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2 The Attributes of Human Service Organizations Yeheskel Hasenfeld

The Enigma of Human Service Organizations Human service organizations, such as schools, hospitals, and social service agencies, play a pivotal role in the lives of people. Individuals and families are highly dependent on them to enhance, maintain, and protect their well-being. As needs change throughout the life cycle, people are likely to seek the services of a broad array of human service organizations, each of which specializes in addressing a distinct set of needs, such as child care, health, education, employment, mental health, or home care. Yet at the time of need, people are never quite certain about the reception they will get when seeking the services of human service organizations. Much depends on the nature of the encounter between them and the staff of these organizations. On the one hand, these encounters typically signal a period of personal transition, such as entry to school or enrollment in a training program, or a time of personal vulnerability, such as ill health or psychological distress. These encounters necessitate a public exposure of highly personal and sensitive information. Yet for the staff, on the other hand, these encounters are generally viewed as routine and unremarkable—part of the “normal” work of the organization. Therefore, the ways in which human service workers respond may evoke different degrees of sensitivity and understanding of the personal circumstances and needs of the service seekers. Not surprisingly, the experiences people have in such encounters will be quite varied, ranging from highly positive to profoundly negative. There are significant differences in the degree of caring and responsiveness that people experience not only in different human service organizations but also within the same organization, and the experiences of some are not predictive of how others would experience the organization. In other words, there is an inherent uncertainty and trepidation about what to expect and what the experience would be when one interacts with human service workers. Moreover, to the general public, human service organizations are viewed as symbols of the caring society, a manifestation of the societal obligation to the welfare and well-being of its citizens. At the same time, these organizations are often seen as overly bureaucratic and rigid, obtrusive and controlling, and inefficient and wasteful. For example, there is a growing sense that public schools, especially in poor neighborhoods, are failing (Boyd, 2000). Similarly, there is broad public dissatisfaction with hospitals (Donelan, Blendon, Schoen, Davis, & Binns, 1999). Negative attitudes toward human services are particularly acute for those organizations that serve devalued populations, such as the homeless, the chronically mentally ill, or the welfare recipient. These contradictions are often manifested in the organizations themselves. Public assistance, for example, provides cash aid to poor families but also deters the “undeserving” and enforces the work ethic (Handler & Hasenfeld, 2007); child welfare agencies are expected to work toward family reunification but at the same time are pressured to remove endangered children from their homes. Schools are set to educate but spend considerable energy on discipline, often at the expense of education. To the recipients of their services, human service organizations are expected to embody the values of caring, commitment, trust, and responsiveness to human needs. They often do so. At the same time, these organizations can represent formidable bureaucracies burdened by incomprehensible rules and regulations, where services are delivered by rigid and occasionally unresponsive officials. Gross (1986) captures these contradictions in his description of patients' encounters with the Mayo Clinic: When people do come, hoping for, if not a miracle, at least help, there is a rude and quite unexpected shock. They find themselves, very soon, in a large waiting room where… dozens of persons like themselves sit waiting hour after hour, even day after day, for their names to be called by white-clad clerks at long counters. For a place of healing, it seems to look highly bureaucratic. (p. 139) Desjarlais (1999) describes the conflicting attitudes of the homeless mentally ill toward their shelter in an illuminating case study: Alice was therefore deeply ambivalent about staying in the shelter: while it provided more comfort and companionship than she found on the street, it also put her under the power and authority of the state's mental health bureaucracy. “You know,” she said in rushing up to greet me one day, “they put me into a hospital and forced me to take meds. They're just monsters. They won't leave me alone. They'll probably take me to court to force me to take meds, and they'll win.” “What do the meds do?” I asked. “All they do is make me stuff myself with food. They're supposedly to heal my supposed illnesses.” (p. 468) Welfare recipients required to participate in job preparation activities as a condition of receiving aid also express considerable ambivalence: That job [club], that was a waste of money… I won't say that I didn't get anything out of it; I did. I learned what to do and what not to do on filling out the application, which was really helpful. I learned how to do a résumé; they did it for me. What to say and what not to say [in an interview]; I did learn that. Little minor things… like [learning that] if I wrote my phone number down, [I should] put the area code with it…. But it was really a waste, because it didn't teach you a lot. (Michalopoulos et al., 2003, p. 54) Thus, people who must rely on human service organizations for needed resources may experience both hope and fear, caring and victimization, and dignity and abuse. Put differently, despite the ubiquity of human service organizations in the lives of people, they remain an enigma to them. To the human service workers, these organizations reflect their own commitment and dedication to improve the quality of life of people in need and offer them the opportunity to practice their professional and occupational skills. They provide them not only with extrinsic benefits but also with the intrinsic rewards that come from helping people. But these organizations are also a source of great frustration, constraining workers from serving their clients in accordance with their professional and personal norms and values, denying them the resources they need to serve their clients, burdening them with too many rules and regulations, and discounting their own views on the best ways to serve clients. For example, Smith and Donovan (2003; see also B. Smith, this volume) show that although workers in child welfare agencies are trained to engage parents, to use a strengths-based approach, and to work with parents toward change, caseworkers indicate that time pressures and competing goals, partly stemming from caseload sizes and their many responsibilities, hinder their capacity to adhere to the practice guidelines presented in training. (p. 549) How can we account for the apparent incongruities inherent in human service organizations? How can we explain the disparate and contradictory experiences people have in such organizations? I propose that the answer lies, at least in part, in the distinct attributes of these organizations. People as “Raw Material” All organizations need raw material as input to produce their products. Human service organizations are distinguished by the fundamental fact that people are their “raw material.” By using the term raw material in this context, I do not wish to imply that the people served by these organizations are merely treated as inanimate objects without regard to their humanness. Nor does the term imply that the staff who work on people do so without compassion. Rather, it is a metaphor of the work done on people under the jurisdiction of these organizations, work that aims at altering and reshaping their personal attributes. For example, when the hospital admits people as