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CHAPTERs.docxCHAPTER 13 WORKING WITH PEOPLE WHO LIVE WITH HIV AND AIDS: THE PROBLEM AND HUMAN SERVICES
WM. LYNN MCKINNEY
As a human service worker, you are almost certain to have clients who are people living with human immunodeficiency virus (HIV) and persons living with AIDS (PWAs). This is true because AIDS affects people of all ages, sexual orientations, and ethnic and minority groups and because the needs of PWAs and people living with HIV are numerous and span virtually all human service programs. Because AIDS is an illness, there are medical needs. Since most PWAs eventually must stop working, they have income needs. The number of children who have HIV is growing, and these young people may have educational needs. For several reasons, there are likely to be psychological and social needs.
First of all, AIDS occurs primarily in people younger than fifty, which means that PWAs must deal with a fatal illness at an early age. Second, AIDS is found mainly in marginalized people such as homosexual men, injection drug users, and racial and ethnic minorities. Still another reason that PWAs may have psychological needs is that many of them will have many friends who are seriously ill or who have died. The effects of such losses are potentially enormous. Thus, the entire human service system is involved in working with people living with AIDS and HIV. So, as you enter the field, it is important that you know about HIV and AIDS and society’s reactions to the disease.
Working with people with AIDS and HIV presents particular challenges. Many people with this illness will not have close ties with their families who may have turned their backs on what is perceived to be a social embarrassment. Most will be poor, some because they were poor when they became sick and others because the disease is impoverishing. Death from AIDS-related causes can be horrible; the diseases and infections that affect a PWA can leave people thin and weak and seemingly defenseless for long periods of time. Unlike those with other illnesses, PWAs may be very sick and close to death for a while and then go through long periods of good health when they can lead happy, productive lives. As more cases of AIDS are diagnosed among drug users, more clients may be difficult to work with. Finally, with more women contracting the virus and dying, there are orphaned children who are not infected as well as children who were born with the virus. Many of these children are not or cannot be cared for by their mothers or other relatives.
However, working in the HIV field can be rewarding. As you must know, as you are planning to enter the human service field, all work with people is rewarding. If your interest is in research, you can become involved with learning more about the virus, thus increasing the probability of a cure, a vaccine, or better care for people who are HIV positive. If you work with individual clients, you will no doubt develop intense, deep relationships with many of them; some of these will be enormously enriching, revealing to you some of the best aspects of humanity. Work with HIV will probably stretch you professionally, broadening your knowledge and experience so that, should you decide to change jobs, you will present an attractive array of qualifications to prospective employers. Finally, you can gain satisfaction knowing that you are working with people, many of whom live on society’s margins, and doing what you can in response to a pandemic—a worldwide outbreak of a disease affecting an extraordinarily large percentage of the population.
You probably knew some things about HIV by the time you entered college. But because it is a politically charged issue, the quantity and quality of HIV education varies greatly. Although we may review in this chapter some material that you already know, there will also be material that is new to you. The objectives of this chapter are (1) to solidify your basic medical understanding of HIV and AIDS, (2) to help you understand some of the social ramifications of HIV, and (3) to acquaint you with current issues. This chapter is only an introduction to the topic. Reading about HIV and AIDS in books, newspapers, and professional journals should be a part of your professional growth. We urge you to become involved in AIDS service organizations (ASOs) as well. Practical experience is an excellent means to expand your knowledge.
HIV AND AIDS AS MEDICAL ISSUES
In 1985 the specific virus that is believed to cause AIDS was identified. It is human immunodeficiency virus (HIV). Today there are two strains of HIV active in the United States. The most prevalent strain is HIV-1, which has been with us since the early 1980s. The virus is constantly mutating as new medications are developed. We still know much less about HIV and AIDS than we wish we did. Fortunately, research is revealing new information to us regularly.
Acquired immune deficiency syndrome (AIDS) was first noted in the United States very early in 1981, but it was not until three or four years later that it was identified as a syndrome and given a name. Doctors in San Francisco and New York began to notice that they were treating a new group of patients, primarily gay and bisexual men in their twenties and thirties, for a series of diseases that were highly unusual among healthy young people. Initially what doctors were seeing was called gay-related immune deficiency (GRID) because it was noted exclusively in gay men. Eventually the medical profession developed the description Acquired Immune Deficiency Syndrome (AIDS). The words that make up the acronym AIDS provide specific meaning. (For an incisive account of the early years of the disease in the United States and for insight into the politics of this illness, read And the Band Played On by Randy Shilts.)
The A in AIDS, which stands for “Acquired,” indicates how a person gets the disease. AIDS is a communicable disease; a person must get it from someone else. In this sense, it is like hepatitis, a cold, or measles. AIDS is not inherited like some diseases such as sickle cell anemia and Tay-Sachs disease. Unlike some other diseases, (e.g., cancer), it does not just begin inside an individual, in many cases for unknown reasons. People have to get AIDS from someone else, and it is not easy to get (we emphasize this fact and explain what it means later in this chapter).
The I and the D stand for “immune deficiency,” which refers to the characteristics of this disease that make it unlike any other disease. Instead of making you sick directly, HIV attacks the helper T cells in the human body. These helper T cells are important for us to be able to fight off infections. When they become weakened, our bodies become vulnerable to other diseases, virtually all of which we ordinarily are resistant to. This literally causes a deficiency of the body’s immune system, leaving the infected individual susceptible to a wide variety of infections that ordinarily would not affect noninfected individuals.
Finally, the S stands for “syndrome.” A syndrome is a collection of symptoms and effects of other diseases. AIDS is considered to be a syndrome because a person with AIDS does not die of AIDS but rather of other diseases, most of which were rarely seen in the United States until the advent of AIDS. These diseases, commonly called “opportunistic infections,” can occur because T cells are destroyed and can no longer ward off infections.
People with HIV may continue to be asymptomatic for many years, but eventually symptoms will appear and a diagnosis of AIDS can be made. For two reasons it is important to have a clear diagnosis. First, there is a psychological impact on the infected individual of having AIDS versus having HIV. Different sorts of supportive services may be necessary as an individual progresses from knowing that he or she is infected with HIV to knowing that he or she has AIDS.
Second, once someone is determined to have AIDS, he or she may become eligible for a variety of state and federal programs. Initially a person was diagnosed with AIDS if he or she had any one of two or three diseases or opportunistic infections; pneumocystis carinii pneumonia (PCP) and Kaposi’s sarcoma, a rare form of skin cancer, were the most common. In early 1993, the Centers for Disease Control (CDC) in Atlanta changed the way in which it defined whether a person had AIDS. Now a person is classified as having AIDS if his or her helper T lymphocyte count falls below 200 (ordinarily the helper T count ranges from 800 to 1,200) and if he or she also has at least one of the specific diseases associated with AIDS.
The definition was changed because it had been much more useful in diagnosing AIDS in men than it was in women. Since women experience the disease differently and since more and more women now have AIDS, it was important to change the definition.
The two opportunistic infections that are the greatest killers of men are PCP and toxoplasmosis. Toxoplasmosis is a chronic, severe brain infection. Toxo is a common parasite that is found in most everyone. As is true of all other opportunistic infections, it is fought off by healthy immune systems. However, in individuals whose immune systems are compromised, toxo can become activated, resulting in blindness, paralysis, and dementia. Fortunately there are now prophylactic treatments for both of these diseases.
Women with HIV are more likely to develop other diseases, particularly yeast infections, invasive cervical cancer, recurrent bacterial pneumonias, and bloodstream infections. Recently an increase in the number of cases of pulmonary tuberculosis has been noted.
Unless it is your intention to enter the medical field, this is probably enough for you to know about the medical aspects of AIDS and HIV. As you become involved with PWAs, you may need to increase your medical knowledge, but, as we repeat often in this chapter, knowledge about AIDS is increasing rapidly, and you should learn more as part of your continuing professional development and as the need confronts you.
The Transmission of HIV
HIV is transmitted through bodily fluids, specifically blood, semen, and vaginal fluid. Although the virus is present in other bodily fluids such as tears and sweat, it is found in such slight concentrations that these fluids are not considered dangerous. HIV is difficult to transmit. There are very few ways in which HIV can be transmitted from one person to another. Unprotected sex and sharing needles are the two most common ways. A third way is across the placenta from an infected woman to her unborn child. Until 1985, HIV was occasionally transmitted by blood transfusions, but since that time the U.S. blood supply has been considered safe because of donor screening and because all blood to be used for transfusions is tested before it is given to someone.
HIV is not easy to catch because, for a person to be exposed to the virus, it must enter a person’s bloodstream. This can occur when individuals share an unsterilized needle to inject steroids or other drugs. It can also occur during unprotected sex, either vaginal, anal, or oral. But again, for infection to occur, the skin must be broken. This often occurs during anal intercourse, can occur during vaginal intercourse, and can occur during oral sex if the person performing oral sex has skin breaks such as canker sores or unhealthy gums. Tears in the skin need only be microscopic in size for transmission to occur.
Sexual transmission of HIV from men to women is much more common than from women to men. This is true because the skin must be broken for the virus to cross from one individual to another and because the virus is present in dangerous concentrations in semen. It is more likely that the lining of the vagina or anus will experience a tear during sex than it is that the penis will suffer some sort of skin break. Infection from a man to a woman is more likely because sex commonly results in the ejaculation of semen. The most risky form of sex between men is unprotected (i.e., without a condom) anal intercourse.
Infection is less likely during oral sex but can occur if semen is ejaculated. It is possible for the person performing oral sex to infect his or her partner only if infected blood somehow enters the sexual partner’s penis such as if he or she has strep throat or other infectious lesions in the throat. Sex between two women and oral sex by a man on a woman rarely result in transmission, but it is possible. Use of dental dams during such oral sex is urged.
One quarter of babies born to infected mothers are born with the virus, but we now know that pregnant HIV-positive women who take AZT during the last three months of pregnancy and receive an infusion of AZT during labor and delivery can reduce to 8 percent the probability that their babies will be born infected. Why the virus crosses the placenta in some cases and not in others is not known at this time. As part of your continuing professional growth, you should regularly read newspaper and journal articles about AIDS and HIV to stay informed. Research is making great strides, and you, as a human service student and professional, are responsible for keeping your knowledge current.
CHAPTER 15 HELPING FOR ALCOHOL AND DRUG ABUSE
MARCEL A. DUCLOS MARIANNE GFROERER
The statistics describing the use and abuse of alcohol and other mind-altering drugs ring familiar on the nightly news, find bold print in the newspapers, and flavor everyday conversations. General hospitals treat medical/surgical patients suffering from medical complications due to abuse and dependency. Emergency mental health and medical services are often faced with management of the intoxicated person. Community mental health centers daily confront the detrimental poly-drug use of scores of deinstitutionalized patients, including the dually diagnosed. School personnel, counselors, teachers, and administrators alike witness the ebb and flow of the season’s most preferred or most accessible substance on the school grounds. They must additionally contend with the far-reaching effects of substance use on students, families, and neighborhoods. Along with community workers and social service agency staff, law enforcement officers also struggle to overcome a gnawing defeatism when children and youth sustain, as victims, the ravages of their own or others’ use in a cycle of destruction and even death.
No age group, no socioeconomic status, no level of education, no geographic area—urban, suburban, or rural, mountain, plain, or coast—no occupation or profession, and no religious affiliation—whether church, temple, synagogue, or mosque—protects from the insidious and infectious spread of the problem. Our society’s cultural heritage of ambivalence reveals itself by the earliest promotion of the use of alcohol in the colonies and the colonial militia, combined with a primitive “righteous” response to inebriation. No time period in U.S. history, not even the years of Prohibition, provided a drug abuse–free environment for the growth and development of citizens. Nor can such an environment be anticipated for the near future. It is a dream, an idealistic vision. Human service practitioners must face the disillusionment of the present reality and continue to attend hopefully in the expectation of manageable goals realistically attainable by troubled and afflicted clients.
