SW: Final Case Assignment: Application of the Problem-Solving Model and Theoretical Orientation to a Case Study

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Social Work Treatment

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Social Work Treatment Interlocking Theoretical Approaches Sixth Edition

Edited by

Francis J. Turner

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Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2017

First Edition Published in 1974 Fourth Edition Published in 1996 Fifth Edition Published in 2011

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Library of Congress Cataloging- in- Publication Data Names: Turner, Francis J. (Francis Joseph), editor. Title: Social work treatment : interlocking theoretical approaches / edited by Francis J. Turner. Description: Sixth edition. | Oxford : New York : Oxford University Press, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2016037926 (print) | LCCN 2016051317 (ebook) | ISBN 9780190239596 (alk. paper) | ISBN 9780190239602 Subjects: LCSH: Social service. Classification: LCC HV37 .S579 2017 (print) | LCC HV37 (ebook) | DDC 361.3—dc23 LC record available at https://lccn.loc.gov/2016037926

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For my sisters Patricia and Cecil, both members of religious orders and missionaries, one as a teacher in a distant town in Eastern Canada and the other as a midwife in various parts of rural Guiana, Brazil, and the Philippines. Through their professional activities, each taught me much about our responsibilities as social workers to seek to understand the complexity and inherent differences in our clients and, so doing, learn to appreciate how to build on such differences as we seek to effect change in their bio- psychosocial realities.

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It is with great pleasure that I write this foreword to the sixth edition of Social Work Treatment: Interlocking Theoretical Approaches, edited by Francis J. Turner. The first edition of this book appeared in 1974— a very different time in the history of social work practice. Over the years and in subsequent editions, some of the theories covered remain, some have fallen away, others have been added— but all have evolved. In his characteristic manner, in this volume, Professor Turner has brought together seasoned and well- recognized experts in the field and emerging scholars, blending experience and history with the work of future leaders in our field.

While it is not my remit, I  feel obligated to take the writing of this foreword as an oppor- tunity to reflect on the vast contributions that Francis J.  Turner has made to the discipline of social work and social work education over his long, illustrious, and remarkably productive career. Professor Turner began his social work career in child welfare in 1951, having obtained a BA and BTh from the University of Western Ontario, returning to complete his BSW and MSW at the University of Ottawa, and later his DSW at Columbia University (1963). His aca- demic career has included appointments as chair of schools of social work at Memorial University of Newfoundland and York University; Dean of Social Work at Wilfrid Laurier University on two separate occasions 20  years apart; and Vice- President, Academic, and Executive Vice- President at Laurentian University. In addition, he has been a visiting professor and lecturer at universities worldwide, including Case Western, Hunter College (City University of New  York), and Oxford University. These many appoint- ments underline Turner’s deep and abid- ing commitment to social work education, a

commitment that is further evidenced by the broad use of his books in social work programs across the world. These books, including Social Work Treatment, Social Work Diagnosis, Social Work Practice, and Canadian Social Welfare, have shaped the learning experiences of five decades of social work students and, ultimately, the field of social work. His work as editor- in- chief of the International Journal of Social Work demonstrates the manner in which his influence has reached far beyond the boundaries of North America. This work has also reflected profound changes in the environment in which social workers work.

Professor Turner began his career in social work just four years after the first social worker was hired by the Toronto Lunatic Asylum (subsequently named “the Toronto Psychiatric Hospital” and then “Centre for Addiction and Mental Health”). At that time, phenothiazines, major tranquilizers for the treatment of psycho- ses, were invented, provoking an abrupt shift in mental health treatment (Regehr & Glancy, 2010). In 1957, the first community- based men- tal health center was established in Burnaby, British Columbia; and in 1959, the Ontario Ministry of Health drafted the first proposal for community- based treatment, including the provision of psychiatric beds in general hos- pitals. This marked the beginning of the de- institutionalization movement, and between 1965 and 1981, the number of beds in provincial psychiatric hospitals across Canada dropped by 70%— unfortunately resulting in psychiatric ghettos and a rapid rise in the number of indi- viduals suffering from major mental illnesses in the jail system (Regehr & Kanani, 2010). Social work practice in mental health has thus evolved,

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responding to the lived experiences of individu- als wherever they are.

In 1952, the American Psychiatric Association published the first edition of The Diagnostic and Statistical Manual for Mental Disorders (DSM- I), identifying two categories of disorders: those associated with brain tissue (e.g., dementia), and psychogenic disorders without a clear phys- ical cause (e.g., psychosis). Now in its fifth edi- tion (DSM- 5), the DSM has seen many changes over the years, including the introduction of homosexuality as a mental disorder in the sec- ond edition, and as a result of outcry, the change to Ego- Dystonic Homosexuality in DSM- III. Over the years, at first thought revolutionary and then understood to be damaging, theories and concepts such as the “schizophrenogenic mother” have come and gone from mental health social work practice (Regehr & Glancy, 2014). In the 1970s, the return of soldiers from the Vietnam war whose horrifying experiences left them scarred, and the growing awareness of rape and its aftermath, resulted in recognition of post- traumatic stress disorder (PTSD) and its inclusion in DSM- III (Regehr & Glancy, 2014). Trauma- informed care is now a central element of social work practice.

In the world of health care, since Turner entered social work, AIDS emerged as a domes- tic epidemic. First identified by the Centers for Disease Control and Prevention (CDC) as a rare lung disease in June 1981, by the end of that same year, 270 cases of severe immune deficiency were reported among gay men, 121 of whom had died (aids.gov, 2016), and fear spread throughout the community. By 2016, a decade- long clinical trial determined that antiretroviral therapy is highly effective, not only in prolong- ing life, but also in preventing sexual transmis- sion of HIV (aids.gov, 2016). Stigma associated with the disease continues to be addressed by social workers in policy, community, and hospital- based practices.

In 1967, the first successful human heart transplant was performed by Christiaan Barnard in South Africa. Now organ trans- plants are routine operations, and social work- ers are engaged in working with donor families and recipients and their families (Anthony et  al., 2014). The major challenge has become, not survival, but securing sufficient donated

organs (Regehr, Kanani, McFadden, & Saini, 2015), and as laboratories throughout the world work to grow human organ tissue, social work interventions will shift again.

In 1950, the life expectancy for men in the United States was 65.6 and for women was 71.1; in 2015, it was 76.4 and 81.2, respectively (CDC, 2016). As the aging population has grown, social work has responded, establishing the field of gerontological social work, focusing on issue of elder justice, caregiver well- being, and healthy aging.

In 1955, Rosa Parks was arrested in Montgomery, Alabama, for refusing to give up her seat in the bus, sparking the Montgomery bus boycott led by Martin Luther King, Jr., and the civil rights movement. Nine years later, the Civil Rights Act of 1964 was enacted, pro- hibiting discrimination in public places and providing for the integration of schools. Then, following the march on Selma, the Voting Rights Act of 1965 was enacted, outlawing dis- criminatory voting practices against African Americans brought into force after the Civil War (ourdocuments.gov, 2016). Our students today remind us through Black Lives Matter protests that racism and systemic discrimina- tion continue to exist and that social work must continuously challenge our theories and our practices. Such views can be found in the theo- ries covered in this book.

Child welfare social work has also seen enormous shifts in the past 65  years. In the 1960s, the consequences of, first child abuse (the battered child syndrome), and later, child sexual abuse, expanded and enforced the man- date of child welfare agencies to protect child- ren, in part because of public outrage over the issue. Removal of children from their homes was a relatively informal process, affording little protection for vulnerable families, par- ticularly Aboriginal Canadians and African Americans. As a result, in the 1970s, the child protection system came under public scrutiny, and the legislative balance shifted to favor- ing the “least restrictive” actions. Then, in the 1990s, public scrutiny turned to deaths of children who were known to child welfare services, and social workers and the agen- cies where they worked were held to be liable (Regehr et al., 2015). Child welfare social work

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practice has thus changed over the decades and continues to change as society as a whole balances the needs and rights of families with those of vulnerable children.

The legislative framework governing the social work profession has also changed, and in Canada, Turner has had a profound effect on these changes. In 1964, he was a founding member of the Ontario Association of Social Workers; he served as president of the Canadian Association of Social Workers (CASW) and received both the CASW Distinguished Service Award and the Outstanding National Service Award. Noting that Ontario was one of the last jurisdictions in North America where social workers were not regulated, Turner chaired the Project Legislation Committee, whose advocacy led to Canada’s Social Work and Social Service Act of 1998. In advocating for social work as a profession, he simultaneously sought to ensure protection of the public by ensuring that those who serve them adhere to the highest profes- sional standards and accountability.

Over the course of Turner’s career, he has witnessed profound changes in society and pro- found changes in our profession. His advocacy and scholarly work have both reflected these changes and shaped the profession. His books have presented generations of social work stu- dents with the most current challenges, theo- ries, and research in social work— informing their thinking and future practices. I  have had the privilege of writing chapters in five different books edited by Professor Turner— including the fifth edition of Social Work Treatment. I am

deeply honored to have been invited to write the foreword for this most recent book, and have relished the opportunity to reflect on where we have come as a profession over the years of his illustrious career.

Cheryl Regehr

References

AIDS.gov. (2016). A timeline of HIV/ AIDS. Retrieved from https:// www.aids.gov/ hiv- aids- basics/ hiv- aids- 101/ aids- timeline/ .

Anthony, S., Nicholas, D., Regehr, C., Dipchand, A., Solomon, M., MacCulloch, R., & West, L. (2014). A struggle to survive:  The experience of awaiting pediatric heart transplantation. Pediatric Transplantation, 18(8), 868– 874.

Centers for Disease Control (CDC). (2016). Life expectancy. National Center for Health Statistics. Retrieved from http:// www.cdc.gov/ nchs/ fastats/ life- expectancy.htm.

Ourdocuments.gov. (2016). Voting Rights Act 1965. Retrieved from http:// ourdocuments.gov/ doc.php? flash=true&doc=100.

Regehr, C., & Glancy, G. (2010). Mental health social work practice in Canada. Toronto:  Oxford University Press.

Regehr, C., & Glancy, G. (2014). Mental health social work practice in Canada (2nd ed.). Toronto: Oxford University Press.

Regehr, C., & Kanani, K. (2010). Essential law for social work practice in Canada. Toronto:  Oxford University Press.

Regehr, C., Kanani, K., McFadden, J., & Saini, M. (2015). Essential law for social work practice in Canada (3rd ed.). Toronto: Oxford University Press.

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Fifty years is a long time! Within the scope of the last fifty years, this book has gone through five editions, with the present one being the sixth. The process began at a time in our profession’s his- tory when the continuance of a search for a single theory for social work practice was over. Rather, the profession had come to the realization that a “psycho- social” thrust of social work better fitted the profession, at least in this part of the world.

As our profession expanded in scope and in recognition, so too did an appreciation of the importance and richness of many aspects of social sciences; hence the growth and interest in the application of the various schools of psycho- therapy to our profession expanded. Now our interest lay in the adoption of knowledge and skills of the various schools of thought to social work treatment, practice, and relevant research. Thus the body of both the psychological and the social thought systems became the theoret- ical bases from which the profession presented its credentials to the world of teaching, prac- tice, and research. One educational factor that influenced this development was the reality that the profession, because of a variety of important sociological factors, had moved into the uni- versity world on a wider scale. This meant that many students were registered in the academic structure at both the master’s and doctoral lev- els. Only later did social work education move into the baccalaureate and community- college levels.

From the earliest days, social work education included a strong interest and commitment to the research challenges at a university level. The wealth of social work research and the impact of teaching and practice have been and continue to be dramatic, as reflected in this volume. It has created a rich setting for research and its subse- quent publication.

One of the ongoing challenges to our profes- sion was, and continues to be, how to get impor- tant research and practice findings into the hands of practitioners and academics in a convenient and effective way. A format we have found useful is to address the development and plans for this vol- ume and its various editions by inviting colleagues (each of whom is a recognized spokesperson for one of the 38 theories discussed in this edition) to present an updated summary of a particular prac- tice theory, which includes a current reference list of relevant material related to a specific theory.

This process has led to our publishing a set of six editions, each of which updated the prior edi- tions, in a format that has been found useful and helpful to teaching practitioners and research- ers although initially we thought that one of the goals of the earlier editions was to encapsulate the full range of theories in use in practice.

Clearly, the practice world has come to appre- ciate the complications and inherited challenges of social work practice. Although in an earlier day we presented groups of theories in a scholarly comparative manner, we have now become more comfortable in also seeing them as groups of ther- apeutic resources. That is, we are learning to pre- sent groups such as this volume as a discussion of resources on which a practitioner can draw. Each theory is viewed as a neutral resource that may or may not be drawn upon in a particular case.

To date, we have not found a way to evaluate our cluster of 38 theories and their differential use in different situations. How we might do this is a challenge the profession faces. In the meantime, we shall begin to gather data as to how and where the profession finds use for each theory by encouraging practitioners to share their experiences with us.

Francis J. Turner

Preface

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On each occasion that I engage in the process of writing the traditional paragraph of acknowl- edgements, I  am humbled by an awareness of the many persons who have assisted in the multiple tasks of bringing the book to fruition. I  suspect that this network is much broader than I  am aware of. Over the years, my family has been consistently supportive of my pub- lishing activities, albeit from the distances that their lives have taken them. Joanne plays a much more direct role in recent projects.

I am most pleased that Oxford University Press has recognized the need for a sixth edition and has been most helpful through the edit- ing process. I am most grateful for the support

and assistance of Dr. Dan Andreae and Dr. Alex Polgar, and the research support of York University.

Finding and assembling the group of con- tributors was a challenging process, and the collegial help of the group as it developed served to make the process manageable and functional. Throughout, my research assistant, Carlos Pereira, played a major role in planning and implementing the required and constantly changing strategy that eventually brought the book to fruition. To him and to all, I am grateful.

Toronto, February, 2016

Acknowledgments

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Contributors xix

1. Attachment Theory and Social Work Treatment 1 Timothy Page

2. Chaos Theory and Social Work Treatment 23 Sandra Loucks Campbell

3. Client- Centered Theory and the Person- Centered Approach: Values- Based, Evidence- Supported 34 William S. Rowe

4. Cognitive Behavior Theory and Social Work Treatment 54 Ray J. Thomlison and Barbara Thomlison

5. Cognitive Theory and Social Work Treatment 80 Pranab Chatterjee and Suzanne Brown

6. Constructivism: A Conceptual Framework for Social Work Treatment 96 Donald E. Carpenter and Keith Brownlee

7. Social Work Theory and Practice for Crisis, Disaster, and Trauma 117 Diane M. Mirabito

8. Ecopsychology: Adding “Eco” to the Biopsychosocialspiritual Perspective 131 David S. Derezotes

9. Empowerment Approach to Social Work Treatment 142 Judith A. B. Lee and Rhonda E. Hudson

10. Existential Social Work 166 Donald Krill

11. Feminist Theory and Social Work Practice 191 Eveline Milliken

12. The Four Forces: An Inclusive Model 209 Au- Deane Shepherd Cowley

13. Functional Theory and Social Work Practice 223 Katherine M. Dunlap

14. General Systems Theory 240 Nancy Riedel Bowers and Anna Bowers

Contents

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15. Gestalt Theory and Social Work Treatment 248 Elaine P. Congress

16. Hope Theory and Social Work Treatment 266 Alexander T. Polgar

17. Hypnosis and Clinical Social Work Practice 276 Elayne Tanner

18. Life Model of Social Work Practice 287 Alex Gitterman

19. Meditation and Social Work Practice 302 Thomas Keefe

20. Mindfulness and Social Work 325 Kirstin Bindseil and Kate Kitchen

21. Narrative Theory and Social Work Treatment 338 Patricia Kelley and Mark Smith

22. Neurolinguistic Programming Theory and Social Work Treatment 351 G. Brent Angell

23. Oppression Theory and Social Work Treatment 376 Susan P. Robbins

24. Problem- Solving and Social Work 387 Micheal L. Shier

25. The Psychoanalytic System of Ideas 398 Elizabeth Ann Danto

26. The Psychosocial Framework of Social Work Practice 411 Emilia E. Martinez- Brawley and Paz M.- B. Zorita

27. Relational Social Work: A Contemporary Psychosocial Perspective on Practice 420 Carol Tosone and Caroline Rosenthal Gelman

28. Relational Theory and Social Work Treatment 428 Dennis Miehls

29. Resilience Theory and Social Work Practice 441 Robbie Gilligan

30. Role Theory and Concepts Applied to Personal and Social Change in Social Work Treatment 452 Dennis Kimberley and Louise Osmond

31. Social Learning Theory and Social Work Treatment 471 Bruce A. Thyer

32. Social Networks and Social Work Practice 481 Elizabeth M. Tracy and Suzanne Brown

33. Social Work Practice in the Time of Neuroscience 497 Robert J. MacFadden

34. Socially Constructing Social Work 504 Dan Wulff

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35. Solution- Focused Theory 513 Mo Yee Lee

36. Task- Centered Social Work 532 Anne E. Fortune and William J. Reid

37. Trauma- Informed Social Work Treatment and Complex Trauma 553 Dennis Kimberley and Ruth Parsons

38. Emerging Theories: Electronic Exchanges 574 Emilia E. Martinez- Brawley

Epilogue: Social Work Treatment, Sixth Edition: Some Final Comments 586 Index 587

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G. Brent Angell, PhD, LCSW, RSW, School of Social Work, University of Windsor

Kirstin Bindseil, MSW, RSW, Practitioner, Toronto, Ontario

Anna Bowers, MA, PhD Student, Ontario Institute for Studies in Education, University of Toronto

Nancy Riedel Bowers, RSW, Rpt- S, Cpt- S, PhD, Faculty of Social Work, Wilfrid Laurier University

Suzanne Brown, PhD, LICSW, School of Social Work, Wayne State University

Keith Brownlee, PhD, School of Social Work, Lakehead University

Sandra Loucks Campbell, PhD, Department of Social Work, Renison College, University of Waterloo

Donald E. Carpenter, PhD, Department of Social Work, University of Minnesota– Duluth

Pranab Chatterjee, PhD, Mandel School of Applied Social Sciences, Case Western Reserve University

Elaine P. Congress, MA, MSSW, DSW, Graduate School of Social Service, Fordham University

Au- Deane Shepherd Cowley, PhD, College of Social Work, University of Utah

Elizabeth Ann Danto, PhD, Hunter College School of Social Work, City University of New York

David S. Derezotes, PhD, College of Social Work and Peace and Conflict Studies Program, University of Utah

Katherine M. Dunlap, PhD, ACSW, School of Social Work, University of North Carolina at Chapel Hill

Anne E.  (Ricky) Fortune, PhD, School of Social Welfare, The University at Albany, State University of New York

Caroline Rosenthal Gelman, PhD, LCSW, Silberman School of Social Work, Hunter College, City University of New York

Robbie Gilligan, MA, CQSW, School of Social Work and Social Policy, Trinity College Dublin

Alex Gitterman, EdD, School of Social Work, University of Connecticut

Rhonda E. Hudson, PhD, LCSW, School of Social Work, Union University

Thomas Keefe, DSW, Department of Social Work, University of Northern Iowa

Patricia Kelley, PhD, School of Social Work, University of Iowa

Dennis Kimberley, MSW, PhD, School of Social Work, Memorial University

Kate Kitchen, MSW, RSW, Practitioner, Toronto, Ontario

Donald Krill, MSW, PhD, Graduate School of Social Work, University of Denver

Judith A.  B. Lee, DSW, Dmin, School of Social Work, University of Connecticut

Mo Yee Lee, PhD, College of Social Work, Ohio State University

Robert J. MacFadden, PhD, Factor- Inwentash Faculty of Social Work, University of Toronto

Emilia Martinez- Brawley, MSS, PhD, ACSW, School of Social Work, College of Public Programs, Arizona State University

Contributors

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Dennis Miehls, PhD, School for Social Work, Smith College

Eveline Milliken, MSW, PhD, RSW, Faculty of Social Work, University of Manitoba

Diane M. Mirabito, DSW, LCSW, Silver School of Social Work, New York University

Louise Osmond, MSW, School of Social Work, Private Practitioner, Nova Scotia

Timothy Page, MSW, PhD, School of Social Work, Louisiana State University

Ruth Parsons, PhD Student, School of Social Work, Memorial University

Alexander T. Polgar, MSW, PhD, RSW, Practitioner, Hamilton, Ontario

William J. Reid, PhD, (1928-2003), School of Social Welfare, University of Albany, State University of New York

Susan P. Robbins, PhD, LCSW, Graduate College of Social Work, University of Houston

William S. Rowe, DSW, Department of Social Work, Southern Connecticut State University

Micheal L. Shier, PhD, Factor- Inwentash Faculty of Social Work, University of Toronto

Mark Smith, MSW, PhD, Social Work, Barry University

Elayne Tanner, MSW, PhD, RSW, Practitioner, Milton, Ontario

Barbara Thomlison, PhD, School of Social Work, Institute for Children and Families at Risk, Florida International University

Ray J. Thomlison, PhD, School of Social Work, College of Public Health and Social Work, Florida International University

Bruce A. Thyer, PhD, LCSW, College of Social Work, Florida State University

Carol Tosone, PhD, LCSW, Silver School of Social Work, New York University

Elizabeth M. Tracy, MSW, PhD, LISW, Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University

Francis J. Turner, MSW, DSW, Faculty of Social Work, Wilfrid Laurier University

Dan Wulff, PhD, Faculty of Social Work, University of Calgary

Paz M.- B. Zorita, PhD, School of Social Work, Arizona State University

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Social Work Treatment

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Attachment Theory and Social Work Treatment

Timothy Page

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History and Development of the Theory

Origins

Attachment theory was originally created in the mid- 20th century by the British psychiatrist John Bowlby, director of the Department for Children and Parents at the Tavistock Clinic in London.1 The first public presentation of attachment the- ory occurred in three seminal lectures Bowlby gave to the British Psychoanalytical Society in London, one each year, from 1957 to 1959 (Bretherton, 1992). His audience was the child psychiatry establishment of that era, including such notable figures as Anna Freud, Melanie Klein, and Donald Winnicott, and their view of human development and psychotherapy was firmly rooted in Freudian psychoanalytic theory.

The classical psychoanalytic model of human development was based on a concept of psycho- sexual drive energy as its primary motivating force (Greenberg & Mitchell, 1983). In the Freudian view, the process of buildup and discharge of psycho- sexual drive energy creates internal fantasies that ultimately are responsible for the emergence of personality, social relationships, and virtually every other aspect of human development. This so- called “hydraulic model” of motivational drive was based on ideas taken from 19th- century phys- ics concerning the process of accumulation and discharge of energy within closed systems, the goal of which is a state of relative quiescence. In the classical Freudian theories of development and psychoanalytic treatment, internally cre- ated fantasies are even more important to the

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course of human growth and development than the child’s actual experience.

Bowlby’s attachment theory diverged from Freudian theory in many important ways, none more so than in his emphasis on the importance of actual experience to human development (Bowlby, 1982). In Bowlby’s view, the quality of interactions between infant and caregiver(s), beginning at birth, motivated specifically by the child’s needs for safety and protection, is cen- tral to life span development. Reaction from the Psychoanalytical Society, including his own mentors, to his attachment papers was immedi- ately condemnatory because of his explicit rejec- tion of core tenets of Freudian theory. Although he remained a member of the Society for the rest of his life, he never formally presented a paper there again (Bretherton, 1992).

A New Model of Instinct

In attachment theory, Bowlby replaced the Freudian notion of instinct as psycho- sexual drive, and the hydraulic model’s relative empha- sis on internally derived motivation, with a model conceptualizing instinct as an interaction of organism and environment. Taking language primarily from the field of cybernetics and adapting this to studies in ethology and human development, Bowlby saw instinctive behav- ior in terms of “control systems.” He saw the expression of an intrinsic need as goal- directed behavior in a relational context. Modification of the behavior occurs through feedback from the environment, especially the quality of response from the relational partner involved, a proc- ess he referred to as “goal- correction.” Bowlby integrated the control systems model with the term “behavioral system,” which he borrowed from ethology, to explain the basic processes governing instinct- based social behavior in humans (Stevenson- Hinde, 2007). He discussed the hunting behavior of a falcon in flight and a frightened infant’s seeking of his caregiver as analogous to the way the power steering mech- anism works on a car (Bowlby, 1982). In each of these cases, there is a goal the object is directed to, and behavior is modified or corrected as information is fed back about its progress toward the goal— be it the hunt, the turning of the wheel, or the comfort- seeking of the infant.

By conceptualizing “instinct” as an interaction of inherited predispositions and environmental response, he laid an important theoretical foun- dation: What we consider to be the “normative” parameters of human experience must include considerable diversity and variation.

The influence of the field of ethology on Bowlby’s work is reflected in the comprehen- sive analyses and syntheses of scores of diverse studies, particularly primate studies, he used to establish attachment theory within the larger theory of Darwinian evolution. Attachment theory has been called a “major middle- level” evolutionary theory (Simpson & Belsky, 2008) because of its foundation in and refinement of Darwinian theory. Evolutionary theory became increasingly established as the dom- inant paradigm of the natural sciences in the 20th century, though it had not, until Bowlby, had a significant place in our understanding of human psychosocial development. One of the great achievements, therefore, of Bowlby’s attachment theory is that it represented the first time that a major theory of human psychosocial development became integrated into the dom- inant paradigm of modern biological sciences.

Attachment Behavior

Among the ethological researchers of his time, Bowlby was profoundly influenced by the now- classic studies of Konrad Lorenz (1935) on “imprinting” in ducks and geese, and Harry Harlow (1958) on infant rhesus monkey behav- ior toward wire adult models. This and other ethological research inspired Bowlby to see that the formation of social bonds in these species was not dependent on feeding, an insight he then applied to human development. In doing so, he explicitly rejected the views of Freudian and behavioral theories alike, which posited that the formation of social bonds between human children and their caregivers is sec- ondary to the oral gratification associated with feeding. If social bonds form independently of feeding and not secondary to pleasure, however, he had to explain what their larger purpose was.

Bowlby’s main interest was the formation, beginning in infancy, of the behaviors that collectively compose the attachment behav- ioral system. He saw in the development of

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attachment behavior powerful relational themes influencing the entire life course. Much as the neonate responds to tactile stimulation of the lips and hard palate with grasping and suck- ing, Bowlby proposed, the infant also responds to conditions of vulnerability such as fear, pain, cold, hunger, fatigue, and illness, with an array of behaviors that result in the maintenance of proximity to the caregiver. Around the age of six months, the early behaviors of crying, clinging, smiling, visually following the caregiver, sig- naling, and, later, movement toward the care- giver become increasingly organized into the attachment behavioral system (Bowlby, 1982). The attachment system becomes activated in conditions of vulnerability, including distance and separations from caregivers. The caregiver’s response to the infant’s activated attachment behavior amounts to, in control systems termi- nology, the “feeding back” of information to the infant, and it produces, under favorable condi- tions, calming and a growing sense of security. Proximity- seeking directed to a specific care- giver is the fundamental component of attach- ment behavior, whose proximate purpose is to calm feelings of insecurity, and whose ultimate, evolutionary function is to ensure the survival of the infant and species (Bowlby, 1982).

The term “attachment figure” is applied to the specific caregivers to whom, by virtue of their protective role for the child, children direct their attachment behavior. Attachment relationships typically involve parents, and may include other relatives such as grand- parents, aunts, uncles, and older siblings, or close relationships with non- family members. Attachments— the internalized bonds that form in attachment relationships— reflect specific dyadic qualities and interactive histories, yet are considered characteristics of the child. An attachment bond involves, is indeed defined by, the child’s affective tie to a specific attachment figure, not the attachment figure’s bond to the child. The term “attachment” is therefore not used in the colloquial sense of “connection” and specifically refers to an emotional bond expe- rienced by a relatively more vulnerable person in relation to a relatively stronger one. Most children, fortunately, have multiple attachment bonds, each specific to the relational history with the individual attachment figure. Bowlby

(1982) believed that, despite the presence of multiple attachments, children organize attach- ment relationships in some form of hierarchy, with one preferred attachment figure, usually the mother, above others, a principle he referred to as the “monotropy” of attachment bonds.

Attachment, Fear, and Exploration

The attachment behavioral system functions in direct relation to two other major behavioral systems within the child (Bowlby, 1982), the fear/ wariness and exploratory behavioral sys- tems, representing, respectively, the instinct to withdraw from frightening circumstances and the instinct to explore novel situations. Bowlby proposed that the attachment and fear/ wari- ness behavioral systems operate in close, but not absolute, synchrony. Very frequently, but not always, Bowlby argued, attachment behav- ior is activated by fear- inducing conditions that simultaneously activate withdrawal from the feared object. Attachment behavior may also be activated, however, according to Bowlby, in conditions not directly associated with an instinct to withdraw, such as fatigue and illness. The exploratory behavioral system, in contrast to the fear/ wariness system, plays a role fully equal in importance to the attachment system in determining how attachment behavior ulti- mately becomes expressed and, thus, how the attachment bond is formed. A natural, instinc- tive desire to explore the social and physical environment is normally activated in condi- tions where the child is relatively stress- free. Through this process, the child learns about the world, taking in new information and develop- ing perceptual, analytical, and motor skills that provide opportunities for the child’s develop- ment of mastery and autonomy.

Inevitably, however, the child experiences depletion in energy or becomes distressed by encounters with unfamiliar objects or events, or from the separation from an attachment fig- ure, all of which produce feelings of vulnera- bility, activating the attachment behavioral system. In this way, exploratory and attach- ment systems are regarded as polar dimensions of a larger process, whereby the activation of one normally involves the relative deactiva- tion of the other. In order for the child to be

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able to explore the world with confidence, s/ he must be able to trust in the availability of the “secure base” of the attachment relationship, as described by Ainsworth (Ainsworth & Bowlby, 1991), from which the child ventures outward, and to which the child can return, as a “safe haven” for care and protection when needed. The way in which the attachment figure accu- rately perceives and responds to the child’s alternating needs for exploration and attach- ment will determine the nature of the attach- ment bond that the child will form with the attachment figure. As Ainsworth (1989) later demonstrated, the transactions associated with exploration and proximity- seeking pro- vide the infant with opportunities to learn an array of communication and social skills that become a foundation for social relatedness in ever- widening social spheres as the infant matures into childhood. Essential relational styles involving the communication of needs, and the expectations of others’ responses to expressions of need, are therefore first learned in infancy in the first attachment relationships.

Bowlby’s emphasis on predictable func- tions of behavioral systems led some critics in the Psychoanalytical Society to label him a “behaviorist” (Bretherton, 1992), referring to the mechanistic competing theory of the day, “behaviorism,” or “social learning theory.” Although, to a great extent, attachment theory is compatible with and can subsume important tenets of behaviorism, it is profoundly differ- ent from it in several ways. First, as discussed above, attachment theory contains a theory of instinctive motivation for safety and protec- tion. Behaviorism, in contrast, has no theory of instinctive motivation beyond the pursuit of pleasure. Ainsworth and Bowlby repeatedly emphasized the dangers of employing a behav- iorist model to understand children’s distress when in need of their caregivers. According to behaviorism, children’s expressed distress is presumed to be learned behavior. Learning theory predicts that when parents respond to fussy or distressed behavior with comfort, the behavior will be reinforced and is thus likely to continue, and the child is thereby in danger of developing “dependency” or insufficient auton- omy. The risk to children of this approach is that it ignores their intrinsic needs for safety,

comfort, and protection, and that to withhold comfort from them risks creating long- standing anxiety and emotional insecurity. Autonomy, from the attachment viewpoint, is enabled, not through withholding comfort, but through security- enhancing behavior, including ample provision of comfort when needed.

Cognition and Development

Bowlby’s interest in the development of attach- ment in children led him to theorize that the attachment behavioral system had to operate as part of the central nervous system circuitry, in which memory systems play a crucial role. Through repeated experiences with an attach- ment figure in times of distress, the child learns, and begins to make generalizations, about the responsiveness and reliability of the caregiving environment. These early experiences become increasingly organized in memory in structures Bowlby (1973, 1982)  referred to as “internal working models,” a term first used by the philos- opher and cognitive psychologist Kenneth Craik. Bowlby preferred this term to more static rep- resentations of cognitive structures, because it communicates a sense of patterned responses to the social environment and, at the same time, the capacity for ongoing revision, based on learning from new social experiences. Internal working models, thus, can account for continuity of indi- vidual development as well as individual change. Internal working models become increasingly established and resistant to major revisions as the child grows, however. (The conceptualiza- tion of stability and change in cognition is one of several areas where Bowlby [1973] acknowl- edged the influence of Piaget on his thinking.) According to Bowlby, the primary adaptive func- tion of internal working models is to provide the developing child with the capacity to predict the likely responses of potentially protective figures in situations where the child experiences vulner- ability. Expectations of responsive care from oth- ers derive from and further promote emotional security, an attribute that can facilitate the build- ing of positive relationships and provide a buffer against future negative interpersonal experi- ences (Bretherton, 2005).

The process of organizing internal working models of attachment relationships is theorized

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to begin at the approximate age at which the for- mation of “object permanence,” in the Piagetian sense, begins for most children. The cognitive capacity of object permanence is, therefore, thought to have a functional role in the devel- opment of internal working models (Bowlby, 1980). From this initial period of approximately age six months until approximately 18  months, Bowlby viewed the child’s development of inter- nal working models as embryonic. At the latter age, the child, under favorable conditions, is able to apply the representation of attachment figure in a new capacity. From the approximate age of 18  months to three years, the child’s internal working model of attachment figure becomes increasingly available for the purpose of execut- ing increasingly complex behavioral plans, espe- cially those that involve venturing farther away from the caregiver. The child is now able to use the internal representation of the caregiver to make predictions concerning his/ her availability (Bowlby, 1980). As most children approach the end of their third year, the internal representa- tion of the caregiver begins to carry with it the security- providing functions that, for the infant, were previously associated only with the actual presence of the attachment figure.

The young child’s developing capacities to organize memories into internal working models is a central element in what Bowlby referred to as the four major “phases in the development of attachment” (1980, p. 265). The first of these begins at birth and lasts for the next approximately eight to 12 weeks. This first phase is actually a phase of non- attachment, or pre- attachment, in which the infant’s orienta- tion to caregivers and communication signals occurs with “limited discrimination of fig- ure.” That is, in these early weeks, the infant has not yet achieved the capacity to discrimi- nate among individuals beyond olfactory and auditory stimuli. In the second phase, lasting from approximately 12 weeks to six months, the infant’s visual capacities to discriminate among individuals emerge, with obvious abili- ties to orient and respond to them, particularly primary caregivers. The third phase, which lasts from approximately six months to three years, is characterized by the capacity to dif- ferentiate known caregivers from strangers, with the emergence of “stranger wariness”

and, simultaneously, “clear- cut” attachment behavior directed toward caregivers. In the fourth phase, the toddler, now in his/ her third year, increasingly uses “goal- corrected systems” involving internal working models of caregivers and him/ herself to achieve the experience of proximity to the caregiver. These new cognitive capacities eventually allow the child to develop sophisticated abilities to gain insight into the caregiver’s feelings and motives, further refining the child’s ability to construct models and interactive plans of the relationship.

While an approximate developmental chro- nology is useful for tracking these changes, it is important to note that Bowlby disliked the use of “watershed”- type age- markers. He saw the development of internal working models as a gradual life process, which changes qualita- tively over time and is susceptible to revision. At the same time, however, according to theory, it is the formation of internal working models in infancy that accounts for the enduring qual- ity of early attachment relationships throughout life (Bowlby, 1982).

Internal Working Models, Adversity, and Defensive Processes

In optimal conditions, attachment figures respond adequately and consistently to chil- dren’s experiences of vulnerability. A  child forms internal working models of attachment figures as reliable and trustworthy when these conditions are present. When a child consist- ently encounters behavior by an attachment fig- ure that does not adequately address conditions of vulnerability, however, the child is likely to form conflicting internal working models of the same attachment figure:  a conscious one that preserves a sense of the parent as trustworthy, and one that is defensively excluded from con- sciousness containing the information regard- ing the parent’s inadequacy (Bowlby, 1973). If the mental representations of the untrustworthy parent were integrated into the child’s conscious internal working model, according to Bowlby, the resultant experience of threat and persist- ent insecurity would be overwhelming to the child. In order to preserve some sense of safety and security, therefore, the child maintains an

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illusory mental model of a reliable and respon- sive parent.

The formation of the internal working model of self reflects an appraisal process:  A  small child makes appraisals of him/ herself inferred from the nature of responses received from attachment figures. Internal working models of self and attachment figures are, thus, likely to be complementary (Bowlby, 1973). In non- optimal circumstances, where an attachment figure has not consistently responded to the child in reas- suring ways, the internal working model of the child’s self is likely to take on qualities of inad- equacy. An unloved child will appraise him/ herself as unlovable.

Effects of Prolonged Separations from Caregivers

One central, organizing idea of attachment theory that propelled much of Bowlby’s work and set him apart from most psychoanalysts of his day is that children’s intense reactions to prolonged separations from, or loss of, their primary caregivers provide direct and observ- able evidence for the existence of attachment bonds (Bowlby, 1982). Classical psychoanalytic theory discounted the experience of mourn- ing in young children as a result of its empha- sis on internal vs. actual experience. Prolonged separations from or loss of attachment figures during the critical period for the formation of attachment, six to 36  months, and the quality of the subsequent care children receive, may have profound developmental effects across the life span.

Bowlby incorporated a stage theory of chil- dren’s reactions to prolonged separations, first developed by social worker James Robertson, a colleague of Bowlby’s at Tavistock. Robertson proposed, based on filmed observations he made of children separated from their parents in hos- pitals (1952), as well as observations he and his wife, Joyce, made of their foster children, that young children normally react to prolonged separations from their attachment figures in phases characterized by protest, despair, and lastly (if the separation is not addressed) detachment. In the first stage, the child exhibits a high level of anger, uncooperative behavior, searching, and anxiety, the function of which

is, according to Bowlby, to challenge and elimi- nate interpersonal barriers standing in the way of reunion with the attachment figure. The pro- test of this stage is thus connected to the activa- tion of attachment behavior, whose expression may take different affective forms; it is designed to accomplish proximity to the missing attach- ment figure.

The next stage, despair, begins after the young child’s protest at the separation has gone unanswered by the attachment figure. Depending on circumstances, this stage may begin after a period of days or weeks follow- ing the separation. At this stage, sadness and withdrawal are common features, though typically still intermingled with anxiety and/ or anger.

In the final stage, if the attachment figure has failed to appear for the child and no sub- stitutes are available, a virtual shutdown of the systems responsible for the child’s attach- ment behavior begins, and the child detaches emotionally from significant others. The lon- ger that separation from the attachment fig- ure continues, under circumstances where no substitute caregivers are available, the greater the risk for a progression into detachment and despair.

Bowlby’s theory of grief and mourning, influenced by the work of Colin Murray Parkes (Bowlby, 1960, 1980), involves a normative pro- gression through four major phases of adjust- ment: (a) numbing and shock; (b) yearning and searching, accompanied by anger and disbelief; (c)  disorganization and despair, including the dismantling of internal working models of the relationships; and (d) reorganization and redef- inition. This theory proved to be very influential on the work of others in the field, including that of Kubler- Ross (1969).

Conditions in the grieving child’s life may or may not promote the child’s successful reor- ganization of internal equilibrium. Often, the most important variable affecting this process is the way in which significant adults in the child’s life react to the loss themselves and how they appraise and respond to the child’s needs at this time. According to Bowlby, the most basic and, perhaps, the single most helpful thing a signifi- cant adult in the child’s life can do to promote the child’s successful grieving of a lost figure is

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to permit and encourage the child to express, uncensored, the emotions associated with the loss (Bowlby, 1980). In this way, the risk to the child of developing a rigid, defensive exclusion of the emotions associated with the loss and with the actual relationship with the lost figure is minimized. The ability of significant adults to provide a child with opportunities for grieving necessarily depends on their own capacity to accept and express the range of emotions asso- ciated with the loss.

When conditions do not favor a person’s successful resolution of loss, characteristics of “disordered mourning” are likely to appear. Among the manifestations of disordered mourning discussed by Bowlby are:  Chronic mourning, when the resolution of the loss is not effected, and the person remains “stuck ” in earlier phases of searching/ yearning or disorganization/ despair; and the absence of grief, when the experience of the loss is largely defensively excluded from conscious awareness. Bowlby describes several types of symptoms associated with children’s reactions to loss, which fall generally under these two major rubrics, including the following:  fear that a surviving parent will die; fear of the child’s own death; hopes for death as a way to be reunited with the lost figure (this is espe- cially likely for children who do not perceive death as irreversible); persisting blame, of self or of others, or guilt; aggression and destruc- tive outbursts (Bowlby believed that virtually all children who react in this way have a hid- den sense of guilt for the loss); compulsive care- giving; compulsive self- reliance; eupho- ria and depersonalization; and the develop- ment of symptoms similar to those the lost person had (Bowlby, 1980).

In Bowlby’s view, psychological defense, separation anxiety/ reaction, and grief and mourning are interrelated processes, func- tioning as part of one larger process involving initial activation and subsequent deactivation of attachment behavior for a missing, lost, or unresponsive attachment figure; thus the meaning and function of these processes were recast as expressions of attachment behavior (1973). He also emphasized that the course taken in childhood in reaction to separation or loss may well affect a person throughout the

entire life span, depending to a great extent on the way in which attachment behavior was expressed in the relationship and the nature of response received from t he caregiv ing environment.

The Contributions to Attachment Theory of Mary Ainsworth and Colleagues

Bowlby’s crowning achievement was the con- struction of an elegant, new developmen- tal framework. In contrast, he participated less in empirical research. The application of attachment theory to empirical research was left by and large to his colleagues and fol- lowers, beginning, most notably, with Mary Ainsworth, an American developmental psy- chologist and colleague of Bowlby’s at the Tavistock Clinic. Ainsworth conducted the first major empirical studies of attachment, beginning with work she did in rural Uganda (Ainsworth, 1963)  and later in Baltimore (Ainsworth, Blehar, Waters, & Wall, 1978). Her interest in children’s emotional security went back to her days as a doctoral student in Toronto, where her dissertation, completed in 1940, incorporated the “security theory” of her mentor, William Blatz (Ainsworth & Marvin, 1995).

Ainsworth’s research utilized primarily observations of mother– child interactions, which became a major part of her enduring legacy, the inspiration for which she cred- ited Robertson’s observations of children in hospital settings. In their Baltimore study, Ainsworth and colleagues created a major innovation in observational research meth- ods, the “Strange Situation Procedure,” a laboratory assessment containing several pro- gressive steps designed to observe firsthand how infants react to separations from their mothers. Significant associations were found between home observations of the quality of mother– child interactions and attachment patterns observed in the Strange Situation, suggesting that the laboratory observations were valid indicators of interactive behavioral patterns between mother and child, and prob- ably represented enduring dyadic relationship qualities.

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In brief, the Strange Situation Procedure consists of the following seven episodes:

1. The caregiver and infant enter a small room containing several toys, and the infant is allowed to play and explore as desired;

2. A  “stranger”/ assistant enters the room and sits quietly at first, then engages in conversa- tion with the caregiver;

3. Caregiver leaves the room, leaving the infant alone with the assistant, who freely interacts with the child;

4. The caregiver returns, and the assistant leaves the room;

5. The caregiver departs, leaving the infant alone; 6. The stranger returns to the room; 7. The caregiver returns to the room, and the

assistant leaves.

Each of the major episodes lasts three min- utes, unless curtailed because of infant distress.

In her Baltimore study, Ainsworth’s sub- jects (n  =  106) were collected over four sepa- rate projects; all were white and middle- class. Observations of the infants’ responses to absences from and, especially, reunions with the mother were recorded by scoring numer- ous types of infant behavior in interaction with their mothers. On the basis of these observations, Ainsworth created three main categories (composed of eight subgroups) of attachment security:  Insecure- avoidant (A); secure (B); and insecure- ambivalent (resist- ant) (C). Avoidant babies tended to display little attachment behavior and little emotion, in general, toward their mothers. They typi- cally avoided their mothers upon their return by turning their backs or snubbing maternal overtures toward them. Secure babies showed clear distress and attachment behavior toward their mothers during separations. When reunited with mothers, they approached and sought contact, and after a period of com- forting, returned to exploration. These babies were distinguished from the other groups by their ability to regain emotional equilib- rium and regulation after reassuring contact with the mother. Ambivalent babies tended to approach the mother upon her return but remained dissatisfied and angry, not soothed, by her presence.

Ainsworth’s findings supported and eluci- dated several important aspects of Bowlby’s theory of attachment, especially the notion that attachment behavior will look different for children depending on their life experiences. Consistent with theory, the three main cat- egories of attachment security were primarily distinguished by patterned activation or deacti- vation of attachment behavior and the qualities of synchronous interaction of parent and child. In Bowlby’s original terms, the attachment rela- tionship provides the infant with an interper- sonal system of regulation, which eventually leads to the child’s own physiological regula- tory capacities (1982). Ainsworth’s classifica- tion system identified specific variations in how this goal is accomplished. Parents of securely attached babies, in contrast to those of inse- curely attached children, were notable for their sensitivity and responsiveness toward their chil- dren. They were expert at understanding their children’s needs for them, with great insight into the child’s point of view, and had the nec- essary personal resources to be able to respond to them according to their needs.

The Strange Situation Procedure (SSP) was important, first, because it provided a standard behavioral measure of attachment for infants up to approximately two years of age (it is typ- ically used for infants between the ages of 12 and 18  months). (Two of Ainsworth’s stu- dents, Jude Cassidy and Robert Marvin, adapted the original SSP for use with preschool children up to age five [Cassidy & Marvin, 1992].) It also came to be viewed as, essentially, a “shortcut” in the assessment of parent and child interaction that normally would be done in the naturalis- tic setting of the home (Ainsworth & Marvin, 1995). Assessment in the SSP, then, has become a standard to which other measures of attach- ment, especially those taking place later in child- hood, are compared. In some ways, Ainsworth regretted that the classifications derived from Strange Situation assessments had become essentially synonymous with attachment, and presumed by many to be sufficient for under- standing attachment behavior in parent– child dyads. She advocated all her life that behavioral scientists study children by observing them in their natural environments, especially their homes (Ainsworth & Marvin, 1995), which she

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regarded as essential to capturing a full under- standing of attachment relationships.

As researchers around the world began to use the SSP, providing validation in var- ied settings, it became apparent to many that a significant minority of children were dif- ficult to classify according to the Ainsworth tripartite system, especially those in high- risk samples. Mary Main, another of Ainsworth’s former students, and her colleagues ultimately discovered consistencies in behavioral pro- files for many of these children, resulting in a fourth category of attachment behavior, the Disorganized/ Disoriented category (Main & Solomon, 1990). Characteristics observed in the SSP reunion behavior of children assigned to this group are immobilization and diso- rientation upon the mother’s return, contra- diction in physical movements, and, inferred from the contradictory physical movements, contradictions in intended, or planned, behav- ior. The disorganized/ disoriented attachment pattern is considered a more severe adaptation to inadequate caregiving circumstances, distin- guished by the absence of any coherent strat- egy for engagement and interaction. As such, it is considered a “non- organized” attachment strategy, compared to the original three catego- ries identified by Ainsworth. Even though the avoidant and ambivalent patterns are insecure attachment strategies, they are at least organ- ized strategies; that is, predictable patterns of interaction that function to maintain contact with attachment figures, however limited. In contrast, the young child with disorganized attachment is disoriented, without a predicta- ble means of engagement with attachment fig- ures. Disorganized attachment has been shown to be prevalent among maltreated children (as high as 82% reported in Carlson, Cicchetti, Barnett, & Braunwald, 1989). As the child matures, however, many do develop patterned interactions with their caregivers, but not in the sense of reliance on them. By the age of six, role- reversed, controlling interactive patterns, of punitive or caretaking dimensions, have been observed among many children classified in infancy as insecure- disorganized (Main & Cassidy, 1988). These behavioral adaptations, of course, are not oriented to the child’s needs, and they are not typically stable or predictable, since

they tend to occur in the context of a maltreat- ing relationship.

Ainsworth stressed the importance of recog- nizing secure and insecure attachments as vari- ations, or individual patterns, of attachment bonds and not, except in relatively rare circum- stances, as equivalent to the presence or absence of attachments per se. Insecure children by and large have attachments to their caregivers that are equal in intensity to those of secure chil- dren. Child welfare workers and foster parents see this every day of their professional lives, in the protest and activated attachment behavior in children who have been seriously maltreated. When such behavior is not seen for what it is, the anxious, insecure child who has been separated from a parent will often be misunderstood and perceived simply as having a behavior problem.

Another major innovation in the develop- ment of attachment theory and research was marked with the publication of a seminal paper by Main, Kaplan, and Cassidy (1985), which brought attention to the study of the represen- tational dimension of attachment. Following Bowlby’s theory of internal working models, Main, Kaplan, and Cassidy argued that attach- ment organization could be assessed beyond infancy with evidence of organized memo- ries, the internally represented dimension, of attachment- relevant experience. This approach to measurement is critical for the study of attachment in older children and adults, since attachment behavior becomes attenuated as the child matures, and observational measures lose their utility.

A major innovation to arise from this line of research was created by Mary Main and col- leagues, the Adult Attachment Interview (AAI), to which Main applied her background in psy- cholinguistics with her knowledge of attachment in infancy gained from her years in Ainsworth’s infant laboratory (Main, 1999a). The major innovation of the AAI was the discovery that the assessment of attachment organization in adulthood could be accomplished primarily on the basis of nonverbal discourse qualities, par- ticularly the coherence of discourse, moderation in affective expression, and sense of objectivity regarding important events. Coherence of dis- course involves qualities such as consistency, flow, truthfulness, and richness of supporting

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memories offered in responses, as well as the succinctness, completion, relevance, and clarity of responses (Hesse, 2008). The AAI questions focus on the respondent’s history of care received as a child, especially major events relevant to safety and protection. Attachment classifications are identified based on the discourse qualities revealed in the telling of this personal narrative. Four main adult attachment classifications are used, reflecting the four similar classifications used for infants: Secure/ autonomous; dismiss- ing (avoidant); preoccupied (ambivalent); and unresolved/ disorganized. The process of recall in the interview activates feelings associated with early attachment- related events, as well as the respondent’s characteristic style of making sense of and coping with these. The degree to which the respondent has access to the mem- ory systems involved is an important indicator of the extent of past emotional pain and defenses employed to address this. Dismissing adults tend to have difficulties accessing the often- intense affect associated with these memories, coping to a great extent by relying on emotional distance. Preoccupied adults tend towards the reverse, with relatively greater access to affectively charged memories, to the point of being over- whelmed with intense and unfocused emotion, with relatively weak abilities to use synthesized memories to gain a more dispassionate and bal- anced perception of past events. The unresolved/ disorganized classification is characterized by evidence of lack of resolution of past trauma or major loss (Hesse, 2008). Numerous studies over the past 20- plus years attest to the reliability and validity of the AAI as a measure of attachment organization in adulthood (see Hesse, 2008, for a review).

Concurrent linkages between infant SSP classifications and parents’ AAI classifications have been found in several studies, with mod- erately strong effect sizes. Hesse (2008) reports four U.S. samples, involving a total of over 200 subjects where high, though not absolute, con- cordances between SSP and AAI classifications have been found for individuals longitudinally, across their life spans. The AAI has also been used, most impressively, to prospectively pre- dict attachment security in dyads. AAI clas- sifications of mothers assessed in their third trimester of pregnancy have been found to

predict their infants’ attachment classification to them when the children were 12 months old (Fonagy, Steele, & Steele, 1991). The AAI has led to a new understanding of the significance of discourse qualities in speech and has spawned a new generation of interview protocols that reflect these insights (Koren- Karie, Oppenheim, Dolev, Sher, & Etzion- Carasso, 2002; Zeanah & Benoit, 1995).

Current Research

Since the publication of the first volume of Bowlby’s Attachment and Loss trilogy in 1969, attachment research has grown exponentially. A  cursory search of indexed databases shows applications of attachment theory in all major areas of human development and therapeutic intervention and across all major related disci- plines. Attachment theory is regarded, accord- ing to the eminent developmental scholar Michael Rutter, as the leading theory of the development of early social behavior in child- hood (Rutter & Rutter, 1993).

The body of evidence, including major lon- gitudinal studies of attachment in different countries, has confirmed the major tenets of Bowlby’s theory:  that it is universal, transmit- ted across generations, relatively enduring, pre- dictive of major developmental sequelae, yet subject to environmental influence across the life span. Due to space limitations, a sampling of selected topics, with perhaps particular rele- vance to social workers, is presented here.

Attachment Across the Life Span

Several longitudinal studies have now shown strong consistencies in attachment security from infancy, into childhood, and adulthood. Many developmentally relevant correlates of secure attachment have been discovered across the life span. In this very large body of research, attachment security assessed in infancy has been shown to predict supportive social networks, including peer relationships, ego resilience, emotion regulation, positive self- concept, conscience development and pro- social behavior, emotion understanding, and empathic responsiveness in childhood (see Thompson, 2008, for a review). In short,

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secure attachment is regarded as an essential developmental foundation that is the basis for the acquisition of critical social skills that determine social and emotional functioning beyond infancy and across the life span.

Developments in representational assess- ments have enabled researchers to advance the study of attachment into early and middle childhood. Among these, the Attachment Story Completion Task (ASCT; Bretherton, Ridgeway, & Cassidy, 1990)  and the MacArthur Story– Stem Battery (MSSB; Bretherton, Oppenheim, Buchsbaum, Emde, & the MacArthur Narrative Group, 1990) are based on Bowlby’s theory that attachment experience becomes organized, and increasingly relied upon, via internal work- ing models. Children aged four to seven are presented short story “stems” depicting every- day stressors (e.g., the parents go away for an overnight trip and the grandmother babysits), enacted with basic family doll figures and props. In response, the children create spontaneous narratives, which researchers videotape and code for themes of interest, such as enactments of caregiving, conflict, attachment behavior, and coherence. A growing body of story- completion task literature has demonstrated that children’s story- stem responses are significantly correlated with indices of attachment security, includ- ing infant SSP classifications and mothers’ AAI classifications (Bretherton, 2005), and a vari- ety of other measures of social and emotional well- being, including pro- social behavior with peers, anxiety, maltreatment history, and moth- ers’ depression (Emde, Wolf, & Oppenheim, 2003; Page, 2001). Story- stem responses have also been used as a dependent variable follow- ing a parenting intervention, showing change in children’s perceptions of their parents (Toth, Maughan, Todd Manly, Spagnola, & Cicchetti, 2002), as well as a measure of perceptions of mother– child interactive qualities associated with observed behavior in the home (Dubois- Comtois & Moss, 2008).

Attachment has also been increasingly studied beyond childhood, into adolescence and adult- hood, a subject that Ainsworth was particularly interested in and wrote about in the latter part of her career (1989). This emerging empirical liter- ature began with Hazan and Shaver’s (1987) dis- covery of attachment- oriented interactive styles

in romantically involved young adults that were conceptually consistent with Ainsworth’s origi- nal attachment categories. Subsequent findings from two prospective longitudinal studies have found that attachment security in infancy indi- rectly predicts the quality of romantic relation- ships in early adulthood, via a developmental pathway through childhood peer relationships (Berlin, Cassidy, & Appleyard, 2008).

Social Ecology/ Social Systems

Attachment theory is an “ecological theory,” taking into account biology and individual, micro- system interdependence, as well as larger system influences, external to the family, on the development of emotional security in children (see Belsky, 2005). At its core, attachment is a dynamic concept. The behavioral systems gov- erning its operation are in constant interaction, in states of relative activation and deactivation, with overarching system goals of balance and regulation characterizing their optimal func- tioning. The infant develops within a dyadic, mutually regulatory, interactive system that promotes and eventually leads to the achieve- ment of more internalized management of reg- ulatory capacities (Bowlby, 1982).

Attachment patterns tend to be transmit- ted intergenerationally, though not absolutely; that is, children tend to develop the same basic attachment type as their attachment figures (Bretherton & Munholland, 2008), but vari- ous forces operating in the social ecology affect this process. Attachment type thus represents a learned coping strategy. Since attachment type is specific to a given dyadic relationship, a child may have different attachments within the fam- ily, depending on the attachment figure. How children synthesize their attachment experi- ences into a dominant attachment interpersonal style is likely to be influenced by their primary attachment figure, though as yet little is known about this process.

Attachment and Developmental Psychopathology

Attachment theory has proven to be use- ful in understanding the developmenta l

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consequences of risk, resilience, and trauma for children, including the emergence of psy- chopathology. Bowlby (1973) adapted the con- cept of the “developmental pathway” from the biological sciences to explain how early events, especially those affecting attachment security, can come to influence later development, not necessarily linearly, but in interaction with var- ious other events and circumstances the grow- ing child encounters in the environment over the years.

Attachment insecurity has been shown to be associated with specific forms of psychopa- thology, but these relationships are complex and determined by other risks encountered in the child’s social ecology, including child char- acteristics (primarily biologically inherited characteristics), insensitive parental practices, and family- level risks (DeKlyen & Greenberg, 2008), among which poverty has a dominating influence. The evidence thus far is consistent with theory:  Organized insecure attachments (avoidance and ambivalence) are moderate risk factors for the development of some forms of psychopathology (e.g., affective disorders, con- duct disorders; DeKlyen & Greenberg, 2008), whereas disorganized/ disoriented attachment presents significantly stronger risks, in particu- lar for conduct, affective, self- injurious, and dis- sociative disorders (Sroufe, 2005).

Trauma and Child Welfare Services

Attachment theory has contributed to signifi- cant innovations in thinking about the needs of maltreated children in foster care systems, and children who are exposed to chronic extreme distress, such as family violence. Seen from an attachment perspective, traumatic events are damaging to children first and foremost because they threaten a child’s sense of safety and protection. Kisiel et al. (2014) used attach- ment theory to inform a “developmental trauma framework,” applying this to an examination of the impact of complex trauma in maltreated children in the child welfare system. Their major finding was that children exposed to the combination of trauma engendered by fam- ily violence and nonviolent trauma involving attachment- related risk were nine times more likely to experience trauma- related symptoms

and functional impairments than children with either form of trauma alone.

A child whose attachment figure inflicts abuse and trauma faces an unresolvable dilemma:  Attachment behavior is instinctively activated toward the very source of this distress, a desire for proximity with the person who pres- ents the most immediate threat. This dilemma is the heart of disorganized attachment, and its confused and contradictory behavioral strate- gies are familiar to every child welfare worker and foster parent, as well as many adult victims of domestic violence, and are a powerful influ- ence in the emergence of the psychopathology associated with disorganized attachment.

Recovery from trauma must begin with the reestablishment of confidence in the safety and protection of the caregiving environment. Attachment theory has been instrumental in demonstrating that children need to have pro- tective adults, including adoptive and foster parents, make emotional investments in them, as opposed to guarding against emotional commitment as a way to protect the child (and themselves) from the pain of potential or even- tual separation (Dozier & Rutter, 2008).

Reactive Attachment Disorder

The psychiatric literature has been influenced by attachment theory, particularly in the men- tal disorder known as “reactive attachment disorder” (RAD). The 2013 revision of The Diagnostic and Statistical Manual of Mental Disorders (DSM- 5; American Psychiatric Association, 2013)  reorganized the diagnostic criteria for RAD by separating out the crite- ria for a related disorder— disinhibited social engagement disorder— whose tie to attachment experience is still not well understood. The new conceptualization of RAD, on the other hand, is tied more explicitly to attachment processes, characterized by the absence of selective attach- ments and extreme neglect of care. Evidence for RAD must appear before age five years and per- sist for at least 12 months. Children with RAD typically exhibit extreme emotional withdrawal and compromised capacities for emotion regu- lation involving various emotional states (e.g., sadness, fear, anger). Attachment disorders, thus, are not simply insecure attachments, and

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must be thought of as extreme disruptions or deprivations in attachment, associated with the most profound of developmental risks.

The Neurobiology of Attachment

The study of the brain physiology associated with attachment processes has recently witnessed a significant expansion, revising our under standing of the biological foundation of attachment and related developmental processes. When young children experience separations from caregivers, for example, stress- response systems are activated involving the neuroendocrine system, particu- larly the hypothalamic- pituitary- adrenal (HPA) axis (Cassidy, Ehrlich, & Sherman, 2014; Sheridan & Nelson, 2009). When caregivers provide sooth- ing to their young children, re- regulation of the child’s stress response system occurs. The neu- ropeptide oxytocin, found throughout the brain and body, interacts with the HPA axis and dopa- mine receptors to facilitate regulatory processes (Feldman, 2014). The extent to which caregivers and their children achieve mutual coordination in behavioral interactions— the “biobehavioral synchrony” of caregiver and child of gaze, touch, proximity, and vocalization— is highly correlated with oxytocin levels in both (Feldman, 2014). Evidence from studies across mammalian species shows that distress related to separation from a caregiver, and the instinctive calls of protest that result from this, are associated with decreases in the secretion of oxytocin and opioids as well as increases in stress- related hormones (Panksepp et  al., 2014). Pleasure associated with reunion with that caregiver involves the dopamine reward system. Neurochemical dysregulation associated with prolonged states of separation distress and the absence of pleasure specifically associated with reunion with a loved one, particularly a caregiver, have been shown to have important roles in the development of depression (Panksepp et al., 2014).

Recent applications of neuroimaging have shown that mothers tend to respond differ- entially to pictures of their own and of other infants’ faces. Pictures of their own infants tend to differentially activate the cortico- ventral basal ganglia circuit, specifically the orbito- frontal cortex, which is involved in affective appraisals of people, and sub- cortical reward

regions (Bretherton & Munholland, 2016). Strathearn (2011) showed that visual depictions of their children affected the release of oxyto- cin and dopamine reward systems in mothers differently, depending on the mothers’ attach- ment security. Compared to securely attached mothers (as assessed with the AAI), insecure/ dismissing mothers were significantly less likely to activate the ventral striatum, a component of the cortico- ventral basal ganglia circuit, and mesocorticolimbic reward pathways, regions of the brain associated with oxytocin and dopa- mine production. Recent evidence has also been provided for specific neurobiological processes involved in the formation of attachment- related internal working models. Specific brain regions, particularly the hippocampus, have been shown through neuroimaging studies to process mem- ory storage and retrieval, as well as simulations of future interactive behavioral scenarios based on learned experience, thus identifying specific brain functions that appear to provide a neu- roanatomical explanation for Bowlby’s orig- inal formulation of internal working models (Bretherton & Munholland, 2016).

The advancement of neurobiological research in attachment extends Bowlby’s original formu- lation of attachment as a physiological proc- ess and product of evolutionary selection that is shaped through learning. Expansion of our understanding of the neurophysiology underly- ing attachment will further illuminate explana- tions for the intergenerational transmission of interactive qualities involving care and respon- siveness, as well as linkages to psychopathology associated with prolonged periods of dysregu- lated attachment processes.

Pseudoscience

It is important to note, finally, that attach- ment theory has been seriously misapplied, at the expense of children’s lives, by some pro- ponents of so- called attachment therapies. In perhaps the most notorious of these cases, a 10- year- old girl was smothered to death by ersatz “therapists” practicing “holding ther- apy” (Mercer, Sarner, & Rosa, 2003), a danger- ous treatment without evidentiary basis that does not derive in any logical way from attach- ment theory (O’Connor & Zeanah, 2003). It

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is imperative that social workers and other human services professionals have accurate information about what attachment is and is not, and that their practice be consistent with developmental knowledge and evidence- based approaches.

Current Status and Relevance in the Social Work Profession

Attachment scholarship has been the prov- ince primarily of developmental psycholo- gists, ever since Mary Ainsworth’s pioneering studies in the 1960s. Social work has been comparatively late in integrating attachment theory into its research and practice, espe- cially in the United States, but this is chang- ing quickly. The fifth edition of Social Work Treatment in 2011 marked the first time that attachment theory was included among its chapters. Contributions by social work schol- ars toward integrating attachment theory into social work practice now appear across a wide range of topics, including: theory development (McMillen, 1992; Sable, 1979); as a theory of placement change in foster care (Tucker & MacKenzie, 2012); practice roles (Howe, 1995); clinical supervision (Bennett, 2008; Bennett & Deal, 2009); assessment and intervention with foster children and/ or foster parents (Fish, & Chapman, 2004; Schofield & Beek, 2005); paren- tal visitation in child welfare (Haight, Kagle, & Black, 2003); adoption (Howe, 2001); narrative assessments with young children (Page, 2001); childbearing motivations (Warren, Sable, & Csizmadia, 2008); risk for disruptive behav- ior problems in childhood (Keller, Spieker, & Gilchrist, 2005); treatment for reactive attach- ment disorder (Drisko & Zilberstein, 2008); eating disorders (Barth, 2008); parenting assessments (Farnfield, 2008; Koren- Karie, Oppenheim, Dolev, Sher, & Etzion- Carasso, 2002; Lewis, 1999; Rosenblum, Zeanah, McDonough, & Muzik, 2004); adolescent par- ents (Hans & Thullen, 2009); and intervention with couples (Solomon, 2009)  and parents (Page & Cain, 2009), among others. Special issues of the Clinical Social Work Journal and Child and Adolescent Social Work Journal in 2008 and 2009, respectively, were dedicated to addressing applications of attachment theory

to clinical social work practice. Haight and Taylor’s (2007) text for social work courses on human behavior in the social environment was the first to use attachment theory as a major organizing framework, and stands in marked contrast to the cursory treatment attachment theory gets, if it is mentioned, in most other human behavior texts in social work courses. Bennett and Nelson’s edited volume (2011) on applications of attachment theory to clini- cal interventions with adults is particularly noteworthy.

Assessment and Intervention

Attachment theory has proven to be a very fer- tile theoretical foundation for psychotherapeu- tic interventions for people across the life span, a topic that was of special concern to Bowlby (1988). According to Bowlby, a therapist should be sensitive to the primacy of safety and pro- tection in the developmental experience of the client. Interpretations and analysis of the cli- ent’s relational experience, including within the therapeutic relationship, should be based on an understanding of the centrality of the expression of attachment behavior in social experience and with regard to the creation of personal identity. Psychotherapy from an attachment perspective provides the conditions in which the client can “explore his represen- tational models of himself and his attachment figures with a view to reappraising and restruc- turing them in the light of the new understand- ing he acquires and the new experiences he has in the therapeutic relationship” (Bowlby, 1988, p.  138). The integration of attachment theory in psychotherapy brings a heightened under- standing of the characteristic ways in which needs for safety and protection are expressed in current relationships, including defensive strategies, and the extent to which these behav- iors represent attempts to cope with unrespon- sive attachment figures, learned early in life. Discussions of clients’ perceptions of the thera- peutic relationship should include sensitivity to the client’s regard for the therapist as an attachment figure, and the actual limitations of this role.

Attachment theory has been particularly effective in structuring and guiding direct

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dyadic psychotherapy with young children and their caregivers to address problems in parent- ing and children’s emotional and behavioral dysregulation. Standardized intervention proto- cols such as Parent– Child Interaction Therapy (PCIT; Eyberg et  al., 2001)  and Child– Parent Psychotherapy (CPP; Lieberman & VanHorn, 2009)  and its variants (e.g., Toth et  al., 2002)  emphasize building parental capacities for sensitivity and responsiveness, active imagi- nation about the child’s internal perceptual experience, and attention to the child’s specific attachment- related needs in the relationship. Multiple Family Group Intervention (MFGI; Keiley, 2002)  utilizes similar principles to pro- vide an attachment- based treatment for adoles- cents with conduct disorder in a group setting with their parents.

Attachment theory has provided a particu- lar impetus to psychotherapeutic interventions for parents using videotape. The SSP validated the use of attachment ratings based on labora- tory observations. By extension, psychothera- pists realized that videotaped interactional sequences had great utility for clinical inter- vention, particularly when using attachment theory to understand relationship qualities and identify focal points for intervention. Several evidence- based attachment- related interven- tions using videotapes of child– caregiver interactions have been created, most nota- bly: Interaction Guidance (McDonough, 2005); the Seeing Is Believing component of Steps Toward Enjoyable, Effective Parenting (STEEP; Egeland & Erickson, 2004); Video- feedback Intervention to promote Positive Parenting (VIPP; Juf fer, Ba kermans- K ranenburg, & van IJzendoorn, 2007); the Circle of Security (Hoffman, Marvin, Cooper, & Powell, 2006); At tachment a nd Biobehav iora l Catch- up (ABC; Bernard et  al., 2012); Promoting First Relationships (PFR; Spieker, Oxford, Kelly, Nelson, & Fleming, 2012); Group Attachment- Based Intervention (GABI; Steele et  al., 2014); and a variation of VIPP for maltreated child- ren (Moss et  al. 2011). Each of these inter- vent ions empha si z es t he i mpor t a nce of strengthening caregiver capacities for “men- talisation” (Fonagy, Steele, Steele, Moran, & Higgitt, 1991), or the capacity to reflect upon and be curious about the child’s mental states

and perceptual experience, and sensitive responsiveness to children. Strengthening these capacities, according to Fonagy and col- leagues, has broad implications for the well- being of the relationship:  As the caregiver strengthens her or his mentalizing capacities and sensitivity, s/ he further strengthens obser- vational skills and, in so doing, more firmly defines relationship boundaries and empathic attunement to the child. This reinforces his/ her knowledge of and confidence in the role of caregiver. Caregivers who are confident in their roles are more likely to communicate a sense of security to their children and, in this process, facilitate the child’s physiological, emotional, and behavioral regulation and, ultimately, emotional security.

Specific services for maltreated children and their caregivers have become another major area where attachment theory has been effectively employed to structure and guide interventions. Four notable studies utilizing randomized control trials compared attachment- based interventions with parent– child dyads to more routine child welfare family services. Three of these (Bernard et al., 2012; Moss et al., 2011; and Spieker et  al., 2012)  drew their inspiration to a great extent from the VIPP model, which is also notable for its relatively short duration (approx- imately 10 sessions). Toth and colleagues’ inter- vention, Preschool Parent Psychotherapy (PPP; 2002)  was longer (approximately 32 sessions over 12 months) but focused on similar parent- ing qualities. All interventions demonstrated improvements in their targeted outcomes, including parental sensitivity and child attach- ment qualities.

There is a particular imperative for social workers, including social work educators, to be thoroughly grounded in attachment theory and research. As a profession, we have a unique responsibility to provide services to the most vulnerable of our society’s children in our child welfare systems. Making the best- informed decisions about the well- being of these children requires thorough knowledge of the processes through which children form attachments to their caregivers. It is a professional imperative, therefore, that we understand these issues in depth and keep abreast of the current state of knowledge in the field.

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A Case Example

This case involves Jerri, a 21- year- old mother, who was reported to Child Protective Services for inad- equate supervision of her son, Brian (both names are pseudonyms). At age two, Brian was found wander- ing alone along a busy highway, the latest of several incidents when he had been found wandering outside unsupervised, necessitating police involvement. After a brief stay in kinship foster care, Brian was returned to Jerri’s custody, and Jerri was referred for parenting services. Jerri worked an afternoon/ night shift as a nursing home attendant, often up to 16 hours, and child care was inconsistently provided. At the time of this intervention, Jerri had been a client of the child welfare system for two years. In childhood, she had been severely emotionally and sexually abused by her father. She had attained a ninth- grade education (she dropped out in tenth grade), and had been diagnosed with dyslexia.

The parenting service provided was the Circle of Security® (Hoffman et al., 2006; Marvin, Cooper, Hoffman, & Powell, 2002; Page & Cain, 2009), a small group intervention for six to eight par ticipants based on attachment principles. Children’s interac- tions with caregivers are presented as representing the two principal behavioral systems discussed by Bowlby— attachment and exploration— integrated as continuous and alternating dimensions of one interactive circle. Empathic understanding and responsiveness toward children’s alternating needs for exploration and attachment are taught prima- rily through videotape- review sessions where par- ticipants watch themselves in interaction with their children. The video segments are selected from pre- intervention assessments by group leaders to illustrate key relationship qualities as identified in treatment plans. Each par ticipant receives three review sessions.

Assessments included attachment ratings for child and mother provided by the SSP (parent attachment was assessed with Marvin’s Caregiver Behavior Scales, rated by the author, Robert Marvin [Britner, Marvin, & Pianta, 2005]; child attachment classifications were also provided by Robert Marvin). Parent insightful- ness (“the parent’s capacity to invoke motives that underlie the child’s behavior”; Oppenheim & Koren- Karie, 2002) was also assessed using an attachment- inspired interview, the Insightfulness Assessment (IA; rated by its authors, David Oppenheim and Nina

Koren- Karie). All assessments were rated indepen- dently. Jerri and Brian were assessed at the pre- test observation with disorganized attachment, and Jerri was assessed with the most problematic of three classes of insightfulness, corresponding to disorga- nized attachment (Oppenheim & Koren- Karie, 2002). The intervention was led by this author.

The following dialogue was taken from Jerri’s sec- ond tape- review session. Second tape- review ses- sions are designed to focus on the most profound problems in the relationship, conceptualized as the parent’s difficulties in responding to the child’s expres- sions of exploration, or attachment, or both. For Jerri, as for parents in other dyads rated with disorganized attachment, the major relationship difficulties typi- cally involved inconsistent responsiveness to both the child’s exploration and attachment. In the following excerpt, we see Jerri’s frustration and irritation with Brian’s anxiety and need for her, which were often activated when she came home from work feeling emotionally and physically depleted. The therapeu- tic challenge was to reframe Brian’s behavior so Jerri could understand it as activated attachment behavior.

Jerri: You know, when I  work, he is usually up at six o’clock in the morning waiting for me to get home…  . He is very demanding in the morning time. He is like, “I don’t want to go to school, I want to stay home with you,” and I am like, “You can’t stay here, you have to go to school, so we are going to sit here and watch TV.” … It is very aggra- vating at times, only from exhaustion, because you know I am so exhausted sometimes… .

Later in this session, a short video clip was shown to Jerri of her interaction with Brian in the SSP, show- ing her reunion with him after a brief separation, to illustrate and explain Brian’s attachment behavior directed toward her:

Group Leader 1: So this first clip, you have been out of the room, and we are looking at how he is responding to you when you return. What are we seeing?

Jerri: Going back to his mom. Group Leader 2: He made a beeline for you. Jerri: Yeah, he does that all the time. It’s like he can

smell me when I  walk in the door, whether he sees me or not, he knows when I walk in the door. Sometimes I try to sneak, he’s in his room, so I try to shower before he comes out, and he’s like, “Mama, let me in.” He knows, he knows.

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Group Leader 1: This kind of behavior has been stud- ied a lot. That behavior has been identified in every mammal on the planet. When there has been a separation, you see the exact same thing. I am imagining that, it can kind of feel aggravating at times, but it is also important to see that it’s normal.

Jerri: Oh yeah, as much as it aggravates me when he runs up to me, my back is killing me and he goes, “Hold me,” there is nothing I like better than when he runs up to me and hugs me and kisses me and holds me and I don’t want to let go.

Group Leader 1: Right. He just wants to be near you… .

Later, Jerri reflected on her conflict over wanting Brian to be more autonomous and for her to have more emotional “space,” yet at the same time fearing separation from him, the loss of his love, and her own abandonment.

Jerri [discussion turned to anticipation of Brian’s visits with his father]: I am so jealous. I want him to be all mine. I don’t like to have to share him. I had him by myself this whole while, so I don’t want to share him with anybody. I  don’t want to know that he could love somebody else more than he loves me. … Man, they grow up so fast. You want them to be able to do their own little thing, but once they do it, it sucks. The older they get, the less they act like they need you to be there.

Later in this session, Jerri reflected further:

Jerri: Most of my [anxiety] comes on when I feel that threat that he is going to be taken away from me or he is going to love someone more than me. I guess my mother did this to me, she was the same way. If we ever acted like we had more fun at my father’s, she would be like, “You had more fun with him than you did with me.”

Group Leader 1: You put your finger on the idea that … you feel anxious about being separated. It is important to look at where that leaves him. He gets a little confused. Keep in mind, when you are in that situation, “Is he feeling like he needs to soothe me or am I  being the ‘bigger, stronger, wiser, and kind’ person?” [a phrase used in the intervention to refer to the authoritative role]

Jerri: I think it is good for your children to feel like they help you as much as you help them. I  think it is good for him to feel needed. Even though I hate when I feel that way, it only takes a second of his wonderful personality to make me better

… as soon as I  notice that he notices that I  feel that way and he is like, “Give me a hug, let’s lay down mama,” I  automatically perk up and smile and everything is okay. He doesn’t realize that I am dying inside.

In this passage, we see tendencies toward role- reversal, indicating Jerri’s strong, unmet needs for her own nurture, a characteristic commonly asso- ciated with disorganized attachment and child mal- treatment. Jerri’s primary treatment goal was to become more empathic in recognizing and respond- ing to Brian’s need for proximity to and comfort from her and, in the process, to maintain a nurturing and authoritative parental role. At the same time, she had to learn to cope with her own anxiety about his normally developing autonomy and separateness from her. The intervention thus focused on chal- lenges she faced in responding to “both sides” of the attachment- exploration circle.

Several sessions later, during her third and final tape review, Jerri reflected on how her discomfort at Brian’s expressions of attachment typically evoked a circular set of responses, wherein she became irri- tated and withdrew, which elicited stronger attach- ment behavior and frustration for him. This sort of interchange typically involved hostility and coercion.

Jerri: He does that. He knows right when I am at the boiling point, I am just right there, don’t mess with me, then he is like, he likes to go a couple feet over the edge there.

Group Leader 1: What might that be about? Jerri: Testing. Group Leader 1: What might a child be needing when

you are almost going to boil over? Jerri: I think he is just, because when I am to the point

where I  have just had enough, I  am distant…  . Sometimes when you are distant, a lot of children experience this, it doesn’t, sometimes doesn’t mat- ter good or bad, they want attention.

By conceptualizing Jerri’s struggles with her son in terms of an integrated circle of expression of explora- tion and attachment needs, Jerri was able to reframe Brian’s neediness for her, and she was able to respond empathically to his need. This facilitated her growing capacity to reflect on and cope with her own anxi- eties about separation and abandonment, and her occupation of the authoritative parental role. She very obviously and deliberately began to change her behavior toward Brian to be more nurturing when

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she perceived him to be anxious and needing her, and more supportive when she perceived him to need autonomy.

At the post- test assessments, approximately six months after the pre- test, Jerri and Brian were rated with secure attachment, and Jerri’s Insightfulness Assessment revealed a Positively Insightful rating, which corresponds to secure attachment. Anecdotal follow- up with them in subsequent years has shown that they continue to do well, and Jerri consistently regards the Circle of Security intervention as having provided a positive turning point in her relationship with her son.

Research Challenges Still Lying Ahead

Growth in the field of attachment research has given rise to many new questions about its appli- cability across many dimensions of the human experience (see Main, 1999b, for a discussion of research challenges). A sampling of these issues is presented here.

Cultural Variation

Several cross- cultural studies have shown that attachment is a universal human phenomenon (van IJzendoorn & Sagi- Schwartz, 2008) but that frequencies within attachment patterns appear to vary with culture. Larger numbers of people have been identified, for example, as insecure- ambivalent in Mediterranean countries com- pared to U.S.  and northern European samples. The extent to which attachment patterns are shaped by culture, and the mechanisms through which this occurs, are not yet well understood.

Instinctive Inheritance and the Brain

Attachment theory locates attachment behavior among other instinctive behaviors, whose func- tions ultimately promote species survival. It is still unclear how other instinct- based behavioral systems such as, for example, social dominance hierarchies and mating behavior, may interact and influence or be influenced by the attach- ment behavioral system. Much more study is needed of the brain functions responsible for these behaviors.

Measurement

The best- known systems for measuring attach- ment quality are the categorical systems derived from Strange Situation classifications (secure, insecure- avoidant, insecure- ambivalent, insecure- disorganized). Other approaches to the measure- ment of attachment quality have used dimensional systems, placing variations on a continuum or continua of dimensions of central characteristics, such as security versus insecurity. It is not yet known what the “best” way for conceptualizing differences in attachment quality will prove to be.

Research Applications to Social Work Practice

The needs for new knowledge concerning appli- cations of attachment theory to social work practice are too numerous to include here, spanning virtually every practice area. Little is yet known, for example, about how children who have been exposed to extreme adversity in their caregiving environments form healthy attachments later in childhood, so- called sec- ond attachments, as in the case of placement in foster homes. Other important practice areas in need of more research include: assessments with children, especially adapting representa- tional measures to clinical settings; adult inter- viewing, using the insights of research with the AAI on the significance of discourse qualities to attachment organization; and education for parents and foster parents, applying our devel- opmental, knowledge about the significance of attachment to development to problems in par- enting. Opportunities abound for social work researchers interested in furthering these and other fields of inquiry.

Attachment scholarship, beginning with Bowlby nearly 60  years ago, has profoundly changed our understanding of the human needs for care and protection in close relation- ships. Although the field of social work has been relatively late in understanding and inte- grating this new knowledge, we are now being transformed by it, in many different areas of practice. This is a very promising devel- opment:  The quality of social work services, especially for children and families, depends on our mastery of the most current scientific

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knowledge of human behavior, among which attachment theory must be regarded as a foundational pillar.

Note

1. Significant portions of this chapter appeared in Page, T. & Norwood, R. (2007). Attachment the- ory and the social work curriculum. Advances in Social Work, 8(1), 30– 48.

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Chaos Theory and Social Work Treatment

Sandra Loucks Campbell

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Chaos Theory

A theory emerging from modern mathematics, chaos theory posits that system disorganization is ever- present and that we are in a chaotic social reality from which we can emerge as creative new entities.

Who could argue that chaos exists in our new world? Nowhere is this as true as in the settings where social workers find themselves. Multilayered practice contexts are chaotic, and when the levels of complex- ity increase, the pressure is also increased on workers who are already grappling with increasing numbers of people needing help, new management models, and declining government dollars. In this world, the old ways of working in traditional hierarchies are not working, and social and health service networks are reaching the breaking point. Social workers are finding it increasingly difficult to cope with the new demands and heavier workload imposed by these advancements. The people served by social workers suffer as a result.

Despite our search for order and control in all facets of our lives, unpredictability remains (Tarnas, 1991). And it is out of that unpredictability that chaos theory, sometimes called “complexity theory,” has emerged. As a species, we both create and exist in a state of disequilibrium and unpredictability— chaos. The theory of chaos presents an interesting contradiction, not only to our human tendency to seek control, but also to the work of Isaac Newton (1729) and of Max Weber (1947). This relatively new theory suggests a novel lens for social workers as they work with individuals, families, groups, organizations, and communities— a challenge to social workers. In this chapter, I will describe chaos theory and its origins, and present ideas for the applications it evokes for social workers in the 21st century.

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Background of Chaos Theory

Chaos theory developed in an era ripe for change and new ideas. It was time for move- ment away from the absolutes of the industrial and modern age.

In 1687, Isaac Newton developed and described the Laws of Thermodynamics in his Principia Mathematica, a publication acclaimed by scientists for generations. In this impor- tant touchstone for the science of the natural world, Newton postulated that energy is neither created nor destroyed, and that disorder does not decrease. In other words, he believed that entropy, a measure of the disorganization in a system, was ever- increasing in the natural world (Barber, 2001). His assertion that disorder could be predicted to be ever- present and on the rise served to impose order on the natural world. The world could be seen as predictable.

We might claim similarity between this Newtonian thinking and the work of Max Weber, wherein the latter described bureauc- racy as an “organization of offices” (1947, p.  331) hierarchically developed by the assign- ment of precise roles and sanctions. During the Industrial Age, from circa 1830 to 1970, the metaphor of the machine dominated. Humans understood a whole by learning about its parts and sought order through enhanced knowl- edge of a hierarchy of parts or functions, and we accepted that, over time, most matter moves toward deterioration. Both the laws of the nat- ural world (Newton, 1729; Kuhn, 1962) and the principles of Weber’s bureaucracy in 1947 define and value similar principles:  determinism, sta- bility, orderliness, uniformity, and equilibrium (Prigogine & Stengers, 1984).

But that predictable world has changed. Taken together, the computer age, financial cri- ses and cutbacks, organizational restructuring, and the ongoing quest for information propel all of us, with astonishing speed, into a new social reality (Greenwood & Lachman, 1996; Peters, 1987). As we move away from the certainty of modernity, chaos theorists present an alternate view, an idea that might be called a contradic- tion of Newton’s work. Chaos theory suggests we take a further look at our quest for the pre- cision, balance, and control, lauded in Newton’s natural world and in the organizational world

of Weber. A new metaphor might be useful for social workers during such immense change.

Developers

Chaos theory, primarily a theory of physics and mathematics, originated with Prigogine and Stengers (1984) and was augmented by Mandelbrot (1983) and Lorenz (1963). This rel- atively new theory hypothesizes that creative new entities emerge from chaos (Gleick, 1987; Prigogine & Stengers, 1984). Chaos makes space for complex systems, allowing for the simulta- neous existence of order and disorder, complex- ity and simplicity, and other dualities. Theorists describe a flow of energy through a system that is “self- organizing” (Zimmerman, 1996). As its creators describe the theory’s essential prem- ise, that creativity emerges from chaos, they also point to the initial development of chaos itself. Readers are asked to consider an evolving, erratic, and incredibly complex situation. Far from the homeostasis and balance suggested by traditional systems theory, a vibrant tension exists— at the margin of chaos. It is at the mar- gins, at this point of division, of “bifurcation,” that chaos is set into full motion and creativity surfaces— a new entity emerges. Out of tension comes a new beginning (Gleick, 1987; Prigogine & Stengers, 1984).

Within chaos theory, we have access to two supplementary but fascinating ideas. The first one, the “butterfly effect,” was described by Lorenz (1963) while studying weather patterns. He noticed that even a small change in initial computerized weather conditions could create huge weather changes in his models over time (Gleick, 1987). This challenging idea allows us to pose the question “Can the breeze from the flap of a butterfly’s wing in Brazil cause a tornado in Texas?” (Lorenz, 1972, as cited in Hudson, 2000). He began to discuss this “butterfly effect” as the “sensitive dependence on initial condi- tions” (as quoted in Gleick, 1987, p. 23).

The second supplementary concept, also closely related to chaos theory, was developed and given shape by Mandelbrot (1983)— the “fractal.” Mandelbrot’s contribution, demon- strated in his famous Mandelbrot Set, gives a pictorial representation of an interesting phe- nomenon. Here he defined and gave structure

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to the fractal. This complex, irregular, and almost mathematical form, said to “give form to chaos,” is similarly variable and random on all scales. Repeating their random forms at macro and micro levels, fractals have been described as “exposing the geometric nature of chaos” (Mandelbrot, 1983). The “butterfly” and the “fractal” will be discussed in relation to social work later in the chapter.

The principles of Weber’s bureaucracy and Newton’s laws of the natural world identify and value similar principles noted earlier, including stability, uniformity, predictability, and bal- ance (Kuhn, 1962; Prigogine & Stengers, 1984; Weber, 1947). The chaotic system’s basic ele- ments, as defined by its creators (nonlinearity, numerous parts with no causal relationship, a network of feedback loops, unpredictability, a flow of energy toward self- organization, an openness of the system to the environment), offer us a new vision of reality (Gleick, 1987; Prigogine & Stengers, 1984).

Why Pair Chaos Theory with Social Work?

Certainly, in the scientific world of Newton, the concepts of chaos theory hold fast. This think- ing may lead to a more complete understand- ing of science, itself an open system embedded in society, with feedback loops of learning and expanding knowledge. In his classic book The Structure of Scientific Revolutions, Thomas Kuhn posited that “anomalous experiences … by evoking crisis, prepare the way for a new the- ory” (Kuhn, 1962, p. 146). But can this theory be applied to social work and the settings in which we work?

Since its conceptual origin in the 1980s, chaos theory has found its way into social work literature and practice. With the potential to provide a new frame for practice, chaos expands our expertise with systems theory and builds on our experience as agents of change (Hudson, 2000; Woehle, 2007). Although some social work authors attempt to integrate mathemat- ical and physical origins of chaos theory with social work, this chapter takes a big- picture view. Here, we apply the overarching ideas and the metaphor of chaos to human systems and social work practice.

Most human beings know intuitively that chaos is a part of being human. When we com- pare our nature and that of human organiza- tions, we can see “the systems through which we administer ourselves, have become estranged from the social relations by which we define ourselves” (Sossin, 1994, p.  367). The seem- ing compatibility between the central tenets of chaos theory and the nature of humans, and the contexts we live in, builds on our understanding of systems theory. Human beings may actually thrive in chaotic situations and settings. In our complex world, fast- paced social changes, dis- order, and nonlinear relationships coexist with our search for control— in street gangs, in large corporations, and in health and social serv- ice organizations. Chaos theory offers help in understanding human relationships and organ- izations, but it also demands that we abandon our obsession with control. Our new ability to see the boundary between the control that exists prior to the “bifurcation” point and the creativity that can be released when we abandon that control offers the key.

Yet, the organizations of today’s social work practice resemble the bureaucracies defined by Weber in 1947. As with the machine metaphor of the industrial age, we try to understand the entirety by understanding component parts. We have sought order and control through a hierarchy of functions or roles, and we have been on the alert for deterioration (Prigogine & Stengers, 1984). Ever- watchful internal and external agents assess for risk, ready to move to control when disorder erupts.

Like the impact of a butterfly wing, a small change will lead to creativity only as we accept and learn to live with chaos. In the 20th century, we built myriad mechanisms of control into our interpersonal relationships, in our organi- zations and in our research methodologies. In families, we seek to ensure a family structure that is healthy, not dysfunctional (as defined by the perhaps white, professional social worker). We structure groups according to our own edu- cated stance, built through our enmeshment in the Western educational and professional sys- tems of which we are a part. In organizations, we present the idea that the goals of strategic five- year plans are attainable, even in a chaotic world. We bureaucratize our health and social

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services in an attempt, as predicted by Weber, to ensure control at each and every level. We might ask whether these strategies actually reach the intended goals. This machine- like control described and applied from Newton’s time to today might be questioned. Chaos the- ory presents an interesting counter- thesis to our previously held views about gaining control in chaotic families, in interpersonal relationships, and through our bureaucratization of social and health services.

As we practice social work in this new cen- tury, technological advances, rapid and intensi- fied change, and globalization have catapulted the natural world, its people, and its human organizations into a new reality. Here, cutbacks, restructuring, the ongoing quest for informa- tion occurring at breakneck speed, and the ever- occurring crises and change have become the norm (Greenwood & Lachman, 1996; Peters, 1987).

Against this backdrop of change, chaos theo- ry’s fundamental premise that creative new enti- ties or ideas arise from chaos (Gleick, 1987) is a direct contradiction of the stability and order held as fundamental conditions essential to the machine metaphor, to Newton’s natural laws, and to the built bureaucracy proposed by Weber. The creators of this new theory have described its non– machine- like elements:  non- linearity, multiple components, a labyrinth of feedback spirals, an energy that organizes itself, and openness to the environment. And, like- wise, social work principles engage and reflect nonlinear thinking, complex systems, commu- nication feedback systems, the environment, human systems, a vision of both sides of an issue, and an openness to change. This theory seems ideally suited to social work.

Authors and Practioners of Chaos Theory

Since the genesis of chaos theory, social work and other authors have analyzed and applied the ideas of chaos in many forums. Some claim that chaos theory validates what social workers have always known intuitively, that “things are not that simple or deterministic” (Bolland & Atherton, 1999, p. 370). Stating that “the human mind is naturally creative,” Lee (2008) argues

for social workers to build an environment that will foster creativity. As an example, he outlined a model (2008) to foster creativity and growth that involved changing perspectives of transi- tion, of developing meaningful goals, of doing something new to see what happens, and of modifying thoughts and actions based on the actual outcome. Bolland and Atherton (1999), in their writing about practice and research, also point to chaos theory as a useful frame of reference for thinking about complexities.

Several social work authors have discussed change in relation to chaos. Some use chaos thinking to frame social work counseling, itself a change process, to build on general systems theory and to present a new perspective on change (Halmi, 2003; Hudson, 2000; Woehle, 2007). Bussolari and Goodell (2009), discuss- ing the applicability of chaos theory to life- transitions counseling, contend that instability and lack of control are normal experiences dur- ing a life transition and argue that incorporat- ing postmodern thought, specifically, teaching clients to construct new stories to fit within a context of growth rather than disorder, would be helpful. Woehle (2007) provided detail about the relationship between change and chaos by comparing four processes of change:  (1)  an entropic/ equilibric process, (2)  a homeostatic/ equilibric process, (3) a complex change process at the edge of chaos, and (4)  a chaotic change process. His findings suggest that chaos the- ory extends entropic and homeostatic processes beyond ecosystems theory while providing a new view of client outcomes. Other authors build on the relationship between change and chaos while applying the theory to social work practice in very specific ways. Halmi, for exam- ple (2003), contends that this new understand- ing of change could lead to the development of specific interventions at the micro- level of prac- tice, noting that brief therapists, for example, hold assumptions and beliefs consistent with ideas basic to chaos theory.

Stevens and Hassett (2007) and Stevens and Cox (2008) discussed the application of chaos theory, sometimes called “complex- ity,” in child- protection practice specifically. Stevens and Cox asserted that current applica- tions of linear thinking and processes, which tend to be static and narrow, may oversimplify

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assessment, hypothesis building, and interven- tion, leaving service providers with a false sense of security about their accuracy. In their study of child welfare, Stevens and Cox suggested that social workers develop assessments that incor- porate a systemic view. This broad view could point to the use of techniques and interventions that would enhance workers’ understanding of complex adaptive systems in child protection, including their own professional involvement in the system, and account for unanticipated events. Stephens and Hassett used chaos theory to frame risk and risk assessment in child wel- fare. They argued that a linear approach of cause and effect can lead to cause- and- blame explana- tions for harm to children (e.g., too few visits by the social worker). They suggest a complexity- based model using a nonlinear spatial analysis approach to focus on processes and interactions of systems at macro- levels rather than on proce- dures and tasks. This model seeks to identify the boundaries of instability in an effort to provide effective interventions.

Other authors have applied chaos theory to group processes. In describing a participatory- action research project, Traver reported that the “act of centralizing empowerment of mul- ticultural groups becomes a process that moves towards complexity” (2005, p.  3) and is best understood through a chaos lens. She used chaos theory to frame the characteristic uncer- tainty in the lives of immigrants and refugees in her meso/ macro- level qualitative study. The concept of bifurcation led Traver to bet- ter understand and explain crisis points in the lives and interaction of researchers with study participants and helped demonstrate complex- ity and uncertainty in the system. “This project, in a state of constant change, seemed to be an embodiment of the participants’ unpredicta- ble lives” (2005, p.  16). In their study of turn- taking in a youth group therapy session, the use of chaos thinking and nonlinear dynamics led Pincus and Guastello (2005) to see strong cor- relations between turn- taking in groups and control, closeness, and conflict in groups. They found the existence of coherent yet complex patterns of interaction, consistent with their other studies and with the fractals of chaos.

Bolland and Atherton (1999) argued the chaos theory framework provides, not only

an alternative to cause- and- effect thinking, but also a basis on which social workers can clarify their understanding of how people are connected with the environment as well as better understand the complexities of clients’ varying perceptions of reality. Ramsay (2003) compared 11 traditional and transformative concepts of social work in an effort to mod- ernize the working definition of “social work ” for the next century. He suggested that use of the idea of equilibrium (balance and sta- bility) to indicate healthy social function- ing should be replaced with the postmodern understanding, based on Prigogine’s discover- ies, that far- from- equilibrium states are ideal for one’s health and well- being as they permit flexibility and adaptation to change in one’s environment.

Brenda Zimmerman (1993) and others applied chaos theory to organizational dynam- ics (Nonaka, 1988; Tetenbaum, 1998). She proposed that the chaos lens enhances under- standing of organizational change in this time of unparalleled societal change and postulated that, although an organization may appear dis- organized, there may be an order, not always visible, beneath the surface (Zimmerman, 1996). She recommended that executive offi- cers view management in an evolving system, or set of systems, not as managing change, but as managing “changeability” (Zimmerman, 1996, p. 16).

Several authors have commented on the limitations of chaos theory as currently applied in social work venues. Hudson (2000) observed that, for the application of the the- ory to social work to move beyond conceptual aspects, additional research and skill devel- opment will be needed. He asserted that the theory does not offer exclusively good news to the field of social work, suggesting that, in accepting the existence of chaotic processes within social systems, the theory makes it dif- ficult to predict therapeutic or other outcomes. However, since chaos theory is helpful in pre- dicting overall trends, processes, and change in a client’s life, it can be used to plan interven- tions. Woehle (2007) also recommended that the field of social work benefit from additional research to understand and apply chaos theory at the levels possible.

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Application Concepts

Chaos theory pushes us as social workers to advance our work in a number of ways. We are challenged to stretch our imagination as we look at the systems we work in, and at the sys- tems in which our clients live. We are drawn to notice flourishing interactions with co- workers and with clients as we work together in thriv- ing networks of communication feedback loops. These somewhat covert challenges to our pro- fession ensure an ongoing emergence of novel social work interventions from this new theory, chaos. However, if we truly engage with chaos, the future outcomes may be unpredictable. In fact, our need to control, even if only to sat- isfy the naysayers, may be our undoing in this venture. If we are truly to accept chaos theory and its basic premise, we will need to resist the temptation to seize control. We may be asked to consider the impact of randomness, the con- sequences of giving up control, and the true meaning of creativity in social work practice. This section of the chapter provides a few basic examples as a starting point for readers who wish to “think chaos” in their practice.

Micro Practice

As we listen to an individual’s story, how do we respond? Do we look at the client’s complex, perhaps chaotic world, through a lens of accep- tance? Do we ask ourselves if this client will find the creativity, the new way of being, that will emerge from the edge of his or her chaotic world? Or are we intent on working with our cli- ents to control chaos and build predictable sys- tems into their world? Rather than imposing the order and calmness that could activate a move toward entropy, we might look for indicators that foreshadow an emerging novel approach in the individual’s life. Can the social worker help the client move toward a new, creative reality?

Consider this example. You meet with a young woman who tells a story of her life bouncing around the country as her parents changed loca- tions through her childhood. She reports attend- ing 12 different schools through her childhood. Now she finds herself unable to settle into a con- sistent life, wandering around from one home to another, from one job to another, and from one

friend to another. She reports that her friends and family suggest she is a failure because she is not building solid roots from which to grow. You might find yourself wishing to assist her in settling into a friendly neighborhood and a solid job so she can find some peace. Yet, as you trace her history with her, listening without imposing your own life goals and priorities, you may dis- cover an excitement in her as she moves from place to place, finding different parts of herself in each location and job. Perhaps you could sup- port her in her movement— perhaps reframing the pattern as a “treasure hunt,” an “adventure.” As she moves and grows, she may find the treas- ure, she may find her future. And her future may emerge from her scattered early years, captur- ing a positive essence from each experience. She may need a worker with a chaos lens, a worker who can see the energy bursting forth, the cre- ative potential, that could emerge from her cha- otic experiences.

Fractals

Social workers often observe and analyze pat- terns in the lives of their clients. Fractals allow us to build our expertise in this kind of analysis. In the previous example, we can see fractals in the foreground of the story, between the lines of the case, the “same degree of irregularity on all scales” (Gleick, 1987, p. 98; Mandelbrot, 1975) in the life of this young woman. Her relationships, homes, schools, and jobs share the same pat- terns, irregular but similarly irregular. Perhaps in the future, these degrees of irregularity will merge into colorful, repeating patterns of rich experience. That experience may give this client exactly what she needs to build a life of creativ- ity and richness.

Butterfly

In the example, we can see the “butterfly ris- ing” as the young woman, emerging from her first meeting with the liberating social worker, feels, perhaps for the first time in many years, accepted and supported in her chaotic life. She begins to wonder if there might be some hope for her to retain the lifestyle she has secretly enjoyed, where she may finally find her trea- sure. The small change, the support of a social

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worker, could lead to a transformational shift in her life.

Meso Practice

During an era of lawsuits and demands for accountability in a world of flourishing tech- nology and burgeoning information, health- care teams are increasingly influenced by the governing policies and standards under which they function. In fact, government and insur- ance regulations, demands for efficiency (Stein, 2001), and concerns about liabilities can easily slip onto center stage, taking the spotlight off quality care.

The chaotic environment of a layered bure- aucracy is complicated further by its interdis- ciplinary nature and increasing costs. When cuts to available funds lead to lower staff levels, workers are stressed to the limit. Managers seek control through high- level planning, restructur- ing, smaller staff teams, through streamlined meetings and processes, enhanced documenta- tion requirements, and demands for uniformity. Social workers are further stressed as fewer team members do more work to serve more people. Staff shortages can also lead to essential inter- disciplinary team meetings being cancelled or shortened, or conversely, team meetings may be held with some disciplines unable to attend due to their workload. In a setting where teamwork has been determined to be vital to the overall success of an institution, cancelled meetings can pose a problem (Wituk et al., 2002).

Interdisciplinary groups, with members often wearing their discipline on their sleeve, can slide into a situation of restrained conflict, where some members seek control of the agenda, primarily to gain control of their own mandate and workload. When meetings are cut and team members each work in isolation, there can be an atmosphere that encourages individual workers to hunker down, do the work, go home, recover, return to work, and hunker down again … and on it goes. Efforts by managers to impose con- trol may actually backfire. Some might claim this pattern of work leads, not to a controlled environment, but to chaos.

Weber’s bureaucracy and Newton’s linear thinking, along with the temptation to control, are easily spotted in healthcare settings. Here,

uniformity, black- and- white choices, and con- trolled risk are sought; variability, changeabil- ity, creativity, and chaos are to be avoided. In a complex environment where managers find it difficult to impose control, chaos thinkers might question whether the current model is, indeed, the best path to success in interdisci- plinary health care.

Workers comfortable with change who can manage and work through challenges may have skills to work through chaos rather than trying to block it. We might question what would hap- pen if teams worked together— interdisciplinary teams flying in evolving formation through the chaos together (Zimmerman, 1996). A  team member thinking about chaos may propose the enhancement of interdisciplinarity rather than its diminishment. This social worker could won- der whether creative solutions would surface from teams’ meeting more often, not less. Chaos thinking suggests that a novel approach might develop, not in sporadic small- team meetings, but rather from meeting together more often, sometimes spontaneously, brainstorming new solutions and enhancing team support of each other in the work.

Rather than imagining isolated workers hunkering down and doing the work, consider the image of workers spending time together, providing mutual support, helping each other, having breakfast together, and watching the edge of chaos. This unified team, riding the wave and welcoming change, using trial- and- error strategies, brainstorming for new creative ideas, might learn to manage and work through ongoing “changeability” (Zimmerman, 1996, p.  16). Teams might move from cutting meet- ing times and numbers of staff to natural and unstructured, but joint, decision- making about programs, client needs, staffing, and bud- gets. Instead of isolating themselves from each other, team members will come closer together. Members of cohesive teams in an organiza- tion with open budget documents may offer, for example, to take a week off without pay so someone else can earn more. True team members could build solid cross- disciplinary relationships, having each other’s back, like a family pulls together when faced with adversity. Managers need only to trust the creativity and competence of the team.

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Fractals

Social workers often identify and use parallel processes in their work with clients where their therapeutic relationship with a client has quali- ties similar to those of the client’s relationships with others in his or her life, or when the social worker’s relationship with the client bears simi- larities to the social worker’s relationship with his or her own supervisor. In clinical practice, I have observed similarities, and perhaps parallel pro- cesses, arising at different levels between client and worker, client and family, and worker and environment. One day, working in a long- term care healthcare setting, while listening to nurses talking about their bosses, I  was surprised to hear the nurses using the same words about their bosses as I  had heard their patients use about their nurses. This observation led, finally, to the development of a research project using the frac- tals of chaos as a base metaphor of analysis of lay- ers of parallel levels of decision- making power in a long- term care facility (Campbell, 2003).

Butterfly

Perhaps one unit’s small interdisciplinary team can develop competencies riding the crest of change while keeping the rigidities of the larger bureaucratic system at bay. The principle of the butterfly effect would suggest that this small area of competency could grow and develop to surprising levels. Perhaps individual workers or teams could build transforming change in a sec- ond team, rotating through the facility, spread- ing and teaching a new, chaotic way to think about the work.

Macro Practice

Consider the implications of replacing the firm bounds of a traditional organization with the more flexible boundaries suggested by chaos. In such a system, managers would need to trust that a more open process would unfold to produce something better, through employee creativity. Such an evolution would be main- tained by manager and worker commitment rather than by the power of those in charge (Helgesen, 1990). Supervisors would encourage staff to take responsibility for the organization’s

credibility. Traditional management methods (re- engineering, quality control, strategic planning, and others) impose control and view equilibrium and stability as signs of success (Zimmerman, 1996). Chaotic management strategies make trust, not control, the essential element.

In traditional organizations, management has sought order from the top down. Management by objectives, strategic planning, and hierarchi- cal flowcharts have often been the result in these ordered and machine- like, non- chaotic systems. But they may quash creative potential along the way. Chaos theory, on the other hand, fits with and explains some of the uncertainty and ran- domness of organizations (Zimmerman, 1996). In “chaotic” organizations, the valued worker learns quickly and is comfortable with ambigu- ity and chaos (Tetenbaum, 1998). Work becomes de- bureaucratized (Peters, 1987). Though the system with fewer barriers of control is much less predictable, many more options become possible (Peters, 1987; Zimmerman, 1994). As we begin to see the connecting relationships and the sup- pressed energy, we will be free to let go of control and release creativity. Like fractals, the assets of the organization (employee creativity, adapt- ability, and novel ideas) will exist at all levels (Zimmerman, 1996).

If the true state of our natural and human world does allow for coexistence of order and disorder, irregularity and stability, simplicity and complexity, closed systems and open sys- tems, perhaps organizations can accommodate a similar duality. During crises, when decisions to downsize and make rapid change are ques- tioned, bureaucratic managers often try to regain control through rational processes and plan- ning. Managers who follow chaos principles, on the other hand, would manage through the cri- sis, giving staff the autonomy, freedom, and the power to develop their potential (Prigogine & Stengers, 1984; Tetenbaum, 1998; Zimmerman, 1996). While organizational boundaries may appear rigid and closed, there are few truly closed systems, even in the scientific world. Most orga- nizations are, underneath all the mechanisms of control, open and creative. They exchange energy with the environment— compatible with the sys- tems described by chaos theorists. The chaotic terms “edge of chaos,” “far from equilibrium,” and its point of dynamic tension could well apply

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to a social or health system undergoing change (Prigogine & Stengers, 1984, pp. 178, 231).

Fractals

While working in long- term healthcare settings in Canada, I began to wonder about power, par- ticularly about the flow of power through the organization. Here we have some of the most powerful people, titled scientists and top- level bureaucrats, working in one of the largest organ- izations in the Canadian government. These powerful people provide service to some of the most powerless service recipients— frail elders living with cognitive impairment. I  wondered whether the power I could see was held at the top, or whether the power at the top actually ema- nated from the powerlessness at the bottom. In a related study, I  used chaos theory and fractals to define a research question about parallel pro- cesses of decision- making power in long- term- care organizations. I  found that similar levels of perceived decision- making power, or lack of decision- making power, existed at all organiza- tional levels:  care recipients, frontline workers, middle managers, senior managers, and the chief executive officer. None of these groups or indi- viduals believed they had any decision- making power. I began to see that, like fractals, the power in human relationships and organizations at one level might be parallel to the processes and rela- tionships at other levels (Campbell, 2003).

Butterfly

You can see the “butterfly” emerge in organiza- tions with “the impact of a simple memo as it flows through an organization, demonstrating Lorenz’s butterfly effect” (Campbell, 2003, p. 53) as the note moves from desk to desk with esca- lating impact. A  carefully worded memo can sometimes create the transformational shift of the metaphorical butterfly.

Social Work Research

Our compliance with deterministic thinking in our work can be seen in vestiges of Weber’s bureaucracy, in our use of the medical model, and in our preference for pure scientific quantitative research methods while excluding qualitative

methods. Yet social workers have always worked at the edge of systems— where clients meet con- texts. We work with life’s complexity at indi- vidual, family, small group, organization, and community levels. Although complying with the dominant linearity in some ways, social work- ers can also be found encouraging flexibility and openness in spite of our maintenance of the sta- tus quo thinking of the day. We call ourselves agents of change. But can “traditional positivist methodology” truly reflect social work realities accurately (Halmi, 1999, 243)?

Perhaps we need to consider a more fun- damental change, such as that emerging from the “disciplines of nonlinear dynamics— chaos and complexity” (Warren et al., 1998, p. 357). The creative thought of chaos theory could not only deepen our understanding of family or system complexity, but also give comfort with the uncertainty we face (Bolland & Altherton, 1999). Although the word “chaos” can be fright- ening, this way of thinking may accurately reflect the deeply embedded complexity in human dynamics we have struggled to under- stand over the years. Bolland and Altherton state that social workers “have intuitively know(n) all along— things are not that simple or determin- istic.” (1999, p. 370) The creative response sug- gested by chaos theory may also be exactly what is needed as researchers attempt to shed light on an increasingly complex world at the intersec- tion of client and context and at the intersection of the scientific model and qualitative methods.

Fractals

As we consider the levels of social work practice identified— micro, meso, macro, and research, we have a more complete picture of the fractal. At each level of practice, we can describe the connection and the parallels between levels. We can see patterns of irregularity recurring, but like the fractal, the patterns may not be imme- diately obvious.

Butterfly

The butterfly might be seen in qualitative prac- tice as researchers doggedly repeat data col- lection and analysis processes until they reach “theoretical saturation” when new findings no

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longer emerge (Punch, 1998, Fig. 7.1). Here, the researcher moves forward to the next step hav- ing exhausted the study’s capacity to find new data. Like the breeze from the wing of the butter- fly, the next step may hold the transformational shift in findings essential in our complex social reality.

Future Possibilities

The opportunities for social workers to develop our profession from a base of chaos are virtu- ally limitless. Social work authors have applied this theory to change. Social workers are change agents. It is here, where client meets context and where change happens, that social workers do their best work. When we consider our profes- sional goals, to intervene and advocate for cli- ents in an atmosphere of respect, chaos theory can play a central role. To maximize the possi- bilities for our profession, we will need to engage in further research; develop chaos- based inter- ventions at the micro, meso, macro, and research levels; and find ways to prove their worth, despite the unpredictability essential to chaos.

Conclusion

Chaos theory provides space for an open, inter- related world where randomness happens, where disorder and order coexist, and where, in the midst of disorder, we can find creative new entities. The pressure defined at the borders of disorder or chaos, the creativity that is thought to follow that pressure, and the subsequent set- tling back into equilibrium all can be related to human beings and their relationships. As a fluttering memo creates hushed conversation at water coolers, and as stressed, overworked workers try to help their clients, chaos is every- where. Social workers work for change in and with systems, where the individual meets the context (Gray & Webb, 2009). Chaos theory, a theory based in concepts of change, is ideally suited for our profession.

Social work has long been thought to be part science and part art (Martinez- Brawley & Zorita, 1998). Chaos theory, with its emphasis on non- linearity, creativity, and unrestrained human capacity, takes us, with renewed energy, to the “art” of social work. Here, we can find

our way back to fundamental social work prin- ciples and processes. We can revisit the relation- ship between multiple parts of a system in an open environment. We can call for “feedback loops” of communication in our work. And we can look beyond modernity and postulate new ideas about parallel processes metaphori- cally pictured in the fractals of Mandelbrot. The unbridled energy in the client system and the possibility of working simultaneously with dualities at all levels of practice opens the doors of social workers who want to develop the “art” of social work.

Here we can question whether the idea of an “edge of chaos” (Gleick, 1987; Prigogine & Stengers, 1984)  may be a useful way to chal- lenge conventional views of individuals, fami- lies, groups, and organizations. We can consider whether the “butterfly effect” might help the social worker leap from his or her traditional social work role in an ineffective system to a changed role working to create the broad impact, the transformation, imagined by Lorenz (1963). We can visualize new connections in the social work milieu of overlapping relation- ships, perhaps parallels or “fractals,” for use in this world of contradiction and complexity— the 21st century.

Chaos thinking will help us understand and adapt as we take a broad view of multiple inter- section points between person and context. It calls us to expand our already well- developed understanding of layers of contextual reality exponentially and invites us to consider that all doors are open. In a profession that prides itself on being contextually competent, chaos theory may call our bluff.

References

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Bussolari, C. J., & Goodell, J. A. (2009). Chaos theory as a model for life transitions counseling: Nonlinear dynamics and life’s changes. Journal of Counseling and Development, 87(Winter), 98– 107.

Campbell, S. L. (2003). Chaotic patterns of restrain- ing power:  The dynamics of personal decision

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making in a long- term care facility. Dissertation Abstracts International, A:  The Humanities and Social Sciences, 64(1), 286– A.

Gleick, J.  (1987). Chaos:  Making a new science. Middlesex, UK: Penguin Books.

Gray, M., & Webb, S. (2009). The return of the politi- cal in social work. International Journal of Social Welfare, 18(1), 111– 115.

Greenwood, R., & Lachman, R. (1996). Change as an underlying theme in professional service organi- zations: An introduction. Organizational Studies, 17(4), 563– 572.

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Helgesen, S.  (1990). Female advantage. New  York: Doubleday.

Hudson, C.  G. (2000). At the edge of chaos:  A  new paradigm for social work. Journal of Social Work Education, 36(2), 215– 230.

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Client- Centered

Built on the work of Carl Rogers (and now called “person- centered”), “client- centered” theory emphasizes and builds on a person’s self- actualizing techniques to achieve individual or collective life goals

I had ventured in the fifth edition of Social Work Treatment that client- centered theory and the person- centered approach might better be described at this point as “values- based, evidence- supported” prac- tice. It is becoming increasingly clear that many of the principles underlying Carl Rogers’s client- centered theory and person- centered approach are essential elements in delivering effective evidence- based inter- ventions that have become standards of practice in a variety of service arenas. Silberschatz and George (2007) noted that many of the ideas are pertinent to current intensely debated issues such as the role of techniques in therapy, therapeutic relationships, therapeutic alliances, and empirical research in psy- chotherapy. LaCombe (2008) cited a 2006 survey asking counselors, “Over the last 25  years which fig- ures have most influenced your practice?” Of the 2,598 who responded, they overwhelmingly said “Carl Rogers.”

Rogers passed away in 1987 after a rich and varied life that saw the development, expansion, and globalization of his theories. Prior to his death, he had continued to test and develop his theories by applying them to some of the more complex social dilemmas and exploring areas of convergence with other significant thinkers in psychology and human behavior (Rogers, 1986). Even though the paral- lels with social work thinking and social work activity remain constant, the vast majority of literature in person- centered theory and practice is now developed and expanded outside of social work and, indeed, for the most part, outside of the United States. Some examples include new applications in pas- toral care (Snodgrass, 2007)  and nursing (Green, 2006)  and expansions in Brazil (da Silva, 2005)  and

Client- Centered Theory and the Person- Centered Approach: Values- Based, Evidence- Supported

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Historical Origins

Client- centered theory and Carl Rogers have been all but synonymous for over four decades. When an individual is so central to a thought system, biographical data tend to illuminate the theory as well as the per- son (Seeman, 1990). What is unique about Rogers’s influence on client- centered theory is that, even though he was its parent and chief proponent, his force was derived more from the integration and organization of existing concepts than from the generation of new ideas. This may account for the lack of author- itative rigidity and dogma that is characteris- tic of client- centered theory.

Therefore, the persons and ideas that shaped Rogers’s early development also influenced the formulation of client- centered theory. Rogers’s ideas were both an expression of and a reaction to the suburban, upper- middle- class Protestant family he was born to in 1902. His experience on the family farm, which they moved to when he was 14, led to an interest in agriculture and to scientific methodology and empiricism, which later became an important feature of client- centered theory (Rogers, 1961b). However, after studying agriculture at the University of Wisconsin, Rogers decided to pursue a career in the ministry and attended the Union Theological Seminary (UTS) in New York City.

Rogers later applied the liberal religious outlook that he found at UTS to client- centered theory by stressing the importance of

individuality, trust in feeling and intuition, and non- authoritarian relationships (Sollod, 1978). Even though Rogers was at UTS for a short time, he helped organize a study group that was reminiscent of later “encounter groups.”

After deciding that the ministry was too constrictive for his own professional growth and development, Rogers elected to pursue an M.A.  in education and psychology at Columbia University. It was here that Rogers was signifi- cantly influenced by the pragmatic philosophy of John Dewey and the educational wisdom of William Kilpatrick. Kilpatrick, as a leader of the progressive education movement, stressed learner- focused education and redefined educa- tion as a process of continuous growth (Kilpatrick, 1937). The connection between Kilpatrick’s ideas and what was later articulated as client- centered theory is by no means coincidental.

Rogers began his professional career as a psychologist at the Rochester Child Guidance Clinic while continuing to work on his doctor- ate at Columbia. The academic and professional isolation he experienced in Rochester allowed him to develop his approach to working with clients in a relatively unencumbered manner. In this pragmatic creative environment, Rogers first became interested in effective therapeutic methods as opposed to psychological ideolo- gies. After attending a two- day seminar led by Otto Rank, he found that his practice was sim- ilar to that of the Rankians. Rogers learned even more about Rank’s theories from a social worker at the Rochester Clinic who had been

Japan (Shimizu, 2010) Others have incorporated person- centered principles into evidence- based prac- tices such as solution- focused brief therapy (Cepeda & Davenport, 2006) and motivational interviewing (Miller & Rollnick, 2014).

Many of the tenets of client- centered theory have been hallmarks of the social work profession since its beginnings. The term “client” as opposed to “patient” was in popular use by social workers long before the field of psychology embraced client- centered theories. In addition, the values espoused by client- centered theorists were established and accepted by the earliest of social workers, including Octavia Hill and Mary Richmond (1917). Today, the principles of client- centered theory can be seen in patient- centered medical practice, student- centered learning, and even customer- centered business practices.

The fact that most of the theory and research in the client- centered approach has developed outside of the social work profession is somewhat of a historical anomaly. Carl Rogers developed many of the original principles of client- centered theory via the influence and observation of social work practitioners (Rogers, 1980). The following pages present the historical origins and basic principles of client- centered theory, explore its confluence with and divergence from social work practice, and reflect on new developments in and uses for person- centered theory.

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trained at the Philadelphia School of Social Work (Rogers, 1980).

In 1939, Rogers published The Clinical Treatment of the Problem Child, a book that drew heavily on the work of Jessie Taft and relationship therapy. Many aspects of Rankian- based relationship therapy, as expressed in this book, show up later as tenets of client- centered theory. Among these are an emphasis on pre- sent experiences and circumstances, a positive valuation of the expression of feelings, a focus on individual growth and will, and a devalu- ation of the authority relationship in therapy. Relationship therapy continued to be developed in psychology by Rank, Taft, and Patterson, and in social work by the “functional school” led by Taft, Virginia Robinson, and Ruth Smalley (1967). In “relationship therapy,” Rogers found the practical affirmation of the progressive educational concepts that he had embraced earlier. There can be no mistaking the similar- ity between client- centered theory and the fol- lowing description of the therapist attitude by Taft (1951):

It is not so easy as it sounds to learn to ignore con- tent and to go through it to the fundamental attitude and emotions behind it, but it is possible, if one has no need for the patient to be or feel one thing rather than another and then is free to perceive and accept what is happening even if it means rejection of the therapeutic goal. The analyst in this view has no goal, has no right to one. He is passive in the sense that he tries to keep his own ends out of the situation to the extent of being willing to leave even the “cure” so- called, to the will of the patient.

Rogers’s definition and articulation of the essential elements of the counseling and psychotherapy he had practiced for a dec- ade began at Ohio State University, where he received an appointment in 1940. In the same year, he attended a symposium at Teachers College at Columbia that was presided over by Goodwin Watson, who at the time was attempting to discover the essential elements of effective therapy. The model of therapy articulated by Watson at this time was simi- lar to the non- directive model that was to be the basis for Rogers’s ideas in Counseling and Psychotherapy. Rogers identified this as an emerging viewpoint for which there was a “siz- able core of agreement” (1942).

During his tenure at Ohio State University, Rogers reaffirmed his earlier commitment to empiricism. In his own work and the work he did with his graduate students, he attempted to operationalize and study the process of psychotherapy. The recording and analysis of interviews and outcome research were signifi- cant innovations for the time. Those activities brought Rogers’s ideas into the mainstream of psychology.

In 1945, Rogers accepted an invitation to head a new counseling center at the University of Chicago. The 12 years he spent there resulted in his wide recognition as a leading therapist, theorist, teacher, and researcher. This period also signaled the shift from the theoretical per- iod described as non- directive to the period described as reflective or client- centered. It was during this period that interest in Rogers’s ideas developed in an ever- widening circle. As Rogers described it later, “To me, as I try to understand the phenomenon, it seems that without know- ing it I  had expressed an idea whose time had come. It is as though a pond had become utterly still so that a pebble dropped into it sent ripples out farther and farther and farther having an influence that could not be understood by look- ing at the pebble” (1980, p.  49). Theoreticians and practitioners from various fields, who grav- itated to the principles that Rogers espoused, advanced client- centered theories in their own disciplines. Rogers’s flexibility and non- authoritarian stance helped characterize him as the benign parent of client- centered theory in a variety of areas to be described later in this chapter.

In 1957, Rogers moved to the University of Wisconsin, where he helped bridge the gap between psychology and psychiatry through the completion of his work on schizophrenics and the loosening of the psychiatric monopoly on the practice of psychotherapy.

In 1964, Rogers moved to California, where he was able to fully develop the work with encounter groups that he had begun in Chicago. In 1968, Rogers and several staff members left to found the Center for Studies of the Person at La Jolla, California. Through the center, Rogers was able to apply the person- centered approach to perplexing problems in Northern Ireland; South Africa; Warsaw, Poland; Venezuela,

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and many other areas. With the publication of Carl Rogers on Personal Power (1977) and A Way of Being (1980), Rogers moved person- centered theory into the realm of politics and philosophy.

Rogers continued to be an extraordinary phi- losopher and scientist up to his death in 1987. He attended the Evolution of Psychotherapy Conference at Phoenix, Arizona, in 1986, where he presented a paper that compared his person- centered theory with the work of Kohut and Erikson (Rogers, 1986). This author was fortunate to take part in some “conversation” and “demonstration” sessions that illustrated Rogers’s personification of the theories he had developed and espoused. In his 80s, Rogers retained the clarity, honesty, personal warmth, and therapeutic effectiveness that had set the standard for an entire field of psychology. Even after Rogers’s passing, person- centered theories continue to be debated and advanced in the literature, in terms of both fundamental the- ory (Moreira, 1993; Purton, 1989)  and practi- cal application (Lambert, 1986; Quinn, 1993; Silberschatz & George, 2007).

Principal Proponents of Client- Centered Theory

Counseling and Clinical Psychology

By far, client- centered theory has had its great- est impact on the field of counseling and clin- ical psychology. From the outset, it was clear that this approach represented a third force in American psychology. Many therapists embraced it as a desirable alternative to ortho- dox analysis or rigid behaviorism. The term “client,” as opposed to “patient” or “subject,” suggested the person’s active, voluntary, and responsible participation.

The process, or “how to,” of psychother- apy was described for the first time, allowing students to study and become proficient in observable counseling skills. A  second attrac- tive feature for counselors was the attention to the expression of positive humanistic values in a pragmatic approach to therapy. Finally, the continuing concern with effectiveness and out- come in the client- centered approach added to the credibility of the worker.

Many of the individuals who were influ- enced by Rogers and client- centered theory developed orientations of their own. Eugene Gendlin (1978) furthered the concept of “focus- ing” as a significant tool for change. Robert Carkhuff (1969), along with Bernard Berenson (Carkhuff & Berenson, 1977)  and C.  B. Truax (Truax & Carkhuff,1967), advanced the client- centered principles in greater depth and with greater precision. Greenberg, Rice, and Elliot (1993) and Rice and Greenberg (1984) also advanced the notion of “process- experiential,” which remains closely aligned with the person- centered approach. Numerous others have incorporated the essential elements of client- centered theory, which is likely to ensure that it will continue to be a major component of the theoretical base of both counseling and clinical psychology.

Psychiatry

Rogers was for some time engaged in a strug- gle to get the field of psychiatry to recognize the value of client- centered theory to psycho- therapy. Psychiatry to that point had retained a virtual stranglehold on the practice of psycho- therapy. It was not until the results of his work with schizophrenics were published that psy- chiatry as a whole began to recognize the value of his approach (Gendlin, 1962; Rogers 1961a). Currently, client- centered theory is an accepted, if not widely practiced, orientation in psychia- try. Even though recent studies have reaffirmed the effectiveness of Rogerian counseling with patients diagnosed as paranoid schizophrenic (Gerwood, 1993), the approach does not appear to have been developed or expanded in psy- chiatry. After Rogers turned his attention to working with “nonpathologica1” clients in untraditional or unstructured settings, psychi- atry as a whole appeared to lose interest in this form of counseling.

Some encounter group principles are still utilized in psychiatric settings in group psy- chotherapy and therapeutic communities. But as psychiatry has increased its concern with the organic etiology of the more severe psycholog- ical impairments, there has been a diminish- ing interest in client- centered theory and much greater emphasis on psychopharmacology.

