Below are 2 videos(less than 5 minutes each) on the US prison population. 1. Please elaborate on how these videos impacted you. What are your thoughts about how interventions may or may not work to reduce our prison population and the impact these incarcerations have on people of color? Also use what you have read in the textbook to answer these questions or to give information about the topic. https://www.youtube.com/watch?v=Hfie5bHG1OA&t=17s https://www.youtube.com/watch?v=lUt_fIB6A_Y Groups in Need LEARNING OBJECTIVES li@sl Understand the nature and scope of America's poor. Consider the nature and consequences of unemployment. Examine chiidren in need and the changing American family. (@ Learn about the survivors of domestic violence. Develop an understanding of lesbian, gay, bisexual, and transgender communities. Understand the role of aging and the needs of senior citizens. IKSSI Learn about the needs of people with disabilities. Learn about the needs of people with mental illness. Understand the nature of substance abuse and substance abusers. 41 Develop an awareness of Real Life Human Services Work. Explore the nature of drugs in the United States. Gain knowledge about criminality in the United States. Learn about people with intellectual and developmental disabilities. Examine homelessness in the United States. Identify the nature of HIV/AIDS and the HIV/ AIDS pandemic. 60 CHAPTER 2 GROUPS IN NEED Ontroductiori line, provided by the Social Security Administration and the Census Bureau. These thresholds are used mainly for statistical purposes, for instance, preparing estimates of the number of Americans in poverty each year. All official poverty population fig­ ures are calculated using the poverty threshold. This figure is based on the fact that an average low-income family spends one-third of its total income for food. The poverty line, then, is the food budget for a family of a given size multiplied by 3. Adjustments are made for changes in the cost of living for a given year. Another consideration is whether the family lives on a farm. Farm families supply some of their own food and are therefore assigned a lower figure. The poverty line should be taken as a general measure of economic well-being. It is not necessarily the income level used to determine eligibility for government assistance, a figure that varies by locality. Another slightly different version of the federal poverty measure is the pov­ erty guidelines. They are issued each year in the Federal Register by the Department of Health and Human Services. The guidelines are a simplification of the poverty thresholds used for administrative purposes to determine, for example, financial eligibility for certain federal programs. Some programs using these guidelines for eligibility include Head Start, the Food Stamp Program, the National School Lunch Program, the Low-Income Home Energy Assistance Program, and the Children’s Health Insurance Program (Federal Register 2015). The official poverty threshold allows convenient comparisons of poverty lev­ els from year to year. It is not implied that the family could actually live on that amount. If total family income was less than the appropriate threshold for that family’s size, then that family was considered to be living in poverty (U.S. Census Bureau, retrieved March 26, 2009). Schwarz and Volgy (1992) proposed a more realistic alternative measure. Their self-sufficiency threshold is defined as an eco­ nomic budget that would allow a family of four to purchase minimum but essential items for food, housing, clothing, transportation, and medical and personal expenses and to pay taxes. In other words, a family of four actually needs about 150% of the poverty-line amount to get by. It is estimated that there are about 24 million persons among the working poor—that is, those who are employed full-time, receive no welfare benefits, and live below the self-sufficiency threshold. Z3 This chapter is devoted to groups of people in need of help from human services. They are sometimes called target populations or consumers of human services. The poor, senior citizens, mental patients, abused children, and teenage runaways are examples of groups that have been targeted by specific programs and agencies. There is nothing permanent about target populations. Current public opinion, avail­ ability of funding, and political climate determine which groups may be relatively favored at a particular time. Populations that have always existed may suddenly be chosen for benefits. For example, victims of crime have only recently been targeted for benefits in a systematic way. The critical question of who determines which groups will receive aid is discussed in Chapter 7. As there are literally hundreds of target groups of varying sizes, all of them cannot be covered here. Discussion is limited to some of the larger groups that are being helped in an organized way. For each group, a rough estimate of the number of people is given, along with a brief account of some of the programs and services provided. In regard to kinds of help provided, emphasis is placed on large-scale fed­ eral programs, because these have become the vital bedrock of support for millions of Americans. You are encouraged to investigate some of the smaller target popula­ tions, as well as some of the local and private helping agencies, on your own. (America’s ) L01 The United States is one of the wealthiest nations in the world; its gross national product (the value of all goods produced and services provided) has been higher than that of any other country. Yet, despite this high level of affluence, millions of Americans are not sharing in the general wealth, as shown by the data in Chapter 1. Their relative deprivation affects the style and quality of their lives; it extends beyond mere distribution of income and includes inequality in education, health care, police protection, job opportunity, legal justice, and other areas. There is continuing debate about the degree of hardship faced by the nation’s poor people. Conservatives point out that many poor people receive noncash ben­ efits such as food stamps now referred to as the Supplemental Nutritional Assis­ tance Program (SNAP), public housing subsidies, and health insurance that help provide the necessities of life. The federal government provides assistance through Temporary Assistance for Needy Families (TANF). TANF is a grant given to each state to run its own programs for the poor. At present, it is difficult to know how many Americans are living in poverty because the number depends on the standard used to define poverty. Poverty gen­ erally means that household income is inadequate as judged by a specific standard. Translating this concept into practical terms produces ideological debate as well as technical problems (Ambrosino, Ambrosino, Heffernan, &c Shuttlesworth, 2016). The Institute for Research on Poverty (2013) views the poverty rate as representing an average over the entire population. It does not convey poverty levels between and among the various groups in society. According to the Current Population Sur­ vey (2016 Annual Social and Economic Supplement), one of the federal sources of poverty estimates, the number of people living in poverty in 2015 was 46.7 million people. Perhaps the most widely used measure is the threshold, or poverty I 61 □ Who Are the Poor? ■ Obviously, poor people are those with a relative lack of money, resources, and pos­ sessions. Beyond this shared characteristic, America’s poor may have little else in common. One important subgroup of poor people consists of those who have suf­ fered a temporary setback that has reduced their ability to be self-supporting. These groups include workers who have been laid off, partners who have been deserted by their spouses, and persons needed at home in a family crisis. Most of these people would be considered able-bodied poor because they are potentially employable. Not all people living in poverty are unemployed. Approximately 48% are poor because their work hours were reduced and 18% became poor because of losing the family breadwinner through divorce (Oswald, 2005). A quite different subgroup of poor, sometimes called the “deserving poor,” is made up of people who are not able to be self-supporting. Included are the aged poor, young children of poor families, some discharged mental patients, and people who are permanently disabled. Diversity among subgroups of the poor has been an obstacle in developing satis­ factory programs to help the poor; programs that suit one group may be inadequate 62 CHAPTER 2 GROUPS IN NEED for another. For example, to encourage the able-bodied poor to enter the job mar­ ket, an aid program should pay low benefits. However, low benefits would be an undeserved penalty to a person who could not work in any case. As I create the 10th edition of this text in 2016-2017, who will be helped, in what manner, and how much are questions still very much tied to our cultural political landscape. As I will discuss in later chapters, similar obstacles are still present in our human services delivery system making it difficult to reach those most in need. Chapter 1 points out that a disproportionate number of poor can be found among minority groups. The poverty rate for African Americans and Latinos is considerably higher than for whites. Women and children are also overrepresented among the ranks of the poor. In fact, the great majority of those living in poverty consist of women and children; they are the major recipients of welfare benefits and other programs for the poor. O Welfare The single most important weapon in President Lyndon Johnson’s “War on Pov­ erty,” introduced in the 1960s, was public welfare. It is difficult to provide a clear picture of welfare because it was not one but many programs. Local, state, and federal governments were all involved in a complex, interlocking fashion. The basic responsibility rested with local (i.e., county or city) governments, which determined who was eligible for welfare and what benefits would be given. There was great variation in benefits paid by the various states, even when differences in cost of liv­ ing were taken into account. Southeastern states, for example, tended to pay much less than California or some northern industrial states. Aid to Families with Dependent Children (AFDC), no longer with us, was the program most people meant when they referred to welfare. Before this program was enacted, few acceptable options were available to a parent with no means of sup­ porting young children. One alternative was to turn the children over to an orphan­ age; another was to seek work outside the home, leaving the children unsupervised. Neither alternative was satisfactory to the family or to the community. Some commentators blame welfare for the great increase in out-of-wedlock births to teenage girls. A teenage mother is much less likely to complete high school and is more likely to be poor in later life than is a mature mother. Babies born to teenage mothers are at relatively high risk of illness, low birth weight, and develop­ mental delays (Ventura, 1994). Clearly, they are at risk to perpetuate the cycle of poverty and end up as welfare recipients themselves. It is adult males, 20 and older, who are responsible for the majority of babies born to teenagers aged 15 to 17. What has changed in recent decades is that pregnant teenage girls no longer marry the father. Although some girls choose older boyfriends whom they regard as mature, a sizable amount of teenage sex is not consensual. In some poor areas, teenage girls report high rates of rape and sexual abuse. Many of the fathers in depressed areas are not able to provide support for a family. In one study, 32% of the adult male partners of teenage girls were neither working nor in school at the time of the child’s birth (Shapiro, 1995). Under these circumstances, it is not surprising that the girls seek welfare support. WELFARE REFORM During 1995, there was a growing political consensus that the welfare system needed a complete overhaul. The welfare state was criticized for 63 breaking up families (discussed in Chapter 1), rewarding irresponsible behavior, and minimizing work incentives for the poor. Democrats conceded