At-risk behaviors due to disinhibition and impaired judgment caused by mind-altering substances obligate human service practitioners to consider strategies—educational, medical, economic, political, sociological, psychological, and spiritual—to address the problems on the contemporary scene. These problems include the ones the nation shuns the most: the growing AIDS epidemic, all forms of child abuse, and the persisting plague of violence in our society. The long multicultural history of the human services teaches that the “cure” of human ills, including substance abuse problems, cannot come from logic alone but requires authentic caring. For the human service practitioner, caring in its concrete, active form means consistent and care-filled attention to the details of a realistic treatment plan.
CHALLENGES FACED BY HUMAN SERVICE WORKERS
The human service worker stands, as a generalist, in the middle of a network of providers, ready to work cooperatively with the many specialists assessing, developing treatment/service plans, delivering care, evaluations, and outcomes. In the arena of alcohol and drug abuse, the key challenge to the worker remains the same: achieving the earliest detection for possible prevention. Yet in the reality of the service delivery systems, the challenge almost always involves the detection of intoxication, the history of abuse, the possibility of dependence, and/or risk as victim or victimizer. No accurate or appropriate care can be designed and provided in any context without knowledge of the effects of drugs on a client’s life. Failure to identify the contributing and resulting connections between substance abuse and the client’s presenting problems with health, the law, money, work, school, society, family, and self will spell a decisive failure in care, however well packaged the plan and well intentioned the delivery. The old psychiatric rule “diagnosis predicts prognosis and therefore directs treatment” applies here as well.
The first challenge, then, is one of accuracy. However, much client care may be a matter of heart; it must be guided by knowledge and experience. Accurate knowledge of the psychoactive substance use disorders and their associated intoxication and withdrawal syndromes arms the worker with necessary information to intervene at the earliest possible moment. The continuum of care reaches from direct immediate crisis intervention to consultation and referral as required.
The second challenge lies in the subjective domain, in the human service worker’s own personal story. Few individuals can claim never to have been touched by the effects of substance-induced behaviors, though they might claim, for themselves, lifelong abstinence. Whether in personal, social, or professional experiences, the human service worker will have accumulated learned responses to this population. The challenge of empathic acceptance, of healthy emotional distance, or disidentification of a client-enhancing response to countertransference calls for clear, helpful supervision. Whether the service being delivered to the client entails modest assistance with some agency paperwork or involves the complex, long-term work of case management, the energy at the meeting of client and practitioner will generate the atmosphere of change. It therefore becomes an inner challenge for the worker to know her or his own story and to use that level of awareness to promote the client’s good and to attempt to cause no harm.
The third challenge pertains to the temptation of the human service practitioner to view himself or herself as competent to function as a substance abuse counselor despite a lack of specialized academic training and clinical experience. The treatment of substance abuse and dependence is a multidisciplinary enterprise. The work of a substance abuse counselor is defined by observable and measurable competencies. For the human service worker who serves an addicted population, it is an ethical imperative to know one’s limits of competence and role within the agency and to consult and refer as necessary.
The worker who is unfamiliar with the neurological impairments caused by particular substances abused would be in danger of placing the client, self, and others in physical and/or psychological jeopardy. Depressants, stimulants, narcotics, and hallucinogens present their own sets of impairments and their own relative levels of danger. Confusion about the client’s antecedent or resultant developmental and personality disorders would make the adoption of an individualized helping style difficult. Early trauma in combination with many years, even decades, of substance abuse exacts heroic transformational work on the part of the recovering person. Overestimation of the addicted person’s ability to stop using and become sober without sufficient time for emotional healing and behavior change would lead to errors in the selection of strategy, in the expectation of outcomes, and in the fundamental process of defining the real problems. The nature of the disorder and of rehabilitation leads to paradoxes for the recovering addict as well as for the human service practitioner.
Again, the history of drug use gives us a clue about the paradoxical nature of psychoactive substances, of the disease of substance addiction, and of the recovery process. The ancients and the alchemists taught that nature cured disease with either similars or opposites, depending on the illness. Substance abuse and dependence is such a disease. The substances themselves produce their opposites: depressants can rebound into anxiety; stimulants can plunge into depression; narcotics produce their own pain; hallucinogens can lead to loss of self. That which the user originally sought through partaking of the drug eventually eludes the abuser. The drug exacts due payment for all experiences—soothing, exciting, painless, or expansive. All that was beyond the ego’s humble ability to integrate into the psyche and beyond the body’s physiological capacity to metabolize into vital energy returns with a vengeance.
The enslaving addiction to the drug releases the abuser to an opposite dependence, binding her or him to a committed pursuit of inner freedom hard won by selfless courage. In the tradition of recovery, the paradox of the twelve-step program of Alcoholics Anonymous (and Narcotics Anonymous) describe that which will nurse the recovering person back to sanity with an elixir of opposites—a bitter medicine that many will reject. No recovery program anywhere can sidestep the necessary laws of nature that direct bodies, minds, and souls from illness to health.
The client’s life calls for a complete turn-around—nothing less will do. The cleverness and cunning that characterized the addiction must become slowness and carefulness, accepting the wisdom of another, allowing the unshakable inner self to put aside the false grandiose ego projected by the substance. A new life begins only with the death of the old one. It is ultimately the paradox of life and death because substance dependency is a matter of life and death.
HUMAN SERVICE RESPONSES TO SUBSTANCE ABUSE
The human services respond to the problem of addiction in society in three ways: education, prevention, and treatment. The choice of response is determined by the level of addiction, which is the target of the approach. Limiting considerations to the individual, the human services distinguish between the person who has never used drugs for recreation, the one who only rarely uses chemicals for recreation, the person who uses frequently and whose abuse leads to some personal and professional problems, the individual who is dependent to the point of resulting medical complications, and the small percentage of individuals who, in their chemical dependency, are also socially isolated and face predictable death. Because chemical dependency is potentially life threatening, the human services respond according to the immediacy of the danger to self and others.
Education
Successful drug education programs have incorporated in their materials and services the knowledge, attitudes, and behavior necessary to optimize the choice of a drug abuse–free life. Some programs emphasize convincing the audience of the dangers of drugs, whereas other programs underline the objective facts about the substances, advocating neither abstinence nor reasonable use. Other programs utilize the power of identification with a noteworthy person in recovery to score a point with the listeners or viewers. Still other programs, especially those geared toward the school- and college-age population, are even more direct in their approach, providing training in assertively resisting encircling pressures.
Prevention
Prevention does not only refer to those persuasive efforts aimed at stopping abuse before it starts. It also involves those interventions aimed at signaling to a user in the early stages of abuse that continued use could result in damaging consequences. Early diagnosis with crisis monitoring, crisis intervention, and referral are such interventions. For those individuals who are in the later stages of abuse that lead to dependency, the prevention efforts address the goal of halting the slide to that conclusion. In this instance, intervention efforts could take the form of early treatment, monitored maintenance, or social/medical detoxification. The motto “the best defense is a good offense” applies in this domain.
Treatment
Because drug abuse and drug dependence are characterized as mental disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), medicine, nursing, and psychology are the disciplines that have traditionally taken responsibility for the treatment of these illnesses. Social work and mental health counseling have also sought to remedy the social and societal ills related to substance addiction. The profession of substance abuse counseling, newly emergent in the early 1970s, has now taken on a prominent role in the treatment of individuals suffering from substance- related disorders. Human service providers who are certified by the International Certification Reciprocity Consortium as alcohol and drug abuse counselors have given evidence of specialized competence in their assigned roles and functions as they work alongside some of the other traditional professions. These particular individuals have passed an objective exam and have been successful in an oral defense of a case presentation before a member state board. They also may choose to become a member of the National Association of Alcoholism and Drug Abuse Counselors (NAADAC).
All of these professionals, according to their own training and skills, cooperate to promote the client’s achievement of physical and psychological health, social and financial stability, and behavioral and interpersonal satisfaction. In all of this there still remains a key role for the generalist in the human service field: that of case manager, as the coordinator of all those services that promote follow-through and attainment of the treatment goals.
Whether the goals are abstinence after detoxification, management of disruptive behavior, stability of employment or housing, or improved overall self-care and health, the variety of treatment settings and assortment of approaches employed is as diverse as the developmental needs and problems of the clients. Depending on the severity of the addiction, the setting might be an in-hospital treatment program, a residential center, or a day program or out-patient individual, family, or group contact. The human service worker plays a valuable role in all of these settings as a team member with other providers.
It is important to note that treatment facilities vary, depending on the population served and the substance treated. Though they have commonalities worth acknowledging, treatment facilities may, in order to focus on specific areas of need, specialize in work with the elderly, adolescents, women’s issues, cocaine or heroin abuse, homeless individuals, or the dually diagnosed. In each case, the facility will function along standard guidelines of substance abuse treatment but with its own particular focus. With this in mind, an outline of the most commonly found treatment facilities follows.
In-Hospital Treatment Program
Used for:
· Detoxification from physical dependence
· Individuals unable to remain substance-free without supervision
Provides:
· Medical monitoring of withdrawal
· Group psychoeducational counseling and introduction to support groups such as AA/NA
· Possibly some social services/case management
Length of stay:
· Twelve to twenty-eight days (some may be as brief as three to seven days, depending on insurance coverage)
· May transition into outpatient program
Residential Treatment Center
Used for:
· Long-term maintenance of sobriety/drug abstinence after detoxification
· Individuals without financial resources in need of halfway house/therapeutic community for recovery
Provides:
· Necessities of daily living (shelter, nutrition, life-skills training, education)
· Role modeling, direct reality-based feedback in daily living situations, and promotion of self-discipline
Length of stay:
· Three months to two years (usually funded by public or private nonprofit agencies)
· Includes assistance for vocational, social, and emotional transition back into community/family living
Outpatient Services
Used for:
· Transitional treatment after detoxification or residential treatment
· Individuals with early stage or less severe problems, those not physically addicted, those able to maintain employment during treatment, or those living in a stable and supportive environment
· Individuals unable to afford or not eligible for inhospital or residential treatment programs
Provides:
· Counseling, education, support system for individual, couple, family, or group
· Possibly some case management, transportation, and socialization
· Assessment and referral to more intensive types of treatment if needed
Length of stay:
· Participation varies according to need and facility; may be once a day, all day, each evening, twice weekly, or once every two weeks; some facilities provide open-ended “drop-in” groups for occasional support of program “graduates”
· No set limit on length of service use; may be feefor-service based on ability to pay or supported by public or private funds
Skills and Training Needed by Human Service Workers
To function as a valuable and valued team member in such settings, the human service student must be attentive to the skills needed in the field. Employers expect trained human service practitioners to understand how the health and human services work. Students must, therefore, gain skills in coordinating the services a client receives while being able to help the same client access the services of other agencies as the need arises. Given the multiplicity of needs and problems that the substance abuser presents, the student is obligated to at least know how to access the multiple services required to meet treatment goals developed by the program.
Knowing the resources is one thing, but helping the client to choose and use a service is another. Perhaps the most fundamental skill that the student has to offer this troubled client is the skill of professional helping. To be more specific, this is the art of attending: the quiet, focused, other-centered attention that develops an investment in the process of change on the part of the client. Consistent, focused attending can raise a client’s self-esteem; foster, perhaps even repair, trust; and increase feelings of effectiveness. These basic building blocks of a successful life are the inevitable results of the authentic, professional, helping relationship. This is really the central gift at the heart of all the human service practitioner’s efforts. To attend in a way that invites the client into eventual self-direction stands out as the main contribution that can enliven the delivery of care.