patients, it signifies that they will be worked on by the medical staff to treat their illnesses. By designating children as students, the school certifies the authority of the teachers to work on them so that they become educated. When poor single mothers become welfare recipients eligible for cash assistance, welfare workers are given the authority to transform them into wage earners. It is this transformation process to which people are subjected that defines them as the raw material of the organization, and it is precisely what differentiates human service organizations from other bureaucracies. Like any raw material that needs to be sifted, sorted, and categorized, people served by human service organizations are also subjected to a process of sorting, classification, and categorization, which defines how they are going to be transformed. Mental health agencies, for example, use the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) to affix a diagnostic label that legitimizes their intervention practices. Child protective services employ various assessment tools to determine the risks of child sexual, physical, and psychological abuse, which, in turn, prescribe organizational responses. Moreover, analogous to the ways in which raw material is controlled and shaped according to production requirements, the people being processed by human service organizations encounter various mechanisms of control that limit and define what personal attributes are relevant to the organization and what behaviors are expected of them. In medical encounters, for example, physicians routinely limit the ability of patients to express their personal troubles by focusing on the technical aspects of their diagnosis and treatment (Waitzkin, 1991). In other words, they are expected to conform to an organizationally prescribed role of “patient” or “client.”1 Those who fail to meet these expectations maybe discarded by being cooled out, defined as inappropriate or inelligible clients, or referred elsewhere. Of course, as I point out below, unlike innate raw material, people do react and respond to the processes they experience, and by doing so, they influence what happens to them in the organization. In a broader sense, clients through their self-presentations and their responses to workers also affect how the workers structure their daily routines. Human Services as Moral Work Working on people as raw material is inherently moral work. Indeed, the raison d'être of the human service organization is that its work on people is guided and driven by moral values it aims to uphold and that such work is framed by them. The license that the organization has to gain access to the private lives of its clients is justified on the basis of its adherence to institutionalized moral rules, which define what client attributes it can address and work on, in what manner, and for what purposes. That is, it is the appeal of the organization to dominant moral values and rules that grants it such a license. Moreover, every action taken on behalf of the clients represents not only some form of concrete services, such as administering medication, issuing a welfare grant, or counseling the family, but also a moral judgment and a statement about their social worth. When human service workers work on people who are themselves imbued with values, the workers' actions cannot be morally neutral. First, the very act of affixing the client with a label or diagnostic category signifies a moral status because the label is inextricably connected to the social status of the client and his or her valuation by significant others. When mental health professionals ascribe to their clients certain DSM-IV diagnostic labels, they are not merely engaged in a technical activity, because they cannot isolate themselves and their clients from the broader social and hence moral context in which they work and live. In this context, the label conveys a statement of social worth—most likely with a negative connotation. Second, the worker's response to the client inherently involves commitment of scarce resources, be they material assistance, psychological support, or medical treatment, and these are justified on the basis of moral labels. As observed by Varcoe, Rodney, and McCormick (2003) in their studies of nurses as moral agents, Drawing on the ideology of scarcity in a context characterized by high acuity and high workloads, nurses and others needed to make quick judgments, judgments that, because of the lack of time devoted to developing “authentic presence,” were not necessarily based on trusting relationships with patients. In a context demanding rapid judgment but where nurses were constrained from developing authentic presence with patients, labels and stereotypes offered substitute ways of understanding patients. Thus stereotypical ideas about people, based on age, class, race, ability, and so on, found purchase in health care relationships. (p. 966) Similarly, in psychiatric emergency rooms, physicians were more likely to recommend involuntary commitment when patients were perceived to be dangerous, when they were brought to the hospital by the police or their family, and when they were female (Lincoln, 2006). Undoubtedly, these factors are moral signifiers that have significant influence on the well-being of the patients. Likewise, when students are tracked into different curricular paths, such as vocational versus precollege, they are also tracked morally because of the impact these paths have on their life chances (Lucas, 2001). Put differently, the inevitable rationing of resources to clients is a moral act, because whatever the rationale and merit of the allocation rule may be, fundamentally it conveys an evaluation of social worth, since some clients become more deserving than others (Lipsky, 1980; Prottas, 1979). Third, and equally important, the clients themselves use their moral and social resources to appeal for needed services and negotiate their relationships with the workers. Thus, when comparing the treatment received by patients with diabetes of lower socioeconomic status (SES) with those of higher SES, Lutfey and Freese (2005) found profound differences that affect the long-term survival of the patients. Higher-SES patients were able to access clinics that were staffed with specialists, provided continuity of care, and offered in-clinic educational resources, all of which made the management of diabetes more effective, in sharp contrast to the clinics and services that lower-SES patients were able to access. These differential consequences, in turn, affirm and reproduce the differential moral worth of the clients, not only externally but internally as well. The clients must absorb the moral meanings of the labels and the workers' responses as a reflection of their own self-identity, which may evoke some sense of personal valuation. As Estroff (1981) suggests, the administration of medication to the chronically mentally ill, while generally endorsed by the professionals as essential to the functioning of the patient, also has important symbolic meaning, especially that of powerlessness. As she puts it, “These long-term intrusions into clients' inside space may represent exercises of power, legitimated by medical affiliation of the treatment system, which underscore to clients their lack of control over themselves in relation to others” (p. 116). Taken together, vulnerable and powerless clients not only tend to experience greater moral devaluation by the organizations from which they seek services but are also likely to internalize them, thus reinforcing their own sense of helplessness and powerlessness. As noted by Seccombe, James, and Walters (1998), welfare recipients, for example, are quite conscious of their devaluation by welfare workers. Yet they tend to endorse these negative stereotypes as applying to other welfare recipients while trying to buffer themselves from the stereotypes by considering themselves the exception. Still, many do express a sense of fatalism that conditions beyond their control prevent them from escaping welfare (Seccombe et al., 1998, p. 860). As a