Unit 3.1 DB: Physical Development and Brain Functioning

We have established that the attainment of developmental milestones is directly related to human behavior. We have also established that within any individual, the biological, psychological, and social aspects of development mutually affect each other. Together, they interact and significantly impact growth, change, and ultimately, well-being.

Biological development and maturation affect both how adolescents perceive themselves and how they behave. Rapid and uneven physical growth may cause awkwardness, which may result in feeling self-conscious and consequently uncomfortable in social interactions. For example, some psychological and behavioral differences exist between males who develop earlier or later and those who develop at an average rate.

Biological development often affects the transactions between individuals and their immediate social environments. For instance, when adolescents begin to attain physical and sexual maturity, sexual relationships may begin to develop. Likewise, new and different alternatives become available to adolescents and young adults as they mature. For example, alternatives concerning sexuality may range from no sexual activity to avid and frequent sexual relations. These new alternatives merit evaluation in terms of their positive and negative consequences. Decisions need to be made about such critical issues as whether to have sexual relations and which, if any, methods of contraception to use.

A Perspective

6-2bThe Growth Spurt

The initial entrance into puberty is typically characterized by a sharp increase in height. During this spurt, boys and girls may grow between 2 and 5 inches. Before the growth spurt, boys tend to be 2 percent taller than girls. However, because girls start the spurt earlier, they tend to be taller, to weigh more, and to be stronger than boys during ages 11 to 13. By the time both sexes have completed the spurt, boys once again are usually larger than girls.

The adolescent growth spurt affects virtually the entire body, including most aspects of the skeletal and muscular structure. However, boys and girls grow differently during this period. Boys’ shoulders get relatively wider, and their legs and forearms relatively longer, than those of girls. Girls, on the other hand, grow wider in the pelvic area and hips. This is to enhance childbearing capability. Girls also tend to develop a layer of fat over the abdomen, hips, and buttocks during puberty. This eventually will give a young woman a more shapely, rounded physique. However, the initial chubby appearance can cause the adolescent a substantial amount of emotional stress. Crash and starvation diets can create a physical health hazard during this period.

Adolescents tend to have unequal and disproportionate growth. Most adolescents have some features that look disproportionate. The head, hands, and feet reach adult size and form first, followed by the legs and arms. Finally, the body’s trunk reaches its full size. A typical result of this unequal growth is motor awkwardness and clumsiness. Until the growth of bones and muscles stabilizes, and the brain adjusts to an essentially new body, awkward bursts of motion and misjudgments of muscular control will result.

6-2cThe Secular Trend

People generally grow taller and bigger than they did a century ago. They also reach sexual maturity and their adult height faster than in the past. This tendency toward increasing size and earlier achievement of sexual maturity is referred to as the  secular trend.

The trend apparently has occurred on a worldwide basis, especially in industrialized nations such as those of Western Europe and Japan. This suggests that an increased standard of living, along with better health care and nutrition, is related to the trend.

This secular trend seems to have reached its peak and stopped. A 14-year-old boy of today is approximately 5 inches taller than a boy of the same age in 1880.

6-2dPrimary and Secondary Sex Characteristics

A major manifestation of puberty is the development of primary and secondary sex characteristics.

Primary sex characteristics are those directly related to the sex organs and reproduction. The key is that they have a direct role in reproduction. For females, these include development of the uterus, vagina, and ovaries. The ovaries are the major sex glands in a female, which both manufacture sex hormones and produce eggs that are ready for fertilization.

For males, primary sex characteristics include growth of the penis and development of the prostate gland and the testes. The prostate gland, which is located below the bladder, is responsible for a significant portion of the ejaculate or whitish alkaline substance that makes up semen, which carries the sperm. The testes are the male sex glands that both manufacture sex hormones and produce sperm.

We have already defined  secondary sex characteristics to include those traits that distinguish the genders from each other but play no direct role in reproduction. These include menstruation, hair growth, development of breasts, growth of reproductive organs, voice changes, skin changes, and nocturnal emissions.

One of the most notable indications that a female has achieved the climax of puberty is her first menstruation, also called  menarche.  Menstruation is the monthly discharge of blood and tissue debris from the uterus when fertilization has not taken place.

Girls today are experiencing first menstruation at earlier ages than girls growing up three or four decades ago. The average age for first menstruation, menarche (pronounced “men-ar-key”) in the United States is now  years. That means that many girls have their first period before the end of seventh grade, and many begin as early as fourth or fifth grade. It also means that many girls will at least be in the eighth grade before their first period, and some may be seniors in high school before they get a period. All of these situations are normal. (Greenberg, Bruess, & Oswalt, 2014, p. 417)

Note that frequently young females begin to menstruate before they begin to ovulate, so they might not be capable of becoming pregnant for two or more years after menarche (Hyde & DeLamater, 2017) During puberty, females also experience an increased blood supply to the  clitoris (a small structure at the entrance to the vagina that’s highly sensitive to stimulation and gives sexual pleasure), a thickening of the vaginal walls, and significant growth of the uterus, which doubles in size from the beginning of puberty to age 18 (Hyde & DeLamater, 2017)

Some adolescent boys also undergo temporary breast development. Although this may cause them some anxiety concerning their masculinity, this enlargement is not abnormal. Hyde and DeLamater (2017) indicate that this occurs in approximately 80 percent of boys in puberty. The probable cause is small amounts of female sex hormones produced by the testes. The condition usually disappears within about a year.

Voice Changes

Boys undergo a noticeable lowering in the tone of their voices, usually fairly late in puberty. The process involves a significant enlargement of the larynx or Adam’s apple and a doubling in the length of the vocal cords. Many times it takes two years or more for boys to gain control over their new voices.

Girls also experience a slight voice change during adolescence, although it’s not nearly as extreme as the change undergone in boys. Girls’ voices achieve a less high-pitched, more mature tone due to a slight growth of the larynx.

Skin Changes

Adolescence brings about increased activity of the sebaceous glands, which manufacture oils for the skin. Skin pores also become coarser and increase in size during adolescence. The result is frequently a rapid production of blackheads and pimples, commonly referred to as acne, on the face and sometimes on the back. Unfortunately, a poor complexion is considered unappealing in many cultures (Hyde & DeLamater, 2014). Acne adds to the stress of adolescence. It tends to make young people feel even more self-conscious about their bodies and physical appearance.

Nocturnal Emissions

Approximately 90 percent of men and 40 percent of women experience nocturnal emission sometime in their lives (Yarber & Sayad, 2016). A  nocturnal emission, also referred to as a wet dream, is the ejaculation or emission of semen while a male is asleep. The highest frequency of approximately once a month tends to occur during the late teens. The number then tapers off during the 20s, and finally stops after age 30.

Nocturnal emissions are a natural means of relieving sexual tension. Often, but not always, they are accompanied by sexual dreams. It’s important that adolescents understand that this is a normal occurrence and that there’s nothing physically or mentally wrong with them.

Females also have orgasms during sleep (Yarber & Sayad, 2013). However, these apparently don’t occur as frequently or as early as males’ nocturnal emissions.

6-3Explain Psychological Reactions to Physical Changes

LO 3

One thing that marks adolescence is self-criticism. Physical imperfections are sought out, emphasized, and dwelled on. It may be a large lump on a nose. Or it may be an awesome derriere. Or it may even be a dreadful terror of braces locking unromantically during a goodnight kiss. Adolescents seek to conform to their peers. Any aspect that remains imperfect or too noticeable becomes the object of criticism. Perhaps it’s because the age is filled with change and mandatory adjustment to that change that adolescents strive to conform. Perhaps before an individual personality can develop, a person needs some predictability and security.

A substantial amount of research focuses on adolescents’ perceptions of themselves. Special areas of intense interest include body image, self-concept, weight level, weight worries, and eating disorders.

6-3aBody Image and Self-Concept

Perception of one’s body image and attractiveness is related to adolescents’ level of self-esteem, especially for girls (Bearman, Presnall, Martinez, & Vaughn, 2006; Moore & Rosenthal, 2006; Newman & Newman, 2015) People who consider themselves attractive tend to be more self-confident and satisfied with themselves.

By adulthood, the differences between early and late maturers become much less clear (Kail & Cavanaugh, 2014; Santrock, 2012b). So many other elements are involved in a person’s development, including those that are cognitive and social, that it is difficult to predict the effects of any one variable, such as maturation rate. This illustrates an area where practitioners should continue to review and evaluate the research in a pattern of career-long learning in order to understand the dynamics involved in and effecting adolescence.

6-3cEarly and Late Maturation in Girls

A number of studies report that early-maturing girls are disadvantaged in various areas. Santrock, 2016) explains:

In recent years, an increasing number of researchers have found that early maturation increases girls’ vulnerability to a number of problems… Early-maturing girls are more likely to smoke, drink, be depressed, have an eating disorder, engage in delinquency, struggle for earlier independence from their parents, and have older friends; and their bodies are likely to elicit responses from males that lead to earlier dating and earlier sexual experiences… And early-maturing girls are less likely to graduate from high school and more likely to cohabit and marry earlier. (p. 424)

Maybe, as with early-maturing boys, their lack of life experience, level of cognitive development, and naivete put them at risk of problems. They may have to make “adult” choices before they are ready to accept the consequences of behavior or even acknowledge such consequences.

Sigelman and Rider (2012) explain the situation for late-maturing girls:

Late-maturing girls (like late-maturing boys) may experience some anxiety as they wait to mature, but they do not seem to be as disadvantaged as late-maturing boys. Indeed, whereas later-developing boys tend to perform poorly on school achievement tests, later-developing girls outperform other students (Dubas, Graber, & Petersen, 1991). Perhaps late-developing girls focus on academic skills when other girls have shifted some of their focus to extracurricular activities. (p. 159)

The differences between early- and late-maturing girls in adulthood are complex and tentative (Sigelman & Rider, 2012). As with boys, the picture is much more complicated than simply focusing on the life results caused by one specific variable, such as early maturation.

6-3dBrain Development during Adolescence

An adolescent’s brain also undergoes physical changes in response to new hormonal production. Such changes can result in behavioral and emotional consequences. Consider that

During adolescence, boys experience greater changes in their brains than girls (Goldstein et al., 2001; Segovia et al., 2006). This “may account for the increased aggressiveness and irritability often associated with adolescence” (Martin & Fabes, 2009, p. 448).

6-3eAdolescent Health, and Substance Use and Abuse

During any time of life, including adolescence, lifestyle directly impacts health and the ability to function effectively. Discussed here is the use of mind-altering drugs, alcohol, and tobacco.

Use of Mind-Altering Substances

Berk (2012b) summarizes the current situation:

Teenage alcohol and drug use is pervasive in industrialized nations. According to the most recent, nationally representative survey of U.S. high school students, by tenth grade, 33 percent of U.S. young people have tried smoking, 59 percent drinking and 38 percent at least one illegal drug (usually marijuana). At the end of high school, 15 percent smoke cigarettes regularly, and 16 percent have engaged in heavy drinking during the past month. About 24 percent have tried at least one highly addictive and toxic substance, such as amphetamines, cocaine, phencyclidine (PCP), Ecstasy (MDMA), inhalants, heroin, sedatives (including barbiturates), or OxyContin (a narcotic painkiller) (Johnston et al., 2010).

These figures represent a substantial decline since the mid-1990s, probably resulting from greater parent, school, and media focus on the hazards of drug taking. But use of some substances—marijuana, inhalants, sedatives, and OxyContin—has risen slightly in recent years (Johnson et al, 2010). Other drugs, such as LSD, PCP, and Ecstasy, have made a comeback as adolescents’ knowledge of their risks faded. (p. 560)

Use of mind-altering substances by adolescents can have devastating effects.

Tomas Rodriguez/Fancy/Corbis

Use of Alcohol

We have established that many young people drink alcohol. Small amounts of alcohol may have a calming effect. However, immediate dangers from alcohol consumption include potential death when used with other drugs and accidents while driving. A scary finding of recent research is that extensive alcohol use as a teenager can cause impairment of mental functioning later on in life (Berk, 2012b; Newman & Newman, 2015)

Variables putting adolescents at risk for alcohol and other substance abuse can be clustered into four categories: environmental factors, peer influences, family influences, and personal characteristics (McWhirter, McWhirter, McWhirter, & McWhirter, 2012).  Environmental factors including poverty, inadequate education, high unemployment, lack of positive role models, and absence of opportunity can place pressure on young people to escape through mind-altering substances.  Peer pressure is a second major influence (Lewis, Neighbors, Lindgren, Buckingham, & Hoang, 2010). If “everybody’s doing it,” it may be more tempting.  Parental factors related to drug use include lack of involvement with children and parents’ failure to monitor adequately their children’s behavior (Dishion, Kavanagh, Schneiger, Nelson, & Kaufman, 2002). If parents appear not to care or don’t provide support or direction, it’s easier for adolescents to succumb to temptation. Another parental factor is the use of alcohol and other substances by the parents themselves. Parents can provide role models for abuse.  Personal characteristics of adolescents that increase risk of alcohol and other substance abuse include poor coping skills in response to the powerful emotional pain often experienced in adolescence, relationship and achievement problems at school, and a desire for excitement and self-gratification.

One of us worked with a 13-year-old boy named Joe for two months after Joe’s mother requested that he receive counseling. She and her husband, Joe’s stepfather, were concerned about his poor school performance, his acting out, his group of “delinquent” friends, and his alternately hostile and completely withdrawn behavior at home.

Joe’s stepfather was a machine operator who provided severe yet inconsistent discipline. Joe disliked his stepfather, and he reported that the dislike was mutual. He described his mother as “nicer,” but complained-that she did not permit him to do what he wanted. His mother was primarily a homemaker, but occasionally she did temporary office work. She frequently placated her husband so that he would not get angry with Joe. She felt Joe needed to change, however, and believed that counseling might “fix” him. Joe’s parents refused to come in for counseling as a family because Joe was the problem.

Joe spent a great deal of time with his friends both during and after school. He reported smoking marijuana and cigarettes fairly regularly. Shortly after our first counseling session, he was arrested for possession of drug paraphernalia. His parents refused to let him see any of his friends after the arrest.

Joe’s school performance and effort were poor. Joe probably had a mild learning disability, but a recent psycho-educational evaluation had been inconclusive. Joe’s primary problem at school was his acting out. Unfortunately, when Joe got into trouble with a teacher, lie was inadvertently rewarded for his disruption. He could effectively avoid the schoolwork that he found so difficult and distasteful by sitting in the assistant principal’s office “listening to stupid stories.” Joe was doing so poorly at school and misbehaving with such frequency that his stepfather threatened to send him to a strict boarding school unless his behavior improved. Joe said that would be fine with him because he had heard that the work was easier there. His step-father’s threat to cut his hair short was the only consequence he seemed concerned about.

Joe’s situation resembles that of many young people at risk for alcohol and other substance abuse. He received little support and no steady, coherent discipline from his parents. He was in constant conflict with his stepfather, whom he disliked intensely. He experienced serious difficulties in school and was rapidly falling behind. It was easy to turn to peers who probably experienced similar problems. Peer pressure then could reinforce problem behaviors and his substance abuse. Joe felt abused, isolated, and neglected by parents and school. He avoided responsibility for his behavior by escaping through drugs. His parents failed to see problems from a family system perspective and refused to participate in treatment. They eventually removed Joe from counseling. What do you think happened to him?

Ethical Questions 6.2

Masturbation

Masturbation refers to self-stimulation of the genitals that causes sexual arousal. It appears that masturbation begins fairly early. By the time they reach age 19, the end of adolescence, 86 percent of all males and about two-thirds of all females have masturbated (Crooks & Baur, 2014). Some data indicate that adolescents are beginning to masturbate earlier than they have in the past (Bancroft, Herbenick, & Reynolds, 2003; Hyde & DeLamater, 2014).

Boys are more likely to masturbate than girls (Crooks & Baur, 2014; Laumann et al., 1994; Yarber & Sayad, 2016). Such gender differences may be related to sex roles and sexual expectations of men and women. Our society expects men to be sexual—and sexual athletes at that. Additionally, it may be possible that many women take longer to become comfortable with their own sexuality.

Greenberg et al. (2014) describe the masturbation process:

Males masturbate by stroking the shaft of the penis, often stimulated by erotic literature, films, or the internet. Some men use gadgets to assist them. Artificial vaginas, furlike clothes, inflatable dolls, and other devices have been reported as masturbatory aids by some men.

Women masturbate by rubbing the vulva [the female’s external genitals]—in particular, the clitoris—or inserting an object (a finger, a dildo, a banana, or a similarly shaped object) into the vagina. There are, of course, many variations on this theme, and the use of a vibrator to stimulate the vulva, cream to decrease friction on the area rubbed, pillows or other soft objects to rub the genitals against, and squeezing together of the thighs are all common adjuncts to the standard masturbatory techniques. (pp. 505–506)

Kelly (2008) describes how adolescents talk about masturbation:

Adolescent boys have tended to discuss masturbation among themselves—often in a joking way—more than adolescent girls. Consequently, more slang terms have evolved to describe male masturbation (jerk off, jack off, whack off, beat off, beat the meat) than for female masturbation (rubbing off, rolling the pill, fingering). (p. 153)

Other terms for female masturbation include “flick your Bic” and “itch the ditch.” Additional terms for male masturbation are “bop your bologna,” “wax the cucumber,” “burp the worm,” “play the piccolo solo,” “choke the chicken,” and “tickle the pickle.”

It’s important to address the issue of masturbation. As we’ve already established, it is very common among adolescents. However, it is also looked down on. The numerous slang terms used to describe it are very uncomplimentary. Perhaps the traditional negative attitude about masturbation can best be expressed by the statements of H. R. Stout in the 1885 edition of Our Family Physician:

When the evil has been pursued for several years, there will be an irritable condition of the system; sudden flushes of heat over the face; the countenance becomes pale and clammy; the eyes have a dull, sheepish look; the hair becomes dry and split at the ends; sometimes there is pain over the region of the heart; shortness of breath; palpitation of the heart (symptoms of dyspepsia show themselves); the sleep is disturbed; there is constipation; cough; irritation of the throat; finally the whole man becomes a wreck, physically, morally, and mentally. (p. 333)

After such a tirade, it would be a wonder if a person would dare to masturbate. This presents quite a contradiction and a source of confusion for adolescents. They are actually participating in the activity of masturbation. Yet there is some tendency for it to be considered an unappealing and even disgusting, behavior. Although attitudes are more positive than they have been historically, negative feelings can include anxiety, defensiveness, embarrassment, and guilt (Greenberg’ et al., 2014; Hyde & DeLamater, 2014).

Adolescents need to understand; that masturbation is not abnormal or harmful. In a period of their lives when they are coping with many physical changes and new life situations, they do not need to be burdened with unnecessary confusion and even guilt. Masturbation is a normal means of relieving sexual tension and other stress, allowing a means of self-discovery, learning to control sexual needs and impulses, and fighting isolation and loneliness. Masturbation is even a prescribed means of treatment for sexual dysfunction. Women with orgasmic dysfunctions (i.e., the inability to experience orgasms) are counseled to use masturbation. This helps them overcome anxiety and understand their sexual responses. This information can later be transferred to a partner.

Another trend from the 1950s to 1970s was having sexual intercourse at younger and younger ages across many ethnic groups (Crooks & Baur, 2014). Today, the average age for first intercourse for females is 17.2 and for males 16.8 (Kinsey Institute, 2015)

There are a range of reasons why adolescents have sexual intercourse (Rathus et al., 2014).

6-4Describe Sexual Activity in Adolescence

LO 4

A major trend characterizing adolescent sexual activity from the 1950s to the 1970s was a dramatic increase in teenagers having intercourse (Crooks & Baur, 2014). This was more true for boys than girls. Today, 25 percent of males and 26 percent of females have had sexual intercourse by age 15; 69 percent of males and 77 percent of females have had sexual intercourse by age 19 (Kinsey Institute, 2010).

Many adolescents, especially young men, are responding to the surge of hormones their bodies are experiencing. Many men and women say they have intercourse because they’re curious about it or because they’re simply ready for it. Showing love and affection is yet another reason for sexual intercourse.

Teen pregnancy has a number of other strikingly negative consequences. First, such pregnancies are marked by increased physical risks, both to the child and to the mother (Crooks & Baur, 2014; March of Dimes, 2012). Such problems include prolonged labor, anemia, toxemia, hemorrhaging, miscarriage, and, in the extreme, the pregnant teen’s death. The babies have a much greater chance either of being premature or of having a lower-than-normal birth weight (March of Dimes Foundation, 2012). A related finding concerning maternal and child health is that many teenage mothers are poverty-stricken and receive very little prenatal health care (Hyde & DeLamater, 2014; Yarber & Sayad, 2016). This contributes to the health risks of the mothers and their babies.

Other, longer-term research indicates that negative effects continue long after the baby’s birth. Teen mothers are much less likely to finish high school than their peers who are not mothers (Downs et al., 2009). Adolescent mothers are often poor and dependent on social services (Crooks & Baur, 2014; March of Dimes, 2012). Later in life, they are more likely than their peers without children to be unemployed or underemployed (Crooks & Baur, 2014). Teen mothers also may have poorer parenting skills (Crooks & Baur, 2011; Klein and the Committee on Adolescence, 2005). Thus, the added stress and responsibility of motherhood tend to take a toll on teen mothers. Raising a child demands time, energy, and attention. Time taken to care for a baby must be subtracted from the time available for school and recreational activities. There are potentially serious impacts on the mental health and daily functioning of young mothers.

The children themselves are more likely not only to have a low birth weight, but also a higher mortality rate (March of Dimes Foundation, 2012). Long-term studies also reveal negative effects on the children of teen mothers. As these children mature, they tend to have more emotional, intellectual, and physical problems than do their counterparts born to adult mothers (Crooks & Baur, 2011; Downs et al., 2009; Rathus, Nevid, & Fichner-Rathus, 2011).

The consequences of teenage parenthood are emphasized here to provide a realistic perspective on teen pregnancy. Teenagers need to be at least intellectually aware of the impacts of motherhood. They need this information in order to make more realistic decisions for themselves concerning their sexual activity and their use of contraception. The other reason to focus on the consequences of teenage pregnancy concerns helping young mothers who have already had their babies. Social workers need to understand the problems of teenage parenthood. This is needed to help young mothers realistically appraise their situations, make decisions about what to do for themselves, and get involved with the supportive services they need.

On a more positive note, Klein and the Committee on Adolescence (2005) report:

Research suggests that long-term negative social outcomes are not inevitable. Several long-term follow-up studies indicate that two decades after giving birth, most former adolescent mothers are not welfare-dependent; many have completed high school, have secured regular employment, and do not have large families. Comprehensive adolescent pregnancy programs seem to contribute to good outcomes, as do home-visitation programs designed to promote good child health outcomes, (p. 6)

6-4bTeenage Fathers

Variables making a person more likely to become a teen father include living in an inner city, doing poorly in school, being poor, and being involved in delinquent acts (Klein and the Committee on Adolescence, 2005; Yarber & Sayad, 2016). Yarber and Sayad (2016) comment on the situation facing adolescent fathers:

Some teens are embarrassed to find and purchase contraceptive apparatus or are concerned about confidentiality (Crooks & Baur, 2014). Others may feel uncomfortable talking to partners about sexual matters or lack assertiveness to do so. For instance, a young woman may find it difficult to talk to a partner about such intimate issues as putting on a condom or placing a diaphragm in her vagina. Depending on the information to which they’ve had access, adolescents may not have adequate knowledge about contraceptive methodology and its effectiveness (Crooks & Baur, 2014).

Other adolescents adhere to erroneous myths (Crooks & Baur, 2011; Rathus et al., 2011). For instance, many teens inaccurately believe that they are not old enough to conceive, that “the first time” doesn’t count, that they must have intercourse much more frequently than they do in order to conceive, that it is perfectly safe to have sex during certain times of the month, and that withdrawal before ejaculation is an effective birth control method. Some young women may illogically feel that if they ignore the issue of potential pregnancy, it will cease to exist. If they don’t think about their own sexual activity, then they don’t have to worry about it.

There are yet other reasons why teens may not use birth control. They might not like the bother of using contraception. They might feel sexual activity is more pleasurable without it. They may worry that parents will find out. They may feel invulnerable to pregnancy, that it’s something that only happens to other people. Finally, they may simply think that they want to get pregnant.

6-5Assess Sex Education and Empowerment

LO 5

Two fallacies can be pointed out in this approach. First, it assumes that adolescents have little or no access to sexual information other than that which adults choose to give. In reality, most teenagers say they’ve learned the most about sex from the media and their friends (Hyde & DeLamater, 2017)

Obviously, adolescents are functioning within a complex environment that exposes them to many new ideas. They are not locked up in a sterile cage. The media place tremendous emphasis on sexuality and sexual behavior. Television, the internet, magazines, newspapers, and books are filled with sexual episodes and anecdotes. Adolescents indeed have numerous exposures to the concept of sex.

A second fallacy is that adolescents will automatically try anything they hear about. If a parent tells a young person that some people are murderers, will the young person go out and try murdering someone? Of course not. Although adults, especially parents, might wish they had such control over adolescents, they do not.

Perhaps an analogy concerning sex education could be made to the situation of buying a used Ford SUV. An analogous assumption would be that it would be better to have no information about how the van works before buying it and hope for the best. This is ludicrous. In this situation, you would want as much information as possible to make the best decision about whether or not to buy the van. It would be wise to take the van to a mechanic to have it thoroughly evaluated. You would both need and want information. People, including adolescents, need as much information as possible in order to make responsible decisions about their own sexual behavior and avoid ignorant mistakes. It is illogical to deprive them of information and have them act on the basis of hearsay and chance.

One primary source of information about sex is friends; yet friends probably don’t know much more about sex than they do. Information that is available from friends is likely to be vague and inaccurate. Just because adolescents use sexual terms does not mean they are very knowledgeable about sexuality.

Over half (55 percent) of teens in grades 7 to 12 have researched sexual information online when they had a question related to themselves or to their friends; however, in one survey of relevant websites, 46 percent of those providing information about contraception and 35 percent of those dealing with abortion were inaccurate (Guttmacher Institute, 2012a).

6-5aSex Education by Parents

Another aspect of the sex education controversy is the idea that sex education should be provided by parents in the home. Among teenagers, 70 percent of males and 79 percent of females do talk to parents about sex; however, questions tend to fall within at least one of six categories (Guttmacher Institute, 2012a). These categories include saying no to sex, methods of contraception, how to get contraception, how to use a condom, sexually transmitted infections (STIs), and how to avoid contracting an HIV infection. However, consider the potential effectiveness of such sex education provided by parents (Guttmacher Institute, 2012a). First, teens may only talk to their parents about one of these issues, not all. Second, more girls talk to parents about sex than boys. Third, girls tend to focus on ways to “say no” and types of contraception. Fourth, parents may often provide “inaccurate” or “incomplete” information.