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Coincidently, a body of literature has sur- faced in family medicine and general practice that is referred to as “patient- centered” (Stewart, Weston, Brown, McWhinney, McWilliam, & Freeman, 1995). The parallels are obvious, and physicians appear to be embracing the concepts as they are increasingly faced with a diverse patient body that is informed, empowered, and demanding a more equal helping relationship.

Administration and Leadership

The whole field of administration and leadership training has been noticeably affected by client- centered theory. Client- centered principles found easy application in conflict resolution, organiza- tional behavior, and employer– employee rela- tions. Many of the practices were utilized and expanded by those involved with the National Training Laboratories in Bethel, Maine, and the numerous Training Groups and sensitivity train- ing sessions that were organized to help groups work more effectively and meaningfully (Lewin, 1951; Maslow, 1971). Helen MacGregor’s “Y theory” and Abraham Maslow’s “Z theory” of management both clearly reflect the applica- tion of client- centered principles to this area (Maslow, 1971).

These ideas have lost some of their allure in today’s highly competitive workplace, which is increasingly less concerned with the person as an entity than with a set of skills that serve the corporate purpose and can be discarded when necessary. As people adapt to the modern work- place, their need for personal fulfillment, inter- relatedness, and community building is likely to be expressed in a different form. Hence, there may be an even greater role for person- centered theory in the workplace of the future.

Social Work

Client- centered theory was highly acceptable to social workers from its inception. This is partly due to the fact that, in its infancy, client- centered theory was more or less a conceptualization of many of the practices of relationship therapy, which was the central force of the functional school of social casework. Many of the values that are expressed in client- centered theory are fundamental to social work practice.

Rogers found himself closely aligned with the social work profession in the early part of his career, and in fact held offices in social work organizations at both the local and national levels while in Rochester, New  York (Rogers, 1961b). In the 1940s, Rogers and client- centered theory became identified with the field of psy- chology. Since social work had become entan- gled in the debate between the diagnostic and functional schools of casework, client- centered theory as a separate entity received less atten- tion. Many of the principles of client- centered theory continued to be applied by social work- ers, but relatively little of this was reported or researched.

In the 1950s and 1960s, the profession turned its attention to the development of a unified theory of social work based on the person– environment continuum. Client- centered theory to this point had appeared too person- centered to be of much use in this effort. Barrett- Lennard’s description of client- centered theory and its usefulness in social work prac- tice theory was the first major reference in social work literature to Rogers’s contribution (Barrett- Lennard, 1979).

In the 1970s, an increased concern with effectiveness and accountability sent theo- rists and investigators in search of methods that could be demonstrated and evaluated. As a result, there was a resurgence of interest in client- centered theory and its utility in social work, since it was one of the few demonstra- bly effective treatment approaches. It was fol- lowed up by investigations into the value of client- centered principles in training social workers (Keefe, 1976; Larsen, 1975; Rowe, 1981; Wallman, 1980). Today, most interpersonal skills training takes place in the undergradu- ate curriculum, and it is increasingly difficult to differentiate client- centered principles from good basic interviewing skills. At this point, practice skills texts utilize client- centered the- ory and practice, but as part of a set of generic or eclectic skills that are framed in a social work context. Recent contributions to the lit- erature by Greene (2008), Shulman (1979), and Brodley (2006) have demonstrated the prac- tical utility and generally positive application of person- centered approaches. Social work educators continue to incorporate some of the

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person- centered ideas related to complex social and political problems into the macro and international spheres of the curriculum.

Theoretical Perspectives and Basic Concepts

Theory Building

As noted earlier, Rogers was more a coordinator than a generator of the principles that are asso- ciated with person- centered theory. Because he essentially followed a deductive reasoning proc- ess in his early investigations, his personality theory emerged ex post facto.

Epistemologically, his work is best described by the term “humanistic phenomenology” (Nye, 1975). Rogers’s “humanism” is related to his belief that humans are essentially growth- oriented, forward- moving, and concerned with fulfilling their basic potentials. He assumes that basic human nature is positive, and that if indi- viduals are not forced into socially constructed molds but are accepted for what they are, they will turn out “good” and live in ways that enhance both themselves and society.

Phenomenology is concerned with the indi- vidual’s perceptions in determining reality. Rogers believes that knowledge of these percep- tions of reality can help explain human behav- ior. Objective reality is less important than our perception of reality, which is the main deter- minant of our behavior. The phenomenologi- cal approach guided Rogers’s approach to both therapy and research as he struggled with the difficulty of perceiving reality through another person’s eyes.

As a scientist, Rogers sees determinism as “the very foundation stone of science” (Rogers, 1969); hence, he is committed to objective study and evolution. He sees this approach as incomplete in fostering an understanding of the “inner human experience” and embraces free- dom as critical to effective personal and inter- personal functioning.

Basic (Key) Concepts

Rogers gave a detailed presentation of his theories of therapy, personality, and inter personal relationships in volume three of Psychology: A

Study of a Science (1959). The following are nine propositions that outline the personality theory underlying this approach:

1. “All individuals exist in a continually chang- ing world of experience of which they are the center.” The “phenomenal field,” as it is some- times called, includes all that the individual experiences. Only the individual can com- pletely and genuinely perceive his experience of the world.

2. “Individuals react to their phenomenal field as they experience and perceive it.” The per- ceptual field is reality for the individual. Individuals will react to reality as they per- ceive it, rather than as it may be perceived by others.

3. “The organism has one basic tendency and striving to actualize, maintain and enhance the experiencing organism.” Rogers suggests that all organic and psychological needs may be described as partial aspects of this one fundamental need.

4. “Behavior is basically the goal- directed attempt of individuals to satisfy their needs as experienced in their phenomenal field as perceived.” Reality for any given individual is that individual’s perception of reality, whether or not it has been confirmed. There is no absolute reality that takes precedence over an individual’s perceptions.

5. “The best vantage point for understanding behavior is from the internal frame of ref- erence of the individual.” This includes the full range of sensations, perceptions, mean- ings, and memories available to the con- scious mind. Accurate empathy is required to achieve this understanding.

6. “Most ways of behaving adopted by the indi- vidual are consistent with the individual’s concept of self.” The concept of self is basic to client- centered theory. Self- concept is an organized internal view consisting of the individual’s perceptions of himself alone, himself in relation to others, and himself in relation to his environment and to the values attached to these perceptions. Self- concept is seen as an ever- evolving entity.

7. “The incongruence that often occurs between an individual’s conscious wishes and his behavior is the result of a split between the

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individual’s self- concept and his experiences.” As the individual gains an awareness of self, he develops a need for positive regard and positive self- regard. When the individual feels loved or not loved by significant others, he develops positive or negative self- regard.

8. “When there is incongruence between the individual’s self- concept and experiences with others, a state of anxiety results.” This anxiety is often the result of the incongruence between the ideal and real self. To lower an individu- al’s anxiety, the self- concept must become more congruent with the individual’s actual experiences.

9. “The fully functioning individual is open to all experiences, exhibiting no defensiveness.” Such a person fully accepts himself and can exhibit unconditional positive regard for others. The self- concept is congruent with the experiences, and the individual is able to assert his basic actualizing tendency.

With regard to motivation, Rogers believed the organism to be an active initiator that exhibits a directional tendency (Rogers, 1977). He agreed with White’s description of motivation as more than simple stasis:  “Even when its primary needs are satisfied and its homeostatic chores are done, an organism is alive, active and up to something” (White, 1959). Rogers affirmed that there is a central source of energy in the organ- ism that is concerned with enhancement as well as maintenance (Rogers, 1977).

The following are some of the most signifi- cant assumptions of Rogers’s personality theory from the perspective of therapy:

We behave in accordance with our perception of reality. In light of this, in order to understand the client’s problem, we must fully understand how she perceives it. We are motivated by an innate primary drive to

self- actualization. The individual will automatically develop her potential under favorable conditions. These conditions can be established in therapy and the stance of the therapist must, as a result, be nondirective.

The individual has a basic need for love and acceptance. This translates into a focus on relation- ship and the communication of empathy, respect, and authenticity by the therapist.

The individual’s self- concept is dependent upon the nature of the acceptance and respect she expe- riences from others. The client’s self- concept can be

changed by her experiencing unconditional positive regard in therapy.

Values

The valuing process has been discussed at some length in client- centered theory. Rogers hypothesized that “there is an organismic com- monality of value directions” and that “these common value directions are of such kinds as to enhance the development of the individual himself or others in his community and to make for the survival and evolution of his spe- cies” (Rogers, 1964). This positive and hopeful view of human beings is by and large acceptable to a profession like social work that is dedicated to the enhancement of social relationships and functioning.

In addition to being concerned with the “organismic valuing process,” client- centered theory professes both general and specific atti- tudinal values. In its early stages, client- centered theory was essentially neutral regarding values. Over the years, it has progressed to the point where person- centered or humanistic values are asserted (Carkhuff & Berenson, 1967). These include the following (Boy & Pine, 1982; Rogers, 1964, 1977):

1. The counselor who intends to be of service to a client must value the client’s integral worth as a person.

2. Responsible action occurs within the con- text of respect for the dignity and worth of others.

3. The counselor who values the client has a fundamental respect for the client’s freedom to know, shape, and determine personal atti- tudes and behavior.

4. The client possesses free will; she can be the determiner of a personal destiny.

5. A  person’s free functioning not only tends toward development of the self, but also includes a responsibility to other persons.

6. The client enhances the self by fulfilling obli- gations to herself and others.

7. The client begins to relate to others with a sense of personal responsibility and ethical behavior.

8. Love and peace are basic strivings and must be advanced during one’s lifetime.

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These values are universally expressed and pro- fessed in social work. A belief in the fundamen- tal dignity and worth of an individual is similar to values 1 and 2. Social work’s commitment to self- determination is captured in 3 and 4.  The importance of social responsibility and reciproc- ity has also become a more broadly accepted value (Compton & Gallaway, 1979; Siporin, 1975)  and is reflected in 5, 6, and 7.  Number 8 (a commitment to the advancement of love and peace) is a value that few social workers would reject, although it is not articulated and asserted by the mainstream in the profession as yet.

The major values of the person- centered approach appear to be closely aligned with those expressed in social work. This is partly because of the similarity of historical roots, but it is also due to the cross- cultural, time- tested effective- ness of these values. In other words, they appear to be functional as well as philosophical.

Sociocultural Sensitivity

Person- centered theory, especially that charac- terized by Rogers’s early work, has come under criticism for placing too much emphasis on indi- vidualism and independence, although depend- ency on family, friends, and authority figures is considered appropriate and necessary in many cultures (Usher, 1989). Rogers recognized the importance of a client’s natural support systems and traditional healing methods in his later writings, and others have managed to find sig- nificant points of convergence in cross- cultural settings (Hayashi et  al., 1992). It is notable that person- centered theory has received more attention and generated more interest in mul- ticultural settings outside of North America in the past decade than in its historical stronghold.

Treatment

The basic goal of client- centered therapy is to release an already existing capacity for self- actualization in a potentially competent individ- ual. The underlying assumptions are as follows:

1. The individual has the capacity to guide, reg- ulate, direct, and control himself, providing certain conditions exist.

2. The individual has the potential to under- stand what is in his life that is related to his distress and anxiety.

3. The individual has the potential to reor- ganize himself in such a way as not only to eliminate his distress and anxiety, but also to experience self- fulfillment and happiness.

In 1957, Rogers postulated the following ele- ments that he believed were necessary and suf- ficient for a positive outcome in therapy:

1. The therapist is genuine and congruent in the relationship.

2. The therapist experiences unconditional pos- itive regard toward the client.

3. The therapist experiences empathic under- standing of the client’s internal frame of reference.

4. The client perceives these conditions at least to a minimal degree.

These “core conditions,” as they came to be known, have been linked with positive outcomes in therapy for a wide variety of clients in various settings (Carkhuff, 1971; Carkhuff & Berenson, 1967; Truax & Mitchell, 1971). Additional dimensions of the therapist, such as concrete- ness, confrontation, self- disclosure, and imme- diacy, have been recognized as important (Carkhuff, 1969). Quinn (1993) has argued for an expansion of the concept of “genuineness” to include a developmental- interactional com- ponent, and Natiello (1987) has suggested that the therapist’s personal power is so crucial that it should be treated as a fourth condition. The process of therapy and counseling in the client- centered approach is basically the following:

1. The therapist and client establish a mutual counseling contract.

2. The therapist presents an attitude in the relationship characterized by the core conditions.

3. The client’s greatest capacity for problem- solving is released because he is free from the anxiety and doubts that were blocking his potential.

It is difficult to make a comprehensive statement about person- centered therapy because, true

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to its basic philosophy, it has been changing, evolving, and actualizing since its inception. Table 3.1, adapted from David Cole (1982) and J.  T. Hart (1970), illustrates some of the major points associated with those changes over the past 40 years.

The person- centered developments referred to in the table are more indicative of Rogers’s orientation since 1970. Some proponents of person- centered theory have continued to develop and refine the microlevel counseling aspects. Carkhuff and his associates have devel- oped specific training programs in which the novice counselor first learns how to discrimi- nate between high- level responses (understand- ing and direction) and low- level responses (little understanding or direction). Second, the stu- dent counselor learns how to communicate high levels of accurate empathy, authenticity, and pos- itive regard. The following dialogue exemplifies this process:

Client: I don’t know if I’m right or wrong feeling the way I do, but I find myself withdrawing from peo- ple. I don’t seem to socialize and play their stupid little games any more.

Counselor’s response (Low level): Friendships like this are precarious at best.

(Medium level): You’re really down because they won’t let you be yourself.

(High level): You feel really bad because you can’t be yourself and you want to be. The first thing you might do is spend a little time exploring who you are without them.

Client: Sometimes I question my adequacy raising three boys, especially the baby. Well, I  call him the baby because he’s the last. I can’t have any more, so I know I kept him a baby longer than the others. He won’t let anyone else do things for him. Only Mommy!

Counselor’s response (Low level): Could you tell me, have you talked with your husband about this?

(Medium level): You feel concern because your son is so demanding.

(High level): You’re disappointed in yourself because you haven’t helped him develop fully and you really

Table 3.1 The Development of Client- Centered Therapy

Therapy Therapist Goals Therapist Roles

Nondirective cognitive orientation (insight) 1940– 1950

1. Create an atmosphere of permission and acceptance

2. Help client clarify thoughts and feelings rather than interpret for him

3. Help client increase knowledge of self

1. Passive, nonjudgmental listening

2. Empathic 3. Nonconfronting 4. Nonsharing of self 5. Feedback objective, rephrasing,

repeating, clarifying

Client- centered or reflective emotional orientation (self- concept) 1950– 1957

1. Develop the conditions necessary and sufficient for constructive personality change

2. Communicate to client: • empathy • unconditional positive regard • genuineness

1. Active listening 2. Accurate, emphatic 3. Nonconfronting 4. Sharing of self 5. Noninterpretive 6. Feedback, subjective indicating

how therapist believes client feels

Experimental existential/ encounter orientation (humanistic) 1957– 1970

1. Establishing therapeutic relationship

2. Reflecting client experiencing 3. Expressing therapist

experiencing 4. Client as a unique individual

and as a group member

1. Active listening 2. Accurate empathy 3. Confronting 4. Sharing an authentic

friendship 5. Interpreting, if appropriate 6. Feedback is subjective prizing,

loving, caring

Person- centered • Community • Institution • Political orientation (militant

humanism) 1970 to present

Humanize and facilitate the actualization of communities, institutions, and political systems

1. Apply effective components of person- centered approach to such organizations

2. Assert humanistic values 3. Quiet revolutionary

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want to. Now a first step might be to design a little program for you and for him (Carkhuff, 1976).

Person- centered theory can no longer be described or evaluated in a singular fashion. So many individuals and groups have embraced the approach that the underlying philosophy and principles are evident even in approaches that are not specifically identified as “client- centered.” For the beginning counselor or therapist, person- centered theory still appears to offer a comprehensive approach. In a refine- ment of this approach, Angelo Boy and Gerald Pine offered the following reasons for utilizing person- centered theory in counseling (Boy & Pine, 1982):

• Possesses a positive philosophy of the person • Articulates propositions regarding human per-

sonality and behavior • Possesses achievable human goals for the client • Possesses a definition of the counselor’s role

within the counseling relationship • Has research evidence supporting its effectiveness • Is comprehensive and can be applied beyond the

one- to- one counseling relationship • Is clear and precise regarding application • Has an expansive intellectual and attitudinal

substance • Focuses on the client as a person rather than on

the client’s problem • Focuses on the attitudes of the counselor rather

than on techniques • Provides the counselor with a systematic response

pattern • Provides flexibility for the counselor to go beyond

reflection of feelings • Can be individualized to the particular needs of

a client • Enables client behavior to change in a natural

sequence of events • Can draw from the process components of other

theories of counseling and human development

Not surprisingly, person- centered theory is most often identified with the “person” end of the person– environment continuum. The con- cept of self is so important to Rogers’s view of personality that it is often referred to as “self- psychology” or “self- theory.”

Rogers viewed human nature as growth- oriented and positive and believed that mal- adaptation is generally more a problem in the environment than in the person. In most cases,

client- centered therapy is predicated on the belief that the client’s innate self- actualizing tendencies will flourish if the conditions are right. This view recognizes the importance of the environment and places the locus of change in that area. Essentially, the environment should be altered or adjusted to suit humans, rather than the reverse.

This view has received limited acceptance in social work. Most social work approaches afford equal importance to both aspects of the person– environment continuum, at least in theory. In practice, a great deal of social work activity is directed toward helping the individual adjust to society. Person- centered theory is at odds with both of these.

Social Work with Individuals

Person- centered theory has found both accep- tance and expression in social work with indi- viduals, or “social casework.” Person- centered theory is most closely aligned with the func- tional approach to social casework, although there are areas of convergence with and diver- gence from the other major approaches. This is understandable given Rogers’s involvement with social work and the functional school in the 1930s.

Psychosocial History. The place of a psychosocial history in casework, firmly established by Mary Richmond (1917), for the most part has been broadly accepted by the profession. Person- centered theory has historically placed little emphasis on this aspect of the helping process. In applying the person- centered approach nar- rowly, workers would concern themselves with history- taking only to the degree the client was willing. A  broader interpretation of person- centered theory would also promote history- taking, since a full appreciation and credible acceptance of the client can be better realized when the worker is cognizant of both the past and the present. History- taking is one of the areas that has become more acceptable to person- centered therapists in its more eclectic form.

Diagnosis. Another area of traditional diver- gence has been the place of diagnosis in casework. Person- centered theory has been

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fundamentally opposed to diagnostic classifi- cation. This theory’s belief in the uniqueness of the person disallows the categorization, classifi- cation, and dehumanized labeling of individu- als. Diagnosis has been and continues to be an important concept in social casework (Hollis, 1972; Turner, 1968, 1974), where it is generally viewed as a dynamic and functional process. Smalley’s approach, in which the worker and client are both fully considered in the diagno- sis, is most reminiscent of the person- centered approach.

Rogers and others have demonstrated that the person- centered approach is effective with a variety of diagnostic categories, including schizophrenics and psychotics (Gerwood, 1993; Rogers, 1980; Rogers et al., 1967). This research, coupled with the person- centered philoso- phy, has established some of the rationale for rejecting the concept of diagnosis. The person- centered approach in social work need not reject this concept wholly, and may indeed discover that person- centered theory applied within the diagnostic framework can increase its effective- ness. This latter approach would undoubtedly be more acceptable to social caseworkers.

The Helping Interview. By far the greatest con- tribution person- centered theory has made to social casework has been the helping interview. Most approaches to social casework recognize the utility of the “core conditions of helping.” These conditions of communicating accurate empathy, authenticity, and positive regard in the helping interview have been demonstrated as effective by Truax, Carkhuff, and Mitchell. In the 1970s, social work educators introduced train- ing in the core conditions to the social work cur- riculum (Fischer, 1978; Hammond et  al., 1978; Wells, 1975). Silberschatz and George (2007) fur- ther suggest that these necessary and sufficient conditions of therapeutic personality change are still pertinent to many of the major techniques commonly used in counseling. Clearly the core conditions appear to be a good base from which to begin skill development in the helping inter- view. In order to be more broadly useful and acceptable to social caseworkers, they need to be expanded and adapted to fit the wide variety of situations and circumstances.

Case Example

Brian is a client who has reportedly suffered from low self- esteem and feelings of anxiety for several years. According to Brian, these issues have intensi- fied recently and he’s not sure why.

Brian: “Today has been an awful day. I have always felt like less of a person compared to everyone else, but recently it seems as though things have gotten worse and I don’t know why.”

Therapist: “I understand that you feel bad. This is a very difficult time for you and I wonder if it feels a little scary to be unsure of what is wrong.”

Brian: “It is scary, because I don’t like to feel as if I’m not in control of myself. Also, sometimes I  feel like there is no one around me who understands how I feel, or they just think my feelings are wrong. I mean my family gets mad that I don’t talk to them enough, but how can I open up to them when they won’t understand me?”

Therapist: “Currently, things seem so overwhelming to you and you feel that you have no one in your personal life who understands what you’re going through, so you can’t see the point of sharing your feelings with them.”

Brian: “Yes, they just don’t get it. Maybe I’m just not worth the trouble of listening to.”

Therapist: “Well, I  believe that you are worth listening to. I am glad to see you when you come for sessions and share your thoughts and feelings. I also believe that you are able to make your own decisions about who you want to speak to and when.”

Brian: “You are confident in my ability to make my own decisions. I am afraid that I will ruin my life, but you aren’t afraid of that for me.”

Therapist: “You are a competent person who is capable of determining the correct choices for your life.”

Brian: “Well, I think if I try to look at my life more pos- itively than negatively I  will be better off. If I  think more positively, then I will start to speak and act in more positive ways, which will lead to a much hap- pier and more positive life. That’s all I want, and now I believe that I actually deserve it and can achieve it.”

Therapist: “I feel so proud of you and the bravery you have shown while in therapy. I am honored to have shared in your personal journey and growth.”

Using a client- centered therapy approach provided the ability for Brian to decide what to talk about and

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when, without direction, judgment, or interpreta- tion by his therapist. The therapist’s unconditional positive regard, empathy, and congruence allowed Brian to feel more comfor table expressing himself without any worries. This gave him the oppor tunity for plenty of self- exploration and personal growth. His therapist’s confidence in him empowered Brian to take back the control in his life that he felt he was losing and to be more open in his personal relationships.

Social Work with Families

Person- centered principles have had a wide impact on the whole area of work with children and families. Rogers (1939), in his doctoral dis- sertation and his first book, focused on therapy with children and found it necessary to include the entire family.

A few years after Rogers published Coun- seling and Psychotherapy (1942), Virginia Axline (1947) presented a work that drew from his nondirective principles and from the rela- tionship therapy orientation of Taft (1951) and Allen (1942). Axline’s approach to nondirec- tive play therapy included the basic principles of acceptance, relationship, freedom of expres- sion, and freedom of behavior. Others, like Clark Moustakas (1953), expanded and devel- oped these principles to help make the person- centered approach a significant force in child therapy.

By the late 1950s, therapists were increas- ingly including parents and family members in the counseling context and applying person- centered principles to work with families. Guerney described a process of filial therapy in which parents were taught person- centered skills so they could deal with their children themselves (Guerney, 1964Guerney, Guerney, & Andronico, 1970). Some explored the devel- opment of self- concept in families (Van der Veen et  al., 1964), while others used person- centered principles in working with couples (Rogers, 1972).

While the person- centered approach to work- ing with families has by and large been found useful and philosophically acceptable by social workers, it has essentially been overshadowed

by concurrent developments in the applica- tion of systems theory to both family work and social work. These two schools of thought appear to be fundamentally divergent in terms of basic assumptions, but some have attempted to establish a dialogue between the two. For example, O’Leary (1989) has written:  “Family members need to be received as subjects while being encouraged to face their reality as part of a system with patterns not entirely in their con- sciousness or control. They need to be acknowl- edged as mysteries as well as confronted with the limits and unacknowledged potential in their interpersonal living.”

Social Work with Groups

Group work in the person- centered tradition has received sporadic acceptance in social work circles. Social work had a rich history in group work long before person- centered principles were applied to this area. The major application of person- centered principles to group work has been in the form of the encounter group or T- group, as developed by Rogers (1970). The encounter group began in the 1940s at the University of Chicago with Rogers, and in Bethel, Maine, with Kurt Lewin. Rogers viewed the intensive group experience as an important vehicle for therapeutic growth and attitudinal change, whereas Lewin focused on the improve- ment of human relations and interpersonal interaction.

Rogers (1970) noted the following as cen- tral to the process of change in intensive group experience:

Climate of safety Expression of immediate feelings and reactions Mutual trust Change in attitudes and behavior Understanding and openness Feedback Innovation, change, and risk Transfer of learning to other situations

Many of the above are seen as essential elements of mutual aid in social group work (Shulman, 1979). Also, the following description of the goals of the therapist leader (Beck, 1974)  are

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not incompatible with the orientation of many social group workers:

1. The facilitation of group members to take responsibility for themselves in whatever way is realistically possible

2. The clarification and solution of prob- lems and conflicts by a process of self- understanding and the development of an empathic understanding of others

3. Recognition of the client as she is and recog- nition of her reality as she sees it

4. Attempts to offer an attitude that is nonjudg- mental in order to facilitate exploratory and self- reflective behavior in the client

5. Recognition of the significance of main- taining as high a degree as possible of clar- ity about the leader’s own views, feelings, and reactions while he is in the therapeutic relationship.

The expression of the core conditions by group leaders has been shown to have a positive impact on increasing client self- exploration (O’Hare, 1979).

Given the therapeutic aim of encounter groups and their focus on the individual in group, they are most readily identified with the remedial model of social group work. However, many of the underlying principles and some of the techniques are more reminiscent of the reciprocal model of social group work. Some aspects, such as adherence to democratic prin- ciples, are aligned with social group work in general. Recently, some researchers have argued that there may be points of compatibility between structuring group process and nondi- rectiveness (Coughlan & McIlduff, 1990). This opens the door for a much wider use of person- centered group work with, for example, low- functioning or involuntary clients (Foreman, 1988; Patterson, 1990).

Social Work with Communities

The more recent developments in person- centered theory have included an interest and involvement in the concept of community. Rogers applied the fundamental principles of person- centered theory to both community concerns and community development.

Much of this was initiated at the Center for Studies of the Person in workshops and learn- ing laboratories. Some concurrent efforts con- tinued at the University of Chicago, where Gendlin and others established a therapeutic community called Changes, which was based on person- centered principles (Rogers, 1980). The experiments in community have included work with a wide variety of neighborhoods, cul- tures, religions, and political situations.

In the tradition of the person- centered orien- tation, writers have first concerned themselves with establishing propositions that describe the basic assumptions concerning communities. Barrett- Lennard (1979) has postulated that “a well functioning community would be an open system in interface with other systems … con- tinually in process … and characterized by an organismic egalitarianism.” William Rogers (1974) suggests that, from the person- centered viewpoint, “individuals seek a community of belonging, understanding and mutual support that will enhance the actualization of life,” and that “persons within a community are poten- tially better able to understand and articulate the identity and hopes of that community than are persons from outside.” William Rogers moves to the next phase by considering the necessary steps in the process of social change. Some of the person- centered principles con- tained in his approach are:

The importance of listening deeply to the needs and concerns of individuals and groups within the constituent communities

The facilitation of community self- perception The recognition and encouragement of indigenous

leadership The facilitation of the communication among diver-

gent groups The identification of community goals

In work with communities, person- centered theory is most clearly aligned with the princi- ples of locality development. The person- cen- tered approach to community development articulated by William Rogers is both astute and pragmatic. As such, it is generally more acceptable to social workers than the more eso- teric, unstructured offerings developed at such places as the Center for Studies of the Person and Changes. Many community workers in

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social work find the community- building tech- niques developed and experimented with in the person- centered approach to be useful in conjunction with their own theories. To this end, the person- centered approach affords an important laboratory for exploring different aspects of community building. Curiously, it is possible that the person- centered approach as it has evolved may be too value- laden and prescriptive for most social work community organizers to embrace.

Social Work Administration

For many years, Rogers viewed the tenets of person- centered theory as applicable to all human interaction. In Carl Rogers on Personal Power (1977), he described how these features have been successfully applied to agencies and organizations. Rogers provided examples of how person- centered approaches resulted in greater productivity, as well as greater career and per- sonal satisfaction. In this approach, leadership is characterized by influence and impact, rather than power and control. The person- centered administrator, where possible, gives autonomy to persons and groups, stimulates independ- ence, facilitates learning, delegates responsi- bility, encourages self- evaluation, and finds rewards in the development and achievements of others (Rogers, 1977).

Person- centered theories of administration did not originate with Rogers, but were articu- lated in administration circles since the early part of this century (Schatz, 1970). The major contribution of Rogers has once again been the operationalization and application of the con- cepts within an organized framework.

Social workers have found many aspects of person- centered administration to be com- patible with their values. There has been a great deal of interest in and experimentation with participatory management approaches (McMahon, 1981; Schatz, 1970)  and equality- based supervisory practices (Mandell, 1973). Rogers’s approach to administration, with its antiauthoritarianism, is limited in its broad application in social work. As they are applied and refined, however, the principles may mature into an acceptable, coherent, and functional administrative orientation.

Empirical Base

Investigators received a new impetus from the study of client- centered theory. Rogers’s personal commitment to empiricism and to outcome- and- evaluation research opened new avenues in research that had previously not been considered. Rogers’s objective observa- tions of the subjective experience of counselors and clients through hypothesizing and testing were clearly innovative. While his initial inter- est was in the systematic description of the pro- cess of psychotherapy, his attention later turned to effectiveness and outcome measures, and finally, to attempts to substantiate his theoreti- cal postulates.

John Shlien and Fred Zimring (1970) identi- fied four stages in the development of research methods and directives in client- centered the- ory. In stage 1, the emphasis was on the client in the context of therapy. In stage 2, the empha- sis expanded to cover the phenomenological aspects of perception and personality. In stage 3, the emphasis shifted to the study of the thera- pist, and in stage 4, all three elements merged into a process conception of psychotherapy. An extraordinary number of studies have been generated in all of these areas. Although many support the original claims, some challenge both the original assumptions and the external validity of some of the findings. Investigators such as Charles B.  Truax and Robert Carkhuff further refined, expanded, and substantiated the basic principles of client- centered theory.

The research on the core conditions of therapy is especially notable. There is consid- erable agreement across a number of profes- sions, including psychology, psychiatry, social work, and nursing, that the core conditions are demonstrably linked with effective counseling practices. As such, the core conditions remain one of the only substantive elements of effective counseling, and are supported by numerous studies.

With the possible exception of behavior ther- apy, no other approach has had such an intensive research orientation. This is in part attributable to the fact that, unlike most schools of therapy, client- centered theory was developed primar- ily in the university setting. As Rogers (1960) remarked, “Client- centered therapy will at least

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be remembered for its willingness to take a square look at the facts,” and this emphasis has been embraced by most of those associated with the client- centered orientation. The methods employed in client- centered research appear to be particularly adaptable to the needs of social work research. The stages of development in client- centered research are closely aligned with social work concerns.

The first level of development in client- centered research was the recording of cases, the definition of concepts, the development of objective measures of the concepts, the appli- cation of the concepts, and the establishment of relationships among the concepts. This is similar to attempts in social work research to quantify and evaluate practice, as in Larry Shulman’s study on casework skill (1978). It is widely acknowledged that much of what is considered to be practice wisdom in social work would be better understood and uti- lized if it were subjected to this kind of rigor (Siporin, 1975).

Another stage of research in client- centered theory that is directly useful to social work is outcomes research. Numerous effectiveness and outcome studies have been done using creative investigative techniques such as the Q- sort. Social work researchers are increasingly con- cerned with the same issues in light of increased demands for accountability. As social workers become better able to define and operationalize their objectives, these research techniques have proven useful.

In the past decade, social work research has increased significantly and social workers have expanded their repertoire of research meth- ods. Heuristic models and qualitative research methods are finding increasing use in social work, and their congruence with the empiri- cal base in person- centered theory is clear (Barrineau & Bozarth, 1989). As direct practice becomes more eclectic in nature, the challenge is to establish how person- centered approaches are more or less useful, under what conditions, and with what particular disorders or needs (Lambert, 1986). A  good example of this is seen in a recent work by Joseph (2004) where he looks at the practical applications of client- centered therapy for posttraumatic stress disorder (PTSD) and posttraumatic growth.

While most of the major texts on PTSD make no reference whatsoever to client- centered therapy, Joseph suggests that PTSD symptoms may simply be another way of talking about what Rogers described as the breakdown and disorganization of the self- structure. He points out that the person- centered approach forces us view recovery from PTSD in terms of posi- tive movement toward posttraumatic growth.

Prospectus

There are numerous areas of convergence and compatibility between person- centered theory and social work practice. Given the similarities in philosophy and practice, it is in some ways curious that person- centered theory is not more accepted by the profession. For example, not long ago, Howard Goldstein (1983) published an article, “Starting Where the Client Is,” in which he competently articulated the value of his longstanding social work adage. It is odd that he made only passing reference to Rogers and person- centered theory, considering the amount of theory and research available to support his thesis. Rogers presents what many believe is a naive and one- sided view of human nature.

Many social workers support this posi- tive view of humanity in theory, but decades of practice with some of the more disturbing problems in society (poverty, child abuse and neglect, family violence) diminish enthusi- asm for such beliefs. Much of person- centered theory was developed in controlled university settings, whereas the social worker’s practice environment is often far more unpredictable. Much of the work done in the past decade has advanced the use of person- centered meth- ods with difficult- to- serve clients (Gerwood, 1993; Patterson, 1990; Murphy,2009) and should help to bridge this gap. Those who have advanced the work of Martin Luther King Jr. and use his ideas and methods to work with both perpetrators and victims of terror, gang violence, and even genocide readily trace their techniques and approaches to Rogerian val- ues and philosophy. This is especially clear in the wide acceptance of Kingian Nonviolence Conflict Reconciliation strategies and pro- grams. (LaFayette & Jehnsen,1995).

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Most of the research validating the concepts takes the expressions of the clients at face value and gives little attention to unconscious pro- cesses. Many social workers firmly believe in the importance of understanding unconscious motivations and have experienced the useful- ness of this understanding in both assessment and intervention. Some of the theory- bridging begun by Rogers (1986) and furthered by others (Purton, 1989; Quinn, 1993; Kolden, et al,2011) will allow for more convergence on these issues in the future.

Another area of divergence between person- centered theory and social work pertains to the concept of authority. Rogers took an extreme position against authority and saw it as an essen- tially destructive component of relationships. While many social workers deemphasize author- ity, the major concern is more often how to make positive use of it, as opposed to simply denying its existence. Not all person- centered thera- pists are as adamant about this issue as Rogers was, and some of the more recent contributors have included rather than rejected the concept of authority relationships (Boy & Pine, 1982; Coughlan & McIlduff, 1990; O’Leary, 1989).

The development of person- centered the- ory in many ways has been a microcosm of the development of the social work profession. Both began with the worker– client interaction and progressed to include groups, families, organ- izations, communities, and political systems. Person- centered theory has matured along with social work theory to the point where Orlov (1990) made reference to “person- centered poli- tics,” a concept that would have been unthinka- ble a short time ago. Solomon (1990), in a work entitled “Carl Rogers’s Efforts for World Peace,” demonstrated advances in the application of person- centered theory that have significant ramifications for international work.

Many social work students, upon their intro- duction to person- centered concepts, dismiss them as simplistic and unsophisticated. It is only when workers have had significant expe- rience that they are in a position to rediscover person- centered theory, with its many layers of depth and meaning. Miriam Polster captured this well when she referred to Rogers’s work as “informed simplicity,” not unlike a Picasso painting (Zeig, 1987, p. 198).

The term “person- centered” is highly appropriate for both theory and practice in a profession that has traditionally attempted to encompass both science and compassion. In essence, both the emphasis on the person and the research practices of person- centered theory are valuable to social work. In the past few years evidence- based practice has taken a central role in social work practice and social work education. At first glance it may appear that the ordered protocols inherent in evidence- based practice appear to be at odds with many of the fundamental tenets of client- centered theory as articulated by Rogers and as practiced by Rogerians. Actually, virtually all of Rogers’s early work was based on observa- tion and experimentation at a time when oth- ers were using mostly post- report information often gathered from the therapists themselves. As noted at the beginning of the chapter client- centered theory might better be described at this point as values- based, evidence- supported practice. Overall it is essential that, as profes- sional boundaries become less distinct and multidisciplinary practice becomes more the norm, we re- embrace person- centered the- ory and all that it has to offer in its old and new forms.

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Rogers, C.  R. (1972). Becoming partners:  Marriage and its alternatives. New York: Delacorte.

Rogers, C.  R. (1974). Person- centered and symbolic perspectives on social change: A schematic model. In D. A. Wexler & L. M. Rice (Eds.), Innovations in person- centered therapy. New York: Wiley.

Rogers, C. R. (1977). Carl Rogers on personal power. New York: Dell.

Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.

Rogers, C.  R. (1986). Rogers, Kohut and Erikson. Person- Centered Review, 1(2), 125– 140.

Rogers, C.  R., Gendlin, E.  J., Kiesler, D.  J., & Truax, C.  B. (Eds.). (1967). The therapeutic relationship and its impact: A study of psychotherapy with schizo- phrenics. Madison: University of Wisconsin Press.

Rogers, W. R. (1974). Person- centered and symbolic perspectives on social change: A schematic model. In D. A. Wexler & L. N. Rice (Eds.), Innovations in person- centered therapy. New York: Wiley.

Rowe, W.  (1981). Laboratory training in the bacca- laureate curriculum. Canadian Journal of Social Work Education, 7(3), 93– 104.

Schatz, H.  A. (1970). Staff involvement in agency administration. In H. A. Schatz (Ed.), Social work administration. New  York:  Council on Social Work Education.

Seeman, J. (1990). Theory as autobiography. Person- Centered Review, 5(4), 373– 386.

Shimizu, M. (2010). The development of the person- centered approach in Japan. Person- Centered and Experiential Psychotherapies, 9(1), 14– 24.

Shlien, J. M., & Zimring, F. M. (1970). Research direc- tives and methods in person- centered therapy. In J. T. Hart & T. M. Tomlinson (Eds.), New directions in person- centered therapy. Boston:  Houghton Mifflin.

Shulman, L. (1978). A study of practice skills. Social Work, 23(4), 274– 281.

Shulman, L.  (1979). The skills of helping. Itasca, IL: Peacock.

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Silberschatz, & George. (2007). Comments on “The necessary and sufficient conditions of therapeu- tic personality change.” Psychotherapy:  Theory, Research, Practice, Training, 44(3), 265– 267.

Siporin, M. (1975). Introduction to social work prac- tice. New York: Macmillan.

Smalley, R. E. (1967). Theory for social work practice. New York: Columbia University Press.

Snodgrass, J.  (2007). From Rogers to Clinebell: Exploring the history of pastoral psychology. Pastoral Psychology, 55(4), 513– 525.

Sollod, R.  N. (1978). Carl Rogers and the origins of person- centered therapy. Professional Psychology, 4(1), 93– 104.

Solomon, L.  (1990). Carl Rogers’s efforts for world peace. Person- Centered Review, 5(1), 39– 56.

Stewart, M.  A., Weston, W.  W., Brown, J.  B., McWhinney, I. E., McWilliam, C., & Freeman, T. R. (1995). Patient- centered medicine. Thousand Oaks, CA: Sage Publications.

Taft, J. (1951). The dynamics of therapy in a controlled relationship. New York: Harper.

Truax, C.  B., & Mitchell, K.  J. (1971). Research on certain therapist interpersonal skills in relation to process and outcome. In A.  E. Bergin & S.  L. Garfield (Eds.), Handbook of psychotherapy and behavior change:  An empirical analysis (pp.  299– 344). New York: Wiley.

Turner, F.  J. (1968). Differential diagnosis and treat- ment in social work. New York: Free Press.

Turner, F.  J. (Ed.). (1974). Social work treatment. New York: Free Press.

Usher, C.  (1989). Recognizing cultural bias in counseling theory and practice:  The case of Rogers. Journal of Multicultural Counseling and Development, 17(2), 62– 71.

Van der Veen, F., et al. (1964). Relationships between the parents’ concept of the family and family adjustment. American Journal of Orthopsychiatry, 34(January), 45– 55.

Wallman, G.  (1980). The impact of the first year of social work education on student skill in commu- nication of empathy and discrimination of effec- tive responses. Doctoral dissertation. Adelphi, Garden City, University, New York.

Wells, R.  A. (1975). Training in facilitative skills. Social Work, 20, 242– 243.

White, R.  W. (1959). Motivation reconsidered:  The concept of competence. Psychological Review, 66, 315.

Zeig, J.  K. (Ed.). (1987). The evolution of psychology. New York: Brunner/ Mazel.

Annotated Listing of Key References

Boy, A.  V., & Pine, G.  J. (1982). Person- centered counseling:  A  renewal. Boston:  Allyn and Bacon. The authors focus on the current application of person- centered theory to individual and group counseling. Boy and Pine recognize the shift of most person- centered authors to applications in teaching, administration, community building, race relations, and conflict resolution. They offer a refinement of the original person- centered coun- seling principles and renewed possibilities for individual and group application. In addition, Boy and Pine critically discuss the counseling con- cerns of personality theory, values, accountability, evaluation, and counselor education.

Carkhuff, R.  R., & Berenson, B.  G. (1977). Beyond counseling and therapy (2nd ed.). New York: Holt, Rinehart and Winston. Carkhuff and Berenson have significantly advanced person- centered the- ory through both clinical and research efforts. This book supplies a comprehensive statement of the research and clinical observations that sup- port their view of the person- centered model of helping. The authors compare the person- centered approach with other major helping theories and show the rationale for their particular beliefs. In addition, the philosophy, values, and content of a training approach for counselors are outlined.

Fischer, J.  (1978). Effective casework practice. New  York:  McGraw- Hill. Fischer presents an approach to casework that bridges the gap between research and practice. He describes an eclectic approach that consists of empirically validated helping models. Fischer’s “integrative model” includes components of behavior modifi- cation, cognitive procedures, and the core condi- tions of helping. A model for training and learning the core conditions is presented. Fisher’s book represents one of the few significant references to person- centered theory in social work literature.

Greenberg, L.  S., Rice, L., & Elliot, R.  (1993). Facilitating emotional change:  The moment- by- moment process. New York: Guilford Press.

Rice, L., & Greenberg, L.  (Eds.). (1984). Patterns of change: An intensive analysis of psychotherapeutic process. New York: Guilford Press.

Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin. This is a classic work that helped establish Rogers and person- centered theory as a major force in American psychol- ogy. Rogers articulates the culmination of three

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decades of theory development, clinical prac- tice, and clinical research as a cohesive approach to helping and personal growth. As such, it is an excellent first reading for individuals interested in the person- centered approach.

Rogers, C. R. (1977). Carl Rogers on personal power. New  York:  Dell. Rogers describes the impact of the person- centered approach on relationships, education, administration, and political systems. He reiterates the theoretical foundation of this approach and shows how it translates into a base for political activity and what he terms the “quiet revolution.” Rogers details the principles of the person- centered approach and describes a num- ber of examples of these principles in practice, in the workplace, and in the political arena. In con- clusion, Rogers offers some humanistic alterna- tives to polarized conflict and entrenched political structures.

Websites

Association for the Development of the Person- Centered Approach: http:// www.adpca.org.

World Association for Person Centered & Experiential Psychotherapy & Counseling: http:// pce- world.org

Classics in the History of Psychology, by Christopher D.  Green:  http:// psychclassics.yorku.ca/ Rogers/ personality.htm.

Carl Rogers Biography:  http:// www.nrogers.com/ carlrogersbio.html

Sofia University— Transpersonal Pioneers: http:// www.sofia.edu/ content/ transpersonal- pioneers- carl- rogers

Person- Centered Counseling:  http:// www.person- centered- counseling.com/ index.htm.

Personality Theories, by Dr. C. George Boeree: http:// webspace.ship.edu/ cgboer/ rogers.html.

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The treatment of social, emotional, and behav- ioral problems of children, adolescents, and adults has developed remarkably in the past decades. Reviews of the evidence have con- sistently found that cognitive behavioral treat- ments produce lasting favorable changes for many problems. The purpose of this chapter on cognitive behavior therapy (CBT) is to provide the reader with an overview of this approach to social work practice. This overview is placed within the context of the development of CBT on the base of the late 1960s clinical approach known as “behavior modification.” Since the earlier editions of this book (Turner, 1996), considerable change is noted in the evolution of behavior modification to behavior ther- apy, and then to the current concept of CBT. In large part, this has been driven by advances

in research, practice, and training, and driven by the importance of increased accountabil- ity. These transitions reflect, to some degree, the movement from the early emphasis by the behaviorists on the need for clients and clini- cians to focus on observable behavior. While this principle served to discipline the clinicians and provide a systematic basis for the early clin- ical research models, it gave way to pressures to broaden and unify various contributing elements of the impact on behavior of cogni- tive and affective factors. Essentially, behavior modification, behavior therapy, and CBT are similar in that they share an emphasis on client behavior as the focus for therapy. CBT, however, refers to the inclusion of thoughts and beliefs in the determination of clients’ problems and their alleviation. The idea behind CBT is that if you

Cognitive Behavior Theory and Social Work Treatment

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can change the way you think, you can change the way you feel.

A second purpose of this chapter is to acquaint the reader with a brief overview of the history of CBT. Numerous researchers and clinicians have influenced the development of CBT. To have a basic knowledge of this history is essential because it provides the clinician with a necessary understanding of the ration- ale for why this approach has departed from the more traditional psychotherapy approaches. In essence, CBT emerged from a commitment to the empirical study of human behavior and, specifically, conditions under which prob- lem behaviors or maladaptive behaviors and responses are maintained, and then altered or changed. Learning new, more adaptive behaviors will lead to more rewarding behav- iors. There is no single definition of CBT, as it encompasses a broad array of techniques that are based in the behavioral conditioning theo- ries, learning theory, and cognitive theory. One factor does separate CBT from the earlier tradi- tional psychotherapies, which is that the focus of clinical treatment is on the present. In terms of intervention, therefore, the conditions for change are viewed as being actions taken by the clients themselves and, where possible, by per- sons in the client’s environment.

A third purpose of this chapter is to illustrate some common applications of behavior modi- fication, behavior therapy, and CBT. Also, the authors hope to demonstrate the compatibility and applicability of CBT to social work treat- ment and to inspire social workers to integrate these approaches into their treatment model.

Development of Cognitive Behavior Therapy

The development of behavior therapy over the past decades has been referred to as the “Three Waves of Behavior Therapy” (Hayes, 2004; Moran, 2008). Briefly, these “waves” or groupings are divided into the early behavior- modification therapies, including the contin- gency management, stimulus control, exposure, and modeling approaches. The second wave reflects the major influences of cognitive theo- ries of Aaron Beck (1976), Albert Ellis (1989),

and Donald Meichenbaum (1977). Specifically, this second wave includes the cognitive appr- oaches of rational emotive therapy, cognitive therapy, problem solving, thought stopping, and stress inoculation. The third wave, which remains somewhat controversial and challeng- ing to the very roots of behavior therapy, com- prises the three more recent therapies, identified as acceptance and commitment therapy, dialec- tical behavior therapy, and mindfulness- based cognitive therapy. These three therapies, as their names suggest, share the assumption that, by focusing less on painful thoughts, feelings, and experiences and accept their discomfort, one can live life by committing to important values and alternative ways of achieving one’s life goals. Acceptance and mindfulness are important ele- ments in Buddhism, in respect to the experienc- ing one’s life situation without judgment and evaluation.

In the recent, fifth edition of their book Contemporary Behavior Therapy, Spiegler and Guevremont (2010) offer a succinct descrip- tion of the third wave or generation of behavior therapies:

Acceptance and commitment therapy (ACT) pos- its that psychological inflexibility— a narrowing of options for behaving— is at the core of psycholog- ical suffering and is maintained by six interrelated processes:  (1)  cognitive fusion (taking thoughts lit- erally rather than seeing them as just thoughts); (2)  attachment to the conceptualized self (how we view ourselves); (3)  experiential avoidance (escape from or avoidance of unpleasant thoughts and feel- ings); (4)  disconnection from the present moment; (5)  unclear personal values, and (6)  inaction with respect to values (failure to act in accord with what is personally important). These six sources of psycho- logical inflexibility are treated in ACT to foster psy- chological flexibility. (p. 415)

Included in this third wave of behavior ther- apy is dialectical behavior therapy, developed by Marsha Linehan (1993). This therapy mode involves a relatively structured form of both individual and group therapy, and, consist- ent with ACT, it merges the core conditions of acceptance and change with acceptance. This approach was developed for the treatment of borderline personality disorders. The approach evolved in her work with suicidal patients, who

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she concluded were overwhelmed by change expectations but who also felt their problems to be ignored by acceptance theory. The synthesis of both a structured skills training approach and acceptance of the self, she argued, provides a more effective outcome to therapy.

The third- wave applications continue to the broader field of CBT as social workers become more familiar with the theory and practice of these approaches. Importantly the efficacy of these approaches continue demonstrate impressive clinical results (Leahy, 2008; Ost, 2008). “Behavior therapy”1 refers to the sys- tematic application of techniques intended to facilitate behavioral changes that are based principally, but not exclusively, on the condi- tioning theories of learning. It is more appro- priate to refer to “the behavior therapies” rather than to imply that a single method of behavior therapy exists. Behavior therapy is, however, characterized by multiple theories and techniques much like other therapies, such as psychotherapy, marital therapy, and family therapy.

Behavioral practice can trace its begin- nings to the first quarter of this century in the works of Ivan Pavlov associated with respond- ent or classical conditioning; Thorndike, Hull, Watson, and Skinner associated with operant conditioning; and Bandura noted for contribu- tions of social learning theory (Franks, Wilson, Kendall, & Foreyt, 1990). The contributions of Pavlov and Skinner are well documented in both the behavioral and social work literature.

Pavlov’s studies of the salivation reflex of dogs are familiar to most students of human behavior. The basic experimental procedure for the learning process involved placing food within the view of the dog. Salivation was elic- ited, and the relationship between the uncondi- tioned stimulus (food) and the unconditioned response (salivation) was established. An arbi- trary event (stimulus)— for example, a ring- ing bell— was then established to occur at the same time as the presentation of the food. Over a number of such pairings, the bell (the con- ditioned stimulus) took on the power to elicit the response of salivation (the conditioned response). This behavioral learning proc- ess is referred to as “respondent condition- ing” and remains as a foundational theoretical

explanation for a variety of anxiety and phobic disorders in contemporary behavior therapy (Thomlison, 1984b).

Skinner’s contribution to behavior ther- apy was initially motivated by a different set of objectives than those of Pavlov. Skinner was dedicated to the objective of the scientific study of human behavior. While he did not deny the possibilities of the internal mechanisms postu- lated by other theorists, he argued that human behavior could only be empirically investigated through the measurement of observable behav- ior. Underlying his approach was the belief that, if we are to use the methods of science in the field of human affairs, we must assume that behavior is lawful and determined. We must expect to discover that what an individual does is the result of specifiable conditions, and that once these conditions have been discovered, one can anticipate and to some extent deter- mine one’s actions (Skinner, 1953, p.  6). It is necessary to understand that this commitment to science set relatively stringent requirements on the pursuit of knowledge within the behav- ioral school, not least of which was the need to develop techniques of measurement compatible with the exploration of human behavior.

True to his commitment, Skinner evolved one of the most empirically based theories of human behavior and set the foundation for contemporary behavior therapy. At the heart of this Skinnerian theory was the concept of “reinforcement.” Operant behavior (voluntary behavior) emitted by an individual could be increased in frequency of occurrence if such behavior was positively or negatively rein- forced. Alternatively, the frequency of occur- rence of a behavior could be decreased by either administering punishment or withhold- ing reinforcement; this latter process being referred to as “extinction.” In other words, the essence of the Skinnerian or operant model of conceptualizing human behavior relied heav- ily upon an understanding of the environmen- tal (behavioral) events that preceded and/ or followed the behavior(s) under scrutiny. This theoretical explanation of human behavior- acquisition has been refined and elaborated on as a result of clinical experience and research. Importantly, however, the interaction of behav- ior and its prior and consequent events remains

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the foundation of most contemporary behavior therapy.

In addition, cognitive behavioral approaches are also regarded as part of the behavioral par- adigm, and are illustrated by the contributions of Beck (1976), Ellis (1989), and Meichenbaum (1977). Cognitive approaches developed directly from behavior theory, but they are considered distinct ideas, and therefore are discussed in a separate chapter, “Cognitive Theory and Social Work Treatment,” in this book.

It was not until the late 1960s that behavioral approaches appeared in social work, at the same time that psychodynamic theories were under attack. Much of the impetus and contemporary development of behavior therapy to social work is represented by the practice and research con- tributions of Bruce Thyer (1987a; 1988; 1989; 1990; 1991; 1992). Other significant initial social work contributors are Ray Thomlison (1972; 1981; 1982; 1984a; 1984b) for the applications of behavior theory to marital problems and phobic disorders, and its effectiveness for clinical social work practice; Richard Stuart (1971; 1977)  in the development of behavior theory to deal with delinquency, marital problems, and weight man- agement; Sheldon Rose (1981) for behavior ther- apy conducted in groups; and Eileen Gambrill (1977; 1983; 1994)  for her work with clinical problems.

Criticisms of the Cognitive Behavioral Approach

Before proceeding with an overview of the cog- nitive behavioral approach and its application to problematic conditions and behaviors, sev- eral comments are in order regarding critiques leveled at the model by some clinicians. There have always been some questions raised about behavioral therapy, both within and outside the behavioral schools of thought, regarding the place of human psychological or cognitive pro- cesses. Given recognition of the increased inter- est in the role of cognition in shaping behavior, the debate regarding the place of cognitions in behavior therapy has centered on several asser- tions by traditional behaviorists. Some theo- rists, such as Skinner (1988) and Wolpe (1989), argued that behavior therapy was sidetracked by the inclusion of cognitively based techniques

and principles. They proposed that a reliance on cognitions in behavior therapy led to a general abandonment of individualized behavior anal- ysis in favor of treating classes of problems. Behaviorism is based upon the idea that behavior is measurable, and that behavior can be changed through the application of various behavioral principles such as classical and operant con- ditioning. It was thought that the empirical nature of behavior therapy was eroded through the inclusion of feelings and thoughts that were inaccessible to direct, external observation. Furthermore, some argue, analyses of research data comparing behavior therapy outcomes to those of cognitive and/ or cognitive- behavioral therapy indicate that, in general, outcomes have not been improved through the addition of cog- nitive components to behavior therapy (Sweet & Loizeaux, 1991; Wolpe, 1989). For example, Sweet and Loizeaux (1991) reported that 83% of the 40 clinical outcome studies used in their analysis demonstrated that “no more benefi- cial outcome was achieved by adding therapy modules that specifically attended to cognitive- semantic variables” (p.  176). However, the effi- cacy of treatment methods tended to vary according to the type of problem. When follow- up versus immediate post- treatment results were considered, cognitive- behavior interven- tions seemed to offer longer- lasting results. The acceptance of CBT by so many clinicians is also due to the shorter- term treatment compared to other therapies. In CBT, clients see their thera- pist for an average of 10– 16 sessions. In today’s managed care world, time is money.

Another criticism concerns the focus of CBT. CBT focuses on changing flawed thought pro- cesses, as well as the behavior caused by these thoughts. If you change the way you think, then you will behave differently. It is “based on the assumption that a re- organization of one’s self- statements will result in a corresponding re- organization of one’s behavior” (Corey, 2009, p. 275). On the surface, it may sound simple, but simply being told that a view doesn’t accurately reflect reality doesn’t actually make individuals feel any better, and they may continue to worry and behave in the same way. But to suggest that a cognitive behavioral therapist merely tells the client something is wrong is to unfairly under- mine the approach.

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In CBT, active client participation is essen- tial. The client and therapist, through the rela- tionship, must work together to identify faulty thought processes and goals and then help their clients attain a more positive and healthy way of thinking about these things. Some criticize these therapists as assuming too much of an authority role, which, for many clients, is not helpful. From this perspective, some people may also feel that the therapist can be “lead- ing” in their questioning and somewhat direc- tive in terms of their recommendations. For clients who are comfortable with introspec- tion and self- exploration, the basic theoretical approach of cognitive therapy may not be good match. Clients who are less comfortable with any of these approaches, or whose distress is of a more general interpersonal nature— such that it cannot easily be framed in terms of interplay between thoughts, emotions, and behaviors within a given environment— may be less well served by cognitive therapy. Currently, cog- nitive and cognitive- behavioral therapy is the most investigated treatment for clients suffering from depression, anxiety, panic, and obsessive- compulsive disorder. Whatever the final res- olution of this debate, there is no doubt that a cognitively based behavior therapy has devel- oped, one that is quite compatible with social work practice.

Areas of Well- Developed Cognitive Behavioral Practice

Social work clinicians need to take a close look at the support for the efficacy of CBT. An impressive and extensive research base exists for CBT, which includes over 120 randomized controlled clinical trials between 1986 and 1993 (Hollon & Beck, 1994), and 325 outcome studies on cognitive behavioral interventions for numerous disorders and problem behaviors (Butler, Chapman, Forman, & Beck, 2006). In 16 high- quality meta- analyses of a review of CBT for different disorders, CBT was identified as effective, and it was strongly suggested that across many disorders the effects are main- tained for substantial periods beyond treat- ment termination (Butler, Chapman, Forman, & Beck, 2006). The research continues on out- come studies and on the treatment protocols

and less focus placed on further research of a given disorder. The advances in CBT treatment of psychological disorders from the perspec- tive of evidence- based practice has developed technology or procedures of behavior change that necessarily differs from disorder to dis- order with more or less proven effectiveness. Furthermore, considerable clinical skill is required to apply this technology most effec- tively (Barlow, 2014, p. xi).

Much of the social work literature sup- porting the relative success of various thera- pies depends on anecdotal material from the case reports of social workers. Many of these accounts are unidimensional, and relatively few are based on empirical findings, with before- and- after measures, or with clear rela- tionships established between the therapeutic intervention and client change. The cognitive behavior therapies have, on the other hand, a built- in opportunity for data collection by both social workers and clients. Behavioral procedures involve the systematic application of specific techniques intended to facilitate observable behavior change. Measurement of change is therefore an integral part of CBT. This emphasis on problem assessment and concrete indicators of progress has led to the extensive development and use of standard- ized measures. One example of a widely uti- lized behavioral measure is the Achenbach Child Behavior Checklist (Achenbach, 1991). Behavior therapy has championed the use of single- system research design (Gambrill, 1994; Hersen, 1990; Thyer & Thyer, 1992), as well as studies in group outcome research (Barrios, 1990; Kazdin, 1989).

Individual Cognitive Behavioral Therapy for Problems

Many cognitive behavioral interventions have been developed and are available to clini- cians with treatment manuals for working with children and adults. These offer a highly desirable opportunity for improving social work clinical practice. Treatment manuals in which interventions are illustrated on a step- by- step basis are standardized treatments that have been empirically validated for use with precisely defined populations and problems

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under clearly defined conditions. Social work- ers can find cognitive behavior interventions in the Handbook of Child and Adolescent Treatment Manuals (LeCroy, 2007), Handbook of Prevention and Intervention Programs for Adolescent Girls (LeCroy & Mann, 2007), and Cognitive- Behavioral Methods for Social Workers:  A  Workbook (Corcoran, 2006). This maturity and richness in empirical literature is the result of decades of clinical application of cognitive behavioral interventions and rig- orous research. For example, large effect sizes have been found for CBT for unipolar depres- sion, generalized anxiety disorder, panic disorder with or without agoraphobia, post- traumatic stress disorder (PTSD), childhood depressive and anxiety disorders, and inter- nalizing and externalizing behaviors (Butler, Chapman, Forman, & Beck, 2006). Strong moderate effect sizes were found using CBT for marital distress, anger, childhood somatic dis- orders, and chronic pain had effect size in the moderate range (Butler, Chapman, Forman, & Beck, 2006). These findings are consistent across reviews of CBT.

The development of cognitive behavioral interventions as applied to a wider, more spe- cific spectrum of disorders and challenging and problematic behaviors is needed. For example, CBT applications for substance abuse, bipo- lar disorder, personality disorders, and ano- rexia nervosa are among the areas receiving recent empirical attention. Evaluation of the long- term effects of CBT and the continuous evaluation of the effects of CBT compared to alternative treatments is needed. It should be noted that, for some problems, behav- ior therapy is routinely and effectively used in conjunction with pharmacotherapy (e.g., adult depression, attention deficit hyperactiv- ity disorder [ADHD], obsessive- compulsive disorder [OCD]). Figure 4.1 shows selected problems and research studies identifying evidence- based practices for CBT in produc- ing individual change with a wide range of problems.

Couples and Families: Cognitive Behavioral Therapy for Problems

Couple and family counseling are two other areas where social workers frequently uti- lize a behavioral approach. Jacobson (1992) asserts that cognitive behavioral interventions are the most effective in reducing marital dis- tress. Communication, conflict- management, and problem- solving- skills building are the most common behavioral interventions used. Behavioral procedures have been demonstrated to be effective with a multitude of problems and circumstances, with diverse populations and settings. Indeed, behavioral social work treat- ments have been found to be superior to other treatment modalities (Shadish & Baldwin, 2005). More recently, approaches focused on couples and families, detailing the use of cogni- tive behavioral techniques, have been provided by Dattilio (2010). Among the strengths of this approach is the recognition of family interac- tion, system influences, and the need for joint interviews, elements long recognized by social workers to be essential in working with couples and families.

Group Cognitive Behavioral Therapy for Problems

Cognitive behavior approaches to group work have a recognized place in social work, prima- rily due to the excellent research of Rose (1981; 2004), Gambrill (1983), Tolman and Molidor (1994), and others (Gambrill, 1983)  who have used the behavioral approach successfully with a variety of groups including adults and child- ren (Finkelhor, Ormrod, Turner, & Hamby, 2005; Gamble, Elder, & Lashley, 1989; Tallant, Rose, & Tolman, 1989; Thyer, 1987b; Van der Ploeg- Stapert & Van der Ploeg, 1986). Group work often focuses on teaching assertive behav- iors and other interpersonal skills. It has been used extensively in the treatment of depres- sion, eating disorders, parent and child skills training, and addictions. Tolman and Molidor

Antecedent Event(s) ---------- > Behavior ---------- > Consequence(s) (A) (B) (C)

Figure 4.1 Generalized Cognitive Behavioral Paradigm

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(1994) reviewed group work within social work practice throughout the 1980s. They noted that 69% of the articles reviewed had a cognitive- behavioral orientation. Child social skills train- ing and other behavior problems of children and adolescents were the most frequently tar- geted fields of social work practice research reviewed that utilized cognitive behavioral group work (Jenson & Howard, 1990; LeCroy, 2007; Zimpfer, 1992).

Community Behavioral Practice

Finally, applications of behavior therapy prin- ciples to community practice have been some- what more limited, but they have not been ignored. Importantly, however, there are numerous examples of community projects based on behavioral principles reported in the literature (Mattaini, 1993; Mattaini & McGuire, 2006; O’Donnell & Tharpe, 1990; Rothman & Thyer, 1984). Areas such as community violence or natural disasters are stressful conditions that may result in a PTSD reaction. The behavioral interventions employed are the same as those utilized for individual change (for example, modeling, feedback, contingency management). Some of the problem areas addressed through behavioral community practice have been increasing the level and quality of community participation, as well as decreasing undesirable and increasing prosocial community practices (Guide to Community Preventive Services, 2009; Mattaini & McGuire, 2006).

The current evidence overall shows CBT as efficacious for many problems compared to other treatments and relative to other approaches, with wide variety of mental health disorders and behavioral problems. Clearly, more research is needed comparing CBT with other forms of therapy. Several gaps in our knowledge and research are noted in the literature. These gaps include the maintenance and generalization of the behavioral changes. “Maintenance” refers to the durability of the behavioral change over time, whereas “generalization” refers to behav- ioral change in contexts different from the one in which the intervention took place. Strategies to enhance both maintenance and generali- zation need to become part of any behavioral change program and to be validated through

empirical research (Gambrill, 1994; Kendall, 1989; Whisman, 1990). Identifying critical vari- ables that predict which clients will benefit from which intervention procedures can be advanced by, not only looking at the clients for whom a specific behavioral procedure is effective, but also considering the clients who fail to improve from the treatment (Goldfried & Castonguay, 1993; Steketee & Chambless, 1992). The quality of efficacy and prediction research will improve if a number of common methodological prob- lems are addressed, particularly if limitations of the meta- analytic approach are considered in the statistical analyses of the randomized clini- cal studies (Chambless, 2002).

Central Premises of Cognitive Behavioral Treatment Programs

Cognitive behavioral treatment is grounded on several interrelated theoretical perspectives and underlying assumptions. First, behavioral approaches to change are based on the general view that problems can be understood within a behavioral context, and that all behaviors can be changed. Therefore, problem behaviors can be replaced with more positive adaptive behav- iors, as well as by improving communication and problem- solving skills. Second, cognitions (i.e., beliefs and attitudes) play a significant role in shaping behaviors. Therefore, behavioral changes should be accompanied by cognitive shifts that support long- term, adaptive change. Finally, effecting positive, meaningful behav- ioral and cognitive changes requires a system- atic approach. Effective cognitive behavioral treatments are contingent on accurate assess- ment and planned intervention strategies tai- lored to the specific individual, with systematic, ongoing evaluation of the change. The assump- tions in the following sections are central to cognitive behavioral interventions.

Assumption 1: Problem Behaviors Can Be Identified and Changed

All behavior is assumed to be learned and can be both defined and changed. It is first important to identify the problem targeted for intervention. “The problem” is formulated as

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the undesirable behavior, which can be under- stood through systematic exploration and modified through specific behavioral tech- niques. Thus, personal and social problems are translated into behavior that is observable, measurable, and changeable. Understanding the mechanisms that reinforce behaviors is an essential early step in assessing the prob- lem. These contingencies of reinforcement are identified as targets of intervention. Change occurs through rearranging contingencies of reinforcement— that is, altering what hap- pens before and after the specified behavior. Behaviorists believe that behavioral change is brought about through changes in reinforce- ment by significant others in the person’s environment, or environmental transactions, as well as by an enhanced perception of the self that comes from acquiring new behavior. CBT acknowledges that there is a large num- ber of both reinforcing and aversive events that can be operative in any given behavioral exchange. Identifying current and alternative stimuli is essential. By changing the contin- gencies of reinforcement, the behavior that needs to be changed can be extinguished, or other behavior can be conditioned to replace it. The learning and changing of behavior can be understood using social learning theory. Specific approaches to using social learning theory are described later in this chapter.

Assumption 2: Cognitions Shape Behaviors

In its broadest definition, “cognition” incorpo- rates many of the elements of human thought processes characteristically of concern to social work. Such a broad definition would include the processes by which information (input) from the environment is translated, consid- ered, integrated, stored, retrieved, and eventu- ally produced as some form of personal activity (output). Simply stated, how one thinks about one’s experiences shapes one’s experiences. Therefore, the process of examining one’s atti- tudes, beliefs, and values is relevant for prac- titioners to understand, not only how clients view their own behaviors and environment, but also potential deterrents and/ or motivators for change. Cognitive- behavioral practitioners

have selected and explored certain cognitive elements in behavior change. The following ele- ments of cognitive theory are used in modify- ing behavior:

1. Information processing: the acquisition, stor- age, and utilization of information; encom- passing attention, perception, language, and memory;

2. Beliefs and belief systems:  ideas, attitudes, and expectations about self, others, and experience;

3. Self statements:  private monologues that influence behavior and feelings; and

4. Problem- solving and coping:  conceptual and symbolic processes involved in arriving at effective responses to deal with problematic situation. (Schwartz, 1982, p. 269).

CBT incorporates both the behavior and cog- nition in the assessment and targeted interven- tion of cognitive processes to effect long- term behavioral change.

Assumption 3: Effecting Behavioral Change Requires a Systematic Approach

Behavioral approaches to assessment, interven- tion, implementation, and evaluation share a number of characteristics with the basic social work problem- solving process. Foremost, the plan for change must include a systematic proc- ess of intervention that begins with a thorough assessment of the problem and ongoing assess- ment of effectiveness of the intervention. In general, the goals of cognitive behavioral social work treatment are increasing desirable behav- iors and reducing undesirable behaviors in order that those affected by the circumstances can improve their day- to- day and moment- to- moment functioning. As with all social work practice, relationship skills form the foundation to work with client systems. The basic behav- ioral assessment method is used to analyze the client’s problem and assist in a plan of change through development of appropriate behavioral change goals. The selection of a specific inter- vention is based on the assessment process dur- ing which presenting problems are translated into observable behaviors. Then, specific behav- ior techniques and strategies to be followed are

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detailed in a treatment contract to address the client’s problems and circumstances.

Conducting a behavioral assessment requires a focus on the here- and- now of the problem, as well as current environmental factors related to the problem behavior. Also, a clear descrip- tion of the intervention is provided, along with concrete ways to measure progress. Building on client strengths while developing new skills and increasing their knowledge- base is another char- acteristic of behavioral intervention. Generally, the etiology of the behavior is not investigated, nor is the provision of a diagnostic label pur- sued. Both of these factors are deemed stigma- tizing and uninformative when considering behavioral change. Nevertheless, much of the behavioral research literature utilizes diagnos- tic labels (for example, agoraphobia, attention deficit disorder, and PTSD) in the description of the problem behavior under investigation. This has resulted from the integration of behavior- assessment methods with traditional psychiat- ric diagnostic classifications. This practice has been criticized as promoting a neglect of indi- vidual differences between clients (Gambrill, 1994; Wolpe, 1989)  and potentially masking outcome differences between types of interven- tion (Eifert, Evans, & McKendrick, 1990).

Social Learning Theory and the A- B- C Paradigm

A classic perspective of behavioral change is the “A- B- C paradigm,” which is based on social learning theory. This theory assumes that behavior is learned within social contexts and thus should be changed within the social envi- ronment. Social learning theory identifies three major elements:  target behaviors, antecedents, and consequences (Bandura, 1976).

1. Target behaviors are the behaviors that are the focus of the behavioral analysis. These are often identified during the period of assessment as undesirable, problematic, or the behavior that needs to be changed.

2. Antecedents and consequences are the inci- dents, behaviors, or environmental events that precede or follow the problematic or target behaviors, respectively. They are often identified as the controlling or maintaining

conditions for the problem behaviors. For instance, an antecedent may incite a behav- ior to occur, while a consequence may deter the behavior from occurring again.

These events serve as the focus of the behavioral assessment. The interaction of these three ele- ments is described as the A- B- C behavior ther- apy paradigm and is represented in Table 4.1.

It must be noted that this paradigm serves to label one exchange in an ongoing sequence of exchanges between individuals. In order for the social worker to determine the antecedents and consequences, a decision as to the problem or target behavior must first be made. With this target behavior in mind, the social worker then identifies the events or behaviors that precede or follow the target behavior. This identifica- tion process is usually done by direct observa- tion by the social worker or by client self- report. This process is known as behavioral analysis and is considered essential to effective behavior therapy.

To illustrate the application of this social learning paradigm in a behavior therapy assess- ment and change program, a common parent– child behavioral exchange is as follows:  Mr. S. complains that his child, Josh, will “never do what he is told.” One of the concerns is that Josh will not come to the dinner table when he is called. The presenting situation, as explained by Mr. S., is shown in Table 4.2.

In order to assess the behavior further, it is generally necessary to examine the nature of the consequences that might be provided for Josh. Behavioral consequences differ in terms of their quality and purpose. Some are of a posi- tive (pleasing) nature, while others are of a neg- ative (displeasing) variety. The former category is referred to as positive consequences, which are employed to increase the occurrence of a behav- ior. The latter category is usually referred to as punishments and are frequently observed when a parent attempts to prevent the recurrence of an undesired behavior by spanking the child; that is, using physical punishment. While the use of physical punishment as a consequence is acknowledged as a means of decreasing the fre- quency of a behavior, it is viewed by behavioral social workers as an unacceptable means of altering behavior. In addition to humanitarian

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Table 4.1 Empirically Supported Behavioral Treatment Problems

Problem Area Empirical Research*

Addictions Acierno, Donohue, & Kogan, 1994; Goldapple & Montgomery, 1993; Hall, Hall, & Ginsberg, 1990; Lipsey & Wilson, 1993; Peyrot, Yen, & Baldassano, 1994; Polansky & Horan, 1993; Sobell, Sobell, & Nirenberg, 1988

Anxiety disorders Acierno, Hersen, & Van Hasselt, 1993; Beck & Zebb, 1994; Butler, Chapman, Forman, & Beck, 2006; Emmelkamp & Gerlsma, 1994; Lipsey & Wilson, 1993; Mitte, 2005; Rachmann, 1993; Van Oppen, De Haan, Van Balkom, Spinhoven, Hoogdin, & Van Dyck, 1995

Attention deficit hyperactivity

Fabiano, Pelham, Coles, Chronis- Tuscano, O’Connor, & Gnagy, 2009

Autism Celiberti & Harris, 1993; Ducharme, Lucas, & Pontes, 1994; McEachin, Smith, & Lovaas, 1993; Reichow & Wolery, 2009; Scheibman, Koegel, Charlop, & Egel, 1990

Child maltreatment Centers for Disease Control, 2009; Gambrill, 1983; Finkelhor & Berliner, 1995; Gaudin, 1993; Lundahl, Nimer, & Parsons, 2006; Meadowcroft, Thomlison, & Chamberlain, 1994; Wekerle & Wolfe, 1993; Wolfe, 1990; Wolfe & Wekerle, 1993

Conduct disorders Bramlett, Wodarski, & Thyer, 1991; Christophersen & Finney, 1993; Dumas, 1989; Kazdin, 1990; Lochman & Lenhart, 1993; Maag & Kotlash, 1994; Magen & Rose, 1994; Raines & Foy, 1994

Couple problems Granvold, 1994; Epstein, Baucom, & Rankin, 1993; Halford, Sanders, & Behrens, 1994; Hahlweg & Markman, 1988; Lipsey & Wilson, 1993; Montang & Wilson, 1992; O’Farrell, 1994; Thomlison, 1984a

Depression Beach, Whisman, & O’Leary, 1994; Frame & Cooper, 1993; Hoberman & Clarke, 1993; Norman & Lowry, 1995; Rohde, Lewinsohn, & Seeley, 1994

Developmental disabilities

Butler, Chapman, Forman, & Beck, 2006; Feldman, 1994; Hile & Derochers, 1993; Kirkham, 1993; Nixon & Singer, 1993; Thomlison, 1981; Underwood & Thyer, 1990

Eating disorders Garner & Rosen, 1990; Isreal, 1990; Kennedy, Katz, Neitzert, Ralevski, & Mendlowitz, 1995; Lipsey & Wilson, 1993; Morin, Winter, Besalel, & Azrin, 1987; Saunders & Saunders, 1993; Wilson, 1994

Family violence Edleson & Syers, 1990, 1991; Faulkner, Stoltenberg, Cogen, Nolder, & Shooter, 1992; Peled & Edleson, 1992; Tolman & Bennett, 1990

Gerontology Fisher & Carstensen, 1990; Hersen & Van Hasselt, 1992; Nicholson & Blanchard, 1993; Widner & Zeichner, 1993

Juvenile delinquency Bank, Marlowe, Reid, Patterson, & Weinrott, 1991; Hagan & King, 1992; Lipsey & Wilson, 1993; Meadowcroft, Thomlison, & Chamberlain, 1994; Zimpfer, 1992

Obsessive compulsive disorder

Franklin & Foa, 2014; Watson & Rees, 2008

Pain management Biederman & Schefft, 1994; Gamsa, 1994; Holroyd & Penzien, 1994; Lipsey & Wilson, 1993; Subramanian, 1991, 1994

Phobic disorders Donohue, Van Hasselt, & Hersen, 1994; King, 1993; Newman, Hofman, Trabert, Roth, & Taylor, 1994; Turner, Beidel, & Cooley- Quille, 1995

Post- traumatic stress Butler, Chapman, Forman, & Beck, 2006; Caddell & Drabman, 1993; Corrigan, 1991; Mitte, 2005; Monson, Resnick, & Rizvi, 2014; Richards, Lovell, & Marks, 1994; Roberts, Kitchiner, Kenardy, & Bisson, 2009; Saigh, 1992

Psychosis Liberman, Kopelowicz, & Young, 1994; Lipsey & Wilson, 1993; Morrison & Sayers, 1993; Scotti, McMorrow, & Trawitzki, 1993; Tarrier, Beckett, Harwood, Baker, Yusupoff, & Ugarteburu, 1993

Sexual deviance Camp & Thyer, 1993; Hanson, Steffy, & Gauthier, 1993; Marshall, Jones, Ward, Johnston, & Barbaree, 1991; Kaplan, Morales, & Becker, 1993; Marques, Day, Nelson, & West, 1994

Sleep disturbances Lichstein & Riedel, 1994; Minde, Popiel, Leos, & Falkner, 1993 Stress management Dubbert, 1995; Lipsey & Wilson, 1993 Substance abuse Dutra, Stathopoulou, Basden, Leyro, & Powers, & Ottow, 2008; Powers, Vedel,

& Emmelkamp, 2008

*When possible, review articles and research directly applicable to social work practice were selected.

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reasons, physical punishment is generally con- sidered unacceptable because in many instances it suppresses a behavior without providing an alternative, more desirable behavior. Behavior therapy requires that any agreed behavioral change must be defined in terms that are recog- nized to be desirable and to be increased in fre- quency by the participants. This requires that all parties to a behavioral change contract define what behaviors are desired, not simply what is undesired. This is often a difficult requirement, as it is almost always easier to tell someone to stop doing something that is undesirable than it is to them to engage in a desired behavioral alternative. The use of positive consequences to increase desirable behavior is the strength of the social learning approach to behavior ther- apy. The research strongly supports the use of positive consequences as a means of facilitating desired behavior. However, it is not always easy to put this principle into practice. For example, Mr. S.  may feel that, if Josh would do what he was told, then all would be okay, but until Josh changes, Mr. S.  feels he cannot give Josh any positive messages or praise. Unfortunately, Josh and his father have reached a stalemate wherein, even if they agree that change is desirable,

it is difficult because they are into a coercive exchange (Patterson & Reid, 1970).

Attempting to control another person’s behavior by command and threat is famil- iar to most of us. In many instances, however, it has the effect demonstrated by Josh and his father. The commands and threats escalate until finally the child complies in order to termi- nate the threats and/ or yelling. By the time the child obeys the parent’s command, the parent has become agitated enough to lose any moti- vation to acknowledge, in positive terms, the child’s compliance. This coercive process, then, can be conceptualized using Skinner’s notion of a negative reinforcement process— this is the termination of a behavior (threats) upon occur- rence of the desired behavior (compliance); and extinction process— that is, the withholding of a positive reinforcer upon the occurrence of the desired behavior (compliance); as well as a positive reinforcement process— that is, Mr. S. achieves what he set out to get (compliance).

In other words, when Josh cooperated as he was asked to do— for example, sat down at the table— his father chose to ignore his compliant behavior. On the other hand, Mr. S.  achieved his objective and to some degree was positively

Table 4.2 Application of the A- B- C Paradigm

Antecedents (A) Behavior (B) Consequences (C)

Behavioral Analysis of Presenting Situation

Mr. S. calls Josh several times to the table. There is an escalation of threats and yelling when Josh does not immediately respond.

Josh ignores his father’s first requests but eventually presents himself angrily at the table and begins to eat.

Father is silent and appears angry.

Behavior Change Contract

Mr. S. makes one verbal request in a pleasant tone for Josh to come to the table.

Josh comes to the table when called.

When Josh arrives at the table as requested, Mr. S. verbally praises Josh and places a check mark on Josh’s tally sheet.

If Josh chooses not to respond to his father’s request, Mr. S. will begin eating alone, ignoring Josh’s absence. Josh will forego the opportunity for his father’s praise and tangible, positive acknowledgement for this dinner time.

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reinforced, except for the feelings of frustra- tion and anger. The difficulty is that one person (Josh) is being negatively reinforced, and the other (Mr. S.) is being positively reinforced. This behavioral exchange will therefore be strength- ened and can be predicted to increase in fre- quency unless an alternative exchange can be identified and practiced by both.

In order to help Josh and his father alter their undesirable interaction, the social worker will need to help by devising a program by which the father can give a clear cue or instruction to Josh and award positive consequences to Josh if he complies by arriving at the dinner table at the desired time. Intervention requires that a target behavior for desired change be clearly identi- fied. In this case, such a target might be labeled as “Josh’s coming to the table when called.” New antecedents or instructions would be identified, as well as new consequences for this new target behavior. An agreement to change might well be formalized as a contractual statement detailing the new behavioral target, its antecedents, and its consequences (see Table 4.2, “Application of the A- B- C Paradigm”).

This brief example serves to demonstrate the basic procedures of assessment and intervention in accordance with the A- B- C paradigm. While the overall behavior therapy program would require a more detailed assessment and a more comprehensive intervention strategy, behav- ior, and its controlling antecedents and conse- quences, remains the focus of this approach.

Behavioral Social Work Practice

The most common behavior therapy techniques social workers use include:

1. Cognitive behavioral procedures such as cognitive restructuring, self- instructional training, thought stopping, and stress- inoculation training;

2. Assertiveness training; improves communi- cation skills in personal, work, and other rela- tions in how one expresses rights, requests, opinions, and feelings, honestly, and directly through body language and self- awareness;

3. Systematic desensitization; and variants of this procedure such as eye movement desensitization, procedures involving strong

anxiety evocation (e.g., flooding, paradoxical intention), operant- conditioning methods (e.g., extinction, positive or negative rein- forcement); and

4. Aversion therapy; inducing dislike of the problem behavior, but a method that is less respected, although historically used in addiction and paraphilias.

Each of these approaches requires a more exten- sive discussion than is possible here. Books on behavior theory and practice will provide descriptions of the application of these proce- dures and their effectiveness (Corcoran, 2006; Franks, Wilson, Kendall, & Foreyt, 1990; Granvold, 1994; LeCroy, 2007; Sundel & Sundel, 1993; Thomlison, 1984b, 1986; Thyer, 1992; Wolpe, 1990). The choice of a specific inter- vention method should be based on a careful assessment of client need and the empirically determined effectiveness of a procedure to meet that need (see Table 4.1, “Empirically Supported Behavioral Treatment Problems”).

Cognitive Behavioral Assessment and Intervention

Behavior therapy provides a planned, sys- tematic approach to social work intervention. Indeed, there are specific stages through which all behavior therapy must proceed. While there is a range of activities that are specific to each of the different behavior therapy approaches, there is also a basic set of general procedures that serve as a framework. It is important to remem- ber, however, that this framework is essentially a summary of a behavior therapy approach and is based primarily on the social learning para- digm. The procedural outline is based on the authors’ practice and research with married couples, children, and families. Since much of clinical social work practice is carried out in the context of the family, the outline is presented as an approach to working with the family system.

Beyond the procedural steps identified here, it is important to emphasize that behav- ioral social workers strongly believe that it is important to build a positive therapeutic rela- tionship early in the client’s contact with the client system and actively involve the client as much as possible in each step of the assessment

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and intervention. The importance of this rela- tionship building is not to be underestimated, as it establishes trust, rapport, and the neces- sary support for the analysis and management of problem behavior. Once the client system is engaged through the relationship, behavioral procedures can occur. A  behavioral assess- ment to determine the client’s problems is the next step.

Assessment

Social workers will use procedures during a behavioral assessment. The goal is to define as clearly as possible the problems or events tar- geted for change, and the desired outcome.

1. Compilation of the problematic behavior inventory. (a) Begin by asking one member of the fam-

ily group to identify the perceived prob- lems that have resulted in the meeting.

(b) Clarify these perceived problems by ask- ing for behaviorally specific examples. Most perceived problems can be trans- lated into statements of “who does what to whom” within what context.

(c) As each family member offers their perception of the problem, there is a high probability that the ensuing dis- cussion will stimulate disagreements among family members. It is important to observe who disagrees with whom, and over what behavioral statements. Therefore, these interchanges must be allowed to occur; however, they can become counterproductive to the objec- tive of the assessment, and you must rec- oncile discrepancies. When this occurs, the social worker should intervene, requesting the family members to ter- minate the debate, yet acknowledging that differences of opinion are expected. Assure all family members that their perceptions of the problems are impor- tant and that each member will have an opportunity to present personal views.

2. Identify priority behavioral problems and their maintaining conditions. (a) Attempt to identify the antecedent

events of at least the behaviors that

arouse the most intense feelings among family members. Antecedent events are the conditions that exist immediately prior to the occurrence of the target behavior; e.g., what other members of the family are doing or not doing prior to the occurrence of an undesired behavior.

(b) Identify the consequences of the prob- lem behaviors that elicit the more intense family feelings. Identify the con- sequences of the events that occur after a target behavior; e.g., what other fam- ily members do after one of the problem behaviors has occurred.

3. Identify the contingencies existent for the provision of consequences. That is, what rules appear to govern the conditions under which these consequences are provided? For example, find out when a child is rep- rimanded versus when he is not, or when privileges are withdrawn versus when they are not.

4. Observe and record behavioral exchanges. Identify recurrent behavior patterns in the exchanges among the family members. These behaviors will include coercive exchanges, shouting, avoidance responses, excessive demands, etc.

5. Secure a commitment from each member of the family system, ensuring that they wish to work toward change. This commitment should clearly explicate:  (a)  that they will work as a unit on these family problems, and (b)  that they, as individuals, will work toward behavioral change. At this point in the assessment procedure, the social worker should be able to demonstrate to the fam- ily the interconnections of their individual behaviors in that, when one individual behaves, all family members must respond in the same manner; that is, behaviors do not occur in isolation. For example, when the adolescent youth repeatedly violates her curfew, the resultant parent– youth conflict affects all members of the family.

6. Begin to identify possible behavior targets for change. The target behaviors should be desirable behaviors with the objective of increasing their frequency of occurrence. This identification is often assisted by asking

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each family member to answer two ques- tions:  “How could you behave differently to make this a happier family?” “How would you like to see others behave to make this a happier family?”

Homework Assignments

These questions may be given as homework assignments, with the instructions that each family member provide as many answers as possible to each question. The social worker should point out to the family members that this assignment is a challenge, as it requires the identification of desired behaviors. Individuals are more often accustomed to identifying what behaviors they do not like to see, rather than those they prefer. Homework is used to rein- force the new thinking and behaviors that are introduced during the session.

7. On the basis of the family’s homework assignment, discuss possible appropriate behavioral targets for change. (a) Select behaviors that are to be accelerated

in frequency in order to maximize the opportunities for positive consequences.

(b) Select behaviors that appear to be most relevant to enhancing this family’s defi- nition of its own happiness.

(c) Strive to select behaviors that are incom- patible with the occurrence of undesir- able (problematic) behaviors.

(d) For each child, select at least one behav- ior that is low- risk for change. A  low- risk behavioral target is one that be easily attained by the child and one that, if performed by the child without positive reinforcement (a violation of the change contract), will not jeopardize the growing trust of the child. An example of a child’s low- risk target behavior change might be combing her hair in the morning, or cleaning up after dinner each evening.

(e) Attempt to select behaviors that are com- monly identified among family members; e.g., mealtime behavior, family get- together, tidying- up cooperation, play- time with siblings or peers.

(f ) Remember that a behavior must be observable to all; therefore, it is

necessary to explicate the indicators of some behaviors in order to mini- mize debates over whether the behav- ior has actually occurred. For many parents, the behavior of cleaning up the child’s room is a desired behavior- change objective. Interestingly, what appears to be a very clear behavior has a great deal of opportunity for individ- ual interpretation. It is therefore nec- essary to pinpoint such behaviors as picking up clothes, placing them in the appropriate locations, making the bed, placing trash in appropriate containers, and so on.

8. Commitment for change. Allow time for all family members to present their concerns and their support for the target behav- iors. Certain behavior choices will elicit strong feelings from some family members. Negotiation must take place before selected behaviors are settled upon and must always take place within the spirit of the agreement, acceptance, or commitment for change. If one or more family member wishes to reeval- uate this commitment in light of the selected targets for change, then this request must be honored. Such reevaluation may have to take place within the context of the consequences of no change; that is, all persons have a right not to be required not to change. There are, however, certain consequences for not chang- ing. What are they for the individual and the family?

9. Record baseline data/ information. When tar- get behaviors have been agreed upon, set the conditions for a baseline measure. (a) Before instructing the family to change,

request that the parents monitor the fre- quency of occurrence of the target behav- iors. This will allow for some “before =” or baseline behavior frequency measures. These measures should be recorded and can be used at a later date to assess the ongoing behavioral change within the family.

(b) Appoint the parents as the monitors of the behavior targets. Give the parents a tally sheet and instructions to record the frequency of occurrence of each target behavior.

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10. Behavioral intervention is compatible with the assessment in progress. Throughout the assessment phase, the social worker may identify problems with an individual or the couple that require specific attention. On occasion, the assessment period indicates that the change process should be focused on the couple rather than on the child. With the couple’s agreement, the intervention may be temporarily suspended in light of the rec- ognized need to concentrate on the couple’s problems.

Intervention

The intervention or implementation phase of a behavioral therapy program is marked by the identification of new contingencies between identified behaviors and their consequences. To this point, the focus has been on the appropriate targeting of behaviors for change. At the time a program for change is to be implemented, a con- tingency contract might be formulated in order to facilitate a systematic, cooperative effort by the family in facilitating change.

1. Clearly identify the target behaviors that have been agreed upon as the focus for change.

2. Establish new antecedent events for each of these target behaviors.

3. Establish new consequences that are to be provided for each occurrence or non- occurrence of a targeted behavior.

4. Formulate a written contract specifying the following conditions: (a) The target behaviors for change and their

pinpointed elements. (b) New antecedents. If these are to be

instructions, then specify by whom these instructions are to be given.

(c) New positive consequences that might include the tangible check marks and/ or tokens provided upon behavioral occur- rence, as well a social reinforcer such as affection and praise.

(d) Specify what is to happen if there is a vio- lation of the contract; that is, if a behavior does not occur, or an undesired behavior occurs, then it must be clear what others in the family are to do. For example, if a target behavior focuses on “good dinner

time behavior” and one or more of the children violate this agreement, then all family members must be clear about what is to happen when unacceptable behavior occurs at the dinner table.

(e) Specify the positive consequences that are to act as bonus reinforcers, particu- larly when certain behavioral objectives are accomplished. For example, it is often helpful to include special privileges, such as family outings, as bonus reinforcers for a designated behavioral achievement; such as a target behavior that occurs at the desired level for a period of one week or more.

(f) Specify the persons in the family unit who are to be responsible for recording the frequency of behavioral occurrences. This is usually one or both of the parents. These tally records are important in com- municating to the family members the degree and intensity of change.

(g) Contracts may be written in various ways, but they must all contain the con- dition:  Who does what to whom, under what conditions! Many different exam- ples of contracts may be found in the literature.

5. After a program has been implemented, it is necessary to follow up with a series of tele- phone calls to ensure that the program is being implemented. In addition, these tele- phone calls provide the opportunity for mem- bers of the family, particularly the parents, to ask any questions that might have arisen as a result of implementing the program for change. These calls need not take long and should be limited only to the pragmatics of the program implementation. Any conflict among family members reported at this time should be directed back to the family for reso- lution. If resolution is not possible, the per- sons in charge of recording should make note of the nature of the conflict and the context in which it occurs. This will be dealt with at the next meeting with the social worker.

6. Difficulties in implementing the program are inevitable. These problems usually pertain to such things as tally recording, differences in target behavior definitions, and lack of cooperation by certain family

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members. In order to deal with these prob- lems, the social worker must remember that the contract is the reference point. Once it is agreed to, all problems arising with the behavioral changes must relate to the original document. Changes in the contract must be negotiated by all members of the family. Remember that all problems related to the implementation of and adher- ence to a contract for family interactional modification may eventually have to be related back to the original commitment for change agreed to by the family during the assessment period.

7. Each interview with the family after imple- mentation should begin with an examina- tion of the tally recording provided by the family members. Where change is evident in these data, the social worker must pro- vide positive reinforcement by acknowl- edging the change and the hard work of all family members.

8. Discussion must then shift to focusing on problems arising between sessions. These discussions may flow to more general aspects of the family’s functioning, and special techniques such as role playing, modeling, and behavioral rehearsal may be introduced in an effort to assist the family in dealing with these problems.

9. Since much of the family’s energy goes into problem- solving activity and conflict reso- lution, the social worker must spend time on these areas of family life. One of the advantages of having required the family to negotiate a contingency contract is that they have experienced a process of successful problem- solving and negotiation. Examples derived from that process can be utilized in the ongoing problem- solving and conflict- resolution training.

10. Where the monitoring of change has indi- cated that little if any change is taking place, it is necessary to examine certain aspects of the program design. Depending on the area in which the program is failing, it will be necessary to consider changes in target behavior, consequences, and viola- tions of the contract. It is often necessary to assess whether people are in fact fol- lowing through on the requirements of the

contract. For example, it might be that a parent has agreed to read a bedtime story for successful achievement of a behavioral objective during the day, but fails to deliver.

11. When target behaviors have been achieved at the desired level of frequency, it is time to identify new behaviors for change, or move toward termination of the behavioral ther- apy program.

Evaluation for Maintenance of Change

1. Together with the family system, evaluate the progress in relation to the objectives of the contract.

2. If the decision is to terminate, then set the conditions for behavioral maintenance.

3. Behavioral maintenance requires the social worker to review with the family the basic learning principles identified during the mod- ification of the target behaviors, such as giving positive consequences versus punishment.

4. Instruct the family to continue the tally recording over the next four weeks but with- out the regularly scheduled appointments.

5. Set up an appointment for four weeks from the last interview for termination and follow- up.

Follow- up

The follow- up interview should be an assess- ment interview related to whether or not the behavioral changes have been maintained. If these changes have not been maintained at a level consistent with the expectations of the social worker and/ or the family, it will be nec- essary to reinstitute the program structure. If, on the other hand, the social worker and fam- ily think that the behavioral changes have been maintained within desired parameters, then termination may take place. Termination, of course, does allow for the family to contact the social worker at any point in the future where they feel the need.

From the perspective of clinical evaluation, it is important that the social worker analyze the results of the behavioral change program. Furthermore, it is helpful for the social worker to assess the maintenance of change by contacting

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the family members at a three- month and a six- month interval to ascertain the degree to which the behavioral changes have been maintained.

Implementation Considerations in Cognitive Behavioral Interventions

It is widely acknowledged that CBT reliably produces desirable effects, but does it work with everyone? Examples of designated evidence- based cognitive behavior therapeutic interven- tions include applications to anxiety (Butler, Chapman, Forman, & Beck, 2006; Mitte, 2005a, 2005b); attention- hyperactivity (Fabiano, Pelham, Coles, Chronis- Tuscano, O’Connor, & Gnagy, 2009); depression (Butler, et  al. 2006); substance abuse (Powers, Vedel, & Emmelkamp, 2008); obsessive compulsive disorder (Watson & Rees, 2008); schizophrenia (Zimmermann, Favrod, Trieu, & Pomini, 2005); phobias (Mitte, 2005); couples (Shadish & Baldwin, 2005), and others. For a more complete review, the reader is directed to Dobson and Dobson (2009).

During the past two decades, one of the most important areas of behavioral practice to emerge has been that of dealing with parent- ing, parent training, and child management and skill acquisition. Using the basic A- B- C paradigm, many childhood problems have been reconceptualized as behavioral prob- lems resulting from interactional exchanges between children and parents. By systemati- cally altering these exchanges in the context of behavior therapy, it has repeatedly been dem- onstrated that both parental and child behav- ior can be altered toward desired objectives (Dangel, Yu, Slot, & Fashimpar, 1994; Graziano & Diament, 1992; Sundel & Sundel, 1993). Typical child problems addressed using behav- ioral techniques include noncompliance, chore completion, enuresis, eating disorders, inter- rupting, fire- setting, sleep problems and bed- time anxieties, and hyperactivity (Butterfield & Cobb, 1994). Conduct disorders or antisocial behaviors in children have received consider- able clinical and research attention in the past decade. Behavioral techniques have been dem- onstrated as effective in changing these behav- iors (Christophersen & Finney, 1993; Doren, 1993; Jensen & Howard, 1990; Kazdin, 1990).

It has been estimated that 3– 5% of school- age children have attention deficit- hyperactivity disorder (ADHD), which has been identified as a risk factor in conduct disturbance and antisocial behavior (DuPaul, Guevremont, & Barkley, 1991). Social workers encounter these children and adolescents within the program contexts of child welfare, treatment foster care, juvenile incarceration, therapeutic day pro- grams, residential and school- based programs (Centers for Disease Control and Prevention [CDC], 2009; Meadowcroft, Thomlison, & Chamberlain, 1994).

Home- based interventions with families and children are the preferred intervention setting for many child- and parent- related problems (CDC, 2009). The focus is on family interac- tion supported by the social learning model. Maltreatment or risk of maltreatment of child- ren by primary caretakers has become a focus of in- home intervention. Problem- solving and skills training for parents usually includes child- management skills, anger management, and addressing parents’ issues involving substance abuse, communication difficulties, and social isolation (CDC, 2009; Gambrill, 1994; Hodges, 1994; Kaminski, Valle, Filene, & Boyle, 2008).

Since the late 1950s, the treatment of choice for many professionals working with anxiety and phobic- disordered clients has been Joseph Wolpe’s (1990) “systematic desensitization.” Clients suffering from the inhibitory effects of phobic disorders have been the subjects of a great deal of effective intervention by behav- ioral social workers. Combined with the basic systematic desensitization, new cognitive- behavioral approaches are promising even more effective outcomes. In fact, it is now to the point where a social worker would be hard pressed to make an argument for an alternate treatment method for any of the phobic disorders.

At the same time, there is a serious problem concerning the slow and incomplete transfer of these evidence- based findings into day- to- day social work clinical practice (Fixsen, Blase, Naoom, & Wallace, 2009). Examining the quantity of behavioral articles in social work journals and books, behavioral social work has been characterized as a “major school of prac- tice” (Thyer, 1991, p.  1). In a survey of clinical social workers, one- third of the practitioners

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who participated in the study preferred a behav- ioral approach to their practice (Thyer, 1987a). Social workers reported that behavioral inter- ventions were most influential when applied to disorders such as anxiety, depression, phobias, addictions, sexual dysfunction, and relation- ship distress. Nevertheless, many misconcep- tions about behavior therapy continue to persist and may account for why more social workers do not employ evidence- based behavioral strat- egies in practice.

Education and Training

Training for behavior therapy occurs in a vari- ety of educational contexts. The content, for- mat, and objectives of behavior training vary widely (Alberts & Edelstein, 1990). A  social work curriculum generally provides an over- view of behavioral change principles and techniques but not detailed training (Thyer & Maddox, 1988). More intensive training may be offered in organizations or treatment settings to social workers, foster parents, and teachers of child and family centers and schools. Given the emphasis on evidence- based processes, the efficacy of behavioral methods, and the exten- sive application to problems identified in clini- cal practice, an argument can be made for the inclusion of CBT as part of the core curriculum in social work education. As evidence- based practice— it works!

Culturally Responsive Behavioral Practice

Concern for the needs of culturally different groups has received attention from behavior therapists as the population has increasingly become more diverse. Behavior theory, like many practice theories, emerged from Western cultural values, assumptions, and philosophy. In reality, both clients and behavioral social workers are racially and ethnically diverse. Efforts to offer ethnically sensitive social work practice are very much affected by the politi- cal, social, and economic power, and status of each group and setting. Disparities are well documented and barriers exist in terms of accessibility and participation in social work interventions. Barriers include philosophical

and values differences, languages, as well as individual and organizational structures asso- ciated with Western helping systems (Corcoran & Vandiver, 1996).

Working with culturally diverse individu- als involves recognizing diversity in both the context and behavior of individuals. Each cul- tural group develops its own coping strategies for problems, and like any identified group, cultural groups are not homogeneous. Its pro- file originates from the group’s cultural values, history, rituals, religion, migration experiences, organization and family systems, and class val- ues and norms (Devore & Schlesinger, 1996). Pay attention to the levels of assimilation, and factors such as language, religion, lifestyle, expectations, and attitudes toward helping (Thomlison, 2010). Many of the techniques used by Western- trained behavioral social work- ers may employ strategies that run counter to the values, beliefs, and family traditions of the cultural group. For example, an understand- ing of time is critical to the concept of shaping, reinforcement schedules, and extinction. This concept may be understood differently by those who measure time by activities. Also, what constitutes problematic behavior, help- seeking behavior, and inappropriate behaviors is inter- woven into a Western culture perspective of the person, and what behaviors, thoughts, and feelings make up the person. Many behavioral social workers argue, however, that on a theo- retical basis, the principles underlying behav- ior cross the boundaries of culture. The main concern actually is the fact that the assump- tions beneath principles of learning are not universally accepted. For example, a positive reinforcer, operationally defined as an event that increases behavior frequency, would not be culturally determined, albeit a specific positive reinforcer such as TV watching, which works in one culture may not work in another.

It is therefore very important for behavioral social workers at the beginning of assessment to understand how the concept of family and the individuals who constitute a family are defined in a given culture and recognize that individu- als make different choices based on their culture (Thomlison, 2010). If social workers mislabel behavioral interactions, then interventions can compound rather than resolve parenting

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dilemmas or other problematic behaviors. Therefore, interventions should be carefully sculpted to fit the client’s cultural orientations and preferences. It requires modification of existing interventions and understandings of behavior, so that behaviors are grounded in local contexts for understanding (Landrine & Klonoff, 1995).

It is suggested that organizations in eth- nic and diverse communities ensure that serv- ices have diversity represented in the social work staff and that staff have a high level of self- awareness and openness. Behavioral social workers need to remember that individuals develop problem- solving styles that fit their cul- ture and values, and therefore solutions must fit the cultural attributes of diverse populations. In summary, current research of the relationship between cultural competencies, behavior the- ory, and outcomes requires further study.

Conclusions

This chapter has taken the reader through the evidence- based world of cognitive- behavioral therapy and discussed how to proceed with assessment and intervention in social worker practice. Evidence has accumulated for the efficacy of a variety of treatments for men- tal health and behavioral problems, and the application of cognitive- behavioral practices to real- world clinical practices is possible. As for final thoughts, we conclude with the following summary:

1. CBT is action- oriented and relies heavily on an educational focus for client change. For those who want insight or talking psycho- therapy, this approach is not appropriate.

2. The focus is on behavior and/ or cognitive change, or both, and generally requires a structured approach to change by both client and therapist.

3. Some non- professionals and profession- als misunderstand or misrepresent the approach, seeing it as very simple and a quick fix for complex problems. Such misunder- standing is probably most often illustrated by inappropriately designed child- management programs that rely on aversive methods of punishment for undesired behavior, often

coupled with the unsystematic use of rewards for compliant behavior. Such interventions are devoid of the elements of behavior anal- ysis and the systematic use of behavioral techniques that is essential for successful behavioral change.

4. The behavior therapies are often thought to be derived from a homogeneous theory, when in fact they are made up of numerous theories of behavior with an array of optional intervention strategies and techniques. Many social workers fail to understand that differ- ent approaches are often available for specific problems identified through the process of behavioral assessment. Matching technique to problem is essential. Differential applica- tions relate to the problem and are guided by the behavioral analysis of the conditions under which the problem behavior occurs.

5. Cognitive behavioral techniques depend on relationship development and sensitivity to the client’s needs.

6. Because CBT has been applied to clients who have severe, debilitating or difficult- to- treat conditions, ethical considerations play a prominent role in behavior therapy. Many programs have established protective mechanisms, such as treatment- review pro- cesses, to address the issues of utilizing aver- sive procedures, determining appropriate individualized assessment and intervention, and keeping written records and assessment checklists and questionnaires (Sundel & Sundel, 1993).

To summarize then, CBT, as it has been pre- sented here, comprises a variety of distinctly different approaches to facilitating behavioral and, in some cases, cognitive changes. It has been developed from a strong commitment to planned and systematic assessment, a dis- tinct strength over other therapeutic mod- els of change. Intervention strategies evolve from the prescriptive approach to assessment, within a context of empirical inquiry, utiliz- ing nominal and ratio levels of measurement to establish the frequency and duration of problems. Its impact on social work practice continues to be felt, both directly in clini- cal practice and indirectly in practice areas such as task- centered approaches, as well

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as in single- system designs in research, and evidence- based processes. Behavior therapy has been demonstrated to be effective in most areas of social work practice. Behavior theory as an effective therapeutic intervention is well established, and it can be argued that behav- ior theory is the most advisable therapeutic option. CBT will be invaluable to social work- ers in every practice situation.

Note

1. Some argue that the concepts of “behavior therapy” and “behavior modification” are dif- ferentially applied (Franks, Wilson, Kendall, & Foreyt, 1990). For this chapter, we prefer “behavior therapy,” but the concepts will be used synonymously.

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The famous French philosopher Rene Descartes (1596– 1650) made a statement that has become well known in the annals of intellectual his- tory:  “I think, therefore, I  am” (Descartes, 2014). This statement guides one to the area of human thought, ways of organizing and clas- sifying human thought, and the various forms of behavior that are then influenced by it. It is this study of human thought and consequent behavior that has come to be known in mod- ern social sciences as “cognitive theory.” Social work and other helping professions use this the- ory for interventions with individuals, families, groups, communities, and organizations.

A dictionary definition of the word “cogni- tion” is “the process of knowing, or the capacity for it” (Merriam & Merriam, 1957, p. 160). The term “cognitive theory” has come to mean the art and science of understanding how humans

perceive, think, and process various forms of information and then respond to them. It has emerged as a discipline in sociology, anthro- pology, sociobiology, psychology, biology, soci- olinguistics, and social work. It engages in the study of how humans reason, make judgments, make decisions, and engage in problem solving. It includes how the human mind forms con- cepts that help us respond to various forms of situations.

The development of cognitive theory has been significantly influenced by the fields of computer and information technology, with their interest in information- processing and memory. Alternative forms of intelligence, logic, and memory were applied by theorists to the human mind and its processing of mem- ory and cognition. In the social sciences, the rise in popularity of “logical positivism,” with

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its focus on phenomena that are empirically verifiable, also contributed significantly to the development of cognitive theory and interven- tions. In the social sciences, logical positivism encouraged movement away from a belief in internal drives and unconscious forces as causes for human behavior. It pointed toward more observable and measurable phenomena such as environmental events and internal identifiable cognitions. The “personal construct theory” of George Kelly (1958), with its focus on interpre- tation and reasoning, further influenced the development of cognitive theory and interven- tions (Walsh, 2008). Of special importance here is Kelly’s notion of “personal constructs” (1955), referring to how individuals learn, create, and use important ideas to understand social realities.

Kelly (1955) identified three primary con- struct types, or “frames,” through which individuals interpret the world: preemptive con- structs, constellatory constructs, and proposi- tional constructs. The “preemptive constructs” prevent the reexamination or reintegration of new information, and allow individuals and events to be placed only in one realm (Hjelle & Ziegler, 1976). Once an opinion has been made, new information is not utilized to change or modify that opinion, and once a label is applied to a person or event, that label remains fixed. Rigid or fundamentalist belief systems may be considered to be preemptive constructs. In psy- chological terms, the concept of learned help- lessness (cf. Seligman, 1992; Peterson & Ma, 1993)  may be considered a preemptive con- struct. Individuals with learned helplessness have taught themselves over time that their actions are always ineffective, leading to hope- lessness and a sense of helplessness in the face of problems. For these individuals, the preemptive construct of helplessness prevents them from considering alternative actions and generating effective solutions to problems.

Like preemptive constructs, Kelly’s (1955) “constellatory constructs” also encourage fixed assignment of individuals or events to one group. However, unlike preemptive constructs, constellatory constructs allow more flexible thinking (Hjelle & Ziegler, 1976). Stereotypes are exemplars of constellatory constructs; an individual who belongs to a certain ethnic

group is also assumed to reflect the stereotypes assigned to that group. A  “propositional con- struct,” however, allows individuals to change their opinions based on new information and maintains room for the examination of new information and the reinterpretation of events (Hjelle & Ziegler, 1976). Kelly (1958) also iden- tified lesser constructs:  comprehensive con- structs, incidental constructs, core constructs, and peripheral constructs. An extension from the idea of personal constructs is the constructs developed and used by groups, communities, and organizations, variously known as collec- tive cognition, groupthink, definition of the sit- uation by a group, or the social construction of reality.

Disciplines and Political Correctness

Cognitive theory may be used to understand how the individual client or patient thinks about a social reality and how such thought, in turn, influences his or her behavior. It follows that this client can be a group, a family, a commun- ity, or an organization, and a helping process defines or guides ways of assessing and altering their thought and behavior. However, this very process can be turned around to ask: How does the help- provider organize his or her thoughts about the client or the patient? Often an aca- demic or professional discipline may get caught in the appropriateness or “political correctness” (the idea that people should be careful to not use language or behave in a way that could offend individuals or a particular group of individu- als) of a word, a concept, a linguistic usage, and ideas to understand clients or patients, and then some pathways to intervention become “polit- ically correct” while others are seen as “politi- cally incorrect.” Before one ventures into how clients or patients and their cognition should be understood to guide intervention, it is impor- tant to review how the cognition of the help- provider is often immersed in the norms of political correctness of a professional culture.

Our first example of such political correct- ness emerges from the professional help pro- vider’s notion of “functional” or “dysfunctional” thought and behavior. Within a modern soci- ety, the United States, for example, disciplines

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of clinical psychology and clinical social work often define an individual or a family as func- tional or dysfunctional within its environment. Such a way of defining an individual or a family is often supported by a “medicalized” (mean- ing using the traditions, rituals, and vocabulary of the medical profession) culture. Sometimes, however, defining a group or a community culture as functional or dysfunctional is seen by others within that profession or those out- side the profession as politically incorrect:  for example, gender role norms differ for both men and women across different cultures within the United States. This is something that is known to social work professionals, but it is considered not appropriate to interpret these differences as evidence of a dysfunctional community culture. In the discipline of social work, it is this norm of not seeing a community culture as dysfunc- tional that has contributed to what is known as “the strengths model” (Saleeby, 2005), or delib- erately not focusing on “the deficits” of a group or a community.

Comparable to the concepts of functional and dysfunctional are those of “adaptation and maladaptation,” “normalcy and deviance,” “nor- mal and pathological,” and “wellness and illness.” All of these concepts are used by academic dis- ciplines and the helping professions to define an individual client, a family, a group, a commun- ity, or an organization. These constructs, when seen as cognition and consequent behavior in a given environment, however, may still be use- ful, because they guide social workers in setting goals and in identifying what kind of thoughts or behaviors need to be changed. The profession of social work has long used the term “person in environment” (and by derivation, a family in an environment, a group in an environment, a com- munity in an environment, or an organization in an environment), and use of this paradigm clari- fies how clients are functional or dysfunctional, adaptive or not adaptive, normal or deviant, well or ill, and normal or pathological within one or more social environments.

Origins in Sociology

Goffman’s (1974) concept of “frames” and frame analysis is also helpful to our understanding of how social workers conceptualize problems

with individuals, groups, and communities. Frame analysis is a method of social inquiry that analyzes the cognitive schemas influenc- ing the interpretation of events by individuals and groups. In Goffman’s own words regarding frames, the “definition of a situation is built up in accordance with principles of organization which govern events … ; frame is the word I use to refer to these basic elements” (Goffman, 1974, p.  10). An example of the use of frames is our interpretation of popular rap music lyrics such as Eminem’s

Now I don’t wanna hit no women when this chick’s got it coming.

Someone better get this bitch before she gets kicked in the stomach.

Our interpretation of such lyrics either as empowering creativity and expression for young, urban, poor, primarily black men— or as oppressive misogyny for women— is ultimately determined by the frame we use to analyze and define the situation.

The classic work of Chicago sociologist W. I. Thomas (1923) introduced the phrase “defi- nition of the situation,” which meant how any given situation can be seen, interpreted, and acted upon differently by different individu- als from different backgrounds. His axiom was then used in the classic study of Polish peasants in Europe and America (Thomas & Znaniecki, 1927). The Polish immigrant in American soci- ety, for example, viewed a situation very differ- ently than did a peasant who was a member of Polish society. Since the work of Thomas (1923), the axiom “definition of the situation” has become an important way of understanding how different individuals see and react to the same situation differently. Since the work of Thomas, Talcott Parsons (1951) added the idea of “pattern variables,” which suggests that there are about five ways one can view and respond to a given situation. One of these five ways is a definition of the situation prompted either from affectiv- ity or from affect- neutrality. A  tragic accident may create serious wounds to a given person, and an onlooker may define this situation with affect and start screaming. A medic or an emer- gency room physician is likely to respond to the same situation from affect- neutrality, since the response is prompted by years of medical and

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technical training that mandates a calm and problem- solving demeanor.

A further development of the ideas of Thomas and Parsons can be found in the trea- tise by Berger and Luckman (1966), where they introduce the idea that “reality” is socially con- structed. An example of this way of thinking can be found in the story of Teresa of Avila dur- ing the Spanish Inquisition. In this story, about 14 nuns were found to be communicating with spirits and other beings that most people could not see or hear. Some professionals in clinical social work today would label this behavior as hallucinations and delusions. The church fathers of the time, however, defined this behav- ior as “evil,” and called for them to be tied to a stake and burned alive. At this point, Teresa is supposed to have said that the nuns should be treated as comas enfermas, meaning that they should be treated as if sick (Bates, 1977, p.  9). In this example, the first construction of real- ity was done by the church fathers when they defined the situation as “evil.” Then, the second construction of reality was done by Teresa of Avila, when she declared that the nuns should not be treated as “evil,” but defined as “sick.” The definition of the situation by the church fathers called for burning the women, whereas that by Teresa called for putting them in the custody of persons qualified to provide treatment.

The changing of a definition of the situa- tion by Teresa of Avila from “evil” to “sick” can be called a form of “cognitive restructuring” (Cuncic, 2014). Here, the cognitive structure of the church fathers is being restructured. Later in this book it will be shown that cognitive restructuring is an important technique used by psychologists and social workers.

Many individuals past and present believe that the experiences of Teresa of Avila were genuine experiences of God’s actual presence, through which Teresa gained the wisdom and strength to establish convents and monaster- ies throughout Spain. Furthermore, Teresa’s visions are presumed to have led her to a deeper, more reflective spiritual practice, and the dis- semination of her spiritual understanding through inspirational writings. For individuals with more mystical religious beliefs, a situation may be defined as a significant religious or spir- itual experience. Walsh (2008) reminds us of the

importance of incorporating this understand- ing into the social work assessment process.

The concept of the definition of the situ- ation has seen important usages in current studies of managers in industry (Trompenaars & Hampden- Turner, 1997), who point out that managers in industry learn how to think and solve problems using their own personal, organizational, and other backgrounds. The study of organizational culture today, in order to understand management behavior (Schein, 2010) and make management effective and effi- cient, evolves from these contributions by soci- ological theorists.

Origins in Anthropology

How humans think and react to a situation was the subject of an elaborate study by the anthro- pologist Malinowski (1955). The variety of ways in which different cultures appraise a situation was the focus of his study. For example, the finality of death is a universal experience in all human groups. However, how to give meaning to death by socially constructed funeral proce- dures varies from culture to culture.

A controversial paradigm emerged in anthropology when Lucien Levy- Bruhl (1926) introduced the idea of “cognitive relativism.” His work suggested that all human groups develop a cultural style of adaptation to their environments. This cultural style, in turn, teaches their members how to think. Within the different styles of thought, some are more func- tional (that is, they help in the group’s adap- tation to its environment better) than others. The implication of this is that certain cognitive styles adopted by some cultures may be “supe- rior” to those of others. The contemporaries of Levy- Bruhl saw this theory of cognitive relativ- ism as somewhat ethnocentric. However, even to date, the idea of functional versus dysfunc- tional cognition at the individual level is very much accepted, and current psychologists and clinical social workers engaged in cognitive- behavioral intervention use the idea of func- tional versus dysfunctional cognition (that is, an individual client or patient’s way of thinking is either adaptive or maladaptive) in their pro- fessional practice. The controversy begins when one suggests that the cognitive style taught by

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one culture is more functional than that of another.

Origins in Sociobiology

An important pioneer in sociobiology is Edward O. Wilson (1978), who argued that human cog- nition and behavior cannot be well explained by the ideas of individual development, social environment, or cultural context, and should be understood as having emerged from an evolu- tionary sequence. This means that human cog- nition and behavior originate, not exclusively from individual development (as many psy- chologists suggest) or from group or commun- ity culture (as sociologists, anthropologists, and social workers suggest), but from genetic and biological adaptation. This position created a controversy, and it was hotly disputed by many social scientists who argued that it was close to the ideas suggested by social Darwinism (the belief that persons are subject to the same laws of natural selection as plants and animals) and eugenics during the latter part of the 19th and early part of the 20th centuries. This idea in sociobiology is especially unpopular in social work, since it leads to a position that many forms of human cognition and behavior are bio- logical in origin, and subsequently not subject to social intervention.

Origins in Psychology

The work of Swiss psychologist Jean Piaget is usually seen as an important beginning of cognitive theory in the discipline of psy- chology. Piaget was the first to propose that “schemata” form the basic structures of mind that allow individuals to organize informa- tion and intellectually develop (Piaget, 1932; Robbins, Chatterjee, & Canda, 2012, pp.  264– 277). He further proposed that humans main- tain two biologically inherited cognitive functions:  “Organization,” which refers to the tendency to blend and coordinate physical or mental structures into higher- order structures; and “adaptation,” which refers to the ways the mind changes information in order to accom- modate the external environment (Robbins et al., 2012, p. 278). According to Piaget, impor- tant processes in cognitive development include

three areas:  (1)  assimilation, meaning the ways in which new information is assimilated into existing mental schemata; (2)  accommodation, which is the development of new schemata through assimilation; and (3) memory, which is the ability to learn and maintain new learning over time.

Piaget (1951) further proposed a linear and stage- based model of cognitive develop- ment where each stage is built upon the previ- ous stage. Stages are associated with a specific childhood age, and in each stage, the child is expected to master specific sensorimotor and cognitive tasks. Stage one, the sensorimotor stage, occurs between birth and age two, during which children develop goal- directed behav- ior, gain a sense of objects and permanence, and develop the capacity for symbolic thought and for mentally representing objects (Robbins et al., 2012, pp. 264– 266). Stage two, the preop- erational period, occurs between ages two and seven and involves the development of language, increased use of symbolization and mental representations, and increased skill in under- standing interrelationships between objects. In stage three, concrete operations, which occurs between ages seven and eleven, children learn the cognitive functions of reversibility and compensation. They become capable of focus- ing on more than one perception at once (com- pensation) and of undoing or redoing an action in their minds (reversibility). Stage four, formal operations, occurs between ages eleven and fif- teen, and includes the development of reasoning and increased capacity for abstraction.

While Piaget  also proposed a theory of moral development that included a premoral stage, moral realism, and moral relativism, it was Kohlberg (1969) who proposed a more complex theory of moral development in child- ren. Kohlberg’s is a six- stage theory divided into three levels (Robbins et al., 2012, pp. 276– 277). The first level, the preconventional level, includes the obedience and punishment stage and the egoistic orientation stage. This level is distin- guished by its focus on rules, punishment, and rewards as motivators for moral behavior. The second level, the conventional level, includes the stages of the good boy/ nice girl orientation and authority- maintaining morality. The focus at this level is on approval from authority figures

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and the avoidance of social disapproval. In the final level, the postconventional, which occurs from age 16 into adulthood, social contracts and the principled conscience are developed. At this level, “emphasis is placed on democrat- ically accepted law and consensus as well as an understanding of the greater good and the potential to modify an unjust social contract” (Robbins et al., 2012, p. 278). It is important to note that Kohlberg believed that this third level was rarely achieved by most individuals.

A simple extrapolation from Kohlberg’s the- ory of moral development, however, can be used to return to the matter of cognitive relativism of Levey- Bruhl (1926). This extrapolation may be framed in the following manner. Kohlberg proposes (1969) that formal education can be an important contributor to the development of postconventional morality. This may mean that the more the formal education an individ- ual has, the greater the probability of attaining a moral frame that can be considered postconven- tional. However, formal education is also often used as a measure of social class (Hollingshead, 1975; Beeghley, 2007). That is, the more the formal education one has, the higher the like- lihood of one’s placement in a higher social class. Does that mean that persons placed in a higher social class are more likely to attain postconventional morality? This very awkward (and perhaps politically incorrect) position was raised by Kanjirathinkal (1990). Since his work, this politically incorrect question has not been pursued in subsequent research in the social sciences.

An example may be important here. Preserving the environment is a moral position adopted by many individuals. Is this a postcon- ventional morality? Is it more common among the members of the upper classes than among the members of the poverty classes? Do the members of the upper classes have more invest- ment in preserving the environment than those from the bottom end of the socioeconomic ladder? It is questions like this that return to the idea of cognitive relativism, and the polit- ical correctness of questions like this remains unsettled.

Three other scholars have made substantial contributions to cognitive theory in the disci- pline of psychology:  Jerome S.  Bruner, Leon

Festinger, and Albert Bandura. Bruner, influ- enced by the work of Lev Vyogotsky, contrib- uted to understanding how children learn in a social environment. He called it the “the- ory of cognitive scaffolding,” which describes how children learn more when provided with enough support during the initial stages of learning (Bruner, 1966; Bruner, 1979; Bruner, 1990; Bruner, Goodnow, & Austin, 1956). By implication, it means that all human beings acquire more knowledge when provided with cognitive support. Recent research has revealed that cognitive support of children provides sub- stantially more and better learning than the use of corporal punishment (Reid, 2014).

Psychologist Leon Festinger suggested that humans often struggle to reach cognitive con- sistency. He suggested that “cognitive disso- nance” is an antecedent condition that leads to activity toward dissonance reduction, much like hunger leads toward activity that leads to hun- ger reduction (Festinger, 1957). Festinger’s work continues to develop new works about cognitive consistency and what it does to human behavior (cf. Hamilton- Jones & Mills, 1999).

Albert Bandura (1977; 1986; 1989) delineated how cognitive and social factors influence imi- tative behavior, which, in turn, influences learn- ing. He suggested four processes that contribute to learning:  attention, retention, production, and motivation. First, a child must pay attention to selected stimuli and filter out other stimuli. Second, the child must retain selected stimuli, either by semantic symbols, or by visual repre- sentation. Third, the child must be able to pro- duce a given behavior that has been retained. Fourth, a child must have the motivation to produce a given behavior. These four processes affect the cognitive and social factors that medi- ate learning.

Biology and Cognitive Theory

Recent years have seen an increase in interest in and research on the biological basis of cogni- tion. Biological and neurological research has examined the ways neural systems mediate the relationships between cognition and the social environment, leading to increased understand- ing of disorders such as autism (Nurius, 2008). Technological methods for examining and

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measuring neuronal activity related to cog- nitive functioning such as positron emission typography (PET), which measures cerebral blood flow, and functional magnetic resonance imaging (fMRI), which measures brain acti- vation, have been widely used over the past 15 years.

It is assumed that better understanding of the neurological components of cognition will allow researchers to understand the effects of different types of neuronal activity on informa- tion coding, processing, and interpretation (Morris, Tarassenko, & Kenward, 2006). One important insight regarding cognitive processes established from neurobiological research has been in the area of implicit cognitions. Research has found that separate brain areas are respon- sible for explicit cognitive processing which is reflective and controlled, and for implicit processing which is more impulsive process- ing responsible for automatic appraisals that we may not be aware of (Wiers & Stacy, 2006). This dual cognitive- processing model has informed social workers’ understanding of emotion regu- lation and impulse- control disorders, especially those associated with addiction and trauma (Shapiro & Applegate, 2000).

As neurobiologically driven interventions are utilized, some may be concerned that they could make social work interventions obso- lete. However, these areas of research have informed new clinical interventions that have been adopted by social work practitioners. These include mindfulness- based interventions (Bowen, Chawla, & Marlatt, 2011)  and dual- processing models of intervention (Matto & Brown, 2013)  that address implicit processing in addictive disorders and relapse. Additionally, neurobiological research on the effects of trauma on cognition support experimental interventions such as movement, art, and music that many social workers integrate into clinical practice (van der Kolk, 2014). Recent research on the effects of environment on cognitive pro- cesses mediated through neurobiological mech- anisms also offers social workers an enhanced evidence base from which to advocate for poli- cies that improve ecological, social, and educa- tional environments that impact neurological and cognitive development (Odom, Pungello, & Gardner- Neblett, 2012).

Language Use and Cognitive Theory

Begley (2009, p.  31) has summarized several research findings suggesting that language usage may shape cognition. An example given by her is that a very tall bridge in the south of France, the Viaduct de Millau, is seen as femi- nine by German speakers. In French, it is seen as masculine. German speakers see it as a form of beauty, whereas French speakers see it as a powerful structure with an impressive pres- ence. Begley then goes on to suggest that each language is embedded in a culture, and even though she does not use the term “cognitive rel- ativism,” she concludes that each and every lan- guage defines a situation in a unique way that is different when seen in comparison with other languages. Thus, within a language, words cho- sen to define a situation may vary from person to person, from group to group, and from pro- fession to profession. Furthermore, in two dif- ferent languages, as shown in the example cited above, a situation may be defined in one given way in one language and in another way in another language.