that their party had failed to strongly support the federal safety net for poor people (Toner, 1995). Some Democrats admitted that they had failed to keep vigil over welfare programs with the result that the programs did not change with the times. Governor Mario Cuomo of New York said, “We blew it. We were in power for a long time. We didn’t correct ourselves. We didn’t stay up to date, and we paid the price” (quoted in Wines, 1995, p. El). The result was that 87 of 100 senators, including 3 of 4 Democrats, voted to abandon the federal welfare system that had been in place for three decades. With the passage of the Welfare Reform Act of 1996 (The Personal Responsibil­ ity and Work Opportunity Reconciliation Act of 1996), the states of the union now have primary responsibility for managing welfare programs. Increased money in the form of block grants, titled Temporary Assistance for Needy Families, is being sent from federal to state levels. In fact, many states seized the initiative in reorga­ nizing welfare programs. The names of some of the newer state programs provide an explanation of the direction of the changes.'Consider the Virginia Independence Program, Wisconsin’s Work Not Welfare Program, and Colorado’s Personal Respon­ sibility and Employment Program. In Massachusetts, the Department of Public Welfare became the Department of Transitional Assistance (1995). It seems obvious that recipients are being told to assume more self-responsibility, prepare to work, and not expect benefits for an extended period. In 2016-2017, the term welfare is rarely used being replaced with the phrase “welfare-to-work.” AFDC was phased out in favor of a variety of workfare programs. In 1998, the mayor of New York City, Rudolph Giuliani, announced his goal for New York City s poor. The plan was to end welfare completely by the end of the century (Swarns, 1998). The old system would be replaced by a universal work requirement for anyone hoping to receive financial help from the city. New York City created experimental job centers to replace certain welfare offices. Welfare applicants are required to meet with a financial planner to help them find alternatives to aid from the city. They are given a five-year lifetime limit on welfare and advised that some form of work is mandatory in order to receive benefits. New York, like other states, must create alternative workfare jobs for such a system to be effective. Under such policies, only the most seriously disabled people will continue to receive cash assistance without working. Critics of these new policies point out that drug addicts, the disabled, and new mothers must receive additional forms of help in order for them to convert to a work-for-welfare system. Additional child care systems must be made available for those taking workfare jobs to get public checks, and expanded drug treatment centers and job training programs must also be cre­ ated. Thus, it is anticipated that restricting welfare further will actually increase spending on each recipient through the necessity to expand child care and other services. These policies of New York, modeled after similar initiatives in Wisconsin, have as their basis a universal work requirement. Various other states have imposed a time limit on welfare benefits. The idea is to prevent welfare from becoming a permanent lifestyle. Other proposals aim at promoting socially desirable behavior. In Maryland, for example, there is a 30% reduction in welfare payments unless parents prove they have paid rent, kept chil­ dren in school, and obtained preventive health care (e.g., vaccinations). Other ideas are aimed at keeping the family together. For instance, some states have a “wedfare” component that allows the woman to retain a portion of grants after marriage. I GROUPS IN NEED I 64 CHAPTER 2 su..a.y.. appear their own welfare programs. Ideal y, ^ productive lifestyles. As many tive programs that successfully move r P ^ ££ during 2016 due as 1 million of the nation's P-^Xtuets for “ployed adults aged 18-19 to the 3-month limit imposed on ^NAP benet who are not disabled or raising : , possibility of negative competition turning welfare over to the states. benefits, the object being to discourbetween states to see who can offer th » j„ocates for the poor have expressed age welfare migration into the home ^ constitutional provision concern about the fact that only one state N Connecticut has that guarantees aid to its poorest ‘ jp benefits and the imposition of no such responsibility, paving the way for cutba . £995) The idea that Le WtsL how long benefits be se«ns on. of poor people are entitled to a guarantee of at least minim favor at both federal and state Jewels. welfare reform does not address Liberal commentator doubts that some individuals abuse the basic ptoblen. of ^who teceive welthe welfare system, it ™P , suggests is that viable opportunities are f„e do wan. to work. The real jobs sinrply do no. pay not available to everyone '°”'SIniLm-wage jobs such as fast-food, clenSraSng ?o:^^°do nor ply enough to keep a fatnlly above the poverty level. , • r 1 lot wViat has happened since the passage of the Persona=^"-"^^^ WELFARE REFORM-AGAIN reevaluated the Personal f »"k for'^much of the law expired in °2oJfit.IS“rlny nuior goals of the law were accontpltshed, individuals back to the states. Je^eiop and implement their own programs to each state, thus enabling ^h^s^Sed in the title to part of the new law. to help the needy. The second g Families (TANF). Temporary was It was named Temporary Assistance J poverty” that was the key word. The f'd ote as an ongoing, never-ending process, seen by conservatives, legislators, an 8 ^ concomone in which people would remain ^J^^d p-blem was dealt with irant increase in —0 and social ^ by setting a five-year lifetim individuals off welfare rolls but also to third goal was not only to get ^ the program were engaged tnake sure that those ^s were in fact required to be in an lation, was partially due to incomp e eligible—or not Sr ^=Xate programs. Some felt that there 65 was little or no congressional oversight to assure that funds were used only for the stated purpose of the legislation. Other critics raised significant questions regarding the level of jobs, training, benefits, and income obtained by those taken off welfare. As for the time limits, questions were asked about what happened to those who were not engaged in work activities within the 24-month period and to those who required help after the five-year lifetime limit had passed. The Deficit Reduction Act of 2005 authorized TANF recipients increase their work participation rates and each state must impose a rigorous requirement for all hours of participation which must be verified and documented. The social welfare provisions for the poor have continued to diminish. Assistance today is worked-based and forces many mothers to work outside the home for very small wages. The federal government has thus far not created a sustained system to develop employment opportunities (Giffords & Garber, 2014). □ Other Programs for the Poor The federal government supports a number of other programs for people with lim­ ited income. These include food stamps, now known as the Supplemental Nutrition Assistance Program and Women’s, Infants’ and Children’s (WIG) Programs, free or reduced-price school lunches, housing subsidies, and Medicaid benefits. Let’s take a closer look at some of these programs. Some low-income families are eligible for food stamps, which can only be used for the purpose of buying food in an authorized food market, with the use of an electronic card. They cannot be used for buying liquor, beer, cigarettes, soap, paper products, or other nonfood items. The U.S. Department of Agriculture defines hun­ gry or starving people” as “food insecurity.” Food insecurity, they site, is the lack of resources required to sustain the nutritional needs of family members. As of 2016, approximately 52 million people, including 18 million children, experienced food insecurity. As of 2017, this number continues to rise. Poor people may also be eligible for various kinds of help with housing. Some communities provide low-cost housing, often called projects, for poor people. In some cases, welfare provides a rent subsidy for those unable to pay the full amoimt of their rent. Homeless people are put up in low-cost hotels until a permanent place is found. Regardless of the form of housing, poor people tend to be placed together in ghetto-like environments where crime, addiction, and substandard conditions are common. , r,. • ju u The federal government provides health care to those of limited income through Medicaid, a system that offers an array of inpatient and outpatient medical services. Although it has helped poor people gain access to improved medical care, the pro­ gram is riddled with abuses, especially in poor areas. Some unscrupulous people set up “Medicaid mills” in poor neighborhoods, where the patient is routinely run through a lengthy series of tests and procedures, many of which are unnecessary. Another problem with the Medicaid system is that many doctors simply refuse to accept Medicaid patients because the level of reimbursement is too low. ^ Not all programs for the poor are concerned with basic survival needs.x For example, many city and state governments provide low-cost or free college education for low-income students. Many of these colleges have an open enrollment policy and make some provision for the underprepared student in the form of remediation courses. GROUPS iN NEED 66 67 CHAPTER 2 Most of the programs just meiitioned whose total financial support falls below a certain ^ Although these and other programs have improved the qual ty poor persons, life for the poor is far from'^asy, one reason that there co tinues to be a strong undercurrent of hostility toward the f Many hardworking Americans, convinced that wel are tecipie themimmoral people, bitterly resent paying tax money to suppor e . thinking, selves sometimes have incorporated these negative attitu es m o values to They feel ashamed of not being independent and self-reliant, Americans. These attitudes may be shared by the politicians who and eligibility requirements, as well as by the workers who f It is not surprising that welfare recipients often band together into i ^ tical where they may find not only understanding and support but also more practica This section can best be closed by recalling Will Rogers s remark, It s no crime to be poor, but it might as well be.” (SioaestedCiasr/^ignment__ __H ■■■ —^ Report on the welfare system in your state, answering the following items: • What are the eligibility requirements for entering the program?