Showing papers in "Health & Social Work in 2002"

Predictors of Psychological Well-being among Assisted-Living Residents

Abstract: Assisted-living facilities are a rapidly growing source of supportive housing for frail elderly people. This study examined the psychological well-being of elderly assisted-living residents and factors associated with well-being. Participants were nondemented elderly residents of an assisted-living community in the urban southeast. Depression, life satisfaction, and demographic, health, and social support variables were measured through face-to-face interviews. A sizeable minority of the residents reported high levels of depressive symptoms and low life satisfaction. Female gender, self-reported health, functional impairment, perceived social support, and participation in activities were significantly associated with well-being. The predictive value of gender and health variables were reduced when social support was introduced. Implications for policy and social work practice are discussed.

Mental Health Recovery Paradigm: Implications for Social Work

Abstract: Social workers have long been involved in developing, administering, and providing services for people with psychiatric disabilities. Critics of the system, including social workers and mental health consumer-survivor practitioners, have noted that the medical model has been a driving force in policy and services provision. This model is detrimental to consumers' self-efficacy and sense of hope and conflicts with a number of central social work values. The article argues that the values and beliefs of the consumer-survivor recovery movement are closely aligned with those of the profession, and that the movement offers social workers a more promising perspective from which to practice. The primary concepts and values of the evolving recovery paradigm are delineated, and implications for direct practice, administration, policy making, education, and research are discussed.

Parents of Mentally Ill Adult Children Living at Home Rewards of Caregiving

Abstract: In the context of parents caring at home for an adult child with mental illness, this study explored the positive aspects and rewards of caregiving. Specifically, it measured the extent to which parents perceive their ill child as providing assistance and support--practical and emotional--and perceive their own caregiving as emotionally and mentally rewarding. One parent from each of 93 households completed a self-administered questionnaire. All the parents reported receiving help and support from their child, but perceived the satisfaction gained from fulfilling their parental duties and from learning about themselves as far more important. Their assessment of this satisfaction was entirely unaffected by the subjective and objective burdens on them and the severity of the child's illness.

One Last Pleasure? Alcohol Use among Elderly People in Nursing Homes

Abstract: Literature on the use, misuse, and abuse of alcohol by older people has been slowly developing in recent years (see reviews by Johnson, 2000; Liberto, Oslin, & Ruskin, 1992; Patterson & Jeste, 1999; Robinson & Schonfeld, 1990; Vinton & Wambach, 1998). Gurnack and Hoffman (1992) identified five reasons for the expanding interest with problem drinking among older adults in the United States: (1) the growing population of people over age 65; (2) the likelihood of increasing mental health services utilization among future cohorts of older people; (3) the presence of fewer abstainers and more heavy drinkers among successively younger cohorts; (4) the tendency for health professionals to mistake the effects of alcohol abuse in older patients for consequences of irreversible dementia; and (5) the high costs involved in treatment of alcohol abuse. Yet, as with other emerging explorations of social phenomena, research findings are sometimes inconsistent. For instance, although it is commonly reported that the number of people who are abstinent increases with age and the number of heavy drinkers declines (Blow, 1998; Stall, 1987), it is also reported that individual drinking patterns remain remarkably stable as the person ages (Atkinson, 1990). Similarly, although it is more commonly reported that the proportion of all older alcoholics suffering from "late onset" alcoholism is approximately one-third, estimates of late onset alcoholism have been reported as high as 68 percent (Atkinson, 1993). Some have specifically suggested that this image presented by the literature on alcohol and the elderly population is paradoxical (Morse, 1988) in that alcohol consumption is presented as declining (in amount and frequency) among older men and women, as well as being a leading cause of psychiatric admissions for elderly people. Although the standard for defining such problems does not differ between older adult populations compared with younger groups, a part of these di fferences in research findings is undoubtedly attributable to the multiple definitions for alcoholism, abusive drinking, or problem drinking that exist in the literature. In addition, standards for identifying abuse that rely on increasing tolerance of alcohol or negative work-related consequences of alcohol use may not be equally meaningful for use with older people (Patterson & Jeste, 1999). One area of research findings that remains remarkably constant in the emerging data concerns the degree to which alcohol consumption is problematic among institutionalized populations. High levels of alcoholism, heavy drinking, or problem drinking have been consistently reported in veterans hospitals (Joseph, Atkinson, & Ganzini, 1995), acute care hospitals (Adams, Yuan, Barboriak, & Rimm, 1993), and psychiatric hospitals (Atkinson, 1990). Published information on the prevalence of alcohol problems among residents of nursing homes is limited (Joseph et al.); however, it has been reported that as many as one-half of all nursing home residents have alcohol-related problems (Joseph, 1997; Select Committee on Aging, U.S. House of Representatives, 1992). These findings should not be surprising. To some degree, institutional placements reflect the direct and indirect results of high levels of alcohol consumption. The physical effects of lifelong heavy drinking mirror many of the physical limitations for which peopl e enter nursing homes and other institutions. However, in recognition that alcohol consumption is a normal part of adult social life in the United States, some nursing homes provide cocktail hours as an opportunity for social interaction among residents, with the belief that alcohol serves as an aid to sociability. Kastenbaum, Slater, and Aisenberg (1964) offered an early test of this hypothesis. They reported that residents demonstrated a range of more positive social behaviors, including more frequent and spontaneous conversation and more positive interactions with staff. …

Group Therapy Intervention for Male Batterers: A Microethnographic Study

Abstract: Treatment of male batterers has been a controversial issue for study and practice in the field of behavioral health care. Empirical evidence on success of treatment of male abusers is mixed. Little is known about what makes a treatment successful for an individual abusive man. Knowledge of how batterers learn and change in therapy and how they apply this learning in their day-to-day lives can be useful in designing successful treatments. The microethnographic study of a group therapy for male batterers discussed in this article describes change processes in abusers and examines the dynamics of unsuccessful processes. In doing so, this study provides a useful evaluation of group therapy as it is offered to batterers. The authors conclude by discussing the implications of microethnographic methods for social work students learning to evaluate their practice.

Perinatal Care for Women Who Are Addicted:Implications for Empowerment

Abstract: Perinatal drug abuse is the use of alcohol and other drugs among women who are pregnant. The National Institute on Drug Abuse estimates that 5.5 percent of the women in the United States have used illicit drugs while pregnant, including cocaine, marijuana, heroin, and psychotherapeutic drugs that were not prescribed by a physician. More than 18 percent used alcohol during their pregnancy, and 20.4 percent smoked cigarettes (Marwick, 1998). Literature reports the increased use of drugs during pregnancy (Lieb & Sterk-Elifson. 1995), using therapeutic communities (Stevens & Arbiter, 1995) and neighborhood context (Perloff & Jaffee, 1999) for addressing perinatal drug abuse; access barriers for low-income ethnic minority women who are addicted and pregnant (Cook, Selig, Wedge, & Gohn-Baube, 1999); the importance of effective policy making (Harrison, 1991); referrals to child protection services (Azzi-Lessing & Olsen, 1996); and other responses to perinatal drug abuse (Azzi-Lessing & Olsen; Irwin, 1995; Lieb & Sterk-Elifson; Marwick, 1998). Women who abuse drugs while pregnant face severe consequences, which include becoming stigmatized as immoral and deficient caregivers (Carter, 1997; Kearny, Murphy, & Rosenbaum, 1994; Lieb & Sterk-Elifson, 1995). A behavioral outcome of societal attitudes toward perinatal drug abuse is the degree to which the drug-taking behavior of pregnant women is criminalized (Lieb & Strek-Elifson). Criminalization refers to using legal approaches, such as incarceration, for medical problems of clients rather than referring them for treatment (Keigher, 1999). Community response to the increasing number of women who give birth to infants addicted to crack cocaine, for example, has been to prosecute women for perinatal drug abuse (Lieb & Sterk-Elifson). Similarly, the number of mentally ill inmates in jails and prisons is estimated as being twice that in state hospitals (Keigher). Individuals in helping professions also display stigmatic attitudes toward perinatal drug abuse. Disparaging interactions with women in some perinatal care facilities (Irwin, 1995), for example, include rude and judgmental comments to clients and violation of their confidentiality. Uncomfortable relationships with health care providers and fear of reprisal on the part of pregnant women who are addicted make women four times less likely to receive adequate care (Carten, 1996; Cook et al., 1999), thereby creating health risks for women who are addicted, their unborn fetuses, and their other children. In this article I discuss contemporary responses to perinatal drug abuse, including ways in which the behavior of women who abuse drugs is criminalized or subjected to legal interventions. Vignettes from an ethnographic study of 120 women who used heroin, crack cocaine, and methamphetamine while pregnant (Irwin, 1995) depict the attitudes and behaviors of health care providers, society at large, and women themselves toward maternal drug abuse. This article demonstrates how poor women and women of color encounter legal interventions--such as prosecution or reports to city or state child protective services (CPS)--more frequently for using drugs during pregnancy than their more affluent, white counterparts. Because criminalizing perinatal drug abuse presents substantial risks to the health of women and children, empowering (Gutierrez, DeLois, & GlenMaye, 1995) strategies are suggested for redefining perinatal drug abuse less as a legal issue and more as a health concern. The strategies are consistent with eleme nts of the national health plan of the U.S. Department of Health and Human Services (DHHS), such as creating access to health care and minimizing risks to maternal, infant, and child health (DHHS, 2000). SOCIETAL ATTITUDES TOWARD PERINATAL DRUG ABUSE Over the past 100 years, there has been an overall shift in obstetric medicine to a focus on fetal protection (Harrison, 1991). …