Students in the field of human services who seek additional proficiency in the area of alcohol and drug abuse may seek specific training in the following skills:
· 1. Taking an alcohol and drug use history
· 2. Identifying abuse and dependency, including the withdrawal syndromes
· 3. Recognizing the complications of drug interactions
· 4. Using the pertinent resources in the community
· 5. Imparting accurate information about abusable substances
· 6. Adapting services to the needs of specific populations
A question remains to be addressed: What specific body of knowledge and array of skills would provide the proficiency required to work effectively in the service delivery field of alcohol and drug abuse as an independent professional? For the sake of brevity, this article will only identify and parenthetically discuss major categories of competency.
These categories have been grouped under the headings of the Twelve Core Functions of a Counselor, which define and describe a professional human service provider as a specialist in more than forty states. Furthermore, training for these core functions is available at the associate’s, bach-elor’s, and master’s levels of formal education. It is also available to individuals through approved professional workshops, staff development, and continuing education courses. Currently, the federally funded network of Addiction Training Centers (ATCs) and the Center for Substance Abuse Treatment have identified and published the Addiction Counselor Competencies report, which summarizes the knowledge- and skill-based instruction leading to eligibility for certification, registration, or licensing through the aforementioned consortium under the laws of member state boards. These same competencies ensure competent and ethical practice for the protection of the consumers of substance abuse services.
Under these guidelines, a specialist/counselor in this field must be able to screen potential clients to determine whether they are eligible and appropriate for admission into the available program. If the person in need meets the established criteria for admission, the counselor will conduct the intake process to ensure the clarity of the emerging treatment contract and development of trust and rapport between the client and the program. At this point, the counselor will orient the client in the ways and means, rules, and structure of the recovery program, providing an inner and outer safe millieu for the start of the work of recovery. With the information gathered so far by all the professionals involved, the counselor will pursue the formulation of an assessment of the individual’s strengths, weaknesses, problems, and needs relevant to the mutual work of change. The focus of both client and counselor becomes the partnership necessary to decide on an individualized treatment plan. Problem identification, rank ordering of changeable problems, time lines of change, and methodologies all become part of the client-approved plan or strategy for change.
This plan must be multidimensional. It must include all the domains of human growth and development and all the health and human services as necessary. To this end, the specialist must be a fundamentally sound individual, group, and family counselor. Because of the problems and needs of clients beset by the ravages of chemical addiction, the specialist must be able to coordinate the many services prescribed in the treatment plan. In the course of treatment, there will almost always be at least one crisis. The certified counselor will be able to respond to crises in a way that maximizes safeguarding the client’s rehabilitation and turns the threat to recovery into an opportunity for continuing growth.
Throughout the treatment efforts, imparting accurate and germane information about addictions and the road to recovery remains a major function of the trained counselor. When the needs of the client cannot be met by a particular provider or by a particular program, the obligation to refer guides the accessing of other sources of help. This obligation may be exercised from the moment of screening to the time of discharge, aftercare, and follow-up.
Finally, in carrying out all of the above functions, including intra- and interagency consultations, the human service specialist in this field of addictions as in all other branches of this profession must be able to accurately keep records and write reports. It is essential that all records and reports maintain overall privacy and confidentiality while being clear, understandable, and complete. Careful handling of information allows for the effective continuum of care for the client’s benefit.
Alcohol and drugs are perhaps the most constant variable in the synergistic forces that trouble the lives of human service clients. The arguments in favor of continued specialized training flow from the case management records of service delivery agencies. Whether as a generalist, specialist/counselor, or student practitioner, the goals of the human service worker in helping for alcohol and drug abuse remain ultimately the same. The worker’s purpose is to encourage, assist, and enhance the recovery process with specific skills, knowledge, humanity, and genuine caring. It is to promote a life that will empower the recovering person to be, as an anonymous poet wrote, “tender enough to cry, human enough to make mistakes, strong enough to absorb pain, and resilient enough to come back and try again.”
CHAPTER 22 LEGAL FOUNDATIONS IN HUMAN SERVICES: CONSIDERATIONS FOR CLIENTS AND WORKERS
DAVID C. MALONEY AND PETER CLARK
It is our intent and purpose in this chapter to meet three basic goals for the reader. First, inasmuch as your work will be performed in the service of others, you will need to know what rights and privileges are given to clients by law and how these rights and privileges are typically dealt with by human service professionals. In this way, you may begin to appreciate the extent to which legal considerations will influence what you are required to do with and for the people you service, and you will understand what helping others involves with regard to their freedoms and their choices as recipients of your service.
Second, as a beginning student preparing to eventually enter the field of human services, you will need to understand how legal principles will influence the work you do. The readings to follow are designed to present relevant information regarding these principles.
Third, after reading this chapter, you will gain a greater appreciation of the law through your knowledge of the origins of those ethics that guide and direct the professional behaviors of human service workers by setting limits to help ensure that such workers always are doing the “right” thing, for the “right” reason, at the “right” time.
As “bookends” to the above goals, the authors will begin by providing a brief outline of the relationship between law and society and finish with some relevant applications of specific laws in relation to human services and mental health.
LAW AND SOCIETY: BASIC PRINCIPLES
In modern civilizations, as well as in known past societies, humans united by a common bond of purpose have always had a shared reliance upon a set of rules that structure the conduct of behavior and the relationships between and among the group’s members. Stability and continuity of society are the products of these laws and rules (Abel, 1995 ).
Laws are the rules of behavior that members of a given society are directed to follow. Whatever benefits are offered to members of a society (e.g., protection, support, income, status, freedom, etc.), those rewards are the product of adhering to the rules inherent to that society. In our society, our laws (rules) originate from two basic sources: either they have been legislated by federal and state elected bodies or they have evolved (case law) from the interpretations of our judiciary system (all branches, state and federal).
As a nation, our original basic principles of legislated law are set forth in our Constitution, its amendments, and the Bill of Rights. In the two hundred or so years since the required nine states ratified these sets of rules, all subsequent laws created and voted upon by federal and state legislatures have had to conform to the original constitutional laws. Thus, stability and continuity were preserved for every state in the Union and for the nation, a democratic republic, as a whole (Rembar, 1980).
Rights and Restrictions
The products of law are statements that describe the rules by which people, their activities, and their relationships are constantly governed. The process of law is the interpretation of those laws via the court system on a case-by-case basis. As original laws are upheld they are constantly being interpreted and reinterpreted through the judgments of the court(s). When new and different judgments are rendered and upheld via the appellate courts (state and federal) they become the prevailing (case) laws. Thus, law is not an arcane code, never to change or bend and intelligible only to lawyers and judges, but rather a substantive, living set of rules subject to review and reevaluation and available to criticism and modification and when in the best interests of all citizens, also subject to repeal. Law is not a monolith of rules, but always in flux as it adapts to social changes of the day.
Rights are insured for all citizens of this country by constitutional law. Human service workers should understand the rights guaranteed by the U.S. Constitution in its original form. There are few terms in the Constitution, or its twenty-six amendments, that the average human service student will need to consult a dictionary to comprehend. The conciseness and clarity of these writings are the cornerstones of their longevity and resilience. Collectively, they represent the heart of our civil court system and are exercised daily throughout the country.
Laws are also utilized to establish the limits of behavior; that is to say, they present the restrictions imposed both on individuals and on institutions (including the government itself). These limitations, properly administered, form the ground rules for our liberties and our freedoms as citizens. As a student of the Constitution, with all of its rights and restrictions, you will gradually grow to appreciate its depth, its power, its simplicity, and its utility for all citizens within our society, especially those in need.
Freedoms and “Humanitarian Ethos”
As citizens of a democratic republic, we enjoy a bounty of freedoms and liberties guaranteed by law. Countless numbers of disputes throughout our country’s history have been ultimately resolved and remedied by the application of these laws. Another cornerstone of our society is the moral obligation we carry to help those who are in need and less fortunate than others, by nature or by circumstance. In the broadest historical review of these two centerpieces of modern civilization, there appears a gradual synthesis of legal philosophy (jurisprudence) and Judeo-Christian ethics, expressed as a marriage of earlier “common law” and later “civil law,” especially as it applies to the poor, the disabled, the ill, the deprived, the disadvantaged, and others whom we deem “at risk.” In each of these categories of subgroups in society we can identify the human service client, and thus we understand how our laws to protect and to help them are a reflection of our moral duty (humanitarian ethos) as a society.
Having explored the broad outlines of history, law, and social ethics, let us now see how these concepts are more specifically represented in the people we serve and the nature of the help we provide as professional human service workers.
RIGHTS OF HUMAN SERVICE CLIENTS
Only in the last three or four decades have the rights of human service clients been codified in laws. The initial impetus was provided by the debate concerning civil rights of racial and ethnic minorities in America and by the strength of the commitment of well-known activist leaders of that era, including Hubert Humphrey, Martin Luther King, Jr., and John and Robert Kennedy. Other groups in need were eventually also recognized (the physically disabled, the mentally ill, the mentally retarded, and so on). From these beginnings, programs on equal opportunity compensatory education, nondiscrimination in school and work, and other equal-rights concerns were legislated and made laws. Again, all of these efforts, being grounded on constitutional rights, guaranteed to all citizens a national spirit of moral obligation (humanitarian ethos) devoted to helping those in need.
Right of Privacy
Probably the most fundamental right of human service clients is their right of privacy. Inasmuch as such clients rely heavily on the trust of professionals, their intimate and personal revelations in therapy and treatment must be held, at all costs, confidential and private. For this reason, the Federal Privacy Act of 1974 was passed (referred to as PL 93-579).
The background of the law was a concern that consumers (clients) were not adequately informed of the records being maintained on them and were not able to have full access to these files. The original Privacy Act pertained to federally funded and administered programs as well as some non-federal programs receiving federal grant monies. All such programs had to abide by the regulations in the cases of consumers receiving services through such monies. The Social Security Administration, Department of Veterans Affairs, Supplemental Security Income (SSI) programs and other programs (Medicaid, Medicare, for example) that employ social workers, psychologists, psychiatrists, and other helping professionals were all affected.
The highlights and provisions of the law are summarized below. They represent guidelines that medical and health care professionals, human service agencies and institutions, and practicing providers must follow:
· 1. The individual on whom a record is maintained has the right to:
· a. find out what records are being maintained on him or her and how they are used and disseminated by the agency;
· b. prohibit those records that are to be used for a particular purpose in the agency from being used for any other purpose without his or her written consent;
· c. have access to records and be accompanied by a person of his or her choosing, whether as counsel or as support;
· d. have copies made of any or all of his or her records, although the agency may charge a fee for this service;
· e. correct or amend the record as he or she feels is necessary to render it complete and accurate.
· 2. The agency must secure the individual’s written consent before it can release information from that person’s record to another person or agency.
· 3. When an agency makes a disclosure of information, it must keep records of
· a. the date of the disclosure;
· b. the nature and purpose of the disclosure; and
· c. the name and address of the person or agency to whom disclosure was made.
· d. In addition, (a) through (c) must be retained by the agency for a minimum of five years or the life of the record, whichever is longer.
· e. (a) through (c) must be available to the individual whose record is involved.
· f. The agency keeps note of all amendments or corrections made by the individual to his or her record. If the information involved has been disclosed to someone prior to the addition of the corrections or amendments, the agency must inform all persons to whom the disclosure was made of the additions or corrections.
· 4. The individual has the right to correct or amend the record.
· 5. Agencies must follow certain guidelines in gathering material for their records:
· a. The agency must keep only information that is relevant and necessary for agency purposes.
· b. It must collect the information directly from the individual if it is information that may lead to negative decisions regarding federal benefits or rights.
· c. The agency must provide the following information to people whose records are maintained:
· (1) by what authority the agency is allowed to gather the information;
· (2) whether the information can be disclosed to the individual whose record is involved;
· (3) the purposes for which the information is to be used;
· (4) the effects on the informant, if any, of not providing all or part of the requested information.
· 6. The agency has a responsibility to set policies regarding the handling of records and the safeguarding of confidentiality.
· 7. A legally appointed guardian may act on behalf of an adult individual who has been declared incompetent, or if a minor is involved, the legal guardian and/or the parents of the child can act on behalf of the child.