^ . Describe the benefits, including cash awards, housing subsidies, and other allowances. . Describe the recipient population in terms of age, gender, race, and education. . What arrangements are made regarding employment, job training, or education? [ • What changes, if any, have been made in the system m recent years? • How does this program compare to those of neighboring states? • How do recipients feel about the program? • How does the program deal with unmarried teenage mothers? (The Unemployed Let’s begin our discussion of unemployment with some of the obvious benefits that L02 typically come from having a steady job. • It provides income needed for the necessities of life. • It helps one to be independent and self-supporting. • It helps one feel like a useful member of society. • • • • It structures time in a useful way. It provides social contacts with others. It may place one in a stimulating environment. It provides an opportunity to use and develop talents. / □ Consequences of Joblessness The benefits that come from having a job obviously vanish when a worker is laid off or fired. Instead, there is often a sense of absence of control over one’s life, coupled with a fear of having to depend on others. The unemployed person begins to feel cut off from the mainstream of life, a feeling that deepens as time goes on. The devastating consequences of unemployment were highlighted by a study of white-collar men who had lost their jobs in the recession of the mid-1970s; they showed signs of severe psychological stress (Braginsky & Braginsky, 1975). Although many were college graduates and had held prestigious managerial posi­ tions, their self-esteem was sharply lowered by the experience. Most suffered deep shame, avoided friends, and felt isolated from society. They felt insignificant and suffered from the feeling that they had lost value in the eyes of family members. Another consequence of their prolonged unemployment was a deep cynicism toward established institutions. Since the last recession which began in 2007, many more individuals found themselves unemployed. Workers who lose their jobs in an eco­ nomic downturn typically suffer a double problem; they not only lose their income but most times, their employer-based health insurance as well. n Unemployment Rates Each month, the U.S. Bureau of Labor Statistics reports the official rate of unem­ ployment in the labor force. The labor force is defined as people 16 years of age or over who worked one hour for pay during one survey week or who did not have a job and were actively seeking work. The nation’s official unemployment rate in recent years has ranged from 7.1% during the 1991 recession to 5.5% during’ the recovery of 1995 (Hershey, 1995) to 4% in 2000 and back to 5.7% in 2001 (Bloomberg News, 2001). This statistic does not include the estimated 1 million discouraged workers who are no longer even trying to find jobs. Nor does it include the underemployed people who are working part-time because they could not find full-time jobs. In 2009 the unemployment rate in the United States was the highest it has been in over a quarter of a century. As a result of this and other economic turmoil facing the United States, President Obama had proposed an expansion of unemployment benefits. As of early 2012, the U.S. Bureau of Labor Statistics showed an 8.3% unemployment rate or 12.8 million unemployed. As of August 2016, the Obama administration has brought down the unemployment rate to 5% with 7.8 million unemployed. The jobless rate for whites is less than that for African Americans^-with the Latino rate falling between these groups (U.S. Census Bureau, 2015). While still painfully high, unemployment has fallen from its peak and various economic indi­ cators of 2016 seem to evidence a growing economy. We can only hope this trend continues. □ Unemployment Insurance The unemployment compensation system is our society’s way of helping people' who have been laid off from their fobs. The states regulate unemployment insurance programs, which vary in rules and eligibility requirements. In most states, work­ ers and employers contribute to the program. Often the amount and duration of GROUPS IN NEED 68 CHAPTER 2 n Children of Single-Parent Families payments are baaed on ,h. “/^XaTd efits program is sometimes activated w en u high in a particular state; it P--" ^ A further increase in the jj^^^ber of v^ek t P ^ £ regular benefits, provided by Conn^^ximum supplements are fySat^fn re'^ptXX □ Impact Of Unemployment on H^an Services^^ Increases and decreases in unemployment ^™ i^^^ly show that effects on human services. Various surveys, -P^’illnesL, elevated negative economic changes result m increases mcepy crime rates, and increased first admissions swnso^^^ tals. These and other negative effects of econom livelihood may to fully aevelop. It appears that the stress ^eact to this stress have aWterm, ias.diou, effect. '> betoX^ may sufin very different ways. Some las on nnemployment ultimately and a variety of other agencies. ildren in Need I 69 LOS Children are endangered not only understanding, the inability of paren children are a high-risk group for Srpil^Ts^troTphyllf:::^ ^mo^nal P,« “^iXmsrtirenX .0 re,ni^^ssio^^^^^ choses and the intellectually ^ trpme shvness. These and other dysfunctions, Mriettd^n^'bllSS psVology ing changes have affected children. □ Children and the Changing American Family Xpter f discussed the dramatic ehangs " "a^lX” family in recent decades. It ^£ ^g^g^t past. More children are growworse off in some respects than c ^ parent, and stress due to ing up with fewer parental Resources. children are living below the povseparations and divorce. An (Smiley, 2016). This situation dramatiXXXS—sTs:So&ahes’.hem more susceptible to numerous maladaptive behaviors. The overall rate of single-parent families has slowly increased from 2000 to 2015. According to the U.S. Census Bureau (2015), the rate is now about 11-12% of fam­ ilies. In addition, the findings suggest that the percentage of children in such homes is disproportionately high in our central cities. The great majority of these homes are headed by a single'parent. As Chapter 1 mentioned, one of the disadvantages of single-parent families is the greater likelihood of children living in poverty. Mother-only families have very high rates of poverty. After a divorce or separation, the mother’s earnings become the major source of family income, and usually, the postdivorce income of women is significantly lower than that of divorced men. For single parents of both sexes, there are likely to be problems associated with combining work with child rearing. Job mobility, earning power, freedom to work late, and job performance are all likely to be negatively affected (Amato, 2005). Children from single-parent families also have above-average levels of youth suicide, mental illness, violence, and drug use. When you add poor school perfor­ mance to the list of problems, it becomes obvious that this population is likely to be in need of help from a range of human services agencies. The psychological aspects of single parenthood are problematical in that the single parent must play both mother and father roles. In addition to providing love and nurturance, the single parent must represent the family interests to society at large, interpret society for the children, and be a figure of authority and discipline for them (Costin, Bell, & Downs, 1991, p. 137). For many single parents, the pres­ sures of playing these roles, along with the need to make a living, create considerable stress. However, as Kunz (2012) and Princeton University & Brooking Institution (2005) point out, there may be benefits for children in single-parent families that are not possible in traditional families. For example, a stronger bond with the single parent, extra responsibilities that build skills, and the development of a wider net­ work of adult friends and community. Helping efforts for the children of single parents have been centered in the schools. One approach that has enjoyed some success is peer counseling in the form of “rap groups” for children. Whether sponsored by the school or a local counseling agency, these groups help the youngster to ventilate strong feelings about their home life and also to reduce the sense of isolation that some feel. In the group setting, children realize that their feelings are shared by .many others in similar situations. In some cases, the child may be in need of more professional help. Some com­ munity agencies, such as child guidance centers, offer individual or family therapy with a social worker, psychologist, or psychiatrist. Some of these agencies maintain a reference library of books, pamphlets, and films on death and divorce for use by clients and families of clients. In addition to psychotherapeutic intervention, a great many other kinds of ser­ vices may be available to these children and their families—so many, in fact, that only a brief listing is provided here: • Daytime care programs for young children aim to foster optimal intellectual^ development and to help overcome some of the emotional effects of early deprivation. • Parent-assistance programs are designed to help the inexperienced or overburdened parent^to deal with some of the practical problems of child and home care. GROUPS IN NEED vices for which they rrray be ehgib e. ,,d Abused and Neglected family !& have contribIt is not known how much the ‘^.^^ertain only thit there has been a uted to the apparent increase in child abuse, “ne r^Jdecades. Some experts huge increase in the number of ° finding and reporting, irnplymg that attribute part of the increase to m reported. During recent decades, t similar cases existed m the past b • _ .^^hich have increased public awar media have reported many ®'f-buse It is even possible that our con:L of .he rfering of y”".” °of over-,.porting of doubtful or cern for these youngsters has ushered in p , , , unfounded cases of abuse ,^„ltreatment defined? Abuse and neglect Exactly how is child abuse o . , uniform definition. A prelimi- list offers an idea of the various w=s of mateeatureut that have come to the attention of human services wor . Children have beaten, kicked, slapped, I’*'y®'“'’^“““mplement sui as a knife, whip, or strap scalded with a hot liquid. -.afv nf acts ranging from fondling of . T"h"tS form of emotional assaults, such as threatening, belit. tr. las ten conhned b, being tied up, chained, or locked in a closet or room. . Neglect of the child’s needs f included outright abandonment o care, inadequate supervision, . j child’s education, and disregard of the abusive. Examples have f^ji^re to provide needed medical ^j^^dequate clothing, neglect of the ^ A distinction is usually thrcaSi*et, meaning a voluntary act, usually an aa of commission on the par, ofoar.^ , ,be "vJteL neglect is an -t f tf n^^^ am involunmry on the part child’s welfare is not provided. Many mstanc 71 of the parent or caregiver. Sometimes, the caregiver may be unable to provide for the child because of illness, incarceration, loss of income, or some other unforeseen event. The number of cases of child abuse and neglect cannot be stated with cer­ tainty because estimates come from so many different sources. According to the United States Department of Health and Human Services (USDHHS) (2010), over 3 million reports of child abuse are made every year in the United States. In 2009, approximately 3.3 million child abuse reports were filed involving over 6 million children. Professionals such as teachers, human services workers, and physicians made over half of the referrals. Families, friends, neighbors, and community mem­ bers made the rest. Although these data are the most comprehensively available, it should be kept in mind that they include only those cases that actually come to the attention of community agencies. Many cases probably go unreported. Some people who sus­ pect that a child is being abused may decide not to make a report because they are afraid of retaliation on the part of the abuser or perhaps doubt that the authorities will take any effective action. In addition, it is clear that false reporting of child abuse cases is a disservice to the children who are involved. They are forced to undergo the pressures of public hearings and are generally placed under great stress. Another problem is that the unfounded cases necessitate the waste of professional time, which could be put to better use in valid cases. Many factors play a role in child abuse. Some have to do with environmental stress, whereas others involve the personality traits of the abusing caregiver. Abusive parents tend to be young, of lower economic-class status, frustrated, unemployed, alcohol abusers, and often suffer from marital discontent (National Alliance on Mental Illness, 2009). Child abuse also takes place in middleand upper-class homes, but the affluence of the parents is often used to prevent inci­ dents from becoming known. Regardless of class, the abusing parents often take out their frustrations on their helpless children. Socially supportive organizations such as Big Brothers/Sisters may help fill the gap in a child’s life that was left by a departing parent. Very often, abusing parents lacked effective role models in childhood and were themselves abused or neglected. However, it would be a mistake to conclude that child abuse inexorably repeats itself in successive generations. The cycle is less likely to be repeated in adults who have a loving, supportive relationship with a spouse or a lover and who have relatively few stressful events in their lives. It also helps if the adult consciously resolves not to repeat the cycle of abuse and seeks counseling to discuss effective parenting. ~ Although abusing parents may come from any background, there is a very strong relationship between poverty