result, devalued clients are far less likely to exercise a “voice” option, through protest or collective mobilization, to influence the very policies that denigrate them, and by their acquiescence, they reinforce them. The fact that human service organizations engage in moral work tends to be underemphasized since, understandably, our concern is with the actual services they provide. Moreover, seldom are these moral choices made explicit. Because they are embedded in the organizational routines, they become a part of the “invisible hand” that controls workers' behaviors and actions. Yet I would propose that it is the moral decisions that determine and justify the actual services that clients obtain. Roth (1972), in his classical study of hospital emergency services, shows that the responsiveness of the medical staff to the patients was greatly influenced by staff perceptions of their social worth (e.g., the young were more valuable than the old), their assumptions about who is a deserving patient (e.g., drunks were undeserving), and what they considered were legitimate demands on their work roles (e.g., emergency room pediatricians complaining about cases of sore throats and snotty noses). Intake workers at the welfare department are also guided by a moral conception of client “need.” As noted by Prottas (1979), workers are obviously impressed when applicants have sick children who need a special diet or by applicants who have no place to sleep. But when the needs are broadly similar, there remains another sort of need which influences how much personalized attention an applicant will receive. In these roughly comparable cases differences in need reflect the applicant's apparent inability to look out for her own interests and her predilection to accept the worker's help as a gift and not merely her due…. Applicants who have these characteristics can generally expect a sympathetic hearing, good quality information, and even a little extra effort from the intake worker. (p. 39) Being perceived as “deserving” may mean the difference between receiving immediate assistance and being shunted through a bureaucratic maze. Similarly, the invisibility of moral work is reinforced by the service technology, which masks the underlying moral assumptions that guide its application. Cloaked in professional language and a system of classification accessible mostly to human service workers, decisions about the client's access to resources (eligibility), the definition of problems and needs (diagnosis), the desired outcomes (prognosis), and the course of action (treatment) are presented as being guided by technical rationality. Yet as noted by Burr (2003), accepting for the moment that the presence of “disease” can unambiguously be established, this by no means leads us to an easy judgment about whether or not the person is ill. This is because illness is not a physiological matter—it is a social one…. Much of our judgment rests on cultural prescription, norms and values surrounding our ability to perform our usual activities. (p. 37) That is, all these decisions rest on knowledge, symbols, and practices that are socially constructed and legitimated by an institutional logic—“a set of material practices and symbolic constructions—which constitutes its organizing principles and which is available to organizations and individuals to elaborate” (Friedland & Alford, 1991, p. 248; Thornton & Ocasio, 1999). Such logic sanctions the moral assumptions and practices by which human service workers organize and construct their work, which, in turn, reproduces the institutional logic. In this context, the organization or the workers can also become moral entrepreneurs as they challenge existing institutional logic by choosing to pursue alternative moral assumptions and practices. The organization may ignore, defy, or manipulate the logic in its practices (Oliver, 1991), or the workers may embed their own moral values in their practices (Hasenfeld & Weaver, 1996). The Primacy of the Institutional Environment Recognizing that human service organizations engage in moral work implies that they must constantly seek and maintain legitimacy for what they do. They do so by making references to institutionalized moral systems in their environment. That is, they adopt and uphold moral systems and cultural frames that resonate well with their significant audiences, such as legislative bodies, government bureaucracies, regulatory agencies, professional associations, other human service organizations, various civic and political associations, and clients (Scott, 2008). In this sense, human service organizations are archetypically “institutionalized organizations.” That is, their growth and survival depend less on the technical proficiency of their work and more on their conformity with dominant cultural symbols and belief systems, that is, institutional rules (Meyer & Rowan, 1977). For human service organizations, the primary sources of these institutional rules are generally the state and the professions. Compliance with state policies and regulations provides the legal foundation for the organization's existence and is a prerequisite for the attainment of public funds. The professions, in turn, sanction the service technologies used by the organization. Thus, human service organizations are highly dependent on their institutional environment for legitimacy, and it is the key to garner other resources. Yet the institutional environment in a culturally pluralistic society is both heterogeneous and turbulent. It consists of diverse interest groups upholding conflicting values and norms. Despite the hegemony of the state and the professions, they too embody competing ideologies, resulting in instability and change. Moreover, social forces such as increasing ethnic heterogeneity, the aging of the population, the entry of women into the labor force, and the introduction of new technologies all find normative expressions, which contribute to the turbulence in the institutional environment. As a result, human service organizations often encounter multiple and conflicting institutional logics. On the one hand, these different logics provide the organizations with the opportunity to choose those that are more consonant with their own ideologies and adaptive to their particular environments. But such a choice comes with a price as the organizations face challenges, opposition, and competition from those adhering to alternative logics. In addition, the organizations must also accommodate new, ascending moral systems. What was considered an acceptable way of serving people yesterday may rapidly become unacceptable today. For example, the moral precept that gay or lesbian couples are unfit to be foster care or adoptive parents is being seriously challenged, and advances in medical technologies have produced moral dilemmas for health professionals regarding prolonging the life of the terminally ill. Operating in a turbulent institutional environment means that human service organizations cannot take their legitimacy for granted. Welfare departments, for example, experience periodic legislative amendments, reflecting changing moral assumptions about poor single mothers that redefine who is “deserving” of public aid and under what conditions. These new institutional rules, in turn, are expressed in the structure and processes of the departments (Hasenfeld, 2000). The state of “chronic crisis” that many human service organizations find themselves in is often attributed to fiscal uncertainties. While these may be real, typically most human services experience relatively small fluctuations in funding levels from year to year (Gronbjerg, 1993). Rather, it is the need to periodically reaffirm the consonance of the organization's mission with changing and conflicting institutional logics in order to justify its quest for resources and shore up its legitimacy that generates the aura of a crisis. For example, nonprofit human service organizations are facing a changing institutional environment, particularly the adoption by funding organizations of New Public Management (NPM), which emphasizes the