Drug Abuse Risks for Acculturating Immigrant Adolescents: Case Study of Asian Indians in the United States

Abstract: Acculturation has been defined as the accumulative social learning process in which immigrants assimilate the values of their new, or host, country culture while retaining the values of their old, or country of origin, culture (Oetting & Beauvais, 1991; Padila, 1980). In immigrant families, U.S.-born or second generation children tend to acculturate more quickly than their foreign-born or first-generation parents (Austin, Prendergast, & Lee, 1989; Kim, Coletti, Williams, & Hepler, 1995). This generational difference in acculturation rate may result in stressful family conflicts over role expectations and individual behaviors. For example, in their study of Cuban immigrants, Szapocznik and Hernandez (1988) found that acculturation-related family conflicts precipitated delinquent behavior and drug abuse on the part of the younger generation. ASIAN INDIANS IN THE UNITED STATES Demographics Asian Americans come from more than 20 ethnic groups and speak more than 30 different languages (O'Hare & Felt, 1995). Between 1990 and 2000, the Asian American population of the United States rose from 6,908,638 to 10,242,998, an increase of 48.3 percent. By 2000,787,047 Asian Americans were living in New York City. Of this number, 170,899 were Asian Indians (people originating in India), New York's second largest Asian American group after the Chinese (357,243). New York City, the focus of the present study, is home to 21 percent of all Asian Indians in the United States. Between 1990 and 2000, the Asian Indian population nationwide grew by 80.7 percent--a far more rapid increase than for Chinese (53.4 percent), Filipinos, (27.2 percent), and Japanese (34.5 percent) (U.S. Bureau of the Census, 2000). The increase of the Asian Indian population marks a dramatic shift in U.S. society's cultural composition. Many social work practitioners and researchers now emphasize the critical need to understand the family stresses this new immigrant population may encounter, especially during the acculturation process. Prevalence of Drug Abuse among U.S.-Born Asian Indian Adolescents An extensive literature search did not locate any empirical research studies that specifically examined drug use by U.S.-born Asian Indian adolescents. Studies of U.S.-born adolescents of Chinese and Japanese heritage, found that, wit acculturation, their use of drugs (including alcohol and tobacco) approached that of white youths (Chi, Lubben, & Kitano, 1989; Kitano & Chi, 1990). If they acculturate similarly to other Asian Americans, U.S.-born Asian Indian adolescents should demonstrate a comparable shift to "mainstream" levels of drug use. This prediction might also be made on the basis of articles critiquing the notion of Asians as a homogeneous "model minority" (Fong, 1992; Sue & Nakamura, 1984). However, it is also possible that the rates and patterns of drug use or abuse vary among the highly diverse subgroups of the Asian American population. The present study ameliorates the lack of data on drug use among 115.-born Asian Indian adolescents. It documents drug use in a sample from this population; compares selected characteristics of drug users, nonusers, their peers, and their parents; and identifies sociocultural factors that may protect against or lead to drug abuse. Except in discussions focused on a single substance, the term "drug abuse" includes the abuse of alcohol. Because tobacco is a well-recognized gateway drug, its use was explored also. The reduction of drug abuse among young people is a national goal. As counselors, outreach workers, case managers, and therapists, social workers provide prevention, intervention, and treatment services to clients from an increasing range of cultural groups. Scientific research on drug use, especially among ethnic minority groups, is essential to creating effective clinical interventions and public policies. …

Consumer Drop-In Centers:Operations, Services, and Consumer Involvement

Abstract: The idea of people with mental illness providing services to their peers is not a new concept. Stemming from historical roots that began in the early part of this century, peer-based services increased in visibility as a result of the ex-patient movement of the 1970s and subsequently developed as alternatives to traditional community mental health (CMH) programs and psychiatric institutions. A widening of consumer involvement in federal community support services programs occurred in the 1980s, with increased consumer presence in advocacy systems, national conferences, and protest literature. Consumerism is now emphasized through psychosocial rehabilitation programs, policies such as person-centered planning and legislative initiatives for rights protection and advocacy. (Since the 1970s various terms have been used to describe individuals with a mental illness, for example, consumers, recipients, survivors, ex-patients, clients, and so forth. We recognize and respect the terms these individuals use to descr ibe themselves. However, for brevity, "consumer" is used in this article.) Authors, researchers, consumers, providers, and advocates have articulated the value of consumer-operated services. The most often-stated aspects of consumer-operated services are increasing a sense of personal control and empowerment (Salem, 1990), which counteracts typical feelings of powerlessness (Chamberlin & Rogers, 1990); offering choices (Connelly, Keels, Kleinbeck, Schneider, & Cobb, 1993); promoting independence and competence, providing social support, and individualizing services (Chamberlin, 1984); providing support that is more empathic, concrete, and relevant (Mowbray, 1997); offering role models, organizational involvement (through a flattened administrative hierarchy), and group empowerment (Segal, Silverman, & Temkin, 1993); and working for social justice and social change on behalf of individuals with serious mental illness (Chamberlin & Rogers; Segal et al.). The range of consumer-operated programs described in the literature includes drop-in centers, housing and homeless support services, advocacy, case management services, respite care, and businesses (Chamberlin, Rogers, & Ellison, 1995; Conrad, 1993; Mead, 1997; Meek, 1994; Miller & Miller, 1997; Mowbray, Moxley, Jasper, & Howell, 1997; Mowbray, Wellwood, & Chamberlain, 1988; Trainor, Shepherd, Boydell, Leff, & Crawford, 1997). The services offered usually include mutual support, cultural activities, advocacy (including assistance with legal problems), knowledge development and skills training, public and professional education, and economic development (Chamberlin et al.; Trainor et al.). CONSUMER DROP-IN CENTERS The most frequently described of consumer-operated mental health services models is the drop-in center (Kaufmann, Ward-Colassante, & Farmer, 1993; Mowbray et al., 1997; Mowbray & Tan, 1992, 1993). The historical origins of consumer drop-in centers have not been documented. However, the first consumer-operated program was probably the WANA Society (later Fountain House, which provided a psychosocial support system for its members leaving state institutions; Moxley & Mowbray, 1997). In 1961 the report of the Joint Commission on Mental Illness and Health identified four types of ex-patient alternatives. Consumer drop-in centers appear similar to their "social clubs," which were organized to provide ex-patients with support, recreation, and social interaction. Consumer drop-in centers provide a wide range of services to consumers (Van Tosh & del Vecchio, 1998). At their most basic, they offer a place that is accepting, safe, supportive, and normalizing; where consumers can feel needed and grow in self-worth, dignity, and self respect; and where they can learn about community support (Meek, 1994; Mowbray & Tan, 1992). …

Health Implications of Animal Hoarding: Hoarding of Animals Research Consortium (HARC)

