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Safety of Net Political Controversy and Human Services
Sources of Need Satisfaction Falling Through the Safety Net Political Controversy and Human Services
A Conservative Point of View A Liberal Perspective Sweden: A Study in Contrast The Bush Administration: A Kinder, Gentler America? The Clinton Administration The Election of 1994: A Political Revolution? The Election of 1996: The Second Clinton Administration The Congressional Election of 1998: A Setback for Conservatives
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The Elections of 2000: the Bush Administration The Congressional Election of 2002: A Setback for Liberals The Ebb and Flow of Support for Human Services
The Impact of Contemporary Problems on Needs
Natural Disasters Technological Disasters Terrorism Poverty Prejudice and Discrimination Social Change Economic and Technological Changes A Crisis in Morals? Psychological Stress Developmental Crises The Crisis in Health Care The Canadian National Health Plan: A Model for the United States? Managed Care Interaction among Problems
Summary Additional Reading References
INTRODUCTION Over the years, human services in the United States have evolved into a network of programs and agencies that provide an array of services to millions of Amer- icans. The one feature shared by all of these services is that they are designed to meet human needs. Because services are invariably linked to needs, it is impor- tant to understand the full range of human needs. Thus, this chapter begins with a consideration of human needs and the kinds of services that seek to meet them. Some service agencies are devoted mainly to helping people meet basic survival needs such as food and shelter, whereas some are concerned with helping clients achieve more satisfying relationships or attain other kinds of personal fulfill- ment. Primary social supports, such as family and friends, also play a role in meeting human needs, and we examine that role in this first chapter.
There is controversy about just what needs should be met by agencies sup- ported by public or private funds. There is, in fact, a great deal of controversy about questions involving the scope and quality of human services. In this chap- ter, we provide an overview of human services that addresses some of these ques- tions. Critics argue that human services are wasteful and inefficient, whereas supporters are convinced that more should be done to meet people’s needs. Some social planners want to cut funds for services, but others demand increased funding. Because these conflicts are fought out primarily in the political arena, it is vital to grasp the liberal and conservative positions that underlie the count- less debates about specific programs. We outline these positions here.
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This chapter also includes a survey of some contemporary problems that may affect the ability of Americans to meet their own needs. For example, a person involved in a natural disaster such as a hurricane or earthquake is very likely to need help from human services on an emergency basis. Social prob- lems such as discrimination, poverty, and unemployment may also reduce a person’s ability to be self-supporting. Some victims of these problems need help only temporarily, but others receive help for an extended period.
So this chapter introduces some of the topics basic to a study of contem- porary human services. At first glance, they may appear to be simple topics, but closer examination shows them to be very complex—so much so that the brief preliminary information given in this introductory chapter is elaborated on throughout the book.
HUMAN NEEDS: FOCUS OF HUMAN SERVICES A number of schemes have been proposed for conceptualizing human needs. The one suggested by Maslow (1968) is useful for present purposes. He conceived of needs as existing in a kind of pyramid or hierarchy, as shown in Figure 1.1.
At the base of the pyramid are the basic physiological needs such as hunger, thirst, and the need for oxygen. These are matters of life and death. It is only when survival needs are satisfied that the individual focuses on safety needs,
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Need for self-actualization
Ability to direct one’s own life, a sense of meaning and fulfillment
Esteem needs
Self-esteem, esteem of others, achievement, recognition, dignity
Belongingness and love needs
Love, affection, belongingness; need for family and friends
Safety needs
Security, stability, freedom from anxiety and chaos; need for structure and order
Physiological needs
Homeostasis; specific hungers; food, water, air, shelter, and general survival
f igure 1 .1 maslow’s hierarchy of needs
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which involve the need for a stable, predictable, and secure environment. Clearly, this includes decent housing in a safe neighborhood.
Once partial satisfaction of safety needs has been attained, the need for belongings and love begins to emerge, expressed by a desire for affec- tionate relations with others. This includes accept- ance by one’s family, lover, or some larger group. Once the three lower needs have been partly satis- fied, esteem needs come to the fore, such as the need to be respected as a competent or even a superior person. Most of us desire the recognition and appreciation of others.
The highest need, that for self-actualization, has to do with fulfilling one’s innate tendencies and potentials. This need involves expressing one’s inner
nature and talents. For one person, the path to self-actualization might be artistic creativity; for another, it might be studying Eastern religions. This highest level of motivation generally becomes prominent in later life. Young adults are generally preoccupied with making a living and winning the love and approval of others. Maslow (1970) estimated that the average American adult has satisfied about 85% of physiological needs and that the percentage of needs satisfied declines at each step up the hierarchy. At the top step, only 10% have attained satisfaction of self-actualization needs.
Maslow (1987) believed that needs arrange themselves in a hierarchy in terms of potency—that is, physiological needs are stronger than safety needs, which in turn are stronger than love needs, and so on. The higher the need, the less imperative its fulfillment is for sheer survival and the longer gratification can be postponed. Deprivation of higher needs does not produce the kind of desperate emergency reaction triggered by deprivation of lower needs. For example, needs for belongings are a luxury when food or safety is denied.
Maslow (1987) also pointed out that for higher needs to be satisfied, envi- ronmental conditions must be favorable. By this he meant that a person must have a supportive family, a decent income, opportunities for a good education, and so on. People without these kinds of advantages face an uphill struggle to attain the higher levels of need satisfaction. In general, Maslow stated, coun- seling and psychotherapy are more appropriate and effective in helping people achieve higher needs than lower needs. At the lowest need levels, psychother- apy is not much use at all. People who are struggling for basic survival are too worried and preoccupied to give much thought to higher needs. Social plan- ners agree that society must offer tangible kinds of help like food and shelter and medical care to the truly disadvantaged.
Some human services devote themselves to safety needs. The criminal jus- tice system, which includes law enforcement and corrections, is designed to meet safety needs. Citizens want to live in secure communities and go about their daily activities without fear of being threatened, robbed, or assaulted. To
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this end, the public spends millions for police, courts, and corrections. In Chapter 2, we discuss some reasons for the partial failure of the criminal jus- tice system to create a safe environment.
One of the most consistent findings of social research is that the risk of physical or mental illness is greatest when the individual cannot find a place in the social order. Persons who have been deprived of meaningful social contact for any of a number of reasons are at relatively greater risk of developing tuberculosis, alcoholism, accident proneness, severe mental illness, and suici- dal tendencies (Cassel, 1990). Some human services help people to feel that they belong and are valued members of a group. It is expected that such mem- bership may help keep a person out of an institution and, therefore, serve an important preventive purpose. For example, some agencies set up senior clubs for elderly people who would otherwise be living a lonely, isolated life. Another example is the establishment of psychiatric residences for former mental patients who have no family.
Some human services agencies are primarily concerned with meeting the higher needs for esteem and self-actualization. Others help indirectly by meet- ing basic needs, thus allowing the individual to pursue higher needs on his or her own initiative. Education, particularly at the higher levels, is attuned to helping students attain fulfillment and satisfaction through pursuit of a career. In general, human services workers encourage people to function at their high- est possible level. More tangible kinds of help are provided in the form of schol- arships and grants offered by a number of governmental and private agencies.
Criticisms of Maslow’s Theory The idea that our lower needs must be satis- fied before we move to the next higher ones is contradicted by several kinds of evidence. In some societies, for example, people periodically go hungry but, at the same time, exhibit strong social ties and a strong sense of self. In fact, a certain degree of hardship in meeting basic needs can bring people together and give them a sense of purpose in working together to overcome adversity (Neher, 1991). Similarly, many couples in our own society report that a strong bond was formed during a period of early struggles that was weakened by later affluence. Contrary to Maslow’s theory, these examples suggest that dep- rivation of basic physiological needs may sometimes facilitate satisfaction of higher needs, such as the need for intimacy. Aside from anecdotal evidence, there are a number of research studies that have attempted to test Maslow’s concepts. The results, according to Neher’s (1991) review, have been mixed: some support and others refute various hypotheses.
In general, the research conducted in work settings has not supported Maslow’s theory. For example, Wahba and Bridwell (1976) asked workers to list their needs in order of importance and found that the rankings did not fit Maslow’s hierarchy. Other investigators suggested that more than one need may be operating at a time (Geen, Beatty, & Arkin, 1984). In other words, a person may be striving to fulfill simultaneously both basic and growth needs. Still other studies have suggested that moderate levels of deprivation stimulate creative potential, ward off boredom, and enhance a sense of competence (Neher, 1991).
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This idea runs counter to Maslow’s notion that higher needs emerge only after complete satisfaction of lower needs. It may be that some need deprivation is experienced as a challenge and, ultimately, is growth enhancing.
THE ROLE OF PRIMARY SOCIAL SUPPORTS IN MEETING NEEDS Most people seek gratification of needs through a network of social relation- ships. For example, needs for nurturance and intimacy can be met by family, friends, and peer groups. Religious and social groups help meet needs for belonging, esteem, and spiritual enrichment. A job satisfies crucial economic needs and also provides a setting for social interaction with coworkers. Addi- tional support may also come from informal social contacts. For example, bar- tenders and hairdressers are well known for listening sympathetically to the problems of their customers. This network of relationships, which makes up the primary social support system, is the traditional source of need satisfaction in our culture. One important feature of this support system is that usually some sense of mutual obligation underlies the transactions. In other words, a person is expected to give something, to meet certain needs of others, in exchange for what is received. Sometimes, it is enough to simply let others know that one is ready to help if the need arises.
Too many people in this country are still sadly lacking in primary social supports. They may have no friends, no family, no job, and therefore no way to meet important needs. In some cases, a person may have family and friends who would be willing to help but who lack the means to do so. As detailed in Chapter 3, certain human services came into being to meet the needs of peo- ple who have nowhere to turn for help. Over the years, human services have expanded greatly and now go far beyond helping the poor, sick, and disabled. Gradually, they have taken over some of the functions of primary social sup- ports. For example, the task of caring for poor elderly persons, once assumed by the family, is increasingly being accepted by governmental human services agencies.
Self-Help Groups
These are basically mutual-help groups made up of people who have similar problems. They occupy a position somewhere between traditional social sup- ports and formal agencies that provide services. The increasing popularity of these groups may be due partly to the decline of the extended family and other traditional sources of support in our society (Bloch, Croch, & Reibstein, 1982). Whatever the cause, these groups have grown from 300 in 1963 to 500,000 in 1992, with more than 15 million current members.
Riesman (2000) points out that “More Americans try to change their health behaviors through self-help groups than through all other forms of pro- fessional programs combined” (p. 47). What distinguishes these groups from
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formal service organizations is that they operate without professional leader- ship. Many professional therapists view self-help groups as useful adjuncts to treatment and urge clients to participate in them (Comer, 1996).
A wide variety of problems or disorders may be the focus of a self-help group. Alcoholism, drug abuse, compulsive gambling, bereavement, overeat- ing, phobias, rape victimization, unemployment, and physical illnesses (for example, heart disease, diabetes, and cancer) are some examples of issues that may be addressed in support groups. Some advantages of self-help groups are that they are less expensive and less threatening than a professionally led group. Of course, they are designed to offer the support that comes from peo- ple who share a problem. A number of self-help groups are mentioned or described in various sections of this book.
The Effects of Social Programs on Primary Supports
During the 1960s, there was a vigorous expansion of social programs designed to eliminate poverty, remove slums, and improve the health and education of poor people. By the end of the decade, some social planners had come to real- ize that (a) the programs were not always having the desired effect and (b) new problems were being created. For example, it appeared that welfare programs were having the unintended effect of breaking up families and sometimes lead- ing to family nonformation. The programs were administered in such a way that a mother with limited income received not only cash but also a package of other benefits including medical insurance, food stamps, and rent subsidies. If a father was present, he was usually a low-paid worker at risk of being laid off. He could jeopardize the entire benefits package if he attempted to support the family alone. If he left, little effort was made by the welfare program to require him to support the family in any way. In fact, the family was more eco- nomically secure without him. Clearly, the system provided little incentive for the family unit to stay together.
Although we cannot go into great detail about the possible impact of gov- ernment programs on other primary supports, we can note the evidence, reviewed by Butler and Kondratas (1987), that well-intentioned government efforts had the effect of weakening neighborhood associations: “there can be lit- tle doubt that the erosion of America’s poor communities stems in large part from the explicit attempt of . . . reformers to fold them into the larger ‘national’ community” (p. 105). There was a tendency, the authors assert, on the part of federal planners to view poor communities as pockets of pathology and to see nothing of value in them. Too often, they failed to recognize and support church, civic, and neighborhood groups that were supportive to the community.
The lesson to be drawn from this part of our national experience is that programs designed to help, however well intended, may have perverse or unexpected consequences. When these programs weaken the family and the neighborhood, there is good reason to be concerned. The strength of such pri- mary supports is essential if individuals are to cope with a complex society. They are the basic linkages of one person to another. We agree with Butler and
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Kondratas (1987), who argued that America has a strong public interest in government programs that strengthen families; when the family is fragmented, what often follows is poor education, poor skills, and poor performance. This in turn causes the perpetuation of poverty, and the vicious cycle continues.
AN OVERVIEW OF HUMAN SERVICES “What are human services, anyway?” is one of the questions students most fre- quently ask. We would like to provide an “official” or generally accepted defi- nition, but there is no such thing. Actually, ideas about human services have changed over the course of time. As discussed in Chapter 3, early approaches to human services were centered on the hazards of illness, disability, and eco- nomic dependence. Programs were designed to help people who were unable to take care of their own needs. It was recognized that people with little or no income in increasingly complex industrial societies were at risk of starvation or serious distress. This view, which equates human services with providing ser- vices to the economically dependent, now seems rather narrow.
Another approach is to define human services in terms of the activities of modern society that enhance the well-being of its citizens. Hasenfeld (1983), for example, suggests that human services are designed to “protect or enhance the personal well-being of individuals” (p. 1). This is a broad definition that might include a wide spectrum of services, ranging from job creation to main- taining a clean, safe, and pleasant environment for efforts to help people achieve the highest possible level of self-sufficiency.
Experts do not agree on the range or type of helping activities that should be included in human services. We prefer a definition that falls between the very narrow and the very broad ones just discussed. Human services are organized activities that help people in the areas of health care; mental health, including care for persons with retardation; disability and physical handicap; social welfare; child care; criminal justice; housing; recreation; and education. Another type of service that might be included is income maintenance, a term that refers to programs, like unemployment insurance and social security, that provide income to people who are unemployed or retired (Schmolling, 1995).
