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chapter_9.docxYou may have gathered by now that the human services field is quite complex. Complete agreement regarding philosophies, methods, goals, services, funding, or anything else just does not exist, nor, from our point of view, should it. At times controversies and differences are stimulating, healthy, and valid and lead to creative solutions. At other times, these disagreements are repetitious, meaningless, and destructive. Too frequently they consume time, energy, and resources that might better be used providing needed services. To this end, it is highly recommended that students become familiar with the books in the Opposing Viewpoints series, published by the Greenhaven Press, which deal with issues of concern to human services workers.
The purpose of this chapter is to present a sampling of basic controversies and issues in the field of human services that have not yet been resolved and may never be resolved to everyone's satisfaction. The questions raised in this chapter influence all human services workers. The human services worker is more directly affected by some issues than others, but they all impact the worker and the services provided. Prior knowledge of these and other controversies helps workers know what they can expect from colleagues, politicians, consumers of human services, and the general public. This knowledge can be instrumental in helping workers provide more effective services.
No attempt is made to resolve these issues here. Views are often implied by the way issues are presented. Furthermore, there is no expectation that the reader will come to any specific conclusions or agree with any particular point of view. Issues, conditions, and people change, and many old issues reemerge that give the appearance of new issues. These so-called new issues have, in all probability, been with us in one way or another, and to one degree or another, for as long as the human services profession has existed. Some examples are discussed in this chapter. The idea is to examine them and understand their significance to human services workers and to the provision of human services, for they very frequently raise questions regarding one's personal and professional values and ethics.
CLASH OF VALUES IN SOCIAL POLICIES
At the outset, it is worth repeating that complete agreement about social policies in the human services rarely occurs. Social policies are supposedly based on morals and values; however, no consensus exists about what is morally right. Jansson (1988) was one of the first to identify five moral issues involved with social welfare policies that are still relevant today. In discussing them, it will become quite clear that they are all closely related and overlap each other in many ways. Following are the issues and some of the questions they raise.
1. Morality of social services. Who shall receive services, and on what terms? (p. 5)
Questions: Shall services be given to only those who are unable to work? What about (a) those who cannot find work or (b) those who cannot earn enough to stay above the poverty line? Should those who receive benefits be required to work in the community? Should those on welfare not receive increased benefits for additional children?
2. Nature of social obligations. For what needs and problems is society responsible, and which shall receive priority? (p. 5)
Questions: Are we our brothers' keepers? Is society responsible for providing for all who cannot care for themselves? Should society provide for only food, shelter, clothing, and medical care? What about education, cultural enrichment, and economic needs?
3. Preferred interventions. What kind of policy remedies should be chosen to address specific social problems? (p. 5)
Questions: Should drug abusers be jailed, or should drugs be legalized? Should society emphasize treatment and prevention of drug abuse, or should the focus primarily be on keeping drugs from entering the country and on enforcement of anti-drug laws? Should society prohibit abortions, or continue to allow them, and on what terms? Should there be gun control, and on what terms? Should society force the homeless into shelters or hospitals, or jail them if they refuse to go to either?
4. Compensatory strategies. Should society give preferential assistance or treatment to members of specific groups that lag behind the rest of the population in economic and other conditions? (p. 5)
Questions: Does not society do this through welfare and other programs? The real question is, to what extent and when does society provide assistance and treatment? Should society guarantee basic health care for those who cannot afford such care? Should affirmative action programs, which seek to guarantee jobs, education placements, and contract work to members of minorities, take precedence over equal opportunity programs?
5. Magnitude of federal policy roles. What policy powers should federal authorities possess, and what should be the magnitude of federal social spending? (p. 5)
Questions: Is the federal government too large? Are state and local governments better able to know and understand the needs of their people? Should the federal government step in to meet the needs of its citizens if state and local governments cannot? Does the federal government, through its policies and funding power, wield too much influence on state and local policies and practices? Should federal social spending be limited to maintaining a balanced budget or until additional taxes are needed?
The various interest groups continue to disagree in their answers to these and many other questions. A brief look, however, at just three specific issues dealing with welfare, life, and death will further exemplify the problem.
The proposals being considered some years ago by states regarding benefits to single mothers on welfare who then have additional children raise many moral issues. Conservatives felt that such benefits reward welfare mothers for having more children, thereby providing an incentive for them to become welfare dependent. Conservative opinion was that it is basically irresponsible to bring children into the world if one cannot adequately provide for them. Should society support this perceived irresponsible behavior? Liberals argued that society has an obligation to take care of those in need and that children should not be punished for the behavior of their parents. They also question the assertion that denial of benefits for additional children is an effective way to help the mothers become more independent. They question whether the proposed cuts would really discourage these women from having additional children. Could not society find better ways of helping welfare mothers become independent of the welfare system?