Consider also the many remaining children who receive no sex education in the home (Hyde & DeLamater, 2017). There may be several reasons for this. Adolescents may feel uncomfortable talking about such intimacy with parents, and vice versa. Many young people have extreme difficulty envisioning their parents and grandparents being involved in sexual scenarios. Similarly, parents often don’t relish the picture of their children involved in such acts either. Parents may fear that by talking about it, they will encourage children to have sex, a fallacy we have already discussed. Parents may also fear their own ignorance. What if their children ask them questions they can’t answer? An implication of these concerns is that it is probably easier to avoid the issue altogether.

Sex educators do not want to take the parents’ place in this sphere. Rather, they want to ensure that children have adequate and accurate information about sex. Many times parents are uncomfortable or embarrassed talking about sex with their children. One student shared her 8-year-old son’s reaction to her own discomfort in talking to him about sex. As she was trying to explain to him some of the basics of human reproduction, he put his hand on her arm and said, “It’s okay, Mom, I get the general idea.”

6-5bCurrent Policy and Sex Education Programs

The major focus of the current sex education debate is on the type of program that should be offered in schools. Most sex educators promote a comprehensive program providing a wide range of information to students. The opposite approach involves abstinence-only-until-marriage programs.

6-5cAbstinence-Only-before-Marriage Sex Education Programs

Abstinence-only programs discourage young people from engaging in any sexual behavior, exaggerate the negative effects of sexual involvement, and frequently omit information on contraception or prevention of STIs (Carroll, 2013). Supporters often say that this approach drives home the point to young people that there is no choice when it comes to nonmarital sexual activity—they simply should not do it.

The Bush administration strongly supported the development and operation of such programs (Stein, 2010). More than $1.5 billion in state and federal support was made available for these programs over the past 30 years (Greenberg et al., 2014). The current Obama administration still made $55 million available in 2012 (Kiff, 2012). As of November 2013, 37 states require that information about abstinence be included; 25 of these states mandate that abstinence be emphasized (Guttmacher Institute, 2013h). Nineteen states mandate that sex education programs stress the significance of engaging in sexual activity only within the context of marriage (Guttmacher Institute, 2013h). (Note that the terms “abstinence-only” and “abstinence-only-before-marriage” are used interchangeably here.) The Trump administration has indicated plans to return to a more conservative approach to sex education programming.

Do abstinence-only programs work? A range of studies indicate that they do not work. Research indicates that abstinence-only-before-marriage programs failed to fulfill their sole purpose—namely, increasing the rates of sexual abstinence (Carroll, 2013; Kirby, 2007; SIECUS, 2007b, 2008; Week, 2008). One analysis studied the effects of involvement in abstinence-only programs on teenagers who took virginity pledges compared with matched teens who took no such pledges (Rosenbaum, 2009). She found that teenagers who took the pledge did not delay sexual involvement any more than did their nonpledging peers, were less likely to use contraception, were less likely to get tested for STIs, and were more likely to go untreated for such a disease for longer periods if they did contract one (Rosenbaum, 2009). Other research found that participants in abstinence-only-before-marriage programs had the same rate of STIs as their peers who did not participate in these programs (Bearman & Bruckner, 2005; SIECUS, 2005m, 2007b). Yet other research found that participation in abstinence-only programs produced no significant effects in sexual behavior generally (Kirby, 2007; Trenholm, Devaney, Fortson, Quay, Wheeler, & Clark, 2007).

The following is an example of a virginity pledge:

I,, promise to abstain from sex until my wedding night. I want to reserve my sexual powers to give life and love for my future spouse and marriage. I will respect my gift of sexuality by keeping my mind and thoughts pure as I prepare for my true love. (Sex Respect, Parent Guide, p. 13, cited in SIECUS, 2005d)

1. Abstinence-only curricula contain false information about the effectiveness of contraceptives. Many curricula misrepresent the effectiveness of condoms in preventing sexually transmitted diseases and pregnancy. One curriculum says that “the popular claim that ‘condoms help prevent the spread of STDs,’ is not supported by the data”; another states that “in heterosexual sex, condoms fail to prevent HIV approximately 31% of the time”; and another teaches that a pregnancy occurs one out of every seven times that couples use condoms. These erroneous statements are presented as proven scientific facts.

2. Abstinence-only curricula contain false information about the risks of abortion. One curriculum states that 5 percent to 10 percent of women who have legal abortions will become sterile; that “premature birth, a major cause of mental retardation, is increased following the abortion of a first pregnancy”; and that “tubal and cervical pregnancies are increased following abortions.” In fact, these risks do not rise after the procedure used in most abortions in the United States.

3. Abstinence-only curricula blur religion and science. Many of the curricula present as scientific fact the religious view that life begins at conception. For example, one lesson states: “Conception, also known as fertilization, occurs when one sperm unites with one egg in the upper third of the fallopian tube. This is when life begins.” Another curriculum calls a 43-day-old fetus a “thinking person.”

4. Abstinence-only curricula treat stereotypes about girls and boys as scientific fact. One curriculum teaches that women need “financial support,” while men need “admiration.” Another instructs: “Women gauge their happiness and judge their success on their relationships. Men’s happiness and success hinge on their accomplishments.”

5. Abstinence-only curricula contain scientific errors. In numerous instances, the abstinence-only curricula teach erroneous scientific information. One curriculum incorrectly lists exposure to sweat and tears as risk factors for HIV transmission. Another curriculum states that “twenty-four chromosomes from the mother and twenty-four chromosomes from the father join to create this new individual”; the correct number is 23.

There is one additional criticism of abstinence-only curricula. Emphasizing how important it is to wait for sexual interaction until heterosexual marriage tends to alienate lesbian and gay youth even more than they already are (SIECUS, 2005j, 2008). Gay marriage remains a highly controversial issue. Lesbian and gay students are already at great risk of being threatened or harassed. More than twice as many lesbian and gay high school students (19 percent) as heterosexual students (8 percent) are threatened or harmed with a weapon (SIECUS, 2005j). Ninety-two percent of lesbian and gay students “in middle and high school report that they frequently or often hear homophobic remarks, such as ‘faggot,’ ‘dyke,’ or the expression ‘that’s so gay’ from their peers. Almost one in five of these students heard homophobic remarks from faculty or staff at their school” (SIECUS, 2005j).

6-5dComprehensive Sex Education Programs

The Obama administration has treated the concept of sex education quite differently than the Bush administration. The Affordable Care Act of 2010 includes a program called the Personal Responsibility Education Program (PREP); PREP makes $75 million available annually for comprehensive sex education programs that ensure the provision of medically accurate information (Greenberg et al., 2014). With proposed changes to/elimination of the Affordable Care Act by the Trump administration, this program could be at risk.

In contrast to abstinence-only programs, comprehensive sexuality education empowers young people by teaching them “about both abstinence and ways to protect themselves from STDs, HIV, and unintended pregnancy” (SIECUS, 2005e). Note that most Americans support the provision of sex education that includes content on abstinence in addition to information about contraception and STIs (Carroll, 2013). Thus, a range of concepts are included in comprehensive sex education programs. These include abstinence, having the right to say no to a sexual encounter, the value of good communication, and the importance of taking responsibility for one’s own behavior. Some research found that teenagers who received information about both abstinence and contraception were more likely to use condoms, were more likely to delay their first experience with sexual intercourse, and established “healthier” relationships with partners (Guttmacher Institute, 2012a; Wind, 2012).

1. Information. Sexuality education seeks to provide accurate information about human sexuality including growth and development, human reproduction, anatomy, physiology, masturbation, family life, pregnancy, childbirth, parenthood, sexual response, sexual orientation, gender identity, contraception, abortion, sexual abuse, HIV/AIDS, and other sexually transmitted diseases.

3. Relationships and interpersonal skills. Sexuality education seeks to help young people develop interpersonal skills, including communication, decision making, assertiveness, and peer refusal skills, as well as the ability to create reciprocal and satisfying relationships. Sexuality education programs should prepare students to understand sexuality effectively and creatively in adult roles. This includes helping young people develop the capacity for caring, supportive, non-coercive, and mutually pleasurable intimate and sexual relationships.

4. Responsibility. Sexuality education seeks to help young people exercise responsibility regarding sexual relationships by addressing such issues as abstinence, how to resist pressures to become involved in unwanted or early sexual intercourse, and the use of contraception and other sexual health measures. (2004, p. 19)

Highlight 6.3

Initiating Kissing and Sexual Intimacy

A faculty member we know occasionally asks students in some of his classes the following question: “Assume you are out on your first or second date with someone you find very attractive. You really desire to kiss and hug this person. What would you do to seek to initiate this activity?”

Many students respond that they would use body language to convey their interest. To this response I usually ask “Tell me, specifically, what types of body language would you use?” Students usually are unable to give a specific answer to this question.

Think about your past romantic experiences. How did you, or the person you were with, convey an interest in kissing and hugging?

Body language sends ambiguous messages. We may misread the body language of someone. Sadly, romantic movies and soap operas usually model that participants in romantic encounters use body language to determine the other person’s interests in a romantic relationship.

If someone does not want to be kissed by you, and you kiss them, you may see physical reactions of that person rejecting you—and in rare cases even slapping you in the face. (Some sexual harassment complaints are now being filed over unwanted kissing.)

Why is it that our society socializes us to convey romantic interests through body language?

Why is it that traditionally males (in male-female relationships) are expected to initiate an interest in hugging and kissing? In our contemporary society that advocates equality between the sexes, should not females have the same right to initiate hugging and kissing (in male-female relationships)?

Michael J. Domitrz in May I Kiss You? makes a strong case that we would be better off by using verbal communication to seek to convey our interest in hugging and kissing a person we are highly attracted to.  Would not saying something like the following be more constructive and respectful than seeking to use body language? “I am very attracted to you. I’d really like to give you a kiss. Would that be OK with you?”

A second question that the above faculty member sometimes asks students is: “Assume you have been dating someone you are highly attracted to for quite a length of time. You have kissed and hugged this person a number of times, but yet have not become sexually intimate. Also assume you desire to become sexually intimate. What would you do to seek to initiate this activity?”

Again, many students respond that they would convey this message through body language. (Again, movies and soap operas often convey that this is the best way of sending such a message.) Sadly, the high number of date rapes clearly document that body language (along with physical force) is not the most constructive or respectful way of conveying such a message.

Often, female students respond to this question by saying it is “up to the male” to initiate such moves. Should not females in our society have the same rights as men in this area?

Domitrz in May I Kiss You?  again makes a strong case that your interest in initiating sexual intimacy with someone is best conveyed, and most respectfully conveyed, by a verbal communication, such as the following: “I find you highly attractive. I really desire to become intimate with you. Could you tell me your thoughts about this?” Such a question shows your respect for the other person, and it conveys your feelings with much greater clarity than body language. (If you use body language and start groping someone, aren’t you sending confusing, and perhaps alarming messages—which even makes you vulnerable to a sexual assault charge?)

Another advantage of using verbal communication is that it enhances the chances that you (and the person you are with) will have an honest discussion about the limits and types of sexual intimacy (such as oral sex being the type and limit) that are desired. Verbal communication also can facilitate a discussion of using contraceptives if sexual intercourse is agreed upon.

Research has determined that effective sex education programs that delay first intercourse, reduce the frequency of intercourse, decrease the number of sexual partners, and increase contraceptive use have seven characteristics (Kirby, 2001, 2007; Kirby et al., 1994; SIECUS, 2005c; United Nations Program on HIV/AIDS, 1997). First, they focus on decreasing specific risk-taking behavior that could potentially lead to pregnancy or STDs. Second, they’re based on social learning theory that emphasizes assuming responsibility for behavior, recognizing consequences, and teaching effective strategies to protect oneself, thereby enhancing motivation to adopt those behaviors. Third, they provide vital, practical, and accurate information about the risks of sexual behavior, how to avoid risks, and how to protect oneself from pregnancy and STDs. Fourth, they address how the media encourage young people to become involved in sexual behavior and help them think about how to respond. Fifth, they provide examples of and opportunities to practice “communication, negotiation, and refusal skills” (Greenberg et al., 2014, p. 423). Sixth, such programs reinforce values that address the worth of postponing sexual activity and avoiding risky sexual behavior. Seventh, they use interactive teaching approaches to engage participants and help them personalize what they learn (e.g., using small-group discussions and roleplaying).

Comprehensive sex education programs help adolescents make responsible decisions about romantic involvement and sexual behavior.

Ethical Questions 6.4

If unchecked, gonorrhea usually spreads from the cervix, up the uterus, and into the fallopian tubes. It then can cause pelvic inflammatory disease and possibly sterility. Because men feel pain as a symptom, they are much more likely to seek treatment. Otherwise, for both genders, the organisms can move into other sexually related organs, causing pain and possibly fever. Sterility in men is possible, although it occurs infrequently. Other possible results of gonorrhea include infection and the resulting inflammation of organs such as the heart, brain, or joints.

Diagnosis of gonorrhea involves obtaining a sample of the discharge and conducting laboratory tests. Treatment entails administering antibiotics. Note that increasingly resistant strains of gonorrhea are evolving throughout the world, making treatment increasingly more difficult (CDC, 2015). People remain contagious to others until they are cured.

6-6cSyphilis

There are approximately 63,000 cases of syphilis annually in the United States (CDC, 2015). Although it is not as common as either gonorrhea or chlamydial infections, syphilis is much more deadly. Syphilis is transmitted during sexual intercourse through a mucous membrane, usually by means of the genitals, vagina, anus, rectum, mouth, or lips. Also, a fetus may become infected by its mother; results include being stillborn, experiencing developmental delays, having seizures, or dying soon after birth (CDC, 2015.)

The symptoms of syphilis progress through four phases. The first is the  primary stage. Most notable during this phase is the appearance of a round, crater-like sore, which, despite its very unpleasant appearance, is painless. The  chancre, as this lesion is called, marks the spot where the bacteria initially penetrated the body. Most frequently, syphilis enters the body through a mucous membrane, around the tip of the penis, in the vagina, or at the cervix. Syphilis can, however, also be contracted through a cut anywhere on the skin. The chancre usually appears from 10 to 90 days (an average of 21 days) after infection and disappears after three to six weeks (CDC, 2011b).

The  secondary stage begins with lesions in mucous membranes and a rash that may occur almost any place on the body. The rash neither itches nor hurts. This stage usually begins as the chancre is healing or a few weeks after it vanishes (CDC, 2015). By this time, the bacteria have spread throughout the body. A number of other symptoms may characterize the secondary stage, including sore throat, hair loss, headaches, weight loss, nausea, joint pains, and fever. Most of these symptoms could also characterize a number of other illnesses, masking the fact that a person has syphilis. The individual might not seek treatment at all or seek it for some other illness.

Another aspect of the disease makes it difficult to pin down and diagnose. The time periods during which these generalized symptoms occur vary greatly and can be long. It’s difficult to relate the symptoms of a disease like syphilis to a time perhaps six months earlier when it was contracted.

The  latent stage begins sometime after all secondary stage symptoms have disappeared. No symptoms occur during this stage. The bacteria concentrate in some organ of the body such as the brain, spinal cord, or bones. After about one year in the latent stage, they are no longer contagious (Carroll, 2013). One exception is a pregnant woman, who may still pass the disease on to her child.

About 15 percent of the people who progress to the latent stage and remain untreated enter the final  late stage of syphilis (CDC, 2015). During this phase, the bacteria viciously attack the organs where they’ve concentrated. The disease may cause serious damage to the heart, eyes, brain, spinal cord, digestive organs, liver, or endocrine glands. Even death may result.

6-6dPubic Lice

Pubic lice, or “crabs,” are tiny insects that cling to pubic hair and feed off the blood vessels in the skin of the pubic area. People become infected through direct contact. The primary symptom is itching, which can range from slight to extreme. A case of pubic lice can be diagnosed by visual observation of them and their eggs. Treatment involves applying Kwell, a prescription ointment or shampoo, to the affected areas for a period of 12 hours. Because pubic lice are highly contagious, all clothing, towels, and bedsheets coming into contact with the lice should be boiled or washed in very hot water.

6-6eScabies

The mite Sarcoptes scabiei causes scabies. People become infected through direct contact with the organism. Symptoms include a red skin rash and severe itching. Diagnosis is through visual observation of the rash. Various creams are available for treatment. Like pubic lice, scabies are highly contagious, so all clothing, towels, and bedsheets coming into contact with them should be thoroughly cleaned.

6-6fTrichomoniasis

About 3.7 million people are infected with trichomoniasis in the United States (CDC, 2011). Caused by a single-celled protozoan parasite, it can be contracted through sexual intercourse or by genital-to-genital area contact. After infection, women usually experience a vaginal discharge that is yellow-green in color. Men experience either no symptoms or mild burning in the urethra after urination.

Diagnosis requires a laboratory test. Trichomoniasis is readily treated by prescription drugs such as metronidazole or tinidazole taken by mouth in a single dose. It is recommended that all sexual partners of the person with the disease be treated at the same time. Sexual intercourse should not resume until all symptoms have vanished. Trichomoniasis also makes people more susceptible to HIV infection (CDC, 2011; Hyde & DeLamater, 2017)

6-6gGenital Herpes

Across the nation, of people aged 14 to 49, 15.5 percent have genital herpes (CDC, 2014). Genital herpes is caused by herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2). Most cases of genital herpes are of the HSV-2 type, which causes outbreaks of painful blisters that break open and become sores. HSV-1, traditionally causing fever blisters or cold sores often found in and around the mouth, has only minor differences in its genetic code from HSV-2. Because of the increase in oral sex, HSV-1 has also often infected genital areas by mouth–genital contact. Either HSV-l or HSV-2 infecting the genitals is considered genital herpes. Genital herpes can also occur by touching fingers to infected areas and subsequently touching other receptive mucous membranes such as those in the genital area or in the mouth. We used to think that people were only contagious when they were broken out in sores. However, now we know that infected people can also transmit the disease to others when sores aren’t evident.

The first genital herpes outbreak usually occurs within two weeks of infection, although it may not happen for years (CDC, 2011b). This occurrence may last for two to four weeks before healing. Most people experience four to five outbreaks within the first year and then outbreaks tend to decrease in frequency over time (CDC, 2011b). After the first outbreak, subsequent ones tend to be less severe. In addition to the sores, other symptoms may resemble the flu, including headache, fever, and muscular aches. One of the most serious consequences of herpes is that it may be passed on to a developing fetus through the placenta. Often, a cesarean section is performed at birth.

Diagnosis is performed by visual observation, testing tissue specimens, or administering blood tests. Because it’s a virus, genital herpes can’t be cured; at this point, no virus can. However, oral antiviral medications can shorten episodes, decrease their severity, or prevent them from occurring while the medication is being taken. Psychological stress may also be related to outbreaks (Carroll, 2013).

6-6hHuman Papillomavirus (HPV)

HPV can cause cervical and other cancers (e.g., cancer of the penis or throat) (CDC, 2016). Due to the prevalence of cervical cancer, it is recommended that women have regular PAP smears for early detection and treatment.

Because most sexually active people will contract HPV at some time, the Centers for Disease Control (2013f) urge use of the HPV vaccine:

HPV vaccines are routinely recommended for 11 or 12-year-old boys and girls, and protect against some of the most common types of HPV that can lead to disease and cancer, including most cervical cancers. CDC recommends that all teen girls and women through age 26 get vaccinated, as well as all teen boys and men through age 21 (and through age 26 for gay, bisexual, and other men who have sex with men). HPV vaccines are most effective if they are provided before an individual ever has sex.

6-6iHIV (Human Immunodeficiency Virus)

6-7Explain Major Methods of Contraception

LO 7

Anyone who is considering becoming sexually active and who is not intentionally trying to conceive a child needs accurate and specific information about contraceptive methods.  This includes adolescents; without adequate information, they cannot make responsible decisions. Information helps to prevent people from taking unnecessary risks. We’ve already established the importance of sex education. Information concerning contraception is especially important. The risk of unplanned pregnancy and the resulting impact on the lives of adolescents are too important to ignore. Over 99 percent of American women aged 15 to 44 who have been sexually active have used at least one type of contraceptive method (Guttmacher Institute, 2015).

Major methods of contraception are described in the following sections. Hormonal methods of contraception include the contraceptive pill, the birth control patch, the vaginal ring, Depo-Provera injections, hormonal implants, and emergency contraception. Spermicides are chemical contraceptives. Barrier methods of contraception include condoms for men, the female condom, the diaphragm, and the cervical cap (FemCap). The birth control sponge (Today Sponge) serves as both a chemical and barrier method. The intrauterine device (IUD), including the ParaGard IUD and hormonal IUDs (Mirena and Skyla), is inserted inside the uterus. Other means of contraception include withdrawal, fertility awareness methods (FAMs), and sterilization.

Each method’s level of effectiveness is indicated, and the advantages and disadvantages of each method are explored. No one best method of birth control exists for everybody. Each individual must select a method according to how it fits with his or her lifestyle. Some methods are easier to use than others. Some methods require responsible adherence to a schedule. Other methods are best suited for persons who have only occasional sexual contacts.

6-7aThe Pill

Birth control pills or oral contraceptives are one of the most effective forms of contraception other than sterilization. There are two major types of birth control pills. Various companies produce numerous brands of these two types of pills. The most commonly used type combines a synthetic  estrogen (a female hormone that helps regulate the menstrual cycle) and progestin (a synthetic version of progesterone, a female hormone that makes the lining of the uterus thicken). The  combined pill targets a 28-day menstrual cycle and is distributed in monthly packs.

Combined pills are taken in one of three ways. The most commonly used brands of combined pills are sold in packages of 21 pills, which should be taken daily until they are used up. A woman then refrains from starting her next monthly pack of pills for seven days. During this time she will have her menstrual period. Other brands of combined pills come in packs of 28 pills. These include placebos or ineffective sugar pills for the last seven days of the cycle. This serves to reinforce a woman’s habit of taking one pill each day. A third way of taking birth control pills involves pills (brand name Seasonale) that are taken daily “for three straight months, followed by one week of inactive pills”; “a woman gets her period about four times a year, during the 13th month of her cycle” (National Institutes of Health [NIH], 2011). Combined pills prevent the ovaries from ovulating, or releasing a ripened egg ready for fertilization. In a sense, they trick the body into thinking that the woman is pregnant. A pregnant woman temporarily stops ovulating in order to prevent multiple pregnancies. Combined pills also contain progestin, which makes the cervical mucus thicker and more acidic, thereby making it more difficult for sperm to infiltrate. Progestin also alters the lining of the uterus, making it more difficult for egg implantation. Progestin can also hamper ovulation.

However, the combined pill’s actual effectiveness rate is approximately 91 percent (Planned Parenthood, 2014). Actual effectiveness refers to how effective the method is in actual daily use. The differences between the two rates can probably be explained by human error. For example, forgetting to take a pill one day increases the chance of pregnancy as hormonal levels may change enough to allow a woman to ovulate.

In addition to the combined pill, so named because it combines some amount of estrogen with progestin, there are other pills. These include triphasic pills and the progestin-only pill.

The progestin-only pill or  minipill contains only progestin, as its name implies (NIH, 2011). We have established that progestin affects the consistency of cervical mucus and alters the uterine lining. The progestin-only pill’s effectiveness rate is somewhat less than that of combined pills (Hyde & DeLamater, 2017; NIH, 2011). About half of women taking progestin-only pills fail lo ovulate at all; progestin also inhibits implantation in the uterus should fertilization take place (Greenberg et al., 2014). Progestin-only pills can provide a useful alternative for women who are breast-feeding, as combined pills sometimes interfere with that process (Hyde & DeLamater, 2017). Progestin-only pills are also a better possibility for women who, for some reason, cannot use estrogen (Greenberg et al., 2014).

The  triphasic pill involves three stages, where the dosage of hormones is increased for each of the three weeks they are taken (instead of maintaining a constant dose over the three-week period as is the case with the combined pill) (Carroll, 2013). The idea is to decrease the total amount of hormones consumed (Hyde & DeLamater, 2017).

Contraceptive pills should be taken regularly at approximately the same time each day. Today’s birth control pills have lower dosages of hormones than they did three decades ago. This is to minimize unpleasant side effects. However, their low dosage makes it more important that they be taken at approximately the same time each day. Otherwise, there is a chance that their pregnancy-inhibiting abilities will be decreased to the point that they will not work. With combination pills, it is important that the hormonal levels maintained by the pill do not drop to a level that makes ovulation possible. Once ovulation occurs, pregnancy is risked. With progestin-only pills, if the internal reproductive environment is not kept hostile enough to prevent fertilization and implantation, pregnancy may occur.

Even the most organized, conscientious woman may occasionally forget to take her contraceptive pill. Should you miss taking a pill, you should take it as soon as possible and then resume taking your next pill at the regular time; should you miss taking more than one pill, you should consult a health-care professional and also use an alternate form of contraception for backup during the rest of your cycle (Crooks & Baur, 2014).

Advantages of taking either form of birth control pill are numerous. They are very effective. They are fairly easy to use, in that they must simply be swallowed daily. Nothing needs to be inserted into the vagina. No complicated process is involved. Nothing interferes with the spontaneity of a sexual encounter. Those who are frequently sexually active are always prepared. The method is readily reversible. Both combination and progestin-only birth control pills can decrease menstrual cramping, produce lighter menstrual periods, and provide some defense against PID (Planned Parenthood, 2016b). Combination birth control pills can also provide some protection against endometrial (the  endometrium is the lining of the uterus) and ovarian cancers, ovarian cysts,  benign (not cancerous) breast growths, iron deficiency anemia, acne,  ectopic pregnancy (a pregnancy that develops outside of the uterus that is very dangerous for the mother), uncomfortable symptoms occurring prior to menstruation such as headaches and depression, and vaginal dryness linked to menopause (Planned Parenthood, 2016).

Disadvantages to taking birth control pills include undesirable side effects such as nausea, vomiting, bleeding between menstrual periods, and breast tenderness (Planned Parenthood, 2016b). These side effects resemble those of the first trimester of pregnancy; they are due to similar changes in hormonal levels. These symptoms usually disappear after two to three months, as they do in pregnancy. Changing brands of birth control pills sometimes helps because different brands often have minor variations in hormonal dosages. Such variations affect various women differently. Another disadvantage of birth control pills is that they provide no help in preventing STIs.

Note that after discontinuing pill use, menstrual periods may not resume until a month or two later; sometimes, a woman will remain irregular for up to six months (Planned Parenthood, 2016b). Although it appears that after stopping the pill, women may take from 0 to 26 weeks to resume ovulation (with an average of 2 weeks), no long-term effects on fertility have been found (Hatcher & Nelson, 2004).