It should be noted that human services do not include the help given by family, friends, or other primary supports. The help is provided by some type of formal organization, be it a clinic, hospital, nursing home, agency, bureau, or other service institution.
Obviously, human services cover a lot of ground. During recent decades, human services have increased greatly in size and scope in the United States. This increase is reflected by the fact that the total cost of social welfare is esti- mated to have gone up from $1.162 trillion in 1992 to over $1.669 trillion in 2001 (U.S. Office of Management and Budget, 2001). Included in social wel- fare are expenses for social security, welfare, veterans’ programs, education, housing, and other public programs. The federal government is the major provider of social welfare benefits. In fact, most of the huge federal budget,
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approximately 90%, goes for social programs of one kind or another. The Per- sonal Responsibility and Work Opportunity Reconciliation Act of 1996—bet- ter known as The Welfare Reform Act of 1996—has had a significant impact on the cost of social welfare programs that is still to be determined. By any standard, the human services industry is one of the largest industries in the United States. The Bureau of the Census lists many occupations that we gen- erally include under the heading of human services. The following chart high- lights the projected percentage change between 1992 and 2005 of the fastest-growing occupations (Statistical Abstracts of the United States 1995, Bureau of the Census):
Home health aides 139%
Human services workers 135%
Personal and home care aides 130%
Computer engineers and scientists 112%
Systems analysts 110%
Physical and corrective therapy aides 95%
Physical therapists 87%
Paralegals 84%
Occupational therapy assistants and aides 78%
Teachers and special ed 75%
Correction officers 70%
Child care 66%
Occupational therapists 60%
Respiratory therapists 48%
Psychologists 48%
Human Services Workers
The personnel at human services agencies can be divided into four general categories: (a) those who provide help to recipients, (b) supervisory personnel, (c) administrators who determine the policies of the agency, and (d) support personnel who do clerical, maintenance, and security work. In addition, some settings, such as hospitals and nursing homes, require kitchen, housekeeping, and other support workers. In smaller agencies, workers sometimes have to do work in several of these categories.
A great many job titles, positions, and professions are included under the general heading of human services worker. These range from positions that require relatively little formal training, such as mental hospital aide and teacher assistant, to those that require extensive formal training and educa- tion. Clinical and counseling psychologists, psychiatrists, social workers, and nurses are included in the latter category. Chapter 6 goes into detail about a wide range of career options in the field.
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There is considerable variation in the extent to which different profes- sionals identify themselves as human services workers. Social workers, for example, have generally been more accepting of the term than have psycholo- gists or psychiatrists. The term human services worker is more than a way of identifying workers in a particular field; it carries with it a certain attitude or philosophy about the field. The underlying idea is that the separate disciplines should emphasize what they have in common—serving people’s needs—rather than emphasize their differences.
Some activists would like to phase out specialty training in favor of gen- eralist training in human services. However, there is considerable resistance to this idea from professionals who wish to preserve separate identities as psy- chologists, social workers, psychiatrists, and so on. We apologize if all this sounds confusing; it is confusing because the field of human services is under- going rapid change. It is not possible to know for certain how human services workers of the future will be trained or what their job titles will be.
Kinds of Help Provided
Human services provide many kinds of aid and services. Perhaps the most basic kind of direct aid consists of tangible items such as food, clothing, shel- ter, tools, and other useful articles. Victims of natural disasters and homeless poor persons may be in dire need of this kind of help. The Salvation Army and the Red Cross are well known for providing hot meals and shelter to homeless people.
In most situations, cash transfers can readily be exchanged for needed goods and services. Social security, welfare, and unemployment insurance are among the most important benefits of this kind because millions depend on them for economic survival. These cash benefits can be used in any way the recipient sees fit. This freedom worries some politicians who fear that the money will be used for nonessential or even destructive items. This explains why some benefits are offered with strings attached—in other words, the ben- efits can be used only for some specified purpose. Food stamps, for example, are given to eligible poor persons but can be used only to buy food. Another example is a housing subsidy paid directly to the landlord for a welfare recip- ient’s rent.
In addition to these forms of aid, some services are designed to increase clients’ capacities to gain satisfaction of needs by their own efforts. The next few paragraphs give brief preliminary definitions of some of the major kinds of services offered by human services workers.
Primary prevention refers to services designed to prevent people from developing an illness or psychological problem. These services are usually offered to healthy or relatively well functioning individuals and often have an educational or informative component. A school program designed to inform teenagers of the hazards of alcohol abuse is an example of primary prevention.
Counseling helps people consider their choices and options in life. Coun- seling may focus on career choice, budgeting, legal matters, or marital prob-
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lems. Career counseling, for example, may help a client select a suitable occu- pation, whereas marital counseling may focus on a decision about continuing a marriage. Some forms of counseling become involved in helping a client deal with personal problems and, therefore, overlap with psychotherapy.
Psychotherapy has the general goal of changing a client’s behavior or emo- tional responses to improve psychological well-being. Typical goals of therapy are to reduce anxiety, to improve social relationships, and to control undesir- able behavior patterns. There is an implication that the client suffers from some degree of psychological impairment.
Crisis intervention is a special form of help designed to meet the needs of a person faced with an unusually difficult life situation. The word crisis implies that the person’s usual coping mechanisms may not be enough to han- dle the situation. There is a risk of severe emotional upset or even disorgani- zation. Situations that might trigger a crisis include loss of a loved one or being the victim of rape, assault, serious accident, or large-scale disaster. The helper provides support and suggests effective ways of coping with the crisis. The goal is not to change the person’s personality but to restore the client to the precrisis level of functioning. Crisis intervention may be done in the context of face-to-face meetings or by means of a hotline. The latter is a telephone ser- vice that allows the caller to get in touch with a counselor at any time of the night or day. The most familiar hotlines are designed to help suicidal individ- uals. Hotline services are also available to battered women, to rape victims, and to people actively struggling with alcoholism or other chemical depen- dence. A closer examination of crisis intervention follows in Chapter 5.
Rehabilitation is designed to help people with disabilities achieve the highest possible level of productive functioning. Some experts make a distinc- tion between habilitative and rehabilitative programs: the former aim to help those who have never been productive, whereas the latter focus on restoring skills to those who were once capable. In either case, the emphasis tends to be on practical skills such as those involved in self-care and earning a living. The type of disability may be physical, emotional, or developmental.
Social support may be offered in various forms to those who can benefit from a strengthening of social ties. An example is a club for senior citizens that enables them to get together with peers once or twice a week. Other familiar examples are the athletic and social programs for teens provided by many Ys and community centers. In addition, many self-help programs such as Alco- holics Anonymous emphasize social support in their therapeutic approach.
Community organizing represents another indirect form of support for those in need. The general idea is that the human services worker works with community leaders to provide some program needed by an unserved popula- tion in the community. For example, the worker may help the community set up a training school for persons with delayed intellectual development.
Many human services agencies provide a mix of aid and services to clients. Both mental hospitals and prisons, for example, provide aid in the form of food and shelter and may also provide counseling, therapy, or rehabilitation. The employment services of some states link direct cash benefits to job and
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career counseling. At the other end of the scale are smaller programs that offer only one service or a limited range of services to clients.
Sponsors of Human Services
Human services organizations may be sponsored—that is, organized and funded—by private citizens, by religious and other groups, or by government.
Private agencies may be operated on either a profit-making or nonprofit basis. Nursing homes, rehabilitation hospitals, and agencies providing home nursing care are often private profit-making corporations that are run in basically the same way as other businesses. This means that management is under pressure by owners to keep costs down and to show a profit at the end of the year.
Many other private agencies are organized on a not-for-profit basis. Youth employment and child care agencies are sometimes nonprofit. The Red Cross and the Salvation Army are examples of large nationwide private human ser- vices agencies operated on a nonprofit basis. Typically, such agencies are con- trolled by a board of directors that lays down general policies and selects the administrative officers who are responsible for the day-to-day operation of the agency. These agencies raise money by appealing to the general public for donations. An important advantage of nonprofit status is that it exempts the agency from certain taxes, which, in effect, allows more of the income to be used for helping consumers of the service.
Religious and other groups also sponsor nonprofit helping agencies. The Federation of Jewish Philanthropies, Catholic Charities, and the Lutheran Brotherhood are supported by major organized religions. In addition, unions, fraternal organizations, and ethnic groups sponsor countless helping agencies all across the country. The necessary funds are raised by appealing to parish- ioners and members for donations. Increasingly, both private and religious agencies are making use of professional fund-raisers who are paid on the basis of a percentage of the income they raise.
There has been an increase in voluntary giving in recent years. For exam- ple Americans contributed $212 billion in 2001 in spite of the weakening econ- omy and a shattering act of terrorism. According to the survey of the American Association of Fund-Raising Counsel Trust for Philanthropy, the biggest sur- prise was a sharp increase in giving to human service agencies, which received a bit under $21 billion. Individuals accounted for roughly 75% of the contri- butions. (Strom, 2002)
Who receives this money? Religion gets the largest share, with the remain- ing funds divided by education, health, human services, the arts, and other causes. Not all of this private giving goes to help poor people. Much of the money goes to groups active in environmental issues, civil liberties, women’s rights, pro- and antiabortion issues, museums, and symphony orchestras.
Without minimizing the importance of private and religious human ser- vices agencies, it is certain that governments (local, state, and federal) have
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become the major providers of direct and indirect aid to those in need. The scope and purpose of huge federal programs such as Social Security will be dis- cussed in the next chapter. State governments play a major role in education, administer unemployment insurance, and manage most of the nation’s mental hospitals. Local governments are responsible for actual administration of wel- fare programs, and they also provide many other kinds of help such as pro- grams for seniors and teens.
Studying Human Services Firsthand
One of the best ways to learn about human services is to identify and study the different agencies and facilities within your geographical area. This kind of study readily lends itself to a team approach because students can divide the work and share information with one another. The information can come from many sources, including literature available at agencies, on-site visits, and meetings with staff members.
Your class might list all of the human services agencies, programs, and facilities in your area and provide answers to the following questions:
tion serve? Hundreds? Thousands? • What does the service cost the consumers? What are the eligibility criteria? • Where does the money come from? If several sources are involved, list
them in order of contribution. • How many and what kinds of human services workers are employed by
the human services agency?
You may also share your subjective impressions of the agencies you visited. Did you feel welcome? Did the service seem to be well organized? How were clients treated by staff?
Human Services Workers and Bureaucracy
Students beginning their training in human services rarely express the ambition to become bureaucrats. Nevertheless, the great majority of them will eventually find themselves working in the type of organization called a bureau or a bureaucracy. The fact is that welfare agencies, hospitals, employment services, nursing homes, and psychiatric clinics are all examples of this kind of organi- zation. Bureaucracies, which may be small or large, public or private, are defined by certain formal arrangements including some form of central control and a clear division of labor among administrators, supervisors, workers, and clerical staff. The employees are usually arranged in a hierarchy from higher to lower, and exchanges between the lower and upper levels without “going through channels” are often discouraged (Macht & Ashford, 1990, p. 227).
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One of the frustrating features of the large bureaucracy is the difficulty a worker may experience in feeling that he or she makes a difference. Each per- son may feel like a small cog in a big machine. Despite the shortcomings of these kinds of organizations, they have adapted and survived. No one has developed a more efficient means of providing services on a large scale.
We agree with Macht and Ashford (1990) that educators often fail to pre- pare students to become effective bureaucrats. When bureaucracy is discussed in class, it is often in terms of the potential conflict between agency goals on the one hand and client or worker goals on the other. Or the discussion may focus on the organization as a cause of low morale among workers. It is all too easy to lose sight of the fact that specialization of workers, clear lines of com- mand, and other features of the bureaucracy enable it to deliver services on a large scale and in an efficient manner. Rather than focus on the negative aspects, it is more productive to help students develop the knowledge and skills to work effectively within the bureaucracy. To this end, the student should be acquainted with the patterns of organization in human services organizations. We think so highly of this idea that we initiated a course in human services organizations taught at the undergraduate college level (rather than at the grad- uate level). Some of the topics explored are the use of power, funding sources, specialization, and delivery of services. Also discussed is the important topic of how to bring about constructive changes in the organization.
The Trend toward Privatization
The process of arranging for private companies to do certain jobs formerly done by government is called privatizing or privatization. Recent decades have seen an increase in the trend to privatize government services along with an increasing role for profit-making companies. The push to privatize is a reaction against “the fact that much of government has become entangled in its own power, stifling creativity and productivity. Government agencies responsible for serving the people have become muscle bound, almost to the point of paralysis when it comes to considering more effective performance” (Linowes, 1995, p. 86). He added that government agencies are trying to solve social problems with outmoded designs and solutions. Clearly, Linowes is giving voice to the dislike of government bureaucracies shared by many conservatives.
Opposition to the trend to privatize has come from government employees, including many human service workers. Perhaps the best-organized resistance has come from the nation’s unions of public employees. Although industrial unions have declined in influence since the end of World War II, unions of gov- ernment employees have increased in size and power. By the end of 1992, and for the first time in American history, more people were employed by govern- ments than in manufacturing (Peterson, 1994, p. 190). Many government workers are organized into civil service employee unions. Like other special interest groups, these unions lobby state and local legislators, contribute to campaign funds, and may deliver a sizable block of votes in elections. The pur- pose of this lobbying is, of course, to secure the kinds of benefits unions have
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always sought for their members: decent pay, job security, and fringe benefits such as pensions and medical insurance. During recent years, an increasing number of taxpayers began to resent the favorable contracts won by these unions. By contracting with private companies to do certain jobs, it was possi- ble to cut costs while weakening the power of the unions. How are private com- panies able to achieve significant savings? They hire nonunion workers at salaries lower than those of union workers, and they typically provide limited (or no) fringe benefits.
The Westchester Experience The county executive of Westchester, a subur- ban community in New York, was quoted by Wilson (1995) as saying, “Our [county] workers have priced themselves out of existence. The government has a right to save money. Taxpayers are important people, and if there is a better way to do things, we should do it” (p. 1A). In previous years, this same county executive had accepted the endorsement of the county workers’ union and had agreed to generous contractual benefits for the members. Now there was con- cern that hospital laundry and housekeeping workers were earning $12–15 an hour when the going rate in nonunionized facilities was closer to $5 an hour. Union officials complained angrily that the move to privatize was intended to “bust” the union. Union workers were very much afraid of losing their jobs and predicted that privatization would result in a decline in the quality of the services provided. They wondered how workers could live and support a fam- ily on $5 an hour.