importance of efficiency and the superiority of corporate management tools. The new institutional logic clashes with what Frumkin and Andre-Clark (2000) term “the expressive character of nonprofit activity—the way nonprofits allow people to demonstrate commitment to social ends and values” (p. 142). Indeed, one of the characteristics of human service organizations is that they experience cyclical legitimacy crises. The organization maybe founded as a response to moral entrepreneurship, such as the community mental health movement. As the organization institutionalizes the new moral system through its service system, it is gradually taken for granted, and the social awareness of the problem may fade into the background. The organization may find that its legitimacy begins to erode, especially when some disappointment sets in that the social problem has not been resolved (Hirschman, 1982; Zucker, 1988), as exemplified in the limited success in integrating the chronically mentally ill into the community. Moreover, changes in the environment, such as the increasing number of homeless chronically mentally ill persons, may cast a new perspective on the social problem and give rise to contending moral systems, which challenge the organizational legitimacy. A legitimacy crisis ensues from questioning, for example, the wisdom of community-based care for the chronically mentally ill (e.g., Johnson, 1990). The organization is forced to buttress its legitimacy through renewed moral entrepreneurship and realignment of the moral system that guides its services. Once the crisis is weathered, the cycle is bound to repeat itself. Moral entrepreneurship is common in human service organizations as they attempt to influence public conceptions via the moral categorization of their clients and the services they provide (Hasenfeld & Gidron, 2005). For example, rape crisis centers have had a profound effect on the responses of law enforcement agencies and hospitals to rape victims (Martin, 2005). Cress and Snow (2000) show how social movement organizations advocating for the homeless were successful in obtaining social rights for the homeless (e.g., the right to vote, go to school, obtain welfare, and be protected from discriminatory practices by the police), in part by the ways they framed the issue to resonate well with dominant moral beliefs, for example, that homeless children for no fault of their own should be able to go to school. Moral entrepreneurship, however, also occurs through the day-to-day work with clients. Nurses, for example, can be viewed as “moral agents” because they develop their own conceptions of who is a “good” or “compliant” patient, which may be quite at variance with the official norms. Yet their own conceptions influence their interactions with patients (Varcoe et al., 2003). More generally, as noted by Maynard-Moody and Musheno (2003), police officers, teachers, and counselors regularly act as moral agents, responding to their clients by making moral decisions that are not dictated and may even contradict their official “state agent” roles. The Institutional Bases of Human Service Technologies Moral work in a highly institutionalized environment requires human service organizations to select technologies that are socially approved and sanctioned. These technologies must be consonant with dominant cultural beliefs about what is desirable and acceptable to do to people. Hence, the ability of the organization to select a service technology is constrained not just by the available repertoire of technologies (i.e., the technological environment) but mostly by the sanctioned practices (i.e., institutional logic) endorsed by key institutional actors such as regulatory agencies, funding organizations, other human service organizations, academic and research organizations, and professional associations. There is, clearly, considerable interdependence between the technological and the institutional environments. Institutional rules and enforcement agencies define and constrain the technologies that human service organizations can use, while technological innovations and developments challenge and modify existing institutional rules. Technologies ascend in importance as they gain greater legitimacy in the institutional environment. They do so not only because of their demonstrated efficacy, which in itself is a negotiated process, but also because they are supported by politically powerful interest groups that influence the discourse, the knowledge, and the cultural symbols that reinforce the merits and moral benefits of the technologies. Maguire (2002), for example, points to the critical importance of patients with AIDS (PWA) and their advocates in organizing for obtaining approval of experimental drugs on the basis of “compassionate use” and clinical use by a community network of physicians, criteria normally unacceptable to the Food and Drug Administration (FDA). A whole network of PWA, advocacy groups (i.e., ACT UP), physicians, and clinical researchers used their political power and cultural resources to force the FDA to abandon its institutional rules and accept a new discourse about what counts as evidence of drug efficacy (see also Meyer, this volume). Professional dominance enables its practitioners to legitimate service technologies that protect and enhance the values and exclusivity of the profession. The use of psychotropic drugs to treat the chronically mentally ill has become the dominant mode of treatment, because they have been shown to reduce clinical relapse, the major criterion of effectiveness adopted by psychiatrists. Effects on the quality of patients' life, the impact of “side effects,” the alternative uses of social therapy, and the feelings of the patients themselves toward the medication, while recognized as significant issues, assume only secondary, if not marginal, importance in the social validation of the technology that is dominated by the medical model (Estroff, 1981). Similarly, Heritage and Lindstrom (1998) show how community nurses who visit first-time mothers dialogue with them in ways that assert the nurses' “baby expertise” while raising questions about the competence of the mothers and reinforce what the nurses consider appropriate practices. The importance of cultural values, political forces, and bureaucratic inertia in adopting service technologies can also be gleaned from the dominance of “work first” in the implementation of the welfare reform legislation known as Temporary Assistance for Needy Families (TANF). There is a standard content and sequence to “work first.” Recipients must attend an orientation, followed by a period of time in job club, before proceeding with an individualized job search. Welfare recipients who fail to get a job are typically recycled through the sequence again, with the possible addition of remedial education or time-limited vocational training. “Work first” has become the dominant service technology because it affirms the myth that welfare recipients lack in work ethic and prefer to depend on welfare. It employs ceremonies for sending recipients to job club/job search as confirmation that little preparation, but rather motivation, is needed to find a job. It comports well with the eligibility culture of welfare departments by providing a readily available “work test” of deservingness. Applicants or recipients failing to participate in job search become undeserving of cash aid. The service technology can be easily routinized. The processing of recipients into job search does not require extensive individualized practices, nor does it entail implementing complex employment services. The “work first” service technology relies on sanctions and threat of sanctions to attain compliance. It precludes the need to invest in extensive worker-client relations. At the same time, it grants case managers considerable discretion. Finally, “work first” is relatively inexpensive, requires limited case management expertise, and has the virtue of deterring applications and hastening exit (Handler & Hasenfeld, 2007). Human Service Technologies in Practice: Managing Indeterminacy A key