and abuse. In fact, family income is probably the most powerful single indicator of child abuse and neglect (USDHHS, 2015b). Various studies from the Department of Health and Human Services point to the fact that maltreatment was much more likely to occur in families with an annual income under $15,000 than in families with an income above this figure. Nothing about this finding is very surprising, because poverty is likely to bring with it frus­ tration, insecurity, and stress. People with low incomes tend to have more children than those from upper income levels while having fewer resources to take care of them. Substance abuse, criminal behavior, and high rates of mental illness are just a few of the other negative factors that tend to be prevalent in poor families and that contribute to abuse. CAUSES OF CFIILD ABUSE T t GROUPS IN NEED 72 73 CHAPTER 2 HELPING THE ABUSED OR NEGLECTED CHILD Many private and government agencies offer child protective services. Some of the most important are state social service agencies, which may be designated as the department of social services, the department of human resources, or the department of human services. These agen­ cies process most of the cases of abuse and are responsible for making a determina­ tion of whether to accept the case for services. If a case is accepted, the agency must decide what services are needed. Some­ times the parents will be helped to improve their level of care by means of counsel­ ing. However, if the abusing parents are not cooperative, the case may be referred to court, which may in turn assign legal custody to the agency. In these cases, parents are granted physical custody of the children only if they accept monitoring and services by the agency to make sure there is no further maltreatment of the child. Various community services, such as tutoring or recreation, may be provided to the children while the parents are taught the skills needed to be successful caregivers. In a minority of cases, the court and the agency may decide that the child would be seriously endangered by remaining in the home. Foster placement then becomes the option of choice. An increased demand for placements, due to the spread of crack-cocaine use among women, has come at a time when fewer foster homes are available because more women have joined the workforce. This situation has prompted many state and local agencies to cut corners on foster home investigations. Children are some­ times placed in overcrowded homes with unsuitable guardians. Consequently, there have been many reports of children being raped, beaten, and neglected in their fos­ ter homes. It should be pointed out that most foster parents are decent people who raise children for little monetary reward. States and localities are generally raising the amount paid to foster parents. Other steps taken to deal with the crisis in foster care are the recruitment of more (and better) foster parents, training of foster par­ ents, increasing the number of caseworkers, and, when feasible, helping the abusive biological parents to keep their children at home. The preferred approach is to hold the family together if that is at all possible and to give the parents the support they need to become adequate parents. Rather than to punish the parents, the goal is to help them break the cycle of abuse. One approach is to use groups to teach effective parenting to those whose own parents were usually disastrous role models. The abusing parents are encouraged to call the staff of the mental health agency when they feel the impulse to hurt their children. It must be understood by all concerned that effective parenting does not come natu­ rally but must be learned in a step-by-step fashion. The study of child abuse makes it quite obvious that maternal and paternal “instincts” cannot be relied on to pro­ duce love and care for a child. Parenting involves a wide range of skills, attitudes, and knowledge that are normally acquired from one’s own parents. Child abusers often fall into the pattern of imitating the abusive parents that raised them. Another approach to treatment is Parents Anonymous (PA), a group founded in 1970. Being a self-help group, it avoids the angry feelings that are often generated by an outside authority intruding into a home. Often, the abusing parents feel guilty about their maltreatment of their children. They are very sensitive to being shamed and belittled by authorities, however much they may “deserve” it. In the PA meet­ ings, modeled after Alcoholics Anonymous, the abusing parents voluntarily admit their tendencies to others like themselves. With the support of the group, they struggle to control themselves and to find other ways of dealing with their children. Although it is too early for a definitive assessment of the effectiveness of this approach, it can be said that PA is growing in popularity, with more than 100 chapters in the United States. Children are members of many target populations. Additional references to children may be found in subsequent sections on people with disabilities, mental illness, and retardation. (Survivors of Domestic Violence L04 Domestic violence, an increasingly common problem seen by mental health profes­ sionals, is abuse by one person of another in an intimate relationship. It can apply to people who are married to each other, living together, dating, in a heterosexual relationship, or part of a gay or lesbian couple. It can include physical or emotional abuse. Physical violence may take the form of slapping, kicking, hitting, punching, burning, throwing things, or any other behavior that is intended to physically hurt another. Emotional abuse is often a way in which a batterer attempts to control his or her victim by destroying that person’s self-esteem with name-callingrridicule, and shame. As part of emotional abuse, the abuser may withhold money; forbid the other from working, socializing, or seeing family; and threaten the victim with harm. Sexual abuse is often part of the abuse picture. Forcing someone to have sex when she doesn’t want to, or engage in sexual acts she does not like, forcing some­ one to have sex with others, are all forms of sexual abuse. Domestic violence has been described as any act that causes the victim to do anything that she or he does not want to do, prevents the victim from doing what he or she wants to do, or causes the victim to fear the abuser (Kunz, 2012). □ Who Are the Victims? This poster makes a powerful appeal on behalf of abused children. The number of women wfio are abused every year is staggering. Each year, millions are severely injured by male partners, and many die. Battering does not discriminate. 74 CHAPTER 2 GROUPS IN NEED 75 Victims may feel helpless, trapped, and unable to escape their batterer. Some feel that they love their abuser and hope that they can change the abusive behavior. Others have been financially dependent while raising children. Some lack the skills necessary to work, as the abuser kept* them away from the workplace. Often the abuser isolates the victim from friends and family, so the victim has nowhere to turn for social support. Some victims of abuse have a childhood history of abuse. Many do not. Some may be economically dependent, whereas others may be successful in their careers. In other words, the stereotype of the battered woman as passive and fragile is often untrue. Many do try to stand up to the violence but find that it is too difficult. Often survivors are too frightened to leave, having been threatened with death if they do. Indeed, when the batterer knows that the relationship is ending, there is an increased risk of severe and sometimes fatal injury to the victim. □ Theories Domestic abuse shelter. I as women from all ethnic backgrounds, cultures, and economic classes are victims of domestic violence. However, the poor and vulnerable are more likely to come to the attention of social workers and other mental health professionals, due to their limited resources. Domestic violence continues to be the leading cause of injury and death to American women (National Coalition against Domestic Violence, 2015). Three mil­ lion women reported being abused in a year, and one in five reported being abused or raped in her lifetime (Gate^, 2012). Estimates are that at least another 3.5 mil­ lion batterings go unreported. When women do leave abusive relationships, they are most likely to be killed or injured when attempting to break off the relationship (Bureau of Justice Statistics, 2015). Although most of the victims of domestic violence are women, and the major­ ity of the perpetrators are men, husband battering does exist; as many as 24,000 men per year have reported being abused. Some of these men are in gay relation­ ships, and some are in heterosexual relationships. Domestic violence in the gay and lesbian community is estimated to have similar prevalence rates as in heterosexual communities (Gosselin, 2003). Researchers have isolated the issue of control and dominance as a defining predicator of risk for violence. (Kunz, 2012, p. 224). A. Violence against women has existed for centuries. Even in the United States, wife beating was legal until the late 1800s and early 1900s. In 1882 Maryland became the first state to pass a law that made wife-beating a crime, punishable by 40 lashes or a year in jail. By the beginning of the twentieth century, domestic violence was no longer legally sanctioned. However, courts rarely intervened in domestic matters, and what occurred “behind closed'doors” was of little concern to the law. In the 1960s, domestic violence became a subject of both social and legal concern. In the 1980s, mandatory arrests of batterers were found to be effective deterrents to future escalating violence. The National Center on Women and Eamily Law concluded that policies of mandatory arrest laws do result in increased arrests of batterers and enable victims to contact helping agencies, as well as promoting the message that domestic violence is a crime. In 1994 the U.S. Congress recognized the severity of violence against women and enacted the Violence against Women Act. This act cre­ ated new provisions to hold offenders accountable and created programs to provide services for the victims of such violence (Trevino, 2015). This Act was last enhanced in 2013 with improved legal tools and additional protections and now includes pro­ tections for women who are undocumented immigrants. Native Americans, and the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBT) population. Early explanations for why women remained in violent relationships suggested that battered women were masochistic. That is, they were attracted to men who would cause them to suffer. Dr. Lenore Walker, an expert in the field of domestic violence, refuted that theory, stating instead that women feel powerless in domestic violence situations due to gender-role socialization. This powerlessness, or learned helplessness, explains why women see themselves as responsible for the battering and remain helpless to escape from the situation. This is part of the battered woman syndrome and an aspect of the cycle of domestic violence. There is almost never a single episode but rather an ever-increasing buildup of power and control on the part of the abuser, with concomitant denial and accommodation on the part of the victim. Eerraro (1997) and Childress (2013) discuss four phases of the abusive relationship. Phase I: During the first six_ months of the relationship there is no battering. She enjoys time alone with her partner and does not see his desire for social exclusivity as oppression but as mutual affection. I ,1 76 CHAPTER 2 GROUPS IN NEED Phase II: The first act of physical violence is met with disbelief. The woman rationalizes the assault and denies the uncharacteristic victimization. The perpetra­ tor blames her through some imagined provocation. It is unlikely that the violence will be deterred by the minor sanctions of criminal justice action unless it occurs in the early stages and in certain types of battering relationships. Societal pressure frequently forces the woman into “making the best of it.” Phase III: A change in the severity or frequency of the abuse may trigger a tran­ sition into this stage. Defensive violence