This drama is being enacted in many other communities across the nation. It is of great importance to the reader for the obvious reason that government provides most human services. Here is a list of some of the services that have been privatized in some communities:
These examples show that parts of larger operations may be privatized by government. More ambitious efforts to privatize may involve entire programs and facilities. For example, Brown County, Wisconsin, has turned over its wel- fare program to an outside private organization, and Corrections Corporation of America has more than $100 million in contracts for prisons and detention centers in nine states (Linowes, 1995).
There are potential dangers involved in either government-run or priva- tized services. Programs run by government are at risk of becoming job pro- grams for union employees and political appointees. The needs of the workers
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may take precedence over the needs of recipients. The danger of privatization, on the other hand, is that the profit motive may come to dominate all other considerations. For example, one firm providing halfway houses for prisoners was charged with hiring low-paid, untrained employees and with allowing liv- ing conditions in the facility to deteriorate markedly. Fire hazards such as exposed electrical wires went unrepaired, and vermin were permitted free run of the place (Sullivan & Purdy, 1995). There are even serious discussions today regarding the privatization of the social security system in spite of the possible problems and dangers to future recipients.
suggest ion for a class report or term paper Examine the effects of a specific program or service that has been privatized in your county or state. What was the effect on the government workers who previ- ously provided the service? Describe the new workers in terms of salary and qual- ifications. Was there any change in the quality of the services provided? Interview some people who were directly affected by the change and report their reactions.
SOURCES OF NEED SATISFACTION Figure 1.2 is a flowchart that illustrates the relationship among needs, primary sources of help, and human services. A person in need often seeks help from primary sources such as family and friends before going to a human services agency. For example, a person with financial difficulties may seek help from the family before applying for welfare. Similarly, a person with emotional problems may seek advice from a priest, minister, or rabbi before going to a psychiatric clinic. It is often more comfortable to appeal to familiar persons than to an impersonal agency for help. The bureaucratic procedures of some agencies make people hesitate to go to them: Some agencies make clients wait for hours, require that complicated forms be filled out, and process the claims in a cold, perfunctory manner.
In some circumstances, however, a person may prefer to go to a human services agency rather than to primary sources. For example, an individual may want to conceal an unwanted pregnancy from family and friends. Others may feel too embarrassed about certain behaviors to even discuss them with friends or family. Child abusers, gamblers, and drug addicts may well fall into this category. In these cases, the human services agency offers the opportunity to deal with the problem in a confidential manner. And to those lacking pri- mary social supports, the human services often represent the last defense against personal disaster.
FALLING THROUGH THE SAFETY NET An unknown number of people need help from human services but don’t get it. These are the people who fall through the safety net provided by basic ser- vices. Some needy people are not eligible for help based on the criteria of the
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agency in question. For example, a worker may not be eligible for unemploy- ment benefits if he or she did not work for a specified number of months dur- ing the previous year. Other needy people may simply be unaware of existing programs. For example, some illegal immigrants do not know about programs designed to help them. Still other needy people may be fully aware of pro- grams but are too proud to accept the help available.
What happens to those people who are not helped either by primary social supports or by human services? Many thousands of them end up in the streets. The story of America’s homeless is told in detail in Chapter 2. Runaway chil- dren, long-term alcoholics, and former mental hospital inmates may be included in the ranks of “street people.” During severe weather, some of them try to secure admission to jails or mental hospitals. Some depend on handouts from passersby, and many take meals provided by soup kitchens or shelters. There is continuing debate about what to do with these people, usually with one agency or level of government trying to shift the responsibility elsewhere.
Up to this point, we have emphasized the role of human services in attempting to meet needs. However, human needs are only one consideration in the design and delivery of services. Let’s examine some other potent factors that influence human services in the United States.
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Human needs and desires
Nutrition
Shelter
Safety
Money
Status
Identity
Health
Intimacy
Self-actualization
Primary social supports
Family
Friends
Peer groups
Employer
Coworkers
Church
Informal social contacts
Human services
Medical care
Rehabilitation
Recreation
Public housing
Criminal justice
Education
Mental health
Mental retardation
Substance abuse
f igure 1 .2 the relationship among needs, primary social supports, and human services
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POLITICAL CONTROVERSY AND HUMAN SERVICES The magnitude, scope, and purpose of human services are shaped only in part by people’s needs. Other considerations are the resources available for helping and the attitudes of various groups toward human services. Unfortunately, there is no consensus of opinion about the issue of who should receive what kind of help. The ultraconservative view is that government support for human services should be cut to the barest minimum. Liberals see the need for increases in all human services. In our society, there is constant conflict between those who would cut and those who would increase expenditures for human services. This has resulted in an ebb and flow of governmental support for human services. One unfortunate consequence is that human services have not been allowed to develop in an orderly, rational manner. Services are initi- ated under one administration only to be limited or eliminated by the next administration. The political forces underlying these conflicts are generally labeled liberal and conservative. Of course, people are not consistent within these frameworks. A particular individual may take a liberal position about one kind of service but a conservative position on another. Let’s look more closely at these positions.
A Conservative Point of View
Conservatives wish to preserve traditional American values, including a strict adherence to the Constitution and respect for the rights and property of oth- ers. They profess a deep respect for the values of the American pioneer with a strong emphasis on hard work, perseverance, and self-reliance. Jealous of their personal liberty, conservatives tend to distrust big government and wish to limit its role to the barest essentials. This resentment against interference extends into the economic sphere. Generally, conservatives favor a free market and maintain that free enterprise and the pursuit of private profit have made the United States the richest nation on Earth.
Conservatives today oppose social programs in a somewhat less auto- matic, reflexive fashion. They recognize that there are some circumstances when people, through no fault of their own, require help from government. Few, if any, conservatives now favor elimination of the Social Security pro- gram, although some would favor a reorganization along the lines of a volun- tary insurance program or some other form of privatization. Conservatives also accept the need for some form of welfare benefits for those who are unable to meet immediate needs. However, they would like to see built into the system incentives that would induce individuals to become self-supporting. Conservatives also generally favor unemployment insurance, partly in recog- nition of the fact that workers are often caught up in economic problems far beyond their individual control. It must also be recognized that all of these programs are beneficial to the economy because they help individuals main- tain purchasing power.
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Conservatives are likely to oppose programs that go beyond meeting basic survival needs. They express concern that help from the government tends to weaken the initiative of the recipient, creating an attitude of passive depen- dence. They also believe that the federal government has assumed excessive control over our lives through its massive programs and that power and con- trol should be returned to the individual states.
A Liberal Perspective
Liberals see themselves as champions of the disadvantaged. They are con- vinced that conservative rhetoric about liberty and self-reliance doesn’t mean very much to a person who is hungry, broke, and unemployed.
There was a basic shift of political power from big business to big gov- ernment. The liberal tradition was carried on by the administrations of Harry Truman, John F. Kennedy, and Lyndon Johnson (known for his Great Society). All perceived that government must take a leading role in working for the health, safety, and welfare of the people.
Mario Cuomo (1994) has contrasted the liberal and conservative positions in the following way: Liberals accept the idea of collective responsibility, a sense that we are all in this together, whereas conservatives are more reluctant to get involved in sharing benefits or burdens. Cuomo argues that people don’t have to love their needy neighbors, but they should at least consider their own self- interest. “If we bring children into this world and let them go hungry and une- ducated, if we are indifferent to the drugs and squalor that surround them . . . , then all of us will share the outcome,” he writes (p. 9), adding that we will all be obliged to spend more on jails and police while we live in fear.
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One of thousands of homeless people living in the streets of our cities Michael Newman/PhotoEdit
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Sweden: A Study in Contrast
Sweden’s approach to human services provides a sharp contrast to that of the United States. It may be viewed as the ultimate welfare state. Sweden puts about 30% of its entire national wealth into human services, compared to 14% for the United States. That money is used to provide paternal leave from work; day care for children between ages 2 and 7; free education, including university and continuing education; large-scale public housing; health care; and worker benefits including job placement, training, and sheltered employment for the disabled (Barkan, 1991). Furthermore, the Swedes deliberately act to equalize the distribution of income between workers in different industries. They also use taxes to further equalize income between individuals. The proportion of families living in poverty is about 5%, compared to a much higher rate for the United States. The great disparity in health between children of different social classes found in the United States does not exist in Sweden. The rate of violent crime is much lower than in most other industrialized nations. Although other factors may be involved, it seems fair to say that social services contribute to the high level of personal security that Swedes enjoy.
Of course, there is a downside to all of this government nurturing. Swedes pay much higher rates of taxation than do U.S. citizens. It seems doubtful that Americans would sit still for a 50% rate of income tax. They would prefer
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fewer government services and more money in their pockets. The Swedes themselves are having second thoughts about the costs of their welfare state. Recent political developments in that country suggest that some reduction in benefits may now be favored by a majority of citizens.
The Bush Administration: A Kinder, Gentler America?
Although President Bush generally adhered to the conservative principles of his predecessor, he was often viewed as a more practical and less doctrinaire leader than was President Reagan. Bush’s speeches suggested that he wanted to be seen as a man who was deeply concerned about the needs of the nation’s downtrod- den. The “points of light” campaign was central to the domestic policy of the Bush administration. The phrase entered political consciousness when George Bush accepted the nomination of his party at the 1988 Republican convention. He spoke of “a brilliant diversity spread like the stars, like a thousand points of light in a broad and peaceful sky.” Each point of light was a volunteer group or individual who provided service to someone in need. This approach is very much in line with the conservative idea that, whenever possible, private efforts are to be preferred over the expansion of government programs. According to a White House aide, such volunteers bring something that the sick and needy value: a purity of motivation that government workers lack (DeParle, 1991). Social healing is turned into a daily part of life. A privately managed Points of Light Foundation, near the White House, presented commercials on radio and television. A point of light coordinator in the White House designated a daily “point of light” for providing outstanding volunteer service.
This Bush initiative was subjected to scathing criticism by the political opposition. Some commentators charged that the points of light campaign was designed to cover up the callous indifference of the administration to glaring social problems: It was a public relations effort that allowed the government to shirk its responsibility (DeParle, 1991). Cartoons of devastated communi- ties were identified as “a thousand points of blight.” By placing the burden on the private nonprofit sector, the critics said, the administration avoided the task of raising revenue to finance the large-scale government efforts that alone can solve our problems.
The Clinton Administration
When Bill Clinton announced his candidacy for president of the United States, he presented himself as a champion of the middle class, stressing the values of work, family, self-responsibility, and community. He promised to fight for the “forgotten” middle class: “Middle class people are spending more hours on the job, spending less time with their children, bringing home a smaller pay- check to pay more for health care and housing and education.” He would not stand by “and let our children become part of the first generation to do worse than their parents” (quoted in Greenberg, 1995, pp. 182–183).
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During the campaign, Clinton ran as a “new” Democrat, carefully dis- tancing himself from the liberal policies of the failed Dukakis campaign dur- ing which Republicans had portrayed Democrats as weak on defense, soft on criminals, catering to minorities, and incapable of balancing a budget. Clinton moved close to the political center as he battled his two opponents. He won the election of 1992 but with only 43% of the vote. He was a minority presi- dent without a strong mandate for his policies.
The Clinton administration quickly became embroiled in controversies. Administration support for gays in the military, the strong leadership role assumed by First Lady Hillary Rodham Clinton, and the preference shown to women and minorities in appointments to high positions not only generated criticism by conservatives but suggested a commitment to an agenda that had been concealed from the voters. Scandals and vacillating foreign policies cre- ated further difficulties for the administration. Successes were passage through Congress of a gun control bill, an anticrime bill that would put more police officers on the street, and a family leave bill. The major initiative was reform of the nation’s health care system. The failure of this attempt, to be described in a subsequent section, was a serious blow to the Clinton presidency.
The Election of 1994: A Political Revolution?
The 1994 election signaled a shift in public opinion toward conservative poli- cies. What was surprising was the decisive nature of the victory for conserva- tive forces represented by the Republican party. For the first time in 40 years, Republicans won control of both the House and the Senate. The new con- gressional majority leaders were Representative Newt Gingrich of the House and Senator Bob Dole of the Senate. The strength of the victory was shown by the fact that no sitting Republican governor, senator, or representative was defeated. Republicans spoke of a political revolution and of a strong mandate to balance the federal budget. The voters seemed to be calling for smaller gov- ernment, lower taxes, and more individual freedom and personal responsibil- ity instead of more government power (Clymer, 1994).
The Contract with America This is the name of a document that was signed in September 1994 by the members of the Republican party in the House of Representatives. Here are some of its provisions:
ditures for dubious projects that are embedded within larger bills. • Require convicted offenders to pay full restitution to victims. • Relax rules of evidence at trials so that the guilty will not get off on minor
technicalities. • Limit death penalty appeals. • Streamline deportation of criminal aliens.
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ment that the states provide certain services that are not accompanied by federal funding).
number of terms someone can serve in Congress. • Provide for a sweeping revision of welfare programs, including aid to fam-
ilies with dependent children, child nutrition, food stamps, and supple- mental security income (Toner, 1995).
Leading Democrats conceded that the Republicans at least knew what they wanted to do. As Senator Daniel Moynihan, Democrat of New York, said, the Republicans did not find themselves in the majority asking “What now?” Senator Moynihan was also quoted as saying that the Contract with America represented “the harshest, most regressive legislation in our history” (Toner, 1995, p. 18). Mario Cuomo (1994) also expressed concern that Amer- icans were heading back to an earlier historical period when exploitation of the poor was the rule. In his view, we must not let the safety net woven by the New Deal and the Great Society become unraveled.
The Election of 1996: The Second Clinton Administration
For the first time since Franklin Delano Roosevelt was president, a Democrat, Bill Clinton, was elected to a second term as president. Clinton was reelected with over 49% of the popular vote in spite of the many controversies and scandals that plagued his first administration. It became clear that the voters cared little about Clinton’s personal problems as long as the economy was growing and unemployment was at its lowest level in decades. In addition, with a balanced budget and a significant surplus, Clinton was perceived as doing a very good job as president. At the same time there was a slight shift in the makeup of the Congress. A gain of seven seats in the House by the Dem- ocrats indicated a slight but significant change in the attitudes of the Ameri- can public toward the conservative thrust of the 1994 “revolutionaries.”