characteristic of many human service technologies is their indeterminacy. That is, they generally lack certainty and predictability about the outcome of their application. While cause-effect relations might be demonstrated through experiments and clinical trials, these intervention models are typically decontextualized in that they do not account for variations in the environment, including cultural, political, economic, and demographic factors. Thus, once the technology is put into practice, many contextual factors can intervene to undermine its expected efficacy (on the difference between treatment efficacy and effectiveness, see Nathan, Stuart, & Dolan, 2000). At the institutional level, as noted above, competing service technologies can often be justified by appeals to dominant values, norms, and rules. At the organizational level, resource constraints, competing demands from key stakeholders, quality of staff, and internal systems of monitoring and rewards are likely to affect how the technology is actually practiced (B. Smith, this volume). At the worker level, personal beliefs, knowledge, expertise and experience, and conditions of work influence how each worker applies the technology and adapts it to his or her work context. At the client level, the attributes targeted for intervention vary from person to person, and the attributes interact with others in ways that cannot be readily isolated and controlled (Hasenfeld, 1983). In the face of technological indeterminacy, human service organizations and their workers have considerable discretion in making assumptions about the attributes of their clients and the state of knowledge of how to serve them. As noted above, they do so by taking into account the institutional logics that are dominant in their environment and balancing them with their own organizational, professional, and personal interests and needs. The assumptions the organization makes about the attributes of its clients and about the state of its knowledge and technical know-how constitute its practice ideology. Hence, the service technology is an enactment of the organization's practice ideology. Consider, for example, two popular social work intervention technologies, ego-psychological and cognitive-behavioral. Each is based on a distinct practice ideology. According to Turner (1995), ego-psychological social work assumes that (a) ego development is a process of learning and maturation, (b) ego strength indicates neutralization of instinctual energy, (c) people strive for self-reliance and are rational, (d) people can change through broadening of coping skills and integrative abilities, (e) the focus of therapy is on ego functioning and defenses, and (f) the role of the social worker is to provide support, clarification, ventilation, and insight. Cognitive-behavioral therapy assumes that (a) thinking shapes behavior, (b) individuals are rationally motivated and strive for self-actualization, (c) the person's nature is neither good nor bad but can be trained in each direction, (d) people are highly rational, people can change through cognitive reorganization, (e) the focus of therapy is on teaching and reflective thinking, and (f) the role of the social worker is to point to cognitive contradictions and to do reality testing. One can readily surmise how each practice ideology will enact a very different service technology for people with the same psychological needs. Similarly, different practice ideologies about nursing care will result in distinct practices. In some nursing homes, staff members tend to assume that their residents are all alike and focus mostly on their common physical needs. The technology becomes largely custodial, with standardized routines followed in managing the residents' daily lives. Other homes, in contrast, are more likely to acknowledge and respect the differences among the residents and to recognize their psychosocial needs as well. The technology becomes more complex and treatment oriented, with a mixture of standardized and individualized daily management procedures (Shield, 1988). Practice ideologies are self-reifying in the sense that they provide the rationale for the organizational practices, which, in turn, confirm the validity of the ideologies. For example, research has shown that child welfare workers tend to base their placement and service decisions mostly on the gender, age, and prior labels assigned to the child (e.g., “sexually abused,” “substance abuser”) rather than on the basis of the assessment instruments that the workers administer (Martin, Peters, & Glisson, 1998). By ignoring the assessment results, the service and placement decisions reify the very practice ideologies that justify their decisions. Finally, measures of effectiveness in human service organizations also involve explicit or implicit moral choices, which are embedded in the practice ideologies. What is evaluated includes not only some objective measures, such as reduction in morbidity or prevention of physical abuse, but also subjective constructs that give moral meaning to these measures. Measuring reduction in morbidity without attention to the quality of life of those who survive is a moral choice. Assessing the effectiveness of welfare work programs in reducing welfare costs without consideration of the psychological costs and benefits to the mothers and their children casts the objective measures in a particular subjectively constructed moral context. Consequently, measures of effectiveness of human services invariably emanate from the moral systems embraced by the organization (on the issues of measuring effectiveness, see D'Aunno, 1992). There is another important source of technological indeterminacy that distinguishes human service organizations, which has to do with the ability of the clients to react and influence the course of the service technology. The reactivity of the clients and their potential capacity to neutralize the effects of the service technology means that the organization cannot take for granted the processes and outcomes of its service technology, even if it is assumed to be highly determinate. The ability of the clients to respond and the need of the staff to react to these very responses are captured in the concept of service trajectory (Strauss, Fargerhaugh, Suczek, & Wiener, 1985, p. 8). This denotes not only the course of the client's problem or need itself but also the entire social organization of the work that is done over that course. It encompasses the responses of the staff to the client as well as to each other as they work with the client, the reactions of the client and significant others (e.g., family, friends), and the subsequent responses of the staff. There are two interrelated features to the service trajectory that must be addressed: the handling of contingencies and the management of client compliance. Contingencies arise because neither the reactions of the clients nor the responses of the staff are fully controllable. This is especially the case when (a) the client presents multiple problems or needs, (b) others in the client's social network are involved, and (c) several workers interact with the client. The primary aim of the staff, then, is to manage the contingencies in order to control the service trajectory and to minimize unanticipated consequences. Diagnosis is a key mechanism to control the trajectory because it provides the staff with a defined course of action. Diagnosis is the process of collecting and assessing information about the client's attributes to typify them into known and “normal” service categories while discarding what are considered irrelevant attributes. As Abbott (1988) puts it, “Diagnosis not only seeks the right professional category for a client, but also removes the client's extraneous qualities. If the client is an individual, such extraneous qualities often include his or her emotional or financial relation to the ‘problem’” (pp. 40–41). Abbott further suggests that the diagnostic classification is constrained by the body of knowledge adopted by the staff and by the availability of treatment schemes. Thus, the diagnosis