is one tactic that may be used to ward off attacks. The woman may attempt to leave the emotional and economic bond that had developed. Threats or psychological torture make early attempts difficult and often they return. About one-half of those who leave are successful in this attempt. Phase IV: Convinced by threats from constant surveillance and punishments, women believe that they cannot get away. Failed attempts to leave reinforce the perception. This stage is horror-filled and may bring about depression and posttraumatic stress syndrome. Suicide may be contemplated. A severe altercation may lead to homicide as the final stage in what becomes a “kill or be killed” scenario. (Gosselin, 2003) Studies report the incidence of posttraumatic stress disorder (PTSD) to range from 25% to 84% of women who suffer from physical abuse (Carlson & Choi, 2001). Symptoms of PTSD include depression, anxiety, nightmares, flashbacks, and generalized fear. Justice Centers were opened in the United States, which attempted to improve the lives of family violence victims through community collaboration and com­ prehensive services in one location. These centers, which have since opened in New York City, San Diego, San Antonio, and 12 other cities around the country, offer access to medical care, counseling, law enforcement assistance, social ser­ vices, employment assistance, and housing. They are, for the most part, drop-in centers, where no one is turned away. They are staffed by non profit agencies and supported by community leaders, government agencies, and caring individuals. In spite of all the publicity that this population has received and the change in society’s attitude about domestic violence, the numbers of domestic violence survi­ vors continue to rise. Obviously, we have not done enough, as a society, to ensure that women are safe in their own homes. Some of these new programs are promising, but community support is crucial. Fewer people are asking, “Why doesn’t she leave?” and instead are trying to find n'ew ways to stop the violence by education, compassion, and action. Lesbian, Gay, Bisexual, and Transgender Communities LOS □ Interventions As awareness of domestic violence has increased, attitudes have changed. The wom­ en’s movement was instrumental in bringing attention to this problem as well as to other often overlooked issues that affect women, such as rape and incest. Since the first hotline for battered women was opened in 1971, there have been national and local hotlines to provide callers with information on resources for victims of domes­ tic violence. The first shelter for battered women opened in St. Paul, Minnesota, in 1974 (Gosselin, 2003). More than 2,000 shelters exist across the United States, providing refuge and resources for battered women who have no other place to go. Shelters usually assign women to counselors who assist the resident in obtaining needed services, such as legal services, finances, educational help for the children, emergency medical care for the family, and counseling services. There residents learn about orders of protection, access custody information, obtain public assistance if necessary, and learn about educational and/or vocational opportunities for them­ selves. Shelters usually conduct educational groups about domestic violence for their residents, consisting of infori^ation about the causes, impact, and cycle of battering and the consequences of remaining in a violent relationship. Most shelter stays are short term, and residents are assisted in locating permanent housing. However, there are not enough shelters available to meet the needs of all battered women. Unfortunately, the long waiting lists for housing and the lack of funds avail­ able to battered women have caused many women to flee their abuser, only to become homeless. This issue, along with the lack of coordination of services for battered women, has led to some changes in domestic violence policy and in the way in which domestic violence survivors receive help. As a result of the frag­ mented and sometimes disjointed system of separate organizations attempting to coordinate services for victims of domestic violence, the President’s Family Justice System Initiative was launched in October 2003. In 2005 the first Family 77 Previous editions of this textbook have spoken about various target populations that are in need of special attention in terms of support, counseling, and unique challenges. However, over the past several years, no community has seen such an increase in visibility and focus as the LGBT communities. According to Gates (2012), it is estimated that 4 million people who live in the United States identify as Lesbian, Gay, Bisexual, and Transgender. Unfortunately, much of the attention has not been for positive strides and advances. Instead, people in the LGBT com­ munity have historically been, and continue to be, a focus for discrimination and abuse at many levels. This can range from laws that overtly discriminate against people based on gender expression or sexual identity to the largest shooting mass­ acre in modern American history of LGBT individuals in June 2016 in Orlando, Florida. Fortunately, not all news is bad. Over the past decade, there has been a steady increase in the number of countries, including the United States, that allow such individuals to marry whom they chose, as well as provide legal protections in terms health insurance, employment, spousal, and inheritance rights. In 1973, the Ameriqah Psychiatric Association slowly began removing homo­ sexuality from the DSM. Prior to that homosexuality was viewed bydaypeople and many professionals as a mental illness in need of treatment. However, it was not a complete removal. With subsequent editions of the DSM, other diagnoses, such as Sexual Orientation Disturbance and Gender Identity Disorder, eventually became part of the professional literature. In fact, the latest edition of the DSM-5 (2013) still includes Gender Dysphoria as a diagnosis, and the World Health Organization’s International Classification of Diseases (ICD-10) includes a diag­ nosis of Egodystonic Sexual Orientation for people who wish their gender iden­ tity or sexual preference to be different, because of associated psychological and behavioral disorders, and thus may seek treatment (World Health Organization [WHO], 1992). (An 11th edition is expected to be published in 2018.) Although professional groups, such as the American Psychiatric Association, the American Psychological Association, and the National Association of Social Works, do not GROUPS IN NEED view homosexuality or most other forms of sexual diversity as mental illness, many strong religious and cultural teachings still view LGBT individuals, as either ill, in need of intensive reparative therapy, or even dangerous. Thus, they may seek to change or “repair” such individuals, with the goal of converting them to hetero­ sexuality. More will be discussed about the dangers of reparative therapy further in this section. Guidelines for Mental Health Practitioners Even the most well-intentioned counselor can sometimes forget that they too are a product of their environment. Despite being as empathetic and open-minded as we may think we are, we have still been raised in a country and world that does not fully embrace those with nonnormative sexual and gender identities. Many people are raised in a culture or religious background that, at many different levels, harms LGBT individuals. However, in 2009, the American Psychological Association reaffirmed its 1975 stance that homosexuality does not imply an impairment in judgment, psychological instability, or general capabilities. They state that, “... same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality regardless of sexual orien­ tation identity” (American Psychiatric Association [APA], 2009, p. 121). In 2012, the APA released 21 updated guidelines for psychologists in their work with lesbian, gay, and bisexual individuals. These guidelines address the therapist’s personal attitudes, relationship considerations, diversity, and socioeconomic, edu­ cation, and research concerns (APA, 2012). What follows are a quoted summary of the 21 guidelines: Attitudes toward Homosexuality and Bisexuality Guideline 1. Psychologists strive to understand the effects of tigma (i.e., preju­ dice, discrimination, and violence) and its various contextual manifestations in the lives of lesbian, gay, and bisexual people. Guideline 2. Psychologists understand that lesbian, gay, and bisexual orienta­ tions are not mental illnesses. Guideline 3. Psychologists understand that same-sex attractions, feelings, and behavior are normal variants of human sexuality and that efforts to change sexual orientation have not been shown to be effective or safe. Guideline 4. Psychologists are encouraged to recognize how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated. Guideline 5. Psychologists strive to recognize the unique experiences of bisex­ ual individuals. Guideline 6. Psychologists strive to distinguish issues of sexual orientation from those of gender identity when working with lesbian, gay, and bisexual clients. Relationships and Families Guideline 7. Psychologists strive to be knowledgeable about and respect the importance of lesbian, gay, and bisexual relationships. Guideline 8. Psychologists strive to understand the experiences and challenges faced by lesbian, gay, and bisexual parents. 79 Guideline 9. Psychologists recognize that the families of lesbian, gay, and bisex­ ual people may include people who are not legally or biologically related. Guideline 10. Psychologists strive to understand the ways in which a person’s lesbian, g4y, or bisexual orientation may have an impact on his or her family of ori­ gin and the relationship with that family of origin. Issues of Diversity Guideline 11. Psychologists strive to recognize the challenges related to multiple and often conflicting norms, values, and beliefs faced by lesbian, gay, and bisexual members of racial and ethnic minority groups. Guideline 12. Psychologists are encouraged to consider the influences of religion and spirituality in the lives of lesbian, gay, and bisexual persons. Guideline 13. Psychologists strive to recognize cohort and age differences among lesbian, gay, and bisexual individuals. Guideline 14. Psychologists strive to understand the unique problems and risks that exist for lesbian, gay, and bisexual youth. Guideline 15. Psychologists are encouraged to recognize the particular challenges that lesbian, gay, and bisexual individuals with physical, sensory, and cognitive-emotional disabilities experience. Guideline 16. Psychologists strive to understand the impact of HIV/AIDS on the lives of lesbian, gay, and bisexual individuals and communities. Economic and Workplace IssuesGuideline 17. Psychologists'are encouraged to consider the impact of socioeco­ nomic status on the psychological well being of lesbian, gay, and bisexual clients. Guideline 18. Psychologists strive to understand the unique workplace issues that exist for lesbian, gay, and bisexual individuals. Education and Training Guideline 19. Psychologists strive to include lesbian, gay, and bisexual issues in professional education and training. Guideline 20. Psychologists are encouraged to increase their knowledge and understanding of homosexuality and bisexuality through continuing education, training, supervision, and consultation. Research Guideline 21. In the use and dissemination of research on sexual orientation and related issues, psychologists strive to represent results fully and accurately and to be mindful of the potential misuse or misrepresentation of research findings. Affirmative Therapy Despite the slow and steady removal of homosexuality and gender identity dis­ orders from the DSM, and increased visibility globally, it has been consistently reported that rates of anxiety, depression, and suicide attempts are significantly higher among adolescents who identify as gay, lesbian, or transgender compared to peers who identify as heterosexual (Bostwick, Boyd, Hughes, 8c McCabe, 2010; Haas et al., 2011). Thus, there is a clear need to address the mental health con­ cerns of this vulnerable population. Affirmative therapy is an effective approach to