Abstract: Hoarding behavior in humans can involve pathological self-neglect and is associated with a variety of psychological conditions, particularly obsessive-compulsive disorder (OOD) (Damecour & Charron,1998; Frost, Krause, & Steketee,1996) Some evidence exists that elderly people may be disproportionately affected (Steketee, Kim, & Frost, 2001) Animal hoarding is a recently described behavior that shares many features of OCD hoarding but seldom has been considered a symptom of psychopathology (Frost, Steketee, & Williams, 2000; Patronek, 1999; Worth & Beck, 198l)In typical cases, people are living with dozens to hundreds of alive and dead animals in apartments, trailers, and single-family homes (Patronek; Worth & Beck) Lack of insight into the severity of their living circumstances and denial of the risks or harm to animals is common This public health problem is believed to occur in every community but is poorly understood (Patronek, 1999) Our experience and studies of news reports (Hoarding of Animals Research Consortium [HARC], 2000) suggest that animal hoarding knows no social or economic boundaries Although typically identified among unemployed and socially isolated individuals, anecdotal reports indicate that animal hoarding also has been discovered among physicians, veterinarians, bankers, nurses, teachers, and college professors Employed hoarders appeared to be able to live a double life, with coworkers never suspecting the true conditions in their homes until animal rescue authorities were called to investigate Despite its seriousness, almost no empirical research exists on this problem (Frost et al, 2000) Recently, two studies examined animal hoarding A review of 54 cases initiated by animal care agencies primarily to rescue the animal victims indicated that public health officials who were aware of the problem ignored indicators of clinically significant human health concerns (Patronek, 1999) Ignoring the health concerns was common, despite ample evidence to suggest substantial impairment in functioning of the hoarders, and severely cluttered and unsanitary living environments that posed a threat to human safety and health In 11 percent of cases, the residences were condemned as unfit for human habitation In 26 percent of cases the hoarder was eventually institutionalized or placed under some type of protected care, suggesting very serious mental and physical impairment (Patronek)A recurring comment from investigators was that some agencies responsible for monitoring human health concerns had declined to intervene and were unaware of the implications of the behavior Another study examined cases of hoard ing of possessions generated by complaints from neighbors, police, fire departments, social services agencies, and service personnel to local health departments in Massachusetts In hoarding cases that involved animals, public health officials reported significantly worse sanitary conditions, threats to individuals' health, and involvement of a greater number of agencies in the investigation (Frost et al, 2000) These findings support our belief that animal hoarding is a serious public health problem that has received virtually no attention from the clinical or research communities Findings from case reports (Patronek, 1999) and in-depth interviews of a small number of animal hoarders have suggested various models of psychopathology (HARC, 2000) The study reported in this article provides more information about the degree of impairment of activities of daily living (ADL) associated with animal hoarding, as well as the frequency and severity of effect that this behavior had on the health and safety of household members METHOD Because no single agency is responsible for responding to reports of animal hoarding, we solicited reports from a broad spectrum of people likely to encounter cases of animal hoarding (for example, animal control officers, humane law enforcement or other police officers, public health veterinarians, elder services case workers, and health departments) …

Social Work in Restructuring Hospitals: Program Management Five Years Later

Abstract: Hospital restructuring in North America has involved re-engineering, downsizing, reorganizing, and remodeling of traditional hierarchical functional organizations into multisite programmatic conglomerates. The implications for professional disciplines have been dramatic in that departments such as social work have been dismantled and social work practice has come under the domain of program managers representing multiple disciplines. In this study 12 hospitals in Ontario, Canada, that were studied in the early stages of restructuring in 1995 expanded to 22 sites by 1999. The effect of the mergers and moves to program management on the social work profession was examined. The key findings are that social work line positions were not lost, but accountability and recruitment were no longer in the hands of the discipline. These findings suggest that it is more critical now than ever for social workers to champion their contributions to health.

Parenting Adolescents with Attention Deficit Hyperactivity Disorder: Analysis of the Literature for Social Work Practice

Abstract: Parenting an adolescent with ADHD presents a number of unique challenges and stressors. Social workers can play an important role in providing psychosocial therapies for clients with ADHD and their families. However, practice with this population has not been well-addressed in the social work literature. This article analyzes theories of parenting stress; stress, appraisal, and coping theory; and the research literature about parenting and ADHD, with a focus on relevance for social work practice.

Gun Violence and Children:Factors Related to Exposure and Trauma

Abstract: The study discussed in this article investigated the relationship between access to firearms and parental monitoring on rural youths' exposure to gun violence and examined the effect of gun violence exposure on the mental health of these youths. A survey was administered to rural students who participated in a student assistance program (n = 162) that provided in-school support groups for students in grades 6 through 12. Results indicated that a substantial number of students were exposed to gun violence and exposure was significantly related to firearm access and parental monitoring. Furthermore, gun violence exposure was significantly associated with trauma among the youths. Implications for social workers include advising high-risk clients and their families on gun removal and safe storage practices.

The Impact of Hospital Restructuring on Social Work Field Education

Abstract: Hospital restructuring has had a dramatic impact on social work practice and field education. In a qualitative focus group study of nine educational coordinators responsible for educational programs in teaching hospitals with 25 to 100 social workers each, four main themes emerged: (1) difficulty managing field education when the actual change experienced in restructuring hospitals was far less progressive and systemic than the hospital missions espoused; (2) a struggle to maintain stable student programs when change was unpredictable; (3) the importance of support, reciprocity, and advocacy from the university; and (4) the need to be creative in delivering the educational program while undergoing organizational change.

Shyness and social phobia: a social work perspective on a problem in living

Abstract: Social phobia is classified as an anxiety disorder in psychiatric nomenclature. It represents a fear of performance or social interaction that significantly interferes with a person's social or occupational functioning. The author takes issue with the fact that social phobia is considered by many professionals to be a mental illness that is often treated best with medication. Social phobia can be conceptualized from a social work perspective as an extreme shyness that can be overcome with cognitive learning and behavioral rehearsal. This article reviews the biopsychosocial causes of social phobia and presents a summary of cognitive and behavioral interventions with empirically demonstrated effectiveness.

Treatment with lesbian alcoholics: healing shame and internalized homophobia for ongoing sobriety.

Abstract: Traditionally, within the field of mental health, all forms of homosexuality have been viewed as pathological. This belief system reflects the larger societal attitude of heterosexism. According to Herek (1986), heterosexism is a "world-view, a value system that prizes heterosexuality, assumes it is the only appropriate manifestation of love and sexuality, and devalues homosexuality and all that is not heterosexual" (p. 925). Heterosexism is enforced by intimidation, harassment, and exclusion of those who are different (Rivers & D'Augelli, 2001). Until 1973 homosexuality was labeled a disease in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1973). It was removed from the disease classification after research by Hooker (1968) documented that as a group, homosexuals showed no greater pathology than did the general population. More recent literature has stated that homosexuality itself does not cause or indicate pathology; but that heterosexist society's response to homosexuality, homophobia, causes severe problems for gay people. "The impact of heterosexism on gays/lesbians/bisexuals in today's society is hampering individual growth and development by instilling shame.., shame due to heterosexism" (Neisen, 1993, p. 51). The phenomenon of homophobia is prevalent in our society. Homophobia can be defined as "fear, disgust, anger, discomfort and aversion that individuals experience in dealing with gay people" (Hudson & Ricketts, 1980, p. 358). This fear becomes generalized to a societal endorsement of negative myths and stereotypes about gay men and lesbians (Berkman & Zinberg, 1997). Understanding lesbians, then, rests on the recognition of homophobia as an ongoing oppressive force. It is also dependent on the awareness of the specific problems faced by all women. Lesbians are oppressed not only because they are homosexual, but also because they are women. As women, lesbians face problems not faced by gay men. Lesbians in treatment therefore require a different perspective from the therapist. According to Miller (1976), all women experience a degree of shame for being women in our patriarchal culture. Spaulding (1993) redefined heterosexism as being necessarily inclusive of sexism: "Heterosexism can be viewed as a form of social control in which values, expectations, roles and institutions normalize heterosexuality which, in turn, is promoted and enforced formally and informally by structures in which men are dominant, i.e. the patriarchy" (p. 232). The sanctioned norm in U.S. society is that men are entitled to more control, privilege, and status than women are and that heterosexuals are entitled to more acceptance, privilege, and rights than homosexuals are. Not only are lesbians devalued because they are women, they are again devalued, more severely, because their existence is not dependent on a relationship with a man. The lesbian poses a provocation to the status quo of the patriarchy and therefore is continually devalued by the patriarchal culture as a whole to maintain the status quo. This essential provocation to the patriarchy puts the lesbian at risk of continual denigration and stigmatization by the larger society. "Any woman can be threatened with the label 'lesbian' if she rejects male domination and control" (Ellis & Murphy, 1994, p. 52). The ever-present possibility of harassment creates continual pressure on lesbians to remain as invisible as possible. The lesbian "exits the heterosexual assumption," putting herself outside the norm to "recognize her same sex desire and identify as lesbian" (Schneider, 2001 p. 84). The degradation in status created by this position outside the expectations of society creates a need for secrecy and hiding. The need to hide has damaging psychological consequences. "The sense of 'otherness' results from isolation from those with similar feelings and from messages that homoerotic feelings are shameworthy" (Rivers & D'Augelli, 2001, p. …

Crisis in caregiving: a call to action.