Serious problems resulting from the contraceptive pill are very rare. They include cardiovascular problems such as a “heart attack, stroke, having a blood clot in the legs, lungs, heart, or brain, or developing high blood pressure” as well as “liver tumors, gallstones, or yellowing of the skin or eyes ( jaundice)” (Planned Parenthood, 2016b). Variables that can increase risk include being age 35 or older, being overweight, smoking, and suffering from a number of specified health problems such as high cholesterol, high blood pressure, or diabetes (Planned Parenthood, 2016b).

One important factor to consider before using the pill as a means of contraception is a person’s general approach to life. In other words, a person must be notably responsible and conscientious in order to take the pill regularly every day. Many people, despite their good intentions, find it difficult to follow a regimented procedure. Women who are only occasionally sexually active might also find it unappealing to take the pill every day.

6-7bThe Birth Control Patch and Vaginal Ring

Both introduced in 2003, the birth control patch (with the brand name Ortho Evra) and the vaginal ring (with the brand name NuvaRing) use the same hormones—estrogen and progestin—as the combination birth control pill.  Ortho Evra consists of a thin patch of material that sticks to the skin and releases hormones into the body to prevent pregnancy. Patches are applied to the skin once a week for three weeks; then a week passes without a patch application. They can be placed “on the buttock, abdomen, upper outer arm, or upper torso” (Crooks & Baur, 2014, p. 291).

The  NuvaRing is a “2-inch-diameter soft and transparent” flexible ring that’s inserted into the vagina “between day 1 and day 5 of a menstrual period” and left in place for three weeks (Crooks & Baur, 2014, p. 291). After insertion, vaginal “moisture and body heat activate the release of hormones” (Carroll, 2013, p. 353). The ring is then removed for a week, and a week later replaced with a new ring.

The actual effectiveness and most of the advantages and disadvantages of both the patch and the vaginal ring are the same as for combination birth control pills. They have the additional advantage of being somewhat easier to use, as a woman doesn’t have to remember to take a pill at the same time every day. She must, however, remember to change the patch after seven days and the ring after three weeks. A disadvantage of both is that they don’t help prevent STIs.

The patch has the potential disadvantages that a woman must take care not to dislodge it and that it may cause skin irritation.

Many women using the vaginal ring indicate that they “have more regular, lighter, and shorter periods” (Planned Parenthood, 2014). However, sometimes the vaginal ring can cause “increased vaginal discharge, vaginal irritation, or infection” (Planned Parenthood, 2014).

6-7cDepo-Provera Injections

Depo-Provera is the most commonly used hormonal injection method for contraception. It is a progestin-only method like the progestin-only birth control pill. A shot is administered once every 12 weeks. Theoretical effectiveness is over 99 percent, and actual effectiveness is 94 percent (Planned Parenthood, 2014). Actual effectiveness is better than that of the contraceptive pill, patch, or vaginal ring, probably because there is less room for human error.

Advantages of Depo-Provera include avoiding the use of estrogen (thus evading potential negative effects such as cardiovascular problems); a high actual effectiveness rate; convenient, easy use; and decreased risk of endometrial cancer (Planned Parenthood, 2014). As with other hormonal methods, one disadvantage is the lack of protection against STIs. Other potential disadvantages include disturbances in the menstrual cycle (e.g., fewer, lighter periods; longer, heavier periods; or increased spotting between periods), weight gain, breast tenderness, headache, nausea, and depression (Planned Parenthood, 2014).

6-7dHormonal Implants

A hormonal implant with the brand names  Implanon or  Nexplanon consists of a “thin, flexible plastic implant about the size of a cardboard matchstick” (Planned Parenthood, 2014). A health-care provider places it under the skin of the upper arm, where it can remain effective for up to three years. Although not yet readily available everywhere, increasing numbers of health-care providers are being trained in the insertion procedure.

Implanon and Nexplanan involve a progestin-only hormonal method of contraception, so their functioning and effects resemble those of other progestin-only approaches. Their actual effectiveness rate is over 99 percent (Planned Parenthood, 2014).

A hormonal implant has several advantages (Planned Parenthood, 2014). It’s easy to use because it is long lasting and requires no direct action by the woman using it. It is an appropriate option for women who can’t use estrogen or who are breast-feeding. Women can become pregnant relatively soon after removing the implant. A woman can choose to have the implant removed by a health-care provider at any time.

There are also disadvantages (Planned Parenthood, 2014). The most common complaint is irregular bleeding, including spotting between periods. Menstrual periods may be longer and heavier, fewer and lighter, or may stop altogether. Hormonal implants provide no protection against STIs. Less common consequences include changes in sex drive, headache, nausea, pain or discoloration at the insertion site, and sore breasts (Planned Parenthood, 2014). Warning signs of rare but potentially serious side effects include bleeding or pus at the insertion site, development of a breast lump, movement or expulsion of the implant, stoppage of menstruation after having had regular periods, or unusually heavy vaginal bleeding (Planned Parenthood, 2014).

6-7eEmergency Contraception (EC)

Despite the controversy over newer chemical methods of abortion, several types of emergency contraception have been approved and are available in the United States (NIH, 2011; Planned Parenthood, 2014).  Emergency contraception (EC) is typically used when unplanned, unprotected intercourse has occurred; when another method of contraception fails (e.g., a condom breaks); when a woman forgets to take birth control pills; or after a sexual assault. EC is intended for emergency use only. EC is different than the “abortion pill” in that it is meant to be taken after sexual intercourse to prevent pregnancy rather than after pregnancy has already occurred (NIH, 2011).

Three types of EC are approved for use in the United States; two of them are pills containing synthetic hormones and one an IUD (Planned Parenthood, 2016). One type of pill contains levonorgestrel (a synthetic progestin hormone). There are two brands marketed under the names Plan B One-Step and Next Choice. Both brands involve taking a single tablet as soon as possible after unprotected intercourse occurs.

Means of access to EC vary depending on the type of EC (Planned Parenthood, 2016c). Any woman regardless of age can acquire Plan B One-Step over the counter without having to obtain a medical prescription. It is available at drugstores, Planned Parenthood clinics, and other family planning centers. To obtain Next Choice, a prescription from a health-care professional is needed for women age 16 or younger.

EC pills potentially prevent pregnancy by suppressing or delaying ovulation so that the sperm cannot make contact with an egg to fertilize it. Note, therefore, they do not cause an abortion because there is no fertilized egg to abort.

No severe difficulties have been reported by the millions of women who have taken EC pills; disagreeable side effects may include menstrual periods that occur “earlier or later, or are heavier or lighter than usual,” headaches, breast tenderness, or nausea and vomiting (Planned Parenthood, 2014). It is strongly recommended that EC pills not be used as an ongoing means of contraception, because such a practice may affect the predictability of menstrual periods and cycles (Planned Parenthood, 2014).

After ejaculation in the vagina, the condom must be held at the base of the penis as the penis is withdrawn from the vagina. This is to make sure that none of the sperm is spilled and can enter the vagina. Condoms should not be reused.

A major advantage of condom use is protection from STIs. It is recommended that condoms be used for disease prevention even in conjunction with other contraceptive methods; this is especially important for women, who are 10 to 20 times more likely to contract an STI than men because of the shape and location of their sexual organs (Planned Parenthood, 2014). Condoms may also be used to prevent the spread of STIs during oral sex.

There are other advantages as well. Condoms provide the only nonsurgical means of giving the male some direct responsibility for contraception. They are readily available at a relatively low cost. They don’t require a prior physical examination or a medical prescription. They are small and easy to carry for use at any time. They help some men maintain a longer erection. Some people incorporate their use into their sex play prior to intercourse. Condoms cause no adverse side effects, except for people who are allergic to latex. Such people, who comprise up to 6 percent of the population, should use plastic condoms instead (Planned Parenthood, 2014).

Other than an allergic reaction, there are some other potential psychological disadvantages (Planned Parenthood, 2014). Some couples feel that condoms interfere with the spontaneity of lovemaking. Other men and women feel it reduces sensation during sexual intercourse. Some men feel embarrassed about putting them on or pressured to maintain an erection once they are on. Such feelings are unfortunate. Ideally, it is best to develop a perspective that focuses on the usefulness and purpose of condoms instead of on negative psychological issues.

6-7hThe Female Condom

The  female condom, available since 1994, provides one of several vaginal barrier forms of contraception. It consists of two rings connected by latex. One ring fits over the cervix; the latex protects the cervix from contact with either the penis or semen. The other ring rests outside the vagina; here the latex forms a pouch for the penetrating penis, thus protecting the penis from vaginal contact. A lubricant or spermicide should be put outside of the closed end to facilitate insertion (Planned Parenthood, 2014). After use, the female condom should be discarded (not in a toilet). They should never be reused. A female condom should never be used together with a male condom because they might stick together, “causing slippage or displacement of one or both devices” (Cates & Stewart, 2004, p. 366). It is also useful during anal intercourse where it is inserted into the anus instead of the vagina (Planned Parenthood, 2014).

The female condom’s theoretical effectiveness rate is 95 percent, although the actual rate is 79 percent (Planned Parenthood, 2014). As with the male condom, a major advantage is protection from STIs. Another advantage is that the female condom enables a woman to take responsibility for both contraception and protection from STIs. Other advantages include not requiring a prescription and not affecting a woman’s natural hormones.

Disadvantages may involve reactions such as rashes resulting from a latex allergy or minor problems like skin irritation (Cates & Stewart, 2004; NIH, 2011). Other disadvantages include the possibility of slippage during intercourse and the potential reduction of sensation (Planned Parenthood, 2014).

6-7iThe Diaphragm and Cervical Cap

In addition to male and female condoms, two other barrier methods of contraception are the diaphragm and the cervical cap (brand name FemCap). Each is currently available in the United States with a prescription from a health-care provider. Each is inserted through the vagina and fits around the cervix. Because of their similarities, they will be discussed together.

The  diaphragm is a thin circular piece of rubber stretched over a flexible ring of wire. It is shaped like a dome. A woman inserts it by pushing it with her fingers up into the vagina to cover the cervix. Because a cervix will vary in size from one woman to another, a woman must be fitted for the correct size diaphragm.

Each of the devices should be used with spermicidal cream or jelly that is placed inside the bottom of the cup or dome and spread around the edges. The diaphragm can be inserted up to 6 hours before intercourse and left in place for no more than 24; FemCap can be inserted up to 8 hours prior to sexual intercourse and remain in place for no more than 48 hours (Crooks & Baur, 2014). Leaving any of these devices inside the vagina for a longer time poses the danger of  toxic shock syndrome (TSS), a potentially fatal bacterial infection. When using the diaphragm, more spermicide should be injected into the vagina if intercourse occurs more than six hours after insertion or before each subsequent act of intercourse. When wearing FemCap, the device should be checked to be sure it is in place before subsequent acts of intercourse, and more spermicide may be applied.

The diaphragm has a theoretical effectiveness rate of 94 percent and an actual rate of 88 percent (Planned Parenthood, 2014). FemCap has an actual effectiveness rate of 86 percent for women who have never been pregnant and 71 percent for women who have given birth vaginally (Planned Parenthood, 2014). Effectiveness for both methods can be enhanced by using spermicide as recommended, using a latex condom in addition to the diaphragm or cervical cap, and making certain that the device is snugly in place over the cervix (Planned Parenthood, 2014). Cates and Stewart (2004) caution that the “contraceptive effectiveness of vaginal barriers is influenced by the characteristics of the individuals using them. The most important fact in determining effectiveness is correct and consistent use” (p. 370).

Neither method should be used by women who have allergies to the substances involved, find the device difficult or uncomfortable to insert, have experienced some trauma to the uterus, have an infection in the area, or have vaginal obstructions (Planned Parenthood, 2014).

There are a number of advantages to using the diaphragm or FemCap (Planned Parenthood, 2014). They are easy to carry with you. They can be used only when you need them. They don’t interfere with normal hormones. They’re effective right away. They can be inserted hours before intercourse occurs, so they don’t have to interfere with spontaneity.

Both methods also have disadvantages (Planned Parenthood, 2014). They may be pushed out of position during some sexual positions or behaviors. They are not effective unless they’re in place every single time intercourse occurs. As with many other contraceptive methods, these devices don’t help prevent STIs. Both diaphragms and FemCap may necessitate being refit for another size. Women may be allergic to the materials they’re made of or to the spermicide used. Some women experience recurrent bladder infections when using the diaphragm or a cervical cap. Some women experience pain when using a cervical cap. FemCap should not be used while menstruating.

6-7jThe Birth Control Sponge

The  contraceptive sponge, one brand of which is called the Today Sponge, is currently available over the internet and possibly in some stores. It is a soft, cuplike sponge device that can be inserted into the vagina and covers the cervix. It is saturated with a spermicide to provide additional protection. Before insertion, it should be moistened with tap water. It can be inserted up to 24 hours before sexual intercourse occurs; the sponge should be left in the vagina for at least 6 hours after sexual intercourse, but no longer than 30 hours because of the potential of TSS (Planned Parenthood, 2014).

The sponge’s effectiveness is based on three principles. First, it acts as a barrier to prevent sperm from entering the cervix. Second, the chemical spermicide it contains acts to kill sperm. Third, its potential for absorbing sperm is also thought to be beneficial. Like the cervical cap, it is significantly more effective for women who have never had children than for those who have had children. Its theoretical and actual effectiveness for women who have not had children are 91 and 88 percent, respectively; the respective rates for women who have borne children are 80 and 76 percent (Planned Parenthood, 2014).

6-7kThe IUD (Intrauterine Device)

The  intrauterine device (IUD) is a plastic device that is placed in a woman’s uterus. IUDs, which are made in various shapes, need to be inserted by a physician or trained health professional. Today IUDs are widely used around the world (Crooks & Baur, 2014). Two types of IUDs are available in the United States (Planned Parenthood, 2016c). One goes by the brand name ParaGard, introduced here in 1988 as the Copper T. The ParaGard has fine copper wire wrapped around the base of the T which releases a tiny amount of copper into the uterine environment. Once inserted, it is effective for up to 12 years (Planned Parenthood, 2016d).

The second type of IUD, available in the United States since 2000, is hormonal. Such IUDs also assume a T shape and go by the brand names Mirena or Skyla. Hormonal IUDs release a small amount of progestin into the system and remain effective for up to six years (Planned Parenthood, 2016d).

Both types of IUDs work in two ways (Planned Parenthood, 2016d). First, they alter how sperm move and prevent sperm from fertilizing the egg. There is no pregnancy without a fertilized egg. Second, they change the interior lining of the uterus, the endometrium. It is thought that this prevents a fertilized egg (in the event that one does become fertilized) from attaching itself to the endometrium, although no factual evidence for this exists.

Hormonal IUDs also produce effects because of their progestin. As we know, progestin prevents ovaries from releasing eggs for fertilization. Additionally, it thickens cervical mucus, making it more difficult for sperm to enter the uterus.

Either type of IUD is attached to a string that hangs out of the cervix. A woman should check the IUD regularly, especially for the first few months after initial insertion because that’s the time it’s most likely to slip out. She can check by inserting her finger into the vagina and feeling if the string is still there. (The cervix feels like the tip of your nose.)

A range of contraceptive methods have been developed, having various rates of effectiveness.

Charles Thatcher/The Image Bank/Getty Images

The IUD is one of the most effective contraceptive methods available, with an actual effectiveness rate over 99 percent. There are other advantages as well (Planned Parenthood, 2016d). An IUD provides long-term contraception, requiring no effort other than occasionally checking the string. Using an IUD places no restrictions on spontaneity in lovemaking. Shortly after removal of the IUD, a woman can become pregnant. ParaGard IUD does not affect a woman’s natural hormones. Hormonal IUDs may decrease menstrual cramping and diminish menstrual flow by an average of 90 percent (Planned Parenthood, 2016d).

IUDs also have disadvantages (Planned Parenthood, 2016d)). Many women experience spotting between menstrual periods. Some women have more severe cramping. ParaGard may cause increased menstrual flow in addition to worse menstrual cramps (Planned Parenthood, 2016d). Of course, IUDs don’t help prevent STIs. Very rarely, women may experience pelvic inflammatory disease or IUD perforation of the uterine wall. Infrequently, an IUD may slip out unnoticed, especially in women who have never been pregnant.

6-7lWithdrawal

Withdrawal, or  coitus interruptus, refers to withdrawing the penis before ejaculating into the vagina. Although it has often been considered a relatively ineffective method of birth control, in actuality its effectiveness resembles that of the barrier methods of contraception.

Theoretical or perfect effectiveness is 96 percent and actual effectiveness 73 percent (Planned Parenthood, 2014). One problem with this method is that a few drops of semen are expelled by a pair of glands called Cowper’s glands before the full ejaculation. Both urine and semen pass through the urethra. Urine is acidic. An acidic environment is not conducive for sperm. It is thought that these few drops of semen are discharged before ejaculation in order to clear the urethra of some of its acidic quality and better prepare it for sperm (Crooks & Baur, 2014). However, sometimes live sperm remain in the urethra. It is possible, although not probable, that these sperm can be transported out through the tip of the penis by the Cowper’s glands’ secretion and still impregnate a woman.

Major advantages of withdrawal are that no extraneous devices or substances are needed and it’s free. A primary disadvantage is that its effectiveness depends mainly on the man’s ability to withdraw in time. In the heat of emotion, it may be difficult for some men to exercise great control over ejaculation.

6-7mFertility Awareness Methods

Fertility awareness methods (FAMs) (sometimes referred to as the rhythm method) involve monitoring a woman’s ovulation cycle and initiating sexual relations only during the safe times of her cycle. Because so many variables are involved, it’s difficult to calculate theoretical effectiveness. These methods are much more effective when the couple can accurately identify the woman’s window of fertility and the couple is capable of following clearly specified procedures in monitoring the menstrual cycle (Jennings, Arevalo, & Kowal, 2004).

There are at least four types of FAMs (Planned Parenthood, 2014). Due to their complicated procedures, we will not address them in detail here. The  calendar method is the simplest of the three. It involves counting the days of the menstrual cycle and trying to determine when ovulation occurs. The idea is to have intercourse only when it is certain that the woman is not ovulating.

A second method is the  basal body temperature method. A woman’s body temperature undergoes minor predictable variations depending on where she is in her ovulatory cycle. Using this method involves taking her temperature every morning as soon as she wakes up. A problem with this method is that the major temperature differential occurs only after ovulation has taken place. By this time pregnancy prevention could be too late.

A third type of FAM is the  cervical mucus (or ovulation) method. It necessitates that a woman examine her cervical mucus throughout her menstrual cycle. The consistency, amount, and clarity of the mucus tend to change predictably depending on where she is in her ovulatory cycle.

Using any two or all of the methods together is referred to as the  symptothermal method. This tends to be more effective than when one method is used alone, because information from one data-gathering method can provide input useful in monitoring another method. It can enhance accuracy.

The actual effectiveness rate for using these methods is 76 percent; effectiveness can be enhanced when the methods are used correctly and consistently (Planned Parenthood, 2014).

Advantage of using a FAM or FAMs is that there is no manipulation of hormones and that nothing must be done directly prior to sexual intercourse. A major disadvantage is that using any of the FAM methods requires conscientious attention to gathering data every day. FAMs do not help prevent STIs.

6-7nSterilization

Sterilization is “rendering a person incapable of conceiving with surgical procedures that interrupt the passage of the egg or sperm” (Kelly, 2008, p. 314). It is one of the most common family planning methods used in the world; it is also common for couples who are of fertile age in the United States (Carroll, 2013). The procedures are considered to be permanent, although they can be reversed in some cases.

Many young people ask whether sterilization interferes with sexual responsiveness. They wonder if having a vasectomy means that a man will not be able to ejaculate or have an orgasm. Neither concern, of course, is valid. Most of the milky liquid contained in semen is produced by the seminal vesicles and the prostate gland, other organs that feed into the vas deferens later in the ejaculation process. This liquid is still ejaculated, but without any sperm in it. Because sperm are so tiny, the volume of semen ejaculated is virtually unaffected. Sterilization has no effect on either men’s or women’s ability to respond sexually or enjoy sexual activity.

An advantage of sterilization is that it is considered permanent. No more attention need be given to contraceptive methods. A disadvantage is that a person may change his or her mind about having children. Sterilization allows little room for that choice. Another disadvantage is that sterilization has nothing to do with preventing STIs.

Ethical Questions 6.5

This chapter will focus on some of the major psychological growth tasks and pitfalls confronting adolescents. Psychological systems involve such aspects of growth and development as forming an identity and developing a personal morality. An individual’s psychological system interacts with biological and social systems to affect behavior.

We have already addressed some of the interactions between biological and psychological systems. For example, maturation rate and body weight (which relate to an individual’s biological system) can affect body image and self-concept (which relate to the psychological system). Knowledge of psychological milestones normally negotiated during adolescence is important for the overall assessment of behavior and functioning. Additionally, this chapter will discuss two categories of critical issues that affect many individuals in this age group: assertiveness and suicide.

7-1Explore Identity Formation in Adolescence

LO 1

Personal identities crystallize during adolescence. Through experimentation and evaluation of experience and ideas, the adolescent should establish some sense of who he or she really is. In other words, people get to know themselves during adolescence. Explored here are Erikson’s psychosocial theory and Marcia’s categories of identity.

7-1aErikson’s Psychosocial Theory

Erik Erikson (1950, 1968) proposed a theory of psychological development comprising eight stages. This theory focuses on how personalities evolve throughout life as a result of the interaction between biologically based maturation and the demands of society. The emphasis is on the role of the social environment in personality development. The eight stages are based partly on the stages proposed by Freud and partly on Erikson’s studies in a wide variety of cultures. Erikson writes that the society in which one lives makes certain psychic demands at each stage of development. Erikson calls these demands  crises. During each psychosocial stage, the individual must seek to adjust to the stresses and conflicts involved in these crises. The search for identity is a crisis that confronts people during adolescence.

Forming your identity is a process of serious reflection about who you are and you want to became.

SW Productions/Photodisc/Getty Images

Each stage of human development presents its characteristic crises. Coping well with each crisis makes an individual better prepared to cope with the next. Although specific crises are most critical during particular stages, related issues continue to arise throughout a person’s life. For example, the conflict of trust versus mistrust is especially important in infancy. Yet children and adults continue to struggle with whether or not to trust others.

Resolution of each crisis is an ideal, not necessarily a reality. The degree to which crises in earlier stages are resolved will affect a person’s ability to resolve crises in later stages. If an individual doesn’t learn how to trust in stage 1, that person will find it very difficult to attain intimacy in stage 6.

Stage 1: Basic Trust versus Basic Mistrust

For infants up to 18 months of age, learning to trust others is the overriding crisis. To develop trust, one must understand that some people and some things can be depended on. Parents provide a major variable for such learning. For instance, infants who consistently receive warm, loving care and nourishment learn to trust that these things will be provided to them. Later in life, people may apply this concept of trust to friends, an intimate partner, or their government.

Stage 2: Autonomy versus Shame and Doubt

The crisis of autonomy versus shame and doubt characterizes early childhood, from 18 months to 3 years. Children strive to accomplish things independently. They learn to feed themselves and to use the toilet. Accomplishing various tasks provides children with feelings of self-worth and self-confidence. On the other hand, if children of this age are constantly downtrodden, restricted, or punished, shame and doubt will emerge instead. Self-doubt will replace the self-confidence that should have developed during this period.

Stage 3: Initiative versus Guilt

Preschoolers aged 3 to 6 years must face the crisis of taking their own initiative. Children at this age are extremely active physically; the world fascinates them and beckons them to explore it. They have active imaginations and are eager to learn. Preschoolers who are encouraged to take initiative to explore and learn are likely to assimilate this concept for use later in life. They will be more likely to feel confident in initiating relationships, pursuing career objectives, and developing recreational interests. Preschoolers who are consistently restricted, punished, or treated harshly are more likely to experience the emotion of guilt. They want to explore and experience, but they are not allowed to. Instead of learning initiative, they are likely to feel guilty about their tremendous desires to do so many things. In reaction, they may become passive observers who follow the lead of others instead of initiating their own activities and ideas.

Stage 4: Industry versus Inferiority

Stage 5: Identity versus Role Confusion

Adolescence is a time when young people explore who they are and establish their identity. It is the transition period from childhood to adulthood when people examine the various roles they play (e.g., child, sibling, student, Catholic, Native American, basketball star) and integrate these roles into a perception of self, an identity. Some people are unable to integrate their many roles and have difficulty coping with conflicting roles; they are said to suffer from  role confusion. Such persons feel confused and uncertain about their identity.

Stage 6: Intimacy versus Isolation

Adolescents experiment with roles that represent the many possibilities for their future identity. For instance, students take certain courses to test out their future career interests. They also experiment with a variety of part-time jobs to test occupational interests. They date and go steady to test relationships with the opposite sex. They may struggle with their sexual identity. Dating also allows for different self-presentations with each new date. Adolescents may also experiment with drugs—alcohol, tobacco, marijuana, cocaine, and so on. Many are confused about their religious beliefs and seek in a variety of ways to develop a set of religious and moral beliefs with which they can be comfortable. They also tend to join, participate in, and then quit a variety of organizations. They experiment with a variety of interests and hobbies. As long as no laws are broken (and health is not seriously affected) in the process of experimenting, our culture gives teenagers the freedom to experiment in a variety of ways in order to develop a sense of identity.

Erikson (1959) uses the term  psychosocial moratorium to describe a period of free experimentation before a final sense of identity is achieved. Generally, our society allows adolescents freedom from the daily expectations of role performance. Ideally, this moratorium allows young people the freedom to experiment with values, beliefs, and roles so that they can find a role in society that maximizes their personal strengths and affords positive recognition from the community.

The crisis of identity versus role confusion is best resolved through integrating earlier identifications, present values, and future goals into a consistent self-concept. A sense of identity is achieved only after a period of questioning, reevaluation, and experimentation. Efforts to resolve questions of identity may take the young person down paths of emotional involvement, overzealous commitment, alienation, rebellion, or playful wandering.

Many adolescents are idealistic. They see the evils and negatives in our society and in the world. They cannot understand why injustice and imperfection exist. They yearn for a much better life for themselves and for others and have little understanding of the resources and hard work it takes for advancements. They often try to change the world, and their efforts are genuine. If society can channel their energies constructively, adolescents can make meaningful contributions. Unfortunately, some become disenchanted and apathetic after being continually frustrated with obstacles.

Importance of Achieving Identity

Labels have a major impact on our lives. If a child is frequently called stupid by his or her parents, that child is apt to develop a low self-concept, anticipate failure in many areas (particularly academic), put forth little effort in school and in competitive interactions with others, and end up failing.

Because identity development is a lifelong process, positive changes are probably possible even for those who view themselves as failures. In identity formation, it is important to remember that what we want out of the future is more important than past experience in determining what the future will be. The past is fixed and cannot be changed, but the present and the future can be. Although the past may have been painful and traumatic, it does not follow that the present and the future must be so. We are in control of our lives, and we largely determine what our future will be.