counseling that is positive, embracing, and supportive of LGBT relationships and experiences (Bigner-& Wetchler, 2012). This is in stark contrast to reparative GROUPS IN NEED 80 81 CHAPTER 2 therapies, such as Conversion Therapy, which is a heteronormative therapy that views a lesbian, gay, bisexual, or transgender identity as an illness. Furthermore, Conversion Therapy and Other Sexual Orientation Change Efforts ( see to treat, change, or “cure” individuals, as they claim that any sexual orientation other than heterosexuality can (and should) be corrected. Often, various conver sion therapies are based on religious belief systems and not behaviora science, n fact, the American Psychological Association stated there is no scientifically rigorous research establishing that Sexual Orientation Change Efforts are e ectiye in changing a person’s sexual orientation and has even been reporte y some m i viduals as harmful (Anton, 2010). Furthermore, the APA advises parents, guar ians, young people, and their families to avoid SOCE that portray homosexua ity as a mental illness or developmental disorder ...” (2010, p. 31). States sue as California, New Jersey, and Oregon have even outlawed conversion therapies due to the potential harm it poses, and other state legislatures are expected to fo ow in the years to come. • -ru It is now widely accepted by mental health professionals that Affirmative 1 herapy is a helpful approach to counseling sexually diverse people. Stated previously. Affirmative Therapy is a supportive approach that affirms, rather than denies or minimizes, the experiences of LGBT individuals (Bigner & Wetchler, 2012). Part of the affirmative approach is to acknowledge the existence of homophobia, transphobia, heterosexism, heteronormativity, and the depth of discrimination that is still commonplace today. Affirmative Therapy begins with having counsel­ ors acknowledge and reflect on their own attitudes, values, and biases regarding heterosexism and differences in sexual practices. Through this, counselors will begin to recognize what may make them uncomfortable or how certain state­ ments or terminology may be perceived as offensive to others. For example, using the term “sexual preference” connotes that sexuality is something that is chosen, and therefore can be changed. There is much evidence that this is simply not sup­ ported. Most LGBT individuals state that their sexual orientation or gender iden­ tity was something that was never chosen but rather a part of whom they are from as early as they can remember. Thus using the term “sexual orientation” takes out the assumption of choice and is much more affirming of one’s true experience. It is also more accurate and affirming to use the term “gay” or “lesbian, rather than “homosexual,” as the word homosexual simply focuses on the physical and does not acknowledge the many other parts of being gay. In essence, affirmative thera­ pists become aware of their own attitudes and beliefs, empathetically listen to how clients describe who they are, and use the individual’s terminology, avoid jud^ ment, and fully acknowled^ the many different challenges a person in the LG or any other community fa^s. -i • u It is important to note tnat one area that is often difficult to reconcile is the intersection between religion and sexual orientation or gender identity. Whitman and Bidell (2014) discuss the importance of addressing this conflict when training students of conservative religious backgrounds on the use of Affirmative Therapy with lesbian, gay, and bisexual individuals. They provide several recommendations addressing this concern when teaching this particular group of future counselors. These recommendations can also be extended to a more general population of coun­ selor trainees who may not be from a conservative religious upbringing but because of strong, ingrained cultural beliefs find themselves in a dilemma when providing supportive help for LGBT people. □ An Important Note about Differenoes It has become popular practice to categorize anyone who is not heterosexual under the umbrella of LGBT. Although providing historically marginalized and disenfran­ chised people with a distinct group to which they can own and gain empowerment from, it can also lead to the erroneous belief that all sexually diverse individuals face the same challenges or take the same path in their identi,ty development. This could not be farther from the truth. As with most populations, there is much greater vari­ ability within the group of people than there is between groups of people. For exam­ ple, a lesbian mother who is able to be comfortable and open about her life will not have the same experience as a gay man who was in the military when there was a ban of gay individuals being able to serve in any branch of the U.S. Armed Forces. Furthermore, the experiences of a bisexual individual may be qualitatively differ­ ent than that of a gay man or lesbian woman. Transgender individuals may face an entirely different set of discriminatory and personal challenges than others within the lesbian, gay, communities. Moradi, Deblaere, and Fiuang (2010) even posit that the “T” should not be lumped into the acronym because there is not enough profes­ sional literature to adequately address the experiences of transgender individuals. As stated earlier, there are often more differences within groups than between them. This is no different for the LGBT community. In fact, with such variance between individuals there is a myriad of other ways in which people identify. Some do not like the labels of “straight,” “gay,” or “lesbian” and prefer to identify as “questioning” or “queer.” Some consider themselves as “gender fluid.” Some may identify as heterosexual and engage in same-sex behaviors but do not see themselves as gay or lesbian. Still other terms or labels include cisgender, bi-curious, pansexual, asexual, and many others. What is important to learn is not that we must become experts of all the possible labels and categories that we so often use to help us grasp ' differences but rather understand that a large range of terminology simply reflects the large range in human identity and experiences. In line with Affirmative Therapy, we should move away from trying to box someone into a group, but rather support them where they are, understand they are the experts in their own developmental narrative, and be open to learning from them about how and why they identity as they do. Doing so will greatly facilitate our ability to help others heal and grow. -enior Citizens L06 According to projections from the U.S. Census Bureau, baby boomers in the United States are entering retirement age in record numbers. By 2050, the number of people 65 years old and older will essentially double from 35 million today to more than 70 million and represent nearly 20% of the total U.S. population (Trevino, 2015). The segment that is 85 years old and older (the “old-old”) will also experience rapid growth from 5.8 million in 2010 to 19 million in 2050. In recent years, the old-old have been the fastest growing segment of the population (Vincent & Velkoff, 2010). This huge increase in the senior citizen population will have a profound influ­ ence on human services, because the chances of needing outside help increase sharply ^ with age. The percentage needing the help of another person to perform personal care or home management is 14% for those aged 65 to 74, 26% for those aged 75 to 84, and 48% for those 85 and older. Older people account for a relatively high percentage of hospital stays, have longer hospital stays, and average more visits to GROUPS IN NEED the doctor than people under 65. Also to be considered is the fact that senior citi­ zens suffer higher rates of depression and suicide than the general population. Older people inevitably undergo physical changes that increase susceptibility to diseases such as cancer, heart disease, arthritis, and diabetes. As the body declines in vitality, it becomes less able to deal with stress and malfunction. Physical problems are compounded by social and psychological difficulties. For example, the senior citizen has to face up to the loss of loved ones as well as to the possibility of feel­ ing less useful and more of a burden to others. Financial problems are also likely to come with old age. The majority of senior citizens leave the workforce, sometimes pressured to do so by rules and regulations of their employers. With retirement, income drops sharply. This explains why Social Security benefits are of such vital concern to many senior Americans. Politicians continue to debate whether the coun­ try can afford to care for the increasing number of older people and whether the government programs such as Medicare and Social Security will go broke. Social Security The federal government plays a major role in providing for the needs of senior citi­ zens. The Old-Age, Survivors, and Disability Insurance (OASDI) program, popu­ larly known as Social Security, is the largest social welfare program in the United States. During 2015, more than 56 million individuals received OASDI benefits. The majority of the beneficiaries were retired workers and their spouses; a smaller num­ ber were disabled workers. The amount of money received is adjusted yearly and is pegged to the Consumer Price Index. The idea is to help beneficiaries keep up with the rising costs of living (Social Security Administration, 2015). Headlines have sometimes conveyed the impression that Social Security may be going broke. There is, in fact, no immediate problem. It is true that the funds will be exhausted by 2030 unless Congress takes action, for several reasons. The loom­ ing retirement of 70 million baby boomers (persons born during the late 1940s and early 1950s) is one factor. Another is that people are living longer and, conse­ quently, collecting benefits for a longer time. Even more important is the fact that there will be fewer workers in the future to support more beneficiaries. In 1950 there were 16 workers for every person receiving benefits; today the ratio is 3:1, and by 2030 it will be 2:1. These figures again reflect the fact that the propor­ tion of senior citizens in the U.S. population is increasing steadily (Social Security Administration, 2015). Health Care for the Aged “No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings they have so carefully put away over a lifetime.” These words were spoken by President Lyndon Johnson in 1965 when Medicare was created as an amendment to the Social Security Act (Connell, 1995, p. 3B). At that time, only half of the American seniors had any health insurance. In 2015 about 47 million held Medicare cards. Medicare provides hospital benefits, operating room charges, regular nursing care, and medical supplies. It also cov­ ers some services at home such as part-time skilled nursing care for convalescents who no longer need to be in a hospital. However, the program does not cover all preventive services. 