Abstract: As social workers well know, the population of the United States is aging rapidly (Keigher, Fortune, & Witkin, 2000). Galambos and Rosen (2000) noted that in the 20th century, "the percentage of Americans ages 65 and older...more than tripled, and the number...increased nearly 11 times" (p. 13). Between 1970 and 1999, median age in the United States increased from 28 years to 36 years, and in 2030, more than one of five people will be over age 65 (Council on Social Work Education/SAGE-SW, 2001). By 2050, the percentage of older adults in the population will exceed the percentage of children and the population of "oldest-old" (85 and older) is also growing rapidly (Hooyman & Kiyak, 2002). The aging of the population will exacerbate an existing crisis of informal caregiving in the United States. Currently, approximately 100 million people suffer from chronic conditions, and 41 million of these people face limitations in their daily activity (Older Women's League [OWL], 2001). Although disability rates have declined among older adults in recent years, the rapid aging of the population, along with the growth in the population of oldest old, is likely to increase the number of individuals with chronic and disabling conditions (Manton & Gu, 2001; OWL, 2001). More than 40 percent of individuals over age 85 require assistance with activities of daily living (Quadagno, 2001). For many people with disabilities, informal (or unpaid) caregiving from family or friends is a crucial form of support. In 1997, 27.6 million adults provided an average of 17.9 hours of care to adults in the United States (Arno, Levine, & Memmott, 1999). The total number of informal caregivers may be as high as 52 million (OWL. 2001). In 1997 the economic value of informal caregiving amounted to $196 billion (versus $155 billion for paid services and support) (Arno et al.). Many older adults with disabilities rely on informal caregivers as their "sole source of support" (Takamura, 2000, p. 130). Yet, despite the importance of informal caregiving, our society offers minimal support to those who offer these services and support (OWL, 2001). NEEDS OF CAREGIVERS The primary burden of informal caregiving is borne by women, usually daughters providing support for aging parents. Indeed, almost 75 percent of caregivers to older adults are women (OWL, 2001). Although men also support aging parents, the "division of labor among caregivers" parallels the "division of labor" in society, with men assisting with "household chores" and "financial management" and women offering "hands-on care such as feeding, dressing, bathing, or cleaning up after a bowel accident" (Quadagno, 2001, pp. 338-339). Women also provide more care than men provide and experience "higher levels of stress and less satisfaction with life than sons" (Quadagno, p. 340). The typical caregiver is a middle, or "sandwich generation," female caring for aging parents and children and, in some cases, grandchildren (OWL, 2001). Female caregivers also often work full-time. Caregiving is a particular problem for women of color. More than 50 percent of African American and Latina (and Latino) caregivers care for both an older person and a younger one, "compared with 20 percent to 40 percent of the general population" (OWL, 2002b, p. 15). The changes in the role of women in society offer a useful context for understanding the impact of becoming a caregiver. Women are participating more and more in the workforce (Cherlin, 1992). Their options are no longer limited to unpaid caregiving roles in the home. Although things are slowly changing, women are still concentrated in segments of the economy where wages are low and security and fringe benefits minimal (Hooyman & Gonyea, 1995). Women also assume responsibility for a disproportionate share of work in families. Employed caregivers are at higher risk of health-related problems than nonemployed caregivers (King, Oka, & Young, 1994). …

Tracking Change in Psychological Distress among Homeless Adults: An Examination of the Effect of Housing Status

Abstract: Given the profound physical and social deprivations associated with homelessness, it is not surprising that earlier research has consistently documented higher levels of psychological distress among homeless people compared with members of the general population (Ritchey, La Gory, Fitzpatrick, & Mullis, 1990, Robertson, 1992; Robertson & Winkleby, 1996). The elevated levels of psychological distress have been interpreted as indicative of a link between mental health problems and homelessness. A critical but largely unexamined question is whether distress symptoms experienced by homeless people are endogenous to the psychiatric disorders that an individual may experience or are otherwise caused by environmental factors tied to the individual's homelessness (Koegel & Burnam, 1992). Given the high levels of distress symptoms reported in clinical studies of psychiatric patients (Husaini, Neff, Harrington, Hughes, & Stone, 1980; Wold, Rosenfield, & Dwight, 1982), it is reasonable to assume that symptoms experience d by homeless people with serious mental illness (SMI) constitute a rather enduring feature of their lives and are less responsive to objective circumstances such as change in housing status. On the other hand, among those who do not experience psychiatric problems, symptoms of distress are more likely to be attributable to stresses and strains emanating from their homelessness and should diminish when these individuals have made the transition to more favorable circumstances, such as the procurement of permanent housing arrangement. Using longitudinal data collected from a probability sample of adult homeless people, this article looks at the pattern of change in psychological distress over time among homeless people with SMI (including those with a co-occurring substance abuse disorder), homeless people with drug or alcohol problems (but not SMI), and homeless people with neither diagnosis. The article also examines the extent to which the change in levels of distress symptoms is associated with change in housing status among homeless people with different psychiatric diagnoses. MENTAL HEALTH AND HOMELESSNESS Since homelessness became a major social problem in the late 1970s and early 1980s, there has been an emerging consensus that mental health issues, broadly conceptualized, are linked to homelessness. An early wave of psychiatric-oriented studies found mental illness to be pervasive among members of the homeless population, documenting that as many as three-quarters of the homeless adult population had a diagnosable mental disorder (Arce, Tadlock, Vergare, & Shapiro, 1983; Lipton, Sabatini, & Katz, 1983). Although such estimates have been discarded as having questionable validity because of various methodological limitations, the prevailing image of homeless people as suffering disabling functional deficits from their psychiatric disorders has remained unchanged. Recent empirical studies have concurred that one-third of the adult homeless population has an SMI (Dennis, Buckner, Lipton, & Levine, 1991; Shlay & Rossi, 1992). Although this estimate is substantially higher than those reported in earlier studies, the rate of SMI among homeless people is considerably higher than that reported in the housed population (Wright, Rubin, & Devine, 1998). Moreover, using the Diagnostic Interview Schedule (DIS) from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition--Revised (DSM-III-R) (American Psychiatric Association, 1987) and other standardized diagnostic instruments, empirical studies have broadened the assessment of psychiatric disorders to include alcoholism and drug disorders. These studies found that problems of drug and alcohol abuse are more widespread than SMI and that there is a high rate of co-occurrence of substance abuse disorder among homeless individuals diagnosed with SMI (Cohen & Burt, 1990; Devine & Wright, 1997; Koegel, Burnam, & Farr, 1988; Struening & Padgett, 1990). …

Brief motivational intervention for substance-abusing delinquent adolescents: guided self-change as a social work practice innovation.

Abstract: Multiple processes influence adolescent sub stance abuse and delinquency, contributing to their acceleration and increased risk of a broad range of associated problem behaviors, mental health problems, and victimization experiences (Fergusson & Horwood, 1996; Huizinga & Jakob-Chien, 1998). Substance abuse interventions are critical to interrupt processes related to the onset and maintenance of these adverse outcomes among youths and to provide skills to increase their educational, social, and economic opportunities (Pickrel & Henggeler, 1996; Zeitlin, 1999). Although controlled clinical trials of adolescent substance abuse interventions are underway, few intervention programs have been rigorously evaluated (Wagner & Waldron, 2001). This article describes an innovative intervention program currently undergoing a controlled clinical trial. The article describes the development of the brief motivational intervention for substance abuse, Guided Self-Change (GSC), as well as its modification for use with delinquent adolescents. Strategies are outlined to promote the flexible implementation of GSC in community settings with diverse groups of adolescents. GUIDED SELF-CHANGE Guided Self-Change (GSC) is a brief skills-oriented motivational intervention for addressing alcohol and other drug problems (Sobell & Sobell, 1993, 1998). It can be used with individuals, with couples, or with groups with minor variations in format and materials. Individual GSC treatment is the prototype and has been standardized and published for clinical and research applications (Sobell & Sobell, 1993). The effectiveness of clinic-based GSC treatment among adults, with or without a relapse prevention component, has been documented: a 53.8 percent reduction in reported alcohol consumption following treatment, a near doubling of abstinence rates one year after treatment, and high consumer satisfaction ratings (Sobell & Sobell, 1993). Subsequent studies have found the intervention to be effective with multiple populations, including community-dwelling problem drinkers recruited through the mail, married problem drinkers and their spouses (Sobell & Sobell, 1998), as well as problem drinkers in Mexico City (Ay ala-Velazquez, Echeverria, Sobell, & Sobell, 1997). Because GSC uses both fundamental behavioral change principles and motivational engagement strategies, it necessarily incorporates individualized treatment targets, change strategies, and substance use goals based on clients' personal experiences. It is this individualization, or idiographic perspective, that makes GSC especially promising for use with diverse client populations. Such an idiographic perspective has been argued to be essential for psychotherapy programs to be successful with multicultural populations (Palmer, 2000). This behavioral, motivational modality may be especially effective for young multicultural clients because of its adaptability for use with adolescent and ethnic minority populations, focus on skill building and client empowerment, and short-term cost-effective nature. In addition, GSC has been translated into Spanish and implemented with success among Mexican adolescents and adults with alcohol and drug problems, which suggests its transportability across cultures (Ayala-Velazquez et al., 1997). Our research group developed a youth-specific version of GSC treatment for use with juvenile offenders as part of a study funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The general format of GSC remains the same, but materials were modified to make them developmentally appropriate for use with adolescents, applicable to problems that often accompany teenage alcohol and drug use (that is, violence, coping with stress, social skills deficits), and available in either English or Spanish. In anticipation of this study, we conducted pilot work with 15 substance-abusing juveniles. …