echoes these constraints and has a reifying quality in that it establishes a set of behavioral expectations for both clients and workers. Only when workers' expectations of the client are not met is the diagnosis questioned and revised. At the same time, it is important to emphasize that the application of diagnostic categories such as DSM-IV not only reflects the particular professional orientation of the practitioners (i.e., psychologist, psychiatrist, social worker) and their own personal background but is also affected by the gender and ethnic background of the client (Pottick, Kirk, Hsieh, & Tian, 2007). Isolating the client from “extraneous” factors and compartmentalizing the client's problems and needs are additional mechanisms to control the service trajectory. The isolation, at times, maybe physical (i.e., hospital, prison), but most likely it is social and psychological. Such isolation takes place by limiting the ability of the client to introduce social relations and attributes not deemed relevant into the service process. For example, welfare recipients learn quickly that their difficult and often unpredictable life circumstances might not be taken into account when they are required to comply with work requirements (Brodkin, 1997). Compartmentalization of the client's needs means that the staff can specialize by attending to a limited set of client attributes while delegating to other workers client concerns and issues that are not perceived to be within their purview. The total service trajectory can become fragmented into distinct subtrajectories, each more readily controllable than the whole. Messinger (2006) recounts, in a case study of psychiatric ER, how the psychiatrist, social worker, addiction counselor, and activity therapist, applying their own distinct competencies, develop competing perspectives and approaches to the same case without necessarily coordinating with each other. In doing so, they reaffirm their own occupational domain. Clients must be controlled so that their reactions do not neutralize the effects of the technology and indeed are appropriate and supportive of workers' activities on their behalf. In many instances, the success of the technology hinges on the very active involvement of the clients in their treatment, as in the case of renal dialysis. How to achieve client compliance becomes a major concern in managing the service trajectory. Control is initiated at the point of entry by selecting clients who are viewed as amenable to the service technology and by “cooling out” those who are deemed undesirable. For example, knowing that to get medical care in public hospitals' emergency rooms would entail a very long waiting time screens out many patients who, despite being ill, opt out from getting needed services (Wellstood, Wilson, &Eyles, 2005). Control is also exercised through “tracking” the clients into various service trajectories, which, in turn, limit and constrain their options. Tracking tends to be self-reifying in the sense that the consequences of tracking reaffirm its rationale. Condron (2008) shows that when teachers instruct students in homogenous groups on the basis of initially unequal reading skills, this promotes accelerated learning among high-grouped students but decelerated learning among low-grouped students compared to what would have occurred had the students not been grouped. (p. 386) Once embarked on a service trajectory, workers use their power resources to attain client compliance, without which they cannot control the behavior change process. The power resources include a mix of inducements, threats, and persuasions (Hasenfeld & Weaver, 1996). The choice of strategies reflects not only the nature of the technology itself but also the organizational practice ideologies, especially the assumptions staff make about the moral status and the determinants of the behavior of their clients. When clients are accorded a higher moral status, workers are more likely to rely on persuasion. In contrast, when clients, such as welfare recipients, are morally suspect, threats, such as sanctions, are the predominant means of control (Hasenfeld, Ghose, & Larson, 2004). In turn, this mix will determine the degree of trust that will be formed between workers and clients, the commitment of clients to the change process, and the extent to which clients try to stay with or escape the program's prescriptions. Several studies have shown that client compliance increases the more workers rely on inducements and persuasion. In contrast, when workers rely on threats, such as sanctions, clients tend to engage in flight behavior, and compliance is not improved (Lee, Slack, & Lewis, 2004). Of course, compliance is never fully assured because clients can use their agency capacity to find active and passive ways to evade the means of control. Therefore, the service trajectory cannot be completely controlled, thus introducing an element of uncertainty into the technology even when it is quite standard and routine. The Centrality of Client-Worker Relations It should become apparent from the discussion thus far that client-worker relations are at the core of human service organizations. These relations are the primary vehicle through which workers carry out their work. Worker-client relations structure the content and interpretation of the information elicited from the clients to assess their service needs. They set in motion a typification process that affixes clients with officially sanctioned categories that, in turn, prescribe and justify an array of interventions and services clients are assigned to. In the case of welfare-to-work, for example, the typification may include categories such as job ready, deferred, noncompliant, or exempt, each of which triggers a set of service decisions. Assessment, typification, and service assignments establish a trajectory through which clients are expected to traverse in order to reach the desired outcomes. Worker-client relations also structure the manner and content in which workers monitor the trajectory course of their clients and the extent to which they use the information, including feedback from their clients, to make trajectory corrections. The interpersonal exchanges between workers and clients are a central feature of workers' intervention tool kits. It is through these exchanges that workers attempt to bring about the desired behavioral changes. Workers use their persona to motivate and influence the clients to adopt the desired behaviors. As noted below, workers engage in emotional work to produce the desired responses from their clients (Leidner, 1999). As a result, workers adopt a series of scripts and modes of self-presentation to handle their clients, which, in turn, influence how well the clients respond. The quality of client-worker relations becomes paramount when any one or more of these conditions exist: (a) clients must have continuous contact with the organization, (b) the technology requires extensive exploration of the client's biographical time and space, (c) interpersonal relations are a major mode of intervention, (d) the client's compliance is essential, and (e) the stakes of the intervention are high—it can alter the client's welfare or well-being. When any of these conditions prevail, the effectiveness of client-worker relations hinges on their ability to generate client cooperation. From the perspectives of both the organization and the clients, the best form of cooperation is that which is based on trust. Cooperation that arises from either fear or manipulation of rewards is neither stable nor efficient. It requires the organization and the clients to maintain constant vigilance and to expend considerable resources in maintaining it. In contrast, cooperation based on trust is more stable, and once attained, it is intrinsically rewarding. Trust is an elusive concept. According to Baier (1986), trust means that I rely on the goodwill of another person, which makes me vulnerable to the limits of that goodwill. Such vulnerability creates the potential of being harmed by the other person, yet the essence of trust is that I have