7-1cMarcia’s Categories of Identity

James Marcia (1980, 1991, 2002; Marcia & Carpendale, 2004) has done a substantial amount of research on the Eriksonian theory of psychosocial development. He identifies four major ways in which people cope with identity crises:

· (1)

identity achievement,

· (2)

foreclosure,

· (3)

identity diffusion, and

· (4)

moratorium.

People may be classified into these categories on the basis of three primary criteria: First, whether the individual experiences a major crisis during identity development; second, whether the person expresses a commitment to some type of occupation; and third, whether there is commitment to some set of values or beliefs.

Identity Achievement

To reach the stage of  identity achievement, people undergo a period of intense decision making. After much effort, they develop a personalized set of values and make their career decisions. The attainment of identity is usually thought of as the most beneficial of the four status categories.

Foreclosure

People who fall into the  foreclosure category are the only ones who never experience an identity crisis as such. They glide into adulthood without experiencing much turbulence or anxiety. Decisions concerning both career and values are made relatively early in life. These decisions are often based on their parents’ values and ideas rather than their own. For example, a woman might become a mother and a part-time waitress as her own mother had done, not because she makes a conscious choice, but because she assumes it’s what she is expected to do. Likewise, a man might become an auto mechanic or an accountant just because his father was an auto mechanic or an accountant, and it seemed a good way of life.

It’s interesting that the term foreclosure is used to label this category. Foreclosure involves shutting someone out from involvement, as one would foreclose a mortgage and bar a person who mortgaged his or her property from reclaiming it. To foreclose one’s identity implies shutting off various other opportunities to grow and change.

Identity Diffusion

People who experience  identity diffusion suffer from a serious lack of decision and direction. Although they go through an identity crisis, they never resolve it. They are not able to make clear decisions concerning either their personal ideology or their career choice. These people tend to be characterized by low self-esteem and lack of resolution. For example, such a person might be a drifter who never stays more than a few months in any one place and defies any serious commitments.

Moratorium

The  moratorium category includes people who experience intense anxiety during their identity crisis, yet have not made decisions regarding either personal values or a career choice. However, moratorium people experience a more continuous, intense struggle to resolve these issues. Instead of avoiding the decision-making issue, they address it almost constantly. They are characterized by strong, conflicting feelings about what they should believe and do. For example, a moratorium person might struggle intensely with a religious issue, such as whether there is a God. Moratorium people tend to have many critical, but as yet unresolved, issues.

In order to develop a success identity a person must experience both love and worth. Glasser and Zunin (1979, p. 3l2) state,

We see worth and love as two very different elements, consider, for example, the extreme case of the “spoiled” child. One may fantasize that a child, if showered with “pure love,” whose parents’ “goal” was never to frustrate on stress or strain this child in any way, and when he was faced with a task or difficulty always had his parents to perform this task for him, this child always relieved of responsibility would develop into an individual who would feel loved but would not experience worth. Worth comes through accomplishing tasks and achieving success in the accomplishment of those tasks.

A person can also feel worthwhile through accomplishing tasks (for example, a successful business person), but believe s/he is unloved because s/he cannot name someone who “I love and who loves me.” Experiencing only one of these elements (worth or love) without the other can lead to a failure identity.

A failure identity is likely to develop when a child has received inadequate love or been made to feel worthless. People with failure identities express their sense of failure by becoming mentally ill, by delinquency, or by withdrawal. Almost everyone with a failure identity is lonely.

Why do some people become “mentally ill”? Glasser indicates that people who are labeled mentally ill are those who deny or distort reality. They change the world in their minds, in order to seek to feel important, significant, and meaningful. Having a failure identity is experienced by a person as being intensely discomforting, and changing reality through fantasying is one way of dealing with this discomfort. Glasser and Zunin (1979, p. 313) further elaborate:

The person who is mentally ill has distorted the real world in his own fantasy to make himself feel more comfortable. He denies reality to protect himself from facing the feeling of being meaningless and insignificant in the world around him. For example, both the grandiose delusion and the persecutory delusion of the so-called schizophrenic provide support or solace for him.

Glasser (1976, pp. 19–20) describes the choice aspect of those who decide to become “crazy”:

Crazy, psychotic, nuts, loony, bonkers, schizophrenic. There are a dozen popular, as well as pseudoscientific, words for this condition. I happen to prefer “crazy” because it is understandable; it doesn’t have the pseudoscientific connotation of schizophrenia, it is not technical, and it emphasizes much better than any of the other terms the choice aspect of this category. Schizophrenia sounds so much like a disease that prominent scientists delude themselves into searching for its cure, when the “cure” is within each crazy person who has chosen it. If he can find love or worth he will give up the choice readily—a big “if,” I will admit, but hundreds do each day as they are discharged from good hospitals and clinics. With adequate treatment they learn to become strong enough to stop choosing to be crazy. Becoming crazy is actually a fairly sensible choice of the weak because no one expects a crazy person to fulfill his needs in the real world for the obvious reason that he is no longer in it. He now lives in the world of his mind, and there within his own mind, crazy as it may be, he tries to find, and to some extent usually succeeds in finding, a substitute for the adequacy he can’t find in reality. Within his own mind, within his own imagination, out of his own thought processes, he may be able to reduce the pain of his failure and find a little relief. For inadequacy he provides delusions of grandeur; for loneliness, hallucinations to keep him company. He may have a delusion that everybody loves him or that he is an overwhelmingly omnipotent person, which does relieve his pain. Every mental hospital has one or two Jesus Christs, the acme of omnipotence and power. When all of this is created within a person’s own mind we call it crazy, but it makes sense to him because it doesn’t hurt as much as being lucid but miserably inadequate.

Other individuals seek to handle the discomfort of a failure identity through withdrawal. Still others seek to handle the discomfort by ignoring reality, even though they are aware of the real world. Glasser and Zunin (1979, p. 313) describe these people:

A success identity or a failure identity is not measured by finances or labels, but rather in terms of how a person perceives him/herself. It is possible for individuals to regard themselves as failures, while others view them as being successful. Formation of a failure identity usually begins during the years when children first enroll in school. It is at about this age (five or six) that children develop the social and verbal skills, and the thinking capacities to define themselves as being either successful or unsuccessful. Children, as they grow older, then tend to associate with others having a similar identity; those with failure identities associating with others having a failure identity, and success identities associating with other successful people. As the years pass the two groups associate less and less with each other. Glasser and Zunin (1979, p. 312) note:

For example, it is indeed rare for a person with a success identity to have, as a close and personal friend, someone who is a known criminal, felon, heroin addict, and so forth.

People with success identities tend to compete constructively, meeting and seeking new challenges. Also, they tend to reinforce one another’s successes. On the other hand, people with failure identities find facing the real world to be uncomfortable and anxiety-producing, and therefore choose either to withdraw, to distort reality, or to ignore reality.

7-1fComments on Glasser’s Theories on Identity

Glasser is undoubtedly accurate that every child/adolescent needs to receive “love” and a sense that they are “worthwhile” in order to develop a success identity. In fact, it is also important that every adult receive love and someone to convey that are worthwhile. Many parents simply do not have the resources (emotionally or financially) to convey sufficient “love” and “worth” to their children. Therefore, “it takes a village to raise a child.” There are a number of established programs to help convey “love” and “worth”, such as Big Brothers/Big Sisters, Boys and Girls clubs, Special Olympics, and Youth mentoring programs in schools. In a very real sense every teacher, adult friend, and adult relative should have the value system of doing what they can to convey “love” and “worth” to children/adolescents, and to the adults they interact with.

7-2Examine Race Culture, Ethnicity, and Identity Development

LO 2

The… model states that ethnic and racial minorities enter adolescence with poorly developed ethnic identities (diffusion) or with an identity “given” to them by their parents (foreclosure). They may sink into an identity crisis, during which the conflicts and challenges associated with their minority status are sorted out (moratorium), and should all go well, they achieve an ethnic identity that is positive and gives high salience to ethnicity (achieved ethnicity). (p. III)

Spotlight on Diversity 7.1

Lesbian and Gay Adolescents: The Need for Empowerment

2. Dissonance stage. Usually initiated by some crisis or negative experience, the person during this stage “becomes aware that racism does exist, and that not all aspects of minority or majority culture are good or bad. For the first time, the individual begins to entertain thoughts of possible positive attributes” of his or her own culture and “a sense of pride in self” (p. 79). Suspicion about the values inherent in the dominant culture grows.

3. Resistance and immersion stage. “Movement into this stage is characterized by the resolution of the conflicts and confusions that occurred in the previous stage” (p. 79). The person’s awareness of social issues grows along with a growing appreciation of his or her own culture. “A large amount of anger and hostility is also directed toward White society. There in turn is a feeling of dislike and distrust for all members of the dominant group” (p. 80).

4. Introspection stage. During this stage, the individual “discovers that this level of intensity of feelings is psychologically draining and does not allow time to devote energy into understanding one’s racial/cultural group; the individual senses the need for positive self-definition and a proactive sense of awareness. A feeling of disconnection emerges with minority group views that may be rigid. Group views may start to conflict with individual views… The person experiences conflict because she or he discovers there are many aspects of American culture that are desirable and functional, yet the confusion lies in how to incorporate these elements into the minority culture” (pp. 80–81).

5. Integrative awareness stage. Persons of color in this stage “have developed an inner sense of security and can appreciate various aspects of their culture that make them unique. Conflicts and discomforts experienced in the previous stage are not resolved, hence greater control and flexibility are attained. Individuals in this stage recognize there are acceptable and unacceptable aspects of all cultures and that it is important for them to accept or reject aspects of a culture that are not considered desirable to them. Attitudes and beliefs toward self are self-appreciating. A positive self-image and a feeling of self-worth emerge. An integrated concept of racial pride in identity and culture also develops. The individual sees himself or herself as a unique person who belongs to a specific minority group, a member of a larger society, and a member of the human race” (p. 81). The person begins to view those in the dominant culture in a selective manner, allowing trust and relationships to develop with those who denounce the oppression of minority groups.

7-2bCommunities and Schools Can Strengthen Racial and Cultural Identity Development for Adolescents

A positive social environment that celebrates cultural strengths can enhance the development of a positive I racial and cultural identity and pride (Delgado, 1998a, 1998b, 2000b, 2007). Both schools and the community-at-large can stress cultural strengths of resident groups. School curricula can have relevant historical and cultural content integrated throughout. Assignments can focus on learning and appreciating cultural strengths. “A social studies teacher, for example, might assign a student to interview an elder member of his or her family or community about life in his or her place of origin as part of a lesson on ethnic origins” (Delgado, 1998a, p. 210). Schools and recreational facilities can develop programs that emphasize cultural pride and help adolescents “come to terms with their newly developing [racial and cultural] identities as individuals and as participants in an increasingly multicultural society while preserving essential links to their history, families, and culture” (Delgado, 1998b, p. 213).

For example, one such program, called Nuevo Puente (New Bridge), was designed initially to address substance abuse by Puerto Rican youth. Staff developed an educational curriculum

Level 2: The Conventional Level

Level 2 of Kohlberg’s theory is the conventional level, in which moral thought is based on conforming to conventional roles. Frequently, this level occurs from ages 10 to 13. There is a strong desire to please others and to receive social approval. Although moral standards have begun to be internalized, they are still based on what others dictate, rather than on what is personally decided.

Within Level 2, stage 3 focuses on gaining the approval of others. Good relationships become very important. Stage 4, “authority-maintaining morality,” emphasizes the need to adhere to law. Higher authorities are generally respected. “Law and order” are considered necessary in order to maintain the social order.

Level 3: The Postconventional Level

Level 3, the postconventional level, involves developing a moral conscience that goes beyond what others say. At this level, people contemplate laws and expectations and decide on their own what is right and what is wrong. They become autonomous, independent thinkers. Behavior is based on principles instead of laws. This level progresses beyond selfish concerns. The needs and well-being of others become very important. At this level, true morality is achieved.

Within Level 3, stage 5 involves adhering to socially accepted laws and principles. Law is considered good for the general public welfare. However, laws are subject to interpretation and change. Stage 6 is the ultimate attainment. During this stage, one becomes free of the thoughts and opinions expressed by others. Morality is completely internalized. Decisions are based on one’s personal conscience, transcending laws and regulations. Examples of people who attained this level include Martin Luther King Jr. and Gandhi.

7-3bCritical Thinking: Evaluation of Kohlberg’s Theory

Many questions have been raised concerning the validity and application of Kohlberg’s theory (Helwig & Turiel, 2011; Killin & Smetana, 2008; Santrock, 2016; Walker & Frimer, 2011). For one thing, Kohlberg places primary emphasis on how people think, not what they do. Presidents and kings talk about the loftiest moral standards, but what they do is often another matter. Richard Nixon espoused high moral standards but was forced to resign after his cover-up of the Watergate break-in and theft of Democratic Party documents was brought to light. Many times, difficult moral decisions must be made in crisis situations. If you find yourself in a burning building with a crowd of people, how much effort will you expend to save others before yourself? What is the discrepancy between what you think is right and what you would really do in such a situation?

A second criticism of Kohlberg’s theory is that it is culturally biased (Kail & Cavanaugh, 2013; Santrock, 2012a). Even Kohlberg (1978) himself has conceded that stage 6 may not apply across all cultures, societies, and situations. Snarey (1987) studied research on moral development in 27 countries and found that Kohlberg’s schema does not incorporate the higher moral ideals that some cultures embrace. Examples of higher moral reasoning that would not be considered such within Kohlberg’s framework include “principles of communal equity and collective happiness in Israel, the unity and sacredness of all life forms in India, and the relation of the individual to the community in New Guinea” (Santrock, 2008, p. 361).

7-3cMoral Development and Women: Gilligan’s Approach

A major criticism of Kohlberg’s theory is that virtually all of the research on which it is based used only men as subjects. Gilligan (1982; Gilligan & Attanucci, 1988; Gilligan, Brown, & Rogers, 1990) maintains that women fare less well according to Kohlberg’s levels of moral development because they tend to view moral dilemmas differently than men do. Kohlberg’s theory centers on a  justice perspective, in which each person functions independently and makes moral decisions on an individual basis (Hyde & Else-Quest, 2013; Newman & Newman, 2012; Santrock, 2016, p. 231). In contrast, Gilligan maintains that women are more likely to adopt a “ care perspective, which views people in terms of their connectedness with others and emphasizes interpersonal communication, relationships with others, and concern for others” (Santrock, 2012a, p. 231). In other words, women tend to view morality in terms of personal situations.

Gilligan maintains that females’ sense of morality emphasizes personal relationships and the assumption of responsibility for the care and well-being of those close to them. Here, two close friends enjoy sweet treats together.

Thinkstock/jupiter images

Gilligan and her associates (Gilligan, 1982, 1996; Gilligan & Attanucci, 1988; Gilligan et al., 1990) reason that women’s moral development is often based on their personal interest and commitment to the good of others close to them. Frequently, this involves giving up or sacrificing one’s own well-being for others. Goodness and kindness are emphasized. This contrasts with a common male focus on assertively making decisions and exercising more rigid moral judgments.

Gilligan initially targeted 29 women who were receiving pregnancy and abortion counseling. She postulated that pregnancy was an area in women’s lives in which they could emphasize choice, yet it still was an intimate area to which they could relate. Gilligan interviewed the women concerning their pregnancies. She arrived at a sequence of moral levels that relate specifically to women. She found that women tend to view morality “based on an ethics of caring rather than a morality of justice” (Dacey, Travers, & Fiore, 2009, p. 248). She maintains that women’s perspective on right and wrong emphasizes interpersonal relationships and the assumption of responsibility for the care and well-being of others close to them. This contrasts with Kohlberg’s more abstract view of morality as the determination of what is fair and right in a much more general sense.

Gilligan describes the following levels and transitions of moral development for women.

Level 1: Orientation to Personal Survival

This level focuses purely on the woman’s self-interest. The needs and well-being of others are not really considered. At this level, a woman focuses first on personal survival. What is practical and best for her is most important.

Transition 1: Transition from Person Selfishness to Responsibility

This first transition involves a movement in moral thought from consideration only of self to some consideration of the others involved. During this transition, a woman comes to acknowledge the fact that she is responsible not only for herself but also for others, including the unborn. In other words, she begins to acknowledge that her choice will affect others.

Level 2: Goodness as Self-Sacrifice

Level 2 involves putting aside one’s own needs and wishes. The well-being of other people becomes important. The “good” thing to do is to sacrifice herself so that others may benefit. A woman at this level feels dependent on what other people think. Often a conflict occurs between taking responsibility for her own actions and feeling pressure from others to make her decisions.

Transition 2: From Goodness to Reality

Level 3: The Morality of Nonviolent Responsibility

Level 3 involves women thinking in terms of the repercussions of their decisions and actions. At this level, a woman’s thinking has progressed beyond mere concern for what others will think about what she does. Rather, it involves accepting responsibility for making her own decisions. She places herself on an equal plane with others, weighs the various consequences of her potential actions, and accepts that she will be responsible for these consequences. The important principle operating here is that of minimizing hurt, both to herself and to others.

Gilligan’s sequence of moral development provides a good example of how morality can be viewed from different perspectives. It is especially beneficial in emphasizing the different strengths manifested by men and women. The emphasis on feelings, such as direct concern for others, is just as important as the ability to decisively make moral judgments.

7-3dCritical Thinking: Evaluation, of Gilligan’s Theory

Some research has established support for Gilligan’s proposed gender-based differences in moral reasoning. For example, some studies have found that females consider moral dilemmas concerning caring aspects of social relationships more important and a greater moral dilemma than males do (Eisenberg & Morris, 2004; Wark & Krebs, 2000). Another study found that girls were more likely than boys to use Gilligan’s caring-based approaches when addressing dating predicaments (Weisz & Black, 2002). However, yet another study found “that girls’ moral orientations are ‘somewhat more likely to focus on care for others than on abstract principles of justice, but they can use both moral orientations when needed (as can boys…)’” (Blakemore, Berenbaum, & Liben, 2009, p. 132; cited in Santrock, 2012a, p. 231).

Other research has found that little if any difference exists between the moral reasoning of men and women (Blakemore et al., 2009; Glover, 2001; Hyde & Else-Quest, 2013; Walker, 1995; Wilson, 1995). One mega-analysis involved examining the results of 113 studies focusing on moral decision-making. Results question the accuracy of Gilligan’s belief in significant gender differences concerning moral development (Hyde, 2007; Hyde & Else-Quest, 2013; Jaffee & Hyde, 2000). This study found that the overall picture revealed only small differences in how females and males made moral decisions. Although females were slightly more likely than males to use Gilligan’s caring-based approach instead of Kohlberg’s justice-based perspective, this disparity was larger in adolescence than adulthood. Whether caring- or justice-based approaches were used depended more on the situation being evaluated. For example, both females and males were more likely to emphasize caring when addressing interpersonal issues and justice when assessing more global social issues.

Coon and Mitterer (2013) comment:

Indeed, both men and women may use caring and justice to make moral decisions. The moral yard-stick they use appears to depend on the situation they face (Work & Krebs, 1996). Just the same, Gilligan deserves credit for identifying a second major way in which moral choices are made. It can be argued that our best moral choices combine justice and caring, reason and emotion—which may be what we mean by wisdom. (Pasupathi & Staudinger, 2001, pp. 110–111)

Concept Summary

Gilligan’s Theory of Moral Development for Women

· Level 1: Orientation to personal Survival

· Transition 1: Transition from personal selfishness to responsibility

· Level 2: Goodness as self-sacrifice

· Transition 2: From goodness to reality

· Level 3: The morality of nonviolent responsibility

7-3eEthical Applications of Gilligan’s Theory to Client Situations

Children aged 2 to 6 continue developing their ability to glean meaning from their environments. What children are exposed to in terms of spiritual language and experiences is what they conceptualize about their faith. During stage 2, children are egocentric and manifest preoperational thought patterns. Their view of faith and religion lacks in-depth conceptualization and application to life experiences. Their view of faith is that it is out there someplace; it is whatever they’re exposed to. For instance, to Herman, whose parents adhere to strict Wisconsin Synod Lutheran Church beliefs, faith is going to church, singing hymns, attending Sunday school, and saying bedtime prayers every night. If asked where God is, he says, “Everywhere,” because that’s what he’s been told.

Stage 3: Mythic-Literal Faith (Ages 6 to 12)

Development of conceptual thought continues over this period. Stories are especially important as ways to help children develop their thinking about life and relationships. Individuals can be deeply moved by dramatic representations and spiritual symbolism, such as religious ceremonies. The concrete operations period helps children distinguish between what is real and what is not. During this stage, children think more seriously about aspects related to faith, although their “beliefs are literal and one dimensional”; Frame (2003) explains:

People in this stage often develop a concept of God… as a cosmic ruler who acts with fairness and moral reciprocity (Fowler, 1987). Persons in the mythic-literal stage often assume that God rewards goodness and punishes evil. They might exhibit a kind of perfectionism in their efforts to be rewarded for their goodness. On the other hand, they could be self-abasing, assuming that because they have been abused or neglected by significant others, they are inherently bad and will be punished. (p. 41)

Stage 4: Synthetic-Conventional Faith (Ages 12 and Older)

During this stage, individuals develop their ability to conceptualize and apply information in new ways. They are exposed to much more of the world through social, school, and media experiences. They no longer perceive the world as literally as they did in stage 3. On the one hand, people begin to think more abstractly and, in some ways, view the world from new perspectives. On the other hand, they strive to conform. They have not yet critically evaluated the fundamental basis of their faith. Rather, they adhere to conventional ideology. Duffey (2005) reflects on stage 4:

Faith is seen as that which brings people together and provides a unifying concept and sense of belonging for family, congregation, and society. For many, this is the terminal stage of development. In this stage, individuals do not acknowledge differences in faith practices of others and view their faith as the “one right, true, only way.” An example of this stage can be seen in adolescents who form groups based on fitting in: if you wear these clothes, listen to this type of music, like these people, etc., then you are part of the group. At this stage, any image of deity is seen as a companion and ally. Faith is rule bound and hierarchical with no questioning of the group’s norms and beliefs. (pp. 323–324)

Stage 5: Individuative-Reflective Faith (Early Adulthood and beyond)

Critical thinking about the meaning of life characterizes stage 5. “The focus of faith moves away from being viewed as the unifying concept of the group and more as making sense of the individual” (Duffey, 2005, p. 324). People confront conflicts in values and ideas, and they strive to establish their individualized belief system. For example, a young woman will seriously consider the extent to which her own personal beliefs coincide with conventional religious practices and beliefs. If her church condemns abortion, does she agree or not? If her church denies membership to lesbian and gay people, does she support this or not? Stage 5 marks the construction of a more detailed internal spiritual belief system that reflects an individual’s critical evaluation of the physical and spiritual world. “This stage may occur in those who stay within organized religious practice, as well as in those who leave” (Duffey, 2005, p. 324).

Stage 6: Conjunctive Faith (Midlife and beyond)

Stage 7: Universalizing Faith (Midlife and beyond)

Universalizing faith is characterized by selfless commitment to justice on behalf of others. In stage 6, people confront discrepancies and unfairness, integrating them into their perception of how the world operates. However, the self remains the primary reference point. An individual accepts and appreciates his own vulnerability, and seeks his own continued existence and salvation. Stage 7, however, reflects a deeply spiritual concern for the greater good, the benefit of the masses, above oneself. Such commitment may involve becoming a martyr on behalf of or devoting one’s life to some great cause at the expense of personal pleasure and well-being. Only a tiny minority of people may reach this point. Martin Luther King Jr., Mother Teresa, and Joan of Arc are examples.

7-4bCritical Thinking: Evaluation of Fowler’s Theory

Fowler provides a logically organized theory concerning the development of faith. It follows Piaget’s proposed levels of cognitive development, advancing from the more concrete to the more abstract. It makes sense that people increase their ability to think critically, integrate more difficult concepts, and develop deeper, more committed ideas and beliefs as their lives and thinking progress.

However, at least three criticisms of the theory come to mind. First, the sample on which it was based is very limited in terms of race and religious orientation. Questions can be raised regarding the extent to which it can be applied universally to non-Christian faiths worldwide.

Second, concepts of human diversity, oppression, and discrimination are not taken into account. There is an inherent assumption that all people start out with a clean slate. In reality, some are born richer, some poorer, some in high-tech societies, others in third-world environments. To what extent do people’s exposure to more ideas and greater access to the world’s activities and resources affect the development of faith? Are all people provided an equal opportunity to develop faith? Do oppression and discrimination affect one’s spirituality and the evolution of faith?

A third criticism is the difficulty of applying Fowler’s theory to macro situations. How does the development of faith from an individual perspective fit into the overall scheme of the macro environment? How does faith development potentially affect organizational, community, and political life?

Ethical Questions 7.4

Boyle, Hull, Mather, Smith, and Farley (2009) expand upon the significance of spirituality for social workers:

Social work and other helping professions have begun to recognize the immense power these beliefs can have over the ability of clients to withstand trauma and tragedy when things look the darkest… Spirituality helps some people make sense out of a sometimes senseless world. For others, it is part of an attempt to better understand themselves and to answer the question, “What is my purpose?”…

Spirituality and religious beliefs tend to play even more crucial roles in the lives of clients who are coping with critical events such as a terminal illness, a bereavement, or serious health issues. In these and similar situations, social workers should be comfortable raising the topic of religion or spirituality with clients. Likewise, social workers have come to recognize the importance of these issues for many ethnic and minority groups. For many such groups, the church and religion play a major role in their everyday lives and in efforts to bring about institutional and environmental change…

Social workers should be alert to the fact that their clients may have significant religious or spiritual beliefs and values and be familiar with the commonalities across various religious doctrines. At the very least, the practitioner should ask clients about this area and listen carefully when clients identify their religion or other spiritual beliefs as a coping resource. Failure to explore this area prevents social workers from understanding a major area of strength for many clients and a potential area for some others. (pp. 297–298)

However, as important as it is to consider spirituality as a potential strength, it is just as important for social workers not to impose their own values and spiritual beliefs on clients. Van Hook, Hugen, and Aguilar (2001) explain:

Incorporating spiritual and religious diversity into social work practice raises a challenging question for each social worker of faith: How do I hold my truth to be The Truth, when everyone perceives the truth differently? The professional challenge is to learn to listen intently to another person’s explanation of reality, even when that worldview differs significantly from one’s own. As practitioners, we need not share a client’s view of reality, nor even agree with it. But if we are willing to listen, we will come away knowing clients in new ways—and this knowledge and awareness will not only increase our own cultural sensitivity but also help us demonstrate a genuine respect for clients by truly honoring their religious and spiritual perspective. (p. 6)

Social workers may encounter a wide range of situations involving clients’ spirituality that require careful thought regarding how to proceed ethically. For instance, Roeder (2002) cites the following practice situation:

You work for a faith-based organization that offers services to teens who are pregnant, in hopes of preparing them for motherhood. You are the first social worker ever to be hired onto the staff, which is composed mostly of religiously trained persons and committed volunteers. During your first staff meeting in this organization, you find that staff are reviewing a policy that suggest “all who work with clients should pray with them to develop their relationship with God.” During the meeting you are asked for your input on this policy. What would you say in response? (p. II)

Each of these issues may be viewed from either a psychological or a social perspective. They will arbitrarily be addressed in this chapter, which focuses on the psychological aspects of adolescence.