Dimensions and Predictions of Professional Involvement in Self-Help Groups: A View from Within

Abstract: Much has been written about the relationship between professionals and self-help groups, largely from the professional perspective. This article discusses the perspective of self-help group members on the involvement of professionals in these groups. The concept of self-help groups developed around the notion that people with a common problem can share and learn from each other without the help of professionals, making indigenous leadership the defining variable (Riessman & Carroll, 1995; Schubert & Borkman, 1991). Professional involvement has since been used in the literature in reference to a wide range of roles and activities, from indirect consultation and referral (Cherniss & Cherniss, 1987; Lotery, 1987) to direct initiation and ongoing leadership (Stewart, Banks, Crossman, & Poel, 1994). In the context of this article, professional involvement pertains to the use of professionals as a source of knowledge and consultation. How members of self-help groups perceive professional involvement and what they d efine as the dimensions of such involvement are analyzed. Also, models to predict these identified dimensions are suggested. At the basis of both modes of help lies the distinction between professional and experiential knowledge (Borkman, 1976, 1990). Although some scholars view the relationship between professionals and self-help as essentially antagonistic (Adams, 1990), others see it as dialectical (Riessman & Carroll, 1995) or refer to the potential collaboration between the two (Jacobs & Goodman, 1989; Kurtz, 1990; Lotery & Jacobs, 1994; Stewart et al., 1994). Indeed, there are empirical findings demonstrating the successful collaboration between self-help groups and professionals. Research shows that a considerable number of self-help organizations were in fact initiated by members of the helping professions (Katz & Bender, 1990). Moreover, the rate of professional involvement in self-help groups is reported to be as high as 70 percent (Burstein, 1985; Lotery & Jacobs, 1994; Madara, 1990; Meissen & Warren, 1993; Toseland & Hacker, 1982). It is now commonly recognized that the role played by professionals in self-help organizations is such that there is no longer any sense in dwelling on the traditional question of contradictory versus complementary relationships between self-help groups and professionals (Jacobs & Goodman, 1989; Lotery & Jacobs, 1994). This question has been replaced by more specific questions regarding the potential roles that professionals may play in self-help organizations and in the promotion of self-help groups. Scholars have identified the following roles as appropriate for professionals to take vis-a-vis self-help groups: consultant, referral resource, initiator, trainer, speaker, support provider, linking agent, facilitator, researcher, and member of advisory board. Research documenting self-help group members' perspectives on their relationship with professionals suggests that they are more inclined toward the use of indirect functions and are less supportive of the initiator role. Moreover, findings show that the preferred modes of interaction between professionals and self-help groups center on mutual referral and complementary services (Cherniss & Cherniss, 1987; Levy, 1983; Lotery, 1987; Stewart, 1990; Toro et al., 1988). Some research attention also has been directed toward the barriers to partnership, including power struggles, attitudinal differences, and role definitions. It has been found that whereas the interaction of professionals with self-help groups is desirable, their lack of information concerning self-help and their lack of preparation for appropriate roles are perceived as barriers to interaction (Stewart et al., 1994). Research also shows that many professionals do not interact closely enough to accurately perceive how self-help group members assess them (Spaniol, Jung, Zipple, & Fitzgerald, 1987). …

Families Helping Families: Implementing a Multifamily Therapy Group with Substance-Abusing Adolescents

Abstract: The professional literature identifies a variety of risk factors that indicate whether an adolescent is at risk of substance use (Hawkins, Catalano, & Miller, 1992). Many of these risk factors revolve around family composition and dynamics such as family drug use, family interaction patterns, and boundaries (Smith & Springer, 1998). Therefore, in treating a substance-abusing adolescent, the family is a key target of intervention. Multifamily therapy groups (MFTGs) have been used to involve families in treatment and have been found to be effective with a variety of populations across many settings (Meezan & O'Keefe, 1998; O'Shea & Phelps, 1985). We developed an MFTG model that was used in conjunction with individual and family therapy with substance-abusing adolescents. This article provides a theoretical overview of the MFTG model and describes and illustrates the implementation of the model with substance-abusing adolescents and their families. STRUCTURE OF THE MFTG Our MFTG model was a treatment component of a therapeutic milieu for substance-abusing adolescents. As part of the program, adolescents and their families voluntarily attended weekly individual family therapy sessions and a multifamily therapy group. The average size of the MFTGs was four to five families, for a total of from 12 to 15 clients. (MFTGs much larger than this are not recommended because they can become overwhelming for all involved.) Each group session lasted 1 1/2 hours. The average age of the adolescent group members was 15 years. Most of the adolescents were polysubstance abusers, using primarily alcohol and marijuana, and had coexisting mental health diagnoses such as depressive and anxiety disorders, oppositional defiant disorder, and attention-deficit hyperactivity disorder. The MFTG was an open group. Membership changed each week, so each group session began with introductions and a brief review of the group rules, such as "What we say in group stays in group." Adolescent members introduced themselves and the rest of their family. Sometimes, the group leaders began the sessions with a brief 10-to 15-minute presentation of psycho educational material. However, some group leaders began sessions simply by inviting families to share how their week had gone and what type of progress they were making on their goals. Very often, this approach led to intense groups marked by member-to-member interaction. OVERVIEW OF THE MFTG MODEL The proposed MFTG model integrates techniques and interventions primarily from four modalities: solution-focused and structural family therapy, and an interactional and mutual aid approach. Solution-Focused Therapy Solution-focused therapy (SFT) (Berg & de Shazer, 1991; de Shazer, 1985; Selekman, 1997) underscores the positive attributes that clients bring with them to treatment. It is a strength-based approach. Using SFT, clients are encouraged to develop future-oriented, positively worded goals. Practitioners are encouraged to work in partnership with clients and to foster collaborative relationships with resources that may benefit the client. We used two techniques from SFT: (1) the scaling question and (2) the miracle question (Berg & de Shazer, 1991; de Shazer, 1994). The scaling question provides a direct and nonthreatening way to monitor client functioning on goals over time. Consider the following illustration. Johnny's primary goal was to get along better with his parents. Using the scaling question, the group leaders asked Johnny to rate, on a scale from 1 to 10, how well he got along with his parents during the preceding week, with 1 indicating that he did not get along with them at all and 10 indicating that he got along with them great. Suppose Johnny gave a rating of 6. The leaders would then ask Johnny what he and his parents could do over the next week to make it from a 6 to a 7. …