Better yet, cannot society find a way to end poverty?
Euthanasia is usually viewed as an intervention in hastening the death of an individual. The issue of euthanasia was revived suddenly and sharply when a doctor helped a woman suffering with Alzheimer's disease commit suicide. The doctor was charged with murder, but the case was dismissed because there was no state law that prohibited assisted suicides. The same doctor, through the use of devices he developed, assisted two other women to commit suicide (Two doctor-assisted suicides, 1991). In both instances, the doctor provided the means, and the women committed the act. There was no doubt that the women wanted to die; however, several disturbing ethical questions remain: Should assisted suicides be allowed? If so, other questions need answering: Who is to assist, and under what circumstances? Should these decisions be made by the patient, family, doctor, community, all of these, or a combination of some of these?
What criteria should be used to justify active (assisted) or even passive (unassisted) euthanasia? Should the criteria be age, finances, quality of life, life expectancy, health, or any other condition? Should euthanasia be legalized? Should the federal government attempt to override the decision of the voters of a state to legalize euthanasia? Reflecting the cultural and religious diversity in this country, there is a wide range of public opinion about euthanasia. However, in 2002, a Gallup survey indicated 72% of Americans supported euthanasia. The Hemlock Society, which reorganized in 2005 under the name Compassion and Choices, is an advocacy group that supports suicide and assisted suicide for the dying; it strongly endorses the right to die and the legalization of euthanasia (Humphry, 1991). This group, along with other like-minded advocacy groups, was successful in its lobbying efforts with the voters of three states. Presently, Physician Aid in Dying (PAD) or assisted suicide is legal in Oregon, Montana, and more recently (in 2008) in the State of Washington. However, there is a difference between euthanasia and PAD. Euthanasia requires the physician or another third party to administer the medication, whereas PAD requires the patient to self-administer the medication and determine whether or when to do this (Quill, 2008).
Let us take a closer look at how the clash of values creates problems that directly affect human services workers, consumers, and people in general. In presidential campaigns and budget or legislative battles, one constantly hears politicians speak of American values, or what is right. Are the American values of conservatives more valid than those of liberals? Who decides what values are American values? Do liberals know more about what is right than do conservatives? What about individuals, schools, churches and synagogues, or any other institutional perceptions of American values, or of what is right or moral? How one resolves these questions is essential, for it is their attempted resolution that allows us to struggle with occasional success in this democratic society. Some issues that highlight this struggle, touched upon in previous chapters, follow.
For example, is it an American value or morally right both to perpetuate corporate welfare and significantly limit welfare for the poor? Some claim that each is an American value and morally right because it helps the poor get off welfare and helps the economy and the effort to balance the budget. Others claim that corporate welfare should be cut because it is too costly and helps corporations and businesses rather than the individuals in need.
Is it an American value or morally right to maintain a minimum wage that does not provide enough income to raise individuals and families above the poverty level? Some still claim that raising the minimum wage any higher will create inflation and cause the loss of jobs; therefore, it is better not to increase it. Completing the exercise “Ranking American Values” at the end of this chapter might help clarify the many differences and issues regarding the use, and frequent overuse—most often by political candidates and their supporters—of the concept of American values.
Aside from these being significant moral issues and sources of controversy in our society, they are perfect examples of how social policies are influenced through the interpretation of policies and laws (as discussed in Chapter 7).
When does life begin? This is a question that has been fiercely debated for many years. For some it is a philosophical or scientific question, while others view it as a religious one. The issue of abortion and whether women should have the right to choose whether or not to have a child is a deeply personal belief as well as a national political issue. The Supreme Court in its 1973 Roe v. Wade decision affirmed that women should have the right to choose. Since that time antiabortion and pro-choice groups have continued to battle on many fronts.
Various Supreme Court decisions since the 1973 landmark case have weakened the original Roe v. Wades decision. In 1992 the Supreme Court upheld a Pennsylvania law requiring physicians to give counseling to women seeking abortions and mandated a 24-hour waiting period before receiving an abortion. Several other states have passed laws restricting abortions in various ways. Additional restrictions include informed consent, parental notification, and allowing abortion only in cases of rape, incest, and risk to the woman's health. Many of these restrictions are now being contested in the courts (Mandell & Schram, 2012).