7-5Assess Empowerment through Assertiveness and Assertiveness Training

LO 5

Assertiveness involves behavior that is straightforward, yet not offensive. The behavior can be either verbal or nonverbal. Assertiveness involves taking into account both your own rights and the rights of others. It sounds simple, but for many people appropriate assertiveness is difficult to master. For instance, consider the two people sitting in front of you in a movie theater who are talking loudly. How should you react? Should you ignore them even though it’s the scariest portion of the latest horror film? Should you scream, “Shut up!”? Or should you tap one of them gently on the shoulder and politely ask the person to please be quiet?

Your best friend asks to borrow your car. Your friend emphasizes it’ll only be for one time and it’s needed for such an important reason. You happen to know that your friend is not a very good driver, has gotten two speeding tickets in the past six months, and sometimes drives after drinking. Should you say, “No way! You know what a horrible driver you are”? Should you say, “Sure”? Should you say, “Well, okay, I guess so”? Or should you say, “No. You know I don’t let other people drive my car. Would it help if I drive you somewhere?”

Assertiveness involves specific skills that can be taught. This, of course, is referred to as  assertiveness training. Adolescents and young people may find assertiveness skills especially valuable as they decide how to react in new situations, especially when under social pressure. For example, they might struggle regarding how to respond in sexual situations: What do I want to do versus what does my partner want to do? Or they might wonder about taking drugs: Everyone is doing it; what should I do? Here we will discuss, in more depth, the meaning of assertiveness and some concepts involved in assertiveness training.

Most people remember occasions when they wish they had been more assertive. Yet at those moments, they felt very uncomfortable doing so. Many people have also experienced situations in which they “lost it,” and exploded in a loud burst of anger. An example is a newly married 22-year-old woman who is “at her wits’ end” with her husband’s best friend. He continues to make derogatory racial slurs against almost anyone who is not white, of a certain religious group, and of European heritage. The young woman, a newly graduated social worker, tries everything she can think of to turn the friend’s comments off. She tries ignoring him. She tries to change the subject. Yet she doesn’t want to offend the man. After all, he is her husband’s best friend. Finally, something snaps and she screams, “I can’t stand it anymore. I think you’re a disgusting bigot. Just shut up!” This outburst does little for their relationship.

7-5aThe Relevance of Assertiveness

Assertiveness and assertiveness training are included here for three reasons. First, appropriate assertiveness is an important skill to be acquired in adolescence. When someone uses an assertive approach, that person values both his or her own rights and the rights of others. Assertiveness is a critical aspect of establishing both a personal identity and a moral perspective toward other people.

Nonassertive communication is the opposite of aggressive. Speakers devalue themselves. They feel that what the other person involved thinks is much more important than their own thoughts. For example, for lunch, one day Cassie orders a hamburger well done. The waitress brings her a burger that’s practically dripping blood. However, Cassie is afraid of what the waitress will think if she complains. She doesn’t want to be seen as a “bitch.” So, instead of assertively telling the waitress that the hamburger is much too rare, Cassie douses it in ketchup and forces herself to eat half of it.

There is no perfect recipe for what to say to be assertive in any particular situation. The important thing is to take into consideration both your own rights and the rights of the person you are talking to. Following are a few examples.

Situation 1

A 16-year-old girl is on her first date with a young man she likes. After a movie and pizza, they drive around a bit and find a secluded spot in the country where he pulls over and parks. The girl does not want to get sexually involved with the young man. She thinks this is too soon in their relationship. What will he think of her? She doesn’t know him well enough yet to become intimate. What can she say?

· Nonassertive response: She says nothing and lets him make his sexual advances.

· Aggressive response: “Get your slimy hands off me, you pervert!”

· Assertive response: “I like you, Harry, but I don’t think we know each other well enough yet to get involved this way. Would you please take me home now?”

Situation 2

· Nonassertive response: “Okay.”

· Aggressive response: “No way, Jose! Get off my butt, Biff!”

· Assertive response: “You know I like my job here, Biff. However, I’m sorry, but I can’t work extra hours next weekend. I’ve already made other plans.”

Aggressive behavior reflects the dominance of the aggressor and devalues the rights and needs of others.

RubberBall/Alamy Stock Photo

Situation 3

Dinah Lee and Hannah, both 18, hang around with the same group of friends. However, they don’t like each other very much. Dinah Lee approaches Hannah one day and says, “It’s too bad you’re gaining so much weight.” What can Hannah say?

· Nonassertive response: “Yes, you’re right. I’m trying to go on a diet.”

· Aggressive response: “I’m not nearly as fat or ugly as you are, Buzzard Breath!”

· Assertive response: “No, I haven’t gained any weight. I think that was a very inappropriate thing to say. It sounded as if you were just trying to hurt my feelings.”

7-5cThe Advantages of Assertiveness

Developing assertiveness skills has many benefits. For one thing, you can gain more control over your interpersonal environment. Assertiveness may help you avoid uncomfortable or hostile interactions with others. You will probably feel that other people understand you better than they did before. Your self-concept can be enhanced as the result of your gain in control and interpersonal effectiveness. Appropriate assertiveness helps to alleviate building up undue tension and stress and diminish such psychosomatic reactions as headaches or stomach upsets. Finally, other people may gain respect for you, your strength, and your own demonstration of respect for others. People may even begin to use you as a role model for their own development of assertive behavior.

7-5dAssertiveness Training

Assertiveness training leads people to realize, feel, and act on the assumption that they have the right to be themselves and express their feelings freely. Assertive responses generally are not aggressive responses. The distinction between these two types of interactions is important. For example, a woman has an excessively critical father-in-law. Intentionally doing things that will bother him (bringing up topics that she knows will upset him, forgetting Father’s Day and his birthday, not visiting) and getting into loud arguments with him would be considered aggressive behavior.

An effectively assertive response, however, would be to counter criticism by saying, “Dad, your criticism deeply hurts me. I know you’re trying to help when you give advice, but I feel that you’re criticizing me. I’m an adult, and I have the right to make my own decisions and mistakes. The type of relationship that I’d like to have with you is a close adult relationship and not a father-child relationship.”

As we know, social work is practical. Therefore, you can use the suggestions provided to enhance both your client’s assertiveness and your own. Alberti and Emmons (1976a, 1976b, 2001, 2008) developed the following 13 steps to help establish assertive behavior:

1. Examine your own actions. How do you behave in situations requiring assertiveness? Do you think you tend to be nonassertive, assertive, or aggressive in most of your communications?

3. Select and focus on some specific instance when you felt you could have been more appropriately assertive. Visualize the specific details. What exactly was said? How did you feel?

4. Analyze how you reacted. Examine closely your verbal and nonverbal behavior. Alberti and Emmons (2008, pp. 71–81) cite the following seven aspects of behavior that are important to monitor:

1. Eye contact. Did you look the person in the eye? Or did you find yourself avoiding eye contact when you were uncomfortable?

2. Body posture. Were you standing up straight, or were you slouching? Were you leaning away from the person sheepishly? Were you holding your head up straight as you looked the person in the eye?

3. Gestures. Were your hand gestures fitting for the situation? Did you feel at ease? Or were you tapping your feet or cracking your knuckles? In the beginning of his term, people often criticized President George H. W. Bush for moving his arms and hands around during his public speeches. This tended to give the public the impression that he was frantic. Professional coaches helped him gain control of this behavior and present a calmer public image.

4. Facial expressions. Did you have a serious expression on your face? Were you smiling or giggling uncomfortably, thereby giving the impression that you were not really serious?

5. Voice tone, inflection, volume. Did you speak in a normal voice tone? Did you whisper timidly? Did you raise your voice to the point of stressful screeching? Did you sound as if you were winning?

6. Timing. It is best to make an appropriately assertive response just after a remark is made or an incident happens. It’s also important to consider whether a particular situation requires assertiveness. At times it might be best to remain silent and just “let it go.” For example, it might not be wise to criticize your professor for being a “dreary bore” in a class presentation you are giving and that your professor is simultaneously grading.

7. Content. What you say in your assertive response is obviously important. Did you choose your words carefully? Did your response have the impact you wanted it to have? Why or why not?

5. Identify a role model, and examine how he or she handled a situation requiring assertiveness. What exactly happened during the incident? What words did your model use that were particularly effective? What aspects of his or her nonverbal behavior helped to get points across?

6. Identify a range of other assertive responses that could address the original problem situation you targeted. What other words could you have used? What nonverbal behaviors might have been more effective?

7. Picture yourself in the identified problematic situation. It often helps to close your eyes and concentrate. Step by step, imagine how you could handle the situation more assertively.

8. Practice the way you envisioned yourself being more assertive. You could target a real-life situation that remains unresolved. For example, perhaps the person you live with always leaves dirty socks lying around the living room or drinks all your soda and forgets to tell you the refrigerator is bare. Or you can ask a friend, teacher, or counselor to help you role-play the situation. Role-playing provides an effective mechanism for practicing responses before you have to use them spontaneously in real life.

9. Once again, review your new assertive responses. Emphasize your strong points, and try to remedy your flaws.

10. Continue practicing steps 7, 8, and 9 until your newly developed assertive approach feels comfortable and natural to you.

11. Try out your assertiveness in a real-life situation.

12. Continue to expand your assertive behavior repertoire until assertiveness becomes part of your personal interactive style. You can review the earlier steps and try them out in an increasingly wider range of situations.

13. Give yourself a pat on the back when you succeed in becoming more assertive. It’s not easy changing long-standing patterns of behavior. Focus on and revel in the good feelings you experience as a result of your successes.

7-5eApplication of Assertiveness Approaches to Social Work Practice

Helping clients learn to be more assertive is appropriate in a wide range of practice situations. For example, teenagers may need to develop assertiveness skills to ward off the massive peer pressure engulfing them. This means more than “just saying no” to drugs, sex, or any other activity they feel pressured to participate in. Assertiveness training involves helping people identify alternative types of responses in uncomfortable situations. Finally, assertiveness training involves working out and practicing these alternative responses ahead of time so that they become easier and more natural.

Another example of a client needing assertiveness training is a shy, reserved client who needs to ask his landlord to do some repairs needed in the client’s apartment. Still another client might need help becoming more assertive in preparation for a job interview.

Workers themselves need to develop assertiveness skills in order to advocate for services on behalf of their clients. Good communication skills and a respect for others are basic necessities for social work practice. You can lead your clients through each step of assertiveness training to become more competent and effective communicators.

Either as a friend or as a social worker, you can be very helpful in assisting another person—your “client”— to become more assertive. The following guidelines are suggested:

1. Together identify situations or interactions in which your client needs to be more assertive. Get information about such interactions from your observations and knowledge of the person and from discussing in depth the interactions in which the person feels a need to be more assertive. You may also ask the person to keep a diary of interactions in which she or he feels resentment over being nonassertive and interactions in which she or he was overly aggressive.

2. Develop together some strategies for the person to be more assertive. Small assignments with a high probability of successful outcomes should be given first. A great deal of discussion and preparation should take place between the two of you in preparing for the “real event.” For a person who is generally shy, introverted, and nonassertive in all interpersonal relationships, it may be necessary to explore in great detail the connection between nonassertive behavior and feelings of resentment or low self-esteem. In addition, for very shy people, certain attitudes, such as “don’t make waves” or “the meek will inherit the earth,” may need to be dealt with before developing strategies for the person to be more assertive.

3. Role-playing is a very useful technique in preparing for being assertive. The helper first models an assertive strategy by taking the shy person’s role. Shy clients concurrently role-play the role of the person with whom they want to be more assertive. Then the roles are reversed; clients role-play themselves, and the helper plays the other role. Besides the previously mentioned benefits of modeling and practice experience, role-playing has the added advantage of reducing the shy person’s anxiety about attempting to be assertive. For feedback purposes, if possible, record the role-playing on audio or videotape.

4. Explain the 13 steps described earlier that your client can use on his or her own to handle future problem situations involving assertiveness. If possible, provide reading material on these steps.

7-6Explore Suicide in Adolescence

LO 6

Why do people decide to terminate their lives? Is it because life is unbearable, painful, hopeless, or useless? Suicide can occur during almost any time of life. However, it might be considered especially critical in the years of adolescence and youth. This is the time of life when people could enjoy being young and fresh and looking forward to life’s wide variety of exciting experiences. Instead, many young people decide to take their own lives.

7-6aIncidence of Suicide

Suicide is one of the most critical health problems in the United States today. Consider these frightening facts (Jason foundation, 2016):

· Suicide is the second leading cause of death of youth, ages 12–18, in the United States.

· More teenagers die from suicide in the United States than from heart disease, cancer, AIDS, stroke, birth defects, influenza, pneumonia, and chronic lung disease, COMBINED.

· Each day in the United States there are an average of over 5,400 attempts by young people grades 7–12.

Psychological variables, usually relating to depression, make up the third arena for problems leading to suicidal thoughts. One such factor is low self-esteem (Coon & Mitterer, 2014; McWhirter et al., 2013). When people don’t feel strong internally, they find it very difficult to muster the support necessary to cope with outside pressures.

Feelings of helplessness and hopelessness may also contribute to suicide potential (Coon & Mitterer, 2014; McWhirter et al., 2013; Sue, Sue, Sue, & Sue, 2013). As adolescents struggle to establish an identity and function independently of their parents, it’s no wonder that many feel helpless. They must abide by the rules of their parents and schools. They suffer from peer pressure to conform to the norms of their age group. They are seeking acceptance by society and a place where they will fit in. At the same time, an adolescent must strive to develop a unique personality, a sense of self that is valuable for its own sake. At times, such a struggle may indeed seem hopeless.

Impulsivity, or a sudden decision to act without giving much thought to the action, is yet another variable related to adolescent suicide (McWhirter et al., 2013). Confusion, isolation, and feelings of despair may contribute to an impulsive decision to end it all.

Adolescents experience many pressures and anxieties. Young people are not sure that they will find a job with which they can support themselves when they get out of school.

7-6cLesbian and Gay Adolescents and Suicide

Although a person of almost any age may attempt and succeed at suicide, the risks are greater for some age groups than for others. Statistics indicate that people ages 15 to 24, or 65 or older, are in the high-risk groups (Coon & Mitterer, 2014). Older white males are especially at risk (Coon & Mitterer, 2014). Suicide accounts for 20 percent of all deaths for people ages 15 to 24 (CDC, 2012). However, the number of suicides among middle-aged Americans has recently risen significantly, which may affect the assessment of suicidal potential in the future (Jaslow, 2013).

Depression

Depression, characterized by a disheartened mood, unhappiness, and pessimism, can contribute to an adolescent’s suicide potential.

Previous Attempts

People who have tried to kill themselves before are more likely to succeed than people who are trying to commit suicide for the first time (Coon & Mitterer, 2014; Nairne, 2014; NIMH, 2010).

Ethanol and Other Drug Abuse

People who abuse alcohol and other drugs are much more likely to commit suicide than people who do not (CDC, 2014; Coon & Mitterer, 2014; Nevid, 2013; Rathus, 2014d). Mind-altering substances may affect logical thinking, causing emotional distress to escalate.

Rational Thinking Loss

People who suffer from mental or emotional disorders, such as depression or psychosis, are more likely to kill themselves than those who do not (McWhirter et al., 2013; Nairne, 2014; NIMH, 2010). Hallucinations, delusions, extreme confusion, and anxiety all contribute to an individual’s risk factors. If a person is not thinking realistically and objectively, emotions and impulsivity are more likely to take over.

Social Supports Lacking

Loneliness and isolation have already been discussed as primary contributing factors (Coon & Mitterer, 2014; McWhirter et al., 2013). People who feel that no one cares about them may feel useless and hopeless. Suicide potential may be especially high in cases in which a loved one has recently died or deserted the individual who’s threatening suicide.

Organized Plan

The more specific and organized an individual’s plan regarding when and how the suicide will be undertaken, the greater the risk (Coon & Mitterer, 2013; McWhirter et al., 2013; Sheafor & Horejsi, 2012; Sue et al., 2013). Additionally, the more dangerous the method, the greater the risk. For instance, the presence of a firearm increases suicide risk (CDC, 2014; Coon & Mitterer, 2014; NIMH, 2010). A plan to use the loaded rifle you have hidden in the basement tomorrow evening at 7:00 p.m. is more lethal than a plan of somehow getting some drugs and overdosing sometime. Several questions might be asked when evaluating this risk factor. How much detail is involved in the plan? Has the individual put a lot of thought into the specific details regarding how the suicide is to occur? Has the plan been thought over before? How dangerous is the chosen method? Is the method or weapon readily available to the individual? Has the specific time been chosen for when the suicide is to take place?

No Spouse

As adults, single people are much more likely to commit suicide than married people (Coon & Mitterer, 2014; Sue et al., 2013). “The highest suicide rates are found among the divorced, the next highest rates occur among the widowed, lower rates are recorded for [never married] single persons, and married individuals have the lowest rates of all” (Coon, 2006, p. 521). Generally, people without partners have a greater chance of feeling lonely and isolated.

Sickness

People who are ill are more likely to commit suicide than those who are healthy (Coon & Mitterer, 2014). This is especially true for those who have long-term illnesses that place substantial limitations on their lives. Perhaps in some of these instances, their inability to cope with the additional stress of sickness and pain eats away at their overall coping ability.

Other Symptoms

Other characteristics operate as warning signals for suicide. For example, rapid changes in mood, behavior, or general attitude are other indicators that a person is in danger of committing suicide (Coon & Mitterer, 2013; James & Gilliland, 2013; Kail & Cavanaugh, 2013; McWhirter et al., 2013). A potentially suicidal person may be one who has suddenly become severely depressed and withdrawn. But a person who has been depressed for a long time and suddenly becomes strikingly cheerful may also be in danger. Sometimes in the latter instance, the individual has already made up his or her mind to commit suicide. In those instances, the cheerfulness may stem from relief that the desperate decision has finally been made. Suddenly giving away personal possessions that are especially important or meaningful is another warning signal of suicide potential (Kail & Cavanaugh, 2013; McWhirter et al., 2013; Rathus, 2014b). It is as if once the decision has been made to commit suicide, giving things away to selected others is a way of finalizing the decision. Perhaps it’s a way of tying up loose ends, or of making certain that the final details are taken care of.

We have indicated that the SAD PERSONS scale was developed to aid physicians in training. It is most likely that such physicians will not be proficient in addressing mental health problems themselves. Thus, there is an emphasis on referral to someone else and on hospitalization. Social workers, on the other hand, may often be called upon to work directly with suicidal people. Some guidelines are described next.

7-6fGuidelines for Helping Suicidal People

Two levels of intervention are possible for dealing with a potentially suicidal person. The first involves addressing the immediate crisis. The person threatening to commit suicide needs immediate help and support literally to keep him or her alive. The second level would address the other issues that worked to escalate his or her stress. This second level of intervention might involve longer-term treatment to address issues of longer duration that were not necessarily directly related to the suicide crisis.

For example, consider a 15-year-old male who is deeply troubled over the serious problems his parents are experiencing in their marriage. This preoccupation, in addition to his normally shy personality, has alienated him from virtually any social contacts with his peers. The result is a serious consideration regarding whether life is worth it. The first priority is to prevent the suicide. However, this young man also needs to address and resolve the problems that caused the stress in the first place—his parents’ conflicts and his lack of friends. Longer-term counseling or treatment might be necessary.

Reactions to a Suicide Threat

You get a phone call in the middle of the night from an old friend you haven’t heard from in a while who says she cannot stand living anymore. Or a client calls you late Friday afternoon and says that he is planning to shoot himself. What do you do? Specific suggestions for how to treat the potentially suicidal person include the following.

· Remain calm and objective (Kail & Cavanaugh, 2013; Smith, Segal, & Robinson, 2013). Don’t allow the emotional distress being experienced by the other person to contaminate your own judgment. The individual needs help in becoming more rational and objective. The person does not need someone else who is drawn into the emotional crisis. Ask the person if they are suicidal and determine if a specific plan for suicide exists.

· Identify the immediate problem (Jobes et al., 2005; Sue et al., 2013). Help the person clearly identify what is causing the excessive stress. The problem needs to be recognized before it can be examined. The individual may be viewing an event way out of perspective. For example, a 16-year-old girl was crushed after her steady boyfriend of 18 months dropped her. In this instance, the loss of her boyfriend overshadowed all of the other things in her life—her family, her friends, her membership in the National Honor Society, and her favorite activity, running. She needed help focusing on exactly what had caused her stress—the loss of her boyfriend. To her, it felt like she had lost her whole life, which was a gross distortion of reality.

· Identify strengths (Jobes et al., 2005; Sue et al., 2013). It is helpful to identify and emphasize the person’s positive qualities. For example, the individual might be pleasant, unselfish, hardworking, conscientious, bright, attractive, and so on. People who are feeling suicidal are most likely focusing on the “bad things” they perceive about themselves. They forget their positive characteristics.

· Decrease isolation (Jobes et al., 2005; McWhirter et al., 2013). Another source of strength lies in people close to the suicidal person. Who can that person turn to for emotional support and help? These people may include family, friends, a religious leader, a guidance counselor, or a physician—people the person trusts and can communicate with. In the case of an emergency, it may be necessary to rely on the support of emergency professionals (police officers or medical staff).

Creation of a  suicide prevention task force provides a potentially effective means to evaluate the need for services and decide what types of services to offer. A  task force is a group established for a specific purpose, usually within the context of an organization or community, that pursues designated goals and disbands when these goals have been achieved (Kirst-Ashman & Hull, 2012a). A task force can be made up of interested individuals within an organization or a cross section of professionals and citizens within a community. The task force can then make decisions regarding how the agency or community can best meet the community’s need for suicide prevention services. It can answer a number of questions and decide on a plan of action. Who are the potential clients? Are there services already existing within the community that can best meet the suicide prevention need? If not, what types of programs should be initiated? What resources are available to develop such programs?

For example, the Task Force on Suicide in Canada was established to evaluate extensively suicide in Canada and report its findings and recommendations (Health Canada, Health Programs and Services Branch, 1994). The group addressed the needs of the entire country instead of smaller community systems. The report’s intent was to

deal with the nature and extent of suicide and suicide-related problems, discuss demographic and sociological parameters, and identify the Canadian groups at greatest risk…; it also summarized knowledge of etiological processes [reasons and causes of the behavior] and gathered information on programs of suicide prevention, intervention, and postvention…

Prevention refers to the implementation of measures to prevent the onset of suicidal crises by eliminating or mitigating particular… situations of heightened risk…, by promoting life-enhancing conditions, and by reducing negative societal conditions. Several such measures… [included] improved approaches to media coverage, broader-based public education programs (disseminating information about how to recognize a potentially suicidal person, what to do and where to go for help), and a reduction in the availability and lethality of means.

Intervention refers to the actions aimed at the immediate management of the suicidal crisis and the longer-term care, treatment and support of persons at risk. Actions involved include identification of potential sources of referral, crisis recognition, risk assessment, -reducing the intensity of the crisis, and treatment and support of the person at risk… [The task force recommended] education and training for health care professions and gate-keepers, especially in areas such as “first-aid” interventions and methods of treatment for those who are in acute and chronic suicidal crises.

Postvention refers to activity undertaken to deal with the aftermath of a suicide. The purpose of such actions is twofold: to provide social support and counseling to bereaved persons, and to collect psychological autopsy information for the purpose of reconstructing the social and psychological circumstances associated with the suicide. (Health Canada, Health Programs and Services Branch, 1994, pp. xi–xiii)

Recommendations were also made concerning the ways the legal system could address the suicide problem (e.g., by decriminalizing attempted suicide). The task force emphasized the need for research regarding the reasons for suicide, the most effective treatment approaches, and the evaluation of suicide prevention programs.

Another example of an ongoing task force addressing suicide is the Task Force for Child Survival and Development. Although its base is in Georgia, it focuses on both domestic and international health issues. Its purpose initially was “to help public and private organizations achieve their mission in promoting health and human development by building coalitions, forging consensus, and leveraging scarce resources” in the prevention of suicide (Task Force for Child Survival and Development [TFCSD], 2004a). In recent years, its focus has expanded “to include other aspects of child health and development” (TFCSD, 2004a, 2011, 2014). Its goals have included the promotion of public awareness about suicide, the creation of suicide prevention programs, the provision of training programs concerning suicide assessment and treatment, and the promotion of research (TFCSD, 2004b).

Another example of a community system’s approach to suicide prevention is the establishment of a  peer-helping program, such as Teen Lifeline (2013) in Arizona. The “heart” of the program is its Peer Counseling Hotline that provides daily access to a Peer Counselor. Troubled teens often want to talk to other teens about their problems. Volunteer Peer Counselors “can empathize and understand the problems of the callers because, in many cases, they have or are going through the same things themselves.” The program receives more than 11,000 calls annually, many from teens who are depressed or suicidal. Participant volunteers receive 70 hours of Life Skills training that focuses on “listening skills, communication skills, self-esteem, problem solving and relevant teen issues.” The hotline is supervised by a master’s-level mental health clinician. The program also provides opportunities to schools for community education on suicide and a variety of other issues including “depression, grief, dying, stress/anxiety, and substance’ abuse.”

The fourth example of a community system’s response to the suicide problem is the development and provision of suicide prevention training programs for community professionals and other caregivers. Caregivers include professionals such as social workers, psychologists, psychiatrists, and counselors. Caregivers may also include any others that potentially suicidal people may turn to for help. These include clergy, family members, nurses, teachers, and friends. Training as many caregivers as possible significantly increases the chance for a potentially suicidal person to make contact with someone who can help.

Ethical Questions 7.5

In school, she saw herself as a failure and hung out with other students who viewed themselves as failures. In high school, she frequently skipped school and partied. Eight weeks before graduation, she was expelled for skipping too much school. Her parents and the school system had tried numerous times to motivate Laura to apply herself in school; she even had a number of individual sessions with three different social workers and a psychiatrist.

Laura’s parents are especially irate when she leaves home for three or four days at a time and parties in an abandoned house in the inner city of Milwaukee. She has lied to her parents about her sexual activities, when the truth is she has a variety of partners. Fortunately, she is taking birth control pills; however, she does not always use a condom to protect herself from sexually transmitted diseases. Some of Laura’s male friends are putting pressure on her to become a prostitute so that there will be more money to buy drugs and party. Laura and her friends have had several encounters with the police for shoplifting, running away from home, drinking liquor under age, kicking police officers while being arrested, and driving in high-speed auto chases after radar detected they were speeding.