The Congressional Election of 1998: A Setback for Conservatives
The congressional election of 1998 was a serious blow to the Republican majority in the House of Representatives. The loss of five seats for the major- ity in an off-year election was unique. The loss, according to political pundits, was due to the manner in which the Republicans handled the scandal,
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impeachment, and trial in the Senate of President Clinton. It was felt generally that all of the consuming efforts of the conservatives to unseat the president rather than deal with legislative issues of concern to the majority of people caused the major reversal for the Republicans. The American public made it very clear that they did not want the president impeached. They were, in fact, pleased with his performance as president. When the Republicans ignored the obvious wishes of the public, they paid the price at the polls.
The president and Democrats, meanwhile, focused on their philosophy of maintaining a sound economy and balanced budget, among other efforts. It was then the Democrats who had the political momentum to gain control of the House and further their program. These kinds of changes constantly occur over time. They, however, create uncertainty of policies and funding that directly affect human service programs and workers.
The Elections of 2000: The Bush Administration
The 2000 presidential election was a most controversial one, the outcome of which was finally determined 36 days after Election Day. George W. Bush became president when he obtained the electoral votes from the state of Florida due to the intervention of the United States Supreme Court. The actual popular vote in Florida, however, was and still is in doubt. Mr. Bush became president with over half a million fewer votes nationwide than his opponent Vice President Gore. The implications of these events in terms of domestic policies are yet to be fully realized.
In the congressional races the Republicans initially maintained control of both the House and Senate by very slim margins. In fact, the Senate was split 50-50 with Republicans retaining control because of the tie-breaking vote of Vice President Cheney. However, the Bush administration’s political and eco- nomic agenda gave rise to enough concern on the part of a Republican sena- tor to induce him to leave the Republican Party and become an Independent. This one act gave the Democrats control of the Senate providing significant obstacles for the Republicans to overcome in order to achieve their legislative goals. The new administration consists of a large number of former conserva- tive administrators, ex-CEOs, and politicians on the far right of the political spectrum. The legislation proposed and thus far passed—such as the tax cut, and reductions in mental health and similar programs—reflects a sharp turn to conservatism.
Shortly after the Bush administration took charge it became apparent that the economy was in a recession. Bush and Republicans claimed the recession began during the Clinton administration. They also asserted that the tax cut they urged prior to the election of 2000 would not only help the individual tax- payer but would stimulate the economy and overcome the effects of the reces- sion. One of the first acts passed by the Bush administration, with the help of some conservative Democrats, was in fact the huge tax cut. Liberals asserted that the tax cut was a gift for a relatively few wealthy individuals and of little
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or no consequence to the majority of taxpayers. They also claimed that such a large tax cut would certainly eliminate the surpluses obtained previously. It was those surpluses that liberals had hoped to use to help pay off the national debt; secure the existence and growth of Medicare, Medicaid, Social Security; and obtain a prescription drug plan for the elderly, among other human service pro- grams. Instead with the surpluses virtually gone, deficit spending returned and support and funding for human service programs diminished.
In addition, the unemployment rate, according to the Bureau of Labor Sta- tistics, rose from 4% in 2000 to 5.7%, with nearly a million layoffs in the year 2001 (Bloomberg News) and further increased to 6% in April 2002 (Associ- ated Press, 2002). The number of workers obtaining unemployment benefits rose to nearly 4 million (Associated Press 2002). In spite of this, economists, both governmental and private, gave assurances that the economy was still growing but at a slower pace. During the financial scandals of many huge U.S. corporations, which were a major factor in the stock market plunge of approximately 20% in less than three months, hundreds if not thousands of individuals, workers, and investors lost jobs, pensions and retirement funds due to corporate greed and the illegal manipulation of funds by executives of many large corporations. The belief of many is that there may still be other executives illegally manipulating funds and causing additional financial and emotional damage. The sudden growth in the number of unemployed and number of individuals who lost investments, savings, and pensions (increasing their vulnerability to psychological, emotional, and physical problems) increased the need of additional human services.
Most of the problems described took place before the terrorist attack of September 11. The terrorist attack on the World Trade Center and Pentagon initially put all domestic issues and problems on the back burner, as Bush ini- tiated the “war on terrorism.” The impact of the attacks on the economy was and is significant. (The impact of the attacks on the need for human services is described later in the chapter.) The war on terrorism requires additional expenditures of billions of dollars that have yet to be totaled, which increases the deficit and further limits funding for the human services and other domes- tic programs. While the war on terrorism continues, however, domestic issues once again are coming to the fore.
The Congressional Elections of 2002: A Setback for Liberals
The 2002 congressional elections were clearly a victory for conservatives. Both houses of Congress plus the White House and a majority of governor man- sions are presently in control of conservatives. With such control, fewer major obstacles need be overcome for conservative goals to be reached. The War on Terrorism, the establishment of the Department of Homeland Security and the possible war with Iraq shifted priorities primarily to international issues and domestic security concerns. As for domestic matters, conservatives claim that large tax cuts, increased corporate subsidies, and reduction of levels of support
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for social programs would help stimulate a shaky economy and help solve many domestic problems. Liberals, however, while supporting the war on ter- rorism, believe that such economic policies during a weak economy, growing deficits, increased unemployment, increased numbers of people living in poverty and without health insurance will exacerbate those and other domes- tic problems. Regardless of who is right, policies and funding for human ser- vices programs will be profoundly affected.
The Ebb and Flow of Support for Human Services
Aside from threats to national security or catastrophes, a major factor that determines the degree of public support for human services is the state of the economy. In good times, tax revenues increase and more money is generally made available for human services. During economic downturns, funding for services is likely to be reduced.
Changes in the public’s attitude toward government also affect funding for services. In recent years, the public’s confidence in government seems to have reached a low point. Some people feel that the less money we send to govern- ment, the less it will have to waste.
Supporters of human services argue that it is futile to attempt to save money by cutting funds for human services programs. For example, if we pay less for child care services now, we will have to spend more later for support- ing people in mental hospitals and correctional facilities. If we cut back on funds for probation, we reduce our chances of rehabilitating offenders. Over- crowding in our prisons coupled with a lack of therapeutic programs is responsible for the high rate of recidivism. Is there really any long-run saving to be derived from “dumping” former mental patients into communities that are unable or unwilling to provide supportive services for them? By short- changing human services agencies, we prevent them from reducing the num- ber of dependent and dysfunctional people.
Human services programs need sufficient funding and an orderly, pre- dictable flow of funds from one year to the next to fulfill their missions. In fact, government, regardless of economic conditions, seems to provide for human services on a hand-to-mouth basis with the threat or actuality of sig- nificant cutbacks to individual program budgets always possible. These varia- tions in funding are most often related to political and economic factors that have little to do with the needs of the agency or its clients. It is difficult to do an effective job, maintain employee morale, and keep the confidence of the clients under such unstable conditions. This is why human services workers are increasingly seeing the need to organize effective lobbying groups. They recognize that well-organized groups such as the gun lobby, the tobacco lobby, and other special interest groups are often successful in securing favorable leg- islation. On a practical level, the political system works through the applica- tion of this kind of direct pressure. Unrepresented groups, no matter how worthy their cause, are likely to be overlooked. This issue is discussed in more detail in Chapter 7.
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THE IMPACT OF CONTEMPORARY PROBLEMS ON NEEDS Human services do not operate in a vacuum; they are shaped by social, envi- ronmental, political, and economic conditions that prevail in a given time and place. The purpose of this section is to pinpoint some contemporary problems that affect the ability of Americans to meet their own needs.
In recent years, there have been decreases in population both in farming areas and in the centers of our large cities. Many people have left the north- ern, industrial states for the Sun Belt—that is, the tier of southern states rang- ing from California to Florida. This is also a time of rapid social and technological change. Whereas all of these changes may bring opportunities for some, they create problems for others. To be fully effective, human services need to be based on an up-to-date grasp of the obstacles confronting people. Services need to be constantly modified to keep pace with changing needs.
Natural Disasters
Although natural disasters have occurred since antiquity, this topic is included in a discussion of contemporary problems because the rate of casualties from natural disasters is increasing sharply and will continue to go up in the fore- seeable future. A disaster is a phenomenon that can have devastating social consequences when the awesome forces of nature come into contact with peo- ple. On a worldwide basis, nearly a quarter of a million people die in natural disasters each year (Frazier, 1979). Earthquakes, floods, hurricanes, torna- does, and volcanic eruptions are among the natural hazards with the greatest potential for destruction.
In the United States, several trends are acting to increase disaster tolls. One is the vulnerability brought about by increasing dependence on inter- linked computer systems and surface electrical power lines. The New York City power blackout of 1977 was triggered by a lightning strike on electronic switching equipment. Another trend that increases the potential for disaster in this country is the shift in population. More and more people are moving into flood plains, seismic risk zones, and coastal areas exposed to hurricane winds, storms, and erosion. There is also an increased risk due to the spread of pop- ulation to California, where landslides and earthquakes are serious hazards. More than half the population now live in places highly susceptible to natural disasters (Frazier, 1979).
In the event of a disaster, people usually first seek help from family, friends, and neighbors. However, if the disaster is severe, local service agencies are called on to help the sick and homeless. The police, fire department, church organizations, social welfare groups, and medical services may all play important roles, depending on the nature of the disaster. Restoring communi- cation, effecting evacuations, rescuing survivors, and providing temporary shelter and emergency first aid are just some of the important jobs that may
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need to be done. It is obvious that well-trained, well-organized service work- ers function more effectively than untrained ones. Many of these observations apply just as well to disasters for which humans are responsible, such as mine cave-ins or the collapse of buildings and other structures.
Hurricane Andrew An excellent example of the many roles of human ser- vices workers during the aftermath of a natural disaster occurred after Hurri- cane Andrew. One of the most devastating natural disasters in U.S. history hit the coast of Florida in the summer of 1992. The storm, which generated winds of 150 miles an hour, hit land on August 24 and devastated south Dade County, creating a zone of destruction larger than the city of Chicago. More than 80,000 dwellings were demolished or rendered unlivable. Thirty billion dollars worth of property was destroyed. Owing to the fact that many resi- dents had obeyed evacuation orders, the death toll was only 43 in Florida; 15 more people were killed when the storm reached Louisiana (Gore, 1993).
After the storm, Dade County residents found themselves sweltering in the sun without food, electricity, or transportation. Thousands of cars were demolished, trees were down, and traffic lights were blown away. Almost as bad as the storm itself were the looters who suddenly appeared in large num- bers. These predators made off with their neighbors’ TVs, VCRs, and other valuables. Help was urgently needed but slow to arrive. Apparently, state and federal officials did not grasp the scope of the disaster until two days after the hurricane. Southern Baptist organizations were the first on the scene, setting up mobile kitchens and distributing thousands of meals a day. The Red Cross set up emergency shelters, and relief workers brought in medicine and other necessities. The most massive aid came from a joint military task force that directed traffic, restored order, and brought in supplies by means of truck con- voys and helicopters (Gore, 1993).
Six months later, the region still looked like a war zone, with emptied housing projects, roofless homes, boarded-up shops, and thousands still living in tents. Many children showed signs of having been traumatized by the event. A dozen elementary school children had attempted suicide, one by hanging and another by jumping in front of the school bus. Many children, and some adults, became anxious and upset during storms after the hurricane, afraid that Andrew had come back. Counselors and school psychologists reassured parents that these responses were entirely to be expected under the conditions. In school, counselors watched for signs of despondency among the students. Not surprisingly, grades were falling and more students were being disruptive in class; others fell asleep during the day. In some instances, parents were con- tributing to the problem because they themselves were stressed out and short- tempered with their children. One counselor hit upon the idea of giving out toys during therapy sessions and found that even older children could take comfort from stuffed animals. An 11-year-old boy clutched a pink bear and said, “A whole buncha houses come down and fall on mine” (Gelman & Katel, 1993, p. 65). It seems clear that the work of psychological counseling needs to go on for an extended period after a disaster.
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There are many other examples of the roles of human service workers dur- ing natural disasters. They were demonstrated during the floodings in the Midwest, the earthquakes in California, and the aftermath of El Niño.
Technological Disasters
Technological disasters differ in some respects from natural disasters. They are usually due to human error, carelessness, avarice, or, in some instances, a cal- lous disregard for human values in the pursuit of profit (Rice, 1987). Because they are preventable, generally more rage and anger erupt among victims fol- lowing a technological disaster than after a natural disaster.
The nuclear accident at Three Mile Island, Pennsylvania, in 1979 was a major technological disaster. It began when a malfunction at one unit caused a release of radioactive gases into the atmosphere. During the immediate cri- sis, which lasted several days, there was massive disruption of life and evacu- ations from the surrounding area. The threat of radioactive leaks lasted for over one year. The victims exhibited increased psychological distress, increased physical complaints, and heightened levels of adrenaline, indicating high anx- iety and tension. It was also reported that residents who had little or no social support showed more stress than those with good support (Fleming, Baum, Gisriel, & Gatchel, 1982).
An even more terrible disaster took place during 1986 at the Chernobyl nuclear power plant in the Soviet Union. Thirty-one people died in the initial explosion and fire at the Number 4 reactor of the plant, and about 300 have died subsequently. Initially, the plant managers delayed in informing the government of the extent of the damage, thereby slowing the evacuation of nearby residents. The Soviet government then misled the world and its own citizens about the seri- ousness of the problem; only later did the government admit to severe medical and environmental consequences (Barringer, 1990). Specifically, it was revealed that 4 million people in the Ukraine and western Russia are living on contami- nated ground. Their exposure to radioactivity is resulting in high rates of thyroid cancer, leukemia, and premature death. The initial cover-up of the accident’s scope prevented timely actions aimed at protecting people from radioactivity.
As a consequence of the incidents at Three Mile Island and Chernobyl, there is intense worldwide controversy about the safety of nuclear power. Although the workers in and around the plants are at greatest risk, nuclear accidents also pose a threat to people living far away from the scene. Radioac- tivity may be carried by wind currents and contaminate distant soil, plants, and animals as well as people.
The Needs of Emergency Services Workers Although the victims of disaster are of immediate concern, the mental health needs of emergency workers must not be overlooked. In attempting to help victims under stressful and chaotic conditions, these workers may suffer extreme fatigue, stress reactions, and burnout. The National Institute of Mental Health (1985) has provided some suggestions that will help prevent and control stress among workers.
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Preventive efforts might include predisaster training in the mental health aspects of the work. Workers can learn to recognize the stresses inherent in their work and to develop strategies for dealing with those stresses. For exam- ple, the workers can learn about resources, such as debriefing and counseling, available to them for dealing with stress. The workers should also receive training in their particular role in the organization’s overall plan and should participate in disaster drills.