· 8. There are situations in which an agency is allowed to maintain records on an individual that the agency does not have to disclose to the individual:
· a. Material that would reveal the identity of a source who gave the information to the government under promise that identity of the source would be kept confidential does not have to be disclosed to the individual on whom the record is kept.
· b. The agency does not have to disclose to the individual information that was gathered prior to the effective date of the Privacy Act if at the time an implied promise of confidentiality of the identity of the source was made.
· c. An individual does not have to be given access to any information “compiled in reasonable anticipation of a civil action or proceeding.”
· d. Records maintained by the CIA do not have to be disclosed to the individual.
· e. Records maintained by an agency concerned primarily with the enforcement of criminal laws do not have to be disclosed to the person.
· 9. An agency cannot require an individual on whom it keeps records to disclose to the agency his or her Social Security number.
· 10. A Privacy Protection Study Commission is established to
· a. monitor application of the Federal Privacy Act;
· b. study “data banks, automated data processing programs and information systems of governmental, regional, and private organizations to determine the standards in force for protection of personal information”;
· c. recommend additional legislative action as needed to protect privacy rights of the individual;
· d. look for violations of the Federal Privacy Act;
· e. study the information systems of governmental, regional, and private organizations to determine the procedures in force for the protection of personal information. Following this study, the Commission must recommend the extent, if any, to which the principles and/or requirements of the Privacy Act should be applied to those organizations not currently subject to them.
The Buckley Amendment.
Sponsored by Senator Robert Buckley of New York, this addition to the Acts of Privacy extended its mandated application to students (all ages, all levels) and to schools, training facilities, and educational institutions.
Recent Modifications to Privacy Laws.
The Health Insurance Portability and Accountability Act (HIPAA) was an outgrowth of earlier legislation sponsored by Senators Nancy Kassenbaum (R-KS) and Ted Kennedy (D-MA). The HIPAA law was designed to protect Americans who had been ill from losing their insurance when they changed jobs or residences. Another intent of the law was to streamline the health care system through the establishment of standards for transmitting information uniformly via electronic health claims. Last, these legal standards would have to be carried while still protecting the privacy of the client and preserving the security of the storage of this information.
The privacy rule focuses on the application of effective policies, procedures, and business service agreements to control the access and use of patient information.
The proposed security rule addresses the provider/organization’s physical infrastructure such as access to offices, files, and computers to assure secure and private communication and maintenance of confidential patient information.
The essence of this recent modification is to safeguard the health care information of human service clients vis à vis the use of electronic-based storage and communication systems (primarily computers and their files). This information is now referred to as Protected Health Information (PHI). Such information and the standards for limiting the accessibility of this information applies, by law, to all human service work, from mammoth hospitals and medical insurance companies to individual, solo practices in psychology, social work, mental health counseling, and so on. It will be yet another area of legally based rules and information that human service workers will be required to know and operate within. Full implementation was scheduled for October 2003.
Accessibility and Release of Client Information.
Beginning with the client’s first contact with the human service agency or worker, all information, including basic identification data such as name and address, is private and confidential. In other words, having access to it or releasing it to others is restricted by law.
The rules outlined earlier in the Privacy Acts identify who, by law, is allowed access to client information, and under what conditions the release of this information is allowed. Essentially, only the client, and those directly involved in working with that client, have access to client information. In releasing information on clients, the human service worker must secure signed consent by the client to release the information maintained by the agency or worker on that client.
We will now examine further details of clients’ right to consent.
Right to Consent
Other than in very specifically defined circumstances which will be discussed later in this section, clients’ legal right to grant consent or permission to do something on their behalf (e.g., consent to release information or consent to receive treatment) requires that an individual’s permission be given knowingly, intelligently, and voluntarily. In the vast majority of situations this permission by the client is recorded in writing and confirmed by the signature of the client. In some cases, a witness’s signature to the consent is also recorded.
Types of Consent.
There are basically two classes of consent, both of which can be legally binding if the consent is obtained according to proper procedure(s).
· 1. Informed (Express) Consent
Written, signed, dated, and witnessed consents constitute informed or express consents. They may still, however, be invalid if the client can prove that consent was not given knowingly, intelligently, or voluntarily. Final questioning of the client, in the presence of another party (usually a professional colleague or a personal responsible party known to the client) may help to avoid any future consent issues. One such client question protocol would include:
· (1) “Do you understand what you are consenting to?”
· (2) “Do you understand why this consent is important?”
· (3) “Do you give your consent freely and voluntarily and not under threats or any other form of duress?”
· 2. Implied Consent
There are times during which consent can be deduced from a client as a consequence of prior circumstances or previous consents. Examples might include consent to release information to insurance companies who require such information in order to process the billing claims for the services provided to the client. Some insurance companies require such consents from their subscribers at the time of application or enrollment. Another example would be drawing a blood sample from a patient who had been admitted to a hospital. In this case, consent would be implied based upon the consent on file that was taken during the admission process.
Extensions and Limitations to Rights of Privacy and Confidentiality
Confidentiality is a general standard of conduct that obliges a professional provider not to divulge information about a client to anyone. In this country, it directly includes all medical professionals (physicians, nurses, and so on), allied health professionals (occupational therapists, physical therapists, speech therapists, and so on), mental health professionals (psychologists, social workers, counselors, therapists, and so on), educators (principals, teachers, and so on), as well as fiduciary professionals (accountants, financial/estate planners, and so on).
Confidentiality and Privileged Communication.
In contrast with confidentiality, privileged communication is a legal construct that refers to a rule in evidence law that “provides a litigant with the right to withhold evidence in a legal proceeding that was originally communicated in confidence” (Rule 504 of the Federal Rules of Evidence). In other words, standards on confidentiality have evolved to protect the client from having private information divulged within the courtroom. The underlying rationale for testimonial privilege is based upon the assumption that the benefit to justice in allowing the testimony is outweighed by the potential injury to the relationship between the professional and the client that is based squarely upon trust and confidence. In most situations, privileged communication is respected in the courts as it applies to doctors, lawyers, and “confessional” clergy, but in some states, like Massachusetts, it has also been extended to psychologists, social workers, and therapists. One important limitation to the construct of privileged communication is that the right to have information revealed in court is the client’s choice and not that of the professional. As such, if the client consents to having information revealed in court, the professional has no legal recourse to refuse and may be punished for doing so (contempt finding); that is,
· ...clients, not therapists, are protected under privilege statutes. Once a client waives his/her privilege, a therapist is legally obligated to testify (unless the therapist is willing to assume the possible penalty for violations of the law by refusing on ethical grounds to break confidentiality). (Jagim, R. D., et al., p.462, 1978 ).
“Need to Know.”
Restrictions on access to client information apply to other professionals who may be otherwise qualified but are not directly involved with the client as such. Professionals, despite working together at the same agency, hospital, or institution, do not have a professional right to access files of clients whom they are not directly servicing. In other words, they must have a “need to know” about such information. “Need to know” means that in order to carry out their work-related responsibilities, they must have access and exposure to the client file. If they fail to meet the “need to know” requirement, they have no right to access the client’s file. Besides direct service providers, other professionals with a “need to know” would include clinical supervisors who meet regularly with workers to review and discuss cases they are working on, utilization review committees and internal audit teams who randomly evaluate client files for completeness and quality, and to a more limited extent, billing clerks, approved researchers, and external auditors doing site visitations.
Limits of Confidentiality.
Under what conditions are the laws governing access and release of private and confidential client information intentionally breached or broken? The following list outlines those circumstances whereby confidentiality is limited by higher priorities or more important reasons.
· 1. If withholding information would threaten the client’s safety or the safety of others.
· a. If the client is clearly dangerous to himself and refuses to accept further treatment, the therapist may take steps to seek involuntary hospitalization. The therapist may also contact members of the family or others if necessary to protect the safety of the client.
· b. If the client threatens to kill or seriously hurt someone and the therapist believes he or she may carry out the threat, or if the client has a known history of physical violence and the therapist believes he or she will attempt to kill or inflict serious harm on someone, the therapist may:
· i. tell any reasonably identified victim;
· ii. notify the police;
· iii. arrange for the client to be hospitalized voluntarily; or
· iv. take steps toward involuntary hospitalization.
· 2. If it is necessary to place or keep the client in a hospital for psychiatric care.
· 3. If the therapist is a “mandated reporter” and is required to notify government agencies because he or she reasonably believes a child, a handicapped person, or an elderly person is suffering injury as a result of abuse or neglect.
· 4. If the client reveals information that pertains to an instance of physician misconduct. In such cases, the therapist is required to report the physician to the board of registration in medicine.
· 5. In the following types of legal proceedings:
· a. In a court proceeding wherein it is alleged that a child is without proper guardianship due to the death, unavailability, incapacity, or unfitness of the parent or guardian, or in a proceeding to dispense with the need for parental consent to adoption.
· b. In a child custody or adoption case if the judge thinks that the therapist has important evidence about a parent’s ability to provide suitable care.
· c. In any other court proceeding in which the client might introduce his or her emotional condition as an element of a claim or defense. (For example, if the client is fired from a job and sues the employer for wrongful discharge and claims to have suffered emotional trauma, the client has “introduced their mental or emotional condition” and the therapist can be required to testify about issues and communications in therapy.)
· d. In the event of the client’s death, the therapist may be required to testify in a proceeding where the mental or emotional condition is introduced as an issue.
· e. If the client brings a legal action against the therapist and disclosure is necessary or relevant to a defense, the therapist may disclose confidential communications.
· 6. If it is necessary to provide information regarding the client’s diagnosis, prognosis, and course of treatment to an insurance company that is paying for these services.
· 7. If the Agency must use a collection agency or other process to collect amounts the client owes for services. In this case, clinical information will not be released, other than the client’s name and address.
Right to Treatment
Human service clients have a right to receive adequate and proper treatment. Application of this right is binding by law, regardless of the client’s status (i.e., inpatient vs. outpatient, involuntary vs. voluntary, competent vs. incompetent). This right also applies to all clients regardless of their special classification (e.g., minors, criminal inmates, mental retardates, and so on). The adequacy and properness of treatment also extends to the number and competency of treatment providers. It further incorporates the accuracy and validity of diagnosis and assessment, which in most cases determines the type(s) of intervention best designed to deal with or treat the problem(s) identified diagnostically. The client’s right to treatment also includes the right to the least intrusive treatment necessary to alleviate the particular problem. Factors such as permanency of change, non-beneficial side effects (including mental/physical debilitations), costs, time and follow-up services are just a few considerations. All of the foregoing issues related to the right to treatment help to define standards in the quality of care and its specific delivery. A final extension of the right to treatment is the client’s right to choose between treatments and to be informed of the differences between treatment approaches or modalities. Unless otherwise directed, the responsibilities for ensuring clients’ right to treatment lie with the human service providers.
Right to Refuse Treatment
While the right to refuse treatment has multiple reflections of legal support in the First, Eighth, and Fourteenth Amendments to the U.S. Constitution, it nevertheless creates endless debates on its utility and relevance, especially in the face of other legal issues that its argument automatically draws into fire (i.e., competence, safety, custody, etc.). As Kraft notes, it pits “patient against doctor, expert against layman, clinician against lawyer” (Kraft, 1985 ) In the wealth of related literature on the subject it appears that the problems or issues lie not with the refusal right itself, but rather, with the circumstances under which it is applied. Most actual cases of the right to refuse treatment involve (a) administration of medications as treatment, or (b) intrusive treatment modalities (psychosurgery, electroconvulsive treatment, insulin shock treatment, and so on), and (c) refusal is more likely to occur in underfunded public institutions than in well-staffed private hospitals (Ford, 1990 ; Michaels, 1981 ).
In contradiction to the commonly held position that such legal dilemmas are best clarified and settled in the appellate court system, it does not appear that the states or the supreme courts have thus far remedied the matter in any consistent manner, other than reiterating that such a right should, in fact, exist. If nothing else, the debate has underlined the need for the Right to Due Process.