A Trauma Education Workshop on Posttraumatic Stress

Abstract: As our world becomes increasingly "globalized," extremely stressful or "traumatic" life events appear-more frequent and widespread, almost commonplace. Not a day goes by without media attention being given to an airplane or automobile crash, an act of tragic abuse or neglect, a murder, a suicide, a murder--suicide, a natural disaster, and so on. Although prompt attention is usually paid to these events as "news," in a relatively brief period afterward, the relevance of these events to our present life seems forgotten; our interest turning to other issues we regard as more relevant or "newsworthy." The traumatic event is over and normal life resumes, or so we are led to believe. (The events of September 11, 2001, and their aftermath are an exception to the usual response to specific traumatic events--that is, a catastrophic, traumatic experience affecting all of society, with global consequences.) For the victims of traumatic events, as well as those who work with them, the period after the traumatic event may be more realistically identified as a beginning rather than an ending, an often prolonged time and space of suffering, pain, and hardship--a hell on earth (Matsakis, 1998). Historically, adaptation after a traumatic life event is given little attention not only by society, but also often by health providers and health care institutions. Primary focus of attention in mental health work frequently centers on the provision of symptom relief, using medicine or other procedures to ease reported pain and enable immediate return to functioning. Providing symptom relief appears as today's mental health "treatment of choice" because it is often perceived as time and cost-efficient and minimally intrusive into the lives of the clients. Such a focus, it is argued, tends to ignore the underlying process of adaptation in the aftermath of traumatic events and the active and responsible role of the individual as an agent of change. For example, a person who lives in the aftermath of a traumatic event may be treated for a presenting depression or anxiety without awareness or understanding of the nature of the trauma and the means for achieving successful adaptation in life. RATIONALE Clinical social work with people who have experienced a traumatic life event is, at best, a time- and energy-consuming endeavor, complex in process and procedure. The Trauma Education Workshop program offers the clinical social worker a brief, time-limited, comprehensive resource for educating other health care providers, adult clients, and significant others of adult and child clients about "the basics" of posttraumatic stress and successful adaptation-in-life. This program offers several benefits to participants, including the following: * knowledge about the varied aspects of posttraumatic stress, including stressors, manifestations of stress, coping responses, antecedent factors, and adaptation-in-life. Lack of knowledge about posttraumatic stress, it is argued, serves as a formidable obstacle that counteracts problem solving. Contrary to popular folk belief, "what a person doesn't know can hurt them?' Many people who are traumatized suffer needlessly or more severely than necessary because they are not aware of what is wrong or how to change their thoughts, emotions, and behavior correctively. * presentation of a "nonthreatening" learning environment for clients, wherein participants may experience the group process with others who may be suffering similarly, and, thereby, be helped to perceive their life situation realistically. Presenting a compassionate, safe, and reality-oriented environment for learning about posttraumatic stress may be expected to enhance trust and self-confidence and dispel fears and defensiveness, reinforcing the potential value of future individual and group counseling. * a learning experience to help clients realize the significance of self-awareness and self-mastery as an essential component for successful adaptation-in-life. …

The Role of Cognitive Control in Mediating the Effect of Stressful Circumstances among Korean Immigrants

Abstract: The study reported in this article investigated relationships among stressful circumstances, cognitive control (the individual's perception of control over life), and distress among Korean immigrants in the United States. Specifically, it was hypothesized that cognitive control mediated the effect of exposure to stressful circumstances on distress. A total of 159 Korean immigrants participated in the study. The result of the study provided strong support for the role of cognitive control in mediating the relationship between stressful circumstances and distress. The detrimental effect of exposure to stressful circumstances on distress was weakened by cognitive control. Implications for social work practice and future research are discussed.

Using customer satisfaction surveys to improve quality of care in nursing homes.

Abstract: ********** The public policies that pertain to quality of care in nursing homes were last stated in the 1986 Institute of Medicine (IOM) Report (Hawes, 1991) and the subsequent Nursing Home Reform Act, which is part of the 1987 Omnibus Budget Reconciliation Act (OBRA) (P.L. 100-203) legislation. These documents remain the basis for regulating the nursing home industry. State and federal regulations drive the evaluation standards for nursing homes, and annual inspections help determine certification for both Medicare and Medicaid reimbursement. Despite considerable efforts, however, regulations cannot guarantee the quality of care received by nursing home residents. One hurdle is the lack of a universally accepted definition of quality. Donabedian (1988) conceived of quality of care in three categories: structure, process, and outcome. Structure refers to attributes of the physical setting (that is, facility, equipment, money), human resources (that is, number and qualifications of personnel), organizational structure, and methods of reimbursement. Process refers to hands-on patient care. Outcome refers to the effects of care on the patient and patient satisfaction with that care. The three categories are interconnected--good structure increases the likelihood of good process, which increases the likelihood of good outcomes--and together constitute quality of care. Regulations concentrate on the process and structural aspects of quality of care because they are easy to measure and document. Nursing homes routinely collect and report information about their performance. Our case study site measures quality of clinical care with 24 clinical quality indicators including fractures, weight loss, prevalence of pressure ulcers, use of antipsychotic medications, and so forth. These indicators are monitored on a monthly basis. Structural characteristics such as staff-to-patient ratios, and process assessment (the provision of actual health care) are used as proxy measures to demonstrate quality, but compliance with the regulations on those measures will still not ensure that the resident receives quality care (Davis, 1991). Outcome assessment is the most consumer-oriented portion of Donabedian's framework; it alone addresses the actual impact of care on the resident's physical and emotional well-being (Davis, 1991). The IOM committee, in 1986, and Congress, in the 1987 OBRA regulations, agreed that it was important to focus on "the quality of life experienced by residents, as well as making the regulations more resident-centered and outcome-oriented" [emphasis added] (Hawes, 1991, p. 158). Resident-centered care emphasizes quality of care as defined by the resident. Although the views of all stakeholders are important, it is vital to focus on the residents' views because they may not agree with the views of others about the importance of many items (Young, Minnick, & Marcantonio, 1996), and they are difficult to assess accurately. Many believe there has been too little emphasis on the quality aspects most meaningful to residents (Davis, Sebastian, & Tschetter, 1997). A customer satisfaction survey can monitor concerns about nursing home quality. In fact, a survey can empower residents, because its primary purpose is to communicate "the point of view of the people for whom long-term care services are created in the first place" (CohenMansfield, 2000, p. 1). Despite well-known limitations to surveys of nursing home residents (such as fear of reprisals, difficulty in interviewing residents with dementia, disagreement about what to measure), satisfaction surveys may be the best way to comprehend and address resident-identified problems. It is interesting that quality assurance mechanisms that have looked at other areas are now beginning to focus on resident rights and on techniques to assess resident satisfaction with care (Applebaum, Straker, & Geron, 2000). Social workers are essential to this type of assessment given their communication and interpersonal skills and training. …

Structured Stories: Reinforcing Social Skills in Rural Substance Abuse Treatment

Abstract: Rural communities have drug and alcohol problems (Edwards, 1992) Treatment approaches grounded in urban approaches cannot be used in rural areas without changes However, there is little information about the changes required to make therapies designed for urban populations useful for rural substance abusers (Leukefeld, Godlaski, Hays, & Clark, 1999), and only a few projects have focused specifically on rural drug and alcohol treatment (Robertson, Sloboda, Boyd, Beatty, & Kozel, 1997) With support from the National Institute on Drug Abuse, a therapy for rural drug and alcohol users was developed that incorporates clinical approaches used with substance abusers: social skills training (Monti, Abrams, Kadden, & Cooney, 1989), motivational interviewing (Miller & Rollnick, 1991), case management (Rapp, 1992), and thought mapping (Leukefeld, Godlaski, Clark, Brown, & Hays, 2000) The therapy was developed and piloted over three years by rural therapists and university faculty The purpose of this article is to describe how structured stories can be used as part of a therapy for rural substance abusers and to discuss how this approach can compliment social skills training After discussing social skills training and describing the use of stories, we present an example of a structured story focused on negative thinking The article concludes with a discussion of the possibilities of using structured stories and implications for social work SOCIAL SKILLS TRAINING Social skills training sessions begin after each client is engaged, an assessment or evaluation is completed, and an individualized behavioral contract, as part of individual sessions, is developed Social skills training is an approach to drug and alcohol treatment based on cognitive--behavioral theory Behavioral therapy focuses on how people learn specific behaviors over time For example, children learn how to respond to social situations by watching their caregivers and then imitating This is not a planned process, but something that occurs naturally as a child grows As a child "experiments" with these behaviors, a second process occurs: The child's behavior is reinforced, causing an increase in the frequency of that behavior: or the behavior is not reinforced, causing a decrease in or disappearance of the behavior Reinforcement can occur on many levels The combination of watching, learning, imitating, and receiving a response from the environment is quite powerful and leads to new personal habits an d automatic responses to situations Cognitive--behavioral theory stresses integrating new skills into personal cognitive frameworks Social skills group sessions usually incorporate the following structure: * Group members are introduced The group begins with a review of previous session and, as appropriate, discussion of the last session's review exercise * The therapist presents the session's background and discusses the sessions messages by listing key points on a flipchart and distributing handouts * The therapist lists and briefly discusses the skills to be introduced and practiced in the session * A group exercise is used to practice the skill Different exercises are used in each session * Each group ends with a discussion of a practice exercise for the next session STORIES Stories are part of culture (Schank, 1990) and are more than entertainment Very early stories facilitated individual and group survival by improving memory and recall, allowing efficient communication, and retaining information from generation to generation Stories incorporate effective actions to project from the past into the future (Rush, 1996) Just as language is related to cognitive structure (Chomsky, 1968), stories are related to the structure of language Language is a symbolic representation of experience, and stories are a representation of the relationships within experiences …

Evaluating HIV mental health training: changes in practice and knowledge for social workers and case managers.