Laura is asking herself a number of questions: Should she prostitute herself? Or should she stop associating with her friends and try to make peace with her parents by getting a high school education and a better-paying job? Whenever she has tried to achieve the middle-class goals of her parents, they have criticized her as being a failure. She wonders what her chances are of heading in a better direction this time. The one thing she has found enjoyable in life is partying with her friends, but she realizes her friends are getting her in trouble with the police. She is worried that cutting ties with her friends will result in living a life in which she will be continually rejected and put down by others. She wants a better-paying job but realizes her chances are not good, especially because she hasn’t completed high school. She wants a one-to-one relationship with a caring male, but because she has a low self-concept, the only thing she feels that males will find attractive about her is sexual intercourse. This is one reason she has had multiple sex partners. She is increasingly concerned that being so sexually active is not right and may result in her acquiring a sexually transmitted disease (such as AIDS). What should she do about all of these concerns? She is deeply perplexed and confused.

A Perspective

This chapter will focus primarily on the social changes and some social problems encountered by adolescents. The social growth from puberty to age 19 involves a number of passages: from being dependent on parents to becoming more independent, from adjusting to puberty to establishing a sexual identity, from beginning to date to serious dating and perhaps marrying, from being a child with parents to sometimes parenting children, from earning money from babysitting to having a full-time job or attending college, from buying baseball gloves and playing ball to buying a car, and from drinking soda to drinking beer and hard liquor and experimenting with drugs. The pressures and stresses of this time period produce many casualties who suffer from a variety of problems.

8-1Describe the Social Development Changes That Adolescents Undergo

8-1aSocial Development Changes in Adolescence

During adolescence, people move from dependence on parents to becoming more independent and establishing peer relationships and perhaps intimate relationships.

8-1bMovement from Dependence to Independence

Young people often are in a conflict between wanting to be independent of their parents but on another level realizing their parents are providing for many of their wants and needs: food, shelter, clothes, emotional support, spending money, and so on. Many young people see their parents as having shortcomings and conclude that they know more than their parents. Yet when their car breaks down and they have no idea of how to fix it, mom or dad almost always knows what to do to get it fixed.

In the pursuit of independence, adolescents often rebel against their parents’ attempts to guide them and reject their views as being out-of-date and stupid. They sometimes do things to shock their parents, as if to say “See, I’m my own person, and I’m going to live my life my way!” Interestingly, once young people become more independent in their 20s and have to pay their own bills, they tend to have a greater appreciation for their parents’ knowledge. Mark Twain noted (as quoted in Papalia & Olds, 1981, p. 375), “When I was fourteen my father knew nothing, but when I was twenty-one, I was amazed at how much the old man had learned in those seven years.”

Children who are raised in families in which the parents have provided opportunities to learn self-reliance, responsibility, and self-respect tend to make a smoother transition from dependency to adulthood interdependence. Children who are raised in families where the parents are overly permissive or take little interest in their children’s behavior tend to have greater difficulty making the transition to adulthood. These young people lack structure or a system of standards and values to gauge whether their behavior is suitable and their decisions are appropriate. Children who have overly protective parents also have difficulty making this transition; they usually do not learn how to assume responsibilities or make important decisions.

Some parents are wary about their children growing up. In particular, some fathers and mothers become alarmed and uncomfortable when their “little girl” starts dating. Many parents worry that their daughter may become sexually involved and pregnant, which they believe will interfere with their dreams and hopes for her having a good life. When teenagers assert their right to becoming more independent, it changes the components of the family system.

Any change in the components of the system will create tension within the family. This tension is expressed by teens with such statements as “You don’t understand me,” “Get off my back,” “I know what I’m doing—don’t treat me like a baby,” and “Chill out.”

I-messages, in essence, are nonblaming messages that communicate only how the sender of the message believes the receiver is adversely affecting the sender. I-messages do not provide a solution, nor are they put-down messages. It is possible to send an I-message without using the word I (“Driving this fast really frightens me”). The essence of an I-message involves sending a nonblaming message of how the parent feels the child’s behavior is affecting the parent.

You-messages are generally put-downs that either convey to youths that they should do something or that convey to them how bad they are In contrast, I-messages communicate to young people much more honestly the effect of the behavior on the parent. I-messages are also more effective because they help teenagers learn to assume responsibility for their own behavior. An I-message tells a teenager that the parent is trusting the teen to respect the parent’s needs and that the parent is trusting him or her to handle the situation constructively.

You-messages frequently lead to an argument between parent and youth; I-messages are much less likely to do so. I-messages lead to honesty and openness in a relationship, and generally foster intimacy. Teenagers, as well as adults, often do not know how their behavior affects others. I-messages produce startling results; parents frequently report that then teenagers express surprise upon learning how then-parents really feel.

Note that I-messages will work only if the youth does not want his actions to adversely affect his parent. If the youth does not want to cause discomfort in his parent, he will seek to change his adversive behavior when informed by an I-message of how he is adversely affecting his parent. However, if the youth enjoys causing discomfort in his parent, then the use of an I-message by the parent is apt to result in an increase in the youth’s adversive behavior because he is how more fully aware of how to cause discomfort in the parent.

No-Lose Problem Solving

In every parent-teenager relationship, there are inevitably situations in which the youth continues to behave in a way that interferes with the needs of the parent. Conflict is part of life and is not necessarily bad. Conflict is bound to occur because people are different and have different needs and wants, which at times do not match. What is important is not how frequently conflict arises, but how the conflicts get resolved. Generally, in a conflict between parent and youth, a power struggle is created.

In many families, the power struggle is typically resolved by one of two win-lose approaches. Most parents try to resolve the conflict by having the parent win and the young person lose. Psychologically, parents almost always are recognized as having greater authority. The outcome of the parents’ winning is that it creates resentment in the teenager toward his or her parents, leads to low motivation for the teenager to carry out the solution, and does not provide an opportunity for him or her to develop self-discipline and self-responsibility. Such teenagers are likely to react by becoming either hostile, rebellious, and aggressive, or submissive, dependent, and withdrawing.

In other families, fewer in number, the win-lose conflict is resolved by the parents’ giving in to their teenagers out of fear of frustrating them or fear of conflict. In such families, teenagers come to believe that their needs are more important than anyone else’s. They generally become self-centered, selfish, demanding, impulsive, and Uncontrollable. They are viewed as being spoiled, have difficulty in interacting with peers, and lack respect for the property of feelings of others.

Of course, few parents use either approach exclusively. Oscillating between the two approaches is common. There is evidence that both approaches lead to the development of emotional problems in children (Gordon, 1970).

Gordon seriously questions whether power is necessary or justified in a parent–teenager relationship. For one reason, as teenagers grow older, they become less dependent and parents gradually lose their power. Rewards and punishments that worked in young years become less effective as youths grow older. Teenagers resent those who have power over them, and parents frequently feel guilty after using power. Gordon believes that parents continue to use power because they have had little experience in using nonpower methods of influence.

Gordon suggests a new approach, the  no-lose approach to solving conflicts. In this approach, parents and youth solve their conflicts by finding their own unique solutions acceptable to both.

The no-lose approach is simple to state: Each person in the conflict treats the other with respect, neither person tries to win the conflict by the use of power, and a creative solution acceptable to both parties is sought. The two basic premises are

· (I)

that all people have the right to have their needs met and

· (2)

that what is in conflict between the two parties involved is not their needs but their solutions to those needs.

Gordon (1970, p. 237) lists the following six steps in the no-lose method:

1. Identifying and defining the heeds of each person

2. Generating possible alternative solutions

3. Evaluating the alternative solutions

4. Deciding on the best acceptable solution

5. Working out ways of implementing the solution

6. Following up to evaluate how it worked

Stage 2 is “awareness and mutual education” (p. 138). After expressing feelings, homeless youth should be encouraged to talk about their experiences, as painful as they have been. Articulating and sharing experiences can help young people organize their thoughts and identify themes characterizing their lives. Rees (1998) comments that “this stage of dawning awareness gives practitioners a chance to encourage young people to construct their stories so they can begin to think of different choices in their lives. Usually their stories reconstruct experiences of powerlessness… Such spelling out is a crucial part of empowerment” (p. 139).

Stage 3 is “dialogue and solidarity” (p. 140). After telling their stories, continuing to exchange information and share feelings with others provides opportunities to learn from and support each other. Such discourse can involve their rights to education, services, income, housing, and legal assistance. They can help each other begin to formulate plans for empowering themselves and demanding access to resources. Together, homeless youth can establish solidarity, supporting each other in their quest for empowerment.

Stage 4 is “action and political identity” (p. 141). This involves a sense of self-confidence in one’s ability to make progress, seek changes in conditions, and improve one’s overall quality of life. Political identity is the sense that one has the right and power to seek improvements in life. Effects can include an improved self-concept, more effective communication skills, better relationships with professionals and family, and more productive interactions with resource providers and legal system representatives. Rees (1998) furnishes two example of homeless youth experiencing empowerment. Sean’s empowerment involved seeing that his future could become more than an early, violent death. He gained confidence in his ability to advocate for himself with healthcare professionals, the police, and resource providers. The second youth, Dean, indicated that for the first time he had hope that someday he would get a job and even live in a home of his own, things he never thought were possible before. He began to like himself more and eagerly participated in a job-training program.

8-2Describe Some Major Problems Encountered by This Age Group: Eating Disorders

8-2aSocial Problems

In addition to the normal phases of social development, such as becoming more independent, a number of situations and life crises tend to occur in adolescence (or in the years following adolescence). The following pages will focus on certain social problems: eating disorders, emotional and behavioral problems, crime and delinquency, and delinquent gangs. The latter two can be viewed as macro-system problems because large systems are often involved in the planning and carrying out of criminal activity, and large systems are involved in investigating, prosecuting, preventing, and curbing criminal activity.

8-2bEating Disorders

Eating disorders are occurring in epidemic proportions. Although they have existed for a long time, the dramatic increase in the number of individuals affected is now a major concern for mental health professionals. The majority of people who have eating disorders are female; however, the number of males with eating disorders is increasing. The three primary eating disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder. All three are serious disorders that create life-threatening health problems.

Anorexia Nervosa

Anorexia nervosa means “loss of appetite due to nerves.” This definition is inaccurate, because people with anorexia do not actually lose their appetite until the late stages of their starvation. Until then, they do feel hungry; they just do not eat. Anorexia nervosa is a disorder characterized by the excessive pursuit of thinness through voluntary starvation. The predominant features of this disorder include excessive thinness, intense fear of gaining weight or becoming fat, a distorted body image in which anorexics view themselves as being overweight, and there may be amenorrhea (cessation of menses) in females.

On the surface, someone who is prone to develop anorexia appears to be a model child. She is eager to please, well-behaved, a good student, and someone who appears to get along well with her peers. She rarely asks for help, and she is unlikely to indicate that anything is wrong. Behind this mask is an insecure, self-critical perfectionist who feels she is unworthy of any praise that she receives. She is also apt to be concerned about whether other people like her.

The development of this disorder usually proceeds according to the following pattern:

1. It begins with a diet. Dieting for these individuals usually begins just before or just after a major change occurs—such as entering puberty, breaking up with a boyfriend, or leaving home for college.

2. Dieting creates a feeling of control. At first the person feels better about herself because dieting is something she can do successfully. Soon, however, food and the fear of becoming fat become the major concerns in life.

3. Exhausting exercise is added. The anorexic exercises excessively, such as running 10 miles before eating.

4. Health begins to fail. Weight loss and malnutrition begin, leading to mental and physical deterioration. Although the person may sense something is wrong, she refuses to conclude that she needs to start eating more. Anorexia can lead to the shrinking of internal organs, including the brain, heart, and kidneys. As the heart muscle weakens, the chances of irregular heart rhythm and congestive heart failure increase. Other complications include muscle aches and cramps, swelling of joints, constipation, difficulty urinating, inability to concentrate, digestive problems, and injuries to nerves and tendons. In addition, loss of fat and muscle tissue makes it difficult for the body to keep itself warm, which leads to the sensation of feeling cold. The unusual growth of fine body hair (especially on the arms and legs) may be the body’s response in seeking to make up for heat loss.

A large number of anorexics engage in excessive exercise for prolonged periods of time in an attempt to lose more weight. They prefer solitary activities (such as running and exercise machines) over team sports. At mealtimes, to avoid conflicts with others over eating so little, they are apt to say that they have already eaten, or if they are forced to be at the table with others, they may dispose of their food by slipping it into a container under the table. Because they are always hungry, anorexics are preoccupied with food, grocery shopping, nutritional information, and cooking. They may collect cookbooks and memorize calorie charts.

Anorexics, even in warm weather, tend to wear several layers of bulky clothing, or sweaters and baggy pants, to warm their cold bodies, and to conceal their thinness. (Their thinness often brings questions or criticisms from relatives and friends, so wearing bulky clothing is a way to avoid being questioned.) Anorexics usually deny that they need help with their eating patterns; they insist their bodies are normal and attractive.

Anorexics tend to maintain rigid control over nearly all aspects of their lives. To avoid criticism, they often withdraw from others and are introverted. They often develop compulsive rituals involving exercise, food, housekeeping, studying, and other aspects of their lives. A favorite ritual is to weigh themselves several times a day. They may cut their small morsels of food into tiny pieces and then spend extended time eating each piece. They find security in discipline and order. To achieve greater control of their lives, they tend to avoid social activities, sexual relationships, parties, and friends.

Some anorexics occasionally yield to their hunger pangs and eat—and perhaps even binge. After eating and bingeing, they are apt to feel guilty because they failed in their efforts to always follow a restricted diet.

Anorexics tend to think in black-and-white terms. They view themselves, and others, as being right or wrong, successes or failures, beautiful or ugly, fat or thin. They do not deal well with complexity or shades of gray. Anorexics seek to be perfectionists in all aspects of their lives, including relationships, school or job responsibilities, and personal appearance.

It is important that anorexics seek help from medical professionals, including primary physicians, psychiatrists, nutritionists, and social workers. There are a wide range of services available including outpatient services, day treatment programs, group homes, inpatient services, and residential treatment.

To prevent death by starvation, severe anorexics frequently need hospitalization. Studies estimate mortality rates of between 5 and 18 percent from a variety of medical complications, including heart attack, kidney damage, liver impairment, malnutrition, and starvation. Starvation weakens the body’s immune system, which leaves the anorexic vulnerable to pneumonia and other infections. Suicide following severe depression is also a danger (Lagasse, 2015).

Bulimia Nervosa

The term  bulimia is derived from a Greek word meaning “ox-like hunger.” But the binge–purge cycle that is characteristic of bulimics is triggered not by physical hunger but by emotional upset. Binge eating is the rapid, uncontrolled consumption of large amounts of food. A binge may last from a few minutes to several hours. Purging is the process of getting rid of the food eaten during a binge. The most frequent method of purging is self-induced vomiting. Other methods of purging include strict dieting or fasting, vigorous exercise, diet pills, and abuse of diuretics and laxatives. Some bulimics chew food to enjoy the taste and then spit it out to avoid calories and weight gain. Estimates of the incidence of bulimia nervosa among high school and college-age females range between 4.5 and 18 percent (Lagasse, 2015).

The development of bulimia tends to proceed according to the following pattern:

1. A diet is started. The person wants to lose weight and improve self-esteem. However, dieting increases hunger and leads to a craving for sweet, high-calorie food.

2. Overeating begins. The overeating is often triggered by stress such as anger, depression, loneliness, frustration, and boredom. Food helps to relieve hunger and also is a comfort for emotional pain.

3. Guilt develops. The person feels guilty about gaining weight in a society where “thin is in.”

5. A binge–purge habit takes hold. Binge eating and purging become a way of coping with life and emotional pain. Bulimics tend to fear that others will discover their habit and view it as disgusting.

The average bulimic binge involves between 1,000 and 5,500 calories, although daylong binges of more than 50,000 calories occur in some bulimics. (The average American’s food intake is about 3,000 calories a day.) Bulimics tend to binge on high-calorie junk foods, such as sweets and fried foods. Bulimics generally feel considerable shame about their bulging and purging, but continue to resort to the binge–purge cycle as a way to relieve the pain of their daily problems.

Most bulimics are within a normal weight range, although some are somewhat overweight or underweight. Obesity in adolescence may be a contributing factor in the development of the disorder in some bulimics. The parents of bulimics are often overweight, and close relatives of bulimics have a higher-than-chance frequency of alcoholism and depression (Lagasse, 2015).

The usual age of onset for bulimia nervosa is late adolescence or early adulthood. Alcohol and other substance abuse are fairly common among bulimics. This is because the psychological dynamics that lead a person to abuse alcohol or drugs are similar to the dynamics that lead a person to be bulimic. Substance abuse may be easier to treat than bulimia, however, because a substance abuser can completely abstain from using alcohol or drugs, but a bulimic needs to continue to eat (which acts as a trigger to bingeing) in order to survive.

Because bulimia nervosa is seldom incapacitating, the disorder can go undetected by family and friends for years. Physical complications, however, begin to develop. Chronic vomiting can lead to gum disease and innumerable cavities, because of the hydrochloric acid content of vomit. Vomiting can also lead to severe tearing and bleeding in the esophagus. Chronic vomiting may result in a potassium deficiency, which then may lead to muscle fatigue, weakness, numbness, erratic heartbeat, kidney damage, and, in severe instances, paralysis or death. Digestive problems range from stomach cramps, nausea, ulcers, and colitis to a fatal rupturing of the stomach. Sore throats are also common. Bulimia can also lead to diabetes.

Dehydration and electrolyte imbalance can occur and in some cases cause cardiac arrhythmias and even death. Psychotropic drugs (such as tranquilizers and antidepressant drugs) may affect the body differently because of changes in body metabolism. For bulimics who are substantially below normal weight, physical complications associated with anorexia nervosa may also occur.

Both anorexia and bulimia lead to serious health problems. Stating the obvious, nutritious meals are needed for good health and survival. Anorexics risk starvation, and both bulimics and anorexics risk serious health problems. Fat synthesis and accumulation are necessary for survival. Fatty acids are a major source of energy. When fat levels are depleted, the body must draw on carbohydrates (sugar). When sugar supplies dwindle, body metabolism decreases, which often leads to drowsiness, inactivity, pessimism, depression, dizziness, and fatigue.

Although a few bulimics at times binge with friends, usually bulimics binge alone and secretly. Because bingeing leads to guilt, anxiety, and fear of weight gain, the process of purging serves as a reinforcer for bingeing because purging often results in a sense of again being in control with a flat stomach. However, many bulimics feel shame and personal disgust about their bingeing–purging cycle.

Bulimics tend to be people pleasers who crave affection, attention, and approval from others. Unlike anorexics, they usually have active social lives with a number of friends and acquaintances. However, they are often filled with self-doubt and insecurity. Although they want close personal relationships, they also tend to fear such relationships, partly because they fear their eating disorder is more apt to be discovered. Many bulimics are sexually promiscuous, partly because they want affection and have low self-esteem. Some bulimics may shoplift and steal food. Most bulimics feel they do not have control of their lives, and feel especially out of control around food. They worry that once they begin to eat, they will be unable to refrain from bingeing. Bulimics are more likely than anorexics to seek help for their eating disorder.

Binge Eating Disorder

Treatment is recommended for persons whose body weight is more than 20 percent over ideal body weight (Lagasse, 2015). The more overweight a compulsive overeater is, the greater the health risks. Being overweight is correlated with such health problems as hypertension, elevated cholesterol levels, and diabetes. People who are overweight are also prone to heart attacks and other heart diseases.

Individuals with binge eating disorder have many of the characteristics that are commonly found in bulimics. A key distinguishing factor between the two disorders is that bulimics frequently engage in purging, whereas binge eaters seldom, if ever, do. Similar to bulimics, binge eaters tend to binge in an effort to temporarily escape painful problems in their lives. Individuals with binge eating disorder generally feel considerable shame and embarrassment about their eating patterns and their weight. Alcohol and other substance abuse are common. Like bulimics, binge eaters tend to be people pleasers who crave attention and approval from others and who are often filled with self-doubt and insecurity. Binge eaters have a high incidence of depression and are apt to have low self-esteem. Age of onset of the disorder is usually during adolescence.

Individuals with binge eating disorder are apt to display one or more of the following characteristics:

1. Frequent diet plan failures. Binge eaters attempt and fail at numerous diet plans. They are apt to try nearly every new diet fad briefly, believing that their latest effort will be the one that achieves permanent weight loss. No diet fad really works for them. Repeated diet failures result in a sense of hopelessness and self-deprecation.

2. Avoidance of health warning signs. Being excessively overweight eventually leads to health problems, such as diabetes and hypertension. Binge eaters tend to ignore early warning signs of health problems, choosing instead to continue bingeing rather than making a commitment to developing healthier eating patterns.

3. Social isolation. Binge eaters often feel shame and guilt about being overweight; as a result, they may seek to reduce interpersonal contact. For some, avoiding interactions with others becomes a dominant behavioral pattern.

4. Nutritional ignorance. Binge eaters often lack adequate knowledge of basic nutrition. Many have a distorted view of what constitutes a well-balanced and healthy diet.

5. Selective eating amnesia. Individuals with binge eating disorder are unlikely to conscientiously count their calorie intake. They are also apt to binge several times a day without keeping track of the frequency of their bingeing.

6. Binge eating as a response to unwanted emotions. When binge eaters feel unwanted emotions such as loneliness, frustration, insecurity, anger, and depression, they are apt to ease the pain of these emotions through bingeing. Bingeing temporarily takes their mind off their concerns, so it does work—but only during the short time while they are eating. After bingeing, overeaters are not only apt to feel the pain of their original unwanted emotions, which now return, but also to feel shame and guilt over their excessive eating.

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse impact on health, leading to increased health problems and/or reduced life expectancy. Obesity increases the likelihood of various diseases, including heart disease, certain types of cancer, breathing difficulties during sleep, type 2 diabetes, and osteoarthritis. Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults and children. Authorities view it as one of the most serious public health problems of the 21st century. Alarmingly, two-thirds of U.S. adults are either obese or overweight (Mooney, Knox, & Schacht, 2015).

Obesity is most commonly caused by binge eating, lack of physical activity, and genetic susceptibility. (More rarely, obesity may be caused by endocrine disorders and by certain medications— such as steroids, some antidepressants, and some medications for seizure disorders.)

The primary treatments for obesity are dieting and physical exercise. In case these two treatments do not work, antiobesity drugs may be taken to reduce appetite or inhibit fat absorption. In severe cases, surgery may be performed to reduce stomach volume and/or bowel length—thereby reducing the person’s ability to absorb nutrients from food.

Interrelationships Among Eating Disorders

Eating disorder symptoms and behaviors seem to exist on a continuum. On the extreme left are those struggling with anorexia, who achieve drastic weight loss by severely restricting food intake. Moving to the right toward the center are individuals with anorexic bulimia who eat and binge on occasion, but primarily maintain a much lower than normal weight by strict dieting and purging In the center are normal-weight bulimics who repeatedly binge and purge thousands of calories per episode, yet are neither significantly under or over normal weight. Although overly preoccupied with body shape and body image, it is not unusual for normal-weight bulimics to experience rapid weight fluctuations of ten or more pounds because of intense cycles of bingeing and purging. At the other end of the continuum, the binge eater will repeatedly eat excess amounts of food, gaining significant amounts of weight without engaging in any of the purging behavior associated with anorexia or bulimia nervosa. Individuals may move back and forth along this continuum, alternatively restricting or bingeing, depending on their circumstances and the progression of their disorder. (p. 28)

8-3Understand Theoretical Material on the Causes and Treatments of These Problems

8-3aCauses

Many factors contribute to the development of an eating disorder. The factors differ from one individual to another. Some bulimics and binge eaters may be genetically predisposed to these disorders. Depression or alcoholism tends to be present in parents or other family members. People with an eating disorder tend to feel inadequate and worthless. Their low self-esteem combined with their quest for perfectionism leads them to be intolerant of any flaws. They tend to compare themselves to others, and usually conclude “I’m not good enough.” A significant number of anorexics and bulimics have been victimized by molestation, rape, or incest (Lagasse, 2015).

Anorexics and bulimics have some similarities. Both are likely to have been brought up in middle-class, upwardly mobile families, where their mothers are overinvolved in their lives and their fathers are preoccupied with work outside the home. For the most part, bulimics and anorexics were good children, eager to comply and eager to achieve in order to obtain the love and approval of others. Both tend to have a distorted body image in which they view themselves as being fatter than others view them. Both have an obsessive concern with food. Their parents tended to be overprotective and did not allow them to become more independent and learn from their mistakes. Their parents still treat them as if they were young children rather than teenagers and young adults. A smaller number of anorexics and bulimics come from nonsupportive and non-nourishing families that were demanding, critical, and rejecting. Others with eating disorders were raised by parents who combined obsessive concern with criticism and rejection, which places the children in a double bind of wanting to protest but feeling guilty because their parents are so “caring.” Still others were raised by parents who have good parenting skills and show love and act appropriately with their children. In such families, other factors lead to the development of an eating disorder.

Bulimics are often overachievers, and in college tend to attain high academic averages. Purging for bulimics often becomes a purification rite because it is frequently viewed as a way to overcome self-loathing. They tend to believe they are unlovable and inadequate. Through purging, they feel completely fresh and clean again. These feelings of self-worth are only temporary. They are extremely sensitive to minor insults and frustrations, which are often used as excuses to initiate another food binge.

Because family dynamics are usually contributing factors to an eating disorder, family therapy is also important, particularly if the affected person is living at home. Other family members are always affected, and sometimes victimized, by the turmoil experienced by the individual with the eating disorder. Through therapy, family members are better able to understand the dynamics of the eating disorder and can make changes that provide increased support for the affected person. The family therapist seeks to improve family functioning, which facilitates the recovery of the individual. Family sessions are also helpful to eating-disordered individuals who are struggling with issues of separation from their primary family.

Group therapy is also an important intervention. It may be provided in a variety of forms, including self-help, psycho-educational, and behavioral therapy. Through group interaction, members are able to put then problems in perspective because they see that others have problems as serious as theirs. Groups also enable members to test out more appropriate interaction patterns. Members can also share their unwanted emotions and problematic behaviors, and discover ways to think and act in more realistic ways. Groups also provide interpersonal support. Groups are useful in confronting members about the health hazards of their eating patterns. Group treatment provides an arena for diminishing feelings of isolation and secrecy, sharing successful techniques for better coping with common problems, demystifying eating disorders, expressing feelings, obtaining feedback from other members, and facilitating realistic goal setting.

Nutritional counseling is an essential component of any treatment plan. A registered dietician can provide information about proper nutrition and the body’s need for nutritious food. The dietician can provide information on the physiology of dieting and weight management, and can help the affected person to establish healthier eating patterns as well.