Another example of linguistic construc- tion of reality comes from how “madness” is defined in English- speaking cultures (Bates, 1977) and how its translation in Bengali (called paglami) is defined in Bengali- speaking cul- tures. In English- speaking cultures, “madness” essentially has two definitions, and at times they can be overlapping (cf. Kutchins & Kirk, 1997; Watters, 2010). The first leads to defining a person who is not in contact with reality as the larger society knows it, and the person is seen as having hallucinations or delusions. This definition often leads to seeing the person as “sick,” as was done by Teresa (discussed above) during the Spanish Inquisition. This definition often calls for appointing members of the med- ical and psychological professions as custodians of the situation. A second definition also exists in English- speaking cultures, and this leads to defining a person as “deviant” according to the norms of larger society, and requires ostraciz- ing or incarcerating the person. In the latter case, members of the justice system are seen as appropriate custodians of the situation. Thus one can suggest that English- speaking cultures,

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for the most part, maintain two definitions aris- ing from the use of the word “madness.”

In Bengali- speaking cultures, however, the two above- mentioned situations also pre- vail. In addition, the behavior of a person who gives up living as an everyday householder and pursues the meaning of life by deep introspec- tion, or persons who go from village to village engaged in wanderlust and support themselves by begging and singing, may often be framed as additional forms of madness or paglami (Bhattacharya, 1984; Chatterjee, 2009). The act of begging is not seen with stigma in Bengali culture. However, the same act in Europe and America, as done by the Hare Krishna groups (and the ideology of the Hare Krishna group was imported from Bengal to Europe and America) is seen as an annoying form of mild deviance that calls for both expressions of dis- approval and, at times, forcible removal from public spaces by law- enforcement authorities. The implication of this position is that language used by a therapist, a clinical psychologist, or a clinical social worker may guide the cognition of a patient or the ways in which a client thinks and acts. Thus, a therapist’s choice of words may influence the outcome of therapy.

Yet another example of language use and cognitive theory can be derived from the use of the Arabic word haram (or haraam). It means “sinful.” In Islam, it can be applied to any act that is forbidden by God (Allah). It is applied to any act or object in the human experience that is prohibited, and carries immense power. In Nigeria, it is used to name the fundamental- ist Islamic group Boko Haram, which means Western education for girls is sinful and pro- hibited. Just the utterance of the word defines a situation as sinful and calls for violent suppres- sion of that situation.

Using Kelly’s (1955; 1957)  idea of preemp- tive constructs, it can be suggested that a cul- ture may use language to create preemptive constructs. Thus, the word haram may be used as a preemptive construct by Arabic- speaking people, or the word may be imported into other languages where Islam is the eminent religion. Similarly, the word nigger is used by English- speaking people as a preemptive construct to define persons of dark skin, or the word ach- chhut (meaning “untouchable”) may be used

by Hindi- speaking people to define persons of certain lower castes. Yet another example is the use of the word asati (meaning “unchaste”) by Bengali- speaking people to describe some women. Just the utterances of these words are used as preemptive constructs.

Social Work Treatment with Individuals and Families: Current Ideas

The focus of cognitive theory and intervention is on the conscious thought processes, which are considered the basis for all behavior and emo- tion (Walsh, 2008). The underlying assump- tions of this theory are that behavior is affected by thoughts or cognitions, that these cognitions may be modified, and that behavior change may occur through the modification of these cogni- tions (Dobson, 2001). Albert Ellis, the developer of “rational- emotive” therapy (Ellis & Bernard, 1985), is considered one of the parents of cogni- tive theory in the field of psychology. Trained in psychoanalytic methods, Ellis decided to pursue more active treatment methods. Ellis developed what has come to be known as the “ABC model” for assessing symptoms. This model maintains that an activating event (A), is followed by an individual’s cognition or belief about the event (B), which leads to an individual’s symptoms or consequences (C). This ABC model remains cen- tral to assessment in cognitive therapy. Ellis fur- ther maintained that individuals are irrational, and he identified common beliefs or cognitive distortions to which individuals are vulnerable (Cuncic, 2014; Dobson, 2001). This concept is also central to current cognitive theory, which emphasizes the identification of cognitive dis- tortions in assessment and intervention.

During the 1970s, Aaron Beck made sig- nificant strides in the use of cognitive theory to develop interventions for the treatment of individuals with depression and anxiety (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979; Beck, Emery, & Greenberg, 1985). Beck developed his cognitive theory initially for the treatment of depression. Trained as a psychoanalyst, Beck attempted to embrace psychoanalytic theories of depression, but he eventually concluded that depression was maintained by negative cogni- tions and negative schemas. These negative

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schemas were composed primarily of “personal ineffectiveness, personal degradation, and the world as an essentially unpleasant place” (Walsh, 2006; 2008). Beck’s most significant contribution to cognitive theory was the impor- tance of identifying automatic thoughts and challenging them (Leahy, 2004; Leahy & Dowd, 2002). As Beck continued to develop his cogni- tive theory and interventions, he extended the technique to include treatment for anxiety, pho- bias, and personality disorders.

Glasser (1988) further extended cognitive theory in his development of “choice theory,” which informed his approach to intervention. It was called “reality therapy.” Choice theory main- tains that humans, rather than being externally motivated, have five intrinsic motivating needs for survival:  love, belonging, power, freedom, and fun (Corey, 2009). Glasser’s theory is based on the assumptions that individuals choose their behaviors and that the only thing individuals have control over is their own behavior (Glasser, 2001). Furthermore, individuals’ behavior is based on their thoughts, feelings, physiology, and prior experience (Austad, 2009). Emerging from this theory, reality therapy encourages individu- als to take responsibility for their choices, main- tains a present focus in treatment, and rejects focusing on symptoms (Corey, 2009).

Recently, cognitive theory has led to the development of treatment for a variety of indi- vidual and relational problems. These include treatments for post- traumatic stress disor- der (Foa, Keane, & Friedman, 2000), eating disorders (Fairburn, 2008), anxiety (Beck, 1976), stress and coping (Meichenbaum, 1996), depression (Ellis, 2006; Beck, 1976), obsessive- compulsive disorder (Steketee, 2006), schizo- phrenia (Kingdon & Turkington, 2004), other personality disorders (Linehan, 1993), and relational concerns (Dattilio & Padesky, 1990). Emery, Hollon, and Bedrosian (1981) extended the use of cognitive theory in the treatment of the elderly, individuals with sexual dysfunc- tion, and individuals with alcohol depend- ence. Granvold (1994) added the dimension of constructivism to his discussion of cognitive theory highlighting the individual’s respon- sibility in forming their own reality. This line of cognitive- constructivist thought eventu- ally developed into “narrative theory” and the

narrative approach to counseling and psycho- therapy (White & Epstein, 1990).

In the field of social work, at the level of what was earlier called “casework practice,” and now called “case management practice,” the use of cognitive theory became popular in the late 1970s (Goldstein, 1982; Chatterjee, 1984). Goldstein (1982) identified the development of psychoanalytic therapy as the impetus for the use of cognitive theory in social work: “Caseworkers at that time were admonished not to dabble in the psychoanalyst’s domain of the unconscious … (therefore) social workers assumed guard- ianship of the more conscious and cognitive realms of their clients’ lives” (p.  546). Werner (1982) underscored the humanistic underpin- nings of cognitive theory as a theory focused on the human capacities of thought, reasoning, and learning. An earlier book by Werner, A Rational Approach to Social Casework (1965), had marked the beginning of the purposive use of cognitive therapy in the field of social work. More recently, Sharon Berlin modified established principles of cognitive therapy to propose a “cognitive- integrative perspective.” While relying on estab- lished cognitive interventions, this model also focuses on the social causes of meaning in a cli- ent’s cognitions and utilizes other therapeutic approaches such as advocacy or case manage- ment for intervening in the client’s environment (Berlin, 2002; Berlin & Barden, 2000).

The task- centered methods used in social work practice are also derived from cogni- tive theory. The task- centered model is usually time- limited and focused on the client’s prob- lem as defined by the client. In this model, the individual’s beliefs, or views of him- or herself and the world, are considered to be the motiva- tion for action (Reid, 1978). Emotions are the product of an individual’s beliefs. The distance between what individuals want and their evalu- ation of their capacity to attain that is the focus here. Values underlying this model include cli- ent self- determination, a present– future focus, time- limited intervention, and “contracting,” which means an agreement between client and social worker regarding the work to be done, and empirical orientation (Fortune, 1985). Many of the underlying values and assumptions of this model are similar to the values and assumptions of cognitive theory.

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Assessment, as informed by cognitive the- ory, includes the identification of cognitive distortions (cf. Grohol, 2014)  through Socratic questioning. Cognitive distortions include over- generalizing, negative scanning, personalization, catastrophizing, dichotomous thinking, emo- tional reasoning, magnifying, minimizing, and selective abstraction (Gambrill, 2006; Grohol, 2014; Walsh, 2008). Socratic questioning is done with the purpose of assisting people in identify- ing the distorted aspects of their thinking. Such questioning allows client and worker to under- stand the client’s core beliefs about a situation and to examine the evidence both supporting and refuting those core beliefs. Cognitive ther- apy interventions include cognitive restructur- ing (see Cuncic, 2014), where the worker assists clients in changing their perception of a problem and generating alternative interpretations of it. The task then is to develop and use coping skills that entail learning new behaviors and thought processes such as problem- solving techniques and communication (Walsh, 2006; Walsh, 2008).

Case Example

Martha is a 34- year- old married mother of three young children. She has been referred to treatment by her primary care physician, who noticed her depressed mood and irritability during her most recent doctor’s visit. When questioned, Martha revealed that she has been feeling “overwhelmed” recently, irritable with her children, and discouraged by what she considered their “bad behavior.” She also complained of mari- tal concerns and a deteriorating relationship with her husband. Martha was referred by her physician to the area outpatient mental health center and was seen by a social worker. During the initial assessment, Martha described herself as depressed and anxious. She had three children under the age of six, and a husband whom she described as “withdrawn” and “unhappy.”

Assessment

After gathering a complete family, psychiat- ric, and medical history from this client, the social worker began to monitor the cognitive distortions evident in Martha’s thinking. These

included over- generalizations such as thinking, “I am a horrible mother,” and “My children hate me.” Magnifying and catastrophizing occurred frequently with Martha. When her eldest child was sent to the principal’s office at school for talking during class, Martha immediately had thoughts such as, “My child is heading for trou- ble,” and “I have failed as a mother and my chil- dren are failing.” The social worker then utilized Socratic questioning to challenge the rationality of Martha’s thought process. The social worker also used an example presented by Martha that described a common and repetitive interaction between Martha and one of her children. Using the client’s own example, the social worker identified the ABCs in this scenario: the activat- ing event, belief about the event, and Martha’s responses of hopelessness and depression.

Intervention

The social worker worked with Martha on cog- nitive restructuring (cf. Cuncic, 2014). Using a typical event— her child spilling his milk at the dinner table— Martha was made to identify her belief that her child was “purposefully trying to get my goat” and the anger and resentment that resulted. This event was usually followed by Martha yelling at this child. Her son would then tell her he hated her (activating event), leading to Martha’s thought that she was a bad mother (core belief) and the resulting hopelessness and depressed mood (emotional consequence).

Following an exploration of the ABC process in Martha’s scenario, the social worker encour- aged her to consider other thoughts and inter- pretations with which to replace the identified distortions. The social worker asked Martha to generate and consider other reasons why her son might spill his milk at the dinner table. He asked her:  “Can you imagine how you would feel if you thought that David’s behavior was simply an accident or that he was tired from a long day at school? How might you react dif- ferently if these were your thoughts?” In this way, Martha was able to consider alternative interpretations to events and generate differ- ent emotional responses within herself. The social worker attempted to challenge Martha’s irrational beliefs by setting up tasks for her to try in her daily life in order to test the veracity

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of her distortions. The social worker encour- aged Martha to try an experiment at home, and instructed her that “when David spills his milk this week, calmly give him a towel with which to clean up the mess. Then notice the ways in which the outcome of this event changes.” Martha was also instructed in the use of self- instruction training (Meichenbaum, 1996)  or positive self- talk. The social worker helped Martha create statements that she could say to herself when upset with her children during dif- ficult parenting moments. These included such statements as “My children are doing the best that they can,” “Everyone makes mistakes, and this one isn’t the end of the world,” and “All in all, I am an adequate mother.”

Given that Martha’s depressed mood was also related to marital discord, the social worker rec- ommended couple’s treatment for Martha and her husband, Mark. Following three months of work with Martha individually, the social worker invited Martha’s husband in to engage in the couple’s treatment. Cognitive restructuring, communication skills training, and training in problem solving were utilized with Martha and Mark. Each member of this couple was able to identify distorted core beliefs that affected their interactions with each other. Using Beck’s (1976) model, the social worker helped Martha identify the event— Mark’s withdrawal from her; her automatic thought— “He refuses to help me with the house and kids”; her core belief— “I am unappreciated”; and her emotional reac- tion of depression and resentment toward Mark. Mark identified his automatic thought in response to Martha’s resentment, which was “She’s unhappy with me and I don’t know why.” His core belief was “I am inadequate,” lead- ing to his withdrawal from the relationship. Over time, the social worker helped Mark and Martha use “I” statements in communicating with each other, to reflect back to each other the thoughts and feelings expressed by the other, and to make clear requests of each other.

Social Work Intervention with Groups: Current Ideas

At times, the use of the “treatment” metaphor may give an impression (or define the situation) that cognitive theory is more often applicable to

social work intervention with individuals and families in clinical social work. This is not true, because cognitive theory is also useful in social work interventions with groups, and such inter- ventions can be done for attaining ends of pri- mary socialization (as in school social work and in neighborhood- based community centers), re- socialization (as in prisons and other settings where juveniles and adults are incarcerated), and treatment (as in purposive group work with patients and substance abusers). Cognitive theory can also be used to accomplish what is called “consciousness- raising.” For example, it can be a useful tool in working with groups of victims of domestic violence, child abuse, or elder abuse. The purpose of such intervention using the method of group work is to change the cognition of the group members from a defini- tion of the situation of “I am a victim” to “I am capable of overcoming a victim role.”

The legacy of Grace Coyle (1937) can be sug- gested as an intellectual journey that had its foundations in cognitive theory. Even though formally not referred to as an intervention based on cognitive theory (it was called a paradigm based on theories of socialization), the practice goals of this paradigm were focused on helping a group (like adolescent peer groups and other various types of human groups) change its cog- nitive style. Thus, for example, a group worker dealing with working class adolescents would struggle to teach this group that the pursuit of success in schools and that developing a career is more functional than the pursuit of gang violence.

Social work practice with groups has evolved into multiple areas of practice since the pioneering work of Coyle. Today, it can be used in healthcare settings to teach groups about cognition and behavior that contribute to wellness, avoiding addictions, and engaging in prevention of illness. It can be used in pris- ons and juvenile incarceration settings so that inmates in these settings learn how to become productive members of society. It can be used to bolster support groups for victims of domes- tic violence or child abuse. Groups that develop as “cults” or “new religions” often use a new form of cognition to indoctrinate their mem- bers. Thus, for example, the Nation of Islam may teach cognitive styles to its members that

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are different from those offered in Christianity or Judaism. The same holds true for groups like Moon’s Unification Church, Scientology, or Hare Krishna groups. Depending on social position, one may identify these groups as “cults” or as “new religions.” Also, there have been interventions developed in psychology and social work about how to engage in depro- gramming persons who have become indoctri- nated by one or more of these groups.

Case Example

Jamal Bana is the third Somali- American from the city of Minneapolis to head for Somalia and die there. He is one of more than a dozen missing Somali- Americans whose families believe that they have gone back to fight a holy war. “Someone must have put some- thing in his mind,” Omar Jamal of Minneapolis’ Social Justice Advocacy Center said. “He must have been somewhat disillusioned and indoctrinated because he didn’t have any clue about Somalia at all” (CNN.com/ world, 2009).

Interpretation

Viewed from the discipline of sociology, this is a case of ideological indoctrination of an American young man to join al Qaeda and become a part of the Islamic fundamentalist war call. Viewed from the discipline of psychol- ogy, this is a case of a cognitive structuring of a Somali- American young man to join a call to war by a terrorist group. This was a case that, viewed from a psychological perspective, called for a cognitive restructuring. Such a restruc- turing would have deprogrammed Jamal Bana from thinking of al Qaeda as a noble organi- zation to recognizing it as a very destructive and deviant group. Here, cognitive structuring could be undertaken by two groups:  the first were the recruiting agents of al Qaeda program- ming Jamal to go and fight in Somalia; and the second are the psychologists and clinical social workers who might have been able to engage in deprogramming Jamal to help him reject ideas to engage in terrorist causes. In this case, the act of deprogramming never happened.

Social Work Intervention with Communities: Current Ideas

Just as “truth,” “justice,” and “morality,” are cul- turally constructed (cf. Geertz, 1973), so are “domestic violence,” “child abuse,” “elder abuse,” and “setting up and utilizing mental health ser- vices.” For example, violence in a family may be defined by one group as a situation requiring intervention, and by another group as a pri- vate matter in a family that should be ignored. Similarly, child abuse, elder abuse, or not seek- ing help for personal problems may be seen by one group as problems requiring intervention, and by another group as private matters that should be left alone. Working with community groups may necessitate developing awareness at the community level that these social problems require solutions at the community, regional, and national levels. Community organization and community development efforts can be established toward the pursuit of these ends. A special example of such efforts is in the work of Paolo Freire (1970), who taught that members of a community can be taught to see the inherent contradictions within a community culture, and that such an education can create a new form of cognition in disadvantaged communities. He called this form of change in the cognitive struc- tures of the disadvantaged conscientization.

Two other traditions contribute to the study of cognitive structures at the community level, and they generate ideas for social work practice with communities. They are the semiotic tradi- tion and the tradition that explores how the use of authority is socially constructed in a com- munity culture. The semiotic tradition focuses on the study of meaning that a given behavior, ritual, art form, or procedure has for a given community (Danesi & Perron, 1999). In fact, the term “semiotics” means the study of seman- tic or linguistic structure. The common method for doing such studies is to develop narratives of these behaviors, rituals, art forms, or pro- cedures in such a way that the cognitive foun- dation and meaning inherent in them emerge by themselves. The discipline of cultural or social anthropology has pioneered this tradi- tion, though the discipline of cultural sociology has also contributed to such efforts. This tradi- tion can be used to develop narratives about

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an entire community culture, or about some important parts of a community culture, like how justice, morality, adolescence, or providing and utilizing mental health services are viewed in this culture.

Yet another tradition in community- based work may be called “explorations in different forms and sources of authority.” This tradition focuses on the study of different types of author- ity and their legitimacy in different sociocul- tural situations. Often this tradition is seen as having started with the work of Weber (1999), and his influence on modernization theorists (Jaffee, 1998), on the works in economic sociol- ogy (Swedberg, 1990; 2003), and the work in the social construction of reality by Berger (1977) and Berger and Luckman (1966). The method used here is the tracing of events that show the bedrock of the authority structure in a given social setting, assessing whether that authority is based on tradition or modernity, and imply- ing that authority and methods of production and governance based on modern knowledge are more likely to produce social and economic development.

Social Work Intervention with Organizations: Current Ideas

While the classic work of Weber (1999) can be seen as a formal beginning of the study of orga- nizations, a current development influencing how organizations should be seen is emerging from the ideas of Schein (2010). At least two types of organizations are important in social work practice: social agencies that are the means of social service delivery (where the personnel are mostly social workers); and organizations built for empowerment of community members (where the members of the organization often are community residents and are clients of social workers). Schein’s work informs us that, in order for organizations of both types to be effective (meaning, is this organization capable of attaining the goals it has set for itself?) and efficient (meaning, is this organization capable of pursuing its goals with efficient use of its resources, or is it caught in efforts that are not always cost- conscious?), organizational culture and the cognitive assumptions that maintain this culture must be considered. Schein’s work

is informing social workers that it is important to learn how the “cognitive scaffolding” of an organization may have developed, which, in turn, is sustained by the culture of that orga- nization, and that this cognitive scaffolding is either capable of making an organization effec- tive and efficient or may be caught in its “trained incapacity” (a term coined by Veblen, 1997).

Conclusions

Many disciplines have contributed to the ways in which cognitive theory is used to understand human thought and its consequent behavior, and have fed the development of interventions in the field of social work. The early developments of computer processing and logic, the anthropolog- ical and sociological examinations of culture and society, and the psychological understanding of cognitive development and intervention, have all contributed to the person- in- environment per- spective, encouraging the use of cognitive the- ory at multiple levels. Cognitive theory is a very useful tool in social work practice, community organizing, social casework, and nonprofit man- agement, as well as clinical social work. While it has emerged as a popular form of intervention at the level of social work practice with individuals and families, it also has immense potential for social work practice with groups, communities, and organizations.

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Constructivism as a conceptual framework for social work practice is relatively new. While various practice perspectives and treatment approaches in social work have historically reflected constructivist concepts and principles, only relatively recently have these been recog- nized as such. Constructivist ideas, however, have a long history in human thought, having found expression in such diverse fields as art, mathematics, literary criticism, philosophy, the social and behavioral sciences, and related help- ing professions. Any exhaustive examination of constructivism for its relevance to human behavior alone would lead to the complex delib- erations of philosophers on metaphysics, episte- mology, and ontology, as well as to the studies of psychologists on the nature of perception, cogni- tion, and learning, and more recently, an explo- ration of the burgeoning field of neuroscience

would need to be included. While an investiga- tion on this scale is obviously beyond the scope of this chapter, aspects of these fields of inquiry will be visited in formulating a constructivist conceptual framework for social work practice.

In classifying the various theory develop- ment approaches taken by social work, Turner (2011) identified a variety of new theoreti- cal approaches that represent innovative ways of conceptualizing social work treatment. Constructivism, as will be shown in this chapter, is indeed a relatively new system of thought for social work that has remained on the “fringes” of the profession (McWilliams, 2015, p.  1) and is specifically identified here as a philosophical- behavioral- methodological thought system. Philosophically, constructivism is concerned with the nature of reality and being (metaphys- ics and ontology) and the nature and acquisition

Constructivism: A Conceptual Framework for Social Work Treatment

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of human knowledge (epistemology). According to Baerveldt (2013),

constructivism maintains that cognition is funda- mentally adaptive and that knowledge needs to be “viable” rather than “true.” Constructivists empha- size that knowledge emerges when cognitive agents actively try to make sense of their experience by con- structing ideas, concepts, or schemas that organizes this experience in a coherent way. (p. 157)

The behavioral aspect pertains to certain understandings of human perception and cog- nition, personal and interpersonal dynamics, and the nature and execution of change. From the philosophical and behavioral components, methodological implications emerge for social work practice. It will also be shown that con- structivism as a postmodern relativist theory can be deployed as a meta- theory for attaining a deeper understanding of the nature of modern or realist theories.

It should be clarified at the outset that con- structivism is not a practice theory but a con- ceptual framework that can inform given practice theories, in the sense that ecological- systems theory informs the Life Model of prac- tice, as one example. While general practice guidelines can be inferred from constructivist concepts and principles, some of which will be identified later in this chapter, specific and detailed practice guidelines reflecting construc- tivism as a conceptual framework can be found in a number of practice theories (e.g., narrative and solution- focused theories) described else- where in this volume.

Historical Foundations

Historical Context

One can trace the ideas of constructivism as early as Kant (1781), Piaget (1929), Kelly (1955), Maturana (1975), Watzlawick (1976), and Von Glasersfeld (1984). The intent to infuse these ideas into the helping professions, including social work, has continued to this day, with more recent theorizing by Baerveldt (2013), Carpenter (1996), Lindquist (2013), Mahoney (1991), McWilliams (2015), and Strong (2014). Constructivism as a thought system is best understood when placed in a context of major historical ideas about reality (ontology) and how

human knowledge develops (epistemology). Three historical periods can be identified in the evolution of major human belief systems— pre- modern, modern, and post- modern— each characterized by certain approaches to under- standing ourselves as humans, the world, and indeed the universe. These understandings become reflected in the nature of the theories that we devise for helping people with psycho- social problems. Following is an overview of human belief systems based on Sexton (1997), adapted from Mahoney (1991).

During the pre- modern period (the sixth century BC through the Middle Ages), ideal- ism, religion, and faith mixed with rational- ism were the primary mechanisms people employed for understanding the major ques- tions raised about human life. During the mod- ern era (from the Renaissance to the end of the 19th century), the predominant approaches for understanding the world were empiricism (sense experience is the only true source of knowledge), logical positivism (observation is the prime means of accessing truth), and scien- tific methodology (a highly rational approach to objective truths, primarily through testing hypotheses of deductive theories).

Whereas the pre- modern and modern periods stressed the discovery of objective knowledge and fixed truths, the postmodern constructivist era stresses the creation of knowl- edge and relativity of truth. The proposition that knowledge is constructed, not discovered, is a major contribution of constructivism to social work practice theory, the implications of which will be discussed in a subsequent section of this chapter.

During this postmodern/ constructivist era (the current era), there has been less emphasis on the validity of knowledge (characteristic of an emphasis in scientific research in the modern era), but rather an emphasis on the viability of knowl- edge and increasing concern with how we know what we think we know (Sexton, 1997, pp. 4– 6).

Early Beginnings of Constructivism

While constructivism has gained visibility in the social and behavioral sciences only recently in historical terms, the deepest roots of con- structivism as a general theory are in the soil of

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antiquity (i.e., the pre- modern era). The Greek Sophist Protagoras of Abdera (c. 490– c. 420 BC) maintained that “humans are the measure of all things— of things that are, that they are, of things that are not, that they are not”:  For Protagoras there was no “objective” world and no percep- tion any truer than another, although some were more useful and should be followed (Ide, 1995, p. 752). Emanuel Kant (1724– 1804), in his Critique of Pure Reason (1781/ 1938), argued that the human mind has an inherent structure that it imposes on both thought and experience and that a priori knowledge (knowledge independent of, or prior to, experience) is possible and in fact occurs. Kant maintained that the mind is not a passive slate upon which experience is written but a result of the proactive molding of experi- ence. The Kantian epistemological tradition con- cerning the nature and acquisition of knowledge, frequently cited as a major foundation block of constructivism, maintained that human knowl- edge is ultimately a function of the interaction of the world of experience (empirical) and the basic nature (a priori state) of the human mind.

Another major constructivist, Hans Vaihinger (1852– 1933) emphasized the importance of cognitive processes in determining behavior. Vaihinger formulated the philosophy of “as if,” which postulates that we hold concepts and beliefs as if they were true because of their utility (Mahoney, 1991, pp.  97– 99). Vaihinger’s “as if ” concept is related, though not identical, to the postmodern- constructivist concept of “viabil- ity”: an idea or action is viable if it works relative to a stated purpose, and it need not represent some assumed fixed quality or truth, as a state of validity is presumed to establish.

The epistemological position of philosophers such as Protagoras and Kant is in direct oppo- sition to that of the Lockean empiricists. John Locke (1632– 1704) maintained that knowledge is imparted to the human mind from an exter- nal objective world by way of the senses and that, contrary to what Kant had maintained, a priori knowledge is not possible (Wolterstorff, 1995, pp. 437– 440).

More Recent Contributions

In more recent times, the developmental psy- chologist Jean Piaget (1886– 1980), from his

studies in child development, formulated a theory of developmental epistemology. Piaget concluded that the newborn comes equipped with mental regulatory mechanisms (evolution- ary in origin), which, in interaction with the child’s environment, result in the development of intelligence (1929, 1950, 1970). The cognitive psychologist George Kelly has contributed sig- nificantly to constructivism with his theory of personal constructs, which he predicates are the means by which an individual construes, per- ceives, interprets, understands, predicts, and controls his or her world (Kelly, 1955). For Kelly, mental constructs are imposed on the world, not imposed by the world on the mind. Another psychologist, Paul Watzlawick (1976, 1984, 1990), must also be cited as a major contribu- tor to modern constructivist theory, especially to constructivist epistemology, in his examina- tion of our assumed “realness” of an “objective” world and of the possibility of constructing more desirable individual “worlds.” Two other theoreticians, Ernst von Glasersfeld (1984) and Heinz von Foerster (1984), must be credited for significant contributions to constructivism. Each has accomplished important formulations of the aspect of constructivist epistemology that is concerned with the nature of reality as observer- dependent.

Two Chilean neurobiologists, Humberto Maturana and Francisco Varela, have exerted perhaps the most basic influence on present- day constructivist thought in the biological and behavioral sciences, and this influence has most recently found its way into the behavioral help- ing professions. From their experimentation with animals have come some rather astound- ing conclusions about the basic organization of living systems and the nature of the influ- ence of perception on behavior (Maturana, 1980; Maturana & Varela, 1987). According to Maturana and Varela, living systems are “auto- poietic” or self- organizing. The behaviors of organisms are not directly influenced by their mediums (environments) but are determined by their structure— that is, their neurophysiological makeup (Maturana & Varela, 1987, pp.  95– 97). The neurobiological contributions of Maturana and Varela to constructivist theory are seen to hold important implications for social work practice theory and will be drawn on throughout

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the formulation here of a constructivist frame- work for social work practice. It is important to recognize that “despite their steadily grow- ing influence, constructivist psychologies have not evolved into a single, coherent, theoretically consistent orientation. Given numerous theo- retical differences, there is not even agreement among constructivist psychologists that arriving at a singularly recognizable orientation is desir- able” (Raskin, 2002, p. 1). Therefore, a variety of evidence and ideas will be presented throughout this chapter that represent various contributions to constructivism.

Path into Social Work

Constructivism has been making its way qui- etly along the path into social work theory for some time, but only recently has it been recog- nized as such. All theoretical frameworks that stress the importance of the individual’s inter- nal processes, especially perception and cogni- tion, for understanding human behavior have kinship with constructivism. Some of these will be discussed in a later section of this chapter comparing constructivism with other theories that actually have constructivist elements that have traditionally gone unrecognized.

Examples of contributions to the applica- tion of constructivism to social work are Butt and Parton (2005), Cooper (2001), Fisher (1991), Granvold (2001), Laird (1993), Longhofer and Floersch (2012), and Strong (2014). Other spe- cific case applications are in Dean and Fenby (1989), Hartman (1991), Dean and Fleck- Henderson (1992), Greene and Lee (2002), and Tijerina (2009).

Variants of Constructivism

While the general theory of constructivism is clearly rooted in philosophical relativism, two major varieties of the theory can be identi- fied. Longhofer and Floersch (2012), Mahoney (1991), and Raskin (2002), make a clear distinc- tion between the two:

Radical constructivism is on the idealist end of the spectrum and has been differentially endorsed and expressed by Heinz von Foerster, Ernst von Glaserfeld, Humberto Maturana, Francisco Varela, and Paul Watzlawick. This perspective is most

elegantly expressed in theory and research on the concept of autopoiesis (self- organizing systems). In its most extreme expressions, radical constructivism comes close to the classical position of ontological idealism, arguing that there is no (even hypothetical) reality beyond our personal experience. Essentially, reality or our perception of ourselves cannot be independent from social constructions of it, accord- ing to radical constructivism. The self can be seen as a mere concept resulting from human interaction (Longhofer & Floersch, 2012).

Critical constructivists, on the other hand, do not deny the existence and influence of an unknow- able but inescapable real world. They are, instead, critical or hypothetical realists, admitting that the universe is populated with entities we call “objects” but denying that we can ever “directly” know them. Representatives of modern critical constructivism include Guidance, Hayek, Kelly, Mahoney, Piaget, and Weimer. For critical constructivists, the individual is not a self- sufficient, sole producer of his or her own experience. Rather, the individual is conceived as a “co- creator” or “co- constructor” of personal realities, with the prefix co emphasizing an interactive inter- dependence with their social and physical environ- ments. (Mahoney, 1991, p. 111)

The radical variety of constructivism is so termed because of its assumptions about the nature of reality. It questions certain basic beliefs whose validity most people take for granted. For example, it questions our “com- mon sense” notion that reality is obviously what all competent observers know is “real” or “true” about the world in which we live. It maintains that, instead of there being only one reality, as might seem to be the case, there are as many “realities” as there are perceivers of reality (Goodman, 1972, pp.  31– 32; Watzlawick, 1990, pp.  131– 151). Common sense would have us believe with Gertrude Stein, for instance, that “a rose is a rose is a rose” because all competent observers agree that a certain kind of flower is a rose and not an elephant. Radical construc- tivists (Baerveldt, 2013; Raskin, 2002)  would maintain, however, that greater accuracy is achieved by saying there are as many “rose realities” as there are individuals who experi- ence the things we call roses. Each individual will experience “la rose” in some different way and derive a somewhat different meaning from the experience than all other individuals, but each will still call it a rose. By the same token, a

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therapist in her office with a mother, father, and three children is not in the presence of a family but as many families as there are family observ- ers (the family members plus the therapist). For the radical constructivist, the roses and families that we ordinarily refer to are products of our nervous system. Radical constructivism moves sharply away from the Newtonian- Cartesian certainty of a single reality and a knowable objective world.

In contrast to radical constructivism, criti- cal constructivism, which is frequently referred to in the literature as “social constructivism,” does not deny the existence of an objective external world to which we all react. It does maintain, however, that we cannot “know” this world directly, but only indirectly through the filtering mechanisms of perception, cognition, affect, belief systems, and language. Despite disagreements about particulars, the different constructivist approaches nevertheless all chal- lenge mental health professionals “to refocus their attentions on the critical importance of the human meaning making process” (Raskin, 2002, p. 18).

Presuppositions of Constructivism

Philosophical Relativism

The philosophical component of constructiv- ism reflects the basic conceptions of a school of thought in Western philosophy known as epis- temological relativism. This position expresses the idea that our frameworks of thinking, ways of seeing things, values, and interests are all affected by our life experiences and sociocul- tural situations and therefore can influence and make a difference in how we see or approach situations (Lawson, 2003). The relativist posi- tion denies certainties, absolutes, and perma- nence. Although writing a few decades ago, the philosopher Nelson Goodman (1972), a propo- nent of philosophical relativism, highlights this position well; this justifies its inclusion when discussing this topic here.

There are very many different equally true descrip- tions of the world and their truth is the only stan- dard of their faithfulness. And when we say of them that they all involve conventionalizations, we are saying that no one of these different descriptions

is exclusively true, since the others are also true. None of them tells us the way the world is but each of them tells us a way the world is (Goodman, 1972, pp. 30– 31)

In opposition to the position of relativism is that of philosophical realism, which maintains essentially opposite notions about the “real- ness” and “objective” existence of the world:

Reality is a singular, stable order of events and objects external to and independent of mind and mental processes … the senses and other techni- cal methods of observation are said to reveal, albeit imperfectly, regularities and principles of reality. (Mahoney, 1991, p. 36)

While realists hold the position that an ontolog- ically existing world is not observer- dependent for its reality, relativists contend that such a world, while seeming to exist, is actually observer- dependent relative to the nature of the perceptual and cognitive apparatus of human beings, which reveals, not a world, but, as Goodman says, versions of a world (Goodman, 1984, pp. 29– 34). It is the relativist position that is the philosophical bedrock of constructivism.

Constructivist Epistemology

An age- old problem for philosophers pertains to what is knowable by humans and the means by which knowledge is acquired. In construc- tivist epistemology, knowledge is not composed of impressions of an objective world or “reality” existing independently of knowers, but instead is the creation of individual knowers, resulting in as many “worlds” or “realities” as there are world/ reality observers. If this is so, how, then, do individuals seem to experience a common, objective world? Constructivists maintain that what we refer to as common human experiences are based on a consensual world of language, thought, and experience. Boiled down to its essence, reality is what we agree on. The “we” can refer to a unit as small as a dyad or as large as a society. For example, during the pre- modern era of history, a common understanding was that the earth was flat and the sun circled around it. That was our “reality,” upon which our beliefs and actions were based. World explorers care- fully plotted their routes across the seas so as not to sail off the edge of the earth. We thought

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(agreed) this was the “truth” of earth geography. At this present point in history, however, based on the scientific knowledge of geographers and astronomers, we say this understanding was not true. The earth is spherical, and orbits the sun; “we” (most people) now believe this to be true. However, to further illustrate the constructivist concept that truth is agreement, there are a few individuals who still believe what most people of the pre- modern era believed about the shape of the earth and the danger of going over the “edge:” This small number of individuals con- stitutes another “we,” and they tell each other that “we believe the earth is flat”:  this is their “truth” and their “reality.” (Interested readers can check “flat earth beliefs” on the Internet.)

A practice- related example of the construc- tivist conception of “true” and “real” is pro- vided by Cottone (2007):

What becomes real, for instance, about drugs to teen- agers in a drug culture may be quite different than what is “real” to a parental system linked to a drug prohibitionist culture: therefore, whether drugs can be labeled as “good” or “bad” is defined in the com- munities of understanding within which a teenager or a parent is imbedded. And of course, a counselor, being imbedded in the sociolegal system, is limited when defining acceptable behavior related to use of illegal substances. So, in effect, social constructiv- ism appears to form a triangle with objectivism and subjectivism, in a position outside the objectivism- subjectivism continuum and representing a differ- ent view about how things are known to be “true,” i.e., truth derives from consensualizing [agreement). (Cottone, 2007, Social Constructivism Movement section, para. 4)

To appreciate the constructivist view of the nature of human knowledge and its acquisition requires a willingness to set aside some very basic prevalent beliefs about the phenomenon we have called “knowledge.” As McWilliams (2015, p.  7) observes, “The constructivist per- spective suggests that we invent or develop knowledge, as interpretations of experience, and that such understanding emerges in histor- ical contexts and depends on human activity.” Constructivism encourages the social worker, therefore, to regard knowledge as progressive and modifiable rather than static. This implies that the knowledge or understanding that peo- ple, including social workers, have is limited

by the experiences that they have encountered. Knowledge based on this experience would develop due to a constantly changing exter- nal world and can be seen as ever evolving. It requires suspending notions of certainty, real- ness, objectivity, and externality, and the belief that these are indeed the anchors of human experience:

the phenomenon of knowing cannot be taken as though there were “facts” or objects out there that we grasp and store in our head. The experience of any- thing out there is validated in a special way by the human structure, which makes possible “the thing” that arises in the description … every act of know- ing brings forth a world. (Maturana & Varela, 1987, pp. 25– 26)

The major contributions to epistemological the- ory have traditionally come from philosophy and psychology. Constructivist epistemology, however, has acquired foundational contribu- tions from the experimental work and theo- retical formulations of these two biologists, Maturana and Varela. Much of what they have contributed runs counter to traditional realist views. The following, pertaining to the nature of the functional relationship between the brain and the environment, is an example:

The nervous system does not “pick up information” from the environment, as we often hear. On the contrary, it brings forth a world by specifying what patterns of the environment are perturbations (stim- uli) and what changes trigger them in the organ- ism. The popular metaphor of calling the brain an “information- processing device” is not only ambig- uous but also patently wrong. (Maturana & Varela, 1987, p. 169)

The central importance of constructivist epis- temology for practice is that people behave and lead their lives based on what they believe to be true and real, and this is where the practi- tioner must initially “meet” his or her clients if effective help is to be given. Appreciating that knowledge is ambiguous assists social workers with encounters situated in cultural and per- sonal differences, in that a social worker would recognize that a client’s knowledge is equally affected by the specific cultural influences and experiences they have encountered. A  case example is provided in a subsequent section of this chapter.

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Conceptual Framework

Structure Determinism

The conceptual framework for constructivism as formulated here draws primarily on the neuro- biological conceptions of Maturana, Varela, and associates. In gathering evidence in support of their concept of organisms as closed systems, they conducted several biological experiments. One of these, cited by Bell (1985), is represen- tative of the nature and general outcome of the experiments:

[Maturana] demonstrated that no correlation could be established between colors (as defined by spectral energies and the relations of activ- ity of retinal ganglion cells of either pigeons or human beings) (Maturana, Uribe, & Frenk, 1968). Instead, he found that the nervous system demon- strated its own internal correlations:  the relations of activity of retinal ganglion cells correlated with color- naming behavior of the organism (but did not correlate with the actual colors as defined by spectral energies). The implication of this finding is that the nervous system functions as a closed, internally consistent system and does not con- tain representations or coded transforms of the environment. (p. 6)

Efran, Lukens, and Lukens (1990) elaborate on this radically different conception of the relationship between the neurophysiological makeup of the individual and the environment:

People are brought up to believe they perceive the out- side world. The visual system, for example, appears to provide direct and immediate access to our surround- ings. The eyes are said to be our windows of the world. However, although the eyelids open, the neurons of the retina do not. Energy waves bump up against the retinal surface … but outside light cannot get in… . Obviously, experiences we attribute to light— as well as all our other experiences— are created entirely within our own system. … This is evident in dreams, in response to sharp blows (when we “see” stars), when neurons are directly touched with electrical probes, and when chemical substances are ingested. At a fireworks display, there may be a lot going on out- side, but nevertheless the sparkling colors we see are internal creations. That we are fooled into believing that we “see” the world outside dramatizes how well coupled we are with our environment. (pp. 67– 68)

Based on this conception, what one actually “sees” in a visual experience is not an “outside”

world but the nervous system itself, a counterin- tuitive conception indeed.

An important consequence of the structure- determined state of organisms is immunity to the reception of “information”:  contrary to prevalent views in communications and sys- tems theories, Maturana and Varela hold that structure determined systems are information- ally closed. What Maturana and Varela call “instructive interaction,” which is the direct influence of one person on another, is held to be impossible. Mahoney (1991) explains:

The ongoing structural changes (and exchanges) that living systems undergo are the result of “perturba- tions”:  which can arise from interactions with their medium (environment) or, recursively, with them- selves. These perturbations “trigger” structural changes in the organism but do not automatically convey information about the nature or properties of the perturbing entity. They are not, in other words, “instructive” in the traditional sense of that term. Perturbations do not “cause” changes in the organ- ism by putting something into it (like “information”), they simply trigger changes of state that arc structure- determined by the organism. From this perspective, “information” is not something transferred or pro- cessed. Instead, “information” is literally, translated from its Latin origin: in formare, “that which is formed from within.” (p. 392)

Another important aspect of structure deter- minism pertains, again, to neurobiological considerations and distinguishes feedback (information processing) from the constructiv- ist concept of feed- forward (information creat- ing). Mahoney (1991) provides an example of feed- forward:

On the assumption that visual experience is highly correlated with neurochemical activity in the visual cortex, only about 20% of that activity can be attrib- uted to impulses from the retina … impulses from the retina can influence— but do not specify— activity in the visual cortex. On the average, as much as 80% of what we “see” may be a tacit construction “fed forward” from the superior colliculus, the hypo- thalamus, the reticular formation, and the visual cortex itself. (p. 101)

In other words, the elements that finally result in a visual experience point to an “inside- in” pro- cess (feed- forward) rather than an “outside- in” process as in feedback. Structure determinism, and autopoiesis, to be discussed in the following

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section, form the cornerstones of constructivist theory as formulated by Maturana and Varela.

Autopoiesis

Because they are structure- determined and organizationally closed, living systems are said to be autopoietic or self- organizing enti- ties. Autopoietic entities are autonomous in the sense that they survive, prosper, or perish under the “self- law” of their own makeup (Mahoney, 1991, p.  393). In contrast to a state of autopoi- esis is that of allopoiesis, which is the essential principle of systems theory. A number of parts interrelate among themselves to produce a spec- ified outcome. An example is an automobile. It is composed of a number of interrelated parts that work in unison to propel it down the road, but it has no capacity to produce and maintain itself as an autopoietic system does:

Autopoietic entities, because of the way they are structurally organized, are engaged in the process of producing more of themselves. This process is mani- fest at every level of organization, from the cell to the colony. Cells grow and split, forming additional like- structured cells. Parents have offspring, perpetuat- ing the family line… . Living, from the ingestion of food to the excretion of waste, consists of cycles of self- production. For a living system there is a unity between product and process:  in other words, the major line of work for a living system is creating more of itself. (Efran et al., 1990, p. 47)

Structural Coupling

It is the constructivist principle of structural coupling that explains how autopoietic individ- uals interact with entities other than themselves and their own nervous systems. The principle of structural coupling also allows constructiv- ist theory to avoid the epistemological pitfall of solipsism or a state of complete self- reference. Structural coupling corresponds roughly to the more traditional concept of “interpersonal interaction” that takes place in a “relationship” between individuals but with the important dif- ference that the interaction is seen to be between closed, not open systems:

… Maturana and Varela assert that the interactions of living systems with their medium [environment] are “structure determined”; meaning that changes

in either are “triggered” (as contrasted with “pro- duced”) by their interaction. Thus, learning does not consist of being “instructed” by external agents or environments. Maturana and Varela have also asserted that learning cannot consist of the “pickup” of pre- packaged information from outside the living system, nor can it be understood as the acquisition of internalized “representations” of its medium. The changes exhibited by an organism in the course of its “structural coupling” with its medium reflect the organization and structure of the organism. They do not offer information about the medium itself. (Mahoney, 1991, p. 391)

Episodes of interactions between individuals and their environments are instigated through mutual “perturbations” or triggering stimuli. These perturbations form the basis for changes in each (person and environment) but do not determine the changes, which are instead brought about by the nature of their respec- tive structures. One person does not “cause” another person to do anything; this would be instructive interaction, or direct influence, which, according to Maturana and Varela, is not possible because of the closed nature of each person as a system.

Based on its epistemology, which blurs subject– object distinctions and questions notions of objectivity and reality, constructiv- ism shift us to a “many worlds” frame of refer- ence and away from normative views of truth and falsehood, right and wrong, functional and dysfunctional. Significant practice implications arise from the “many worlds” constructivist way of thinking about human behavior and experience.

Implications for Assessment, Diagnosis, and Treatment

Implications for Assessment

The case assessment process involves the knot- tiest of all problems in understanding human behavior— that of causality. Positivist causal explanations have assumed that a great deal of both individual and aggregate behavior is the direct result of identifiable “external” influ- ences. Constructivist causal assumptions, however, are based on a view of the nature of the human nervous system and its relation- ship to the environment. This view maintains

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that the nervous system can only be perturbed or “bumped up against” but not “entered” by external stimuli, indicating a closed system. What, then, are some constructivist implica- tions for assessment if the individual is viewed as a structure- determined closed system?

In constructivist theory, the individual is the only unit of attention seen to have ontologi- cal existence. Aggregate units such as family, group, and community are reifications existing only in language and thought and are devoid of ontological existence. While the term “sys- tem” is used in constructivist- based practice theories, it is only a convenient term referring to two or more individuals in relation to each other or to an individual made up of various bio- psychological components. The construc- tivist practitioner may think in terms of work- ing with systems but keeps in mind that there are as many “systems” involved in a case as there are system observers (i.e., clients and oth- ers). A major implication of this for assessment is that the practitioner must bring to each client case a “many worlds” mindset, and from within this mindset must dedicate himself or herself to learning as much as possible about each indi- vidual client’s ongoing views, understandings, and intentions toward self and others concern- ing problems being discussed. It is the client’s sensing that the practitioner’s main concern is to learn about him or her as a unique individual that conveys to the client a sense of high respect from the practitioner. This sense of being valued and respected helps free the client to develop alternative views or “stories” of problems and to reconstrue or reframe his or her problem- atic life situation. In this sense, constructivist theory supports the time- honored assessment principle in social work of starting (and staying) where the client is.

On the clinical level, essentially what is assessed in a constructivist- based approach is the client’s frame of reference (constructions) pertaining to the problems being discussed, and the nature of reciprocal perturbations between the client and relevant aspects of his or her medium (environment). This is a process rep- resenting close collaboration between practitio- ner and client in which the client is made to feel that it is the practitioner who is learning and the client who is teaching.

According to Strong (2014), the reflexivity of these negotiations must be clear to clinicians so that the active role of the client is fully under- stood and respected. The implications for social work practitioners is that they cannot influence events or decisions made within therapy from an objective stance, but rather must embrace the duality involved in being an active agent in the change process and working collaboratively within practice situations (Cooper, 2001).

Implications for Diagnosis

“Diagnosis,” in the sense that it has been used in the so- called medical model by the behavioral helping professions, is not supported by con- structivist theory. “What’s wrong” is not seen as an entity in the same sense that the physician views a fractured leg or as inflamed appendix as entities having ontological existence. The principle of structure determinism negates the validity of externally imposed predetermined categories and labels. In the approach repre- sented by The Diagnostic and Statistical Manual of Mental Disorders (DSM), for example, the diagnostic task in a case falls to the practitio- ner and his or her skill in use of the classifi- cation system applied to a particular client’s “symptoms.” The client’s role becomes that of passive recipient of the practitioner’s expertise. A  constructivist- based approach to developing ideas about the nature of problems stresses the need for practitioner– client collaboration and mutuality, with the expert role of the practitio- ner being redefined from its usual meaning. The practitioner’s expertise is in assuming a learn- ing stance with the client by approaching each case assuming he or she knows nothing about the client. A  case example in the next section illustrates this stance.

Treatment Implications

While radical and critical constructivism were previously discussed as the two major variet- ies of constructivism, considerations for treat- ment as discussed here will refer predominately to the assumptions of critical constructivism, generally referred to in the social work litera- ture as social constructivism (see, for example, Cottone, 2007). Social constructivism assumes

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the existence of an objective reality, but one that is knowable only through perception, language, and mentation. In the social constructivism view, the “reality” of structural and psychoso- cial social problems is fully acknowledged.

In more traditional practice approaches, especially psychodynamic ones, uncovering the “real problem” in a case has been seen as an essential job for the practitioner. The “real problem” concept implies that there is an objective pathological/ dysfunctional condition of the client and/ or his or her situation that can be discovered through the clinical skills of the practitioner, as when the physician finds malignant cells and diagnoses cancer— the “real” problem underlying the patient’s pain and other symptoms. In constructivist- based assessment and treatment, however, no “real” problem is assumed to exist in the sense that there is an underlying problem with objective consequence[s] not yet glimpsed by the client but that the practitioner will help him or her discover. This should not be misconstrued to mean that in the constructivist view no prob- lem exists. Through the lens of critical con- structivism (social constructivism), clients are seen as co- constructing their personal realities through interdependence with their social and physical environment. Contrary to a widespread practice among practitioners in the behavioral helping professions, the practi- tioner using a constructivist- based treatment methodology (e.g., narrative therapy) would not attempt to get the client to “own his prob- lem” but to cognitively divest himself or herself of it instead.

For some cases dealt with in a narrative approach to treatment, separating the prob- lem from the person is seen to be essential. A  technique called “externalizing the prob- lem” is frequently used, often with dramatic positive results (see, for example, White, 1989; O’Hanlon, 1994, p.  24). It is believed that externalizing the problem (essentially a pro- cess of giving it a name as apart from the cli- ent) helps free the client to view the problem as an adversary outside instead of inside him- / herself, thus freeing him or her to develop alternative problem versions and solutions. This is thought to be especially helpful in cases where the client has seemed to incorporate the

problem with his or her identity, such as, for example, in anorexia.

Client Self- Determination

The observance of client self- determination has been held as a major intervention mandate in social work from the beginnings of the profes- sion. Constructivism views self- determination, not only as a treatment mandate to be followed, but also as a natural state of the person based on the individual’s structure- determined, auto- poietic nature. If the responses of individuals are structure- determined, they are by defini- tion self- determining. The practitioner has no option of respecting or not respecting this as a practice principle. A  practitioner could believe that he or she is executing a “controlling” tech- nique of some kind (e.g., giving a client paradox- ical instructions); however, the client’s response would not be determined by the paradoxical instructions, but only selected by them— that is, they would “trigger” some response but would not determine what response, which would be brought about by the individual’s neurophysi- ological structure and psychological makeup. However, acknowledging the client’s self- determining nature does not mean accepting everything the client might want to do.

While accepting that there are multiple versions of reality, we may choose not to accept versions that are congruent with the perpetuation of racism, domestic violence, school dropouts, runaway teen- agers, and other destructive behaviors. We may still try to change uglier versions of reality. (Colapinto, 1985, p. 30)

Practitioner Demands

Because of the counterintuitive flavor of con- structivist theory, a certain tolerance for ambi- guity is required of practitioners— this making it possible to embrace the “many worlds” per- spective of constructivism to accommodate the subjective (constructive) variability among their various clients while staying attuned to a presumed normative world to which they and their clients must respond. Some may feel uncomfortable with such a paradoxical- sounding professional mindset, while others will have no difficulty.

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Case Example

Perhaps one of the most difficult aspects of construc- tivism to comprehend pertains to its epistemology, which deemphasizes traditional normative percep- tions and understandings of an “objective” world and stresses instead the importance of the individual’s subjective idiosyncratic world as the primary basis for behavior. For those who may think constructivism is too philosophical to be practical, a case example may help clarify. The following vignette, described by Harlene Anderson as cited by Sykes Wylie (1992), illustrates a practice implication of the constructivist epistemological stance.

A family came to therapy after the children had been removed from their home and the mother had gone to a shelter because the father had so severely beaten them. The mother came in looking disheveled, wearing house slippers and missing several teeth. The father— a huge man, barefoot, weighing probably 300 pounds and wearing denim, bib- front overalls with no shirt on underneath— began shouting as soon as he was in the room that he was poor, white trash, he’d never be anything, but he would not be told what to do by anybody. He would handle his family the way he saw fit, and the only reason he was there was because “the fuckers downtown” had made him come. He also announced, rather mysteriously, that he “hated niggers.”

At that point, says Anderson, “everyone behind the mirror instinctively moved their chairs back,” except Harriet Roberts, a consultant to the clinic, and a black woman. She got up, walked into the therapy session, calmly introduced herself and with appar- ently complete sincerity said she wanted to learn more about what he was saying and why he disliked blacks.

Rober ts continued the therapy. Seeing both husband and wife separately and together (the wife had gone back to live with him, as she always had in the past), bringing in the man’s mother, and the staff from the shelter where the woman had stayed, and consulting with the child protective agency. Gradually, as he became more human in therapy, his behavior outside improved: after the first ses- sion, he stopped beating his wife, and when his children were eventually returned, he did not beat them again, either. (Sykes Wylie, 1992, p. 28)

A practice principle applied here, derived from constructivist epistemology, was in evidence from the therapist’s assumption of the role of learner with the client— a client who at the moment was potentially dangerous to her and had proven himself dangerous to his family:

According to Anderson, the therapists [refer- ring to other therapists subsequently involved] entered therapy with an attitude that they did not know, objectively, better than the man or his wife or the children or any of the other people involved in the case, what con- stituted universal truths about good and bad families, emotional pathology and health. They did not feel that their professional expertise allowed them to “write the story” for the fam- ily. Instead, they believed that in conversation, all these participants together could come up with a better, more humane story that locked nobody out of the process of creating it.

What seems to have happened is that a man who has felt ignored, ostracized and gen- erally loathed for most of his life, meets a ther- apist who is unafraid of his hostility, uninsulted by his bigotry and unoffended by his repulsive persona… . He says that for the first time in his life he feels he has been listened to and understood. (Sykes Wylie, 1992, pp. 28– 29)

By walking calmly into the client’s presence saying she wanted to understand more about why he dis- liked blacks, the consultant demonstrated her respect and unconditional positive regard for him in the face of his anger and implied threats, making it possible for him to reconstrue his constructive world. Through her actions, the consultant recognized the client’s structure- determined nature as reflected in his insis- tence that he would “handle his family as he wanted” and that he had the right to hate black people. In her acknowledging the very being of this man as the only person he could be at the moment, he then became free to reconstrue his meanings closer to those of his medium (environment).

This case analysis reflects narrative intervention concepts (e.g., helping the family rewrite their story to a less destructive one). For more extensive dis- cussion on narrative intervention as a constructivist- based approach, see Chapter 19. A case example of treating depression using the narrative approach can be found in Neimeyer (2009, pp. 97– 100).

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Convergence with Neuroscience

From its birth in antiquity as a philosophi- cal framework, constructivism has evolved in importance from the utility of its various applications. From the structure determinism and autopoiesis formulations of Maturana and Valera, constructivism can now be related to the burgeoning field of neuroscience. While vari- ous definitions of “neuroscience” can be found in the literature, depending on the particular focus of concern, it can be defined appropri- ately here (for relating it to constructivism) as the field of study pertaining to the structure and function of the brain and nervous system as related to various aspects of subjective expe- rience and behavior. While an extensive exami- nation of relevant aspects of neuroscience for the further understanding and development of constructivism is beyond the scope of this chap- ter, the topic is being flagged here for its poten- tial significance. Toomey and Ecker (2007) have written about the convergence of constructiv- ism and neuroscience:

Psychological constructivism’s central insistence on the active role of the individual in shaping experi- ential reality receives extensive corroboration from findings on how the brain functions … the neuro- scientific community appears to be converging to a consensus regarding the capabilities of individual neurons and neural networks to actively shape and define what is experienced as reality. The emerging paradigm, which has been referred to as neural con- structivism (Quartz & Sejnowski, 1997), aligns well with psychological constructivism. (p. 205)

This view points to the influence that specific realist (“objective”) entities (i.e., neurons and neuronal networks) exert on our experience of “reality.” While constructivists have maintained all along that the human experience of reality is subjective, Toomey et  al. now cite the specific brain structures responsible for that experi- ence. These authors further state: “Not only are neural networks constructivist in their organiz- ing and model of reality, but the way the brain forms and organizes [constructs] those neuro- nal networks is itself a significantly experience dependent constructivist process” (p. 209).

An interesting development between neu- roscience and constructivism involves neu- ral networks and the learning properties of

constructive development. Much of the neuro- science research highlights networks with fixed architectures that are often described as in place and unchangeable from birth. However, in line with constructivist theories, a growing body of literature is now focusing on constructive neu- ral networks (Quartz, 1999). Constructive neu- ral networks stress the capacity of the neural architecture to be altered and modified based on learning (Quartz & Sejnowski, 1997; Quinlan, 1998). Consequently, constructive thinking within neuroscience highlights the importance of a rich learning environment for infants and young children in order to help encourage neu- ral growth and development. Exposure to a variety of experiences within our environment can lead to structural changes within our neural system, which supports the idea of constructive learning and growth instead of a preset mental capacity that is predetermined at a young age.

Although it may seem burdensome for a neu- ral system to learn through activity- dependent change, from a constructivist perspective, this is a positive method of learning and growth. It anticipates an immature system’s learning solu- tions to novel and increasingly complex prob- lems that are encountered in one’s environment. Therefore, the learning capabilities that will be required for human development and success in the future are constructed through experien- tial exposure. Instead of beginning this process with a fixed neural architecture and then selec- tively only using some processes, starting with a limited but evolving architecture allows a net- work to pass “through a phase of limited rep- resentational power during early exposure to some problem and then build successively more powerful representational structures” (Quartz, 1999, p.  52). This implies “that cortical devel- opment involves the progressive elaboration of neural circuits in which experience- dependent neural growth mechanisms act alongside intrinsic developmental processes to construct the representations underlying mature skills” (Quartz, 1999, p. 48).

The idea of constructive learning is not intended to be a return to tabula rasa learn- ing, but rather represents a unique and dynamic interaction between changing envi- ronmental conditions and neural mechanisms. Constructive learning acknowledges that

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there are general constraints imposed by neu- ral architecture, but this does not mean that representations for specific cognitive problem domains are preexisting. Rather, constructive learning builds these classes of representations under the influence of the environment, acting in tandem with the natural constraints within neurobiological architecture. This view allows for the possibility of “powerful learning abili- ties while minimizing the need for domain- specific pre- specification and so avoiding the heavy burden that nativism places on genetic mechanisms” (Quartz & Sejnowski, 1997, p. 539).

Developments in both constructivism and neuroscience would seem to warrant further investigation of the ways in which they con- verge, potentially providing constructivism with a foot in science to help balance its more philosophical aspects. One avenue of investiga- tion that would seem to be productive relating to practice concerns is the nature of the cli- ent’s subjective experience (psychological con- structions) related to specific brain structures thought to be the ground of subjective experi- ences. Following is an example of a therapist’s attending to these considerations:

When these authors first began reflecting on the possibility of viewing psychotherapy through the lenses of neuroscience, there was a fear that increasing consideration of brain function would lead to coldness and estrangement in the psycho- therapy process. It has been surprising that the opposite has been the case. For example, empathy with a client being overwhelmed by flashbacks of previous trauma has seemed stronger when these authors reflected on the implications of research indicating that visual cortex used to encode cur- rent information is also required for recall of mem- ories of previously established visual images; while being used during visual memory of a traumatic event, visual cortex is unlikely to be available for processing of current experience. How frightening it must be not to be able to see the therapist even though the client can hear the therapist’s voice “in the distance” during a flashback. Clients have seemed remarkably reassured when their inability to see the therapist is explained in terms of possi- ble brain mechanisms for such an experience; the apparently “crazy” experience of not being able to see someone sitting in front of them now makes sense. (Folensbee 2007, p. 2)

The constructivist element here is the practitio- ner’s acknowledging the “realness” of the client’s intense subjective experience (his constructed world harboring a flashback) while staying in touch with another “reality,” which was his knowledge and utilization of brain science— an example of a therapist’s observing the construc- tivist “many worlds” conception and the relative nature of “truth” and “realness.”

In addition to increasing the efficacy of psy- chotherapy by utilizing knowledge of brain science, Folensbee also sees an additional important dimension:

Assessment, conceptualization, intervention, and communication in therapy all seem likely to improve when the underlying nature of brain functioning as currently understood is kept in mind during the implementation of psychotherapy. Consideration of psychotherapy in terms of the framework of brain function offers the potential for integrating and coordinating various traditional treatment modali- ties within a structure that can facilitate commu- nication between proponents of various schools of treatment, and can support collaborative rather than competitive interventions. (p. 186)

While social workers in their formal training typically receive minimal exposure to the topics of neuroscience, rapid advances in behavioral neuroscience with implications for various psy- chosocial problems dealt with by social workers may bring about increased attention to this area in schools of social work, particularly on mas- ter and doctoral levels. Examples for further reading in neuroscience related to psychother- apy can be found in Badenoch (2008), Pliszka (2003), Cozolino (2002), and Gabbard (1992).

Constructivism and Emotions

The constructivist view of emotions has arisen as a growing field of interest, along with that of neuroscience. From a constructivist perspec- tive, “emotions are emergent conditions reflect- ing multiple modalities of affective reactions to psychologically important situations” (Clore & Ortony, 2013, p. 336). Emotions can therefore be considered a variable set of reactions for coping with the diverse situations that one encounters (Lindquist, 2013). The exact emotions that a per- son exhibits in a situation are subjectively cho- sen by the individual, based on their previous

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life history and their interpretation of the cur- rent situation. Therefore, stereotypical beliefs about how a person should respond emotionally in a specific situation are not necessarily predic- tive of individual behavior from a constructivist perspective.

The constructivist view of emotions and emotional themes highlights the idea that the themes we encounter most within our life experiences become prototypes, schemas, or stereotypes. We then use our preferred emo- tional schemas to organize, understand, and communicate our own personal stories and life experiences (Clore & Ortony, 2013). Humans have a tendency to use these emotional schemas to infuse meaning and reorganize events into emotional vignettes. During the retelling of stories, we often infuse such emotion and pas- sion into these stories that listeners and readers may feel some of that emotion, too. This ability to detect emotions that others are experiencing or describing can be considered adaptive, as it enables the detection of dangerous situations, and also allows for companionship and bond- ing during pleasant emotions.

Although having these emotional schemas appears useful and adaptive in everyday life, there are also costs associated with having these clear schemas. As researchers and social work- ers, we may readily become engrossed in ana- lyzing the responses of participants, searching for the “emotional modules” that correspond to specific emotions, and we may confuse these emotional stereotypes with reality (Clore & Ortony, 2013, p.  343). Instead, emotions can provide a key gauge of important life events for purposes of understanding and planning for action. It is not necessary that we under- stand exactly where in the brain these emotions originate, even if they are constructed by life experiences.

This overview of emotion from a construc- tivist viewpoint confirms that we develop our schemas or stereotypes about emotion based on experience. These emotional schemas are not fully present from birth and cannot develop without life experiences and exposure to vari- ous emotional states in others. The nativist opinion of emotional modules’ being present from birth and predetermining what emo- tional schemas one will possess is therefore

discounted. Rather, individuals construct and change their emotional stereotypes and sche- mas throughout their lives, and, although the basic cognitive structures are necessary in order to recognize and process emotion, people construct emotions based on their experiences in the social world. Therefore, constructionism holds that emotions are “events that are created in the mind of a perceiver to fit a certain situa- tion” (Lindquist, 2013, p. 356).

According to Lindquist (2013), constructiv- ism offers a better understanding of how dis- crete perceptions and experiences of emotion are due to a variety of psychological ingredi- ents being combined based on past situations and life events. When a person experiences an emotion, this could be considered a percep- tion of the body, in that it involves categorizing internal and external sensations and perceiving these as specific emotions (Bar, 2009). Since the construction of emotions depends heavily on context, emotions are sometimes referred to as “situated conceptualizations” (Lindquist, 2013), in that emotions may be used specifically for interacting with different situations.

While neuroscience and the construction of emotion appear to coincide through the corre- spondence of brain regions to emotional states, the observation that a particular anatomical area of the brain shows increased activity dur- ing an emotional experience does not mean that this particular anatomical area should be considered the circuit for that particular emo- tion category. “Neural activity should instead be thought of as a snapshot in time of a par- ticular combination or ‘recipe’ of networks that correspond to basic psychological ingredients” (Lindquist, 2013, p.  364). It is clear from this overview that emotions evolved for a purpose, even if the emotions are not packaged in a modular way but instead represent more basic processes that flexibly combine in humans to produce our reactions to events in the world around us.

In respect to social work treatment, it would seem beneficial for social workers to understand emotions from a constructivist perspective. For a practitioner trying to understand how an indi- vidual is feeling before and during treatment, this perspective sheds light on how meaning is subjective for each individual and is developed

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on a personal level. It implies that social work practitioners must attend to the level of mean- ing for a person, and that this meaning will be unique for every client.

Empirical Base

Attitude Toward the Empirical Stance

The constructivist view of positivistic sci- ence as a component of constructivist theory and the use of empirical evidence as data in its approach to research have evolved over time. Some constructivists hold the belief that empirical evidence does not play a significant role in evaluation due to the fact that there is no such thing as a pre- given known reality; rather, they hold that reality is fundamentally subjective, and therefore knowledge must be viable and malleable rather than empirically true (Baerveldt, 2013). Therefore, many con- structivists do not acknowledge whether their position can be empirically supported, as this is redundant from their perspective. This clearly puts constructivism at odds with empiricism, maintaining that it cannot be evaluated by something it dismisses as an invalid instru- ment. While some constructivists would still agree with this statement, a competing stance has lately gained prominence. Morris (2006) provides a clear statement of and basis for this competing stance in the constructivist approach to research:

The Oxford Dictionary defines research as “careful search or inquiry after or for or into; endeavor to discover new or collate old facts, etc., by scientific study of a subject, course of critical investigation.” This definition rests on facts and science. It does not state that only variables measured quantitatively are facts, or that science is positivism. Constructivists argue that subjective constructions are facts and that the constructivist approach is science. A  sub- jective description of living with HIV- AIDS is some- thing that is known to have occurred or be true; it is precise, its existence cannot be ignored, and it is real. All these are criteria for deciding whether something is a fact according to the same Oxford Dictionary. The constructivist approach develops knowledge that is systematic, deduced from self- evident truths, and follows consistent principles. Constructivist research thus builds a legitimate body of knowledge using a methodology that is sci- entific. (p. 196)

In this view of constructivism’s relationship to the science paradigm (of which empiricism is the hallmark), which is very different from its earlier stance, we see the manifestation of a basic tenet of constructivism applied to the theory itself— that is, change and variation are inevitable for progress.

Connections to Other Theories

A cursory examination reveals numerous theories that are compatible with constructiv- ism. The phenomenological/ humanistic- based theories such as client- centered and existen- tial approaches place heavy emphasis on the client’s perceptions, feelings, and attitudes. Other notable examples are the psychodynamic approaches that emphasize the importance of perception, meaning- making, and idiosyn- cratic subjective experience (e.g., the psycho- social model and psychoanalytically oriented approaches). There are, of course, clear connec- tions with approaches based in cognitive theory, with its emphasis on the “knowing” processes and mentation. Agreements are also to be found between the feminist perspective and constructivism. Both maintain that reality is socially constructed, and that each person has his or her own reality, of equal worth with all others. Both emphasize the oppressive influence that certain sociocul- tural norms can exert on individuals, families, groups, and organizations, and the contribution of these “toxic norms” to the development of psychosocial problems on all levels. Theoretical perspectives that emphasize the individual’s subjective experience and autonomous func- tioning will find compatibility with construc- tivism. Theories that may be trapped in an echo chamber hearing only their own voices saying they have found the truth will find less kinship with the constructivist perspective.

Another observation is being made here concerning constructivism’s relationship to major value positions and goals of the profes- sion. While constructivism draws attention primarily to the autopoietic nature of the indi- vidual (structure- determined, organizationally closed), it should be emphasized that there is no implication of blaming the victim or negating social work’s concerns with problems of social

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justice, discrimination, oppression, domestic violence, or other psychosocial or structural problems of concern to the profession. It does, however, require a constructed ever- changing view of reality from client case to client case. Granvold (2001) has written about the compat- ibility of constructivist approaches with the profession’s more traditional ones:

Constructivist treatment is highly compatible with a generalist- eclectic social work practice perspective. Constructivism emphasizes the client’s strengths and possibilities (Saleebey, 2012). A  collaborative relationship is sought with the client in which the therapist assumes a non- authoritarian, albeit knowl- edgeable, stance. Although the primary focus of constructivist assessment and intervention is on the meaning- making process (internal dispositions), in the social work tradition, environmental conditions and social factors are considered in the promotion of the client’s immediate goals and ultimate per- sonal development. The profession’s distinctive focus on person- in- situation and the interdependence between people and their environments remains intact with constructivism in the social work theory arena.

Constructivism as Meta- Theory

Constructivism can be seen to connect with other theories on various levels. One of these, which has received little attention in the litera- ture to date, utilizes constructivism as a meta- theory for understanding the deeper nature of theories that have traditionally been classified primarily in the realist/ objectivist tradition. Hansen (2007) has argued that a seemingly paradoxical situation, which he calls “epistemic contradiction,” is present in many theories used by the counseling professions. As an example, referring to Freud’s famous case of Little Hans, who was diagnosed with a displaced Oedipal complex, Hansen writes:

When evaluated from an epistemological perspec- tive, the archeological metaphor is simultaneously constructivist and objectivist. It is constructiv- ist in the sense that psychic artifacts determine individual perception, as Hans’s image of horses was internally constructed by ancient, psychically buried conflicts. The counselor (i.e., archeologist), using a psychoanalytic shovel, can dig through the psyche, thereby bringing to light the ancient rel- ics in their pristine form. In this latter sense, the

archeological metaphor is objectivist, because the counselor is deemed able to discover the essential nature of the buried conflict, as Freud discovered Hans’s Oedipal conflict. Clearly, then, constructiv- ist and objectivist epistemic assumptions are each present in the archeological metaphor. (Hansen, 2007, p. 113)

Hansen maintains that this oscillation between subjectivity and objectivity in counseling theo- ries reflects an essential part of human experi- ence that is not simply subjective or objective, but both. He further contends that cognitive, humanistic, and even behaviorist theories all have elements of constructivism, although presumably built on foundations of objectivist assumptions. Examining other theories, then, for this epistemic subjective- objective oscil- lation reveals that not only postmodern theo- ries have constructivist elements in their very architecture (Hansen, 2007, p.  112). As stated at the beginning of this chapter, constructivist elements have been around in theories used by social work for some time, but have not been specifically recognized as such.

Training for Constructivist- Based Practice

Constructivist ideas are beginning to find their way into the Human Behaviour in the Social Environment (HBSE) curriculum, practice theory courses, field instruction, and research courses in most schools of social work. To help ensure a thorough grounding in the principles of constructivism as formulated in this chapter, social work students should have course work pertaining to all three aspects of construc- tivism as a thought system— philosophical, behavioral, and methodological. For the philo- sophical aspect, social work students should have an introductory exposure to the basics of epistemology in order to compare realist and constructivist epistemologies. Study of the behavioral aspect of constructivism should expose social work students to topics in psychol- ogy such as sensation, perception, and cogni- tion presented on a level directly related to basic constructivist concepts such as structure deter- minism, autopoiesis, and structural coupling. Due to further development of the convergence of constructivism with neuroscience as pre- sented in this chapter, topics in basic behavioral

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aspects of brain science would be in order. For the methodology aspect, the basic concepts and postulates of constructivism would be trans- lated into assessment/ treatment principles, techniques, and strategies, with opportunities provided for social work students to learn prac- tice applications in their field experiences. One practice model that is specifically based upon constructivism, and a model that could receive more attention within social work, is George Kelly’s personal construct theory.

As noted earlier, Kelly’s personal construct theory (PCT) proposed that people organize experiences that they have as constructs by interpreting experience and developing dif- ferent dimensions of meaning (Raskin, 2002). These constructs are utilized by individuals to predict how the world and people in society might behave (Winter, 2012). The model sug- gests that a person’s constructs are continu- ally tested in everyday life, based on how well they predict life circumstances, and that an individual might be challenged to revise a con- struct when it is no longer useful or are accurate (Winter, 2013). Kelly coined the term “hostility” to refer to individuals who continue to hang on to faulty constructions even if there is discon- firming evidence for those constructions. In other words, “hostile people” fail to alter their constructions to better fit the world and prefer to force their experiences in the world to fit their constructions (Raskin, 2002).

PCT allows social workers to better under- stand how clients come to view their sense of self, and which aspects of this sense of self are malleable and flexible, and which are fixed and more resistant to change. In PCT, the self is viewed as constructed and generated by the way a person successively construes her or his self (Efran, McNamee, Warren, & Raskin, 2014). However, there are also basic constructs that are developed early in life that become deeply embedded constructions of self (Raskin, 2002). These become more impermeable to self- reflection and alteration. It is important for social workers to understand that these endur- ing senses of self and aspects of individual identity are the most difficult to modify, and individual clients may rebel against threats of change to these constructs (Winter, 2013). Although social and relational factors may play

a role in the constructive process, individuals are still viewed as the primary source of their own constructions. This is also important for social workers to understand, as oftentimes social workers may assume that environmental causes contributed solely to a person’s sense of self, when in reality, the client played an active role in that construction.

Kelly also developed the idea of “fixed role therapy,” in which a client acts out the role of someone psychologically different from himself or herself in everyday life (Raskin, 2002). This is considered an avenue to encourage the client to experiment with new modes of behaving and new constructs for a set period of time. A client is not explicitly instructed to incorporate these new constructs into his or her sense of self. However, many clients feel as though new pos- sibilities are available as they have the opportu- nity to incorporate new perspectives into their current constructions (Efran et  al., 2014). This theory clearly incorporates constructivist ideas, as experimenting with new vantage points is viewed as central to change within clients. This is especially helpful for clients who have been stuck in ineffective problem- solving modes, because it encourages the revision of these per- sonal constructs.

In essence, PCT allows social workers to build new perspectives with clients from a construc- tivist point of view. This provides clients with the power to construct new models or roles for themselves that enable self- efficacy and empow- erment. The social worker encourages the client to incorporate these new identities into her or his sense of self to bring about clinically signifi- cant change. PCT has a strong support base and has been actively developed through the Journal of Constructivist Psychology (Strong, 2014) sug- gesting that it can be an important perspec- tive for understanding client experiences and behavior and an effective method of creating change for clients.

Some of the study topics mentioned hereto- fore are highly technical and specific to disci- plines other than social work, and might require broad areas of study. This, however, should not deter social work educators. The virtual explo- sion of findings from the life sciences taking place makes it essential for social work educa- tors to move in the direction of incorporating

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highly technical/ scientific material in course- work if social work is to remain a highly cred- ible discipline among related professions such as psychology and psychiatry. For an excellent source of information on some of the ways constructivist ideas have been incorporated into social work curricula, see Laird (1993), Revisioning Social Work Education:  A  Social Constructionist Approach. Although this is a 1993 publication, the material remains sound in terms of its presentation of the theory of con- structivism and strategies for training students to incorporate constructivist concept and prin- ciples in their practice. Articles by Dean (1994) and Greene and Lee (2002) also provide sound guidelines for the application of constructivist concepts to practice.

Limitations and Problems

As is always the case with any new theory (and old ones, too), controversies and various con- cerns have arisen about constructivism and its implications for human behavior and change. On the conceptual side, it can be difficult to know if there are substantive differences with non- constructivist concepts that are seemingly essentially similar. For example, Bell (1985) has questioned the validity of Maturana’s view of interpersonal causation:

When Maturana says that causality is impossible, he means, for example, that the professor’s lecture did not determine the response of his students (that would be instructive interaction). The professor’s lecture selected the students’ responses, but their structure determined their responses… . Maturana is claiming that our everyday use of the word “cause” always implies or threatens to imply a determin- ing in the sense of instructive interaction— whereas “causation” is always only a selecting. Thus, he says causality is impossible. (p. 8)

Other concerns about conceptual and practical aspects of constructivism have been expressed by Mahoney (1991):

Beyond the heuristic abstractions of “structure determination,” “organizational closure,” and “structural coupling,” what is it that determines an organism’s adaptations to/ of its environment? What are the parameters of “congruence” between the structures of a living system and its medium? Why are some systems capable of much wider ranges of

self- restructuring than others, and what are the explicit implications for parent, education, and psy- chological services?

Another way of expressing this reservation is to say that … current autopoietic theory pays too little attention to the world in which the living system lives, not to mention the mentation involved and the processes by which that system learns, changes, or develops…  . As many cognitive therapists have learned over the last two decades, psychotherapy clients can be urged to “restructure” their percep- tions and beliefs about self and world, but the self- perpetuating aspects of that self and the everyday constraints imposed by that world are not always conducive to that undertaking. (p. 396)

It should be noted, in relation to Mahoney’s concern about the lack of an adequate concept in constructivist theory to account for the indi- vidual’s adaptation to the environment, that Mahoney, as a psychologist, is not taking into account, nor would he be expected to, the role of constructivism as only one member in the family of theories employed by social workers. Systems and ecological theories have long been effectively incorporated by social workers in their practice for understanding how the indi- vidual adapts to the environment (see chapters in this volume on the Life Model [Chapter  18] and Systems Theory [Chapter  14]). Mahoney’s observation, however, about the need for fur- ther development of the abstract concepts in constructivism toward the operational level remains valid.

Conclusions

The selective use of an ever- expanding body of knowledge and theory in social work becomes increasingly important in order to meet the challenges of the increasing complexity of social work practice demands. Constructivism as a conceptual framework for social work practice has recently added to the profession’s available technology. The future for constructivism in the profession will most likely unfold according to the extent to which it is found to be compatible with social work values, useful to practitioners, and effective with clients. Payne (1991) wrote what is still true today:

New ideas within social work theory arise in vari- ous ways and go through a process of naturalization

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by which they become adjusted to the conventional framework of social work. Some theories have not fully naturalized, because they do not deal well with some of the important features of social work within the period in which they become important. Theories which do naturalize affect the common fea- tures of social work. (p. 7)

Cole (1992) has distinguished between “core” knowledge in a discipline and “frontier” knowl- edge. The core knowledge, including a rela- tively small number of theories, is the “given” or the “starting point” for that discipline. The frontier component is composed of the knowl- edge that is in the early stages of being devel- oped and about which substantial consensus is still lacking (p.  15). Constructivism as a framework for social work treatment fits into the frontier category at this point. Further use by practitioners and testing of constructivist- based practice approaches by researchers will be necessary for constructivism to arrive at a point where it may slip over into the core of social work knowledge, and it is making prog- ress in that direction.

It has been shown in this chapter how some of the basic postulates of constructivism are not only compatible with major social work practice principles but also provide them with additional support. Constructivist- based practice clearly addresses current major concerns of the profes- sion, such as the need to empower clients; the rights of racial, cultural, ethnic, gender, and age groups to be self- determining; and the need to enhance the degree of dignity and respect accorded to all people. We have also shown that the tenets of constructivism are compatible with recent developments in neuroscience and the neuroscience of human emotion.

The formulation of constructivism set forth in this chapter as a conceptual framework for social work treatment has drawn substantially from the conceptions of Maturana and Varela. These conceptions are rooted in neurobiology, in contrast to the social and behavioral sciences that social work has traditionally drawn on for foundational theory. In closing this chap- ter, a statement of what might be viewed as the essence of the neurobiological constructivism of Maturana and Varela provided in their own words would seem appropriate:

Every human being, as an autopoietic system, stands alone. Yet let us not lament that we must exist in a subject- dependent reality. Life is more interesting like this, because the only transcendence of our individual loneliness that we can experience arises through the consensual reality that we create with others, that is, through love. (1978, p. 63)

From this constructivist duality of the individual standing alone in a subject- dependent reality, a central mandate arises for the practitioner, which is to carefully and persistently respect the individuality of clients as self- determining beings and, by following this mandate, to increase the likelihood of clients’ being able to deal more effectively with the requirements of a normative world while broadening their vision to catch sight of more satisfying ways to conduct their lives (see the Case Example in this chapter).

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A crisis is “an acute emotional upset arising from situational, developmental, or socio- cultural sources and resulting in a tempo- rary inability to cope by means of one’s usual problem- solving devices” (Hoff, Hallisey, & Hoff, 2009, p. 4). Parad and Parad (1990) expand upon this definition by describing a crisis as “an upset in a steady state, a turning point leading to better or worse, a disruption or breakdown in a person’s or family’s normal or usual pattern of functioning” (pp. 3– 4).

As these definitions convey, crises take many forms, including the sudden death of a family member; a school shooting; poverty; a devas- tating hurricane or earthquake; homelessness; diagnosis of a chronic or life- threatening illness; job loss; sexual assault; family, domestic, and intimate partner violence; psychosis; divorce; retirement; physical and sexual abuse; rape or

sexual assault; a family’s immigration from a war- torn country; suicidality; and homocidal- ity. While some social work practice settings specifically provide crisis intervention services such as hospital emergency rooms or mobile crisis programs, most social workers encounter crises, at various times, in all practice settings, with all client populations.

In response to a wide range of crises, trau- matic events, and disasters, many people expe- rience significant distress, do not function at their normal levels, and are in danger of ongo- ing dysfunction if they do not receive appropri- ate help in a timely way. In a similar manner, organizations and communities experience these reactions in response to crises and disas- ter. As is the case with the individuals within it, the organization or community’s continued health and ability to function effectively will

Social Work Theory and Practice for Crisis, Disaster, and Trauma

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depend on receiving prompt and effective crisis intervention.

Danger and opportunity (Hoff, Hallisey, & Hoff, 2009; Knox & Roberts, 2008; Parad & Parad, 1990; Slaikeu, 1990), as represented by two symbols in the Chinese language for crisis, are two words that are frequently associated with crises. “Danger” describes the states of disequilibrium and vulnerability that can result from a crisis and the possibility that individuals will experience long- term distress and impaired functioning. “Opportunity” describes the unex- pected possibilities that exist for growth and development when individuals discover previ- ously unknown or underutilized resources and strengths within themselves or their support systems as a result of a crisis. This opportunity for growth results from the markedly increased abilities individuals have for developing alter- native coping mechanisms when they experi- ence a crisis (Parad & Parad, 1990).

Crisis theory and intervention are histori- cally integral to the social work profession. However, over the past decades, as a result of events such as the September 11, 2001, World Trade Center and other terrorist attacks, more frequent natural disasters related to climate change, and dramatic increases in school and violent mass shootings, social workers have increasingly been called upon to help people respond to a wide range of public emergencies (Mirabito, 2012; Patterson, 2009). Consequently, disaster mental health has become an area of expertise for social workers across all fields of practice, including in hospitals, schools, agen- cies, and within communities (Carp, 2010; Mirabito, 2012; Pomeroy, 2009).

As direct practice providers and as members of crisis teams, social workers are frequently leaders in providing crisis intervention ser- vices to individuals, families, and groups, as well as within organizations and communi- ties. Therefore, in addition to crisis intervention skills for direct practice, it is equally impor- tant for social workers to develop an enlarged vision of practice that focuses on the strengths and resilience of individuals, organizations, and communities that have experienced chaos (Carp, 2010). As highlighted by Patterson (2009), social workers need skills in the pro- vision of micro interventions to assist victims

and survivors of disaster, as well as mezzo and macro skills to intervene with complex systems and entire communities. As a result of the train- ing and education social workers receive in both clinical and organizational responses to crisis and trauma, they are often better prepared than other professionals to provide crisis interven- tion in the aftermath of a traumatic event.

History of Crisis Theory and Intervention in Social Work

Crisis theory and crisis intervention have a rich history in the social work profession, which developed largely during the time period from the 1950s through the 1980s, in collaboration with leaders from other disciplines including psychiatry, psychology, and community and public health. Important contributions that led to the development of crisis theory included observations of soldiers in combat, research on grief and mourning, the expansion of suicide prevention programs, and the proliferation of crisis- oriented services resulting from federal policy initiatives to develop community mental health, disaster relief, and victim services.

Eric Lindemann and Gerald Caplan, both psychiatrists, were the first professionals to con- ceptualize and develop crisis theory and inter- vention and are considered the “pioneers” or “grandfathers” of this area of practice (Knox & Roberts, 2008). In 1944, Eric Lindemann, a com- munity psychiatrist affiliated with the Harvard Medical School and Massachusetts General Hospital, observed, evaluated, and treated 101 survivors and close relatives from the devastat- ing 1942 Coconut Grove nightclub fire, which killed 493 people (Roberts, 2008). In his semi- nal paper, “Symptomatology and Management of Acute Grief,” Lindemann (1944) described a predictable sequence of stages during the grief process. He further established that the dura- tion and severity of grief reactions depended on the success with which the bereaved were able to mourn their multiple losses (Knox & Roberts, 2008; Lindemann, 1944). One of Lindemann’s key contributions was his belief that clinical interventions prevented psychopathology, lead- ing to his development of the first community mental health center for bereaved disaster vic- tims and their families (Roberts, 2008).

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Gerald Caplan, also a psychiatrist, built on Lindemann’s concepts about grief and mourn- ing by extending our understanding about the significance and impact of normative and developmental life transitions and extraor- dinary traumatic events (James & Gilliland, 2013; Knox & Roberts, 2008; Regehr, 2011). Caplan (1981) is credited with advancing the field of preventive psychiatry and psychiatric consultation by developing community- based programs for early intervention of situational stress and also for training medical and men- tal health professionals to intervene in critical life transitions (Goldstein & Noonan, 1999; Roberts, 2008).

Observations of soldiers during World War II and the Korean and Vietnam wars who suffered from “combat fatigue” or “combat neurosis,” now conceptualized as post- traumatic stress disorder (PTSD), led mental health practitioners to understand that soldiers who were exposed to traumatic events could be treated effectively with immediate, brief therapy, at or close to the front lines of battle (Goldstein & Noonan, 1999; Parad & Parad, 1990; Roberts, 2000).

Pivotal developments during the 1960s and 1970s included the expansion of community mental health services and suicide preven- tion hotlines, funded through the Community Mental Health Centers Act of 1963, which contributed significantly to the development of crisis intervention services. In 1958, Bellak developed the first psychiatric emergency 24- hour walk- in clinic in the United States at Elmhurst Hospital in New  York City (Parad & Parad, 1990). Funding through the com- munity mental health movement established 24- hour emergency and crisis intervention ser- vices, which rapidly expanded from 376 centers across the country in 1969 to 796 centers in 1980 (Roberts, 2000). Suicide hotlines were first established in 1906 by the Salvation Army in London, England, and the National Save- a- Life League in New  York City; between 1968 and 1972, almost 200 suicide prevention programs were established throughout the United States (Knox & Roberts, 2008; Roberts, 2000). Federal funding from the National Institute of Mental Health established the Disaster Relief Act of 1974, which provided support for brief crisis services to victims of disaster as well as training

for professionals who provided crisis interven- tion services (Parad & Parad, 1990).

Throughout the 1960s and 1970s, social workers expanded upon the pioneering work of Lindemann and Caplan by further concep- tualizing and integrating key concepts of cri- sis theory and intervention into social work practice. Rapoport (1962, 1967)  advocated that clients have rapid access to crisis intervention services and developed the phases of engage- ment, assessment, and goal setting in crisis intervention services (Roberts, 2000). Golan (1978) delineated the components of “the crisis situation” (p. 7), described later in this chapter. Strickler (1965) identified similarities between crisis intervention and social casework and also recommended that the short- term, focused nature of crisis intervention required modifica- tions in traditional casework practices. Parad & Caplan (1960) and Hill (1958) applied crisis theory and intervention to social work prac- tice with families (Ell, 1996). Other important social work contributors included Kaplan (1962, 1968); Jacobsen, Strickler, and Morely (1968); and Smith (1978, 1979). Parad and Parad (1968a; 1968b) conducted a major descriptive study of 1,656 cases that provided evidence, from both clients’ and clinicians’ perspectives, that dem- onstrated planned, short- term crisis- oriented treatment as an effective intervention.

Key Concepts of Crisis Theory

Naomi Golan (1978) conceptualized the “crisis situation” (p.  7) as composed of five compo- nents: the hazardous event, the vulnerable state, the precipitating factor, the state of active crisis, and the stage of reintegration or crisis resolu- tion (pp.  63– 64). Golan described these five components of the “crisis situation.”

The Hazardous Event The hazardous event is a specific stressful event occurring in a period of relative stability. Changing the previous state of stability, it may initiate a chain of events that further disrupt the previous state of equilibrium. Hazardous events can be anticipated and predictable, resulting in developmental crises, which are experienced during normative developmental stages such as adolescence, aging (adulthood) and retirement,

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or the birth or adoption of a child. In contrast to developmental crises, situational crises are unanticipated or unexpected and are often sud- den, such as job loss, parental divorce, sexual assault, sudden death, a school shooting, a hur- ricane, or a terrorist attack.

The Vulnerable State The vulnerable state describes the individual’s immediate and longer- term response to the hazardous event. Common distressing reac- tions include anxiety, depression, mourning, shame, guilt, anger, and cognitive or perceptual confusion, as well as potentially positive feel- ings of hope, challenge, and excitement.

The Precipitating Factor The precipitating factor is the “straw that breaks the camel’s back” (Golan, 1978, p.  66), or the factor in a chain of events that can convert the vulnerable state into a state of disequilibrium.

The State of Active Crisis The state of active crisis describes the disequilib- rium that occurs once an individual’s previous coping mechanisms have broken down. In this state, predictable responses are experienced, including physical, emotional, and cognitive imbalance, as well as preoccupation with the events that led to the crisis. During the state of active crisis, previous defensive and coping mechanisms are ineffective, and individuals are typically highly motivated to accept and uti- lize assistance. As aptly described by Rapoport (1967), “A little help, rationally directed and purposefully focused at a strategic time, is more effective than more extensive help given at a period of less emotional accessibility” (p.  38). Individuals do not remain in this state of active crisis indefinitely. The time frame for the state of active crisis is variable, though it is time- limited, often described as lasting from one day to four to six weeks (Regehr, 2011).

Two pathways lead to a state of active cri- sis: the precipitating factor can activate a previ- ous vulnerable state that may have been caused by a prior hazardous event(s) or the precipitating factor may be same as the hazardous event. For example, the September 11th terrorist attacks were for some individuals the precipitating fac- tor that activated a vulnerable state created by

a previous hazardous event(s), while for others, the September 11th terrorist attacks were the precipitating factor.

The Stage of Reintegration or Crisis Resolution The stage of reintegration or crisis resolution is the final component in the “crisis situation,” during which individuals struggle to master a cognitive perception of what has occurred, as well as release and accept feelings related to the crisis. In the final stage of reintegration and res- olution, new patterns of coping are developed and environmental supports are identified and utilized, which can include access to, and use of, social work intervention (Mirabito & Rosenthal, 2002; Rosenthal- Gelman & Mirabito, 2005).

Key Concepts of Disaster Theory

“Disaster” is defined by Golan (1978) as “a col- lective stress situation in which many members of a social system fail to receive expected condi- tions of life, such as safety of the physical envi- ronment, protections from attack, provision of food, shelter, and income, and the guidance and information necessary to carry on normal activities” (p. 125). Disaster is followed by three predictable phases: (1) the impact, (2) recoil and rescue, and (3) recovery phases, (Hoff, Hallisey, & Hoff, 2009; Raphael, 2000).

Victims experience the reality of the disas- ter in the impact phase, during which they are concerned about their survival in the immedi- ate present. One sees a wide variety of common reactions during this phase, ranging from peo- ple remaining calm and organized, to becoming shocked, confused, hysterical, and paralyzed with fear (Hoff, Hallisey, & Hoff, 2009). In the aftermath of a disaster, victims may be sur- prised that they were able to function as well as they did during the impact phase.

Rescue activities begin during the recoil and rescue phase. The wide range of common physical and emotional reactions during this phase includes denial, shock, numbness, flash- backs, nightmares, grief and sadness related to potentially devastating loss, anger, despair, and hopelessness (Raphael, 2000). Survivors of the disaster may feel relief and elation, though these reactions are difficult to accept if destruction

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and devastation have occurred. “Survivor guilt” may be experienced if death or injury occurs that they were unable to prevent, or if they do not understand why they survived while others died (Lifton, 1982).

During the recovery phase, individuals and the community face the complex task of return- ing to a new state of “normal.” A primary goal during this prolonged phase is to regain a pre- crisis state of equilibrium. At the outset, individuals and communities may experience an outpouring of altruism and interpersonal connectedness in response to the disaster. Following this initial stage, referred to as the “honeymoon period,” a period of disillusion- ment frequently occurs in which realities of the devastation and loss brought about by the disaster must be faced and resolved (Mirabito & Rosenthal, 2002; Raphael, 2000).

Key Concepts About Trauma and Traumatic Events

Types of Trauma

Traumatic events are extraordinary situations that are likely to evoke significant distress in many people. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM- 5; American Psychiatric Association, 2013), defines traumatic events as “exposure to actual or threatened death, serious injury, or sexual vio- lence” (p.  271) by direct experience, witnessing it, learning that it occurred to others, or expe- riencing repeated exposure to the details of it. Traumatic events include exposure to war, phys- ical assault, childhood physical abuse, threat- ened or actual sexual violence and abuse, being kidnapped or taken hostage, terrorist attacks, torture, natural or human- made disasters, and severe motor vehicle accidents (American Psychiatric Association, 2013, p. 274).

Traumatic stressors may be discreet, one- time events, “Type I  trauma”; or ongoing, chronic life circumstances, “Type II trauma.” Type I  traumas are acute, “single- blow” trau- matic events such as suicide, homicide, sudden accidental death, rape/ sexual assault, acute ill- ness, transportation accidents, natural disas- ters, (e.g., tornadoes, hurricanes, earthquakes, and wildfires), and rare overwhelming events,

such as school shootings, hostage takeovers, or terrorist attacks.

Type II trauma, also known as “complex trauma,” is defined as multiple, repetitive, and continuous trauma (Terr, 1991), such as ongo- ing physical or sexual abuse, domestic violence, community violence, war, genocide, experi- ences of combat or concentration camps, being a prisoner- of- war, or the victim of political tor- ture (Courtois & Ford, 2009). Type II trauma may be perpetrated by an individual known by, or related to, the victim, and can be accompa- nied by a betrayal of trust in primary relation- ships (Courtois & Ford, 2009). Complex trauma can have significantly detrimental effects on emotional and behavioral regulation and stabil- ity; the ability to think, learn, and concentrate; impulse control; self- image; and attachment relationships with others. Complex trauma is associated with a wide range of problems, includ- ing addiction, chronic physical conditions, depression and anxiety, self- harming behaviors, and other psychiatric disorders (National Child Traumatic Stress Network, www.nctsn.org, 2014). Treatment for complex trauma includes a range of trauma- specific service models for chil- dren, adolescents, and adults (Jennings, 2008). For example, trauma- focused cognitive behav- ioral therapy (TF- CBT) is an evidence- based approach for the treatment of complex trauma that develops resiliency- based coping skills with children and adolescents and utilizes active parental involvement to support the treatment goals (Cohen, Mannarino, & Murray, 2011).

Post- Traumatic Stress Disorder

Post- traumatic stress disorder (PTSD) is a syn- drome of persistent reactions following a traumatic stressor that is diagnosed when a combination of symptoms in four categories have persisted for one month or more and when the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2013). The four categories of post- traumatic symptoms identified in the DSM- 5 (American Psychiatric Association, 2013) include: (1) intru- sion symptoms, (2) persistent avoidance, (3) nega- tive alterations in cognitions and mood, and (4) hyperarousal and reactivity.

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Intrusion symptoms include recurrent, involuntary, and intrusive distressing memo- ries of the traumatic event, such as distressing dreams, intense psychological distress or phys- iological reactions to internal or external cues (triggers) related to the traumatic event, and dissociative reactions (e.g., flashbacks, dreams, nightmares) in which individuals can visualize the traumatic event and feel as if it is happen- ing again (American Psychiatric Association, 2013). Dissociation can serve as a protective mechanism in the aftermath of a traumatic event to shield the individual from the full realization of the horror that has occurred. With dissociation, the individual is unable to remember details of a traumatic event, or expe- riences numbness or disbelief that the trauma occurred.

Persistent avoidance includes conscious and purposeful avoidance of distressing memories, thoughts, and feelings, and of situations, places, and people associated with the traumatic event. In efforts to avoid strong feelings that may be overwhelming, individuals may be reluctant to return to places where a trauma occurred and may consciously avoid talking about a traumatic event.

Negative alterations in cognitions and mood include: Inability to remember an important aspect of the traumatic event(s); Exaggerated negative beliefs about oneself, others, or the world; Persistent, dis- torted cognitions about the cause or consequences of the traumatic event that lead the individual to blame himself/ herself or others; Persistent nega- tive emotional states (e.g., fear, horror, anger, guilt, shame); Decreased interest or participation in signif- icant activities; Feelings of detachment from others; Inability to experience positive emotions. (American Psychiatric Association, 2013, pp. 271– 272)

Hyperarousal and reactivity symptoms include alterations in arousal and reactivity associated with the traumatic event. Symptoms include “Irritable behavior and angry out- bursts; Reckless or self- destructive behavior; Hypervigilance; Exaggerated startle response; Problems with concentration; Sleep distur- bance” (American Psychiatric Association, 2013, p.  272). In the aftermath of a traumatic stressor, people frequently report having diffi- culty sleeping, an increased startle reflex, and

“jumpiness” or anxiety, including fear that the traumatic event could happen again.

Acute stress disorder (ASD) includes the same symptoms as PTSD; however, symptoms are present for three days to one month fol- lowing exposure to the traumatic event. The DSM- 5 (American Psychiatric Association, 2013)  includes distinct criteria for symptoms and reactions pertaining to children six years old and younger. Frequently, PTSD coexists with other psychiatric disorders such as anxi- ety, depression, conduct disorders, and sub- stance abuse. As described by Santucci (2012), “While comorbidity among psychiatric disor- ders is high, with PTSD it appears to be the rule rather than the exception” (p. 124).

Many traumatic events include the threat or actuality of death, and almost all deaths involve trauma as well as grief. Many of these deaths are by suicide, homicide, or sudden accidents, and many involve violence, which can elicit both trauma and grief reactions. When grief and post- traumatic symptoms are both pres- ent, post- traumatic reactions must be attended to first, before the grieving process can proceed (Nader, 1997).

Reactions to Trauma and Predictors of Distress

Although traumatic events are defined as extraordinary situations that are likely to evoke significant distress in a large proportion of the population, many individuals experi- ence only mild, transient responses and symp- toms in response to trauma. For those who are resilient in the face of traumatic events and do not develop post- traumatic symptoms, stress can lead to adaptive and constructive psycho- logical growth (Bonanno, 2004). While many people who experience positive outcomes from traumatic events utilize social work interven- tion and support, others handle traumatic stress with their own natural support systems (Mirabito & Callahan, 2016).

Three key variables that predict the intensity of post- traumatic reactions are the meaning of the event to the individual, the amount of past exposure to trauma, and the level of social sup- port available (Webb, 1994). The meaning that an individual attaches to a traumatic event

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is particularly important in predicting and understanding her or his response (Lazarus & Folkman, 1984). Individuals who attach malig- nant meanings to traumatic events have higher levels of distress, while those who are able to find benevolent or positive meanings in these events fare better. Furthermore, there appears to be a natural inclination to try to find some positive meaning in the aftermath of a trauma, and eventually many people find satisfaction in having survived and in having done the best they could under the circumstances.

Another key factor that has an impact on the outcome of traumatic experiences is the amount of prior trauma an individual has experienced. Individuals who have experienced multiple traumas, a lack of family support, or other risk factors such as mental health or other emotional concerns are more likely to be severely affected by trauma. Conversely, individuals who have protective factors, such as stable and support- ive environments, and who possess the personal qualities of “resilience” or “hardiness” are bet- ter able to withstand stressful events.

Finally, social support plays an impor- tant role in protecting an individual from the severest impact of traumatic stress. Numerous studies of normative and traumatic stress have demonstrated that individuals with supportive families and friends cope with trauma more effectively than those without supportive social networks.

Social Work Intervention in Crises, Trauma, and Disasters

Practice Principles for Crisis Intervention

Parad and Parad (1990) define crisis inter- vention as “A process for actively influencing psychosocial functioning during a period of disequilibrium in order to alleviate the immedi- ate impact of disruptive stressful events and to help mobilize the capabilities and resources of the persons affected by the crisis” (p. 4). Goals of crisis intervention include managing the imme- diate crisis, and strengthening the coping and problem- solving strategies of the individual, family, group, organization, or community for the future. The practitioner intervenes at whatever level is necessary— micro, mezzo, or

macro- to help the client system return to the previous state of equilibrium. As noted earlier, while the goal of crisis intervention is to return to the pre- crisis level of functioning, some indi- viduals achieve either a higher or lower level of functioning in the aftermath of a crisis.

Crisis intervention uses the strengths per- spective that is central to social work practice to help individuals mobilize their own strengths, assets, and capacities as well as to identify the resources and supports that exist in their envi- ronments, including within families, social networks, neighborhoods, and communities. In combination with the strengths perspective, an empowerment approach is used to help cli- ents access and use inner and environmental resources. Ego psychological techniques are also utilized to assess the individual’s level of functioning, coping, and adaptation (Mirabito & Rosenthal, 2002).

Consistent with the social work strengths and empowerment approaches and ego psychol- ogy concepts, intervention in situations of cri- sis, trauma, and disaster employs the following key practice principles (Ell, 1996; Rosenthal- Gelman & Mirabito, 2005):

• Help is provided immediately, including out- reach to populations who may not otherwise seek assistance. For example, in the case of a school shooting or natural disaster affecting the entire community, active outreach, such as home visits to isolated residents or hold- ing community meetings, may be provided to reach all community members who are in need.

• Interventions at the time of the crisis or disas- ter are time- limited and brief. Since the “cri- sis state” is time- limited, often lasting four to six weeks, interventions are focused on the immediate crisis with referral for longer- term services, as needed.

• The social worker takes an active, often directive, role in helping efforts. During the assessment process, the practitioner engages quickly and explores sensitive and potentially difficult areas, such as abuse and neglect, vio- lence, suicidality, and dying or death.

• The primary goal of intervention is the reduction of symptoms and a return to the earlier state of equilibrium. While the focus

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of intervention is on the immediate prob- lems, crises can reactivate past, unresolved problems, and provide a “second chance” to rework earlier problems reactivated by the current crisis (Goldstein & Noonan, 1999; Mirabito & Rosenthal, 2002).

• Interventions include a combination of coun- seling to handle emotional concerns, the pro- vision of practical information and concrete community resources, and the mobilization of social and environmental support systems.

• The expression of feelings, symptoms, and worries is encouraged. Intervention strategies such as education, clarification, and reassur- ance about the normative, expectable reac- tions to crisis and trauma help individuals reduce their intense fear and anxieties.

• Strategies for problem- solving and effective coping are encouraged and supported to help individuals return to a state of equilibrium.

The immediate, time- limited nature of crisis intervention requires that engagement, assess- ment, and interventions all occur in an expedi- tious manner to ensure that prompt assistance is provided. This approach capitalizes on the “win- dow of opportunity” during which individuals often are considerably more receptive to helping efforts. A rapid, thorough, and focused assess- ment is needed to determine pre- and post- crisis functioning, including the coping styles and skills individuals have used to handle previous stress- ful life events, crises, and preexisting vulnerable states. Emotionally charged areas of functioning are directly and thoroughly explored, including any potential for self- harm and violence, abuse and neglect, use and abuse of alcohol and drugs, sexual assault, and loss or grief. In situations such as physical and sexual abuse, self-harm, violence, drug and alcohol abuse, rape, and natural or man-made disasters, it is particularly important to assess and ensure clients’ emotional and phys- ical safety, and to collaborate with and engage reliable and supportive individuals, in order to develop detailed safety plans to protect clients.

Case Illustrations of Social Work Skills and Roles in Crisis Situations

Social work practitioners take on multiple roles in crisis intervention, including direct service

provider to help clients express their emotions; educator to provide practical information and psychoeducation; case manager to obtain and coordinate community resources for concrete and mental health services; and advocate and broker to mobilize existing social and environ- mental support systems. The challenges of crisis intervention require that social workers develop skills to provide focused, direct, and in- depth assessments; be effective in taking an active, directive stance in asking difficult questions; engage in making sound clinical judgments and decisions; challenge clients who may be at risk to ensure their safety; and take a confident and proactive stance in interprofessional col- laboration and consultation with a wide range of professionals. The following vignettes of cri- sis intervention provided by social workers in varied settings illustrate the use of the practice principles, skills, and roles utilized in situations of crisis and trauma.

Case Examples

“On- call” evening/ weekend social worker in an urban hospital emergency room: The social worker provides crisis intervention services to the pediatric, adult, and psychiatric emergency rooms and hospital- wide con- sultation regarding discharge problems. The demands are unpredictable and include intervention in an unlimited variety of problems such as death, rape, child or elder abuse, domestic violence, psychiatric emergencies, acute illness, homelessness, and dis- charge problems. The social worker must engage quickly, assess complex problems thoroughly, inter- vene, disengage when the immediate crisis has stabi- lized, and implement a follow- up plan.

On one weekend evening, such a social worker was referred the following cases:  the emergency discharge of an HIV- positive infant to a foster care home; a seven- month- old with a cigarette burn; an 85- year- old frail elderly woman without family sup- port who could not return home alone; a 20- year- old brought to the ER by police due to domestic violence who presented concerns about harming both her children and herself; and a 17- year- old who put his hand through a window while watching his mother die that evening. Crisis intervention in this setting requires a broad set of generalist social work skills, including a high level of skill in clinical assessment,

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intervention, and advocacy with patients; accessing and managing community resources; and providing education and consultation to interdisciplinary hospi- tal staff. Specifically, the social worker must be able to form relationships with patients and interprofessional staff rapidly and effectively; make decisions quickly and authoritatively; work both autonomously and collaboratively; have the flexibility to handle multiple situations simultaneously, and the capacity to con- front and handle considerable emotional distress.

School social worker in a rural high school: A 15- year- old girl in the 10th grade with a history of depression and two psychiatric hospitalizations committed suicide. In response to this traumatic event, the school social worker, as leader of the school crisis team, convened a meeting of the team with goals to help students, teachers, and parents process the trauma and prevent future suicides in the school. The social worker and principal provided team members with psychoedu- cation regarding the range of reactions that could be expected from students and parents in response to this traumatic event. The crisis team prepared a statement that all teachers read in homeroom classes. Teachers were given guidance by the social worker and the team to help them lead classroom discussions so all students could address and process the event and also to pro- vide psychoeducation about depression, suicidality, and problem- solving/ coping strategies. In addition, a drop- in center was set up for students who wanted to further discuss the event. The social worker and other com- munity mental health professionals provided ongoing support and consultation to teachers to help them manage their own reactions to this traumatic event and to guide them in assisting the students. The social worker and the crisis team identified students consid- ered to be at risk for suicidal behavior, including those with a history of serious depression, previous suicide attempts, or suicide in the family; close friends of the deceased student; and other students strongly affected by the death. The social worker conducted detailed, in- depth, thorough clinical assessments of depression and suicidality with all of these students and arranged for safety planning, as needed. In situations of significant risk, the social worker contacted parents and arranged for mental health follow- up in the community. Support groups composed of the close friends and peers from classes met for six sessions to more fully process the untimely death and also to provide opportunities to observe how students were responding to the event in order to refer students who were in need of additional mental health services. The social worker and principal

provided outreach, support, and guidance to parents by leading a parents’ meeting as well as family meetings, as needed. Finally, the social worker helped students and parents organize and implement a memorial service for the bereaved student and a scholarship fund that was presented on the anniversary of the student’s death.

Disaster Mental Health Interventions

The concept of “psychological first aid” (PFA), though not developed by social work prac- titioners, has been used in the field of disas- ter mental health for many years. Five basic principles of PFA that facilitate positive adaptation following disaster include pro- moting:  (1)  safety, (2)  calming, (3)  self and community efficacy, and (4)  connectedness, and (5)  instilling hope (Hobfoll, Watson, Bell, Bryant, Brymer, Freidman, … Freidman, 2007; Vernberg, Jacobs, Watson, Layne, Pynoos, Steinberg, … Ruzek, 2008; Watson, Brymer, & Bonanno, 2011). Components of the PFA model include:  (1)  contact and engagement, (2)  safety and comfort, (3)  stabilization, (4)  information gathering, (5)  practical assistance, (6)  connec- tion with social supports, (7)  information on coping, (8)  linkages with services, and (9)  psy- choeducation (Vernberg et al., 2008). In a simi- lar vein, Brymer, Reyes, and Steinberg (2012) recommend that in the aftermath of a disaster, interventions and services should be “proac- tive, protective, and pragmatic” (p.  147). Three tiers of disaster mental health interventions described in the literature include:

• Tier 1: provides outreach, public health infor- mation, needs assessments, and PFA.

• Tier 2:  provides more specialized interven- tions for those with moderate to severe dis- tress and difficulty functioning.

• Tier 3:  provides specialized psychiatric serv- ices for those who require immediate and/ or more intensive intervention, including psy- chiatric care and/ or hospitalization (Brymer et al., 2012).

According to the National Institute of Mental Health (2002), effective early intervention following exposure to mass violence can be

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facilitated by careful screening and needs assessment for individuals and groups. Follow- up should be offered to individuals and groups at high risk of developing adjustment diffi- culties, including those who:  (1)  have acute stress disorder or other clinically significant symptoms stemming from the trauma, (2)  are bereaved, (3) have a preexisting psychiatric con- dition, (4) require medical or surgical attention, or (5) experienced intense and prolonged expo- sure to the incident.

Watson et  al. (2011) indicate that the major components of a global disaster public mental health approach include screening and assess- ment; multiple, culturally competent interven- tion strategies at different post- disaster time points (early, mid- , and long- term intervention); increasing access to services by using diverse and alternative service delivery methods; and providing training and consultation to increase providers’ abilities to implement evidence- based interventions. Walsh (2007) provides a multisystemic, resilience- oriented practice approach that focuses on strengthening fam- ily, interpersonal, institutional, and community resources in the recovery process. This approach recognizes the widespread impact of traumatic loss in situations of community violence, major disasters, wars, genocide, refugee experiences, and terrorism.

Secondary Traumatic Stress, Vicarious Traumatization, and Self- Care

Intervention with individuals, groups, families, organizations, and communities who experi- ence crises and trauma has a significant impact on the health and well- being of social workers. Secondary traumatic stress (STS), vicarious traumatization (VT), and compassion fatigue (CF) describe the psychological and emotional risks and consequences social workers can experience when they provide services to trau- matized populations (Newell & MacNeil, 2010). These conditions, considered to be occupational hazards resulting from clinical and organiza- tional practice focused on trauma, can poten- tially interfere with professional effectiveness and the social worker’s health and well- being (Bride, Radey, & Figley, 2007).

Given the ongoing challenges and stress of providing intervention to clients who experi- ence crises and trauma, it is essential for social workers to develop and routinely implement strategies for professional effectiveness and self- care. Naturale and Pulido (2012) recommend a range of organizational and personal interven- tions to help social workers minimize the effects of secondary traumatic stress or vicarious trauma. Organizational interventions include organizational support, training, staff and peer supervision, adequate breaks, and workload balance. Personal self- care strategies include getting adequate rest and relaxation, develop- ing and maintaining positive connections with social supports (e.g., family and friends), engag- ing in enjoyable interests and activities, exer- cise, and practicing mindfulness.

Current Trends and Future Directions in Research, Training, and Practice

Critical incident stress debriefing (CISD) is a struc- tured group discussion developed by Mitchell and Everly, which incorporates theoretical concepts from both crisis intervention and trauma theories (Bell, 1995; Miller, 2001; Mitchell & Bray, 1990; Mitchell & Everly, 1995). Though originally devel- oped to help first responders, the CISD model is a commonly utilized group intervention with many populations in diverse settings. The pur- pose of debriefing groups are to: (1) review what occurred, (2) process the wide range of reactions experienced, (3) provide psychoeducation about normative responses to trauma and useful cop- ing mechanisms, (4) engage in problem- solving, support, and mutual aid to help members practice self- care, and (5) provide referrals for individuals who require further services (Miller, 2003; Kirk & Madden, 2003). Miller (2003) points out that the CISD model is consistent with the social work profession’s commitment to empowerment and strengths approaches, group work, and social justice.

There is considerable controversy and dis- agreement regarding the effectiveness of CISD, and further research is needed in this area of practice. While anecdotal accounts have reported debriefings to be helpful, there has been no conclusive evidence that CISD prevents

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PTSD (Miller, 2001, 2003; Pack, 2012; Pender & Prichard, 2009). Moreover, multiple studies and reviews of CISD have not only failed to support its effectiveness but, in some cases, have found it to be harmful (Watson et al., 2011; Bonanno, Brewin, Kaniasty, & La Greca, 2010). As noted by Regehr (2001), the two components of crisis debriefing that have some empirical support are the social support and psychoeducational components. The aspect of the model that is not empirically supported is the detailed review of events, which can cause intrusion symptoms.

Roberts and Everly (2006) provided support for crisis models in a meta- analysis that reviewed 36 of the most commonly used crisis interven- tion treatment modalities. This study demon- strated that both adults with trauma symptoms and abusive families in acute crisis can be helped with intensive crisis intervention services. In 2006, the authors of this meta- analysis noted that research on crisis intervention was in a beginning stage of development. In the past ten years, while research has expanded, further sys- tematic research on interventions in situations of crisis, trauma, and disaster are needed to bet- ter understand what strategies are most effective with specific populations.

Studies of social work field training indicate that the growing challenges of contemporary practice require social workers to assume a vari- ety of roles and intervene at multiple levels with clients who are experiencing severe psychoso- cial stressors and crises (Rosenthal- Gelman & Mirabito, 2005). Several studies have established that practice areas and skills identified as most relevant for training social work students include crisis intervention, short- term treatment, advo- cacy, case management, death and dying, and grief and loss (Birkenmaier, Rubio, & Berg- Weger, 2008; Bronstein, Kovacs, & Vega, 2007; Mirabito 2012). Furthermore, Regehr, Roberts, and Bober (2002) highlight the urgent need for training mental health professionals to develop culturally competent clinical and community skills for both individual and community level intervention in disasters.

Current literature in social work and related disciplines includes discussion of both practice and research using crisis intervention strategies with a wide range of populations, such as vet- erans (Franklin, 2009); suicidal adolescents and

their families (Wharff, Ginnis, & Ross, 2012); families in crisis (Al, Stams, van der Laan, & Asscher, 2011); survivors of disasters and public emergencies (Bonanno et al., 2010; Patterson, 2009); psychiatric patients with dementia (Johnson, Niedens, Wilson, Swartzendruber, Yeager, & Jones, 2013); incarcerated persons with mental illness (Lord & Bjerregaard, 2014); survivors of rape and sexual violence (Westmarland & Alderson, 2013), in a variety of settings including, fire and police depart- ments (Cacciatore, Carlson, Michaelis, Klimek, & Steffan, 2011; Watson, 2010); emergency rooms (Kondrat & Teater, 2010); community- based mental health respite programs (Grant & Westhues, 2012); schools (Werner, 2015); and disaster mental health crisis counseling projects (Rosen, Greene, Young, & Norris, 2010).

Conclusion

Social work professionals are actively and con- tinuously engaged in applying specialized knowl- edge and skills in situations of crisis, trauma, and disaster, with individuals, families, groups, organizations, and within communities, in their practice with a wide range of populations and problems in diverse settings. The modality of cri- sis intervention is a short- term intervention tech- nique with a rich history in social work and other mental health professions. Social workers have ongoing opportunities to practice crisis inter- vention, since clients of all ages can experience crises in response to the challenges of normative developmental stages and life circumstances as well as in response to extraordinary, traumatic events, which can occur to anyone at any time. In response to the ever- increasing frequency of crises, trauma, and disaster in everyday life, it is essential that social workers understand crisis and disaster theory and develop practice skills to effectively provide crisis intervention services to a wide range of clients.

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As never before in our history, humans are being challenged to face the threats to our sur- vival that we ourselves have created. At the same time that we are exploring outer space, and can view the earth from far above, we are realiz- ing that our home planet is an ecosystem that is limited in its resources and under increas- ing stress from human activity. The increasing physical threat to the ecosystems that support all life is also a psychological threat to our indi- vidual and collective sense of safety, security, and a sustainable future.

The threats to our global ecosystem are real. In the 20th century, as our world population quadrupled, our energy use increased by 16 times, water consumption nine times, air pollu- tion five times, and farmland doubled (McNeill, 2000). Global warming is linked to such factors as air, land, and water pollution; the destruction

of local and global ecosystems, and the extinc- tion of plant and animal species. All of these fac- tors are largely human- caused (McBay, Keith, & Jensen, 2011). Global warming continues to accelerate in the 21st century, as annual global temperatures relentlessly increase (Kolbert, 2014). Scientists estimate that, at current rates, annual temperature averages could grow by up to 30 degrees Fahrenheit by 2100 (McBay, Keith, & Jensen, 2011).

The process of global warming has been linked to significant physical health problems worldwide. In the past century, air and water pollution has killed millions of people glob- ally, and damaged the health of many more (McNeill, 2000). Environmental health both directly and indirectly affects the health, safety, and welfare of most humans today (Russ, 2010). As more animal and plant species face

Ecopsychology: Adding “Eco” to the Biopsychosocialspiritual Perspective

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extinction, evidence mounts that the survival of the human species itself will ultimately be at risk as well (Kolbert, 2014).

The term “ecopsychology,” apparently first used by Roszok in 1992, is now the name of an accepted division (Number 34) in the American Psychological Association. “Ecopsychology explores humans’ psychological interdepen- dence with the rest of nature and the impli- cations for identity, health and well- being” (Society for Environmental Population and Conservation Psychology, 2014). Increasing evidence for this interdependence continues to emerge in the psychology literature (Doherty & Clayton, 2011). A global epidemic of depres- sion and anxiety has been linked to our collec- tive refusal to face the reality of global warming (Macy & Johnstone, 2012).

Adding the Ecological (“Eco”) Dimension to Social Work’s Biopsychosocialspiritual Perspective

The person- in- environment perspective has informed our assessments and interventions throughout the history of social work. This per- spective is arguably the most unique and signif- icant contribution of social work theory. Within the person- in- environment perspective, we developed psychosocial assessment, and later added “bio- ” and “spiritual” to the factors we consider in our social work practice. With our broadening and inclusive view of the factors that influence human well- being, we have learned to include micro- , mezzo- , and macro- level issues in our interventions, and related social and eco- nomic justice issues in our curricula. Most social work theorists, however, have emphasized the social aspects of the environment, such as fam- ily, culture, and nation, and have largely ignored the physical aspects (Gutheil, 1992; Kapf, 2010).

Increasing numbers of social workers, how- ever, are recognizing the importance of these physical aspects of environment. A  “global community” paradigm of advanced generalist practice was theorized, for example, that would include an “ecosystem social work” approach to practice. In this approach, the social worker has a responsibility to develop an environmental consciousness in which she sees the connections

between human welfare and the health of the local and global ecosystems (Derezotes, 2000). Similar calls for inclusion of a new world view of social work that addresses our global envi- ronmental crises have been made by a grow- ing number of social work scholars (Coates, 2005). The person- in- environment perspec- tive could be expanded to include a “person is environment” value perspective that may help reduce our modern sense of separateness from the environment, and that has implications for micro- , mezzo- , and macro- level practice (Derezotes, 2005).

Many theorists and scientists have stressed the interconnectedness of the physical envi- ronment with human well- being. In the 1990s, authors started to theorize that the current psy- chological relationship people have with nature is dangerous both to human well- being and eco- system well- being. In 1992, Roszak suggested that the disciplines of psychology and ecology could help inform each other. Hillman (1995) proposed that we need to re- vision our view of human psychology to include a “psyche the size of the Earth,” that re- welcomes our intercon- nection with nature.

Given our growing and collective awareness of our interdependence with the natural envi- ronment, as well as the mounting evidence of human- caused ecological damage and associ- ated physical and psychological impact, a more inclusive model of human development can be postulated. The biopsychosocialspiritual model that has helped inform social work practice can be expanded to an “ecobiopsychosocialspiri- tual” model that informs engagement, assess- ment, and intervention.

Theories and Philosophies Informing Ecopsychology

Ecopsychology is a river with many tributaries. Some of the major sources of ecopsychology are introduced in this section, including shaman- ism, transpersonal anthropology, biophilia, deep ecology, ecospirituality, transpersonal ecology, sustainability, the green movement, ecofeminism, and “eco- nomics.” Although cur- rently adopted by many scholars, the term eco- psychology is not accepted by all theorists and practitioners (Schroll, 1994).

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Shamanism

Shamanism is a spiritual approach to heal- ing that may have origins as early as the Paleolithic age. Shamanism was replaced by other religions in most regions, but is now hav- ing somewhat of a revival, in both some rural and highly urbanized locations. Evidence of shamanic practice has been uncovered in the histories of our ancestors across the world, and shamanic practice may have informed the contemplative practices that are now part of the world’s great wisdom traditions (Harner, 1990). Transpersonal anthropology studies transpersonal experience across cultures, including the altered states of conscious- ness experienced in shamanism (Campbell & Staniford, 1978).

Human beings seem to have a natural affili- ation with nature and other living things. This “biophilia” can be seen in our interest in house plants, pets, windows with views, and subur- ban landscapes. Our biophilia may actually reflect a deep psychological and biological need to connect with natural things (Wilson, 1984). Deep ecology is a modern philosophy that finds intrinsic value in ecosystems and nonhuman lifeforms, regardless of how they may serve the economic, political, or other needs of mankind. Humans recognize our interconnection with and responsibility to care for nature’s ecosystems and other living things (Naess, 1973).

Eco- spirituality

Eco- spirituality is a discipline that studies and promotes the relationship between a reverent life and the natural world (Cummings, 1991). Appreciation and responsibility for the Earth is seen by many spiritually oriented authors as an essential aspect of their spirituality and religiosity (Fox, 2000). Transpersonal ecology integrates philosophy and psychology into a worldview that recognizes the intimate con- nection of person and environment. In this worldview, the psychological, spiritual, and physical well- being of people is viewed as inseparable from the well- being of the eco- systems that sustain and contain all life (Fox, 1990; Metzner, 1991).

Sustainability

Sustainability can be thought of as a multidis- ciplinary effort to understand and promote the lasting health and wealth of natural ecosystems. Most environmental scientists argue that, not only the economic systems and social cultures of mankind, but our very survival, depends upon sustainability. New sustainable economic approaches (Sachs, 2008)  and sustainable political approaches (Romm, 2007)  have been offered that are informed by scientific data. Overpopulation of human beings remains a key threat to sustainability, as food, water, and living space are limited on Earth (Lovelock, 2014). The environmental concerns highlighted in Rachel Carson’s (1962) Silent Spring helped launch the modern “Green movement” in the United States. Concerns about pesticide use helped develop new public policies that helped protect the environment in 1970. Similar movements across the world have pushed for environmen- tal protection and other sustainability- friendly policies, with varying degrees of success.

Ecofeminism

First defined in the 1970s, ecofeminism is a phi- losophy that links the abuses of Western patri- archal culture to the oppression of both women and nature. Women are seen as having a special interconnection with nature, based upon their values and work (Warren, 2000). Some male authors, such as Fox (2008) have also looked at the damage that patriarchal thinking has done to nature, and have offered men a new philoso- phy of ethics towards nature.

“Eco- nomics”

Finally, an emerging approach to economics, which we could perhaps call “eco- nomics,” is deconstructing the dominant paradigm of Western economics and its impact on the well- being of living things and ecosystems that sup- port all life. The current capitalistic economic system has been framed, for example, as a “free market fundamentalism” that ultimately destroys the sustainability of our Earth’s ecosys- tems (Klein, 2014). The study of economics can thus help inform decision- making processes

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that result in social policies that support sus- tainability (Shi, 2004).