confidence that this will not happen. I am willing to put myself in such a state of vulnerability because I need the resources that the other person controls. In this sense, trust is a “risky investment” (di Luzio, 2006). In the organizational context, trust tends to be impersonal, in the sense that it is based on limited and sporadic contact between clients and organizational agents (e.g., social workers, physicians), who, most important, do not share other social ties (Shapiro, 1987). To develop trust in this type of social relationship, two important and interrelated issues must be addressed: (1) discretion and (2) power (Handler, 1990). Staff discretion is endemic in human service organizations precisely because the delivery of the services depends on client-worker relations. Discretion means that the clients become dependent on the goodwill of the workers and are thus vulnerable to abuse. Although administrative due process is designed to protect clients from abuse, Handler (1986) has shown convincingly that reliance on due process to curb discretion is unworkable, especially when clients are dependent on workers for the resources they need and must transact with the workers on a continuous basis. This points to the second feature of the social relationship that impersonal trust attempts to regulate—power. By their very nature, human service organizations have considerable power over their clients because the organization controls vital resources needed by the clients, while they, as individuals, seldom control the resources needed by the organization (Hasenfeld, 1987). Such power advantage is translated into an asymmetry of power between workers and clients and is the ultimate basis for client compliance. Such asymmetry is expressed in workers' control of information, expertise, and access to needed resources. In addition to compliance with institutional rules, human service organizations often rely on a contract to regulate the unequal power relations between workers and clients. As Shapiro (1987) notes, Contracts enunciate the principal's preferences and priorities, disclose the responsibilities and obligations of the agents, explicitly state the procedures agents are to follow and the decision rules they are to employ (thereby limiting agent discretion), plan for contingencies, create incentives for contractual compliance, and specify sanctions to be imposed if agreements are not kept. (p. 632) But I have already noted that the very nature of work on people makes it next to impossible to explicitly enunciate all the conditions of the contract, and it suffers from the same limitations as administrative due process safeguards. A contract also assumes a certain degree of power balance, which normally does not exist in client-worker relations. Thus, the development of trusting client-worker relations is seen as the fundamental safeguard and a sign that the worker's power advantage will not be abused. Yet the difficulty with trust is that it can be “blind”—that is, the powerless clients are expected to trust the workers because the workers are experts, occupy positions of authority, and subscribe to a code of ethics, in short, because they are indeed in a powerful and privileged position. It is easy, and often expected, to attribute trust to persons in socially sanctioned powerful positions. Katz (1984) describes how physicians prefer what he terms “trust in silence,” that is, the willingness of the patient to trust that the physician will make the right decisions without the need for conversation or dialogue. Therefore, the basis for trust becomes an important consideration in assessing the quality of client-worker relations. Baier (1986) distinguishes between morally decent and morally rotten trust. The former is based on the notion that knowing each other's motives for participating in the relationship will strengthen the entrusting qualities of the relationship. As Handler (1990) puts it, such trust arises when “there are mutual respect, common bond, genuine listening, and openness” (p. 103). The problem in developing such trust is that it requires highly personalized relations in an organizational context that, by definition, constrains their development. There are different degrees to which human services organizations can structure their client-worker relations to encourage personalized relationships. Handler suggests three factors: (1) professional norms that advocate active participation by clients, (2) a service technology whose success hinges on client involvement, and (3) financial incentives that reward the workers (and the organization) for treating clients as subjects rather than objects. Such conditions, however, are not readily enacted. Professional norms may be mostly symbolic and ceremonial, what is defined as success is organizationally constructed, and human services are seldom dependent directly on clients for fiscal resources. As Shapiro (1987) argues, “The principals of impersonal trust are vulnerable and impotent” (p. 635) because the clients interact with organizational agents whose ability to develop highly personalized relations, needed for morally decent trust, is restricted. Indeed, there may be good reasons to curb personalized relationships in client-worker interactions because they can undermine other important values such as equality of access and treatment, universalism, unbiased judgment, and protection from favoritism. One of the chief strengths of formal organizations is their ability to purge particularism (Perrow, 1986). Encouraging personalized relationships to promote trust heightens the risk, always present, of particularism taking precedence. In response to this dilemma, human service organizations are embedded in a complex system of internal and external control mechanisms whose purpose is to guard the trustworthiness and fairness of workers' relations with their clients. These include internal mechanisms such as socialization, standard operating procedures and norms about workers' conduct, record keeping and monitoring, and supervision. External mechanisms may include professional accreditation, governmental regulations, liability insurance, and auditing. In general, these mechanisms seem to guard impersonal trust reasonably well. Yet as Shapiro (1987) points out, “By increasing agent liability for failure of trust, we foster self-protective acts—unnecessary tests or surgery, unwarranted conservatism” (p. 651). In human service organizations, these also include excessive paperwork, bureaucratic rigidity, and some degree of distancing from the clients. In the final analysis, a necessary, though not sufficient, condition for morally decent trust to emerge is the existence of some degree of power balance between clients and workers (Hasenfeld, 1987). That is, the well-being of the worker is enhanced by investing in the well-being of the client and vice versa. It is such mutual dependence that is most likely to foster mutual respect and trust. That this condition does not normally exist in human service organizations attests to the difficulty in relying on trust to protect the clients. It also explains why the quality of human services is highly stratified by the relative power that clients possess, and it is a key to understanding the enigma of human service organizations. There are organizational forms that do enhance the power balance between workers and clients. Collectivist organizations, such as feminist service organizations (Bordt, 1998; Hyde, 1992), cooperative schools (Rothschild-Whitt, 1979), and hybrid voluntary organizations (Hasenfeld & Gidron, 2005), have structural characteristics that minimize hierarchical relations, give clients a major voice in shaping the values and mission of the organization, develop a service technology that actively involves clients in the delivery of services, and give clients an important role in monitoring and evaluating the staff. What these organizations share in common is a mission aimed at empowering their clients, a service delivery system that expresses their distinct values, a collective identity that responds to the expressive and social