Because some persons with eating disorders are depressed, antidepressant medication is sometimes beneficial. Such medication is prescribed by a psychiatrist or physician. Couples therapy is sometimes needed when there is significant conflict in a couple’s relationship. Some elementary, secondary, and higher education school systems are now developing prevention programs that seek to inform students about the risks of eating disorders and to identify services for students who are beginning to develop an eating disorder.

8-4Describe Some Major Problems Encountered by This Age Group: Emotional and Behavioral Problems

8-4aEmotional and Behavioral Problems

Emotional problems (involving unwanted feelings) and behavioral problems (involving irresponsible actions) are two comprehensive labels covering an array of problems. Emotional difficulties include depression, feelings of inferiority or isolation, feeling guilty, shyness, having a low self-concept, having a phobia, and excessive anxiety. Behavioral difficulties include being sadistic or masochistic, being hyperactive, committing unusual or bizarre acts, being overly critical, being overly aggressive, abusing one’s child or spouse, being compulsive, committing sexual deviations, showing violent displays of temper, attempting suicide, and being vindictive.

Everyone, at one time or another, will experience emotional and/or behavioral problems. Severe emotional or behavioral problems have been labeled as mental illnesses by certain members of the helping professions. The two general approaches to viewing and diagnosing people who display severe emotional disturbances and abnormal behaviors are the  medical model and the  interactional model.

Medical Model

The medical model views emotional and behavioral problems as a mental illness, comparable to a physical illness. The medical model applies medical labels (schizophrenia, paranoia, psychosis, insanity) to emotional problems. Adherents of the medical approach believe the disturbed person’s mind is affected by some generally unknown, internal-condition. That condition, they assert, might be due to genetics, metabolic disorders, infectious disease, internal conflicts, unconscious use of defense mechanisms, or traumatic early experiences that cause emotional fixations and hamper psychological growth.

The major evidence for the validity of the medical model comes from studies that suggest that some mental disorders, such as schizophrenia, may be influenced by genetics (heredity). The bulk of the evidence for the significance of heredity comes from studies of twins. For example, studies have found identical twins to have a  concordance rate (i.e., if one has it, both have it) for schizophrenia of about 50 percent (Comer, 2014). The rate of schizophrenia in the general population is about 1 percent (Comer, 2014). So when one identical twin is schizophrenic, the other is 50 times more likely than the average to be schizophrenic. This suggests a causal influence of genes, but not genetic determination, because concordance for identical twins is only 50 percent, not 100 percent.

Interactional Model

Critics of the medical (mental illness) model assert that such medical labels have no diagnostic or treatment value and frequently have an adverse labeling effect.

Thomas Szasz (1961a) was one of the first authorities to assert that mental illness is a myth—that it does not exist. Szasz’s theory is an  interactional model that focuses on the processes of everyday social interaction and the effects of labeling on people. Beginning with the assumption that the term mental illness implies a “disease of the mind,” he categorized all of the so-called mental illnesses into three types of emotional disorders and discussed the inappropriateness of calling such human difficulties mental illnesses.

1. Personal disabilities, such as excessive anxiety, depression, fears, and feelings of inadequacy. Szasz said that such so-called mental illnesses may appropriately be considered mental (in the sense that thinking and feeling are considered mental activities), but they are not diseases.

2. Antisocial acts, such as bizarre homicides and other social deviations. Homosexuality used to be in this category, but was removed from the American Psychiatric Association’s list of mental illnesses in 1974. Szasz said antisocial acts are social deviations and are neither mental nor diseases.

Szasz (1961b) asserted that the notion that people with emotional problems are mentally ill is as absurd as the belief that the emotionally disturbed are possessed by demons:

The belief in mental illness as something other than man’s trouble in getting along with his fellow man, is the proper heir to the belief in demonology and witchcraft. Mental illness exists or is “real” in exactly the same sense in which witches existed or were “real.” (p. 87)

The point that Szasz and many others are striving to make is that people do have emotional problems, but they do not have mystical, mental illnesses. Terms that describe behavior, they believe, are very useful. For example, depression, anxiety, obsession, compulsion, excessive fear, hallucinations, or feelings of being failures describe personal problems that people have. But they assert that medical terms (such as schizophrenia and psychosis) are not useful because there is no distinguishing symptom that would indicate whether a person has, or does not have, the illness. In addition, Caplan (1995) points out that there is considerable variation between cultures regarding what is defined as a mental illness, and even within a given culture, psychiatrists frequently disagree on the medical diagnosis to be assigned to those who are disturbed.

In a dramatic study, psychologist David Rosenhan (1973) demonstrated that professional staff in mental hospitals could not distinguish insane patients from sane patients. Rosenhan and seven normal associates went to 12 mental hospitals in five different states claiming they were hearing voices; all eight were admitted to these hospitals. After admission, these pseudopatients stated they had stopped hearing voices and acted normally. The hospitals were unable to distinguish their sane status from the insane status of other patients. The hospitals kept these pseudopatients hospitalized for an average of 19 days, and all were then discharged with a diagnosis of “schizophrenia in remission.”

Ethical Question 8.2

Self-Injury in Adolescents

In working with adolescents, a difficult issue to face is the concept of self-harm or self-injury. The American Academy of Child and Adolescent Psychiatry (AACAP) describes self-injury as “the act of deliberately destroying body tissue, at times to change a way of feeling … that it is seen differently by groups and cultures with in society” (2015, NP). In the DSM V, non-suicidal self-injury disorder (NSSID) has been identified as a condition in need of further study due to its prevalence, especially among adolescents (Zeggergvist, 2015). Signs of self-injury include cuts or burns on the legs, arms or abdomen, scratch marks, making abrasions on the skin, hitting oneself, picking at skin, or finding razors or box cutters in an adolescent’s bedroom (AACAP, 2015; American Association for Marriage and Family Therapy [AAMFT], 2016). It has been found that females tend to self-injure more frequently than males and that rarely are adolescents who self-injure suicidal (AAMFT, 2016). Self-injury is a complex behavior with no key indicators for why it occurs. It is said that adolescents may self-injure due to wanting to get quick relief from emotional distress (creating a rush of endorphins in the body), difficulty talking about their feelings, low self-esteem, wanting to fit in with a crowd that engages in self-injury behavior, or a coping mechanism for other problems (AACAP, 2015; AAMFT, 2016). It is important to help these adolescents find new ways of facing these issues. Treatment options for adolescents who self-injure include individual counseling, family therapy, teaching problem-solving skills, developing positive self-talk, and encouraging the use of stress management skills (AACAP, 2015; AAMFT, 2016).

Adherents of the interactional approach believe that people get labeled mentally ill for two reasons: They may have an intense unwanted emotion, or they may be engaged in dysfunctional (or deviant) behavior. Assigning a mental illness label to unwanted emotions or dysfunctional behaviors does not tell us how the emotions or behaviors originated nor how to treat such emotions and behaviors. The rest of this section, based on a rational therapy approach, does both. It gives us an approach for identifying the sources of unwanted emotions and dysfunctional behaviors, and it provides strategies for changing them.

8-5Understand Theoretical Material on the Causes and Treatment of These Problems

8-5aAssessing and Treating Unwanted Emotions: Application of Theory to Client Situations

Changing Self-Talk

Under Part E, write down the new emotions you want to have in similar future A situations. In writing these new emotions, keep in mind that they will follow from your self-talk statements in D(b). This section may also contain a description of certain actions you intend to take to help you achieve your emotional goals when you encounter future A situations.

Changing the Distressing Event

Social Development in Adolescence

Not all distressing events can be changed. For example, you may have a job that you like but be forced to interact with an employee who displays behaviors you dislike. If you cannot change the behaviors, the only other constructive option is to bite the bullet and seek to adapt to the circumstances. However, when it is feasible and practical to change distressing events, we should seek to do so. If we are successful, we are apt to feel better because we will then give ourselves more positive self-talk about the changed events.

Destructive Ways to Change Unwanted Emotions

Unfortunately, some people turn to two other ways to change unwanted emotions. One of these ways is seeking to temporarily relieve intense unwanted emotions through the use of alcohol, other drugs, or food. Unfortunately, many people seek to relieve unwanted emotions through the use of such mind-altering drugs as alcohol, cocaine, or tranquilizers. When the effects of the drug wear off, the problems and unwanted emotions still remain, and there is a danger that through repeated use a person will become dependent on the drug. Some people overeat for the same reasons. Such people are apt to become overweight or bulimic—or both.

The only other way to relieve unwanted emotions is suicide. This is the ultimate destructive approach to changing unwanted emotions.

Assessing and Changing Deviant Behavior: Application of Theory to Practice

Our thinking determines both our emotions and our actions, as depicted in the following diagram:

To demonstrate this principle, reflect on the last time you did something bizarre or unusual. What self-talk statements were you giving yourself (i.e., what were you thinking) prior to and during the time you did what you did?

Thinking processes determine behavior. The reasons behind unusual or dysfunctional behavior can always be identified by determining what the perpetrator was thinking prior to and during the time the act was being committed. Following are some examples of cognitions leading to dysfunctional behavior.

· Cognition: A 17-year-old boy sees an unlocked Mustang and thinks, “Hey, this is really a neat car to take a ride in. Let me cross the starting wires, and take it for a drive.”

· Behavior: car theft

· Cognition: A 27-year-old man is on his second date, is in his date’s apartment, and thinks, “She is really sexy. Since I’ve now wined and dined her twice, it’s now time for her to show her appreciation to me. She wants it as much as I do. I’ll show her what a great lover I am. She may protest a little, but I’ll overcome that with force. Once we get involved sexually, she’ll be emotionally attracted to me.”

· Behavior: date rape

· Cognition: A 31-year-old bartender thinks, “Cocaine gives me such a great high. Unfortunately, I don’t make the kind of money to buy as much as I need. I have no other choice but to buy more than I use, and then sell some of it for a profit.”

· Behavior: drug trafficking

· Cognition: A 48-year-old bookkeeper of a retail computer firm thinks, “This is an awful financial mess I’m in. I’ve got so many bills: mortgage payments, gambling debts, and tuition payments for two kids in college. Hopefully I can win at the next poker game. But I need a stake. The only way to get it is to take a couple grand from this company and pay the money back in a few weeks. With me handling the books, no one will ever miss it.”

· Behavior: embezzlement

Ethical Question 8.3

Assessing human behavior is largely a process of identifying the cognitions that underlie unwanted emotions or dysfunctional behavior. The stages of this process are as follows:

1. Identify as precisely as possible the unwanted emotions and/or dysfunctional behavior that a client has.

2. Identify the cognitions or thinking patterns that the client has during the time when he or she is having unwanted emotions or is displaying dysfunctional behavior. There are two primary ways of identifying these cognitions. One is to ask the client what he was thinking prior to and during the time when he or she was having unwanted emotions or displaying dysfunctional behavior. If this does not work (perhaps because the client refuses to divulge what he or she was thinking), a second approach is to obtain information about the client’s life circumstances at that time. Once these life circumstances are identified, the professional conducting the assessment needs to place himself or herself mentally into the life circumstances of the perpetrator, and then reflect on the kinds of cognitions that would lead to specific unwanted emotions or dysfunctional behavior. For example, if the client is a 16-year-old female who has run away from home and is unemployed, it is fairly easy to identify (to some extent) the kinds of cognitions that would lead her to turn to prostitution.

3. At home, parents need to supervise their children’s time online. Placing the computer in a common area is a step in this direction.

4. Schools need to develop a formal policy for curbing cyber bullying.

5. Instruct students on how to block communication from cyberbullies.

6. Encourage students to assertively ask friends who are cyber bullying to stop.

7. Encourage parents and teachers to talk to students about the importance of telling a teacher or parent about any cyber bullying that they become aware of.

8. Parents and teachers need to investigate the reasons why a student is withdrawn, depressed, or reluctant to attend school or social events.

Highlight 8.8

Sex Trafficking

Human trafficking involves forcing people to engage in sex or provide labor against their will (Polaris, 2016). The global sex trade is one of the fastest growing forms of commerce, over $32 billion a year (Deshpande & Nour, 2013). Despite some individuals believing sex trafficking is something that only occurs in other countries, sex trafficking does occur in the United States. Although exact numbers are hard to determine due to the underground nature of sex trafficking, Polaris (2016) stated that since 2007, the national hotline was aware of 14,588 sex trafficking cases in the United States. Sex traffickers tend to recruit vulnerable youth, such as runaways, homeless, and victims of violence (Polaris, 2016). It is estimated that one in six teenage runaways become victims of sex trafficking. (Polaris, 2016). Traffickers find adolescents on city streets, through social network, bars, the internet, or even schools (Polaris, 2016; Shared Hope International, 2016). Negative effects of sex trafficking includes the following: physical illness such as sexually transmitted diseases and broken bones, psychological trauma, and social isolation (Deshpande & Nour, 2013). Social workers can assist with sex trafficking by helping to identify victims of sex trafficking, serving on organizations and committees that address this issue, supporting legislation to fight sex trafficking, and educating others about the dangers of sex trafficking (Malai, 2014).

Of course, not all juvenile court judges live up to these principles. In practice, some juvenile judges focus more on punishing, rather than treating, juvenile offenders. Court appearances by children can have adverse labeling effects, such as youths viewing themselves as delinquent and then continuing to break the law.

8-7Understand Theoretical Material on the Causes and Treatments of These Problems

8-7aCauses

Why do people violate the law? There are many theories about crime causation. (For a review of these theories, see Mooney, Knox, & Schacht, 2015.) Crime is a comprehensive label covering a wide range of offenses, such as drunkenness, possession of narcotics, rape, auto theft, arson, shoplifting, attempted suicide, purse snatching, incest, gambling, prostitution, fraud, false advertising, homicide, and kidnapping. Obviously, since the nature of these crimes varies widely, the motives or causes underlying them must also vary widely.

What crime deterrent/prevention strategies are most effective? This is a difficult question to answer. What is effective for one perpetrator may not be effective for another perpetrator.

8-8Describe Some Major Problems Encountered by This Age Group: Delinquent Gangs

8-8aMacro-System Problems: Delinquent Gangs

Juvenile gangs have existed for many decades in the United States and in other countries. In recent years in the United States, there have been increases in the number of gangs, the number of youths belonging to gangs, gang youth drug involvement, and gang violence. Violent, delinquent urban gang activity has become a major social problem. The scientific knowledge base about delinquent gangs is very limited. There is no universal agreement on a definition of “gang” or on the types of groups that should be labeled as gangs (Regulus, 1995). In addition, no agreed-upon recording system exists, and no data on gang offenses are collected in systematic ways by governmental agencies.

The inadequacy of the knowledge base about delinquent gangs is a major obstacle to developing effective intervention strategies. The lack of consensus among investigators is indicated by the numerous and diverse categories that have been used by different investigators to classify gangs: comer group, social club, conflict group, pathological group, athletic club, industrial association, predatory organization, drug addict group, racket organization, fighting-focused group, defensive group, unconventional group, criminal organization, turf group, heavy metal group, punk rock group, satanic organization, skinheads, ethnic or racial group, motorcycle club, and scavenger group (Goldstein, 1991).

8-8bFour Types of Gangs

An illustration of one categorization of gangs is provided by Morales, Sheafor, and Scott (2010), who classified youth gangs into four types: criminal, conflict, retreatist, and cult/occult.

The primary goal of  criminal gangs is material gain through criminal activities. Criminal activities include theft of property from persons or premises, extortion, fencing, and obtaining and selling illegal substances (particularly drugs). Drug trafficking of rock cocaine is presently a major source of income for criminal gangs.

Conflict gangs are turf-oriented and will engage in violent conflict with individuals or rival groups that invade their neighborhood or that commit acts that they consider degrading or insulting. Respect is highly valued and defended. Hispanic gangs are heavily represented among conflict gangs. The Code of the Barrio mandates that gang members watch out for their neighborhood and be willing to die for it.

Retreatist gangs focus on getting “high” or “loaded” on alcohol, cocaine, marijuana, heroin, or other drugs. Individuals tend to join this type of gang in order to secure continued access to drugs. In contrast to criminal gangs that become involved with drugs for financial profit, retreatist gangs become involved with drugs for consumption.

The fourth type of gang is the  cult/occult gang. Morales et al. (2010) describe this type as follows:

The word cult, as used here, pertains to a system of worshiping the devil or evil. Occult means something hidden or secret, or a belief in mysterious or supernatural powers. Not all cult/occult devil or evil worship groups are involved in criminal activity or ritualistic crime. The Ku Klux Klan, for example, may be seen as a cult group, and some KKK chapters, in spite of their hate rhetoric, are law abiding, whereas other chapters have committed criminal acts. The majority of occult groups are composed of adults, although some juvenile groups are becoming interested in satanic and black magic practices and are using them for their own gratification of sadistic, sexual, and antisocial impulses. They are not turf-oriented like conflict gangs but are typically found in middle-class locations. For example, a neo-Nazi subtype of white cult/occult gang groups are the Skinheads, whose racist, anti-Semitic, homophobic “gay bashing,” and other violent behavior has appeared in the South, Midwest, and West Coast. Their group structure and behavior comply with the gang pattern, including use of colors, tattoos, common dress and hairstyle, name, drug use, and criminal behavior (usually “hate” crimes). (p. 196)

Contradictions abound in conceptualizing delinquent gangs. Gangs are believed to be composed largely of ethnically homogeneous minority youths (African American, Hispanic, or Asian); yet some gangs composed of white youths exist. Most gang members are believed to be between the ages of 12 and 18, yet evidence indicates some gangs include and may be controlled by adults (Mooney, Knox, & Schacht, 2015). Gangs are believed to be composed of males; yet some gangs have female members, and a few gangs consist exclusively of females (Regulus, 1995). Gangs are believed to be primarily involved in drug trafficking; yet some delinquent gangs have other illegal foci, such as burglary, robbery, larceny, or illegal drug consumption. Gang activity is thought to be primarily located in large, inner-city, urban areas; yet gang activity is flourishing in many smaller cities and in some suburbs (Regulus, 1995).

At the present time, there are inadequate statistical data on the number of gangs, the number and characteristics of members, and their criminal activities. No uniform definition of a gang-related offense exists across police jurisdictions (even within the same state or city).

8-9Understand Theoretical Material on the Causes and Treatment of These Problems

8-9aSociological Theories: Applications of Theories to Gangs

Numerous attempts have been made to explain why youths join gangs and why gangs engage in delinquent or criminal activities. These explanations include biological, psychological, and sociological theories (see Goldstein, 1991, for a review). No consensus exists as to which theories are most useful, and insufficient research has been conducted to ascertain their validity. In order to illustrate the existing theories, we will summarize four of them: differential association theory, anomie theory, deviant subcultures theory, and control theory.

A retreatist gang.

A. Ramey/PhotoEdit

Robert Merton (1968) applied  anomie theory to delinquency and crime. This approach views delinquent behavior as resulting when an individual or a gang is prevented from achieving high-status goals in a society. Merton begins by noting that every society has both approved goals (for example, wealth and material possessions) and approved means for attaining these goals (going to college, getting a job). When certain members of society want these goals but have insufficient access to the approved means for attaining them, a state of anomie results. ( Anomie is a condition in which the acceptance of the approved standards of conduct is weakened.) Unable to achieve the goals through society’s legitimately defined channels, the individuals’ and gangs’ respect for these channels is weakened, and they seek to achieve the desired goals through illegal means. Merton asserts that higher crime rates are apt to occur among those groups discriminated against (i.e., those groups facing additional barriers to achieving the high-status goals). These groups include the poor and racial minorities. Societies with high crime rates (such as the United States) differ from those with low crime rates because, according to Merton, they tell all their citizens that they can achieve, but in fact they block achievement for some of them.

Deviant subcultures theory offers another explanation for delinquent gang behavior. This theory asserts that some groups have developed their own attitudes, values, and perspectives that support criminal activity. Walter Miller (1958), for example, argues that American lower-class culture is more conducive to crime than middle-class culture. He asserts that lower-class culture is organized around six values—trouble, toughness, excitement, fate, smartness (ability to con others), and autonomy— and allegiance to these values produces delinquency. Miller concludes that the entire lower-class subculture is deviant in the sense that any male growing up in it will accept these values and almost certainly violate the law.

Albert Cohen (1955) advanced another subculture theory. He contends that gangs develop a delinquent subculture that represents solutions to the problems of young male gang members. A gang gives them a chance to belong, to amount to something, to develop their masculinity, and to fight middle-class society. In particular, the delinquent subculture, according to Cohen, can effectively solve the status problems of working-class boys, especially those who are rejected by middle-class society. Cohen contends that the mam problems of working-class boys revolve around status.

Control theories (Hirschi, 1969) ask the question, Why do people not commit crimes? Theories in this category assume that all people would naturally commit crimes and therefore must be constrained and controlled by society from breaking the law. Control theorists have identified three factors for preventing crime. One is the internal controls through the socialization process that society builds up in an individual; it is believed that developing a strong conscience and a sense of personal morality will prevent most people from breaking the law. A second factor is thought to be a strong attachment to small social groups, such as the family, which prevents individuals from breaking the law, because they fear rejection and disapproval from the people who are important to them. A third factor is that people do not break the law because they fear arrest and incarceration. Control theories assume that the basic nature of humans is asocial or evil. Such an assumption has never been proved.

Social Work Roles and Intervention Programs

Various programs have attempted to reduce delinquent gang activities. These have included detached worker programs, in which workers join gangs and seek to transform antisocial into prosocial attitudes and behaviors; formal supervision of those gang members adjudicated delinquent through juvenile probation departments; placement of delinquent gang members in group homes, residential treatment facilities, or reform schools; drug treatment of gang members who have a chemical addiction; programs to support and strengthen families, particularly single-parent families in urban areas; and programs to prevent dropping out of school and to provide academic support (Goldstein & Huff, 1993).

The outcomes of such interventions have not been sufficiently researched. The factors that lead adolescents to join delinquent gangs and then to engage in delinquent activities are multifaceted and highly complex. It is clear that delinquent gang activities are on the increase in our society. The reasons for this increase are largely unknown. Also unknown are the most effective programs to reduce delinquent gang activities.

Of all the helping professions, it would appear that social work is best suited from the perspective of knowledge, values, and skills to develop intervention strategies to use with gangs. Gangs as a focus for practice find the social worker intervening with individuals, groups, families, organizations, and the community (i.e., micro-, mezzo-, and macro-level intervention).

Social workers intervene on a one-to-one level with a delinquent gang member in a variety of settings—as a juvenile probation officer, as a counselor at a group home or residential treatment facility, as a school social worker in a school setting, and as an alcohol and drug counselor in a chemical dependency treatment program. On a one-to-one level, social workers may assume the following roles: counselor, educator, case manager, and broker.

Social workers intervene on a mezzo level with a delinquent gang with a group approach; the worker is viewed as a “detached worker” or “gang group worker.” Working with gangs requires that the social worker spend a considerable amount of time in the gang’s immediate environment rather than in the agency—hence the term “detached worker” or “street worker.” Spergel (1995) found that most gangs are receptive to a worker engaging the gang as a group within the purposes of social work practice, and that a social worker can help urban gangs to change from being a destructive force to being a constructive contributor to the community while maintaining the gang’s right to self-determination. In working with gangs, a worker can function in the roles of group facilitator, educator, enabler, and advocate in helping the gang obtain needed resources. The worker can also function as a negotiator or a mediator when there is intragang conflict or when there is a conflict between rival gangs. At a mezzo level, a worker may also work with the families of gang members to assist them in being constructive forces in curbing their children’s delinquent behavior.

Spergel (1995) presents documentation that gangs develop primarily in local communities that are socially disorganized and/or impoverished. Gang members typically come from communities in which parents lack effective parenting skills, school systems give little attention to students who are falling behind in their studies, youths are exposed to adult crime groups, and youths feel there is practically no opportunity to succeed through the legitimate avenues of education and a good job. Spergel (1995) asserts that youths join gangs for many reasons—security, power, money, status, excitement, and new experiences—particularly under conditions of social deprivation or community instability. In essence, he presents a community disorganization approach to understanding the attraction of joining a gang.

Regulus (1995) asserts that community mobilization appears to be the most effective strategy to reduce gang problems.

Community mobilization is a strategy that attempts to integrate and coordinate the collective resources of citizens and organizations in gang control. In the broadest sense, community mobilization attempts to harness the combined efforts of governmental agencies, schools, police and criminal justice agencies, youth agencies, indigenous grass-roots organizations, churches, and so on within a community. (p. 1052)

8-10Understand Material on Social Work with Groups, including Theories about Group Development and Theories about Group Leadership

8-10aEmpowerment through Social Work with Groups

Today it is not uncommon to find social workers as both group leaders and participants in a myriad of settings, helping solve or ameliorate human or social problems and planning for and creating change. We have established that empowerment is the “process of increasing personal, interpersonal, or political power so that individuals can take action to improve their life situations” (Gutierrez, 1990, p. 149). Groups can provide forceful and effective means to accomplish these ends. Johnson and Johnson (1997) define a  group as “two or more individuals in face-to-face interaction, each aware of his or her membership in the group, each aware of the others who belong to the group, and each aware of their positive interdependence as they strive to achieve mutual goals” (p. 12).

From this description, we can see that the members of a group relate to one another within a context of sensing that they form a distinct entity, that they share a common goal or purpose, and that they have confidence that together they can accomplish as much as or more than would be possible working separately. This commonality is characteristic of a wide variety of groups dealing with a multitude of societal problems. The beginning social worker is likely to be surprised at the diversity of groups in existence and excited by the challenge of practicing social work in groups. This section gives an introduction to social work with groups—including types of groups, theories about group development, and theories about group leadership.

8-10bTypes of Groups

The following types of groups are frequently encountered in social work practice: recreation, recreation-skill, educational, task, problem-solving and decision-making, focus, self-help, socialization, therapy, and encounter groups. This list is not an exhaustive one.

Recreation Groups

The objective of recreation groups is to provide activities for enjoyment and exercise. Often such activities are spontaneous and the groups are practically leaderless. The group service agency (such as the YMCA or neighborhood center) may offer little more than physical space and the use of some equipment. Spontaneous playground activities, informal athletic games, and an open game room are examples. Some group agencies providing such physical space claim that recreation and interaction with others help build character and prevent delinquency among youth by providing an alternative to the street.

Recreation-Skill Groups

Educational Groups

The focus of educational groups is to help members acquire knowledge and learn more complex skills. The leader generally is a professional person with considerable training and expertise in the subject area. Examples of topics include child-rearing practices, assertiveness training, techniques for becoming a more effective parent, preparing to be an adoptive parent, and training volunteers to perform a specialized task for a social service agency. Educational group leaders often function in a more didactic manner and frequently are social workers. These groups may resemble a class, with considerable group interaction and discussion being encouraged.