Ecopsychology as a Bridging Theory in Social Work Education

Ecopsychology is thus an inclusive, multidis- ciplinary collection of theories, or a paradigm, that can help inform social work practice and also ultimately help bridge some of the theoreti- cal “divides” in social work education. Some of the ways ecopsychology might help bridge these divides are introduced here.

Bridging the Micro- Mezzo- Macro Divide

Social work students often receive separate classes in micro- , mezzo- , and macro- level interventions. Ecopsychology can inform inter- ventions on all three levels of social work prac- tice. Examples of interventions on the three levels are described in more detail later in this chapter. The broad ecopsychological theme of interconnectedness of people, other living things, and ecosystems has implications for practice with individuals, families, and local and global communities. A class on ecopsychol- ogy could thus contain examples of assessments and interventions on all practice levels.

Returning Community Organization to Social Work Education

Community organization was especially popu- lar and well- funded in the 1960s and 1970s, but interest has declined since those decades. Ecopsychology can help bridge the gap between social work education and community organiza- tion, because it provides a focus on a large scale issue that affects all people on Earth, and espe- cially the poor and under- represented (Coates, 2005). Community development that focuses on sustainable development is informed in part by population concerns, the women’s move- ment, and environmental concerns (Gamble & Weil, 1997). In ecopsychology, social workers are challenged to integrate social, environmen- tal, and economic goals (Roseland, 2000). Thus ecopsychology could become a major organiz- ing principle in future community work in social work curricula.

Bridging the Practice– Social Justice Divide

Social work students often do not often receive instruction in how to promote diversity and social justice in most practice classes. However, the threat to sustainability is a local and global social justice issue that especially affects poor and under- represented populations. An ecopsy- chology class could offer students interventions that both help heal their clients and empower them to help protect and heal the environment.

Bridging the Body- Mind- Spirit- Environment Divide

The ecopsychology approach helps embody social work practice. Thoreau’s (1862) famous comment “In wildness is the preservation of the world” can be applied here, because as human beings we are, at least in part, wild beings who have evolved multiple ways of knowing the world. Social work students can be encouraged to be, not only intellectually intelligent, but also aware of their “whole- body” intelligence, which includes sensing through emotional, sensory, and social awareness. Instructors can help stu- dents develop this artistic or intuitive aspect of social work practice in their assessments, engagements, and interventions. The student can check out these intuitions by asking the cli- ent for feedback, which is an essential part of what is now called “practice- based evidence” (Hubble, Duncan, Miller, & Wampold, 2010).

Assessing the “Eco” or Ecological Dimension in Social Work Practice

The ecological dimension in social work prac- tice includes all environmental factors, both human- made and “natural.” Social workers can include the following ecological categories in their assessments of each client system.

Human- Made Ecosystems

Social workers assess the impact of the human- made environment on the client system. They assess the potential effects of such factors as the livability of the home, local noise and air pollu- tion, access to local green spaces, and length of

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daily commute to work or school. For example, we know that the chemicals commonly used to purify ordinary tap water can increase food allergies (The Week, 2012).

Local “Natural” Ecosystems

The social worker also assesses the quality of the local ecosystem. He studies the acces- sibility of wild land or water spaces to local people, as well as the quality of local air and water and the availability of local healthy food. We know, for example, that hospital gardens can have such beneficial effects on patients as reduced anxiety, physical pain, and blood pressure, and improved relaxation (Scientific American, 2012).

Ecopsychological Development

Developmental psychology has offered theories of lifespan growth in such areas as human needs (Maslow, 1954), psychosocial development (Erikson, 1964), ego development (Loevinger, 1987), cognitive development (Piaget, 1957), and moral development (Kohlberg, 1981). A  multi- dimensional theory of human development was worked out by Wilber (2006, 2000)  that inte- grated these theories and others into various schema, including his prepersonal, personal, and transpersonal stages of development (see column 3 in Table 8.1, and Cowley’s chapter in this book).

Ecopsychological development can be defined as the biopsychosocialspiritual growth process that a person can have in her or his rela- tionship with the physical environment. The physical environment includes human- made spaces, other living things, and the local, global, and universal ecosystems that support all life.

This developmental theory and its relation- ship with some other theories are illustrated in Table 8.1.

In Table 8.1, column 1, the six levels of eco- psychological development are listed. These levels are a model for the lifespan development of the person’s relationship with other living things and the ecosystems that support all life. The six levels are hypothesized to correspond to three other developmental schemas, in rows 2, 3, and 4.  Column 2 shows what aspects of the body, mind, and spirit are most empha- sized in the ecopsychological levels. Column 3 shows how the levels correspond to Wilber’s (2000, 2006)  levels of consciousness. Finally, column 4 shows how the levels match up with Berne’s (1966) ego states. Following are brief descriptions of these ecopsychological levels:

1. Safety and security:  Environment as womb: When the baby is born, she must leave the placenta and enter the outside environment. Just like a baby is connected to her mother through the umbilical child, the young child appropriately seeks life and nurturing from the environment. Some people might stay “stuck” in this level for years or even through an entire lifetime, expecting the world to nurture them, and not feeling a responsibil- ity to nurture the world in return.

2. Need- based:  Environment as source of my pleasure: The child and adolescent natu- rally uses the environment to seek pleasure and avoid pain. He wants to have his needs met, and is upset when the environment is unfriendly or harsh. He might ask, “Why can’t the weather be nice this weekend?” As the person matures, hopefully he will come to accept that the world is not always plea- surable; sometimes the weather is too hot or

Table 8.1 Ecopsychological Levels of Development

Ecopsychological Levels Body- Mind- Spirit Consciousness Levels (Wilber 2000, 2006)

Ego- states (Berne 1996)

1. Safety and security 2. Need- based

Body- emotional focus Pre- personal (unconscious)

Child dominant (I want, I don’t want)

3. Rebellion ethics 4. External ethics

Cognitive- social focus Personal (conscious) Parent dominant (I should, I shouldn’t)

5. Internalized ethics 6. Interconnectedness

Spiritual- ecstatic focus Transpersonal (beyond the self )

Observing- self dominant (beyond the self )

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too cold, for example, and we must deal with reality as it is.

3. Rebellion: Rejecting the “ letter of the law”: The young adult may need to question authority and even rebel against authority, and thus may reject rules about littering, hunting, fishing, and logging, for example. Rebellion may be a phase in the person’s develop- ment of critical thinking and critical feeling. Many young people think and feel that they are victims of life and thus feel justified in taking whatever they want from the environ- ment. Although the adult will hopefully give up the idea of being a victim, many people may continue to stay in a position of rebel- lion against society and against the environ- ment, however, and thus continue to try to “get away with” taking all they can from the environment.

4. External ethics:  Following “ letter of the law” about the environment: Eventually, the adult accepts society’s rules, including environ- mental laws. If it is socially unacceptable to litter, many adults will comply with the rule out of desire to conform and perhaps fear of punishment. Obedience to the external rules, however, means that the individual is dependent upon what the current culture teaches. Hopefully, the maturing adult even- tually moves past such conformity to levels 5 and 6.

5. Internalized ethics— expressing my own spirit of law for environment; service:  At some point, the adult internalizes those external rules that fit with her own personal eth- ics and values. These rules become the per- son’s own values. A personal commitment to the spirit or intent of the law thus becomes more important than the specific externally imposed rules of the law.

6. Interconnectedness:  I  am “response- able” for the well- being of the environment: Ultimately, the maturing human feels a deep intercon- nectedness with and responsibility for the environment. There is no longer a duality between the self and the rest of the universe. Responsibility is recognized to refer to the awareness of and commitment to what he is able to do for the environment. Thus each individual, having a different ability, has a different responsibility.

How can the social worker use this theory of ecopsychological development to help inform her practice? The worker can first try to assess the stage at which her client currently oper- ates. This will help the worker not only under- stand, interpret, and accept the client’s current thoughts and behaviors related to the physical environment, but also identify possible goals related to the next sequential level of develop- ment. The client may have become “stuck” at this stage for many years, with negative con- sequences (such as feelings of depression and despair). The worker tries to match interven- tions that fit with the client’s current develop- mental level, knowing that she is wise to engage the client “where he is.” Evaluation can also be informed by the developmental model, as the worker looks for new expressed behaviors and thoughts that might help the client see his prog- ress. Clients may shift between different levels over periods of time (see also the case study later in the chapter).

Ecopsychology Approaches in Social Work Practice

Ecopsychology interventions do not replace interventions drawn from other practice para- digms, but rather add the ecological physical- environment dimension to social work practice.

Indoor Micro- Mezzo Approaches

Approaches to social work practice can be organized into four interrelated categories, as shown in Table 8.2. Indoor micro- mezzo approaches include work with individuals and groups, typically in an office or institutional space. Guided visualizations can be used, for example, to help clients identify and work with “sacred landscapes” that they find nurturing or uplifting. Clients might use an empty- chair dialogue technique to have a “conversation” with other living things or ecosystems. Animal- assisted therapy frequently utilizes dogs and other animals to help clients work with difficult emotions or issues. Environmental dialogues can be held between groups of people who have different views about local sustainability issues (such as land or water rights). Some clients

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might want to explore the “wild” aspects of their own lives, and rediscover the roles of such aspects as exercise, sexuality, sleep, and eating in their well- being.

Outdoor Micro- Mezzo Approaches

Outdoor micro- mezzo approaches include work with clients in outdoor settings. Some social workers can take their clients, with permission, on walks outside during counseling sessions. Equine therapy utilizes horses as a vehicle to work with clients. Many people enjoy gardening, and social workers can engage clients in plant- ing, weeding, and harvesting activities as a way to interact and engage in conversations. Some clients might decide to participate in vision quests, in which they find locations in nature where they become receptive to learning more about themselves through interactions with other living things and natural events. Groups of clients might go on outdoor retreats, facilitated by social workers who then do counseling with them, in natural settings.

Indoor Macro Approaches

Indoor macro approaches include indoor environmental- quality work, in which social workers empower clients to work together to improve the quality of the living and work spaces they inhabit every day. Clients can also be organized by social workers to advocate for local sustainability issues, including clean air, clean water, and human population control. Environmental justice work focuses on elimi- nating the unequal burden that the poor and

under- represented populations have in dealing with the negative consequences of environmen- tal pollution and deterioration. In environ- mental dialogues, the social worker facilitates dialogue between groups with different views on sustainability issues. An example of such a dialogue might be a conversation with advo- cates for a new national monument who meet with ranchers and corporate representatives who oppose the monument.

Outdoor Macro Approaches

Finally, outdoor macro approaches include par- ticipation in community gardening and main- tenance of other open urban spaces, as well the development of affordable local holistic/ organic agricultural products. Another area is urban planning and architecture, in which social workers can lead or participate with interdisci- plinary teams of professionals and lay citizens in developing our large- scale towns and cities, transportation networks, and housing and work environments. “Re- wilding” projects are inten- tional efforts to help return land and water spaces to more “natural” conditions, so that indigenous living things can recolonize those spaces.

Case Example

This brief case study shows how social workers might add ecopsychology to their work with clients. The assessments and interventions described here are introduced as examples of ecopsychology work and are not meant to represent a complete case formula- tion and treatment strategy.

Table 8.2 Examples of Ecopsychology Approaches in Social Work Practice

Micro- Mezzo Levels Macro Level

Indoors Guided visualizations Animal- assisted therapy Artistic expressions Empty- chair dialogue Environmental dialogue

Indoor environmental quality (IEQ) Advocacy for clean air and water Environmental justice work Population control initiatives Environmental dialogue

Outdoors Nature walk Equine therapy Gardening Vision quest Outdoor retreat

Community gardening Urban planning and architecture Holistic/ organic agriculture Community environment projects Re- wilding projects

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A school social worker sees a family at her office. The presenting problem is that the oldest girl (Sal, 17  years old) was caught smoking marijuana at her high school. The girl has a younger brother, Rob (14  years old). They are cared for by their father, who has raised the children by himself, after their mother went to prison three years ago. The social worker discovers that Sally has engaged in a number of “externalizing” behaviors, star ting in high school, including truancy from school, unsafe sex, and alco- hol abuse. Her brother, who is an “A” student, has more “internalizing” symptoms, such as moderate depression and anxiety (with no apparent suicidal ideation). The father has two jobs and lately has been concerned that he is not home enough to supervise Sal. The family lives in a poor neighborhood, near a freeway.

The worker starts by asking the family what goals they have for themselves. The children and father all agree that they (1)  want the mother back home, (2)  wish they did not live such separate lives, and (3)  wish they did not worry so much about their individual and collective futures. The worker assesses that family members are operating between the safety- security, needs- based, and rebellion levels of ecopsychological development (levels 1, 2, and 3). She accepts where the family is, understanding many of the contributing familial, cultural, and other influ- ences in their history.

In addition to getting some traditional family counseling for the family and individual counseling for the two children, the social worker introduces some interventions drawn from ecopsychology. She visits the prison, meets with the mother, and with the mother’s permission helps set her up in a new prison gardening program, which the family visits when they come to the prison to see the mother. The social worker, aware of the negative impact of living near a freeway, helps the family relocate to a location near a city park. She helps the father and the two children develop better diets and join aer- obic exercise programs. The social worker finds out that Rob loves horses, and enrolls him in an equine therapy program run in a local suburb. She works with Sal’s probation officer to get her into a diver- sion program. Sal picks a program in which she helps design a community garden near her new high school. With the help of the family, the school social worker evaluates these interventions and makes modifications as necessary.

Limitations of Ecopsychology

Like every other practice approach, ecopsy- chology has limitations. The field is still being defined, and there remains a lack of consensus about how to assess the degree to which our clients are impacted by their physical environ- ments, how to engage them in noticing this impact, and how to help them take actions that could make a difference in their lives. We have had evidence for a long time that people who are committed to take some action— in fact, any action— to deal with their world tend to be physically and mentally healthier than those who do not (Keniston, 1968). We do not know yet how to consistently help people empower themselves to take such actions in effective and nonviolent ways.

Although, as this chapter suggests, there are several theories and approaches in ecopsychol- ogy, the field lacks a unifying theory. There is also a lack of consensus in many areas of the world, often politicized, about whether global warming is actually real, or the extent to which it is human- caused. These limitations are also strengths, of course.

Future Opportunities and Challenges for Scholars

Ecopsychology offers a number of opportu- nities for scholars. The lack of definition con- sensus, the need for more evidence, and the political controversy mentioned above can also be seen as exciting opportunities for explora- tion by young scholars. Although evidence for global warming is now overwhelming, more research will help us understand exactly how, and how fast, human activities are contributing to climate change. More research will also help us better understand exactly how human and natural ecosystems interact with the biopsycho- socialspiritual well- being of people.

Researchers can study the many unexplored aspects of ecopsychology. We need to study the factors that are associated with empowerment and disempowerment of people in reaction to the gradual decline in our ecosystems. Why do some people avoid and deny climate change, while others became active in promoting sus- tainability? Also we need to better understand

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why people sometimes can cooperate to work to protect ecosystems, and why sometimes we fail to do so. We need to show more accurately, the degree to which ecosystem decline affects physical and mental well- being.

Scholarly work is not just restricted to what we call “research.” Scholars can also help develop new models of engagement, assessment, intervention, and evaluation in ecopsychology, on the micro, mezzo, and macro levels. As mod- els of ecopsychology practice are developed, they can also be evaluated, using both practice- based evidence and evidence- based practice approaches. I believe that we can develop effec- tive ways to work with people across the life span and across cultures, to help individuals, groups, and communities empower themselves to do something positive about the threats to global survival.

Conclusion

In 1971, Maslow suggested a Four Forces model of psychological theories, with four paradigms that correspond to the four Western psycho- logical “eras” in which each they were first developed. As summarized briefly in Table 8.3, the First Force was the psychodynamic para- digm, which emerged in the late 19th century. Psychodynamic theory responded in part to Freud’s discovery that his clients suffered from childhood trauma. The Second Force cognitive- behavioral paradigm responded at least in part

to frustrations with changing norms in the larger culture, and with the perceived slowness of psychodynamic work. The experiential Third Force was largely associated with the move- ments for personal expression and freedom in the 1960s. The resurgence of interest in religion and spirituality is seen as a factor in the devel- opment of Fourth Force transpersonalism.

Thus, the first Four Forces of psychology emerged historically, in response to the evolu- tion of Western culture. There is no reason to think that the evolution of culture ended in the 1980s, as transpersonalism developed. In fact, the dates in column 1, Table 8.3, highlight how the changes in our culture seem to be acceler- ating, as the time between the origins of the paradigms seems to be generally shrinking. The greatest underlying psychological issue and threat to all cultures on the Earth today is arguably global survival. If Maslow were alive today, perhaps he would postulate that a new Fifth Force is emerging today, the ecopsychol- ogy paradigm, which is a response to the global survival threats to the ecosystems that support all life on earth.

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Campbell, R.  L., & Staniford, P.  S. (1978). Trans- personal anthropology. The Journal of Trans- personal Anthropology, 2(1), 28– 40.

Table 8.3 The Four Forces and a Possible Fifth Force?

Force/ Paradigm (Time of Appearance)

Underlying Psychological Issue/ Threat

Focus of Paradigm

Psychodynamic (late 19th century)

Rediscovery of family of origin trauma

Exploration of past trauma to help the person get her needs better met now

Cognitive behavioral (early 20th century)

Accelerating expectations to behave, achieve, and demonstrate intellectual mastery

Changing the way we think and act

Experiential/ humanistic (1960s)

A decade of rebellion, questioning, and seeking personal expression and freedom

Awareness and expression of feelings and other internal experience

Transpersonal (1980s)

Resurgent interest in religion and spirituality

Inclusion of the spiritual dimension in practice

Ecopsychology (1990s– 2000s)

Increasing awareness of climate change and other global survival threats

Appreciation of, connection with, and responsibility for our life- sustaining ecosystems

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Today the importance of empowerment as proc- ess and outcome in social work practice is taken as a given. Discourse about empowerment in social work practice began in the late 1970s and flourished throughout the 1980s (Solomon, 1976; Pernell, 1986; Lee, 1989; Parsons, 1989; Cox, 1989; Gutiérrez, 1989; Mancoske & Hunzeker, 1989). It was developed throughout 1990s and the first two decades of the 21st cen- tury. It has gained momentum and acceptance in practice and theory in the United States and globally, remaining relevant to the present time.

“Empowerment” is now a household word, a word in common usage with many mean- ings often related to overcoming obstacles. It is used in many professions as diverse as social work, education, nursing, psychology, politics, ministry and theology, economics, and busi- ness (Read & Laschinger, 2015; Biden, 2013;

Argyris, 1998). Avon, a company known for the selling of cosmetics door to door and the self- employment of women, now sells merchandise to support women’s empowerment. Using the infinity sign as a symbol of empowerment and discussing it in empowerment terms, Avon also sells “empowerment” bracelets and pendants and devotes a portion of their profits to agen- cies serving women who experience domestic violence. Both local and international literature speaks of empowerment zones where indigent people, especially women, can become econom- ically self- sufficient.

There was a large mural on display during a demonstration of community response and out- rage in Baltimore, Maryland, at the killing of a 25- year- old black man, Freddie Gray, in May of 2015. Mr. Gray was given a “rough ride” without a seatbelt in a police van and sustained a mortal

Empowerment Approach to Social Work Treatment

Judith A. B. Lee and Rhonda E. Hudson

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spinal cord injury. The words “Rest in Power, Freddie ‘Pepper’ Gray” were on the mural. Power was on the minds of the demonstrators, and indeed, a fully empowered community is what is needed to overcome the obstacles of rac- ism, poverty, and classism and abuse of author- ity that are still very much alive. Due to similar incidents of brutality in Ferguson, Missouri, New  York, and several other cities, banners reading “Black Life Matters” led large numbers of Americans in processions, both peaceful and not peaceful. After Hurricane Katrina in 2005, Tom Brokaw noted that the public exposure of “the realities of poverty and race in America” gave America a wake- up call (Brokaw, 2007, p. 295). The recent demonstrations, protests, and riots are another jarring wake- up call. In both authors’ social work practice and ministry with the poor, homeless, and marginalized, we have experienced many expressions of how hard life is in low- income communities. For us, helping people to internalize that “your life matters” is a hoped- for outcome of empowerment- oriented practice.

Many helping agencies describe the “empow- erment” of clients as a goal in their mission statements. This frequent use of the concept is potentially helpful, but simply using the word makes nothing happen. As social workers, we need grounded approaches to empowerment- oriented practice that specify meanings, and engender knowledge, values, and especially skills to make the concept of empowerment operable and useful. This chapter operational- izes empowering helping.

The empowerment approach to social work practice that we discuss here is concerned with the unity of the “person– environment” config- uration and the knowledge and skills needed to address this unity. The ultimate hoped for outcome is building the beloved community, a concept and dream first made popular by Dr. Martin Luther King, Jr., to describe a world where social and economic justice and compas- sion prevail. King also spoke of the “giant trip- lets of racism, materialism and militarism” that together are “insurmountable.” By materialism, he meant the greed and concentration of wealth at one end of society and abject poverty at the other end, both locally and globally. He noted that while endless money goes into militarism,

there is no way to solve the problems of poverty. He joined himself with the struggles of the poor and called for “a radical revolution of values” that shifts us from a “thing- oriented society to a person- oriented society” (1967). Noting that we must ask why there were 40 million poor in America in 1967, he challenged structural inequity and the uneven distribution of wealth. Much has changed since then, but much has also remained the same. Now he might ask us to reflect on why there are 45.3 million Americans living in poverty (http:// www.census.gov/ hhes/ w w w/ pover t y/ data / i ncpovh lt h / 2013/ h ig h- lights.html).

Poverty has remained a constant over the years, well known by those who continue to live at the margins and those, including social workers, who stand by them. Such unyielding poverty takes its toll on individuals, families, and communities, draining them physically, emotionally, and spiritually (Katz, 1986). Those who are economically disadvantaged often feel powerless against natural, social, economic, and political forces that overwhelm like a tsunami wave (Ozawa, 1989).

Additionally, the continuing realities of ter- rorism, war, distressed inner cities, rural pov- erty, and natural disasters, including the effects of global warming, present challenging realities demanding our attention. These realities and immersion in endless new technologies are the context in which current social work practice takes place. Wulff (2011, p.  362) notes that the survival of social work in postmodern society is about a search for new paradigms that empower the socially excluded. Adams (2008) notes that “in the postmodern era, empowerment has the potential to become either a unifying or a divi- sive theme of social work” (p. 22). The empow- erment approach discussed here (Lee, 1994, 2001; Lee & Hudson, 2011; Hudson, 2009)  and a variety of related empowerment- oriented conceptualizations (Turner & Maschi, 2014; DuBois & Miley, 2013; Adams, 2008; Hudson, 2009; Miley, O’Melia, & Dubois, 2013; Shera & Wells, 1999; Gutiérrez & Lewis, 1999; Walton, Sandau- Beckler, & Mannes, 2001; Eamon, 2008; and others) are sorely needed at this juncture in postmodern history.

Social work at its best is an empower- ing profession. DuBois and Miley (2013) see

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empowerment as “the heart of social work prac- tice and social justice as its soul.” They affirm Lee’s empowerment approach that links per- sonal and political power, and see general and clinical social work practice that attends to individual need and environmental change as empowering (2013). British social work theo- rist Robert Adams (2008) reminds us, however, that not all social work practice is empowering. Many mandated services are in fact delivered in disempowering ways. They may follow guide- lines that are not responsive to empowerment- oriented principles or to the exigencies of the people served. The authenticity of empower- ment should derive from and be rooted in the circumstances of those who use the services. Adams notes that an empowerment approach must be enacted on multiple levels, often simul- taneously. He says, “To attempt to work at one level and separate it from the others is to risk tokenism at best and, at worst, failure” (p. 3). Furthermore, empowerment practice must take into account global awareness and inter- dependence and apply in developing countries. He notes that Lee (2001) advances an empower- ment approach that does this.

Lee’s empowerment approach (2001) deals with empowering people across the life span individually and in families, groups, and com- munities to develop their capabilities and assets and change noxious environments. Building the beloved community where justice reigns is both the process and the hoped- for outcome of individual and political empowerment. It is where we are going and how we will get there. Lee offers many case examples to illustrate how diverse users of service in relational systems of all sizes are empowering themselves. Turner and Maschi (2014) note that both feminist and empowerment theories and approaches are especially suited to the understanding of indi- vidual and sociopolitical levels of social work assessment and intervention. Both approaches in practice will provide social workers with the knowledge, values, and skills most likely to pro- mote human rights and social justice. They see Lee’s empowerment approach as a clinical and community- oriented approach that contributes to building a better world. Their case example of Claudia, a 33- year- old Hispanic college grad- uate who is struggling with issues of substance

abuse and the aftermath of early sexual abuse and later abusive relationships, shows the power of empowerment- oriented support groups in her life. Claudia develops a sense of self- worth and also becomes an activist against human trafficking, realizing her personal and political empowerment.

The United States of America has experi- enced several defining events that have chal- lenged us to acknowledge that community and individualism are at least equally important, and that local and global interdependence are imperative. September 11, 2001, was a major tragedy that forced us to acknowledge our pos- ition in world politics and our vulnerability and dependence upon one another for survival. Many social work articles describe the heroic, caring, and skillful responses of friends, family, neighbors, and strangers, as well as profession- als in the wake of the trauma caused by the trag- edy and massive crisis. Similarly, terrorist acts, war, and many natural disasters such as torna- does, hurricanes, earthquakes, and mudslides in the past few years demonstrates the care with which people can respond to one another in the midst of tragedy. Ultimately, we are challenged to empower ourselves and one another back to “normalcy,” health, confidence, security, and hope, personally, socially, and economically.

At the same time, the era of managed care and private interest placed a stranglehold on health and mental health care, and all but dictated the kinds of social work practice that would be val- ued— that which is simply and easily measured as “successful” in short periods of time. In 2008, 45.7 million Americans lacked health insurance coverage. The Patient Protection and Affordable Care Act (ACA) signed by President Obama on March 23, 2010, was a clear and major step forward in insurance coverage despite the ran- corous partisan divide on this bill, also called “Obamacare.” By the second quarter of 2015, according to Rand researchers, almost 17 mil- lion (16.9) Americans were covered for the first time. This figure takes into account that 22.8 million Americans were newly covered, while 5.9 million lost coverage, some of whom found other coverage (Diamond, 2015) (www.forbes. com/ sites/ dandiamond/ 2015/ 05/ 06/ how- obam- acare- changed- health- insurance- maybe; www. washingtonpost.com/ national/ health- science/

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obamacare- adds- 164million- tohealth- insur- ance- rolls). The Washington Post saw this as an “especially robust gain for minorities” while acknowledging the need for greater effort in outreach (Bernstein, 2015). The gain for work- ing people is unmistakable. Yet, some working Americans whose salaries are too low continue to fall through the cracks and sadly remain uncov- ered, necessitating further attention to medical coverage for all. When President-Elect Donald Trump takes office in January, 2017, “Obamacare” is on the short list, and likely to be repealed. While some hope to replace it with something more affordable that includes more marginal wage earners, the question is “replace it with what?” And, what will happen to the millions now cov- ered for the first time under “Obamacare”?

The word “empowerment” took on new meaning as the election of the first African- American president of the United States, Barack Obama, in November, 2008, ushered in a new age of hope. The “yes, we can” mentality enliv- ened a wide range of new and first- time vot- ers, including young people and minorities of color. His 2012 re- election was also a product of careful organizing on the grassroots level and continued hope, although it was known by then that “no, you can’t” was a counterpoint to presidential and progressive progress. We saw in Hillary Clinton’s Democratic Party nomina- tion and run for the for Presidency a hope that women will finally break through the class ceil- ing of political power in the USA. We also saw how difficult that is and now our hope and our grass roots level work moves toward a future that includes a woman President of the USA and progress for all people. The challenge is now to move beyond expectations of magic cures and do the hard work to finally make some of the reforms and changes, including continued healthcare reform, actually happen. Ultimately, matters fall into the hands of the people who empower themselves to take action. Frances Fox Piven (1989) suggests that a people’s movement protesting for the changes still needed would, in fact, empower a president (and Congress) to deliver what people need to survive and thrive (2008). Making such change is, fortunately, not in the hands of social workers or any one profes- sion or group of people alone. But, our knowl- edge base, values, and empowerment- oriented

skills superbly fit us to be helpful in the pursuit of distributive justice in the form of health care, income, services, and a range of resources for those who have been left out of the mainstream.

It is important to note that a key factor in the development of personal, group, and community empowerment are strong mediating structures in the community. Viable schools, community centers, youth programs, and churches and other places of worship may be among the strongest of such structures. For many, particularly in low- income, black, and other minority communities, the church remains a center of activity, activism, support, and positive identity (Martin & Martin, 2003). While in more well- to- do communities religious affiliation is on the decline, especially among the young, the spiritual and faith dimen- sions of people’s lives may be sources of strength and empowerment (Canda, 1988, 1998, 2006; Cowley & Derezotes, 2011; Derezotes, 2009; Martin & Martin, 2003).

It is tragic that little has changed for the poor and outcast of the global world except that the ranks of the poor are swelling. Over half of the world’s 6 billion people live under the pov- erty line of $2.00 a day. One point two billion earn less than $1.00 a day. Poverty and its tolls on human life are a global issue of major con- cern. And, while it is not linear, the connection between poverty and violence is well established. Terrorists are known to use poverty as a means of recruitment (Atwood, 2014). For Americans in poverty there has been some progress, as noted above in health care, and also in the over- all poverty rate. While the unemployment rate was 9.8% in 2009, in April of 2015 it was 5.4% (Roubini, 2009; http:// www.bls.gov/ web/ emp- sit/ cps_ charts.pdf). However, the unemploy- ment rate for blacks was 9.6% and for Hispanics 6.9% in 2013, indicating little economic prog- ress for blacks (www.bls.gov/ news.release/ empsit.a.htm). In 2008, almost 40 million (39.8 million) Americans lived in poverty (U.S. Census Bureau, 2009), while in 2013, 45.3 mil- lion people lived in poverty (www.census.gov/ hhes/ wwwpoverty/ data). Poverty data released by the U.S. Census Bureau on September 5, 2014, reveals that child poverty dropped significantly for the first time since 2000, from 21.8% in 2012, to 19.9% in 2013. While child poverty decreased for Hispanic, white, and Asian children, black

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children saw no decrease, and continue to have the highest child poverty rate at 39%.

The empowerment approach to social work practice enables practitioners to co- investi- gate reality and challenge obstacles with peo- ple who are poor, and to stand with people who are pushed to the edge of American or global society. This necessitates a joining with, and validation of, that experience and a dual focus on people’s potentials and political/ structural change. The synthesis of a wide range of theo- ries and skills in the empowerment approach is needed for effective empowerment practice.

Classic theorist William Schwartz (1994b) elaborated on C.  Wright Mills’s notion that the “personal troubles of milieu and public issues of structure must be stated in terms of the other, and of the interaction between the two… . There can be no choice or even a division of labor between serving individual needs and social problems …” (p.  390). Integrating these in theory and practice is the dual focus of the empowerment approach. Despite polarization in the profession throughout history, a focus on dual simultane- ous concern for people and environments can guide social work past falsely dichotomizing individual growth and social change (Schwartz, 1994a, 1994b; Germain & Gitterman, 1996). But even this dual view of function needs an addi- tional component: that people/ clients themselves actively work to change the oppressive environ- ment and mitigate the effects of internalized oppression. A side- by- side stance of worker and client is needed. As bell hooks (1990), African- American feminist writer, notes:  “Radical post modernism calls attention to those shared sen- sibilities which cross the boundaries of class, gender, race, etc., that could be fertile ground for the construction of empathy— ties that would promote recognition of common commitments and serve as a base for solidarity and coalition” (pp. 26– 27). Such empathy is the “sine qua non” of the empowerment process. It enables bridges to be made and crossed so client and worker can stand together to confront both personal blocks to empowerment and injustice.

Empowerment Concepts

The empowerment approach makes connec- tions between social and economic injustice and

individual pain and suffering. Utilizing empow- erment theory as a unifying framework, it pres- ents an integrative, holistic approach to meeting the needs of members of oppressed groups.

As Adams (2008) notes:  “Empowerment is holistic and non- hierarchical. Empowerment is about taking control, achieving self- direction, seeking inclusiveness rooted in connectedness with the experiences of other people. It con- cerns individual achievement and social action. One aspect feeds another” (p. 18). This approach adapts an ecological perspective as advanced by classic theorist, mentor, and our friend, Carel Germain, which helps us see the interdepend- ence and connection of all living and non- living systems and the transactional nature of rela- tionships (1979; 1987; 1991). Potentialities are the power bases that are developed in all of us when there is a “goodness of fit” between people and environments. By definition, poor people and oppressed groups seldom have this “fit,” as injustice and a paucity of resources stifles human potential. To change this unfavorable equation, people must examine the forces of oppression, name them, face them, and join together to chal- lenge them as they have been internalized and encountered in external power structures. The greatest potential to tap is the power of collec- tivity, people joining together to act, reflect, and act again in the process of praxis. This process is fueled by mutual caring and support.

Multifocal Vision

Multiple perspectives are used to develop an empowerment practice framework. This “multi- focal vision” also determines the view of the cli- ent: The historical perspective- learning a group’s history of oppression, including a critical- historical analysis of related social policy; an ecological perspective, including a stress- coping paradigm and other concepts related to coping (a transactional view of ego functioning that takes oppression into account, problem solving, and cognitive restructuring of the false beliefs engendered with internalized oppression); eth- class and feminist perspectives that appreciate the ceilings imposed by class, race, and gender, the concept that power may be developed, and the unity of the personal and political; and a crit- ical perspective, analyzing the status quo; and

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cultural and global perspectives Van Den Bergh & Cooper (1986).

Imagine a pair of glasses with several lenses seamlessly ground in. Our vision is sharpened in particular areas, yet clearly focused. In addi- tion to this multifocal perspective, the empow- erment approach is based on values, principles, processes, and skills that are integrated into an overall conceptual framework to be discussed in this chapter. Helping processes include the sup- port of strengths and ego functioning, challeng- ing false beliefs, challenging external obstacles and unjust systems, developing pride in people- hood, problem solving and problem posing, consciousness raising and dialogue, and build- ing collectivity. These are used in the one- to- one, family, small group, and wider community, including the political arena. The group, in par- ticular the “empowerment group,” is the heart of empowerment practice. The uniqueness of this approach is the integration of the personal/ clini- cal and the political in a direct practice approach relevant to poor and oppressed people.

Empowerment’s Path into  Social Work— Historical and Contemporary Precedents

Three important historical precedents of empowerment practice in social work history are the settlement movement, particularly the work of Jane Addams and her cohorts (Addams, 1910); the generally unrecognized women’s club and social reform work of 19th- century African- Americans and other minority groups with self- help approaches (Gary & Gary, 1975; Berman- Rossi & Miller, 1992; Shapiro, 1991); early group work theorists, particularly Grace Coyle, who worked with a progressive group called the Inquiry (Coyle, 1930); and the work of Bertha C.  Reynolds, the radical psychoanalytic social caseworker (1934).

The great women who are the predecessors of an empowerment approach did not have the right to vote, to live alone or unmarried without scandal, to attend universities of their choice, or to freely enter the professions as they built the profession of social work. The interested reader might see Lee (2001, pp. 104– 121) for a detailed account of the amazing foremothers of empow- erment practice.

In the current time, sociology psychology, political science, economics, and religion, espe- cially feminist theory, oppression theory, libera- tion theology, and the inclusion of spirituality in social work practice, have contributed to social work’s synthesis of empowerment theory for social work practice (Lee, 1994, 2001; Simon, 1994; Simon, 1990; Turner & Maschi, 2014; Valentich, 2011; Martin & Martin, 2003; Robbins, 2011). For some, the concept “liberation” more accurately describes the processes and objectives of empowerment. Social work can assist people in empowering themselves to work toward lib- eration (Germain, 1991). There are two strong streams that feed into empowerment theory for social work practice: social/ political/ economic movements and human development/ clinical theories from the helping professions related to releasing human potentials. The empowerment approach seeks to channel the two streams into one mighty flow.

Barbara Bryant Solomon (1976) was the first major social work thinker who developed the concept of empowerment for the profession. Solomon identified direct and indirect blocks to power. Indirect power blocks represent internal- ized negative valuations (of the oppressor) that are “incorporated into the developmental expe- riences of the individual as mediated by signif- icant others.” Direct power blocks are applied directly by some agent of society’s major social institutions (1976). Powerlessness is based on several factors, including:  economic insecurity, absence of experience in the political arena, absence of access to information, lack of train- ing in critical and abstract thought, physical and emotional stress, learned helplessness, and the aspects of a person’s emotional or intellec- tual makeup that prevent them from actualizing possibilities that do exist (Cox, 1989). The actual and perceived ability to use resources that are available contributes to a sense of power that is directly connected to self- esteem (Parsons, 1989). Society “blames the victim” for power deficits even as power is withheld and abused by dominant groups (Ryan, 1971).

William Schwartz builds on Bertha Reynolds’s mediating function idea, and appreciates the oneness of private troubles and public issues. This is a foundation stone for the empowerment approach (Schwartz, 1994a, 1994b; Shulman,

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2008). Radical casework approaches (Galper, 1980)  seek to unite the personal and political and are an important forerunner of empower- ment thinking. Tully (2000) adapts Lee’s (1994) “conceptual framework” as a model for using the empowerment approach with gay and lesbian people. Gutiérrez and Lewis (1999) apply an empowerment perspective to social work prac- tice with women of color, while Yip (2004) and Hung (2012) apply an empowerment model to the Chinese culture, and Letendre (1999) applies it to school social work. Andrews, Guadalupe, and Bolden (2003) apply empowerment con- cepts to women in poverty, while Johnson and Lee (1994) apply them to homeless women, and Bay- Cheng, Lewis, Stewart, and Malley (2006) discuss empowerment in a feminist mentoring program. Chadiha, Adams, Phorano, Ong, and Byers (2003) explore African American caregiv- ers’ stories of empowerment. The uniqueness of the empowerment approach is that it weaves clinical and political thinking into one fabric.

Empowerment Defined

Empowerment “deals with a particular kind of block to problem- solving: that imposed by the external society by virtue of a stigma- tized collective identity” (Solomon, 1976, p. 21). Merriam- Webster’s (2009) definition of the word “empower” is: “to give power or author- ity to; to give ability to, enable, permit,” which implies that power can be given to another. This is rarely so. Staples, (1984) sees empowerment as the process of gaining power, developing power, taking or seizing power, or facilitating or ena- bling power (Parsons, 1991). Barbara Simon (1994, 1990), who has documented the empow- erment tradition in social work practice, stresses, “Empowerment is a reflexive activity, a process capable of being initiated and sustained only by (those) who seek power or self- determination. Others can only aid and abet in this empower- ment process” (1990, p. 32). The empowerment process resides in the person, not the helper.

Narayan (2002), speaking from a global eco- nomic point of view, defines empowerment as “the expansion of assets and capabilities of poor people to participate in, negotiate with, influ- ence, control, and hold accountable institutions that affect their lives.” Assets are “physical and

financial while capabilities are inherent in people and enable them to use their assets in different ways to increase their wellbeing” (p.  11). Assets and capabilities are social and political, individ- ual, or collective. These may include good health (physical and mental), education, production, belonging, leadership, relations of trust, a sense of identity, the capacity to organize, and values that give meaning to life. Empowerment- oriented social workers may assist people in developing their capabilities so they can increase their assets.

There are three interlocking dimensions of empowerment:

1. the development of a more positive and potent sense of self;

2. the construction of knowledge and capac- ity for more critical comprehension of the web of social and political realities of one’s environment; and

3. the cultivation of resources and strategies, or more functional competence, for attain- ment of personal and collective social goals, or liberation.

In his classic work, Beck (1959) noted that as we partialize and operationalize the concept of empowerment, it is a keystone concept of social work.

The “life model” of social work practice (Germain & Gitterman, 1980, 1996; Gitterman & Germain, 2008; Gitterman, 2011)  fits well with an empowerment approach, as it allows multilevel examinations and interventions that may be clinical or political; it is almost by defi- nition a praxis model; and the empowerment perspective gives direction to life model prac- tice (Mancoske & Hunzeker, 1989). The special- ized assessment and interventive methods used in the empowerment approach (Lee, 2001) build on the categories and the spirit of the life model.

Critical consciousness and knowledge of oppression are power. Power also comes from healthy personality development in the face of oppression, which fuels the ability to influ- ence others. This includes self- esteem/ identity, self- direction, competence, and relatedness (Germain, 1991). Clinical and political interven- tions must challenge the external and internal obstacles to the development of these attributes. Transformation, or throwing off oppression in

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personal and community life, occurs as people are empowered through consciousness- raising to see and reach for alternatives (Harris, 1993). It requires anger at injustice and the dehu- manization of poverty, negative valuations, and the culture of personal greed (Mancoske & Hunzeker, 1989). The strengths perspec- tive of Saleebey (2008, 2011)  and the structural approach of Wood- Goldberg and Middleman (1989) are also compatible with the empower- ment approach. Carol Swenson’s development of the concept of justice as a meta- practice princi- ple in social work practice (1998) is foundational in empowerment- oriented social work.

Social work practice with the oppressed builds on community and not on self- interest and broadens the possibility of the imagina- ble as it goes beyond immediate problem solv- ing to the promulgation of hope (Mancoske & Hunzeker, 1989).

Powerlessness has low social attractiveness due to poor resources— (material and emotional resources and knowledge). To help empower, we must first learn to speak openly about power with clients, then engage in examination of power bases stemming from personal resources and articulation power, symbolic power, value power, positional power or authority, and organ- izational power. Unfair social stratification and unfair distribution of goods are the most dif- ficult questions facing world society. Critical education and guaranteed basic incomes are imperative. International social work can help link different groups/ cultures together to claim a fair share of power resources and resist domina- tion (Staub- Bernasconi, 1992).

Paulo Freire

A major contributor to empowerment think- ing in social work is Brazilian educator Paulo Freire (1973, 1990, 1994). It is the translation of Freire’s critical thinking into social work theory that marks the uniqueness of this empowerment approach.

The “radical pedagogy” and “dialogic process” of Freire (1973) is clearly a relevant method for empowerment in social work (Lee, 1989, 1991, 2001; Mancoske & Hunzeker, 1989; Gutiérrez, 1990; Breton, 1989; Parsons, 1989; Pence; 1987; Freire, 1990; Narayan, 2000). “Every human being

is capable of looking critically at (the) world in a dialogical encounter with others … in this proc- ess… . Each wins back (his/ her) own right to say (his/ her) own word, to name the world” (Freire, 1973, pp. 11– 13). Freire’s group- and community- oriented methods of dialogue promote critical thinking and action.

Liberation theology, with its notions of base communities as units of social and polit- ical change, mutual support, and use of consciousness- raising, is particularly pertinent to social work thinking (Breton, 1992; Mancoske & Hunzeker, 1989; Germain, 1991; Evans, 1992; Lewis, 1991; Lee, 1994, 2001). Freire defines “conscientization” as “learning to perceive social, political and economic contradictions and to take action against the oppressive elements of reality” (1973, p.  20). Critical consciousness- raising and dialogue are the key methods that help people think, see, talk, and act for them- selves (Freire, 1973).

Lorraine Gutiérrez, cites consciousness- raising as goal, process, and outcome in empowerment work (1989, 1990). She sees group work as central to empowerment- practice based practice based on research on the effective use of ethnic iden- tity and consciousness- raising groups with Latino college students (Gutiérrez & Ortega, 1989).

Empowerment Theory and Groups

Empowerment theory applied to group work was first introduced in 1983 by Ruby Pernell at the Fifth Annual Symposium of the Association for the Advancement of Social Work with Groups. She noted that group work is a natural vehicle for empowerment, as its historic goals include “growth towards social ends” (1986).

Noting that black Americans have borne the lion’s share of power insufficiency and inequi- ties, Pernell emphasized that empowerment practice cannot remain politically neutral.

Empowerment as a goal is a political position, as it challenges the status quo and attempts to change existing power relationships… . It goes beyond “ena- bling.” It requires of the worker the ability to analyze social processes and interpersonal behavior in terms of power and powerlessness … and … to enable group members to … develop skills in using their influence effectively. (p. 111)

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The skills of working with indigenous leader- ship, knowing resources— where the power lies and how to get it, and enabling the group members to do for themselves are important in attaining empowerment.

Margot Breton (1994) and Elizabeth Lewis (1983) have been major contributors in integrat- ing humanism, liberation theology, and com- munity group work into empowerment practice. Groups that seek change in the environment are empowering to the degree that group members (not organizers) have actually brought about and reflected upon the change.

The Interactionist approach of William Schwartz (1994a) is a stepping stone to an empowerment approach. The group is a micro- cosm of social interaction. The worker’s role is to mediate the processes through which individu- als and their systems reach out to each other, particularly “when the ties are almost severed.” This approach appreciates reciprocity and the strength of the group itself as a mutual aid and self- empowering system (Berman- Rossi, 1994). Papell and Rothman’s (1980) conceptualization of the “mainstream model” of social work with groups draws on the Interactionist approach. Formed or natural groups can encompass a variety of empowerment purposes. A  blend- ing of critical education and conscientization group methods with the Interactionist and mainstream models form a foundation for the empowerment group (Lee, 1994, 2001, 2011).

Ruth Parsons (1989) emphasizes the impor- tance of the group in empowering low- income girls. Empowerment is an outcome and a process that comes initially through valida- tion by peers and a perception of commonal- ity. Groups may have consciousness- raising, help to individuals, social action, social sup- port, and the development of skills and com- petence as their overlapping foci in order to help members facing oppression gain equality and justice (Garvin, 1987). Reed and Garvin have made important contributions regarding the empowerment of women through groups (1983), while Tully (2000) discusses the empow- erment of gay, lesbian, bisexual, and transgen- dered people. Mullender and Ward (1991), major British theorists, stress that empower- ment group work must be a self- directed (not worker- directed) process. Parsons (1989, 1991)

identifies empowerment as a developmental process that begins with individual growth, and may culminate in social change; a psy- chological state marked by heightened feelings of self- esteem, efficacy, and control; and lib- eration. The conceptual framework presented here integrates these three kinds of empower- ment into a unified approach.

Basic Assumptions

A basic assumption of the empowerment approach is that oppression is a structurally based phenomenon with far- reaching effects on individuals and communities. These effects range from physical death due to infant or child mortality, the death of adolescents and young adults due to gang violence, drugs, other forms of homicide and suicide; to incarcera- tion and the death of hope. Hopelessness leads to self- and other- destruction, despair, apa- thy, internalized rage, and false beliefs about the worth of the self (Harris, 1993). When the effects of oppression become internalized, the maintenance of oppression may become a transactional phenomenon. Strong support networks and good human relatedness and connection are essential to developing a posi- tive sense of identity and self- direction. The assumption is that self is found in community with others (Swenson, 1992). The problems caused by oppression almost always necessitate a dual focus on changing the environment and strengthening the self.

The assumption about people in this approach is that they are fully capable of solving immediate problems and moving beyond them to analyze institutionalized oppression and the structures that maintain it, as well as its effects upon themselves. They are able to strengthen internal resources, and work collaboratively in their families, groups, and communities to change and empower themselves in order to challenge the very conditions that oppress. The basic principle of this approach is that “peo- ple empower themselves” through individual empowerment work, empowerment- oriented group work, community action, and political knowledge and skill. The approach sees peo- ple as capable of praxis: action- reflection— and action, action- in- reflection, and dialogue.

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A unitary conception of person- environ- ment prevents us from victim blaming on one hand and naïveté regarding the panacea of envi- ronmental change on the other. It leads toward developing helping “technologies” (strategies, methods, knowledge, and skills) that are both clinical and political. Feminist social work the- ory, a forerunner of empowerment in social work, necessitates “both/ and” conceptual- izations of practice (Turner & Maschi, 2014; VanDenBergh & Cooper, 1986; Bricker- Jenkins & Hooyman, 1986; Bricker- Jenkins, Hooyman, & Gottleib 1991; Valentich, 2011). People can and must take themselves and their environ- ments in hand to attain empowerment. To envi- sion social change that comes about without the full efforts of oppressed people is to envision a Machiavellian utopia. To envision oppressed people making this effort without changing themselves: to refuse oppression, to actualize potentialities, and to actively struggle to obtain resources is to negate the effects of oppression in the lives of the oppressed. Both changed soci- eties and changed people who will work toward this are the nature of the sought- for change. The goals are collective more than individual, yet these two are inseparable. The assumption here is that both the oppressor and the oppressed, as well as those who seemingly stand by or pass by on the other side, are damaged by oppression and in need of liberation. This view seeks unity and harmony among oppressed groups. Yet, it does not shy away from nonviolent confronta- tion and conflict, which may be a necessary part of liberation.

Value Base of  the Empowerment Approach

Most practice models or approaches that serve “all people” neglect to pay adequate attention to people who are poor, of color, women, and otherwise oppressed (Lum, 1986). The NASW Code of Ethics and the ethical principle of impartiality entreat us to cultivate our knowl- edge and skill to reach out to the clients who face bias and discrimination and to act (with them) to challenge oppression. Attempts at equanimity minimize central aspects of peo- ple’s lives that necessitate exceptional cop- ing abilities. Color, class, gender, stigma, or

difference “blindness” is not useful to clients (Lum, 1986). Empowerment means that people (both workers and clients) draw strength from working through the meaning of these differ- ent statuses in their lives, which enables them to be the fullness of who they are, persons with a rich heritage. The value base and the conceptual framework which underpins this empowerment approach is summarized in Figure 9.1.

A Conceptual Framework

The Empowerment Approach to Social Work Practice

Professional Purpose This is based on a dual simultaneous concern for people and environments:  to assist people who experience poverty and oppression in their efforts to empower themselves to enhance their adaptive potentials and to work toward chang- ing environmental and structural arrangements that are oppressive.

The Value Base This is the preference for working with people who are poor, oppressed, and stigmatized, to strengthen individual adaptive potentials and promote environmental/ structural change through individual and collective action; pref- erence for social policies and programs that cre- ate a just society where equality of opportunity and access to resources exists.

Knowledge Base and Theoretical Foundations Theory and concepts about person– environment transactions in situations of oppression— which include multifocal vision: the history of oppres- sion; ecological, “ethclass,” cultural, feminist, critical theory, and global perspectives; knowl- edge about individual adaptive potentialities, unique personhood, and the ways people cope— ego functioning, social and cognitive behav- ioral learning, and problem- solving in the face of oppression; empowering individual, family, group, and community helping processes; and larger systems and structural change processes in order that we may assist people in empower- ing themselves on the personal, interpersonal, and political levels.

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Method— Principles, Processes, and Skills The empowerment method rests on empower- ment values and purposes and the eight prin- ciples that undergird the approach. The method may be used in the one to one, group, or com- munity relational systems. It depends on a collaborative relationship that encompasses mutuality, reciprocity, shared power, and shared human struggle; the use of empowerment groups to identify and work on direct and indi- rect power blocks towards the ends of personal, interpersonal, and political power; and collec- tive activity that reflects a raised consciousness regarding oppression. The method uses specific skills in operationalizing the practice principles to address and promote action on all levels of living.

The Roles, Processes, and Skills of the Empowerment Approach

Processes and Skills to Promote Coping and Adaptation/ Social Change

In an empowerment approach, the worker pro- motes reflection, thinking, and problem solving on person– environment transactions, includ- ing the client’s role in them and the experience of oppression. Sustaining skills, particularly the use of well- attuned empathy born of multifocal vision and listening, make the difficult work of empowerment possible (Germain & Gitterman, 1996). The worker also assesses ego function- ing and provides ego- supportive intervention to bolster clients’ strengths (Goldstein, 1994, 2011; Lee, 1994, 2001; Lee & Hudson, 2011). Client and worker together then seek to change oppressive conditions, using a range of skills.

According to Carel Germain (1984), peo- ple must develop certain attributes in order to cope and adapt. The attributes achieved by good enough person- in- environment transac- tions are: motivation, which corresponds to the incentives and rewards provided by the envi- ronment; problem- solving skills, which corre- spond to the strengths and efficacy of society’s socializing institutions (including the family and schools); maintaining psychic comfort (including managing feelings), and a favorable level of self- esteem that corresponds to the kind and degree of emotional and other support in

the environment; and self- direction, which corresponds to the provision of information, choices, and adequate time and space (Germain, 1984, 1991).

Empowering Skills to Bolster Motivation

Motivation can only be sustained if basic needs for housing, food, clothing, and support (finan- cial and emotional) are met. As these needs are met by client and worker through gaining resources and opportunities, and attending to presenting problems, the worker can help keep hope alive. In Lee’s current work with the homeless in Fort Myers, she utilizes a “club- house” approach, where people regularly gather on a Tuesday and enjoy lunch and socializing as well as group and individual services. Over sev- eral years, a core group of 12 and a strong, car- ing community have formed where mutual aid abounds and people serve one another. Since this city has few options for shelter and afford- able housing, a strong focus of this practice is to help people obtain basic financial and housing resources. Over six years, more than 100 peo- ple moved from homelessness into permanent housing as a result of the hard work of this help- ing community.

The specific skills that bolster motivation are encouraging the client’s own words about the problems and her unique life and accepting the client’s problem definition. The worker can also reach for and convey understanding of feelings of difference, isolation, alienation, and being misunderstood, as well as experiences of discrimination at the hands of systems needed to sustain life and growth. Lanetta, a white woman, age 48, with a long history of bipolar illness and homelessness, wrote a story about a “throw- away dog” that identified her feel- ings about herself and her struggle (Lee, 2011). Easily agitated, she had literally been thrown out of every program in Fort Myers and slept in the woods and on the streets before she came to live in our Joshua House transitional residence for six months. The worker empath- ically conveyed understanding of “being thrown away.” Lanetta then worked hard indi- vidually and in groups and with a local mental health team to get stabilized on her medica- tions, internalize her self- worth, and turn

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her life around. She left Joshua House with a new sense of the intelligent, creative, witty, and capable person she was. And, she was reconciled with her daughter and grandchild as well. Her disability benefits were in place, and she was able to rent her own small home. She continues to be a respected leader in our “beloved community.” As the worker partial- izes the stressful demands into workable seg- ments with the client, she also encourages the client to share how she has dealt before with similar problems. The skill of having the cli- ent name and own her strengths also provides motivation to continue. Hope of changing the oppressive systems must also be offered through the worker’s skills of lending a vision and beginning to enlist the client’s energy in this thinking. The worker may also use skills of appropriate self- disclosure around dealing with oppressive conditions to build bridges to the client’s experiences and to offer further hope of change. The worker should also use skills of system’s negotiation with the client so that the client gains expertise in this area.

To Maintain Psychic Comfort and Self- Esteem

In helping the client maintain psychic comfort, manage feelings, and attain an optimal level of self- esteem, the worker has the additional tasks of externalizing the sources of oppression in order to reduce self- blame and to foster pride in “peoplehood.” Here she has the role of co- teacher and critical educator as she helps the client identify and own his/ her group’s achieve- ments and heighten awareness and appreciation of the client’s own culture.

The worker uses family and group skills to help members share and validate each other’s experiences with oppression (Wood- Goldberg & Middleman, 1989). As members discover they share a common experience, self- deprecatory feelings may diminish. Here also, the worker co- teaches about the oppressed group’s achieve- ments against the odds, which builds commu- nal and self- esteem. Giving information helps clients gain familiarity with how systems work, diminishes fear, and adds to feelings of compe- tence. The worker also helps mobilize natural helping networks and structures and focuses on

changing systemic inequities that promote the clients’ discomforts and anxiety.

To Enhance Problem Solving and Promote Self- Direction

The skills of problem solving are especially important in an empowerment approach. Ultimately, the aim is to help people to think differently and act differently. Berlin (1983) sug- gests a nine- step cognitive behavioral problem- solving process that moves from awareness of the problem to taking action. Eamon (2008) discusses a cognitive behavioral approach that is empowering as the goals are the cli- ent’s not the worker’s. Germain (1984) adds the dimensions of teaching the skills needed for achieving the solutions by providing group experiences for such learning and working with the environment.

Particular skills are needed to problem- solve in an empowerment approach. These skills include consciousness raising, praxis, and criti- cal education. Skills of maintaining equality in the problem- solving process are critical. This includes observing the rules of symmetry and parity in communication. The worker who is directive and lectures or filibusters or interprets frequently in the process is not providing the conditions necessary for empowerment. Lee’s agency was gifted with a second- year social work student, Lucy Conley, from Flinders University in Australia. A  particularly helpful skill that Lucy used was to ask members of our Tuesday “club” to share their expertise about homelessness in Fort Myers and how they coped with it. A corollary question was what might she do to make herself available to people who are homeless. One of our “elders” told her to watch and listen before she spoke, so she could learn who the people are by what they did as much as by what they said. Another told her to “lead with her love,” not her knowledge. Even as she empowered them in the role of experienced expert, they in turn empowered her as a grow- ing practitioner.

Consciousness- raising is a process of devel- oping a heightened awareness and knowledge base about situations of oppression, which leads to new ways of thinking about the social order. As with all skills and processes discussed here,

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it may be done on the one- to- one, family, group, or community levels. This is a tall order. The four attributes (motivation, psychic comfort, problem solving, and self- direction) are inter- dependent and must be sustained throughout the helping process. A  raised consciousness provides motivation, but motivation and psy- chic comfort are necessary to raise conscious- ness because ultimately it means change in thinking and doing. To view the world differ- ently may be initially both a frightening and a freeing experience. The worker’s skill of work- ing with feelings will include hearing, naming, staying with, validating, and helping the client to express the pain, anger, and sadness that come with consciously realizing that they have been oppressed and victimized socially and economically. The use of “codes” developed by the clients and of their own experiences— for example, using books, art, music, poetry, and other ways of reaching people’s level of con- scious awareness— can be extremely helpful.

The skills of gently sharing information in the co- teaching role are critical here as well. Knowledge is power. To be kept from knowledge is oppression. The skills of cognitive restructur- ing (Berlin, 1983) are needed to raise conscious- ness about being oppressed. The worker helps clients identify thinking patterns, revise false beliefs, devise more adaptive ways of dealing with internalized and external oppression, and to talk and think in a healthier way about her- self, her group, and her situation. The worker then encourages the client to rename and recre- ate her own reality using her own words.

One of the groups that the senior author works with is her church youth group. This group serves from four to nine African- American low- income young people from age 14– 22. They meet regularly on Sundays, and also attend and assist in the summer enrich- ment program with younger children. The building of knowledge and consciousness- rais- ing about African American cultural history as well as religious and moral content is part of the group’s work. They are rewarded for complet- ing workbooks containing this history and per- spective and also for their regular attendance and participation and their school progress. In 2014, five teens earned a trip to Washington, D.C. Their first air flight and first subway rides

were exciting to share with them. Talking with them as we toured the capitol and saw Frederick Douglass, Sojourner Truth, and Rosa Parks etched in bronze statues and then touring the Martin Luther King, Jr., Memorial and the section on slave and freedmen’s contributions in the Revolutionary period at the Custis- Lee Mansion at the Arlington Cemetery was an enlightening exercise in the development of new consciousness. Keeron, 16, said “the King Memorial made me proud to be black and also made me think ‘what will I do with my life’?” He and Keeondra, 14, posed for pictures by the capitol statues, and the group linked arms under the King Memorial and knelt beside the words of the “I Have a Dream speech.” Natasha, 18, who was about to enter college, took notes on the exhibits in the Custis- Lee Mansion, and she took pictures of everything. “I can’t forget this,” she said; “I never knew about freedmen and women and I never knew about any contri- butions of slaves. Knowing about slavery makes me sad, but knowing what they accomplished makes me proud of my people, and of myself in another way.”

The worker’s skills of guiding in the process of praxis are extremely important. As noted, praxis: action— reflection and return to action, involves sometimes painful unpeeling of aware- ness and feeling that take place over time. The ability to promote competence and action is critical. This is also a good time for the worker to share her own struggles in challenging such obstacles. As we relaxed after touring Arlington Cemetery, we reflected as a group on all they saw there. I  then asked them, “What does all of this make you want to do?” Their answers were about working hard in school and making their own contributions to a better world and better community at home. But they thought this would not be easy. Then I asked “So, what’s holding you back?” The need for computers and web access and worries about their hous- ing and family and community troubles were named and looked at as solvable problems. Lack of self- confidence was also a major obstacle for one of the 16- year- old girls— “but talking about it helps,” she said.

It is as important to be a “problem poser” as it is to facilitate problem- solving. The skills of crit- ical education are central to the empowerment

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process. This includes the skill of posing criti- cal questions that help people think about the oppressive situation in new ways. This is com- bined with the skills of information- giving noted above. For example, one can use recent newspaper articles or discuss a local news item.

As noted, Freire’s method of critical educa- tion (Freire, 1973; Mancoske & Hunzeker, 1989; Pence, 1987) has five steps, which are taken with a team of representative persons called a “culture circle.” First, a survey is conducted. The team listens to what is on people’s minds, assessing what people talk about and what their emotions are linked to. This work must include emotion- ally cathected concerns. Second, a theme is cho- sen, and problems are posed in question form. Themes broaden the base of an issue. For exam- ple, a theme in Pence’s battered women’s groups was, “What is the effect of abusive behavior on women?” (Pence, 1987). Third, the problem is analyzed from three perspectives: the personal, the institutional, and the cultural. Questions are asked about each perspective. Fourth, a code is developed. A code is chosen to focus the work when a theme generates work on all three levels. Finally, options for action are generated on all three levels. When actions are taken, a process of praxis is used to consolidate and deepen the work of developing critical understanding and a vision of social change. Ultimately, work that promotes motivation, problem solving, and psychic comfort contributes to a client’s self- direction and empowerment (Weiner, 1964).

Skills to Promote Social Change

Beyond the gains to the self, empowering work can empower communities. Group- and community- centered skills are essential. Much of the above noted- work is done most effectively in small groups, which then may build coali- tions with other groups and forces in the com- munity to effect social change (Breton, 1991). Empowerment group skills include:  making a clear mutual contract that bridges the personal and the political and includes a social change focus (Lee, 1991), establishing the common ground and common cause among members, challenging the obstacles to the group’s work, lending a vision, and reaching for each mem- ber’s fullest possible participation in the process

(Schwartz, 1994a). The worker will also skill- fully pose critical questions and develop codes to focus the group’s work, as discussed above (Freire, 1973). Combined, these become the “empowerment group” method. “Community skills” incorporate these group skills but include coalition- building and the skills of task- oriented action. Here one wants to help members choose initial tasks at which they can achieve success. Wider political skills include lobbying and testifying at legislative hearings as well as organizing meetings, protest, and non- violent resistance activities. These are skills for workers and clients to develop together (Lee, 1994; Staples, 1984; Richan, 1991).

Roles and Stance of the Worker

Above all, the worker in the empowerment approach is a real person who has awareness of her/ his own experiences of oppression and/ or membership in the oppressor group. This awareness begins with self- awareness, includ- ing issues of counter- transference, but goes beyond this to having a raised consciousness about oppression itself and an ability to share this in the helping process through appropri- ate self- disclosure. There is no mysticism about the helper or the helping process. The stance is “side- by- side” and an authentic, transpar- ent, presentation of self. With the youth group, Lee shared that she, too, had lots of “money problems” while growing up poor and living “in the ’hood” like them, and that working and going to college was really hard, but it had to be done so the family could eat. The group members travelled to the home of an African- American woman and art teacher now living in Washington, D.C., whom Lee grew up with, and Lee said, “Both Martha Andrews Gentry and I  shared stories of our youth that brought peals of laughter and a few tears from the kids.” Including them on this personal level opened a deeper level of communication. The helping process itself is shared with the client initially and as the process unfolds.

Assessment is important in this approach. The worker must gain understanding of who the client is in her own story and what tolls oppression has taken on the client’s well- being currently or in past history. The concept of “the

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client’s story” includes the presenting prob- lem as primary but often goes beyond it to the client’s view of historical material that is rele- vant to the problem at hand. This is both a nar- rative and oral history approach, which also seeks to unearth the strengths of individuals and their people over historical time (Martin, 1995). While principles of good clinical assess- ment are utilized, two important differences of this assessment process from “purely” clini- cal approaches are: the level of mutuality of the process as the worker shares what her thinking is openly, while seeking to comprehend how the client “makes sense” of the situation; and the explicit inclusion of “ethclass,” race, gender, and other areas where oppression and power shortages or power deficits may have been experienced by the client. Hence, the assess- ment is of the client in transaction with oppres- sion and of the oppressive environment, not of the client as if he or she exists in a vacuum. For a detailed outline for “An Empowerment Assessment:  Content and Process,” please see Lee (2001, pp. 216– 218).

The contract or mutually derived working agreement then also explicitly includes looking at the experience of oppression as one of the foci of the work. Of course, as in any approach, immediate and material problems have prior- ity. The client may choose, after being made aware of her options, to focus only on imme- diate problem- solving. This approach assumes that poor people and other oppressed groups already have a point of view on their oppres- sion and the ability to reflect on, challenge, and take action to rid themselves and their cohorts of oppression. Many clients already have a raised consciousness and may in fact be surprised that a social worker shares this consciousness. Some, however, have become so accustomed to living in oppression that the anger or despair at victimization and dis- crimination has been unconsciously repressed. This illuminates another level of the term “consciousness- raising.”

Whatever time it takes to both solve the issue(s) at hand and raise consciousness in order to challenge immobilizing oppression is the optimal time frame. It is important to note that this work is not open- ended. At some point in the process, the client feels empowered enough

to continue the work without the worker. The worker, in effect, does herself out of a job as empowered people stand ready with aware- ness, resources, and knowledge to pursue their own goals.

Worker Training Within the Empowerment Approach

Workers need both clinical and political knowl- edge and expertise to do the job. They need to be “generalist- specialists,” both broad and deep (Morales, 1977). They need to be individual and family clinicians, group workers, and com- munity workers and know how to use political process to effect change. Some master’s and bachelor’s programs with integrated curricula aim at producing this kind of graduate. Others are over- specialized in one end or the other of the spectrum of roles. It may take some shift- ing of curricula as well as postgraduate train- ing and supportive supervision to develop this kind of social worker. Team approaches may also help practitioners deliver the breadth of empowerment- oriented services. This kind of work comes to fruition in agencies where there is flexibility in the way workers may approach services.

The vocabulary of empowerment work includes a few new words, which we have defined in this chapter. These include consciousness- raising, praxis, dialogue, and codes. The usual vocabulary of the clinically and politically astute practitioner has been used and explained as well throughout this chapter. As in all empower- ment, as we use different words to describe our thoughts, we begin to think differently. The tried and true approaches to personal/ clinical work and to group, community, and political work and the newer strategies of empowerment are grafted in an approach that is therefore both old and new. Hence the practitioner is empowered with a new, yet not unfamiliar, level of knowl- edge to share in working with oppressed groups. We conclude this chapter with practice vignettes.

Case Examples

Lee’s work with homeless and low- income people in New York City and in Hartford Connecticut, Guyana,

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South America, and now in Fort Myers, Florida, grounded the empowerment approach in practice reality (Lee, 1986, 1990, 1991, 1994, 2001, 2011). All the people she worked with, especially Judith Beaumont (1987), “co- authored” the empowerment approach.

Case Example 9.1

The “Successful Women’s Group”: Formation

Membership in an empowerment group is a matter of personal choice based on knowledge of the expe- rience. A “tr y it and see” philosophy helps members who share common ground understand what it is like to be in such a group. In forming an empower- ment group for women who had “graduated” from the ser vices of the women’s shelter, the co- work- ers began by inviting large groups of “alumnae” to six evening get- togethers. This approximated Freire’s culture circle. The codes and themes for the empow- erment work would emerge from these six meetings, as would a nucleus of women interested in pursuing empowerment together. The format of the evening, which took place in the homey atmosphere of the shelter, included a dinner where introductions and an informal style of sharing mutual concerns could take place, and then a formal period of group discussion when empowerment notions were introduced. Many attended national and local protest activities regard- ing affordable housing that coincided with these meetings. Seven African- American women, ages 22– 34, decided to become the “Alumnae Empowerment Group.”

The co- workers started off as more central to the process in helping the group develop a structure and maintain a focus on issues of empowerment, but they soon took on a more advisory role. Within four months, the group developed a club- style struc- ture with a president who called the meetings and maintained the work focus. They chose the meeting nights, time, frequency (biweekly), outreach to new members, and content of the meetings. The workers bolstered the leadership structure and continued to contribute information and to assist in guiding praxis and reflecting on feelings and facts to deepen the work. The group existed for two years, though some of the members continue to be activists and to be there for each other. This is an excerpt from a meet- ing nine months into the life of the group in which they named themselves.

Tracey, the president, said, “Alumnae just don’t get it.”

“Who are we?” asked Vesalie. “We are successful women,” said Tracey. “Yeah,” said Latoya, “The Successful

Women’s Group.” “No,” said Vesalie, “we can’t call

ourselves that.” “Why?” Shandra asked. Vesalie strongly replied, “It implies too

much power, that we are powerful.” The worker asked if they felt power-

ful. Vesalie said, “Yes we are more powerful now— we’ve got good jobs, we’re good moth- ers, we help others who are homeless, we are meeting our goals, but we haven’t gotten there yet.”

The worker asked, “When you get there, then you have power?”

Tracey replied, “But that’s just it, we need that power to get there, and we’re on our way. Let’s convey that we are powerful women, we are successful women, let’s take that name and make it ours. We deserve to walk with that name!” The others strongly agreed. Vesalie thoughtfully accepted this, and the name “Successful Women” was enthusiastically adopted.

Names mean a great deal. The worker’s questions here are consciousness- raising questions. This renam- ing after nine months of meeting represents a 360- degree turnaround in self- esteem, group pride, and conscientization. The use of codes helped the group achieve this new image.

In the Successful Women’s Group, two themes were codified; one was “barriers to success” and the other was “African American womanhood.” On the first theme, the worker asked the group members to define success. It was defined as personal achieve- ment and “people- centered” accomplishments (giv- ing back to the community). The Wall of Barriers was the code.

The members were asked to imagine and dra- matically act out climbing and pulling bricks down from a wall that represented barriers. The worker posed the question: What are the barriers to young African American women get- ting over the wall to success for themselves and their people? Amika was first to try to dramatize it. She said, “The wall is over there, I’m going

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toward it. OOPS …” she said as she slipped and fell with a great thud, “they greased the ground, I can’t even get to the wall. Forget it!” Everyone roared as Amika, a large, heavily built woman, dramatized falling down in disarray.

Tracey said, “It isn’t really funny, Amika is right, some of us can’t even get to the wall. The grease is prejudice and racism.”

“And sexism,” Ves added, “don’t forget that.”

Shandra said, “Yeah, but determination makes you try and you reach the wall. Like you finish high school and you think you’re some- where, but you didn’t take the right courses to go to college so you got to start all over again.”

Tracey said, “I was angry too when I found out my diploma meant so little… .”

Shandra got up and started using a hammer and a chisel saying, “And this one you got to strike at, its prejudice on the job. You get the job, but they treat you like you’re stupid just because you’re black.” She told of how she was treated by a nurse she worked with … She unwedged the brick and threw it down hard. Everyone applauded.

Ves said, “O.K. Watch out! I’m driving this bulldozer right into the wall. Later for brick by brick, or climbing, the whole thing is coming down. Slam, crash.” Everyone cheered her on.

“Wait,” said Latoya, “a brick hit me, I’m hurt.” She wiped imagined blood from her head:  “It’s the brick of hating myself because I  believed ‘if you’re black stand back,’ and I stood back and didn’t go for even what you all went for, a real job and all. But I survived and stand here to tell it, I’m going to get me some too!” Everyone encouraged her.

The use of humor by African Americans and other oppressed groups is an adaptive mechanism. But no one should mistake the seriousness of the meanings in this dramatic enactment and decoding which was at once therapeutic and political— leading to a variety of actions.

Their next codification on African American womanhood was the reading together of Ntozake Shange’s choreopoem For Colored Girls Who Have Considered Suicide When the Rainbow Is Enuf (1977). After several readings of selected poems and their discussion, Tracey, who had committed some to memory, concluded:

“These are our lives. It could have gone either way for us, we too could have died, or chosen paths that lead to death of our spirits and our bodies. But, we didn’t because we found other women who was feeling what we were feel- ing and living what we was living. I will always see myself in Shandra. I will always be there for her. We found true shelter and we found each other, and we found God in ourselves, like the poem says.”

“Yes,” said Ves, “and we found the truth about our struggles too. And we are free, no turning back.”

For Shandra’s story and a summation of the empowerment work with her, including the tools of empowerment- oriented assessment and the skills of the work phase, please see Lee (2001, pp. 218– 249).

Case Example 9.2

Brenda: The Personal/ Political Empowerment of a Woman with Mental Illness

Brenda Gary, a 39- year- old African American woman with multiple physical problems and chronic paranoid schizophrenia, experienced periods of intermittent homelessness for five years. Leaving her children with relatives, she moved cyclically from the streets, to the hospital, to several shelters. Then she entered a resi- dential support program, which set her up in her own apartment and offered daily support and empower- ment services. For the first time since the onset of her illness, Brenda experienced inner peace. Brenda’s appearance is marred by skin eruptions, but she radi- ates a quiet joy. She is not spontaneous, but when she is called on, her good intellect is revealed. Brenda volunteered to testify at public hearings on proposed state cutbacks of mental health programs. This is an excerpt:

“We need our programs to keep us aware of life’s possibilities. No matter what you want to be it’s possible. These programs kept me on track and looking forward to life. If the State cuts these programs, the State also cuts the good that they do…  . We have a women’s group every week. We talk about what goes on in our lives— the problems we experience and solutions to them by getting feedback from each other… . ”

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To get Brenda and her peers to this point, the worker, Gail Bourdon, prepared the empowerment group to understand the issues and the process of testifying before asking for their participation. First, she shared specific details of the proposed cuts and elicited the group member’s reactions. She proposed that they might want to learn how to testify at the hearings and speak up for themselves. Then, when interest was high, she took two volunteers (Brenda and Vicky) and the staff to a workshop on the legisla- tive process. Two weeks later, during an empower- ment meeting, a summary of the legislative process was given to the group by the worker and the mem- bers who went to the workshop. Brenda volunteered to speak and composed her testimony that night.

Early the next evening we went to testify. Brenda patiently waited two hours in line and the and additional 2 l/ 2 hours before testifying. The testimony was presented in the Hall of the House of Representatives. Brenda and I  pre- sented our testimony. It was a striking image to see Brenda, in her woolen hat, speaking so well from the seat of the Minority Leader. One senator thanked Brenda for her testimony. Brenda was clearly the group leader that night.

The group then reflected on their actions in the next meeting. The worker invited praxis, the mem- bers’ reflections on the process of testifying and going to the legislative hearing.

Group members read the entire newspaper article to each other. I asked what the women thought and felt about attending the hear- ings. Brenda smiled and proudly stated she felt good about having spoken. I  asked Vicky how she felt about attending the hearing. Vicky said, “I was happy. It was one of the happiest times in my life. I saw and heard things I never thought I’d even learn about.” The entire group cheered… .

I asked Brenda if she thought her message was heard. Brenda said she thought so because they did not ask her unfriendly questions. They accepted her word and even thanked her. I  asked the group members who went how it was for them and each replied affirmatively. Vicky added, “I feel like I could do that some- time … I feel the strength.” The entire group agreed, noting that they had a voice and were heard. Ida said that those who simply sat there

also brought support and power in numbers, so they had a presence as well as a voice… . Brenda added, “It’s good to know that I  can accomplish things even with a mental illness. Sometimes people think you can’t do things because you have a mental illness. I  live with the illness, but this does not mean I  am not able to take care of business.” The other mem- bers thoughtfully agreed.

The careful preparation of the members paid off in the group members’ confident action. The skills of guiding praxis helped the members own their gains and expand their understanding and political skill as well as their self- esteem and self- direction.

Use of Groups and Research as an Empowering Process

At the invitation of a Guyanese social work educator, Lecturer Stella Odie- Ali, the senior author, collaborated with the Social Work Department at the University of Guyana in South America, and the Guyanese Association of Professional Social Workers over a three- year period, as a resource person and consultant on empowerment and homelessness. This mutu- ally empowering experience included several workshops, conferences, and research projects, as well as direct practice with Guyanese social workers (Lee, 1999). A group of Guyanese social work students also visited Lee in Fort Myers, Florida, to see empowerment practice in a North American context. The findings of four research studies done by the Guyanese social workers using qualitative and quantitative methods were shared with the appropriate minister in the gov- ernment, and this precipitated some changes in services to the homeless of Guyana. Reports of these studies of the mentally ill, street children, and the total homeless population include: Lee, Odie- Ali, and Botsko (2000); Lee and Odie- Ali (2000); and Lee, Cudjoe, Odie- Ali, and Botsko (2002). In each study, we hear the voices of those who have not been heard before.

Lee conducted a demographic and qualita- tive study with 133 homeless and low- income people who gathered for a meal, socialization, social and material services, and worship on a Friday night in a Fort Myers park over a two- year period. Data were collected in the summers

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of 2007 and 2008. She wanted to know who they were, their experience of homelessness, and what they felt would help empower them. As a pastor, she also wanted to know how they viewed both God and church. Lee and her assis- tants recorded verbatim the words used and the stories told in response to open- ended ques- tions. Some chose to write their own answers. A key finding of this study was the importance of the support system that was developing in the park, of caring and empathy as well as the provision of needed services and goods. Their resilience and the power of their faith in God was remarkable. Most people said thank you for asking for their thoughts and experiences. The interested reader might see Lee, Come by Here: Church with the Poor (2010).

In 2015, Lee asked her Tuesday “Clubhouse” group of formerly homeless and low- income core members if they wanted to share what fac- tors in their life were most empowering. Nine of 15 present (five women and four men, rang- ing in age from 32– 62, six African- American, one white, and two Hispanic) participated by writing the three most important factors in their empowerment. The results of this small study were discussed with great excitement in the next meeting. The study then became an exercise in praxis:  reflection, action, and reflection leading to action again. All nine named faith in God and participation in a faith group as empowering. Seven said that their power comes from God’s love. Eight named relationships with family, friends, group members, and specific people as empowering. Two named helping others as empowering. One named her medication as empowering “because it helps me think more clearly.” One named her job and a social agency as empow- ering. One named specific religious beliefs as empowering. In reflection, they said that the study itself was empowering as their thoughts were important.

Cattaneo and Chapman (2010) have researched the construct of empowerment for research and practice across disciplines, while Jefferson and Harkins (2011) have researched a qualitative research model for empowering homeless and low- income individuals. Andrews, Guadalupe, and Bolden (2003) have studied the empowerment of women in poverty.

A very promising tool for the measurement of gains in empowerment, particularly with a mental health population, is the Empowerment Scale developed by consumers and leaders in the self- help movement and advanced by E.  Sally Rogers at Boston University Psychiatric Services, and her colleagues. This is a well- validated 28- item scale measuring five factors:  self- esteem- self- efficacy; power- powerlessness; community activity- autonomy; options and control over the future; and righteous anger (Rogers, Chamberlin, Ellison, & Crean, 1997); w w w.cpr.bu.edu/ w p- content/ uploads/ 2011/ 11rogers1997c- pdf.) While it is geared toward a specific population, I believe this scale could be used with a variety of populations.

Status in the Profession

Empowerment practice has gained in momen- tum over the years. Many contemporary thinkers are researching and conceptualizing empowerment- oriented practice. Hence, there is a growing empirical base to anchor empow- erment in the professional lexicon of social work approaches. Yet it is difficult to study and measure a concept that is transactionally based and both clinical and political. Perhaps in some ways, such measurement is a moot point, for the power that people develop on the personal, interpersonal, and political levels ultimately makes up a whole that may defy quantifica- tion and over- simplification. At best, the sepa- rate aspects of the approach will be empirically documented (Rogers et  al., 1997). The empow- erment approach is grounded in practice and conceptualized from qualitative data, which, I  believe, is a prerequisite to quantification of such complex ideas (Lee, 1991, 1994, 2001, 2011). Further grounding in such qualitative data would be helpful.

The empowerment approach provides a con- ceptual framework for empowerment- oriented social work practice. It brings social work into the discourse between sociology, political sci- ence, progressive change, and religion. It is rel- evant in education, ministry, community work, and a range of helping professions. It is both old and new, both clinical and political. It is also a paradigm for international social work practice, as it offers social workers a way to challenge

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oppression and build capabilities with people throughout the world.

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Existentialism

Born again in the disillusionment of recent decades, the existential worldview argues for more effective, flexible treatment of the poor and minorities from an enhanced, humanizing perspective.

The impact of existential philosophy upon the social work profession remains unclear. The first article on the subject appeared in social work literature in 1962, and three books by social workers delineated exis- tential perspectives in 1969, 1970, and 1978. The topic of existentialism has seldom appeared at the National Conference of Social Workers.

On the other hand, social workers familiar with the existential viewpoint emphasize that this perspective speaks to the profession’s most pressing needs: for more effective treatment of the poor and minorities; for more present- focused, experiential, task- oriented work with families and individuals; for a more flexible and eclectic use of varied treatment techniques; for a lessening of categorization of people and of paternal- istic efforts by therapists to adjust the values of clients to those of their families or those of the established society. The existential perspective is even seen as providing an important humanizing effect to social work- ers’ present experimentation with social change.

The failure of the existentialist viewpoint to attract major attention among social work professionals may be twofold. In the first place, writings of this type by philosophers, psychologists, theologians, and social workers tend to present a terminology that seems foreign to the average practitioner (“Being, Nothingness, the Absurd, Dread, I- Thou, Bad Faith,” etc.). Social workers tend to be “doers” rather than theoreticians, and even the theo- rists tend to be pragmatic rather than philosophical. Second, existential social work writers have proposed a more philosophical perspective rather than specific working techniques. This is primarily because there does not really seem to be an existential psychotherapy per se. To be more accurate, one might say there is an existential philo- sophical viewpoint of how one sees oneself and one’s client system and what can happen between them. Various theoretical approaches may then be used to provide techniques compatible with this philosophical perspective.

Existential Social Work

Donald Krill

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The Existential Stance

Modern existentialism was born in the ruins, chaos, and atmosphere of disillusionment in Europe during and following World War II. Earlier existential writers, such as Kierkegaard and Dostoevsky, reacted against what they believed to be false hopes for the salvation of humanity and the world through a philoso- phy and politics of rationalism in their times. In the United States, with its boundless faith in achieving the good life through continued growth in economic productivity and scientific advancement, the interest in existentialism has been slower in coming.

The disillusioning events of the 1960s (assas- sinations, the “generation gap,” protest move- ments, Vietnam War) continued into the early 1970s (Watergate, economic instability, mount- ing divorce and crime rates, failures of psycho- therapy hopes). These troubling occurrences opened the minds of many Americans to the existential themes that had previously been the interest of beatniks, artists, and a scattering of intellectuals.

Existentialism has been termed a “philos- ophy of despair,” partially because it seems to emerge from disillusionment. But we may view this emergence as the origin and rooting of existentialism and its turning away from a pri- mary allegiance to the idols and values that it deems have fallen. Where it goes beyond this point depends upon which particular existen- tialist writer, theologian, philosopher, or film director one chooses to follow.

In most of the philosophical literature on existentialism, four themes seem to recur:  the stress upon individual freedom and the related fundamental value of the uniqueness of the person; the recognition of suffering as a nec- essary part of the ongoing process of life— for human growth and the realization of meaning; the emphasis upon one’s involvement in the immediate moment at hand as the most genu- ine way of discovering one’s identity and what life is about (not in any finalized sense but, rather, in an ongoing, open way); and the sense of commitment that seeks to maintain a life of both discipline and spontaneity, of contempla- tion and action, of egolessness and an emerging care for others. In all of these there is an obvious

emphasis upon an inward turning in contrast to the “organizational” or “outer- directed” man of the 1950s.

The existentialists disagree with those who hold human beings to be either essentially impulse- driven animals or social animals of learned conditioning. Both of these ideas deny the individual what is, for the existentialists, one’s source of dignity: the absolute value of one’s individual uniqueness. A person discovers one’s uniqueness through the way one relates to one’s own experience of life. Sartre points out that this subjectivity is a person’s freedom; it is something that is there; it cannot be escaped or avoided; one can only deny one’s own respon- sibility for choices made within this freedom. From the existential view, psychoanalytic the- ory is sometimes misused by encouraging the individual’s denial of responsibility on the basis of impulsive forces; similarly, sociological and learning theory may be misused by excusing a person on the basis of totally determining social forces.

Characters from fiction, drama, mythology, and philosophical tradition have portrayed the existential posture. Stoicism, courage, and indi- vidualism are common attributes. Existentialist heroes are often characterized as living on the edge of the traditions, values, and enticements of their society, prizing the preservation of their own uniqueness and authenticity above all else. They commonly suspect the motives of others, bordering on the cynical, and therefore avoid complete identity with any group espousing a “good cause.” They are tough- minded in hold- ing to their own code, evaluating it and preserv- ing its integrity. They refuse to be “put down” by dehumanizing social forces through conform- ity or by selling themselves out to their rewards. They are against systemic efforts to suppress the individuality of others in society. They live for- ever with a clear awareness of life’s limits, the absurd, the tragic, yet they maintain a commit- ted faith in their groundings of freedom— the springboard for unique assertion. Their interac- tions with life define who they are, rather than the acceptance of some definition of themselves imposed by an outside authority, such as fam- ily, church, or economic system. The rhythm of responsive life- swinging- in- situation is a primary guide.

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Existentialism is rejected by many as a nar- cissistic withdrawal from life when disappoint- ments arise. At first glance, this might appear true, as we hear existentialists proclaim their own consciousness, subjectivity, and unique- ness as the sole absolute: “Truth is subjectivity,” said Kierkegaard. Existentialists do reject the world, in one sense, in their new commitment to their own deepest self. What they reject, however, is not life— its conditions, limits, joys, and possibilities— but the mistaken hopes and expectations they had held about life, which, under closer examination, failed to fit with the reality of their life.

What is real does shatter cherished yearn- ings in us all— about love, about divine protec- tion, about our own abilities and goodness. Yet in surveying the landscape of rubble from bro- ken aspirations and beliefs, we find that we still have a choice of how to relate to these realities. We can allow ourselves to be driven to despair, or to choose new illusional hopes, or we can accept the reality and go from there.

The Hemingway hero is a portrayal of this. We might expect him to say, “We lose in the end, of course, but what we have is the knowl- edge that we were doing great.” One’s man- hood, the sense of realistic pride, comes from the engagement with and assertion of one’s own uniqueness. Each must discern what is right for him in terms of talent and skill, what is of value, and what is enjoyable. This becomes his own private personal perspective for which he alone is responsible. It changes throughout life, but it remains always his own, and hence truly unique.

The blank concept of “soul” has been defined as “the force which radiates from a sense of self- hood, a sense of knowing where you have been and what it means. Soul is a way of life— but it is always the hard way. Its essence is ingrained in those who suffer and endure to laugh about it later.” Soul is the beauty of self- expression, of self- in- rhythm. One swings from inside and in response to what is outside as well. Soul is mind operating free of calculation. It is humor and spontaneity and endurance. This concept of soul is consistent with the existential aim of authenticity. Here we have a shifted view of spirituality emphasizing personal integration arising from direct life engagement. This is not

a remote God, but rather God found at the heart of our daily experience in our interchange with others, ourselves, and nature.

Subjectivity

What is this subjectivity, this freedom, that holds the devotion and loyalty of a person? To Sartre, freedom is “nothingness.” For Kierkegaard, it is the human encounter with the Transcendent— one’s moment before God. Buber sees this as the “I” meeting the “Thou” of life. Kazantzakis speaks of the cry from deep within the human personality. To respond to it is our sole possibil- ity of freedom.

Yet this subjectivity, while termed by some as an encounter with the transcendent, should not be mistaken for a direct expression of the Divine. Each of us is all too soon aware of the finite nature of subjectivity. It is not all- knowing, and subjectivity is different in each person and constantly in the process of change within the same person. Subjectivity exists as a unique responsive relation to the world. Its primary activity is the conveyance of mean- ing through thought and feeling, intuition and sensation, and the assertion of this unique perspective through creative acts. Some would term this the activity of spirit, a divine possi- bility available to human beings. Yet divine and human remain intertwined.

It is this relationship between one’s own sub- jectivity and the outside world that is the basis for responsible freedom instead of narcissis- tic caprice. One experiences failures, misjudg- ments, hurt of others, neglect of self, conflict, and guilt. There is inevitable death, uncertainty, and suffering. These limiting situations, this suffering, becomes a revealing, guiding force of one’s life. In a similar way, one realizes one’s potentials. We sense that the world wants and needs some response from us. We feel called upon to choose, to act, to give, and to imprint ourselves on the world. This awareness of both limits and potentials is the foundation upon which we can judge our own unique perspec- tive and readjust it when necessary. The ongoing encounter between subjectivity and the outside world may be looked upon as a continuing dia- logue, dance, responsive process of inner and outer reality.

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Each of us must assume the burden of responsibility for our own freely chosen per- spective and the associated consequences of our actions. To be a person is to assert our intelli- gence, knowing that we do not have an absolute knowledge of truth and that we may hurt others or ourselves; our efforts will often end in mis- takes or failure.

We fail, finally, in our resurging hopes, the existentialist might say, but then we are a broth- erhood in this— not only with others, but with all of nature. For there is a striving everywhere, a fight, and, in the end, only the remnants of our struggles— and a little later there are no longer even the remnants. Our loyalty is to the thrust behind this struggle in all things. What is this thrust? A  mystery! A  meaningful silence! Can we be sure it is meaningful? Who is to know? The questions of salvation or an afterlife must be held in abeyance. They can no longer be certainties. For many, these very uncertainties become the springboard to religious faith.

The mystical flavor of life is shared by both existential believers and nonbelievers alike. It affirms life as meaningful, not because it has been clearly revealed as such through science or Scripture, but rather because one has sensed a deeper or clearer experience of reality in certain moments. These moments are not dismissed lightly, but are preserved as precious and illu- minating even though the full meaning of their revelation may be unclear. Such experiences as love, beauty, creative work, rhythm, awe, and psychic phenomena suggest seeing “through a glass darkly.” Those followers of religious faiths may find a “rebirth,” an adult reorientation to the message of revelation in religious writ- ings. Yet the revelation of ultimate significance remains personal.

The Bond with Others

If subjectivity and its uniqueness, develop- ment, and expression is valued in oneself, it must be valued in others as well. Since there is no absolute subjective perspective, each per- son’s unique view and contribution contain an intrinsic value. Existentialists feel a bond with others and are responsive to their needs and to friendship, for they respect their subjectivity as being as valid as their own. They also know that

the assertion of courage is difficult and often impossible without occasional affirmation from others. Human love is the effort to understand, share, and participate in the uniqueness of oth- ers. It is validating in others that which we also value within ourselves. Love is sometimes an act of helping, at other times a passive compas- sion. At times it reaches a total merging that takes one beyond the fundamental awareness of isolation.

The existentialists realize, too, the dangers in human relationships. Just as we guard against self- deceptions that tempt us toward a narcis- sistic idolization of ourselves, so we remain on guard in relation to the institutions of society. The assertion of individual uniqueness is often a threat to others and to a smoothly functioning social group. This is because such assertion will frequently defy the rules, patterns, habits, and values that are sources of defined security for others, or a group. Thus society and subgroups within a society will again and again attempt to suppress arising individual uniqueness out of a sense of threat or an inability to comprehend. Conformity is urged. It happens with family, friends, neighborhoods, and church, profes- sional, and political groups. Existentialists often finds themselves estranged from others because of their own creativity and authenticity. Even when there is a relationship of mutual respect, with moments of unity through love, there will also come the moments of threat and misun- derstanding because of the impossibility of one person’s subjectivity fully comprehending that of another.

Yet conflict and threat in relationships do not move existentialists into a schizoid withdrawal. They may display a touch of cynicism as they hear others identify themselves wholly with some group effort or as they proclaim the hope of humanity to be in their sensitive and loving interchange with their fellow man. But existen- tialists know that their growth depends upon both affirmation from others and their occa- sional disagreement with them. Existentialists believe in the beauty and warmth of love even though it is momentary.

The philosophical position described has stressed both faith and commitment to a per- spective of life deemed valid as a result of one’s direct and sensitive involvement in the

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life process. The subjective involvement of the whole person is essential to the life per- spective that we finally conclude is our reality. Human life is highly complex, and we must seek an openness to its totality of experiences if our search is to be legitimate. This should not neglect an opening up of oneself to the meaning of experience as described by others as well.

What becomes apparent is a movement in personal awareness— from egotistical striving to self- understanding; then to I– Thou relation- ships with one’s immediate surroundings; and finally, in the incorporation of some overall principle where humanity and universe are joined. Disillusionment, freedom, suffering, joy, and dialogue are all important happenings along the way. The end of this process does not really arrive until death. It is a continuing way that requires again and again the reaffirma- tion of that personal perspective called “truth.” A  transcendent view of existential freedom might be that of an illuminating light seeking understanding, compassion, and sometimes protective action in the surrounding world. This luminosity may also recognize that this very awareness is shared by all other humans, whether they know and validate it or not.

Professional Contributions

These ideas can be found in philosophical and religious writings as well as in motion pictures, plays, novels, and poetry labeled “existential.” One of the earliest examples of existential lit- erature is the Book of Ecclesiastes in the Old Testament. From the Orient, Zen Buddhism is also often compared with Western existential thinking.

Existential philosophy as we know it today had its initial comprehensive presentation by Soren Kierkegaard (1813– 1855), whose writings were a passionate reaction to the all- embracing system of Hegelian philosophy. Later devel- opments included the thought of Friedrich Nietzsche and Henri Bergson. Modern- day existential philosophers include Martin Heidegger, Jean- Paul Sartre, Albert Camus, Simone de Beauvoir, Miguel de Unamuno, Ortega y Gasset, Nicholas Berdyaev, Martin Buber, Gabriel Marcel, and Paul Tillich. This

array of names suggests the widespread inter- est in existentialism among several European countries.

Much of existential psychology had its ideo- logical rooting among the phenomenologists, most notably Edmund Husserl. Two European analysts, Ludwig Binswanger and Medard Boss, were constructing an existential psychology during Freud’s lifetime.

Viktor Frankl, a Viennese psychiatrist, devel- oped his “logotherapy” following his imprison- ment in a German concentration camp during World War II. Logotherapy is based on exis- tential philosophy, and Frankl remains one of the most lucid writers in conveying existential thinking to members of the helping professions.

Rollo May’s monumental work Existence (May et  al., 1958)  represented the first major impact of existential psychology upon American psychiatry and psychology. May presented the translations of existential psychologists and psychiatrists from Europe, where such thinking had become popular and in many places had replaced psychoanalytic thought. There was a readiness in America for existential thinking, and it quickly became part of the “third force” or humanistic psychology movement. This group included people such as Karen Horney, Carl Jung (1933), Clark Moustakas (1956), Carl Rogers (1961), Abraham Maslow (1962), Gordon Allport (1965), Andras Angyal (1965), and Prescott Lecky. Two journals devoted specifi- cally to existential psychology and psychother- apy began quarterly publication in the United States in the early 1960s.

Existential thought was related to Gestalt therapy (Frederick Perls 1969), the encounter movement (Carl Rogers and Arthur Burton 1969), rational- emotive psychotherapy (Albert Ellis 1962), and R. D. Laing’s provocative “anti- psychiatry” writings (1964/ 1967). Thomas Szasz (1984) pursued a similar attack upon psychiatry, particularly in relation to the “therapeutic state,” the insanity plea, and the dehumanizing use of clinical diagnostic categories. Ernest Becker and Irvin Yalom (1980) presented challenging reappraisals of psychoanalytic thinking from existential postures. Perhaps the most intense descriptions of the existential therapists’ use of self are found in the works of Thomas Hora and William Offman.

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Perhaps the earliest social work writings with a decided existential flavor were by Jessie Taft of the functional school, which had its roots in the psychology of Otto Rank. In his Pulitzer prize– winning book The Denial of Death, Becker produced a monumental integra- tion of the thought of Rank and Freud (Becker, 1958). Social workers, who once avidly debated the “dynamic” versus the “functional” schools of social work theory, appear to have totally ignored Becker’s incisive thought. A welcome scholarly exception to this is Robert Kramer’s work, which links Rank with Carl Rogers and Rollo May (Kramer, 1995).

In 1962, David Weiss’s article appeared in The Social Worker (1962) and Gerald Rubin’s paper in Social Work (1962). Andrew Curry was publishing articles in the existential psychia- try journals. In the late 1960s, several articles appeared in various social work journals, writ- ten by John Stretch, Robert Sinsheimer, David Weiss, Margery Frohberg, and myself. These papers were specifically related to the applica- tion of existential philosophy in social work thought and practice.

There were also several social work papers published during this period that did not specif- ically emphasize existentialism but were related to similar concerns of the existential social work group. These writers included Elizabeth Salomon (1967), Mary Gyarfas (1969), and Roberta Wells Imre (1971).

The first book on the subject of existen- tialism in social work was published in 1969 by Exposition Press. It was Kirk Bradford’s Existentialism and Casework (1969). Its sub- title expresses its intent: The Relationship Between Social Casework and the Philosophy and Psychotherapy of Existentialism. It should be considered an introductory and integrative work rather than a comprehensive or prophetic book. In 1970, Alan Klein related existen- tial thinking to social group work in his book Social Work Through Group Process (1970). A second book was published in 1975 by Dawson College Press of Montreal, authored by David Weiss and titled Existential Human Relations. This was a more comprehensive work applying existential thought to various aspects of social work practice. In 1974, James Whittaker’s book Social Treatment (1994) legitimized existential

thinking as one of the four major theories con- tributing to social work practice. An effort to clarify both spiritual and systemic ideas for social workers appeared in Existential Social Work (Krill, 1968) by myself. Two of my sub- sequent books in practical application were The Beat Worker (1986) and Practice Wisdom (1990). The former focused on psychother- apy and the latter on teaching the integration of self- awareness, philosophical thinking, and the therapeutic relationship to graduate stu- dents. Other social work writers utilized the existential view when addressing instances of child abuse (Brown, 1980), social work educa- tion (Swaine & Baird, 1977), and cross- cultural counseling (Vontress, 1979).

While there appears to be a rising, if some- what limited, interest in existential philosophy in social work literature, it would seem that the interest is far more widespread among social work students and younger professionals. Many of the newer therapeutic approaches being per- formed by social workers are closely akin to the existential view of the therapeutic process. Such points of emphasis as choice and action; here- and- now problem orientation; dispensing with the use of diagnostic categories; stressing the expression of the worker as a vital, human per- son; and recognizing the connection of personal identity with the quality of “significant other” relationships all have their existential linkages.

Therapeutic Concepts

The philosophical perspective discussed earlier suggests five organizing concepts of existential thought:  disillusionment, freedom of choice, meaning in suffering, the necessity of dialogue, and a stance of responsible commitment. These same concepts can provide a way of viewing the therapeutic process (Krill, 1969).

Disillusionment

In existential thinking, one can move from a life of “bad faith” to one of authenticity. To do this, one must risk the pain of disillusionment. Similarly, in psychotherapy, change can be viewed as a result of giving up those very defen- sive beliefs, judgments, symptoms, or manipu- lations that interfere with the natural growth

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process. This growth process would be seen as the emergence of unique personhood through responsive acts in relation to one’s surround- ings. Realistic needs and potentials begin to be the source of choice and action, instead of neu- rotic, self- deceptive security needs.

An important therapeutic task, then, is to help clients experience disillusionment with the various security efforts that block their own growth. Disillusionment will seldom result from a rational exploration of one’s past with the hope of realizing causal factors of present defensive behavior. It is rare that one gives up security patterns because they are viewed as irrational, immature, or no longer applicable. Disillusionment occurs through the pain of loneliness and impotence. On the far side of such despair arise the possibilities of new val- ues and beliefs. It is the therapist’s concern that these be more human values than those aban- doned. The therapist acts as a midwife for the release of the natural growth energies within the personality so that what is wholly and indi- vidually unique may emerge.

Freedom of Choice

Sartre characterizes consciousness as “noth- ingness,” for it is an awareness of oneself that transcends or goes beyond any fixed iden- tity one might have concluded about oneself. Personality is always emerging. To view it as static or secured is our act of self- deception (bad faith). This conception of consciousness as free- dom is a break with conceptions of personality as being totally ruled by “unconscious” or by early learned behavior.

Despite our past, despite any diagnos- tic label pinned upon us, we always have the capacity to change ourselves. We can choose new values or a new lifestyle. This does not always necessitate years or months of “work- ing something through”; it may occur within days or weeks.

Choice is for action and differs from intel- lectual meandering or good intentions. Chosen actions occur in the present. Therapy is, there- fore, present- focused and task- or action- oriented. People learn from experience, not from reason alone, although the very process of understanding how one’s current belief and

value system operates (and its consequences) can itself lead to new choices.

The critical ingredient for change is the cli- ent’s wish to do so. Therapy must, therefore, be designed to clarify quickly the nature of change sought by the client, and the therapist must be able to work within this framework rather than seeking to convince or seduce the client into redefining his or her problems and aiming for some type of change goal that pleases the thera- pist but is only vaguely understood by the client.

A therapist’s belief in the client’s capacity for change is a message of positive affirmation con- veyed throughout treatment. There is no ques- tion but that a therapist’s focus on unraveling the intricacies of past relationships conveys a deterministic message that is a commentary on the weakness and helplessness of a client.

Meaning in Suffering

Just as existentialists see suffering as an inherent part of a life of authenticity based on responsi- bility and freedom, so, too, existential therapists do not seek to discredit or eliminate anxiety and guilt in their clients. Instead, they affirm such suffering as both necessary and directional for a person. They will help reveal what real anxi- ety and guilt may lie disguised behind neurotic (unrealistic) anxiety and guilt. But they would not seek to minimize or eradicate realistic anxi- ety and guilt. Such efforts would themselves be dehumanizing unless used to prevent decom- pensation. In many cases, the normalizing of pain or a problem as a natural consequence of one’s valued conclusions about adjusting to life can enhance one’s sense of responsibility and the potential for changing one’s orientation.

Necessity in Dialogue

People do not grow from within themselves alone. Their emergence happens in responsive relation to their surroundings. They create their own meaning in response to situations, and these meanings become the basis for choices and actions. However, their own meanings are no more absolute than those of any other person. Their own growth has to do with the continued reassessment of personal meanings, and they depend upon feedback from their environment

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(particularly human responses) for this reas- sessment activity. In order to gain honest feed- back, one must allow others to be honest and free in their own expression. In therapy, there- fore, it is critical to help clients open themselves to relationships with others wherein they give up their manipulative or “game” efforts in order to invite free responses from others. In doing this, they not only allow themselves experiences of intimacy, but they also realize that their own emerging sense of self requires such honest transactions with others.

Commitment

Clients’ recognition of and commitment to their own inner emerging unique lifestyle is a hope of the existential therapist. Clients realize this commitment through their experience of the therapist’s own affirmation of their world- view. This unique worldview is affirmed from the beginning in the therapist’s acceptance of how clients perceive their symptoms, problems, conflicts— how they perceive change and what they want changed. The client’s uniqueness is also affirmed during treatment by the way a therapist relates to “where a client is” in each interview. The theme of a session comes as an emerging force from the client, rather than as a rationally predicted starting point made in advance by the therapist. Both the goal- setting process and the activity of entering upon and working with an interview theme are therefore client- centered rather than therapist- centered. When possible, a client’s sense of destiny may be clarified and emphasized.

Clients’ awareness of and respect for their own unique lifestyle might be described as a turning away from self- pity and impotence. Rather than complaining about their lot in life, they discover that they are intricately involved in the life process itself. They learn to listen to what life says to them and find meaning in the response that is unique to themselves. This is what is meant by the existential concept of des- tiny and commitment.

Related Therapeutic Approaches

As suggested earlier, there are obvious differ- ences among therapists who claim the existential

label. This becomes more understandable if we consider the above therapeutic principles and note how they may be activated in a number of differing ways. A  consideration of the rang- ing techniques that may fit with the principles outlined will also clarify how other treatment theories tend to be compatible with the existen- tial view. Existentialism claims no technique system of its own and needs none. Its affirma- tion of the uniqueness of each client results in a perspective that each treatment situation is also unique. Whatever techniques can be used, from whatever treatment theory, become the tools to work toward accomplishment of the special goal chosen. In this sense, existentialism is thoroughly eclectic. Techniques are always placed secondary to the world view of clients and the puzzle they present to the therapist.

Several therapeutic systems are compat- ible with existential thinking. (Some are not, and these will be considered later.) The reality- oriented therapists (Glasser (1965), Ellis (1962), O.  Hobart Mowrer (1961), and Frankl 1965/ 1967) all stress choice and specific behavior change. William Reid (1979), Laura Epstein, and Harold Werner have described similar cognitive- oriented approaches in social work literature. They are present- focused and com- monly propose specific tasks for clients wherein the client is expected to put into immediate practice a decision for change. They tend to use reason to aid the decision for change, but then stress action. The action is usually expected to occur outside of the therapy interview (often as homework assignments), but its results are brought back for further discussion. Reality therapists focus on the disillusionment pro- cess by clearly identifying “faulty or irrational beliefs” that are responsible for problematic behavior. They affirm the client’s freedom to choose and encourage a value shift through action.

Gestalt therapy, psychodrama, client- centered therapy, and provocative therapy techniques all stress a heightening of a client’s awareness through action in the here and now. They seek the immediacy of experience as a thrust for change rather than a rational proc- ess of analyzing causal connections. They dif- fer from the reality therapies in that the stress is upon choice and action that is more immediate;

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it is to occur in the here and now of the ther- apy meeting itself. Whether clients seek to make use of this experience in their outside daily life is usually left up to them. There is less effort to deal rationally with the disillusionment proc- ess of beliefs and manipulations. In group ther- apy, these are dealt with experientially as group members are encouraged to give direct and open feedback to the attitudes and behavior expressed by others. The activity of dialogue is stressed.

Family- system approaches, like those of Virginia Satir (1964), Salvador Minuchin, and Murray Bowen, combine awareness- heightening with choices and tasks, yet add the ingredient of activating the “significant other” system in the helping process. Here the dimension of dialogue and intimacy is at last addressed within its daily living context. Bowen and Satir emphasize indi- viduation, while Minuchin focuses more on action tasks.

There are a few therapists whom the term “existential” fits more accurately than any other:  Carl Whittaker (1989), Frank Farrelly (1974), Lester Havens, William Offman (1976), Walter Kempler, Irvin Yalom (1980), Sydney Jourard (1964), and Thomas Hora (1977). Their common attribute is an intense, often surprising use of their personal self- expression combined with a general disdain for conceptualization about clients from theory. Here the subjective emphasis of existentialism reaches its height of therapeutic expression. When these therapists are paradoxical in their actions, it is seldom as a result of planned strategy. Paradox results from their intuitive response to the client and often expresses the paradoxical life stance of the therapist him- or herself.

From the foregoing comparisons of thera- peutic approaches as they relate to existential thought, several areas of existential theory become more clear- cut. We shall look at these in more detail, considering the therapeutic relationship, nature of personality, concept of change, use of historical data and diagnosis, and treatment methods.

The Therapeutic Relationship

One might conclude that all psychotherapies value theory, techniques, and the therapeutic

relationship, but the priority of their impor- tance varies. Ego psychology clearly elaborates theory in its maze of complexities. Behaviorism delineates a vast variety of techniques, matched to specific symptoms. Humanistic psychology, and especially the existential worker, stresses the relationship itself, its transparency, spon- taneity, and intensity. The therapist’s use of self and the type of relationship he or she seeks to foster with a client will be considered from two vantage points— first, the attitude of the thera- pist toward the client and the client’s problems; and second, the behavior of the therapist as he or she interacts with the client: one’s use of self as a unique person in one’s own right.

There is a critical difference between a thera- pist who sees the client as a complex of defenses or learned behaviors that are dysfunctional and a therapist who views the client as having a unique, irreplaceable worldview that is in the process of growth, emergence, and expansion. The latter is an existential position. It views the problems and symptoms of clients as their own efforts to deal with the growth forces within themselves and the risks these pose to them in relation to their self- image, their relationship with significant others in their life, and their role in society.

The writings of R. D. Laing are aimed at clar- ifying the critical differences between the two types of therapists (1967). He points out that therapists who see the client as a mass of com- plexes, defenses, and dysfunctional learnings see themselves as “the authority.” Their task is to diagnose the nature of these “dynamics” and convey these insights to the client, either through verbal commentary or through specific behavioral tasks given to the client. But in doing so, the therapist also acts as another societal force that seeks to adjust the client to someone’s definition of the “functional” personality. Such a therapist tends to support the view that the client’s symptoms and problems identify him or her as ill (even “dysfunctional” implies the cli- ent is out of step with his or her surroundings). The therapist often becomes another dehuman- izing force in the client’s life in the sense of urg- ing the “patient” to adjust to his or her family, instincts, needs, society’s needs, etc. In contrast, existential therapists have no prescriptions of how the client should live. They see their task as

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that of a midwife, an agent who has knowledge and skills to aid in the unblocking process that will allow the client to resume his or her own unique growth and emergence— whether or not this puts him or her in further conflict with family, friends, and society. The therapist may point out the potential risks and consequences of an emerging lifestyle, but will not negate its potential value.

The existential therapist’s attitude affirms the inherent value of the client as a unique per- son with a very special worldview or lifestyle that is his or hers alone to chart. The client is also aware that the therapist sees in him or her the power of free choice. Instead of being help- lessly at the mercy of forces beyond his or her consciousness, clients can see the significant choices in their present life situation and have the power to decide which way they will pro- ceed in shaping their life.

In one sense, existential therapists do stand for a particular lifestyle, but it is one based on their belief in the nature of humanness rather than a cultural viewpoint of how a person should pursue his or her role in family or society. The values conveyed by the existential therapist are these: Human beings have the capacity for free choice; they are of fundamental worth in their own unique perspective of life and their asser- tion of this perspective; they require an open interaction with their surroundings in order to grow— emergence is a responsive and inter- active process; suffering is an inevitable part of the growth process, for emergence involves risks and unknowns; and self- deception is a potent force.

These values are in opposition to several val- ues supported by society at large:  that an indi- vidual is a helpless creature, both at the mercy of an unknown unconscious and of utter insig- nificance in the complex mechanisms called society; that one can and should find happiness through avoidance of suffering and pain and by means of the distractions and pleasures offered at every turn; that a person is what he is, so he should fulfill his role in his family or social system as best he can and be satisfied with his already finished identity; and that since there are groups of humans considered ultimately wise in politics, in universities, at the executive level of business and the military, in churches,

and in medical buildings, Mr. or Ms. Citizen should essentially consider a conforming obe- dience to what these soothsayers say is best for him or her.

The behavior of the existential therapist reflects his or her philosophical- psychological attitudes toward the client. Another useful axiom regarding the therapeutic relation- ship is this:  What facilitates change in people most powerfully are the values of the worker, not spoken, but demonstrated in his or her response to the client’s concerns. If the worker is not the authority with the answers, what is he or she? Existential therapists do see them- selves as experts, but their expertise has to do with their skills and talents of empathy; under- standing; appreciation of and compassion for individual human beings and their struggles; experience in the process of self- deception, having struggled with growth- defensive proc- ess within themselves; and affirmation of the value of the unique soul, having themselves been disillusioned with all the society- made authorities who offer solutions, happiness, etc.; and an open honesty that offers the client the possibility of genuine dialogue, if the client seeks to engage in such. Existential workers, then, seek to normalize the problems of the cli- ent by reference to the struggles of the human situation. They avoid paternalistic conclu- sions about the client, viewing both problem- and person- exploration as a mutual process. Another way in which the worker avoids pater- nalism is by being honest and clear, rather than hidden and deceptive, in relation to strategies utilized.

Existential workers may exhibit a type of detachment, but this detachment is not the cool aloofness of the objective mechanist who is dis- secting and reforming the patient. The detach- ment of existential therapists is an expression of their profound belief in the freedom of the client. The client has a right to his or her own lifestyle. If the client chooses not to follow a direction of personal growth but chooses to maintain his or her defensive posture for security or other rea- sons, so be it. The therapist’s sense of worth is not in the client’s hands but within himself or herself. His or her detachment is from results, even though his or her actual activity in the helping process will be quite open and involved.

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Detachment must not impair vitality and therefore cannot take the form of intellectual aloofness, analyzing the client from afar. Vital engagement through spontaneity, surprise, and unsettling responses is one of the valued meth- ods of the existential worker. Genuine dialogue calls for an immediacy of feedback in many cases, and considered responses in others. Habitual mindsets and communication patterns of clients require interruption and jostling, on occasion, in order for the new, the creative, to be brought to awareness. The use of vitality, lightness, sponta- neity, and humor will often unbalance a client’s defensive posturing. The client becomes engaged emotionally and often released from a fixed role or value position. At such moments, he or she is freer to experiment with new possibilities.

The relationship between therapist and cli- ent is seen by many existential writers as the essential ingredient of change. The concepts of individual growth and genuine encounter with others are interdependent in the thought of Martin Buber. David Weiss emphasizes this same connectedness in his discussion of heal- ing and revealing (1970). This I– Thou relation- ship need not be seen as mystical. Carl Rogers’s description of this activity suggests that the therapist provides an atmosphere for growth by means of a nonthreatening, affirming, under- standing responsiveness (1961). But this does not mean therapists remain passive. On the contrary, Rogers emphasizes the importance of therapists’ being themselves in the expression of important arising feelings. To offer a dialogue is at least to present one side of it in an open, honest fashion. Therapists reveal themselves in another manner at times. They share some of their own struggles, disillusionment, and expe- riences wherein they, too, sought growth in the face of pain. In both these examples of the ther- apist’s openness, we see that the therapist sees his or her own unique world view as an impor- tant experience to share with the client— not in a “go and do likewise” spirit, but rather show- ing himself or herself as a fellow traveler on the rocky road of human existence.

Human Personality

Freudian theory proposed the ego as a bal- ancing, organizing, controlling, harmonizing

agent among the demands of the superego, the pressures of the “outside world,” and the crav- ings of the id. Behavior theory suggests a pas- sive psyche that is primarily molded by outside forces. What one learns from others is what one is. Both roles render the individual practi- cally helpless to resist the many forces that work upon him or her.

Two key concepts differentiate the existential view from those above. The first is the idea of an integrating, creative force for growth at the core of the personality. The second is the belief that all individuals have the capacity to shift their style of life radically at any moment.

In terms of the human dynamo, the exis- tentialists would not disagree with Freud’s for- mulation of the id as a composite of Eros and Thanatos, or life and death instincts. To this is added, however, the notion of a force that moves one toward meaning and toward relations with one’s surroundings on the basis of meanings concluded. There is an integrative, unifying, cre- ative force within people that synthesizes their own experiences, potentials, and opportuni- ties and provides them with clues for their own direction of growth. No matter how emotion- ally disturbed patients may seem, there is this integrative core within them that prompts them in the direction of experiencing and express- ing their own uniqueness (realistic needs and potentials). They may shut themselves off from such integrative promptings; they may refuse to listen, or mislabel such messages as dangerous. But they are with the person always.

The existential idea of a core integration and creation suggests a conflict- free portion of personality that survives and transcends any dysfunctioning that may possess a person. Such a force toward integration and meaning need not be considered separate from the id. It is an expression of id activity. Teilhard de Chardin (1959) posits such a force as existing in all forms of existence:  animals, plants, and even inanimate matter. Chardin sees in humans the fruition of this drive toward complexity, and it is experienced in the human need for mean- ing and for love. Martin Buber, too, suggests a force in humans that permits them to enter the realm of relationship with nature, ideas, other humans, and God (1955, 1965). This is a force that transcends what otherwise appears to be

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a person’s limited, finite, individual self. This thinking helps distinguish the existential view of the creative force in humans from what the ego psychologists have attempted to add to basic Freudian theory to explain creative functioning through certain basic powers of the ego.

The second major distinction has to do with the power of free choice possessed by every person. Even the most disturbed individuals are not solely at the mercy of chaotic, irratio- nal, destructive forces— an id gone wild. Nor are they at the total mercy of environmental forces that seek to identify, coerce, dehuman- ize, conform, or destroy them. The individual personality is always in the process of chang- ing and emerging. Sartre defined human con- sciousness as a “nothingness.” Since it is always in the process of becoming, it is never fixed and completed. This “no- thing- ness” is an openness to the new, the unknown; it is forever moving beyond whatever identity one has concluded about oneself. Sartre sees this as an essential human construct. One may deny one’s freedom and find ways of avoiding responsibility for this very process of change and emergence, but the process itself goes on. Pathology is not the arresting of growth, but the self- chosen distor- tion of growth (Barnes, 1959).

Human consciousness is itself freedom— for it is a force that moves forever beyond whatever one has become as a fulfilled identity. As such, it is the power within humans to change, to alter their lifestyle, their direction, and their sense of identity. It is an ever- present potential for a conversion experience. “To find oneself, one must lose oneself.” If one has the capacity for free choice and also some awareness of integra- tive promptings toward growth from the very core of the psyche, then why should one choose dysfunctioning, defensive symptomatology, or madness?

Freud’s concept of the superego and his view of defense mechanisms and pathological symptomatology are seen by the existentialist in a more holistic manner. The existential idea of “bad faith” is a person’s activity of denying his or her nature of freedom and emergence for the sake of a sense of security and identity. Such people deceive themselves by a set of beliefs that define specifically who they are and what they can expect from others. This belief system

contains both positive and negative judgments about oneself and suggests how one must relate to other people. It is the center of one’s defensive control efforts, of one’s symptoma- tology, of one’s manipulations of relationships, and of one’s fostering myths about who one is. These people choose to believe certain notions about themselves when they are quite young and undergoing the socialization process with parents, teachers, peers, etc. The beliefs they hold to are used to maintain a sense of secured identity. They are tempted somehow to reas- sure themselves of the solidity of their identity whenever they feel threatened. This they can do through manipulations of others, physical or psychological symptomatology, and reassur- ing beliefs about themselves. The belief patterns may change somewhat over the years, so that ideas implanted by parents may become more personalized. But it is the rigidity and response to threat that characterize this person’s secur- ity image, rather than the nature of the beliefs themselves.

This defensive belief system, or “security image configuration,” has its values, too. It helps the young, developing ego with limited experi- ence and judgment create a manner of survival in a family constellation. The beliefs concluded about self and others provide habit patterns that furnish a sense of security so that one can use one’s energy for other achievements as well. Even the adult ego is occasionally on the verge of exhaustion and needs to resort to the secu- rity image patterns of reassuring contentment. One will at times choose security image behav- ior, even when one knows it to be irrational and defensive, simply as a means of enduring and managing under considerable stress.

Security image patterns take the form of outer identifications, as well as inner passions. “Outer identification” includes all the ways that people use others to decide who they are as a fixed identity— using their parents, spouse, children, friends, employer, profession, poli- tics, church, race, social norms, etc. Inner pas- sions have to do with feeling responses to life’s situations that also fulfill a sense of identity, so that certain feelings become fanned into possessing passions. For the self identified as “Top Dog,” irritation can become rage. For the self- identified “Don Juan,” sensual excitement

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can become lust. For some people, competi- tion becomes greed. For others, pride becomes a quest for power. In the outer identifications, one identifies with beliefs and roles; in the inner passions, one identifies with specific feelings. In either case, the sense of self is experienced as fixed, solidified, and defined, rather than flow- ing, free, and emerging.

The defensive belief system or security image configuration is sometimes referred to as one’s “world design,” composed of self- concluded value positions. These are seldom the ideal- ized values thought to be one’s “ego ideal,” but rather the everyday pragmatic values related to security- based hopes and fears. Such values are easily discerned by attending to the “self- chatter” of one’s thinking at times of troubling stress.

The Process of Change

If you want to know who you are, don’t con- ceptualize about it:  look at your actions, your behavior, your choices. Existentialism is a phi- losophy rooted in personal experience. “Truth is subjectivity,” Kierkegaard’s slogan, and “Existence precedes essence,” Sartre’s assertion, are both ways of rooting identity in personal experience— one’s active and unique response in a situation. Being- in- the- world is a concept of Heidegger’s that asserts the same notion.

There are two components commonly accepted as necessary for the change process— one rational, and the other experiential. Almost every form of psychotherapy includes both these components, despite their occasional assertions to the contrary.

The experiential component has to do with clients’ experiencing themselves in a new and dif- ferent way. They may discover that they are being dealt with differently by a significant other per- son in their life. They may also find new kinds of feelings or symptoms arising within themselves. The rational component has to do with self- understanding through the process of reflect- ing and conceptualizing about themselves— the cause– effect relationships in their background, evaluating how they handled recent situations, considering the meaning to them of a new way they have experienced themselves, and so forth.

The existentialists see values in both compo- nents of change— one reinforces the other when

both occur. The existentialists, however, are particularly wary of the common self- deception of intellectualizing about oneself— of dwelling on self- evaluation and introspection in a man- ner that negates any action or choice in the here and now. The self- understanding of importance is that of one’s world design, its orienting values, and the negative consequences that naturally accompany this.

Here are some therapeutic activities that promote both clarified self- understanding and emotion- inducing experiences:

1. The attitude of the therapist toward the cli- ent can present a new type of affirmation by a significant other person that the client has never experienced.

2. The therapist’s skill with empathy may pro- vide the client an experience of being under- stood more intensely than by others in his or her life.

3. The openness of the therapist about himself or herself as a revealing, engaging person provides an invitation for the client to the dialogical experience. It can also offer an experience of an authority figure as human and of equal status. Such openness by a therapist may constructively take the form of provocative, negative feedback to the cli- ent about his or her appearance, attitudes, feelings, and behavior. Here the client expe- riences a candid honesty that may be other- wise denied to him or her in the everyday world of interactions.

4. Techniques designed for here- and- now heightening of awareness, such as in Gestalt, psychodrama, and encounter groups, or the dealing with “transference” interactions between therapist and client, are obviously aimed primarily at the experiential compo- nent of change. Similarly, efforts to vitalize new interactions between group or family members quickly stir new areas of individual awareness.

5. Action tasks for the client to perform outside of therapy sessions provide new behavioral experiences.

Compatible with the existential therapist’s emphasis on experiential change is his or her lack of interest in historical data. Some history

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may be of value in the early interviews to help the therapist see the client in a more human, better rounded perspective, so that the therapist is less inclined to make superficial judgments about the client in response to the stereotype the client usually presents to other people. But the therapist often does not even need this aid. It is far more important to understand the dynamics of clients’ present struggles, and what their symptoms or complaints reveal about their efforts to grow and meet their own needs (the present beliefs and activities of their defen- sive belief systems).

If client themselves bring up historical mate- rial, the existential therapist will often seek to make it immediately relevant. The therapist may do this by relating the past experience to present choices, or else (using Gestalt tech- niques) by asking the client to bring the early parent figure into the present interview session by role- playing the past interaction that the cli- ent is describing.

The existential therapist is in agreement with Glasser’s (1965) position that an intense focus on early historical material plays into the cli- ent’s feelings of helplessness and/ or efforts to rationalize his or her own impotence. History does, however, sometimes serve a useful pur- pose in relation to understanding a client’s world design. When clients are able to recall patterns of thinking, feeling, and behavior that have recurred time and again, the power of their determining value positions, or conclusions, becomes more poignant.

World Design and Diagnosis

Clinical diagnosis has its value as a shorthand way of communicating to peers about clients, in terms of their areas of conflict and types of defenses. Other than this, it is of questionable value in the eyes of the existential therapist and commonly results in more harm than good. The danger of diagnosis is the categorization of a cli- ent, so as to provide therapists some “objective” way of defining prognosis, goals, the role thera- pists must play as they interact with the client, and their decision about termination. Such “objective” efforts based upon generalizations about clients with a similar history, symptom- atology, and mental status constellation miss

what is unique about a particular client. A fur- ther danger described by Laing is that diagno- sis is often used as a way of agreeing with the family that this client is “sick” and in need of readjustment to the demands and expectations of the family.

This depreciation of the value of clinical diagnosis, however, does not suggest a disre- gard for understanding the nature of a client’s present struggles, conflicts, strivings, and fears. World- design understanding remains of key importance. Here existentialists differ with behavioral modifiers who relate themselves only to a specific symptom without regard for its meaning and the client’s present lifestyle.

It is critical to understand the unique world view of the client. This consists of patterns of relating to meaningful others and expecta- tions of them. It also includes beliefs about oneself, both positive and negative judgments, and assumptions about oneself and how these affect the way one meets one’s own needs and handles one’s frustrations of need- satisfaction. It is important to see how clients are interfer- ing with their own growth, and this includes both the beliefs they hold about the sort of person they are and the notions they have about how they must deal with the significant people in their life. It may even include how they evaluate forces of society that play upon them and attempt to conform their behavior into some stereotype that is useful to society’s needs (employers, church, racial attitudes, etc.). Normalization in the assessment phase conveys this message: “Given your special way of view- ing the world and your patterns of affecting it and responding to it, your problem is perfectly understandable— it is a natural expression of you.” This is not to say that the client created the problem; nor, on the other hand, is he or she a total victim of it.

This type of self- understanding in relation to orienting value conclusions stresses the here- and- now lifestyle— the client’s present being- in- the- world. How the client gets this way is of questionable significance. The values of identity formulations are twofold. First, they provide the therapist with an understanding of each unique client and how the client’s present symptoms are ways of handling a particular stress or con- flict area. Second, world design gives therapists

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somewhat of a guideline to assess their own work with the client, particularly when they discover that their therapeutic efforts are bring- ing no results.