Advances in medical science have created additional reproductive choices as well as further ethical and moral questions. Couples unable to conceive children are increasingly turning to in vitro fertilization (IVF) and/or intrauterine insemination (IUI). The national odds for twins are one pair per 90 live births. However, over the past two decades, primarily as a result of IVF and IUI treatments, the twinning rate has doubled nationally. Another factor contributing to the increase in multiple births is the rising average age of pregnant women; the older the woman, the more eggs released. For women who undergo successful fertility treatments, the rate of multiple births is about one in three. Though the incidence of triplets is still somewhat rare, the rate has gone up 300% in 20 years (Bernard & Lindren, 2006). Some couples who have undergone fertility treatment in the hope of having a single child are now faced with the increased possibility of multiple births. Many such couples have elected to have a “reduction” of the pregnancy to a single fetus—that is, reducing the multiple pregnancy of two or three to one.
Often considerations in regard to having a reduction include the increased health risks to the mother and child associated with multiple births, increased financial strain on the family, and increased potential for marital stress and strain on the couple. Decisions to conceive artificially as well as to reduce the pregnancy are often fraught with a complex mix of legal, moral, religious, and political issues.
As discussed more fully in Chapter 5, a human services worker's personal values are always present when working with clients. Should you attempt to hide your own views so your bias does not subtly influence the choices of your client? Will your values and beliefs interfere with your work with a client when a referral to another worker might be appropriate? These and other ethical questions continue to be debated today. Some within the field suggest that referrals are appropriate when moral, religious, or political values are centrally involved in a client's presenting problems. This may cause the worker to be unable to maintain objectivity. However, as Corey, Corey, and Callahan (2010) point out, merely having a conflict of values does not necessarily require a referral; it is possible to work through such a conflict to a successful resolution. When dealing with individuals for whom issues such as these are of central importance, it is essential for workers to be aware of and clear about their own beliefs and values. Workers must convey their views and make their positions known to the client so that their biases do not interfere with the client's decision-making process.
TARGET POPULATIONS: THE STRUGGLE FOR SUPPORT
It would seem that there will always be reductions in the rate of domestic spending in the United States. However, what specifically will be cut and by how much are examples of a clash of values between conservatives and liberals. One might say there is never enough support as long as over 39 million people live in poverty, over 40 million have no health insurance, and so on. Conservatives and liberals alike point out that we cannot afford to help everyone. Although agreement is found in this regard, little agreement can be found on how much we can afford, who should be helped, and by what means. We do know, however, that too many need health care, jobs, nutrition, shelter, vaccines, treatment for mental illness, and welfare, among many other necessities.
The changes in the budgets of social programs raise key questions regarding the role of government in providing services. Who has the ultimate responsibility for the welfare of those in need? Is it the local, state, or federal government? Does government have responsibility for the welfare of only those who are poor? These and other questions will always be raised as long as there are people in need, funds are limited, and those in power make decisions that reflect their values and philosophies. A look at some of those who seek support and the issues they face will help identify the problems one must deal with as a human services worker.
The struggle for support takes place on two major fronts. One is the struggle to gain the moral support of the public, the media, and professionals. That generally involves convincing others that your goals are just and good. The second front, closely related to the first, is the struggle to gain financial support.
Throughout the late 1990s and early 2000s, three populations frequently made the headlines: welfare recipients, AIDS patients, and the homeless. The reason they were so often in the news was that society was desperately trying to provide additional and more effective programs to help and to cope with these people.
One major problem in trying to develop more successful programs for these groups is how they are perceived by others. Much of the public, much of the media, and many politicians, legislators, and officials have a negative attitude toward these people. Frustration and fear of AIDS have given rise to the passage of a series of laws intended to protect the public from people infected with HIV. Myths about the homeless and welfare recipients contribute to the public's negative attitudes. (These issues will be discussed further later in the chapter.) Although many others have very positive attitudes and do whatever they can to help these groups, effective programs are difficult to develop without significant public, media, and professional support.
A second major problem that makes development of more successful programs very difficult is the diversity of values and points of view regarding the most effective ways of dealing with these groups. These two factors lead to the third problem, namely that of funding programs for these and other needy populations. The variety of possible solutions given by the professionals involved in developing programs, as well as those offered by the public and the media, reflects the different and often conflicting philosophies and values that create problems in shaping effective policies and programs. The first group to be considered here will be people with AIDS.
The question of priorities in the funding of treatment and research programs of various social and medical problems has become quite controversial. Because a limited amount of funding is provided for these programs, if funds are increased for one program, must they be reduced in another program? Such a conflict over distribution of funds has now become quite heated in the fight against AIDS. The powerful AIDS lobby has been demanding significant increases in funding for treatment and research for its constituents. However, significant controversy persists about the level of funding that should be supplied for various diseases.