Right to Due Process
This legal safeguard points to the protection of all of the rights of clients and ensures that prior to the loss of any of those rights, the client must be given “due process.” Due process outlines the steps, mandated to be followed, in the case of any abridgement or loss of any right involving the client. Sufficient cause for the removal of any right must occur only by and through the following series of steps:
· (a) Right to Notice—The right to a written form of petition, which spells out all essential elements of the case;
· (b) Right to Counsel—Availability of an attorney to represent the client and his/her interests;
· (c) Right to a Hearing—Fair and impartial review of all salient matters pertaining to the case;
· (d) Right to Appeal—Any/all decisions rendered in the hearing may be appealed by the client to the local court(s), the State Court of Appeals (including the State Supreme Court), and the Federal Court of Appeals (including the Federal Supreme Court).
“Best Interests of the Child”
An individual is not generally considered legally competent until he or she reaches the statutory age—the age of majority—for taking responsibility for his or her decisions and behavior. Until such chronological age is met or exceeded, the individual remains defined as a “child”—that is, incompetent by reason of immaturity—or of the age of minority (a minor). Typically, until legally mature the minor falls under the custody or control of the child’s parents, unless it can be proven that the parents, as custodians, are not acting in the child’s “best interests.”
On the basis of the “parens patriae” doctrine (i.e., the moral, legal duty of the state to protect its citizens), the state can assume legal custody of the child and make decisions in place of the parents. These situations most commonly arise from (a) the “dangerousness” of the child’s behavior, (b) custody disputes emerging from divorce proceedings and/or physical custody issues arising after divorce, (c) child abuse and neglect (physical, sexual, emotional) by parents, and (d) involuntary commitments for treatment. Frequently the protection of the child’s “best interests” is secured by the state appointing an intermediary guardian—a “guardian ad litem”—who will then act on the child’s behalf. Such appointees are usually charged with investigating all of the salient issues surrounding the specific child’s case and reporting back to the court (usually Probate/Family Court or in some cases, Juvenile Court) with their recommendations.
Many legal dilemmas have been unearthed in cases dealing with the “parens patriae” doctrine, minors, and the Right of Due Process in those proceedings. In some highly publicized cases (in re Gault 1967), minor children were taken by police to detention centers without parental notice; hearings were held without principal parties present; no transcripts/recordings were made; and subsequently, commitments were effected without access to counsel. Needless to say, these convictions were reversed by the Supreme Court’s decision. In more recent years, competency motions upheld by judges have frequently led to otherwise minor children being tried and adjudicated in adult court. It would appear these trends demonstrate a shift in the underlying juvenile justice rationale for the “best interests of the child” which was designed to offer the child “individualized justice and treatment rather than impartial justice and punishment” (Halleck, 1967 , p. 245). Only time will tell.
Organizations dedicated to following these trends and advocating for minor children, such as the Child Welfare League of America, The American Professional Society on the Abuse of Children, and The National Association of Counsel for Children, monitor landmark cases, advocate and lobby for protective legislation, and evaluate/research strategies for improving the safety and welfare of all children.
Let us now turn our focus to those legal and ethical issues that directly apply to the profession of human services.
EFFECTS OF LAWS ON THE HUMAN SERVICE WORKER
Credentialing and Competence
Professional Licensing Law.
Competence in one’s profession is a prerequisite for any or all of those occupations associated with the field of human services. In most mental health professions, symbols of professional competency are expressed as licensing, certification, and/or registration. These credentials are generally administered by state or national boards that determine the required education, the amount and type of supervised training, passing scores for examinations, references, and so on.
For government-supported boards, the regulatory bases for these and other activities (i.e., complaint reviews, sanctions, suspensions, and so on) are laws passed in those states. These individual boards of licensing/registration routinely represent the separate professions of psychiatry, psychology, social work, mental health counseling, drug/alcohol counseling, rehabilitation counseling, and others. Allied health boards may represent other professional occupational groups (occupational and physical therapists, speech therapists, and other specialists).
Collectively, these regulatory state agencies attempt to assure the competencies of professional human service workers, to protect the interests of consumers, and to implement ethical and legal hearings when complaints against these professionals are filed.
So far, these comments have been directed to the separate professions that typically work with human service clients. Another movement with similar purpose and function may be found in the work of The National Community Support Skill Standards Project, which is designed to regulate the quality and competency of entry-level (two-year/four-year college degrees) human service workers. Please refer to Chapter 8 for additional specifics on this national credentialing program.
Professional Accountability and Peer Review.
In the foregoing discussion, you have been introduced to how society formally recognizes a profession. In that recognition, leading to a credential, the profession also is made aware of its professional accountability to society. When, and if, society evaluates the professional or his/her practice as substandard, it attaches legal liability as a consequence. This liability is presented as a claim of malpractice and its review and judgment is made in one, or both, of two mechanisms: regulatory reviews conducted by the professional board representing the specific discipline involved, or formal legal complaints presented by means of the civil court system. In some legal cases, criminal charges may also be filed. Inasmuch as the latter two topics will be addressed later in this chapter, we will deal only with the former topic—regulatory reviews—at this point.
The most often utilized procedure for policing professionals in human services is by means of self-regulation via the professional credentialing boards in each state. It should be stated here that there is much state-by-state variance regarding the defined standards of care and how these standards are monitored in the practice of the specific discipline. One must be knowledgeable regarding the statutes governing one’s chosen profession in the state in which one practices.
Notwithstanding the lack of uniform legal references to these credentialed professions, there are fairly common phases or steps involved in how they are processed in any state. In all cases, the professional is protected by the right to due process (notice, counsel, hearing, appeal, and so on).
If a complaint is received, the board will record the complaint with release consent and notify the practitioner, gathering verification of basic information. If the complaint is deemed viable, the board will then request pertinent file material, interviews with all principal parties, and statement of review findings. These activities are normally conducted by colleagues, or peers, appointed by the board for such occasions and representing the standard for self-regulation of its credentialed members. A final step incorporates the conclusion of the board for or against the individual in question. Positive findings typically result in dismissal of the complaint(s), whereas negative conclusions that substantiate the complaint(s) lead to a range of possible reprimands, from a formal warning issued by the board, to suspensions, or to revocation of the professional credential. These Peer Reviews constitute the mainstream procedure for self-regulation of professionals. Boards may also refer the complaints to the proper legal authorities (District Attorney, Attorney General, U.S. Attorney) should their investigation uncover serious criminal behavior(s).
Malpractice in Service Delivery
The delivery of services to human service clients is universally a case process format. The case process for the vast majority of human service clients follows these general steps:
· 1. Intake—Initial data-gathering contacts with clients;
· 2. Assessment—Diagnosing/determining the problem(s);
· 3. Treatment Planning—Planning goals/objectives for helping;
· 4. Intervention—Implementing the help (therapy, medication, self-help, etc.);
· 5. Evaluation—Measuring outcomes of treatment;
· 6. Termination/Referral—Ending services or referring the client elsewhere.
The phases of case process that are most vulnerable to accusations of professional malpractice occur in Assessment/Diagnosis and/or Intervention/Treatment. During these phases, errors of commission or omission can occur. For example, the clinician may misdiagnose a client (commission) or may neglect to provide appropriate/proper treatment for a diagnosed condition (omission). In some cases, complaints may incorporate both types of errors in both phases of case process.
Diagnosis/Assessment.
Clinical skills in the determination of the priority issues for clients vary from one profession to another. For instance, most readers would agree that the use of psychological tests in assessing client problems would be a good choice of tool(s) in such a task. The training and education, however, required to be competent in the administration, scoring, and interpretation of standardized tests lies almost exclusively with doctoral level psychologists. Thus, psychiatrists, social workers, and mental health counselors routinely utilize interviewing techniques to arrive at their diagnostic decisions. For psychiatrists, the mental status exam is the method of choice, while social workers rely on social histories and systems analysis (family, work, school, and so on) to assess the client’s problem(s).
Problems for the professional arise when standards of care are ignored or violated. In the procedures for assessment and diagnosis, the professional must gather complete and relevant information on the client in order to accurately and reliably determine problems. Timeliness of data and information, validity of recorded observations, past assessments and issues, prior hospitalizations, medical issues, and the like must be gathered, reviewed, and interpreted before clinical judgments are rendered. In the use of tests, one’s training and competency in testing must be considered. Latest editions of tests and their norms must be used. Referral questions to be answered by the tests must be clear and relevant. Moreover, in formulating the diagnosis, substantiation of symptomatic behaviors must be documented for each diagnostic label or code used. Thorough knowledge of the content and use of diagnostic reference tools such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), must be acquired. Faulty use of such tools, incomplete supportive information, misuse of tests, use of outdated editions of tests, and going beyond or outside one’s level or area of clinical expertise, are examples of areas where diagnostic errors of commission and omission are typically made.
Therapy/Treatment
Aside from misconduct violations within relationships with clients (a topic that will be addressed later in the chapter), human service workers are more often targets of malpractice suits related to therapy and treatment than to any other area of responsibility. Most often such suits are driven by claims of negligence in the delivery of such services. These actions can range from employing radical and inappropriate treatment methods to physical and/or mental harm arising from improper hospitalizations, medications, or other treatment. In all these circumstances, the plaintiff (the client) must demonstrate:
· (a) A legal duty existed between practitioner and the injured party;
· (b) The practitioner was derelict or negligent in that duty (by commission or omission);
· (c) Harm or injury was experienced; and
· (d) The harm or injury was caused by dereliction of duty (Hogan, 1979 , p. 8).
Ultimately, the determination of whether a professional is guilty of dereliction/negligence of duty will rest upon whether the practitioner conformed to a required standard of care and followed a standard protocol (procedure) for treatment of what was originally diagnosed.
In essence, the student of human service practice must (a) know how to make accurate, valid diagnoses, and (b) since diagnosis drives treatment, understand which treatment protocols or approaches work most effectively with which diagnostic labels or conditions.
Relationship Issues
Civil and Regulatory Infractions.
Many of the complaints made by clients against mental health professionals arise from violations of the therapeutic relationship. Because of the intimacy and trust that form the bond of therapist and client, there cannot be any other relationships between the parties involved. “Dual relationships” are strictly taboo in professional codes of ethics inherent to the field, and penalties for violations can be severe.
Human service professionals cannot develop or encourage social relationships with their clients. Social activities, gift exchanges, regular telephone contacts, transportation arrangements, loans, favors, work, home visits, lunches and dinners, and so on are all outside the limits and boundaries of professionals working with needy clients to help them resolve life’s issues and problems. Professional human service workers must be continuously vigilant as to their professional conduct and the limits of their involvement with clients. Along these lines, the most frequent malpractice complaint of clients against their therapist or counselor involves sexual misconduct.
Criminal Behavior.
In some states such as Massachusetts, sexual misconduct is not only a violation of professional ethics (leading to possible civil litigation) but is also actionable as a criminal offense. Violators may not only lose their professional credential (license or certificate) but also may be subject to fines, civil monetary awards, and prison sentencing.
Consequently, human service workers must know and understand the legal responsibilities of their work, the specific ethical codes adopted by their professional association(s), and the penalties and consequences for ignoring or neglecting those professional responsibilities.
HUMAN SERVICE APPLICATIONS OF LAW
Up to this point in the chapter we have attempted to focus on lawful foundations involving the rights of human service clients and professional issues and responsibilities that human service workers must attend to and resolve. Now we will outline how the law is applied to the field of human services and offer selected noteworthy case references.
Competency and Civil Commitment
Historically during the 1950s and ’60s, it was routinely acceptable to place seriously mentally ill patients into psychiatric facilities with legal support and by orders from the civil courts. These actions, known as civil commitments, were almost always involuntary and frequently lasted for long periods of time. The basis for these actions was the legal tradition of parens patriae, referred to earlier as the prerogative of society to act on behalf of these impaired citizens who lack mental competency to make reasonable decisions on their own behalf and at the same time, to protect society from the potential danger they may present as disturbed individuals.