Task Groups

Task groups are formed to achieve a specific set of tasks or objectives. The following are examples of task groups that social workers are apt to interact with or become involved in. A  board of directors is an administrative group charged with responsibility for setting the policy governing agency programs. A  task force is a group established for a special purpose and is usually disbanded after the task is completed. A  committee of an agency or organization is a group that is formed to deal with specific tasks or matters. An  ad hoc committee, like a task force, is set up for one purpose and usually ceases functioning after completion of its task.

Problem-Solving and Decision-Making Groups

Both providers and consumers of social services may become involved in groups concerned with problem solving and decision making. There is considerable overlap between task groups and these groups; in fact, problem-solving and decision-making groups can be considered a subcategory of task groups.

Providers of services use group meetings for objectives such as developing a treatment plan for a client or a group of clients, deciding how to best allocate scarce resources, deciding how to improve the delivery of services to clients, arriving at policy decisions for the agency, and deciding how to improve coordination efforts with other agencies.

Potential consumers of services may form a group to study an unmet need in the community and to advocate for the development of new programs to meet the need. Data on the need may be gathered, and the group may be used as a vehicle either to develop a program or to influence existing agencies to provide services. Social workers may function as stimulators and organizers of such group efforts as well as participants.

In problem-solving and decision-making groups, each participant normally has some interest or stake in the process and may gain or lose, depending on the outcome. Usually, there is a formal leader, although other leaders sometimes emerge during the process.

Focus Groups

Closely related to task groups and problem-solving and decision-making groups are focus groups. Focus groups are formed for a variety of purposes: to identify needs or issues, to generate proposals to resolve an identified issue, to test reactions to alternative approaches to an issue, and so forth. A  focus group is a specially assembled collection of people who respond through a semistructured or structured discussion to the concerns and interests of the person, group, or organization that invited the participants. Members of the group are invited and encouraged to bring up their own ideas and views.

A  representative group is a version of the focus group. Its strength is that its members have been selected specifically to represent different perspectives and points of view in a community. At its best, a representative group is a focus group that reflects the diversity in the community and seeks to bring these diverse views to the table. At its worst, it is a front group manipulated by schemers to make the community think that it has been involved.

Self-Help Groups

Self-help groups are becoming increasingly popular in our society and are often successful in helping individuals with certain social or personal problems. Katz and Bender (1976) provide a comprehensive definition of  self-help groups:

Powell’s (1987) classification of self-help groups conveys the variety and focuses of these groups:

1. Habit disturbance organizations. These organizations focus on a problem that is specific and concrete. Examples include Alcoholics Anonymous, Smoke Stoppers, Overeaters Anonymous, Gamblers Anonymous, Take Off Pounds Sensibly (TOPS), Women for Sobriety, Narcotics Anonymous, and Weight Watchers.

2. General-purpose organizations. These organizations address a wide range of problems and predicaments. Examples are Parents Anonymous (for parents of abused children); Emotions Anonymous (for persons with emotional problems); the Compassionate Friends (for persons who have experienced a loss through death); and GROW, an organization that works to prevent the hospitalization of mental patients through a comprehensive program of mutual aid.

3. Lifestyle organizations. These organizations seek to provide support for, and advocate for, the lifestyles of people whose members are viewed by society as being different (and the dominant groups in society are generally indifferent or hostile to that difference). Examples include Widow-to-Widow Programs, Parents Without Partners, ALMA (Adoptees’ Liberty Movement Association), PFLAG (Parents and Friends of Lesbians and Gays), the National Gay and Lesbian Task Force, and the Gray Panthers (an intergenerational group that advocates for the elderly).

4. Physical handicap organizations. These organizations focus on major chronic diseases and conditions. Some are for people with conditions that are relatively stable, some for conditions that are likely to get worse, and some for terminal illnesses. Examples of this category include Make Today Count (for the terminally ill and their families), Emphysema Anonymous, Lost Chord clubs (for those who have had laryngectomies), stroke clubs, Mended Hearts, the Spina Bifida Association, and Self-Help for Hard of Hearing People.

5. Significant-other organizations. The members of these organizations are parents, spouses, and close relatives of troubled and troubling persons. Very often, members of significant-other groups are last-resort caregivers contending with dysfunctional behavior. Through sharing their feelings, they obtain a measure of relief. In the course of sharing, they may also learn about new resources or new approaches. Examples of such organizations include Al-Anon, Gam-Anon, Toughlove, and the National Alliance for the Mentally Ill.

The American Self-Help Group Clearinghouse is a web-based database of more than 1,100 national and international self-help support groups for health, mental health, addictions, abuse, disabilities, parenting, caregiver concerns, and other stressful life situations. It is compiled and edited by Barbara J. White and Edward J. Madara, with the web version updated by Anita M. Broderick and Paul Riddleberger, Ph.D. Any self-help group contained in the database can be accessed by typing a keyword on the website. The website can be easily accessed by going to the internet and typing in “American Self-Help Group Clearinghouse.”

Many self-help groups stress

· (1)

a confession by members to the group that they have a problem,

· (2)

a testimony by their members to the group recounting then past experiences with the problem and their plans for handling the problem in the future, and

· (3)

support.

That is, when a member feels an intense urge of a recurrence (such as to drink or to abuse a child), he or she calls a member of the group, and that member comes over to stay with the person until the urge subsides.

When people help each other in self-help groups, they tend to feel empowered and in control of important aspects of their lives. When help is received from the outside (from an expert or a professional), there is a danger of dependency, which is the opposite of empowerment. Empowerment increases motivation, energy, personal growth, and an ability to help that goes beyond helping oneself or receiving help.

Some self-help groups advocate for the rights and lifestyles of people whose members are viewed by society as being different. One such group is the National Gay and Lesbian Task Force. Some self-help groups (such as The Arc of the United States) raise funds and operate community programs. Many people with a personal problem use self-help groups in the same way others use social agencies. An additional advantage is that self-help groups generally are able to operate with a minimal budget. Hundreds of these groups are now in existence. Social workers often act as brokers in linking clients to appropriate self-help groups.

Socialization Groups

A therapy group

Leadership of therapy groups requires considerable skill, perceptiveness, knowledge of human behavior and group dynamics, group counseling capacities, and ability to use the group to bring about behavioral changes. Among other skills, the group leader needs to be highly perceptive about how each member is being affected by what is being communicated. Considerable competence is needed to develop and maintain a constructive atmosphere within the group. The group therapist generally uses one or more therapy approaches as a guide for changing attitudes and behaviors; these approaches include psychoanalysis, reality therapy, learning theory, rational therapy, transactional analysis, client-centered therapy, and psychodrama.

· (1)

the Garland, Jones, and Kolodny model;

· (2)

the Tuckman model;

· (3)

the Schiller model; and

· (4)

the Bales model.

Garland, Jones, and Kolodny Model

Closeness (i.e., the question of how near group members will allow themselves to become to one another emotionally) is the central focus of the model. The question of closeness is reflected in struggles that occur at five levels of growth of the group: preaffiliation, power and control, intimacy, differentiation, and separation.

In the first stage,  preaffiliation, members are ambivalent about joining the group. Interaction is guarded. Members test out, often through approach and avoidance behavior, whether they really want to belong to the group. New situations are often frightening, and the members try to protect themselves from being hurt or taken advantage of in such new situations. They attempt to maintain a certain amount of distance and get what they can from the group without risking much of themselves. Individuals are aware that group involvement will make demands that may be frustrating or even painful. At the same time, members are attracted to the group because they generally have had satisfying experiences in other groups, and this group offers the hope of similar rewards. In the first stage, the leader should seek to increase the attractions toward the group “by allowing and supporting distance, gently inviting trust, facilitating exploration of the physical and psychological milieu, and by providing activities if necessary and initiating group structure” (Garland & Frey, 1973, p. 3). The first stage gradually ends when members come to feel fairly safe and comfortable with the group and view the rewards as being worth a tentative emotional commitment.

The second stage,  power and control, emerges as the characteristics of the group begin to develop. Patterns of communication within the group emerge, alliances and subgroups begin to appear, members begin to take on certain roles and responsibilities, norms and methods for handling group tasks develop, and membership questions arise. Such processes are necessary for the group to conduct its business. However, these processes lead to a struggle as the members establish their places within the group. Each member seeks power, partly for self-protection and partly to attempt to gain greater control over the rewards to be received from the group. In this struggle, the group leader is a major source of gratification. The leader is perceived as having the greatest power to influence the direction of the group and to give or withhold emotional and material rewards. At this point, members realize that the group is becoming important to them.

The second stage is a transitional stage, with certain basic issues needing to be resolved: Does the group or the leader have primary control over the group’s affairs? What are the limits of the power of the leader and of the group? To what extent will the leader use his or her power?

This uncertainty results in anxiety among group members and considerable testing by them to gauge the limits and establish norms for the power of both the group and the group leader. Rebellion is not uncommon; the dropout rate in groups is often highest at this stage. During this struggle, the leader should

· (1)

seek to help the members understand the nature of the power struggle,

· (2)

give emotional support to weather the discomfort of uncertainty, and

· (3)

help the group establish norms to resolve the uncertainty.

It is important that group members develop trust in the leader so he or she will maintain a safe balance of shared power and control. When this trust is achieved, group members make a major commitment to become involved in the group.

In the third stage,  intimacy, the likes and dislikes of intimate relationships are expressed. The group becomes more like a family, with sibling rivalry arising between members and the leader sometimes even being referred to as a parent. Feelings about the group at this stage are more openly expressed and discussed. The group is now viewed as a place where growth and change take place. Individuals feel free to examine and make efforts to change personal attitudes, concerns, and problems. Group tasks are also worked on, and there is a feeling of “oneness” or cohesiveness within the group. Struggle or turmoil during this stage leads the members to explore and make changes in their personal lives and to examine “what this group is all about.”

This kind of individualized therapeutic cohesion has been achieved because the group experience has all along valued and nurtured individual integrity …

The worker assists in this stage by helping the group to run itself and by encouraging it to act as a unit with other groups or in the wider community. During this time the worker exploits opportunities for evaluation by the group of its activities, feelings, and behavior. (p. 5)

The differentiation stage is analogous to a healthy functioning family in which the children have reached adulthood and are now becoming successful in pursuing their own lives; relationships are more between equals, members are mutually supportive, and members are able to relate to each other in ways that are more rational and objective.

The final stage is  separation. The purposes of the group have been achieved, and members have learned new behavioral patterns to enable them to move on to other social experiences. Termination is not always easily accomplished. Members may be reluctant to move on and may even display regressive behavior in an effort to prolong the safety of the group. Members may also express anger over ending the group or even psychologically deny the end is near. Garland and Frey (1973) suggested the leader’s role should be the following:

To facilitate separation the worker must be willing to let go. Concentration upon group and individual mobility, evaluation of the experience, help with the expression of the ambivalence about termination, and recognition of the progress which has been made are his major tasks. Acceptance of termination is facilitated by active guidance of members as individuals to other ongoing sources of support and assistance. (p. 6)

Tuckman Model

Tuckman (1965) reviewed more than 50 studies of mostly therapy and sensitivity groups, of a limited duration, and concluded that these groups go through five predictable developmental stages: forming, storming, norming, performing, and adjourning.

1. Forming. In this stage, members become oriented toward each other, work on being accepted, and learn more about the group. During this stage, there is a period of uncertainty in which members try to determine their place in the group and the rules and procedures of the group.

2. Storming. In this stage, conflicts begin to arise as members resist the influence of the group and rebel against accomplishing the task. During this stage, members often confront their various differences, and the management of conflict becomes the focus of attention.

3. Norming. In this stage, the group establishes cohesiveness and commitment, and in the process discovers new ways to work together. Norms are also set for appropriate behavior.

4. Performing. In this stage, the group works as a unit to achieve its goals. The group develops proficiency in achieving its goals and becomes more flexible in its patterns of working together.

5. Adjourning. In this stage, the group disbands. The feelings that members experience are similar to those in the separation stage of the Garland, Jones, and Kolodny model.

Schiller Model

Schiller (1995) has advanced a relational model of group development that is most applicable to women’s groups. The model has the following five stages:

1. Preaffiliation. In women’s groups, the same dynamics occur as in the preaffiliation stage of the Garland, Jones, and Kolodny model.

2. Establishing a relational base. In contrast to most models of group development that focus on power and control, in this second stage, women in groups focus on establishing common ground and a sense of connection with each other and with the facilitator. Members find similarities in their experiences and seek approval from the facilitator and from other group members.

3. Mutuality and interpersonal empathy. During this stage, members move beyond making connections and recognize their similarities. They have increased trust in one another and feel free to disclose their thoughts and feelings. Members also respect differences and display empathy for one another.

4. Challenge and change. Members challenge themselves and each other during this stage, which facilitates growth and change among members. During this stage, members have a sense of community with one another, which facilitates challenging one another, taking risks, and expressing disagreements without fearing the loss of valued connections made with one another.

Bales Model

· Active listener: Listens and serves as an interested audience for other members, is receptive to others’ ideas, goes along with the group when not in disagreement.

· Trust builder: Accepts and supports the openness of other group members; reinforces risk taking and encourages individuality.

· Interpersonal problem solver: Promotes open discussion of conflicts between group members in order to resolve conflicts and increase group togetherness.

Hersey and Blanchard (1977) developed a situational theory of leadership that serves as a guideline for when effective leaders should focus on task behaviors, when they should focus on maintenance behaviors, and when they should focus on both. In essence, the theory asserts that when members have low maturity in terms of accomplishing a specific task, the leader should engage in high-task and low-maintenance behaviors. Hersey and Blanchard refer to this situation as telling, because the leader’s behavior is most effective when he or she defines the members’ roles and tells them how, when, and where to do needed tasks. The task maturity of members increases as their experience and understanding of the task increases. For moderately mature members, the leader should engage in high-task and high-maintenance behaviors. This combination of behaviors is referred to as selling, because the leader should not only provide clear direction as to role and task responsibilities, but should also use maintenance behaviors to get the members to psychologically buy into the decisions that have to be made.

Also, according to Hersey and Blanchard, when group members’ commitment to the task increases, so does their maturity. When members are committed to accomplishing the task and have the ability and knowledge to complete the task, the leader should engage in low-task and high-maintenance behaviors, referred to as participating. Finally, for groups in which members are both willing and able to take responsibility for directing their own task behavior, the leader should engage in low-task and low-maintenance behaviors, referred to as delegating. Delegating allows members considerable autonomy in completing the task.

8-10eLeadership Theories

There are at least five major approaches to leadership theory: trait, position, style, distributed functions, and servant leadership.

The Trait Approach

Aristotle observed, “From the hour of their birth some are marked for subjugation, and others for command” (quoted in Johnson & Johnson, 1987, p. 39). As implied by this comment, this approach to leadership has been in existence for centuries. The  trait approach assumes that leaders have personal characteristics or traits that make them different from followers. It also implies that leaders are born, not made, and that leaders emerge naturally rather than being trained. The trait approach has also been called the  great person theory of leadership.

Two postulated leadership traits that have received considerable attention are charisma and Machiavellianism.

Charisma

Johnson and Johnson (1987, p. 43) define charisma as “an extraordinary power, as of working miracles.” They give the following definition of a charismatic leader:

The charismatic leader must have a sense of mission, a belief in the social-change movement he or she leads, and confidence in oneself as the chosen instrument to lead the movement to its destination. The leader must appear extremely self-confident in order to inspire others with the faith that the movement he or she leads will, without fail, prevail and ultimately reduce their distress. (p. 44)

Some charismatic leaders appear to inspire their followers to adore and be fully committed to them. Other charismatic leaders offer their members the hope and promise of deliverance from distress.

Charisma has not been precisely defined, and its components have not been fully identified. The qualities and characteristics that any charismatic leader has will differ somewhat from those of other charismatic leaders. The following leaders have all been referred to as charismatic, yet they differed substantially in personality characteristics: John F. Kennedy, Martin Luther King Jr., Julius Caesar, General George Patton, Confucius, Gandhi, and Winston Churchill.

Machiavellianism

Niccolò Machiavelli (1469–1527) was an Italian statesman who advocated that rulers use cunning, craft, deceit, and duplicity as political methods for increasing their power and control. Machiavelli was not the originator of his approach; some earlier theorists had conceptualized leadership in terms of manipulation for self-enhancement. However, the term  Machiavellianism has become associated with the notion that politics is amoral and that any unscrupulous means can justifiably be used in achieving political power. Machiavellian leadership is based on the concepts that followers

· (1)

are basically fallible, gullible, untrustworthy, and weak;

· (2)

are impersonal objects; and

· (3)

should be manipulated in order for the leader to achieve his or her goals.

Christie and Geis (1970) concluded that Machiavellian leaders have four characteristics:

1. They have little emotional involvement in interpersonal relationships, because it is emotionally easier to manipulate others when viewing them as impersonal objects.

2. They are not concerned about conventional morality and take a utilitarian (what they can get out of it) rather than a moral view of their interactions with others.

3. They have a fairly accurate perception of the needs of their followers, which facilitates their capacity to manipulate them.

4. They have a low degree of ideological commitment; they focus on manipulating others for personal benefit rather than to achieve long-term ideological goals.

Although a few leaders may have Machiavellian characteristics, most do not. Few groups would function effectively or efficiently with Machiavellian leaders.

In recent years, the trait theory of leadership has declined in popularity, partly because research results have raised questions about its validity. For example, different leadership positions often require different leadership traits. The characteristics of a good leader in the military differ markedly from those of a good group therapy leader. Moreover, traits found in leaders have also been found in followers. Though qualities such as high intelligence and a well-adjusted personality may have some correlation with leadership, many highly intelligent people never get top leadership positions, and some highly intelligent leaders (e.g., Adolf Hitler) have been emotionally unstable. The best rule for leader selection involves choosing individuals with the necessary skills, qualities, and motivation to help a group accomplish its goals.

The Position Approach

Most large organizations have several levels of leadership, such as president, vice-president, manager, and supervisor. The  position approach defines leadership in terms of the authority of a particular position and has focused on studying the behavior of people in high-level positions. At times, the training and personal background of leaders have also been examined.

Studies using the position approach, however, have revealed little consistency in how people assume leadership positions. Obviously, some individuals become leaders with little related training (in family businesses, for example), whereas others spend years developing their skills. Also, what is viewed as “desirable” leadership behavior in one position may be considered “undesirable” behavior in a different type of position. For example, a drill sergeant in basic military training is not expected to be empathetic, but a sensitivity group leader is. It is difficult to compile a list of leadership traits using this approach. Not surprisingly, the position approach has shown that what constitutes leadership behavior depends on the particular requirements of the position.

It is also difficult to define which behaviors of a designated leader are leadership behaviors and which are not. Certainly not all of the behaviors of a designated authority figure are leadership behaviors. For instance, an inexperienced individual in a position of authority can mask incompetence with an authoritarian attitude. Also, leadership behavior among group members who are not designated leaders is difficult to conceptualize with the position approach, because the position approach focuses only on the behaviors of designated leaders.

Because research on the trait approach was turning out contradictory results, Lewin, Lippitt, and White (1939) took a  leadership style approach. These researchers described and studied three leadership styles: authoritarian, democratic, and laissez-faire.

Authoritarian leaders have more absolute power than democratic leaders. They alone set goals and policies, dictate the activities of the members, and set major plans. They hand out rewards and punishments, and they alone know the succession of future steps in the group’s activities. In contrast, democratic leaders seek maximum involvement and participation of every member in all decisions affecting the group. They seek to spread responsibility rather than to concentrate it.

Authoritarian leadership is generally efficient and decisive. One of the hazards, however, is that group members may do what they are told out of necessity and not because of any commitment to group goals. The authoritarian leader who anticipates approval from subordinates for accomplishments achieved may be surprised to find backbiting and bickering common in the group. Unsuccessful authoritarian leadership is apt to generate factionalism and behind-the-scenes jockeying and maneuvering for position among members, and lead to a decline in morale.

Democratic leadership, in contrast, is slow in decision making and sometimes confusing, but frequently proves to be more effective because of strong cooperation that generally emerges with participation in decision making. With democratic leadership, interpersonal hostilities between members, dissatisfactions with the leader, and concern for personal advancement all become issues that are discussed and acted on. The danger is that the private, behind-the-scenes complaining of the authoritarian approach becomes public conflict in a democratic approach. Once this public conflict has been resolved in a democratic group, however, a strong personal commitment develops that motivates members to implement group decisions rather than to subvert them. The potential for sabotage in an authoritarian group is high, and therein lies the advantage of the democratic style.

The democratic leader knows that some mistakes are inevitable, and that the group will suffer from them. Yet such mistakes require the leader’s ability to stand by without interfering because to do otherwise might harm the democratic process and impede the progress of the group in developing the capacity to make decisions as a group.

In some situations, authoritarian leadership is more effective, whereas in others democratic leadership is more effective (Hare, 1962). As in any situation, the group will be more effective when members’ expectations about the behavior appropriate for that situation are met. When group members anticipate a democratic style, as they do in educational settings, classrooms, or discussion groups, the democratic style usually produces the most effective group. When members anticipate forceful leadership from their superiors, as in industry or military service, a more authoritarian form of leadership results in a more effective group.

In the  laissez-faire style, there is little participation by the leader. The group members are left to function (or flounder) with little input from the designated leader. There are a few conditions in which group members function best under laissez-faire style: when the members are committed to a course of action, have the resources to implement it, and need a minimum of designated leader influence to work effectively.

Because different leadership styles are required in different situations (even with the same group), research interest in recent years has switched to the distributed functions approach.

The Distributed Functions Approach

With this approach, leadership is defined as the performance of acts that help the group reach its goals and maintain itself in good working order (Johnson & Johnson, 1997). The functional approach to leadership seeks to discover what tasks are essential to achieve group goals under various circumstances and how different group members should take part in these actions.

The  distributed functions approach disagrees with the great person theory of leadership. It asserts that any member of a group will at times be a leader by taking actions that serve group functions. With this approach, leadership is viewed as being specific to a particular group in a particular situation. For example, telling a joke may be a useful leadership function in certain situations if it relieves tension, but telling a joke when other members are revealing intense personal feelings in a therapy group may be counterproductive and therefore not a leadership function.

The functional approach asserts that leadership is a learned set of skills that anyone with certain minimal requirements can acquire. Responsible membership is the same thing as responsible leadership; both involve doing what needs to be done to help the group maintain itself and accomplish its goals. This approach asserts that people can be taught the skills and behaviors that help the group accomplish its tasks.

Like any member of a group, the designated leader may be called on or may be forced to adopt one or more of the task or maintenance roles discussed earlier in this chapter. Indeed, the leader has a special obligation to be alert for such occasions and to assume, or to assist others to assume, whichever roles are timely and appropriate. The leader’s contribution to the group is not limited, however, to the assumption of specified roles. Each leader is responsible for a variety of functions. The needs and developmental stage of a group may at different times require a leader who can assume any of the previously described roles as well as those that follow:

· Executive: being the top coordinator of the activities of a group.

· Policymaker: establishing group goals and policies.

· Planner: deciding the means by which the group will achieve its goals.

· Expert: serving as the source of readily available information and skills.

· External group representative: being the official spokesperson for the group.

· Controller of internal relations: controlling the structure as a way to control in-group relations.

· Purveyor of rewards and punishments: determining promotions, or demotions, and assigning pleasant or unpleasant tasks.

· Arbitrator and mediator: acting as both judge and conciliator with the power to reduce or to increase factionalism within the group.

· Exemplar: serving as a model of behavior to show what the members should be and do.

· Ideologist: serving as the source of the beliefs and values of the members.

· Scapegoat: serving as the target for ventilating, members’ frustrations and disappointments.

8-10fThe Servant Leadership Approach

Servant leadership is an approach to leadership that was initially developed by Robert K. Greenleaf (1982). A  servant leader is someone who looks to the needs of the group she is working with, and asks herself how she can help the members solve problems and promote personal development among the members. She places her main focus on the members, as she believes that content and motivated members are best able to reach their goals. In contrast to an autocratic style of leadership in which the autocratic leader makes most of the decisions, decision-making responsibilities are shared with the members in the servant leadership style. The highest priority of a servant leader is to support, encourage, and enable members to unfold their full potential and abilities. (A highly competent teacher probably uses many of the concepts of a servant leader.)

Larry C. Spears and Michele Lawrence (2004) have identified the following ten concepts that characterize a servant leader:

· Listening: A servant leader is motivated to listen to members and is supportive of their opinions, and validates their concerns. The servant leader not only attends to verbalized concerns, but also to what is “unspoken.”

· Empathy: A servant leader seeks to understand and empathize with the members. The members are viewed as people who need respect and appreciation in order to facilitate personal development; and the more that members develop, the more successful and productive they are apt to become.

· Awareness: A servant leader seeks to have a high level of self-awareness, and to be perceptive of what the members are thinking and feeling. She also seeks to be aware of their interpersonal relationships in the group.

· Persuasion: A servant leader does not try to coerce members into compliance with what she wants, but instead seeks to convince members to share decision-making responsibilities.

· Conceptualization: A servant leader thinks beyond day-to-day realities. She also conceptualizes long-term goals and strategies for reaching those goals. She has a personal vision that incorporates what is in the best interests of all members of the group.

· Foresight: A servant leader has the capacity to foresee the likely outcome of possible implementation strategies. (This characteristic is closely related to conceptualization.)

· Stewardship: A servant leader not only seeks to facilitate the personal development and productivity of the group, but also realizes she has an obligation to do what is best for the greater society. Openness and persuasion are more important than control.

· Commitment to the growth of people. A servant leader focuses on nurturing the professional, personal, and spiritual growth of members. She seeks to validate the ideas of all the members, and involves them in decision making.

· Building Community: A servant leader not only seeks to develop a productive and contented group, but also seeks to build a strong community. It is postulated that members will have considerable growth with this style of leadership, which will lead these members to add to the development of the communities in which they live.

Servant leadership is a lifelong journey that includes self-discovery, a desire to serve others, and a commitment to developing the group members that one works with. Servant leaders are humble, caring, visionary, empowering, relational, competent, good stewards, and community builders. They put others first, are skilled communicators, are compassionate collaborators, are systems thinkers, and are ethical. Instead of a top-down hierarchical style, servant leaders emphasize trust, collaboration, empathy, and ethical use of power. Servant leaders do not seek to increase their own power, but seek to lead by better serving others.

Servant leadership not only facilitates the personal development of group members, but has the potential to influence the broader society in a positive way. Group members tend to be attracted to this style of leadership, and tend to be happier and more productive. (Servant leadership is not only an effective approach to leading a group, but is also an effective management style for a supervisor to use in supervising employees. Managers who empower and respect their staff tend to get better performance in return.)

Will servant leadership work well in all groups? Undoubtedly not! Certain settings probably require a more forceful form of leadership—such as in the military or in a prison setting.