More than 20 years ago Edmondson (1990) urged that the fight against AIDS should be funded at a much higher level than before for two reasons. First, two-thirds of those who die of cancer are over 65 years of age, and over half of those who die of heart disease are over 75 years of age. By comparison, most people who die of AIDS are under 40 years old. Thus, the lives of AIDS patients were cut short, often before their real contributions to society could be made. Those who died at later ages had made their contribution and had lived fuller lives. The second reason given by Edmondson for increased funding for the fight against AIDS was that AIDS is infectious. What would you decide if it were in your power and you had to make such a decision?
There are two additional controversial practices regarding the AIDS issue, both aimed at reducing the spread of the virus: (a) exchanging dirty needles for clean ones for drug users, and (b) distributing condoms to high school students. There is no guarantee, according to critics, that the exchanged needles would not themselves be shared among users. The feeling was that such a program also encouraged drug use. Meanwhile, the New Haven exchange program, authorized by the Connecticut state legislature, provided evidence that such programs could be successful.
The distribution of condoms in high schools under specific conditions has been approved in Philadelphia, San Francisco, Los Angeles, and New York City, among other jurisdictions. The approval in each case was not attained without controversy and struggle. In New York City, for example, it was approved only after a long—and still continuing—struggle against the program by many parents, religious organizations, and others. Opponents of the program claim that none of the demonstration programs were actually proven effective, and there was no guarantee that the condoms provided would actually be used. Such programs, it was felt, encouraged young people to engage in sexual intercourse.
These issues regarding funding and how best to develop programs to prevent the spread of AIDS have led to a great deal of frustration and conflict. Attempts by some infected individuals to purposely infect others have created additional fears. Such problems have given rise to a series of laws to protect the public, some of which overrule previous privacy protection. Some require notification of partners of an infected individual. Others demand testing of segments of the population, and many states make it a crime to purposely and knowingly infect someone (Richardson, 1998).
What else can one—should one—do to help prevent the spread of AIDS?
· Isolate victims from the uninfected population?
· Prohibit children infected with the AIDS virus from attending regular school or day-care centers?
· Distribute free hypodermic needles to drug addicts to prevent the sharing of needles and thus the spread of the virus?
· Teach contraceptive methods in elementary and secondary schools as a form of prevention of the spread of AIDS?
· Mandate testing for the virus and specify who should be tested?
· Make the names of those who test positive available to the public?
When one looks at the problems of the homeless, one finds many different attitudes and approaches to solving them. A conservative candidate back in the 1992 presidential race recommended that the homeless be forcibly taken to shelters or jailed if they resisted and tried to sleep on the streets. Other candidates did not appear to feel that homelessness was an election-year issue, even though the problem seemed to be increasing. Advocates for the homeless, however, strongly urge an increase in subsidized low-income housing.
Others believe that deinstitutionalization is a major cause of homelessness and that mental patients make up the majority of the homeless. Mental illness, however, is not a major cause of homelessness. According to the National Alliance on Mental Illness (2009), about 30% of the homeless are mentally ill. Truly major causes of homelessness are unemployment, underemployment , and the lack of affordable rental housing. A survey by the U.S. Conference of Mayors (2008) found that about 35% of the homeless population work and are still without a home.
Nevertheless, in some jurisdictions the mentally ill have become a political football. If, for example, most of the homeless are considered mentally ill, they become a state problem; if they are not, they are a local problem. Many in the field believe that poverty, not mental illness, is the major cause of homelessness, though some homeless people do need psychological treatment. Income and subsidized housing, many workers believe, would resolve the issue.
For the homeless, should we and can we:
· Allow them to sleep in public places and on the streets?
· Allow them to use and sleep in abandoned buildings?
· Allow them in any business or residential neighborhood they choose?
· Allow them to forage in garbage for food or anything else of value to them?
· Force them off the streets and into shelters or hospitals against their will?
· Provide subsidized housing?