As a consequence of mental health reforms of the 1960s and ’70s, laws were passed tightening the rules for involuntary civil commitments and establishing new public social policies regarding the deinstitutionalization of hospitalized mental patients and their re-entry to community-based outpatient treatment programs. At this time, before individuals who were petitioned for involuntary commitment to residential mental institutions could be admitted, four conditions had to be proven to exist:
· 1. The person is mentally ill;
· 2. The person poses an imminent risk of danger to self or to others as a result of the mental illness;
· 3. Treatment for the person’s mental illness is available at the proposed treatment facility;
· 4. Hospitalization is the least restrictive alternative available for the person’s treatment.
As a consequence of the release of large numbers of mental patients from hospitals and the more difficult standards required for involuntary commitments, more and more mentally ill patients had to rely upon community support systems for help. Unfortunately, over time we have witnessed the failures of these changes as more and more mentally ill persons have drifted into homelessness and faced the risks of surviving on the streets. Also noteworthy have been increases in the number and kinds of criminal behavior in which mentally ill individuals have been involved. In spite of the disadvantages of institutional care, it at least provided safety and minimum standards of treatment and care to these unfortunate and needy individuals.
Let us now examine other legal efforts of society to protect and assist those who are incapable of representing their own best interests.
CHAPTER 26 TRENDS AND CHALLENGES OF CULTURAL DIVERSITY
R. DONNA PETRIE
We are born in families, whether small or large, with one or more parenting figures. These families are embedded in a web of other families, all of which are part of a particular society or culture. In the United States families share a common culture because they all live in one country, but they also share a family culture that may or may not be like the culture of the nation. It is virtually impossible to overemphasize the influence an individual’s family culture has on the day-to-day activities of any given person’s life. In this country it is also nearly impossible to overestimate the points of difference within cultures and between cultures. Diversity itself has historically represented a core component of the democratic fabric of that which defines American life. This position and role is as viable today in 2003 as it was during the past two centuries.
The purpose of this chapter is to broadly introduce the challenges of multicultural human service work. These challenges are threefold. First, human service professionals need to have an understanding of specific value areas wherein misunderstanding between cultures is likely to occur; second, workers need to understand different cultural models of healing and caring; and finally, human service professionals, whether they think of themselves as bicultural or as “American,” need to understand how they are seen as “agents” of mainstream American culture.
FUTURE POPULATION TRENDS
A decade ago the New York Times reported that the United States Census Bureau has had to recalculate population growth (Pear, 1992 ). The population of the United States, it appears, will continue to grow through 2050 rather than decline after the year 2038. To summarize, for the years 1990 to 2025 there will be more babies born, particularly to new immigrants, and the proportion of men to women is likely to even out, as the life expectancy of men appears to be rising faster than that of women.
Despite this overall increase in the number of people in the United States, whites will account for a declining share in the population. The numbers of black Americans, Asian Americans, and Hispanic Americans will grow appreciably. Using the 1990 census, the Bureau predicts a 412.5 percent population growth for Asian and Pacific Islanders; a 237.5 percent growth in numbers for Hispanic Americans; a 109.1 percent increase in the number of Native American Indians, Eskimos, and Aleuts; and a 93.8 percent increase for black Americans. These figures contrast significantly with the 29.4 percent projected growth of white Americans from 1992 to 2050.
The Census Bureau makes the future trends somewhat more complex by noting that immigration by itself will account for the expected growth in the Asian American population and not the number of births. Birth rates are increasing among the black and Hispanic populations. The birth rate of whites, however, is not expected to increase. In the United States the youngest population group is Hispanic Americans. In fact, whereas the median age of all Americans is thirty-three, more than one-third of the Hispanic population in the United States is under the age of eighteen.
In addition to shifts in the growth of ethnic populations, other demographic variables are also changing. For example, in the age category of 55 years or older, 13 percent are over 65, with the quickest rate of change observed in the nonwhite population, especially Latinos and Asian Americans (Gelfand and Yee, 1991 ). With this sociocultural picture and the continuation of “urban sprawl,” jobs traditionally available to typical city dwellers will be less available. Consequently, human service workers on the two coasts (namely New York, northern New Jersey, Long Island, Los Angeles, Anaheim, and Riverside, California) will likely experience more interpersonal racial and ethnic conflict because of the greater numbers of immigrants and the greater density mixes of black, white, yellow, and brown cultures. Other urban areas such as Miami and Fort Lauderdale, Florida; Houston, Galveston, and Brazoria, Texas; and San Francisco, Oakland, and San Jose, California, may also experience the effects of polarizing differences between Hispanics and Asians and between Asians and blacks (U.S. Department of Commerce, 1991 ). Color consciousness and ethnic intolerance, although longstanding and typically a white-black issue in this country, is no less a problem between and within other racial and ethnic groupings.
Social characteristics of various cultural groups in this country add to the complexity of the challenge of working with culturally diverse client populations. Whereas the percentage of persons twenty-five years of age and over who have not completed an elementary school education (zero to eight years) is lowest for Asian Americans (6.4 percent with five years or less completed) and highest for Hispanic Americans (34 percent), the percentage of whites is 11 percent and of blacks 17 percent. Level of education, unemployment, and poverty have a high degree of correspondence for all cultural groups in America, except for whites. The unemployment rate for whites is the lowest of all groups, as are their numbers in families living below the poverty line, and this despite the fact that 11 percent of the white population has only an elementary school education (U.S. Department of Commerce, 1991 ).
These population trends can help us create an accurate picture of current and future clients seeking human services. People of color will continue to dominate the social welfare client rolls and will continue to have multiple problems. The clients will be very young or very old, their formal education will be limited, and they will have trouble finding work. If they are immigrants or children of immigrants, they will likely have problems navigating family and personal cultural issues as well.
Although individuals from this client population profile are well known to any entry-level human service professional, the human service model of helping does not automatically attribute deficiency or mental illness to these individuals (Schmolling, Youkeles, and Burger, 1992 ; Papa-john and Spiegel, 1975 ). On the contrary, many such clients, although wanting economic security, may not subscribe at all to the American values of materialism and of being “bigger and better” or more successful than one’s forebears. Indeed, on many levels, not only their needs and wants may be different from mainstream cultural stereotypes presented in the media, but individual clients may be very different from the culture or family in which they were raised (Pedersen, 1976 ).
BASIC AREAS OF DIFFERENCE IN CULTURAL VALUES
We can safely assume that all people in the United States, regardless of cultural affiliation, want to have an optimal life (Speight, Myers, Cox, and Highlen, 1991 ). Given that definitions of an optimal life differ and that individuals living in an increasingly multicultural and multilingual society will often have to interact or negotiate with members of another culture, on what subjects are they likely to have interpersonal misunderstandings?
Apart from differences in individual communication style and language usage (Sarbaugh, 1988 ; Baruth and Manning, 1991 ), cultural anthropologists have categorized differences between ethnic groups in the following ways: (1) their understanding of authority, (2) their definitions of success, and (3) their beliefs about how people should conduct themselves and their relationships (Carter, 1991 ; Baruth and Manning, 1991 ). Understanding the values of each client group on the previously stated dimensions can help to clarify how an individual may be in conflict with his or her own culture or with the larger multiethnic culture. In the next several paragraphs we will look at a number of ethnic groups’ general responses to these questions.
What motivates human beings? Are they basically good or well meaning, or are they born with evil intentions? The answer to this question is a basic building block of an individual’s belief structure. Research has shown that blacks and Puerto Ricans often contrast sharply with Eurocentric Americans in their view of human nature (Carter, 1991 ). Although several studies of white, middle-class Americans provide mixed views of human nature, none offer evidence that Euro-Americans think human beings are born malevolent in character; blacks and Puerto Ricans are more fatalistic, believing some people do evil things because they are evil.
Similarly, Euro-Americans tend to differ from blacks, Chinese, Africans, Italians, Cubans, and Native American Indians in their belief that individuals exert control over life events and that each person should use willpower for one’s own gain (Carter, 1991 ; Helms, 1992 ; Pinderhughes, 1989 ). While many blacks, Cubans, and Native Americans believe people live in nature and are partners with all of nature, other blacks, Italians, and Chinese believe that people have little control over natural forces or what happens to people and also what they can do about what has happened. Clearly, trying to help an individual who believes that personal effort is futile because “that’s the way things are” and that one must comply with fate is likely to “feel” frustrating and futile to Euro-American and Japanese American intake workers who have put themselves through college. Euro-American culture believes in action, in achievement, and in self-expression (Carter, 1991 ; Helms, 1992 ). Action is centered in the individual, who not only has the right but is expected to be autonomous from the group—to, in effect, place his or her goals ahead of those of the group (Carter, 1991 ). This “rugged individualism” is so widespread in the United States, it has become almost synonymous with American culture. But not all cultures in America hold individualistic values. Puerto Ricans, Italians, and Greeks, to name a few, do not (Carter, 1991 ), and, interestingly, some studies of Euro-American college students indicate a movement away from mastery over nature and action value orientations (Carter, 1991 ).
What is success, and what should be emphasized in social relations between people? Typically Euro-Americans believe success occurs somewhere in the future, that success is usually gained through individual effort, and that success will be observable in material gain or achievements (Carter, 1991 ; Helms, 1992 ). Few other cultures put as much emphasis on the value of delayed gratification or material well-being as white, middle-class Americans do. For other cultures, either traditional customs or the activities and events of the present are of central importance (Carter, 1991 ). So, again, human service college graduates who seek to help individuals from a different culture must be open to other definitions of success and achievement (Pinderhughes, 1989 ).
To summarize this section, human service workers who have graduated from college have learned how to function successfully within the mainstream value culture of this country. Specifically, they have been encultured by others who believe in rugged individualism, delayed gratification, material success, personal effort and responsibility, and the basic goodness of human nature. Because human service workers have negotiated the educational system, they can assist in educating clients about American culture and work habits so that clients may also become multicultural. The helper’s self-knowledge can also prevent possible misunderstandings in interpersonal communication.
Still and all, there is no way to simplify cross-cultural diversity. Pinderhughes ( 1989 ) lists at least fourteen different sources of cultural differences between people. When within-group differences are added, as in immigrant second-and third-generation groups, gaining a comprehensive knowledge of any single culture becomes impossible. The best students can do to meet the challenges inherent in cross-cultural helping is to know their own culture, to stay open and accepting of other cultures, and to keep an eye on what “works” in the dominant or mainstream culture. C. Gilbert Wrenn ( 1987 ), a longtime researcher in cross-culture counseling and therapy, suggests that students (1) read positive long-range-thinking scholars who talk about the spiritual as well as the beautiful, (2) unlearn something every day to make way for change, (3) trust that there is a light at the end of the tunnel, and (4) risk acceptance and validation of another’s experience. The latter point is important to the next section, which explores kinds of caring.
KINDS OF CARING
Textbooks in human services usually emphasize one-on-one talking or group talking as the most frequently used helping interventions. Sometimes the skills of brokering, advocacy, outreach, and community organizing are also added (Schmolling, Youkeles, and Burger, 1992 ; Okun, 1992 ; Shulman, 1982 ). There are other ways of intervening with clients. Madeleine M. Leininger ( 1987 ) persuasively argues for transcultural caring as an innovative and essential approach to helping people “live and survive in diverse and changing contexts” (p. 107). She believes that helpers must learn what “cultural-care” behaviors are likely to be accepted by helpees before “real care” or service can be given. Other researchers have highlighted culturally specific interventions, too. What follows are summary findings from Leininger ( 1987 ), McGowan ( 1988 ), Vontress ( 1991 ), Prince ( 1980 ), and Tseng and McDermott ( 1981 ) about kinds of caring in different cultures (see Table 26.1 ). The summaries are not meant to be exhaustive but rather to provide evidence of the diversity of helping methods.