During the disaster, workers should be provided with as much factual information as possible about what they will find at the scene, and they should be informed about the well-being of their family members. Workers should be checked by supervisors for signs of stress and, perhaps, rotated among assign- ments of varying difficulty. Workers should be required to take breaks, espe- cially if their capacity to help is diminishing.
After the disaster, all who participated in the work should be debriefed. The debriefing may be one-to-one or it may be a group meeting in which the emotional aspects of the experience are discussed. The leader should be skilled in group dynamics and be trained to handle strong emotions. The debriefing is usually held between 24 and 48 hours after the incident, allowing time to overcome the initial fatigue and numbness. Two to four hours should be allowed for the debriefing, and both the positive and negative emotional responses should be reviewed. Finally, the organization should have some means of monitoring the worker’s recovery from traumatic events, and, if needed, the worker should be referred for counseling.
Terrorism
Since the horrible and momentous events of September 11, 2001, the lives of Americans have been significantly altered. The television and media cover- age during the days, weeks, and months following the terrorist attack have made all of us suddenly become aware of how vulnerable we are to further attacks. These were not the first acts of terrorism in the United States or the world; however, for the United States, these acts of terror came to symbolize a new era when President Bush declared a worldwide war on terrorism.
Terrorism is both a violent and political act. A symbolic target is selected to convey a political message to a group, usually a government, in an attempt to alter some form of government policy. The targeting of innocent people is central to the tactics of terrorism, setting it apart from other forms of warfare. The terrorists’ goal is to disrupt the daily routines of people’s lives and create psychological disequalibrium resulting in a heightened sense of vulnerability, insecurity, anxiety and/or apprehension. In this, the terrorists unfortunately succeeded for the first time in the United States, and therefore increased the need for further services. Additional stress is generated when warnings by the government of potential attacks are given without knowing when, where, or what kinds of attacks are imminent. Further anxiety and a sense of helpless- ness occur due to lack of information on how to prepare for and deal with such events.
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Medical disaster teams have been in place in large cities for some time, but the events of September 11 demonstrated the immediate and dramatic need to establish organized mental health disaster plans. According to Chip Felton, an associate commissioner at the New York State office of metal health, “. . . the sheer scale of the event dwarfed most of our disaster metal health plants. In fact, emotional force of the attacks was so strong that many officials suspected that even people used to coping on their own might seek profes- sional help. Trauma experts warned that people with severe posttraumatic stress disorder might not come forward for months or years” (Goode and Eakin, 2002). Specifically trained and coordinated mental health crisis teams work alongside other medical teams to attend both the physically injured as well as those in the immediate area who have witnessed the event. Even if one does not suffer a direct injury resulting from a disaster, actually witnessing a disaster can cause psychological trauma to individuals. Many viewers watch- ing the news coverage of the September 11 attacks on television have reported symptoms of psychological trauma.
When the disaster teams arrive at the scene, the initial task is to assess the level of severity and the scope of need. All coordinated efforts focus on reduc- ing an already chaotic situation. Mental health teams work directly with those most immediately affected, seeking to reduce their fears, anxiety, and facilitate emotional ventilation. The team members help to determine priorities for those who need immediate additional services. Within the next days and weeks following the disaster, team members meet with those affected individuals and possibly with their families to provide crisis counseling and whatever addi- tional mental health and human services assistance may be necessary.
The incidence of crisis behaviors (also known as posttraumatic stress dis- eases) is usually substantially higher for those individuals who had the great- est degree of exposure to the disaster. Human services workers providing crisis counseling in the periods after disaster, such as the one that occurred on Sep- tember 11, work with individuals suffering from a wide range of problems. They may include severe depression, disorientation, hostility, phobias, hyste- ria, nervousness, sleeplessness, increased irritability, amnesia, or psychoso- matic reactions and nightmares. More severe problems can include psychosis, characterized by an apparent personality change, highly unusual behavior, and irrational thinking. The human services crisis worker must be aware that emo- tional problems experienced by disaster victims may be severe. They must also recognize that such problems may not be readily apparent until months after the actual event.
Research in the field of crisis intervention and disaster response has indi- cated a pattern of post-disaster phases. These phases seem to indicate a sequence of reactions experienced by victims of disasters. Faberow (1977) sur- veyed a variety of the studies which are still relevant today and discussed the following phases:
Heroic phase Individuals react to the immediate disaster through positive action, saving not only their own lives but the lives of others. A sense of
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shared experience, brotherhood and feelings of altruism are present. This may last several weeks. Early crisis behavior symptoms may develop.
Honeymoon phase Focus is on rebuilding and regaining a sense of community and control. Expectations are high that organized help is forthcoming. Post- disaster behavioral symptoms are present. This may last up to six months.
Disillusionment phase Individuals experience a loss of community and of a shared experience. Anger may develop from perceived delay or insufficient response to promised help. Emotional and/or behavioral problems may become apparent. This may last up to one year.
Reconstruction phase Victims come to the realization that they alone must act to solve their own problems. Constructive efforts to resolve problems are initiated.
Solomon and Davidson (1997) estimated that about 5% of men and 10 to 12% of women in the United States will experience events in their lifetime resulting in posttraumatic stress disorder. One can only wonder if these esti- mates will be sufficient in light of the escalating incidences of terrorism in the United States and the world. The victims of disasters and terrorism, however, are a small percentage of those who receive aid from human services. Most people who receive help are victims of social conditions such as poverty, dis- crimination, and technological change.
Poverty
Poverty was the norm among the successive waves of immigrants to this coun- try during the previous century. Most immigrants regarded it as a temporary state that could be overcome by hard work and a bit of luck. During the 1800s, this optimism was justified by the dynamic growth of the nation and by the ample space for expansion westward. The enterprising individual had abundant opportunities, and the second generation was expected to surpass their immigrant parents in financial achievement.
In modern times, poverty sometimes tends to persist from one generation to the next. The poverty cycle is perpetuated by the fact that the disadvantages of poverty hinder the next generation’s chances to succeed. The high preva- lence of broken homes and single-parent families sometimes results in insuffi- cient supervision of and encouragement to children. Poor language skills and a lack of early environmental stimulation may make it difficult for children to take full advantage of educational resources. It becomes difficult for children to develop the skills and attitudes necessary to break out of the poverty cycle.
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Of all social problems, poverty is the one that has received the largest share of attention from social planners. Poverty is a critical problem because so many other problems are linked to it; juvenile delinquency, criminality, drug abuse, and mental illness are disproportionately represented in poor commu- nities. Serious health problems and high rates of infant mortality are also found in poor neighborhoods. Affluent persons are often appalled by the con- ditions existing in poverty areas and sometimes blame the victims for choos- ing to live so badly. The poor, on the other hand, think of themselves as having few options and as being trapped by the culture of poverty.
Poverty is a particular problem in the inner cities. Many of the big cities of this country contain decaying neighborhoods occupied mainly by poor households and devastated by arson, vandalism, high crime rates, and aban- doned housing. Cities are tending to concentrate poor residents who have a great need for services and limited ability to pay for them. Controversy per- sists about what to do about this immense problem. Some social planners have thrown up their hands and suggested that it is futile to pour any more money into inner cities. They fear that increased services would only attract more poor people to the cities. Others have proposed that city governments should do everything possible to encourage middle-class people to return to the big cities. This would provide additional tax revenues, which could be used to benefit the poverty population. By and large, however, the inner cities still con- stitute an enormous reservoir of unmet needs. In addition to those social plan- ners who have “thrown up their hands” at the plight of the poor in and out of the inner cities, some human service workers have also turned away from helping those living in poverty. Specht and Courtney (1994) state this issue clearly: “The poor have not gone away; there are more of them now than at any time in recent memory. . . . Certainly many professional social workers are still committed to the public social services, to helping poor people, and dealing with social problems . . .” (p. x).
Prejudice and Discrimination
The problems of poverty, racism, and prejudice are so deeply intertwined in this country that it is difficult to talk about one without referring to the oth- ers. Prejudice is based on preconceived attitudes and feelings about certain races, religions, or ethnic groups and people of a certain gender. These atti- tudes reflect negative stereotypes that are often nothing more than simple- minded overgeneralizations about certain groups. Typically, these attitudes are not based on real experience with the group in question but are learned from prejudiced individuals. Prejudicial attitudes not only attack the self- esteem of victims but are often the basis for discrimination in employment, housing, and education. Patterns of discrimination aim to keep certain minorities at the bottom of the economic ladder and in a specific neighbor- hood or ghetto. Although the United States has made progress in reducing discrimination in recent decades, the lingering effects of mistrust are still with us.
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Discrimination against African Americans, Latinos, and women is dis- cussed in the following sections. These groups are highlighted because of their large numbers and because of their great importance to human services. There are, of course, many other groups that have been victims of discrimination, and you are invited to study these independently. Probably no other group has been treated with such consistent savagery as Native Americans. Brown’s (1971) Bury My Heart at Wounded Knee provides a moving account of this shameful episode in American history. At times, Asian Americans have been victimized by the white majority. See the Additional Reading section at the end of the chapter for recommended books on this and related topics.
Discrimination Against African Americans For a number of historical rea- sons, African Americans for many years were denied access to the political and social life of the United States. They were segregated in regard to where they lived and went to school. They were relegated to low-level jobs that often pro- vided little more than a marginal income. Family life was disrupted by many factors including the greater availability of jobs for African American females than for African American males. While successive waves of European immi- grants were being assimilated into mainstream America, African Americans were held back by their obvious racial features. Even when they achieved wealth and fame, they were not readily accepted by affluent white communi- ties. Discrimination tended to force African Americans into a circular pattern in which limited education barred them from higher education and career opportunities.
The African American people made slow but definite progress toward equality during the century following emancipation. This was followed by a period of accelerated progress beginning in the mid-1960s. The political ini- tiatives of the 1960s and 1970s, described in Chapter 3, were successful in achieving a higher level of opportunity for African Americans. These positive trends continue to the present day. African Americans are gaining in political power; their income is on the rise and more are now seeking higher education than ever before; a small but significant African American middle class has been established. But it is also clear that much remains to be done. Many African Americans are still deeply rooted in poverty and deprivation. Per capita unemployment is significantly higher among African Americans than whites, and African American teenagers have high rates of unemployment.
A Census Bureau report confirmed that more African Americans are get- ting a piece of the American dream—finishing their educations and finding good jobs. Specifically, 78% of African Americans aged 25 and older com- pleted high school in 2000 compared to 73% in 1994. About 16.5% of African American adults had bachelor’s degrees in 2000 compared to 13% in 1994. However, the income gap between blacks and whites remains wide. Median family income in 2000 for white families increased to $44,226, but the income of African American families increased to only $30,436. The really bad news was that 33.1% of African American children lived in poverty in 1999 compared to 13.5% of white children (U.S. Census Bureau, 2001).
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Discrimination Against Latinos Spanish-speaking Americans have also been victims of a pervasive pattern of discrimination that limits their opportunities for advancement. Virtually every indicator of well-being reflects the results of this discrimination: Their unemployment rates tend to be high; their health is not as good on the average as that of whites; and their educational achieve- ment scores tend to be low, partly because of the language barrier (Freeman, Jones, & Zucker, 1979).
Although Latinos are a smaller group than African Americans in the United States, it is difficult to determine their precise number. Included in their ranks are a large but unknown number of illegal aliens. Migrant workers are another group not usually included in census surveys. In any case, Latinos can- not be considered a homogeneous group. Some can trace their ancestry back to the origins of this country and are well established in their communities. Many others are recent immigrants who came here looking for work. Those who came from Mexico tend to be concentrated in the Southwest, whereas Puerto Ricans tend to live along the East Coast. Many Cubans have settled in the greater Miami area. Other Spanish-speaking people have come here from Central and South America. The tendency of these various subgroups to retain their separate identities has frustrated efforts to join together to advance polit- ical and economic objectives.
One group in urgent need of help are the migrant workers who follow the harvest from south to north along the Pacific Coast. The plight of these work- ers, who are mostly of Mexican origin, has been publicized in books, movies, and magazine articles. However, they have not benefited greatly from this media attention. They work for low pay and are often provided with filthy, substandard housing. The state laws regarding living conditions are sometimes ignored because of official indifference and corruption (Garza, 1973). Even today they are very often exploited not only by the growers but also by recruiters who take a percentage of their wages. Perhaps the best hope of improving their living conditions comes from the increasing strength of agri- cultural unions.
Illegal immigrants are another group in need of assistance. Although ille- gal workers come from Ireland, India, the Caribbean, Asia, and poor countries all over the globe, the great majority are Spanish speaking, with Mexicans making up the largest single subgroup. They may be employed in agriculture, the garment industry, factories, hotels, restaurants, gas stations, and many other settings. For the most part, they get the jobs that are dirty, demeaning, boring, offer little hope of advancement, and pay badly to boot (Crewdson, 1983). They typically lack union representation and do not usually receive sick leave, insurance benefits, or other fringe benefits. Their illegal status makes them easy prey for unscrupulous employers. These conditions still exist. To make matters worse, many American citizens resent their presence and blame them for taking away scarce jobs. Moreover, their position in this country has been made even more precarious by subsequent legislation.
The Immigration Reform and Control Act of 1986, the most important piece of legislation pertaining to immigration in decades, attempted to deal
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with the problem of illegal immigration by granting amnesty to illegal aliens living continuously in the United States since January 1, 1982, and to agricul- tural workers if they worked here for at least three months from May 1985 to May 1986. The act also provides stiff penalties for employers who hire undoc- umented workers. In 1991, the federal government admitted that the 1986 law had not stopped the influx of illegal workers (Pear, 1991).
These workers are ineligible for welfare or other services sponsored by the government for the benefit of U.S. citizens, but they are periodically accused of taking advantage of these services anyway. The evidence reviewed by Crewdson (1983) suggests that they use social services far less than do Amer- ican citizens. They tend to shy away from contact with authorities and some- times even avoid services that are legally available to them. For example, they are sometimes reluctant to seek medical treatment except in emergency cir- cumstances. This poses a serious public health problem in Southern California and other areas of high concentration, because illegals suffer higher rates of infectious disease than do American citizens. Obviously, these workers are not examined for communicable diseases before entering the country. They may seek help from agricultural unions, immigrant fraternal organizations, and church-sponsored helping agencies. For the most part, however, these private agencies do not have the resources to provide more than temporary emergency help for some of those who need it.