The world- design understanding of an existential social worker will often emphasize family dynamics (interactions, scapegoating, alliances, etc.). These usually make up the most significant area of the client’s lifestyle function- ing. Intervention efforts will frequently involve other family members for the same reason. The existential understanding of the person as “being- in- the- world” is wholly compatible with the dual focus model of social work. The per- sonal, unique truth of the individual is known best through his or her relations with others and forces beyond his or her own ego— usually social, but at times, perhaps, transcendental in nature.

Even when the problem is not set forth as family or marital in nature, the therapist will tend to see the presenting symptom as a means of dealing with significant others in the client’s life. An interpersonal appraisal of symptoms is attuned to the absence, loss, breakdown, or dys- functioning of important human relationships in the person’s life. Therapeutic work will com- monly be addressed to the creation, the restora- tion, or the improvement of such relationships. This interpersonal focus upon symptomatol- ogy need not neglect the individual’s subjective experience of attitudes, values, and feelings; the two are obviously interdependent. However, the existential therapist sees catharsis and self- understanding as a vehicle for altering the per- son’s world of human relationships, which is the fundamental goal. This interpersonal emphasis distinguishes the existential social worker from most existential psychiatrists and psychologists.

Treatment Methods

It is difficult to talk of treatment methods with- out first considering the types of clients and problems for which the methods are used. In one sense, the existential perspective is loyal to no particular treatment system. It is eclectic and uses whatever techniques will best meet the needs of a particular client. In another sense, the existential therapist may be considered best equipped to work with clients whose problem

involves a loss of direction, a value confusion, a shaken identity in a swirling world of anomie. For these clients, certain techniques have been developed to focus precisely on such difficulties. However, it should be clearly understood that the existentialist works out of his or her unique philosophical perspective with all clients and should not be viewed only as a specialist with clients experiencing personal alienation.

There are three principles of treatment that clarify the therapeutic approach of the existentialist:

1. A client- centered orientation 2. An experiential change emphasis 3. A  concern with values and philosophical or

religious perspectives.

Client- Centered Orientation

The client- centered focus has already become apparent in our introductory comments on the existentialist’s anti- authoritarian stance. Client centeredness was also the major issue in the discussion on diagnosis and world- design formulation. Two other areas exemplify client- centeredness: goal formulations and work with an emerging theme in any given interview.

Goal formulation involves the therapist and client working out a mutual agreement in the early interviews as to the purpose of future treatment. What must be guarded against here is the type of therapeutic dogmatism that seeks to convince the client of the “true implications” of his or her symptoms or problem so that he or she will work in the manner the therapist wishes. The most important initial step in treat- ment, following the age- old social work prin- ciple, is to “start where the client is.” This adage refers to focusing on how the client is experi- encing the problem, what it is the client wants changed, and other ideas about the type of help the client is seeking.

Elsewhere, I  enumerated a framework of possible goals from which social workers may proceed with treatment (Krill, 1966, 1968, 1978). These are:  provocative contact, sustain- ing relationship, specific behavior (symptom) change, environmental change, relationship change, directional change, and combinations of the above.

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The type of goal left off this list is the extensive insightful analysis that a client who enters psychoanalysis may be seeking. Whether or not the client ends up with any more significant change through insightful analysis than in some of the above- mentioned goals is highly questionable at this point in time, considering research efforts into the effects of treatment.

The previously- stated goals can be briefly differentiated by considering the client’s view of change in each category:

Provocative Contact. The client seeks neither change nor help of any kind. The case- worker assertively seeks to provoke a client into wanting change. This occurs often in protective services, in residential treatment centers for children, and in the “back wards” of psychiatric hospitals and institutions for the developmentally delayed. It is also com- mon with the “hard- to- reach” families who present various problems to the commun- ity via the schools and police departments. Just how far caseworkers should go in their provocative efforts is itself an ethical deci- sion related to the right of a client to his or her own unique lifestyle. Nevertheless, pro- vocative efforts are often justified insofar as they provide an outreach effort and offer an opportunity that the client might otherwise never consider.

Sustaining Relationship. Here the client seeks help, in that he or she is lonely and wants an affirmative, interested contact in his or her life, but the client has no hope for changing his or her lifestyle in any way and will resist any such efforts. The client’s need is for an affirming relationship without expectations of changed behavior. Change will commonly occur anyway as the client’s self- esteem is boosted through a caring, non- demanding relationship.

Specific Behavior (Symptom) Change. The cli- ent is distressed by a particular troublesome behavior but has no interest in widening the problem area by seeing how this particular symptom is related to his or her past or pres- ent lifestyle and system of relationships. The client’s motivation is restricted to symptom alleviation.

Environmental Change. The client sees his or her difficulty in relation to the environment beyond his or her family. The problem may have to do with employment, education, social contacts, or community forces that he or she experiences as dehumanizing. The cli- ent does not see himself or herself as part of the problem. The client seeks help in dealing with social institutions and systems.

Relationship Change. Here the client experi- ences difficulties in relationships with sig- nificant others in his or her life— spouse, children, parents, relatives, friends. The cli- ent realizes his or her own involvement and wants to alter a relationship pattern.

Directional Change. The client’s sense of iden- tity, of values, of personal direction is con- fused. He or she has difficulty in making choices and feels impotent in relation to the immediate future. The conflict is experi- enced as within himself or herself.

The mode of therapy used (individual, couple, group, family) or the types of techniques (real- ity, behavioral modification, encounter, psycho- analytic ego, Gestalt, etc.) will vary, of course, in accordance with the interest of the client, the skills of the therapist, and the nature of the treatment setting itself. However, certain techniques are obviously more appropriate for certain goals. Behavior modification would be particularly useful with the goals of provoca- tive contact and specific behavior (symptom) change. The core conditions elaborated by Carl Rogers (1961) will be most useful in providing a sustaining relationship for a client. Social work literature provides many useful approaches to accomplishing the goal of environmental change. The goal of relationship change can be dealt with using communications theory (Satir, Haley 1976, Jackson) and other fam- ily and marital therapy models. Directional change can be effected by techniques described by Rogers, Farrelly, the Gestaltists, reality ther- apy, cognitive therapy, task- centered casework, and psychoanalytic psychotherapy. The criti- cal point here is that the therapeutic approach must fit the unique goal and needs of a client, rather than fitting clients into some pet system of psychotherapy and dismissing the misfits as “unmotivated.”

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What is important to understand in this goal framework is that it provides a starting point for treatment in a manner that recognizes the unique experience of the client as valid. The goal may change during treatment as the client begins to experience his or her problems in some other light. The goal must also be tested out in early interviews so as to ascertain whether the goal agreed upon is merely a verbalized goal of the client, or whether it is indeed the way in which the client experiences the need for help and hope for change. With this framework, the therapist engages the client in a manner by which they can both “talk the same language” and have similar expectations about what is to follow.

There would appear to be a contradiction between some of these therapeutic goals and what has previously been described as the exis- tential focus upon disillusionment, freedom of choice, finding meaning and suffering, discov- ering the growth value of dialogue, and coming to a sense of personal commitment in relation to one’s future. Such a focus seems most appli- cable to the goal category of directional change. The existential therapist, however, is not bound to pursue such a focus if it does not seem appro- priate. Existentialist therapists’ concern with client- centered treatment and an emphasis on experiential change enable them to assert their philosophical perspective to a degree in all goal categories described.

The other client- centered activity deals with the interview theme of any given session. The client is not a problem to be solved, a puzzle to be completed; the client is a person who is undergoing constant change from week to week, day to day. Change occurs in the client’s life for both the good and the bad, apart from what happens during therapy sessions. For the therapist to pre- plan an interview, picking up where the last one ended or getting into what the therapist considers to be an area of increas- ing importance, is often presumptuous.

The interview begins and the therapist lis- tens to both verbal and nonverbal expressions of the client, staying alert to possible inconsisten- cies among what the client says and the client’s feeling state and behavior. The therapist’s most important listening tool is his or her capacity for empathy. In the initial stages of the interview,

therapists must free themselves of preconcep- tions about the client and preoccupations with themselves in order to open themselves to the whole person before them.

How the theme is made known and how it is dealt with are related to the goal of ther- apy (thinking in terms of the goal framework described earlier) and what particular therapeu- tic approach a therapist favors for work on such a goal. The therapist and client work together from the point of thematic clarity.

An Experiential Change Emphasis

The experiential emphasis has already been dis- cussed. The activities encouraging experiential change include:  attitude of therapist, empathy, therapist’s openness or transparency, height- ening of here- and- now awareness, tasks for choice, and action. In the earlier discussion of how various theories of therapy reflected exis- tential points of emphasis, it was apparent that techniques could be tapped from many theo- retical sources.

It is clear by now that the existentialist is radi- cally concerned with the here- and- now encoun- ter between a person and the person’s world. For it is in this moment of responsiveness, of being- in- the- world, that one experiences freedom of choice and meaning- making. Who the person is stems from what he or she does— the choice he or she activates— not from the intellectual con- ceptualization he or she holds about the self, nor from any dogmas or groups to which he or she holds allegiance in exchange for some bestowed identity.

A Concern with Values and Philosophical or Religious Perspectives

The concern with pinpointing, challenging, and clarifying values and philosophy or religious perspectives is also dealt with by various writ- ers. There are strong similarities between the rational- emotive psychotherapy of Albert Ellis and the Morita therapy of Japan. Both pinpoint “irrational” or “unrealistic” beliefs and specifi- cally propose other, more realistic and human beliefs in substitution for the dysfunctional beliefs. Hobart Mowrer’s integrity therapy fol- lows a similar course, where the emphasis is on

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helping client see their guilt as a contradiction between the values they hold in common with their “significant others” and their behavior or actual lifestyle. Frankl has developed two techniques, “dereflection” and “paradoxical intention,” that are designed to help clients reexamine and alter their philosophical per- spective to affirm a new way of viewing them- selves in relation to their symptoms, choices, and life direction.

These “reality- oriented” approaches include four common ingredients:

1. Pinpointing specific values (attitudes, beliefs, and judgments about self and others) mani- fested by the client’s lifestyle

2. Clarifying how these very values may be interfering with the client’s own growth and intimacy needs or efforts

3. Helping the client consider more realistic, human values and beliefs rather than the dysfunctional ones so that the client’s realis- tic growth and intimacy needs might achieve more direct satisfaction

4. Encouraging decisions, choices, and actions (often as homework assignments) in order to activate the new values concluded to be more valid.

Thomas Hora (1977) discusses values by distin- guishing between two versions of reality:  “the way it seems” and “the way it is.” The first of these describes the distorted and limited views the client has about his or her lifestyle and its related value perspectives. The second view of reality is that expanded by the therapist as he or she highlights other values in the client’s life- style that are being ignored or minimized. Like Offman, Hora will also clarify negative conse- quences in relation to some of the client’s value positions and pose alternative possibilities for the client’s consideration. Hora emphasizes the personal stance of the therapist to be one of a “benevolent presence” through which the ther- apist may convey peace, assurance, gratitude, and love as important human realities.

This therapeutic emphasis on values and a philosophical perspective is designed for cer- tain types of clients— those whose working goal is directional change. There is a growing recog- nition of the effects of anomie in modern culture

with its resulting personal alienation from the roots of human needs and human strivings. Jung reported this phenomenon many years ago, and existential novelists, philosophers, and psychologists have been emphasizing the extent of alienation ever since.

In relation to religion and spirituality, the existential teacher would strongly endorse a recent development in some graduate social work programs. Related to the emphasis on diversity, schools are developing courses on religion and spirituality in order for students to address their own prejudices and appreciate the varied religious resources in the lives of their clients.

The American culture has finally felt the same impact of alienation that shook Europe during and after World War II. In America, this awareness was helped along by the revolt of the youth, minority groups, and poor people. At this point, it is unclear whether alienation is a problem of a particular client population or whether it is really at the root of all emotional distress. The writings of Laing, Becker, and, recently, Irvin Yalom are certainly weighted toward the latter view.

Considering the three therapeutic principles discussed (the client- centered orientation, focus upon experiential change, and concern for val- ues and philosophical perspectives), it becomes clear that existential caseworkers seek to work with all types of clients and human problems, and that they could function with any kind of social agency or therapeutic setting, provided they were given the administrative approval to work as they wished. It is also clear that the existential position is in opposition to the ther- apeutic practices that seek to adjust clients to family and social norms or to prognostic norms stemming from the rigid use of diagnostic cat- egories. The authoritative misuse of behavior modification and psychoanalytic theory is a major concern of the existential social worker.

The existential social worker is also con- cerned with how monetary preoccupations of insurance companies and funding sources of agencies are dictating therapeutic approaches. The popular emphasis on short- term, symptom- relief therapies ignores the existentialist’s view that a presenting problem is commonly a warn- ing sign of more troubling value issues of the

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client’s lifestyles. This Band- Aid, patchwork approach simply reinforces the inclination of many clients to view themselves in a superficial manner.

Considering the eclectic use of treatment approaches suggested by the existential per- spective, it is also apparent that social workers can make more creative and varied use of the existential perspective than can psychiatrists, psychologists, ministers, or nurses. This is because of the wide- ranging problem activities that engage the efforts of social workers, neces- sitating a manner of work that includes multiple skills.

The modes of therapy (individual, couple, family, and group) are all effective ways of conducting an existential- oriented treatment. Application to individual counseling has been elaborated upon, particularly by Rogers (1969), Farrelly (1974), May (1961, 1967), Frankl (1967), and Perls (1969). Work with groups with an existential perspective has been described by Helen Durkin (1964), Carl Rogers (1961), Arthur Burton (1969), and Irvin Yalom (1980). Social work writer Alan Klein relates the group work approach to existential thinking. Family therapists whose approaches are highly com- patible with the existential perspective include Jay Haley, Virginia Satir, John Bell, and Carl Whittaker.

The existential approach fulfills two major needs of modern social work practice. First, it is the only social work approach that emphasizes value issues related to the client’s problem. With the apparent increase of alienation and anomie, social work may require methods of response to value questions. Second, the emphasis on the human ingredients of the therapeutic rela- tionship, coupled with an “atheoretical” under- standing of the client as a person, results in a restoration of humanitarian helping. Self- aware workers are better able to appreciate all clients as more like themselves and less as objects for diagnostic categorization and manipulation.

Case Example

The case presented here could be considered an example of the existential social work approach. It involved short- term casework with an individual from

the goal framework of specific behavior change. It should be clear from the previous discussion about differing goals and the eclectic use of treatment techniques that other case examples would take much different forms than the one described. The three existential principles of client- centered focus, experiential change, and value focus are illustrated in this case.

A Latin- American woman, aged 34, came to me complaining of a severely inhibiting depression. In the course of the evaluation, it appeared that she had little interest in or sensitivity for seeing any con- nection of her symptoms to her past or present liv- ing situation. She was somewhat troubled over her recent divorce, which had happened only a year ago. There was also a problem with her mother (living across the street), who tried to dominate her and provoke her guilt, and who often took care of her two teenage daughters. Some rebellion in the older teenage daughter was apparent. She also believed herself “hexed” by her former mother- in- law. These were areas of complaint, yet she saw no prospects for changing them. Her concerns for change were very concrete:  she could not do her housework or cook the meals or discipline the children, for she would usually go to bed soon after she returned from work. In bed, she would either sleep or fantasize about how badly off she was, and the running of the house was left to the children, particularly the rebellious older one. She feared losing her job as a nurse’s aide at the local hospital and had already missed several days of work because of feeling too tired. She had given up on going out with her boyfriend and felt extremely alone and worthless.

Within ten interviews, seen on an alternate week basis, the depression had lifted. She managed her housework well; disciplined the children— the older one was much less rebellious; she could stand up to her mother on a realistic basis; she was dating again; and she was taking a training course to become a practical nurse. The goal was specific behavioral change, although its successful accomplishment resulted in a broadening of this woman’s constructive activity in several areas of her life.

My techniques dealt primarily with the symptoms of depression and helplessness. In the second inter- view, I emphasized what I sensed to be her inhibited potential:  I  said that she could make herself get out of bed (or refuse to enter it) by performing the tasks of her housework and by going to her hospital work every day, no matter how tired she felt. I recognized

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that feelings of depression were strong within her, but pointed out that they represented a part of herself that seemed to be trying to convince her that she was no good. She could go on believing this or she could challenge this idea. In the third interview, I dealt actively with another belief, challenging its power and questioning her need to be dominated by it. She thought the depression resulted from being “hexed.” I told her that I had doubts about the magic of hex- ing, and if there was anything to it, it probably had to do with her own reaction to the notion that she had been “hexed.” I linked this belief with the part of her that was trying to convince her that she was helplessly useless and inadequate.

As sessions went on, she did bring up material about her mother, former husband, children, job, and relatives, but this was more from the standpoint of content for discussion in what she felt to be a positive, affirming relationship. The actual therapeutic effort, in terms of pinpointing her problem and a way of deal- ing with it, was primarily in relation to the depressive symptom described. The techniques used were my ways of responding to her area of concern and view of change. We could communicate through the goal of specific behavior change. She was able to see the depression as being a self- defeating part of her. This freed her from the belief that the depressive symp- tom was a condemnation and failure of her whole personality, which had been implied in her notion of “being hexed.”

While this was a limited shift in the belief sys- tem of this woman, it could still be a significant one. Furthermore, her resumption of responsibility in the family had its rewarding feedback responses from the children, as well as from her own mother, who was closely involved with her family.

Note the three principles involved:  a client- centered focus in terms of goal selection and inter- view management; emphasis on experiential change through use of task assignment as well as through the attitude of the therapist toward the client’s poten- tial strengths; and finally, an effort to deal with the woman’s value system, specifically suggesting that she did have some capacity for free choice and need not identify herself completely with her symptoms (feel- ings of fated helplessness).

This case raises an interesting cultural issue in relation to the client’s view of the change process and how she viewed change as possibly occurring. An alternative approach might have been a referral of this woman to a curandera to handle the “hexed”

issue. Had she been unresponsive to my rational efforts to deal with her belief about “being hexed,” I would have considered such a referral. Since she had sought out my help, I  chose to deal with this belief issue in this more personal, challenging way. I felt free to share my personal view of most hexing experi- ences after sensing that she wanted to differentiate herself from her mother, who had been emphasizing the power of hexing.

Existentialism and Community

Existentialism is sometimes criticized as an individualistic philosophy lacking a social ethic. This is a misconception. Philosophers such as Camus (1969), Berdyaev (1944), Tillich (1952, 1960), and Buber (1955, 1965) have writ- ten extensively on the application of existential thinking to social issues. Members of the help- ing professions have also related existential phi- losophy to social concerns. Edward Tiryakian (1962), a sociologist, compares existential thought with that of Durkheim. Lionel Rubinoff writes a critique of modern philosophical, psy- chological, and sociological thought on the subject of the individual and his relationship to society. Rubinoff ’s (1967) basic premises are existential. R. D. Laing (1967) also uses an exis- tential framework in his critique of society and of the helping profession often being dehuman- izing extensions of society’s values.

Beginning with the existential belief that truth is not found in an objective fashion, within a doctrine or within a group of people, we find some implications for a view of society and social change. In the first place, the existen- tialist stands against tyranny in any form— not only by politically conservative, status- quo- oriented leaders, but also by the rational social engineers who would seek to establish the uto- pian society necessitating many controls and committed to adjustment of individuals to a “properly functioning” society. The existential- ists are a prime opponent of B. F. Skinner (1971) in his appeal for a society that meets humanity’s needs by limiting freedom and nonconformity.

The existentialists know that power corrupts, and that much of the evil perpetrated is unpre- dictable at the moment of its inception. If, on the other hand, there is an effort to decondition

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evil- producing behavior, this effort itself, if suc- cessful, would result in the profoundest evil of all: the dehumanization of people by depriving individuals of freedom— the only valid source of their sense of personal meaning and dignity.

On the other hand, an appeal for a com- pletely free and open society, such as proposed by Charles Reich’s Greening of America (1970), is again a naïve position founded on a disregard for the sometimes self- defeating, the aggres- sive, and the evil- producing behavior of people. Spontaneously “doing one’s own thing” is too simple a commitment. We can be defeated by our own instincts and self- deceptions as easily as by our efforts to organize and construct the happy state.

Power itself results in an increased effort toward solidification and self- perpetuation. Society must be a dynamic, growing system, just as an individual is a being of responsive emergence. The healthy society is one attuned to the creative ideas and efforts of individuals and groups within its structure that propose change and new ideas. A participatory democracy is an expression of the existential affirmation of the unique perspective of each individual. In a par- ticipatory democracy, groups are seen to pos- sess their own truths, which will differ from the attitudes and values of others who have not had the same life experiences.

The direction for a society’s emergence stems from the sufferings and potentials of its people, and not from an elite group of rebels or social organizers. Eric Hoffer was right in saying that the most creative and innovative shifts in a soci- ety stem from its outcasts, nonconformists, and those who experience the failures of its present functioning. The existential model for social change would be one wherein the very people who suffer from dehumanizing social forces would be the indicators of what sorts of changes are needed. The community organization social worker would have a facilitating, clarifying, enabling role here, perhaps, and once a direc- tion is clear, he or she may use his or her knowl- edge of power structure and change tactics in order to mobilize the social change effort.

The “antiexistential” community organizer would be one who decides for himself or her- self what change other people really need and then uses his or her knowledge and skills to

“educate,” seduce, and pressure a disadvantaged group into deciding what their problems are and the change that is indicated. The worker’s basic notions of change, here, come either from his or her own needs, or his or her rational, ana- lytical conclusions of what this group or com- munity lacks in comparison with some ideal he or she holds about how people should live. The impetus for change is worker- oriented rather than community- oriented.

The opposite extreme, also antiexistential, is sometimes seen in community mental health clinics. Although such clinics are commit- ted, by their very purpose (and federal fund- ing), to a community- outreach stance, there is often little genuine effort at dialogue with the needy members of the community who do not enter the portals of the clinic itself requesting some specific help. In contrast, the genuinely committed community mental health clinic is actively seeking contact with the groups in its community who are known through police, welfare, and schools to have problems, but who are not availing themselves of any helping ser- vices. Primary prevention at times of family or neighborhood crisis becomes a major way of help, and this most often takes the form of con- sultation with police, welfare workers, teachers, nurses, ministers, and physicians.

As discussed earlier, the existentialists see many of the forces of society as being in opposition to the individual’s effort to create an authentic lifestyle, establishing his or her unique direction out of an awareness of his or her own freedom, responsibility, and what he or she learns through personal suffering. Modern society encourages anomie and personal alien- ation by its forces of seduction and oppression. Insofar as the economic- political system uses people as objects in order to preserve its own efficient functioning, it may be said to be dehu- manizing. Various social institutions combine their efforts to achieve this goal. Certain roles in the system are rewarded with status, finan- cial remuneration, and prestige, while others are ignored. Happiness is defined in such a way as to keep the public at large an active con- sumer of economic goods. An attunement to personal suffering is discouraged through the various tranquilization forms of drugs, alco- hol, treadmill activities, and a work ethic that

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implies a solution to all of one’s problems with the purchase of the next automobile, house, or packaged vacation plan. Such writers as Erich Fromm (1955) and Henry Winthrop (1967) have elaborated on the multiple forms of social dehu- manization, which are too numerous and com- plex to mention here.

Helping professionals are faced with a criti- cal choice in relation to social dehumanization. They can become a part of this system that is a purveyor of anomie by the very way they per- form their helping role. Or, on the other hand, they can be members of a vanguard actively in touch with many of society’s victims, who can help bring individuals and groups to an active awareness of themselves as free and responsible beings despite the negative forces bestowed upon them by society. Beyond such awareness, such workers will help them toward personal direction and actions that affirm human dig- nity in the face of tyrannical and dehumanizing social forces.

The institutions of society can and do pro- vide constructive, affirming forces for individu- als and groups, of course, through education, employment, protection, health and welfare care, as well as valued traditions, a sense of his- tory, and a national spirit that affirms a set of values that is generally accepted and may be quite compatible with the freedom, respon- sibility, and valuing of uniqueness and per- sonal dignity that characterize existentialism. The existential helping professional realizes, however, that the constructive forces of soci- ety cannot in themselves bring an individual to authenticity. The matter of personal choice and acceptance of responsibility for one’s own worldview and lifestyle remain essential. The existentialist is, therefore, cynical in response to social utopians who seek to construct a society of needs- met, happy people.

Research and Knowledge Gaps

The existential approach eludes research. Its lack of a specific theory of personality, its emphasis on subjectivity and uniqueness, its eclectic use of varied techniques, and its concern about val- ues are all factors that make structured stud- ies difficult. On the other hand, the existential perspective extends the hand of gratitude to

the numerous research studies that have clearly unseated dogmatic- authoritative assumptions proselytized by “sophisticated” adherents to the varied theories of personality. When it comes to practice, the existential worker tends to agree with the behaviorist:  We should utilize what was proven effective in practice to avoid forc- ing clients to submit to our favored (though ineffective) methods. Research indicates that effective treatment can occur with the follow- ing conditions: client and worker who like each other; use of the “placebo” effect in structuring the treatment process; core conditions (warmth, genuineness, empathy) when combined with attitude change; attitude change when accom- panied with emotional change as well as task assignments; and the use of significant others in the assessment and treatment process wherever possible (Krill, 1986).

Another important conclusion from practice research has been that no theory of treatment has proven itself superior to any other model. The existentialist sees this as a crucial statement about the place of theory in practice. Theory does not seem to be the important ingredient in helping people, and is therefore considered of secondary (informative) value. While it is not clear what, then, is the magic ingredient, the existential worker would suggest it to be human sensitivity as developed over time through both self- awareness and learning from many expe- riences with clients. The better one comes to know oneself, the more clearly is one able to see oneself within the client’s experiences as well. This is a most important area for future research study.

How are social work education programs preparing students for present practice? Do they foster ingredients that may eventually result in a wise practitioner, given a few years of additional experience? Here the existential- ist has serious concerns. An educational tradi- tion has existed for many years in social work that has emphasized the pragmatic, diagnostic, rational- authoritarian approach. Teachers have often viewed students in this categorical man- ner and have in turn urged students to view their clients in a similar way. This has been the phony guise of “scientism” that has sought to identify social workers as “scientific,” when in fact the “objective nature” of most of their

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knowledge would be scoffed at by physical sci- entists. Many students, in their insecurity, seek comfort in categorizing clients according to the knowledge system taught them. Other students, rebelling against what feels like a rigid authori- tarianism, will completely abandon diagnostic understanding of any type and naïvely seek to provide “Band- Aid” answers to problems posed by clients. It would appear that students need to be somehow “humanized” rather than “objectified.” Self- awareness has been a goal of social work education, but it would seem that new educational approaches need to be devised to achieve this goal more effectively. Only by appreciating one’s own personal complexity can one begin seriously to understand the complex- ities of others.

Human sensitivity is a bed- partner of humil- ity. Humility results from personal disillusion- ment, or humiliation, providing the student is warned against too quickly attaching oneself to the notion that one has now achieved some “sophisticated maturity” as a result of personal insights. Humility can be also the springboard toward creativity. As one realizes one’s personal blind spots, gaps in awareness, and withdrawal from knowledge and situations posing threat, students find a personalized direction for their reading and openness to new experience. They sense, too, that their search for expanding truth will enable them to understand and help more clients.

I have found the classroom situation a use- ful “experimental lab” for generating human sensitivity among students. Assessment of cli- ents is dealt with simultaneously with students’ self- exploration. Personal exercises to promote such examination are used in class as well as through homework assignments. Peer sharing in small groups engenders honesty, spontaneity, and supportive feedback in relation to results of exercises (Krill, 1990). Exercises explore dimen- sions of the interplay between personal prob- lems, emotions, attitudes, and values; of roles with family and significant others; and of trou- ble spots in personal response to certain clients. Reading of theory is encouraged, then, as the student’s means of building upon and expand- ing self- knowledge in the directions necessary to handle areas of confusion, insufficient self

or client understanding, and intrigue with new ideas. Values need to be clarified by both the instructor and the students in terms of how they are used constructively with clients. Vitality and spontaneous engagement with clients are dem- onstrated and practiced in role- plays of common client– worker situations.

In conclusion, the existential stance provides a philosophical perspective that can be related to the many avenues of social work practice. One does not need a profound acquaintance with existential philosophy in order to benefit from the perspective. One might, instead, view the existentialists as emphasizing a sense of direc- tion and a style of working that are primarily concerned with a greater humanization of the social work profession. From their emphasis on the value of the uniqueness of the individual there comes an affirmation of a client- centered focus and an awareness of the dangers of ano- mie in a mechanistic society. From their view of growth through choice and action there comes a primary effort aimed at experiential change with clients. From their model of humans as meaning- making beings there comes a recognition of the importance of values, philosophy, and religion as ingredients of the casework process. From their emphasis on dialogue there comes the concern for therapist transparency and authenticity, as well as the valuing of a participatory democracy. And from their appreciation of the powers of self- deception at work with human beings, there comes an emphasis on personal commitment in the face of suffering and uncertainty, as well as a suspicion about any authority that establishes itself as knowing how other people should live their lives.

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Rogers, C.  (1961). On becoming a person. Boston: Houghton- Mifflin.

Rogers, C. (1969). The group comes of age. Psychology Today, 3(7), 29.

Rubin, G.  K. (1962). Helping a clinic patient mod- ify self- destructive thinking. Social Work, 7(1), 76– 80.

Rubinoff, L.  (1969). The pornography of power. New York: Ballantine.

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Salomon, E.  (1967). Humanistic values and social casework. Social Casework, 48(1), 26– 32.

Satir, V.  (1964). Conjoint family therapy. Palo Alto, CA: Science and Behavior Books.

Skinner, B.  F. (1971). Beyond freedom and dignity. New York: Knopf.

Swaine, R.  L., & Baird, V.  (1977). An existentially based approach to teaching social work practice. Journal of Education for Social Work, 13(3), 99– 106.

Szasz, T.  (1984). The therapeutic state. New  York: Prometheus Books.

Teilhard de Chardin, P.  (1959). The phenomenon of man. New York: Harper & Row.

Tillich, P. (1952). The courage to be. New Haven, CT: Yale Press.

Tillich, P. (1960). Love, power and justice. New York: Oxford.

Tiryakian, E. A. (1962). Sociologism and existential- ism. Englewood Cliffs, NJ: Prentice- Hall.

Vontress, C.  E. (1979). Cross- cultural counselling: An existential approach. Personnel and Guidance Journal, 58(2), 117– 122.

Weiss, D. (1962). Ontological dimension in Social casework. Social Worker, 30(1), 2– 16.

Whittaker, J.  (1994). Social treatment:  An Introduc- tion to Interpersonal Helping in Social Work Practice. New Jersey: Transaction Publishers.

Winthrop, H.  (1967). Culture, mass society, and the American metropolis; high culture and mid- dlebrow culture:  An existential view. Journal of Existentialism, 8(27), 371.

Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.

Annotated Listing of Key References

Bradford, K. A. (1969). Existentialism and casework. Jericho, NY:  Exposition Press. A  short review of existential thought in terms of its philosophi- cal development and its entry into the field of

psychology. A comparison and integration of exis- tential psychology and social casework concepts.

Buber, M.  (1965). The knowledge of man. New York: Harper & Row. Articles relating Buber’s philosophy of dialogue to the psychotherapeutic relationship.

Curry, A. (1967). Toward a phenomenological study of the family. Existential Psychiatry, 6(27), 35– 44. The effects of existential despair on family life, described as a “web of unrelatedness.”

Frankl, V.  E. (1965). The doctor and the soul from psychotherapy to logotherapy. New  York:  Knopf. A  very readable development of existential psy- chology in comparison with other psychologies and its application in therapeutic practice.

Krill, D. F. (1978). Existential social work. New York: Free Press. A delineation of existential and related thought applicable to both theory and practice in social work. An eclectic- interpersonal perspective is emphasized.

Sinsheimer, R. (1969). The existential casework rela- tionship. Social Casework, 50(2), 6– 73. Concepts from existential psychology are related to the case- work relationship in terms of the I– Thou dialogue and encounter.

Stretch, J.  (1967). Existentialism:  A  proposed philo- sophical orientation for social work. Social Work, 12(4), 97– 102. Existentialism provides a view of life that accepts the perennial crises of people as opposed to utopian hopes of a secured society.

Sutherland, R. (1968). Choosing as therapeutic aim, method and philosophy. Existential Psychiatry, 2(8), 371– 392. The applicability of the concept of freedom of choice in specific techniques of psychotherapy.

Weiss, D. (1970). Social work as healing and reveal- ing. Intervention, 50. Development of Buber’s philosophy of dialogue according to the concepts of Being, Becoming, Belonging and Sympathy, Empathy, and “Compathy.”

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In Changing Their World: Concepts and Practices of Women’s Movements, Srilatha Batliwala (2008) describes feminism as

both an ideology and an analytical framework…  . The past three decades of activism, advocacy and research, and changing global geopolitical context, have generated powerful insights and experience about our gains, setbacks, and the challenges of the future… . We now stand not only for gender equal- ity, but for the transformation of all social relations of power that oppress, exploit, or marginalize any set of people, women and men, on the basis of their gender, age, sexual orientation, ability, race, religion, nationality, location, class, caste, or ethnicity. (p. 11)

It is an exciting time to be a feminist social worker. “Rising feminist advocacy for human rights, social justice and gender equality” is noted in the Canadian Association of Social Workers’ (CASW, 2008)  Social Work Scope

of Practice (p.  1). The advent of the Internet, the ubiquity of smartphones and tablets, the ease and cost of international communication via text, Skype, and blogs, and access to solar technologies and wireless communication in places without widespread electrical grids have enabled feminists to communicate worldwide. Classrooms can be created anywhere through distance delivery. Social movements are cre- ated now, not at a kitchen table or workplace, but via tweets with hashtags. #SayHerName is informing and mobilizing against violence. #BringBackOurGirls demands the return of 273 Nigerian kidnapped schoolgirls. #AmINext raises awareness about murdered and miss- ing Aboriginal women. Feminist journal- ists can create their own followers through e- zines, blogs and web publishing. Facebook, Instagram, Twitter, Whatsapp, Tumblr, etc.,

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enable the global distribution of stories not deemed important enough to be covered in mainstream media:

The fact that we can send messages via Twitter and Whatsapp to each other and a global response occurs around our issues whether it be rape, or sexual vio- lence, or violation of the our human rights, proves that the notion of sisterhood is one that has existed for centuries and continues to be a strong part of this movement. (Moiyattu, 2015)

Activism has been rejuvenated. SlutWalks and Take Back the Night marches, which became anemic in the 2000s, were rejuvenated and joined by immigrant and indigenous women’s groups. While in the 80’s and 90’s activists may have walked from “the campus” to “the capital,” they are now more likely to meet in impoverished neighborhoods like “Murderpeg” (Macdonald, 2015)  or the Highway of Tears (Carrier Sekani, n.d.), to bring attention to marginalized and exploited women. Pan- Canadian feminist gath- erings, such as the 2011 Rebelles Conference in Winnipeg, Manitoba, attract hundreds of young feminists. Pussy Riot, a feminist, punk- rock protest- band in Russia, challenged both church and state in 2012, and gained worldwide recognition and support through mass media. National Equal Pay Day, started in 1996 by the National Committee on Pay Equity (2015), con- tinues to highlight that, still, on average, women who work full- time earn only 78 cents for every dollar a man makes.

Consequently, feminism has developed a global reach. Activist movements are made vis- ible worldwide through their websites, allowing for global networking:

There is a burgeoning women’s rights movement in Muslim- majority societies today. From Pakistan to North Africa, each country has a network of activ- ists, writers and academics struggling to bring wom- en’s rights to their countries and overthrow centuries of patriarchal oppression. Networking on the inter- net and on social media enables them to … [be] a transnational one. (Friedland, 2014)

Many feminists were at the forefront of the Arab Spring, and have used that impetus to con- tinue their campaigns (Clarion Project, 2015). African feminism has become a phenomenon to celebrate (Banya, 2015). Movements in British Commonwealth countries, like UK Feminista

(UK Feminista, 2015), and the Australian Women Against Violence Alliance (AWAVA, 2015)  share this community. The Feminist Majority Foundation (Feminist, 2015) identifies that collective action can bring change.

In 2015, feminist messages reached huge audiences through the confluence of fame, technology, and global reach. A  Kenyan poet- activist, Chimamanda Ngozi Adichie (2014), is widely known, through her TedTalk, as “a happy feminist.” A  teenage girl from Pakistan, Malala Yousafzai, advocating for education, earned a bullet to the head, then a Nobel Peace Prize. British actor Emma Watson (“Hermione Granger” in the Harry Potter movie series), launched the HeForShe campaign at the United Nations in 2014, and reminded the audience that no country in the world can yet say they have achieved gender equality. Pop singer Beyoncé’s performance at the 2014 MTV Video Music Awards in front of the huge word “Feminist” brought attention to feminism to millions glob- ally, and the “Beyoncification of feminism” entered the popular lexicon.

Yet, since its inception, there has been no shortage of those who wish to dismiss feminism as dead, irrelevant, or failed. Valentich (2011a) observed, “the media often questioned whether feminism was dead” (p. 207). Surprisingly, within the last few years, some feminist social work authors also have appeared to express wea- riness. Iconic feminist Phyllis Chesler, whose Women and Madness in 1972 revolutionized psychiatry for women, more recently (2005) wrote The Death of Feminism: What’s Next in the Struggle for Women’s Freedom? Irish social work theorist Garrett in 2013 considered again the question of the “death” of feminism and the “post- feminist era” (p. 10). My own expe- rience, teaching both feminist perspectives on social welfare policy and social work practice, is that despite this vast feminist conversation and influence, students are generally unaware of the policy implications, practice skills, and theo- retical underpinnings of feminist social work theory.

The disconnection with feminism extends to those in practice. Students in my “Feminist Perspectives” course interview staff in agencies originating in feminist social work fields such as reproductive health, family resource centers,

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intimate partner violence, immigrant women, indigenous women, sexuality education, and housing and resources for sex trade workers. To the question, “Does your agency identify as ‘feminist’?” only one of 15 said “Yes.” While some admit to having “pro- feminist values,” equivocations like “it depends on who is listen- ing,” “we have to conform to the community’s comfort zones,” and “avoiding push back from funders” were common responses and indi- cate that “there has been a societal backlash to feminism and a trend to social conservatism, resulting in feminist theory and practise stand- ing at a threshold” (Valentich, 2011a, p.  205). Valentich’s (2011b) contention that “the process of identification as a feminist social worker is not straightforward” (p. 26) seems correct.

What is the reason for this disconnection? Mandell (2009) and others have suggested that there is sense that feminism has achieved all its goals and consequently is no longer needed. Mandell notes, “Most young Canadian women and men have grown up in a world in which feminism as a social and ideological move- ment is firmly established” (p. ix). Yet research done with women and gender studies students reveals “a legacy of ambivalence, contradiction, backlash, and marketing; … even though young women and men consider gender equity the norm, traditional and often contradictory dis- courses on masculinity and femininity remain intact” (p. ix). Noting the increase in levels of sexual violence, feminization of poverty, and the loss of social welfare supports for vulner- able women, influential British feminist social worker Lena Dominelli (2002) is incredulous: “I marvel at the idea that feminist cause has been realized” (p.  1.). She scoffs at the “relegation of feminism to the annals of history” (p. 2).

In order to appreciate the ebb and flow of feminist and feminist social work theory today;

to see the gains that have been won, lost, or are at risk; and to avoid repeating history, it is helpful to clarify distinctions and gains of past generations. Newcomers to the subject may find helpful a brief orientation to the language of “Waves,” types of feminism, and history. Gray and Boddy (2010) and Valentich (2011a) have examined this history in detail, and reviewing their work is recommended.

For the sake of introduction, the following chart (Table 11.1) is offered, with three caveats attached.

The first caveat is that such description will have the limitations of essentialism, the fallacy that complex movements may be reduced to a few or even single characteris- tics. Essentialism is a viewpoint of patriarchy in which an “authoritative universal voice— usually white male subjectivity masquerad- ing as non- racial, non- gendered objectivity” (Crenshaw, 1989, p.  154), obscures variations and nuances of reality. Feminism has not had a need for such discreet and arbitrary categories. Furthermore, the written record of each Wave has not yet fully described the diversity of par- ticipants and activity, in part due to women’s varying levels of access to education and pub- lication at the time. For example, there have always been women representing minority groups within feminism, but they have often not been represented in academic works. How many know of Birdye Haynes, a black activist colleague of Jane Addams in creating the set- tlement movement? African- American pioneer Birdye Haynes served in prominent leadership roles in New York and Chicago’s settlement house establishment. Haynes commitment to the African- American community compelled her to the social work profession in an era of segrega- tion and oppression. Haynes’ calling was to serve as an advocate in educating other professionals to

Table 11.1

First Wave Late 1800s– 1945

Second Wave 1960s– 1990s

Third Wave 1990s to present

Maternal Radical Intersectionality embraced; postmodern/ post- structural; post- colonial continue to expand theoretical and activist definition; more voices developed in third wave

Equal rights Liberal Marxist Socialist

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understand problems within the context of a racist system that denied African- Americans equal access to resources. (Nsonwu, Casey, Cook, & Armendariz, 2013, p. 8)

Steinem has since pointed out that, contrary to the partial written record, “if you look at the numbers and the very first poll of women thinking about responding on women’s issues, African- American women were twice as likely to support feminism and feminist issues as white women” (Vagianos, 2015). For that rea- son, Tamaki (2001) rightly insists, “Feminism is two parts definition and one part struggle— a constant processing of defining, redefining and struggling against definitions (p.  2)” (cited in Mandell, 2009, p. 63).

The second caveat is that the various social issues addressed by the many feminist philoso- phies were not limited to particular Waves. For example, gender violence has been a concern in varying ways through all three Waves. During the First Wave, women had no legal right to pro- tection from certain types of violence (such as rape by a spouse). Although the Second Wave succeeded in naming the issue and created rape crisis centers and women’s shelters, the problem of violence and the murder of girls and women continued into the Third Wave interval.

In Canada, that there are more than 1,000 missing and murdered indigenous women defies understanding. Richardson (2010) notes that:

Aboriginal clients experience a disproportionately high level of violence compared to European Canadians … and may encounter social and judicial responses that are primarily negative. Agencies may function with a set of assumptions that see the client as having equal access to resources and opportunities. (p. 125)

Similarly, immigrant women “suffer from eco- nomic, social, linguistic and cultural marginal- ization” (Mandell, p. 179). “National surveys of ethnic minorities in UK higher education have found women of color are more than any other group to report being victim of sexual harass- ment and discrimination at work” (Mirza, p.  2). As female bodies are the site for much scrutiny, control, and oppression (Dominelli, 2002), the work of feminist social work schol- ars such as MacDonald, Carter, Hanes, Skinner, and McMurphy (2014) on feminist analysis of women and disability, is crucial.

In some countries, local feminists are fighting today for rights achieved in Europe and North America in the First Wave (see, e.g., Sampson’s Equality Effects2, 2015). Pandya (2014) notes that “the realities of women in India are narra- tives of oppression, invisibility, and subsequent revolt” (p. 500). On International Women’s Day, Rogers (2015) commented, “Gendered issues faced in Haiti are cyclical and directly tied to women being treated as second- class citizens, extremely harsh economic situations and the lack of access to schools and good education” (n.p.).

The third caveat is that tables such as Table  11.1 obscure the importance of intersec- tionality in which multiple social characteristics have a compounding effect. Crenshaw (1989), for example, explained that problems cannot be solved simply by including, say, black women within already established analytical struc- tures, because the effect of additional (inter- secting) experience is greater than the sum of racism and sexism. Theory must be rethought and public policy rewritten.

With those caveats in mind, the conventions of First, Second, and Third Wave feminism may be explained. These terms primarily help to locate various stages of feminist development on a timeline. The metaphor of waves signals that, like life- supporting water, feminist theory has fluidity, rhythms, movement, and is some- times tumultuous in order to remain healthy and not stagnant. The Waves do not neces- sarily signify differences of social issue focus, but rather the stages of evolution of feminist thought.

Next, it is useful to comment on labels attached to various forms of feminism. While “feminism can be broadly characterized by a concern with the systematic disadvantage of women and the means by which equitable out- comes can be achieved, it has never had one dis- tinct set of beliefs or a unified position” (Gray & Boddy, 2010, p. 368) and “recognition of dif- ference features prominently in all forms of feminism” (p. 380). Terms like “liberal,” “social- ist,” and “radical feminism” point toward the various foci feminist philosophies and feminist social work theorists were pursuing. “Maternal feminists” believed that women are biologi- cally different from men, and consequently the

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biological quality of mothering suggests that women be “social housekeepers” in society. Guided by this view, women’s experiences and voices need to be valued more fully.

“Equal rights feminists,” as represented by suffragettes around the world, sought access to voting privileges. Equal rights feminism of the First Wave became “liberal feminism” in the Second Wave, which continued to pursue jus- tice for each person regardless of sex or social class. Essential to this perspective is the belief that changing laws and policies is the catalyst needed to eliminate discrimination. From the perspective of liberal feminism, it was thought, sexism could be eliminated by enabling women to have legal access to divorce, to birth control and abortion, to owning property, to having custody of children, and so forth.

“Marxist feminism’s” focus on class and gender rights related to how work was valued differently according to gender, and gave rise to “socialist feminism.” Socialist feminism argued that structures of the economy are at the root of inequality, and that changing a few laws was insufficient to address this underlying bias. A connection is drawn between a capital- ist economic system and oppression, as women owned neither the means of production nor the products of labor. Work at home is not accorded value; women around the world are primary producers of goods and services for which they are not paid (Waring, 1988).

“Radical feminism” is an evolutionary descendent of maternal feminism. Male per- spectives have created patriarchy, the root cause of all oppressions:

Patriarchy is a political- social system that insists that males are inherently dominating, superior to everything and everyone deemed weak, especially females, and endowed with the right to dominate and rule over the weak and to maintain that domi- nance through various forms of psychological ter- rorism and violence. (hooks, n.d.)

Radical feminism therefore argues for opposing the very structures of society created by patri- archy, and the creation of healthier relation- ships and associations by women. Women- only spaces were seen as crucial to emancipation.

“Cultural feminism” extends radical femi- nism’s view of inherent differences of women

and looks to build a women’s culture. “Lesbian feminism” challenges heteronormativity in policies and practice (including language that restricts definitions of family, and myths about “the nuclear family”); confronts homophobic assumptions and practices (such as discrimina- tion in foster parenting policies), and advocates for legal recognition and human rights. “Eco- feminists” see a connection between how the earth (including the environment, animals, and resources) is mistreated, and mistreatment of people, especially the exploitation and abuse of females.

With the caveats, waves, and types of femi- nism in mind, it is possible to get a sense of the history of the development of feminist theory that underpins feminist social work theory. During the First Wave, feminism as a theory was in the process of being articulated. As the movie Suffragettes (Owen & Ward, 2015) shows, activism, rather than the development of a clearly expressed philosophy, was the goal of the early women’s rights movement. From the mid– 19th century to the end of World War II (1945), women fought for the vote, personhood, basic legal rights to own property, and the ability to have custody of their own children.

Jennissen and Lundy’s (2011) book One Hundred Years of Social Work describes the link between the stories of countless women and the development of the profession of social work. Using their own (and their “sisters’ ”) experi- ences and capacities to reflect and comment, social workers began to build the foundations of feminist social work theory upon the work of their activist feminist foremothers. Wahab (2015) points out that the social work theory concepts of collective action, analysis, and justice, were built upon Jane Addams’s (1902, 1916) dedication to building community, Mary Richmond’s (1917) attention to documentation and objective analysis, and Bertha Reynolds’s (1935, 1942) commitment to a socialist drive for equality and fairness for all. It was during the First Wave that the first schools of social work were developed in the late 1890s in Britain and Europe, 1898 in the United States (Columbia University in New  York), and 1914 at the University of Toronto in Canada.

Betty Friedan’s The Feminine Mystique (1963) is widely recognized as starting the Second

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Wave of feminism, by naming the- problem- with- no- name as patriarchy. Having had the opportunity to be “helpers” in the war effort as men were serving in armed forces, women for a time had participated fully and “equally” with males in society. Yet, the postwar era saw women forced back into the stereotyped and limiting roles of caregivers of others, as a mat- ter not of choice but of public policy. Through the 1960s, American civil rights activism and the anti- Vietnam war movement contributed to social unrest and the rethinking of relation- ships. The Stonewall riots transformed the gay rights movement and led to formation of, for example, the first transgender organization in the late 60’s. Women’s liberation was one of the many liberating movements that gained energy in those tumultuous years.

In Canada, the issues, and consequences of that patriarchal system, were catalogued by the Royal Commission on the Status of Women (1977). One hundred sixty- seven recommen- dations from that report raised Canadian con- sciousness of “new” justice issues, including participation of women in pension plans, pay equity, minimum wage, unemployment insur- ance, and legalization of birth control. Feminist scholars worldwide detailed the effects of such lack of rights in many and various aspects of being:  economic (Waring, 1988), family (Meyers- Avis, 1985; Laird, 1995), psychologi- cal (Greenspan, 1983; Penfold & Walker, 1986; Miller, 1976; Belenky et. al., 1986; Gilligan, 1982; Levine, 1976), political (Dominelli & McLeod, 1989; Ursel, 1992; Eichler, 1988), and the philo- sophical analysis of the ethic of care (Manning, 1992; Baines, Neysmith, & Evans, 1991).

It was during this blossoming of “liberatory” consciousness and movements in the Second Wave that developing feminist social work the- ory flourished. Schools of social work began offering and evaluating feminist social work courses (cf. Pennell, Milliken, Flaherty, Gravel, & Neuman, 1993). Theorists like Levine (1976), Norman and Mancuso (1980), Berlin and Kravetz (1981), Russell (1984), Valentich (1996), Bricker- Jenkins and Hooyman (1986), Van Den Bergh and Cooper (1986), Collins (1986), Dominelli and McLeod (1989), Hanmer and Statham (1989), Van Den Bergh (1995) and Land (1995), to name several, applied the feminist

perspective to a wide range of social work issues. Valentich (2011a) noted, “by the mid- 1990’s social workers in diverse fields of practice were aided by the growth of qualitative research that elicited women’s own voices … theory building emanates from what social workers actually do” (p.  207). She also observed that developing this body of feminist social work literature, and hav- ing a feminist theoretical framework and model accepted into social work texts and curricula, was a great accomplishment of the second- wave feminist social workers (1996).

In 1992, Rebecca Walker coined the term “Third- Wave Feminism” in a Ms. Magazine arti- cle (pp.  39– 41). Thus she began a conversation that reflects on the impact of postmodern per- spectives for feminist ideals. “Postmodernism” here is understood as an amorphous philo- sophical trend in the late 20th century in which singular meanings were overturned by relativ- ism, universal standards were challenged by multi- dimensionality, empirical certainty was undermined by principles of scientific uncer- tainty, and the distinction between subject and object was dissolved (c.f. Keep, McLaughlin, & Parmar, 1993).

Consequently, postmodern feminism began to challenge binary gender definitions and enabled thinking about gender and sexuality as more fluid identities. Terms like “cis- female” (someone who identifies as biologically and psychologically female) were coined, adding to the number of possible identities and creating space for transsexuals. Thanks to “postmodern deconstruction” (the dismantling of the assump- tion/ perception that social observations are real, absolute, or universal, and the demonstration that such meanings are socially and locally con- structed), many feminisms could be articulated.

Post- colonial feminist analyses emerged through this conversation (hooks, 1994; Lorde 1984; Mirza, 1997; Weedon, 2000). Those who had lived in former colonies described their experience of dealing with inequality within the context of colonial dominance and subsequent effects of that oppression embedded in systems that lingered. In The Equality Effect2, Canadian feminist Fiona Sampson (2015) observes:

Women in Canada and in Ghana, Kenya and Malawi, continue to experience the oppression that

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is the result of this legal legacy [colonization]— a leg- acy that is characterized by laws that are often sexist in their roots, and disadvantage women. In Canada, the impact of this legacy is especially significant for Aboriginal women (n.p.).

The publications of indigenous voices like Maracle (1996), Waters, (2003), Corbiere Lavell & Lavell- Harvard (2006), Green (2007), Sinclair (2007), Pompana et  al. (2008), Absolon (2009), Monture- Angus and McGuire (2009), Anderson (2011), Baskin (2011), Milliken, Campbell, DiUbaldo, and Pelletier (2012), and Carriere and Richardson (2013) enrich the growing post- colonial feminist literature in Canada.

Informed by post- colonial and postmodern philosophies, the Third Wave continues today, an expanding movement to include those pre- viously not expressed in written work. Third Wave feminists continue to give wider voice to issues of gender violence, race, heteronor- mativity, class, ableism and ageism, global care, immigrants, constructions of families, and the amplifying effects of intersectionality (Crenshaw, 1989; Heywood & Drake, 1997).

For Sands and Nuccio (1992), “postmodern feminist theory” is:

highly compatible with social work. … [Postmodern- ism’s] emphasis on differences … recognizes the diverse constitution of client populations and their unique needs. Furthermore the focus on context is in keeping with person- in- situation perspective. … The use of deconstruction uncovers the suppressed voices of marginalized populations. (p. 493)

They noted that words and experiences are his- torically and culturally bound, thus recognizing that issues have many faces and speak in multi- ple voices, depending on the context. Meanings cannot be considered absolute and universally real in themselves, but rather are constructed (p.  491). This compatibility between feminist theory and social work practice has been cor- roborated by many writers (e.g., Collins, 1986; Gould, 1987; Nes & Iadicola, 1989; Van Den Berg & Cooper, 1986). “Feminist principles are closely aligned with social work values and eth- ics (Bricker- Jenkins & Hooyman, 1986; Van Den Bergh & Cooper, 1986), and some would say that social work is inherently feminist (Collins, 1986)” (cited in Lazzari, Colarossi, & Collins, 2009, p. 348).

Feminism is not only of academic inter- est to social work theory. It is also a method of social work practice. Feminist social work not only shares the tenets and values of feminism, but also adapts and merges them with existing social work values, and puts them to work:

Feminism and social work share a commitment to the unique nature and essential dignity of all peo- ple…  . Furthermore, social work’s emphasis on the person- in- environment is congruent with the central methodological theme of feminism— the personal is the political— and the feminist value of personal empowerment is a key underlying theme of social work intervention. (Collins, 1986)

Land (1995), in particular, identified the basic skills feminist social workers employ:

• Validating the social context; revaluing posi- tions enacted by women;

• Recognizing difference in male and female experience;

• Re- balancing perceptions of normality and deviance;

• Adopting an inclusive stance; • Attending to power dynamics in the thera-

peutic relationship; • Recognizing how the personal is political; • Emphasizing a de- constructive perspective, a

partnering stance and inclusive scholarship; • Challenging reductionist models; • Employing empowerment practices; • And challenging the myth of value- free psy-

chotherapy (pp. 6– 11).

These practices help social workers function in an explicitly feminist way to make visible and conscious the negative effects of patriarchy and to develop alternative narratives in individu- als and communities, to provide for alterna- tive (just and egalitarian) expressions of social relationships.

The value of feminist social work practice has been demonstrated empirically. Noting that “empirical evaluations of feminist social work interventions are generally underrepresented in the profession’s peer reviewed literature,” Gorey, Daly, Richter, Gleason, and McCallum (2002) compared 35 independent studies of feminist interventions with 44 independent studies of social work practice that were based on other theoretical orientations. For this study, Gorey

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et al. identified the general attributes of feminist interventions as the following: The importance of gender is explicitly addressed, including addressing inegalitarian resource development and oppression; efforts are made to eliminate false dichotomies; power is reconceptualized; and a strengths perspective is emphasized (p. 40). Finding that “nine out of every ten femi- nist social work participants do better than the average non- feminist participant” (p.  37), they declare that when “methods have been so vali- dated, it appears that (feminist social work) may be among the profession’s most effective strate- gies” (p. 50). Given the broad range of theoreti- cal applications in feminist social work, ongoing evaluation is needed to address concerns that the volume of research in feminist social work literature is declining.

When social work values are so aligned with feminist values and when praxis is deemed so effective, why, then, is it still necessary to have to justify and fight for the legitimacy of femi- nist social work? Many challenges remain in the movement toward the equality of all, the end to which feminist social work theory aspires. These challenges may be external or internal to the movement, but at root, they are expressions of a presumption (patriarchy) that is familiar to theorists and activists of the three Waves. As Lazzari et al. (2009) declare: “Patriarchal struc- tures are alive and well” (p. 353). While contem- porary expressions of this harmful viewpoint take on new shapes with new technologies, the dynamics remain similar. Patriarchy continues to seek to objectify in order to demean, humili- ate, or control by violence. Its institutions con- tinue to undervalue the work of women. Its minions work to exert controls that prevent human rights.

Objectification is a key dynamic of patri- archy that leads to violence. Second Wave femi- nists had been hopeful that research (hooks, 1997; Kilbourne, 2010)  and activism (Jhally, 2007) to expose the misogyny of media objecti- fication of women would lead to a reduction in violence against women and vulnerable others. They could not have predicted the development and popularity of misogynistic software like Grand Theft Auto V (Rockstar, 2013)  that liter- ally make it a game to link sexual arousal and violence and “win” points for horrific violence

against women. Nor could they have predicted the worldwide distribution of violent sexual exploitation of females through webcam RATS (remote admission tool software); cellphone cameras used, covertly or predatorily, to film females in sexual acts, leading to extortion and suicide, and those pornographic images circu- lating perpetually within the worldwide web.

Controlling women is a central dynamic of patriarchal structures. The “body politics” literature, identifying female bodies as a “bat- tleground” for control, is abundant:  from de Beauvoir (1949), Firestone (1972), and Butler’s (1993) earlier feminist interrogations of women as body, through to the current burgeoning lit- erature on this topic. “The powers at play in body politics include institutional power expressed in government and laws, disciplinary power exacted in economic production, discretion- ary power exercised in consumption, and per- sonal power negotiated in intimate relations” (Body Politics, n.d.). Sjoberg and Peet (2011) observe that “both in domestic and interna- tional policy, and in actual conflicts, functions of gender hierarchy in the theory and practice of both state and global politics mean that wars are … fought on the bodies and lives of ‘their’ women” (p.  176). Valentich (2011b) catalogued other recurring issues such as intimate part- ner violence, sexual assault, survival sex work, human trafficking, and homelessness, and stated the obvious, that social workers “would agree that there is still much work to be done, locally, nationally, and internationally, by those committed to feminisms” (p. 22). Undervaluing women’s contribution is a major result of objec- tification and patriarchy.

Globalization (the closer integration of eco- nomic, social, political, environmental, and legal policies across nations) has the poten- tial to promote social justice agendas; uniting of nations, eradicating inequality, ensuring mutual sustainability and peace. However, we are seeing much of the opposite:  policies that exploit, increased poverty, environmental deg- radation, political and economic insecurity, amassing wealth for corporations and investors. The rise of the global market has put pressure on local and national social agendas, impeding some feminist accomplishments and eroding others. The economic bottom line is held up as

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more important than social justice and commu- nity caring. Those in a position to benefit from the globalization of the marketplace (that is, the dominant patriarchal culture) promote global- ization to its own advantage and the disadvan- tage of others.

Members of lesbian, gay, bisexual, trans- gender, two- spirited, and queer* communi- ties continue to be “victims of socio- economic, psychological and economic abuse because of their sexual orientation” (Mandell, 2009, p. 178). Economically, women continue to be the major- ity of single- parent heads of household. Women’s work is still not paid equitably. Women are still doing the majority of the child caring and house- hold labor (Home, 2004). Older women con- tinue to bear the brunt of a lifetime of economic inequality, having made less money at work, or to live with results of unpaid work at home, so they may not have earned a pension. A  reduc- tion in the social service net has collided with the entrance of large numbers of “the Baby Boom generation” into their senior years. Having duti- fully fulfilled their society roles as caregivers, and paying the price economically, senior women are now being characterized as “problems” for the larger society. “A postmodern welfare state that relies on individuals purchasing their own wel- fare instead of pooling social resources for the benefit of all … is one only privileged people can afford” (Dominelli, 2002, p. 62). Clearly, the need for feminist social work remains.

Furthermore, the rise of neoconservative governments has meant a decline in financial support for social work services. Dominelli (2002) not only cautioned that the “market context has devalued professional social work” (p.  52), but added that “social work is con- stantly being restructured by the state” (p.  15). Dominelli decried the assault on professional- ism that is occurring in an increasingly neo- conservative world:  “State measures linked to globalization have whittled away professional power by devaluing its expertise” (p. 10).

“Neo- conservatism promotes a more tradi- tional society based on patriarchal gender- role arrangements that are explicitly anti- feminist and anti- egalitarian” (Valentich, 2011a, p. 208):

The notion that caring comes naturally to women fails to consider the significance of the socially

patterned roles and the processes of socializa- tion through which sex is translated into gender as women and men learn to incorporate into their behaviour and attitudes, assumptions related to masculine and feminine roles…  . It is women who learn to take their place in society as informal care- givers to children and elderly relatives, and who transfer this to the public sphere and provide formal caring services as cleaners, child minders and teach- ers. (Bricker- Jenkins & Hooyman, 1986, p. 17)

When neoliberal (economic and political theory that places the free market system as the cen- tral value of policy making) initiatives seek to move these tasks back into the sphere of family care, it is overwhelmingly women, low- paid or unpaid, who end up shouldering the burden of work. Rather than full- time, permanent, union employment, “flexible” private sector work has meant fewer workers, less coverage, shift work, contracts, split shifts, part time, casual labor, and expanded reliance on volunteers (Baines, 2011a, p. 35). As social work is primarily a pro- fession of women for women, the impact of this shift is highly gendered:  women still receive lower pay, care work is racialized, and women dominant professions are associated with low status (p. 43).

Changes that have taken place in social work include a shift from engagement with clients and community to an emphasis on regulation and evidence- based practice (Nsonwu et  al., 2013, p. 5). Managerialism views work as requir- ing pro- market, businesslike management solu- tions rather than social connection, equality, and public service. As a result, work condi- tions have often deteriorated; caseloads have doubled; standardization has led to a focus on paperwork, not people; issues to be addressed are reduced to checklists, leaving out important contextual information, and the influence of policy and systems upon problems.

Valentich (2011b) argues these trends sus- tain a public retreat from explicit identification with feminist social work. Despite all of the hard work by feminist social workers to anchor practice in empowerment and collaboration, managerialism and neoconservatism seem to be damaging these gains (p.  27). Commenting on the organizational context of supervision in social work, Davys and Beddoe (2010) note that “most helping professionals work in highly

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bureaucratic, organizational contexts and increasingly fewer can claim to control their own work or knowledge” (p. 69). Baines in 2011 asked:  “How do managerialism and standard- ization restrict social workers’ opportunities for social- justice oriented practice? Have 20  years of restructuring reduced or removed social workers commitment to, and capacity for social justice practice?” (p. 25). She goes on to remind us that the “source of social work’s intellectual integrity … is connection to people’s every day struggles for dignity and well- being, its ability to alleviate their pain and to address deep roots of inequality and injustice that generates dis- tress” (p. 25).

This constant controlling supervision is tir- ing. Referring to feminist social work theory, Valentich (2005, p.  148) notes that “its further development remains in the hands of increas- ingly overburdened and politically constrained social workers and social work educators” (cited in Valentich, 2011a, p. 205). The Gray and Boddy warn that notions of “post- feminism” fuel neo- liberal consumerist inequality, thus “intensify- ing the need for feminist social work critique, scholarship, and activism” (Gray & Boddy, p. 368). Overall, there is a reduction of ability to use critical theory in decision making.

Diminishing the visibility of women’s work and value is not only a result of patriarchy for individual women— it also affects women col- lectively. A  neoconservative climate affects the academy (research and education) and feminist social work practice. A challenge that seems to be both external and internal is the invisibility of feminist social work achievement. The work of feminists, like the work of women, is made invisible. The tiredness of overloaded social workers and instructors, and the lack of sup- port available, contribute to a decline in femi- nist social work research and a decline in the visibility of feminist social work principles and action in the public arena. Observing a lack of contemporary feminist scholarship in social work practice, Gray and Boddy (2010) note that:

Social workers deliver innovative services in their daily work and are uniquely positioned to dissem- inate valuable practice experience, but this exper- tise is seldom disseminated publicly. They would do well to engage in more practice- based research that

examines effective feminist approaches to social work practice. (p. 384)

Feminists do not get credit for the gains they have achieved for others. Taylor and Daly (1995) suggest that social work’s roots as a profession of women for women resulted in patriarchal devaluing of women’s work to “social house- keeping,” and that this laid the foundation for “an underestimation and misrepresentation of the analytical, organizational, and management skills that women in the profession employ to effect radical changes in society” (p.  11) that continue. Schiebinger (1999) observes the same invisibility when she notes: “It is a curious phe- nomenon that when feminist practices or points of view become widely accepted in science, medicine, engineering, or the culture more gen- erally, they are no longer considered ‘feminist,’ but simply ‘just’ or ‘true’ ” (n.p.). To the extent that this integration is so thorough, the credit due feminism is quickly lost, and the rights so gained are assumed to have always been pres- ent. That women are legal persons, that they can vote, hold jobs, obtain credit, receive parental benefits and custody of children, may well be seen as natural rights, not the legacy of hard- won feminist social work advocacy. The invis- ibility of women’s work has now shifted to be the invisibility of feminist social worker’s work.

Feminist thought and feminist social work theory are diminished in academia when these perspectives are subsumed under larger, “more inclusive” categories, such as gender studies, human rights courses, or anti- oppressive prac- tice. Brown and Strega (2005) decry the con- tinuing dismissiveness: “Despite the emergence of critical, feminist and Indigenous approaches to research, anti- oppressive and critical research methodologies still rate little more than a men- tion in most research methods” (p.  4). Though feminist theorists (e.g., hooks, 1994; Mehrotra, 2010) identified the concept of intersectionality, anti- oppressive practice writers such as Brown and Strega (2005), and Baines (2011), while declaring themselves to be feminists, neverthe- less appear to reduce the centrality of the femi- nist contribution by suggesting, for example, it is an “older theor[y] ” (Baines, p. 10), one of sev- eral interchangeable theories that (mis)articu- late the same larger problem. This seems to be

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another way of avoiding association with the feminine in feminist theory. It is feminist social work theory that continues to point out the gen- der bias of these larger categories. Obscuring violence serves to perpetuate it, to excuse it, and to discourage perpetrators from being held accountable for it (Richardson, 2010, p. 138).

Hence, striving to remain visible is a key challenge and priority for feminist social work. Identifying that the world

we know as racist, sexist, heterosexist, classist, neglect- ful, colonizing, occupying, and violent is the problem (Brown, 2006, p.  22), we social workers can create culturally competent practices that support equity and social justice only by understanding the ways in which we are not meeting these goals. (Gentlewarrior, Martin- Jearld, Skok, & Sweetser, 2008, p. 2)

Social workers are committed to advocating for others but are not as effective at educating the public and other professions about our successes and contributions. Our invisibility lets others define and disparage the profession and that ultimately hurts not only us but those we serve.

For that reason, feminist social work research is crucial (Gottlieb & Bombyk, 1987; Gringeri, 2010). In considering what social work will look like in 2044, Howard and Garland (2015) urge a commitment to

social workers as public intellectuals … there is little or no social work presence in public venues such as speaking tours, radio talk shows, television news shows, popular magazines, newspaper editorials, op- ed pages, or other mechanisms that inform the pub- lic about welfare and public policy issues. (p. 200)

Wahab, Anderson- Nathe, and Gringeri (2015) urged feminist theorists to take up the chal- lenge of research in social work, when they wrote Feminisms in Social Work Research:

Showcasing the breadth and depth of exemplary social work feminist research, the editors argue that social work’s unique focus on praxis, daily proximi- ties to privilege and oppression, concern with social change and engagement with participatory forms of inquiry place social workers in a unique position to both learn from and contribute to broader social sci- ence and humanities discourse associated with fem- inist research. (Publisher notes)

The importance of feminist thought in their theoretical constructions is visible as the

cornerstone of other theories. In 1997, Wachholz and Mullaly affirmed that “feminist research literature … offers the most well- articulated body of knowledge that is congruent with struc- tural social work values, beliefs and principles” (p.  25). A  challenge to face, therefore, is the advancement of feminist social work research. By finding their voice, Third Wave feminists can create a new reality, for language has always had power; “words make worlds” (Hartman, 1991).

Education is one of the challenges facing feminist social work today. The purpose of university education is debated, but it seems to me that we are committed to transforma- tion through developing intellect, broadening awareness, encouraging questions that unsettle and transform, and pursuing holistic develop- ment that attends to students’ emotional, psy- chological, and spiritual wellness. Faculties of social work prepare students for a range of possibilities, offering opportunities to conduct ground- breaking research, collaborative com- munity engagement, insightful policy analysis, beneficial program evaluation, compassionate leadership, and skilled clinical practice. As the “key ingredient of a feminist classroom is help- ing students find their voice … [to] help build confidence to take action” (Curry- Stevens et. al., 2008, p. 297), feminist social work education guides that excitement and potential, and with bell hooks (2000), asks us all to “Imagine liv- ing in a world where there is no domination … where a vision of mutuality is the ethos shap- ing our interactions. Imagine living in a world where we can all be who we are, a world of peace and possibility” (p. x).

Exciting opportunities abound in feminist social work education to continue to blend our values and commitments to self- reflection leading to social action. Assignments I  employ invite engagement through creative expression. For example, students create manifestos that capture their passion for social action toward an issue of personal significance for them, expressed through described visual art, song/ drumming, poetry, rap, or other public per- formance. To inspire, I show examples of mod- ern feminist leaders, such us Crystal Valentine (Workneh, 2015)  reciting her powerful poem “Black Privilege,” and describing what she feels being black in America means today. Building

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on feminism’s roots in the community, we join teaching elders in round rooms, ceremonies, and sweat lodges; get out of the academy to blog about students’ experiences at the Canadian Museum for Human Rights, which includes seeing original documents like the Magna Carta and Treaty One, touching a ballot box from the 1994 South African elections that elected Nelson Mandela president of South Africa, and viewing a dress worn by an American teen who, in 2013, successfully fought for a racially integrated high school prom in Rochelle, Georgia. A student in the class I am currently teaching wrote:

I have come to realize I have much to unlearn when it comes to dealing with oppressed people. My con- cept of help was based on patriarchal values. While unintentional, I  had a concept of “applying treat- ment” which I now realize could create more harm. I think a feminist perspective— the philosophy I had been taught to devalue and belittle— may empower people more than any other approach I have learned so far in my education. (Personal communication, used with permission)

Feminist social work education must attend to accessibility of knowledge, inclusiveness, con- tinued social action, resilience in the face of the increasing corporatization climate within universities, and continuing commitment to feminist social work education. In a January 2005 interview, offering advice for the jour- ney, Steinem reminded academic feminists that “knowledge that is not accessible is not helpful” (Denes, 2015). Similarly, Gray and Boddy ques- tion “the ascendance of academic feminism and the disappearance of feminist political action” (p. 368). Feminist social workers are required to expand the circle of inclusiveness. The perspec- tive of Felly Nweko Simmons, a black woman academic who writes “the world I  inhabit as an academic is a white world… . In this white world I  am a freshwater fish that swims in sea water” (1997, p. 227) (cited in Mirza, 2014, p. 1) is not surprising when research shows that “only 85 of the UK’s 18,500 professors are black (university and college union, 2013), and only 17 are black women (Grove, 2014)” (cited in Mirza, 2014, p. 2).

Ensuring forms of leadership in social work, other than managerial control, is a challenge facing contemporary feminist social work. In

1995, Chernesky identified the leadership style of feminist administrators as interactive, trans- forming, and empowering; the mode of opera- tion as caring, nurturing, teaching, cooperative, facilitative, and inclusive; structures created are collaborative, horizontal, and decentralized; problem- solving style is qualitative, contextual, consensual, participative, and process- oriented, and tasks are to flatten hierarchy, diffuse power, share decision making, equalize rewards, and increase worker participation (p. 80):

A feminist theory of leadership should apply to, and closely monitor or observe, all levels of leadership power and influence, both formal and informal; the sex differences that exist; gendered expectations; and the process and goals of leadership … this practice involves reconstructing power as empowerment. (Lazzari et al., 2009, p. 351)

There is no biological essentialism in feminism or leadership. Men can be feminist leaders, which is important because “in the social work profession, more men than women hold formal positions of power (Sakamoto et  al., 2008)…  . This gendered power imbalance presents chal- lenges for all” (cited in Lazzari et  al., 2009, p. 353).

It is a sign of hope that Andrea O’Reilly (2008), founder of the Motherhood Initiative for Research and Community Involvement (MIRCI), has succeeded in having motherhood recognized as topic of scholarly inquiry. Feminist scholars (Caplan & Hall- McCorquodale, 1985; Caplan, 2000; Chesler, 2005; Swift, 1995; Turnbull, 2001)  were influential in naming “mother blaming” as a patriarchal presumption, and in questioning the lifelong limits assigned to females due to their biological ability to bear children. Hundreds of titles since have been published:  including articles on queer mother- ing, mothering and activism, war zone mother- ing, and mothering and “disAbility.”

By way of response to the need for more social work research, Howard and Garland (2015) rec- ommend a concerted effort to increase funding for doctoral students and fellowships; creation of a national institute in Canada for social work research; improvement in teaching stu- dents to write for publication, and, importantly, attending to social work research’s crisis: “My hope is that by 2044, social work research will

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have resolved its identity crisis, garnered stable funding, grown the number of researchers it produces, and achieved greater recognition for having tackled some of society’s toughest prob- lems with notably positive results” (n.p.).

A second sign of hope is that feminist social workers of all ages, experiences, languages, and cultures continue to collaborate. As our history illustrates, the strengths of social work and roots of feminism are in collaboration, blending grass- roots, the academy, and the front line. There are considerable resources in the communities we belong to and those with whom we engage, the academy, and practice sites; hence, it is impor- tant to rededicate ourselves to revitalizing those links. The shared interest in challenges to profes- sionalism affect both the Canadian Association of Social Workers/ Association Canadienne des Travailleuses et Travailleuses Sociaux (CASW/ ACTS) and the Canadian Association for Social Work Education— l’Association Canadienne pour la Formation en Travail Social (CASWE- ACFTS), so working together benefits us all. In 1995, women’s rights were finally recognized as a global human right by the United Nations:

A global feminism has evolved [Bunch,  1993] and events around the world from femicide [Caputi and Russell,  1993] to rape [Valentich,  1994] and genital mutilation [Berg,  1995] have captured the attention and engaged the energies of feminist practitioners who none the less, may be working in one domain of feminist practice. (Valentich, 1996, p. 284)

Wetzel (1995) encouraged feminist social work- ers to keep to their original purpose, to con- tinue to work collectively, sharing experience, not in retreating into isolation, but in keeping connected with others:

Women’s concerns are the concerns of the world. Their well- being is directly linked to the well- being of families, communities and nations. To practice effectively in the 21st century, therefore, social work- ers must view women as a priority… . If economic, political or social conditions, ranging from health care to education are to improve, the advancement of women from a human rights perspective must be embraced as a concept, indeed as a mission. To do so is to advance not only women, but men and children alike— in short, the people of the world. (p. 190)

Yet another sign of hope is that feminist social work theorists continue to publish. For

30 years, Affilia has been and continues to be a source for feminist social work writing, provid- ing access to feminist social work voices from around the globe. For example:  Pandya (2014) wrote, “Feminist social work has praxis as its core … women’s realities are not universal and essential, but differential; intertwined with cat- egories of caste, class, ethnicity, and faith which create layers of intersections of power domina- tion and hierarchy that need to be countered” (p. 500). Herizons: Women’s News and Feminist Views is a Canadian feminist magazine that has been publishing since 1979. A  host of contem- porary feminists theorists continue to write about contemporary issues in North America (c.f. Baumgardner & Richards, 2010 [(Gen X women]; Valenti, 2014 [full frontal feminism]; Hernandez & Rehman, 2002 [postcolonial feminism]; Nam, 2001 [Asian American femi- nism]). In his introduction to a new book on social work theories, Garrett (2013) acknowl- edges the significance of feminism and affirms that the book is informed by feminist analysis (p.  11). The developing literature on cultural safety (Milliken, 2013, 2012; Gentlewarrior et al., 2008) is part of that hope, articulating as it does an approach to inter- cultural coopera- tion that intentionally reduces the latent power inequalities that favor those in dominant cul- tures, whether they are racial or gender- based.

What, then, shall we conclude? Gloria Steinem (1995) once said feminism is the only major social movement that has to reinvent itself every generation. Gray and Boddy (2010) affirm:

Feminism is far from a finished project. Women worldwide are oppressed, marginalized, abused, and disadvantaged because of their gender. Neoconservative values have undermined feminism. If we are to offset antifeminist movements, we must keep social work critique, scholarship, and activism alive. (p. 27)

Though the challenges are significant, Dominelli (2002) retains an optimism, “as feminists con- tinue to envision a world in which people and the environment they live in matter” (p. 2). Finn and Sadye (2011) speak for many when they conclude that social workers

care deeply about feminism and its relevance for the transformative practice of social work. … Inspiration

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in new languages and practices of feminism and power in creating spaces for dialogue and reflection … appreciation of the complexity of feminisms; the rich and vibrant directions in which feminist practice is being pursued; the possibilities for bold and coura- geous action in teaching, research, and practice; and the need for communities of connection and support … commitments to feminist research, teaching, and practice … a collective desire to build community and translate our inspiration into action. (p. 348)

In 2014, Shulamith Koenig, recipient of the 2003 UN Prize in the Field of Human Rights, noted the direct relation between the atrocities experi- enced by females around the world and the lack of human rights:  “Human rights equal peace. Human rights are all about equality; equality is dignity. Patriarchy has put women down. To survive women should not have to exchange equality” (Koenig, 2013).

It is necessarily a struggle to eradicate the ideology of domination that permeates cultures on various levels and in varying ways, as well as a commitment to reorganizing society so that the self- development of people can take precedence over imperialism, economic expansion, and material desires. (hooks, 2000, p. 26)

It may be tiring, frustrating, disappoint- ing, discouraging, and even dangerous work. Abramovitz’s encouragement remains valid: “Take time to envision feminist solutions to the country’s woes and convert them to fair and humane social policies … we must organize for the long haul … without struggle there can be no change” (Abramovitz, 1996, p. 256).

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Moving Toward a Mega Theory

Turner (2011) proposed that, in the search for a “mega” or totally inclusive theory, one of the major goals was the need to increase our abil- ity to use our various theories differentially. He called for the development of the kind of pro- fessional clinical expertise and theoretical clar- ity that provides clinicians with guidelines “to match theory to clients and situations” rather than the reverse. Acknowledging how challeng- ing it is to compare and evaluate the usefulness of the plentiful and diverse possibilities availa- ble, Turner agrees with Corey (1995) when he further opines that what we need is to find a way to compare theories so we know where they are similar and in what ways they are different.

The Four Forces is an inclusive model that meets the above criteria. It offers a systematic

process for comparing the four major theories that have developed historically in Western psy- chology:  First Force, dynamic theory; Second Force, behavioral theory; Third Forces, expe- riential, humanistic, and existential theories; and Fourth Force, transpersonal theory. Several charts and theoretical guidelines have already been provided to facilitate the therapist’s choice of which of the multitude of psychological theories, models, and specific interventions will help provide the most theoretically based intervention to serve a specific client or situa- tion (Cowley, 1996). The Four Forces Model is inclusive enough that its broad umbrella will provide a home for most, if not all, of the theo- retical treatment approaches featured in Turner’s compendiums of social work treatments over the years.

The Four Forces: An Inclusive Model

Au- Deane Shepherd Cowley

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Seeking a Science of Consciousness

Robert Ornstein (1972) made the observation that psychology is and always has been pri- marily the science of consciousness. Bugental (1978), expanded on Ornstein’s definition by calling psychotherapy the art, science, and prac- tice of studying the nature of what may reduce or facilitate the development of consciousness. In Western psychologies, attempts to facili- tate the development of consciousness (or the increased structuralization of ego) were aug- mented by Freud’s insights. However, accord- ing to Bruno Bettelheim (Bettelheim, 1983), key concepts of Freud’s work have been mistrans- lated and therefore totally misunderstood. For instance, Freud wrote about a process of intro- spection called “soul making” through which an individual was called to an internal exploration of the self with the intention of bringing issues that were unconscious to conscious awareness. Freud never intended analysis of the psyche (soul) to be a process controlled by an external other who psychoanalyzed a person defined as a client. Additionally, the terms Freud used when he divided the structure of consciousness into a hierarchy with three levels still remain misrepre- sented. Freud wrote about the chaotic “it,” not id; the “I,” not ego; and the “above I” rather than the superego (Bettelheim, 1983).

Jung also called attention to the centrality of developing consciousness. Like Freud’s, Jung’s concept of consciousness was three- tiered. The bottom or most primitive level he called shadow, the middle level ego, and the highest level Self (with a capital S (Campbell, 1971). In like man- ner, Roberto Assagioli (1965), an Italian contem- porary of Freud’s, designated three levels in the structure of consciousness: lower consciousness, middle consciousness, and superconsciousness. In 1986, Ken Wilber delineated what he called “the major fulcrums of self- development” and

divided it as had his predecessors into three general levels: prepersonal, personal, and trans- personal (Wilber, Engler, & Brown, 1986, p. 120).

Although Freud, Jung, Assagioli, and Wilber all posited a level of consciousness beyond ego, only Wilber (1986) joined the psychologies of the East with Western versions and offered a full spectrum of consciousness rising out of an undifferentiated matrix to form nine gen- eral levels (or basic structures) of conscious- ness:  three prepersonal levels (sensoriphysical, phantasmic- emotional, and rep- mind); three personal levels (rule/ role, formal reflexive, and existential); and three transpersonal levels (psy- chic, subtle, and causal or non- dual). In his groundbreaking work, Wilber also described what pathologies are likely to develop at each fulcrum of the full spectrum of consciousness as well as which interventions are most suited for each of the nine levels of development along the continuum of consciousness.

The Development and Differential Role of the Four Forces

According to London (1974), therapy has always been “a reactive trade” whose theories and mod- els have operated as social indexes by evolving “to serve the social ills of the day.” As each of the Four Forces emerged out of its own unique place in history, each has offered distinctive perspec- tives about human growth and development, what constitutes health and pathology, what the primary concern or focus of the therapist should be, and what the role of the therapist should be. Various models and interventions that comple- ment each of the Four Forces were delineated by Cowley (1996) for use in transpersonal social work (see Table 12.2). A practitioner utilizing all of the resources of the Four Forces, along with Cowley’s (1996) multidimensional devel- opment assessment method (see Table 12.3), is prepared to treat specific issues at six different

Table 12.1 Three Levels of Consciousness

Freud Jung Assagioli Wilber

“Above I” (not superego) Self Superconsciousness Transpersonal level “I” (not ego) Ego Middle consciousness Personal level “It” (not id) Shadow Lower consciousness Prepersonal level

Cowley. A. (1993/September). Transpersonal social work: A theory for the 1990s. Social work, 38(5), 532.

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Table 12.2 Multi- Dimensional Development

Krueger (1989) (Physical Development)

Basch (1988) (Affective Dev.)

Ivey (1986) (Cognitive Dev.)

Erikson (1950) (Psycho- social Dev.)

Kohlberg (1981)/ Woolf (1984) (Moral Dev.)

Wilber(1986) (Spiritual Dev.)

6. Self- mastery Self- soothing Self- empathy

5. Attunement 6. Deconstruction: Paradox

8. Ego integration vs. despair Accrued strength = wisdom

(60 yr. +)

6. Universal mind Harmony

Congruence

9. Causal level 8. Subtle level 7. Psychic level

5. Dialectic: Thesis, antithesis, synthesis

4. Empathetic understanding beyond self- referential

7. Generativity vs. self- absorption Accrued strength = caring

(34 yr.– 60 yr.)

5. Principled Reciprocity “Spirit of the law” I AM

6. Existential

5. Self- as- a- whole Integration of “bodymind” (36 mo.– 6 yr.)

4. Formal: Identifying patterns

(12 yr.)

6. Intimacy vs. isolation Accrued strength = love

(22 yr.– 34 yr.)

5. Formal- reflexive

3. Concrete: Emphasis on objective

reality (7 yr.– 12 yr.)

5. Identity vs. identity diffusion Accrued strength = fidelity

(12 yr.– 22 yr.)

4. Law- oriented Cares about: Self, other, context “Letter of the law”

4. Rule/ role mind

3. Emotion Feeling states are joined with experience (24 mo.)

4. Industry vs. inferiority Accrued strength

= competence (6 yr.– 11 yr.)

3. Pleaser Cares about: Self and other

1. Body mind Mental representation of one’s body (18 mo.– 36 mo.)

2. Feeling sensations are abstracted, objectified (18 mo.– 24 mo.)

2. Preoperational: Magical, irrational,

ineffective thinking (2 yr.– 7 yr.)

3. Initiative vs. guilt Accrued strength

= purpose (4 yr.– 6 yr.)

3. Representational mind

3. Body self Physical boundaries (15 mo.– 18 mo.)

2. Autonomy vs. shame and doubt Accrued strength = will

(18 mo.– 4 yr.)

2. Self centered Cares about self

2. Phantasmic- emotional (Image mind)

2. Symbiotic (1 mo.– 15 mo.)

1. Undifferentiated (0– 1 mo.)

1. After Unconscious Automatic responses (0– 18 mo.)

1. Sensorimotor: Embedded in own sensory construction of the world (18 mo.– 24 mo.)

1. Trust vs. mistrust Accrued strength = hope (0– 18 mo.)

1. Premoral Doesn’t know how to care

1. Sensoriphysical Undifferentiated matrix

Numbering explanation: 1=Least developed developmental stage (bottom of chart) to 5- 9=Highest level of development in each multi- dimensional development model (top of chart).

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Table 12.3 The Four Forces

Theory Dynamic Behavioral Existential Humanistic Experimental

Transpersonal

FOCUS Pathology Dynamics/ past

Specific behaviors Specific symptoms

Awareness Experience Self- responsibility

Spiritual development

Self- transcendence LEVEL OF

INDIVIDUATION FOCUSED ON

“It” Prepersonal

“I” Personal

“I” Personal

Above “I” Transpersonal “Beyond ego”

VIEW OF PATHOLOGY

Unconscious conflicts Sexual repression Disorganization of ego Repetition compulsion Deficits

of development

Faulty learning Maladaptive

behavior Neurotic anxiety Negative patterns Irrational ideas

Alienation from feelings

Reduced potential Ennui Meaninglessness Lacking purpose

Spiritual malaise Dis- spiritation Morbid preservation Egoitis Dark night of the

soul VIEW OF HEALTH Ego over id

A personal self Firm ego boundaries Ability to love/ work

Symptoms controlled

Appropriate behavior

Self- management Anxieties in check

Self- actualized Authentic Purpose of life Open to goodness

Wholeness “Beyond” ego Accepting “what is” Transcender

CURATIVE PROCESS

Insight Long- term/ intense Interpretation Introspection Reveal unconscious Structure- building

Action Short- term/

structured Education Diagnostic tests Behavioral contracts Skills training

Eclectic Here- and- now focus Use of relationship Removing blocks Heart- to- heart Making meaning

Healing is “wholing” Meditation Integration Dis- identification Connecting to all Mystical experience

NATURE OF THE HELPING RELATIONSHIP

Vertical Medical model Interpretive Developmental

partnering

Vertical Education model Modeling Coaching Goal oriented

Horizontal Person- to- person Process oriented Phenomenological Remove blocks

to growth Facilitator

Reciprocal Servant/ co- voyager Mutuality Guide Midwife Evocateur

MODELS Drive psychology Ego psychology Object relations Self- psychology Jungian Adlerian Eriksonian

Behavior modification

CBT* RET* Reality therapy Task- centered

Case Work Redecision therapy

Humanistic Person- centered Experiential Gestalt Existential Logotherapy

Psychosynthesis Self- creation Holotropic Full spectrum Jungian Process- oriented Transpersonal Social

Work INTERVENTIONS

(SKILLS/ TECHNIQUES)

History taking L.S.I.G.* Early recollections Uncovering Free association Sentence stems Interpretation Use of transference Catharsis Analyses of dreams Freudian slips Working through Spitting in the soup Script analysis Ego- gram Ego- state analysis Play therapy Re- parenting Corrective experience

Anchoring Reinforcement Desensitization Behavioral contracts Shaping/

substitution Aversion therapy Perturbation Role- play Education Homework Bibliotherapy Skills training Self- monitoring Stress management Relaxation training Cognitive

restructuring Thought- stopping Positive self- talk Rehearsal

Therapeutic love Visualization Creative imagery Stream of awareness Experiential

exercises Being present Gestalting dreams Top- dog/

bottom- dog Empty- chair work Psychodrama Choreography Mind journeys Journaling Strength

bombardment De- repressing Clearing exercises Burning bowl Dereflection Philosophizing

Mediation Spiritual practice “I AM” affirmation Dream work Breath work Use of seed thoughts Listening within Detached observer Interpreting up Interpreting down Socratic dialogue Wisdom circles Community building Shamanic journey Study with guide Contemplation Path of the yogis Path of the saints Path of the sages

*CBT— Cognitive Behavorial Therapy; *RET— Rational Emotive Therapy; *L.S.I.G.— Life Style Interview Guide

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dimensions of being as well as the specific issues that present from the three general levels of consciousness: prepersonal, personal, or trans- personal. This kind of multimodal approach gets close to meeting Nelson’s (1994) insightful observation of what a therapeutic intervention should entail; that is, “only when people engage in treatment specific to their level of conscious- ness can they resume growth” (p. 375).

The First Force: Dynamic Theory

Freud’s theory grew out of an “age of repres- sion” as experienced by the traditional or inner- directed man (London, 1974). From the beginning, psychoanalysis was essentially a theory of intrapsychic functioning (Pine, 1985, p.  11). Dynamic theory began to take human behavior out of the realm of mystery. It also made it clear that unconscious drives and impulses were so powerful that, left undiscov- ered, they could sabotage consciously chosen goals. Even though Freud wrote about a process of intense introspection he called “soul making” (Bettelheim, 1983), the bulk of his work focused on pathology and the basement of human nature. For example, the index to Freud’s com- plete works cites over 400 references to “neu- rosis” and none to “health” (Walsh & Shapiro, 1983, p. 5).

Freud’s model of man as an organism seeking relief from tension, and society, leaves even the most suc- cessful negotiator in a position of impoverishment and is as pathological, in its own way, as any that can be found in the diagnostic manual. (Walsh & Shapiro, 1983, p. 38)

Historically, First Force theory has viewed ther- apy as a process whereby the patient replaced neurotic conflict by learning how to live with everyday unhappiness. According to Brown (1988), this view was essentially pessimistic.

Pine (1985) divided the evolution of First Force theory into three great Waves or models. Freud’s drive psychology was the first Wave. Ego psychology, with a view that focused on the ego, its development, and its functions, was the sec- ond. The third Wave, object relations, added key understandings about the importance of early relationships, the potentially serious effects of developmental deficits in early childhood, and

the role of defense mechanisms. Object rela- tions’ focus on the observation of child develop- ment and the progressive differentiation of self from other gave birth to a body of literature on self- esteem and self- psychology.

Generally speaking, all of the models of dynamic theory did a better job of theorizing about pathology and offering developmental explanations about how it came to be than they did in providing guidelines for specific clini- cal interventions. Having uncovered repressed psychological issues, many practitioners were left unsure about what to do about them. How could such mysterious unconscious forces ever be tamed? Another problem limited the use of this approach as time went on. Its concepts were not readily amenable to empirical research.

The Second Force: Behavioral Theory

Over time, criticism accumulated about the exclusive hold dynamic theory had on psycho- therapy prior to World War II. Its methods were too deterministic, expensive, and slow to suit the other- directed man in the “age of anxiety” (London, 1974). As society began to expect quick and mechanistic responses to life challenges, both clients and therapists became more interested in finding relief from specific symptoms than they were in a seemingly end- less search for insight into some unconscious, underlying “cause.” This led to a search for more practical and precise conceptualizations. Psychoanalytic premises related to repression weren’t a good fit for the symptoms of the day in a time characterized by free love, sexual revolu- tion, and value deficits (Schnall, 1981). As psy- chotherapy reacted to the need for more direct, action- oriented methods, Second Force (behav- ioral theory) came to the fore.

The behavioral approach sought to create empirical order out of phenomenological chaos. By focusing on the importance of social learn- ing and the process of socialization, it hoped to demonstrate that much of human behavior could be objectified, operationalized, tested, and shaped with proper reinforcement. Specificity and concreteness in understanding human behavior provided, not only concepts and inter- ventions that could be quantified, but also more

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predictable relief for specific behavioral symp- toms. Structural, strategic, and cognitive mod- els of behavioral theory delivered observable results. This more empirical focus brought con- fidence to the scientific- minded research/ prac- titioner in an age of accountability.

The Third Force:  Experiential, Humanistic, and Existential Theories

In the middle to late 1940s, again reflecting changes in the social context, the longing for a more holistic view of human possibilities and a more humanistic connection between the healer and the client called forth a new approach. Virginia Satir described it like this:

At the end of World War II, we all heaved a sigh of relief and had hope of building a more just world. The United Nations was a manifestation of that dream. These hopes were also translated into a new psycho- logical construct— the human potential movement. In 1946 we heard the voices of Abraham Maslow, Rollo May, Carl Rogers and others who believed that human beings are and can be more than what their behavior led us to believe. We set on a journey to find out what else there was to the human being that had not yet been discovered and assessed. (Satir, 1987, p. 60)

That journey of discovery emerged out of an “age of existential alienation” to serve psychologi- cal man in his efforts to combat ennui through embarking on a search for self- fulfillment (London, l974). It resulted in the development of three Third Force theories:

1. Experiential theory, to work with cli- ents who knew so much but felt so little, to bring back sensation, feeling, and the phenomenological;

2. Humanistic theory, to help individuals who felt isolated and bored to reconnect to life and become more fully human and self- actualized;

3. Existential theory, to deal with ultimate con- cerns and crises that occur when life loses its meaning and purpose.

Third Force theories dared to suggest that a per- son didn’t need to be sick in order to get bet- ter. According to London (1974), the idea of

undergoing a therapeutic process for the pur- pose of growth rather than cure represented a dramatic change in focus:

Until now, psychotherapy has been mainly reactive to feeling bad, that is to having symptoms. Now it is reacting to not feeling good— that is, to a faulty life- style…  . Men want to be healthy, wealthy and wise in that order. As each is gained, the next gets wanted more. (p. 68)

And so it was, as individuals in an affluent soci- ety became healthier, many of their contempo- rary ailments began to express in existential symptoms that required remedies that were more experiential and philosophical in nature.

The rise of Third Force psychology during the 1970s and 1980s reflected a culture- wide shift away from the Newtonian- Cartesian world- view. Nontraditional therapists began to move out of the mainstream of Western psychology to explore the contemplative practices and psy- chological traditions of the Far East. When they began to include alternative views and report data that were trans- rational and extrasen- sory, reactions from other professionals ran the gamut from horrified to celebratory. However, neither reaction altered the determination of Third Force pioneers to expand psychology to transcend the limits of the observable and the measurable (Grof, 1985).

Ultimately, it took the courage of an intellec- tual loner like Maslow (1968, 1971) to challenge mainstream psychological research to pursue the search for the farther reaches of human nature:

Abraham Maslow was convinced that the value- life of human beings is biologically rooted. There seemed to him to be a species- wide need (comparable to the need for basic food elements and vitamins) for what he called “B” (for being) values, e.g., truth, goodness, beauty, wholeness, justice, playfulness, meaningful- ness, etc. These values are biological necessities for avoiding illness and for achieving one’s full potential. The epidemic of spiritual illnesses (“metapathologies”) resulting from deprivation of these values include B values include; anomie, alienation, meaninglessness, loss of zest for life, hopelessness, boredom, and axi- ological depression. (Clinebell, l995, p. 92)

Maslow’s early work radically revised our pic- ture of the human species and created a vastly expanded map of human possibilities (Leonard,

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1983). In his later work, Maslow’s view of human potential continued to expand, and his explorations of human potential delineated three groups of optimally healthy people:  self- actualizers, transcenders, and transcending self- actualizers. Eventually, Maslow came to believe that even his definition of self- actualized tran- scenders was not expansive enough to encom- pass the highest levels of human potential:

Maslow has found that the self that was actualized could still be isolated in an alien world. Building on the theory of Erich Fromm (and resonating with Carl Jung and William James before him), Maslow pos- tulated that we long to transcend our aloneness and belong to the cosmos. Even when we have fulfilled every secular need, the hunger for transcendence is not satisfied. So it was a short step from actualiza- tion to transcendence and from plateau experiences to the “cosmic connection.” (Bradshaw, 1988, p. 228)

Maslow, who read extensively in Eastern litera- ture, is considered the philosophical father of both humanistic and transpersonal theories. Near the end of his life, Maslow was still seek- ing more. He made yet another call for a fourth psychology that would be “transpersonal, trans- human, centered in the cosmos rather than in human needs and interests, going beyond humanness, identity, self- actualization, and the like” (Wittine, 1987, p. 53).

The Fourth Force: Transpersonal Theory

By 1969, this “fourth psychology” had not only come into being, but had established some com- mon parameters. The professional Journal of Transpersonal Psychology was introduced, and in the forward of its first issue, Anthony Sutich made history when he defined the transper- sonal domain as “concerned specifically with ultimate values, unitive consciousness, peak experiences, ecstasy, mystical experience, awe, transcendence of the self, spirit, oneness, cos- mic awareness, and related concepts, experi- ences and activities.”

Transpersonal theory evolved out of a cul- tural context exacerbated by, not only an exis- tential vacuum, but a spiritual one as well. It arose to serve the dis- spirited man or woman in an age characterized by spiritual poverty and a lack of what Schnall (1981) called “limits”

or traditional values. In 1988, when Bradshaw described this pain as “a hole in the soul,” his words resonated with those whose suffering was spiritual in origin. In 1980, Goldberg labeled this postmodern crisis in consciousness “a mal- aise of the soul”: “In a word, we live in an era in which men find it onerous to accept responsibil- ity for their own actions and for the embittered and hollow course their existence has taken Much of our agony is in the soul” (p. l). In a post– 9- 11 world, much of our individual and societal pain is lodged in the moral and spiritual dimensions. Transpersonal theory is particularly suited to treat postmodern mala- dies characterized by economic insecurity, addiction, violence, and a religious extremism that can result in mass casualty terrorism. The most prominent presenting symptom of the day (often oversimplified as clinical depression) is a sense of demoralization or “dis- spiritation” (Bugental & Bugental, 1984). Hence, practitio- ners are increasingly being challenged by the people they serve to take their spiritual con- cerns, value conflicts, and existential angst (Park, 2000)  into account. Excellent resources to aid the social worker are readily available in the transpersonal literature.

Since each of The Four Forces has a different focus, view of pathology, and distinctive prem- ises about what constitutes health or pathology, the curative process, and the nature of the help- ing relationship, each practitioner must make at least four conceptual decisions when design- ing a person- in- situation specific multimodal intervention.

1. Which dimension(s) of self- development will be focused on initially? (The physi- cal dimension, the emotional dimension, the cognitive dimension, the psycho- social dimension, the moral dimension or the spiri- tual dimension?)

2. Which of the Four Force theories (dynamic, behavioral, experiential, humanistic, exis- tential or transpersonal) will best serve each dimension of self- development chosen?

3. Which model(s) will be the best fit with each theory selected?

4. Which clinical skills or interventions match or complement each theory and model being utilized?

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(See Figure  3 on multidimensional develop- ment, and Figure 2 on The Four Forces.)

What Relevance Does the Four Forces Model Have in a Post– 9- 11 World?

Life on planet Earth changed dramatically with the terror attacks events of 9- 11. Since then, an omnipresent threat of violence continues to take a toll on both individual and collec- tive consciousness. An individual cannot run a marathon, go shopping at a mall, ride a sub- way train, eat out at a cafe, etc., any place in the world, without dealing with feelings of uncer- tainty (Pema, 2013). “Death anxiety” (Yalom, 2008)  is often disguised by other symptoms or complaints, but it is no longer just a concern for the elderly. Other social ills of our day include economic uncertainty, loss of trust, cynicism, addictions of all kinds, and for many, a loss of traditional values that makes sure that children in our culture have little opportunity to experi- ence the innocence of childhood.

It would be difficult, if not impossible, to ascertain how events and changes in the larger systems in which we are all embedded affect our individual lives. For instance, researchers are even raising questions about the toll that social media may be taking on, not just interpersonal relationships, but the actual development of the human brain. The list of “new” challenges for practitioners could go on and on. The existen- tial angst (not just in America but around the world) is so palpable that one who is aware can almost taste it. Add to all this the ecological concerns that arise when everyone on the planet is told that climate change or other natural and unnatural factors may destroy our one and only planetary home.

All of the Four Forces will always have their own special domain and usefulness in helping individuals, groups, couples, and families solve the problems of living. This chapter is propos- ing that (particularly in the terror- filled world we live in today), Third and Fourth Forces have become especially relevant. The challenge to educators becomes answering questions like these: How many practitioners have been intro- duced to Third and Fourth Force theories and interventions? How frequently do those who

seek for answers in such complex and troubling times find the help and guidance that existen- tial and transpersonal theories offer? Third Force Theories are effective in helping those at the personal level of consciousness become self- actualized and fulfill their human potential as rational, caring human beings. Yet far too little is included in public education courses to explicate what such a mature person would look like. In a time when irrationality runs rampant and immaturity is modeled daily on television, where are our models for future generations of mature thinking and behavior? Do we as thera- pists know and articulate what the epitome of the maturation process looks like so individuals may aspire to become their best possible selves? Jean Houston called this providing “a lure to Being.” Harry and Bonaro Overstreet offered a classic description of the “gifts” that maturity can bring that merits a prominent place in every social work classroom and therapist’s office:

What are the gifts that maturity brings? It brings gifts of perspective; established purpose; sense of respon- sibility toward others; pride in good workmanship, and enough knowledge and disciplined skill to be able to deliver the goods. It brings also certain types of understanding that apparently do not become possible to a human being until he has coped with his share of unwanted experiences— of loss, disappoint- ment, failure, grief and come to terms with these. One chief gift of maturity, in brief, is that of seasoned judgment; judgment that does not confuse the taw- dry with the excellent, but which recognizes that the excellent is not always easy to come by. (Overstreet & Overstreet, 1956, p. 25)

Just as our society has too often failed to provide models of mature behaviors, it has also shied away from entering the domain of spiritual development. Even though many of our clients come seeking help with religious and spiritual issues, unless their therapist has been schooled in the Fourth Force or transpersonal theory, they may not have the necessary knowledge and skills to meet that challenge.

Assessing Religious Maturation

Ironically, some of the religious worldviews that have provided solace for many individuals and stability for nations throughout history have now become part of our “social ills of the day”— part

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of the problem instead of part of the answer. Mental health workers have even been called to intervene in situations where religious groups have been spiritually abusive to their members (Derezotes et al., 2008). Although unimaginable atrocities have been committed throughout his- tory in the name of religion, it has only been pos- sible in the technologically brilliant postmodern world for terrorists to instantly transmit pictures of the terrible deeds done in the name of religion worldwide to a horrified global audience.

As social workers and other professionals are called to intervene in the aftermath of traumatic, barbarous atrocities attributed to a distorted reli- gious worldview, it becomes increasingly clear that practitioners must develop a knowledge base broad, deep, and high enough to help dif- ferentiate between religions that are mature and authentic and those that remain “shallow, pseu- domystical rationalizations” that may generate or maintain psychological pathology in their members (Anthony, Ecker, & Wilber, 1987, p. 2). Clearly, the worker dealing with the person- in- situation today needs to understand as much about the client’s level of spiritual development as possible. It would be helpful to know how many schools of social work have integrated content on spiritual development into their curricula.

Fowler’s (1981) research on the “stages of faith” offers a non- threatening way to approach the topic of faith- based issues. A  discussion of how most people experience an evolution of understanding as they develop through a life- time can normalize the fears and/ or guilt that disturbs some individuals. As they begin to think as adults, some people may start to ques- tion what they have been taught as a child. It is helpful when workers are prepared to talk with them about Fowler’s research and the six levels of faith that he identified:

Level 0 begins at birth. It is described as primal and indifferent. Faith at Stage l is intuitive and projective in nature. Stage 2 faith has a mythic- literal quality. At stage 3, faith becomes more synthetic or conven- tional. Stage 4 is a level of individuated or reflective faith. Fowler called Stage 5 faith “conjunctive.” At stage 6 an individual has developed an inclusive or “universalizing” faith.

In a time when world peace has been torn asun- der by political differences and deeply held

religious and sectarian animosities, it may not be easy to make distinctions between the many different levels of spiritual development we are exposed to daily. The word “religion” comes from the Latin “religio,” which means “to tie back.” Whether religious values edify and lift its adherents to higher consciousness or keeps them fixated at levels unproductive for self, oth- ers, or the world at large is a question that needs to be asked and answered. According to Peck (1987), world peace will ultimately depend upon our ability to make such distinctions. Just as Peck has written that we all must learn to accept and celebrate diversity and the contributions of many different cultures, he has also cautioned that acceptance should not imply that all cul- tures and religions are equal in their levels of maturation.

Peck delineated four distinct stages of spiri- tual development:

Stage I.  Chaotic and antisocial:  Spiritual development at Stage l is basically an anti- life position. It includes “people of the lie” whom Peck described as individuals who behave in uncaring, unprincipled, self- serving, and manipulative ways (Peck, 1983). Unsocialized children. and perhaps one in five adults, fall into this lowest level of spiritual development. If Peck were writing today, he might have included in Stage I those who justify terrorist agendas in the name of religion.

Stage II. Formal and institutional:  At this more socialized stage of spiritual development, people are attached to the form, liturgy, or the- ology of their religious institution rather than to its spiritual essence. Because the letter of the law has provided a sense of order to their lives by liberating them from chaos, they feel threat- ened by the thought of change. The majority of orthodox churchgoers identify with this stage.

Stage III. Skeptic and individual:  People at Stage III are independent thinkers. Because they are active truth- seekers, those who are true believers may consider them to be nonbelievers. This level of spiritual development often includes people who are involved with social causes.

Stage IV. Mystic and communal:  At this highest level of spiritual development, instead of seeking security, one finds mystics who embrace the unknowable mysteries of life. Consequently,

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they do not fear the unknown or resist change. Operating out of the principles of an acceptance for diversity and a commitment to the unity of all life, they are inherently world- centric.

In order to help raise individual and col- lective consciousness to its highest spiritual potential, there must be some definition of how healthy spirituality would reveal itself. Consider this description offered by transpersonal thera- pist, educator, and author Frances Vaughan:

Healthy spirituality acknowledges both our human- ity and our divinity, inspires a reverence for life and enhances our capacity for love, peace, and joy. It affects experience in both the inner and the outer world and has far- reaching personal, social, and cul- tural implications…  . As a subjective experience of the sacred, authentic, healthy spirituality does not hinge on a particular concept of God or religious observance. It depends, rather, on how we relate to ourselves, to each other, to the earth, and to the cos- mos. (Vaughan, 1995, p. 51)

Promoting the ideal of a spiritually connected whole is not an easy or popular thing to do in a world that tends to demean and marginalize the mystical. Sometimes it seems as if too many peo- ple in our postmodern society must have suffered a collective lobotomy of the spirit, or what some have described as a “spiritual bypass.” Instead of venerating the most spiritually evolved among us, our scientifically oriented culture may treat them as if they were an embarrassment, or at least irrelevant (Cowley, 2014). However, there are some also promising signs that we are not headed away from spirit, but toward it.

Finding Darwin’s Lost Theory

Like Freud’s, Charles Darwin’s work and visionary view of human evolution have largely remained misunderstood. In his book Darwin’s Lost Theory, David Loye (2007, 2010)  tries to set the record straight. Instead of proposing the “survival of the fittest” with the “selfish gene” in control, Darwin wrote about love and moral sensitivity as the vital and prime drivers of human evolution. Darwin sought to correct the prevailing misconceptions of his book On the Origin of Species Through Natural Selection (1859) when he wrote The Descent of Man (1871). In The Descent of Man, Darwin described

his original vision about the human species. Darwin believed that the human being had “a desire for good, more compelling even, than our desire for self- preservation” (Loye, 2007, 2010. Commenting on Loye’s book, Mihaly Csikszentmihalyi (co- founder of the field of positive psychology) had this to say:

In times like these a new worldview often arises at the margins of power, at the periphery of the action unfolding on the main stage. David Loye’s central insight … is in my opinion right on the money… . The organizing principle of a new faith— a faith of human beings; about human beings is evolution itself. Not the traditionally taught evolutionary sce- nario determined by competition and selfishness, but an understanding closer to the original Darwinian one that sees cooperation and transcendence of the self as the most exciting parts of the story. (Loye, 2007, 2010, p. ii)

Many sages, saints, gurus, philosophers, and psychologists support the view that it is nature’s biological plan for the human species to have an unlimited potential. Self- transcendence, not a survival mentality, is our innate nature and our ultimate goal.

Spiral Dynamics and Macro Practice

In psychology’s quest to make the unconscious conscious, its “reactive stance” to the social ills of the day has served us well. With the develop- ment of the Four Forces model, we have theories, models, and interventions that help us move individuals up the “great chain of being” from the “chaotic it” to the prepersonal, personal, and even transpersonal levels where the tran- scendence of the little self becomes a possibility. Now, in a time when the human species (and even our planet) are perhaps more than ever before “in a race between self- discovery and self destruction” (Elgin, 1981), it is time for us to broaden our area of concern and research from the micro to the macro level, from a basically reactive stance to one that is more proactive.

In the fifth edition of Social Work Treatment: Interlocking Theoretical Approaches, Turner wrote that one of his major premises was that we should increase our efforts to use our various theories in a differential manner (2011, p. 576). “Spiral dynamics,” arising out of the work of

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Graves (l 970), popularized by Beck and Cowan (1995), and embraced by Wilber (2003), is a the- ory that may hold great promise for providing some of the answers to the person- in- situation in today’s world. In spiral dynamics, the evolu- tionary flow is “up” the ladder of consciousness from the level of mere survival toward the pos- sibility of self- transcendence. It describes the evolutionary journey taken by individuals or an entire culture. This journey spans eight different waves of existence in terms of a value orienta- tion. It is divided into two “tiers.”

I have made some alterations to the theory to adapt it for possible use by the social work profession. For example, colors were added to represent each of the eight levels, but I  elected not to use them. I  have also chosen not to uti- lize the word “memes,” generally used as a label for different value sets. The two tiers of spiral dynamics include:

Tier One

The lowest six waves of development in the spiral dynamics model have been designated “subsistence levels.” They are marked by “first- tier thinking.” This means that over 60% of the world’s population is estimated to operate out of what amounts to a survival mentality. In addition, each of the first six stages believe their worldview is not only the best one, but the only one anyone in the world should have. Thus, it follows that all six waves of development in Tier One are totally exclusive in their interactions with others.

1. Archaic- instinctual values:  Life lived at this beginning wave is an existence that basically relies on instincts and habits. The primary goal of life is just to survive, and it’s pretty much an “everyone for him/ herself ” way of living. Members of these primitive groups band together for safety and spend most of their energy searching for food, water, warmth, and sex. Wherever it is found, it is definitely a prepersonal state of consciousness.

2. Magical- animalistic values:  The world at wave two is viewed as a mysterious, magi- cal place where superstition and irrational- ity reign. Curses and spells, voodoo- like practices and blood- oaths abound. Such

tribal minds are most commonly found (but are not exclusive to) Third World settings. Anyone who has a tribal mentality only has one concern or loyalty, and that is to the tribe. Anyone outside the tribe is likely to be seen as an enemy and therefore dispensable.

3. Power gods: At the third wave, more distinct selves begin to rise above the masses. Using power and force, egocentric and exploitive values make it possible for those who seize power to provide protection to their under- lings in exchange for total obedience and labor. This value set is not just to be found in feudal lords and famous power gods like Attila the Hun, but anytime or anywhere the power- hungry exploit the weak or helpless to serve their egocentric goals.

4. Mythic traditional values:  Life at this wave of development has brought order out of chaos. A  strict view of what is right and what is wrong brings a sense of meaning, purpose, and direction to members who comply with a prescribed order of conduct that is absolutist in nature. Rewards and punishments are deter- mined by an all- powerful leader. This wave has been called “saintly/ absolutistic,” but it can also operate in a secular or atheistic setting.

5. Modern/ rational/ individualistic values: At wave five, the developing self begins to reject the values of the herd mentality and authori- tarianism of patriarchal/ matriarchal systems for a more rational and objective way of living and thinking. As a modern mindset prevails, the laws of science, politics, and the economy are more likely to be seen as resources that provide opportunities for personal, material- istic gain. Although individuals and organi- zations at this level utilize a more liberal value set, they are still most likely to be motivated by self- interest.

6. Postmodern/ pluralistic values: The last wave in Tier One is often referred to as “green.” At this wave, a sensitivity usually has developed that leads to a longing for human equality and human bonding. It often includes the capacity for a sense of ecological responsi- bility to the earth, or Gaia. Communities of like- minded individuals create networks to work together on projects that go beyond self to benefit pluralistic and equalitarian values. Communication styles emphasize the values

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of dialogue and the importance of building relationships. The sphere of concern and caring begins to show a greater proclivity to care for not just the self or one’s group, but for the whole. A shift of gigantic importance is coming into view.

Tier Two

In spiral dynamics, the quantum leap of growth that divides First Tier and Second Tier was described by Graves (1970) as “a momentous leap,” where “a chasm of unbelievable depth of meaning is crossed.” This value set is relatively rare. In a world population of 7.13 billion, it is estimated that 2%, or about 142.6  million, will achieve this leading edge of collective evolution; the transpersonal kind of consciousness that has the capacity to see and appreciate the entire spectrum of development. Those who reach Tier Two understand that each wave of the spec- trum of consciousness is vitally important to the whole. Since each wave transcends and includes all that came before, each (according to Wilber) is “instrumental in moving from relativism to holism, or from pluralism to integralism.”

The Two Major Waves in Tier Two

7. Integrative/ systematic values:  This wave’s highest priorities include flexibility, spon- taneity, and functionality. Knowledge and competence are also deeply valued. The few who operate at this level are so sensitive to the existence of different realities worldwide that they are able to move up and down the spiral dynamically within the global community. Their developmental capacity enables them to facilitate cooperation and mutual accep- tance between groups despite the complexity involved and the skill required.

8. Holistic/ universal- mindedness values: When an individual’s value set develops to this highest state, the potential for self- transcendence is a viable possibility. Wilber estimates 0.1% of the population will ever achieve this level. However, Tier Two individuals are exactly the kind of mor- ally mature leaders the human species is innately intended to be.

Spiral Dynamics and Macro Practice

Research on the spiral dynamics model forces us to ponder an old question: “To be— or not to be?” As human beings in the process of becom- ing, are we going to continue to devolve, or will we get back on an upward evolutionary course? It seems abundantly clear that the cul- ture in which one is embedded will either lift its members toward self- transcendence and a love of self, others, and the world, or it will act as a regressive force likely to produce members who have little time, interest, or opportunity to spend in self- improvement. A  Tier I  survival mentality doesn’t care about others who are just competitors in a life revolving around staying alive and destroying one’s enemies. Surely the human species is destined for more than this.

Pierce (2007) points out that there are many factors that can operate as a “negative field effect” and sabotage development. Consider the disadvantage of being born in a chaotic and unloving family or in a culture with a domi- nant value matrix that loves death more than it loves life. Pierce is not the only one to assert that “love is evolution’s raison d’ être.” Yet, there is so much that we need to learn in order to become loving that is what psychologists call “state- dependent.” We must have good models and positive educational encounters, as well as uplifting life experiences, in order to balance each stage of our development in a positive direction. To succeed, the individual’s thrust toward his/ her highest potential requires the support of a benevolent family, a healthy earth, and a social matrix with virtuous leaders. Each time an individual is able to give up toxic ideas for more healthy ones, to move beyond self- interest toward a reverence for all life, he or she is doing his or her bit to help raise the collective unconsciousness.

Man is not, as some current motivation theories would like to make us believe, basically concerned with gratifying needs, and satisfying drives and instincts, and by so doing, maintaining or restoring homeostasis, i.e., the inner equilibrium, a state with- out tensions. By virtue of the self- transcendent qual- ity of the human reality, man is basically concerned with reaching out beyond himself, be it toward a meaning, which he wants to fulfill, or toward another

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human being whom he lovingly encounters. In other words, self- transcendence manifests itself either by one’s serving a cause, or loving another person. (Frankl, 1977, p. 9)

The Four Forces can offer a fuller understanding of human potential, not only to our social work educational programs, but also to the lay public. Together with others who are concerned about the current quality of life in our postmodern world, we can build coalitions and play a more relevant part in combating the global challenges and social ills of our day, that, if left unchal- lenged, threaten to destroy us all. Experience has demonstrated that education is our best hope. What happened to the original idea of using public education to promote good citizens, and the intentional use of character education to help build a mature character? (Lickona, 1982). Why has political correctness prevented us from educating the moral and spiritual dimensions of our students? Where is the effort to promote the development of what Erikson (1950) called “virtues”? How many Americans know the char- acteristics of self- actualized people? Why have we not followed up on Rudolph Steiner’s idea that “the heart is not mainly a pump but also a major source of knowledge.” or Robert Wolff ’s studies on “the original wisdom of aboriginals” (Pierce, 207, p. 13). Just imagine what might be accomplished if we trained our innate intuitive gifts and educated not only the brain but also the heart. Ultimately, human beings change through evolution not revolution. We are already using and teaching so much less than we know, and we know so little compared to what we can glean from searching on the margins for hid- den treasures about human potential like Loye’s book, and models like spiral dynamics that offer so much to our understanding of how macro issues affect local lives. We need to initiate more research that continues the search for the farther reaches of human nature and look for more pre- cise answers to the question, “Who are we capa- ble of being?”

… we are basically good … we are driven by moral sensitivity. … We are also driven by love to tran- scend selfishness … though, of necessity fiercely motivated to survive and prevail, we are also driven by the transcendent need to respect and care for the needs of others. (Loye, 2007, p. 7)

It’s a moment of truth time for the planet Earth and all who love it. We need to discover how to lure more of the earth’s population “beyond ego” by helping them develop a capacity for car- ing about the needs of others. So many sages and philosophers have made it clear throughout human history that whether or not we reach our full potential depends on the level of our devel- opment in the moral and spiritual dimensions of being. Will we choose to continue to devolve, or will we achieve the individual and collective greatness that Nature intended? Ken Wilber (2003) posited that, even though each individual (and culture) starts at square one and less than 2% of the world’s population is at Tier Two of the Spiral Dynamics model in terms of develop- ment, “it is an elitism to which all are invited.”

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Functional Theory

An early, almost- forgotten theory developed by Otto Rank, this stresses personal growth and not determin- ism, and using agency structure with clients to define the focus, direction, content, and thrust of service

In a dramatic saga that is now mostly forgotten, early 20th- century social work leaders hotly argued over which practice method the profession should adopt. Most followed the medical profession and advocated the psychoanalytic principles developed by Sigmund Freud. A smaller group embraced the functional prin- ciples promulgated by German psychoanalyst Otto Rank. The emotional climate was so charged that at least one national convention was disrupted by shouting (Dr. Alan Keith- Lucas, personal communication, circa 1984). In the short run, the psychoanalytic school prevailed; however, the principles of functional social work have survived and now underpin many current methods of practice. Functional theories have had a dramatic impact on contemporary social work, yet most educators and practitioners have had limited exposure to the functional roots of modern methods. This chapter recapitulates the historical conditions from which the functional school emerged, explains its major tenets, reviews its applications, and examines the future of a once- powerful approach to social work practice.

The principles of functional theory were first developed by Otto Rank, a German psychoanalyst and erstwhile student of Sigmund Freud. Functional theory was subsequently adapted for social work practice by Jessie Taft and the faculty of School of Social Work at the University of Pennsylvania. Although only a few schools and agencies adopted this approach, functional methods were applied to individual, group, and community practice as well as to supervision, administration, research, and social work education, particu- larly on the east coast of the United States.

Functional Theory and Social Work Practice

Katherine M. Dunlap

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Historical Antecedents

Functional theory was incorporated into social work practice in the United States during the turbulent 1920s and 1930s, but its roots must be traced to three antecedents: the emergence of the field of psychiatry during the first decades of the 20th century; concomitant changes in sci- entific thought; and the influence of Otto Rank, a disciple of Freud in Germany before the First World War. The following sections summarize the contributions of Freud, review scientific changes, and explore the life and work of Rank.

Psychoanalytic Theory

Sigmund Freud revolutionized the study of human behavior by developing the first sys- tematic, scientific theory of personality. Today, Freud’s contributions are well known. When first proposed, however, psychoanalytic the- ory was considered radical and controver- sial. Freudian methods were initially rejected by some; however, this theory offered hope to others seeking effective treatment for troubled people.

Freud’s work was based on principles of scien- tific determinism. He and his disciples assumed that present behavior has meaning and can be understood through intense examination of past events. To garner meaning, they focused on the inner world of the self— thoughts, feelings, impulses, and fantasies.

Using case study methods, Freud and his fol- lowers engaged in a process of diagnosis. Their primary goal was to discover the cause of pres- ent difficulties. They assumed that by removing a cause, they could remove its symptoms, as in medical practice.

One of the keystones of Freud’s personality structure was the concept of the unconscious mind, which he claimed to have discovered

through his experiments in hypnosis and the study of dreams. To produce “unconscious” material without hypnosis, Freud proposed the technique he called “free association.” To elicit material, the analyst was instructed to maintain an attitude of dynamic passivity. Freud declared that these techniques would enable the analyst to uncover the underlying motives that prompt behavior. Tentative hypotheses were confirmed by interpretation, a process through which the analyst shared insights gained “through the careful weighing of evidence and critical com- parison” (Aptekar, 1955, p. 9). By analyzing the progress of people treated with these new meth- ods, Freud identified several patterns of predict- able responses, including resistance, blocking, and transference. The goal of psychoanalysis was understanding, not change. Freud main- tained that rational people who understood their motives could make necessary changes independently of the analyst.

Several of Freud’s theories have gained wide exposure, including the epigenetic process of psychosexual development; the organization of personality into three structures that together govern knowledge, emotion, and behavior; the creation and maintenance of defense mecha- nisms; and the presence of instinctive drives toward pleasure and death. As the following sections indicate, these theories were embraced by the diagnostic school of social work.

A Scientific Revolution

As Freudian theory reached maturity in the early decades of the 20th century, the entire arena of scientific thought experienced what Kuhn (1970) would call a “paradigm shift.” Drucker (1959) explained that there was a “phil- osophical shift from the Cartesian universe of mechanical cause to the new universe of

Functional social work is a therapeutic approach derived from psychoanalytic theory. Three charac- teristics differentiate functional social work from the Freudian or diagnostic school, which was the only other clearly formulated approach extant in the early 1920s (Smalley, 1971). First, functional theory was predicated on a psychology of growth, not determinism. To this end, the functional school replaced the concept of treating patients with that of helping clients. Second, functional theory assumed the structure of the agency defines the focus, direction, content, and duration of service. Third, functional theory stressed the concept of process, not diagnosis. Within the functional therapeutic relationship, the client and clini- cian work together to discover what can be done with the help that is offered.

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pattern, purpose, and process” (p. xi). Scientists abandoned the deterministic search for irre- versible causes as they faced the realization that the only thing predictable is unpredict- ability itself. Researchers in diverse fields began to explore the concept of growth as an orderly process with a universally recognizable pur- pose (Corner, 1944; Sinnott, 1950). Yelaja (1986) summarized four assumptions first articulated during this period:  (1)  the goal- directed whole of an organism transcends the sum of its parts; (2)  despite common patterns, each being is unique; (3)  the observer affects the observed; and (4)  will and freedom exist and impel indi- vidual growth. These presumptions had pro- found implications, particularly for theorists in the field of human services (Mead, 1936).

Innovations of Otto Rank

Freud was surrounded by an inquisitive, dedi- cated circle of disciples who worked with him to elaborate and refine “psychoanalytic the- ory,” as the new school of thought came to be called. One of the most dedicated and brilliant of this circle was Otto Rank, and it was Rank who devised the concepts that led to functional social work. Since Rank is less well known than Freud, his life and work are recapitulated here.

Otto Rank was born Otto Rosenfeld in 1884, the third child of an alcoholic jeweler. According to Rudnytsky (1991), the family was economically and emotionally deprived. Rank’s older brother Paul received academic training and a law degree, but Otto Rank was forced to attend trade school and work long hours in a machine shop. He still found time to attend the theater, and he read voraciously (Taft, 1958). Rank charted his own intellectual development in diaries and daybooks containing quotations, references, cryptic scribbles, personal notes, and theories. His ambition was to live fully and creatively (Lieberman, 1985).