The third group, welfare recipients, is also of major concern to society. Many taxpayers resent paying taxes to support welfare recipients, who are all too frequently stigmatized and stereotyped as being lazy, cheats, and welfare dependent. However, few of these same taxpayers and others realize how many people receive government benefits in one way or another. For example, tobacco, sugar, and dairy farmers, among others, are paid billions of tax dollars each year to limit production and to maintain price levels that ensure profits. Are they the truly needy? What about all those who are able to take deductions on income taxes for health costs, interest on mortgages, entertainment for business, and other items? Although the government does not actually pay cash to these more affluent people, it is, in effect, telling them that they can keep the money they would have to pay were the deductions not allowed. These deductions total billions each year. Actually, it turns out that the more money one makes, the more benefits one may get through increased deductions (Abramovitz, 1991). What about community and state college students who obtain federal and state aid? Tax monies are supporting them in obtaining an education even if they are paying the full tuition. Do they and the others mentioned see themselves as “welfare recipients”? Clearly, we taxpayers have fewer problems with government aid dispensed to “us” rather than to “them,” especially when the “others” are poor and in need of food, clothing, and shelter. The question really is, why are these kinds of benefits acceptable and those for the truly needy less so?
Should it be mandated that welfare recipients
· Take whatever jobs are available, including dead-end jobs?
· Accept jobs, even if the wages would be less than their welfare benefits?
· Participate in job-training programs?
· Perform community service, if jobs are not available, in exchange for some of their benefits?
· Have their extra benefits reduced for additional children?
· Pay the actual cost of their education in community and state colleges (all of which are subsidized by state and local tax monies)?
The many questions raised with each of these groups are controversial enough in their own right. Additional questions arise that may be of particular concern to human services workers. One question has to do with the problem of individual rights versus the rights of the public. Another question has to do with the apparent effort to control these target populations in some fashion. Are we not really attempting to devise behavioral and social controls for people who, for the most part, are victims of situations beyond their control and who, for the most part, have not broken any laws? Other controversies in the human services center around the effects of a conservative government and/or a recession on social programs. The basic question is, whose benefits will be cut?
Regardless of who has control of the purse strings, be they liberals or conservatives, there will always be a limited amount of funds made available for social programs. This is clearly a political decision. The general trend has been that in times of prosperity and/or when liberals are in power, social programs are funded more generously. When conservatives are in power, support for social programs is usually significantly reduced. The major questions then become: Which programs will be reduced or eliminated? Will it be programs serving senior citizens, or school lunch programs, or programs for people with disabilities? What about programs for the homeless, the intellectually and/or developmentally disabled, or the poor? Who will make the decisions?
What criteria would you use in making these choices? These kinds of questions and their answers create all kinds of tensions in the human services field. Oftentimes budget cuts are far deeper in subsidized housing, in job training, and in welfare and education programs than in programs the middle class utilizes most—social security, Medicare, civil service, and military pensions.
Although it is generally acknowledged that all of the groups receiving support have a legitimate claim to that support, it becomes clear that some programs will lose funding when cuts have to be made. Several things happen in such situations. First, the agencies serving the different target populations, and the members of those populations, start competing strenuously with one another for available funds. The most articulate and organized of the various target populations, the ones with the most political influence, generally are more successful in gaining support and funding. As an example, the outcry some time ago by the recipients of social security about the threat of reduced benefits tempered efforts in benefit reduction.
When funds are cut and staff reductions occur, caseloads tend to increase. This then requires a screening process that ensures those in most need get service, while others are turned away. The increased caseload puts additional pressure on the workers, and services to the needy often suffer. Competition and struggle for existence shift the focus, energies, and resources away from a unified effort by target populations and the human services field to increase overall funding for social programs.
SEXUAL EXPRESSION AMONG OLDER ADULTS
In the past, the subject of sexuality among older adults was a topic that received little or no attention. Human services and health care professionals, for the most part, discouraged any type of sexual activity for this group. The prevailing opinion was that older people should gradually disengage from active pursuits, and that this disengagement should include withdrawal from sexual interest and expression. Many professionals even believed that sexual needs and desires simply ceased to exist among older adults.
An active senior couple takes a break from cycling to kiss each other.
Today, however, as we continue to live longer and healthier lives, human services and health care professionals are beginning to reexamine their beliefs about sexuality in late life. Advances in medicine, pharmacology, and medical technology have given all of us the opportunity to pursue an active lifestyle well into later life, including the expression of sexual intimacy. Because of these changes, part of the new role of professionals, especially those working in residential facilities, is to understand the role of sexuality in later life and to promote conditions that allow sexual expression among older adults. As McInnis-Dittrich states in her book Social Work with Older Adults(2009), “sexual interest [among older adults] is an expression of a continuing need for love and intimacy.”
Unfortunately, many professionals have been slow to respond to this need to reexamine attitudes about sexual expression in later life. Some find it difficult to change because of traditional attitudes or because the mere thought of a parent or grandparent engaging in any type of sexual activity is distasteful. Others still view sexual activity among older adults as a health risk, while some others view it as immoral. Clearly, these attitudes can influence how human services and other professionals interact with their older clients, and whether or not they are supportive of their clients' desires for sexual intimacy.