83 Medicare does not by any means pay all of the costs of medical treatment. There are significant deductibles and limitations of coverage. The deductible, now $100, is the amount the person must pay out of pocket per year before the insurance goes into effect. Once the deductible is met. Medicare pays a set fee for covered doctor and hospital services and procedures. When all is said and done. Medicare ends up paying about 45% of the actual expenses incurred (Connell, 1995). This is why many senior citizens buy private “medigap” insurance to help cover the costs not covered by Medicare. Medicare spending in 2012 was in excess of $572.5 billion, approximately 21% of national health expenditures (Ambrosino et al., 2016). Providers complain about the complexity of the system and about the need to hire clerical staff to process the paperwork. Huge manuals, listing each procedure along with a designated fee and code number, must be consulted. Frustrating delays occur when a provider tries to get through to a representative to correct errors or resolve complaints. Some doctors do not “accept assignment,” meaning they do not accept what Medicare pays as full payment. The patient must then pay the differ­ ence. In fairness, it must be said that many of the same kind of complaints by pro­ viders are made about private medical insurers. In spite of its limitations. Medicare is a very popular program with senior citi­ zens. Consequently, politicians who fear the wrath of the program’s recipients at election time consider changes in the program with caution. However, it is widely accepted in Washington that changes are necessary. Medicare is financed, in pari^ by a payroll tax that has been increased fre­ quently since its inception. Some policymakers now feel that tinkering with the existing system will not solve the problem. They favor a complete redesign along the lines of a voucher system. Presently, the government acts as the insurer, paying doctors and hospitals for covered services. Under one proposed plan, the govern­ ment would contribute a fixed amount of money to each Medicare beneficiary, who would then go into the marketplace to purchase his or her own insurance plan. Individuals could choose among different benefit packages and, of course, different premiums. They would receive cash rebates if they selected a plan charging less than the standard federal payment. □ Medicaid for Senior Citizens Medicaid was created as part of the Social Security system at the same time as Medicare. It was intended primarily to provide health insurance for people with low incomes or serious disabilities. In practice, senior citizens and people with disabili­ ties consume two-thirds of Medicaid’s dollars, with poor, able-bodied individuals taking up the rest. A major expense is caring for senior citizens in nursing homes. Two of three nursing-home residents have their bills paid by Medicaid (Stanfield, Cross, 8c Hui, 2012). The remainder must “spend down” their savings until they have become paupers, at which point Medicaid kicks in. □ Dementia Dementia is not one but a group of disorders caused by damage of brain tissue. Regardless of the specific type of damage, individuals suffering from any of these disorders tend to show similar deficits, such as short-term memory loss, reduced ability to learn new material, and difficulties in nnderstanding abstract or symbolic ideas. Problems in concentration, judgment, and emotional control are likely to i 84 GROUPS IN NEED CHAPTER 2 become more noticeable as the disease progresses. Eventually, the person may have difficulty in recalling words or the labels of common objects or may begin repeating the same phrases over and over again. Finally, the victim may be unable to recognize friends and family. Until recently it was assumed that these dysfunctions were in all cases due to arteriosclerosis, popularly known as “hardening of the arteries.” We now know that this disease is responsible for only about 15-20% of dementia cases (Administra­ tion on Aging, 2010). In this form of dementia, certain areas of the brain show infarcts, or areas of dead tissue, the result of small strokes that damage blood ves­ sels feeding the brain. Those with multi-infarct dementia, as this condition is called, often have a history of strokes and high blood pressure. The most common dementia of later life is Alzheimer’s disease, which accounts for over 50% of all cases of dementia. The diagnosis of Alzheimer’s disease can be absolutely confirmed only after a patient has died and the brain tissue is exam­ ined: the typical features are neurofibrillary tangles (distorted nerve fibers) and senile plaques (nerve fiber lesions) in the brain tissue..However, early diagnosis can now be made with a high degree of accuracy, based on an extensive series of physical and psychological tests. The prevalence rates of this disorder tend to increase sharply with age. Although less than 2% of the general population under age 60 are afflicted, rates climb to 20% for those over the age of 80. Even higher rates have been reported for those over age 85 (Center for Disease Control, 2015f). Unfortunately, no completely successful treatments for dementia are available. However, many victims can benefit from changes in the environment aimed at help­ ing them find their way around. Simplified routes from room to room can be indi­ cated with tape or markers. Written schedules of activities and written directions for cooking, bathing, and taking medications can serve to support the victim’s memory. It is also important to maintain a regular schedule and to keep the patient actives. Victims of dementia are generally aware that something is wrong with them, so depression is a real possibility. Everything feasible should be done to help engage the person in recreational activities. Ideally, these kinds of therapeutic steps will help slow the rate of deterioration. The dementias may have devastating consequences for the victims and their loved ones. It is estimated that some form of dementia, or senility, is involved in over 50% of admissions to nursing homes. For every American who suffers demen­ tia, there are three close family members who are affected by the emotional, physi­ cal, social, and financial burdens of caring for the primary patient. Family caregivers often face the prospect of witnessing the gradual deterioration of a loved one’s intel­ lect and personal relationships. To make matters worse, health, social, and personal care services in the community are often unresponsive to the needs of patients and families, and institutional care is often characterized by a lack of thorough assess­ ment, heavy reliance on convenient drug therapies, and little attention to psycholog­ ical interventions that may help families to cope. The economic costs of the dementias are huge and steadily increasing. The total cost of caring for the disease per patient ranges from about $49,000 to $500,000 depending on the patient’s age at the onset of the disease. These figures do not include lost productivity of afflicted people. Unfortunately, there is no way to fully insure against the economic costs of these disorders, and insurers and government programs have been reluctant to make chronic diseases eligible for any coverage. The families of victims must often pay thousands of dollars out of pocket. 85 □' Community Programs for Senior Citizens Aside from Social Security, an array of programs help maintain the senior citizens in the community. Senior Americans with low income may be eligible for food stamps and low-cost housing. In addition, many communities have senior centers that offer a range of services, including social clubs, counseling, leisure-time skills training, and inexpensive meals. The general thrust of these programs is to reduce the isola­ tion that many senior citizens experience, especially after the loss of a spouse. An attempt is made to connect the person with a lively social group and to enhance the sense of commitment to the community. Some agencies provide visitors for homebound seniors or escorts for those who need help getting to the doctor, bank, or market. Meals on Wheels provides hot meals to seniors who can’t get out of the house. These programs provide the link between the person and the community, some­ times delaying or preventing institutionalization. Of course, not all seniors avail themselves of these programs, seeing themselves as extremely capable, not “old” at all, and resenting any implication that they need help. n Nursing Homes The great majority of senior citizens are able to live in the community, and only a small percentage live in institutions, including hospitals for the chronically ill, men­ tal hospitals, prisons, and nursing homes. By far, the greatest number of institution­ alized senior citizens are living in nursing homes. Nursing homes vary in the amount of skilled nursing care that they provide. Some care for significantly disabled A helping professional working with the elderly. Itee-*** GROUPS IN NEED physical deterioration or to loss of loved ones. Older people often need help in accepting their realistic losses before they can go on to develop new activities and new social relationships. These realistic limitations only partly explain why some human services work­ ers do not seek to work with the aged. This trend has been observed in social work, psychology, medicine, and other helping professions. Various studies have cited reasons for negative staff attitudes toward older clients. For example, senior citi­ zens stimulate the workers’ fears of their own old age and also arouse the workers’ conflicts with parental figures. Some helpers believe that old people are too rigid to change their ways, and others are concerned about devoting a lot of time and energy to a patient who might soon die. Those workers who put their fears and prejudices aside find that working with the aged can be very rewarding and enjoyable. The prognosis is not usually as negative as feared, and there are pleasures and delights to be derived from contact with old people. In our experience, student workers often begin fieldwork train­ ing with the aged with distaste but come away from the experience with positive feelings. Often, students are deeply touched by their contacts with senior shut-ins and nursing-home residents. They felt rewarded by the sense of really making a difference in a client’s life. individuals, whereas others cater to those with less severe limitations. It should be made clear that nursing homes are not hospitals—they do not provide service for the acutely ill. Rather, they maintain those with a chronic condition who do not require active medical intervention. These may be people with mild brain damage or physical handicaps that limit mobility. What factors determine the need to place a senior citizen in a nursing home? Some of the most common are physical deterioration, lack of support services in the community, and the inability of the family to provide the level of care needed by the older person. There is little evidence to support the belief that large num­ bers of senior citizens are “dumped” into institutions. Usually, American families try to keep their older members in the community if at all possible. In fact, many senior citizen members with mild limitations do live with their relatives. However, sometimes the senior citizen deteriorates to the point where round-the-clock care is required. As suggested before, the changing patterns of the family, especially the increase in working mothers, make it increasingly difficult to care for an infirm senior citizen at home. The number of senior citizens living in nursing homes has increased in recent years. This rise may be in part owing to changing family patterns, but it is also related to the increased availability of nursing homes. This increase was spurred by federal funding for this purpose in the 1960s when it became clear that there was a shortage of facilities for senior Americans. The availability of Medicaid in the mid1960s also stimulated the growth of nursing homes. Most residents pay for their care through Medicaid. The costs are so high that relatively few individuals could afford to pay out of their own resources. The idea of putting an older person in a nursing home arouses strongly nega­ tive feelings on the part of all concerned. Some of this revulsion is due to horror stories about nursing homes that neglect or even abuse patients in their care. Some critics believe that many nursing homes are chiefly concerned with the profit and convenience of management. It is true that the nursing-home industry is com­ posed largely of private, profit-making concerns, many of which are part of larger chains. There is no doubt that abuses do occur and that some nursing homes seem to be places where patients wait to die. The general trend, however, is that most homes provide adequate custodial care along with token recreation and rehabili­ tation programs. Even in places where physical care is beyond reproach, the patients seem to spend inordinate amounts of time just sitting around. They are often babied to an unnecessary degree because it is faster and easier for staff to feed, bathe, and dress them than to wait for patients to do it themselves. The lack of therapeutic programs is due simply tp the fact that it costs money to provide them. Many nursing-home administrators are unaware that improvements can be made with no increase in cost by training existing staff to encourage patients to function maximally. Working with Senior