When Rank was 21, Alfred Adler introduced him to Sigmund Freud. This was a dream come true for Rank (Rudnytsky, 1984). Freud read- ily accepted Rank into his circle of disciples, for Rank enriched the medical group with his discerning understanding of history and cul- ture. Freud brought Rank to the center of the group by making him secretary, and for many

years Rank prepared the minutes of the weekly meetings of the Vienna Psychoanalytic Society (Klein, 1981).

Recognizing Rank’s creative capacities, Freud helped him publish his first book, Der Künstler (The Artist), in 1907 (Rank, 1925). Freud also financed Rank’s studies at the University of Vienna, where Rank obtained his doctorate in 1912 for his dissertation on the Lohengrin leg- end. Rank was the first to employ psychoana- lytic methodology in a doctoral dissertation, and he was also the first in psychodynamic lit- erature to explore death symbolism and relate it to birth symbolism (Lieberman, 1985).

This was a period of great productivity for Rank. Under Freud’s guidance and with his support, Rank engaged in theoretical research, edited journals, wrote monographs, organized the psychoanalytic movement, and practiced lay analysis for two decades (Progoff, 1956). However, as psychoanalysis began to harden into a standardized procedure, Rank reassessed and rejected many of Freud’s notions and con- tinued to experiment with innovative ideas of his own (Karpf, 1953).

Rank was surprised by the storm of contro- versy generated by the publication of Trauma of Birth in 1924 (Rank, 1924). Although the book was dedicated to Freud, it posited new, innova- tive concepts and was not well received by Freud or his followers.

The criticisms of the Vienna circle were sharp and bitter. With his subsequent depar- ture for Paris, Rank dissociated himself from the official psychoanalytical group and contin- ued to formulate his own theory and approach. His physical move to the United States was fol- lowed by an emotional breach with Freud that was never repaired. What began as a theoreti- cal disagreement between colleagues grew into a vendetta that persisted for decades (Menaker, 1982). The two met for the last time in April of 1926 to say goodbye. Rank was 42 and Freud was nearing 70.

In Art and Artist (Rank, 1932), Rank explained his view of the human condition. Rank was not a feminist, but he respected wom- en’s freedom of choice, and he recognized the significant power in the mother– child bond (Sward, 1980– 81). Using the metaphor that “life is a loan, death the repayment,” Rank presented

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life as a series of separations beginning with a painful birth. He focused on the importance of living fully— with creativity, humor, and joy— in the limited time between beginnings and endings.

Rank believed that people oscillate between their need to merge with a larger entity and their desire for separation. To achieve a unique identity and live an abundant life, the individual must exercise personal will (Menaker, 1984).

The concept of will is elaborated in Will Therapy and Truth and Reality, written in 1928 (Rank, 1928) and 1929, respectively, and trans- lated by Jessie Taft into English in 1936 (Rank, 1936). Rank explains “will” as a complex, organizing element that delineates the total personality of the person, including creative ideas, feelings, and the energy of action. Will arises from “counter- will,” or the oppositional stance of “not wanting to,” a condition readily observed in young children. Rank maintains that people appropriately use will to adapt situ- ations to their own unique needs. The situation may be external, as in an unhappy childhood, or internal, as in a counterproductive attitude. Regardless, individuation is achieved through active acceptance and adjustment.

As an analyst, Rank viewed each therapeutic hour as a microcosm of life, a time with its own beginning and end. In his therapy sessions, he emphasized the present, rather than the past or future. He encouraged patients to “expe- rience” rather than to analyze the thoughts, feelings, and behaviors arising from the thera- peutic process. He focused on recurring inter- actions and patterns instead of isolated events (Taft, 1958).

Rank is perhaps most famous for setting time limits. He used this strategy to help cli- ents crystallize their conflicts regarding con- tinuation or termination of therapy. Within this context, the conscious use of will becomes a therapeutic agent. For example, Rank noted that people must consciously choose to accept a course of action, even if there appears to be no other choice. By making ambivalence explicit, Rank enabled clients to mobilize their will. In the preface to his last book, Beyond Psychology (Rank, 1941), Rank explains, “Man is born beyond psychology and he dies beyond it but he

can live beyond it only through vital experience of his own” (p. 16).

Relationship is the determining element in this therapeutic process. Rank rejected the stance of dynamic passivity. For him, the help- ing relationship is marked by mutuality, as in teaching and learning, but not by reciprocity, as in friendship. The therapist first establishes a setting in which the client can discover and use the strength that arises from vulnerability. Then the therapist becomes the tool that enables the client to explore and expand the will. Finally, the therapist precipitates termination by setting limits so that the client can achieve autonomy and avoid dependency.

Rank saw psychotherapy as an art as well as a science. Since every person is different, every therapeutic encounter will be different. The therapeutic alliance is characterized by sponta- neity and creativity, for the analyst must fabri- cate conditions for growth in every session. It is this intense emotional process that produces change.

Rank frequently lectured in the United States. Although he scrupulously guarded the identity of his clients, it is known now that he worked with many famous individuals, including Henry Miller and Anaїs Nin. He led courses at the University of Pennsylvania School of Social Work, the New York School of Social Work, and the Graduate School for Jewish Social Work (Lieberman, 1985). Until his untimely death in 1939 at age 56, Rank continued to develop and revise his theories about the human condition.

Although he has had a major impact on the development of personality theory and psychotherapy, Rank’s list of publications is not large, and his material is not widely read. There are several reasons for this. First, not all of his books are available in any one language. Some, originally written in German, have not been translated into English; others, written in English, have not been translated into German. Second, Rank’s complex, Germanic style has made translation difficult. Third, his lack of pre- cision has frustrated many scholars.

The Emergence of Two Schools

In the field of psychology, the two great poles during the 1920s were psychoanalysis and

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behaviorism (Lieberman, 1985). In the field of social work, the primary focus was also on the internal problems of the individual (Kadushin, 1959), and there was relative indifference to behaviorism, social problems, or social reform (Meyer, 1970). Instead, the profession became deeply committed to the medical model, which in turn embraced psychoanalytic theory. The pace toward professionalism accelerated as the two factions, labeled the “diagnostic” and “functional” schools, endorsed and adapted psychoanalytic methods.

The Diagnostic School

Like the young Otto Rank, most social work- ers in the United States were enamored of the theories of Sigmund Freud. As the new theory swept through the profession, a major branch absorbed Freudian methods (Hollis, 1970). This group, first called the “diagnostic” and later the “psychosocial” school of social work, found in Freudian theory “the first great opportunity in history to break through to an understanding of the hitherto hidden mysteries” (Barlett & Saunders, 1970).

The diagnostic school evolved and expanded (Hollis & Woods, 1981), but in its early forms, diagnostic social work was based on scientific determinism, or the assumption that people are products of their past. The emphasis was on the past, for proponents maintained that only an understanding and acceptance of previous experiences can bring relief. The goal of treat- ment was to overcome blocks to normal, healthy functioning by bringing unconscious thoughts to mind (Hamilton, 1937a, 1937b). Research was conducted through the meticulous analysis of case materials (Hollis, 1939).

This approach assigned well- defined roles to social workers and clients. The client was pre- sumed to be psychologically ill and in need of services. It was the worker’s responsibility to collect information through the social history, to diagnosis the illness, and to provide treat- ment. Usually the presenting problem was viewed as a symptom of a deeper, all- pervading psychological problem (Hamilton, 1936).

The worker treated the client over an indefi- nite period of time, assuming sole responsibil- ity for the goals and direction of treatment.

As Hamilton (1937) explains, “Not everyone is equally capable of self- help, and the amount we must do for people is directly inverse to what they can do for themselves” (p. 171).

To avoid countertransference, the worker operated from a stance of dynamic passivity. The client was encouraged to expose deep- seated emotions that the worker subsequently interpreted. Hamilton (1940) explained that the effect of past influences was irreversible, so that the goal of treatment was not change, but adjustment or mitigation of “the crippling effects of deprivations or pathological expo- sures” (p.  168). She added, “Case work is less often able to free its clients than to help them live within their disabilities through social compensations” (p. 168).

Treatment rarely reached the termination stage in those early days. Hamilton (1940) recalled,

When social studies were being worked out, case workers carried on so much investigation that they scarcely got around to treatment. In the twenties, case workers became so interested in the psychoge- netic causes of difficulty that long histories were a major activity and often the treatment did not prog- ress, stagnating in a dead center of diagnosis. (p. 141)

The Great Schism

For many years, the diagnostic and functional schools competed for supremacy (Hamilton, 1941). Each group defended its stance with evangelistic fervor, for each believed it had found the way to end psychic pain and mental illness. The polemic was public and painful, and the subject of casework became a contentious one for social workers and others. (Kasius, 1950; Murphy, 1933).

In trying to integrate the two disparate schools of thought, Aptekar (1955) prepared a comparison of the primary tenets of each:

Summing up, we might say that the chief conceptions of Freud which have been taken over and widely used by caseworkers as follows:

1. Unconscious mind as a determinant of behavior.

2. Ambivalence in feeling and attitude. 3. Past experience as a determinant of present

behavior.

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4. The transference as essential to therapy. 5. Resistance as a factor to be dealt with in all

helping.

The chief conceptions of Rankian thinking, taken over by the functional school and substi- tuted for the above, are:

• The will as an organizing force in personality. • The counter- will as a manifestation of the

need of the individual to differentiate himself. • Present experience as a source of therapeutic

development. • The significance of separation. • The inherent creativity of man. (p. 35)

The principles and presuppositions of func- tional social work are explored more fully in the following sections.

Path into Social Work

While the majority of social workers espoused Freudian theory, a small group adopted the approach of Otto Rank. Led by Jessie Taft and the faculty of the School of Social Work at the University of Pennsylvania, this group came to be called the Rankians or “functionalists,” a term coined by Taft to describe the controls imposed by agency parameters. (The term “functional” in this context bears no relation- ship to the same term used in sociology.)

A child psychologist by training, Taft attained her doctorate from the University of Chicago in 1913. At the time she met Rank, she was a supervisor of the Foster Home Department of the Children’s Aid Society of Pennsylvania. Their first contact occurred on June 3, 1924, at a meeting of the American Psychoanalytical Association where Rank discussed the ideas contained in The Trauma of Birth. Two years and many letters later, Taft began analysis with Rank in New York City (Robinson, 1962).

At first, Taft was ignorant of Rank’s feud with Freud, but it was not long before she real- ized that she would have to “face Freudian dif- ference, painful as it was, not merely through Rank but in my own thinking, reading, and use of the therapeutic relationship” (Robinson, 1962, p.  126). Taft immersed herself in Rank’s philosophy and methods as she translated Will

Therapy and Truth and Reality (1936). In addi- tion to her agency employment, she concen- trated on her psychoanalytic practice, studied the new theories, supervised others, and taught at the University of Pennsylvania School of Social Work. It was through these activities that Taft introduced the ideas of Otto Rank to social work.

Evolution of Functional Theory

Rank was a catalyst. After his break with the established psychoanalytic community, he lectured at the University of Pennsylvania School of Social Work, but he never related his theory to the profession of social work. In his later years, he did not even recognize the term “functional” (Smalley, 1971). The evolution of Rankian theory into functional social work was fostered by others.

Virginia Robinson was one of its leaders. A  lifelong colleague and companion of Taft, Robinson participated in therapy with Rank in 1927. At the time, Robinson was head of the casework department at the University of Pennsylvania School of Social Work. She was impressed by her brief experience with analysis. Like Taft, she adopted and applied Rank’s ideas.

Colleagues of Taft and Robinson, and those who followed them— including Aptekar, Dawley, de Schweinitz, Faatz, Gilpin- Wells, Hofstein, Lewis, Phillips, Pray, Smalley, and Wessel— elaborated and expanded Rankian concepts into functional social work (Smalley, 1970). Taft (1937) added the pivotal concepts regarding agency function.

While functional theory was predicated on Rankian philosophy, it also incorporates mate- rial from George Herbert Mead, W. I. Thomas, James Tufts, and John Dewey— masters whom Taft and Robinson had encountered in Chicago (Robinson, 1978). Functionalism accepted the scientific changes of the time and embraced the proposition elucidated by Corner (1944) and Sinnott (1950), to wit:  “human growth expresses purpose and constitutes a process” (Smalley, 1971, p. 86).

The functionalists read widely in diverse fields, including philosophy, education, sci- ence, art, and literature, as a cursory perusal of the Journal of the Otto Rank Society attests.

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As Smalley (1967) reports, many assumptions were imported from psychology. From Gordon Allport (1955) came the confirmation that peo- ple have autonomy, the ability to reason, and the capacity to make choices in a free society. Kurt Lewin (1935) added an understanding of the dynamic nature of change and the impor- tance of environment and context. Erik Erikson (1940) contributed his early notions predicat- ing an epigenetic unfolding of the human life cycle replete with psychosocial crises, or chal- lenges, and opportunities for revitalization. Helen Merrel Lynd (1961) posited a psychology of abundance to replace what she saw as the psy- chology of economic scarcity.

In addition, Maslow (1937) delineated the concept of self- actualization, and Karen Horney (1939) portrayed anxiety and inner strivings as the positive sign of a continuously maturing individual. Moustakas summarized the contributions of Lecky, Angyl, Goldstein, Rank, and others in The Self:  Explorations in Personal Growth (1956). All of these theorists were expanding on the same themes: the capac- ity for positive growth and change, the unique- ness of the individual, and the ability of people to shape their own destinies.

Basic Assumptions of the Functional School

Increasingly dissatisfied with the restrictive, pessimistic Freudian view of people, the early functionalists eagerly endorsed the proposition that people are purposeful, change- oriented masters of their own fate. Biological and envi- ronmental forces were not ignored in Rankian thought, but these were relegated to a secondary position.

Optimistic Underpinnings Robinson’s milestone work, A Changing Psychology in Social Casework (1930), intro- duced Rankian philosophy to the broader social work community. Robinson presents a posi- tive and hopeful view of individuals’ creatively using inner and outer experiences and resources to determine their own lives. The functionalists replace the psychology of illness with a belief in human growth, and they replace the obligation to treat with a mandate to serve (Lewis, 1966).

Ruth Elizabeth Smalley (1971), dean of the School of Social Work at the University of Pennsylvania, summarized the optimistic underpinnings of the functional approach:

The functional school sees the push toward life, health, and fulfillment as primary in human beings, and the human as capable throughout his life of modifying both himself and his environment, in accordance with his own changing purposes with the limitations and opportunities of his own capac- ity and his own environment. (p. 90)

The individual is the “central, active figure” in the process (Faatz, 1953, p. 47). Functional case- workers embraced the view that basic human nature is inherently good. Consequently, in a move considered revolutionary, they aban- doned “ judgmental standards of approval or condemnation of behavior” (Faatz, 1953, p. 22). Caseworkers presumed that change was not only possible, but inevitable, since each indi- vidual is endowed with an innate push toward psychological growth and a fuller, more inte- grated self. As Smalley (1960) suggests, the view sees people “as not only responsible for [their] own future evolution but capable of it” (p. 107).

Role of Will The primary tenet of functional theory is Rank’s revolutionary concept of will and self- determination. This new concept established the foundation on which all else rests. As Taft (1932) explained:

The anxious parent, the angry school teacher, the despairing wife or husband must bear their own bur- dens, solve their own problems. I can help them only in and for themselves, if they are able to use me. I can- not perform a magic on the bad child, the inattentive pupil, the faithless partner, because they want him made over in their own terms… . Here is a beloved child to be saved, a family unity to be preserved, an important teacher to be enlightened. Before all these problems in which one’s reputation, one’s pleasure in utilizing professional skill, as well as one’s real feeling for the person in distress are perhaps pain- fully involved, one must accept one’s final limitation and the right of the other— perhaps his necessity— to refuse help or to take help in his own terms, not as therapist, friends, or society might choose. My knowledge and my skill avail nothing unless they are accepted and used by the other. (p. 369)

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Caseworkers realize that even when change is wanted, it comes with a price— the sacrifice of certainty and security. Accordingly, functional- ists understand that people resist change even as they reach for growth. As Taft (1950) explains, “Only at points of growth crisis, where the pres- sure for further development becomes strong enough to overcome the fear of change and dis- ruption, is the ordinary individual brought to the necessity of enlarging his hard- won integra- tion” (p. 5).

The Value Base of Functionalism As the preceding quotation illustrates, case- work implies a collateral relationship marked by mutuality. Furthermore, functionalists main- tain that one person cannot change another, for the other is also endowed with will. Early writ- ers did not specifically address issues related to sociocultural or ethnic sensitivity; they consid- ered each person as a unique human being with distinct needs and particular gifts to contribute to the casework experience.

Putsch (1966), recounting her participa- tion in the civil rights movement in Georgia, affirmed this philosophy. Her agency had worked hard to develop an atmosphere in which people of many different colors and convictions could work out a more satisfying way of living together. Putsch reflected, “As I  had learned from my own experience, when we know too surely what is right we are impatient of differ- ence and miss the opportunity for attaining full understanding through considering different viewpoints” (p. 95).

Significant others and environmental pres- sures and resources are considered from Lewin’s (1951) perspective; that is, they are elements in the topography of an individual’s life space. They are part of the problem if they inhibit growth, and they are part of the solution if they allow or promote change. Although the func- tionalists accepted the common premise that people are subject to the physical laws of nature, their belief in growth suggests that a harmony with nature is possible and desirable. People were encouraged to use natural resources, but individual responsibility was stressed.

The functionalists always focus on the pres- ent time, and this “now” orientation is a hall- mark of the functional theory. The past is

explored only to the extent that it impinges on current concerns. The future is projected only as a guide for present activities. Aware that the future is always uncertain, caseworkers help people learn to live in the present, making the best of themselves with the resources that are currently available.

The overarching goal of casework is the exer- cise of free will moderated by responsibility; however, functional caseworkers never specu- late on the type of change anticipated or desired, for setting goals is considered the prerogative of the client. The role of the caseworker is to help the client obtain and use whatever tools are needed to forge the future. Recognizing the limitations inherent in the situation, only the client can determine what that future can and should be.

Major Concepts of Functional Social Work Practice

Smalley (1971) summarized three basic assump- tions that, when combined with the concept of self- determination, describe functional social work practice. These three concepts, para- phrased below, were derived from Rankian methods, but they have been modified and expanded. They are applicable in private and public settings, with individuals, families, and communities.

Understanding the Nature of Humanity The functional group works from a psychology of growth, which occurs in the context of rela- tionship. The impetus for change lies with the client, not the worker. Taking social and cul- tural factors into account, the worker helps cli- ents release their own potential for choice and growth through the power of the relationship. The functionalists use the term “helping” rather than “treatment” to describe this method.

Understanding the Purpose of Social Casework The agency gives focus, direction, and con- tent to the worker’s practice. By so doing, the agency protects both the worker and the client. Casework is not a form of psychosocial treat- ment; it is a method for administering a specific social service.

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Understanding the Concept of Process in Social Casework Casework is a helping process through which agency services are made available. Workers take the lead in initiating, sustaining, and ter- minating the process; however, they enter the relationship without classifying the client, prescribing a particular treatment, or assum- ing responsibility for an anticipated outcome. Together, the work and client discover what can be done with the help offered (Smalley, 1971, pp. 79– 81).

Treatment Through Functional Social Work Methods

Functional social work is an insight- oriented therapy. Although its primary method is collo- quy, proponents focus on the casework relation- ship, which offers an opportunity to reject old patterns in favor of new approaches that pro- mote growth. In addition to the basic presup- positions listed above, Smalley (1967) captures the mature tenets of the functional school in the five generic principles, paraphrased here:

Diagnosis should be related to the use of agency services. It should be developed jointly, mod- ified as needed, and shared with the client.

Time in the social work process— beginnings, middles, and endings— should be fully exploited for the use of the client.

Agency function gives focus, content, and direction to social work processes, ensures accountability by society, and engages the client in the process characterized by par- tialization, concreteness, and differentiation.

Conscious use of structure furthers the effective- ness of social work processes by using a myr- iad of elements such as application forms, agency policy, and the physical setting to define and delimit service.

All effective social work processes take place within relationship. The purpose of the rela- tionship is to help clients make propitious choices.

Functional therapy flows directly from these key tenets. Because they are vital to the helping process, each is described and examined here in greater detail.

Diagnosis Functionalists eschew diagnosis as an objective of data collection (Austin, 1938). Diagnosis is considered important only when naming a con- dition helps a client modify it. In the same vein, history is important only as it encroaches on the present, and early childhood experiences are analyzed only when the client and caseworker agree that they may be contributing to the cur- rent difficulty. The assessment process is a joint endeavor (Dawley, 1937), and it constitutes the first phase of therapy.

Relationship and the Process of Change Instead of focusing on diagnosis, the func- tionalists stress relationship and the process of change. These two are considered to be insepa- rable, for all change takes place within the con- text of relationship. The act of giving and taking help is a dynamic process that occurs over time (Hofstein, 1964). Furthermore, the process is “never static, never finished, always chiefly sig- nificant for its inner quality and movement, for its meaning to those it engages, rather than for its form or status or outcome at any instance of time” (Pray, 1949, p. 238).

Since every human being is unique, each person develops a distinct pattern for han- dling critical experiences. The pattern is initi- ated during the first separation, or beginning, which Rank called the birth trauma; it is rein- forced through subsequent opportunities for change. The nature of the relationship with others determines whether an experience will produce or limit growth. For example, when early relationships with the mother are positive and constructive, the will learns to accept the inevitability of separation and to adapt to the limitations of reality. If early experiences with the mother are negative or destructive, the will develops a pattern of refusing to accept separa- tion. This usually results in repeated and futile attempts to complete the self through the other person in the relationship.

To the functionalists, the concepts of will, counter- will, and resistance are not only inevi- table but also necessary for “movement,” a functional term connoting change or growth. Conflict is considered inherent in human growth as individual wants and needs clash with the wants and needs of other people and with

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society. The counter- will, or negative aspect of will, opposes the will of others and resists real- ity as presented by society. The counter- will car- ries with it a connotation of guilt. Resistance, a natural attempt to maintain the self, is inevi- table in the beginning of the casework relation- ship. Resistance is not seen as a problem or deficit; rather, it is considered a sign of strength indispensable to new growth.

The term “transference” is rarely used in functional literature. Taft (1933/ 1962) explains, “Transference, like resistance, is accepted for what it is, a stage in the growth process, in tak- ing over of the own will into the self ” (p.  97). Caseworkers assume that clients want to make themselves known, and the only way they can do this is to project their desires, fears, and conflicts onto the worker (Robinson, 1942). A  competent worker must be sensitive enough to identify with these projections without get- ting lost in them (Aptekar, 1941). Throughout the course of therapy, the caseworker estab- lishes and maintains sufficient separateness from the client so that neither confuses the self with the other. The worker’s identification with agency function helps preserve this necessary separation.

Regardless of how negative previous expe- riences may have been, people have an oppor- tunity to embrace growth and attain potential through the casework relationship. The thera- peutic process consists of a beginning, a mid- dle, and an ending phase. From the beginning, the caseworker displays a consistent attitude of respect and an unwavering belief that clients can change. The worker also creates an atmosphere in which clients feel safe and free to be them- selves. The worker presents both reality and acceptance, creating for the client a “situation so safe, so reassuring that none of his defenses is needed and, therefore, fall away, leaving his underlying fears, loves and jealousies free to express themselves” (Robinson, 1962, p. 113).

During the middle phase of therapy, move- ment occurs as clients take increasing respon- sibility for their own actions. Caseworkers offer something new— either a new view of the situation or a new grip on it (Lewis, 1966), and relationships deepen as caseworkers continue to build on client strengths. Clients practice new behaviors with the caseworker and through this

rehearsal gain a heightened sense of accom- plishment and power.

Endings are both feared and welcomed, for they embody both the emptiness of loss and the pride of accomplishment. During termination, the client and therapist recapitulate goals, assess movement, and summarize gains. When ther- apy has been successful, endings signal a rebirth of the client, now armed with courage, confi- dence, and a capacity for other healthy unions. Yet, termination also signals the end of the pow- erful alliance that gave the client this new life. Thus, the ending is marked by sadness and joy, emptiness and fullness, security and challenge.

Some terminations are established by agency function, as when a patient leaves the hospital. More often, however, endings are introduced by the caseworker to help the client consolidate gains and move along independently. The tech- nique of setting time limits is another hallmark of the functional approach.

Use of Time Time is a critical element in functional case- work, for it is the only medium through which help can be offered and received. Faatz (1953), who has written extensively about the nature of choice in casework, emphasizes the importance of the immediate present— the here and now— as the only setting in which change can actually occur. In this, Faatz anticipates systems theory, noting that emotions and events experienced during the therapeutic hour can influence and change the remainder of a client’s life.

As Taft (1932) wrote, “Time represents more vividly than any other category the necessity of accepting limitation as well as the inability to do so, and symbolizes therefore the whole problem of living” (p.  375). Taft elaborated on this precept with examples from therapy. She explained that the person who arrives very early bears responsibility for self and other, while the person who arrives very late is abdicating responsibility. By addressing these problems in the therapeutic hour, the therapist enables the client to live that one hour fully and thus con- quer the secret of all hours.

There is no predetermined or ideal dura- tion of treatment. For some people, a few ses- sions may suffice, while for others, therapy may continue for an extended period of time.

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Functional therapists frequently establish time limits in order to facilitate movement, a tech- nique that has been misunderstood. Time lim- its may be derived from natural time periods, such as a school year or a season. The limits may be recommended by agency function, or they may evolve from therapeutic needs. Regardless of the origin, appropriate limits are never rigid or arbitrary; instead, they are derived from the situation. Appropriate time limits become an incentive to use the present productively and wisely.

Agency Function and the Conscious Use of Structure The concept that may be the most relevant to social work involves the use of agency function and structure in the helping process. It was Taft (1937), not Rank, who first identified the impor- tance of agency function. Taft viewed therapy as too unreal and public relief as too real. The concept of agency function enabled early case- workers to find a productive place “between pure therapy and public therapy” (p.  11). Taft’s introduction of agency function as the unifying theme in social work practice gave functional social work its moniker.

The principle is simple:  the creative, posi- tive acceptance of agency parameters can have significant philosophical and psychological benefits for both caseworker and client (Taft, 1937). In the conscious decision to work within the parameters of a specific agency, the worker accepts a circumscribed area of service. The caseworker’s responsibility is mediated by what the agency can and cannot do. Worker attitude is important. The caseworker must not sink into resignation, chafe publically at limitations, revolt, or secretly resolve to overlook rules. When caseworkers recognize, accept, and use limitations, agency function becomes one of their most valuable tools.

Agency function is also a valuable tool for clients. When clients choose to accept agency limitations, they identify with the social pur- pose of the agency. Personal risk is minimized, for clients need not submit to an entire person- ality reconstruction. Rather, they can ask with help with specific concerns and know that their request will be respected. Through the case- work relationship, clients learn to use limits to

deal responsibility with reality in the pursuit of personal goals.

The structure and forms of service arise from the function of the agency. Agency policy is the primary authority that determines all other forms and structures. As we have seen, time is used deliberately. All forms and structures are consciously designed for the maximum effec- tiveness of all social work processes. Every item— from intake procedures, application forms, and assessment to termination rituals— is planned (Bellet, 1938). Even the setting— the structure of place— is considered important in defining and delimiting agency function. Because change is constant, forms and struc- tures are reassessed regularly to ensure congru- ence with intent.

The relationship between freedom of choice and agency function is clear when a client vol- untarily applies for service and then freely chooses to accept or reject the help that is offered. This relationship is less clear when the client participation is involuntary. Pray (1949), whose experience was primarily in the field of corrections, has written extensively about this apparent dilemma, and he argues that freedom and authority are not mutually exclusive. Pray identifies two conditions essential for success in an authoritarian setting. First, the authority must reflect the will of society, not the will of an individual. Second, within the setting, the cap- tive client must be free to reject the service that is offered. Only by being free to reject can a cli- ent be free to accept and find fulfillment within the bounds (Yelaja, 1971).

Principal Applications of Functional Social Work

Functional methods were initially limited to work with individuals. In fact, when the University of Pennsylvania School of Social Work hired its first group worker, Helen Phillips, in the 1940s, the two areas were kept entirely separate (Robinson, 1960). Over time, their similarities became more apparent than their differences (Phillips, 1957). After World War II, the number of opportunities for group work expanded dramatically (Eisen, 1960).

In her definitive summary, Smalley (1967) indicated that functional methods are effective

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with many types of groups and a wide variety of problems. Smalley cited case materials from a leisure- time group of adult women being served by a Jewish community center and from a ther- apy group of chronically mentally ill men in a psychiatric hospital. Although she acknowl- edged that specific knowledge and skill are required in these applications, she combined these dissimilar examples with case notes from a community organization to illustrate the five generic principles previously described.

Eisen (1960) reiterated the commonalities between group work and casework, adding that the group worker must also possess, not only special knowledge about the impact of the group process on individuals, but also special skill in using group interaction. Eisen under- scored the range of services that can be pro- vided in functional groups, listing four types of groups that might be formed in an inpatient unit for the chronically mentally ill. These are special- purpose groups, such as an orientation for new patients; a unit group for patient gov- ernance; peer groups for support and leisure activities; and community- focused programs.

The power in the group or community is essentially the same as the power in the indi- vidual (Smalley, 1967). Each is in process, striv- ing toward self- fulfillment or purpose. Whether the goal is personal adjustment or social agita- tion, the worker facilitates the process through a helping relationship that is clearly delimited by agency controls. As Eisen (1960) explained, “Our service should be geared to helping patients overcome their disabilities, enhanc- ing their capacity for group and self- direction. Toward this end, the group process becomes an individual experience” (p. 114).

The earliest writings acknowledge the importance of families (Taft, 1930) and address parent– child interactions, especially as related to abuse, neglect, and incompetence (Mayer, 1956). However, functional principles were not systematically applied to the family as a unit until the early 1960s. The process was initially called “family casework.”

Rappaport (1960) was an early proponent of family- focused service. Recognizing that fam- ily problems are often rooted in the problems of society, she called for “more vibrant and vital ways of helping” families with multiple

problems, and she recommended social action and coordination of resources as well as the application of functional principles to family practice (p. 86).

Berl (1964) also affirmed the relation- ship between family and society and noted that the major challenges of family casework involve a dynamic balance between the ele- ments necessary for successful functioning, the integration of knowledge and practice, and systematic progress toward health and growth. He recommended the application of functional methods to prevention and crisis intervention, to treatment settings and educa- tion institutions, and to society at large. The field of family casework evolved slowly, how- ever, for in 1967, Smalley presented generic principles for functional casework, group work, and community organization, but she did not mention family work.

Whether practiced with individuals, dyads, families, groups, or communities, functional social work is most appropriate for client sys- tems seeking solutions to problems they have identified and embraced. Functional casework is especially effective for people seeking per- sonal growth. It provides an insight- oriented process appropriate for children and adults (Taft, 1930). Neither formal education nor high intelligence is a prerequisite, and individuals with cognitive limitations can benefit if they have the capacity for reflection. The only quali- fications needed to benefit from this method are an ability and willingness to engage in the pro- cess of self- examination and change.

Because the worker and client explore the process of change together, functional methods are applicable whether the participants have similar or dissimilar backgrounds. The first tasks of the worker are to establish rapport and acquire a rich understanding of the situation from the perspective of the client. Through this exploration, the worker comes to appreciate and value both similarities and differences in racial/ ethnic heritage, culture, background, tradition, and experience. The recognition and affirma- tion of difference is reinforced in supervision, a process that scrutinizes client– worker differ- ences so that workers can maintain appropri- ate roles and separate their personal needs and goals from those of the client.

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Proponents identify few limitations or con- traindications; however, functional methods alone are not sufficient for clients who also require medical or pharmaceutical interven- tion. Functional practice is rarely effective with people who have psychotic disorders; demen- tia; or antisocial, paranoid, schizoid, or bor- derline personality disorders. With specific populations or problems, functional methods may require adaptations to be developed by the worker (Smalley, 1971).

Since participation is entirely voluntary, risks are few. When a client’s problems lie outside the agency’s function, workers are obliged to refer the client to a more appropriate venue where help can be obtained. The functional method can be successfully applied to even the most complex problems, including psychosocial cri- ses, introspective concerns, interpersonal con- flicts, environmental issues, and social strife.

Administrative and Training Factors

The University of Pennsylvania School of Social Work developed the first master’s program in this method around 1934 under the leadership of Taft (Robinson, 1960). From that point for- ward, caseworkers were expected to obtain the master’s degree before they were allowed to pro- vide therapy to clients. Educators assumed that these professional social workers would become leaders and administrators in their employ- ing agencies (Pray, 1938), but no requisite knowledge or skill— other than the functional method— was identified.

Supervision is a critical element in training students and overseeing experienced workers (Faith, 1960), for before workers can help others, they must become aware of and manage their own inner and outer conflicts. Intrapersonal material, in addition to case content, constitutes the substance of supervision (Robinson, 1936).

The supervisory relationship is considered a special derivative of the therapeutic relation- ship, for it includes all the controls of the thera- peutic alliance plus the needs of a third system. Sometimes the third entity is the agency, and sometimes it is the client (Robinson, 1949). In either case, effective supervision is indispensa- ble, for it binds people to agency function. It also prevents the condition often called “burnout.”

Hughes (1938) acknowledged that not all agency employees have professional training. In functional agencies, paraprofessional workers and volunteers are still required to uphold func- tional principles. As Hughes explained, “Lack of skill in knowing how to use our function help- fully is costly to the agency in time, in money, and in human misery” (p. 73).

Empirical Base

Single case studies have been conducted using agency records, but they often contain only idiosyncratic process recordings. These inves- tigations focus more on product than process, since, by definition, goals are set by the client and can change during the course of therapy. They add little information about the overall effectiveness of functional methods.

Marcus (1966) maintained that functional principles are drawn from a substantive sci- entific base, and Smalley (1962, 1967)  stressed the fact that casework students were con- sistently trained in research methods. De Schweinitz (1960) urged the university com- munity to collaborate with practitioners. Lewis (1962) exhorted agencies to add the function or research analysis to agency services. Both Lewis and Smalley (1967) suggested engag- ing a research specialist, as Mencher (1959) recommended. Sprafk in (1964) accepted this challenge but reported on the process, not the outcome. Despite the attempt to embrace the scientific method, functional social work would not meet the rigorous standards of statistical analysis that have been developed during the past 20 years.

Prospectus

This chapter has described the lively and dra- matic debate that shaped social work practice during the first half of the 20th century. At its zenith, functional social work was practiced and taught at the universities of Pennsylvania, North Carolina, and Southern California; the Graduate School for Jewish Social Work; and, briefly, at the New  York School of Social Work (Robinson, 1978). The 16th edition of the Encyclopedia of Social Work devoted 12 pages to the functional method (Smalley, 1971), but

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by 1977, that number had already dropped to 11 pages (Smalley & Bloom, 1977). By the 19th edition in 1995, the topic had been dropped completely.

Currently, no graduate schools of social work in the United States teach the functional meth- ods as a unitary approach, and few institutions explore the historical roots of this tradition; however, a few historians and psychoanalysts have rediscovered Otto Rank (Lieberman, 1985; Menaker, 1982; Rudnytsky, 1991; Timms, 1997). With passing reference to functional authors, a number of articles have encouraged a return to relationship as the context for helping and change (Ganzer, 2007; Reupert, 2006; Sudbery, 2002; Trevithick, 2003). Timms (1997) has rec- ommended a reevaluation of functional social work.

In fact, the revolutionary concepts that engendered such controversy have been modi- fied, adapted, and ultimately subsumed into the major theories of social work today. Theorists have incorporated once- heretical ideas— such as freedom of choice and self- determination, the human potential for change, and the use of time and agency constraints as treatment elements— without reference to their stormy origins in the functional school. In the 1950s, Helen Harris Perlman developed the “problem- solving casework model.” For some, this approach represented a synthesis of the diag- nostic and functional schools. This systematic approach appears today in the form of cognitive therapies and evidence- based practice (Pozzuto & Arnd- Caddigan, 2008).

Carl Rogers (1951), who studied Rank extensively, championed unconditional posi- tive regard and an emphasis on the impor- tance of the authentic relationship in which change or healing could occur. These concepts inform self- help groups, transactional analysis, Gestalt therapy, and group therapies (Berlin, 2005). Reality therapists regularly promote the functional limits of an agency (Glasser, 1965), and the empowerment movement was built on client strengths and capacities for change within the context of community (Saleebey, 1992). Today, few clinicians acknowledge the functional roots undergirding their modern methods.

Economic conditions today resemble those found in the 1920s and 1930s in the United States. As then, economic necessities compel agencies to maintain services strictly within budget realities. Communities wish to avert suffering, especially for children, but they do not have resources. To this end, elected offi- cials are reviewing mandates, setting limits on allotments, and demanding personal respon- sibility. An understanding and intentional use of agency function can ensure accountability to society and the attainment of social work objectives (Smalley, 1967). A deeper awareness of historical antecedents can enable the pro- fession to meet the needs of a changing envi- ronment with greater efficiency and increased effectiveness.

Acknowledgment

This chapter is dedicated to my teacher and men- tor, Dr.  Alan Keith- Lucas (Feb. 5, 1910– Aug. 5, 1995). A graduate of Western Reserve University in the diagnostic tradition, Dr. Keith- Lucas was brought to the University of North Carolina to “clean up that functional mess.” Instead, he joined forces with the functionalists, and for more than 50  years, his ideas and influence shaped social work services and group child care in North Carolina and the Southeast.

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Systems theory is a broad view which far transcends technological problems and demands, a reorienta- tion that has become necessary in science in general and in the gamut of disciplines from physics and biology to the behavioural and social sciences and to philosophy.

— Ludwig von Bertalanffy, Foreword, General Systems Theory (1968, p. vii)

Introduction

For as long as civilization has been evolving, there has been an importance accorded to “sys- tems” and their contribution to survival and progression of societal changes. With respect to current efforts to collaborate in program pla- nning, mental health intervention, and systemic changes, no time is better than now to review systems theory and its application to social

work practice. Consideration of the individual, family, and community within the context of the larger system is no longer an option. It is an essential part of ethical and learned practice for the mental health professional.

As Ludwig von Bertalanffy wrote in 1986, “So innumerable problems are arising in pro- duction, commerce, and armaments … thus, a ‘systems approach’ became necessary” (von Bertalanffy, 1986, p.  4). Ackoff has supported the need for this theory development, suggest- ing that “Systems, of course, have been stud- ied for centuries, but something new has been added … the tendency to study systems as an entity rather than a conglomeration of parts” (Ackoff, 1959, p. 145). The inception of “general systems theory” (GST) paralleled the trends of the 1950s. This chapter reviews aspects of this theory and its relevance to systems theory, in

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order to apply the current trend of collaboration in social work and mental health practice.

The concept of systems theory saw its incep- tion, or at least its rise to prominence, with the theory of von Bertalanffy and has now morphed into many variations on the theme, but it is commonly understood as “a general science of wholeness” (von Bertalanffy, 1968, p.  37). The application of this model to the functioning of systems from business designs, medical and mental health planning and implementation, and other entities that involve an interactionary process for survival has been one of the great movements of this last century. It affects virtu- ally everything. However, there is not a single definition that would stand to fully define gen- eral systems theory (Smith- Acuna, 2011).

This chapter serves to review explanations of general systems theory and systems theory that have been proposed, including those of Dan Andreae found in Social Work Theories, 5th edition (Turner, 2011). An anecdotal his- tory of Bertalanffy and his colleague’s work to create the concept of “systems theory” will be discussed. In order to discuss both general systems theory and its contribution to systems theory, the second part of this chapter will pro- vide two contemporary applications of the psy- chotherapeutic process. Both are applicable to mental health, including social work, practice highlighting a focus on the individual within the concept of the system and community per- spectives. The first case example reveals a sys- tems perspective on an intervention with a child with a learning disability within the context of the family and ecosystem, and the second, a narrative approach to family healing within Bronfenbrenner’s ecological systems theory, serve to illustrate the current applications of systems theory used in mental health healing today. The chapter concludes by highlighting the application of systems theory to the collabo- rative approach to mental health.

Of special note, diversity as it pertains to cul- tures around the world, economic variations, sexual orientation choices, and physical, emo- tional, intellectual, and developmental chal- lenges are inherent and intrinsic to all aspects of the discussion of systems and their application. Given the evolution of general systems theory and the collaborative efforts seen currently, we

are reminded that general systems theory advo- cates organized unity of the system and speaks to this unity in terms of diversity.

The Evolution of Systems Theory

Interestingly, von Bertalanffy recounts his jour- ney in the development of his observation of “open systems and steady states which essen- tially is an expansion of conventional physical chemistry, kinetics and thermodynamics … and so I  was led to a still further generaliza- tion which I called ‘General Systems Theory’… which corresponded to a trend in modern thinking” (von Bertalanffy, 1968, p.  90). The defining of a “system” and its applications are varied and diverse. But it may be defined as a complex of elements with interactions, arguably of both an ordered and a non- ordered nature. In a system, the whole necessarily become more than the sum of the parts, and as Andreae sug- gests, they are in “constant movement with the interfaces between systems … constantly in the process of change” (Andreae, 2011, p. 243).

The importance of systems theory was orig- inally grasped by von Bertalanffy (1901– 1972), the founder of systems theory, who recognized that a system has holistic properties that are not found separately within the parts. He concep- tualized general systems theory as a complex of component parts or interacting elements that may together form an entity. This new syn- thetic approach to understanding nature can be defined as “an interdisciplinary doctrine elaborating principles and models that apply to systems in general irrespective of their par- ticular kind, elements and forces involved” (von Bertalanffy, 1981, Introduction, p. xv). His concept of the “open system” is based on the hierarchical order of systems, the relationships between and within suprasystems, systems, and subsystems. The utilization of intersystem generalization renders their differentiation and specialization possible.

Following the applications of science discov- eries and the relevance of the general system, Gregory Bateson, a cultural anthropologist by training, but a man who had a profound inter- est of “cybernetics” (the study of methods of feedback control within a system), provided many of the theoretical underpinnings for the

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application of systems theory to human rela- tionships. Norbert Wiener, neuropsychologist Warren McCulloch, social psychologist Kurt Lewin, along with G.  Bateson and Margaret Mead were considered the “Who’s Who” in sys- tems theory. A  systems approach was increas- ingly seen as adding an emphasis on seeing problems in context, looking at how interactions create and maintain problems, and examining the ways that patterns can remain constant or change (Smith- Acuna, 2011).

Application of this concept of perpetual shift- ing emphasizes the existence of circular causality, which helps conceptualize a family’s behavior in current transactional terms, as a network of cir- cular loops in which every member’s behavior affects everyone else. People mutually affect one another, even in the absence of a specific behav- ioral event (Goldenberg & Goldenberg, 1994). Indeed, an essential way in which a system, such as a family, maintains itself as a self- regulating system is through the constant exchange of infor- mation “fed back” into the system. This informa- tion automatically triggers necessary changes to keep the system fluid and functional. In systems theory, “feedback loops” (circles of response from which there is a return flow of information into the system) are operating, and information is being processed through the system. The con- cept of feedback loops was developed by Norbert Weiner, a mathematician and pioneer in the field of cybernetics, who defined feedback as a method of controlling systems by reinserting into it the results of the past performance.

The application of this research discov- ery, albeit through scientific experimentation, has direct application to social work practice. The social work practitioner needs to analyze the various repetitive links that keep the loop locked in place regardless of the system under study (and thus maintain the mutually defeat- ing interaction patterns) that prevent individu- als or units who make up the particular system from moving on to more productive and fulfill- ing activities.

Application of Systems Theory to  the Intervention Process

Historically, the major focus in the behavioral sciences prior to the understanding of general

systems theory had been on individual func- tioning as reflected in such approaches as psy- choanalytic theory, classical behaviorism, and neo- behaviorism, as well as learning theories. While different in nature, these theories share commonalities, particularly vis- à- vis the con- cept that the psychological organism is reactive. The principles of general systems theory and their application to the theory often referred to in social work literature and related rhetoric as systems theory are seen as reactive and also potentially learned (Andreae, 2011). Among the applications for various theoretical frameworks applied to the psychotherapeutic process by social workers and other mental health practi- tioners, systems theory may be applied from a variety of perspectives. Andreae (2011) suggests that social workers are provided a theoretical overview of systems theory, that systems are “interrelated, interconnected and interdepen- dent” (p.  242). Social workers and associated mental health professionals observe any indi- vidual within the context of their entire system with consideration given to the effects that vari- ous levels and aspects of their systems have on their functioning.

The major roots of systems theory within the field of psychology that have had effects on most aspects of mental health come from three major areas:

1. Gregory Bateson studied psychopathology from a systems perspective, joining with Don Jackson, a psychiatrist from California, in the study of families with schizophrenic members. The Mental Research Institute was created in 1959 with Paul Watzlawick and John Wealand, along with Jay Haley and Virginia Satir.

2. In 1946, Murray Bowen, working with mothers and their schizophrenic children at the Menninger Clinic, expanded this work to include large family groups, including the extended family (Smith- Acuna, 2011).

3. In the 1950s, Nathan Ackerman expanded traditional psychodynamic definitions of relationship problems at the Family Mental Health Clinic in New York.

These three distinct developments in systems theory saw the shifting away from examining

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problems in an individual and linear manner to looking more at context and circular causality, as noted by Smith- Acuna (2011).

As is noted and summarized by Andreae (2011), from the perspective of the psychoana- lytic therapist, forces that affect a person are likely to result from early childhood experi- ences. For the behaviorally oriented therapist, causes are more likely to be found in the past and present combined. From the biologically oriented healer, behavior may be seen, in part, as determined by genetic inheritance.

It is the context that contributes to the holis- tic and more accurate understanding of the individual; i.e., the system in which the indi- vidual is involved. The systems view is holistic and attuned to targeted interpersonal relation- ships and stresses the reciprocity of behaviors between people. Circular causality suggests that the causal chain assists in the explanation of the person’s life and relationships. The mechanistic view of linear causality is fundamental to the consideration of an individual’s psychobiologi- cal behavioral with the goal of reestablishing equilibrium (homeostasis) (Andreae, 2011).

As has been suggested thus far, in the early 20th century, an alternative view of human problems and their alleviation began to emerge, along with a growing dissatisfaction with the mechanistic view of linear causality. The con- cepts of developmental psychology as reflected in Piaget’s “genetic epistemology” as well as neo- Freudian developments such as Carl Rogers’ “client- centered therapy,” Abraham Maslow’s “self- actualization” psychology, the personality theories of Murray Allports, and phenomeno- logical and existential approaches such as that of Fritz Perls’s Gestalt therapy, all provided a new view of circular causality. “The common features to all of these emerging alternatives is that they did not treat human beings as reactive robots but rather as active personality systems, and recognized that systems are capable of dynamic change and growth as opposed to the homeo- static models of earlier times” (Compton & Galway, 1989, p. 123, as cited in Andreae, 2011).

Bowen concretized the application of the original concepts of systems theory to the mental health and psychology field with his profound thoughts regarding the healthy sys- tem’s being able to promote differentiation by

providing closeness and connection, valuing the unique identities of each group member. These values may be present simultaneously, sequen- tially, or in conflict, but they are expressed. Ultimately, the more a person feels grounded and accepted in a secure relationship, the more he or she will be able to express and be true to her or his identity (Smith- Acuna, 2011). While Whitaker and Satir focused more on affect than on theories that were perceived as creating dis- tance, a current clinician/ theorist, Sue Johnson, uses a current application of systems theory by applying attachment theory, thereby enriching the understanding of human communication. A  more recent application of systems theory is that of Daniel Siegel, who employs his attach- ment research in neurobiology and describes the intricate communication patterns seen between children and their caretakers. He claims that early attachment relationships can be repaired by fostering accurate emotional communication.

With this new understanding of the person– environment interrelatedness, general systems theory and now systems theory have come to provide social work and mental health practi- tioners with a conceptual framework that shifts attention from the cause- and- effect relationship between paired variables to a person/ situation as an interrelated whole. The person is observed as part of his or her total life situation, which is only observable when the entire system is stud- ied. “The social work practitioner must strive for a full understanding of the complex inter- actions between the client and all levels of the social and physical system as well as the mean- ing that the client assigns to each of these inter- actions” (Teevan, 1993, p.  256). Collaboration between the individual and the system provide a new and important addition to the contribu- tions of systems theory.

Case Example 14.1

Systems theory and families of children with special needs (Author: Anna Bowers)

Families function within a complex system in which they impact and are impacted by interrelated com- ponents, including characteristics of individuals, the context in which individuals develop, and time

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(Bronfenbrenner, 1979). The socio- ecological model of development of Uri Bronfenbrenner, a develop- mental psychologist, created a model known as the “ecological systems theory.” This model considers the entire system in which families are functioning in order to better understand their interactions with the environment. Biopsychosocial characteristics are thought to set in motion a family’s ability, experience, knowledge, and skill, that are condusive to effective functioning (Bronfenbrenner & Morris, 2006).

It is widely recognized that a child with a devel- opmental disability is part of a larger family system, with reciprocal interactions occurring between them (Bailey & Simeonsson, 1988). The family affects the child, and the challenges of the child alter the fam- ily’s functioning and quality of life. Bronfenbrenner’s (1994) socio- ecological model of development con- siders the child to be “nested” within a family, which in turn is nested within a broader community sys- tem. This model provides a framework to explore and better understand the interactions that both a child with special needs and the family have with their environment.

The socio- ecological model of development rec- ognizes characteristics that prompt or deter reac- tions from the social environment (Lerner, 2002). Research indicates that social support improves coping and adaptation for families of children with a developmental disorder (Gray, 2002). Drawing upon Bronfenbrenner’s (1994) socio- ecological model of development, the entire system in which these fami- lies are functioning and growing must be considered in order to better understand how and why they are interacting with their environment in the way that they are. Thus, the various microsystems that the child participates in influence the seeking of and engagement in therapeutic services. Additionally, the mesosystem in which families function helps dictate the support services that are necessary and availa- ble to address the needs of the family. This model provides a framework to explore and clarify the com- plex factors that families face and the interactions between the child/ family and their environment that prompt the need for differentiated services for both child and family.

Professionals working with children assume responsibility for establishing partnerships with fami- lies in addition to fostering relationships between school professionals and families, and providing train- ing to better understand the interrelated systems of children’s lives (Manz, Mautone, & Martin, 2009).

Bronfenbrenner’s ecological systems theory pro- poses that considering the reciprocal components of a child’s developmental process facilitates a person- context relational view of the child’s functioning (Bronfenbrenner, 1977). As professionals assume the role of catalyst in establishing collaborations, consid- eration must be given to biopsychosocial characteris- tics in order to understand how children interact with others in their world and exhibit active agency in their own development (Lerner, 2002; Manz et al., 2009).

Case Example 14.2

Systems Theory and Its Effect on Narrative Therapy (Authors: Alan McLuckie and Melissa Rowbotham; from Riedel Bowers, 2013, pp. 117– 119)

Narrative therapy emerged as a mainstream model of psychotherapy in the 1990s (Gurman & Messer, 2003), offering a new paradigm of practice that espouses a social constructionist worldview. Social constructionist thinking within therapy represents a departure from family systems thinking (i.e., that a person’s reality, including life’s problems, arises from and is sustained by interpersonal interactions within the family environment) and constructivist thinking (i.e., that a person’s reality, including life’s problems, is created via one’s interpretations/ perceptions of the world). Simply stated, social constructionist think- ers believe that a person’s reality (e.g., the stories we have about ourselves and our world), including life’s problems, arises from and is maintained through interpersonal interactions that occur within, and are influenced by, forces within the broader environ- ment. The environment within social constructionist thinking includes the family unit but goes beyond its confines to include broader cultural, historical, and socio- political forces. Morgan (2000) summarizes the important role of broader environmental factors by stating:

The ways in which we understand our lives are influenced by the broader stories of the cultures in which we live … some stories will have positive effects and some will have negative effects on life in the past present and future … there is always a context in which the stories or our lives are formed … this context contributes to the interpretations and meanings that we give events … the context[s]

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of gender, class, race, culture etc. are powerful contributors to the plot of the stories by which we live. (Morgan, 2000, p. 9)

An underlying assumption of social construction- ist psychotherapies is that our stories about “who” we are as people are not constructed in isolation, independent of other people’s influences and the influences of our social context. Our life stories, including who we are, do not simply arise as a prod- uct of genetic materials inherited from our parents nor result solely from our family upbringing. Rather, these stories are co- constructed across time within a developmental context that extends well beyond the parent– child dyad or family system to also include wider sociocultural influences. Brown and Augusta- Scott (2006) describe this co- construction process as follows:

We do not, and cannot, create our stories by ourselves, as they can emerge only within a pre- existing context of meaning. This context of meaning is always social, as meaning cannot

exist independent of social life. The human capacity to produce meaning and to attach it to social events and experiences requires social interaction. (p. xix)

In our opinion, although it is not a social construc- tionist theory by design, Bronfenbrenner’s (1979) eco- logical systems framework effectively depicts how an individual’s story about him/ herself unfolds or develops within a nested system, ranging from the broad socio- cultural context (i.e., macrosystem) to the inner core of the nuclear family system or the parent– child relation- ship (i.e., microsystem) (see Figure 14.1). Transactions occurring within each system, such as at the level of the family, are highly influential on an individual’s life story. Transactions between systems also have marked influ- ence on the realities of children and families. For exam- ple, children and families can be shaped by government policies related to such things as health care (i.e., mac- rosystem), or by experiences parents have with work- place policies (i.e., exosystem), or by the opportunities children have at school (i.e., mesosystem).

SOCIALLY CONTRUCTING PROBLEMS AND SOLUTIONS

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B ro

ad er

C ul

tu re

Local Community Politics/Services

(Adapted from Bronfenbrenner, 1979)

N ational

Political System s

Figure 14.1 Ecological/Nested System

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Unfor tunately, Bronfenbrenner’s model (1979) does not explicitly account for the fact that child- ren and families do not all begin on equal footing within their par ticular social context. Sociocultural forces are seldom experienced the same way by all children and families. Not everyone has the same power, privilege, and oppor tunity within the various levels of society, including the broader macrosystem. Social structures are often socially constructed by the dominant group(s) in a fashion that maintains a privileged position within society for the dom- inant group(s), thereby resulting in oppression of other groups. For example, racism is alive and well in a Nor th American context as well as worldwide. Discrimination due to such factors as race/ ethnic- ity, gender/ sex, sexual orientation, age and physical ability/ disability, continue to erect barriers to young people and families within major institutions (e.g., school and the employment sector) and society. Real and potential sources of oppression with society must be acknowledged within the therapeutic con- text because these forces wield a negative influence on the development of children and families.

Conclusion

This chapter intends to review the evolution of general systems theory, the application of this

overview for the development of systems theory for the explicit purpose of mental health care, and the current trends in this application. As Bateson (1972) and Watzlawick et  al. (1967) suggest, patterns in relationship conflicts are categorized in complementary and symmetri- cal interactions. The notion of circular causal- ity suggests that complementary interactions can be self- reinforcing and, at times, polarizing, which can lead to role rigidity and inhibit con- flict resolution (Smith- Acuna, 2011).

Applying a “systems approach,” thereby resolving conflict and tensions collaboratively, the patterns of relationship distance and detach- ment may be halted, and even reversed. Other variables come into play in this collaborative effort to work within the ecosystem, drawing on the internal resources of the individual, and sup- port from the family, extended family, and alter- nate caretakers and communities. Following the ecosystemic framework, the uniqueness of the diverse aspects of the context of the person, both challenges and strengths, contributes to a bet- ter understanding of the life story of those indi- viduals who seek out social workers and mental health practitioners for insight, and, for some individuals, change.

In summary, the nature of collaborative men- tal health intervention, whether it be focused on

UNDERSTAND THE PERSON WITHIN THE CONTEXT OF

THEIR (ECO) SYSTEM

COLLABORATE WITH THE PERSON TO UNDERSTAND THEIR

LIFE STORY, CHALLENGES AND UNIQUENESSES

WITH THE PERSON'S OWN UNDERSTANDING AND MEANING OF THEIR LIFE, APPROACH STABILITY OR

TRANSFORMATION and CHANGE

Figure 14.2 Collaborative Mental Health Intervention

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the child, adolescent, or adult within the context of the family, is affected by the system and its effect on family patterns, equilibrium, and changes.

The original insight of von Bertalanffy, partic- ularly putting forth the concept that the “system is a part of the whole,” along with its adaptation by Bronfenbrenner for a better understanding of the ecosystem, the layers, and the interplay between all the parts of the person’s unique world have been presented in this chapter. There have been many applications of these models, and there will be many more. The concept of collaboration, though, is not actually unique but a reworking of the obvious need of the person to seek out strengths when available, deal with challenges when evident, and apply such insights for a better world, a skill that clinical and community- based social workers are often skilled to do.

The systemic conceptualization of collabo- rative healing provides a progressive model of attachment and resilience provided by the eco- system that surrounds the person in the context of their environment. Von Bertalanffy concep- tualized the framework; Bronfenbrenner pro- posed the importance of the ecosystem; based on the importance placed on the general sys- tems theory and systems theory, new construc- tions of the same will follow.

References

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Andreae, D.  (2011). General systems theory. In F. Turner (Ed.), Social work treatment (pp. 242– 254). New York: Oxford University Press.

Bailey, D., & Simeonsson, R.  (1988). Family assess- ment in early intervention. Columbus, OH: Merrill.

Bateson, G.  (1972). Steps to an ecology of the mind. New York: Ballantine Books.

Bronfenbrenner, U.  (1977). Toward an experimen- tal ecology of human development. American Psychologist, 32, 513– 531.

Bronfenbrenner, U.  (1979). The ecology of human development:  Experiments of nature and design. Cambridge, MA: Harvard University Press.

Bronfenbrenner, U.  (1994). Ecological models of human development. In T.  Husen (Ed.), International encyclopedia of education (Vol. 3, pp. 1643– 1647). Oxford, UK: Elsevier.

Bronfenbrenner, U., & Morris, P.  A. (2006). The bioecological model of human development. In W.  Damon & R.  M. Lerner (Eds.), Handbook of child psychology, Vol. 1:  Theoretical models of human development (6th ed., pp.  793– 828). New York: John Wiley.

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Compton, B.  R., & Galaway, B.  (1989). Social work processes. Belmont, CA:  Westworth Publishing Company.

Goldenberg, H., & Goldenberg, I. (1994). Counselling today’s families (2nd ed.). Pacific Grove, CA: Brooks/ Cole Publishing Company.

Gray, D. E. (2002). Everybody just freezes. Everybody is just embarrassed: Felt and enacted stigma among parents of children with high functioning autism. Sociology of Health & Illness, 24(6), 734–749.

Gurman, A. S., & Messer, S. B. (Eds.). (2003). Essential psychotherapies. New York: Guilford Press.

Lerner, R. M. (2002). Concepts and theories of human development. Mahwah, NJ: L. Erlbaum Associates.

Manz, P.  H., Mautone, J.  A., & Martin, S.  D. (2009). School psychologists’ collaborations with fami- lies:  An exploratory study of the interrelation- ships of their perceptions of professional efficacy and school climate, and demographic and train- ing variables. Journal of Applied School Psychology, 25, 47– 70.

McLuckie, A., & Rowbotham, M.  (2013). Narrative play therapy with families. In N.  Riedel Bowers (Ed.), Play therapy with families:  A  collaborative approach to healing. New York: Jason Aronson.

Morgan, A.  (2000). What is narrative therapy? Adelaide, Australia: Dulwich Centre Publications.

Riedel Bowers, N.  (Ed.). (2013). Play therapy with families:  A  collaborative approach to healing. New York: Jason Aronson.

Smith- Acuna, S.  (2011). Systems theory in action. Hoboken, New Jersey: John Wiley and Sons.

Teevan, J. J. (Ed.). (1993). Basic sociology: A Canadian introduction (4th ed.). Scarborough, ON: Prentice Hall Canada.

Turner, F.  (Ed.). (2011). Social work treatment (5th ed.). New York: Oxford.

Von Bertalanffy, L.  (1968). General system theory: Foundations, development, applications. New York: George Braziller.

Watzlawick, P., Bevalas, J., & Jackson, D.  (1967). Pragmatics of human communication:  A  study of interactional patterns, pathologies and paradoxes. New York: W.W. Norton.

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Gestalt

This system aims to produce enhanced self- awareness of inner and outer selves as a unified whole, by focus- ing on dysfunctional boundaries of confluence, interjection, projection, and retroflection.

Contrary to popular belief, Gestalt theory is much more than a collection of techniques, as this model is firmly rooted in existential philosophy (Perls, 1992). Derived from a German word denoting “wholeness,” Gestalt refers to the holistic nature of human experience. A Gestalt is seen as much more than its collected parts. Although Gestalt therapy focuses on the “figure,” the experience of the individual in current context, there is also consideration of the “ground,” the present as well as past background of the individual. While the here and now is stressed, past experiences and relationships are examined in the present in order for the client to gain greater understanding about his or her current situation.

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Overview

Historical Origins

First developed in the late 1940s, Gestalt theory introduced a new approach to understanding personality, human development, and therapy that differed from widely accepted psychoanalytic

theory. The founder and principal proponent of Gestalt theory and therapy, Frederick (“Fritz”) Perls, disagreed with the Freudian lineal approach, which stressed the past, focused on individual pathology stemming from Oedipal conflicts, and promoted a treatment method that fostered dependency on the therapist.

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Written over 60 years ago, Ego, Hunger, and Aggression:  A  Revision of Freud’s Theory and Method (Perls, 1947)  presents the initial devel- opment of Gestalt theory. Perls disagreed with traditional psychoanalytic theory and instead embraced existential philosophy and Gestalt psychology. Although traditional psychoana- lytic theory was rejected, there have neverthe- less been some linkages to the more modern psychoanalytic self- psychology (Jacobs, 1992). Perls was greatly influenced by the existen- tial focus on individual responsibility for one’s experience within the present. The Gestalt ther- apeutic relationship is likened to the I– Thou relationship described by Buber (1958) in which the therapist unconditionally accepts the unique personality of the client. In the I– Thou relationship, the barrier between self and oth- ers is minimized, and each person connects on a human level. From Gestalt psychology, Perls derives his focus on the total person as an entity that is much more than a collection of compo- nent parts. In contrast to psychoanalytic theory, which presents sex and aggression as primary drives, Gestalt theory proposes that the basic human drive is that of self- actualization.

Gestalt therapy was most popular in the 1960s, and Fritz Perls conducted many work- shops and seminars to disseminate his theory during that time. Miller (1989) has suggested that Gestalt therapy, which focused on here- and- now experiential methods, was particu- larly suitable to the radical revolutionary nature of the Sixties. Gestalt therapy, however, is not only is a collection of dated dramatic tech- niques designed to bring about rapid personal- ity change, but it also presents a philosophical worldview and a therapeutic method that has continued to have relevance and a following into the 21st century.

Literature on Gestalt Theory and Therapy

Originally, Frederick Perls was the principal author of literature on Gestalt theory. Important books by Perls that outline theoretical and treat- ment concepts of this model include Gestalt Therapy Verbatim (Perls, 1969a), In and Out of the Garbage Pail (Perls, 1969b), The Gestalt Approach and Eye Witness to Therapy (Perls,

1973), and Gestalt Therapy (Perls, Hefferline, & Goodman, 1951). Other authors on Gestalt therapy include Panning (2009), Polster (1992), Smith (1992a), Harman (1990), Korb, Gorrell, and VanDeRiet (2002), Clarkson (1989), Smith (1992a, 1992b), Nevis (2000), and Melnick & Nevis (2009).

Gestalt therapy has been linked to psycho- analytic models in the work of Yontef (1987), to transactional analysis and redecision theory in Goulding (1989), to self psychology in Breshgold and Zahm (1992), to insight- oriented therapy in the work of Scanlon (1980), and to attachment theory (Sternek, 2007). Within the last 15 years Brownell (2008), Houston (2003), Melnick and Nevis (2009), and Yontef (2005) have published books on Gestalt therapy. Many recent publi- cations on Gestalt therapy have originated in Europe rather than in the United States, where Gestalt therapy began.

Recent literature on Gestalt therapy has focused on the use of body movement in psy- chotherapy (Klepner, 2001)  and group super- vision with supervisees (Melnick, 2008). The International Journal of Gestalt Therapy (renamed in 2002 from Gestalt Therapy) is a continual source of current work on Gestalt theory and practice. Applying Gestalt princi- ples to increase understanding of child behavior has been a particular focus for current Gestalt therapists (Arfelli- Galli, 2006; Trombini, 2006, 2007). Trombini (2007) uses focal play therapy based on Gestalt principles to work with child- ren with eating disorders. Currently there is a focus on client groups, such as Wedam’s (2007) application of Gestalt principles to clinical work with traumatized refugees in which refu- gees who have experienced torture must learn through therapeutic relations to develop new structures. In addition to clinical work, Gestalt principles have also been used to understand communication patterns, including audience reactions to media. Members of the audience are not passive receivers of information, but instead actively seek out information they need (Umphrey, 2007).

Much literature on Gestalt therapy has focused on specific age groups:  children (Geldard & Geldard, 2009; Botha & Dunn, 2009); adolescents (Williams, 2010; McConville, 2012), and the elderly (O’Leary & Barry, 2006).

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Other articles look at the use of Gestalt ther- apy with different psychiatric diagnoses such as clients with schizophrenia (Arnfred, 2012), bipolar disorders (van Balalen, 2010), and post- traumatic stress disorders (Perera- Dilitz, Laux, & Toman, 2012). A third type of article looks at different problem areas such as those affected by substance abuse (Carlock, O’Halloran, Glaus, & Shaw, 1992; Clemmens, 2005; Brownell, 2012), domestic violence (Little, 1990), clients suffering from bereavement (Cheung & Nguyen, 2012), clients with suicide attempts (Young & Lester, 2002), and cardiac patients (O’Leary, 2006).

Relationship to Social Work

Although Gestalt theory was originally devel- oped by a psychiatrist, Fritz Perls, and his wife, a psychologist, Laura Perls, and the majority of literature has been written by psychologists, there are many tenets that seem particularly pertinent to social work. Both Gestalt and social work focus on beginning “where the client is.” What Gestalt therapists describe as the “figure/ ground experience” is similar to the social work focus on the “person- in- environment ecolog- ical perspective.” Social work’s concern about the total person, including the physical, cogni- tive, behavioral, and emotional, and verbal and nonverbal, resembles the Gestalt therapy focus on wholeness. Increasing self- awareness for the therapist, as well as the client, is an important tenet for both the Gestalt and the social work therapist.

Senreich (2014) points out that the princi- ples of Gestalt therapy are very compatible with the National Association of Social Workers Code of Ethics (2008) which stresses social jus- tice and the respect for the worth and dignity of each person. Four major themes of Gestalt therapy (field theory, creative adjustment, the I– Thou relationship, and the phenomenological approach) are seen as particularly relevant for social workers (Senreich, 2014). Just as a Gestalt therapist looks at the total Gestalt affecting a client, the social worker is encouraged to view the total multifaceted environment of family, community, school, work, health and social service agencies, as well as other resources and liabilities. A  comprehensive approach is sought in both perspectives. Similar to a Gestalt

therapist’s not working with patients based upon one factor, a social worker would not use a straight lineal causal approach; for example, parental substance abuse would not be consid- ered the only cause of a child’s acting out in school. The I– Thou approach of Gestalt therapy is similar to the approach in social work that sees the therapeutic relationship as less hierar- chical, since both therapist and client partici- pate in helping the client achieve greater mental health. This is also similar to the focus in social work research of participatory research. Clients are not just subjects who provide information, but are actively asked to participate in develop- ing pertinent research questions.

“Creative adjustment” is a familiar concept in both Gestalt therapy (Melnick & Nevis, 2005)  and social work treatment. For example, in Gestalt treatment, psychiatric symptoms are frequently seen as the way a client deals with life stresses, while social workers also may interpret behavioral symptoms such as adolescent’s join- ing a gang as a “creative adjustment” to lack of attention at home (Senreich, 2014).

Finally, there is a close link between the phe- nomenological approach of Gestalt therapy that focuses on the subjective experience of the cli- ent and the social work approach to cultural competency and, most recently, cultural humil- ity. Social workers are encouraged to learn from clients, especially when they come from differ- ent cultural backgrounds.

Extent of Social Work Literature

Social work literature on Gestalt therapy has been limited. In the chapter on Gestalt therapy published in the last edition of Social Work Treatment (2011), a review of Social Work Abstracts from 1968 to 2009 yielded only 10 journal articles and three dissertations, only half of which had been published in social work journals. A  promising sign, however, is that there now are more journal articles on Gestalt and social work in professional journals, as a recent search for journal articles on this topic yielded 16 articles in the last five years. In Levenson (1979), differences between Gestalt therapy and psychoanalytic psychotherapy are considered. Other social work authors have focused on the application of Gestalt therapy

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to clinical practice (Lammert & Dolan, 1983), to groups for chronic schizophrenics (Potocky, 1993), to marriage counseling (Hale, 1978), and to training groups in Gestalt therapy (Napoli & Walk, 1989). In an earlier edition of this book, Blugerman (1986) discussed the usefulness of Gestalt theory for social work practice and research. A 2014 article summarized important concepts of Gestalt therapy in relation to social work practice (Senreich, 2014).

Basic Concepts

Gestalt theory presupposes a belief in the wholeness of human experience and the value of each person. The six main concepts in Gestalt therapy are wholeness, awareness, contact, fig- ure/ ground, self- regulation, and the here and now (Smith, 1992a, 1992b).

Wholeness: Gestalt theory stresses the whole- ness of the person without separation between mind and body, thought, emotion, and action. The problems or symptoms presented by clients are viewed as integral parts of their experience.

Awareness:  The Gestalt therapist seeks to help the client become more aware of internal feelings and processes as well as others in the external environment. As children, all human beings have the capacity for awareness and growth, but they are often encouraged to mini- mize certain thoughts and behaviors as inap- propriate. For example, a young girl may be taught that girls should never be assertive and should always be passive and accepting. This may lead to conflicts as an adult when a boss places unreasonable demands on her. A Gestalt therapist would help this client become aware of her feelings of anger, which she had not been able to express as a child. By becoming more aware of both inner and outer experiences as a child and now as an adult, she can move toward developing more appropriate assertive behavior in the here and now.

Contact:  The focus of Gestalt therapy is to expand the range and scope of contact between a person’s inner and outer self and environ- ment, as well as between client and environ- ment. The Gestalt therapist views transference as a contact boundary disturbance and tries to increase the client’s awareness of this distortion (Frew, 1990).

Figure/ Ground:  This concept, which stems from Gestalt psychology, alludes to the human being in relation to the environment (Perls, Hefferline, & Goodman, 1951). A Gestalt thera- pist helps the client to increase awareness of “figure” as a unified personality at the point of contact between the external and internal world, while the “ground” becomes everything that is not the focus of attention at the experi- enced moment.

Self- Regulation: Pursuant to the existentialist focus on personal responsibility, Gestalt thera- pists believe that each person has the capacity to regulate his or her own actions. Contrary to Freudian- determined drives of aggression and sexuality, Gestalt therapists believe that human beings can self- regulate their own needs, as well as self- support and self- actualize. This process is enhanced when clients increase self- awareness at contact points and view themselves in a more unified way.

Here and Now:  The Gestalt therapist’s focus on the here and now represents the most radical departure from psychoanalytic theory. While a Gestalt therapist is primarily concerned with increasing a client’s self- awareness at the current contact point between client and external envi- ronment, it is assumed that the past does affect the present experience of the client. The Gestalt therapist, however, does not dwell on past expe- riences and instead is more likely to use exer- cises to help clients understand past experiences in the context of the here and now. When the client is able to assume new roles or become aware of previously unarticulated feelings, the client learns how past experiences impacted the here and now and can begin to work through “unfinished business” from the past.

Gestalt Definition of “Personality”

Gestalt theorists define personality as “the rel- atively stable or predictable ways in which one person will behave differently from another, under the same external conditions” (Wheeler, 1992, p.  115). This theory of personality departs markedly from psychoanalytic the- ory, which postulates that all people progress through certain well- defined developmental stages. The diversity of individual personality is stressed. Also in contrast to the Freudians,

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Gestalt therapists stress the unity, the total Gestalt of personality. Freudians emphasize the structural theory of personality, and psy- chodynamic therapy focuses on helping clients gain insight into different structural parts and making the ego dominate. While Perls in early Gestalt writings spoke of the ego, superego, and id, and in Gestalt Therapy Verbatim (Perls, 1969a) even added an “infraego,” Gestalt ther- apists in general focus, not on the divisions of personality structure, but rather on the total- ity and integration of different parts of the personality.

Nature and Process of Change

Unlike most other psychotherapies, the focus of Gestalt theory is not to produce change in the client, but rather to produce increased aware- ness. Consistent with an existential approach, the Gestalt therapist accepts the client as a uni- fied whole without judgment or criticism (Cole, 1994). The therapist does not seek to change the client according to the former’s evaluation of the client’s problems and/ or pathology. Therapeutic change is defined as increased awareness of inner self and outer self as a unified whole. The client has the capacity to change, grow, and self- actualize, while the therapist serves only as a facilitator in this process.

Role of Significant Others

Gestalt therapists minimize the role of signifi- cant others in contributing to a client’s move toward change and self- actualization. In fact, the Gestalt prayer, “I do my thing, and you do your thing. I am not in this world to live up to your expectations and you are not in this world to live up to mine,” which Perls includes in the introduction to Gestalt Therapy Verbatim (Perls, 1969a), stresses the focus on the individ- ual without regard for either support from or hindrance by others. Other Gestalt therapists, however, have recognized the importance of significant others, and Gestalt techniques have been used in marital counseling (Hale, 1978). With Gestalt marital therapy, each partner is encouraged to develop basic awareness of the other and of the effect of the partner on the self during each here- and- now moment.

Role of Resources

Similar to other psychological theories, Gestalt theory focuses primarily on the person of the client, rather than on environmental resources that may or may not be available to the client. Although Gestalt therapy may not concentrate on concrete resources in the client’s environ- ment or teach the client skills to access them, a Gestalt therapist does acknowledge the impor- tance of the totality of a client’s experience, which includes environmental resources as well as psychological resources.

Values Base of Theory

Time Orientation

The focus of Gestalt theory is most clearly on the present, the here and now, yet Gestalt therapists acknowledge that past experiences often influ- ence the perception and behavior of clients in the present. Past relationships with significant others, especially parental figures, are often reenacted in the present to help clients develop greater understanding of how the perceptions and distortions of these relationships are affect- ing the here and now. Contrary to the Freudian deterministic belief that the past has inextricably influenced the present, Gestalt therapists believe that a client can revisit the past to reshape the present and future. Neither the future nor the past is the primary focus of Gestalt therapy.

Unlike many current therapy models, such as cognitive behavioral theories, Gestalt therapy is not goal- directed. The existential moment is the most important, the way the client experi- ences the world with increasing self- awareness. The future in terms of client or therapist goals is unknown and not considered as important as the current process of Gestalt therapy.

Basic Human Nature

Gestalt theory presents an optimistic view of human nature. Each person is viewed as capable of self- actualization and increasing self- aware- ness. Each has the ability to see himself or her- self as a unified whole. People are viewed as neither bad, vulnerable, nor sick. Consequently, focus on social problems and/ or psychological dysfunction is minimized.

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Relationship

A key relationship within Gestalt theory is the therapeutic relationship between therapist and client. This relationship resembles Buber’s I– Thou relationship in which power differentials do not exist. Other positive relationships within a person’s here and now should follow a similar format. The nature of activity for Gestalt therapy is primarily emotional experience rather than behavioral change. The goal is to help the client understand his or her Gestalt rather than change behavior. Gestalt theory views people as existing in harmony with nature rather than in conflict or as dominant. By increasing self- awareness, a human being can become more aware of the impact of nature on the total Gestalt.

Social, Bi, and Ethnic Sensitivity

Perls nor other Gestalt theorists do not have a primary focus on cultural and ethnic dif- ferences. Most of the early Gestalt clients were from white, middle- class, American, or Western European backgrounds. Gestalt ther- apy is thought to foster an American individu- alistic perspective (Saner, 1989). Yet the focus on self- actualization, acceptance of diverse per- spectives, and concentration on the whole per- son seems particularly relevant for work with ethnically and culturally diverse people. Recent articles have focused on systems of oppres- sion and privilege (Billies, 2005), cultural issues (Fernbacher, 2005), a Gestalt approach in a Brazilian favela (Neville, 2008), and on Gestalt treatment with Asian clients (Cheung & Nguyen, 2012). Gestalt therapy has also been suggested as an effective form of treatment for those affected by violence in religiously divided Ireland (Keenan & Burrows, 2009)  or Israel (Bargal & Peled, 1986).

Gestalt Therapy

Principal Therapeutic Goals

Although Gestalt therapists avoid specific goal- setting with individual clients, the following general goals are relevant to Gestalt therapy:

1. Increase the variety of behaviors used by clients: Often clients have a very limited

repertoire of behaviors. Gestalt therapy encourages them to expand their use of dif- ferent behaviors.

2. Encourage clients to take more responsibil- ity for their lives: While clients may initially blame others for their life situations, Gestalt therapy helps clients accept their own roles in creating their current situation.

3. Maximize experiential learning:  Gestalt therapy encourages clients not to rely only on cognition, but to integrate this type of thinking with their emotions.

4. Complete unfinished business from the past and integrate these experiences into their present:  Gestalt clients with disturbing past experiences that detrimentally affect their current functioning are encouraged to bring these experiences into the here and now. By reliving and reworking through these expe- riences, clients become more receptive to new life experiences.

5. Increase opportunities for clients to feel and act stronger, more competent and self- supported, with conscious and responsible choices, thereby facilitating good contact (Korb, Gorrell, & VanDeRiet, 2002).

Principal Therapeutic Concepts

Gestalt therapy’s goals are achieved through the nature of the therapeutic relationship and the variety of techniques employed by the Gestalt therapist. In Gestalt therapy, the focus is always on the client. It is assumed that clients have all the tools required to make any desired personal changes (Korb, Gorrell, & VanDeRiet, 2002). The therapist functions as a facilitator who aids in the client’s discovery of what the cli- ent is doing and how the client is doing it, and explores the underlying processes that influ- ence the behavior. The client is helped to accept responsibility for his or her behavior, not for the situation or other people’s actions. The therapist enables the client to explore and take responsi- bility for his or her actions.

Nature of Therapeutic Relationship

The nature of the therapeutic relation- ship is crucial in Gestalt therapy. The most important quality for a Gestalt therapist is

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authenticity— that is, to have achieved good self- awareness and to be open and honest with the client. The therapist must be able to enter into the client’s world. Gestalt therapists must develop a close, personal relationship with clients, rather than have a distant and objec- tive connection (Korb, Gorrell, & VanDeRiet, 2002). The Gestalt therapist minimizes the power differential that occurs between ther- apist and client. The establishment of an authoritarian relationship between therapist and client (in which the therapist knows what is best for the client) is avoided, as the Gestalt therapist respects the client’s desire to change, as well as desire to remain the same (Cole, 1994). The client’s reality is considered par- amount, and the client is seen to possess the capacity to grow and change with minimal assistance from the therapist. The therapeutic relationship is likened to Buber’s I– Thou dia- logue, which implies complete acceptance and respect for the other.

Unlike psychoanalysts, the Gestalt thera- pist does not foster the development of a trans- ference relationship. Yet Gestalt therapists acknowledge that clients come into therapy with expectations that the therapist will relate to them in ways similar to what they experi- enced in childhood. The I– Thou position of the therapist, however, “chips away at the client’s expectation of trauma in the client relation- ship” (Cole, 1994, p. 84). The Gestalt therapist may present himself or herself as the “good parent,” but only to facilitate the growth and change of the client. Transference in Gestalt therapy only functions as a means to an end, not as an final goal as in psychoanalytic treatment.

Perception of and Importance of History

Although the main focus of Gestalt therapy is on the here and now, it is a mistake to think of Gestalt therapy as ahistorical. A person’s history is crucial, as all that is unfinished from the past manifests itself in the here and now (Huckabay, 1992). In contrast to the psychoanalytic model, which encourages clients to talk about past experiences, the Gestalt therapist uses exercises to help clients relive past events and relation- ships in the here and now.

Perception of and Importance of Assessment

A Gestalt therapist’s assessment of a client dif- fers significantly from a social worker’s psycho- social assessment. Neither a discussion of the physical, psychological, intellectual, cognitive, and emotional characteristics of the client nor an analysis of familial, social, and environmental resources can be found in the Gestalt therapist’s assessment of a client. In terms of diagnosis, Gestalt therapy does not focus on pathology. Diagnosis according to symptom descriptions in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM- 5; American Psychiatric Association, 2015), defense mecha- nisms, and even client “problems” are not rel- evant to a Gestalt therapist’s “assessment” of a client (Yontef, 1987). Statements such as, “This is a manic- depressive, single parent, or welfare recipient” are avoided. While psychoanalysts see the defense mechanism of resistance as a nega- tive force to be eliminated, Gestalt therapists see the need “to enliven the resistances to awareness, so as to give them new flexibility and contact with the realities of the self and the social world” (Cole, 1994, p. 72).

While Gestalt therapy does not recognize assessment and diagnosis according to the psy- choanalyst, psychiatric DSM- 5, social work psychosocial model, problems that occur at the point of contact, dysfunctional boundary dis- turbances, introjections, projection, and retro- flection can be identified in clients and become the focus of treatment. Even the word “distur- bances” has been considered too judgmental for Gestalt therapists; it has been suggested that “processes” would be a better descriptive word (Swanson, 1988).

Specific Therapeutic Definitions

The four disturbances (processes) that occur between person and environment can be described as follows.

Confluence involves the denial of differences and an unrealistic focus on similarities. It is sim- ilar to the psychological phenomenon of accom- modation and generalization. For example, if one places a hand on a wall, at first one is very aware of temperature and tactile differences, but these

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differences blur within a short period. Similarly, in some marriages, differences between the part- ners are denied and a false sense of togetherness ensues. Gestalt therapy helps couples examine their ambivalent feelings about each other, as well as the “shoulds” and expectations of their relationships (Hale, 1978). Couples become more aware of individual needs apart from their confluent relationship.

A second contact disturbance, introjection, refers to the inappropriate intake of information from others, especially significant historical fig- ures. Often parental messages become internal- ized, with the result that the client is plagued by commands of “I should,” “I ought to,” or “I have to.” When introjection is a client’s disturbance, the Gestalt therapist may encourage the client to assume a voice apart from the introjected parent and carry on a dialogue in the here and now. The purpose of this exercise is to help cli- ents differentiate themselves from the parental introject. While psychoanalysts would assess introjection as an ego defense against anxiety, Gestalt therapists perceive introjection as a dis- turbance between person and environment that can be readily be remedied in the here and now.

A third contact disturbance, projection, describes the process of disavowing parts of oneself and projecting these parts onto others. Ego psychologists consider this phenomenon a defense mechanism in which unacceptable parts of one’s own personality are rejected and attrib- uted to another. This defense mechanism is con- sidered a lower- level type of ego defense that is used most frequently by the severely mentally ill. Gestalt therapists, on the other hand, do not consider that clients who use this process are more mentally ill, but rather that these clients have lost a significant part of themselves. This behavior takes away power from them and gives the environment more control than warranted. Gestalt therapists would help clients reclaim lost parts of themselves. For example, a client who thought all men were angry at her might be helped to acknowledge her own feelings of anger toward significant men past and present.

A final disturbance of contact, retroflec- tion, describes the process during which indi- viduals do to themselves what they would like to do to someone else or to have someone else do to them. This behavior sometimes is a very

healthy response, as when an angry mother very actively cleans the kitchen rather than abusing her child, or a woman rejected by a boyfriend buys herself a new suit (Polster & Polster, 1973). Retroflection can be overused, however, and a person may not be able to function in the cur- rent here and now because of powerful forces from the past. For example, clients rejected by their parents as children may not reach out to others as adults and may depend only on them- selves for support. A  Gestalt therapist would work with clients to help them understand that they no longer have to be the primary source of their support and that they can connect with others in their current environment.

The assessment of contact- point distur- bances occurs at the very beginning of treat- ment. Assessment is not viewed as a prerequisite to treatment. The integration of assessment and treatment from the very beginning serves to bring the Gestalt therapist and client together immediately, thus avoiding the professional distance created by a more formal, diagnostic assessment process.

Specific Techniques and Strategies

Gestalt therapists often use a variety of strategies or techniques in working with clients. Respect for the personhood of the client and flexibil- ity are main principles that govern the choice of specific techniques to use with clients. The choice of techniques depends on the health and readiness of the client. Therapy often creates the safe emergency in which the client learns that it is acceptable to be angry, elated, or unhappy (Stevens, 1975). Translating this safe emergency into action is often accomplished through the use of an experiment (Polster & Polster, 1973). A  Gestalt experiment has been described as “an attempt to counter the absolutist deadlock by bringing the individual’s action system right into the room” (Polster & Polster, 1973, p. 234). In general, experiments help clients under- stand themselves better through acting out problems and feelings, rather than only talking about them.

While an important role for the Gestalt ther- apist is facilitator, the therapist often assumes the role of director in introducing and carrying through the following experiments. Some of the

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main classic experiments can be summarized as follows (Korb, Gorrell, & VanDeRiet, 1989).

Dialogue, the best- recognized of Gestalt ther- apy techniques, is commonly referred to as “the empty chair technique.” Although this technique is often criticized as being overly dramatic, it should be remembered that it was originally designed to teach others about Gestalt therapy, as well as to facilitate growth in an individual cli- ent (Blugerman, 1986). When a client has con- flict with another person, past or present, or with a part of his or her personality, the Gestalt ther- apist asks the client to imagine that this person or personality aspect is in the empty chair. By promoting this separation, the client is often able to achieve greater understanding of, and insight into, what is frequently an area of conflict. For example, a client who is very demanding and a perfectionist in his behavior may benefit from the experience of having his imagined father sit in the empty chair and having the opportunity of “talking” with his father about the latter’s multi- ple demands for perfection.

Enactment of dreams often permits clients to become aware of issues and conflicts they are unaware of. In contrast to psychoanalytic theorists, who encourage clients to discuss their dreams to provide greater understanding of the unconscious, Gestalt therapists see dreams as “existential messages” about the current situ- ations in the client’s life (Latner, 1992, p.  51). While psychoanalysts stress interpretation of dreams as most important, Gestalt therapists encourage clients to act out their dreams as an expression of their current Gestalt.

Exaggeration occurs when the Gestalt thera- pist asks the client to exaggerate some motion or speech pattern. This exercise may help the client get in touch with feelings about which there was no previous awareness. For example, a Gestalt therapist noted that a client frowned when she discussed an impending visit by her in- laws. After the client was encouraged to exaggerate her frown, she became more aware of her nega- tive feelings about her in- laws’ visit.

Reversal involves suggesting that a client reverse a statement that has been made. Polarities are common in human experience, and encour- aging clients to state the opposite often leads to greater awareness and acceptance of integrated feelings toward significant others. For example, a

mother who was having a difficult time separat- ing from her ten- year- old son stated that she did not want her child to go to summer camp as he was too young to take care of himself away from home. When the client was asked to reverse the statement, she became more in touch with part of herself that really wanted to encourage her child to be more independent.

Rehearsal serves to prepare the client before seeking any change. Clients often lack a self- support system and fear there will be dire consequences if they try a new experience. Practicing words beforehand often gives the cli- ent confidence to approach a new situation. For example, the client who is fearful of asking the boss for a raise may benefit from the opportu- nity to rehearse this experience with the thera- pist. Many cognitive behavioral therapies also make use of this rehearsal technique.

Making the rounds is a Gestalt group work technique that provides an opportunity for the client to rehearse and receive feedback from other group members. By introducing the envi- ronment of other members, the client is helped to become clearer about his or her own expe- rience. For example, a group member strug- gling with his plans to separate from his wife was asked to rehearse this discussion within the group and hear group members’ reactions.

Exposing the obvious is a technique in which Gestalt therapists are encouraged to follow up on a client’s initial statements and movements, which are often indicative of deeper processes. This technique is familiar to social workers, who learn it to follow up on both verbal and nonver- bal communication. An example of this occurred in Gestalt therapy when the therapist noted to the client that he had been yawning repeatedly since he came into the session.

Directed awareness experiments help clients establish contact with different inner and outer experiences. Gestalt therapists use these tech- niques to help clients gain a clearer picture of sensory as well as internal body sensations.

In Creative Process in Psychotherapy, Zinker (1977) outlined the following steps in a Gestalt therapy session:

1. Laying the groundwork 2. Negotiating a consensus between client and

therapist

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3. Grading (assessing that an experiment is challenging, not frustrating)

4. “Surfacing” the client’s awareness 5. Locating the client’s energy 6. Generating self- support for both client and

therapist 7. Generating a theme 8. Choosing an experiment by mutual process 9. Enacting the experiment

10. Insight and completion

Reorientation is necessary after the use of a Gestalt experiment (Heikkinen, 1989).

Length of Treatment

Gestalt therapy, like other therapies, delineates the following four stages:  (1)  establishing a rela- tionship, (2)  exploring a problem in depth, (3)  determining steps for the client to take, and (4)  providing support and encouragement for growth (Egan, 1986). Gestalt therapists believe that, for some clients, all four stages may occur in the first session, whereas with other clients the process may span several years. The average client often falls somewhere in between (Korb, Gorrell, & VanDeRiet, 2002). Flexibility in duration of treatment is consistent with Gestalt theory, which supports a client- centered focus on treatment. The client, not the therapist, makes decisions about the length of treatment. Allowing the client to make decisions about the length of treatment seems to contradict both the traditional psycho- analytic model, which favors long- term treat- ment, and the current managed- care model of brief treatment. In general, however, Gestalt ther- apy is not usually considered a long- term model.

Because the focus is on flexibility and the acceptance of each client, Gestalt therapy is often short- term. This factor increases the use- fulness of Gestalt therapy for those who prac- tice in a managed- care environment.

Importance of Specific Methods

Work with Individuals and Groups

The founder of Gestalt therapy, Fritz Perls, was primarily an individual therapist. Even when he led groups, he worked primarily with one indi- vidual at a time, with little interaction from other

group members (Nevis, 1992). Groups were seen to provide an excellent opportunity to demon- strate Gestalt theory and practice to others. An early Perls group would consist of placing one individual in the “hot seat” and exploring a par- ticular topic, with the other group members as spectators. Other members might be asked to contribute in a structured way about the client in the hot seat. A client usually stayed in the hot seat about 10 to 30 minutes, and in a two- to three- hour session, two to four participants would take the hot seat (Korb, Gorrell, & VanDeRiet, 2002).

Currently the most frequently used Gestalt group therapy model is the Gestalt group pro- cess model (Huckabay, 1992; Zinker, 1977). With this model, the therapist continues as the director of experimentation but is more recep- tive to interventions from other group members (Korb, Gorrell, & VanDeRiet, 2002). Group interaction and the development of cohesive- ness are encouraged. With this model, one group member may express awareness of a par- ticular theme, which is shared by other group members. The group leader may lead the group in an activity related to this issue.

Although Gestalt therapy began as an indi- vidual model and is still used as an individual model, four features of Gestalt therapy are par- ticularly suitable to working with groups:  self- regulation, contact and the contact boundary, awareness, and an emphasis on the here and now (Frew, 1988). Groups, like individuals, demonstrate their own tendency to self- regulate and seek wholeness. The possibilities of contact between different group members, different subgroups, and the group leader are manifold in a group process. Awareness or focused atten- tion is even more important in group work than in individual work. Finally, a focus on the here and now is paramount in group work. With this focus, Gestalt group therapy is short- term, which is particularly advantageous in the cur- rent managed- care mental health environment.

Work with Dyads

In addition to individual and group work, Gestalt therapy has also been applied to work- ing with couples. Treatment of couples, how- ever, may be difficult for the Gestalt therapist who has been trained to focus on the individual

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and his or her boundary in relation to the exter- nal world (Zinker, 1992). The Gestalt therapist must focus on the couple as a system, a Gestalt, and the boundary of the couple as they relate to the outside world. Couples’ therapy consists of prescribing certain exercises for the couple to increase their awareness and interaction with each other (Hale, 1978; Zinker, 1992).

Work with Families

While not initially developed as a family ther- apy model, Gestalt theory has been used in family therapy. Kempler, a Gestalt family thera- pist, applied Gestalt theory and techniques in his work with troubled families (Kempler, 1974). Other family therapists, including Satir, adopted an experiential, existentialist approach in working with families and developed Gestalt- like family therapy techniques such as family posturing and family sculpture (Satir, 1983).

Work with Community

Gestalt therapy as it was originally developed was intended primarily for micro- practice with individuals and other small systems, includ- ing couples, groups, and families. Although not directing change efforts toward the community, Smith, a contemporary Gestalt therapist, writes, “My power to influence social change resides in my person and the effect of my person on oth- ers through intimate contacting” (Smith, 1992a, p.  294). Others have seen Gestalt therapy as being more socially and community- focused, in contrast to American individualism (Brown, Lichtenberg, Lukensmeyer, & Miller, 1993). Gestalt therapy has been used to study macro- organizational patterns (Critchley & Casey, 1989)  and has also been used in therapeutic milieu settings such as psychiatric hospitals, group homes, day treatment centers, and shel- tered workshops. More recently, Maurer (2005) and Neville (20080 have applied Gestalt treat- ment to macro- practice.

Principal Applications

Social Work Practice

Gestalt therapy was first developed for use with depressed, phobic, and obsessive clients with

adjustment to neurotic disorders. Most clients are and have been from a white, middle- class background. Yet the existential focus of Gestalt therapy, which stresses the uniqueness and value of each client’s experience, seems particu- larly well suited to the diverse economic, social, cultural, and racial clients with whom social workers work.

Gestalt therapy has been used primarily with young and middle- aged adults, but it has also been applied successfully in work with children (Oaklander, 1992)  and older persons (Crouse, 1990; O’Leary & Barry, 2006). Other clients who have benefitted from Gestalt therapy include battered women (Little, 1990), abused children (Sluckin, Weller, & Highton, 1989), amputees (Grossman, 1990), people with AIDS (Klepner, 1992; Siemens, 1993), clients with family mem- bers who have committed suicide (Bengesser & Sokoloff, 1989), and those with substance abuse problems (Brownell 2012; Clemmens, 2005).

Risks of Gestalt Therapy

A prevailing belief has been that Gestalt therapy is inappropriate for clients with severe person- ality disorders or psychoses (Shepard, 1970). Clients who have difficulty differentiating real- ity from fantasy may become more disoriented during guided fantasies, a frequent experiment used in Gestalt therapy. It has been suggested that Gestalt therapy can be modified for work with people who have been diagnosed as hav- ing borderline personalities (Greenberg, 1989), groups of people diagnosed as chronic schizo- phrenic (Potocky, 1993), and individuals hos- pitalized for psychoses (Harris, 1992). There is greater risk, however, in using Gestalt therapy with people who have a tenuous grasp of real- ity and sense of self, as they may not be able to return easily from fantasy to the real world.

Limitations of Gestalt Therapy

While Gestalt therapy presents risks for many clients with severe psychotic disorders, this model of therapy also may not be appropriate for poor clients for whom environmental advo- cacy and securing of resources is needed. Most successful with middle- class or working- class clients with neurotic or adjustment disorders,

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Gestalt therapy seem to differ from case man- agement, a current treatment model for work with the chronic mentally ill and others who require therapist activity in securing and coor- dinating community resources.

Administration and Training

Training for Gestalt Therapists

Gestalt therapy is often briefly covered in graduate social work or psychology programs, and most Gestalt therapists receive their train- ing in postgraduate training centers located in many large cities. There are three major Gestalt therapy associations:  the Association for the Advancement of Gestalt Therapy (AAGT), which is based in the United States; the European Association for Gestalt Therapy (EAGT), founded in 1985; and Gestalt Australia and New Zealand (GANZ).

There are no universal guidelines for the extent of training, but most educators in the Gestalt therapy field believe that the three main areas to be covered in Gestalt training are (1)  theoretical grounding, (2)  intense per- sonal Gestalt work, and (3)  extended super- vision (Korb, Gorrell, & VanDeRiet, 2002). Educators believe that beginning students must study extensively the theoretical orientation of Gestalt therapy in order to have an understand- ing of this method that is more than a collec- tion of techniques. Because of the importance of the therapeutic relationship in Gestalt work, the therapist must have a good understanding of herself or himself as explored through his or her own Gestalt therapy. Finally, ongoing supervision is considered essential for students studying the Gestalt method.

Importance and Function of Recording

Recording for Gestalt therapists focuses on the verbal and nonverbal process of the inter- view, similar to the process recordings of social work students. Diagnosis, history taking, and psychosocial assessment are usually absent from Gestalt recordings because these areas are not part of Gestalt therapist work with cli- ents. Instead, Gestalt literature on practice with clients often focuses on the initial awareness

contact phase with clients. What is stressed is the process that occurs between therapist and client.

Role of Setting

Although the agency context is certainly part of a client’s total Gestalt, Gestalt therapists minimize the role of the agency setting. Most Gestalt therapy occurs within Gestalt training institutes or in private practice, although many professionals may use some Gestalt techniques with their clients in a variety of mental health settings.

Case Example 15.1: Individual Gestalt Therapy

Susan, a 25- year- old married woman, had been referred for therapy because of recurring symptoms of depression characterized by feelings of low self- esteem and crying spells. The therapist introduced herself as “Nicole Smith.” Immediately the therapist noted that Susan seemed to sink into the chair and did not make any comments until asked. In this first session, the therapist asked Susan to describe how she was feeling, to which Susan responded “terrible,” but she did not understand why she felt this way as her husband was very supportive, and she had a good job and a nice home. The therapist was careful to stay with the original feeling Susan had expressed and asked her to describe in more detail the experience of feeling terrible. After some encouragement, the cli- ent indicated that she felt like a piece of garbage. The therapist asked the client to explore what being a piece of garbage felt like. The client described herself as feeling dirty, unclean, and rejected. She remem- bered that once as an adolescent she had cooked dinner and her mother had said the food tasted like garbage, and that her room had been compared to a garbage dump. It became apparent that Susan was very angry at her mother for such criticism, but had turned this anger inward.

As a Gestalt therapist, Nicole saw that her client was suffering from retroflection, a process by which a client turns back on himself or herself what he or she would like to do to another, and Nicole decided to use the Gestalt exercise of the empty chair to help Nicole get in touch with and verbalize some of her previ- ously unexpressed angry feelings toward her mother.

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(With Gestalt therapy, the past is not ignored, but brought into the present.) Susan was able to express angry feelings toward her mother (sitting in the empty chair) and after the exercise reported that she felt better than she had in a long time.

Case Example 15.2: Group Gestalt Therapy

The second case example focuses on Gestalt work with a group whose members had recently been diagnosed as HIV- positive. This group followed a Gestalt group process model, rather than the original Perls individual- in- group model. This group consisted of six homosexual men ranging in age from 20 to 35 who had learned of their HIV status within the past month. Group members were each asked to intro- duce themselves and tell what they expected to get out of the group. Most group members were in a state of denial about their illness. Several made no reference to having HIV; one said he was sure he was misdiagnosed; another indicated that once he took medication he would no longer have the diagnosis. The Gestalt group leader was supportive of where each member was. When one member mentioned how hopeless and helpless he felt, the group leader again was able to support this member’s awareness. The focus was on the here- and- now feelings of group members, not historical events.

In the beginning, the group leader related to each member individually, but was very encouraging when another group member reported that he, too, had felt powerless when he learned of his diagnosis. He reported that he had last felt this powerless when his mother died when he was 16. At this point the client started to cry; the other members were very sup- portive, as was the group leader.

The group leader tried to facilitate this inter- action by asking if others had experienced losses. Reliving this loss in the here and now was an impor- tant experience because it allowed the client to work through issues of loss that had never been com- pletely resolved. This interaction also served to pro- mote group cohesiveness, as many group members reached out to this client, while before they had all been quite isolated. Also, this sadness over a past loss led to a discussion about current losses, health and impending disability, and fears of future losses (that is, death). Finally, this incident demonstrated a Gestalt therapist’s concern about the whole person— that each person in the group was not only just a person

who was HIV- positive but also had a history and cur- rent Gestalt, of which HIV was only one part.

After each member had the opportunity to express himself and some initial group cohesive- ness was developed, the group leader introduced a Gestalt experiment. Group members were asked to imagine that they had a treasure box in which they could store all that was most precious to them. One member spoke very concretely, saying that he would use this box to store T- cells for a time he might need them in fighting his illness. Another expressed con- cern about his younger brother and visualized that he would store him in this box to prevent him from being harmed. Another would store in his box all his successes in life, such as when he was selected to give the graduation address in college and when he was named director of his division at work. A group member saved sunsets and the first day of spring. This exercise served to create connection between the men and helped them begin to confront the present reality of their illness.

Empirical Base

Extent of Research Base

Because Gestalt theory focuses on the expe- riential rather than the empirical nature of treatment, single- subject case studies greatly outnumber large research studies on Gestalt therapy. Some of the many reports of clients who benefitted from Gestalt therapy can be found in Harman (1989), Smith (1992a, 1992b), and Nevis (1992). There has been clinical research on Gestalt methods (Clarke & Greenberg, 1988). “Good moments in psychotherapy,” including extra- therapy behavior change, acceptance of a problem, and increased general well- being, have been linked with specific Gestalt treatment methods (Mahrer, White, Howard, & Gagnon, 1992). Research on Gestalt therapy has demon- strated its effectiveness in resolving decisional conflict (Greenberg & Webster, 1982), in groups (Anderson, 1978; O’Leary & Page, 1990), and in teaching (Napoli & Walk, 1989).

Gaps in Research

In general, empirical research on Gestalt ther- apy has been limited, and there is a need for more research to substantiate its effectiveness

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as a treatment method. There are difficulties, however, in conducting empirical research on an experiential, highly individualistic form of treatment, and most Gestalt therapists mini- mize the need for research of this type.

Present Status and Influence on Current Practice

While in the political and social climate of the Sixties Gestalt therapy focused more on a indi- vidualistic model of self- actualization, more recently there has been a focus on relational Gestalt therapy promoted by Fritz Perls’s wife, Laura Perls (Senreich, 2014). Many Gestalt therapy institutions exist around the country, and the International Gestalt Journal continues to publish articles of current interest to Gestalt therapists. While Gestalt therapy has frequently been accused of relying too extensively on tech- niques, current Gestalt therapists have argued that Gestalt therapy is more philosophical than technical (Perls, 1992), and that creativity, not technical skill, is essential for Gestalt therapists (Zinker, 1991). Also, Gestalt therapy groups have changed over the years from the therapist’s focus on individual clients in the group to the current emphasis on increasing clients’ interac- tions with each other (Frew, 1988; Frew, 1992; Harman, 1989).

Contributions to the Social Work Profession

Many aspects of Gestalt therapy are particu- larly pertinent for the social work profession. First, the Gestalt focus on the point of contact between person and environment suggests social work’s attention to person- in- situation. Also, the Gestalt figure/ ground concept relates to the profession’s use of the systems approach. While Gestalt stresses the I– Thou relationship, social work speaks to the importance of devel- oping an empathic helping relationship with the client. Both Gestalt therapist and social work professionals see much importance in increas- ing self- awareness and use of self.

Gestalt therapists, as well as social workers, focus on clients’ strengths. Also, Gestalt therapists and social workers agree on self- actualization as a primary treatment goal. Finally, the Gestalt

therapy’s concern with the total Gestalt resem- bles the social work focus on the total person, including physical, cognitive, behavioral, emo- tional, verbal, and nonverbal dimensions.

Implications for Practice

Current social work practice includes clients from very different social, economic, and cul- tural backgrounds. Gestalt therapy, which begins with the acceptance of the client and his or her Gestalt, would seem very useful for social workers in working with very diverse cli- ents. Now more than ever, social workers work with clients from diverse cultural and socioeco- nomic backgrounds. A  psychotherapeutic the- ory that speaks to the importance of accepting and valuing each person as he or she is seems particularly relevant to social workers.

Gestalt therapy, however, may not be an effec- tive treatment modality for all social workers in all settings. Social workers who treat clients with severe psychiatric or socioeconomic prob- lems may not be able to use this model. Also, the I– Thou relationship of Gestalt therapist and client may be difficult for social workers who define their primary role as that of professional experts. Furthermore, the Gestalt therapist’s lack of emphasis on history taking, diagnosis, psychosocial assessment, and goal setting may not be acceptable to social workers and their agencies who have been schooled in a more psycho- dynamic or psychosocial approach.

Connection to Other Models

In terms of treatment modalities, Gestalt ther- apy, which stresses the here and now, resembles current treatment modalities of brief treatment, problem solving, and crisis intervention, which are often used by social workers. Also, since most Gestalt therapy is brief, this treatment modality works within a short- term, financially mindful treatment environment that introduces many time constraints into treatment.

Future of Gestalt Theory for  the Profession

Currently, many social workers are enrolled in Gestalt training institutes. Social workers often

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learn little about this treatment modality dur- ing graduate education, and those who wish to develop their expertise in this area usually attend a Gestalt therapy institute for postgradu- ate training. For social workers interested in this model, Gestalt therapy will continue to be a sig- nificant practice method for use in social work treatment.

Gestalt therapy’s focus on and acceptance of the individual person- in- environment points to its current, as well as future, value in social work treatment. The clients we serve are becom- ing increasingly diverse. The applicability of this model in working with clients from different cultural and socioeconomic backgrounds sug- gests that social workers can make greater use of Gestalt theory and therapy in their under- standing and treatment of clients.

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Hope is so much a part of our daily vernacular that we hardly take notice of it or concern ourselves with what, exactly, this concept means. Even when we become mindful of hope as a critical aspect of life, we lapse into using the concept imprecisely. Often we assume a shared understanding of the word and most often use it to state the blatantly obvious, saying, for instance, at our child’s wed- ding, I hope they will be happy. Almost the same can be said of the extent to which counselling pro- fessionals attend to how clients experience hope and how hope is used in the therapeutic process. For the most part, counselling professionals inter- pret a client’s presence as indicative of hope that their lives can be improved upon by the assistance they are about to receive.

While many have thought about and stud- ied hope, it remains a rather obscure area of knowledge and skill among professionals in

all human service disciplines. Moreover, there is no discernible evidence of hope being a core topic of study in any undergraduate or gradu- ate curriculum, including in schools of social work. When it comes to hope, it is safe to say most of us simply do not know what we do not know. Most assuredly, however, there is much more to hope than meets the proverbial eye of the beholder.

This chapter will explore the long history of hope being thought about and studied across a broad range of disciplines. Based on a synthe- sis of the broad range of views about hope, the premise will be argued that hope is an innate propensity that develops over time as a func- tion of interaction between the individual and the environment. Because hope is argued to be a cognitive developmental phenomenon expe- rienced differently at various stages of life, the

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occurrence of which is environmentally deter- mined, it is of particular relevance to the bio- psychosocial perspective of social work. The challenge for the profession, therefore, is to transform the common use of hope into a mind- ful, deliberate focus that is persistently applied. When the use of hope becomes fully informed, the argument is that outcomes of interventions with individuals, couples, families, groups, and communities will proportionally improve.

Historical Background

The experience of hope, a positive expecta- tion for the future, has been a central theme of human thought since the beginning of recorded history. Periodically, hope has been formalized into systems of belief for the explicit purpose of shaping or prescribing behaviors, with the promise of a better future for all. Most notable of the formalized systems are the messages of the prophets. Without exception, each prophet conveyed a positive expectation of the future dependent on and determined by prescribed behaviors. Arriving at the Promised Land, achieving nirvana, or gaining access to the kingdom of God are all messages of hope for a better future. Notwithstanding subsequent sec- ular distortions of the prophets’ original mes- sages as to how the better life could be achieved, the message of many religions is one of hope. It is noteworthy that there are theologians of hope (Moltmann, 1967; Marcel, 1962) and that more has been written about hope in a religious con- text than in any other field of thought.

The other major formalizations of hope into systems of belief and prescribed behaviors are political ideologies. The message of all politi- cal ideologies, also without exception, is hope for a better future once its proponents are elected and mandated by the majority of vot- ers to implement their policies and practices. In response to messages of hope, the primary reason for casting a vote is one of hope. Ernst Block (1954, 1955, 1959), a Marxist philoso- pher, for example, considered communism to be the only ideology with a full and consistent positive view of humanity’s future. Of course there were and continue to be contrary polit- ical views on the means by which to achieve a better future.

In parallel to religious and political ide- ologies, all of philosophical thought has been grounded in hope, an expectation of a better future derived literally from figuring things out. The education of youth for the purpose of creat- ing a better future through a better informed, more capable and knowledgeable populace also was first a philosophical notion. Most notably, Socrates, some 2,500 years ago, engaged young men in a process designed to develop their reasoning abilities. For his troubles, he was accused of corrupting their minds, was found guilty, and given the option of exile or suicide by drinking hemlock. He chose the hemlock. In spite of this inauspicious beginning to for- mal education, it could not be curtailed, and it eventually evolved into what many believe to be humanity’s greatest purveyor of hope. As var- ious academic disciplines emerged, hope for a better future was and continues to be the pri- mary goal of their focus.

The Place of Hope in Key Theories About the Human Condition

Imagination is a wonderful human attribute and it is alive and well, especially in acade- mia. Not surprisingly, academic theoreticians and researchers have explored and continue to explore the various manifestations of how we think about the future. Expectation the- ory is an area of study concerning how people behave when they formulate a belief about the future based on any number of factors. Robert Rosenthal and Jacobson (1966) of Harvard University conducted a study of how teachers behave when provided specific information about their students. They demonstrated that teachers behave significantly differently and produce predictable results, depending on what they are told by credible people. In this seminal experiment, equally capable students were ran- domly assigned to two groups in one classroom with the same teacher. One group was described to the teacher as gifted, and the other as not. As predicted by exception theory, the group described as “gifted” objectively performed significantly better at the end of the academic year than the group described as “not gifted.” Needless to say, no academic ethical review board would allow such an experimental design

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today. While subsequent researchers have been challenged to devise better and fairer ways of studying this powerful phenomenon, expecta- tion theory closely linked to hope continuously demonstrates that where you end up is signifi- cantly determined by where you start.

Hope also is an integral component of oppres- sion theory, which emerged out of several differ- ent ways of seeking to understand the dynamics of power, discrimination and prejudice, and systemic ways in which the status quo is main- tained. Marsiglia and Kuklis (2009) capture the core definition of “oppression.” For oppression to occur, two basic elements are required: a group that is being oppressed and an oppressor who benefits from such oppression. Given the key element of one benefiting from oppressing the other, it is no wonder that incidents of such relational dynamics are global and exponen- tially growing as evidenced by wealth becoming concentrated in the control of an increasingly smaller group of people.

In the context of this discussion, oppression is the creation of what is referred to in the lit- erature as hopelessness. In this subtly insidious process, often those being oppressed are not aware of it. When oppression is pervasive and optimal, the status quo prevails because focus on survival predominates and overshadows any hope for a better future. Without hope, it is uni- formly reported, planning and working for a better future become very rare. The victims of oppression, those without hope as described in the literature, are negatively affected in ways that range from the tyranny of materialism, to which all cultures are being socialized, to sys- temic discrimination against groups of people because of some discernible difference.

Oppression is closely associated with the absence of social justice. What constitutes social justice has been explored since Plato’s Republic, written some 2,500 years ago, and more recently conceptualized by John Rawls (1971) as that which is chosen behind a veil of ignorance. Both views constitute hope for a better future. Social justice, in particular, is a belief that all people should have the same rights, equal access to the resources of society, and receive fair treatment regardless of their circumstances (Heinonen & Spearman, 2001). Social work embraced this idea at the beginning of the 20th century

in relation to advancing the settlement house movement, intended to improve the conditions of poor immigrants. Advocating and seeking measures for social justice, while an enlightened idea, did not, however, enjoy continuous sup- port nor prominence over time. It was and con- tinues to be a revolutionary idea that threatens the status quo, which even the oppressed inad- vertently protect. Moreover, since social work practitioners were and continue to be largely institutionally based, without being fully aware, have strayed into advocating social policies and practices that support at least some discrimina- tory, unfair practices (Reisch & Andrews, 2001). In response to blatant and progressively unjust practices, the focus on social justice reemerged in the early 1960s and is currently most prom- inent in anti- oppression movements and many schools of social work.

In summary, it would not be unreasonable to conclude that the notion of hope, always in the context of creating a better future, is an inte- gral component of key theoretical frameworks dealing with the human condition. Even the dismal view of human nature, that people are nothing more than flesh and blood machines as described by Thomas Hobbs (1909), is hopeful, if no other reason than once it is understood and accepted for what it is, coping with life becomes easier.

Hope and Social Science

It would be safe to say that the first social sci- entists were educators. The science and art of teaching, shaping the minds of young and old, have evolved through trial and error as well as excellent research to test methods of instruc- tion. There is a considerable body of research on how best to build on the hope with which a child enters the educational system.

There is also considerable research on how best to instill hope in the unfortunate ones who as children already are without hope (Freire, 1994; Webb, 2010). It is noteworthy that in this literature, hope is conceptualized in a rather curious way. There is a focus on how to build on hope, which implies some semblance of it exists, and there is a focus on instilling hope where there is none. The implication that hope can be enhanced is an important one.

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While hope has been a focus of considerable attention in philosophy, religion, politics, and education, it had not been extensively studied in the social sciences until the middle of the last century. Sigmund Freud (1905– 1968) the best- known proponent of psychoanalytic theory, considered the benefits of the approach to be creation of expectations, colored by hope and faith. Not much later, Karl Menninger (1959) urged all mental health practitioners to study hope, which he characterized as a basic but elu- sive ingredient in our daily work.

As if in response to Menninger’s urging, psychologists began to study hope, at first as an essential motivation to implement a plan with which to achieve a predetermined outcome. In short order, other disciplines began to study hope from their respective perspectives. As could be expected, there is not yet a consensus about what hope is and how it is experienced by different people at different times. For example, Beavers and Kaslow (1981) are of the view that hope constitutes an emotional state, whereas Drahos (2004) takes the position that hope rep- resents a psychological process. Capps (1995) posits that hope is a matter of perception or intuition. Others have defined hope as positive expectations that include both cognitive and emotional factors (Miceli & Castlefrachi, 2010). In spite of their differences, all agree that hope is related to optimism about what is possible.

Recognizing the importance of hope, social scientists interested in facilitating the occur- rence of positive outcomes have mostly con- cerned themselves with hope- enhancing strategies. Snyder (2002) a psychologist, like hope theorists in general, believes that a posi- tive expectation for the future is learned in a variety of ways, including through a therapeu- tic process. From his perspective, loss of hope, despair, and hopelessness, therefore, also are learned through various life experiences. Later life events such as personal losses, divorce, and death (Steinbock, 2004) are sited as antithetical to a positive expectation of the future. Not sur- prisingly therefore, high- hoping individuals are reported to cope better with life’s vagaries than low- hoping ones; this justifying the interest in and testing of hope- enhancing strategies.

In search of objectivity, social scientists and researchers like Snyder (1995, 2000)  have

developed self- report standardized question- naires to measure the intensity of people’s hope (Obayuwana et  al., 1982). Such tools can be extremely useful for research purposes, as long as their internal validity correlates with how investigators chose to define the hope that they are studying. It is noteworthy that much inconsistency exists, even about fundamen- tal issues such as whether hopelessness means the absence of hope, or hope is present but at a very low degree of intensity. Nevertheless, such tools have been used to study how hope can be enhanced in the terminally ill (Dufault & Mortocchio, 1985) and those suffering from the death of a loved one (Cutcliffe, 2004). While less is written and studied about hope in social work, what does exist concerns mostly settlement work (Yohani, 2008; Yohani & Larson, 2009).

Given the volume of literature and research in this area, Weis and Speridakos (2011) con- ducted a meta- analysis of hope- enhancement strategies in clinical and community settings. They found no overall effect with respect to the hope- enhancing strategies alleviating the psychological/ emotional distress of individu- als. Nevertheless, at the very least, the reported studies serve to underscore just how powerful and important expectations or hope for a better future are when it comes to shaping the behav- iors in which human beings engage.

A Cognitive Developmental Perspective

A synthesis of what has been written and dis- covered about hope supports a conclusion that it is not a zero- sum phenomenon. Hopelessness does not exist. The data support a conclu- sion that there is always hope; it is innate and undergoes a developmental process that is envi- ronmentally determined. As such, hope is not learned in the traditional way of reinforcement- supported acquisition of a behavior or thought pattern. Hope develops over time and is experi- enced differently until it reaches its full poten- tial. Hope, like other developmental potentials, can be and often is obstructed from its evolu- tion by adverse environmental conditions.

The premise of this treatise also is that the notion of the conservation of neurons as it con- cerns some areas of human innate propensities

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is inappropriately applied to hope:  in other words, the “use it or lose it” notion that if a pro- pensity is not activated by a critical time, such as the ability to speak several languages flaw- lessly or to behave cooperatively, it is lost forever (Chugani, 1998; Huttenlocher & Dabholkar, 1997; Katz & Shatz, 1996).

This hypothesis about hope being an innate developmental cognitive process, always with an emotional overlay, parallels other processes that evolve over time. Lawrence Kohlberg (1969), a Harvard psychologist, after experiencing the inhumane treatment of one group by another, full of hope, sought to understand how people justify their behavior. Building on the work of Jean Piaget (1948), J.  Dewey (1930), and G.  H. Mead (1934), Kohlberg described a cognitive moral developmental sequence about how peo- ple reason out what is the fair or right thing to do when faced with a situation of competing claims. In addition to describing stages of development that occur in an invariant hierarchical sequence and that the underlying structure of a stage is universal, developmentalists like Kohlberg and Piaget  also reveal the unique essence of being human. The essence of being human, which also applies to hope, is an innate lifelong pro- pensity for growth and development unless it is obstructed by adverse environmental factors.

When environmental conditions are con- ducive to fostering the human developmental potential, there is harmony with being human. When the innate propensity for hope is fostered, most likely other developmental potentials also are activated. When the newborn cries out in discomfort and in response is comforted, the innate propensity for hope is activated. When the toddler in distress raises both arms in need of comforting and in response is affectionately hugged, hope also is activated. In brief, every time a child’s expectation of a primary need is met, hope is activated to progress along a hier- archical sequence.

Insofar as development cannot occur in a vacuum, the quality of the environment is a critical factor in the human condition. The environment not only determines the rate and extent to which development occurs, the envi- ronment also determines, in this discussion, whether innate hope flourishes or becomes stag- nated at its earliest stage of being experienced.

The Biopsychosocial Perspective

The biopsychosocial perspective, that which defines social work perspective in particular, is that individuals are born with an array of innate developmental potentials, which are environ- mentally activated. The sum total of the acti- vated, or not, potentials then combine to define an individual’s personality. If indeed hope is a developmental process experienced differently at each stage, it is not learned or instilled by life experiences as Beavers and Kaslow (1981) con- tend. If hope is learned, an infinite number of ways of experiencing it would be required for the complexities of life.

Instead, the premise of this chapter is that hope evolves in stages with an underlying struc- ture that is relevant across a myriad of situa- tions. In other words, hope about life in general is experienced in stage- specific ways, and the evolution of how hope is experienced is envi- ronmentally determined.

The importance of one’s environment is noth- ing new to social work. It emerged out of the 19th century charity organizations; Mary Richmond (1917) was the first to define the benefits of a combined focus on people and their environ- ment. This person- in- situation focus continued to evolve and now more than ever underscores the critical importance of one’s environment on how an individual functions and to what extent individual potential is actualized.

While learning in its various forms shapes behavior, emotional reactions, values, and beliefs, developmental preconditions are required before certain types of learning can occur. In order to achieve the prerequisite developmental gains, environmental condi- tions must be conducive to them. The absence of such conditions obstructs development and is a factor in explaining an individual’s dysfunc- tionality. For example, the same conditions that create failed attachment also obstruct the devel- opment of various innate propensities, includ- ing hope. Later life events such as divorce, the loss of a loved one, or how one is treated in one’s physical and mental decline also have a del- eterious effect on how hope is experienced. The danger of negative life events often is that they precipitate regression to earlier stages of reason- ing and feeling about the present and future.

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Social Work’s Challenge

So far, social work, like other areas in the social sciences, has restricted its conceptualization of hope to either having it or not. Efforts to enhance hope not surprisingly have failed to produce stellar results, although it is unclear whether the efforts were to instill it as opposed to enhance it. There is a difference. On close examination, it would not be unreasonable to conclude that it would be more accurate to interpret the reported therapeutic strategies as efforts to instill hope where there was none. In fact, however, the premise being advanced here is that there is always hope, but it is either stag- nated at a very early- in- life way of experienc- ing it, or there has been a regression because of adverse environmental conditions. Regardless, the prevailing variable is the environment.

Seldom acknowledged, in spite of its crucial importance, is that there are not only micro- but also macro- environmental factors that impact the lives of those served by social work. Specifically, there are deliberate and inadver- tent macro- and micro- environmental forces in play that maintain the status quo (Polgar, 2009), including conditions that negatively influence hope. The insidious and pervasive nature of these forces parallels or even exceeds the oppression that social work is committed to eradicating.

From this perspective, social injustice is not only perpetrated on vulnerable individuals or groups; the forces of status quo maintenance impact virtually everyone. Addressing this inter- play between individuals and their environment has been and always will be the lot of social work. As we build knowledge, the challenge for the profession is increasingly more complex, especially when we have to also look within.

Since most social work practice is institu- tionally based, the very organization that is the employer and the provider of services also could be an inadvertent protector of the status quo. Recognizing environmental barriers when immersed in them can be a difficult task, espe- cially when there is a vested interest, such as continued employment, involved. Social work, therefore, has the demanding task of carefully addressing systemic institutionalized barriers to sustainable change as well as individual spe- cific environmental factors that compromise

how hope is experienced by clients or the group to which they belong. Sometimes, both can be addressed simultaneously in the context of building a therapeutic relationship. Before exploring the hope component in social work intervention, further reflection about hope being environmentally determined is required.

Most, if not all, who avail themselves of social work services live under siege conditions. By definition they are constantly under attack and as such are too busy trying to survive to engage in reflective activities, the necessary ingredient for development to occur. Under siege, people’s experience of hope is quite basic. At best, hope is experienced as an expectation that there is a tomorrow but never a better one. All too often, this limited and narrow way of experiencing hope is intergenerational. These are the clients who do not follow through with the best planned actions with which to achieve a desired outcome. Why would they, if how they experience hope precludes a better tomorrow?

The unique biopsychosocial perspective about which social workers are educated and into which they are socialized is ideally suited to addressing the environmental and individual factors that obstruct innate development and rob individuals of a quality of life for which they have the potential. To fully implement the social work perspective, however, requires a lifelong commitment to learning and a functional dis- satisfaction with the status quo. In the context of this discussion, the status quo includes how hope is conceptualized and how hope is incor- porated into everything that social workers do.

A significant advantage of the cognitive developmental conceptualization of hope is that it mirrors an axiom of operant learning. Specifically, the axiom is that it is easier to increase the strength and frequency of an exist- ing behavior than it is to teach a completely new one. The same should be true of advancing how hope is experienced, as opposed to instilling hope where there is none.

The intent of conceptualizing hope as innate and developmental is not to suggest that focus- ing on hope should become a new intervention strategy. Social work does not need a therapy of hope- intervention modality. What social work does need to do is to incorporate a focus on hope in everything that practitioners do, when

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building therapeutic/ constructive relationships with individuals, couples, families, groups, or communities. When a therapeutic relationship does not evolve into what it could, most likely missing in the encounter is a sufficiently mindful and skillful focus on hope. This is not to say that hope is not addressed, this is to say that greater focus on it could greatly improve outcomes.

Facilitating the evolution of how hope is experienced is not a simple task, nor should its challenging nature be underestimated. Its evolution, however, must be facilitated, and its facilitation must be interpreted, discussed, and explained at every opportunity. Moreover, the obstructed way in which hope is experienced must be challenged. Without the cognitive con- flict this creates, the active construction of a bet- ter way of experiencing hope cannot develop. Concomitantly, social work’s challenge is to keep an equally focused eye on the complex environ- mental factors that obstruct how hope is expe- rienced. The environmental factors can include intergenerational ways of experiencing/ talking about hope, or systemic social obstacles such as restricted educational or employment oppor- tunities. Once the environmental factors are identified, the next challenge is to address them. Sometimes social work can take on an advocate role and literally run interference for a client. The opportunity for this is rare. Most often, it is the client who must take on the environmen- tal factors with guidance and better- informed strategies. If the client’s experience of hope is not addressed, even the best laid plans will not be acted on. Mistakenly, then, the client becomes labelled as noncompliant. An alternate, bet- ter conclusion is that the social worker had not addressed adequately how the client experiences hope. To state the obvious, the task begins with building a therapeutic relationship that incorpo- rates a focus on hope.

At this point, it will be useful to interpret with a different view what goes into building a therapeutic relationship. The more the process is understood, the more likely it is that the prac- titioner will do it better.

Listening

Active listening serves to invoke different hope because it counters previous obstructive

experiences when reaching out was dismissed, ignored, or even ridiculed.

Validating

When trauma, singular or continuous of any and all kinds, is compassionately acknowledged, this serves to validate the person’s experiences as significant and thereby invoke different hope because someone finally understands.