It is crucial that professionals reexamine their attitudes toward sexual intimacy needs in later life, because the number of older adults is rapidly growing. The U.S. Census Bureau (2008) estimates that by 2030, one out of five of our population will be age 65 or older. If current trends continue, a significant proportion of these individuals will decide to live in some type of residential facility such as senior housing, assisted living, or adult homes. Many of these seniors will wish to continue to experience sexual intimacy. The human services professionals who serve them will therefore need to develop constructive attitudes toward late-life sexual expression in order to ensure quality of life for their clients.
Clearly there is a need for educational workshops to inform professionals about the sexual needs of older adults (Edwards, 2003). These workshops should also help professionals examine their own personal feelings in this area. Over the past 10–15 years, some workshops have been developed to address this need for professional training; however, most of these have been too brief and were often received with amusement or lack of interest by the professionals attending them.
Recent research (Low et al., 2005) suggests that workshops about late-life sexuality should include several main components.
Phase 1: Sensitivity training. In order for professionals to develop new strategies for helping older adults meet their sexual needs, the professionals themselves must be open to a new way of thinking about late life sexuality. This phase of training should focus on helping professionals to change their negative or outdated attitudes toward sexual intimacy among older adults.
Phase 2: Information and education. This phase of training involves providing professionals with information about late life sexuality. For example, professionals need to know that the number one preferred sexual activity for older adults is kissing and hugging, while sexual intercourse is third. It is also important for professionals to understand the potential benefits of sexual expression among older adults. For instance, in a 2004 AARP survey, older adults reported that sexual activity improved the quality of their lives.
Phase 3: Assessment and evaluation. The third, and for some professionals the most important phase, should be assessment and evaluation. Our ultimate objective as professionals is to help older adults make healthy, self-directed decisions about their lives. However, we also need to ensure that older adults who suffer from dementia are protected against sexual exploitation. Therefore, professionals need training in how to assess decision-making capacity in older adults so they can determine whether the older adult truly understands the potential benefits and consequences of sexual activity. How to adequately address the sexual intimacy needs of older adults with dementia is a challenging, controversial, and difficult question.
An alternative approach is to include older adults along with professionals in educational groups focused on late-life sexuality. Some facilities in New York City, for example, are developing groups that include both staff and residents. Under the guidance of a trained group leader, staff and residents express their needs and concerns regarding sexual expression among residents. Many facilities are also trying to find ways to provide the necessary privacy for sexual expression within the context of a residential living situation.
· What are your personal feelings about sexual intimacy among older adults?
· Should nursing home residents who are not married be allowed privacy for sexual intimacy?
· How do you balance the need to protect people with dementia from sexual exploitation versus their need for sexual expression?
· How do we best help older adults protect themselves against sexually transmitted diseases?
· To what extent should a staff member assist an older adult in sexual expression? For example, should they go as far as purchasing sexual aids for them?
PROFESSIONALISM IN THE HUMAN SERVICES
Two major but muted struggles have developed among human services workers over the years. Both struggles involve money, status, and levels of responsibility. One conflict occurs between generalist human services workers and traditional professional human services workers. The other conflict occurs among traditional professional human services workers themselves. Fortunately, these quarrels have not had significant ill effects on the direct services provided by the human services workers. It is nonetheless important to know and understand the different points of view of the various sides in the disputes, as well as to recognize that all is not sweetness and light in the helping professions. A brief description of the issues follows.
Since the introduction of indigenous community leaders as paraprofessionals in the War on Poverty of the 1960s, the number of workers in the human services has grown steadily and rapidly. In addition, the responsibilities, knowledge, training, and competence of generalist human services workers have, from their point of view, increased to a level comparable to that of traditional professional human services workers. Furthermore, large numbers of generalist human services workers, and some traditional professional human services workers, believe strongly that many generalists outperform traditional professional workers. These convictions on the part of generalist human services workers are the basis for strong feelings about the differences in pay, status, responsibilities, and opportunities for advancement between generalists and traditional professional human services workers.
Many educators believe that graduates of recognized undergraduate human services programs should be considered professionals. Generalist human services workers assert that, although they do not have graduate degrees, the combination of their life experiences and limited formal education are “credentials” equal to those obtained through advanced formal education.