Citizens Older people who are active and in control of life are less likely to be depressed and are more successful in coping with problems. Although encouraging older people to be active is desirable, it must be kept in mind that older people may have some realistic limitations on their activities. These limitations might be due to irreversible 87 □ Current Aging Trends Despite some unwanted physical and psychological changes that occur as we age, the new generation of older people are, in sofne measure, redefining growing old. The new generation, often referred to as the “baby boomers,” are working lon­ ger than ever before, changing jobs later in life and still others volunteering for a vast array of projects helping the lives of others. Nearly 19 million adults past the age of 55, a quarter of older Americans, contributed an average of 3 billion hours of volunteer service from 2008 to 2010, according to the Corporation for National and Community Service, a federal agency that promotes volunteerism. These volunteers provided 64 billion dollars of economic value annually (Kadlec, 2011). Many volunteers ^rve as mentors, tutors, fundraisers, food distributors, and drivers. Many experts expect the baby boomer generation to work as long as they are physically able and to transition when possible into jobs that offer high personal satisfaction. Part of. the impetus for this expected new path is, of course, finan­ cial. Many boofners are less likely than the previous generation to have pensions financing their post-work years (Landau, 2010). In addition, a great number of older individuals are reinventing themselves as entrepreneurs. The highest rate of entrepreneurship, starting new businesses, belongs to the 55-64 age group (Moeller, 2010). CPeople with Disabilities L07 Included in the category of the disabled are people with a physical or mental impair­ ment that limits one or more major life activities such as seeing, hearing, speaking, or moving. Thus, not oiily those who are blind, deaf, physically impaired, intellectu­ ally and/or developmentally impaired, or mentally ill afe considered to be disabled GROUPS IN NEED but also those with hidden impairments such as arthritis, diabetes, heart and back problems, and cancer. Some authors make a distinction between the terms handicap and disability. Disability refers to a diagnosed condition, such as blindness or deaf­ ness, whereas handicap refers to the consequences of the disability. The implication is that the consequences can be greater or lesser depending on various factors, such as society’s attitude toward the disability in question. There are no exact estimates of the number of people with disabilities, partly because of the uncertainty about including people with mild impairments. It is esti­ mated that the total number of disabled in the United States is more than 36 million or about 15% of the entire population. It has also been estimated that 10% of the children under 21 are disabled and that more than 50% of those 65 and over report various health impairments. By any estimate, the number of people with serious dis­ abilities is awesome. Mainstreaming People with Disabilities The history of society’s treatment of the disabled historically has been very poor. People with disabilities have often been denied their rights and have not been read­ ily admitted into the mainstream of American life. It is only in recent decades that this country has witnessed a wave of activism and accomplishment for these peo­ ple. Various social and_legal steps have been taken to help people with disabilities. For example, federal courts have issued landmark decisions that state that physical handicap is not a legitimate excuse for denying a person’s constitutional rights. Con­ gress passed the Rehabilitation Act of 1973, which prohibits discrimination against qualified handicapped people in regard to federal programs, services, and benefits. Perhaps even more important is the Education for All Handicapped Children Act of 1975, which calls for a free, appropriate education for children with disabilities in the least restrictive setting. Despite these positive steps, the struggle to admit people with disabilities into the mainstream of social and economic life has been a struggle. The person with a disability who wishes to participate more fully in commu­ nity life is often faced with a wide array of barriers. Some of these are physical or architectural. For example, a person in a wheelchair cannot climb stairs or may not be able to open a door without help. A person on crutches may not he able to use certain kinds of public transportation. Governments on all levels have taken steps to eliminate these architectural barriers. To an increasing extent, people with dis­ abilities are being provided with ready access to public buildings. Ramps enable the wheelchair user to enter buildings with relative ease. Sidewalks are being modified to allow passage of wheelchairs, and doors and elevators are being changed to per­ mit easier operation by the disabled. The considerable costs of these alterations have kept them from being instituted in some settings. Despite legislation calling for the inclusion of children with disabilities in regu­ lar classrooms, some school systems have not fully complied with the law. It must be stated, however, that the special needs of disabled children do impose extra expenses on a school budget that may be tight in the first place. Aside from the costs of physi­ cal renovations, there may he additional expenses of providing special equipment and transportation. For example, visually impaired youngsters might need learning materials on tape or in Braille. The right of individuals with disabilities to equal opportunity in employment is clearly established. Yet, a problem centers around the fact that Social Security and 89 Medicare regulations tend to discourage disabled people from looking for work. Their support payments and medical benefits often exceed what they could earn after taxes, particularly if their jobs are not steady. If a person with a disability earns above a specified amount, she or he risks losing government support. There isn’t much incentive to work under these conditions. □ Psychological Barriers against People with Disabilities Negative societal attitudes are another obstacle that limits the acceptance of people with disabilities into the mainstream. Amferican culture prizes competence, auton­ omy, and physical attractiveness. Americans are daily subjected to a media barrage of sexy, youthful, healthy people who entertain, sell products, and provide role mod­ els. In this atmosphere, it is inevitable that disability, particularly obvious disability, would have a negative impact on a person’s sense of self-worth. Some people with disabilities have incorporated these negative cultural attitudes and made them the basis for self-defeating behaviors; in other words, they behave in such a way as to unnecessarily limit their participation in life roles and functions. Some may feel that there is no use in trying because they will not be accepted anyway. Abundant evidence exists that people with disabilities arouse strong negative emotions in able-bodied people—in particular, anxieties about loss, vulnerability, and weakness. The able-bodied person may be repulsed or embarrassed by anything awkward or unusual about the disabled person. It is not surprising, then, that some nondisabled people prefer to avoid social contact with the disabled. When forced to interact, they may behave in unnatural ways. For example, the able-bodied person is apt to go to one of two extremes: either pretending that the disability doesn’t exist and doesn’t matter or feeling sorry for the disabled person and being excessively helpful. It is often difficult for the able-bodied person to get beyond another’s dis­ ability and relate to that person on the basis of shared human feelings and desires (Asch, 1984a). Adrienne Asch (1984b) contributed the following reflections about her experiences as a person with a disability. Although she wrote this more than 30 years ago, Adrienne Asch’s (1984b) reflections about her experiences are still relevant today. Personal Reflections of a Blind Psychologist Once, in a group dynamics program, I had to decide under which sign I would stand for an exercise in difference and group identification—white, strai^t, young, Jewish, woman, or disabled. Because many of the participants had focused on my disability in their dealings with me during the two-week program, because I had already revealed many aspects of myself, including my similarities with others (whether or not they had been seen), and because no other person with a disability was there to convey what it meant to be disabled, I stood under the disability sign. An acquaintance overheard me say that it had been hard to decide whether to stand under the sign for disabled or that for woman. “If you hadn’t identified as disabled,” she said, “I would have said you were denying.” With more honesty and'^ irritation than tact, I replied, “It’s for people like you that I have to stand under that sign. You and your attitudes have put me there, not my blindness itself.” Were it not a social problem, disability would require no discussion. In a more just world, disability might not be a social, economic, or political problem. It would 90 CHAPTER 2 GROUPS IN NEED not be a topic for meetings and discussions. I write out of conscience, anger, and disappointment that to live with myself, to better myself and others like me, I have no choice but to speak about what could have and should have been a rather incon­ sequential part of myself and my life. I write in neither pride nor shame, but simply because I have no other choice. I long for the day when I, other disabled psychologists, and other disabled peo­ ple will go into any room in any convention, any meeting, or gathering or job in the world and be greeted, evaluated, rejected, or accepted for who we are as total human beings. We need such a forum not because disabled people are so special, separate, or unique but because we must let people know of our desire and right to be part of the world from which we should never have been excluded. (Adrienne Asch, 1984b, pp. 551-552) □ The Rehabilitation Process The process of helping people with disabilities to achieve the highest possible level of productivity and independent functioning is a team effort in which many different professionals play a role. Clearly, the task of physicians, nurses, and other medical specialists is to help the person with a disability attain maximum use of self. This is one step in the process of rehabilitation. Psychological aspects of the process are of equal importance. In some cases, the person with a disability may become so discour­ aged as to be unresponsive to counseling. Some patients refuse to accept the serious­ ness of the disability or any limits that it may impose. The rehabilitation counselor helps the patient to deal with psychological obstacles, oversees the patient’s progress, and is usually available to the client from the beginning to the end of the process. In the rehabilitation agency, the patient’s school and job history is reviewed in light of future job or training possibilities. A counseling psychologist may be asked to administer a battery of tests to reveal the person’s abilities, interests, and aptitudes. Using all of the available information, a plan is developed that involves either training or actual placement on a job. Some large rehabilitation centers are equipped with workshops where clients can try various activities such as carpentry, clerical work, and machine operation. Here, they are able to gain confidence by achieving success at various tasks. An occupational therapist may be assigned to help them increase skills and to build tolerance for sustained work. Even after the client is placed on a job or begins school in the community, follow-up interviews are arranged to resolve any problems that come up in the placement. The disabled are often perceived by others in a somewhat distorted way. The disability tends to generalize in the minds of others to the whole person—that is, to induce others to see dis...
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