Genuinely Curious Engagement

Being genuinely curious serves many purposes, not the least of which is to invoke a different hope that, through this relationship, change is possible because, as people explain their cir- cumstances, glimmers of alternative interpreta- tions emerge.

Acknowledging Siege

To acknowledge that being in constant survival mode it is virtually impossible to solve prob- lems, let alone strive for a better future, is mark- edly liberating. It frees up energy consumed by having to rationalize failure, and it invokes a different hope that help will come from some- one who understands.

When it comes to addressing hope, there- fore, no new strategies are required. As noted earlier, the premise of this argument is that bet- ter results can be achieved if a focus on hope is incorporated into everything the social work practitioner does. Perhaps the only new strategy is to draw attention to how hope is being expe- rienced and how else it could be thought about.

Case Example

People primarily are a product of their past as well as their current situation. Joshua, a 30- year- old with considerable cognitive intelligence, grew up in a mark- edly impoverished environment void of empathic nurturance. Secure attachment failed to emerge, and this relationship trauma began to manifest itself early in a variety of negative ways. After numerous psychi- atric hospitalizations, instances of cutting himself, and suicide attempts, he was granted a permanent dis- ability status. While on probation for a minor criminal

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offense, he was referred for social work services as a condition of his sentence. At intake he reported liv- ing in deplorable conditions. He slept on a cot in an unfinished basement without a refrigerator or even a hot plate. As well, unpredictably the sewer backed up, covering the floor with feces. By his bedside, he kept rubber boots so that he would not in the dark step into raw sewage.

Joshua’s clinical presentation was that of a person in the process of disengaging from the unbearable and inescapable reality of his circumstances. His experi- ence of hope was limited and stuck at the expecta- tion that he was going to be alive tomorrow and that he was not going to step into raw sewage in the dark.

Acknowledging that his despondence was an appropriate response to his circumstances served to release his hope from survival mode to hoping for a better future. Once he could hope differently, he was able to explore and seek out options available to him. A plan was formulated with small, easy to accomplish steps that culminated in Joshua moving into markedly better accommodations. As he settled into his new home, treating it as his sanctuary, his need to escape into his head discernibly diminished.

The case of Joshua illustrates that, in the midst of all that goes on in the lives of people, hope is at the core. When hope is obstructed from its development, people languish in their state of dysfunctionality, which can include escaping their reality by a variety of means such as self harm, or withdrawing into their self- cre- ated world. In contrast, when the experience of hope is facilitated by building a therapeutic relationship, the seemingly impossible can and does happen.

Future Research

Since no one has yet fully entertained the notion that hope is an innate, environmentally acti- vated, cognitive developmental propensity with variable emotional overlay, it is unknown how hope is experienced at different developmental stages. Knowing this is important at several lev- els, not the least of which concerns building a therapeutic relationship by engaging clients at a conceptual perspective close to how they expe- rience hope; a closer, more adaptive perspective of hope a client can relate to more easily than a markedly divergent one.

There are various existing methods for discovering and describing how an innate

propensity develops over time as a function of interactions between an individual and the envi- ronment. Nancy Eisenberg (1976) expanded on Kohlberg’s (1969) stages of moral reasoning to define the development of prosocial reasoning. She described a parallel sequence of prosocial reasoning, each stage being qualitatively differ- ent from other stages, each representing a total way of thinking, not just an attitude toward a particular situation. June Tapp (1971) similarly extrapolated from Kohlberg’s scheme to describe how a sense of law and legal justice develops over time as a function of environmental conditions. As could be expected, the building of knowl- edge about how innate propensities develop continues. Martin Hoffman (2000) described an empathy- based sequence of moral reason- ing. Empathy, according to Hoffman, is a pre- disposition that eventuates in mature prosocial behavior. This predisposition he postulates is actualized through three key factors:  biological basis, cognitive development, and socialization, a perspective remarkably similar to the biopsy- chosocial perspective of social work practice.

If indeed hope is an innate propensity that is environmentally activated, it is incumbent on a discipline that is concerned with the context in which people live and function to, not only dis- cover the hierarchical stage structures of hope, but also to discern what environmental factors are conducive to its development. Fortunately, there are existing methods for doing so that have served well other researchers interested in other innate domains of developmental propensities.

The fact that even the so- called hopeless can alter their lives gives credence to the premise that hope cannot not exist. There is no hopelessness, only hope that is obstructed. Nevertheless, even obstructed hope finds expression, as in the case of Joshua placing the rubber boots by his sleep- ing cot hoping to avoid stepping into backed- up raw sewage.

Conclusion

General systems theory (von Bertalanffy, 1968) introduced into our lexicon the concept of iso- morphism. It refers to the transferability of prin- ciples or laws from one discipline to another. The intent of demonstrating this was to avoid the time- consuming process of discovering the

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same principles in different fields isolated from each other. The purpose was to enhance and expedite knowledge- building in each discipline as its work became informed by that of all the other disciplines. Alas, this lofty ideal has fallen short of its intent, as different disciplines strive on their own to discover for themselves the importance and relevance of hope to their focus of interest. This chapter is essentially a beginning effort at synthesizing from various disciplines the relevance of hope theory for social work practice, now more than ever, firmly ground- ing it in a biopsychosocial perspective. Instead of considering this to be a value- based, idealized perspective, the preceding postulates hope to be an innate propensity of the same order as the propensity to develop various other innate pro- pensities. Insofar as hope is the precursor to any and all actions, positive or negative, it is critically important therefore that all interventions begin and continue with a focus on hope. Moreover, it is critically important that the focus on hope become optimally informed, starting with avail- able objective measures and an awareness that hope probably is experienced, not only in differ- ent magnitude, but also differently at each devel- opmental stage perspective. Perhaps the lack of these considerations has been the critical miss- ing link in optimally facilitating motivation to action that is progressively adaptive. Given the critical importance of hope, hopefully its theoret- ical foundation and means by which to facilitate its growth and development will become part of the core curriculum of every graduate faculty of social work and subsequently better inform how graduates practice.

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A Perfect Fit

Social work is now a recognized, regulated profession with a unique body of knowledge. Because of social work’s holistic perspective that combines the biological, psychological, and social aspects of an individual’s life, while also recognizing the impact of community, cul- ture, social positions, gender, sexual identity, race, and age, to name a few (Mullaly, 2010), many aspects of social work theory originate in other disciplines. That said, a social work per- spective always draws on multiple standpoints while applying a systemic lens to knowledge. “Social work pioneers were among the first to address the significance of deeply connected relationships that constitute the social con- text of people’s lives. Out of this rich herit- age, social work is recognized for its familiar

‘person- in- environment’ perspective” (CASW, 2000, http:// www.casw- acts.ca/ sites/ default/ files/ attachements/ Scope%20of%20Practice_ August_ 08_ E_ Final.pdf). This multifaceted and holistic view invites social workers to explore many modalities of service delivery and use whatever theory or methodology works best for each client. This opens the door for the use of hypnosis in a clinical social work practice.

What Is Hypnosis?

Hypnosis is a physical and mental state of highly focused concentration. A person under hypnosis can respond to questions and is very susceptible to suggestions from the hypnotist (James, 2010). While hypnosis’s legitimacy has been ques- tioned, we do not question the brain’s ability to enter an involuntary dissociative state. “Clinical

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hypnosis uses naturally occurring states and behaviours and amplifies them” (James, 2010, p.  4). We frequently see examples of these nat- urally occurring states in our daily life. Driving the same route that we follow daily to our work- place, we realize that we have arrived but really have no idea of what we passed along the way, unless it stood out as a stark variance from the norm. The brain uses this same ability as a tool to help individuals avoid remembering incidents of physical or psychic pain that would overwhelm their coping capacity. Victims of child sexual abuse will often use this skill of involuntary dis- sociation to block memories of the abuse until they have reached adulthood and are more able to deal with the trauma and process the knowl- edge (Winsor, 1993).

While these are examples of the involun- tary use of trance, hypnosis is the intentional use of this trancelike ability. Although some- times used in popular media for fun and enter- tainment, hypnosis can also be utilized as a very powerful therapeutic tool. As described by the American Psychological Association (2000), hypnosis is a therapeutic technique in which therapists use suggestions and imagery to guide individuals. These individuals have been encouraged to enter a relaxed state where their minds are focused. When in this focused, relaxed state, hypnosis can be very effective as a technique to provide to relief for many different issues, including pain, anxiety, mood disorders, childhood trauma, post- traumatic stress disor- der (PTSD), performance anxiety, dissociative identity disorder, and a variety of obsessive and habitual behaviors. Although a therapist usually initiates the hypnotic trance, individuals can also be taught self- hypnosis so that therapeutic responses can be utilized in settings other than the therapist’s office.

Common Myths About Hypnosis

Now that we have an idea of what hypnosis is, it is important to also recognize the common myths surrounding hypnosis and note what hypnosis is not.

1. Hypnosis is not mind control. The therapist is not able to control the client and make them agree to do or say anything that the therapist

suggests. The client is always in control of their mind.

2. You cannot “get stuck” in hypnosis. Because the client is always in control of their own faculties, they are also always able to come out of hypnosis at any time. Hypnosis can be compared to the moment just before you fall asleep. If you hear an unfamiliar noise, you may choose to get up and investigate, or you might decide to not bother. The client always can come out of hypnosis but generally does not want to until they are told to come back to normal consciousness.

3. The ability to be hypnotized does not signify a weak mind. The ability to be hypnotized indicates that the client has the ability to hear suggestion and relax adequately. It also suggests that the therapist has found a good induction and approach that has captured the attention of the client.

4. Through hypnosis, every past memory is accessible. Sometimes some new memories are accessible through hypnosis, but these are generally memories that were already there but not acknowledged. The process of hypnosis does not open up the mind to be read like a book.

5. With hypnosis, you can find your past lives. Although I  cannot disprove this theory, I have never experienced it occurring.

6. A good hypnotist can hypnotize anyone. A good hypnotist can hypnotize anyone who wants to be hypnotized and who is ready to be hypnotized. The client has to have an under- standing of the process so that they are not afraid to allow themselves to relax and go into hypnosis, and the client cannot consciously be resisting hypnosis. Remember myth num- ber one— the client is always in control.

7. You can be made to do things you would not normally agree to do. While under hypnosis, you are still in control of your mind and your body. Your ethics, values, and knowledge of right and wrong do not vacillate. You cannot be talked into something that you would not agree to if you were not in a trance.

8. If the therapist leaves or dies, you will stay hypnotized for life. If for some reason the therapist stopped the process, you would either wake up naturally or fall asleep and then wake up.

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Hypnosis as a Clinical Tool

Hypnosis is a powerful clinical tool. James (2010, p.  5) states that hypnosis provides five fundamentals that increase the client’s “capac- ity to enhance what is already present.” She notes that as a clinical tool, it can be used to amplify abilities, focus attention on the task in hand, help create a goal to work towards, reduce stress or anxiety, and rehearse events in order to alter autonomic responses. Hypnosis can also be used as an adjunct to other methods of psychotherapy. For this discussion, the uses are grouped into three categories.

Hypnosis for Symptom Reduction

When hypnosis is used for symptom reduction, the client is put into a trance, and a hypnotic suggestion is made that is designed to reduce the symptom. For example, a client who fears needles is told that the injection site is numb and insensitive to pain. The client who fears dental work may be told that the dentist’s chair is a cloud that will take them to a beautiful place where they feel no discomfort, and that any pressure felt in the mouth will intensify the relaxation and deepen the trance. Other areas of aches and pains may be treated with the sug- gestion of an analgesic tap attached to the cli- ent’s body that can be turned up as needed, so that a stream of numbing, relaxing, analgesic liquid can flow through their body, or it may be suggested that they possess an absorbent sponge that will “wick up” all their pain. Since pain is often intensified by stress and is always felt through the brain, altering the brain’s per- ception of the pain can effectively eliminate any discomfort. In this way, hypnosis can persuade the brain to alter and disregard the psycholog- ical experience of pain, as well as modify the brain’s processing of the pain.

Hypnosis to Amplify Abilities

Hypnosis has proven very useful for amplifying abilities. In the relaxed state, the client is able to hear the positive suggestions for personal growth. This can be to enhance relaxation tech- niques, focus on goals, install ego strengths, or visualize completing a stressful activity, to

name just a few. Many of these uses of hypnosis can also be seen as working with other psycho- therapeutic methods, and will be discussed later in this chapter.

Hypnosis as an Adjunct to Other Methods of Psychotherapy

Hypnosis is a powerful adjunct when used as a psychotherapeutic tool with cognitive behavior therapy (CBT). Research suggests that using both hypnosis and CBT together, rather than either technique alone, improves outcomes for approx- imately 70% of patients (Kirsch & Lynn, 1995). Hypnotic trances can enhance the process when used in conjunction with progressive relaxation techniques and with guided imagery to reduce stress and manage anxiety. Anger responds well to these hypnotic techniques, and there are many scripts written as examples of how to both dimin- ish and positively express anger. The intensity of obsessive- compulsive disorder (OCD) can be lessened through a hypnotic trance that changes the obsessive behavior and compulsive think- ing. PTSD, victimization, and childhood trauma all respond well to hypnotic suggestions. The intensity of phobias and debilitating fears can be reduced with hypnotherapy. By preceding the CBT technique with a hypnotic induction and continuing to present the CBT technique with the cadence and tone of hypnosis, the benefits of both approaches are seen to support each other. Hypnosis used in this way also ensures that the CBT directives are presented and received in a very gentle and soothing manner.

It is important to note that, while the hyp- notic trance can be used to install many positive and helpful suggestions, hypnosis has also been implicated in “false memory syndrome.” False memory syndrome, popular in the Nineties, suggested that some memories of child sexual abuse were falsely induced, resulting in court cases for hundreds of people wrongly accused of abuse (Yapko, 1994). While the issue of whether false memory syndrome is a true concern or a fabricated condition designed to provide rea- sonable doubt on behalf of those accused is still disputed, the Supreme Court of Canada in R. vs. Trochym, 2007, has deemed evidence obtained under hypnosis to be inadmissible (Judgements of the Supreme Court of Canada, 2007).

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Overview of the Hypnotic Process

The hypnotic process can be broken into three segments:  preliminary activities, the hypnotic phase, and the awakening. We will consider each of these stages individually; however, there are some common features of each of the phases to look at first.

Styles of Hypnotic Suggestion

Throughout the hypnotic process, the therapist orchestrates all the activity. Therefore, the ther- apist assumes a particular stance that suits the therapist, the client, and the stage and devel- opment of the process. Some therapists may consistently use the same posture, while oth- ers will alter their stance as suits the moment. Therapists are encouraged to “individualize hypnotic suggestions to the unique personality, expectations, motivations and problems of the patient” (Hammond, 1990). Hypnosis consists of hypnotic suggestions and metaphors, and how these suggestions and metaphors are pre- sented can best be understood by considering the three following approaches.

Directive or Authoritarian Suggestion When the hypnotherapist adopts an authori- tarian stance, phrases such as “You will feel …” or “You will notice …” are used. The author- itarian approach is useful when the therapist wants to direct the process so that the client knows what is expected of him or her. In the hypnotic induction, for example, phrases such as “Your muscles have all relaxed” or “Your arms are heavy” are common. An authoritar- ian stance is also useful when bringing the cli- ent out of the trance and the therapist wants to be very firm in getting the client back to an awake and alert state. A directive may be given such as “You are emerging from hypnosis. You will notice that the room is getting lighter. Move your fingers and toes.” These are times when the therapist does not want to give the client a choice. While a directive approach can produce dramatic and quick responses, Brown reflects that using this approach exclusively is effective for less than 10% of the population (Brown, 1986).

Ericksonian or Indirect Suggestion Ericksonian suggestions are delivered in a man- ner that is “nonspecific, indirect, ambiguous— often disguised” (Brown, 1986, p.  53). This indirect approach frequently uses phrases such as “You may”:  “You may notice that the room has become darker” would be one such indirect comment. “Some people notice that they feel a tingling in their fingers, but whether you do or not does not matter” is another. These are times when the therapist does not need the client to feel or experience the things being suggested but wants to keep the client’s attention focused on the tone and the words that are lulling them further into the trance. An indirect approach may reduce resistance and allow the client to feel that they are still in control, while still allowing the therapist to guide their thoughts. The phrase “Do not think of pink elephants” is an example of an indirect directive that in fact captures the listener’s attention. An indi- rect approach as described by Erickson uses metaphors and confusion to hypnotize any- one, whether with or without their knowledge (Brown, 1986). According to Erickson:

You provide a multiplicity of suggestions:  the more suggestions that you give, and the more simply you give them, the greater the possibility of getting some of them accepted. Your task isn’t to force a patient to accept suggestions. Your task is to present a sufficient number of suggestions so that he will willingly take this one and that one. (Hammond, 1990, p. 2)

While an indirect approach is commonly used as described here, true Ericksonian hypnosis as elucidated by Erickson is rarely adopted and is seen as being suitable only for specialized patient populations (Brown, 1986).

Permissive Suggestion To add to the confusion of the various approaches, there is a great deal of overlap in them; also, many theorists will use the same term differently or call the style something other than what is noted here. The permissive approach is at times referred to as “indirect,” while the Ericksonian approach is sometimes perceived as “permissive.” That said, it is up to the reader and the student to establish their own style while being aware of the various approaches.

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The permissive style of hypnotherapy is one that may resonate with social workers, as it appears to maximize client choice and involve- ment. While there are times when it is benefi- cial “to phrase suggestions in a more permissive and indirect way” (Hammond, 1990, p.  12), it is also important to recognize that, no matter which approach the therapist adopts, the client is always in control. Using a permissive role, the therapist will remark, “One of your hands is getting lighter. Look, your hand has become so light that it will float up. Lighter and lighter … it will float.” It is essential that the therapist using a permissive style differentiate between being permissive and lacking confidence or conviction. If, rather than saying “your hand will float,” the therapist continues to repeat “your hand might float up” or “perhaps you will develop a numbness in your hand,” there is a chance that the comment can be miscon- strued as lacking in confidence and experience. That will confuse the client as to the therapist’s expectations (Hammond, 1990)  and can be counterintuitive. Hammond implores the ther- apist to “make the distinction between being confident and authoritative versus authoritar- ian and dominating” (Hammond, 1990, p. 12).

A permissive stance is especially useful in applications such as guided imagery, where the client is encouraged to “imagine” a favorite scene or possibly a series of colors, or is given a choice between an analgesic tap or a pain- absorbing sponge as noted previously. Ego- strengthening techniques or anxiety- and stress- reduction skills are examples of appropriate uses of a per- missive approach. The therapist guides the client to accept a new way of viewing aspects of their life. The language is often still directive, but there is a supportive and permissive component to it. The therapist may say, “You are feeling stronger and calmer every day. Every day you will feel more confident and more able to deal with the concerns in your life.” Used in this way, hyp- nosis is both empowering and strengths- based. Imagery used in hypnosis allows the client to build an image that they will later be able to draw on for self- hypnosis. Relaxing gardens, waves on a beach, floating clouds, or staircases are often used for imagery. The therapist may be com- pletely permissive and vague in this process or they may suggest a number of various scenarios,

asking the client to adopt the ones that seem to be the best fit for them. Frequently, multiple images are used within the same hypnotic trance to accomplish different goals. For instance, the image of going down stairs, or descending in an elevator, or counting numbers in descend- ing order are all techniques often used to deepen the hypnotic trance. Colors are often suggested to both deepen the trance and highly focus the attention. Specific images are most effective once the client has entered a deep trancelike state. That would be the time to plant suggestions regarding the termination of habitual behaviors such as smoking or hand- washing.

Preliminary Activities

Establishing Rapport

When hypnosis is considered as a therapeu- tic tool for a client, a therapeutic alliance must first be established in order for suggestions to be received effectively (Hammond, 1990). If the client does not trust the therapist to be warm, caring, ethical, and honest, they cannot let their guard down enough to enter into a trancelike state. As has been noted, the client is always in control, so they must be willing to go into a hyp- notic state. Ask the client what image they feel might work to eliminate or reduce the problem. Explain what hypnosis is and is not. Taking the time to build this relationship may be the most critical piece in the success or failure of the hyp- notic process.

Assessing Suggestibility

While building this relationship, the therapist will assess for suggestibility and find the imag- ery that will help the client. A suggestibility test can be something that suggests movement. The therapist can tell the client that his or her arm is attached to a helium balloon and being lifted up, and the therapist notes the amount of move- ment the client shows; or it can involve the lack of the ability to move such as would be achieved by telling the client that his or her arms are so heavy and limp that, like a wet rag, they cannot be lifted.

If the client is especially skeptical, it may be necessary to use a number of suggestibility tests

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to assess the speed with which the therapist can move towards hypnosis. By finding the areas of resistance that can be anticipated, the therapist can attempt to address them prior to hypnosis. Simultaneously, it is important to find imagery that the client can truly relate to. Asking what their ideal safe place would look like is often a good way to get details that can be used as needed in the hypnotic process to calm any agi- tation or to strengthen the hypnotic process.

At this stage is also a good time to discover the client’s interests so that the induction is one that is easy for him or her to relate to. Using a gently rocking boat analogy is not relevant to someone who has never been on a boat and may be anxiety- producing to someone who has had a traumatic boating experience.

There is, for example, an induction script that asks the listener to imagine drawing and erasing letters on a chalkboard. I find this to be a very useful hypnosis- induction method for some schoolteachers.

Contraindications

It would be at this stage that the therapist would look for contraindications to the use of hypnosis. Erickson and those who adhere to Ericksonian philosophy believe that everyone can be hyp- notized if the therapist is adequate. Erickson advised the therapist to weave monologues and metaphors into the trance, and said that con- fusion captured the client’s attention (James, 2010). But others recognize that some clients will not always allow themselves to be hypno- tized. A client who cannot relax in the office set- ting, or one who is unable to process the words of the hypnotic trance and suggestions, would be two examples of where hypnosis would not be a suitable technique until these issues are dealt with. A client who has been severely trau- matized would be another case where hypnosis would not be appropriate until the therapist is acutely aware of the triggers that may reactivate the trauma, placing the individual into a poten- tially vulnerable state. Using hypnosis without the prior work in such cases could be retrauma- tizing and unethical.

It is imperative to note, however, that before using hypnosis for any type of physical ailment or pain management, the client must be advised

to seek medical attention to ensure that hypno- sis is not being used to inadvertently cover up symptoms of an untreated medical condition.

Setting the Stage for Success

After a relationship of trust and awareness has been built, the physical environment must be considered. Bright lights, loud noises, and any other intrusions will all interfere with the success of the hypnotic process and must be accounted for. Seating must be comfortable and supportive, and the therapist must strive for a soothing, calm, and controlled voice, delivered in a manner that projects to the client at a slow and deliberate pace.

The Hypnotic Phase

Inducing a Hypnotic Trance

After all the preparatory work is done, it is time to begin the hypnotic process. First, the thera- pist will teach the client how to effectively take a deep, cleansing breath. This deep breathing is useful for many reasons. With each deep breath, the client becomes more relaxed and goes deeper into hypnosis. If the client becomes agitated, a deep, cleansing breath calms them while it also distracts the client from the stressor. Lastly, if the client appears to be falling asleep, asking them to take a cleansing breath lets the thera- pist know if they are still listening, wakes the client up if necessary, especially if their name is used, and helps the therapist evaluate the depth of the trance.

The Induction The trance is the stage of ultimate relaxation and least conscious awareness. As discussed before, this is the state in which the client is hovering between sleep and wakefulness, able to hear everything and take direction, yet unlikely to initiate conscious action.

The therapist will begin the trance by using an induction script, speaking in the future tense in order to advise the client regarding what is about to happen: “You will begin to feel very sleepy.” The same induction will then be repeated but in the present tense: “You are feel- ing very sleepy. Your eyes have gotten heavy.”

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The therapist then becomes directive, making statements such as “Now close your eyes and go down into a very deep and relaxing hypnotic state. You will go deeper and deeper.” The ther- apist will give the client permission to question the process by noting that going into hypnosis is a gradual process and they can go into it at their own pace, as they are ready. This appears to stop much of the internal questioning of whether the client is “doing hypnosis right” or not. The ther- apist creates a positive expectation (Hammond, 1990) at this stage with comments such as “You feel wonderful” and “You are deeper than you have ever been before.”

While the client is in the trance, the observ- ant therapist will often notice changes in their skin color, suggesting lowered blood pressure, and changes in breathing rate as the client begins to breath slower and deeper. It is the therapist’s responsibility to remain aware and visually monitor the client’s wellbeing. The induction is delivered in a musical manner, paying strict attention to the cadence and ensuring a lulling, soothing rhythm. This makes the difference in the success of the hypnotic trance, but it can be very difficult for the therapist, as the controlled tones can be straining on the voice.

Once a desired depth of trance is attained, the therapist, if the client agrees, can add ther- apeutic suggestions and ego- strengthening. The ego- strengthening uses a firmer, more authori- tarian and motivational tone of voice, empha- sizing the positive messages.

There are many scripts available to induce the initial trance state or to attain any of the desired goals of hypnosis, such as smoking cessation, ego- strengthening, or pain management. These scripts are readily available online or in books such as Handbook of Hypnotic Suggestions and Metaphors by D.  Corydon Hammond (1990) or Hypnosis and Suggestion in the Treatment of Pain: A Clinical Guide (Barber, 1996).

Although these scripts are available, it is imperative that a therapist who wants to add hypnosis to their repertoire of skills find a rep- utable hypnosis- training program so that hyp- nosis is not used haphazardly but recognized and respected as the powerful tool that it is. Although the therapist never has control of the client’s mind, the client is put into a posi- tion of vulnerability where fears and memories

are generated and are frequently charged with the same horror as they originally carried. The therapist has a responsibility to know how to contain and manage said emotions and fears while soothing and guiding the process in a healthy and empowering manner.

The Awakening

The purpose of awakening is to bring the client to full, conscious alertness, with any physical limitations that may have been suggested now removed. So, for instance, those arms that had earlier become as limp as a wet rag now must be returned to full feeling and movement. Any post- hypnotic suggestions should be repeated at this point. The client should be reassured that they feel wonderful and are fully alert. The tone of the awakening is more upbeat and moves from the quiet, soothing tones that went down deeper in tone back to the normal speaking tone, and the speed more closely approximates that of the normal speaking voice. The messages presented to the client are in the present and state the facts such as “You are starting to emerge from hyp- nosis,” “You are waking up,” “The room is get- ting brighter,” “The feeling has returned to your fingers and toes— begin to move and feel them again,” “You feel wonderful in every way,” “Take your time as you open your eyes.” These awak- ening messages are accompanied by a counting that goes up in tone. The client is told how long they have and what number the therapist will count to. They then have the sense of control. It is important to not do the awakening in a man- ner that startles the client. Any post- hypnotic suggestions should again be repeated.

The therapist should then debrief with the client after they come out of the trance, answer- ing any questions, reassuring them that all was done correctly, and ensuring that the client is alert prior to leaving the office. The therapist must clarify that the client is awake and alert enough to be able to get home safely.

Hypnosis as a Legitimate Psychotherapeutic Tool

As noted earlier, hypnosis as a legitimate ther- apeutic activity has been challenged and ques- tioned. However, many highly regarded and

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reputable research institutions and individuals do recognize and support the significant con- tribution that hypnosis makes as a therapeu- tic adjunct to psychotherapeutic techniques. Both the American Medical Association and the British Medical Association have long rec- ognized the validity of incorporating hypnotic suggestion into medical treatments in order to alleviate pain. Corydon Hammond (1990), Joseph Barber (1996), and Michael Yapko (1994) are just some of those who have writ- ten extensively on the many uses of hypnosis to relieve symptoms of psychic and physical pain. Hypnosis has proven to be a very powerful tool, but it must be used as such— as a therapeutic adjunct and not as a method in and of itself. The practitioner must be knowledgeable in appro- priate counselling techniques and relevant top- ical knowledge in order to not potentially cause further harm to the client.

Reamer, highly respected for his work on ethics and social work practice, touches on this topic when he refers to hypnosis as a nontradi- tional and unorthodox intervention. He recog- nizes that the legitimacy and validity of these unconventional methods is based on the social worker’s receiving the appropriate formal train- ing, certification, or supervision necessary to appropriately apply the technique. He further- more states that lack of adequate training “in the use of widely accepted clinical innovations— such as … hypnosis … may exacerbate clients’ emotional condition because of their unskilled application of these approaches” (Reamer, 2006, p. 191). Reamer emphasizes the need for follow- ing the procedural standard of care when using innovative and nontraditional approaches, including hypnosis— “the steps that an ordi- nary, reasonable, and prudent social worker should and would take in deciding whether to use [this] technique” (Reamer, 2006, p.  194). He includes consultation and supervision, informed consent, awareness of current rele- vant literature, and proper documenting and evaluating as steps that the social worker should follow to avoid ethics complaints, malprac- tice claims, and even criminal charges. Thus, while hypnosis is accepted and recognized as a beneficial tool, the social worker still has an obligation to exercise the ultimate standards of care to protect both the therapist and the client.

Nontraditional methods do not mean sloppy practice.

Hypnotic Induction and Suggestion

A hypnotic induction has been included here as an example to illustrate the techniques that have been discussed. It must be again empha- sized that, prior to using hypnosis, the social worker must receive proper and adequate train- ing in this technique. This script is not intended to replace that training and skill- building. The following script is taken with thanks from Clinical Hypnosis Textbook: A Guide for Practical Intervention (James, 2010, pp. 19– 22). It should be read in its entirety in a soft and calming voice as discussed. The headings, which are included in the original script, are for the convenience of the reader and not to be read aloud.

Inducing Hypnosis

Make yourself comfortable … place your feet flat on the ground … and … let your hands rest comfortably on your thighs … rest your head back … you can relax now …

and just close your eyes … let them close … and. … you can relax your eyes now … so com- fortably relax them … that they won’t bother to open at all … hey will remain … comfortably closed … comfortably closed throughout … and …

Deepening the State

I would like you to focus in on your breathing … take three deep … relaxing breaths … let them out in your own time … that’s right … and as you do … I  would like you to notice that your breathing has become deep and even … and … in a few moments’ time … I  would like you to take control of the process … and you will start this by deciding how relaxed you choose to go … you can go deep enough to access any informa- tion which will help you to make the changes you want in your life … deeply relaxed … you are in control … so ready … continue to pay attention to your breathing … and as soon as you wish you can take control of the process … you can begin a countdown … silently and mentally …

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using your out breath to time the numbers … you can start when you wish … with the number 100 … and with each breath out you count down to the next number … and with each descending number between 100 and zero … you go deeper and deeper into hypnosis … more and more in control … ever closer to the memories which can help you today … you are in control … completely in control … and as you count … you may wish to see the numbers written on the screen of your mind’s eye … some people hear their own inner voice repeating the word … it is entirely up to you … you can allow yourself to experience this process in any way you wish … because you are in control … and I want you to know that the more control you take of the proc- ess … the more you will relax … and the more you relax the more easily you can access the part of your mind which will help you … it is time for you to take control … complete control of the process … and you will find … that when you do … there may be times when you focus so hard on counting … that you forget to listen hard to the words that I  say … and there may be times when you forget to count … and that will be fine … just fine … you will pick up at the next number which occurs to you … or not at all … it really doesn’t matter … what does matter is that you will hear and remember every- thing of importance for you to hear and remem- ber … whether this is your own inner voice … or the sound of my voice relaxing you … you are in control … and as you count ever deeper and deeper … going more and more relaxed … you may even notice that the sensations in your body are changing … there may be times when you notice that you feel as if you are drifting or float- ing … but that will be fine … it is a very pleasant experience … similar to the moments between waking and sleeping … your body warm and comfortable … completely at peace.

Give the Following Post- Hypnotic Suggestions

And … now you are deeply relaxed … I  am going to teach you how to take yourself into this fully relaxed state … whenever you need it … whenever you want to take time out … and … you will find that the more deeply you can go … it is very simple … all you have to do … is find

a time and a space where you can make your- self comfortable … a place where you can make sure that there is nothing which can disturb you while you practice … but I want you to know … that if … for any reason you need to be immedi- ately alert and aware … you will be … you are completely in control … so for now … you can relax … knowing that you are able to go as deep as you like … when you do this for yourself … first of all … decide how long you want to be in hypnosis … five minutes … ten minutes … fif- teen … it is entirely up to you … your internal clock will tell you when it is time for you to wake yourself up … ten … all you have to do … is sit down or lie down … and close your eyes … take three deep breaths … and … on the last one … hold your breath for a count of three … and … let that breath go … and … as you do … allow every muscle of your body to relax … con- tinue to pay attention to your breathing … notic- ing your chest rising and falling … and be aware that any sounds or sensations around you can just fade into the background … just as they do when you drift off to sleep … you can now notice your thoughts … and let your thoughts … connect themselves to your breathing … so you can start to allow your thoughts to fade in … and out … as if connected to your breathing … and … you will soon notice … that some of those thoughts fade away completely … while others take a while … but it doesn’t matter either way … as you are going into a state of self- hypnosis … you are controlling it … and … you can now begin to count yourself deeper into this state … by using the numbers between ten and one … count on your out breath … this will help you to relax even more deeply … more and more relaxed … and … as you count down … any tension in your body fades away … any feelings you want to release … you can count down to letting them go completely … so by the time you reach the number one you will find that you have let go of any stress or tension … and can just relax … relax and think clearly …

Pause for 5 Seconds … and … once you reach the number one … you can use this time to give yourself a pos- it ive suggest ion … somet hing simple … something that will come in useful for the next 24 hours … you may wish to focus … or to be

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more motivated … or to have some extra con- fidence … keep it simple … you can do this now if you want …

Pause for 5 Seconds … then just let your mind drift … enjoy the peace … enjoy being relaxed and focused … after a little while … your internal clock will tell you it is time to wake … and to wake your- self up … all you need to do is count slowly up from one to ten … and … with each number you become more aware of your surround- ings … and feel more alert … you will wake refreshed and relaxed … and … these benefits will increase … the more often you take time to do your self- hypnosis …

… and … so it is easy for you to fit this into your day … you can do it just before you go to sleep at night … you can give yourself sugges- tions to let go of any tension or frustration from the day … so that you can fall asleep and sleep deeply and will … taking all the benefits from your sleep that you need …

… and … if you want to … you can do it in the morning … just before you are fully awake … to give yourself positive suggestions for the day … suggestions on how you are going to be confi- dent … energized and in control … you can even walk yourself through a situation which you know you have to deal with that day … and imagine yourself and completely in control … confident and at ease with yourself and your surroundings …

… you can do your self- hypnosis whenever you need it … to give yourself a rest … a boost … or positive suggestions … and the more you practice … the better you get at it … the more you improve … the more easily you will take on board the positive suggestions for change …

General Ego Strengthening

And … before I wake you … I would like you to know that when you wake you will be able to notice how much better you feel … and you will feel more relaxed … more focused … and more at ease with yourself and the world around you … you will be aware that you feel stronger … and clearer in your mind … more able to make decisions … more capable, too … and … you will find that these positive feelings continue to

grow … as the days go by … and … from now on … just before you sleep … you will be able to allow your unconscious mind to work through any of your problems as you sleep … so that you can … and you will … sleep deeply and well … and wake feeling refreshed and more positive … so positive that you will find that you can feel in control throughout the day … helping you to cope better … and to be stronger … and more able to deal with anything … anybody … any sit- uation … and as a result of this you will feel more motivated … to make the changes suggested to you today … more focused … more confi- dent, too … confident that you can change … you can take control … you can feel and be dif- ferent … altogether more positive, too …

Awakening

In a few moments in time I am going to slowly count up from one to ten … and … as I count … you will become more aware of your surroundings … more aware of the sensations in your body, too … all healthy … appropri- ate and normal sensations will return to your body … and every healthy … normal … and appropriate part of you will be back here in the present … and at the count of eight your eyes will gently start to open … and you can start to stretch your body … and at the count of ten you will be fully awake … feeling alert and focused … your body relaxed … your mind refreshed … so ready … one … two … three … becoming more aware now … four … five … six … more alert … seven … eight … open your eyes now … starting to stretch … nine … and ten … fully awake … alert … feeling refreshed and relaxed. …

Conclusion

Hypnosis can be a very powerful, yet gentle, tool. The client is able to passively listen to the therapist and enjoy the beautiful images and the relaxing and encouraging messages. Most cli- ents report enjoying the experience and awake feeling relaxed and invigorated. But at those times when the client remembers horrific abuse or re- experiences a punitive or embarrassing life episode, the social worker must know how to respond and remedy the situation so that the

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client feels nurtured and safe. As Reamer (2006) notes, unscrupulous and unethical practitioners can exploit clients for self- serving purposes. It is imperative that all who would like to use this very effective method learn the appropri- ate techniques so that clients can benefit from its very many applications. As social work con- tinues to build its unique body of knowledge, hypnosis properly used is an excellent fit and a wonderful way in which to enhance the social work skills.

References

American Psychological Association. (2000). Encyclo- pedia of psychology (A. E. Kazdin, Ed.). Washington, DC: APA and Oxford University Press.

Barber, J. (1996). Hypnosis and suggestion in the treat- ment of pain:  A  clinical guide. New  York:  W.W. Norton & Company.

Brown, D. P. (1986). Hypnotherapy and hypnoanaly- sis. New York: Routledge.

CASW. (2000). National scope of practice statement. Canadian Association of Social Workers.

Hammond, D.  (Ed.). (1990). Handbook of hypnotic suggestions and metaphors. New  York:  W.W. Norton & Company.

James, U. (2010). Clinical hypnosis textbook: A guide for practical intervention (2nd ed.). London: Radcliff Publishing.

Judgements of the Supreme Court of Canada. (2007, Feb 01). Supreme Court judgements. Retrieved Jan. 24, 2015, from Judgements of the Supreme Court of Canada: https:// scc- csc.lexum.com/ scc- csc/ scc- csc/ en/ item/ 2341/ index.do.

Kirsch, I., & Lynn, S. J. (1995). Altered state of hyp- nosis: Changes in the theoretical landscape. American Psychologist, 50(10), 846– 858.

Mullaly, B.  (2010). Challenging oppression and con- fronting privilege (Vol. 2). Toronto, ON:  Oxford University Press.

Reamer, F.  G. (2006). Nontraditional and unortho- dox interventions in social work. Families in Society:  The Journal of Contemporary Social Services, Spring(4), 191– 197.

Winsor, R. M. (1993). Hypnosis: A neglected tool for client empowerment. Social Work, 38(5), 603– 608.

Yapko, M.  D. (1994). Suggestions of abuse:  True and false memories of childhood sexual trauma. New York: Simon & Schuster.

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The first edition of The Life Model of Social Work Practice (Germain & Gitterman, 1980)  repre- sented a beginning effort to conceptualize and illustrate an integrated method of practice with individuals, families, groups, organizations, and some aspects of neighborhoods and com- munities. Two conceptual mechanisms (degree of choice and problems- in- living) were for- mulated to describe and illustrate integrated practice. Beyond conceptualizing an integrated method, distinctive knowledge and skills such as are required for forming groups or influ- encing organizations were also presented. Ecological theory provided a conceptual frame- work that offered a dual, simultaneous focus on people and environments. In the first edition, the underlying theories and distinctive knowl- edge at various system levels— individuals, families, groups, communities, organizations,

and social networks, as well as the properties of social and physical environments, were also differentiated. In the first edition, a beginning effort was also made to explicate the connec- tions between “private troubles” and “organiza- tional issues.” These emerging ideas were placed within historic and philosophical perspectives.

During the next 16  years (1980– 2006), dra- matic changes took place in our society and profession. Social workers had been increas- ingly working with profoundly vulnerable cli- ents, struggling to survive the economic and psychological consequences of poverty and dis- crimination. Practitioners were dealing with the devastating impact of AIDS, homelessness, substance abuse, chronic mental disorders, child abuse, and family and community vio- lence. Clearly, the miseries and suffering in the 1990s were different in degree and substance

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from those encountered from the 1940s through the 1980s. With “safety net” resources being dismantled, for many clients it was difficult to endure (Gitterman, 2001).

Facing these bitter realities, social workers have been expected to do more in less time with decreasing resources. More than ever, profes- sional courage, perseverance, creativity, and a widening repertoire of professional methods and skills are indispensable elements of con- temporary practice. In response to these con- temporary challenges, a revised and more fully expanded edition of Life Model responded to these pervasive social changes through four major elaborations (Germain & Gitterman, 1996). First, to be responsive to oppressed cli- ents, social workers must develop competence in community, organizational, and legislative influence and change as well as in direct prac- tice. The second edition of Life Model speci- fies methods and skills to move back and forth from helping individuals, families, and groups, to influencing communities, organizations, and legislative bodies.

Second, to effectively respond to people’s varied needs, social workers must practice at whatever levels a particular situation begins and wherever it may lead. The expanded Life Model conceptualizes and illustrates methods and skills distinct to various modalities, as well as continues to describe and specify the com- mon base of social work practice.

Third, people cope with oppression and scapegoating in many different ways. Practi- t ioners must be ca ref u l about bla m i ng oppressed people for their troubles. People’s coping styles, strengths, and resilience must be understood and supported. In the first edi- tion, the concept of “problems in living” organ- ized ideas about professional assessment and interventions. Unwittingly, this formulation may have implied a deficit in the individual and collectivity. In the second edition, a more neutral stressor- stress- coping paradigm was substituted.

Finally, social workers must be sensitive to people’s diverse backgrounds. Stage mod- els of human development assume that social and emotional development follow in fixed, sequential, and universal stages. In subsequent editions, a “life course” conception of human

development replaced the traditional “life cycle” models (Germain, 1990).

In the 19  years since the publication of the second edition, further dramatic changes have taken place in society, and, consequently, in the profession. The third edition (Gitterman & Germain, 2008)  takes into account these per- vasive changes and presents a more fully devel- oped “life- modeled” practice. While retaining and refining the core of the previous work, new concepts and new content are presented. This edition provides social work practitioners and students with the necessary knowledge base and practice guidelines to deal with the many professional, societal, theoretical, empirical, and ethical issues they face. In this edition, a new chapter traces social work practice and its historical traditions from its roots in the char- ity organization societies and settlement house movement, to the development of professional methods, to the current social context that affect people’s lives (global economy, immigration, the role of the federal government, new legis- lation, and cultural and technological changes). The chapter also explores current professional developments such as managed mental health care, practice outcomes and evidenced- based practice, and their respective influences on contemporary practice (Gitterman & Knight, 2013). Another new chapter, “Assessment, Practice Monitoring, and Practice Evaluation” discusses assessment tasks common to all prac- tice approaches as well as a few underlying distinctive ideas to life- modeled practice. The chapter also examines the tasks and skills of practice monitoring as well as the strengths and limitations of different research designs used to evaluate practice outcomes. Ecological the- ory continues to provide concepts that illumi- nate the continuous exchanges between people and their environments. In this edition, people present new concepts from deep ecology and eco- feminism.

Human Ecology

In the revised Life Model, the ecological meta- phor is broadened and deepened and continues to provide the lens for viewing the exchanges between people and their environments. Ecology, a biological science, examines the

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relationship between living organisms and all the elements of the social and physical environ- ments. How and why organisms achieve or fail to achieve an adaptive balance with their envi- ronments are the major questions of ecological inquiry. Deep ecology and ecofeminism deepen and enhance our understanding that all phe- nomena are interconnected and interdependent as well as dependent on the cyclical processes of nature (Besthorn, 2012; Besthorn & Canda, 2002; Besthorn & McMillen, 2002; Bloodhart & Swim, 2010; Drengson, Devall, & Schroll, 2011; Gitterman & Germain, 2008; Kopnina, 2014; Mack- Canty, 2004; Norton, 2012; Putney, 2013; Phillips, 2014; Stephens, 2012; Stephens, Jacobson, & King, 2010; Twine, 2010; Ungar, 2002). Ecological theory, with its evolution- ary, adaptive view, continues to provide the theoretical foundation for life- modeled prac- tice (Germain & Gitterman, 1986, 1987, 1995; Gitterman, 2008a, 2013).

Person: Environment Fit

Over the life course, people strive to improve their level of fit with their environments. When people feel positive about their own capaci- ties and hopeful about having their needs and aspirations fulfilled, and when they view their environmental resources as responsive, they are likely to achieve a reciprocally sustaining condition of adaptedness. Adaptive person: environment exchanges reciprocally sup- port and release human and environmental potentials.

However, when perceived environmen- tal and personal limitations are fueled and sustained by oppressive social and physical environments (e.g., racism, sexism, homo- phobism, ageism, unemployment, pollution), consequences range from heroic adaptation to impaired functioning, to parasitic exploitation, and to individual and collective disintegration. In coping with toxic environments, some peo- ple mobilize inner strengths and resiliency to steel themselves against non- nurturing envi- ronments— to be survivors rather than victims (Gitterman, 2001, 2014). Others internalize the oppression and turn it against themselves through such self- destructive behaviors as sub- stance abuse and unprotected sex. Still others

externalize the oppression, strike back, and vent their rage on others less powerful than they through such behaviors as violence, crime, and property destruction. Readily accessible targets often include family members, neigh- bors, and community residents. Dysfunctional person: environment exchanges reciprocally frustrate and damage both human as well as environmental potentials.

In dealing with environmental demands, people appraise the adequacy of their envi- ronmental and personal resources. Stress is the outcome of a perceived imbalance between environmental demand(s) and one’s ability to manage it with available internal and exter- nal resources. To relieve the stressful situa- tion, the level of person: environment fit must be improved. This is accomplished by an active change either in people’s perceptions and behaviors, or in environmental responses, or in the quality of their exchanges.1

The Environment

Person– environmental exchanges are dynamic rather than fixed processes. Ecological the- ory emphasizes the reciprocity of person– environmental transactions through which each influences and shapes the other over time. People need to receive from their environment the resources essential for development and sur- vival. Reciprocally, the environment needs to receive the care necessary for its evolution.

The environment consists of social and phys- ical layers. The former consists of the social world of other human beings, ranging from intimate social networks to bureaucratic insti- tutions. The physical layer consists of the nat- ural world inherited by human beings and the constructed/ built world of human structures, the space, which supports, contains, or arranges the structures, and the temporal rhythms, fluc- tuations, and periodicities of environments and of human biology (Gitterman & Germain, 2008; Gitterman (2008b, 2015).

Complex bureaucratic organizations, a salient feature of the social environment, are prevalent forces in contemporary life. Health, education, and social service organizations profoundly affect most people’s lives. In order to carry out its social assignment, an organization develops

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a mission and evolves structures (e.g., division of labor, chain of command, policies and proce- dures) to carry out its operations. While organ- izational mission and structures are essential to service delivery, they simultaneously create ten- sions and conflicts for professionals and service recipients. For example, an organization’s divi- sion of labor integrates roles, minimizes dupli- cation, maintains accountability. At the same time, these differential role assignments create vested interest in protecting one’s own turf, and other mischief. Organizational and client needs can be held hostage by turf interest.

Political, economic, and cultural forces affect organizational missions and structures. Economic, social, and bureaucratic forces con- spire to block access and quality services for vulnerable and oppressed people. Politicians redefine the failures of the economy as behav- ioral and personality defects of public assis- tance recipients. Funding sources expect mental health agencies to diagnose and pathol- ogize community residents rather than to view and assist them as residents experiencing life stressors.

Social networks, also a salient feature of the social environment, consist of kin, friends, neighbors, work mates, and acquaintances. Supportive linkages provide essential instru- mental (goods and services), expressive (empa- thy, encouragement), and informational (advice, feedback) resources. They serve as essential buffers against life stressors and the stress they generate.

Not all people are able or willing to use available social supports. Some minimize, negate, or deny their difficulties or their need for assistance. Others, while aware of their life stressor(s), are unable to ask for assistance. Self- esteem issues and shame from negative social comparisons may account for their reluctance. Still others are inhibited by their needs for privacy.

Not all networks are able or willing to pro- vide available social supports. Loosely knit networks may be unaware of members’ difficul- ties. Lacking sufficient contact, a member’s dif- ficulties remain invisible. Some networks have insufficient resources to meet their members’ varied needs. Their resources are too stretched out to incur additional instrumental burdens.

Still others withhold available resources for such reasons as selfishness and punishment (Gitterman & Germain, 2008).

Some networks provide resources, but have a negative impact on recipients. Some reinforce deviance, such as drug and gang networks, by supporting dysfunctional behaviors and sabotaging more functional coping behaviors. Networks may also scapegoat and reinforce negative self- esteem. Exploitative and para- sitic behaviors undermine a member’s sense of well- being.

Life events such as sickness and death, job mobility and loss, marital separation and divorce, dissolve linkages to significant others. Social and emotional isolation are devastating experiences. Without viable networks, people are deprived of life- sustaining instrumental and expressive supports. Widowers who lose social ties maintained by their wives, and peo- ple suffering from chronic mental illness, suffer from impoverished networks.

The ecological concepts of habitat and niche are particularly relevant for understanding the environment’s impact on us (Gitterman & Germain, 2008). Habitat refers to places where organisms are found, such as territories and nesting places. People’s spatial behaviors are mediated by the texture of space, and by their age, gender, sexual orientation, culture, socioec- onomic status, and experiences. The exchanges between people and their habitat take place within the context of personal space, semi- fixed space, and fixed space.

Personal space refers to an invisible spatial boundary that we maintain as a buffer against unwanted physical and social contact and to protect our privacy. Since the boundary is invis- ible, two or more people must negotiate a mutu- ally comfortable distance. When less distance is transacted than desired, people experience crowding and intrusion and react either with subtle physical gestures or with pronounced withdrawal, or with aggression. When more distance is transacted than desired, people feel the unpleasant state of disengagement and either withdraw or pursue greater intimacy. Since the amount of desired space is influenced by many individual and social factors, it car- ries the potential for misperception, misunder- standing, and stress.

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Semi- fixed space refers to moveable objects and their arrangement in space. Furniture, floors, curtains, paint, decorative figurines, paintings, and lighting provide spatial mean- ings and boundaries. People rely on environ- mental props (doors, locks, gates, fences, signs) to regulate interactions with others and to pro- tect their territory within their living dwell- ing and with the outside world. In families, for example, whose members share limited space, the degree of interpersonal coordina- tion required and the structural limits to pri- vacy create stress. The close proximity, social overload, and spatial constraints are potential sources for interpersonal conflict.

The design of immovable objects and their arrangement in space, fixed space, have a pro- found impact on the quality of life. The high- density (i.e., limited space with a large number of people using it) structure and design of high- rise low- income housing, for example, creates unpredictable and indefensible spaces. With limited control over such public areas as eleva- tors, hallways, and lobbies, these spaces rep- resent dangerous threats to survival and are associated with feelings of withdrawal, aliena- tion, and dissatisfaction.

Habitat also consists of the natural world of climate and landscape, water sources, quality of air, and animals and plants. The natural world provides the resources essential to the sur- vival of all species. However, lack of attention to preservation of the natural world and care- less, destructive abuse of our natural resources endanger us. Exploitative power by dominant groups creates technological pollution by cor- porations and government agencies of our air, water, soil, and food. Toxic materials are toler- ated in disadvantaged neighborhoods, work- places, and schools. Beyond supplying resources essential to survival, the natural world also lends special meaning to everyday life. Human beings have a need for a sense of kinship with nature, arising out of our evolutionary heritage. The kinship is expressed in our joy of pets and plants, our pleasures from walks in the park and swims in the ocean. Pets, for example, serve numerous functions such as companionship and protection.

In ecology, niche refers to the status occu- pied in a community’s social structure by its

individuals and groups. Because dominant groups discriminate on the basis of personal or collective characteristics such as color, gender, sexual orientation, socioeconomic status, physi- cal or mental condition, many people are forced to occupy niches that limit their opportunities, rights, and aspirations. Dominant groups coer- cively use power to oppress and disempower vulnerable populations, creating and maintain- ing such “social pollutions” as poverty, chronic unemployment, lack of affordable housing, inadequate healthcare and schools, institution- alized racism and sexism, homophobia, and bar- riers to community participation by those with physical or mental disabilities. Communities of people are placed in marginalized, stigma- tized, and destructive niches such as “welfare mother,” “ex- addict,” “ex- con,” “the underclass,” “homeless,” “borderline,” and so on.

Individuals, Families, and Groups

Over the life course, individuals, families, and groups experience unique developmental pathways.2 Diverse human experiences create distinctive transactional processes that occur and recur at any point in the life course. These developmental processes take place within the context of historical, social, and individual time. People born at the same period of time— birth cohorts— experience common formative influences, which have a profound effect on their opportunities and expectations. Because birth cohorts live through a different historical time and social forces, they undergo develop- mental processes of growing up and growing old differently from other birth cohorts. For example, the Depression of the 1930s, World War II in the 1940s, the civil rights movement and War on Poverty of the 1960s, the Vietnam War of the 1970s, the terrorist act of September 11th, wars in Iraq and Afghanistan, and the dramatic economic changes of the 2000s dif- ferently shaped the experiences and expecta- tions of the respective birth cohorts. Each birth cohort was deeply affected by its generational events.

The timing of collective life issues in a family, group, or community also influences individ- ual bio- psycho- social development; i.e., social time. For example, in contemporary society,

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less predictable timetables exist for beginning and completing school, leaving home, remain- ing single or marrying, having a child, begin- ning a new career, retiring, etc. Similarly, family cultures may have different timetables for male and female developmental expectations. These collective experiences also affect people’s experi- ences over the life course.

Within the context of historical and social time, people construct their respective meaning from life experiences. Personal constructions or narratives, individual time, also profoundly influence human development. Essentially, a life course view emphasizes understanding the impact of historical, social, and individual per- spectives and sensitivity to the differences in human development.

Over the life course, individuals, families, and groups deal with external life stressors and their associated demands (Lazurus & Folkman, 1984). A  life stressor(s) (e.g., job change or loss, separation and divorce, death and dying, chronic and acute illness, interpersonal con- flict, etc.) creates demands for the individual as well as the collective. When we appraise a stressor(s) as exceeding our external and/ or internal resources to deal with it, we experience stress (manifested physiologically and/ or emo- tionally). Stressful reactions and feelings range from unpleasant, to disquieting, to immobiliz- ing. Intensity is determined by dimensions of the actual stressor(s), its meaning to the indi- vidual and the collective, and the availability of environmental supports.

When confronting a life stressor, a process of conscious or unconscious primary appraisal takes place by which people ask themselves, “What’s going on here?” “Can I  deal with it?” “Is this a challenge I can manage or is it a cur- rent or future threat of serious harm or loss?” (Lazarus, 1980). People appraise a life stressor as a challenge rather than a threat when they believe they have sufficient personal and envi- ronmental resources to master it. Although a perceived challenge might be stressful, feel- ings of excitement make adrenaline flow, and anticipated mastery prevails. In contrast, an appraised threat of harm and loss creates feel- ings of vulnerability and risk. One person’s threat is another person’s challenge. The inter- play of cultural, environmental, and personal

factors as well as past experiences affect pri- mary appraisal processes.

When a life stressor is perceived as a threat, a process of secondary appraisal takes place when people ask themselves, “What can I do about this situation?” At this moment, they launch their efforts to cope with the stressor. Coping meas- ures primarily consist of efforts to manage their feelings and/ or to use personal and environmen- tal resources to manage the stressor(s). Personal resources include problem- solving skills, flex- ibility, motivation, belief systems, resilience, optimism, and self- esteem. Environmental resources include informal social supports such as family, friends, neighbors; public and private social agencies, and various institutions; and the build and natural dimensions of the physi- cal environment. The two interrelated functions of coping— problem- solving and management of feelings— have an interesting reciprocal rela- tion to each other. In many coping responses to stressful person– environment encounters, the two functions may proceed together. However, in the early, acute phase of very severe stressors in particular, it may be difficult to proceed with problem- solving until intense negative feel- ings are brought under some degree of control. Otherwise the feelings are apt to immobilize problem- solving efforts. But such feelings may be difficult to control until the person has expe- rienced some degree of progress in the begin- ning steps of problem- solving. A saving grace in this seeming paradox is an ability to cope with the life stressor by unconsciously blocking out negative feelings temporarily in order that some problem- solving can begin. This is frequently seen in the unconscious denial (defense) of peo- ple who have suffered a grievous loss or harm.

When their coping efforts are effective, peo- ple experience a sense of relief. When coping efforts fail, physiological and emotional strains are intensified, which can lead to augmented coping efforts, immobilization, or dysfunc- tional physical, emotional, and social responses. Dysfunctional responses generate more stress- ors in a downward spiral toward deterioration and disintegration. For example, a terminated romance may trigger a reactive depression. To cope with feelings of abandonment and hope- lessness, a person may turn to alcohol to numb the pain. The dependence on alcohol may then

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create additional stressors at the workplace and with other relationships.

The Life Model

Professional Function

Direct Practice Level The professional function as defined by the Life Model is to improve the level of fit between people’s (individual, family, group, community) perceived needs, capacities, and aspirations and their environmental supports and resources. Through processes of mutual assessment, a social worker and service recipient(s) determine the practice focus, choosing to:

1. Improve a person’s (collectivity’s) ability to manage stressor(s) through more effec- tive personal and situational appraisals and behavioral skills;

2. Influence the social and physical environ- ments to be more responsive to a person’s (or collective’s) needs; and

3. Improve the quality of person: environment exchanges.

When people are helped to change their percep- tions, cognitions, feelings, or behaviors, their ability to manage a stressor(s) is improved, or its adverse impact may be reduced. By effectively influencing environmental responsiveness, peo- ple gain access to desired support and resources, and, in turn, they develop greater control over their lives. Finally, when the exchanges between people and their environments are improved, both actively adapt to the needs and demands of the other.

Community, Organizational and Political Levels Social workers in practice today deal with pro- foundly vulnerable populations, overwhelmed by circumstances and events they feel power- less to control. On a daily basis, social workers are bombarded and reminded of the devastat- ing assault on our clients and the dismantling of entitlements and services. The poor (par- ticularly of color), the sick, the children, the immigrants are blamed for their plight and held to pay for the excesses of the affluent in our

society. The anger, the alarm, and the despair intensify as people anticipate the suffering that lies ahead and the inhumanity that permits such injustices.

Corporate and other special interest lobbies assure a widening gap between the poor and the wealthy, as the poor become poorer, the wealthy become wealthier. The gun lobby and polluters reign supreme. While influential voting blocs receive government subsidies, the “safety net” established to mitigate and cushion economic forces is being brutally reduced. Martin Luther King, Jr., mordantly observed that our society preaches socialism for the rich and rugged indi- vidualism for the poor.

When community and family supports are weakened, social deterioration increases the risk of personal deterioration. The task of provid- ing direct services to vulnerable and oppressed populations becomes progressively more dif- ficult to fulfill. Within this social context, our professional function must include involvement at the community, organizational, and political levels. In Life- Modeled practice, professional function includes:  mobilizing community resources to improve community life; influenc- ing organizations to develop responsive policies and services; and politically influencing local, state, and federal legislation and regulations.

In this way, the historic polarity of cause versus function (Lee, 1929)  is replaced with a contemporary melding of cause and function as an essential part of Life- Modeled practice (Schwartz, 1969). Historically, the profession experienced interpersonal and ideological con- flicts between those who emphasized bringing about social change in behalf of social justice, the “Cause,” as the primary characteristic of social work, and those who emphasized “func- tion” as the primary characteristic of social work practice; that is, the technologies used by practitioners to bring about individual change. In reality, however, a cause won requires a func- tion (technology, services, and programs for individuals, families, and groups) to carry it out. A  further and specific technology (organ- ization and political advocacy) is required for successfully winning a cause. Clearly, both cause and function must be hallmarks of prac- tice and education for practice if social work is to ready itself for the new century.

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Problem Definition (Person: Environment Exchanges)

How a stressor is defined largely governs what will be done about it. If, for example, the source of a painful life issue is believed to be inter- nal and defined in psychological terms, a dis- ease model will psychologically guide social work interventions. Goals will refer to internal change through gaining psychological insight.

For example, Billy does not pay attention in school, and the school threatens to transfer him to a special school. Organic disability has been ruled out and the life issue is defined as an emotional disturbance. This emphasis on psy- chopathology leads to a linear, dichotomized view of the child and his environment. He has an internal disorder that requires psychological “excision.” He and his mother might be viewed as having symbiotic difficulties in separating, so Mother is added to the treatment program. Different therapists might treat the mother and child. Help exclusively focuses on psychologi- cal processes. Little or no attention is given to school, social networks, and neighborhood con- ditions that might contribute to the life stressor.

Similarly, if Billy is viewed through a cog- nitive behavioral lens, the emphases will be on teaching and rewarding more adaptive behav- iors and extinguishing maladaptive behaviors. This view will also encourage a dichotomized child- and- environment association. The entire responsibility and burden for change is placed on the child.

If life issues are defined as rooted in social pathology, then intervention is likely to be con- ceived in social- institutional terms, on a social action. Goals will refer to external change, and the practice method will be primarily case or class advocacy. In advocating for Billy, his right to stay in school may be won. He can stay in school, but the life issues that had kept him from learning in school may still remain. However, in Life- Modeled practice, the social- pathological definition does not preclude individual attention to Billy and his mother as well as to advocacy.

If life stressors are defined as disharmonious person– environment exchanges, then interven- tions are likely to be conceived as improving the level of fit between Billy and his environments. Goals will refer to reducing or eliminating the

life stressor if possible, strengthening coping skills, and acquiring environmental instrumen- tal and emotional resources.

Psychologically oriented skills will be directed to progressive forces in the personality or their development. These include sensory- perceptual capacities, positive emotions, and thinking and problem- solving abilities. Supports in the orga- nizational and network fields and physical set- tings will be mobilized and used. If needed, the work will include increasing the responsiveness of the organization affecting the client, including the worker’s own agency.

In Billy’s situation, depending on the source(s) of the stressor(s), several separate or joint entry points into the person– environment field might be possible for effective help:

1. If the stressor arose from Billy’s difficulty with the life transition of adapting to a nourish- ing school environment, help is directed to improving his coping skills through individ- ual or group (other boys in a situation similar to Billy’s) modality (Gitterman & Shulman, 2005).

2. If the stressor arose from the family’s dysfunc- tional patterns, help is directed to modifying those patterns with the family or a few families experiencing a similar stressor (Wise, 2005).

3. If the stressor arose from dysfunctional exchanges between Billy and family and school, help is directed on an individual, family, or group basis toward removing bar- riers in their communication and stimulat- ing mutual problem- solving.

4. If the stressor emerged from the social struc- ture and climate of Billy’s classroom, the social worker and teacher could undertake class- room meetings. Such meetings are designed to help the children (and teacher) learn to express their feelings and ideas about their shared experiences. Such an approach would not only help Billy, but on a preventive level it could be helpful to all the children and to the teacher by reducing scapegoating by the children, biased responses and expectations held by the teacher, or other dysfunctional exchanges.

5. If the stressor came forth from a lack of after- school resources, the worker could try to help the school obtain a grant and develop a program.

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6. If the stressor converged from Billy’s con- cerns about overcrowded classrooms, unsafe school bathrooms, or fears of walking past the neighborhood drug users and dealers or assaultive teenagers on his way to school, his parent(s) could be helped to join with other concerned neighborhood or community par- ents in approaching the school, police, and local legislatures, in order to improve school conditions and to gain safe school routes.

This analysis is purposively oversimplified to highlight the varied practice options emerging from the Life Model’s broad focus on person– environment exchanges. In reality, Billy’s stress most likely arose from multiple sources. Sometimes effective work on one stressor sup- ports coping with others. Other times, work is directed to two or more stressors (guidelines for appropriate focus are discussed later).

The major point is:  a social worker using a Life Model conceptual lens is more likely to “see” diverse points of entry into a complex situation and less likely to fit a client into a narrow theo- retical construction. Our practice theories and models must be responsive to people and their situations rather than fitting their life issues into our own theoretical and practice preoccupations and biases. Similarly, a worker’s specialization in individual, family, group, or community practice should not determine what service is provided, but rather the received service should be based on applicant/ client needs and preferences.

Life Stressors Schema

Over the life course, people must cope with three interrelated life issues:  difficult life tran- sitions and traumatic life events, environmen- tal pressures, and dysfunctional interpersonal processes. Although these three life stressors are interrelated, each takes on its own force and magnitude and provides focus to practice with individuals, families, groups, communities, organizations, and politics.

1. Difficult life transitions and traumatic life events:  Life transitions include biologi- cal as well as social changes. The physical and biological changes of infancy, child- hood, puberty, adolescence, adulthood, and advanced age are universal. While these

changes are universal, social expectations and patterns associated with the changes vary across cultures. For example, puberty is a biological condition; adolescence is a social status.3 Biological factors associated with pubertal changes elicit changing responses and demands from the environment of fam- ily, school personnel, and peers.

People also experience stress from entering new experiences and relationships and leaving familiar ones. Beginnings (entrances) generate stress. Entering a new neighborhood, school, relationship(s), or job; having a baby, or acquir- ing a new diagnostic label are filled with ambi- guity, new role expectations, and challenges. Leavings (endings) are usually more stressful than beginnings. Ending an intimate relation- ship through separation or death, losing a job, leaving a school, separation from a child or parent are characterized by painful loss and change. Unexpected life transitions are more stressful than expected ones. Similarly, when life entrances and exits come too early or too late in the life course, they are likely to be stressful. For example, a young adolescent who becomes a parent, and an older grandparent who has pri- mary responsibility for parenting, may find that the timing of the experience creates additional stress. The abruptness, enormity, and immediacy of traumatic life events cause personal crises and long- lasting residue of pain. Unexpected death and illness, the violence of rape, displacement caused by natural disasters, loss of a cherished home or job can be overwhelming and immo- bilizing. Severe physical, psychological, and/ or social loss is a primary characteristic of trauma.

2. Environmental pressures: The social and phys- ical environments provide essential instru- mental resources and emotional support to the tasks of daily living. They also create significant troubles and distress. For some individuals and collectives, organizational and informal network resources are available, but they are unable to access or use them. For others, organizational and network struc- tures and functions are unresponsive to their personal styles and needs. And for still oth- ers, important organizational and network resources are unavailable, and their basic

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needs remain unmet. Similarly, the physical environment’s natural and built resources may be available, but some people are unable to use them. For others, available physical resources are unresponsive to their styles and needs. And for others, basic natural and built resources are extremely minimal.

3. Dysfunctional interpersonal processes:  For conceptual clarity and consistency, inter- personal processes apply only to when the social worker is involved with a family/ group system or subsystem. If a social worker, for example, is working with an abused woman, but not with the partner, the focus is on life- transitional concerns (e.g., separation, grief) and/ or environmental concerns (e.g., linkage with community resources, negotiating with her partner, securing a court order of protec- tion). In contrast, a focus on dysfunctional interpersonal processes requires joint work with both partners and/ or the children.

In responding to life- transitional and envi- ronmental stressors, the family and group serve as resources and buffers. However, problematic internal family or group relationships and com- munication patterns exacerbate existing stress and/ or become yet another painful stressor in people’s lives. Dysfunctional family and group processes are expressed in such behaviors as scapegoating, rigid alliances, withdrawal, and hostility. While dysfunctional for individual members and the collective, these behaviors may maintain an illusion of functioning and the collective’s continued existence. For example, scapegoating may stave off disorganization in the family or group at the expense of the indi- vidual member. These behaviors become fixed and obstruct potential for mutual support.

Similar dysfunctional processes arise between social workers and clients in the form of discrepant expectations, misunderstandings and misperceptions, value conflicts and differ- ences in backgrounds (Gitterman, 1983, 1989, 2012). These processes interfere with the helping process and create additional stress for clients.

Case Example

A life stressor often generates associated stressors. When it or they are not successfully managed or

resolved, additional stressors erupt (the “spread phe- nomenon”). For example:  Ms. Northern, the man- ager of a single mothers’ residence, referred Marcia, a 23- year- old African American single mother of a two- month- old daughter, Denise, to Family Services. Marcia had been living in the residence for the previ- ous six months, and remaining there was made con- ditional on her accepting the referral to the agency. In the first session, she expressed anger at Ms. Northern for forcing her to come to the agency and blaming her for all the arguments and fights in the residence. At the same time, she wanted help with the stress in her life— particularly being a single parent and her new role as a mother. She said that at times she was overwhelmed and even angry at Denise “for being so needy.” People mutually agreed to focus on three interrelated stressors:

1. She haCh the life transition from living with a part- ner to living as a single parent;

2. She had to deal with problematic environmental transactions with the residence manager and the other residents; and

3. She had to secure permanent housing. 4. A fourth stressor evolved from our work; namely,

her distrust and testing of me (and my reactions).

The life- transitional stressor centered on Marcia’s entry into motherhood and becoming the sole care- taker and responder to the unrelenting demands of a young infant. Marcia’s history fed ambivalence about her single- mother status and its associated roles. She was placed in foster care at age seven, moved from home to home, and lost contact with her mother at the age of 13. While she felt rage at her mother for not wanting her (“I’ll probably forgive my mother someday, but right now I’d like to kill her even though she’s already dead”), she was trying to forgive her because she recognized that her mother was a “victim of the system.” Soon after giving bir th, she looked for a job and child care with minimal suc- cess. She stated, “I feel stuck, isolated, like I have no life of my own…  . I  can’t get off welfare without a job; I  can’t get a job without child care; and I  can’t afford child care while on welfare.” Marcia felt caught in a “vicious circle” that made her want to “throw off all responsibility.”

Marcia’s ambivalence was evident in her vac- illation between poignantly questioning whether Denise’s needs exceeded her ability to give; and vehemently asser ting that she would sell her body, if she must, to keep Denise happy, safe, well- fed, and with her. When Marcia perceived herself to be

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a capable mother, she was responsive to Denise. However, when the urgency of Denise’s needs con- flicted with Marcia’s needs, Marcia became over- whelmed with the depth of her own unmet needs. Marcia’s pain became more intense and intolera- ble. At these moments, she impulsively responded to Denise with anger and impatience. Incidents the worker observed during a couple of sessions illus- trate life- transitional stress:

1/ 11: Denise started to fret a little bit. Marcia responded by talking to her in a non- stop, repetitive manner. Denise tried to follow her mother’s erratic cues, but looked helpless and confused. She began to cry, and Marcia jammed a bottle in her mouth, which began to leak all over. Marcia swore and her anger became overt. Denise began to choke on the milk, and Marcia, trying to control her anger, set Denise on her lap, vigorously patting her back. When Denise regurgitated, Marcia scolded her. She seemed really furious and made a few half- hearted attempts to smooth her rage away by calling Denise by various pet names, and telling her that she was loved.

1/ 25:  At the end of the session, Marcia yelled at Denise, “What the fuck?! … What did you do now? … I  can’t believe this! … Guess what, smarty pants, I  brought another set of clothes— na! na!” Marcia continued to swear and became increasingly agitated, bor- dering on rage, that Denise had soiled her dia- per. She was again talking to Denise non- stop, finally yelling, “And that fucking bastard of a father you have is a good for shit.” She contin- ued talking to Denise as she angrily unsnapped her clothes, saying “stinky, stinky, stinky… .”

Marcia felt that Denise, like the rest of the world, was unfair and taking advantage of her. With unre- solved feelings of being abandoned by her family and by Denise’s father, pressures of being a single parent (“I’m tired … I’m hungry … I hardly got to wash my face today”), and insufficient environmen- tal suppor ts and resources, Marcia was unable to be predictable and consistent with Denise. With so many of her own needs unmet, Marcia’s had diffi- culty viewing Denise as a separate human being with separate needs.

Severe environmental pressures exacerbated Marcia’s difficult life transitions. Marcia lived well below the pover ty line, receiving Aid for Families with Dependent Children (AFDC), Medicaid,

and food stamps benefits. She considered her- self homeless— having a maximum of six months left at the residence before she must leave. She fur ther stated that Ms. Nor thern “kept holding it over me that she can kick me out.” She added with bravado, “I am a survivor— I am not going to take shit from anybody,” least of all Ms. Nor thern and the other “girls” in the residence. With nei- ther sufficient income nor the necessary child care to suppor t herself and Denise, Marcia was feeling increasingly hopeless about getting off welfare. Her relationship to her last foster parents represented the single most enduring relationship in Marcia’s life. She described them as “my friends when I  need them.” Outside of her ties to her foster family, her social network was negligible. She complained that she had no friends, that she pushed people away without realizing it. Finally, she had severed all ties with the remainder of her biological family, many of whom lived nearby, because “I can’t forgive them for refusing to take me and my sister and brothers in when my mom caved in.”

Marcia’s environment was fraught with severe limitations:  chronic racial prejudice and discrimina- tion, lack of affordable housing, limited employment opportunities, unavailability of childcare services, Denise’s father’s heroin addiction, cohabitation with several other young women and their babies, demand for conformity to house rules, a limited social net- work, and finally, the unceasing and ever- present responsibility for being the sole caretaker of an infant. These environmental stressors combined, and acted independently, to lessen significantly Marcia’s ability to tolerate the demands of new motherhood, which had radically changed her life. The social environ- ment only served to exacerbate Marcia’s emotional and social neglect and profound sense of despair and worthlessness with which she probably had struggled with since childhood.

In working together, interpersonal stress also developed between Marcia and me, the social worker. Marcia vacillated between viewing me as a suppor tive listener and advisor, and as an author- ity figure not dissimilar from Ms. Nor thern, who “sat in judgment” of her. In the second session, she commented, “I’ve got to do the political thing, and that’s why I’m here— I’ve got the picture. …” Beyond the obstacle posed by a mandated ser v- ice, Marcia’s and my differences in race, social class, and level of education contributed tension in our communication.

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Assessment

Throughout the helping process, social work- ers make decisions about such issues as points of entry in the person– environment field, goals and tasks, practice modality, methods, time arrangements, and life stressor(s) focus. Professional judgments are made at any moment in time about which messages to explore (probe, chase) or when to respond with information and advice, or when to point out contradic- tions between verbal and nonverbal communi- cation. Similarly, during and after each session, social workers make decisions about focus and next steps. These professional judgments must be based on disciplined reasoning and infer- ences within the context of sensitivity to differ- ences related to values, beliefs, and perceptions derived from one’s social class, race, ethnicity, religion, gender, sexual orientation, age, and mental and physical states.

Valid and reliable decisions rest on three assessment tasks:  collecting, organizing, and interpreting data. First and foremost, profes- sional judgments are based on collected data. To help an individual, family, or group with life stressors, workers and applicant(s)/ client(s) examine available salient information. Salient data include:  the nature of the life stressors and their severity; the person(s)’s perceptions of and efforts to deal with the stressors; the person(s)’s perceptions of the role of family, networks, organizations, and features of the physical environment in cushioning and exac- erbating the stressors; and expectations, if any, of the agency and social worker. Mutuality in stressor definition and collection of other rele- vant data actively engage applicants/ clients in developing with the worker a common focus and direction. These data are collected from the person(s)’s verbal accounts, the worker’s observations of nonverbal responses, signif- icant others’ verbal and nonverbal responses (obtained only with applicant’s/ client’s informed consent), and written reports (also obtained only with the person(s)’s informed consent).

Many applicants/ clients are affected by over- whelming life stressors. Harsh environmental realities, multiple stressors, and the associated pain understandably overwhelm practitioners.

A  schema helps a practitioner to organize data. The life- stressor formulation (i.e., difficult life transitions and traumatic life events, environ- mental pressures, and dysfunctional interper- sonal processes) provides a tool for grouping and organizing data (see the case example of Marcia).

The life stressor schema also provides moment- to- moment assessment guidelines for professional interventions. For exam- ple, at an early moment in the third session, Marcia complained about her loneliness. At this moment, the social worker had to assess whether Marcia was asking for help in explor- ing her grief associated with developmental transition and losses. Or was she focusing on the lack of social connections in her life and asking for help with reaching out to organiza- tions and social networks? Or was she at this particular moment indirectly voicing some degree of dissatisfaction with the worker’s pace or style of helping? At each moment, the worker had to assess with Marcia whether she was asking for help with life- transitional, envi- ronmental, and/ or interpersonal stressor(s). From moment to moment, Marcia might change her focus and the social worker must skillfully follow her cues.

The final professional assessment task is to interpret the collected and organized data. To be valid, professional inferences must be rooted in disciplined inductive and deductive reasoning rather than in personal values and biases. Using inductive reasoning, social workers engage applicants/ clients in patterning and developing hypotheses about their person– environment exchanges, particularly the level of fit between personal strengths and limitations and envi- ronmental supports and obstacles. Deductive reasoning is more of a professional and less of a mutual process. The social worker applies rele- vant theory and research findings to person(s)’s life situation(s). For example, knowledge about post- traumatic stress disorder may help a social worker better understand a person’s reactions to an unexpected life stressor.

The assessment tasks of collecting relevant information, its systematic organization, and the analysis of data are common to most prac- tice approaches. However, several beliefs and goals are distinctive to the Life Model.

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1. Engaging participation of applicant/ client in the assessment process and developing mutual understanding,

2. Understanding the nature of person(s)– environment exchanges and the level of fit between human needs and environmental resources is the core assessment task,

3. Using the life stressor schema to organize and assess data, and

4. Emphasizing moment- to- moment assessment.

Intervention (Modalities, Methods, and Skills)

In helping people with their life stressors, the social worker may be called on to intervene at the individual, family, group, community, social network, organization, physical environ- ment, or political level(s). Social workers must competently work within all modalities, mov- ing from one to another as situations require. In life- modeled practice, mutual assessment of life stressors and the level of person– environment fit determine the selection of modality, rather than professional specializations and preferences.

Based on a belief that many professional methods and skills are common to most modal- ities, the Life Model emphasizes an integrated perspective on practice. A  few formulations are particularly helpful in presenting common practice methods and skills. Life- Modeled practice is, like life itself, phasic. Its processes constitute three phases:  the initial, ongoing, and ending. These phases provide a structure for conceptualizing and illustrating common professional methods and skills. However, in actual practice, these phases are not always dis- tinct; they often appear, recede, and overlap. For example, in brief and episodic work, the tem- poral limits collapse the phases. Similarly, all beginnings are affected by past endings.

In the initial phase, the auspice of the service rather than the modality differentiates com- mon professional methods and skills. Thus, a person(s)’s degree of choice (whether the service is sought, offered, or mandated) integrates prac- tice modalities. For example, when a service is offered, the social worker begins by identifying her/ his organizational auspice and role and pre- senting a clear offer of service, which takes into account people’s perceptions and definition of

their needs. The skills of offering a service are common to work with all modalities. Similarly, the life stressors schema supports an integrated practice related to assessment of, and interven- tions in, life- transitional, environmental, and interpersonal issues.

While emphasizing the common base of social work assessment and interventions, the Life Model also examines the methods and skills specific to each practice modality. For example, in offering a group service, the practitioner must have distinctive knowledge and skill in group formation. Forming a group requires achieving compositional balance; developing appropri- ate time arrangements related to number, fre- quency, and duration of sessions; deciding on group size; and developing organizational sanc- tions and supports. Distinctive knowledge and skill is identified for each respective modality.

While the Life Model presents practice prin- ciples, methods, and skills for integrative prac- tice as well as for specific modalities, they are not prescriptive. This is so because practitioner style and creativity are indispensable. A  mechani- cal “professionalism” expressed by projecting an impression of neutrality and impersonality is not helpful. Professional skills must be inte- grated with a humanness, compassion, and spontaneity. The social worker’s genuine empa- thy, commitment, and willingness to become involved speak louder than assuming the “cor- rect” body posture, saying the “right” words, or making the “appropriate” nonverbal gestures. Effective practitioners are “dependably real” rather than “rigidly consistent” (Rogers, 1961, p. 50).

Conclusion

This chapter is dedicated to Professor Carel Baily Germain. She died on August 3, 1995, just when people were editing the final manu- script of our second edition. She had a profound impact on my intellectual development as well as that of many others. A  brilliant, interna- tionally acclaimed scholar, she left a lasting gift to the profession. A  creative and intellectual explorer and discoverer, she roamed the globe of ideas and discovered their relevance for a profession she deeply loved. Never satisfied with the intellectual status quo, she leaped forward

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into uncharted theoretical territory, found new concepts from ecology, psychology, anthropol- ogy, and sociology, and made them available to us. Her ideas and words resonate throughout this chapter. More than a collaborator, she was a close personal friend whom I loved and miss.

Notes

1. Ecological theory perceives “adaptedness” and adaptation as action- oriented and change- oriented processes. Neither concept avoids issues of power, exploitation, and conflict that exist in the world of nature as well as in the social world of human beings. Adaptedness and adaptation are not to be confused with a passive “adjustment” to the status quo.

2. In the Life Model, “life course” replaces the tra- ditional “life cycle” stage models of human development. Human beings do not experience universally fixed, sequential stages of develop- ment. Race, ethnicity, culture, religion, gender, sexual orientation, social class, and historical con- text have profound influence on individual and collective development.

3. Among some groups or classes in our society, a fully independent adulthood may not be recog- nized until the twenties. Furthermore, “adoles- cence” is not recognized in all societies. In some

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Meditation

This centuries- old methodology aims to teach people the ability to observe interactions and responses, and to make compassionate choices; self- observation reveals problems past and present, and ways of dealing with them.

Meditation is an ancient discipline wedded to several major psycho- philosophical systems arising from diverse cultures. Among others, American Indian, Central Asian Sufi, Hindu, Taoist, widespread Buddhist, and some Christian traditions have cultivated forms of meditation as sources of spiritual enrichment and personal growth.

Over 70 years ago, meditation began to attract Western psychotherapists, and eventually the scrutiny of the rational- empirical tradition of Western science (for a brief history of mindfulness meditation, see Germer, Siegal, & Fulton, 2005). In recent years, it has been operationalized, stripped of its mystical trappings, tested in a variety of contexts, and enriched with empirical understanding. Currently, it is becoming clear that one form of medi- tation that enhances mindfulness or undifferentiated awareness is being adopted by psychotherapists, including clinical social workers, and has been increasingly researched regarding its effectiveness and applications.

Meditation is a method that is adjunctive to social work practice. It is a mechanism for self- regulation and self- exploration. It can help reduce stress and aid coping. Its effectiveness in treating particular problems and persons is finding empirical support. It has the potential to be valuable in work with clients from diverse cultures. Yet meditation as a method continues to demand much from, and occasionally challenges, some theories underlying social work treatment for its full description and explanation. This chapter will track the origins, relevance, development, and application potential of meditation. Meditation, especially mindfulness meditation, has inspired a large and growing volume of needed research, and while a comprehensive review is beyond the scope of this chapter, reference will be made to founding and contemporary studies.

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Description and Explanation:  The Mind as an Open Hand

Meditation is a set of behaviors. Some of the consequences of meditation are directly observ- able; others can be indirectly inferred. For the purposes of this chapter, meditation does not refer to the mind’s wandering and floating in fantasy or to the mind’s laboring along a tight line of logic toward a solution. In contradis- tinction to these common notions, meditation is the deliberate cultivation of a state of mind exclusive of both fantasy and logic. While there are several varieties of meditation, they all share some common characteristics.

In essence, meditation is the development— or discovery, depending on one’s orientation— of consciousness independent of visual and verbal thought. It is the deliberate cultiva- tion of a mental state conducive to intuition. Meditation usually pairs a relaxed state of the body with either a concentrated or merely atten- tive focus of the mind. A  brief description of this common process in meditation will help orient us to the method.

Method

One meditates by focusing attention on a sin- gle thing while physically relaxed. This focus of attention may be a sound (mantra), a design (mandala) (Kapleau, 1967), an object, a part of the body, a mental image, the breath, or a prayer. This ostensibly simple task is seldom immediately mastered. Noises, bodily stimuli, internal dialogues, monologues, images, and emotions can constantly interrupt the task to break one’s attention. Meditation then becomes a task of first, continually noticing or being mindful of a distraction; second, recognizing or naming the loss of attention— e.g., “thinking,” “feeling,” “remembering,” etc.; and third, let- ting go of any resulting chain of associations to return to the meditation focus. Releasing atten- tion to a distraction, easily refocusing attention, and cultivating an attitude of noninvolvement in the distracting chains of association consti- tute meditation for the beginner. A perhaps use- ful analogy would be: “The mind becomes like an open hand. Nothing is clung to. Nothing is pushed away.”

Some theorists and practitioners distinguish between two prominent forms of meditation. One is a concentrative form in which the medita- tor’s attention is riveted to the meditation object to the exclusion of other stimuli. In contrast, insight or mindfulness meditation, described in more detail later, stresses the examination of these randomly occurring mental contents, often with a naming of each, such as memory, fantasy, fear, etc. There are many variations on these two themes. Interestingly, studies of elec- troencephalographic changes accompanying representative variations on these two themes indicate changes in brain activity that paral- lel the form of meditation underway (Anand, Chhina, & Singh, 1984; Kasamatsu & Hirai, 1984). For advanced meditators, easy attention to the meditation object actually facilitates the examination of randomly occurring internal and external stimuli when they adopt the men- tal attitude of an open hand.

Mindfulness

In the past two decades, one branch of medita- tion has been identified as a salient and relatively easily accessed adjunct to various psychothera- peutic approaches (see, e.g., Hick & Bien, 2008; Germer et al., 2005; Roemer & Orsillo, 2009) and useful in coping on a daily basis (Germer, 2009; Williams, Teasdale, Segal, & Kabat- Zinn, 2007). The mindfulness meditation— described pre- viously and at the end of the chapter— is fur- ther subdivided into “formal” and “informal” activity, with the meditation being the formal endeavor and mindfulness being the informal application of mindfulness skills in daily life (Germer et al., 2005; Roemer & Orsillo, 2009).

Hick (2008) describes the current interest in mindfulness: Practitioners such as psychotherapists, social work- ers, psychiatrists, family therapists and other men- tal health professionals, as well as medical doctors, are showing extraordinary interest in mindfulness and how it affects practice, both for themselves and their clients. There is unparalleled interest in mindfulness- based interventions and approaches for a range of issues such as addictions, suicide, depres- sion, trauma, and HIV/ AIDS, to name a few. (p. 4)

Several definitions of mindfulness can help triangulate the mental activity involved

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in mindfulness meditation. Undifferentiated or unconditioned awareness is certainly an aspect of mindfulness. Definitions by research- ers, psychotherapists, and others provide a fuller picture. A  succinct definition comes from Gunaratana (2002), who tells us that, in meditation, “We train ourselves to see reality exactly as it is, and we call this special mode of perception mindfulness” (p.  33). While discussing mindfulness and psychotherapy, Germer et  al. (2005) refine the definition of mindfulness as having three components: “All components of mindfulness— awareness, present- centeredness, and acceptance— are all required for a moment of full mindfulness” (p.  8). Under the influence of mindfulness, a particular attitude of mind and comportment is seen to develop over time. This was seen as the “approach” side of the hard- wired approach– avoidance construct by Williams, Teasdale, Segal, and Kabat- Zinn (2007):  “Mindfulness embodies approach: interest, openness, curios- ity (from the Latin curare, ‘to care for’), good- will, and compassion” (p.  67). Finally, Hick (2008) reports a definition from Lau and his associates, who combined definitions from multiple authors rendering mindfulness as “a nonelaborative, non- judgmental, present- centered awareness in which each thought, feeling, or sensation that arises in the atten- tional field is acknowledged and accepted as it is” (p. 5).

The Experience

A fuller understanding of meditation can be derived from a description of the experience. Most initially find that their attention is dis- rupted by a stream of thought. Distractions by the stream of thought may present themselves in a hierarchy of personal importance. The inci- dents of the recent past evoking the most anx- iety or anger intrude first. These are followed by memories or anticipations of decreasing concern. Thoughts, images, and feelings well up, momentarily distract the meditator, and if not clung to or elaborated upon, burn them- selves out. When paired with the relaxed state of the body and followed by refocusing upon the pleasantness of the meditation object, a global desensitization (Goleman, 1976)  of cathected

thoughts and images occurs. Increasing equa- nimity and objectivity secure the meditator in an attitude of observation of the thoughts and feelings that make up the symbolic self and its constituent concerns.

The meditation behaviors of focusing attention, recognizing when attention is interrupted, sometimes naming the nature of the interruption— e.g., “thinking,” “feel- ing,” “remembering,” etc.— and deliberately refocusing attention are forms of discrimina- tion learning (Hendricks, 1975). Perceptions, thoughts, and feelings are discriminated from the meditation focus. Slowly, the capacity to discriminate thoughts and feelings from any focus of attention is amplified. The medita- tor discriminates memory and anticipation, fear, and guilt from the immediate focus of attention. He or she cultivates a present- cen- teredness. This is operationalized in research as time competence, a component of self- actu- alization (Brown & Robinson, 1993). As this learning to discriminate among the ingre- dients of consciousness or contents of mind becomes easier, an observer self, also called the watcher self (Deatherage, 1975) or witness (Goleman & Schwartz, 1984), emerges. The observer self is helpful in a variety of areas of functioning.

The observer self is not characterized as an alienated, depersonalized, or neurotic self- sustained by disassociation processes or sup- pression of thought and emotion. It is, instead, a secure subjectivity that, at its most refined level, allows mindfulness of internal experi- ence without judgment, defense, or elabora- tion. In the cultivation of this observer self of meditation, several helpful capacities emerge that are taken up later and elaborated on as we examine meditation as a technique in person- ality change.

Capacities Learned in Meditation

For those of us involved in social work treat- ment, examining the postulated lessons transferred from meditation practice into the psychosocial functioning of the meditator may prove valuable. Some of the things learned from meditation can be termed “capacities,” and there are several of them.

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Focus and Inner Direction

The capacity to focus the attention on a single thing or task in present time is enhanced. This is called “one- pointedness of mind” in some traditions. When carried over into everyday life, tasks undertaken with this state of mind are completed with less distraction and with the expenditure of less energy. The Buddhists call this state of mind, carried into everyday life, right mindfulness (Burt, 1955).

Consider the snow skier:  Skiing requires concentration. As her speed increases and the slope becomes steeper and the surface more varied, her concentration must intensify. If the skier suddenly becomes preoccupied with a dis- tant drop- off, a concern with her appearance or relative performance, or with an intruding and distracting fear of falling, her concentration is broken and the possibility of falling is more likely. The “clutched” athlete, the self- conscious speaker, the ego- involved attorney, and the over- identified social worker are all momen- tarily distracted from their intended focus, and this is experienced as loss of inner control. Brown and Robinson (1993), in a study of the relationship between meditation, exercise, and measures of self- actualization, found that med- itation alone or in combination with exercise significantly increased subjects’ inner direction beyond that of both subjects who only exercised and control subjects who did neither.

Discrimination Learning

The capacity to discriminate among internal stimuli, such as memories, fears, anger, etc., provides a measure of enhanced self- awareness that may be useful in empathic relating and communicating one’s responses in social situ- ations. Coupled with a present time focus, the capacity to view these internal processes with a degree of objectivity and non- attached con- cern allows enhanced performance in complex behaviors.

Receptive Perception

Finally, the capacity for an altered mode of perception is cultivated in meditation. The passive– receptive phase of perception, wherein

one allows the senses to be stimulated, delaying cognitive structuring and allowing the things perceived to speak for themselves, is enhanced. Sidney Jourard (1966) and Abraham Maslow (Goble, 1970)  both described this form of per- ception as necessary to supplement the more active, structured, need- oriented perception. Nyanaponika Thera described the Buddhist view of this perceptual mode generated in medi- tation as bare attention. Thera (1970) elaborated:

It cleans the object of investigation from the impu- rities of prejudice and passion; it frees it from alien admixtures and from points of view most pertain- ing to it; it holds it firmly before the eye of wisdom, by slowing down the transition from the receptive to the active phase of the perceptual or cognitive proc- ess, thus giving a vastly improved chance of close and dispassionate investigation (pp. 34– 35).

In sum, we see the results of meditation behav- iors as including such global experiences and capacities as relaxation, desensitization of potentially charged stimuli, concentration of attention, inner direction, intentional present centeredness, enhanced discrimination, self- awareness, and augmented perceptual modes. Some of these theoretical and subjectively observed capacities have been addressed in clinical social work literature (such as Turner’s review, 2009), as a mindfulness skill set: atten- tion, affect regulation, attunement– neurological activation related to interpersonal relationships, and empathy.

While these capacities have implications for generally enhanced personal and interpersonal functioning, meditation is used to counter spe- cific responses or behaviors seen as sympto- matic or problematic for clients. As will be seen later, those supported by research include most prominently anxiety and stress, some forms of depression, substance abuse, phobic reactions, and interpersonal difficulties. Generally arising from traditions that are unhampered by notions of health and illness in relation to human behavior, meditation has been used in the per- sonal growth and consciousness development of both the average lay person and the select initiates of particular religious orders. Used as a tool to extend the potential of its practitioners, meditation has been oriented toward the possi- ble rather than the merely adequate or healthy

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in human functioning. Consequently, there are several ramifications for social work treatment. Meditation has, as shall be seen later, potential for the social work practitioner as well as for the client. It requires no predisposing diagno- sis for its use, although there are empirically supported indications for its use and definite contraindicators. It has potential for use with individuals, families, groups, and in commun- ity settings.

Origins and Paths into Social Work Treatment

As indicated earlier, meditation comes to us from diverse cultures and traditions. Yet the various forms, whatever their source, express a common origin in humankind’s intuitive modes of thought. As an example, the zazen meditation of Zen Buddhism has its origin with the intuitive enlightenment of Siddhartha Gautama, “Buddha,” in about 544 b.c. (Burt, 1955). Siddhartha was said to have led a life of wealth and indulgence and then a life of ascet- icism in his quest to find the cause of suffering in the world. After relinquishing these extremes of self- preoccupation, his answer and enlight- enment came. His Four Noble Truths together with his Eightfold Path served as vehicles for transmission of insight into his wisdom. The Buddha’s Eightfold Path includes meditation as one of the routes to freedom from suffering (Beck, 1967). Thus it is a central practice in all branches of Buddhism, although characteris- tic variations have developed in each tradition. Buddhism is thought to have been carried from northern India of Siddhartha to China in a.d. 520 by Bodhidharma (Kennett, 1972). There the Indian dhyana became the Chinese Ch’an. Influenced by Taoism in China, meditation was transmitted to medieval Japan, where it is referred to as Zen, which literally means “medi- tation.” Zen found its way to the West by several routes and has been popularized by D. T. Suzuki (1964), Allen Watts (1961), and others.

But Zen is only one form of meditation that has ancient and divergent cultural origins. In fact, meditation has been an important prac- tice in the major world religions:  Hinduism, Confucianism, Taoism, Buddhism, Judaism, Islam, and Christianity.

For centuries in India, meditation was taught in the oral traditions of the Hindu Vedas. Then, sometime before 300 b.c., some of these tradi- tions of meditation were written in the Yoga Sutras of Patanjali (Wood, 1959). The techniques used in yoga include mantras, visualizations, breath control, and concentration on various postures or parts of the body. The purpose of yoga meditation is to unify the body, mind, and spirit, allowing an individual to become whole, integrated, and functioning as Atman, a god- like higher self (Prabhupada, 1972). Ultimately, union with Brahman, or God, is achieved. The Bhagavad Gita (200 b.c.) suggests meditation as one of the three main ways to achieve freedom from karma (Prabhupada, 1972), or the world of cause and effect.

In China, Confucius recommended medita- tion as a part of one’s personal cultivation. Later it became the central feature of the Lu Chiu- Yuan school of Neo- Confucianism. Taoists during the same period in China also used meditation to facilitate mystical harmony with the Tao (Welwood, 1977).

Some types of Jewish mysticism incorporate meditation to achieve metaphysical insights. Philo of Alexandria (15 b.c.– a.d. 50) and other Jewish scholars in the Middle Ages used this type of meditation.

Since the 12th century a.d., Sufism, a popu- lar folk Islam, has encouraged various types of meditation as well as other techniques such as whirling to induce trance. Meditation is consid- ered to be an important remembrance of Allah. It is also used to facilitate perceptions of inner reality (Al- Ghazzali, 1971).

Christianity, too, is rich in traditions using a variety of meditative techniques, from the early Christian Gnostics to the medieval mon- asteries to 18th- century Greek Orthodox teach- ings. Some original training manuals include The Philokalis (Greek Orthodox) and The Way of Perfection by St. Theresa of Avila (Jourard, 1966). Recently, the origins of Western forms of meditation have been traced to early Christianity, including meditation’s decline as a Western tradition in the 17th century (Schopen & Freeman, 1992). Driskill (1989) observed that the Christian tradition once recognized the therapeutic as well as the religious value of meditation.

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The more recent work of clinicians and researchers such as Kabat- Zinn et  al. (1992), with their mindfulness- based stress reduction used in pain management, and Huss and Baer (2007), with their integration of mindfulness and cognitive therapy, mindfulness- based cogni- tive therapy, have helped inform the knowledge base for clinical social work. The work of Turner (2009) and Birnbaum and Birnbaum (2008) on mindfulness meditation should contribute to the flow of theory and findings into social work.

Form Follows Philosophy

Interestingly, the philosophies of the Yogic and Buddhist meditators are reflected in their con- trasting meditation behaviors. For example, most Yogic meditators seem to cultivate a habit- uation effect (Ornstein, 1977)  to the object of meditation and experience a loss of perception of the object or a “blending” with it. This subjec- tive experience of habituation corresponds with the brain’s production of electromagnetic alpha waves that accompany relaxed awareness. These Yogic meditators reduce their awareness of out- side stimuli and experience a blissful indiffer- ence sometimes called samadhi. For the Yogi, samadhi is a high state of self- transcendent con- sciousness, a link with the Godhead or univer- sal consciousness to be attained through rigor and single- minded devotion.

Advanced Zen meditators undergo the habituation effect and record increased alpha wave productivity. However, when exposed to outside stimuli while meditating, they respond with sharp, momentary attention, as evidenced by corresponding short bursts of beta wave pro- ductivity. These meditators seem to be able to respond repeatedly to external stimuli with- out habituating to them. Psychologist Robert Ornstein (1977) suggests that they are respond- ing without constructing a visual model or ver- bal label for the intruding stimulus, perceiving it clearly each time. For the Buddhist, the state of nirvana, analogous to samadhi, is attained but rejected by the protagonist in favor of an act of compassion. This act is to enter the world in a state of wisdom, or prajna, there to undertake the work of bringing other sentient beings— or aspects of the larger consciousness— to enlight- enment. In interesting ways, then, the internal

responses of meditators parallel the doctrines of their traditions. Given these parallels found in other traditions, it seems natural that medita- tion should become a part of Western therapeu- tic traditions. The reciprocal influences between meditation and social work should be exciting.

Relevance for Social Work

While meditation comes to the West by several ancient paths, it has far from penetrated to all parts of our industrial culture. Professional social work, a byproduct of the industrial mar- ket system, is itself relatively new in human- kind’s endeavors. Meditation is new to social work. It comes to the profession at a time when variety, diversity, and eclecticism are the norm. As the instability, contradictions, and stresses of socioeconomic change generate a search for relevant modes of treatment, meditation will perhaps be another technique to be taken up in the interest of more effective practice.

This vision of the reasons for the profession’s potential interest in meditation rests on a com- mon contemporary human experience:  stress. Basically because of the contradictions and instability of the economic system, we live in an age of anxiety. Meditation may fill a symbolic and practical need in our personal and profes- sional psyches. To face the fragmentation and contradictions of our lives, a safe and quiet place to recollect, sort out, and relax is a natu- ral balm. Moreover, if meditation is not only a clinical adjunct technique but also a facilitator of other social work skills, and a precursor to action as well, it has relevance for the profession as a whole.

Meditation is used or discussed by various psychologists and psychiatrists. Engler (1984) notes that techniques from all the major medi- tative traditions have been incorporated or adopted for use in psychiatric treatment settings. Psychologists using a biofeedback apparatus are naturally drawn to meditative techniques, and their work influences social work colleagues. Psychologists do the lion’s share of research on meditation (Shapiro & Walsh, 1984).

Meditation as an aid for psychotherapists themselves (Keefe, 1975)  and in the develop- ment of empathic and other therapeutic skills (Germer et al., 2005; Hick & Bien, 2008; Keefe,

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1976, 1979; Roemer & Orsillo, 2009)  has been proposed and examined clinically (see, e.g., Sweet & Johnson, 1990) and by research, with mixed results (Pearl & Carlozzi, 1994). Both endeavors have generated interest among clin- ical social workers and social work educators. Other workers have had experience with med- itation, especially Transcendental Meditation (TM) (Bloomfield & Kory, 1976), and have incorporated it into their work. Finally, inte- grating mindfulness with cognitive and dia- lectical therapy has been clinically developed in treatment of people with borderline per- sonality disorder (Huss & Baer, 2007). While getting a good fix on the extent of its use is difficult without a study, one can assume that as more findings are reported in the literature, more interest will be generated in the social work profession.

Cross- Fertilization and Diversity

As noted in the discussion of the histori- cal origins of meditation, the technique has been refined for personal growth and positive behavior change in several cultural traditions (e.g., Shapiro, 1994). In each of these traditions, meditation is linked to conceptualizations that can help explain for practitioners the subjec- tive experiences of meditation and their behav- ioral and psychosocial outcomes. Each culture has placed meditation in its own context. To use meditation as an adjunct to psychotherapy and social work treatment is to place it within a rational, technological cultural context. In so doing, we can refine and extend meditation techniques and at the same time enrich our own traditions.

Because meditation has its origins in diver- sity, it has a naturally diverse appeal. In the author’s experience, clients and practitioners whose cultures have longstanding meditative traditions have found the contemplative aspects of meditation compatible with their values and self- development. Others’ reactions have ranged from very receptive to wary, depending on their particular backgrounds. While these observa- tions are from limited clinical and teaching experience, a reasonable generalization is that people from cultures and subcultures that value contemplation and intuitive modes of thought

have good potential to be receptive to medita- tion as a treatment technique.

Meditation, the Personality, and the Conditioned Self

The experience and outcomes of meditation related to the organization and dynamics of the personality extend Western psychodynamic conceptualizations. They modify or extend psy- chodynamically and cognitively oriented social work treatment.

The ego or symbolic self in traditional Freudian theory develops out of the need to symbolically represent in thought the real objects that meet our needs. Our capacity to symbolize allows for deferred gratification in keeping with the physical and social reality. Thus, symbol formulation is seen as necessary to the creation of meaning and social interac- tion. Meditation experience does not refute these perspectives, but it does challenge certain assumptions underlying them.

Observing the Self

Observing the Self and the Five States of Mindfulness It may be that an observer requires an object or circumstance to be aware of in order to exist at all. An observer self and a being self are two designations for the core of awareness that all conscious beings share. Insight meditation— identifying each new thought or event as it arises— facilitates the recognition of this con- stantly churning aspect of self. The recognition provides the basis of a core identity with all “sen- tient beings” as the Buddhists name it: “If I have a core of awareness, so must all sentient beings.” Recognition of this shared spark of conscious- ness as being within all sentient beings is a basis for empathy, compassion, and loving kindness toward those beings. “I see the you in me, and you see the me in you. Alas, we are the same.”

Several possible sources of suffering— also called “difficulty” by DAS, 1997— were identi- fied above as resulting from an imbalance or exaggeration of more moderate coping behav- iors. This lack of balance might be seen as a cause of suffering, but also as the source of strat- egies to cope. It can be identified as coping in

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that it involves making choices about mindful- ness states. While meditating, the Buddha had a profound insight rendered as the Four Noble Truths.

One notes how various forms of stress and coping are similar (for a discussion of the vari- ous origins of the teachings, see Das, 1997; Watts, 1957). 1. There is suffering. 2. The cause of suffering is attachment (craving and revulsion) in a world of change. 3. There is a way to cope. 4.  Walk the eight- fold path (the Middle Way). This is advice to maintain, in eight sectors of life, a balance between the extremes, such as self- indulgence at one extreme and self- denial on the other.

In the eight- fold path reflects some of the values and potential shortfalls that are encoun- tered in everyday life that can be defined as stressful and addressed with particular states of mindfulness. Here is a brief list of the path from Lama Surya Das, who provides an acces- sible analysis in Awakening the Buddha Within (1997, p. 93).

Right view— Truth and love and no dysfunctional myths Right intent— Many meanings, one is a compassion-

ate way of life Right speech— Kind words, includes no lies or

gossip Right action or conduct— Compassion driven Right livelihood— One’s one true calling Right effort— Among others, self- discipline in

goodness Right mindfulness— Insight into thoughts and

actions in everyday life Right concentration— Focus energy

While set out as developmental guidelines to liberate the mind from suffering, the steps can be read as various forms of coping with stressful memories or fantasies.

The Mind Like an Open Hand

Mindfulness can be used as a means to avoid extremes that will ultimately cause suffering (stress). There are various strategies in medita- tion and informal mindfulness that help focus attention on the present. In this perspective, memory and fantasy are products of the past or future that may be acutely or chronically stressful and that can be addressed in states

of meditation. We see mindfulness- living as a form of coping in the traditional stress- coping paradigm. However, mindfulness provides a perspective that other coping skill sets do not. This perspective has been described as step- ping back from one’s life and gaining a new view from which one can make choices more objectively and in keeping with one’s values, while avoiding either craving (neurotic addic- tion, infatuation, etc.) or revulsion. Keeping mindfulness in mind, practicing one or more of its components can be facilitated with the image of the simile, “Become like an open hand, cling to nothing, push nothing away, give what is needed.” Together with states of meditation dis- cussed later, this simile— like an open hand— may provide some structure for mindfulness living and meditation.

Process States of Meditation Mindfulness

As the research suggests, meditation is a pro- cess that can include becoming aware, attend- ing, accepting, anticipating, and, depending on the circumstance, acting. Each of these states in meditation can be a part of the meditation process. Different forms of meditation might include one or more of these states. There is a likely ordering of the states that begins and ends with states that interact with the flow of change:

Awareness, beginning, and Action, ending. Discovering and then choosing from the five states of mindfulness is a form of coping. “How shall I address the reality of change mindfully?” Here are intentionally brief definitions of five states (five A’s) found in the meditation process:

1. Awareness: to know of the existence of some- thing, cognizant. “Awareness helped these social workers perceive the connection between their clients and themselves and their clients and communities” (Brenner & Homonoff, 2004, p. 265).

2. Attention: to focus perception. “Bare atten- tion is the clear and single- minded aware- ness of what actually happens to us and in us at the successive moments of perception” (Thera, 1970, p. 30).

3. Acceptance: openness to the reality of some- thing, not approval or disapproval or pas- sive acquiescence. Meditation allowed social

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workers to “keep an open mind and an open heart” (Brenner & Homonoff, 2004, p. 265).

4. Anticipation: curiosity drive in primates. Planning as coping skill vs. hypervigilance or stilted.

5. Action: one- pointedness of mind. Focus. Doing. Perception in keeping with values and acting directly.

The five A’s are states of consciousness associ- ated with the meditation process.

Different forms of meditation, such as con- centrative or mindful, emphasize different states. A  meditator may discover one or more of the A’s as he meditates. Choosing states con- sciously is a form of coping, essentially identify- ing the mental process and making deliberate choices among them as needed (see Figure 19.1).

In clinical uses and operationalization of variables, clarity about which of the five states are “at play” can refine approaches and provide specificity as to what is being measured. For example, sometimes “attention” (to focus per- ception) is used instead of “awareness” (to know the existence of something). Consequently, a phrase such as “awareness with focus” used to define awareness could lead to difficulty in understanding what, exactly, is being used in a therapeutic process or what is being counted

in research. To be aware does not require atten- tion, but attention usually requires awareness.

Stresses can be addressed in one or more of the states of mindfulness (awareness, attention, acceptance, anticipation, and action). Each of these states can itself be observed from a state of bare attention. Conscious selection of states is a form of coping.

Personality Change

While Welwood’s particular definition of “ground” is very different from traditional concepts of the unconscious, it is descriptive of the way in which the meditator experiences the aspects of awareness that are not labeled as “conscious” in traditional psychodynamic terms. In meditation, the ego or symbolic self does not dissolve. The meditator does not become “ego- less.”

Meditation instead facilitates the realization of the socially conditioned nature of the self. That each person has a history of conditioning by the interpersonal context of his world, that he can attend to or be conscious of only a small part of his own social programming at a given time, and that meditation is a means of discov- ering his potential apart from his social condi- tioning, are realized in meditation. These are the sources of personality change in meditation.

From the perspective of meditation, then, the personality is not structured into static conscious– unconscious components. Rather, it is a web of interlacing symbolic meanings, each rooted in the changing social world. This symbolically constructed self is like an eddy in a stream. In a sense, it is illusory.

Conscious Control

In cultivating an observer self, the meditator grasps the illusory nature of the symbolically constructed self. Conflicts, anxiety- arousing ideas, rumination, and repetition compulsions are some of the experienced components of this symbolic self. Seen from the vantage of an observer self, their power and control seem less ominous. This is because the advanced medita- tor discriminates the sources of problems and decides, with a degree of neutrality, alternative lines of action. As her anxiety or anger related

A T T E N T I O N

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Figure 19.1 Mental Processes in Meditation

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to particular incidents or situations is desen- sitized in the relaxed state of meditation, their power and control are further diminished as her capacity for intentional decision about such behaviors and responses is increased. This per- spective can enhance treatment. As Deatherage (1975) puts it: “By becoming aware of the inten- tional process, one can then intercept and cancel unwanted words or deeds before they are mani- fested in behavior— something many patients find useful since it places control of their own behavior back at the conscious level” (p.  136). Not surprisingly, meditation is a component in the field of inquiry and treatment of behavioral self- control (Shapiro, 1994).

These experiences and outcomes of medita- tion, therefore, extend and modify traditional psychodynamic and cognitive perspectives, particularly with regard to the nature and func- tion of the unconscious. They can also give rise to issues of spiritual and social perspectives.

Social Conditions

The traditional cultural contexts of medita- tion universally interjected myths to explain what exactly makes up the conditioning of the psychosocial self. Communication science, ego psychology, symbolic interactionism, and other Western perspectives augment traditional views of the processes that condition the self. However, even Western psychologists and ther- apists who have taken up the practice and sys- tematic study of meditation sometimes fall back on philosophical musings when the parameters of the interpersonal ground are defined. Some use the language of mysticism and speak of the larger self or cosmic consciousness to which each small ego is linked and of which each person is a small manifestation. This language is very global and may fit with the beliefs of a given client or therapist. Such interpretation of the meditation experience has the potential for individuals to relinquish social responsibility and to retreat into a passive acceptance of social conditions that cause physical suffering and oppression. A more precise and critical view of the social realities should not be abandoned for a mystification of social realities. So, without disparaging the potential and wisdom in this view, we need not misuse it to gloss over social

conditions. Indeed, those concerned with spiri- tual development and compassion for those suf- fering may be among the first to acknowledge the inhibiting aspects of social conditions.

Social work, with its particularly broad ori- entation toward human behavior and the social environment, has a special contribution to make toward an understanding of this larger ground of the self. Social workers are cognizant of the extent to which social conditions inter- act with the individual psyche and condition its nature, prospects, and levels of awareness. Briefly extending this orientation, Marx (1966) and other materialists postulated that the eco- nomic organization or structure of society con- ditions or shapes the social and ideological life of a society. We might caution, then, that the global language of mystical traditions need not supplant critical analysis of the experiences of meditation, for these experiences are behaviors that may carry over into daily functioning with positive benefit to the meditator’s personality and social functioning.

Personality and Specific Applications

Self- awareness, physical relaxation, stress reduction, desensitization of anxiety- arousing thoughts, self- regulation of problematic behav- iors such as substance abuse, discrimination of feelings and thoughts from other stimuli and self- exploration, and management of mild depression are specific applications of medita- tion in the treatment of problems. A  thorough review of the bourgeoning literature, especially mindfulness meditation, is beyond the scope of this chapter, but some foundation studies will be noted.

Self- Awareness

First, learning to be more self- aware (aware of feelings and motivations) can inform one’s responses to interpersonal situations. As we shall learn later, the self- awareness or mind- fulness meditation facilitates sensing and then communicating one’s responses to others; both behaviors conducive to empathy. Glueck and Stroebel (1975), in their study of the effects of meditation and biofeedback in the treatment of

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psychotherapy patients, made detailed obser- vations of the physiological changes occur- ring during meditation. They found that TM generated recordable electroencephalographic changes in the brain that parallel relaxation. They think that the repeated sound, or man- tra, is the vehicle of relaxation that eventually involves both the dominant and non- dominant hemispheres of the brain. This response is functional to self- understanding and psycho- therapy by allowing repressed material to come into consciousness more quickly. This has the potential of permitting more rapid recovery of patients than standard therapeutic treatment would allow.

Relaxation and Stress

Second, learning to relax through meditation is conducive to managing anxiety- related prob- lems. For example, Shapiro (1976) found Zen meditation, combined with behavioral self- control techniques, effective in reducing anxiety and stress in a client experiencing generalized anxiety and a feeling of being controlled by external forces. A  three- year follow- up study showed lasting benefit of mindfulness- based stress reduction in the treatment of anxiety (Miller, Fletcher, & Kabat- Zinn, 1995). Several studies have now demonstrated significant results in the use of meditation or meditation as a supplement to reduce trait and state anxiety as well as physiological correlates of stress (e.g., Alexander, Swanson, Rainforth, & Carlisle, 1993; DeBerry, Davis, & Reinhard, 1989; Kabat- Zinn, Massion, Kristeller, & Peterson, 1992; Pearl & Carlozzi, 1994; Snaith, Owens, & Kennedy, 1992; Sudsuang, Chentanez, & Veluvan, 1991). In overcoming insomnia in patients, Woolfolk, Car- Kaffashan, McNulty, and Lehrer (1976) found meditation- derived attention- focusing techniques as effective as progressive relaxation exercises in reducing the time to onset of sleep. Both meditation and relaxation were effective in improving patients beyond controls on six- month follow- up (Woolfolk et al., 1976).

Third, traditional therapy for anxiety- related problems has been broadened in recent years to encompass the domain of ordinary stress. Stress, as a field of inquiry, promises to enrich our ability to prevent more serious symptoms

and mental disorder. Stress is the physical and psychosocial response of a person who perceives external and/ or internal demands as exceed- ing his capacity to adapt or cope (Fried, 1982). Some stress, of course, challenges us or piques our interests. Overstress, however, is a common problem in our industrial society.

Meditation and various forms of relaxation training have been studied for their potential in reducing the physical effects of stress and in helping people self- regulate aspects of their behavior or consciousness related to stress. In the early 1970s, research conducted by Robert Wallace, Herbert Benson, and Archie Wilson (1971) suggested that meditation might pro- duce unique physiological and other changes. Later, other studies suggested that relaxation and various relaxation strategies and hypnosis may have effects similar to meditation’s (Beary & Benson, 1974; Fenwick, Donaldson, Gillis, Bushman, Fenton, Perry, & Serafinovicz, 1984; Morse, Martin, Furst, & Dubin, 1984; Walrath & Hamilton, 1984). Some studies are clear in indicating that meditation is at least as good as relaxation strategies in helping relieve stress and in lowering autonomic indicators of stress (Goleman & Schwartz, 1984; Marlatt, Pagano, Rose, & Marques, 1984). For example, in their study, Woolfolk, Lehrer, McCann, and Rooney (1982) compared meditation, progressive relax- ation, and self- monitoring as treatments for stress. Meditation and progressive relaxation significantly reduced stress symptoms over time. More study is in order in this area.

Coping and Substance Abuse

The advantage of meditation as a strategy in helping clients deal with stress lies in the cog- nitive domain. What causes a person stress is determined in large part by the perceptions of an event or situation. Events viewed as threats are more stressful than those viewed as chal- lenges in which one will grow. Meditation allows the individual to discover the symbolic meanings, the subtle fears, and other internal stimuli evoked by the event. Strategies, oppor- tunities for coping, calm decisions, and pre- vious successes can be distinguished in the mental contents and consciously enlisted in coping strategies. Moreover, one case study and

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some theorists support the aforementioned idea that meditation behavior may be transferred to other aspects of life and consciously enlisted to meet stressful events as they occur (Shapiro & Zifferblatt, 1976; Woolfolk, 1984). Maladaptive coping occurs when stress is responded to in ways that cause more problems for the stressed individual than they help solve. Meditation may help prevent these maladaptive responses, such as substance abuse, which relieve immediate stress but generate long- term physical, psycho- logical, and even interpersonal problems.

Indeed, there is some evidence that medita- tion can help treat these maladaptive problems once they have developed. Several recent empir- ical studies indicate significant beneficial effects of meditation or meditation- assisted treatment in recovery and relapse prevention for substance abuse (Denney & Baugh, 1992; Gelderloos, Walton, Orme- Johnson, & Alexander, 1991; Royer, 1994; Taub, Steiner, Weingarten, & Walton, 1994). Finally, an analysis of mindful- ness applications in relapse prevention with an information- processing orientation (Breslin, Zack, & McMain, 2002) should open new lines of inquiry in the substance abuse field.

A fourth outcome, combining self- awareness and the capacity to relax intentionally, permits an individual to transfer behaviors learned in meditation to other realms of life where there is stress or excessive stimulation that would hamper objective or reasoned function- ing. The results of some studies suggested that meditation may be useful for alcohol and drug abusers to reduce anxiety, detect stimuli that evoke the problematic habits, and cultivate an “internal locus of control” (Benson & Wallace, 1984; Ferguson, 1978; Marlatt et al., 1984). One might reason that anxiety- arousing stimuli are less likely to become self- perpetuating in the symbolic system if they are discriminated and desensitized in the meditative process. For example, some individuals have associated worry over coming events with positive out- comes of those events. Worry, intermittently rewarded, is likely to persist, complete with fan- tasized negative outcomes, anxiety, and preoc- cupation (Challman, 1975). Meditation enables the individual to discriminate worrisome fan- tasy and to observe its impact upon the body and overall functioning. Desensitization and a

secure observer self enable the individual to rec- ognize worry, limit the duration, and allow wor- risome thoughts to burn themselves out, with lessened physiological consequences. As the observer self is cultivated, the not- uncommon state of consciousness of modern Westerners, complete with split attention, worry, preoccupa- tion, and anxiety, can be sharpened to a mind- fulness in which attention is voluntarily riveted to the action at hand. Preoccupation with one- self and how one is performing, worry over consequences, and wandering attention will then interfere less in the tasks one has decided to do. In a sense, the symbolic self is lost in the activity.

Fifth, observation and discrimination of one’s thoughts in meditation enable the medi- tator to use thoughts and images more as tools to represent reality, to communicate, and to serve as intentional guides to action, rather than as illusory and unintentional substitutes for real circumstances. Symbols and cognitive constructs interfere less with clear present- time perceptions.

Depression

Finally, meditation as discrimination train- ing may have specific usefulness in helping to manage depression. In her article “Learned Helplessness,” social worker Carol Hooker (1976) reviewed literature suggesting that reactive depression is dynamically similar to experimentally induced states of learned help- lessness in experimental animals. This stems from extrapolations to humans from the works of M.  E. P.  Seligman (1974, 1975)  and others that suggest that subjects may learn, in effect, not to learn when repeatedly subjected to nox- ious circumstances over which they can achieve no mastery or control. Under such conditions, subjects learn that there is no escape, no solu- tions other than unresponsive withdrawal, with little or no mobility, eye contact, or nor- mal need- fulfilling behaviors. Hooker (1976), drawing on the work of Beck (1967), sees this learned helplessness as having cognitive com- ponents in humans wherein all known avenues of mastery and solution have been tried or rehearsed to no effect. Action and effort have no effect on circumstances. Beliefs about one’s

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lack of effectiveness sustain a depressive reac- tion. Loss of a loved one to death, for example, is an insoluble trauma. Repetition of guilt- evoking thoughts, self- deprecation, and beliefs that there is no future without the deceased may in some cases sustain a depressed mood for extended periods.

Meditation may help the depressed per- son regain a sense of self separate from the dilemma, partially sustained in the symbol sys- tem. In this scenario, traumatic thoughts asso- ciated with a traumatic event are desensitized, and one learns increasing mastery over the con- tents of one’s depression- sustaining rumina- tions. Eventually, thoughts that constitute new tasks and new opportunities for mastery and rehearsal of new roles to play can be sustained intentionally and used as guides for action and mastery. A groundbreaking study of the effects of a meditation- based stress- reduction program found that, not only anxiety and panic symp- toms, but also depression were reduced, and results were maintained in the three- month follow- up (Kabat- Zinn et  al., 1992). In another important study, “Prevention of Relapse in Major Depression by Mindfulness- Based Cognitive Therapy,” patients with three or more episodes of depression were significantly less likely to relapse (Teasdale, Segal, Williams, Ridgeway, Soulsby, & Lau, 2000).

Similar processes, used with both cau- tion and close, informed supervision, may be therapeutic for persons with thought disor- ders. In other words, observation of thinking, not building upon associations and becoming “lost in thought,” is the intent of meditation for enhanced discrimination.

Combining the findings and expertise of four researchers and clinicians— Williams, Teasdale, Segal, and Kabat- Zinn— in their book The Mindful Way Through Depression (2007), have broadened and deepened our understanding of depression and our approach toward helping those beset by it. They formulate their approach on mindfulness and point out the nuances of mindfulness in everyday life that can liberate individuals from the attachment of depression.

In summary, research indicates that medi- tation is an effective adjunct to treatment of a potentially wide variety of problems. Shapiro (1994) summarized research on meditation in

self- regulation and self- exploration, observing that the meditation has been stripped of the original cultural and religious contexts to avoid dilemmas and divisiveness. He makes a strong case, however, for reintroducing the context of meditation, which fits the social work perspec- tive of valuing cultural diversity and working with the whole person. With this idea in mind, we must recognize that some clients and work- ers will find meditation an alien endeavor, even when it is isolated from its original context. Furthermore, there are certain problems that should not be approached with meditation, except with close supervision by workers skilled in treatment of the problem and in medita- tion. While a preponderance of definitive stud- ies show that direct contraindications for the use of meditation are few, some guidelines are emerging.

Cautions and Contraindications

Some people find meditation more suited to their temperament and culture or beliefs than others do. Also, certain severe disorders make the correct practice of meditation difficult or impossible.

Attitude

Anxious but organized people seem to take to meditation quickly. Relaxation and learning control over focal attention is rewarding and rather immediate. With very anxious, driven people, however, a caution is in order. Meditation of the Zen type, which requires a continued refocusing to the breath or another object of attention, or of those Yogic types that require strict postures and attention, can become a “do- or- die” endeavor for these persons. Individuals may incorrectly feel compelled to suppress thoughts and emotion, or they may force their breath in an unnatural way rather than follow- ing their natural breathing rhythms. Often this response is not unlike their lifestyle, in which they constantly push themselves to perform or conform without paying attention to their own desires and physical needs. The attitude of wake- ful awareness is misinterpreted as rigid atten- tion where all interruptions are excluded before their full perception. Sometimes the body is

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not relaxed, but held rigid and tense. With such people, the point must be made clear that they are to let go of interrupting thoughts, not push them away or compulsively follow them. The analogy of the mind as an open hand, neither pushing away nor grasping, helps in cultivat- ing the correct mental attitude. In any case, the social worker/ therapist must make sure that the client is in fact meditating and not magnifying anxiety, building anxiety- provoking images, or obsessing along an improbable chain of associa- tions about hypothetical, destructive interper- sonal events or outcomes.

Ensuring the above attitude may help the meditator avoid some of the experiences dis- cussed by Turner (2009), such as frustration, boredom, and irritability. Clinical profiles including dissociation or post- traumatic stress may indicate a need for gradual introduction and an emphasis on a nonjudgmental attitude and acceptance.

Severe Problems

Two authors have discussed use of meditation by persons who suffer severe mental problems or who are labeled psychotic or schizophrenic. Deatherage (1975), in discussing limitations on the use of Buddhist mindfulness meditation in psychotherapy, cautions,

While this psycho- therapeutic approach is extremely effective when employed with patients suffering from depression, anxiety, and neurotic symptoms, a cau- tion should be issued regarding its use with patients experiencing actively psychotic symptoms such as hallucinations, delusions, thinking disorders, and severe withdrawal… (p. 142).

He goes on to note that the particular medi- tation technique for self- observation requires “an intact and functional rational component of mind, as well as sufficient motivation on the part of the patient to cause him to put forth the effort to do that observation” (p.  142). Arnold Lazarus (1976), discussing psychiatric problems possibly precipitated by TM, cautions that his clinical observations have led him to hypothe- size that TM does not seem to be effective with people classified with hysterical reactions or strong depressive reactions. He warns that some schizophrenic individuals might experience

an increase in depersonalization and self- preoccupation (pp. 601– 602).

As an activity derived from religious tradi- tions, meditation is associated with notions of self- transcendence. This context may be either culturally congruent or very alien for a client. Good judgment and sensitivity to the client’s culture are very much in order when introduc- ing meditation techniques for this reason alone.

Observation of the conditioned self or ego from a perspective of dispassionate neutral- ity can be confused with several problematic behaviors. Engler (1984), for example, cautions that borderline personalities and others without a well- developed self may be attracted to medi- tation. Also, persons in developmental stages struggling with identity may find meditation an unfortunate substitute for dealing with their developmental tasks or discovering who they are (Engler, 1984). Persons with very fragile identities, symptoms related to depersonaliza- tion, and inadequate ego development are not good candidates for meditation except under close supervision.

In general, therefore, clients or patients with fragile self- concepts or those with severe dis- orders, whose reality testing, perception, and logical thinking are such that they cannot fully understand meditation instructions or follow through with actual meditation under supervi- sion, are poor candidates for its successful use in treatment. Just as the anxious client may build upon anxiety- arousing associations or the depressed client may ruminate on ineffective- ness and despair instead of actually meditat- ing, clients with severe thought disorders and problems with reality testing may substitute hallucinations, delusions, withdrawal, deper- sonalization, and catatonic responses for medi- tation, thereby aggravating their problems.