Leininger ( 1987 ), from a study of thirty-five cultures, determined forty-two different ideas about caring for others. Those on the list that are usually taught in human service classes include trust, understanding, empathy, listening, and respect. But there were others current education does not suggest as appropriate to American culture: touching, loving, succoring, protecting, and sharing (Leininger, 1987 ). Whether there are universal elements basic to all cultures has not been determined because the process of helping is complex, and there is often a very hazy boundary between psychological and physical problems (Prince, 1980 ). Methods are made more complicated, too, by the fact that some cultures believe psychological suffering is a fact of living to be accepted rather than an idiosyncratic personality outlook that can be changed (Prince, 1980 ).
Aside from these qualities and purposes of helping, each culture has a characteristic stance on who can effectively do the helping. In many cultures only an expert can be a “healer.” This point of view is true of mainstream American culture—our experts are those who have managed to successfully complete a number of years of post-secondary education. In Africa, as Vontress ( 1991 ) writes, the healing specialists include the herbalist, the fetish man, the medium (usually a woman who is able to transmit messages from the dead to the living), the sorcerer (usually one who can do evil), and the healers (perhaps an equivalent to our generalists). Although different from our experts, they are experts nonetheless.
TABLE 26.1 Value Emphases—Four Major Cultural Groups
In other cultures the community, using traditional rituals, acts in a collateral fashion with individuals to relieve their suffering. McGowan ( 1988 ) described the effectiveness of a community center providing preventive service programs for Puerto Ricans in a Brooklyn, New York, neighborhood. In effect, the program provided sociotherapy in that it maintained over a dozen programs for at-risk families—programs that included an after-school drop-in center, a thrift shop, a mothers’ group, an advocacy clinic, an employment service, and a foster grandparent program. Clearly for Puerto Ricans, being with members of their community is important for healing. Another study (Leininger, 1987 ) found that family sharing (i.e. nonrelatives living with a “sponsor” family) was a particularly important ingredient in helping for the Vietnamese, Philippine Americans, and Mexican Americans. Ethnotherapy is another within-group treatment used by various cultural groups to explore and understand personal identity (Klein, 1976 ).
A final method of helping or caring, one form of which is currently sweeping the United States through twelve-step programs, is the use of self-healing methods. Aron (1992) describes testimonio (testimony) as a therapeutic tool in the treatment of people who have suffered psychological trauma. This method is not unlike the “qualification” at a twelve-step recovery meeting. There are other examples of self-healing techniques: prolonged sleep or social isolation found in Weir Mitchell’s “rest cure,” the Japanese Morita treatment (Prince, 1980 ; Tseng and McDermott, 1981 ), and autogenic training, a form of self-hypnosis practiced in Germany (Prince, 1980 ; Tseng and McDermott, 1981 ).
In summary, the challenges of cultural diversity in human services include not only differences in beliefs, attitudes, and customs between and within cultures but also varying opinions about who can help and how that help can be carried out. Clearly the combinations are so vast in number that any beginning professional might think working with clients outside one’s own culture is impossible. It is not impossible, however, if the helping professional is accepting and open to others and has the knowledge described in the next section.
HUMAN SERVICE PROFESSIONALS IN THE UNITED STATES
Service professionals who are immigrants or first-generation Americans, especially if they are fluent in a language other than English, clearly have an “edge” in working within the culture in which they have their origins. The edge is linguistic. This is not to suggest that anyone who speaks Spanish is going to be a “better” helper to the Hispanic client population. Indeed, if the helper is Mexican American, she or he may have no point of reference, other than Spanish vocabulary, with an Argentinean or Cuban client.
The question remains: Can an American-trained human service entry-level professional, regardless of cultural background, work with diverse cultural groups? Clinicians answer “yes” if that helper understands he or she is an agent of Euro-American culture and also a helper who by definition has power (Pinderhughes, 1989 ; Carter, 1991 ). Although it is important not to be “culturally encapsulated” (Pedersen, 1976 ), it is imperative to have specific knowledge of dominant American values (Carter, 1991 ). For Helms ( 1992 ), Carter ( 1991 ), and Pinderhughes ( 1989 ), that knowledge involves awareness that history affects how our institutions operate and that American history is a history of racial-cultural inequalities. Racism, sexism, ageism, and heterosexism operate unconsciously, so helpers must work to stay open, flexible, and empathic. Central to all “isms” is power and the underlying “better-than” or “less-than” dynamic between helper and helpee that is implicit or inherent to American values. Americans believe in power, in influence, and in the “better-than” ability of the expert. Although mainstream American culture does not value authority, we paradoxically give power to our “experts.”
Thus, power exists with powerlessness, dominance with subservience, control with helplessness, and capability with incompetence—dangerous autonyms, but ones that those who seek help often carry within them. In effect, as Pinderhughes ( 1989 ) suggests, those who are without status or power in American culture often identify with the aggressor and feel doubly victimized. In other words, the “have-nots” not only don’t have things but also hate themselves (thereby believing they deserve what they get) for not having things. Thus helpers, by recognizing that power is built into a helping experience, can speak the unspeakable (Ruebens and White, 1992 ) and clarify the needs and expectations of those interacting. That, by the way, includes the helper’s needs and expectations of the client as well. In short, helpers must diminish their own defensiveness (Pedersen, 1988 ) and monitor and manage their feelings, perceptions, and attitudes (Pinderhughes, 1989 ). As helpers we must realize we have power and be willing to acknowledge what we know and can do and what we don’t know and can’t do.
As Pinderhughes ( 1989 ) further suggests, helpers must realize that all people need to feel positive about their cultural identity and that it is the responsibility of the helper to demonstrate mutuality, self-respect, and respect for clients in the helping relationship. Helpers need to allow clients the opportunity to exercise choice, and to collaborate in treatment goals and in treatment methods. Given that all people in America live in culturally diverse communities, it is important that the helper help all clients become multicultural. Learning to live harmoniously and with self-expression, both within a culture and with others of another culture, are the great rewards and challenges of living in a democratic society.
SUMMARY
Human service workers face the challenges of cross-cultural social service work. Cultural diversity demands an understanding of possible value differences in worldview, in who can be a helper, and how helping is experienced. The human service worker needs to be fully aware and culturally sensitive to self, others, and the helping relationship’s interpersonal variables.
REFERENCES
Aron, A. (1991). “Testimonio: A Bridge between Psychotherapy and Sociotherapy.” In E. Cole, E. D. Rothblum, and O. M. Espin, eds., Refugee Women and Their Mental Health, Vol. 2, Women and Therapy, 173–189. San Francisco: Jossey-Bass.
CHAPTER 28 TECHNOLOGY AND SOCIALITY IN THE NEW MILLENNIUM: CURRENT CHALLENGES FOR THE HUMAN SERVICE GENERALIST
EUGENE M. DEROBERTIS AND ROBERT SALDARINI
Human services can be characterized as a broad social movement designed to counterbalance the emphasis on rugged individualism in American culture (Cimmino, 1999 , p. 13). Thus, part and parcel of the human service orientation toward helping others is the notion that human service generalists place “a portion of responsibility on society for creating conditions that reduce opportunities for people to be successful by perpetuating social problems” (p. 14). Among the myriad challenges that human service generalists address in their work are problems involving the development of the self within the social context (p. 10). As is well known, Maslow’s ( 1968 ) hierarchy of needs speaks to the importance of interpersonal relations in self-development with his articulation of needs for love and belongingness, esteem, and self-actualization. Hansell’s motivation theory also addresses the need for a co-constitution of the self by noting that humans need intimacy, closeness, belonging, self-identity, and social roles (Schmolling and Burger, 1989 ). Accordingly, it is in the interest of competent service delivery for human service workers to be aware of burgeoning trends in the interpersonal dimension of our lives that pose new challenges to a healthy social climate and optimal self-development. Such trends can be found in the ever-increasing reliance on technology in American society.
TECHNOLOGY AND PARADOXICAL HUMAN CONNECTEDNESS
As the sun sets on the past century, so fades the concept of an individual “being out.” With line and cell telephones, beepers, pagers, voice mail, and the Internet, technology has set up an almost ubiquitous communication network. People from all walks of American life are undergoing the process of becoming unceasingly connected. On the surface, it appears that this network would only enhance the quality of life. In fact, technology constantly allots new opportunities for individuals to manage their day-to-day affairs in a more convenient, even life-sustaining way. For example, technological means for managing work affairs, contacting baby-sitters, and going to school on-line offer great potential to help people with limited means meet their responsibilities and strive toward their aspirations.
Ironically, however, this unprecedented technological connectedness is also manifesting a relational paradox. Literature on the connection between the growing reliance on technology and increasing social alienation has been burgeoning since the mid-twentieth century. Recently, a study done at Carnegie Mellon University reported that individuals who spent just several hours a week on the Internet experienced higher levels of depression and loneliness (Kraut et al., 1998 , p. 1028). Thus, the new millennium beckons the exploration of how current technologies and technological trends set the stage for a pervasive sense of loneliness in today’s culture.
TECHNOLOGY AS A CONTRIBUTOR TO ISOLATION AND LONELINESS
As was noted above, the notion that technology has the potential to exacerbate a sense of social alienation is far from contemporary. In 1958, Rollo May wrote:
· . . . Human beings . . . have lost their world, lost their experience of community. Riesman presents a good deal of sociopsychological data in his study . . . to demonstrate that the... lonely, alienated character type is characteristic...of people as a whole in our society and that the trends in that direction have been increasing over the past couple of decades. He makes the significant point that these people have only a technical communication with their world.... (May, Angel, and Ellenberger, 1958 , pp. 56–57)
Despite the enormous changes that have occurred in America since May wrote these words, societal behavior indicates that his observations continue to ring true in the twenty-first century. One can identify at least two interrelated ways in which the force of technology continues to contribute to a culture-wide feeling of loneliness. First, the deepening devotion to technology and its advancement has alienated individuals from sharing a sense of personal meaning and value in life. As Viktor E. Frankl ( 1978 ) once put it, “In the impersonal climate of industrial society ever more people obviously suffer from a sense of loneliness.... People cry for intimacy. And this cry is so urgent that intimacy is sought at any expense, on any level, ironically even on an impersonal level...” (p. 82). Research in the area of television viewing, for example, attests to Frankl’s observations. Studies show that lonely people not only watch more television (Canary and Spitzberg, 1993 ), but also attempt to use television to alleviate their loneliness (Rook and Peplau, 1982 ; Rubinstein and Shaver, 1982 ).
Second, the increasing use of technological language has alienated people from their worlds by disposing them to interpret life in objectivistic, impersonal ways. For instance, in 1992 the Internet was most familiar to those who were trained in technology, yet “dot-com” is presently entrenched in conversational communication. The New York Times Almanac reports that 200 million people are members of the Internet community, and Information Technology (IT) “techno-babble” has become a mainstay of American language. As the millennium progresses, it will be worth noting the degree to which IT-based language contributes to the alienation and loneliness that May refers to in his continuing discussion of Riesman’s famous book, The Lonely Crowd (Riesman, Glazer, and Denny, 1950 ): “... People have only a technical communication with their world.... Their orientation [in Riesman’s study], for example, was not ‘I liked the play,’ but ‘The play was well done,’ ‘The article was well written,’ and so forth” (May, 1958, p. 57). With this said, one can evaluate some of the dimensions of what may rightly be called “techno-loneliness” as they have come to manifest themselves.
For a more concrete understanding of the current, almost technophilic state of the American culture, one needs to examine the shift of technological empowerment from organization to individual. Corporations had possession of “the big machine” (i.e., technology) until well into the 1940s. This point has been widely illustrated in films such as Charlie Chaplin’s 1936 Modern Times. However, as the transistor and micro-circuits gave way to cost-effective digitization, technological tools such as computers no longer served solely as corporate number-crunching machines. With the advent of the Internet, the world received a true naked resource, a completely democratized source of information protected by the First Amendment. The new information technology was transformed into a powerful multimedia communication platform and directed toward an almost insatiable consumer market.