During the past decade, there were signs of increasingly negative attitudes toward the estimated 4 million illegal immigrants in this country (Verhovek, 1994). This trend was most pronounced in states with large illegal populations such as Florida and California. During 1994, Governor Lawton Chiles of Florida sued the federal government, asking for more than $1 billion in reim- bursement for services it had been required to give illegal aliens. Governor Chiles, a Democrat, said the people of Florida were tired of spending huge amounts on services, education, medical care, and welfare for illegal aliens. In addition, there were the considerable additional expenses involved in jailing illegal aliens who committed crimes in the state. He argued that Florida was paying for the apparent inability of the U.S. government to protect its borders (“U.S. Is Sued over Aliens,” 1994).
California voters passed Proposition 187 during the election of 1994. This initiative, strongly backed by Governor Pete Wilson, would have cut off most government services to illegal aliens. Specifically, the measure would deny wel- fare, nonemergency medical treatment, and public schooling to this group. There was no immediate impact of the law because federal and state judges blocked enforcement pending a review. Nevertheless, the passage of the mea- sure illustrates the fact that Americans are becoming increasingly reluctant to provide services to these people. Although it is true that illegal immigrants contribute to the American economy, data provided by the Texas Office of Immigration suggest that on balance they cost more than they contribute in tax revenues. The greatest expense by far is associated with public schooling for the children of illegals. The issue of illegal immigration raises important questions for class discussion:
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Women’s Issues We do not have definite knowledge of the status of women in prehistory (that is, before the development of written records). During the late 1800s, a number of authors advanced the idea that women tended to be dominant in some early societies; goddesses were worshiped, and women con- trolled religion, property, and marriage. These authors then offered various explanations for the shift to male dominance that gradually took place. Fem- inist authors attempted to bolster their current agendas by asserting that male dominance was culturally imposed and should be ended. Others argued that the evidence for matriarchies, or female-controlled societies, was not convinc- ing and that males had always been dominant. Feminist historians Anderson and Zinsser (1988) reviewed these writings and concluded that we simply do not know very much about the relationships between men and women in early societies. There is no reason to believe that either male or female dominance was universal in prehistory. Nor can we conclude that women’s traditional role in giving birth and nurturing children was viewed as secondary or unimpor- tant by members of early societies.
What is certain is that women were clearly subordinate by the time written records began to appear. How did this happen? Based on a survey of many early cultures, anthropologist Peggy Sanday (1981) concluded that as the num- ber of early societies grew, they began to compete with one another for scarce resources. As war and forced migration became the means of survival, women began to assume a subordinate role to men. Physically stronger on the average, males were expected to be more active and aggressive than women. Weapons skills were taught to male children. Once warfare is present, a woman needs protection from other warriors, especially if she is pregnant or caring for an infant or young child. In warrior cultures, men came to be viewed as more valu- able and important than women (Anderson & Zinsser, 1988).
Female subordination was enshrined in the earliest and most sacred writ- ings of the Greek, Roman, Hebrew, Germanic, and Celtic cultures. This idea passed intact to the emerging European culture and was later embodied in Christian beliefs (Anderson & Zinsser, 1988). Women were generally excluded from important activities such as warfare, politics, philosophy, and even the study of sacred books. By the fourth century B.C., Aristotle proclaimed that the male is naturally superior to the female. (He also believed that women had fewer teeth than men.) By the first century A.D., Jewish men in their morning prayers thanked God for not having been made women.
Although there had always been women who believed in equal rights for women, it wasn’t until the 1800s that they developed effective organizations to achieve this goal. In part, the move to organize was a reaction against changes in law, government, and the economy that were limiting women’s
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options still further. Significant progress was made by women’s movements in both Europe and the United States. Most women in affluent Western nations now enjoy full rights of citizenship, including the right to vote, have access to higher education, and enjoy significantly widened employment opportunities.
In past generations, women in this country were discouraged from enter- ing certain jobs or careers. For example, mechanical work, physical sciences, administration, engineering, and police work have traditionally been consid- ered male provinces. Females have been regarded as more suited to clerical and secretarial jobs as well as certain nurturing professions such as nursing and social work. During the past three decades, many occupations, professions, clubs, associations, and government positions—once reserved for men—were opened to women. Although it is true that one in five of all working women holds a secretarial or clerical job, it is also evident that women now make up a majority in a wide range of professions that were once male dominated (Roberts, 1995). Here is a comparison of the percentages of all jobs in certain occupations held by women in 1970, 1990, and 2000:
Occupation 1970 1990 2000
Bartender 27% 57% 51.8%
Chemist 17% 29% 30.8%
Doctor 11% 22% 27.9%
Economist 14% 44% 53.3%
Farmer 7% 17% 18.7%
Industrial engineer 3% 27% 15.3%
Librarian 84% 85% 85.2%
Nurse 91% 94% 92.8%
Police detective 5% 13% 16.5%
Psychologist 43% 59% 64.6%
Public official 24% 59% 52.7%
Secretary 98% 98% 98.9%
Teacher 74% 74% 75.4%
Source: From “Women’s Work: What’s New, What Isn’t?” by S. Roberts, New York Times, April 27, 1995, p. B6. Copyright © 1995 by The New York Times Co. Reprinted by permission. Data for the year 2000 from the U.S. Bureau of Labor Statistics, 2000.
Although there has been an opening up in nontraditional areas, these data make it clear that many women are choosing nurturing professions. About 1 in 20 female workers is a schoolteacher, a proportion that hasn’t changed much since 1940. Nursing continues to be a predominantly female profession, and the majority of psychologists are now women. Add to this the increasing
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role of women in other medical professions and their continued dominance in social work and it becomes obvious that women are the major providers of human services.
For a variety of reasons, women generally still earn less than men within a given job category. One reason is that women tend to have shorter job tenures than men because of their roles as mothers and homemakers. Women also tend to work more often at part-time jobs than men. The third reason is sexism, a pattern of discrimination against women. Some woman activists have discerned a disturbing pattern: When women begin to dominate a field, the pay and prestige begin to go down (Roberts, 1995). There may be some truth to this idea, but there are also other reasons (detailed elsewhere in the book) why salary levels have tended to stagnate in the human services field.
Perhaps even more significant than the movement of women into jobs once held by males is the great increase in the number of women who work outside the home. This has been called “one of the great transformations” in American society (Peterson, 1994, p. 140). Today, 60.2% of all American women aged 16 to 65 are in the labor force compared to 74.7% of the men (U.S. Bureau of Labor Statistics, 2000). Among younger workers, there are almost as many women in the work force as men.
The women’s movement, which did much to change attitudes about the role of women, is one factor that helped create this great change in American life. Although only a small percentage of women belong to activist groups such as the National Organization for Women (NOW), the basic concepts of the movement have become part of the thinking of many American men and women (Mehr, 1995, p. 281). The final victory of the movement was supposed to be passage of the Equal Rights Amendment to the Constitution, which would have made a person’s sex an irrelevant distinction under the law. Although the amendment passed both houses of Congress in 1972, it failed to win ratification from the required three-quarters of state legislatures. A coali- tion of groups, composed overwhelmingly of women, fought against ratifica- tion. Apparently, the women’s movement did not represent all women. Some continued to desire a traditional gender role of homemaker and mother (Fin- sterbusch & McKenna, 1994, p. 43).
We have some reason to believe that a significant number of women are not happy with the changes brought about, in part, by contemporary femi- nism. A majority of women told Gallup in 1994 that the women’s movement is hurting relations between the sexes. When asked whether the changes in women’s lives have made life easier or harder than they were 20 years ago, 48% responded that life was now harder. Gallup polls also showed that large majorities believed that it is now harder for marriages to be successful, and a whopping 82% believed it is now harder for parents to raise children (“Has Feminism Made Lives Harder?” 1995). Another source of opposition directed at the feminist movement is based on the tendency of radical femi- nists to downgrade the traditional roles of women, viewing homemaking as mere drudgery.
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questions for class discuss ion or special ass ignment
Social Change
Americans are gradually changing their attitudes toward the poor and minor- ity groups. Actually, this change is only one aspect of what amounts to a rev- olution in customs and attitudes that has taken place in the last few decades. One major trend has been a liberalization of attitudes toward sexual behavior. Homosexuals are pressing for social acceptance of their sexual preference. Sex is more openly discussed than ever before, and premarital sexual relations are accepted by many teenagers. At the same time, women are challenging tradi- tional roles, and there is much public discussion of alternative lifestyles. The rapid pace of social change, particularly during the late 1960s and early 1970s, has stimulated a conservative reaction that aims to preserve traditional social roles and customs. For example, members of the so-called Moral Major- ity championed a return to values based on fundamentalist religious beliefs. Without taking sides in these controversies, we can note that the rapid pace of these developments has created a sense of insecurity in many individuals. The contemporary American is faced with a bewildering range of options with regard to sexual behavior, role, and lifestyle.
The Changing American Family Family therapists have observed an impor- tant change in the American family during the past several decades: The family is no longer organized primarily around child rearing (Carter & McGoldrick, 1989). The lower birthrate, the longer life expectancy, and divorce and remar- riage rates are some of the contributing factors. In the past, the lives of women were linked to their role in child-rearing activities. Now, as previously noted, more women are entering the labor market and are developing personal goals and an identity apart from the home.
Women who choose primary career goals may find themselves wrestling with a severe conflict. For men, the goals of family and career are parallel, but for women, the goals are more likely to conflict (Carter & McGoldrick, 1989). This conflict is due to the perception that the primary responsibility for child care still rests with women. The traditional view that expects women to assume primary emotional responsibility for family relationships runs counter to the demands of a job or career. It is not surprising that more women than men seek counseling during the child-rearing years.
If it is true that child rearing no longer occupies center stage in family life, then what does? The new priorities have been identified by some writers as
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individualism. This is the belief that people should seek their own happiness, develop their capacities to the fullest, and fulfill their own needs and desires. In other words, the interests of the individual man and woman are taking precedence over the interests of the family. These personal goals are often cen- tered around personal prestige, success, and the accumulation of material pos- sessions. These values are by no means peculiar to the United States but may be found in many Western developed nations. In contrast, Eastern nations, such as India, are more likely to be organized around the family as the primary focus of daily life. An individual’s identity is thus likely to be bound up with the family—usually the extended family.
Some social critics have expressed concern that children are becoming a liability to their parents. The millions of children not covered by health insur- ance are an example. Once cherished, children are now more likely to be merely tolerated by adults. In the worst cases, as described in the next chap- ter, children may be seriously abused or neglected. Columnist William Rasp- berry (1991) has stated that American children are in trouble: “too poor, too likely to grow up in a single parent household, too little supported by their government, and too low a priority for the society at large” (p. 12). He won- ders whether we can eliminate the career costs of parenthood and still do what we need to do for children.
Here is a brief listing of some of the changes in living arrangements and family structure that have taken place in recent years:
and wife are working. • There has been a large increase in single-parent households in recent years. • The number of homosexual people openly living together has also risen. • American children are increasingly products of broken or never-formed
marriages.
Senator Moynihan (1993/1994) compared the changes that have taken place in the American family to an earthquake. A wealth of data shows that intact biological families offer very large advantages compared to any other family structure. For example, the family background of students plays a much larger role in student achievement than standard measures of school quality. Furthermore, continued Moynihan, there is a mountain of evidence showing that children from disintegrating families end up with intellectual, physical, and emotional scars that persist for life. Many of the social problems that con- cern human services workers (for example, the drug crisis, the education cri- sis, teenage pregnancy, and juvenile crime) can be traced to broken homes.
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Moynihan stated that a community that allows a large number of young men to grow up in broken families dominated by women, while never acquiring any stable relationship with male authority and never acquiring any set of pos- itive expectations about the future, is asking for and getting chaos. Crime, vio- lence, and unrest are nearly inevitable under these circumstances (Moynihan, 1993/1994).
Economic and Technological Changes
Dramatic changes have taken place since the 1970s in the way income is dis- tributed in the United States. The very rich were a small number of elite pro- fessionals, bankers, and business leaders. In 1950, fewer than 1 million American families earned as much as $60,000. But by 1980 2.7 million house- holds counted incomes of more than $100,000, and by 1993 this fortunate group doubled to 5.6 million households. At the same time, nearly 1 million households were enjoying incomes of over $200,000. “Nothing like this immense crowd of wealthy people has been seen in the history of the planet,” commented a New York Times editorialist (Frum, 1995, p. A15). This is the first time in history that we have had a mass upper class.
Unfortunately, most Americans today do not share in this great income surge. The proportion of American families earning less than $25,000, about 40%, has remained the same for 20 years (Frum, 1995). And the income of average families, adjusted for inflation, has remained about the same since the early 1970s.
Why were some able to do extremely well in the economic expansion of recent decades, whereas others are barely holding their own? It appears that highly educated, computer-literate workers, skilled in the art of manipulating information, are doing well in the current economy. However, people with lim- ited education find themselves placed in jeopardy by far-reaching develop- ments in the global economy (Peterson, 1994). Secretary of Labor Robert Reich, then in the Clinton administration, put it succinctly when he said, “If you are well prepared, technology is your friend; if you are not well prepared, technology is your enemy” (quoted in Simon, 1995, p. 959).
American workers are in essence competing against workers in other countries who are often paid less than they. Routine production work in man- ufacturing and in data processing can be, and is, done almost anywhere around the world. “So routine workers in advanced economies like the United States find themselves in competition with low-paid workers in Third World nations,” explains Peterson (1994, p. 125). This competition is exerting down- ward pressure on the wages of unskilled workers. Along with these trends went a loss of power on the part of trade unions who formerly acted to pro- tect the wages and working conditions of members. In a climate of global com- petition, an increase in pay for an American worker might place the company at a competitive disadvantage. In any case, the employer could hold out the threat of relocating overseas if wage demands were pressed.
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Many skilled American workers can no longer find industrial employment at all and are seeking “traditional underclass jobs” as janitors, warehouse loaders, cleaners, and security guards. This trend exerts downward pressure on unskilled workers, who face a tighter job market or are being pushed out into the cold. They may then join a large group of discouraged workers who no longer seek regular employment. We elaborate on the unemployed or mar- ginally employed in the next chapter.