Abstract: ********** Social workers, case managers, and other counselors face significant challenges in working with HIV-infected clients and their families. HIV-affected populations typically require a full range of services to manage the illness and the significant stress and problems the infection causes. Service needs are increased when clients have mental health problems in addition to the HIV infection. Although social workers, case managers, and other counselors provide substantial services to HIV-infected people, they are often insufficiently prepared, a phenomenon especially pronounced when serving populations of color (Taylor-Brown & Garcia, 1995). To obtain adequate preparation, social workers must acquire knowledge regarding the unique needs of HIV-affected populations-- limited resources, organizational barriers, variation in service delivery systems. Inadequate preparation may result not only in reduced quality of services to clients and their families, but may lead to increased worker stress, job dissatisfaction, a nd burnout (Ross & Seeger, 1988). Social workers and other mental health providers need HIV training that is updated regularly. The development of combination antiretroviral drug therapies has generated significant breakthroughs in the treatment of HIV (Ho, 1998; Palella et al., 1998), which have implications for social work practice. Infected individuals now may begin treatment sooner and follow very complex drug regimens. Many people with HIV are living longer and often are free of symptoms; HIV/AIDS is increasingly viewed as a chronic rather than a terminal illness (Ho). Although treatment advances have greatly improved the lives of many HIV- infected people and their families, antiretroviral treatments also create challenges, particularly with treatment adherence (Linsk & Bonk, 2000). To be effective, antiretroviral drug regimens must be followed consistently and precisely and often require HIV-infected individuals to alter significantly their daily routines and eating habits. In addition, the drugs often have significant side effects, such as nausea, diarrhea, and headache, that many patients find intolerable (Singh et al., 1996). Compounding these concerns is the fact that the regimens may need to be followed indefinitely. All of these factors combined are especially challenging for patients with comorbid mental illness or substance abuse (Mehta, Moore, & Graham, 1997; Satriano, Rothschild, Steiner, & Oldham, 1999). Inconsistent adherence not only reduces treatment effectiveness, but also may actually promote viral mutation to forms that are resistant to antiretroviral medication (Paterson et al., 2000; Perrin & Telenti, 1998; Sherer, Rajaram, Jasek, Maclean, & Teter, 1999). Viral mutations are harmful for individuals with HIV and also present serious public health risks as drug-resistant strains of the virus spread. Public health officials are already beginning to see newly infected individuals with these drug-resistant strains (Perrin & Telenti). Despite treatment advances, HIV is associated with issues of grief and loss, disclosure to families and employers, fear, uncertainty about the future, decisions about when to start antiretroviral therapy, and potential treatment failures. Given the personal and social consequences of HIV infection, educational programs need to be comprehensive and skill based and need to demonstrate effectiveness in both increasing social worker knowledge and improving the quality of care provided to clients. Earlier research has demonstrated the need for social workers and case managers to receive HIV education (Zibalese-Crawford, Brennan, & Stein, 1995). Also, research assessing the effect of HIV education for social workers and other providers has supported the need to increase providers comfort with HIV/AIDS and willingness to work with the population (Knox, Friedrich, Gaies, & Achenbach, 1994; Riley & Greene, 1993). …

Harm Reduction and Injection Drug Use: Pragmatic Lessons from a Public Health Model.

Abstract: The spread of HIV infection among injection drug users (IDUs) is one of the most challenging and tenacious aspects of the drug problem plaguing the United States. Injection drug use represents a major public health challenge because of the multiple health, psychological, and social problems that must be overcome to address this addictive behavior and disease transmission (Office of National Drug Control Policy [ONDCP], 2000). National statistics indicate that injection drug use continues unabated with an estimated 1.1 to 1.5 million IDUs in the United States (Holmberg, 1996). The twin epidemic of injection drug use and AIDS has exacted a tremendous strain on the U.S. health care system, with the estimated treatment costs for IDUs infected with HIV and in the later stages, AIDS, totaling $3.7 billion (Harwood, Fountain, & Livermore, 1998). According to the Centers for Disease Control and Prevention (2000), 753,907 cumulative cases of AIDS were reported in the United States as of June 2000. Approximately 36 percent (n = 270,721) of the reported AIDS cases occurred among IDUs, their sexual partners, and their children. Because HIV can be transmitted both sexually and perinatally, drug injectors are also placing their potential children at increased risk. This is evidenced by 8,804 cumulative pediatric AIDS cases reported by midyear 2000, with more than half of these cases caused by injection drug use by the mother, or by the mother having sex with an IDU. A disproportionate number of members of racial and ethnic minority groups is being ravaged by the disastrous consequences of AIDS, with African Americans and Latinos accounting for 76 percent of the injection-related AIDS cases in the United States. Until a cure for AIDS is found, or a vaccine for HIV is developed, there is a critical need to reduce the spread of HIV transmission among individuals who choose to inject illicit substances. Harm-reduction interventions and policies have emerged as viable strategies to ameliorate the adverse health, social, or economic consequences associated with injection-related behaviors (Brettle, 1991; Des Jarlais, 1995; Des Jarlais & Friedman, 1993; Inciardi & Harrison, 2000; Marlatt, 1998; Nadelmann, 1998). PRAGMATIC LESSONS FROM A PUBLIC HEALTH MODEL Harm reduction, also called damage limitation, risk reduction, and harm minimization, is a goal of public health policies and interventions aimed at decreasing the deleterious consequences spurred by illicit drug use (Marlatt, Somers, & Tapert, 1993; Newcombe, 1992; Single, 1995). Present drug control measures and treatment philosophies in the United States deem abstinence as the most effective means of reducing the individual and public health risks associated with injection drug use (ONDCP, 2000). Harm reduction is a point of departure from these traditional beliefs. Proponents of the harm reduction model do not view abstinence as the only desirable objective for drug users. By acknowledging the prevalence of illicit drug use in our communities and that drugs may not always be used in a safe manner, harm reduction seeks to remedy these problems through pragmatic, incremental, and nonjudgmental interventions and policies (Des Jarlais, 1995; Des Jarlais, Friedman, & Ward, 1993; Schilling & El-Bassel, 1998). Harm reduction measures do not ascribe to a specific formula, but should reflect specific individual and community needs. Therefore, practitioners should always be conscious of starting "where the client is" during the course of the therapeutic process. The common principles that are central to harm-reduction practice are as follows: * The harm-reduction approach does not attempt to minimize or ignore the pervasive public health consequences associated with injection drug use, but rather accepts that the nonmedical use of psychoactive drugs is an inevitable occurrence in a society that has access to such drugs (Des Jarlais, 1995). …

Tech knowledge: introducing computers for coordinated care.

Abstract: ********** The current health and social services paradigm emphasizes an integrated delivery system in which the basic unit of currency is the referral. Making referrals is a hallmark of social work practice. This positions social workers on the front lines of coordinating patient care. Their skills at relationship building and knowledge of community networks become invaluable to patients, but often time constraints stand in the way of making the best possible referrals. Are there solutions for increasing referral effectiveness? Not surprisingly, technological innovation may provide a sound investment for organizations that deal with challenging populations who have multiple service needs. The research literature and practice wisdom show that technology is increasingly useful in both medical and social work practice (Hodge, Gostin, & Jacobson, 1999; Howard, 1995; Mutschler, 1990). This utility may be extended to building and strengthening referral networks. When appropriately used technology has the capacity to increase efficiency with the advantage of standardized data output. A single application of technology may lead to additional advances, such as linking various types of client services to improve coordination of care. This article describes a three-year intervention project introducing and supporting referral technology in three inner-city health services sites. We detail successes and challenges of the implementation process and provide guidelines for replication in social work practice. We also show how a cooperative partnership between social workers, community organizations, and university researchers may help foster positive change for clients with special needs. INTERVENTION The intervention was designed by a team of applied researchers at the University of Miami School of Medicine in response to reported local concerns about an increase in the number of drug abuse clients who presented with complex health and human services needs. One of the primary aims was to expand and standardize the referral capacity of health and social work professionals through the introduction of technology. The intervention encouraged the use of computer software expressly designed as an information and referral system called Information and Referral Information System, or IRis [R] (Benchmark Enterprises, 1993-2001). Iris [R] provides appropriate referrals for clients using a powerful search engine that scans a database of community services. It also features the capability to standardize client data, computerize reporting forms, and store information about patient referral and service histories. The system was implemented using a three-phase process tailoring the level of change to the respective readiness and available resources at each of three intervention sites. INTERVENTION SITES Three local organizations were selected as participating sites. The final selection was based on data collected from a sample population of 1,500 drug-abusing clients and 300 health and social services program administrators and direct care workers who were interviewed by research staff. (Chitwood, McBride, Metsch, Comerford, & McCoy, 1998; McCoy, Messiah, & Zhao, 2001). Each site represented a different aspect of the health and human services system: a drug abuse treatment center, a primary health care clinic, and a public hospital's emergency services department. All three sites were located within a 10-mile radius. The drug treatment center is a private, nonprofit inpatient facility. The primary health care center is a publicly funded, nonprofit organization specializing in ambulatory care and social services for low-income people. The emergency services department and its corresponding social work office are located in the only publicly funded hospital in the community, which is one of the largest medical centers in the United States. Most drug users in the community eventually present at this hospital because of lack of insurance, transportation, access to other programs, or for expedience. …