This new information infrastructure created communication vehicles that gave connected individuals the ability to “reach out and virtually touch” anyone in the world. Experiencing a heightened sense of empowerment, society at large began embracing these communication systems with exuberance in gadgets ranging from pagers to PCs. To be sure, people in the helping professions now had a more powerful vehicle to access all sorts of information from theoretical and empirical research within the social sciences to information regarding the various social subsystems needed to facilitate human service delivery. However, in tandem with the obvious benefits of efficient, effective information availability in everyday life, American culture has experienced a simultaneous expansion of social isolation.
This phenomenon of technology-induced alienation affects all age groups. In contemporary society, steady advances in communication technology have served to wire children to entertainment. Video entertainment, in a myriad of on-line and off-line forms, is replacing more socially oriented pursuits such as board games and playground activities. Further, video games are enabling parents to acquire personal time and establish a silent environment. Taking this to a broader perspective, one needs to focus on the fact that the video games children are playing often do not promote cooperative, pro-social values. Rather, the object of many of the favored games is to crush, kill, and destroy any and all competitors. Thus, the fact that video gaming is coming on strong as a kind of digitized babysitter raises a renewed concern over the impact of anti-social experiences on observational learning. Studies show that aggressiveness in young children increases with the correlative amount of violence that they view on television (Bandura, Ross, and Ross, 1963 ; Joy, Kimball, and Zabrack, 1977 ), and thus it seems reasonable that one ought to be wary of the alienating potential of such entertainment. It is unsurprising that these concerns are supported by Daniel Goleman’s ( 1995 ) assertions in the area of emotional intelligence that children’s EQs are on a steady decline in America. As he notes, depressive symptomology affects approximately one-third of all teenagers (p. 232).
As the dawn of virtual reality (VR) gaming breaks, the isolation of this new dimension is already evident in its language. Specifically, the human participant is known as “the patron” and his or her virtual self becomes “the puppet.” Disconnecting from the game grid is considered “falling into the meat.” The virtual experience is a true detachment not only from others but also from one’s own body. Should the market demand that VR gaming imitate current video trends, impressionable children will then have the opportunity to practice the worst forms of anti-social behavior in an ever-more-realistic environment sanctified under the word “fun.”
Education has seen massive reform as a result of the exploding emergence of technology for instructional purposes. Pre-literate children are given lessons from training software to “touch the screen,” whereby there is no need for a teacher. Reliance on the computer in lieu of human contact continues into higher education via distance learning. In the years to come, teachers will need to be aware of the pitfalls associated with replacing interpersonal exploration and discovery with repetitive text-image-driven affirmation of content. In tandem, school administrators cannot view distance education as a financially lucrative means of removing teachers from classrooms. The need for human contact is an important part of learning, and the isolated computer-student paradigm does not allow for the touch and feel of warm expression and full empathetic insight by another individual. In addition to the teacher-absent situation, removing the student from the traditional learning environment may alienate students from their peers as well. Unless the educational setting taps into interactive video classroom instruction, the student is visually isolated from classmates altogether.
Paralleling the world of education, the American workplace has seen revolutionary changes in its organization. Telecommuting is burgeoning as a popular alternative to the day-to-day physical commute to one’s place of employment. In past decades business affairs were conducted in suits and dress shoes, but today a wide range of business proceedings can be held in “boxer shorts and bunny slippers.” Without doubt, many who work only from their homes have begun a slow degradation away from cultural ritual whereby they no longer physically prepare to interact with others. For some, the isolation from colleagues and the limited social atmosphere of the home office has been manifested in correlative malaise (Katz, 1987 ).
On a broader scale, managers and clerical support staff throughout the country are spending significantly more time on their jobs, thus making the workday substantially longer than its perceived eight hours. In a recent study by Rosen and Weil ( 2000 ), the number of hours employees use technology after the “end of their work day” increased consistently throughout the 1990s. Included in their findings were the following observations:
· For the Managers/Executives, three-quarters are using their computer after work hours, half are using e-mail and the Internet, and other communication technologies. Clearly, technology has extended the workday long after standard work hours. In fact, when asked how much time they spend using technology after work hours, half said less than one hour per day, one-third said 1–2 hours per day, and one-sixth said they were hooked up for three or more hours a day.
Supporting this perspective, an article in The New York Times based on an Internet survey indicated that a quarter of all regular Internet users reported that the Internet had increased the time they spent at work (Markoff, 2000 ). As a result, people are spending less and less time with colleagues, friends, and loved ones.
With the Internet’s vast communication capacity, technology continues its movement into social relations by intervening in the personal dimension. On-line and connected, the millennium years offer real-time chat. It would be difficult to dispute that when used to provide a cost-free channel for communication it serves its purpose well. At the same time, it must be acknowledged that it is the spirit in which this technology is appropriated that makes all the difference. Should chatting become a substitute for intimacy (e.g., cybersex), interpersonal encounters are avoided. When chatting acts as a habitual surrogate for human contact, the need to pursue a social life is forfeited. The proliferation and easy access to sex chat rooms and bulletin boards may provide a convenient way for some people to avoid investing time and energy into existing relationships. The demand for this type of service far exceeds any other, as pornographic Web sites are the leading E-businesses among those that are acknowledged as E-commerce.
THERAPEUTIC SERVICES AND TECHNO-LONELINESS
Rather than helping to reverse this trend of increasing alienation, psychology has often contributed to the technology-induced loneliness of American culture. As Knowles ( 1986 ) notes, psychologists have generally tended to overlook the fact that human beings exist as “real selves” in dialogue with others (p. 3). Simpatico with the individualistic current within American culture, mainstream psychology has more often chosen to identify human beings with their individual ego functions. People are reduced to organisms whose main task is to adapt to their environments via calculative thought processes and managerial tasks. Other people are thereby interpreted as potential need objects and never true subjectivities, or unique individuals. Thus, psychology has often been a symptom of technologized culture, unable to wrest us from our interpersonal alienation.
A look at the models that have dominated the American psychological milieu since the democratization of information technology will demonstrate the overtly technological current in psychology and psychotherapy. In the 1950s, behaviorism was the dominant force in American psychology. As is widely known, strict behaviorists saw people as biological machinery shaped by environmental contingencies. Consequently, attempts at psychotherapy from the behavioral perspective revolved around instituting processes that would cure individuals of their supposed dysfunctional training, so to speak. Counseling had little to do with anything like baring one’s soul or engaging in interpersonal encounter. The job of the psychotherapist was to perform techniques designed to reorganize behavioral response patterns so as to allow one to once again obtain pleasure from one’s environment. Human beings were viewed as objects of technical manipulation.
In the 1960s, with the advent of the so-called “cognitive revolution,” cognitive psychology began picking up momentum in America and is currently the most prominent trend in mainstream psychology (Robins, Gosling, and Craik, 1999 ). Rather than employing a radically mechanistic view of human existence, cognitive psychologists began to see humans as complex biological computing systems (Ellis and Hunt, 1989 ). As Ellis and Hunt put it,
· The cognitive revolution was... the simultaneous development in six sciences of new knowledge bearing on mental processes. Computer science had by far the greatest impact on psychology. The information-processing (IP) or “computational” model of thinking has been the guiding metaphor of cognitive psychology ever since the 1960s (p. 515).
Utilizing the IP model as their theoretical foundation, cognitive psychotherapists have traditionally framed their work in terms of concepts such as logical decision-making, ego control, and self-regulation. The focus of psychotherapy is typically rational thinking and managerial functions (e.g., stress management, pain management). In the spirit of Gabriel Marcel’s critique of modernity, traditional cognitive psychology views life as a set of problems to be solved by the individual ego, rather than a mystery to be shared with others. Rarely is there an emphasis on probing dialogue or a co-exploration of meaning, value, or purpose. Counsel itself is largely constructed from the language of the lonely.
The field of human services is grounded in a perspective that promotes “a sense of personal gratification in social life” (Cimmino, 1999 , p. 13). Thus, the above analysis suggests that a genuine approach to the delivery of human services would be mindful of the potentially alienating characteristics of technology in the lives of clients. Accordingly, conscientious human service intervention can ideally provide an alternative to traditional intervention strategies and contribute to a therapeutic force that discloses technological entrenchment and guides clients away from the alienating potentials therein.
THE IMPACT OF TECHNOLOGICAL DISTANCING ON COMMUNICATIONS AND PROFESSIONAL ETHICS
Related specifically to the increasing use of communication technology in the human service field, an issue of growing concern is the need to use technologically mediated communications in a professional manner. Computer-facilitated communication is fast becoming an integral part of the work of human service agencies. Since human service workers must display competent communication skills in order to operate within various agency roles (Cimmino, 1999 , p. 18), an understanding of the impact of current information technology on communications is essential.
E-mail is a form of communication that is primarily linear text processing. Since its inception, this means of communicating has quickly beckoned the creation of personalizing characteristics such as emoticons (i.e., faces created with keyboard characters for the purpose of communicating emotional intent). With comparable haste, the term “flaming” was coined to describe loaded and biased language, insults, and derogatory humor intended to offend the reader. Both the necessity of personalization techniques and the emergence of flaming bear witness to the fact that there is a certain shortcoming inherent in this new communication forum: many of the subtleties of human expression cannot be easily conveyed when talk is mediated by a text-driven processing platform. Perhaps more importantly, this distancing has the potential to generate an over-inflated sense of empowerment through anonymity. In effect, individuals are transformed into “sender” and “recipient.”
The anonymity of computer-mediated interactions diminishes the sense of responsibility that is experienced when communication occurs in person. Without the identifying nature of a face-to-face dialogue, informal day-to-day discourse achieves a certain sterility that opens up the possibility for lapses in E-ethics. To quote Rollo May (May, Angel, and Ellenberger, 1958 ):
· The anonymous mode...is the mode of the individual living and acting in anonymous collectivity, such as the dancer in a masked ball or the soldier who kills and is killed by individuals whom he does not know. Certain individuals seek refuge in this mode as a means of escaping or fighting their fellow men; the latter is the case with the authors of anonymous letters . . . (p. 122)
The experience of technologically induced distancing can be taken up as license for a release of accountability. As this sense of pseudo-empowerment increases, individuals may seek to push the boundaries of social propriety. For example, there are documented instances of gross disrespect of authority as demonstrated by e-mailed insults, obscenity, and threats to teachers, employers, and government officials that would not have occurred prior to technologically induced anonymity. Given that the majority of computer-mediated communications are presented as detached from their authors, the human service generalist needs to be mindful of the temptation to stray from the ideals of professionalism in such communications under the cover of facelessness.
FINAL REMARKS
The new millennium is offering ever-expanding opportunities to enhance the quality of life as technology grows at a geometric rate. Current research is being done in areas of biotechnology and information storage that will render obsolete what is currently leading edge. Hewlett Packard and other research laboratories are working on molecular storage, in which information processing will be molecules wide and atoms deep. Already, pharmaceutical companies prepare to program medication. Yet, it should not be ignored that a vicarious byproduct of technology’s greatness is its propensity to obstruct fulfillment of the human need for interpersonal contact and personal growth through social engagement.
The Amish community demonstrates a view of technology that contrasts strikingly with mainstream culture; i.e., containment of technology is viewed as necessary for community. Education of Amish children is completely devoid of scientific theory and the applications of contemporary technologies. Their lives center on human interaction, whereby any object that isolates a member from the community becomes irrelevant. Present-day Americans could benefit from acknowledging the wisdom of the Amish social philosophy. Technology in the new millennium creates both bridges and barriers to human contact. Competent human service delivery in the new millennium will require a fundamental grasp of the benefits and drawbacks of technology in the social world.