What do these trends mean for America’s working poor? The fact is that millions of families hold two or three jobs but still can’t afford the necessities of life. According to the U.S Bureau of Labor Statistics, there are over 7.5 million individuals holding more than one job. Eherenreich (2001) describes the many situations and conditions that require the holding of multiple jobs even when working full time at one job and earning more than the minimum wage. The problems apparently haven’t changed when we consider the situation of Terri Yates as she explained it to a Time magazine reporter. In 1994, Terri earned $10,000 as a full-time cab driver while her husband earned somewhat more driving a cab seven days a week. The Yateses can’t afford a down payment on a house, are paying off a pickup truck, and are deferring repairs on a 10–year-old Pontiac. “I’m making less money than ever in my life, and I’m working more,” Terri told reporter Gibbs (1995, p. 17). She added that she can’t send her daugh- ter to the dentist because money is so tight. The parents feel they have “no life” and don’t see things getting better. They are proud that they have never been on welfare but feel little respect for the politicians who applaud their struggle.
Millions of people are just getting by, one crisis away from disaster. A cri- sis might be an illness to one person in the family, an unexpected loss or injury, or losing a job. The estimated 10 million working poor in the country are vic- tims of the global competition that we have discussed. They are also being replaced by automated, programmed machines that require little human supervision. For example, robots are now doing welding and assembly jobs once done by human beings. Many of the working poor are now stuck in ser- vice jobs that take up so much time and energy that resuming education seems like an impossible dream. They are not eligible for government-sponsored training programs, do not receive free day care, and often do not have med- ical insurance or retirement benefits. They constitute a large group, vulnerable to destitution, that receives little or no help from human services. It is becom- ing more difficult for them to move up the economic ladder and easier to slip into homelessness or welfare dependence.
The implications of these data are disturbing to human services workers. The trend is clearly in the direction of a two-tier society with the very rich sep- arated from the great mass of struggling poor people. The large number of very rich, coupled with the influence that their money assures, gives them increasing power in the political arena. The danger is that they may neglect the interests of their less affluent fellow citizens. We may slip into the situation that prevails in many poor developing countries: the poor simply do without the basic services that are considered essential in affluent nations.
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Population Changes The 1990 census showed that more Americans live in suburbs than in any other social setting. The same held true toward the end of the 1990s. There has been a vast exodus of people and jobs from both farm and city into the suburbs that ring U.S. cities. This shift in population carries with it a shift in political and economic power (Walters, 1992). It is well known that as voters age and move to the suburbs they tend to become more conservative in voting patterns. This may partly explain why politicians are addressing the concerns of middle-class home owners, while downplaying their sympathy for the urban underclass.
What does all this mean for human services? The white Anglo populations of the suburbs, although declining proportionately, are still politically domi- nant. As Walters puts it, the voters of California don’t like crime or property taxes and are only marginally supportive of schools, health, and welfare issues. This seems to reinforce the impression we have gained from other sources: A large increase in unmet human needs in the central cities exists in an increas- ingly hostile political environment. We have highlighted California not only because it is America’s most populous state but because the trends apparent there are visible in other states with significant immigrant populations. Wal- ters described California as the nation’s social laboratory, testing whether a society of dozens of ethnic, linguistic, economic, and geographic subgroups can find any sense of common purpose. “To date, the drift is toward some kind of twenty-first century American tribalism, with suburbanites being the dominant tribe” Walters, p. 89).
A Crisis in Morals?
A number of authors have recently expressed alarm about the general decline in American morals that has taken place since the 1960s. Not only the United States but Great Britain and other affluent countries have undergone an immense increase in many kinds of deviant and antisocial behavior in recent decades. The increase in out-of-wedlock births has been discussed, and in Chapter 2 we provide details about crime, drug abuse, child neglect, and other undesirable behavior. Senator Moynihan (1993/1994) has warned that a dis- astrous social crisis is under way in America. Behaviors once regarded as wholly unacceptable are gradually being accepted as a normal part of Ameri- can life. Crime, teenage pregnancy and suicide, the breakup of families, mur- ders by young schoolchildren, guns in schools, the spread of AIDS, the abuse of children, the battery of women, and drug abuse are some of the behaviors that concern Moynihan and human service workers. Part of the process involves changing the words we use to describe behavior. For example, when the term illegitimate birth becomes out-of-wedlock or single parenting, we imply acceptance of the behavior.
Himmelfarb (1995) points out how we have become very uncomfortable about making moral judgments, particularly about condemning certain behav- iors. “Public officials in particular shy away from the word immoral, lest they be accused of racism, sexism, elitism, or simply a lack of compassion” (p. 240).
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When members of the president’s cabinet were asked whether it is immoral to have children out of wedlock, they refused to put it in moral terms. The Secre- tary of Health and Human Services was quoted by Himmelfarb (1995) as say- ing, “I don’t like to put this in moral terms, but I do believe that having children out of wedlock is just wrong” (pp. 240–241). It is not only our political and cultural leaders who are prone to this failure of moral nerve; everyone is infected by it to some degree.
In an influential book, Magnet (1993) describes the revolution that in the 1960s led to a strange alliance between the haves and have-nots. The intent of social planners was to liberate the poor from the political, economic, and racial oppression that held them in bondage. Along with this went a cultural revolution that liberated the poor from stodgy middle-class values and the Puritan ethic. Magnet argues that these new values had a disastrous effect: By putting down the attitudes that previously made for economic advance— sobriety, thrift, and hard work—they locked many of the poor into permanent poverty.
Some authors make the point that the values and morals of a society pow- erfully influence human services. One example is the Supplemental Security Income Program, which was introduced in 1972 to provide a minimum income for the blind, the elderly, and the disabled poor. The program was sub- sequently extended to drug addicts and alcoholics. This involved redefining behavior patterns that were once considered vices as disabilities. As Himmel- farb (1995) points out, this redefinition has the effect of actually encouraging these disabilities. The program rewards those who fail to overcome the addic- tion and cuts off benefits for those who succeed.
Drawing distinctions between good and bad behavior is implied in all of our thinking about social policy. We may disguise the underlying moral judg- ment when we speak of the pathology of crime, drugs, and welfare depen- dence. When we say workfare is better than welfare, we are again making a moral judgment. Equally, when we consider promoting sexual abstinence among young people, we are making another moral statement. Confusion about this point arises when we try to cover up morality by using scientific terminology.
Luttwak (1993) attributes the decline in U.S. culture to an unrestrained individualism that knows no balance. The United States has historically cham- pioned individual rights over the rights of the general public, but in the past this emphasis on personal freedom was balanced by a strong sense of duty to family and community. However, in recent decades, the balance has shifted toward a drive for self-fulfillment that is pursued at the expense of the family. The interests of young children are often sacrificed by parents who wish to pursue personal happiness.
If the values of the liberal counterculture of the 1960s are increasingly being rejected, it does not follow that conservative values are morally uplift- ing. Conservative values have shifted during recent years toward even greater emphasis on free markets and competition. This change is reflected in the transformation of the American corporation. What Luttwak (1993, p. 164)
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calls the “old quiet-life corporation,” which often provided lifetime jobs for its workers, became the “lean and mean” corporation. To increase profits and maintain a competitive edge, it became commonplace to fire large numbers of midlevel executives, a trend that continues to the present day. At the same time, there was no hesitancy to send assembly-line jobs overseas to take advantage of cheaper labor. In other words, the corporation no longer experi- enced the previous sense of loyalty or obligation to its employees, many of whom have experienced a humiliating loss of self-respect along with a feeling of betrayal. The wholesale firings and layoffs inevitably had a disruptive effect on family life. Conservative economists defended these new policies as exam- ples of creative destruction, meaning that the overall improvement in U.S. competitiveness justifies the sacrifice of certain individuals (Cobb, Halstead, & Rowe, 1995). Luttwak, himself a conservative, argues that workers and their families need stability more than they need new goods on the market. He suggests that conservative politicians do not feel free to talk about this issue because much of their funding comes from corporations.
There has been a sharp decline in public confidence in our political insti- tutions. According to pollster Stanley Greenberg (1995), beliefs that the gov- ernment could be trusted to do what is right declined sharply after 1988.
The lies, the perks, the bounced checks, the waste, the sweetheart deals, the privi- leges, the indifference to popular opinion—all stirred outrage when the country’s leaders could no longer show ordinary Americans the way forward. And no amount . . . of ethics investigations, campaign reform, or term limits will restore the public trust. (p. 19)
The recent scandals involving lying, sexual behavior, and criminal offenses by elected and appointed government officials further helped erode the public trust. Yet, strangely, much of our society seems to accept the lowering of many moral standards.
question for class discuss ion or special ass ignment What impact does the crisis in morals have on human services workers and their professional responsibilities?
Psychological Stress
The large-scale problems just described have their final impact on individuals. In our complex, rapidly changing culture, it is probable that an individual will sometimes be frustrated in trying to meet the needs described at the beginning of this chapter. All kinds of obstacles including prejudice, poverty, and other factors just reviewed can stand in the way of fulfilling needs. Typically, disad- vantaged people are preoccupied with basic survival needs, whereas the more affluent are concerned with higher needs relating to self-esteem and fulfillment of creative urges. To some extent, everyone experiences the pressure of these needs, and this is one important source of psychological stress.
Stress is sometimes defined as the strain imposed on an individual by threatening life events. However, it has been found that some desirable events,
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such as job promotion, may also impose strain on the individual. Bloom (1984) covers both possibilities by defining stressful life events as “those exter- nal events that make adaptive demands on a person” (p. 244). These events may be successfully handled or, in some instances, may lead to illness or psy- chological breakdown.
A team of researchers studied life events that occurred shortly before the onset of serious illness (Holmes & Rahe, 1967; Rahe, 1979; Rahe & Arthur, 1978). They developed a list of 43 life events and scaled them in terms of how much stress they evoke. Although the study took place years ago, the data are still relevant. The list is reprinted here as Table 1.1. It is not particularly sur- prising that death of a spouse ranks as the most stressful kind of event. But it is surprising that joyful life events such as marriage or marital reconciliation prove to be more stressful than financial catastrophes such as bankruptcy or mortgage foreclosure. All of the events listed in Table 1.1 have one feature in common: they require a person to adjust to a change in his or her life situation.
It is not only major life events that have an effect on physical health but also the ordinary hassles of daily life. Hassles are those apparently minor events that can make you tense, frustrated, and irritable. Losing your wallet, getting involved in a minor car accident, and waiting in long lines are just a few of the bothersome situations that interrupt the smooth flow of daily events. When hassles take place frequently over an extended period, they can have a negative impact on health and well-being. In fact, one team of researchers reported that hassles far outweigh major life events in predicating psychological and somatic symptoms (Lazarus & Folkman, 1984, p. 312).
Some people are better able to tolerate stress than others. We have already pointed out that stress tolerance is partly dependent on the amount of emo- tional support one receives from other people. This is why divorce or death of a loved one is particularly stressful; it leaves the victim to face the situation without familiar supports.
Certain personality traits also play a role in how a person handles stress. Kobasa (1979), for example, studied how a person can remain healthy in the face of great stress. She reported that those who do so have a clear sense of their values, goals, and capabilities; a strong tendency toward active involve- ment with the environment; and a belief in their capacity to control and trans- form life experiences.
Developmental Crises
Psychological stress is intensified at certain phases of a person’s development or maturation. This kind of stress is the unavoidable consequence of moving from one phase of development to the next. The stages of development include the prenatal period, infancy, childhood, puberty, adolescence, young adulthood, middle age, old age, and death. During each transition from one stage to the next, a person is subjected to novel challenges and tasks that tend to increase anxiety. The changes might involve new responsibilities, bodily alterations, and new ways of relating to others. For example, the individual entering young
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table 1 .1 social readjustment rating scale
Life Event Stress Value
Death of spouse 100
Divorce 73
Marital separation 65
Jail term 63
Death of close family member 63
Personal injury or illness 53
Marriage 50
Fired at work 47
Marital reconciliation 45
Retirement 45
Change in health of family member 44
Pregnancy 40
Sex difficulties 39
Gain of a new family member 39
Business adjustment 39
Change in financial state 38
Death of a close friend 37
Change to a different line of work 36
Change in number of arguments with spouse 35
Mortgage or loan for major purchase (home, etc.) 31
Foreclosure of mortgage or loan 30
Change in responsibilities at work 29
Son or daughter leaving home 29
Trouble with in-laws 29
Outstanding personal achievement 28
Wife begins or stops work 26
Begin or end school 26
Change in living conditions 25
Revision of personal habits 24
Trouble with boss 23
Change in work hours or conditions 20
Change in residence 20
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adulthood has reached physical maturity and is expected to make serious plans for a career and to begin serious sexual relationships. The major thrust of a per- son’s activities is toward the achievement of independent, self-supporting sta- tus. With support and nurturance from others, most are able to master the demands of the new phase successfully.
However, developmental stresses can overwhelm some individuals, partic- ularly those whose needs for support and nurturance are not being met. There is a wide variation in how people react to developmental transitions. What is a crisis for one may be an interesting challenge for another. A crisis occurs when an individual feels overwhelmed by the demands of the next phase of development. If a person is completely unable to master the requirements of the next developmental stage, further growth is prevented. The consequences of this failure may range from temporary emotional disturbance to serious dis- organization of personality.
During recent decades, there has been a marked change in attitudes of human services workers toward people in crisis. It is now accepted that peo- ple may become anxious or upset during transitions in development and that such reactions are not necessarily a sign of serious mental illness. Hoff (1978) points out that modern crisis theory has established a new approach to people with such problems. It is no longer assumed that they are completely irrational or that they cannot help themselves. Furthermore, it is becoming more accepted that it does not require a highly trained psychotherapist to help peo- ple get through a crisis. Counselors, police officers, nurses, laypersons with training in crisis intervention, and family members can be very helpful in get- ting someone through a difficult developmental phase. A more detailed dis- cussion of crisis intervention follows in Chapter 5.
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Change in school 20
Change in recreation 19
Change in church activities 19
Change in social activities 18
Mortgage or loan for lesser purchase (car, TV, etc.) 17
Change in sleeping habits 16
Change in number of family get-togethers 15
Change in eating habits 15
Vacation 13
Christmas 12
Minor violations of the law 11
Source: Reprinted by permission of the publisher from “The Social Readjustment Rating Scale” by T. H. Holmes and R. H. Rahe, 1967, Journal of Psychosomatic Research, 11, 213–218. Copyright © 1967 by Elsevier Science.