identity needs of staff and clients, and an internal structure that facilitates these multiple aims (Hasenfeld & Gidron, 2005). Still, as I note below, in the case of feminist organizations, such organizational forms are difficult to sustain. Emotional Work The centrality of worker-client relations points to the critical role of emotional work in structuring, navigating, and controlling these relations (see Guy, Newman, Mastracci, & Maynard-Moody, this volume.) In people work, both workers and clients use their emotions as ways to communicate and influence each other. Hareli and Rafaeli (2008) point out that a “person's emotion is a factor that can shape the behaviors, thoughts and emotions of other people” (p. 36). Indeed, the deliberate use of emotions in worker-client relations (i.e., emotional work) sends signals about the worker's and the client's social status and power, competence, credibility, and trustworthiness. Hochschild (1983), in her seminal work on flight attendants, coined the phrase emotional labor, by which she means organizational rules aimed to “induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others” (p. 7). The organization defines how workers should display feelings and in doing so appropriate them for organizational purposes. The displayed feelings may not actually be authentic but rather manufactured to meet specific organizational needs. Hochschild (1983) distinguishes between surface acting, in which workers display emotions that are inauthentic, and deep acting, which conveys true inner feelings and emotions. It has been proposed that when emotional labor is inauthentic, it leads to emotional exhaustion and alienation, though the empirical evidence is mixed (Leidner, 1999). Clearly, the organizational setting shapes emotional work. It is the organization that defines what client emotions, if any, are considered acceptable and relevant and what repertoire of emotions the workers are expected to display. In organizations where the relations between workers and clients are limited to a few encounters, as in the case of welfare eligibility determination, limited attention is given to emotional work. Workers may be scripted on how to handle the encounters, such as to be courteous, to remain unaffected by the applicants' emotional expressions, and to adhere closely to the computer-prompted interview protocol. However, when the relationship between workers and clients is over an extended period of time, as in the provision of case management or counseling, emotional work becomes a major organizational concern, particularly if the leadership and management of the organization view the quality of the relationship as important to organizational success (Leidner, 1999). The organization attempts to ensure proper emotional work through various mechanisms, including the type of workers it recruits, their training and socialization, and the scripting and feeling rules it enacts. Supervision, as a means of controlling emotional work, often centers on the quality of the emotional work and the proper handling of emotional exchanges between workers and clients. These mechanisms, coupled with daily personal and collective practices, teach workers how to manage their own emotions, how to develop needed self-awareness and self-control, and how to use emotions to elicit appropriate responses from their clients. Emotional work can be viewed as an important organizational resource. The organization mobilizes emotional work because it can enhance its service delivery process, improve service outcomes, and contribute to the satisfaction of clients and workers. When the organization harnesses emotional work as a resource, it converts it into emotional intelligence (Goleman, 1998), which is defined as “the ability to perceive emotions, to access and generate emotions so as to assist thought, to understand emotions and emotional knowledge, and to reflectively regulate emotions so as to promote emotional and intellectual growth” (Mayer & Salovey, 1997, p. 5). Since emotional work is generally provided by female workers (see below), there is some evidence that organizations such as public schools benefit from an increase in the proportion of female staff. Meier, Mastracci, and Wilson (2006) find that an increase in the percentage of female teachers is associated with higher classroom attendance, decline in teacher turnover, and improved students' performance. Thus, how the organization manages emotional work will have a significant impact on client experiences and outcomes. Lopez (2006), in his study of nursing homes, distinguishes between two opposing kinds of organizational emotion management. At one end, the organization prescribes what, when, and how workers should display emotions in their encounters with clients. Lopez terms that “emotional labor” because it is coerced on the workers and is essentially inauthentic. At the other end, the organization develops rules and practices that enable the workers to use their emotions as a way of creating a nurturing and caring relationship with the clients. Lopez terms such emotional work as “organized emotional care.” In a nursing home that embraces emotional labor, nurse's aides are expected to act “professionally,” which means to control their emotions, not to express personal feelings, to remain neutral in response to emotional expressions and outbursts by residents, and to avoid sharing personal feelings with them. In contrast, at a nursing home that fosters “organized emotional care,” structured opportunities are created for nurse's aides and other staff to respond positively to the emotional needs of the residents, to deliberately interact with them to reduce a sense of isolation, and to feel comfortable in sharing personal experiences if these enhance the caring relationship. Use of emotions by workers also reflects the moral assumptions staff make about their clients (Maynard-Moody & Musheno, 2003). In his case study of a youth shelter, Karabanow (1999) points out how an organizational culture that accords high moral worth to street youth, accepts the youth for “who they are,” and treats them as subjects and co-equal to the staff is reinforced by intense emotional work. The workers are expected to devote themselves to the youth, “open their hearts” to the kids, be available to them at any time, and provide them with a great deal of emotional support, even when such support taxes the workers' own personal emotions. Similarly, in her study of rape crises centers, Martin (this volume) shows that the centers are driven by a fundamental moral assumption about the trustworthiness of the victims. Therefore, the workers are expected to provide victims with empathic counseling, to always accept their accounts, and to apologize for their experiences, even when the workers may harbor personal doubts about such accounts. Undoubtedly, the organizational demand for such intense emotional work can tax the workers beyond what they may feel is appropriate to protect their own emotional needs. When clients are viewed as morally worthy, workers are much more likely to be sensitive to their emotional expressions and needs and to respond to them positively. Maynard-Moody and Musheno (2003) present the following account by a vocational rehabilitation counselor who deemed his client morally worthy: I met [Carol] for the first time at the… clinic. She was a very angry woman who hated systems and didn't want to ask for help… As Carol was saying different things, she would often cover her mouth when she attempted to smile. At one point I noticed that Carol was missing several of her teeth… In an effort not to embarrass Carol, I decided to give Carol a laundry list of services that the VR is able to offer… When I mentioned dental exams, her eyes lit up and she smiled—immediately covering her mouth with her hand—and said “Oh, I didn't know you did dental stuff…” I set her up for a dental exam. She was very anxious yet excited. It was determined that a partial denture would be the best option. (pp. 111–112) In contrast, when the organization devalues its clients, as is the case of welfare departments, w