Many human services educators are convinced that human services is a profession and that graduates of recognized college human services programs should be considered professionals. In addition, some feel that human services is an evolving profession. These and other human services educators assert that most criteria needed for the establishment of the traditional human services professions have been met in regard to the human services. These criteria include, among others, a professional membership organization, regional and nationwide annual professional conferences, journals, standards for approval of college human services curricula, and an organization to approve college programs (e.g., the Council for Standards in Human Services Education). Furthermore, according to other human services workers and educators, the growth of graduate degree programs in human services is further proof of professionalism in the human services.
On the other hand, human services workers with advanced degrees feel that their intensive training provides them with greater knowledge and skill in providing specific services and enables them to function at a significantly higher level than can generalist human services workers. Professionalism, they assert, is based on the attainment of a specific body of knowledge unique to the field and gained only through traditional professional schools. Much of the knowledge and skill referred to by traditional professionals deals with clinical functions in addition to supervisory and educational responsibilities directly related to their specific profession. These professions might include psychology, occupational therapy, social work, and others described in Chapter 6.
In addition, these professionals feel strongly that until college human services programs are accredited by an organization sanctioned by the Council on Post-Secondary Accreditation, human services is not yet a profession. The council is the only organization sanctioned by the U.S. Department of Education to allow specific groups to provide recognized accreditation. These people also believe that until human services is recognized and incorporated into the civil service system as a profession, it is not to be considered a profession. The struggle goes on, and you will be faced with this issue in one way or another, to one degree or another, as a human services worker.
The efforts of generalist human services workers to gain recognition and parity with traditional professionals are duplicated among the traditional professionals themselves. The main issue is which traditional professionals should be eligible for third-party payment without the need for supervision by those with higher standing or credentials. Third-party payment is payment to the traditional professional by an insurance company, such as Blue Cross or Medicare, for services provided to the client. Third-party payment permits many more individuals to obtain help that they otherwise could not afford. Third-party payment also significantly increases the amount of income for agencies and traditional professionals who provide services to the needy.
Who, then, among the traditional professionals is eligible to receive these thirdparty payments? Most traditional human services professionals, particularly those in private practice, are eager to be included in these programs. Medical doctors and psychiatrists are included in all such programs. In most jurisdictions psychologists are included, and in others they are not. Social workers and other traditional human services professionals are also not included everywhere. In certain situations, some traditional professionals are included in these programs only if they are supervised by a traditional professional of another discipline.
Professionals in one discipline object strenuously to being supervised by those in other disciplines. A more recent issue centers on the armed forces permitting psychologists to prescribe psychotropic medications. Should this practice be permitted for all trained psychologists? Will other professions seek the same or other privileges? Is the practice helpful to clients? These and other questions arise as competition between and among human services workers exists.
Another complication is that competition for jobs has increased in recent years as a result of the growing number of professionals and cuts in programs and services. Unfortunately, little if any positive changes have occurred regarding these professional issues to date.
Acceptance into these insurance programs is achieved, for the most part, through legislative action at local, state, or national levels. Therefore, the professional organizations representing the different disciplines lobby to have their members included in these programs. Professional groups already included in the plans often oppose the inclusion of new groups, claiming that they are only trying to protect the public. Some think there is enough to go around for everyone and that the constant competition for high status, recognition, and control does little for the image and dignity of human services workers.
Another professional issue being raised among many social workers involves whom social workers serve. Specht and Courtney (1994) state the issue clearly:
Today, a significant proportion of social workers are practicing psychotherapy, and doing so privately, with a primarily middle-class, professional, Caucasian clientele in the 20- to 40-year age group. The poor have not gone away; there are more of them now than at any time in recent memory. Certainly many professional social workers are still committed to the public social services, to helping poor people and dealing with social problems, but a large part of the profession is “adrift in the psychiatric seas.” (p. x)
They further claim that it is the former kinds of students and practitioners “that the profession needs if it is to realize its original mission” (p. x). Jacobson (2001) supports this view, asserting that what has been destructive to this mission “has been the encroachment of therapeutic practice on the field as a whole” (pp. 51–61). Few can doubt that we are in desperate need of such human services workers. Huff and Johnson (1993) recognized this issue when they wrote the following:
Since its birth, social work has been in the vanguard of many national reforms, often speaking on behalf of populations who are too beleaguered to forcefully represent themselves. Of late, too many social workers have abandoned the traditional mission as advocates for social justice. Social workers must rededicate themselves to leading a new reform movement dedicated to a more equitable redistribution of America's wealth. (p. 315)
The same might be said regarding many other human services workers.
THE ROLE OF HUMAN SERVICES WORKERS
Is the role of the human services worker to help individuals solve their interpersonal problems? Is it to help them cope with the stress brought on by financial difficulties, physical disabilities, or other outside pressures? Or is it to try to help change those conditions that create the problems in the first place?