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The Crisis in Health Care
The health care system in the United States has become a major source of pub- lic concern in recent years. An editorial that appeared in the American Jour- nal of Public Health charged that this country lacks a coherent national health policy and that the system has become indifferent to the real health needs of society (Sultz, 1991, p. 418). Sultz called for the creation of a network of health services that will care humanely for the poor, the sick, the elderly, and the most vulnerable Americans. We are falling far short of this goal. Although this country spends more on health on a per capita basis than does any other developed nation, millions of Americans do not have access to affordable health care. According to the Census Bureau, there are 43.4 million people in the United States without health insurance (Kilborn, 1999). Herbert (1998) points out that there are 74 million children under the age of 18; over 20 mil- lion do not have access to adequate health care, and over 11 million are with- out insurance. One of the major problems is that the costs of health care were running out of control. In 1999, the total National Health Expenditure, which includes building hospitals, clinics, and the cost of training medical personnel, was $1.2 trillion (U.S. Centers for Medicare and Medicaid, 2002). Why are costs so high? Here are some factors that play a role:
Another difficulty is that our system (if it can be called that) has become very complex and unwieldy. Many other developed nations provide medical care through a unified system of government-operated clinics and hospitals. In contrast, we provide health care via a bewildering mix of public and private facilities funded by a large number of private and government insurance pro- grams. The government insurance programs, chiefly Medicare for the elderly and Medicaid for the poor, provide limited coverage to millions of Americans but do not cover the majority of working people. Many workers receive med- ical coverage, usually through a private insurance company, as a fringe bene-
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fit of employment. The extent of coverage varies greatly, often with a single carrier offering a range of policies to choose from. Of course, the more limited the coverage, the more that must be paid out of pocket by the patient. The physician and patient are typically confronted with complex fee schedules detailing how much is to be paid for each medical procedure. Increasingly, insurance companies and HMOs are questioning doctors’ judgments, particu- larly with regard to costly procedures. There is a chorus of complaints about the forms to be filled out and the difficulties involved in trying to deal with the impersonal bureaucracies that administer the programs.
Many people fall through the gaps in this network of coverage. When medical insurance is linked to employment, the worker may lose the insurance when he or she is laid off or fired from the job. Part-time workers, low-paid workers, and those employed by small firms are often without medical insur- ance at all. These people are in a serious dilemma; they can afford neither to buy their own insurance nor to pay for any extended medical treatment. Con- sequently, they put off doctor visits as long as possible and may end up in emergency rooms being treated for a condition that has become serious or life- threatening through neglect. All too often, the emergency room is replacing the family doctor’s office at a greatly increased expense. Furthermore, HMOs have increasingly dropped poor patients due to the lack of profit.
Another criticism of our health care delivery system is that it tends to emphasize treatment rather than prevention. Most health care providers define successful treatment as the elimination of disease. Physicians understandably give precedence to a patient with existing symptoms rather than to a healthy patient who wants a program of diet and exercise. Many insurance companies do not reimburse subscribers for health maintenance visits, such as physical exams, but reimburse only for definable illness (Prokop, Bradley, Burish, Anderson, & Fox, 1991).
The reform of our health care system was one of the major goals of the Clinton administration. First Lady Hillary Rodham Clinton led a 500-person task force that was to accomplish three basic tasks: (a) extending medical ben- efits to the uninsured at reasonable cost, (b) guaranteeing continued coverage when workers change jobs or get sick, and (c) generally controlling the steadily rising costs of health care.
The Canadian National Health Plan: A Model for the United States?
The citizens of Canada are beneficiaries of one of the most comprehensive health insurance programs in the world. The plan uses provincial (provinces are like our states) tax money, supplemented by federal funds, to provide med- ical care to everyone at no charge. All medical care is free, including long-term home care and nursing home care in many provinces. There are no bills, and no money is paid by patients to doctors; the doctors bill the government. By and large, the doctors are satisfied with the system, although there have been
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battles with the government over fees. Doctors’ charges for services are lower than in the United States, but so are administrative expenses and malpractice premiums (Rosenthal, 1991). Incredibly, the system provides health care to all at less cost than the U.S. system.
It sounds good, but, as in the U.S. health system, there are some disad- vantages. The level of care is probably not as good for wealthy Canadians as that received by wealthy people in this country. There are sometimes waits for tests and treatment, and the system is slow to buy expensive new machines and procedures. Advanced diagnostic equipment is in short supply, and patients in both countries may have to travel in order to benefit from this equipment. Also, wealthy Canadians do not enjoy the same ready access to specialists as do wealthy Americans. The ratio of specialists to general practitioners is 1:1 in the United States compared to 1:4 in Canada.
The basic advantage of the Canadian system is that everyone is covered; the patient’s financial status is never an issue. In this country, there is much greater variation in the level of care, depending on a person’s income and resources. As we have seen, millions of people in the United States have no medical coverage at all, whereas the wealthy have available the latest in advanced medical technology.
The Clinton plan was met with a torrent of criticism and failed to garner the support needed to get through Congress. These criticisms came, for the most part, from the insurance companies and medical profession, which had the greatest interest in maintaining the status quo. Some of the criticisms were that it would make the health care system even more complex and unwieldy than it already was and that it would create brand new bureaucracies entail- ing more government regulations. Paperwork would increase, and treatment decisions would be second-guessed by government officials (Butler, 1993).
The failure of the Clinton plan meant that the original problems were still there. Many alternative plans were considered. One is the Canadian plan, which would allow the government simply to buy medical care for us with tax dollars. This would effectively sweep away the current insurance companies and employer-provided insurance with its choice of services. It would be rela- tively simple and would reduce administrative costs. According to the critics, the disadvantages might be some rationing of care and less freedom to choose providers. Enactment of any such plan would be met by intense opposition from the nation’s insurance companies, which profit from administering the present programs.
The Example of the Federal Employee Health System Another alternative is to model the system on the Federal Employees Health benefits system, which covers nearly 10 million employees, retirees, and their dependents (Butler, 1993). Under this plan, the workers decide for themselves what services they want. Once a year, they receive information on a menu of perhaps two dozen insurance plans available to them where they live. The cost of premiums, the services covered, and the out-of-pocket expenses are all described in detail. The workers pay about one-third of the premium for whatever plan is selected,
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with the government paying the rest. The government has nothing to do with setting the prices or determining the benefits package.
One clear advantage is that costs are held down not by government regu- lation but by the competitive nature of this approach. Each insurer wants to attract clients to its program and tries to offer the most benefits for the least expense. The problem comes in with persons who have no employer to pick up the premium. In the case of a worker who was recently laid off, for example, the government would have to pay the entire tab. The costs would be consid- erable and added to the expenses already incurred by Medicaid and Medicare.
Managed Care
Managed care is an umbrella term for health care insurance systems that con- tract with a network of hospitals, clinics, and private providers (doctors, ther- apists, and so forth) who agree to accept set fees for each service or flat payments per patient. Managed care involves patient care that is not deter- mined solely by the provider. It is estimated that managed care organizations administer between 70% and 80% of the group health insurance coverage provided today in the United States. The growth of managed care developed primarily from the governmental response to the soaring costs of health care and the need for greater accountability to control these escalating costs. Over the past 10 years, the managed care system has had a major impact on the delivery of human services.
It is difficult to generalize about how managed care has affected all providers and patients. Some professional groups view managed care as a threat to their autonomy in setting their own fees and controlling their own course of treatment. They criticize the insurers for frequently providing only limited or assembly-line service and for intruding into the doctor-patient rela- tionship. Other professional groups have found that managed care offers greater opportunities and a new and additional source of patient referrals.
To control and maintain cost, managed care insurers often utilize the external review process. In this approach, before a major service can be pro- vided or a professional reimbursed for a course of treatment, the managed care organization must review the requested course of treatment. This often involves a peer review, provided by the insurer, of the proposed course of treat- ment to find the least expensive level of care that will satisfy the patient’s needs. Those conducting external reviews often seek answers to the following questions:
If a visit to a provider is for minor or routine treatment, the provider or client need not initially contact the managed care organization for approval as
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long as the treatment follows the preset managed care guidelines. Additional features of the managed care approach emphasize early detection and treat- ment, preauthorization for hospital admission, and continuous care manage- ment. A vigilant and continuous management review helps the managed care organization to insure that the treatment guidelines have been followed and to monitor the effectiveness and cost of service. It must be remembered that most managed care systems are profit-making organizations. This often creates con- flicts and problems within the organizations and for the consumers. Loss of income, for example, has moved HMOs to chop poor and elderly members. Pear (1998) reports that potentially 300,000 beneficiaries could be dropped. The role of the case manager is examined more closely in Chapter 5.
Several different kinds of managed care plans are available:
HMO: The health maintenance organization is the most highly structured, providing comprehensive health services for a fixed prepaid rate. Some HMOs have their own clinics, whereas others have a “panel” or network of independent doctors. Care is coordinated by a primary care doctor or “gatekeeper.” The main advantage is that costs are relatively low. The owners of small or medium-size businesses may find that this is the least expensive way of providing workers with medical coverage. The disad- vantage is that patients are limited to the HMO’s clinics and providers. If they go out of network, they must pay the costs out of pocket.
PPO: Preferred provider organizations are groups of doctors and hospitals that agree to provide health services at a fixed rate. The prospective patient is usually given a list of providers and may go directly to any of them. There is no gatekeeper or individual to coordinate care. Typically, the patient must pay a modest copayment fee for the service.
POS: Point-of-service plans also have networks of providers, but patients may seek treatment outside of the network if they are willing to pay a greater share of the cost. This is becoming increasingly popular because patients need not forfeit their freedom to choose their doctors and hospi- tals. Some traditional HMOs, such as Kaiser Permanente, have started to offer a point-of-service option. Coverage for out-of-network benefits varies from plan to plan; for example, some pay 70% of what the HMO considers a “reasonable and customary” fee, which is generally less than the actual charge (Durkin, 1995).
The recent growth of managed care plans is due to the fact that they hoped to provide a means of controlling the escalating costs of medical care. While rising costs have slowed down, other problems have been created. As previ- ously stated, these plans are sometimes criticized for providing limited or assembly-line service and for intruding into the doctor-patient relationship. Furthermore, managed care programs have begun to recognize that many of its hoped-for goals were not reached. Kilborn (1998a) points out that they are entrenched in the economy and provide a different way to pay for care but not a better way to provide it. Many of the problems predicted by the opponents of managed care, such as denied, delayed, and inadequate medical care, were
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realized. The rapid growth of managed care programs created such problems and is presently a major concern of Congress. Kilborn (1998b) describes how anger over the problems of managed care became a major issue. The passage of a patients’ bill of rights is an ongoing struggle between the parties in Con- gress, with the Democrats seeking a sweeping bill, while conservative Repub- licans look for a limited one.
Interaction among Problems
For purposes of description, contemporary problems have been treated here as separate and distinct from one another. In real life, there is a dynamic interplay among these factors. Close examination shows that certain individuals or groups may have to struggle against the cumulative impact of many stressful factors. For example, a technological change that puts a poor southern agricul- tural worker out of work immediately places the family under stress. The need for money may force the older children to quit school and seek work, which reduces their chances of escaping the poverty cycle. If the family relocates to a northern ghetto in search of work, they may be disappointed to find many oth- ers like themselves also out of work. The hopelessness of the situation may pro- mote attempts to temporarily escape by means of drugs or alcohol. High levels of violence, crime, and gang activity may also threaten family cohesion. Med- ical care may be poor or completely inadequate in the community. These nega- tive influences tend to accumulate to the point that cause and effect act in a circular fashion. For example, the mental breakdown and hospitalization of a
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mother may be traced to poverty and other factors; in turn, her breakdown becomes a major obstacle to the adjustment of her children, who may be shunted from one person or institution to another. The cycle goes on.
SUMMARY The United States monitors its economic health by means of a sophisticated system of indicators that provide a basis for informed discussion about eco- nomic activity. In contrast, we do a relatively poor job of monitoring our social health. As Miringoff (1995) points out, social indicators appear less often and are assessed in isolation with no context or connection. Poverty, for example, is reported once a year and teenage suicide every two years. There are no national measures of homelessness and illiteracy. The Fordham Institute for Innovation in Social Policy has published an annual Index of Social Health for the United States. Although not as precise as our measures of economic health, it certainly represents a significant advance in social monitoring. The index consists of 16 social indicators including infant mortality, child abuse, poverty, teenage suicide, drug abuse, unemployment, homicide rates, and oth- ers (Miringoff, 1995).
The results reveal a sharp decline in America’s social health. The decline was due to increased numbers of children in poverty, increased child abuse and teenage suicide, lower average weekly wages, increased homicide rates, a widening gap between rich and poor, and other factors. More vivid than sta- tistics is an eyewitness account provided by Mario Cuomo (1994). When gov- ernor of New York, he visited the neighborhood in Queens where he grew up and found himself unprepared for so many dramatic changes:
Instead of the faint hope of the 1930s . . . I saw the despair of the 1990s. Instead of people of diverse backgrounds working . . . to get ahead, I saw people in des- peration, unemployed, without any purpose or prospects. The houses were crum- bling; children loitered when they should have been in school. . . . Pimps and prostitutes patrolled the streets. I even saw a couple fornicating in the street. My part of South Jamaica, once a pocket of modest dreams, . . . had become . . . ravaged by neglect, a vivid example of societal failure. (p. 158)
These conditions, he continued, are not unique to this neighborhood but may be found in cities all across the country.
In this context, it is clear that an increasing number of people need help from human services. It is therefore ironic, and troubling, that several trends are acting to reduce support for human services at this time. The huge deficits run up by the federal government were partly responsible for this predicament. The federal government spends more paying interest on the national debt than it does on all state and local governments combined. This payment does not build a single building, create a single job, or feed a single person (Cuomo, 1994, p. 5). In the 1996 fiscal year, we spent 12 times as much on repaying interest than on education and twice as much as on poverty programs. The
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impact on human services is enormous because the debt severely limits our ability to fund services adequately and, at the same time, makes our social problems worse. Another trend is the belief on the part of some policymakers that human services programs are adding to our problems.
This may indeed be a time for honest self-examination by service providers. The criticisms of human services need to be taken seriously. Some agencies may in fact be bloated with political appointees and administrators who provide no useful services to anybody. Although we recognize the need for greater account- ability and cost-effectiveness on the part of agencies, we are greatly concerned about the potential dangers of undisciplined cutting of essential services. As people fall through the safety net, they are more likely to become dysfunctional, unstable, and, possibly, violent. Human services are essential to a civil, well- ordered society. A failure to provide important services in a timely fashion is often counterproductive because more serious problems may be created. In the chapters that follow, we will provide many specific examples of this process.
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