Health Care Experiences and Preferences of Uninsured Workers

Abstract: An exploratory study of the experiences, beliefs, and preferences of uninsured workers found that uninsured workers are active in seeking solutions to their health care needs and have decided opinions about health care. They use a cost-benefit analysis in deciding which health problems warrant professional attention. However, uninsured workers also exhibit a contradictory pattern of behaviors and beliefs. They say their health is good, yet many have illnesses that they neglect. They are satisfied with the health care services they use, yet they want health insurance because they believe it provides more choice and ensures better care and treatment. They express few negative feelings about Medicaid, yet even among the poorest of these workers, few have recently used Medicaid. These findings can inform policy options being considered.

Health Care Challenges Created by Substance Abuse: The Whole Is Definitely Bigger than the Sum of Its Parts

Abstract: THE ENORMITY OF THE CHALLENGE What do a six-week-old infant, her 19-year-old mother, an 83-year-old nursing home resident, a 47-year-old landscape designer, and a high school sophomore have in common? The thread that ties-or the rope that binds--is frequently the pervasive challenge of substance misuse. As anyone working in the field of health care and social work can attest, mind-altering substances are so much a part of daily life that few individuals remain untouched by their influence; and few social workers can remain isolated from their daunting challenges (Abbott, 2000). Substance abuse creates a major drain on our personal, social, economic, and professional resources. The burdens on the health care delivery system, to say nothing of the social services system, are immense. In 2001 Alan Leshner, then-Director of the National Institute on Drug Abuse (NIDA), deemed substance abuse as the "most destructive health and social problem facing our Nation today" (Leshner, 2001b, p. 3). According to former Secretary of Health and Human Services, Donna Shalala, in the preface to the Tenth Special Report to the U.S. Congress on Alcohol and Health, "alcohol problems, both those of individuals and those that affect society at large, continue to impose a staggering burden on our Nation. Domestic violence, child abuse, fires and other accidents, falls, rape, and other crimes such as robbery and assault, all are linked to alcohol misuse" (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2000, p. ix). Estimates presented by Kirschstein in the Tenth Special Report indicate that more than 100,000 lives are lost each year because of alcohol misuse. Nearly $184.6 billion, or about $638 for every man, woman, and child in the United States, is spent annually because of alcohol misuse (NIAAA, 2000). Alcohol is third only to tobacco and unhealthy diet or exercise patterns as the leading cause of death in the United States (NIAAA Strategic Plan, 2001-2005, available at ). Startl ing statistics support the reported concerns: 14 million Americans or 7.4 percent of the population meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association, 2000) criteria for alcohol abuse or alcoholism; in almost one of four instances of violent crime, the offender had been drinking before committing the crime; in 1997, traffic accidents involving alcohol resulted in more than 16,000 individual deaths (NIAAA, 2000). The data are equally staggering for drug abuse. Data from the National Household Survey on Drug Abuse, an annual survey funded by the Substance Abuse and Mental Health Service Administration (SAMHSA, 1999), indicated that nearly 15 million Americans reported using illicit drugs at least once in the month before being surveyed; 3.5 million of them were identified as being dependent on illicit drugs. Alarmingly, these figures did not include misuse or dependence on prescription or legal drugs. A recent study combining the economic cost of drug and alcohol abuse estimated that the combined costs were almost $250 billion or nearly $1,000 for every man, woman, and child in the United States. The study estimated that 60 percent was spent on alcohol-related activities, with the remaining 40 percent used on other drug abuse activities. These figures include the full spectrum of costs: health care, motor vehicles accidents, lost productivity, and property damage. It was estimated that only 12.7 percent of the total was spent of alcohol-related health care costs and only 10.2 percent on health care costs related to other drugs (National Institutes of Health, 1998). The Community Epidemiology Work Group (CEWG) of NIDA, which has monitored drug use patterns for more than 25 years, bases its annual reports on a number of indicators, including the National Household Survey on Drug Abuse mentioned earlier, the Drug Abuse Warning Network (based on emergency room statistics), Uniform Crime Reports by the Federal Bureau of Investigation, and data from the National Institute of Justice and the Drug Enforcement Administration (Hatem, 2001). …

HIV-Prevention Capacity Building in Gay, Racial, and Ethnic Minority Communities in Small Cities and Towns

Abstract: ********** HIV disease continues to be a major public health problem. As of June 1999, 711,344 people in the United States had been diagnosed with AIDS, and an estimated 1 million people were infected with HIV (Centers for Disease Control and Prevention [CDC], 1999). HIV infection is most often transmitted through behaviors that are associated with social stigma--sex between men and injection drug use. Of all those diagnosed with AIDS, nearly one-half (48 percent) are men who have sex with men (MSM); 25 percent are women and men who are injection drug users (IDU) (CDC, 1999). Racial and ethnic minority members are disproportionately represented in these groups and may be further stigmatized by their minority community members (De La Rosa, Khalsa, & Rouse, 1990; Diaz, Buehler, Castro, & Ward, 1993; Luckey, 1995; Morales & Fulliove, 1992; Quimby, 1993; Ramirez, Suarez, De La Rosa, Castro, & Zimmerman, 1994). Furthermore, HIV carries its own stigma (Alonzo & Reynolds, 1995). Just being perceived as engaging in high-risk behaviors that lead to infection or supporting those who may can be enough to trigger sanctions (Green, 1995). Taking a public position in support of gay rights, syringe exchange, or increased services for HIV-infected people may "taint" someone. Discrimination based on stigma is compounded in small cities and rural areas because maintaining privacy is more difficult than in larger cities (Burnette, 1999; McGinn, 1996). In addition to the problems faced by individual members of high-risk groups, tensions also exist at the community level. The African American community's experiences with the Tuskeegee study and the sexual-orientation minority community's (lesbian, gay male, bisexual, and transgender) experiences with forced interventions such as castration, confinement in institutions, and aversion therapy re-enforce distrust in these communities and result in reluctance to cooperate with government and medical institutions (Benedek, 1978; Katz, 1994). Stigma and marginality not only explain many of the barriers facing HIV-prevention programs, but also help explain the inability of some providers to reach members of racial, ethnic, and sexual minority groups. The Council on Scientific Affairs of the American Medical Association reported that many providers lack the necessary knowledge, attitudes, and skills to reach members of the gay and lesbian community (American Medical Association, 1996). One way to establish ties and win the trust of stigmatized populations is to bring these populations together in the planning, development, and implementation of public health programs (Stoto, Abel, & Dievler, 1996). Supporting this understanding, the CDC in 1993 announced that state territorial health departments must establish HIV-prevention committees made up of citizens who mirror the AIDS epidemic population. These committees were instructed to develop prevention plans for jurisdictions to use in their requests for funds. Funds could be denied or reduced if a committee's plan was not adequately reflected in the application or if the committee refused to concur with the application. When notified of these new requirements, the Pennsylvania Health Department asked faculty at the University of Pittsburgh's Graduate School of Public Health for technical assistance in designing an HIV-prevention intervention. This article describes the community leadership development model that emerged from this collaboration and presents guidelines for developing leadership among stigmatized groups. INDENTIFYING INDIGENOUS LEADERS If HIV-infected people and members of high-risk communities were to participate at the local level, infrastructures for capacity building were needed in the at-risk communities. Capacity building required the identification and recruitment of competent and committed local people who were members of the groups at risk or who had strong and trusting relationships with these groups. …