During the War on Poverty in the latter part of the 1960s, agencies were formed to fight poverty, racism, and crime, among other problems. Federal, state, and local governments, as well as some private foundations, funded these agencies. The workers in an agency located in a high poverty and crime area helped local residents learn their rights in the courts. The workers went to court with their clients to protest against police brutality when it occurred. They taught them how to organize and conduct rent strikes when the tenants were not getting service. They also defended people who were on welfare whenever they needed help (Krozney, 1966). The focus of human services workers during those years was mainly on helping people cope with injustice. The main concept was gaining and using power, and people did protest and fight against injustice. However, in one case, the protests and struggles aroused those who were threatened by these actions and who in turn brought pressure on those in power to curtail the funding for such projects. This, in effect, changed the nature of the role of the workers. No longer able to use government funds to fight “the Establishment”—government agencies and supporters—human services workers shifted their focus to helping clients adjust to their situation.
There are still many human services workers who feel that helping people adjust to their problems is not a very useful activity. To adjust to poverty, racism, crime, mental illness, and similar problems rather than making every effort to combat or prevent these problems is seen by many as a losing battle.
Poverty still exists, and the gap between the wealthy and the poor continues to grow. The number of people in need of mental health services has increased, even though mental hospitals have released large numbers of patients. Child abuse and partner abuse have increased. Treatment and living conditions of senior citizens leave much to be desired. All this has occurred in spite of the efforts of human services programs to date.
What else, then, can a human services worker do? “Become more of an activist,” urge the activists. “But activists are seen as radicals by the public, government officials, and other human services workers,” is often the reply. It is true that activists in the human services do not often win a lot of friends. The activist role usually stirs controversy and involves some risk. A worker some years ago prevented clients from entering an unlicensed nursing home and was reprimanded by his agency. The worker, with the help of his union, not only had the reprimand withdrawn but initiated action on a state level to change the rules regarding placing people in unlicensed nursing homes. The worker was successful in that instance. Activists, unfortunately, are not always successful; but if there is to be any chance for success in eliminating injustice, there must be activists. Today, however, the practice of advocacy is growing and accepted in the human services professions. (See Chapter 6 for details.)
WHOM DO HUMAN SERVICES WORKERS SERVE?
The answer to this question seems obvious and simple. In theory, it might be. However, in practice, significant issues arise. For example, suppose you are a human services worker in a mental hospital. The policy is to discharge patients as quickly as possible. One of your patients has been selected for discharge, and you are asked to follow through, but you are convinced that the patient is not able to function outside the institution. He is generally stabilized in the institution, however, and has been there for over six months without creating trouble, so “get him out” is the word. What do you do? You are working for the hospital, and it is under pressure to discharge as many patients as possible in the shortest time possible. You are also responsible for the patient's well-being. What happens if you do not discharge the patient? What happens if you do discharge the patient? This situation has actually occurred, not once but many times, in state institutions.
There are several possible answers to the question, “Whom do human services workers serve?” They include the client, the agency for which they work, the government, society in general, and themselves. Some workers would claim that it is possible to serve all of these but not at the same time or to the same degree. In any case, human services workers might soon be required to make difficult choices regarding whom they serve.
An even more complicated situation arises if and when workers who are paid by third parties, such as insurance companies or Medicare, must give detailed reports of service to the companies. These reports identify not only the individuals but also the nature of the problem and the course of treatment. In effect, this is a breach of confidentiality and a way of influencing the treatment provided. Insurance companies and managed care organizations often may attempt to limit or control the course of treatment. Do you as a human services worker go along with this kind of program, thus serving yourself with regard to payment and future patients? Do you refuse such a program and patients enrolled in those programs? Do you work with the patient anyway, even though payment might be reduced? Whom do you really serve—yourself, the insurance company, the client, or all three?
What about the situation in which you might be serving the taxpayer? Such a situation came up when eligibility criteria for disability payments were revised, and thousands of disabled persons were denied payments. The object was to save the taxpayers money and to cut costs to help reduce the federal deficit. What do you do when asked to administer such a program? Where do your human services responsibilities lie? Do they override your fiscal or administrative responsibilities?
The last example involves a much broader issue. It raises the question of not only whom we serve, but when we serve them and at what cost. As we have noted, all the present efforts of human services have not been able to provide services for all those in need. Choices must be made. How do you, the human services worker, make them? Furthermore, if one chooses to become an activist or to work in prevention programs, those in need of specific help are denied your services. These kinds of choices affect those in need, other human services workers, professional organizations, legislators, and the public in general.
