuehn, J. A., Nelson, M. K.,
Perkinson, L. B., et al. (1985). The diverse social and economic
structure of nonmetropolitan America. Washington, DC: U.s.
Department of Agriculture, Economic Research Service.
Blakely, T.]. (1994). Strategies for distance learning. Journal of
Continuing Social Work Education, 6(1),4-7.
Bodor, R. C. (2005). Nonsexual dual and multiple relationships:
When urban worldviews define rural reality. In B. Locke & V.
Majewski (Eds.), Finding our voices, having our say: Meeting the
challenges of rural communities (pp, 104119). Morgantown: West
Virginia University Division of Social Work.
Brown, J. C. (1933). The rural community and social casework.
New York: Family Welfare Association of America.
Carlton-LaNey, I. B., Edwards. R. L., & Reid, P. N. (1999).
Small towns and rural communities: From romantic notions to
harsh realities. In I. B. Cariton-LeNay, R. L. Richards, & P. N.
Reid (Eds.), Preserving and strengthening small towns and rural
communities, pp. 5-12. Washington, DC: NASW
Press. ' Lohmann, N., & Lohmann, R. L. (Eds.). (2005). Rural social work
Cordova, L., Dannerbeck, A., Davenport, J. A., & Rademacker, M.
(2005, September). Latino gangs and community mobilization for
reclaiming communities. Paper presented at the West Central
Missouri Multicultural Forum; Sedalia, MO.
Daley, M., & Avant, F. (1999). Attracting and retaining professionals
for social work practice in rural areas: An example from East
Texas. In I. B. Carlton-Let-ley, R. L. Richards, & P. N. Reid
(Eds.), Preserving and strengthening
small towns and rural communities, pp. 335-345. Washington, DC:
NASW Press.,
Davenport, J., & Davenport, J. A. (1984a). Josephine Brown's classic
book still guides rural social work. Social Casework,
65(7),413-419. '
Davenport J., & Davenport, J. A. (1984b). Theoretical perspectives
on rural/urban differences. Human Services in the Rural
Environment, 9(1), 4-9.
Davenport, J., Davenport, J. A., & Locke, B. (2005). Finding our
voices from our past: The legacies of Brown, Lindeman and
Strode. In B. Locke & V. Majewski (Eds.), Finding our voices,
having our say: Meeting the challenges of rural communities (pp,
176-186). Morgantown: West Virginia University Division of
Social Work.
Davenport, J. A., & Davenport, J. (1995). Rural social work
overview. In R. L. Edwards (Ed.), Encyclopedia of social work (pp.
2076-2085). Washington, DC: NASW Press.
Deavers, K. (1992). What is rural? Public Studies Joumal, 20(2),
183-189.
Dezendorf, P. K., & Green, R. K. (1999). Using electronic social
work to serve the rural elderly. In I. B. CarltonLal-ley, R.
Edwards, & P. N. Reed (Eds.), Preserving and strengthening small
towns and rural communities (pp, 298-312). Washington, DC:
NASW Press.
Galbraith, M. W. (1992). Education in the rural American community:
A lifelong process. Malabar, FL: Free Press.
Ginsberg, L. H. (Ed.). (1976). Social work in rural communities:
A book of readings. New York: Council on Social Work
Education.
Ginsberg, L. H. (2005). Social work in rural communities' (4th ed.).
Alexandria, VA: Council on Social Work Education.
Harper-Dorton, K. V., & Yoon, D. P. (2006). Rural nonprofits and
consumers: Information age, access, and capacities. In B. BJ
Wright (Ed.), Social work in the rural context: Strategies that
empower (pp. 97-103). Frostburg, MD: Frostburg State University
Department of Social Work.
Hassinger, E. W., Hobbs, D. J. (1992). Rural society: The
environment of rural health care. In L. A. Straub & N. Walzer
(Eds.), Rural health care: Innovation in a changing environment
(pp. 178-190). Westport, CT: Praeger.
Jolliffe, D. (2006, September). The cost of living and the geographic
distribution of poverty. Economic Research Report, No. 26, U.S.
Department of Agriculture. Retrieved October 30, 2006, from
http://www.ers.usda.gov
Lindeman, E. C. (1921). The community: An introduction to the study
of community leadership and organization. New York:
Association Press.
practice. New York: Columbia University Press.
Martinez-Brawley, E. E. (Ed.). (1980). Pioneer efforts in rural social
welfare: Firsthand views since 1909. University Park:
Pennsylvania State University Press.
Martinez-Brawley, E. E. (1981). Seven decades of rural social work.
New York: Praeger.
Martinez-Brawley, E. E. (1983). Rural social work as a contextual
specialty: Undergraduate focus or graduate concentration? Paper
presented at the Pre-symposium Institute, Eighth

National Institute on Social Work in Rural Areas. Cheney,
WA.
Miller, P. J. (1998). Dual relationships in rural practice:
A dilemma of ethics and culture. In L. H. Ginsberg (Ed.),
Social work in rural communities (Jrd ed., pp. 55-63).
Alexandria, VA: Council on Social Work Education.
National Association of Social Workers. (2006). HIV/AIDS is
focus oflatest online course offering. N ASW News, 5 J( 8), 5.
National Riffle Association. (2006). NRA membership benefits and
service guide. Fairfax, V A: National Riffle Association.
Patterson, S. L., Memmott, J. L., Brennan, E. M., & Germain, e.
B. (1992). Patterns of natural helping in rural areas:
Imp lications for social work research. Social Work Research &
Abstracts, 280), 22-28.
Rich, R. O. (2005). The New Deal in rural context: Immediate and
continuing impacts. In B. Locke & J. Majewski (Eds.), Finding
our voices, having \OUr say: Meeting the challenges of rural
communities (pp. 176-186). Morgantown: West Virginia
University Division of Social Work.
Strode, J. (1938) Rural social workers do everything. Suro/ey
Mid-Monthly, 74(10), 308-309.
U.S. Bureau of Census. (1991). Poverty in the United States: 1990.
Current population reports (Series P-60, No. 175). Washington,
DC: U.S. Government Printing Office.
RURAL PRACTICE 541
Vice-Irey, K. (1986). The social work generalist in a rural
context: An ecological perspective. Journal of Education for
Social Work, 160),36-42.
FURTIIER READING
Davenport, J. A., & Davenport, J. (1982). Utilizing the social
network in rural communities. Social Casework, 63(2), 106-113.
Rolison, P. A., & Pardeck, J. T. (2006). Homelessness in rural
America: Policy and practice. New York: The Haworth Press.
SUGGESTED LINKS National Association for
Rural Mental Health. www.narmh.org
National Rural Health Association.
www.nrharural.org
Rural Journalism.
www.ruraljournalism.org
National Rural Social Work Caucus.
www.marson-and-associates.com/rural
-JUDITH A. DAVENPORT AND JOSEPH DAVENPORT,
III