Glueck and Stroebel (1975), however, found TM effective as adjunctive treatment with a sample of 96 psychiatric patients who would have been expected to have the kind of dif- ficulties outlined here. Preliminary investi- gation indicated that the higher their level of psychopathology, the more difficult it was for these patients to produce alpha waves. Testing TM against autogenic relaxation and electro- encephalogram (EEG) alpha- wave biofeedback training, Glueck and Stroebel found TM to be

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the only one of the three experimental condi- tions that patients could persistently practice. Consequently, the authors match- paired their meditation sample with a comparison group and found their meditating patients to have higher levels of recovery than both their “twins” and the general patient population. Despite these findings, treatment of severely depressed and psychotic patients with meditation is experimental, and without close supervision and immediate post- meditation checks, it is contraindicated until further research is done.

One phenomenon occurring in most forms of meditation is the intrusion of the memory of events in the meditator’s life into the medita- tive state. Meditators employing concentration techniques experience mental images of signif- icant and emotionally intense events replayed before their relaxed mind. Desensitization of these memories has been discussed. But inten- tional use of meditation to allow the emer- gence of significant facts and events of the psychosocial history is possible. Requesting the client to record these memories follow- ing meditation, for use in the context of treat- ment and for rounding out a more complete psychosocial history, may be helpful to work- ers with psychodynamic and psychoanalytic orientations and those helping clients with family- of- origin work.

The diagnostic value of meditation, implicit in earlier discussions, lies in the nature of the difficulty that the client has in meditating cor- rectly. Elsewhere, the author has discussed opti- mal psychosocial functioning based on Eastern conceptualizations related to and developed from meditation (Keefe, 1978). Briefly stated, the capacity to attend to activities one is about without interference by irrelevant ideation and worry suggests a positive level of functioning. Meditation evokes memories and worries that intrude upon the meditation task. Repetitive anxiety or guilt- associated thoughts will indi- cate to the meditator and the worker or thera- pist the areas of conflict or unfinished business that hinder the client’s functioning. Repetitive self- destructive images will indicate disturbed role- rehearsal or depression. Conflicts from pushing or driving oneself will manifest them- selves in forced breathing or lack of relaxation in meditation.

The Therapeutic Relationship

There are several behaviors learned in mediation that could theoretically contribute to enhanced empathic functioning on the part of the social worker who meditates. First, learning increased voluntary control over one’s attention permits one to shift from attending to the various ver- bal and nonverbal communications of the cli- ent to one’s own emotional responses to the client. This ability to sense one’s own emotional reactions from moment to moment facilitates sensing and verbalizing feelings that parallel those of the client. Accurate reflection of these feelings to the client, of course, is a major com- ponent in therapeutic empathy (Rogers, 1975), a worker skill conducive to positive behavior change for the client.

Second, learning to discriminate internal or cognitive stimuli from perceptual stimuli in meditation and enhancing voluntary control over cognitive processes can enhance empathic functioning in another way. The worker can hold complex cognitive elaboration in abeyance and allow herself to perceive the client as he is, without premature diagnosing or other cogni- tive elaboration coloring her bare attention to the client as he is. This intentional slowing of the perceptual process that allows the client to speak for himself holds the worker in the pres- ent time— where emotions are felt, where the worker can be fully with the client, and where behaviors are changed.

Third, the meditating worker is likely to have cultivated a strong centeredness or “observer self ” not easily rattled by stresses or emotional interaction. Therefore, staying with the client in her deepest feelings, as Carl Rogers (1975) described high- level empathy, becomes more likely. And because such a worker has a perspec- tive on his own reactions, countertransference responses may be more accessible.

Supervision would naturally include sharing of meditation experiences to help in refocusing. Dubin (1991) recommended meditative tech- niques in psychotherapy supervision to help learn theory and case management and to deal with countertransference. Meditation can assist the worker sharing about and dealing with countertransference or other issues of problem- atic attachment.

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Meditation as an adjunctive technique to treat- ment has a virtue common to all profound and shared experiences. It is an experience a worker can teach and then share with the client that may serve as a basis for communication, trust, and mutual discovery when other bases for relation- ships are less productive. In this sense, meditation can be a common ground of mutual experience that can strengthen a therapeutic relationship.

Teaching Meditation:  One Technique

There are several techniques for meditation that are useful as adjuncts for treatment. Among the more prominent are Yogic mantra tech- niques, Benson’s relaxation technique (Glueck & Stroebel, 1975, p.  314), TM (Bloomfield & Kory, 1977), Zen techniques, and the commonly described mindfulness meditation (Birnbaum & Birnbaum, 2008; Kabat- Zinn, 1994; Turner, 2009). The technique to be briefly detailed here is derived from Zen.

The general instructions are readily found in a variety of texts. Expert instruction and a good period of time meditating are recommended for workers considering meditation as an addition to their repertoire of techniques.

The client is instructed to meditate half an hour each day in a quiet place where she is unlikely to be interrupted. The client is asked to record briefly in a log her meditation experi- ences for later discussion with the worker. The meditation posture, as suggested by Kapleau (1967), is as follows:

1. A sitting position with the back straight 2. Sitting cross- legged on a pillow is ideal for

some 3. If uncomfortable, sit in a straight chair with-

out allowing the back to come to rest against the back of the chair

4. The back must be straight for comfort since slumping causes cramping

5. The hands should be folded in the lap 6. The eyes may be open or closed; if open, they

are not to focus on any particular thing 7. Loose clothing around the waist is suggested

The client is instructed to focus on the breath manifested in the rising and falling of the

abdomen and to begin the first session by count- ing each exhalation up to 10 and beginning again. The attention should be focused on the surface of the center of the body about an inch below the navel. Thereafter, the client may sim- ply follow the natural, unforced, uncontrolled breathing for the duration of each session.

The client is told that there will be frequent intrusions of thoughts, feelings, sounds, and physical responses during her concentration. The response to these is in every case an easy recognition that attention has wandered and refocusing to the breath is necessary. Relaxing the muscles around the eyes and the tongue and throat is helpful in letting go of visual and ver- bal thoughts.

Repressed material will usually emerge as insights. These are automatically paired with a relaxed state. The client should be instructed that if the meditation becomes upsetting or frustrating, she should stop and resume the fol- lowing day or wait until the next appointment with the therapist. Particular cautions with special clients were enumerated previously. Generally, if the experience is not pleasant and rewarding, it may be evidence the client is push- ing rather than allowing mental content to flow.

Settings and Levels of Intervention

Meditation is a worldwide phenomenon. It is practiced in settings as varied as Japanese cor- porate offices, quiet monasteries in all parts of the world, downtown apartments, and mental health centers. Most physical settings where social workers practice would be conducive to meditation. While each agency has its own major theoretical orientation or admixture of orientations, few would preclude meditation as an appropriate technique if thoughtfully and systematically introduced. While a psychody- namically oriented worker would define and describe meditation behavior and results dif- ferently than a behaviorist or an existentialist, the technique is not tied to a single system or culture. Therefore, agency acceptance hinges more upon tolerance for innovation, interest in research, and openness to new ideas. Meditation as a social work technique was thought to be well out of the mainstream and esoteric a few years ago, but it has gained wide acceptance

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in related disciplines and promises to become a more common technique in work with indi- viduals, families, and groups.

Because meditation tends to be an individual activity, it is naturally thought of as a mode for individual treatment only. However, in addi- tion to its use and ramifications for individual treatment, meditation can be useful for certain kinds of groups, including families.

Receptivity to meditation a few years ago was largely restricted to young people and the religiously or spiritually oriented. But over the years the various forms— TM (Bloomfield & Kory, 1977)  and mindfulness- based medi- tation in particular— have crossed class and age barriers. Increasingly, meditation can be introduced into group work with a variety of people. In the author’s experience, group medi- tation can enhance group processes. Beginning and ending a group with a meditation session can enhance group feeling and “mellow out” intense feelings enough to allow their sharing, analysis, and discussion. A  group meditation sets the atmosphere for constructive interac- tion. Meditation to end a group meeting can have similar effects and can support solidarity and identity within the group. The author has used individual meditation to begin and group chants to end treatment groups for college- age youth and for sex- role consciousness- raising treatment groups for married persons rang- ing in age from 22 to 45. Meditation for family treatment may help to reduce conflict and give the family a positive, common experience to share and discuss.

The use of meditation to facilitate family- of- origin history- taking suggested here could be a part of an actual family treatment session. Sometimes the level of conflict and individual anxiety is such that constructive communica- tion in a treatment session is hampered. Some minutes of meditation may allow sufficient calming to enhance communication. Except for young children and the contraindications already discussed, family members may be helped regardless of their age. The particular phenomenon of enmeshment, or very dependent adult members without a secure sense of self apart from the family, may be helped through meditation. Just as with individual clients, sen- sitivity to the receptivity and experiences of

each family member would be essential. While not a substitute for other techniques, medita- tion may be useful as an adjunct to family treat- ment, and systematic use and assessment may support its utility.

Claims of increased harmony and lower crime rates have been made as resulting from certain percentages of people engaged in medi- tation in given communities (Bloomfield & Kory, 1977, pp. 283– 284). These findings require some critical assessment, in the judgment of this author. But, obviously, if meditation con- tributes to personal functioning, certain aspects of community life will be enhanced.

Much research must be done to determine the long- term effects of the various forms of meditation on individuals, groups, families, and communities. Optimal personal and group functioning does not lead directly to more har- monious community life if the social order is fundamentally exploitive and contradictory. As with many forms of treatment techniques, the gaps in our knowledge about meditation, as an adjunct to treatment at different levels of inter- vention, is growing, yet more research is still in order.

Implications for Research

Meditation is a widely studied behavior. Never- theless, our understanding of it is incomplete. As a treatment technique, it has been found valuable in a variety of situations. Yet medita- tion is more than a technique. While review of the growing abundance of research is beyond the scope of a single chapter, some positive and some negative signposts are evident, especially in studies that discern patterns and provide guidance (Melbourne Academic Mindfulness Interest Group, 2006; Ospina et al., 2007). There is growing knowledge of the appropriate forms of meditation, contraindications, the relative value of meditation and other relaxation tech- niques, and even the effects of meditation upon stress and anxiety, substance abuse recovery and prevention, depression, the nervous sys- tem, the psyche, and social life. Although there is much clinical evidence and intuitive explo- ration, more research concerning subset med- itation phenomena is needed. These include the desensitization, discrimination, and observer

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self mentioned earlier. Clinicians must begin to refine the appropriate use of meditation for particular kinds of clients and particular kinds of problems. Together with researchers, we must deduce where it helps and where it does not. The articles “Mindful Social Work:  From Theory to Practice” (Birnbaum & Birnbaum, 2008)  and “Mindfulness:  The Present Moment in Clinical Social Work” (Turner, 2009) provide insightful discussions, suggest directions, and contribute to the theory base of clinical social work. Researchers also have rich opportunities to follow the differential effects of meditation used with various clinical problems and various personalities.

In a study that surveyed many available studies, “Meditation Practices for Health: State of the Research,” Ospina et  al. (2007) reported some health effects, such as lowering blood pressure; however, their overall conclusion ended with, “Scientific research on meditation practices does not appear to have a common theoretical perspective and is characterized by poor methodological quality. Firm conclusions on the effects of meditation practices must be more rigorous in the design and execution of studies and in the analysis and reporting of results” (p. v.). Their conclusion could possibly have been anticipated, given the rapid growth of interest and clinical application of meditation. It can serve as a motivator to continue research that has a sound theoretical base and uses qual- ity methodology.

Another study (Melbourne Academic Mindfulness Interest Group, 2006)  surveying the research studies into mindfulness- based psychotherapies more optimistically concluded,

This group suggests, based on this review, that the combination of some well- developed conceptual models for the therapeutic action of mindfulness and a developing empirical base, justifies a degree of optimism that mindfulness- based approaches will become helpful strategies to offer in the care of patients with a wide range of mental and physical health problems (p. 285).

The hope expressed in the earlier version of this chapter remains relevant. Being a tech- nique of potentially great value for social work, meditation must continue to be examined empirically. Hopefully, it will not be picked

up ‘whole hog’ and incorporated into practice without continued critical evaluation. This would render it, like some other techniques, a passing fancy, soon discarded in favor of new approaches. Nor should meditation be dis- regarded as the esoteric product of some for- eign and bygone cultures. Despite barriers that exclude the wisdom of other cultures and other lands from our consideration, a critical open- ness and valuing of diversity in the treatment domains is in order. We must try out, test, and incorporate meditation as an adjunct to treat- ment where it benefits our clients, our practice, and ourselves.

Conclusion

Meditation is, of course, more than just an adjunct to social work treatment. Meditation and its potential for better understanding our- selves and our functioning may flourish in our culture independently of the helping profes- sions and their practice. If we in social work and others in related professions find it a powerful adjunct to treatment, we should not attempt to subsume it as ours alone. Indeed, Shapiro (1994) argues a strong case for reintroducing the cultural contexts of meditation where it is used. Such an endeavor would enrich the diver- sity of the cultural and philosophical basis of the treatment where meditation is used. It may even help us reach clients from particular cul- tures with strong meditation traditions. It gives us new perspectives on the development of the self, amplifies our understanding of subjective experience, provides insights into what consti- tutes optimal psychosocial functioning, and is an empirically supported tool for dealing with stress, anxiety, and maladaptive coping such as substance abuse.

Meditation is at once a vehicle of conscious- ness and a portal to individual potential. It can be used to liberate, to extend individual func- tioning, and thereby to help to create social change in the democratic interest. It could also be used to mystify, to distract people from their social concerns related to their personal prob- lems. How the technique will be used by social work is related to the conscience, wisdom, and position of the profession in the years of pro- found social change ahead.

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This chapter began by identifying medi- tation as a set of behaviors. Meditation is, of course, the embodiment of a larger theory of self, coping, and change. For this reason, it has begun to take interesting routes in the social work profession. It is a part of the field of stress management and finds frequent mention in that literature (e.g., Nucho, 1988). But it is also nat- urally linked to mainstream social work litera- ture (Carroll, 1993; Cowley, 1993; Smith, 1995). As social workers openly discuss addressing the “whole person” or the spiritual aspects of client’s experience, the understandings of that experience can be enhanced by familiarity with meditation- related phenomena such as global desensitization and an observer self. This per- spective does not require adoption of a theolog- ical stance or the introduction of religion as a component of treatment. It does have the poten- tial to help us understand our clients more fully. As long as social work is concerned with help- ing people secure themselves and make good choices, meditation and its body of related the- ory should have a role to play.

Finally, deep in the heart of meditation lies the insight that is the root of both compassion and social action: to help others is to help our- selves. Whether a clinician, a social activist, or both, this is a message every social worker can hear.

Case Example: The Use of Meditation in the Treatment of Functional Bowel Disease

A 36- year- old woman, married and the mother of three children— ages three, seven, and 12— living in California was referred by her physician. She was suffering abdominal pain. Extensive physical examina- tions and tests had all been negative, although she had recently had an increase in pain when she was under stress. She wanted to understand why she was having these troubles and how she could control them.

She had been experiencing an increase in pain over the past year. She had gone on special diets, consulted several healthcare professionals, and taken many different medications, but there was no change in her distress, which was becoming overwhelming. She said she was becoming increasingly depressed, anxious, and overly self- critical as her symptoms con- tinued and there seemed no hope for any change in

them. Psychological tests completed at the time of the initial evaluation confirmed that she was indeed severely depressed, with little energy. There seemed to be an emotional overlay to her pains.

The client was quick to agree to short- term out- patient treatment of eight weekly sessions. The goals would include developing some understanding of her emotions, the stresses in her life, her coping skills and difficulties, and learning various types of relaxation techniques. It was also agreed that the results of the psychological tests would be fully reviewed with her in the third session. In addition, she was helped to work through some unresolved feelings from earlier years that were related to her parents’ divorce and the death of her first husband. She explored how she could utilize some of her past coping skills with some of her present difficulties.

The client was experiencing many stressful and unstable living conditions at the present time while her husband was building their new home. This necessitated their living in a series of different friends’ homes. Her husband had been so involved in building their dream home that he had not involved her in the process. He was included in one of the outpatient sessions in order to increase communication between them and to help them to reinstitute their previous level of positive interactions, which had been present in the year previous to all of these changes.

In the second treatment session, the client was taught a passive, modified hypnotic, relaxation tech- nique that was tape- recorded for her daily use at home. She was quite pleased with her ability to immediately relax and experience a definite decrease in her abdominal pains. She was instructed to listen to the tape recording of the relaxation four times a day and to record her responses each time in a “Relaxation Log” that she was to bring with her to each session.

The following week, the patient had several days without any pain until she would forget to use the technique because she felt “so good.” The patient continued with the passive therapist- directed relax- ation techniques by listening to the tape recording daily. The worker was very directive with this tech- nique. The client was slowly encouraged to try the relaxation technique on her own, without using the tape. She quickly became able to do this.

After the four th treatment session, the client was introduced to a new technique designed to help her relax on her own, to become more comfor t- able with her own body, and to learn how she could

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help herself on an ongoing basis. It was presented to her as a new coping skill that she could continue to utilize after the termination of treatment. Since the client was now feeling much better, she was eager to increase her skills in this area. She was therefore given oral and written instructions for meditation. She was asked to take the instructions home and read them and to try to implement them into her daily routine. Initially she had some difficulty in being totally comfor table with the technique, so she con- tinued listening, once a day, to the relaxation tape. However, she found less need to rely on the tape recording as she increased her ability to relax with the meditation. After one week, the client found that she was able to relax just as fully as she had with the tape recording. Fur thermore, she felt quite proud of her ability to do it on her own. By the last session, she was able to relax without any reliance on the tape. She found that if she meditated once a day, she had no pain, and could reduce any stresses that arose by shor t relaxation techniques, which she would go over in her mind. At that point she had been totally pain- free for three weeks. Follow- up contacts with the patient one month after formal termination of treatment showed that she continued to do her daily meditation, was pain- free, felt much more confident in her abilities and coping skills, and felt that all aspects of psychotherapy, relaxation, and finally meditation had been quite beneficial to her. She recognized the benefits of continuing to prac- tice what she had learned, and her family was quite suppor tive.

Acknowledgment

The author wishes to thank graduate assistant Heather Sells for her help in gathering refer- ences for this edition of the chapter. The author wishes to thank Peter Cote for his contribution in helping to develop the Five Meditation States.

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Annotated Listing of Key References

Germer, C.  K., Siegel, R.  D., & Fulton, P.  R. (2005). Mindfulness and psychotherapy. New  York:  The Guilford Press. This text begins with sound defi- nitions and discussion of Buddhist and Western psychology. The therapeutic relationship and clin- ical applications are presented in readable style. Invaluable for practice.

Hick, S.  F., & Bien, T.  (2008). Mindfulness and the therapeutic relationship. New  York:  The Guilford Press. Integrates mindfulness into the thera- peutic relationship, with many insights into the connections.

Roemer, L., & Orsillo, S. M. (2009). Mindfulness- based behavioral therapies in practice. New  York:  The Guilford Press. Explores in depth the integration of acceptance- based behavioral therapies, theory, research, and application. Good for therapists seeking to enrich and extend their practice.

Williams, M., Teasdale, J., Segal, Z., and Kabat- Zinn, J.  (2007). The mindful way through depres- sion. New York: The Guilford Press. Grounded in research and clinical perspectives, this accessible and valuable book extends meditation and cog- nitive approaches, addressing a sound model of depression and ways to relieve it.

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We are leading a mindfulness workshop for social workers. We begin with the question, “When we say ‘mindfulness,’ what ideas come to mind?” and list the answers on a flip- chart. “Relaxation, attention, a body scan, eating a rai- sin, letting the mind go blank, the breath, yoga, the present moment.” The responses come with some hesitation. They are not sure if they have it right. They are curious and excited about mind- fulness but also a little skeptical. Is there really anything new here? Is this just a restatement of what they already know and practice? A mind- fulness workshop weaves information with experience and encourages participants to find out for themselves. In addition to the discussion, they will learn mindfulness practices:  body scan, sitting and walking meditations, yoga, and awareness of sight and sounds. Over time they will connect with the present moment, and

in observing this connection, find that thoughts become less concrete. They often find that they enjoy the stillness and taking some time for themselves. They often describe the experience as worries melting into the moment and say that they gain a firsthand experience of how this can be helpful for themselves and the people they care for.

Introduction to the History of Clinical Applications of Mindfulness

Meditation and contemplation are found in most cultures and religions; however, this modern adaptation of mindfulness arose out of Western interest in ancient Buddhist practices developed by Siddhartha Gautama (the Buddha), who shared his understanding of how to increase

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one’s happiness and to free oneself from suffer- ing 2,600  years ago in India. This wisdom has had a secular adaptation into clinical practice with what has been called the “Third Wave” of psychological treatments. Linehan (1993) with dialectical behavioral therapy and Hayes et  al. (2011) with acceptance and commitment ther- apy were early adopters of incorporating mind- fulness into clinical treatments. Mindfulness as a treatment for healing has been most popular- ized by Jon Kabat- Zinn (1990) who developed mindfulness- based stress reduction.

Jon Kabat- Zinn developed the mindfulness- based stress reduction (MBSR) program at the University of Massachusetts Medical School over 30 years ago. It uses the principles of mind- fulness meditation to treat patients with both medical and emotional problems. It is generally taught in an eight- week program that teaches mindfulness meditation practices that partici- pants also practice daily. Participants are pro- vided with recordings of the led practices to facilitate their home practice.

Mindfulness- based cognitive therapy (MBCT) was adapted from MBSR by cogni- tive psychologists as an addition to cognitive- behavioral therapy (CBT) to assist in preventing relapse for those with recurrent depressions. It interwove the practices of MBSR with the phi- losophy of cognitive therapy. Just like MBSR, MBCT helps people to be in the moment. In addition, MBCT adds specific exercises to enhance awareness of negative thoughts with the goal of practicing letting them go. At the core of MBCT is learning the concept of decentering (relating to thoughts, feelings, body sensations and impulses as events passing in the mind and body, rather than identifying with them) Segal et al., 2013, p. 91). The Three- Minute Breathing Space, as taught through the program, highlights the importance decentring throughout the day. Like, MBSR, MBCT emphasizes the importance of learning with others in a group format.

Since this innovation, mindfulness has been added to treatments for a wide variety of prob- lems treated by social workers, such as eating disorders (Kristeller et  al., 2014, MB- EAT), and addictions (Bowen, Chawla, & Marlatt, 2011, Mindfulness- Based Relapse Prevention). This has led to an ability to combine best prac- tices of the specific diagnostic profiles within

the structure of an eight- week mindfulness psychoeducation group.

Evidence from Studies of Mindfulness

Scholarly contributions for applications of mind- fulness have exploded over the last decade. Today, on average, a new article is published for every day of the year. The literature is filled with case examples, illness- specific studies, studies explor- ing cultural adaptations, and testing constructs showing the differing capacities of mindfulness. In a series of literature reviews by Baer (2003) positive effects have been found for mindfulness treatment in chronic pain, cancer, fibromyalgia, depression, anxiety, panic, generalized anxiety disorder, eating disorders, general clinical popu- lations, inner city populations, and medical and nursing students, with moderate to large effect sizes, large psychological symptom reductions, and maintenance of benefits over time.

In a series of meta- analyses, mindfulness has been shown to have some moderate effects that improve a variety of symptoms and diag- noses. Grossman et al. (2004) found, in an anal- ysis of 20 studies, that mindfulness enhanced general coping skills with distress and disabil- ity symptoms in everyday life. Most benefits were related to physical health symptoms. In an analysis of 10 studies of mindfulness- based stress reduction for patients with cancer, mind- fulness was found to have some effects with mental health symptoms, and suggested that there was a need for further research on the physical effects (Ledesma & Kumano, 2009). A  more recent analysis of 39 studies for can- cer found improvements for generalized anxi- ety disorder, depression, and other psychiatric or medical conditions. Eberth and Sedlmeier (2012), in an analysis of 29 studies of nonclinical populations, found mindfulness- based stress- reduction groups to have a significant effect on changes in stress reduction, mindfulness, well- being and trait anxiety. Moderate effects have also been found for mindfulness in addressing symptoms of anxiety or mood (Hofmann et al., 2010). Overall, with the abundance of studies, the meta- analyses have shown promising over- all effects on how mindfulness can improve health- related symptoms.

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Randomized controlled studies have also been conducted showing the efficacy of mind- fulness with an assortment of clinical popu- lations. One of the first randomized control studies showed how mindfulness practices can dramatically (four times compared to usual treatment) increase the healing process for pso- riasis (Kabat- Zinn et al., 1998). With the devel- opment of MBCT, mindfulness has been shown to have positive effects for individuals who suf- fer from depression, with improved scores in anxiety, distress including depression, empathy, spiritual experiences, and depression relapse (Teasdale et  al., 2000; Ma & Teasdale, 2004; Segal et al., 2010). Oncology patients have been found to show improvements in mood distur- bance, fatigue, and stress (Speca et  al., 2000; Bower et  al., 2015)  and stress, quality of life, and social supports (Carlson et al., 2013; Monti et  al., 2006). Mindfulness- based stress reduc- tion groups for 117 men who were HIV- positive demonstrated increased positive affect and state mindfulness as well as decreased avoidance after six months compared to control participants (Gayner et  al., 2011). A  reduction in depres- sion symptoms was found for patients who had fibromyalgia without severe functional impair- ment (Sephton et  al., 2007). Medical students during their exam time showed better results in trait and state anxiety and measures of distress, as well as enhanced empathy and spirituality responses after taking an eight- week mindful- ness course (Shapiro et  al., 1998). Female med- ical and psychology students from Norway had reduced mental distress and study stress and increased subjective well- being after taking a seven week MBSR course compared to a ran- domized control group. This was not found to be true for male students. The authors also found higher participation in class and homework were responsible for the improvements (de Vibe et al., 2015). One hundred and thirty- six medical patients with heterogeneous diagnoses showed improvements in quality of life and physical symptoms, and a reduction in psychological dis- tress after an eight- week MBSR group (Reibel et al., 2001). The scholarly literature in mindful- ness is quite varied. There have emerged a series of randomized controlled studies emphasizing improvement beyond stress reduction to include medical, psychiatric, and social symptoms.

What Does Mindfulness Mean for Social Work?

Before it was used as a clinical term, mindful- ness was mostly thought of as a way to pay atten- tion and be careful. Mindful was used to mean “to be more focused on the topic at hand.”

Over the past three decades, there has been a change, and “mindfulness” has taken on a slightly different meaning. In popular culture, it has taken on a meaning that might be closer to relaxing and slowing down. In the media, images depicting mindfulness are often pic- tures of serenity:  a beautiful flower, a difficult yoga pose done serenely, or a facial expression of bliss. It all gives a sense that if we can prac- tice mindfulness, all of our difficulties will melt away; with the image of someone sitting, eyes closed and a gentle smile.

As social workers, we want to think of ourselves as being mindful, especially when relating to others, and may think of it as some- thing we already do. Attending to the present moment in caring for others is a strongly held value, but we also know that there are real lim- its to this when there are so many tasks that we are attending to all the time. Sometimes this means that moment- to- moment aware- ness feels unattainable; a goal for a future time when we do not have such busy lives. Someday we will figure it out.

So, if mindfulness is not a guilt- inducing admonishment to pay more attention or to manage multiple tasks with a serene ease, what is it, and why has it gained such importance for social work? With the increasing interest in a mindful approach to the profession, social workers have discovered how mindfulness can enhance our ability to be present, to remain connected, to listen and be kind to ourselves and our clients as we see them in the individual and group settings.

Social Workers’ Experience of Learning Mindfulness

With the many mindfulness groups we have led over the years, with populations coping with chronic pain, depression, anxiety, addiction, or the experience of being a new immigrant, it has been very important to give words to what

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mindfulness is very early in the group. There is not just a single definition among mindful- ness practitioners. Jon Kabat Zinn (2005) is most often quoted, stating, “Mindfulness is paying attention on purpose, without judg- ment, in the present moment.” Germer et  al. (2005) writes that mindfulness is “awareness, of the present experience, with acceptance.” The Oxford Dictionary (2015) says it is “A men- tal state achieved by focusing one’s awareness on the present moment, while calmly acknowl- edging and accepting one’s feelings, thoughts, and bodily sensations, used as a therapeutic technique.” According to Wikipedia (2015), mindfulness is “the intentional, accepting and non- judgmental focus of one’s attention on the emotions, thoughts and sensations occurring in the present moment, which can be trained by meditational practices.”

Participants take several weeks of practice before the meaning truly comes to life, and the facilitator can help clarify and shape the mean- ing of what is and what is not a mindful approach to the present moment, while honoring group members’ experiences. Often participants come to mindfulness groups looking for relaxation and serenity, and they find it; however, they also find help with their problems by practic- ing returning to the present moment over and over again, and observing how they are relating to that experience. At first, it can seem coun- terintuitive to pay attention to one’s problems, usually physical or emotional pain, but because we tend to avoid painful experiences, we also tend to know little about them. To practice con- necting with one’s world in an intentional way, without getting caught up in avoidance or the judgement that comes with rumination, leads to insight and self- acceptance. This practice helps our patients and clients and ourselves to tap into internal resources. Jon Kabat- Zinn describes this as the experience of “falling awake.”

An example of this occurred in one of our groups. Following a sitting meditation practice, someone described a moment in the meditation when she felt the same sensations as when she was unwell. Her next overwhelming experience was of an intense fear that she would get sick again. During the discussion of the meditation, or “inquiry,” she was invited to expand on these sensations and experiences. As leaders, we saw

this as an opportunity for her to learn more about her internal experience and understand the effect that the fears of getting sick again have on her day- to- day life functioning and even on judgments she makes about her own worth.

She and the group began to appreciate that this is a new and innovative way of working with their problems so that they can gain a better understanding of the situation, but even more importantly, take away the mystery that has kept them feeling fearful and stuck. This allows for greater choices in working with the difficulty and leading to greater confidence in their skill and agility in trying out these choices.

If we stay with each moment, all the expe- riences (emotions, thoughts, sensations) in our lives will come to mind at some point. If we spend our energy working with what is here in the present, where we actually live, we will have the best ability to address each need with more agility and skill.

This phenomenon of understanding also happens in our professional training. The course we teach to professionals is scheduled over three weekends, approximately four weeks apart. Participants start the course on day one absorbing and understanding the simplicity of the program; they see how it can enhance their day- to- day lives. The course validates the importance of self- reflection and self- care. By the second day, questions are fast and furious, as their meditation experiences take them to places they may not have explored within them- selves. This leads to an intense experience of seeing themselves as vulnerable. They question how they will work with their own experiences, and experience doubt that they will be able to learn what is needed to be able to teach mind- fulness and work with what comes up for those they are trying to help. “If I am struggling with some of the difficulties and questions that are coming up for me, how can I  guide others to experience their difficulties? How will I  know what to say?” As the practices continue, some- thing remarkable happens as they explore new experiences of mind and body, moment to moment, while coming out of their automatic responses. These professionals are amazed at what is actually happening at each moment and at the unique choices and options they have when they awaken to their own experience.

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Mindfulness in the Social Work Field

The explosion of mindfulness- based treatments is so vast that it is hard to think of where it has not had some sort of impact on our under- standing of healing and well- being. Although it would be difficult to create exact numbers, Cullen (2011) recorded that individuals from 35 countries around the world have partici- pated in teacher trainings at the Center for Mindfulness in Massachusetts, and this num- ber is trending higher. Mindfulness practice and teaching seem to transcend one’s profession. Every profession is represented in the mosaic of mindfulness teachers and practitioners. As mentioned earlier, we have worked with many different helping professions, including physi- cians, psychologists, occupational therapists, recreation therapists, private counselors, and, of course, many social workers. In our minds, mindfulness does not belong to one profession over another, nor is one profession more aligned to mindfulness teaching.

Although we have learned to emphasize the importance of a professional foundation in pro- viding competent and ethical mindfulness care, we have also learned from our own teaching and attending trainings and conferences that a mindful approach to one’s work is highly per- sonal. The journey we are on as teachers and students of mindfulness is parallel to that of those to whom we provide care. We are all on a path to learn to live more fully in each moment. Our meditation helps us connect further with ourselves and with others. In this way, we are much the same. This is the wonderful paradox of clinical practice; as we enhance our skill and ability, we are better able to learn from those we are engaged in helping, and in turn provide more thoughtful, intentional care.

Although it has been embraced by all the helping professions, there is an emerging litera- ture on the impact of mindfulness in the social work field. In clinical practice, the emphasis has primarily been on how mindfulness can enhance the therapeutic relationship. Turner (2009) discusses how mindfulness assists in enhancing one’s therapeutic presence, which helps to develop the “core mental processes” of the practitioner. He says this helps us deepen

the therapeutic relationship with our ability to attend more accurately to our clients’ viewpoints and needs. This enhancement of our attention can lead to better perception and connection to the client/ patient. In social work psychother- apy, one is often working with individuals with extremely vulnerable histories. This can lead to intense feelings for both clients and social workers. Having one’s own mindfulness prac- tice can help workers self- regulate and remain present, even with painful content. Enhanced attunement and empathy can be an outcome of a mindfulness practice for the psychother- apist who engages in a mindfulness practice. This can help reduce stress on the therapist and support a creative and authentic clinical experi- ence, providing more safety and opportunities for exploration.

Béres (2009) suggests that mindfulness can help the social work clinician take a step back from the Western discourse of the role of pro- fessional as one who tries to end suffering in clients; that, at times, the therapist’s need to be helpful may prematurely cut off beneficial therapeutic processes. This is seen as a “reflex- ivity” of the practitioner’s own thoughts and feelings about the clinical process. Mindfulness is seen to be able to help the clinician become more aware and possibly let go of the reflexive responses, noting when the approach to care is more related to the thoughts and feelings of the clinician than the client’s. Furthermore, a mindful practice helps the clinician develop a better awareness of her own thoughts and feel- ings and be better able contemplate whether there would be benefit to sharing these per- sonal thoughts with the client in the hopes of co- constructing the client’s narrative. “Rather than noting and then letting go of the emotion or thought without refection, it may be possible to note the emotion or thought, make a decision as to whether it would be useful to mention, and then let it go if it would not add anything useful to the discussion” (p. 62). One critically impor- tant aspect of a mindful approach according to Béres is that this process of reflection happens more often in the moment of the clinical session instead of after the clinical encounter or during supervision time.

A second area of inquiry into mindfulness and social work has been to consider mindfulness

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as a way to enhance education practices. One approach has been to examine the role of the educator and the use of mindfulness to support the complexities in the social work classroom. Mishna and Bogo (2007) discuss how, within the social work classroom, there are often dis- cussions of “diversity” and “oppression” as a part of the curriculum, and conflicts will arise as individuals bring their own values and experi- ences to the classroom. Educators will try to set up a “safe” learning environment. The expecta- tion of “safety,” where conflict will be avoided and all expect a certain level of comfort, is not only unlikely in discussions of these value- filled topics but also creates an atmosphere where dis- agreement is considered a problem. This atmos- phere sets the students up to see conflict or discomfort as an annoyance or mistake. This can inflame the classroom discussion and leave the educator unprepared to adequately address the difficult interactions in the moment.

As the topic of diversity and oppression in the social work classroom is inherently fraught with risk and is, thus, inevitably unsafe to some degree it is not feasible in post- secondary and graduate education to aim for safety. Rather, instructors must strive to be prepared to deal with and attend to interactions and conflict in a manner that facilitates social work learning. (Mishna and Bogo 2007, p. 535)

Traditionally, educators may have felt they have prepared the class by setting ground rules based on respect and understanding in an attempt to create a safe environment; however, the authors argue that this approach unrealistic, flat, or two- dimensional and is likely to be insufficient to effectively facilitate learning an emotionally complex curriculum. Mindfulness, according to Mishna and Bogo, is seen as a way to assist the educator to reflect on the classroom discus- sion in the moment and be more responsive and less reactive. With this awareness, one can bring forth an opportunity to explore the challenges with the class while creating an atmosphere of openness. Judgments or conflict can then arise, and there will be an opportunity to clarify the differing perspectives with a nonjudgmental approach and explore the significance of all per- spectives right in the moment. This approach is seen to develop through a practice of mindful- ness in daily life that better equips the educator

to assist with this level of deep learning and understanding. Furthermore, the increase of mindfulness and self- compassion offers per- mission for situations to not always “go well” and allows for an opportunity to further reflect after the fact with colleagues who support the dynamic needs of classroom learning.

Others have written about how mindful- ness can add to the social work student experi- ence. Mindfulness strategies can help students increase awareness of their body sensations and thoughts as well as attend to difficult feelings and judgments (Lynn, 2010). Paré et al. (2009) describe how they have used concepts of mind- fulness to help students learn the art of engaging in a therapeutic conversation in a way that sup- ports one’s ethical practice. They emphasize that, in the clinical relationship, there are many areas of focus in each moment. They provide their students with exercises such as one where they begin an in- person mock clinical discussion and then continue the session online. While they are responding online, they are also typing “off- line” on their word processors to help them rec- ord their internal dialogue simultaneously. The intention of this exercise is to “slow the process down.” While using this process, some students found that they could reflect on the differences within and outside of oneself, while enhanc- ing their awareness of thoughts and emotions. Others found that it was too difficult to maintain awareness of both processes and reported feeling overwhelmed and disconnected. These authors point out that in any clinical discussion, many different “strands” or “trains” of content may be coming forward from moment to moment, along with the student’s own emotional responses. The learning process, therefore, helps the students become more aware of the existence of the dif- ferent trains of content and become better able to focus on a path that facilitates healing.

These are distinct “trains,” and they lead to very dif- ferent outcomes. A therapist who is not mindful will “board” on one or the other without the experience of having chosen to do so, in much the same way that the mind can latch onto discursive strands during meditation practice and drawing us away from atten- tion to the breath. (Paré et al., 2009, p. 82)

As students enhance their mindfulness practice, they become better able to notice and attend to

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these “trains” of thought and focus the clinical discussion in a way that leads to a more compre- hensive and intentional practice.

Birnbaum (2008) followed seven first- year social work students who attended a series of two- hour group sessions over eight weeks, where the group participated in mindfulness practices and had an opportunity to journal and share the experiences of their work both in the classroom and at their placement. The themes from the qualitative analysis highlighted the benefit of having a safe place to explore their experiences; expanding and observing the “self ”; containing and regulating emotions (i.e., fears); exploring relationships with professors and field supervisors; and discussing how the mindfulness practice changes the student in unexpected ways that at times were even unwel- come and overwhelming. The group allowed for a rich opportunity to discuss some of the more nuanced aspects of learning about oneself and managing stress while learning about the pro- fession. An earlier study by Birnbaum (2005) offered 40 students one mindfulness workshop, and a smaller number of students in this group attended three additional sessions. The focus was to help students develop their “inner guid- ance.” Interviews, observations, and student’s notes were used to develop themes. The mind- fulness sessions were a mixture of practices of mindfulness, relaxation, and attending to the student’s internal wisdom. After these sessions, the students were better able to talk about them- selves and others in the clinical experience, and they had developed more skill in deciding when they could be more open to their experience in the moment and when to be more protective and maintain a narrower focus. These students said that they were better at recognizing their inner needs with the experience of the mind- fulness sessions and had an improved ability to explore their choices for responding in the moment.

Gockel et al. (2013) studied how social work students responded to a ten- minute mindfulness session followed by five minutes of discussion in the 28 classes of their clinical interviewing course. These responses were compared to the experience of students in other sections of the course who did not get the mindfulness com- ponent. The group that received mindfulness

training showed an increase in counseling self- efficacy compared to the control group. The mindfulness group was also found to have car- ried the skills into their clinical practice three months after the study. There was not a differ- ence in well- being between the groups, and the authors speculated that this might be because there was such a small “dose” of mindfulness.

These studies highlight how mindfulness in social work education has provided a strong con- tribution to the literature and our understand- ing of how a mindful approach can assist our students and professors. A  third area of explo- ration of mindfulness and social work has been with the discussion of how mindfulness can better support social work in the realm of social justice. Wong (2004) writes about her experi- ences in teaching her social justice class. The first time she offered the course, the discomfort in discussing the societal difficulties was over- whelming for students, and they reacted in ways that tended to close the discussion. The students were confronted with intense feelings and ideas; judgments of good, bad, right, and wrong came forward and ultimately led to a few students blaming the teacher for the unpleasant experi- ence. Wong relied on her mindful practice to stay grounded with her own feelings of teach- ing this difficult course. She decided to prepare students differently when she taught the course for the second time. In this second version, she prepared the students by normalizing the pos- sibility of difficult and contradictory feelings arising and offered them ways to embrace the difficulty, slow down their process, and reflect internally on their own experience within their social context. The mindful approach led to a very different experience: students were able to stay with their feelings, explore how their pre- conceived ideas could change in a way that was exciting and new instead of threatening their sense of self.

Hick and Furlotte (2009) also speak to their personal experience of finding how their own mindfulness practices help inform their work in social justice. With social justice, one is to explore the layers of difficulty, looking into oneself and looking at the injustices of others. Tensions, discomfort, and strong judgments often arise with this type of exploration. The mindful practice can provide a spaciousness in

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opening to the difficult so that even opposing ideas can be faced without judgment. The social worker is challenged to reevaluate entrenched ideas without creating further barriers or divides between themselves and others.

Mindfulness introduces a skilful means for culti- vating and sustaining awareness about ourselves, our everyday experience, and our experience in the world. Taken together, they can enable social work- ers to consciously know their inner and outer expe- rience, the dialectical relationship between the two, and how this plays out in society. (Hick and Furlotte, 2009, pp. 20– 21)

These are some promising ideas about how mindfulness can positively contribute to the work of social justice. Our mindfulness practice allows us to see more of what is happening in each moment, and in the case of social justice, be better able to hold internal and external ideas at the same time without demanding that these ideas be completely aligned. It is the ability to be with the misaligned ideas that allows for fur- ther exploration and understanding to enhance social justice.

Social work scholars are beginning to write about mindfulness in a variety of ways within the context of the profession. Mindfulness and social work practice offers a unique perspective in the literature, with discussions of how to be present with oneself and with others. As more become familiar with the benefits of working with a mindfulness lens, this literature will be able to further contribute to our understanding of social work practice in countless ways.

Accessing Mindfulness

Throughout both of our careers, the question of how we can teach mindfulness and tap into its riches in a way that is accessible and mean- ingful frequently comes up, with students and with peers. How can we be sure we are teach- ing mindfulness? Are there risks of picking up relaxation instead of mindfulness? One exam- ple of this occurred many years ago when we were teaching an MBCT course that was part of a research study. It was comparing the ben- efits of mindfulness versus relaxation. It was decided that once the relaxation group had fin- ished their group, they could be invited to come

into the mindfulness group. We were curious about their perspectives. Interestingly, those who attended the relaxation group did not stay. Relaxation offers a different set of skills— quite often focused on avoidance of difficulty and instead to connect to the pleasant. So partici- pants found it difficult to switch to a new set of skills so quickly. We are not judging relaxation— it is an equally useful skill. Mindfulness is less known to us in our Western culture, so confu- sion can often occur. Mindfulness works with whatever comes up. Someone may become relaxed and enjoy any experience in the present moment, but when one has a difficult experi- ence, mindfulness offers alternative choices to be present with the difficulty. For new practi- tioners, understanding the difference can be confusing because there are opportunities in the mindfulness practice to settle into the pre- sent moment, and at times a release can come. The difference is that it is not our goal to cre- ate or hold onto the pleasant, we simply look to embrace whatever emerges in our practice.

What we have observed is that all of us who are on the journey as healers, including social workers, are searching for ways to ease suffering and enhance happiness. How can we best access mindfulness for others and ourselves? First, we have found the group format to be quite benefi- cial. The group provides a multitude of learning possibilities in each moment. One person will feel warm, another cold, someone will notice a sensation of happiness, whereas another might feel pain, anger, or resentment. In the group environment, all of us are experiencing the same practice at the same time but relating to expe- riences differently. This helps us to realize the contrast between ourselves and others and see firsthand that all of the experiences of daily life can show up at any time. There is also a greater opportunity for the facilitator to respond to the different experiences without valuing one over another. The group quickly sees how we “walk the walk” in that we can “be with” the difficulty discussed in the group, knowing at times we are all looking for a way to “fix” this moment by grasping what feels good or trying to push away what we judge to be difficult.

What we do instead is emphasize the impor- tance of choices. The most rewarding feedback we hear when we teach is that participants

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believed that they could choose what was best for them in the class and in their home prac- tice. In guiding or leading practices, it is key to invite people to explore different ways of being or working within a guided meditation. Many of us automatically do what we are told, espe- cially when the health “expert” is giving the instruction. So, we like to think that we offer many instructions and choices, and the partici- pant is welcome to explore with us or tune into their own wisdom that says “I am going to try something different right now,” or “This does not feel quite right, I  think I  will let this go.” We try to reinforce this message when we talk with the group after the meditation practice. We emphasize how participants are welcome to consider other options if they are overwhelmed or become disconnected in any moment. There is a wisdom in tuning in, and saying no, and acting from their own perspective.

Like all of the mindfulness programs for clinical populations, we teach that different practices or meditations will speak to each participant. Some will connect to mindfulness more through the poetry or a sitting practice. Others are better able to connect to their pre- sent experience through the body scan or walk- ing meditation. This also can change over time. A common experience in the eight- week group is to have participants do the body scan on the first and last days of the group. Participants cannot help but notice how this moment eight weeks later is so different from where they started.

Practices to Access Mindfulness

The following practices are intended to offer some ideas of how to connect into one’s own mindfulness practice and begin to explore ways of helping others develop some skill and under- standing of the properties of mindfulness. At every session, at least one formal practice focuses on either the body, breath, movement, thoughts or feelings/ emotions, and these are from 30– 45 minutes long.

Body

Practices that tune into the body have been seen as foundational. Many of us are unaware of

many of the sensations in the body. And when we do connect with our body, we can make very negative judgments about our body that lead us to try to avoid these sensations. The avoidance of the body, the lack of awareness makes it diffi- cult to receive the signals from the body that can warn us about ways we are injuring ourselves and triggering pain. Practices such as the body scan, where one gives attention to regions of the body as if following an actual map, can help us connect with how the body is functioning in the moment. This practice is often done lying down, but it is quite versatile and can be done sitting or standing. The practice is often done without moving (although moving is “allowed”) in order to notice what sensation is occurring in the region of body in each moment. Some participants will note that there are parts of the body where they do not notice sensation, which allows for a curiosity of the lack of awareness. Another common practice is body movement of some sort stretching, yoga, or tai chi. These all give opportunities for connecting to the body as it is moving and to thoughts and feelings that arise.

Breath

Attending to the breath is often seen as a pre- step into mindfulness. Most see attending to the breath as a concentration exercise and not really a mindfulness practice. The breath is with us at all times and provides a very available focal point. Focusing on the breath can also teach us a nonjudgmental approach to the present moment, particularly if we have an idea about how one is “supposed” to breathe. The practice here is to notice where one can feel the sensation of breathing and the properties of breath such as shallow or deep, long or short, etc. For this reason, the breath is a very useful place to begin. It can also be a very helpful practice to return to if someone becomes overwhelmed during meditation.

Feelings, Emotions

Quite often when we become still for any period of time, feelings will emerge in the practice. We can mindfully practice simply observing the feelings when they arise. Invite

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participants to explore the feeling by explor- ing the qualities of the emotion, such as its intensity or whether it seems to be associated to a particular area of the body. When one can settle into the feeling, one can notice how it changes from moment to moment, even if it is something as intense as a craving. Instead of trying to “fix the feeling,” we can explore it, even if briefly. At this point, one may notice the power in realizing that feelings cannot “hurt” or harm us but instead simply be a short experience. This is further explored when we talk of acceptance, even of the difficult emo- tions. Acceptance is not resignation but sim- ply allowing the feeling to be present, where it does not need to be hidden or changed. One of the helpful practices developed in MBCT is to work with a difficulty (often a feeling of depression) and invite participants to simply breathe with the feeling— breathing in say- ing “soften,” breathing out saying “open.” The participant can be reassured by offering the participant to say “It is okay, whatever it is, let me feel it.” (Segal et al., 2013). It is equally important to explore the pleasant feelings as they arise and offer ourselves the opportunity to settle into these feelings. These are also an important part of fully experiencing our lives.

Thoughts

Thoughts are an area of exploration where we do not have to go far into the practice before they emerge. A  very common reason for peo- ple to say that they cannot meditate is because they feel that they must be able to be void of thoughts. Although it is unclear exactly how many thoughts one has in a day, most have reported that it is somewhere in the tens of thou- sands. Not only do we have all these thoughts constantly coming forward, but they also com- bine with emotions into stories that take us out of the present moment. Our stories can be about past events, planning for the future, or simply developing a series of fantasies to “check out” of the present moment. With all of the thoughts and stories coming forward in the silence of mindfulness practice, there is an opportunity is to notice them and even work with them as they arise. Noticing without judgment allows the practitioner to experiment with refocusing

on breath or body, as suggested in the practice. Alternatively, one can decide to notice that a story has shown up, follow it with curiosity, and explore what might be learned from the experi- ence. Here we see the choice and an opportunity for the individual to explore thoughts or think- ing. It is a common experience to judge one- self for “allowing” the mind to fall into stories. A  frequent guidance is to allow the realization that the mind has been pulled into the story, and once this is realized, one is reconnected to the present moment. Then we can practice con- necting the attention to the next moment with the suggestion of kindness or success of recon- necting into the present.

Another common practice is to focus on thoughts as they emerge in the present moment. This can be guided in many ways. This may be something as seemingly simple as “see- ing” thoughts as if they were clouds forming in the sky, passing by and then dissipating as they move out of view, or perhaps as a projec- tion in the mind’s eye where a thought comes on a screen or a stage and then falls away to be replaced by another. This helps us see thoughts as discrete, but transient, events occurring in each moment, instead of as static, unchangea- ble stories. It can take some practice for prac- titioners to be able to see these thoughts as emerging and falling away. For this reason, this way of working with what comes up in medita- tions is not taught until several weeks into the mindfulness group.

Poetry

Poems are often incorporated into meditation practices, often at the end of a practice. Poems by Rumi, Mary Oliver, or Galway Kinnell are frequently recited because they speak to aspects of mindfulness. Our experience is that many find that the poetry speaks to them in a way that has deep meaning and connection as the mindfulness practice deepens. In contrast, oth- ers find the poetry to be a distraction and are annoyed by it. This is an opportunity for the social worker to reinforce that different mind- fulness practices and experiences speak to dif- ferent people, to notice what shows up with the poetry, explore it, and let it go if it does not seems helpful.

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Informal Practices

For many, there is a tension about whether a formal mindfulness meditation practice will be helpful or if they can even do it on their own. Our perspective is that everything helps. Exploring the informal meditation practices offers a wealth of experiences as one slows down and allows the riches of what is happening right now to unfold. So much of our day can be lived without awareness. Inviting people to practice daily activities such as brushing one’s teeth or doing the dishes mindfully becomes a reminder that life is to be lived in each moment no matter how small the task.

Three- Minute Breathing Space

One short form of meditation that was devel- oped from MBCT is the three- minute breath- ing space. It was developed to help practitioners develop the habit of doing brief (three minutes or less) practices throughout the day and to make use of them when something difficult arises. Our experience has been that this practice, although simple, takes practice to be able to do by one- self. It has three steps:  The first is to attend to the experience in the moment— thoughts, body sensations, and feelings. The second step is to move ones awareness to the rise and fall of the breath. The last step is to expand from the breath into the body as a way to reintegrate the present moment. Once the method is learned, taking the brief time to check in with experience, breath, and body can be helpful when someone is feeling overwhelmed, and regularly throughout the day.

Inquiry

During a group, leaders will guide discussion about members’ experiences during the for- mal practice. This is a rich opportunity to clar- ify any misconceptions about mindfulness and support what is being learned. Although techni- cally we are looking back into the past moments of our meditation, such inquiry helps partici- pants to become more aware of the multiple layers of experience that are occurring in every moment. Inquiry most often occurs in a group where the facilitator helps to explore experi- ences that the participants volunteer. We are

encouraging participants to notice thoughts or feelings related to some portion of the practice. There is a very strong thread of acceptance here.

After a sitting meditation practice, the group is invited to share their experiences of this prac- tice. Here is a small example of inquiry within the group:

Jean: “I was feeling a lot of pain in my back while I was sitting.”

Facilitator: “What part of the back did you experi- ence the pain?”

Jean: “I felt it in the middle of my back” (now point- ing to her back).

Facilitator: “Did you notice any thoughts or feelings associated with the pain?”

Jean: “I feel this back pain all the time.” Facilitator: “Mmm. And did you notice if anything

next?” Jean: “I began to focus on the breath and I began to

feel my spine move as if it is an accordion moving up and down, the pain eased while my spine was moving up and down and I just became aware of the movement.”

This is an opportunity for the group to hear how one can stay with the experience, and the facilitator can encourage Jean and the group to attend to their wisdom to be with whatever is arising in each moment. Inquiry can be fostered in the group or perhaps written in a journal to help expand our awareness in our practice.

Conclusion

Mindfulness has made a remarkable addition to clinical work and within a relatively short period of time— beginning in 1979 with the secular adaptation of mindfulness meditation for stress reduction by Jon Kabatt- Zinn and his colleagues at the Center for Mindfulness at the University of Massachusetts; continuing through the significant work of Segal, Williams, and Teasdale in the development of MBCT for prevention of depressive relapse in 2000; and through the present as clinicians and research- ers continue to study its effectiveness as an adjunct to work with a multiplicity of physical and mental disorders.

With this work it seems to us that the most natural match for mindfulness within the help- ing professions is social work. Like social work, a deeply held value for mindfulness is starting

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with the individual’s experience in relation to the context of the person’s life. Mindfulness is both realistic and optimistic in its approach and, like social work, there is value in both self- care and self- acceptance. Being nonjudgmental is a hallmark of both social work and a mind- fulness approach.

This can be seen clearly in the significant research into how mindfulness can be useful for, and even improve, social work practice. Social workers explore how to improve the indi- vidual, community, and social conscience in our society. Mindfulness is an approach that can help the social worker reflect on all of the layers of experience in any situation— even if these layers are contradictory. Social workers are also keenly exploring how to use mindful- ness practices at the beginning of learning. Our students and faculty can struggle with the chal- lenges in the classroom and in the placement setting. Social work educators are seeing the benefits of mindfulness during this challenging phase of professional development.

With the embracing of humanist values, mindfulness is a natural fit with social work. There are many ways to enhance skills and abil- ities in mindfulness practice. The multitude of choices or opportunities in this approach is not a mistake. To be able to stay present, grounded and aware, one needs a variety of options to work within each moment. Sometimes it is the indi- vidual noting what practice or area of awareness is needed or is worth exploring. Sometimes it is the situation that brings forward a different way of being with one’s experience. For social workers, there is value in having expertise in mindfulness experience and practice to draw upon while working with the complexities of vulnerable populations and acknowledging the challenges of our societal realities. Seeing where these opportunities go for the social work pro- fession in the future is very exciting prospect.

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This chapter is dedicated to Michael White (1949- 2008), who with David Epston co- founded narrative therapy.

Narrative therapy was developed in the late 1980s and rose to prominence in the 1990s, especially in the fields of family therapy and social work with individuals, families, and communities. In this chapter, narrative therapy is described, its historical and theoretical base explored, and how it fits into existing social work practice theory and values addressed.

The Narrative Approach

The narrative approach described and discussed in this chapter draws mainly on the works of White and Epston (1990), family therapists from Australia and New Zealand, respectively (both originally trained in social work, and

Epston also studied community organization). They developed this approach in the 1980s, but it became popularized in North America after their book, Narrative Means to Therapeutic Ends, was published on this continent in 1990. While some elements of their approach were fairly unique at that time, their work emerged and co- developed in relation to theoretical and practice developments concurrently occurring in North America and Europe. Their approach falls under the general rubric of constructivist and social constructionist theories, from which several models emerged at about the same time, which all developed in relationship to the post- modern movement that crossed many aca- demic disciplines (see Carpenter & Brownlee, Chapter  6 of this volume, for further discus- sion of constructivism). In the 1980s, Anderson and Goolishian (1988) in Texas; Boscolo and

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Checchin of Milan, Italy; Penn and Hoffman of the United States, who worked with the Milan group (Boscolo, Cecchin, Hoffman, & Penn, 1987); and Tomm (1987) of Alberta, Canada, who had also studied with the Milan group, all wrote about these newer constructivist/ con- structionist approaches. Freedman and Combs of Chicago (1996) further popularized the ideas by clearly outlining the theory and practice of narrative therapy in their book, The Social Construction of Preferred Realities.

Early on, Hoffman, a social worker and prominent family therapist, described the shift of family therapists away from the emphasis on an intra- psychic focus to systemic views, as swinging back to a greater emphasis on ideas, meanings, beliefs, and myths (Hoffman, 1990). While systems approaches are based on cybernetic thinking, a mechanistic theory of control that Hoffman declared had lost its use- fulness, constructionist therapies are based on “second- order cybernetics,” which renders observations as being dependent upon the observer. Like some behavioral and cognitive approaches emerging in the same period, sys- temic therapies were based on a modernist view of objectivity, rationality, and knowing through observation. The postmodern view holds that many realities and truths coexist and sees real- ity as being socially constructed rather than a given (Neimeyer, 1993).

Relationships to Other Theories

Constructivism and social constructionism both fall under the postmodern movement. Narrative approaches borrow from the con- structivists in the field of literary criticism, where narratives are taken apart and analyzed for meaning, and from the social construction- ists in the field of social psychology, where real- ity is viewed as co- constructed in the minds of individuals in interaction with other people and with socio- cultural beliefs. Neimeyer (1993) characterizes constructivism as a “meta- theory that emphasizes the self organizing and proac- tive features of human knowing” (p. 221) and as a view of humans as “meaning making agents” (p.  222). The roots of constructionist thera- pies can be traced to many sources, especially George Kelly’s “personal construct theory,” first

articulated in the 1950s (Kelly, 1955). Kelly him- self cited semanticist Korzybski (1933), who was also drawn upon by cognitive (Ellis, 1962)  and systems (Watzlawick, Weakland, & Jackson, 1967)  therapists, and by Moreno (1937), who developed psychodrama. Constructivist- based therapies have been compared to and con- trasted with cognitive therapy (Neimeyer, 1993), and to systems approaches (Kelley, 1994), and its emphasis on meaning connects it to the existential approaches (see Krill, Chapter  10). In the development of their narrative therapy, White and Epston (1990) state that they drew on the works of French philosopher and histo- rian Michel Foucault (1980), as well as psychol- ogist Jerome Bruner (1986) and anthropologist Gregory Bateson (1972); system thinkers also drew on Bateson. On one hand, narrative ther- apy became a new paradigm for viewing human change; while in other ways it can be seen as evolving out of existing practice theories.

The narrative postmodern approaches to practice can be useful for social workers who search for the meanings of events and behav- iors as preconditions for action. The empha- sis on understanding and meanings is useful as we work with the diverse clients of today’s practice settings. White (2007a) discussed nar- rative therapy as focusing on the expression of peoples’ life experiences; that life, meaning, and experience are inseparable. The implica- tions of postmodernism for practice have been discussed by social work scholars and others, who found these approaches useful for multi- cultural practice (Holland & Kilpatrick, 1993; Kelley, 1994; Waldegrave et al., 2003); persons facing adversity (Borden, 1992), family violence (Rober, Eesbeek, & Elliot, 2006) and trauma (Denborough, 2006); adolescents (Kelley et al., 2002; Zimmerman & Dickerson, 1996); sexual abuse victims (O’Leary, 2004); grief and loss (Hedtke, 2014; Neimeyer et al., 2009); eating disorders (Weber, Davis, McPhie, 2006); and health care (Wynne, Shields, & Sirkin, 1992). Narrative therapy has also been applied to group work (Dean, 1998; Laube, 2004) and commun- ity work (Epston, 2003; Kelley & Murty, 2003; Vodde & Gallant, 2003). International con- ferences on narrative therapy and community work, are held at various centers and institutes around the world, and The International Journal

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of Narrative Therapy and Community Work has continued quarterly publication since its incep- tion in 2009.

Basic Assumptions

Knowledge is power, and self- knowledge can empower people. White and Epston (1990; White, 2007a) believe that we all “story” our lives to make sense out of them. We cannot remember all of our lived experience; there is too much material and too many experiences unrelated to each other to retain it all, so our narrative structuring of experience is a selective process. We arrange our lives into sequences and into dominant storylines to develop a sense of coherence and to ascribe meaning to our lives. As we develop our dominant storylines, we remember events that support it, and forget (White and Epston say “subjugate”) other life experiences that do not fit into the dominant storyline. The meanings we attribute to expe- rience are influenced and shaped by cultural beliefs and practices (Bruner, 1986). Certain events may be imagined or exaggerated to fill in the gaps of a story. White and Epston’s concept of subjugated knowledge is different from the psychodynamic concept of the unconscious, in that “subjugated knowledge” refers to life expe- riences not remembered because they do not fit into the dominant story, whereas the psychody- namic idea of “unconscious” refers to memories that are repressed because they are painful.

Narrative therapy is similar to postmodern literary criticism, where the storyline is “decon- structed” as the plot, characters, and timelines are reassessed. Many times, presenting prob- lems of clients fall within a dominant storyline, with clients authoring stories of their lives that are problem- saturated. These stories limit the clients’ views of themselves and others and can immobilize them from action. Their problem- saturated stories have been co- constructed with others around them, including employers, social service workers, and other helpers, and are influenced by dominant cultural norms. For example, social service agencies working to help multi- need families can do too much for them (Imber- Black, 1988), giving the message that they are incompetent, and their dominant narrative becomes that of a “multi- problem” or

“dysfunctional” family. Similarly, Wynn et  al. (1992) discuss how, for chronically ill people, the life of the illness may become the dominant storyline, as the family and professional help- ers gradually become more involved with the patient, and the co- constructed reality is that the patient is the illness, as opposed to being afflicted with it. A  goal of narrative therapy is to help the client see more realities, which offer more alternatives for them, and help them to self- empowerment. As Neimeyer has noted (1993), such therapy is more creative than cor- rective and is more reflective and elaborative than persuasive or instructive.

Role of Social Worker/ Therapist

The role of the social worker is collegial. As nar- rative therapy helps clients “rewrite ” their lives through seeing other truths and other possible interpretations of events, the role of the thera- pist is to listen, wonder, and ask reflective ques- tions. Clients are invited to assess other realities, which are not necessarily truer, but are “also true.” For narrative therapists, the harsh reali- ties of many clients’ lives, such as poverty, rac- ism, or violence, are not denied as constructs of the mind, but the power given to these adverse events and the control they have over clients’ lives are challenged. Clients are also challenged to question some “truths” accepted by family and the larger culture, which have affected their views and held them back. Narrative therapists pose reflective questions in order to generate more experientially vivid descriptions of life events, especially descriptions not currently included in the problematic story. These ques- tions help clients assess other ways to view a situation, analyze for alternative meanings, and find other aspects of their lives, often involving strengths and coping, which may have been lost in the over- focus on problems. In this postmod- ern view, the therapist is not an outside, objective observer, but is part of the change system, and there is reciprocal influence between client and clinician as both engage in the construction and performance of preferred identities. Thus, the therapist does not just hear the client’s story, but co- creates it with the client, hopefully with the client creating some new stories. History is not a collection of facts to be remembered, but

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is “created” in the telling. The therapist’s role is non- hierarchical, especially compared to that of psychodynamic or systemic therapists. The therapist is not the expert on the problem or the client’s life; the client is. The therapist takes a “not knowing” position (Anderson & Goolishian, 1988), which invites the client to do more exploring.

Cultural Sensitivity

Among narrative therapy’s signature contribu- tions is its cultural sensitivity because it does not presume a way of being, but aims to under- stand and enrich the client’s reality. The thera- pist listens for ways in which ethnicity, physical ability, gender, sexuality, culture, and social and economic context may shape the client’s world- view and view of self. Clients are encouraged to take action on their behalf, to become their own change agents. Discussions of social justice, poverty, gender, and power are part of social constructionist approaches. At the Family Centre in New Zealand, Waldegrave and col- leagues (2003) have developed “just therapy” (meaning “socially just”), where therapists and clients together weave webs of meaning where political as well as clinical responses are invited, and where cross- cultural consultants are used on the therapy teams. Narrative therapists in general have taken on these social- activist views and practices.

Narrative therapists often engage clients in recognizing how their relationship to problem- saturated stories occurs at the expense of preferred, alternative stories and how these dominant, disabling storylines serve to margin- alize or subjugate other discourses. Examples of these subjugating cultural narratives include practices of patriarchy, heterosexism, racism, Eurocentricity, and binary constructions such as healthy/ unhealthy; normal/ abnormal; and functional/ dysfunctional.

View of Human Nature

The view of humanity underlying this approach is that humans are complex and multifaceted, not simply good or bad. Underlying pathology is not presumed. Rather than listening for under- lying “root causes,” the social worker listens for

other aspects of the client’s life that may also be true and involve strengths to be mobilized. These “unique outcomes” (White & Epston, 1990) exist outside of the client’s problem story, and may involve identity descriptions that have been subjugated. Here similarities can be seen to solution- focused therapy, which also looks for “exceptions” to the problem and was developed by de Shazer and colleagues (de Shazer et  al., 2007). However, differences between solution- focused and narrative therapy need to be noted. In narrative work, the clients are not asked for the “exceptions” to problems; instead, the ther- apist carefully listens for these times and brings them out, co- constructing new realities with the client. In addition, instead of ignoring problems to focus on solutions only, problem descriptions are carefully listened to and deconstructed, and the past is not ignored. Borden (1992) discussed the importance of helping the clients assess the past, experience the present, and anticipate the future as specific life experiences are incorpo- rated into the ongoing life story. While atten- tion is paid to the past, the focus is on helping the client not to be stuck in disabling descrip- tions of the past but to develop a progressive, forward- looking narrative.

Narrative therapists see clients in context, that is, as part of a cultural whole, where views of self and the world are co- constructed in dynamic interaction with cultural and societal norms. Clients are invited to assess the truths they have assumed, and to challenge views that have not been useful. In this way, they may empower themselves to work on their own behalf or for social change. Further, as needs are assessed with client and clinician working together, the client may be made aware of other resources available.

Social Work Treatment

The goal of narrative treatment in social work practice is for clients first to understand and then to broaden and change the stories around which they have organized their lives, and to assess and challenge the socio/ cultural/ polit- ical sources that have influenced them. This work may involve helping the client to chal- lenge the problem- saturated dominant story as the only truth, and to find other aspects of

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his or her life that may also be true. The discov- ery of more realities and more truths can free clients to see more alternatives and ways out of an impasse. Through dialogue between social worker and client, these problem- saturated sto- ries are gradually deconstructed as the worker introduces questions that challenge the client’s “thin” descriptions of reality and draw out fac- ets of the client’s life that have previously been ignored. Narrative therapists recognize that not all stories are seen as equally useful and they help clients challenge those that are disabling or not useful.

The narrative model offered by White and Epston (Epston, 2004; White and Epston, 1990; White, 2007b) is helpful for teaching and for practice because it names specific practices and outlines stages of the process without being too prescriptive or technique- driven. Constructionist therapists in general do not distinguish between the “assessment” and “treatment” stages of practice, for they view assessment as an ongoing and ever- changing process, and hope that all sessions are thera- peutic. All clinicians know, however, that there are some elements of the helping process more appropriate in earlier stages, and some are more useful later in the process. For this reason, White and Epston’s (1990) discussion of their narrative approach as consisting of two main stages, “deconstruction” and “reconstruction,” is useful.

Deconstruction Stage

In the deconstruction stage, the clients’ exist- ing stories are heard and then deconstructed. It is important not to deconstruct or “challenge” the client’s problem story too soon. Most peo- ple need to have their problem stories heard or witnessed before they can move to examining them and their relationships to them. First, the clinician carefully listens to the “client’s story of an experience” that illustrates the problem’s impact on the client’s life: What does he or she define as the presenting problem? How does the client experience it? What meaning is ascribed to it, and how is it viewed in light of histori- cal events and social contexts? This process is similar to the joining or relationship- building process of any good therapeutic endeavor.

Asking questions to elicit the full meaning here is important, as is helping the client to see how most problems are relationally constructed. Who else is involved in this problem? What events in the past have contributed to its devel- opment? How did this problem evolve over time? What has been tried to fight the effects of the problem? How has this problem affected other aspects of the client’s life? As in any good therapeutic encounter, the development of an empathic relationship is important. This empa- thy is important for developing trust, but is also important in helping the clinician understand the client’s reality more fully. While the careful listening and reflecting is similar to most ther- apeutic approaches, the way the questions are worded is specific to the narrative approach.

In this beginning stage, the therapist lis- tens to how the client describes his relationship to the problem and helps the client develop a “map” of the various ways the problem story has had influence on the client’s experience. Externalizing the problem, a key idea in nar- rative therapy, begins in the joining stage and continues throughout the treatment process. The purpose of this externalization is to sepa- rate the person from the problem, to view it, not as intrinsic to the person, but as something that has interfered with the person’s life and needs to be challenged. Thus, at the early stages, where the client’s story is being heard and understood, the nature of the reflective questions gradu- ally shifts the view as to where the problem resides. “When did you first notice that depres- sion began to interfere with your work?” “How did it happen that Andy’s temper took over so much of his life? Who first noticed it? Who has been affected most by it?” It is important to distinguish between viewing a problem as not intrinsic to the person and not taking personal responsibility for one’s actions and the conse- quences of those actions. Clients are encouraged accept responsibility for fighting the effects of the problem and for their own behaviors, but to not see themselves as the problem.

Even the effects of physical illness can be externalized through questions about the effects of the illness on the person’s life, and about the process by which it took on so much power over the person’s life, and about how it has interfered with other aspects of the person’s life, including

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relationships. As the client is able to separate from the problem, it becomes more managea- ble, and the problem, not the person, becomes the target for change. The client and therapist unite to fight the effects of the problem and to enlist others in joining the client in this resist- ance to the problem’s effect. At this early stage, even before deconstruction, the clinician listens carefully to the client’s definition of the problem and begins to objectify the problem through the use of metaphors, through summary, and through the nature of the reflective questions.

The importance of language in sharing meaning has been discussed by many theo- rists and therapists over the years (Anderson & Goolishian, 1988; Bateson, 1972; Ellis, 1962; Watzlawick et  al., 1967), including narrative proponents (Epston, 2004; Freedman & Combs, 1996; White, 2007a). The way questions are worded is an important aspect of this work. A  client may be asked to imagine what their struggle with a particular problem might say about them. Clients are encouraged to estab- lish their own evaluation or judgment about an interpretation of an experience. Specifically, cli- ents are led to recognize that they can choose their own interpretation of an event or expe- rience according their own intentional stance. White (1989) has described the way in which he helped a family with a 12- year- old son with behavior problems to “escape from trouble.” He asked family members to describe the ways in which “John’s” problems had “plagued” his life and “influenced” their lives. White also asked the parents how they had coped with John’s troubles and how they had become involved with them.

Narrative therapists, unlike those from some other schools of thought, do not assume that clients “need” the problem or that it symbolizes a deeper problem, as do some psychodynamic therapists, nor do they believe that it “serves a function” for the family unit, as believed by some systemic proponents. It is assumed that clients want the problem solved or remediated, but that they have gotten stuck in finding ways to do so. Thus, words like “unmotivated” or “resistant” are not considered useful. This belief in clients and what they say is very respectful, and consistent with social work values. While it is not presumed that clients need problems,

it is recognized that they and family members, friends, and helpers may have helped maintain the problems, possibly through their efforts to solve them. Thus “relative influence” questions are useful in bringing about discussion on that matter. For example, family members may be asked how they were recruited into and influ- enced by the client’s problem, and how cultural forces may have influenced them.

After the first part of the deconstruction stage, where the clients’ views are heard, under- stood, and acknowledged, the therapist grad- ually begins to help the client deconstruct the dominant story through continued summariz- ing and questioning. It is important to note here that the client’s view is not disputed or seen as not true, for that would not be respectful, and the client would not feel validated. Instead, the story is fully discussed and analyzed for mean- ing, and other interpretations and other mean- ings can be assessed, bringing about alternative truths that are also valid. Questions help the cli- ents identify two distinct “landscapes” for their stories:  (a)  the landscape of action (what has happened, who was there, where things seem to be at present); and (b) the landscape of identity (what the situation says about the client, what meanings can be inferred, how it fits with the client’s preferred views or intentions). At this point, the relative influence of the problem’s effects on the individual or family is mapped across time and across spheres. How has this problem affected the client in the past, present, and anticipated future across intellectual, per- sonal, interpersonal, and social spheres?

For example, in the White case of helping the family “escape from trouble” mentioned above, it became clear through discussion that John’s “trouble” had interfered with his life at school, academically, and with classmates, and at home in his relationship with his parents. To what degree the school had come to view him as the problem, and the degree to which he had taken on that view were examined. In addition, how the problems had “crept into” his parents’ lives and affected their relationship with each other as well as their own work productivity was assessed. Ways in which “trouble” had caused guilt in John and feelings of helplessness in his parents were discussed. Questions were intro- duced to John to speculate about what would

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happen if he were to further “succumb” to trou- ble, and to his parents about what might be the possible effects of their continued participation in the problem. Should they accept John’s invi- tation to join him in participating in trouble, or should they renounce it and escape from it? This careful dissection of the effects of the problem across all spheres of life and the assess- ment of what might happen in the future if it was allowed to dominate, and to challenge the family to find new ways to handle the problem. The family now could work with the clinician to explore ways to defend itself against the effects of trouble and to fight it when necessary. Since the problem was externalized, the family does not need to define John as the problem, but can join with John and the clinician to find ways to defend against this problem that is interfering with his and their lives.

As the problem stories are gradually decon- structed through a dialogue between client and clinician, the clinician obtains a richer descrip- tion of the problem. The client discusses events that he or she believes led up to the problem’s formation. Not only events, but thoughts, beliefs, and the social environment around the events are assessed for influence in the past, present, and possible future. Clients might be asked to ponder how the same events may have been viewed by others, or even how they might view it themselves if they were not involved. For example, a victim of childhood abuse may have blamed herself or himself, but may now begin to see that being a child in a helpless position, the choices were limited. Alternative futures are also discussed:  How would it be if things were different, and who would do what? Who would first notice the difference? What would a better future look like? Here, again, similarities to de Shazer and colleagues’ (2007) solution- focused therapy may be noted. This “visioning” of a desired future helps clients begin to think about ways in which they might get there. Different from solution- focused therapy, however, is the fact the narrative therapists also look at what might happen if things do not change.

Reconstruction Stage

In the reconstruction stage, other truths are found that are also true but may have been

subjugated because they did not fit into the dominant theme. It is a knowledge- expanding, more than knowledge- changing, experience. This subjugated knowledge is brought out through careful listening for “unique outcomes” or “sparkling events” (White 2007a) as clients tell their stories. These are events or outcomes that cannot be explained by the dominant story. For example, a man has described his problem as being a bully, stating that he has always been mean and has had a temper problem most of his life. He discusses how his experience with bul- lying has interfered with his relationships with peers and colleagues, both as a child and as an adult. He describes how it has caused a breakup of his marriage (the precipitating problem) and interfered with his relationship with his child- ren. The client and worker also examine how his pattern of bullying has also hurt him, caus- ing powerful feelings of guilt and lowered self- esteem. Looking to the future, he sees a lonely existence if this problem continues to dominate his life. It is important to obtain his view of this situation, not to assume that he sees it as “bad” or that he wants to stop it. The purpose of help- ing him to separate from the problem is not to alleviate him from responsibility for his actions, but to help him assess its effects on himself and others, make a decision as to what he wants to do about it, and then develop ways to manage and control it (the problem). In fact, responsi- bility was implied here, as the client was asked about how temper had taken over his life, and did he want it to control his life?

Here the unique outcomes were not easy to find at first, but careful listening helped to uncover some. If he is such a “tough guy,” where did he find the gentleness to visit his grand- mother in a nursing home? How was he able to muster enough caring to take care of his dog so well? Again, the similarities to de Shazer and colleagues’ (2007) solution- focused therapy can be seen, but instead of asking for “excep- tions,” which the client may not see, the ther- apist carefully sorts through the conversation like a detective to find the evidence. Just as the dominant story has been deconstructed to find out who was involved in the construction of the tough- guy identity, now the client is asked to think about who may have helped him develop this gentler side. Gradually, a discussion of

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a relationship with a caring grandfather was brought out, and a gentle but manly teacher is also remembered. In addition, the cultural mes- sage in the media of needing to be tough to be a man is also compared to the conflicting social message about the honorable gentleman treat- ing women and children well. Knowing there is another side to him helps the client find ways to fight the effects of his tough- guy side, allow- ing him to keep some aspects of that side, while exploring and developing his other, gentler, side.

In another situation, a family was viewed by others in the community, as well as them- selves, as being a poor and “out of control” fam- ily with “violent” adolescent boys. This view was challenged regarding its narrow definition of itself. They began to see how they were also a resourceful family that had coped with pov- erty. They had found a way for the mother to be home with the young children by day and earn money holding an evening job with the cooperation of the adolescent boys who babysat for their younger siblings after school. This dis- cussion also challenged the “violent boys” idea, although the fact that they sometimes acted violently in school was not ignored. Seeing other aspects of themselves helped them to see that they had alternatives as to which side of themselves they wanted to develop and in which situations. Here, the social worker did not tell the boys what they must do, but helped them see options and potential outcomes of the options. Both the family and the school reported a marked decrease in violent behavior over the school year.

In another example, a social worker facili- tating a coping skills group for chronic pain patients helped the patients find ways in which they were already coping with the illness and see that there were times when they could fight the effects of the illness and identify when the pain was not as bad. At first, most of the patients believed the pain was always there and there was nothing they could ever do. Through careful listening by the worker and each other, they found that there were times when things were better, and they all found ways in which they were already coping (Kelley & Clifford, 1997). The illness was externalized by the social worker’s asking them, “If this illness were a member of the family, how would you treat it?”

The group members began to discuss this ques- tion with great interest. Some found ways they would fight the illness and reject it, while others said that, since it was there to stay, they would look for ways to accommodate it and learn to live with it. The social worker did not teach them ways to cope, but instead, helped them identify times when the patients were already coping, challenging the view that they were totally helpless. At the end, they reported feel- ing empowered.

At this reconstruction stage, then, clients are helped to reconstruct their views of reality, not by substituting a different story, but by broaden- ing and enriching the story through inclusion of unrecognized or unacknowledged perspec- tives. A depressed woman, who remembers her childhood as one deprived of maternal care because her mother was critically ill and even- tually died when the client was 11, was asked if she remembered any times that her mother had the time and energy to give comfort to her. The client remembered her mother combing her hair every day and how good it felt. The tragedy of her mother being so sick that she only could manage basic tasks was never minimized, but the client was also helped to remember other aspects of her childhood. She reported that she finds it comforting when she feels depressed now to think about how good it felt when her mother combed her hair. Dolan (1991), in her work with sexual abuse survivors, noted that having clients tell their stories over and over can re- victimize them if corrective experiences are not infused into the process. Helping clients broaden their life stories, rather than “polish- ing” their problem- saturated stories, is a correc- tive experience.

The last step under the reconstruction stage is what White and Epston (1990) called “Spreading the News.” Central to narrative practice is the recognition that problems and problem stories are not just “private” but exist within social and relational contexts. Similarly, construction and maintenance of new and less disabling narratives also relies upon their being shared among important social connections and community. After finding alternative views of self and others, it is important for people to notify others of their changes, to reinforce them. At the Dulwich Centre, White and his

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colleagues often had groups where members shared experiences, sang songs, and told stories about their new selves. In another situation, a group of adolescent “girls in trouble” (Kelley et  al., 2002), group members drew pictures of their new selves and shared the pictures and sto- ries with other members. These “performances” of new identity stories have a function similar to that of the “definitional ceremonies” described by Myerhoff (1982) that establish community connection and meaning and can lead to the initiation of collective social action.

Length of Treatment

Because of the philosophical nature of con- structionist treatment, it is often assumed that the process is a long- term one, and questions have been raised about how such a long process can be applicable in today’s social work prac- tice arena. An interesting aspect of the narra- tive approach of White and Epston (1990) is that they use relatively few sessions, often as few as six or seven, although there is no set idea as to the best number. Clients are usually asked at the end of each session if they would like to return, and if so, how soon. Unlike some con- structionist therapists, narrative therapists may ask the clients to do some activities between sessions. For example, in helping the family and boy “escape from trouble,” already discussed, White (1989) encouraged the family to plan “escape” meetings where all the family mem- bers reviewed the progress of their escape. The meetings were formal in structure and even had minutes taken.

While the number of sessions is usually few, they are usually spread out over a longer time period than every week, to give families time to think about and try new things. Playful ideas and metaphors are often used with families to encourage them to try new things. In addi- tion to asking clients to try something different between sessions, White and others used many forms of writing to expand the impact of each session. These “therapeutic letters” summa- rize notes on how the therapist heard the cli- ent describe the problem and also record any solution knowledge obtained in the session. The therapist requests client corrections, dele- tions, and additions to make the statements

more accurate. Clients report that each letter is worth about four sessions (White, 1992). While some might question the time involved in this process, these letters can also be used as case notes. White also finds taking notes in session helpful, not distracting, and he uses these notes to read their statements back to clients to check for accuracy. Morgan (2002) even suggests copying notes taken in session to give to clients. Other forms of writing may add to the value of sessions, too, such as client writing to self or therapist, art or poetry, or charts and checklists (Kelley, 1990). White and Epston use certifi- cates and documents, such as an “Escape from Guilt Certificate” (1990, p.  199), or a “Diploma of Special Knowledge” (p. 201), which are espe- cially useful with children.

White (1992) also reported other strate- gies he used to reduce the number of sessions but expand their power. In addition to the let- ters and documents, he used “ceremonies of redefinition” (e.g., parties for children) where victory over the problem is celebrated, or he may encourage the family to use “consultants,” who are people in the clients’ lives whom they can talk to for enlightenment about a problem or solution. Epston, early on, used the idea of accessing the expert knowledge of commu- nities of people facing similar challenges to support clients in their change, such as his anti- anorexic/ bulimic league. White also sub- scribed to this idea. At first, White utilized Tomm’s (1987) ideas about “reflecting teams” of co- therapists and trainees behind a one- way mirror who traded places with clients, and reflected back their ideas about what they heard. Later, White had the team in the room with the clients, and often used former clients who had faced similar problems to reflect what they heard. Either way, clients report that these teams expanded the impact of each session and reduced the number of sessions.

Principal Applications in Social Work Practice

At first, a primary application of narrative work had been in family therapy and social work with individuals and families. However, its use- fulness in group work has been explored also (Dean, 1998; Kelley & Clifford, 1997; Laube,

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2004). White and others began to move into community work in the later 1990s, and major efforts of narrative work have been in commu- nities (Dulwich Centre, 2009). Waldegrave and colleagues (2003) pioneered this work at their at the Family Therapy Centre in Auckland, New Zealand, where community work and social action went hand in hand with the family ther- apy in their “just therapy.” White also began to focus more on community action and social justice issues and developed the international conferences on narrative therapy and commu- nity work, and the Journal of Narrative Therapy and Community Work noted previously. Epston edited an issue on the subject of narrative com- munity work in the journal Social Work Review (of New Zealand) in 2003 (Epston, 2003).

Potential Problems and Counter- indications

While there is a wide range of applications of narrative- type approaches in social work, some questions have been raised regarding their use with specific populations. Some might fear that the de- emphasis on “reality” and the focus away from the problem story together could mini- mize clients’ problems, especially in cases of sexual abuse, family violence, or severe mental illness. This is a real problem if the social worker deconstructs the story too quickly or denies the client’s reality, but it should not be problematic if the client is carefully listened to and attended, and if referrals are made for complementary services if needed. In a related concern, some might see this approach as superficial because it does not get at “root” causes or underly- ing pathology in deeply disturbed individuals. Since these ideas do not fall within the con- structs of postmodern theory, narrative thera- pists would not see such concerns as relevant. Some social workers might fear that the proc- ess of externalization could reduce a perpetra- tor’s responsibility for violence or other crimes, and its usefulness with mandatory clients could be questioned. White and Epston (1990, p.  65) spoke directly to this matter and noted that helping people separate from the problem and assess it objectively can help them assume more responsibility for it. Social workers and other professionals express the idea that talking is not

enough for some clients, that concrete services and possibly even medication may be required for the amelioration of some problems facing clients. Narrative therapists agree, and believe that their approach can facilitate complemen- tary services. In addition, care needs to be taken in externalizing problems with persons experi- encing serious emotional problems, who may already have trouble differentiating between themselves and outside forces. Finally, there is a practical concern that, without the use of labels, cross- disciplinary discussion may be impeded and that reimbursement for services may be denied. These are concerns to ponder and are not completely solvable. It should also be noted that labels may not have to be discarded in some situations, but the power given the labels can be challenged.

Because the narrative approaches are rela- tively new and there is less empirical research to support its efficacy, it is difficult to say at this time which populations may or may not be well served by this approach. While narrative thera- pists report case studies with successful out- comes with a wide range of clients, future work needs to be aimed at determining which clients are best served by such approaches. Managed- care companies rely on evidence- based services, and using narrative therapy may require com- bining it with a more accepted approach, such as cognitive therapy, since narrative therapy also deals with cognitions (Kelley, 1998).

Administrative and Training Factors

Narrative therapy is used mainly by clinical social workers, family therapists, and psycholo- gists with graduate degrees. It involves more than storytelling; it involves story- changing through intensive listening and questioning in a specific manner, which is usually learned in special post- degree training. The “conscious use of self ” and transference/ counter- transference issues discussed by psychodynamic social workers are also considered important by nar- rative social workers, although they do not use those terms. Narrative social workers need to be very clear about their own issues, views, and experiences, to separate them from those of the clients. Since the client’s history and reality are

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co- constructed through dialogue, the social worker cannot be an outside observer but is part of the change system through reciprocity. Great care must be taken to hear and understand the client’s reality, and to join with each client as an individual as well as being part of a community. Thus, there is no set of techniques or prescrip- tions; each client is viewed differently, and treat- ment involves whatever fits his or her particular situation. A  great deal of self- awareness and willingness to set aside one’s own world view is required to work in such a manner.

Although narrative approaches are infused into some academic social work programs (Kelley, 1995; Vodde & Gallant, 2003), most training is conducted at family therapy train- ing centers or at some social service agencies. In addition to the training centers already noted in Australia and New Zealand, there are several in North America, too. Freeman and Combs offer one in the Chicago area; Zimmerman and Dickerson in the Bay area, California; and Madigan and colleagues in the Yaletown Family Therapy in Vancouver, British Columbia, Canada. In Toronto, The Hincks- Dellcrest Center offers frequent trainings and supervi- sion, while Angel Yuen and Ruth Pluznick co- founded the Toronto Narrative Therapy Centre. In these centers, discussions and clinical work go hand in hand. As noted by Freedman and Combs (1996), narrative therapy is more a way of thinking about people and their situations than specific techniques.

Empirical Base

As noted, little empirical research has been conducted testing narrative approaches. Postmodernism, by definition, denies the possi- bility of objectivity, which is at the core of empir- icism. For this reason, postmodern approaches have been criticized for keeping social work out of the scientific field where it should be placed (Epstein, 1995). While social constructionists are uncomfortable with the assumption of lin- ear relationships among variables needed for most statistical procedures, Neimeyer, Burke, MacRay and van Dyke (2009), a psychologist, has pointed out that there are several research methods that are appropriate to assess outcomes in constructionist therapy. He notes several

examples, including the use of repertory grids, transcript analysis of developmental levels, task analysis of change events, stochastic modeling, and time series studies. He also notes, as have others, that more conversational ways of inquiry and of understanding personal meanings need to be explored, too. He stresses the need for diverse approaches to research for fuller understanding. Besa (1994) reported using single- subject design with some success. Ethnographic qualitative research approaches and transcript analysis have been found useful in studying constructionist approaches (Kelley & Clifford, 1997; Kelley et al., 2002); and White and Epston (1990) and others use the case study method in assessing outcome, noting symptom relief in clients. Finding new ways of measuring outcomes in narrative ther- apy and then conducting more research on these newer approaches are important objectives for the future.

Prospectus

Narrative therapy fits into social work values and practices with its emphasis on respect, individualization, and collegial, client- centered approaches. Its focus on social and cultural forces as important in formation of problems, and its emphasis on social action and politi- cal discourse, increase this fit with the profes- sion. In addition, narrative work bridges the gap between micro- and macro- practice, as it works with all levels. Because this theory is part of a cross- disciplinary trend, and because the approaches are useful with a wide variety of clients, it is appreciated by many social workers. There are problems using such approaches with clients in clinical practice, however, because of managed- care setting parameters, and because of the demand for evidence- based practice in the field. More research needs to be conducted and new ways of conducting research will need to be found, however, before these approaches are fully accepted in the profession. Social worker and family therapist Hoffman (1990) expressed the hope that this movement will facilitate a return of therapy as an art of conver- sation as opposed to a pseudo- scientific activ- ity. She also expressed beliefs that the aesthetic metaphors are closer to home than the biolog- ical or machine metaphors, as we work with

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our clients, and she expressed the hope that these metaphors will also create an “emancipa- tor dialogue” (p.  11) that is socially and politi- cally sensitive to our clients’ needs. Indeed, the aim of narrative approaches of understanding and individualizing each client in his or her social context, and the emphasis on mobilizing strengths, is in the best tradition of the social work profession.

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Overview of Theory

Since the inception of the profession, social work- ers have drawn upon the knowledge, wisdom, and skill from a great many disciplines and experts in order to aid, and lessen the challenges faced by, the people they serve. Our individual and col- lective ability to adapt this information and use it effectively in our active roles as helping profes- sionals reflects the depth of our compassion and creative capacity as social workers. We are collab- orators with clients in the translation and trans- formation of ways of knowing, believing, and behaving. In this chapter, we look at neurolinguis- tic programming (NLP), which is an innovative practice approach that examines how thoughts and beliefs are socially constructed as expressions and behaviors that shape people’s exchanges with the world as it is known and experienced.

Founded on how people make constructs of reality, NLP takes into account the ways in which firsthand and vicarious experiences are arranged, encrypted, and deciphered. Much like travelers, everyone makes sense of what they come into contact with, or learn about through their sensory experiences, and juxtaposes this with what they know, imagine, and have experi- enced. Framed as neuropsychological patterns, or maps, this understanding guides exchanges with others in the bio- psycho- social- spiritual- physical environment. Recognizing that each person’s relationships with others, as well as with the environment, are one- of- kind render- ings, social workers using NLP are able to the- oretically explain how people formulate their feelings, thoughts, and behaviors and make predictions about how they will feel, think,

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and behave in the future. As an approach, NLP practitioners engage clients in a here- and- now exchange using emotions, thoughts, and bod- ily sensations to discover the sensory data to construct “maps.” These maps in turn are ther- apeutically helpful in understanding and fore- telling the challenges faced by clients. Through a process of deconstruction, maps can be edited and replaced and used to overwrite conflicted, unpredictable, and impracticable personal ways of feeling, thinking, and behaving.

NLP was created by co- founders Richard Bandler and John Grinder (Bandler & Grinder, 1975; Grinder & Bandler, 1976) following their examination of the writings and observations of the practices of some of the era’s foremost theorists and therapists. Included in this group were Gestalt’s Fritz Perls, experiential family therapist Virginia Satir, metaphor- based hyp- notherapist Milton Erikson, and cybernetic- anthropologist Gregory Bateson. The common thread between these thinkers and doers was their understanding and use of the sensory- based maps of feelings, thoughts, and behaviors developed by people for use in communicat- ing with others and the world around them. Appreciating that a map is not the “territory” of experience, but a representation or construction of it, Bandler and Grinder observed how these thinkers and practitioners worked with the narratives and sensory expressions of clients to help them make sense of what they were expe- riencing and to make changes in how they felt, thought, and/ or behaved.

As an approach, NLP appeals to social work- ers because it provides a common- sense con- nection between the cognitive, affective, and behavioral aspects of self and how these in turn are expressed in ways that debilitate clients, or help them cope or make changes for the better. NLP also helps practitioners clarify their role as collaborators in the therapeutic relationship. It calls on social workers to have a self- awareness of their own maps and how these in turn can affect the helping process. Having this insight allows practitioners to meld their maps with their practice wisdom in a way that maximizes their differential use- of- self in collaborating with clients to find solutions. Starting where the client is, and winding up where the client wants to be, NLP is an ideal interlocking theoretical

practice approach for finding alternative neu- ropsychological patterns forged from an effec- tive, collaborative, and authentic therapeutic alliance (Angell, 1996, 2001, 2011; Field, 1990; Ignoffo, 1994; House, 1994; Mercier & Johnson, 1984). Appreciating this, it is easy to see how social workers can make use of NLP as a stand- alone approach, or use it concurrently or com- bined with other treatment approaches.

As mentioned, the fabric of NLP is woven from the thoughts and techniques of pur- posely selected thinkers and practitioners in the fields of psychology, philosophy, transforma- tional grammar, and cybernetics. Arising out of this synthesis, social workers are provided with practical ways of working in partner- ship with clients in establishing a meaningful therapeutic alliance, assessing the concerning circumstances, and finding choices, or pat- terns to bring about resolve. From the outset, social workers using NLP appreciate the ease of fit it offers in bringing together the theory and application of the approach founded on thought- based language and behavioral change. Together, practitioners and clients are then able to use a common and understandable linguis- tic template to communicate what is being felt, thought, and enacted, which in turn directs the course of therapy in terms of the selected specialized technique. As Ignoffo (1994) and McDermott and Jago (2001) point out, practi- tioners of all ilks interested in solution- focused and client- centered approaches will discover the power and precision of NLP. This being said, theory and the techniques only go so far, but they can and do set the stage for effective treat- ment. To help understand this better, authors Lambert (1992) and Duncan, Miller, Wampold, and Hubble (2010) tell us that the theory behind a high- quality psychotherapy and the therapeu- tic techniques that arise therefrom account for roughly 15% of the helping process. Used well, the structure of the theory and the processes of treatment lead to the formation of an effec- tive relationship, which represents around 30% of the change process. Having confidence that the approach will work, the expectancy effect, adds yet another 15% to the equation. How this plays out for the client in the environment is an extra- therapeutic factor, which is the largest single influence at 40%. Conceding that what

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happens outside of the office can be and often is unpredictable and uncontrollable, it is vital that the social worker engage the client in under- standing the theory and toolbox of techniques as part of forming a strong therapeutic alliance and belief that the approach will work outside of the session, translating to multiple settings and circumstances. This bridge between theoretical knowing and practical doing provides clients with a sense of being able to overcome adver- sity and deal with a wide range of bio- psycho- social- spiritual- physical challenges (Andreas, 1992; Field, 1990; House, 1994).

Origins

Provocative and unconventional from the beginning, NLP is both an art and a science of what works in therapy (Dilts, 1976; Lankton, 1980). Defying the mainstream trend towards evidence- based practice, NLP has persisted in gaining ground, although skeptics assert that it is pseudoscientific and not worthy of considera- tion. Putting this to the side for the moment, let us take a look at where NLP comes from, what it has to offer, and why it is worth considering as a treatment approach for use by social workers, who ultimately will be the judges of the merits and efficacy of NLP in their work.

Drawing from Noam Chomsky’s (1957) study of the biological structure of language, NLP’s Bandler and Grinder’s developed of their linguistic typology in the early 1970s (Bradley & Biedermann, 1985). Adding to the mix, Bandler and Grinder incorporated phenome- nologist Edmund Husserl’s (Welton, 1999) con- structionist contrasting of the real world with that of perceived human experience. Combined with Wilhelm Wundt’s (Rieber, 2001)  biopsy- chology of mental function, which looked at the thoughts, images, feelings, and beliefs that com- pose the deep unconscious of the inner- mind and emerge to affect the conscious expression of the outer- mind, Bandler and Grinder had the ingredients to further explore and explain how subjective experience was transformed into lin- guistic and behavioral patterns.

To confirm what they had found intellectu- ally, Bandler and Grinder methodically observed and then deconstructed the work of the some of the period’s most prominent psychotherapists.

They noticed similarities in how these experts used communication to interpret and change people’s thinking and behaviors. Deducing that what they were observing were the “ah ha” epiphanies that brought about change and led to client empowerment, Bandler and Grinder structured their “magic” for psychotherapy using a language- based meta- model. By way of the meta- model, they were able to provide helping professionals with a means of untan- gling the dysfunctional affective, cognitive, and behavioral communication constructs of clients and to rebuild or replace them with functional and nurturing narratives.

Applicability in Social Work

Let us now look at how NLP as a practice approach aligns with the professional values and ethics of social work. In considering what works in psychotherapy, we must consider what brings clients to seek help in the first place. A common theme with every client is a feeling or thought of being vulnerable, oppressed, or somehow at risk. The social worker’s chief goal, therefore, is to help clients discover what impedes them from moving forward and to find a way ahead by making new maps or alternative patterns of feelings, thoughts, and behaviors. This is obvi- ously not an easy task, but with NLP’s focus on collaboration, clients come to understand the theory and techniques of the approach (its lan- guage), and learn to anticipate results from the therapy. Delivering the “goods” is made more doable by the social worker’s focus on form- ing a meaningful and trusting relationship with the client, and a dogged determination, embedded in NLP, that resolutions to prob- lems are not only possible, but inevitable. The focus of treatment is on helping clients discover their existing strengths in solving problems, and, where indicated, collaborating with them to create healthy choices in handling stressors and enhancing empowerment. Knowledge and skill are shared goals and responsibilities of the worker– client experiential relationship. It is a purposeful process aimed at personal change, which impacts interpersonal and environmen- tal transactions.

Getting at the origins of client problems, from an NLP perspective, involves drawing out

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the resource- rich lived sensory experiences, which will form the building blocks for new patterns or maps. The past is not viewed as a place of focused concern as in other therapies, which can be retraumatizing for clients, but as a source of information. Often formulated as narratives, client experiences contain content on coping and resiliency on which NLP practi- tioners base their understanding of how people construct affective, cognitive, and behavioral communication. The approach’s use of meta- phors to positively enhance change suggests to clients that they can and will find resolution to their problems and are in control of the treat- ment process.

NLP has long been taught to and used by social workers interested in clinical practice (Angell, 1996, 2002, 2011; MacLean, 1986; Zastrow, 2009; Zastrow, Dotson, & Koch, 1987; Zastrow & Kirst, 1994). From student to seasoned practitioner, the fundamentals of NLP have played an important role in teach- ing helpful communication and interviewing skills. One need only look at texts by Ivey, Ivey, and Zalaquett (2013) and Cournoyer (2013) to appreciate how the approach has infused the curriculum of a broad range of helping profes- sions in the preparation of students for both internships and professional practice. The work of Ivey et al. (2013) on intentional interviewing and counseling draws from NLP to provide an interdisciplinary audience with an orderly set of practice skills and methods. From a social work perspective, Cournoyer’s (2013) influential text has long served as the standard in social work education and incorporates many of the ideas conceptualized by NLP’s Bandler and Grinder (1979, 1982).

Presuppositions of Neurolinguistic Programming

Internal Resources

Practitioners using NLP believe that each and every person has the internal resources to make changes to how they feel, think, and behave (Yapko, 1984). What are “resources”? They are the stored neurolinguistic bits and pieces of data received from lived and vicarious experi- ences, which enter thoughts and memories,

inspire imagination, are expressed as personal narratives, and impact feelings and actions. They shape the personal patterns, or maps, that people operate from and are understood to be unique worldview constructions, which are constantly being reworked as new information is received. Resources are the ingredients for how people make sense of experience and func- tion bio- psycho- socially and are the building blocks for change. Challenges to functioning, therefore, are not seen as limitations per se, but rather as the unsuitability and/ or inflexibility of current ways of knowing and doing in address- ing client- identified concerns, which are emo- tionally distressing.

The first step for the social worker is to locate resources already held by the client, which have been used to handle other, not necessarily sim- ilar, challenges and to bring them to the surface of perception and to explore how they have been or could be used. Resources, and the patterns or maps that arise from them, are reviewed in terms of how they can and should be used to address issues in the here and now. Moving away from a limitation, or deficit perspective, NLP looks at what the client has to work with in terms of resources, the resiliency of those resources in terms of being adequate, relevant, and adaptable, and how they can be reconfig- ured linguistically to bring about preferred affective, cognitive, and behavioral change. As such, this strengths- based point of view does not view the client as inadequate, deficient, and/ or dysfunctional, but rather as someone with limited choices who nevertheless possesses the creative capacity to revise and create alternative patterns or maps to make desired differences in how they feel, think, and behave. Thus decon- structing the narratives of past experiences pro- vides the linguistic components for alternative and new ways of handling present conditions, which enable clients to better determine how to deal with future situations (Angell, 1996, 2002, 2011; Ivey, Ivey, & Zalaquett, 2009; MacLean, 1986; Pesut, 1991).

Sensitivity to Difference

From the perspective of NLP, social workers understand and accept that each and every person is unique and experiences, learns, and

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makes sense of their world in distinctive ways. In saying this, practitioners of the approach appre- ciate that people are social, and that they share, teach, and learn cultural patterns, or maps. This includes language, values, faith, food prepara- tion, art, and other ethnic practices and tradi- tions. Being sensitive to culture, and its impact on personal development and neurolinguistic processing, provides useful insight for both the social worker and the client with respect to each other’s way of life. Why is this important? Well, culture being a multilayered social construct, it aids in understanding, validating, strengthen- ing, and steering the client’s lived and expressed experience. The starting point for sensitivity is, accordingly, an intentional channeling of com- munication between the therapist and the client on the role that culture plays and the value that is placed upon it. Culture is part of how every- one makes sense out of the world and is the con- nection between the self and others in terms of what is considered acceptable and what is not. It is a collage of feelings, thoughts, behaviors, and beliefs used to shape patterns or maps, which provide reference points for interacting with and viewing others. Thus, taking a nonjudg- mental stance on culture from the beginning is critically important. However, to do so requires an appreciation that, although cultures may be constructed similarly, they do differ, and no one culture is any better or worse than any other— they are simply different. Respecting this, NLP practitioners can work with clients and their maps, steeped in culture, to create new accept- able patterns to deal with their bio- psycho- social- spiritual challenges (Angell, 1996, 2002, 2011; Ivey et. al., 2009; Ivey, D’Andrea, Ivey, & Simek- Morgan, 2006; Sandhu, Reeves, & Portes, 1993).

Deep and Surface Structure

Most people are to some extent familiar with how cell and smartphones work and what they can do in terms of sending and receiving voice, text, and video messages. How they do what they do is another thing for most of us to understand. We simply make/ send or receive a call or message. Of course, we realize there is more to it than that, but we usually only become more interested in how our devices work, or

should work, when something goes haywire and we cannot make, get, read, hear, or view our calls and messages clearly or at all. Much like making or getting a call or message, NLP accepts that receiving and sending informa- tion requires the ability to take in, process, and transmit information.

NLP is a compound lexeme of three relational concepts— neuro- linguistic- programming. The body’s neurological system receives, sorts, and stores data received from the environment in the unconscious deep structure. This is the neuro- part of NLP. The actual formulation of thoughts into patterns, or maps, that can be enacted requires the initiation of a retrieval system of sorts that draws upon and organizes needed sensory- based data into a communica- ble format, which can be used at the conscious surface structure level. This is done in a linguis- tic and/ or paralinguistic (nonverbal) way using the patterns, or maps formed from lived and learned experiential data. The communication of these linguistic and/ or paralinguistic patterns, or maps requires encoding, or programming of the data in a way that incorporates the neces- sary content required to acquire to achieve the intended outcome with the greatest probabil- ity of success. For this reason, “programming” refers to how decisions are made, problems solved, and results obtained. It reinforces for people patterns that work and guides them in editing their experiences in ways that lead to more preferred outcomes (Zastrow, 2009).

Sensory data that are received and trans- mitted are kept and processed in the uncon- scious and are referred to in NLP as the “deep structure.” It is the mind’s internal archive of experience from which data are drawn for eve- ryday use in creating emotions, thoughts, and behaviors. The level at which these messages consciously emerge is known as the “surface structure.” Using the cell/ smartphone anal- ogy, neurolinguistic “radio waves” of sensory stimulating energy are constructed from deep structure data and are emitted at the surface structure by way of affective, cognitive, and behavioral “frequencies” from one person’s “antenna” to another. How the messages are put together, sent, and received depends on the ability of the sender to compose a clear mes- sage from the resources at their disposal, and

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the aptitude of the receiver of the communica- tion to be able to decode and make sense of the intent of the message.

The process of receiving, formulating, and sending communication is really quite remark- able when you think about it. We are constantly exposed to and barraged by stimuli in our bio- psycho- social- spiritual- physical environment. Fortunately, handling and making sense of this sensory information is at the heart of NLP, which provides practitioners using the approach with an important advantage (Bandler & Grinder, 1975). Employing a three- part framework for how people sort and select received uncon- scious information for use in creating patterns or maps, which in turn contribute to the person’s conscious presentation of emotions, thoughts, and behaviors, provides social workers with a valuable means of understanding, assessing, and treating the challenges presented by clients. Depending on how the deep structure data are put together and used, the patterns on the sur- face can vary, depending on the situation. They can be calming, soothing, and clarifying, or they can be destabilizing, disquieting, and distorting.

Deletion is one part of this trio. It involves the omission of bits and pieces of sensory data “files” stored in the unconscious, which are superfluous to functioning, and the creation of manageable, abridged patterns used at the sur- face structure in the form of patterns or maps. The process of deleting information allows the mind to keep what is needed and to rid itself of information not needed for daily living. Unlike sorting, “deletion” relates to the removal or erasing of data. If deletion did not occur, indi- viduals would be overwhelmed by the plethora of information present in the deep structure coming to the conscious surface. In turn, this would cause sensory overload and make mes- sages incredibly challenging to understand, if not nonsensical. So, discarding information is important to functioning and communicating. It is an automatic deep structure response to what is being experienced bio- psycho- socially in the environment, and it can be purposefully altered at the surface structure by sorting and selecting information to fine- tune the pattern if the individual determines that the construction of information does not, or is anticipated not to, achieve the desired end.

Let us consider an example of how deletion functions. Imagine that you are in a busy res- taurant where the patrons are all conversing and there is music playing on the sound system. One customer is arguing with the maître d’hô- tel about a reservation. Servers are taking orders from customers at several tables throughout the room. A  busboy is rattling dishes, cups, and glasses as a table is being cleared. Suddenly, you hear the crashing from the kitchen as some- thing metallic hits the floor. After a momentary hush across the room, everything returns to its noisy normal. On top of the obvious, there is a host of subtle things happening around you. Phones are being used; texts are being sent and received; cars and pedestrians are passing by outside; traffic signals are flashing and beeping; people are reaching into pockets and purses; eyebrows are being raised; faces are smiling and frowning; lipstick is being applied; itches are being scratched; and so much more. Somehow, you manage to filter out most of this so that you are able to focus on the conversation you are having with your companion. A choice was already made from all the available sensory data available to you and previously experienced, which allowed you to focus on your friend and incorporate what is needed to be attentive. This is deletion at work. You did not choose what to keep and what to dispense with, you simply responded using the pattern that works best for you in crowded, busy, and noisy places.

Distortion is another method of transform- ing sensory data in the deep structure. If you think of smart technology for modulating the intensity of a light or volume of sound, you can get a sense of how you can magnify or decrease the level of distortion. The same holds true when sensory data are engineered in the deep structure. By assigning more or less sig- nificance to sensory data stored in the deep structure, resulting patterns can be intensified to achieve desired surface structure outcomes. It is a creative, reflective process involving abstracting and/ or fantasizing about what resources are needed and how they need to be put together to achieve a preferred goal. In the right situation, distortion can have a wonder- ful result. All genres of authors and artists use distortion to convey their messages through words, sounds, and images. We, too, use it

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regularly to emphasize meaning in day- to- day communication.

Returning to the restaurant example: Let us suppose that since starting a new job in sales you have not seen your friend for quite a while. Your motive for inviting the person to dinner at this high- end place is twofold. You want to renew your friendship on one hand, and on the other, you are hoping that they will become a customer. You desperately need and want to achieve both goals. The ambiance, service, and menu seem perfect for setting the stage to accomplish what you are after. So, you contour your presentation- of- self in a way that emphasizes how great you are doing. You state in no uncertain terms that you are so busy at the office that you have hardly had any time to do anything else but work, or see anyone outside of workplace. You tell your friend that you miss them very much, but blurt out in the same breath a pitch for your product and suggest to them that they might be inter- ested in buying it. You are expecting an under- standing nod and smile from your friend, but instead you receive a puzzled look of confusion as they try to guess your true motivation for the dinner meeting. As you backtrack and try to make amends by saying that of course your friendship is more important than work, your friend pushes back in their chair and folds their arms. The frown on their face tells you that your plan is not turning out the way you had hoped. The distortion in this case was a double- edged sword and has alienated an important support for you from someone you wanted to be close to, due to the skewed focus. The pattern lacked accuracy and fell outside of what was acceptable to your friend.

Generalization is the third filter. It is useful in drawing together sensory experiences housed in the deep structure to formulate patterns, which can be used across situations when presented at the surface structure. The process involves drawing conclusions, which are used in making determinations about what “things” are alike, or what triggers certain emotions, thoughts, and behaviors. A “generalization” is a particular deduction drawn from specific events about a group, classification, or category, which by infer- ence is used to form an archetypal pattern. This pattern is used to examine sensory experiences and is expressed as all- encompassing emotions,

thoughts, and behaviors. Generalizations are helpful in maneuvering our way in and through the bio- psycho- social- spiritual- physical world. Problems can arise, though, when using gener- alizations one- sidedly as rigid positive/ negative, good/ bad, and/ or right/ wrong all- or- nothing dichotomies. If used so, the ability to differenti- ate where and when to use a certain generaliza- tion can be compromised or lost.

Taking a last look at the restaurant illustra- tion, the failed attempt to reconnect with your friend and to make them a customer has proven problematic. You are feeling fairly frustrated. You are thinking, “What just happened?” You review everything, and the whole thing looks perfect for reconnecting and making an impres- sion, but for some reason the whole evening has fallen flat on its face. You wonder why every time you get ahead in one area of your life, the people who should be there for you abandon you. You are beginning to think that reaching out to peo- ple is not worth the effort. In this scenario, gen- eralizations abound. The idea that one group of people— friends, can be lumped together with another group of people— customers, and that they should respond to your pitch in the same way seems rather absurd. Yet this does hap- pen and is a prime example of a generalization that did not work out the way that was hoped. The dining experience was a useful generali- zation as a means to connect with people, but the assumption that all people, whether they are friends or customers, would respond the same way was not. Certainly, lumping the two together in this example proved disastrous.

In summary, distortions, deletions, and generalizations are valuable deep structure processes for filtering sensory data into con- structions geared towards improving effective functioning. This being said, they can have an adverse effect and at times do degrade perfor- mance by not offering the type of patterned response needed to deal with a full range of environmental issues. What happens in the deep structure does not stay in the deep structure and emerges in the surface structure as patterns that are either need fulfilling or are deficient in some way. It is safe to say that all experiences consist of components with changeable mean- ings and as such can be reconstructed to create new patterns. How well this is done indicates

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the individual’s resourcefulness in being able to mold the elements of sensory experiences into multipurpose maps made up of thoughts, feel- ings, and actions for understanding and func- tioning in the everyday world.

Treatment’s Principal Therapeutic Goal

The basic premise of NLP is founded on per- sonal ability and capacity- building. In principle and practice, social workers using the approach accept that if someone has been able to over- come a challenge, then, in theory, anyone can. It moves client reasoning and believing from the impossible to the possible by focusing on what resources are available to the individual, or need to be introduced, to solve struggles in the here and now. Founded on a sensory per- ception/ processing model of communication, NLP provides practitioners and clients with an understandable cause- and- effect explanation of how emotions, thoughts, and behaviors come about. It also provides adherents to the approach with concrete skills to construct alternative ways of coping with and overcoming obstacles to well- being. Collaboratively, social workers and clients build on the principle that change is achievable, by analyzing the therapeutic goal from the perspective of the client and their bio- psycho- social- spiritual- physical environ- ment. As such, each treatment plan is uniquely matched with the defined needs and aspirations of the client. Furthermore, assessment and treatment are viewed as interconnected and a shared learning experience involving the exper- tise of both the worker and the client. In saying this, social workers can operate from the fol- lowing clinical assumptions:

• Clients expect change and are motivated to modify their feelings, thoughts, and behav- iors regardless of what reason brought them into therapy. They are there for a purpose, and the treatment must be purposeful and collaborative.

• Clients are resourceful in coping with adver- sity. Even though they may feel, think, or act like they are overwhelmed or inadequate, the fact is that they have dealt with and are dealing with their problems, albeit in ways

that may not be as gratifying for them as they want or expect. Drawing upon and enriching this resilience to find more satisfying solu- tions is the therapeutic objective.

• Clients construct their bio- psycho- social- spiritual- physical worldview from their neuropsychological sensory experiences. Stored in the unconscious deep structure and emerging in the conscious surface structure, these experiences are the building blocks for change. The therapist’s presentation- of- self models possibilities, guides decision- making, and provides learning opportunities for cli- ents to locate and create resources needed for constructing new patterns or maps and mak- ing sought- after changes.

Treatment Concepts and Strategies

Primary and Preferred Representational Systems (PRS) Given that NLP is a psycho- neurologically based treatment, clients and users of the approach predictably derive interpretative diag- nostic data from the five senses. Referred to as the “representational system,” they include the intersecting sensory systems of sight, or visual; sound, or auditory; touch, or kinesthetic; smell, or olfactory; and taste, or gustatory. These sen- sory systems automatically gather, sort, and store data in the deep structure according to the associated experience or experiences. As new data are received, they are used to create fur- ther categories or add to existing ones in ways that shape and reinforce surface structure pat- terns of thought, emotion, and behavior. The interconnectedness of the senses provides peo- ple with enough data to form patterns to use in dealing with a range of day- to- day events. How adaptive the sensory- based patterns are in deal- ing with adverse, traumatic, and threatening situations indicates the level of personal resil- ience that has been learned and nurtured by the individual to deal with cognitive, affective, behavioral, and/ or environmentally induced stressors. Accepting that everyone is resilient to a greater or lesser extent, the impact that dif- ferent stressors have on the individual will test the efficacy of their personal resilience to pro- tect them when they are at risk. People using the range of representational systems are more

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often than not the most resilient, and are able to construct more comprehensive patterns than those who draw data from fewer than the entire array of sensory data sources.

Considered from an NLP perspective, when people experience a high level of stress, they revert to a dominant representational system in terms of taking in, analyzing, and respond- ing to environmental inducements. Originally, the PRS was determined through analysis of linguistic predicates used by people and via eye movement accessing cues (Bandler & Grinder, 1975; Grinder & Bandler, 1976). The assump- tion was that the connection between linguistic predicate use and eye movement would be one and the same. However, discussion and clini- cal observation suggests that there could in fact be dissimilarities between how people take in, categorize, and store data in the unconscious, or deep structure, and how they consciously relay information linguistically in the sur- face structure. Therefore, the “primary” way of receiving data may be different from some- one’s “preferred” way of relaying information through language. With this debate, the litera- ture at times interchanges the words “primary” and “preferred” when discussing the same thing, while at other times considers them dif- ferent aspects of the representational system (Einspruch & Forman, 1988; Jupp, 1989). For our purposes, we will accept that people might well have both a primary and a preferred rep- resentational system, and that they may be the same or different. To differentiate them in this chapter, conscious constructions will be referred to as “surface structure preferred rep- resentational systems” or SS- PRS, and uncon- scious constructions will be described as “deep structure preferred/ primary representational systems” or DS- PRS. This calibration of NLP will hopefully allow the practitioners and cli- ents alike to approach the treatment process with more flexibility in terms of establish- ing rapport and trust when conducting clin- ical assessments, and choosing and using communication- based techniques.

One way to determine an SS- PRS is for the social worker to concentrate on the client’s use of predicates (adverbs, adjectives, and verbs) when they speak. A  noticeable preference is likely to appear in the client’s choice of words

due to being under stress, which in turn will inform the practitioner on how best to establish a meaningful line of communication with the client using similar sensory- based predicates. Matching predicates, the social worker can relate directly to clients by starting where they are, using the SS- PRS that makes the most sense to them. It is worthwhile noting that clients can and do use the range of representational system predicates when speaking and will tend to do so during a session; however, the circumstances that led to their seeking help will very often give rise to their focusing on an SS- PRS that they prefer to use when distressed. Therefore, prac- titioners need to be aware of when clients move into issues of concern to them, as it is at these times that the potential for change can be most dramatic. It is worth mentioning that the predi- cates used by clients are related to their cul- tural customs and do vary. In North America, the tendency is to use predicates that are more visual, auditory, and kinesthetic to refer to thoughts, feelings, and behaviors. Olfactory and gustatory predicates do exist for sure, but they are much less prevalent when used in this way in the English language. Nevertheless, social workers need to be mindful that their clients may be using SS- PRS predicates, regardless of their cultural background, which fall out- side the presumed norm. Let us take a look at some examples of SS- PRS predicate– rich client/ worker scenarios and the use of matching by the therapist:

Visual SS- PRS predicate matching:

Client: My mind just went blank when I  pictured myself there with my relatives again. I just couldn’t imagine any way to get out. It was like one of those movies where the scene just keeps getting shown over and over again.

Worker: So if I  understand what you’ve illustrated, it appears as if you can’t imagine the situation being different. Looking at what you’ve portrayed, let’s consider another way to look at it. Sometimes a different perspective can show us a way forward so that the movie has a different storyline and the ending looks different.

Auditory SS- PRS predicate matching:

Client: It is incredible to me that when you say what’s on your mind to people you care about and they don’t even hear you. Incredible. I  just said what

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was on my mind and I got yelled at for simply tell- ing the truth. It seems like you can’t even make a sound anymore without being criticized. I  guess I’ll just go back to mumbling what I  think to myself.

Worker: I hear what you are saying. When you are speaking your mind it can be disappointing, to say the least, when someone you feel affection for doesn’t seem to hear what you’re saying, or hears it in a way different than you intended. It sounds to me that the message you are expressing is not ring- ing a bell with the people the way that you want it to be heard. It is important to be listened to by peo- ple who matter to you. How about we talk about other ways to get your message across so that you are better received?

Kinesthetic SS- PRS predicate matching:

Client: I have been arm- wrestling over what to do about this forever. Every time I get to the point of jumping in to buy a house, I pull back feeling that it would be just too much for me to stomach. It would be easier if I knew I had the support of my family and friends, but I am just not sure if I can handle it alone. I’d like to reach out to someone, but I  am afraid of being pushed away. Even now as I think about it, I can feel the hairs on the back of my neck stand up and my blood pressure going through the roof. I feel so stuck.

Worker: Making a decision like the one you describe can be upsetting. This seems especially hard for you when you don’t feel that you have anyone to turn to for backing. The fact that you keep work- ing at finding a way forward tells me that you are determined to reach your destination of owning a home of your own. Let’s tackle the issue of how to rally those you care about to help you in your struggle to make a choice.

Olfactory SS- PRS predicate matching:

Client: The whole situation stinks. Right from the start, I knew something was fishy. I should have guessed when they invited me to dinner at their place, with all the wonderful food aromas, that it was a setup. Now all I  can smell is that per- son’s cologne and it makes me want to turn up my nose to any other offers of friendship in the workplace.

Worker: It is always difficult to decide what is the right thing to do when you find that what you thought was going to be a good decision reeks of betrayal. The challenge for you now is to pick up the scent of what to do next and whom to trust. My hope is that you come out smelling like a rose.

Gustatory SS- PRS predicate matching:

Client: I don’t know what to say. The affair left a bad taste in my mouth. My partner said that it was a one- time fling, but I  don’t believe them. All they wanted to do was feed their own ego.

Worker: Everyone is looking to be emotionally fed and the decisions they make often can seem unsa- vory. The task for you, it seems, is to figure out what scraps of this relationship, if any, are worth saving. Let’s see what you can cook up.

By attending to the client through predicate matching, the social worker avoids the typ- ical clinical stumble or roadblock that far too often results from therapeutically miss- ing the mark in terms of the client’s mode of communication. We have all either experi- enced or heard of practitioners saying things like “So, how did you feel about that?” using a kinesthetic rejoinder only to have the cli- ent respond using a dissimilar SS- PRS frame- work such as the auditory, “I don’t understand what you are asking me,” or visual, “I am not sure what you are looking for.” Challenging as it may be, matching the SS- PRS of clients makes sense, but in cases where it is difficult to determine this, or when the client uses multi- ple sensory systems, an overlapping predicate approach may be clinically worthwhile to con- sider. Furthermore, by overlapping predicates, the social worker models for the client an optimal way to communicate to others what they are thinking and feeling (Ivey et al., 2009; Lankton, 1980). In the following client– worker interchange, the use of overlapping predicates is presented. Overlapping SS- PRS predicate matching:

Client: Picture this: there I was telling my life story to someone who I  felt would listen to me. You know, appreciate what I was trying to show them. Well, it didn’t work at all. They just looked the other way, shrugged their shoulders, and told me it was my problem, not theirs, to deal with. It left a bad taste in my mouth, and I thought to myself, “This stinks.”

Worker: It sounds to me like they didn’t want to see it your way from the outset. It is always difficult when someone you want to unburden yourself to isn’t there when you need them, or in a way that you want them to be. Distasteful as it may have appeared, there might be a whiff of hope in the air. If you reflect back, what did you do and say when you needed someone’s help?

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Eye Accessing Cues As mentioned, there are different sites where sensory data are found. We have just looked at one located in the conscious surface struc- ture, but as mentioned, PRS can also be found in the unconscious deep structure. Observing eye movement is an expedient way to access the deep structure primary representational system, or DS- PRS, of people. To do this, the practitioner observes the direction in which cli- ents move their eyes when asked a question. It is important to be nonspecific in terms of sensory wording to ensure that the client uses their DS- PRS and not one suggested by the social worker. These “eye accessing cues” help the practitioner determine the primary representational system of the client used in the unconscious deep struc- ture for categorizing and storing sensory data to be used in creating conscious surface struc- ture patterns or maps (Bandler & Grinder, 1979; Buckner, Meara, Reese, & Reese, 1987; Dilts, Grinder, Bandler, & DeLozier, 1980).

In addition to the ease of using eye accessing cues to determine a person’s DS- PRS, it does not require the client to verbalize a response to the social worker. On the contrary, the advantage of the technique is that clients do not have to take their DS- PRS and program or translate their unconscious data into consciously expressed language. Social workers choosing to use the eye accessing cues technique need to be inten- tional in their choice of words. The ensuing examples of sensory- neutral phrases may prove instructional:

Think about how you could do it. Deliberate on what the steps would be. Recall what you have done pre- viously to solve a problem. Consider what resources you would need to get the job done. Deliberate on how you might have done things differently. Reflect on when you were the most satisfied or pleased.

Once the direction of eye movement has been determined, the practitioner needs to assess their findings. A  glance up and to the left or right indicates that the client is using a visual DS- PRS. Similarly, if the client looks straight ahead, they are visual. A look to the left or right, or down and to the left indicates that the cli- ent’s DS- PRS is auditory. Peering down and to the right implies that the client is kinesthetic. Scanning back and forth suggests that the client

is processing the question and trying to access the data from their unconscious deep structure. Much like doing an Internet search on a com- puter, some people will take longer than others in order to find the needed information. This then calls for the social worker to be patient while the client finds what they are looking for in terms of their DS- PRS. (Of note, the afore- mentioned information on eye accessing cues is for right- handed individuals. This diagnos- tic schemata is reversed for those who are left- handed; i.e., down and to the left for kinesthetic, and down and to the right for auditory.)

The Four- tuple Realizing that people are constantly taking in a spectrum of sensory data, it is now understand- able how these in turn influence the cognitive, affective, and behavioral aspects of our bio- psycho- social- spiritual- physical selves. Shaped internally as patterns or maps and conveyed externally via sensory- based linguistic commu- nication, the array of representational systems will be used by people to construct and convey what they are thinking, how they are feeling, and why they are behaving the way they are. Obviously, the flow of information needs to be handled in a sense- making fashion so that the person can understand the information and messages they receive, and make the ones that they send coherent and meaningful to others. In order to do this, a selection is made at both the unconscious deep structure and conscious surface structure levels with respect to which representational system to use and when to use it. This cascading of PRS from best to least desirable choice is based on the situation and circumstances confronted by the person using existing patterns or maps drawn from inter- nal memory or ones constructed from external experiences in the here and now.

Clinically speaking, clients use a “what works” selection process to make sense out of what they are experiencing and to determine how best to act or react to what they are confronted with. Referred to in NLP as the “four- tuple,” a “set” terminology is used by practitioners to describe what they are witnessing from clients (Bandler & Grinder, 1975). The first step is to assign the senses set values. V is used for visual, A for audi- tory, K for kinesthetic, and O for both olfactory